In medicine, not otherwise specified ( NOS ) is a subcategory in systems of disease /disorder classification such as ICD-9 , ICD-10 , or DSM-IV . It is generally used to note the presence of an illness where the symptoms presented were sufficient to make a general diagnosis , but where a specific diagnosis was not made. The DSM-IV, for example, "applies the term not otherwise specified (NOS) to a disorder or disturbance that does not meet the criteria for the specific disorders already discussed". The term was introduced because "it is sometimes impossible for the practitioner completing the diagnostic assessment to categorize all the symptoms that a client is experiencing into one diagnostic category". In the context of mental health diagnoses, four situations have been outlined for which such a diagnosis may be considered appropriate:
38-546: It is noted, however, that the use of an NOS classification invites scrutiny when billing or seeking reimbursement for practitioners. This classification is commonly used in psychiatric diagnoses, such as in: It is also used in the conditions: The ICD-10 also uses this phrase for various things, such as: The phrase is also used within the List of UN numbers , where it refers to a generic entry, e.g. "UN 1993: Flammable liquid, N.O.S.". Medical billing Medical billing,
76-429: A certification credential to reflect professional status. Visiting a doctor might feel like a straightforward one-on-one interaction, but it is actually part of a much larger and more complex system involving information exchange and payment processing. While an insured patient typically interacts only with a healthcare provider during a visit, the encounter is part of a three-party system. The first party in this system
114-419: A connection to every payer, the practice user or software vendor must only connect to the clearinghouse. Once a claim is adjudicated by the payer, some sort of response is sent to the submitter. This usually comes as a paper Explanation of Benefits (EOB) or an Electronic Remittance Advice (ERA). These describe the actions that the payer took on each claim: amounts paid, denied, adjusted, etc. In cases where
152-399: A patient did not have proper insurance, or where insurance coverage did not fully pay the charges, the practice will usually send out patient statements. Practice management software often contains ways for a practice to print and mail their own statements (or other correspondence), and may even contain a way to interface to third-party patient statement printing companies. Almost invariably,
190-472: A payment process in the United States healthcare system , is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed. This bill is called a claim. Because the U.S. has a mix of government-sponsored and private healthcare, health insurance companies - otherwise known as payors - are
228-468: A process known as the billing cycle or Revenue Cycle Management (RCM). RCM encompasses the entire revenue collection process for a healthcare facility, beginning with the design of the RCM workflow. This cycle can take anywhere from a few days to several months, often requiring multiple interactions before achieving resolution. The relationship between healthcare providers and insurance companies resembles that of
266-406: A vendor and subcontractor: healthcare providers contract with insurers to deliver services to covered patients. Step 1: Patient Registration The process begins when a patient schedules an appointment. For new patients, this involves gathering essential information, including their medical history, insurance details, and personal data. For returning patients, the focus is on updating records with
304-418: Is a category of healthcare software that deals with the day-to-day operations of a medical practice including veterinarians . Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payors, perform billing tasks, and generate reports. In the United States , most PMS systems are designed for small to medium-sized medical offices. Some of
342-444: Is critical for the healthcare provider to stay informed about the most recent coverage requirements for each insurance plan. Step 3: Assigning Codes This is where medical billing departs from medical coding. Medical coders are responsible for this step and they rely on two standardized coding systems to document and classify the services provided, which will eventually be put into a bill by medical billers. ICD Codes: Developed by
380-753: Is not legally required to become a medical biller, professional credentials such as the Certified Medical Reimbursement Specialist (CMRS), Registered Health Information Administrator (RHIA), or Certified Professional Biller (CPB) can enhance employment prospects. Training programs, ranging from certificates to associate degrees, are offered at many community colleges, and advanced roles may require cross-training in medical coding, auditing, or healthcare information management. Medical billing practices vary across states and healthcare settings, influenced by federal regulations, state laws, and payor-specific requirements. Despite these variations,
418-491: Is often differentiated by whether it allows double-booking, or whether it uses scheduling or a booking model. Schedules are often color-coded to allow healthcare providers (i.e. doctors, nurses, assistants) to easily identify blocks of time or sets of patients. If the patient carried a valid private or public insurance policy at the time these services were provided, the charges are then sent out as an insurance claim. The process of sending charges may happen on paper, usually with
SECTION 10
#1732851456339456-438: Is the patient. The second is the healthcare provider, a term that encompasses not only physicians but also hospitals, physical therapists, emergency rooms, outpatient facilities, and other entities delivering medical services. The third and final party is the payor, typically an insurance company, which facilitates reimbursement for the services rendered. Medical billing involves creating invoices for services rendered to patients,
