Transcript Coding and Billing For Maximum Return

Coding and Billing For
Maximum Return
A Closer Look at Coding for Medical Necessity
What You Put In Is What You Get
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Far too often the person coding the services provided
to the patients visiting the practice never sees the
corresponding insurance response.
Just because you place a service on a claim form
DOES NOT mean the service will be paid.
In many cases the data entry person does not have a
medical back ground
Sadly, many offices hire inexperienced medical
billers to save money……
Terms
E.O.B. – Explanation of
Benefits. This is the response
from an insurance company
when a medical claim has been
filed.
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Bundled Service – These are
services that have been grouped
together as one service and are
not paid separately.
Example – Suture removal will not
be paid as a separate service
since removal is included in the
price of the original service.
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Medicare – Healthcare coverage
for the elderly
Medicaid – Healthcare coverage
for the indigent
Commercial Insurance –
coverage for the working
population and their dependents
if included. Typically has a copayment per visit.
Indemnity Plan – Sometimes
known as catastrophic coverage.
Typically has a deductible, once
met insurance payment is a ratio
of the covered amount – such as
80/20 (80% paid by ins. 20%
paid by the patient)
Elements of a “Clean Claim”
CMS1500 this is the standardized form
created by the Center for Medicare Service
(formerly HCFA 1500 from the Health Care
Finance Administration) for the purpose of
submitting claims for payment
 Each box on the form contains a number and
description of the information required in that
box.
Example 1
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Elements of a “Clean Claim”
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Each box should have the required information being requested.
Match the patient demographics to the information on their insurance
information. See Example 2.1
Primary, secondary and tertiary insurance should be in the proper order.
Example 2.2
Current and relevant ICD9 Diagnosis codes should be used and linked to
the specific CPT code they correspond to.
Example 2.3
Some CPT codes such as those for Laboratory blood work panels are
bundled and will not be paid separately. Example 3
Make sure to use any insurance specific codes for that insurance only;
examples include special Medicare codes, CHiP codes.
Avoid these Common Mistakes
HCFA Box 14 – Date of current illness, accident or
pregnancy (LMP). When coding for a physical exam other
than a well woman, record the date of the visit and leave the
remainder blank. Example 4
When coding a well woman, use the date of the visit and LMP.
When you are seeing a patient to confirm her pregnancy – be sure
NOT to use the diagnosis code for pregnancy unless your
office will be seeing her for the duration of her pregnancy,
since this is a “global care” code. You can use amenorrhea or
other appropriate code.
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Avoid these Common Mistakes
HCFA Box 24, A,B,C,D,E,F,H,G,I,J
This is where diagnosis codes are linked to CPT codes.
Try not link every CPT code to every diagnosis code
unless it is appropriate to do so.
Consider a well child exam (V20.2) where 4 vaccines
were given in addition to the exam. Be sure to link
the physical exam to V20.2 and each individual
vaccination CPT coding to its corresponding
individual ICD9 code. In the majority of cases there
is only one correct code. Example 5 and 6
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Avoid these Common Mistakes
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For Laboratory testing the CLIA number
should appear in box 23 of the HCFA 1500
form (even though it asks for prior
authorization number!)
Box 32 should show the name and address of
the facility where the services took place
Box 33 should show the name and address of
the physician or provider of service.
Coding for Ancillary Services
Patient presents for a chief complaint of
shortness of breath, wheezing and cough
Upon examination the patient is diagnosed with
an upper respiratory infection and is found to
be asthmatic.
The prescribed treatment includes a nebulizer
treatment in addition to the office visit.
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Coding for Ancillary Services
1. 465.8 Upper Respiratory Infection
 493.12 Asthma, Intrinsic, with acute exacerbation
 786.05 Shortness of Breath
 786.2 Cough
99213 Office visit, established patient, low to moderate
severity. Linked to all 3 diagnosis
94640 Inhalation Treatment linked to Asthma and
Shortness of Breath ONLY
J7613 Albuterol linked to Asthma and SOB ONLY
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Coding for Ancillary Services
Patient presents to the office complaining of
intermittent chest pain, upper back pain and
shortness of breath.
Upon examination of the patient an EKG and
Lipid Test is ordered. The diagnosis are chest
pain, thoracic spine pain and shortness of
breath.
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Coding for Ancillary Services
786.59 Chest pain, other including discomfort,
pressure tightness in chest
 724.1 Pain of Thoracic Spine
 786.05 Shortness of breath
99214 Office visit, established patient of moderate to
high severity linked to all 3 diagnosis
93000 EKG linked to Chest pain
80061 Lipid Panel (this is a bundled service which
includes 82465-Total Serum Cholesterol, 83718
Lippoprotein, 84478 Triglycerides).
