The Jargon of Medical Billing and Coding

April 5th, 2018 Expert Medical Biller

There are many acronyms in the medical billing and coding world, including UCR, CPT, ICD, CMS 1500 and UB04. Understanding these acronyms will simplify your discussions with a medical billing expert and likely create a more efficient process overall. Medical billing and coding has a language all its own. If you and your medical billing expert can speak the same language, you’ll get to the finish line more quickly, and in a business that often charges by the hour, efficiency is key.

UCR, or usual, customary and reasonable, is a term often utilized in the context of personal injury cases. The usual fee includes what the physician usually charges, or the submitted fee for a given service. The customary fee is one in the range of usual fees charged by providers of similar training and experience in a geographic region. The reasonable fee is one that meets both criteria or is justifiable considering special circumstances of the case.

CPT codes, or Current Procedural Terminology codes, are published by the American Medical Association. They are used to report procedures, services and supplies. Visually, you will recognize these as the five-digit numeric (sometimes alpha) codes. These are generally the codes that a medical billing expert is pricing out when looking at your case. There are literally thousands of CPT codes currently in use representing everything from brain surgery to repair of a broken toe. There are changes made to this code set and the rules applied to them on an annual basis and billers and coders also need to keep abreast of these changes.

The next important term to know is ICD9/10 or the International Classification of Diseases, ninth or tenth revision, clinical modification. These codes represent the diagnoses associated with the procedure or service a patient is receiving. The ICD code is used in conjunction with the CPT code.

To make it even more confusing, ICD9, or the 9TH revision, was used in the United States only up until October of 2016, when ICD10, or the 10th revision, was adopted. This is important for you only in that visually, ICD9 codes look different from ICD10 codes. ICD9 is a 3-5-character numeric code with ICD10 I a 3-7 character alphanumeric code. For billers and coders, though, the importance of learning the new code sets was imperative to the billing process. For example, an ICD-9 code for knee pain would be 719.46 which is nondescript. The ICD-10 code for the same diagnosis has more specificity. ICD 10 code M25.561 is for pain in the right knee, ICD-10 Code M25.562 is for pain in the left knee.

While a medical billing expert is reviewing a case, they will look at these diagnosis codes to determine whether the charge is related to the case. For example, if your case centers around a neck injury sustained in a car accident and you submit medical bills for doctor visits to treat a case of sinusitis, it is unlikely that your medical billing expert will include these charges in your claim for damages.

The final pair of acronyms pertain to the claim forms, or the forms doctors and hospitals use to bill insurance companies. There are two types, the CMS 1500 and the UB04. The CMS-1500 is the claim form used by doctors to bill. Whereas the UB-04, Uniform Billing form, is the claim form used by hospitals, nursing facilities, and other inpatient providers. Both of these forms can be a wealth of information for a medical billing expert. There is so much more information on these billing forms than is contained on patient statements, which are often initially provided when records are requested.

Medical Billing Analysts (MBA) is a Nationwide Medical Billing Expert service with offices in NJ, NY, FL, TX, CT, GA, NV, and CA. To see how MBA can assist you in documenting the damages in your Personal Injury cases, consult www.medicalbillinganalysts.com or call 800-557-6141 for a proposal containing the experts’ professional qualifications, fee schedule, and sample Medical Expense Evaluation Report.