494-569: The 19th century, the American colonies abandoned the English honorarium and public calling principles. Instead, physicians could use standard contract and commercial law to set and collect fees. Unlike in England, U.S. courts viewed medical services like goods with fixed prices, allowing physicians to sue for outstanding payments and freely set terms, independent of obligations tied to public service. Before
532-526: The EMR and PMS systems. The integration of the EMR and PMS software is considered one of the most challenging aspects of the medical practice management software implementation. Most practice management software contains systems that allow users to enter and track patients, schedule and track patient appointments, send out insurance claims and patient statements as part of the collection process, process insurance, patient and third party payments, and generate reports for
570-564: The Practice Software on an annual basis. Some, especially smaller firms, leave it entirely up to medical practices. While a lot of insurance payers have created methods for direct submission of electronic claims, many software vendors or practice users use the services of an electronic claim clearinghouse to submit their claims. Such clearinghouses commonly maintain connections to a large number of payers and make it easy for practices to submit claims to any of these payers. Instead of creating
608-538: The Superbill, healthcare providers create a structured summary that facilitates claim submission and ensures proper documentation for payor review. This step is vital in maintaining accuracy and minimizing errors during the medical billing process. Step 5: Preparing and Submitting Claims Using the Superbill, the medical biller creates a detailed claim and submits it to the insurance company for reimbursement. Accuracy and completeness are critical during this step to ensure
646-625: The World Health Organization, the International Classification of Diseases (ICD) codes describe the conditions or symptoms being evaluated or treated. The current version, ICD-10, will transition to ICD-11 in 2025, requiring updated coding practices. CPT Codes: Created by the American Medical Association (AMA), Current Procedural Terminology (CPT) codes correspond to the procedures or treatments performed by
684-419: The administrative and clinical staff of the practice. Typically, using a PMS also involves keeping up to date large sets of data including lists of diagnosis and procedures, lists of insurance companies, referring physicians, providers, facilities, and much more. Practice management systems often include a calendaring or scheduling component that allows staff to create and track upcoming patient visits. Software
722-456: The claim is accepted on the first submission—referred to as a clean claim. Achieving a high clean claims rate is a key metric for measuring the efficiency of the billing cycle. Creation of the claim is where medical billing most directly overlaps with medical coding because billers take the ICD/CPT codes used by the medical coders and creates the claim. Step 6: Monitoring payor Adjudication Once
760-402: The coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. The payor returns the claim back to the medical biller and the biller evaluates how much of the bill
798-401: The cost of individually licensed software packages. Due to the rapidly changing requirements by U.S. health insurance companies, several aspects of medical billing and medical office management have created the necessity for specialized training. Medical office personnel may obtain certification through various institutions who may provide a variety of specialized education and in some cases award
SECTION 20
#1732851456339836-413: The fundamental goal remains consistent: to streamline the financial transactions between physicians and payors, ensuring access to care and financial sustainability for physicians. In 18th century England, physicians were not legally permitted to charge fees for their services or take legal action to collect payments. Instead, patients would offer "honoraria," which were voluntary payments inspired by what
874-491: The healthcare provider. These codes are essential for accurately billing and receiving reimbursement. For every patient encounter, providers must record both ICD codes to identify the diagnosis and CPT codes to document the treatment. Given the vast number of codes—approximately 70,000 for ICD and over 10,000 for CPT—using advanced medical billing software is recommended to streamline the coding process, reduce errors, and ensure compliance with current standards. These steps set
912-551: The latest reason for the visit and any changes to their personal or insurance information. This foundational step ensures the practice has accurate and up-to-date records for billing and care coordination. Step 2: Determining Financial Responsibility Once the patient is registered, the next step is to identify which treatments or services their insurance plan will cover. Insurance policies often include specific guidelines regarding covered procedures and exclusions, and these rules can change annually. To avoid billing complications, it
950-498: The patient owes, after insurance is taken out. If the claim is approved, the payor processes payment, either reimbursing the physician directly or the patient. Claims that are denied or underpaid may require follow-up, appeals, or adjustments by the medical billing department. Accurate medical billing demands proficiency in coding and billing standards, a thorough understanding of insurance policies, and attention to detail to ensure timely and accurate reimbursement. While certification
988-425: The payor receives the claim, they review it to determine whether it is accepted, denied, or rejected. Understanding these outcomes is essential: Accepted Claims Accepted claims are processed for payment. Payment amounts depend on the specifics of the patient’s insurance plan and may not cover the entire billed amount. Medical practice management software Medical practice management software ( PMS )
