im wk 2

Insurance BillingWeek 2 : 

Insurance BillingWeek 2

Learning Objectives : 

Learning Objectives Discuss the purpose of the CPT code set. Describe the structure and content of the index and the main text in CPT. Interpret the formats, conventions, and symbols used in CPT. List the three general steps for selecting correct CPT procedure codes. Discuss the purpose of the ICD-9-CM. Describe the structure and content of the Alphabetic Index and the Tabular List. List the three steps in the diagnostic coding process Discuss the purpose of the HCPCS code set. List the steps for assigning correct HCPCS codes and modifiers.

The ICD-9-CM : 

The ICD-9-CM Expertise in diagnostic coding requires knowledge of Medical terminology Anatomy and physiology Patho-physiology Diagnostic coding also requires keeping abreast of current guidelines and experience applying correct coding rules.

Organization of ICD 9 : 

Organization of ICD 9 The complete ICD-9-CM consists of three volumes The Alphabetic Index, Diseases and Injuries The Tabular List, Diseases and Injuries Procedures

Organization of the ICD-9-CM : 

Organization of the ICD-9-CM Two of the three volumes are used in medical offices One volume is used by facilities Volume 3

Alphabetic Index consists of : 

Alphabetic Index consists of Main terms Printed in boldface type and followed by code numbers Subterms Appear below the main term and may show the etiology of the disease. Supplementary terms Appear in parenthesis to help clarify the term. They are not essential for coding.

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The alphabetic index is used first in the process of coding. The index is organized by condition, not by body part. The reason for a patient’s encounter is found in the physician’s diagnostic statement. Cross-References Always look up the cross referenced term as indicated by the words see or see also.

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Notes are boxed, italicized instructions shown below a main term. The notes are important because they give specific instructions on selecting the correct code. Example: Note - use the following fifth digit Sub classification with categories 345.0, 345.1, 345.4 - 345.9 0 - without mention of intractable epilepsy 1 - with intractable epilepsy

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The abbreviation NEC Means not elsewhere classified Use of the abbreviation means There is no documentation to support a better-defined code or No other code better matches the specific situation. Multiple codes Some conditions require two codes to accurately describe Common Terms Many terms appear more than once in the alphabetic index and are cross-referenced

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Eponyms Eponyms are conditions or procedures named for a person Eponyms are usually listed under that name and under the main term disease or syndrome. Tabular List The codes are arranged in chapters according to etiology or body system. Codes may range from 3 to 5 digits, depending on specificity.

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Includes and Excludes Notes Notes headed by the word includes refine the content of the category or section Notes headed by the word excludes indicate the conditions are NOT classifiable to the code above. A colon : used in the includes and excludes notes indicates an incomplete term. Example: 401 Essential hypertension Includes: high blood pressure hyperpiesia hyperpiesis hypertension(arterial)(essential)(primary) (systemic) hypertensive vascular: degeneration disease

Symbols : 

Symbols Parentheses ( ) used around descriptors do NOT affect the code. Brackets [ ] are used around synonyms, alternative wordings, or explanations. Braces { } enclose a series of terms attached to a statement, similar to a colon, and indicates incomplete terms. A lozenge  shows that a code is not part of the World Health Organization’s ICD. These codes only appear in the ICD-9-CM. This symbol  ( a lozenge) may be ignored when coding diagnostic statements.

NOS and NEC : 

NOS and NEC The abbreviation NOS Means not otherwise specified Use of the abbreviation means The condition is not adequately documented in the medical record. When possible more specific documentation should be requested from the provider. Example: NEC - not elsewhere classified 518.82 adult respiratory distress syndrome NEC NOS - not otherwise specified 368.8 Blurred vision NOS

You may need to use multiple codes when you see : 

You may need to use multiple codes when you see “due to” or “associated with” in the diagnostic statement “code first underlying disease” means use another code as primary “use additional code” or “code also” in the ICD-9-CM

V Codes and E Codes : 

V Codes and E Codes V Codes can be used to describe encounters with healthy patients using routine services therapeutic encounters as follow-up because of a history of a certain disease preoperative evaluations E codes are used to classify injuries from accidents, accidental poisonings, falls, fires

Coding Steps : 

Coding Steps Step 1 Determine the reason for the encounter Step 2 Locate the term in the Alphabetic Index Step 3 Verify the code in the Tabular List

Official Coding Guidelines : 

Official Coding Guidelines 1 Code the primary diagnosis first. Follow with any current coexisting conditions. 2 Code to the highest degree of certainty. Never code inconclusive, rule-out diagnoses. 3 Code to the highest level of specificity. Use fourth and fifth digits when available.

