Top Terms To Know To Understand Medical Bills | Patsy Gallian

Healthcare providers have been relying on digital systems to store and process patient data since the introduction of health information exchanges (HIEs) in the early 2000s. The implementation of digitized patient data of course spilled over into the medical billing and coding process. Several terms have been developed since then to make the payment process easier for insurers, providers, and patients to decode. Becoming well-versed in the basic phrases associated with medical billing can give you the opportunity to digest associated information in a much more comprehensible way.

Many terms used by healthcare providers and insurance companies are easier to decipher than others. For example, an allowed amount refers to the maximum amount of funds that an insurance company is willing to pay out to a provider. Another commonly used term is an appeal, in which a patient or physician submits a formal request for additional services to be covered under the person’s policy. An explanation of benefits (EOB) is another digestible term that is used to describe the official documentation stating what and how much is covered by an insurance company, as well as why a specific claim has been denied.

Some frequently used medical billing terms can be a bit harder to coherently understand. A prime example is an applied to deductible (ATD), which specifically indicates the amount of money that is applied to the patient’s annual deductible. A capitation is another term that is harder for some to define, which refers to the fixed amount that the provider and insurance company settle on beforehand as a sign-on bonus for every new patient that they acquire. Lastly, many patients and billing students wonder what a clearinghouse is. A clearinghouse is a third-party company that is responsible for reviewing claims and making any additional adjustments to it before it is officially sent to the insurance company.

These aren’t the only terms and acronyms found in billing forms, but they are a few of the most common phrases that patients inquire about. Having a more in-depth grasp on what common medical billing terms mean can help you easily decipher the meaning behind any bills or other documents that a provider or insurance company sends you. Keeping a list of them near at all times can give you easy access to their proper definitions whenever necessary.

Originally posted on on June 19, 2019.


The 101 On The Medical Claims Submission Process | Patsy Gallian

Patients typically pay for medical services with medical insurance Healthcare providers submit medical claims to insurance carriers for reimbursement of services rendered.

Charge Entry

A Superbill is used by healthcare providers [physicians] as a primary source of data for creating claims. Superbill has a list of various CPT [Current Procedural Terminology] Codes and diagnosis codes. Physicians select codes that describe patients’ condition(s) and visits. The Billing staff receives Superbill(s) and then enters codes into the billing systems accordingly.

Facilities such as hospitals assign 4 digit codes called revenue codes that represent departments in the facility as follows;

  • 0250 Pharmacy
  • 0300 LAB
  • 0450 Emergency Room

CMS 1500 Claim Form

CMS claim forms are typically used by non-facility providers such as physicians, radiologists, anesthesiologists, etc. Medicare Part B typically accepts CMS 1500 claim forms. NOTE: Medicare Part A processes facility or institutional claims. CMS claim forms do NOT have form locators for Revenue Codes.

UB04 Claim Forms

UB04 claim forms are typically used by facilities such as hospitals, skilled nursing facilities, etc. Unlike CMS claim forms, UB04s have form locators for revenue codes.

Electronic Claim(s) Submission

Claims are batched into groups. The billing software will “scrub” claims for errors. Scrubbing is another term for claim edits. Billers will make necessary corrections, adjustments, etc. The goal is to submit “clean” claims with no errors. Once claims pass the billing edits, then claims are ready for transmission to the clearinghouses via EDI 837 transaction set or files. The clearinghouse will accept batches of claims and then route claims to insurance carriers accordingly. Insurances will then acknowledge claim(s) acceptance and then send responses back through the clearinghouse to providers.

Paper Claims

Some insurances allow paper claim submissions. These claims can either be mailed or faxed.


Clearinghouses also communicate whether a claim was paid or denied. This information is transmitted back to the provider via 835 files. 835 files or Electronic Remittance Advice contain payment details. Also, 835 files will typically contain denial details such as denials for medical necessity, no authorization obtain, coverage and coding issues, etc.

Providers rely on proper tools and skilled staff to maximize efficiency which yields a great patient experience, efficient claims submissions which positively enhances their bottom lines. Sticking to the process, as well as a deep understanding of its complexities and nuances, help medical billing go as smoothly as possible.