1026-458: The practice's premises, which can be seen as a security risk of its own. PMS is often connected to electronic medical records (EMR) systems. While some information in a PMS and an EMR overlaps — for example, patient and provider data — in general the EMR system is used for the assisting the practice with clinical matters, while PMS is used for administrative and financial matters. Medical practices often hire different vendors to provide
1064-444: The primary entity to which claims are billed for physician reimbursement . The process begins when a physician documents a patient's visit, including the diagnoses, treatments, and prescribed medications or recommended procedures. This information is translated into standardized codes through medical coding , using the appropriate coding systems such as ICD-10-CM and Current Procedural Terminology (CPT). A medical biller then takes
1102-507: The process of running a medical practice requires some introspection, and practice management software usually contains reporting capabilities to allow users to extract detailed data on financial performance and patient financial histories. PMS often has both pre-setup reports and allows users to design their own, ad-hoc reports. In some cases, the reporting functionality of PMS interfaces with decision support systems or has similar functionality built-in. The global veterinary PMS industry size
1140-590: The provider, the patient, and the visit, ensuring that the claim is complete and accurate for efficient processing. Components of a Superbill Provider Information Full Name National Provider Identifier (NPI) Number Practice Location Contact Information Referring Provider’s Name and NPI (if applicable) Provider’s Signature Patient Information Full Name Date of Birth Contact Information Insurance Details Visit Information Date of Visit Relevant CPT and ICD Codes Fees Charged for Services Duration of Visit By consolidating this information into
1178-509: The server software on that hardware, while individual users' workstations contain client software that accesses the server. Client-server software's advantage is in allowing multiple users to share the data and the workload; a major disadvantage is the cost of running the server. Internet-based software is a relatively newer breed of PMS. Such software decreases the need for the practice to run their own server and worry about security and reliability. However, such software removes patient data from
Not otherwise specified - Misplaced Pages Continue
1216-505: The sliding scale offered. For several decades, medical billing was done almost entirely on paper. However, with the advent of medical practice management software , also known as health information systems, it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their web interfaces, which negates
1254-410: The software is designed for or used by third-party medical billing companies. PMS is often divided among desktop-only software, client-server software, or Internet-based software. The desktop-only variety is intended to be used only on one computer by one or a handful of users sharing access. Client-server software typically necessitates that the practice acquire or lease server equipment and operate
1292-522: The spread of health insurance, doctors charged patients according to what they thought each patient could afford. This practice was known as sliding fees and became a legal rule in the 20th century in the U.S. Eventually, changing economic conditions and the introduction of health insurance in the mid-20th century ushered an end to the sliding scale. Health insurance became a conduit for billing, and it standardized fees by negotiating fee schedules, eliminating additional charges, and restricting discounts that
1330-480: The stage for efficient claims submission and payment, forming the backbone of the billing cycle. Step 4: Creating the Superbill Once a patient’s visit is complete and they check out, the next step is to compile all the relevant information into a document called the Superbill. This document serves as the foundation for the reimbursement claim submitted to the payor. The Superbill includes essential details about
1368-715: The use of the CMS -1500 form. This form lists the provider who performed the service, the patient, the services performed and the related diagnoses. For institutional (typically hospital) charges, claims may also be sent out on the UB-04 forms (formerly the UB-92 which use of was discontinued in 2007). Claims may also be sent out electronically using industry-standard electronic data interchange standards. In most cases, electronic claims are submitted using an automated software process. Some practice management system vendors will update CPT/ICD-10 codes in
1406-526: Was believed to be a Roman custom. This honorarium rule applied only to non-surgeon physicians. Meanwhile, surgery was treated as a "public calling," allowing courts to cap surgeons' fees to reasonable amounts. The honorarium rule for non-surgeon physicians and the public calling status for surgeons highlighted the unique, non-commercial constraints on medical professionals at the time. These constraints further emphasized professionalism over commerce, distinguishing these professions from regular businesses. In
1444-552: Was estimated to be 323 million in 2016 with more than 120 million from United States. Veterinary PMS is expected to be growing at the rate of 8.9% per year. There are more than 20 different software available in the market for Veterinary PMS. Practice management software (PMS) has traditionally been commercial; few viable free practice management systems exist, though a few open source systems are under development. PMS usually costs about $ 100 to tens of thousands of dollars to license and operate. PMS often needs to interface with
#338661