CPT Coding : 

CPT Coding Accurate procedural coding ensures maximum reimbursement for services Category I Codes Five-digit (no decimals) codes Two-digit modifiers may be added to indicate special circumstances Category II Codes Track performance measures Four digits and one alphabetic character Category III Codes Temporary codes for emerging technologies Four digits and one alphabetic character

6 sections of CPT Manual : 

6 sections of CPT Manual Eval and Management (E&M) (99201-99499) Anesthesia (00100-01999) Surgery (10021-69990) Radiology (70010-79999) Pathology and Laboratory (80048-89356) Medicine (90281-99602)

The index is used first in the processof selecting a code : 

The index is used first in the processof selecting a code Terms are listed alphabetically by Name of the procedure or service Name of the organ or site Name of the condition Synonym or eponym for the term Abbreviation for the term

CPT Index : 

CPT Index The index may use two types of cross-references See is a mandatory instruction to look under a different listing See also refers the coder elsewhere if the procedure is not listed here The main text contains additional entries and important guidelines. CPT Codes are NEVER selected from the index entry alone

Main Text : 

Main Text When a main entry has more than one code a semicolon ; follows the common part of the descriptor in the main heading unique descriptions of the main entry are indented below it Special symbols: • New procedure ? Change in code’s description ?? New or revised information + Add-on codes (procedures carried out in addition to other procedures) Code cannot be used with -51 modifier ? Code includes conscious sedation ? Pending FDA approval

Modifiers : 

Modifiers CPT modifiers are two-digit numbers that communicate special circumstances involved with a service/procedure. A modifier affects the normal level of reimbursement for the code to which it is attached.

CPT Appendix : 

CPT Appendix The thirteen appendixes contain information helpful to the coding process: Appendix A – Modifiers Appendix B – Summary of Additions, Deletions, and Revisions Appendix C – Clinical Examples Appendix D – Summary of CPT Add-on Codes Appendix E – Summary of CPT Codes Exempt from Modifier – 51 Appendix F – Summary of CPT Codes Exempt from Modifier – 63

CPT Appendix : 

CPT Appendix Appendix G – Summary of CPT Codes Which Include Conscious Sedation Appendix H – Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I – Genetic Testing Code Modifiers Appendix J – Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves Appendix K – Product Pending FDA Approval Appendix L – Vascular Families Appendix M – Crosswalk to Deleted CPT Codes

Coding Steps : 

Coding Steps Determine the procedures and services to report Identify the correct codes Determine the need for modifiers

Step 1-Determine the procedures and services to report : 

Step 1-Determine the procedures and services to report Review the encounter slip and/or patient record . Use knowledge of CPT and payer's policies to determine what services may be charged and reported.

Step 2-Identify correct codes : 

Step 2-Identify correct codes Decide what coding system to use (CPT or HCPCS) Look up the main term in the index Verify the code in the main text Report codes ranked in the order of highest to lowest level of reimbursement

Step 3-Determine the modifiers needed : 

Step 3-Determine the modifiers needed Review the procedure or service. Were there any special circumstances? Note the patient’s diagnosis. Does this indicate the need for a modifier?

Steps for selecting E/M code : 

Steps for selecting E/M code Determine the category and subcategory of service based on the place of service and the patient’s status Determine the extent of the history that is documented Determine the extent of the examination that is documented Determine the complexity of medical decision making that is documented Analyze the requirements to report the service level Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination Verify that the documentation is complete Assign the code

What does HCPCS Mean? : 

What does HCPCS Mean? H Healthcare C Common P Procedure C Coding S System Medical procedures, products, services not in CPT Mandated HIPAA code set Maintained by CMS

What are HCPCS used for? : 

What are HCPCS used for? Five characters: Letter and four numbers Tabular list contains sections for each type of service Often code durable medical equipment (DME), supplies, drugs, and services/procedures not in CPT level I such as transportation, orthotics/prosthetics, and vision/hearing services, as well as a large section of temporary codes New services are assigned temporary CMS or national codes released quarterly Permanent codes updated annually

Steps for HCPCS coding : 

Steps for HCPCS coding Coding Steps: Look up item in the index Verify code selection using the Tabular List Report quantities carefully—the code must match the route and the dose Assign Level II modifiers as appropriate

Watch for Medicare! : 

Watch for Medicare! Billing Medicare Review symbols for: Not covered by or valid for Medicare Special coverage instructions apply Carrier discretion And then review Medicare rules: Medicare Carriers Manual (MCM) Coverage Issues Manual (CIM)

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End of Presentation