electronic medical billing


Electronic medical billing is the process by which a health care provider electronically submits a bill, or claim, to a health insurance company, or payer, for the rendering of medical services.

Following a physical examination, a provider identifies the five-digit Current Procedural Terminology code that best describes the level of service rendered during the patient visit. The provider also uses a numerical code, from either the ICD-9-CM or the ICD-10-CM database, depending on what the software supports, to describe the diagnosis. Using this information, the claim is submitted electronically as an American National Standards Institute (ANSI) 837 file. The response that a provider receives from the payer, indicating which portions of the claim will and will not be paid, comes in an ANSI 835 file.

Electronic medical billing was included in the initial notice of proposed rulemaking for Stage 1 of the meaningful use of electronic health record (EHR) technology, which the Centers for Medicare & Medicaid Services (CMS) released at the end of 2009. This meant that hospitals and other eligible providers would have been required to submit a certain percentage of all claims electronically by the end of 2011 in order to receive reimbursement under the Health Information Technology for Economic and Clinical Health Act, or HITECH Act. However, the meaningful use final rule, released on July 13, 2010, omitted the requirement for electronic medical billing in Stage 1. It is expected to be introduced in Stage 2 of meaningful use.

This was last updated in August 2010

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