Originally posted on on June 19, 2019.

How to Become a Medical Biller or Coder


How to Become a Medical Biller _ Patsy Gallian

The job of medical coders and medical billers is an essential one in the healthcare industry. What’s more, there is a growing need for experienced and knowledgeable coders and biller. If you want a fulfilling job helping to bridge the gap between providers, payers, and patients, a career in this field is in reach. Continue reading to learn how to become a medical biller or coder.


There is no formal education, such as an Associate’s or Bachelor’s degree required to become a medical coder or biller. However, having some sort of post-secondary education can be helpful and obtaining an Associate’s degree is never a bad idea. Most medical coders and billers attend either a certification program or work towards an associate degree to learn about the field.

Courses either at a college or a certification program teach medical billing, coding, medical procedures, insurance billing, and medical terminology. Students learn about CPT, ICD-10, and HCPCS and their various medical codes for insurance and reimbursements. Most programs will also teach students how to fill out forms and file claims.

Programs will sometimes ready their students to take certification exams, like the Certified Professional Coder certificate from the American Academy of Professional Coders (AAPC) or the Certified Coding Associate certification from the American Health Information Management Association. It is recommended to find a program that offers such preparation, as it will save you time and money in the future.

Hands-On Experience

An employer will want to know that their hire is knowledgeable and experienced with medical coding and billing. You should take any opportunity you get to receive hands-on experience or training. Try to gain some experience with all aspects of medical billing and coding, including at different types of healthcare facilities, such as at both a private practice and a hospital. The more you’ve been exposed to the industry, the better chance you have at getting hired.

Get Certified

Certification is not always required by employers, but it’s better to err towards the safe side. Additionally, the need to be certified will varies from employer to employer, but you’ll increase your job pool if you have one. Plus, you’ll never suffer from too much knowledge and experience.

Additional Training

If you love the field of medical billing and coding, there are many areas of advancement within the career track. To move up, work towards obtaining more education. If you only attended a training program, consider working towards an Associate’s degree. If you have an Associate’s already, apply for a Bachelor’s in healthcare management. More education will better prepare you for advancement.

Medical coders and billers will always be a necessary aspect of the healthcare industry, even as technology becomes more and more prevalent in the field. The path to becoming a biller or coder is straightforward and rather uncomplicated, and the field is more rewarding and exciting than you might think. If you’d like to become involved in the healthcare industry, this might be the perfect job for you.

Originally published on on May 24, 2019. 

The Basics of Medical Coding and Billing

The Basics of Medical Coding and Billing _ Patsy Gallian

Many people are completely unaware of the intricacies and behind-the-scenes work that happens after visiting the doctor. There’s a whole world, and basically a different language, that enables payers and patients to reimburse service providers. That world consists of medical billing and coding.

In essence, medical coding transmutes billable information from a patient’s medical record and medical billing uses the codes to make insurance claims and bills.

This backstage process occurs after a patient registers with a doctor or service provider, and can sometimes take only a few days or multiple months. The length medical coding and billing takes to process is contingent on the complexity of the services received, whether or not there were claim denials, and how the provider is paid by their patients.

But let’s take a step back and break down medical coding and billing a bit further. Understanding the process can help you understand your bills and become more literate in the healthcare language.

Medical Coding

Medical coding begins when a patient goes to a doctor, hospital, or any other healthcare service provider. Then, the provider writes notes of the service(s) given in the patient’s record. Notes can include why a patient received a certain service, product, or procedure. If a service isn’t detailed in a patient’s medical record, it should not be coded. Providers could find themselves facing a healthcare liability or fraud investigation if they bill patients for services that were documented incorrectly or missing from the patient’s record.

Once the patient leaves the medical facility, a professional medical coder begins their work. First, they review and analyze the notes taken during the appointment and find their respective code. There are many different types, such as diagnosis, charge, professional/facility code, and procedure codes.

Diagnosis Codes

These codes are essential to categorize a patient’s health condition or injury. They also factor in social determinants and patient characteristics. Currently, the medical billing industry utilizes the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) for diagnosis codes.

