A super-bill is a form created specially for an individual office or provider. It normally is prepopulated with the patient's information, including insurance copay, and contains the most common diagnosis and procedural codes used by the office. It may also have a section that indicates the need for follow-up appointments and should also have a space for the physician's signature. The super-bill is great tool for the provider for billing purposes and also proves helpful for keeping track of each patient's visits. In many offices, the super-bill has been replaced by electronic health record (EHR), an all-electronic method of patient recordkeeping. Super-bills, wonderful as they are, can also be the bane of coder's existence. Although checking off billable procedures is certainly easier for the provider, they may overlook adding the detail necessary to support the procedures (and level of the visit) indicated on the bill. If the chart doesn't match the super-bill, it's back to square one for the coder.
Sample Family Practice Super-bill ICD-9 Version - - ->>> Click here.
Sample Family Practice Super-bill ICD-10 Version - - ->>> Click here.
Maintaining Insurance Claim Files
CMS requires providers to retain a copies of any government insurance claims and copies of all attachments filed by the provider for a period of six (6) years (unless state law stipulates a longer period). The Provider could be audited during that period.
CMS stipulated in March 1992 that providers and billing services filling claims electronically must comply with this federal regulations by retaining the financial source document (routing slip, charge slip, encounter form or superbill) from which the insurance claim was generated.
It is recommended that electronic and manual claims files be set up as follows:
1. Open Claims are organized by month and insurance company, but processing is not complete. Open claims include those that were rejected due to an error or omission (because they must be reprocess).
2. Closed Claims are filed accordingly to year and insurance company and include those for which all processing, including appeals, that has been completed.
3. Remittance Advice Files are organized according to date of service because payers often report the results of insurance claims processed on different patients for the same date of service and provider. This mass report is called batched remittance advice.
Example: Carla Joe calls the clinic office to request a copy of the transmittal notice for her last date of service, explaining that she did not received her own copy. Because the information is on a batched remittance advice, the medical biller makes a copy of the page which Carla's information is found. Using the copy the medical biller removes patient's information other than Carla's and mails the edited copy to Carla. The rest of the copy, which contains other patient's information, is shredded.
4. Unassigned Claims are organized by year and are generated for providers who do not accept assignment, the file includes all unassigned claims for which the provider is not obligated to perform any follow-up work.
Tracking Submitted Claims
The medical biller is responsible for tracking insurance claims submitted to the third-party payers and clearinghouses, ensuring that claims are processed and reimbursed in a timely manner. Effective claims tracking requires the following activities:
1. Maintaining a paper copy or electronic copy each submitted claim.
2. Logging information about claims submitted in a paper-based insurance claims log/registry or by using medical practice management software.
3. Reviewing the remittance advice (remit) to ensure that accurate reimbursement was received.
Reasons to Track Claims:
A. Coding errors
1. Downcoding (assigning lower-level codes than documented in the record)
2. Incorrect code reported (e.g., incomplete code)
3. Incorrect coding system used (e.g., CPT code reported when HCPCS level II national code should have been reported)
4. Medical necessity does not correspond with procedure and services codes.
5. Unbundling (submitting multiple CPT codes when just one code should have been submitted)
Note: Unbundling is associated with the National Correct Coding Initiative (NCCI).
6. Unspecified diagnosis codes are reported.
B. Deliquent
1. Payment is overdue, based on practice policy.
C. Denied
1. Medical coverage cancelled.
2. Medical coverage lapsed beyond renewal date.
3. Medical coverage policy issues prevent payment (e.g., pre-existing condition, non-covered benefit)
4. No-fault, personal injury protection (PIP), automobile insurance applies.
5. Payer determines that services were not medically necesary.
6. Procedure performed was experimental and therefore not reimbursable.
7. Services should have been submitted to worker's compensation payer.
8. Services were not preauthorized, as required under the health plan.
9. Services were provided before medical coverage was in effect.
D. Lost
1. Claims was not received by the payer.
E. Over payment
1. Payer may apply offsets to future provider payments to recoup funds
2. Payer over pays provider's fee or managed care contract rate.
3. Provider receives payment intended for patient.
4. Provider receives duplicate payments from multiple payers
5. Payment is received on a claim not submitted by the provider.
F. Payment errors
1. Patient is paid directly by the payer when the provider should have been paid.
2. Patients cashes a two-party check in error (check made out to both patient and provider)
G. Pending (suspense)
1. Claim contains an error
2. Need for additional information
3. Review required by payer (e.g., high reimbursement, utilization management, complex procedures)
H. Rejected
1. Also called soft denials
2. Claims contain a technical error (e.g., transposition of numbers, missing or incorrect data, duplicate charges or dates of service)
3. Payer instructions when submitting the claim were not followed
4. Resubmitted claim is returned (consider submitting a review request to payer)
Retention of Records
Record retention is the storage of documentation for an established period of time. usually mandated by federal and/or state law. (The state in which the healthcare provider practices determines whether federal or state law mandates the retention period). Its purpose is to ensure the availability of the records for use by government agencies and other third parties (e.g., insurance audit, quality of care review). It is acceptable to store medical records and insurance claims (including attachments submitted to third-party payers) in a format other than original hard copy if the storage medium (e.g., microfilm, scanned images) accurately reproduces all original documents.
- Medicare conditioned of participation mandate the retention of patient records in their original or legally reproduced form (e.g., microfilm) for a period of at least 5 years. (Individual state laws may require retention of patient records for a longer period, such as 6 years)
- The Health Insurance Portability And Accountability Act (HIPAA) mandates the retention of health insurance claims and accounting records for a minimum of 6 years, unless state law specifies a longer period.
- HIPAA also mandates that health insurance claims be retained for a minimum of 2 years after a patient's death.
