Basic Concepts of Coding and Insurance Chapter 2 Basic Concepts of Coding and Insurance

Learning Objectives Describe the main differences between fee-for-service plans and managed care plans. List the primary government healthcare programs and the basic eligibility requirements for each. Enter and change insurance carrier information in Medisoft.

Learning Objectives Describe the difference between CPT coding and ICD-9 coding. Explain the process used to identify Evaluation and Management (E/M) codes. Set up diagnosis and procedure codes in Medisoft. Create Medisoft cases.

Chapter 2 Lesson 2.1

Overview of Health Insurance Provides protection for patients against the financial consequences of illness, injuries, and disabilities. Payment for health insurance is referred to as a premium. What are other forms of insurance available to a patient? (Answers will vary but could include short- and long-term insurance.)

Overview of Health Insurance Third-party payers: insurance companies Seven common insurance types include: Medicare Medicaid Medi/Medi TRICARE (managed care insurance for active and retired military)‏ Who qualifies for Medicare? What is the difference between Medicare and Medicaid? What type of patient qualifies for both?

Overview of Health Insurance CHAMPVA (Civilian Health and Medical Program of the Veterans Administration) Workers’ Compensation Managed Care - includes health maintenance organizations (HMOs) and preferred provider organizations (PPOs)‏ Which of these insurance plans cover(s) employees for on-the-job accidents and injuries? The CMS-1500 claim form is always used by Medicare and Medicaid, yet other insurance companies use this form, too. Should you assume that the CMS-1500 is a global claims form or should you check with the individual insurance company?

Overview of Health Insurance Medicare: federally administered insurance program retired people 65 & older on Social Security retired railroad or civil service workers 65 & older blind individuals What is Medicare? Who is eligible for Medicare?

Overview of Health Insurance Medicare: Disabled individuals eligible for Social Security of any age widows of disabled workers adults disabled before 18 whose parents are retired or eligible What is SSA? What is SSI?

Overview of Health Insurance Medicare: Children/Adults with chronic kidney disease or kidney transplant with end-stage renal disease Kidney donors (all expenses related to kidney transplant are covered)‏ There are two parts to Medicare. What are the two parts?

Overview of Health Insurance Medicaid: insurance program to help families whose income is below a specific level, regardless of age Medi/Medi: patients who cannot afford to pay the portion of their bill received by Medicare, may qualify for both Medicare and Medicaid Can an individual be eligible for both Medicare and Medicaid?

TRICARE Formerly CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) Three choices: Standard: receive health care from military providers Prime: voluntary health maintenance organization (optional) Extra: patient does not have to enroll or pay fees, pays visit-by-visit basis at discounted rate Who manages TRICARE?

CHAMPVA Similar to TRICARE Available to spouses, dependent children of veterans who died of service-related injuries Veterans with permanent service disabilities, their dependents What provider options do individuals eligible for CHAMPVA have?

Insurance Carrier Information Entry Used to bill insurance companies Occurs at List menu Four tabs: Address Options and Codes EDI/Eligibility Allowed By default, the Address tab displays When sending in claims, some insurance companies accept claims directly; others require that claims be sent into a clearinghouse. What is the advantage of using a clearinghouse? In what case is a clearinghouse not necessary? On Medisoft, how do you submit forms electronically?

Insurance Carrier Information Entry Address Tab: enter basic address and plan information Options/Codes Tab: some fields are referenced by Medisoft for billing and payments. Billing methods are set from this tab. EDI/Eligibility: used to submit claims electronically Allowed: enter allowed amounts for each procedure code What are some examples of insurance types that might go in the “type” field? What is Medigap?

Chapter 2 Lesson 2.2

ICD-9-CM Coding Overview International Classification of Diseases-9th edition–Clinical Modifications System used to code patient diagnosis Developed by WHO (World Health Organization) What are V codes? What are E codes?

ICD-9-CM Coding Overview Three volumes: Volume 1: disease and condition codes (V codes) (E codes)‏ Volume 2: alphabetic index for Volume 1 Volume 3: contains coding procedures for surgical, therapeutic, and diagnostic procedures used primarily in the hospital Which volume should an allied health professional turn to first?

ICD-9-CM Coding Overview ‏ Each disease assigned three-digit number 4th digit: provides more detail to prognosis regarding site or symptom 5th digit: further classifies the disease (may be required)‏ If fourth or fifth digits are present, do they have to be used?

ICD-9-CM Coding Steps Identify the main medical terms related to the diagnosis. Locate the main term in the alphabetical index, Volume 2. Verify the code number by reading the code’s description in the numerical index, Volume 1. Medisoft allows you to add as many diagnosis codes as needed. Have the students remember a recent visit to the doctor. Have them look up their diagnosis in the ICD-9 coding book.

CPT Coding Overview CPT Coding: Current Procedural Terminology System used to code services and procedures performed by providers Evaluation and management (E/M) codes classify patients with their level of service What is the difference between CPT and E/M codes? Can you list one without the other? Why or why not? What is a superbill?

CPT Coding Overview ‏ Components to determine E/M code: History of problem; provided by patient Examination of problem affecting the body Decision making: level of decision making involved in making a diagnosis New patient Established patient What are the three elements involved in decision making? Can insurance claims be submitted without diagnosis and procedure codes? Why or why not?

CPT Coding Overview ‏ Modifiers indicate special circumstances apply, often an alternation to procedure. Two-digit CPT codes -50: multiple or bilateral procedure -79: unrelated procedure -56: preoperative management only -53: discontinued procedure How do diagnosis and procedure codes impact billing? What happens if codes are missing? Does the insurance company kick the claim back to you? Does it cause delays?

Diagnosis and Procedural Codes in Medisoft In Medisoft, transaction codes not only include the CPT codes, but also: Financial codes Managed care codes Finance charge codes From the Lists menu, click Procedure/ Payment/Adjustment Codes. In addition to CPT codes, what else do transaction codes indicate with Medisoft?

Place of Service Codes Two-digit codes used to identify where the procedure or service was performed. 11: Office 12: Home 23: Emergency room – hospital 24: Ambulatory surgical center 25: Birthing center Have students look up other place of service codes.

Case Information Entry Cases are situations or conditions for which a patient seeks treatment or services. Two main reasons for setting up cases: A case is set up whenever a patient is treated for a new and different condition. When a patient’s insurance carrier changes. Why does Medisoft use cases? (They are used to group together transactions that apply to specific encounters with a provider.)