Medical Insurance Coding Chapter 18 Medical Insurance Coding

Insurance Coding Systems Procedure coding Current Procedural Terminology (CPT) Developed by American Medical Association (AMA) Used to code medical procedures Medicare supplement to CPT system New CPT book issued every October

Insurance Coding Systems Procedure coding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Developed by World Health Organization (WHO) Used to classify all known diseases

Insurance Coding Systems Procedure coding Importance of accuracy Down-coding and up-coding Bundled codes and unbundling

Coding of Medical Procedures Adhere to ethical standards and legal practices Chart documentation must support the code Maintain coding skills through CEUs and networking

CPT Manual Organization and Use Procedure for determining a CPT code Turn to Category I section of the CPT codebook and select one of the sections that constitutes the general classification of the procedure being coded Select the name of the procedure or service that accurately identifies what you are looking for Do not select a CPT code that only approximately defines the service performed Use appropriate unlisted codes if can not find exact code

CPT Manual Organization and Use Procedure for determining a CPT code Unlisted codes are found at the end of each subsection Five-digit code for unlisted services end in 00 Special report must be submitted with an unlisted code Unlisted codes should not be used if a Category III code is available

CPT Manual Organization and Use Procedure for determining a CPT code Category III section is found in the back of the codebook and gives temporary codes 2007 edition provides codes for treatment of patients for virtual office visits

CPT Manual Organization and Use Divided into seven sections Evaluation and Management (E&M) section Anesthesia section Surgery section Radiology, nuclear medicine, and diagnostic ultrasound section

CPT Manual Organization and Use Divided into seven sections Pathology and laboratory section Medicine section Index Modifiers Procedure 19-1 CPT coding Assign or discuss the critical thinking box

Healthcare Common Procedure Coding System (HCPCS) Codes are used as supplements to the basic CPT system Required when reporting services and procedures provided to Medicare and Medicaid beneficiaries HCPCS uses the basic system Level I

Healthcare Common Procedure Coding System (HCPCS) Level II codes Provides codes to enable the provider to report nonprovider services Durable medical equipment, supplies and medications, and ambulance service Level III codes Defined by the Medicare regional Part B carriers

Coding of Medical Diagnoses ICD-9-CM resource manual organization and use Broken into three volumes External cause codes (E codes) Supplementary health factor codes (V codes) Morphology codes (M codes) Code references NEC or NOS Procedure 18-2 ICD-9-CM Coding Assign or discuss the critical thinking boxes

Coding of Medical Diagnoses Coding accuracy Be as precise as possible Do not guess Do not code what is not there

Coding of Medical Diagnoses Watch the video

Coding the Claim Form Encounter form CMS-1500 (08-05) Information transferred to claim form CMS-1500 (08-05) Indicates complexity of visits, diagnoses, and procedures performed EHRs use encoder programs available on CD-ROM or as Internet downloads Review examples of coding

Third-Party Guidelines Patient and provider enter into a contract for specific services when appointment is scheduled First party The person receiving the contracted service Second party Person or organization providing the service Third party Involved with reimbursement procedures

Third-Party Guidelines Confidentiality issues HIPAA and PHI Authorization to release necessary medical information Authorization exceptions See also Chapters 11, 12, 13, 14, and 17 about HIPPA and PHI Procedure 18-3 applying third-party guidelines

Completing the Claim Form Most common claim form is the CMS-1500 (08-05) CMS-1500 (08-05) sections Carrier section Patient and insured information section Physician or supplier information section Discuss how EHR is used in completing the claim form (Figure 18-3)

Completing the Claim Form Uniform Bill 04 (UB04) Accommodates reporting National Provider Identifier (NPI) number Procedure 18-4 Completing the Claim Form

Using the Computer to Complete Forms Optical character reader (OCR) guidelines Common errors in completing claim form Documentation of referrals Benefits of submitting claims electronically Procedure 18-5 Insurance Billing Using Medical Office Simulation

Managing the Claims Process Documentation of referrals Point-of-service device Provides immediate and direct access to patient eligibility information and managed care functions through electronic network Connects medical office and health plan’s computer Maintaining claim register or diary

The Insurance Carrier’s Role Checks that coverage is in force at time of treatment Provider contracted with the insurance carrier No exclusions or restrictions on policy

The Insurance Carrier’s Role No preexisting condition restrictions Diagnosis and procedures are medically necessary and reasonable Verify the billed amount falls within UCR fee

Explanation of Benefits Sent to insured What it includes May act as bill

Compliance Programs Basic elements of compliance program