Category/ Medical Billing
Physician Billing vs. Hospital Billing: Understanding the Key Differences
Physician billing and hospital billing are the two types of medical billing that prevail in the healthcare industry. But what is the difference between hospital billing and physician billing?
This post will cover some essential points regarding the difference between physician billing and hospital billing, which will help you understand what factors come into play while learning about these two types of healthcare claims.
With physician billing and hospital billing, there are specific differences to tackle. For instance, physician billing is based on the percentage of the remuneration earned through procedures or a price for different services rendered. As for hospital billing, its based on the pricier reimbursement model, where the hospital charges the patients insurance plan for the services required and received.
Professional billing relates to physician billing, and institutional billing refers to hospital billing. In the healthcare industry, professionals differentiate between these terms depending on the purpose of the billing process and the services involved. The two methods, however, fall under the general medical billing process.
To highlight the key differences between physician and hospital billing, lets find out how they are used in both cases.
Physician billing: What is it?
Physician billing, or professional billing, refers to the billing process. Where claims submitted by physicians and healthcare providers are reimbursed when performing medical services or procedures on patients covered by insurance, once you decide to become a physician billing service provider, you must help the physicians or healthcare providers with claim submission and other related billing and collection tasks.
CMS-1500 or 837-P is the claim form used for physician billing. The only difference between these forms is that the CMS-1500 is a paper document, and the 837-P is an electronic document.
• Some insurance companies, like Medicaid, Medicare, and others, only accept electronic claims as payment methods. P stands for professional configuration on the 837-P claim form, an electronic version of CMS-1500. Most of the time, expert physician billing services have more to do than institutional or hospital billing services.
Billing a doctor is an important administrative task that controls many other tasks in a medical office, like making appointments, greeting patients, registering patients, and collecting payments.
To make sure that the organizations overall financial and operational goals are met, people who work in medical billing and coding need to know a lot about the policies and practices of physician billing. Because physicians bill insurance companies directly for patient services, a medical offices billing department relies on the accuracy of coding and claims processing to ensure that payments are made promptly.
The organizations ability to stay in business depends on how much money it gets for each service it provides. Medical professionals can improve their ability to collect payments by learning the basics of physician billing.
• Both inpatient and outpatient services can be billed under physician billing; both types can only be billed after patient verification.
• All outpatient and inpatient services will be billed based on the patients insurance policy, so its important to check.
• It is important to keep in mind that physician billing includes medical billing and medical coding as well.
Therefore, medical billers need to learn both billing and coding procedures. Healthcare professionals offices and hospitals employ medical billing and coding teams to handle everyday billing.
The process of physician billing is complicated and detailed. It is also time-consuming and requires a lot of effort and time. Scribe Align makes it easy by connecting healthcare providers with hospitals and insurance companies so they can focus on patient care instead of insurance claim submission. By outsourcing the billing process to a healthcare billing service provider like Scribe Align, you can focus on the doctors practice and patient care instead of worrying about getting paid for the medical services.
Hospital billing: What is it?
• The hospital or healthcare provider submits claims for inpatient and outpatient services in hospital billing. For the same reason, hospital billing can also refer to institutional billing.
• A hospital billing system also accounts for the services provided by skilled nurses. They also bill claims for medical facilities and medical claims for laboratory services, medical equipment, radiology, supplies, etc.
• An institutions configuration is indicated by I. Hospital billing is performed using forms UB-04 or 837-I. In contrast, the UB-04 is a paper-based form, while the 837-I is a computer-based form.
• A physicians billing is similar to a hospitals billing, except that hospital billing only deals with the medical billing process; it does not deal with medical coding. However, physician billing also includes medical coding.
• The hospitals appointed medical biller is only responsible for billing and collection in hospitals. It is challenging to handle hospital billing as compared with physician billing.
Billing for Physicians and Hospitals: how to increase revenue?
• Hospitals and physicians have different billing models when it comes to revenue reimbursements. But their processes have a significant impact on preventing denials and fraud.
• Keeping track of unbilled and unmissed claims and services becomes the physician billers priority. However, the staff should be aware of any billing or coding errors when submitting claims. Technical errors can also cause mistakes for various reasons.
• Outsourcing healthcare billing and coding services is often the best option for hospitals and healthcare providers to avoid errors and payment losses.
• The hospital billing process is quite different from physician billing. A hospital or institutions billing function includes collection and billing.
• As a result, institutional cases are handled only by coding experts because hospital coding is considered more complex than physician coding.
It is essential to avoid violating HIPAA privacy and security rules since physicians and hospital billing staff have access to private and confidential patient health information.
Thank you for reading about Physician Billing and Hospital billing. I am pleased to provide you with information on physician and hospital billing.
