Health Billing: CCAM Codes and Medicare Reimbursement

Introduction

Health billing is a major issue for all actors in the French healthcare system. Between the Common Classification of Medical Procedures (CCAM), agreements with Compulsory Health Insurance (CHI) and Supplementary Health Insurance (SHI), and multiple regulatory constraints, mastering pricing processes has become essential. Incorrect billing can result in reimbursement rejections, significant financial losses, or even administrative sanctions from the health insurance fund. This comprehensive guide is intended for public hospitals, private clinics and healthcare professionals seeking to optimise their financial management whilst complying with the legal framework set out in the Public Health Code.

Understanding CCAM Nomenclature

The CCAM, which came into force in 2005, replaces the former General Nomenclature of Professional Procedures (NGAP) for medical technical procedures. It lists over 7,600 codes organised according to a 7-character alphanumeric structure. Each code precisely identifies a medical procedure, its anatomical location, and its implementation procedures.

CCAM pricing is based on several components: the base rate, modifiers (emergency, night, Sunday), and any additional charges. For example, code HBFA005 corresponds to extraction of a permanent tooth, charged at €33.44 in sector 1. Practitioners must ensure accurate coding to avoid any underpayment, as the health insurance fund has the power to audit retrospectively over 3 years, in accordance with article L.133-4 of the Social Security Code.

The regular updating of CCAM, under the authority of the High Health Authority (HAS) and UNCAM, requires permanent monitoring. Tariff changes are published in the Official Journal and integrated into approved billing software.

The CHI-SHI System and Agreements

Healthcare reimbursement in France is based on a dual mechanism. Compulsory Health Insurance (CHI) covers part of the costs according to the conventional rate (70% for a general practitioner consultation, 60-100% for technical procedures depending on their nature). Supplementary Health Insurance (SHI) intervenes to supplement, via mutual funds and health insurers.

National agreements signed between UNCAM and professional unions define the applicable rates. Healthcare professionals are divided into sector 1 (agreed fees), sector 2 (free fees with out-of-pocket costs) or non-agreed. Since 2017, OPTAM (Controlled Fee Practice Option) has regulated fee exceedances in exchange for social benefits.

Transmission via the SESAM-Vitale standard is mandatory to benefit from dematerialised flows. Generalised third-party payment, provided for by the 2016 healthcare system modernisation law, applies for chronic illnesses, maternity, complementary universal health insurance and emergency health insurance.

Optimisation of the Billing Chain

Effective billing requires the integration of several tools: approved HDS medical software (Health Data Hosting), smart card reader, connection to the ADRi teleservice for real-time verification of rights. Hospital establishments use Activity-Based Pricing (ABP) with Homogeneous Stay Groups (HSG), whilst healthcare professionals mainly rely on CCAM and NGAP.

Rejection management is a critical area: a rejection rate above 3% generally signals structural malfunctions. Analysis of reasons (error codes R, LR) makes it possible to identify areas for improvement: rights not updated, obsolete codes, rating inconsistencies.