Don’t know what all those codes mean on your medical bill? You’re not alone. Medical bills can be hard to understand. In a recent study, more than 1/3 of Americans said they found medical billing confusing.
What is medical billing and coding?
An essential part of the healthcare industry, medical coding is a universal language used to describe medical services in a way all insurance companies and healthcare providers can identify and validate for medical billing. Healthcare diagnoses, procedures, medical services, and equipment are converted into universal alphanumeric codes. These codes also help standardize medical records across healthcare systems.
Medical billing is the process healthcare service providers use to submit and follow up on claims with health insurance companies and patients, to receive payment for services rendered.
For patients, navigating this intricate system can be overwhelming, but learning some of the basics, you can better understand your medical bill and manage your healthcare expenses.
Know the lingo
Understanding the key terms used in medical billing and coding is the first step in demystifying the process. Here are some common billing terms to know:
Copay
A fixed amount you pay for a specific service at the time of your visit.
Deductible
The amount you must pay out of pocket before your insurance starts to cover expenses.
Coinsurance
Your share of the costs of a covered healthcare service, typically calculated as a percentage.
Explanation of Benefits (EOB)
A document from your health insurance company outlining what was billed, what the insurance covered, and what you owe. It’s crucial to understand this document as it helps you verify charges and payments.
CPT (Current Procedural Terminology) codes
CPT codes are five-digit numeric codes used to describe medical, surgical, and diagnostic services.
Examples:
- 99201: Office visit, new patient, low complexity
- 93000: Electrocardiogram (ECG)
- J0171: Injection, adalimumab, 1 mg (for emergency treatments)
- J8499: Prescription drug, oral, not otherwise classified
HCPCS (Healthcare Common Procedure Coding System) codes
HCPCS codes are used to describe products, supplies, and services not covered by CPT codes, such as durable medical equipment (e.g., wheelchairs) and ambulance services.
Examples:
- A0429: Ambulance service, basic life support, emergency transport
- A0433: Advanced life support, emergency transport
- A0425: Ground mileage, per statute mile
- A4649: Surgical supply, miscellaneous
Modifiers
Modifiers are two-digit codes added to CPT or HCPCS codes to provide additional information about a service or procedure. A modifier might indicate that a procedure was performed on a different body part or that it was a repeat procedure.
Examples:
- 22: Used when the work required to provide a service is greater than normal.
- 50: Used to indicate bilateral procedures performed during the same operation by the same physician.
- 51: Used to bill for multiple services and procedures offered to the patient by the same provider in a single procedural setting
NPI (National Provider Identifier)
The NPI is a unique identification number for healthcare providers in the United States. It is essential for billing and is used by insurance companies to verify providers’ credentials.
Insight from our MASA claims team:
What’s on an emergency transport bill?
Your bill for emergency transport will include two key line items: the base rate and mileage. Details about specific services or drugs administered during transport may or may not be included.
It’s important to note that you may first receive an invoice with the phrase “This is not a bill.” In this case, the ambulance provider is typically indicating they need additional information, like your insurance carrier information, before finalizing the charges you owe.
A birds-eye view of billing
Understanding the medical billing process can help you navigate managing your bills more effectively. Once you’ve visited a healthcare provider or used an emergency transportation service and the documentation of your treatment has been coded, the billing process begins. Here’s a step-by-step overview:
Claim submission
The coded information from your emergency event or non-emergency visit is submitted to your insurance company as a claim. This claim contains your details, provider information, and coded services.
Insurance review
Your insurance company reviews the claim, determining what is covered based on your policy. They may accept the claim, deny the claim, or request additional information.
EOB issuance
After processing the claim, your insurance company sends you an EOB, detailing what was covered and what you are responsible for paying.
Patient billing
If there is a balance remaining after insurance payments, the healthcare provider will bill the patient for the remaining amount. This bill will reflect the services provided, the insurance payment, and the patient’s responsibility.
One less bill, more peace of mind
With MASA coverage, you’ve got one less bill to sort out. Just submit your bill through our member portal, then we’ll pay your claim according to your plan details. In the member portal, you can view your MASA claims, see their status, and the amount paid. You’ll also receive a confirmation letter from us once a claim has been paid and closed.
Now that you have a better handle on how medical billing and coding works, you’re prepared to take control of your healthcare expenses, advocate for yourself within the healthcare system, and make more informed decisions about your care.