There are two aspects of diagnosis or (ICD-10) codes. The first are clinical modification (ICD-10-CM) codes, which are used to identify diagnostic codes. The ICD-10-CM code set contains over 70,000 identifiers. The second consists of the procedure coding system (ICD-10-PCS), used to relay inpatient procedures that occur at a hospital.

Procedure Codes

Working hand-in-hand with diagnostic codes, procedure codes show what a provider performed during an appointment with a patient. There are two coding systems for procedure codes: the Healthcare Common Procedure Coding System (HPCPS) and the Current Procedural Terminology (CPT). A lot of the codes overlap between the two systems, but HCPCS codes cover non-physician services (think medical equipment used and ambulance rides) whereas CPT does not.

At the moment, the American Medical Association (AMA) is using the CPT system, which tells private payers which services a patient received during a healthcare appointment. Used with ICD-10 codes, private payers have a clear picture of what occurred during an appointment and why it occurred at all.

Though the AMA prefers the CPT coding system, CMS and many third-party payers will require HCPCS codes. HIPAA, the Health Information Portability and Accountability Act also requires claims to contain HCPCS codes.

Charge Capture Codes and Professional/Facility Codes

Medical coders and revenue cycle managers will regularly attach certain services and order entries with a “chargemaster” code. A chargemaster lists an organization’s prices for their offered services. They will then use the prices in claim reimbursement rate negotiations with payers and charge patients with any remaining balance.

Professional/Facility codes are exactly what they seem to be. They are organization-specific codes that are used by hospitals or physicians to factor in the cost and overhead of providing services. These codes cover the use of equipment, prescription drugs, space, and supplies.

Medical Billing

Much of the medical billing process starts to occur prior to the work medical coders perform. This is known as front-end medical billing. While a patient is checking in, billers and facility financial staff have them fill out related forms and confirm their personal information like their address and insurance provider. Sometimes a co-payment will be collected at check-in, other times it will be collected at check-out.

On the back-end, medical coders and billers are working in tandem to combine the codes and patient information. This collaboration forms what is known as a “superbill,” an itemized form that allows providers to create a claim. A superbill will included provider information, patient information, and visit information. The superbill essentially forms a master sheet that medical billers can pull information from to develop claims.

Medical billers typically encounter the same few forms: the Medicare-created CMS-1500 form, used for non-institutional health facilities (private practices), and the federal program’s CMS-1450 or UB-04 for institutional facility claims. There are other forms used by third-party payers, private payers, or Medicaid, but many have begun to use the CMS forms.

While the claims are being written, medical billers go through them once more to make sure that all codes can be accounted for and are accurate, and that patient information is correct.

Once a thorough check is performed, medical billers will send the claims to payers. They must be sent in accordance with HIPAA standards which requires providers to electronically transmit Medicare Part A and Part B claims and use the ASC X12 format, also known as HIPAA 5010.

Billers can send claims straight to a payer or opt to use a third-party organization, most often referred to as a clearinghouse. These organizations send claims from the provider to the payer, and can be very helpful for smaller providers who may not have a thorough practice management system.

Now, adjudication begins once the claim gets to the payer. At this time, the payer analyzes the claim and discerns whether they will pay the provider and how much they’ll pay. Claims can be rejected, denied, or accepted by the payer. They notify the provider of their decision through an Electronic Remittance Advice (ERA) form.

Once the claim is settled and paid correctly, a medical biller will create a statement for the patient. The charge is typically the difference between what the payer reimbursed and the rate on their chargemaster.

Finally, medical billers process patient payments and send the revenue to accounts receivable management.

The world of medical billing goes on behind the scenes, and few know how complex and complicated a process it is. Medical coders and billers need to be thorough, analytical, and extremely careful in their jobs to ensure codes and claims are accurate.

Originally posted on on May 24, 2019.

