PROCEDUREDIAGNOSIS CODE OVERVIEW. Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations.

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Presentation transcript:

PROCEDUREDIAGNOSIS CODE OVERVIEW

Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations. Learning Objective

Medical coding is a uniform language that allows a reliable means of communication among physicians, patients and third parties. Medical “Code Speak”

HCPCS Codes Healthcare Common Procedure Coding System (HCPCS) is maintained by the Centers for Medicare and Medicaid Services (CMS). Provide a system for reporting the medical services provided to Medicare beneficiaries.

HCPCS Code Ranges A-codes: Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental B-codes: Enteral and Parenteral Therapy C-codes: Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures E-codes: Durable Medical Equipment G-codes: Temporary Procedures & Professional Services H-codes: Rehabilitative Services J-codes: Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes: Temporary Codes for Durable Medical Equipment Regional Carriers L-codes: Orthotic/Prosthetic Procedures M-codes: Medical Services P-codes: Pathology and Laboratory Q-codes: Temporary Codes R-codes: Diagnostic Radiology Services S-codes: Private Payer Codes T-codes: State Medicaid Agency Codes V-codes: Vision/Hearing Services

CPT codes enable healthcare providers to effectively and efficiently communicate with government or private insurance companies about medical, surgical and diagnostic services rendered to a patient. The CPT Coding System

The Current Procedural Terminology (CPT) is a five digit coding system first published by the American Medical Association (AMA) in The Procedure / Service

1 1 ToFrom Medicine Surgery Radiology Pathology Evaluation & Management Hospital DRG CodeDRG-001DRG-999 Anesthesia CPT Code Ranges

Health Insurance Claim Form 1500

Page 2

Medical Record Documentation Cycle DOL/OWCP Review Claim Documents are Coded & Submitted to DOL/OWCP Doctor Examines Claimant Doctor Renders Treatment & Documents Diagnosis Claimant Goes to Doctor Payment Sent Most provider offices use “superbills” for billing purposes.

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