Contents
Differences between Physician Billing and Hospital Billing
CPT Coding: History, Background and How Does CPT Coding Work?
10 steps to find the Best Medical Billing and Coding Companies
Why is Digital Marketing Becoming the Industry Standard?
What is CPT VS ICD 10 & HCPCS Coding? Future of Medical Coding?
What Does a Medical Coder Do? Starting Your Career as a Medical Coder!
What are CPT Codes? Understanding CPT Codes
CPT is a standardized set of codes used to report medical, surgical, and diagnostic procedures and services to various entities, including physicians, insurance companies, and accreditation organizations. Medical bills are billed electronically using CPT codes combined with ICD-9-CM or ICD-10-CM numerical diagnostic codes.
The CPT codes are used to submit claims to federal and private payers when rendering healthcare. As CPT codes provide a detailed description of a procedure or service, they eliminate subjective interpretations of what was delivered to the patient.
The American Medical Association (AMA) developed CPT® codes in 1966 to standardize reporting of medical, surgical, and diagnostic services and procedures provided in hospital and outpatient settings.
The evolution of healthcare – including the availability of new services and the retirement of outdated procedures – is a significant consideration. Every year, the AMA releases new, revised, and deleted CPT® codes and changes to coding guidelines. The AMA also releases more minor updates to various sections of the CPT® code set.
Moreover, the AMA updates CPT® terminology or medical language to reflect advances in medicine. Though the AMA owns the copyright to CPT®, it invites participants to contribute to the ongoing maintenance of the code set and welcomes feedback on the codes and code descriptors.
Understanding CPT® codes
CPT® codes are composed of five characters. In general, codes are numeric, but some codes include a fifth character, such as A, F, T, or U. These are some examples:
92526 Oral function therapy
0638T Ct breast w/3d bi c-/c+
CPT® Code Types: A Quick Guide
Providers assign codes to every service or procedure they perform. It even includes codes for services and procedures not specifically named in another CPT® code, called unlisted codes.
The AMA has organized CPT® codes logically by classifying them into three types based on the wide range of services and procedures they cover:
CPT® Category I: Codes commonly used by providers to report their services and procedures comprise the largest body of codes
CPT® Category II: Additional tracking codes used in performance management
CPT® Category III: Emerging and experimental codes for reporting services and procedures
CPT® Category I:
Most CPT® codes are in Category I. There are a variety of existing services and procedures that are widely used and, where appropriate, approved by the Food and Drug Administration (FDA).
In general, Category I codes, which are typically represented by five characters, are arranged numerically. Codes are resequenced in one discrepancy from the expected order. In order to facilitate quick access to related codes – and help coders select the best codes – the AMA groups similar codes together. Resequenced codes occur when a new code is added to a family of codes, but there is no sequential number assigned to it.
Another exception to numerical code order involves evaluation and management codes (E/M codes). Although E/M codes begin with 9, they are printed first in CPT® code books, as you can see below in the code outline for Category I. E/M services are among the most frequently reported healthcare services, so the AMA chose this order. As with resequenced codes, this arrangement is intended for coding efficiency.
Codes for CPT® Category I fall into six main categories:
Evaluation & Management (99202–99499)
Anesthesia (00100–01999)
Surgery (10021–69990) The code range is further divided into smaller groups by body area or system
Radiology Procedures (70010–79999)
Pathology and Laboratory Procedures (80047–89398)
Medicine Services and Procedures (90281–99607)
CPT® Category II:
Four numbers and the letter F make up Category II codes, which providers can assign in addition to Category I codes. There is no reimbursement associated with Category II codes, unlike Category I codes.
The CPT® code book typically places Category II codes after Category I codes. These codes are listed as follows:
Composite Measures (0001F–0015F)
Patient Management (0500F–0584F)
Patient History (1000F–1505F)
Physical Examination (2000F–2060F)
Diagnostic/Screening Processes or Results (3006F–3776F)
Therapeutic, Preventive, or Other Interventions (4000F–4563F)
Follow-up or Other Outcomes (5005F–5250F)
Patient Safety (6005F–6150F)
Structural Measures (7010F–7025F)
Nonmeasure Code Listing (9001F–9007F)
CPT® Category III:
Category III codes, characterized by four numbers and a letter T, usually follow Category II codes in the code book. Category III codes are temporary codes used to identify new technologies, services, and procedures.
In Category III, temporary codes describing new services and procedures can remain for up to five years. They must meet Category I criteria, including FDA approval, evidence that the procedure is widely practiced, and evidence that it has proven effective. A new Category I code will be assigned to them. Providers can also eliminate Category III codes if they do not use them.
The AMA releases new or updated Category III codes semiannually via its website but publishes the deletions of Category III codes with the full list of temporary codes annually.
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