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Coding for Ancillary Services
Scenario 1 – a 3 year old child presents to the office for a well child exam,
the parent reports no problems with the child
During the physical exam the child receives a urinalysis and hearing screen.
Diagnosis V20.2
99392, Preventive care visit, established patient ages 1-4
81002 urinalysis
92551 hearing screen
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In this scenario, the office can expect to be paid for the visit alone, in some
cases the urinalysis may be paid or not depending upon whether it is
considered a bundled service
The hearing screen for no other diagnosis besides a well exam is generally not
paid separately.
Coding for Ancillary Services
Scenario 2- A 3 year old child presents to the office for a physical examination,
the parent reports that the child is slow to respond when spoken to and watches
television with the volume turned up.
During the physical exam the child receives a urinalysis and hearing screen.
Diagnosis V20.2 well child exam
389.00 Hearing Loss, conductive, unspecified
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99392, Preventive care visit, established patient ages 1-4
Linked to both diagnosis
81002 urinalysis
Linked to well exam only
92551 hearing screen
Linked to hearing loss only
In this scenario, the office can expect to be paid for the visit, perhaps the urinalysis as
well as the hearing screen
In Office Surgeries
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In most cases, when a patient presents with a skin lesion to be
removed, the office visit will not be paid on the same day as
the surgery.
If the office visit and the surgery are done on the same day,
use a modifier 57 (decision for surgery) with your office visit.
It is more likely to have the office visit paid if there was a
SEPARATE reason for the visit such as in the case of a
medication refill or an illness
In this case, code your office visit with a modifier 25
(separate, identifiable service performed on the same day)
being sure to link the visit to ONLY the codes not dealing
with the reason for the surgery.
Is it a Surgery?
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The CPT coding manual considers any invasive
procedure to be “surgical”
Consider a patient who presents to the office with an
ear infection and cerumen impaction.
If you code the office visit to both diagnosis and
include the ear wash (69210 – removal impacted
cerumen. This code is included in with other codes
for removal of foreign body and is considered an
invasive (surgical) procedure; the office can expect
to be paid for ONLY the ear wash as the least
expensive of the two billed codes.
Other in Office Surgeries
Destruction of Skin Lesions- those which are not
considered suspicious are considered “cosmetic” by
many insurance companies and are not a covered
benefit such as 702.0 – actinic keratosis.
 A patient having 5 actinic keratosis removed- 702.0
17000 – Destruction benign or pre-malignant lesion,
first lesion. (bill 1 unit).
17003 – lesions 2-14. (bill 4 units)
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Other Office Surgeries
Other Skin Lesions that are not benign or are
suspicious in nature such as are included in
diagnosis codes 170 – 176.9 for reporting
malignant neoplasms and melanomas
 A patient presents to the office with a 2 cm
malignant melanoma of the upper arm (173.6)
11302 – Shaving of Eipdermal or Dermal
Lesions of trunk, arms, legs 1.1 – 2.0 cm
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Showing Medical Necessity
Sadly in our changing healthcare climate – there are
many offices who are attempting to supplement their
practice income by offering as many services as
possible.
 This is great as long as the services provided are
substantiated and documented!
Does every single patient who comes in for a respiratory
complaint need the test for both Strep A and B?
Does the patient who comes in for Diabetes and
Hypertension management really need a Carotid
Doppler Study?
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Wrapping Up – Great Resources
Every office should have an ICD9 and CPT code
book and KNOW how to use them.
 There are several CD rom programs such as Medical
Manager that have ICD9, CPT, HCPCs and Dorlands
all on one program. This particular program will
also give the Medicare rules for any CPT code when
you double click it.
This can be invaluable when trying to determine why
your code was not paid.
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Wrapping Up – Great Resources
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Become familiar with the Trailblazer
(Medicare) website at
www.trailblazerhealth.com
There are educational resources for physicians
and staff, there is training available, forms,
newsletter and much more.
Medicare is the insurance industry standard
and their rules are closely followed by most
other insurance companies
Wrapping Up – Great Resources
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The Texas Department of Insurance
You can file a complaint on line against an insurance
company on unpaid medical claims (*)
https://wwwapps.tdi.state.tx.us/inter/perlroot/consum
er/complform/complform.html
Standardized Credentialing Form for Texas
http://www.tdi.state.tx.us/company/hmoqual/crform.
html
Summary
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Make sure that claims are properly coded.
Consider cross training front office personnel
Keep yourself and staff updated on new
developments by attending training sessions. This is
an investment in your practice
Periodically review the office payments and EOB’s
to make sure your claims are being paid
Many things can be delegated – but fiscal
responsibility is not one of them.