Blockchain for Healthcare

Protecting Healthcare Data from Cyber Security Attacks_ Patsy Gallian (1)

Blockchain has become quite the buzzword over the past year or so, and for good reason. The technology is set to disrupt the way dozens of industries are run. One such industry, and the industry that poses the greatest potential when teamed up with the new technology, is healthcare.

But let’s back up for a moment and discuss the basics of blockchain. According to, blockchain is “a time-stamped series of immutable record of data that is managed by a cluster of computers not owned by any single entity. Each of these blocks of data (i.e. block) are secured and bound to each other using cryptographic principles (i.e. chain).” Basically, blockchain is a digital ledger of transactions that cannot be edited or falsified since one change would be clear when analyzing the entire chain.

So, what does this mean for healthcare? Experts predict that the use of blockchain in the health sector could increase patient access by lowering the current cost of treatment.

Blockchain has the potential to create a bridge between the numerous EHR silos, make patient’s data easier to access and more secure, and ease the process of revenue cycle reconciliation and supply chains. Furthermore, blockchain could sync data from patient health trackers, such as their Apple Watches or Fitbits, to their ERHs for enhanced care and treatment.

The technology has also found its way into clinical trials. Recently, a German pharmaceuticals company joined up with IBM to explore if blockchain could demonstrate if data accurately holds up in a decentralized framework. If successful, they present an opportunity for blockchain to increase patient safety and improve the success of clinical trials.

Further increasing patient’s safety, blockchain is also poised to be the answer to healthcare’s growing concern towards cyber security. The ledger-like component of blockchain would present a clear track record who had been accessing health records, but also anonymize patient records in a way that safe, but still easy to access to those with credentials.

For many, blockchain is the disruption the healthcare industry needs. With its enhanced transparency and its accessibility widened beyond the scope of just professionals or medical companies, patients may be able to see reduced costs within the industry, better healthcare, and more effective and personalized treatments. Others, however, are more cynical about the technology, citing that it is difficult for many to understand and without education patients may not have heightened accessibility at all.

Regardless of where you stand on the issue, it’s clear to see that technology is rapidly changing the healthcare arena as we know it. How we implement such innovations will be the key to their success.

Originally posted on on April 29, 2019.

Protecting Healthcare Data from Cyber Security Attacks

Protecting Healthcare Data from Cyber Security Attacks_ Patsy Gallian

With the increasing amount of private information located in online databases, companies are more concerned than ever about protecting themselves from cyber security attacks. Such a concern is even more apt in the world of healthcare compliance, as incredibly personal and private information is stored in online databases. Here are a few ways you can ensure your compliance department is taking the appropriate measures to protect against cyber attacks.

Cyber Security Training

If cyber security isn’t currently an aspect of your training, it should be. Not only should it be a part of training, you should host regular training seminars with updates and new techniques. The cyber environment is constantly changing, meaning that they types of threats, ways to protect against them, and how to spot them is constantly changing too. Employees should attend regular trainings that keep them up to date on the risks and threats the company could face.

Keep Procedures Simple

Too many companies have large cyber security manuals and handbooks that are unnecessarily complex, full of technical jargon, and difficult to understand instructions and explanations. Complicated and confusing instructions and procedures hinder employees from taking such risks seriously or dedicating the time to understand how to proceed if a situation were to arise. Keep manuals and handbooks simple with easy to understand language and terminology. Anyone and everyone should be able to read it and grasp what it means.

Monitor Access and System Analytics

Though it sounds a bit like spying, it’s important to know who is accessing files and when they were last seen. Unfortunately, many cyber security attacks or data breaches are performed by those who already have access to files. Installing software that keeps track of employees’ movements within the database ensures that people are not misusing the data or snooping where they shouldn’t be.

Protecting patients’ personal information should be a top priority for healthcare professionals. In 2018 alone, dozens of healthcare companies and medical practices were victim to cyber security attacks that exposed private information and health records. Taking the proper measures to protect patient information is rapidly becoming one of the biggest concerns in the healthcare compliance industry. By instituting effective and regular trainings, rethinking how your company discusses cyber security, and installing software that monitors employee use, your company can ensure that it is effectively preparing for online attacks.

Originally posted on on April 29, 2019.