Billing Background

Diagnosis (ICD) versus Service (CPT) ICD codes are diagnosis codes –Describe new and established diagnoses –Also include symptom codes –headache (symptom code), vs migraine (diagnosis code)

Diagnosis (ICD) versus Service (CPT) CPT codes are service codes –Describe performed services, both procedures and evaluation/management (E/M) –Service codes must be based on necessity determined by diagnosis/ICD-9 codes

ICD or Diagnosis/Disease Codes International Classification of Diseases Developed by the WHO Facilitates classification of morbidity and mortality data and international disease standardization Revised periodically

ICD-9 CM ICD-9 CM: International Classification of Diseases, 9 th Revision, Clinical Modification System modified from ICD, includes more specificity for clinical and billing purposes Revised annually ICD-10 CM has an in use deadline of 1 OCT 15

ICD-9 CM Cont… ICD-9 CM diagnosis codes range from general to specific More specific codes may better support billing i.e. justify why higher level of service was deemed necessary ICD-9 CM Diagnosis Arrhythmia, NOS Atrial fibrillation Diabetes type I Diabetes Type I, Uncontrolled UTI -cystitis UTI – pyelonephritis, acute CHF, left CHF, diastolic unspecified

V Codes (sub set of ICD-9 CM codes) Code for preventative care Usually not reimbursable themselves, but… May allow for reimbursement of other services not otherwise authorized –HIV, asymptomatic (v08) allows for payment of vaccines not otherwise reimbursed –Family history, breast cancer (v16.3) allows for reimbursement of early screening or genetic testing

CPT Codes/Service Codes Current Procedural Terminology Describe performed services, both procedures and Evaluation and Management (E/M) Service codes must be based on necessity determined by diagnosis/ICD-9 codes

CPT Codes Cont… Currently the national standard for almost all health insurers (Medicare, Medicaid and private insurers) 1960’s1970’s1983 Developed by AMA to standardize billing/coding for Surgical Specialties Expanded to include medical procedures and services Adopted and standardized by federal government to include all subspecialties

CPT Codes Cont… 5 digit codes Cover all billable services and procedures –Anesthesia –Surgery –Radiology –Pathology and Laboratory –Medications (ie meds administered) –Evaluation and Management (E/M)

CPT Codes – an example An 65 yo man visits his PCP for his annual checkup and incidentally complains of 2 days of knee pain. On exam his knee is erythematous, warm, tender and swollen. You perform a joint aspiration, and he also receives a Pneumovax as part of his routine preventative care. 3 codes apply (and can all be used for the single visit) –Evaluation and management code –Medication code (for vaccine) –Surgery code (for joint aspiration)

Medical Necessity Rule There must be a connection between the diagnosis and the corresponding service CPT code MD must decide what is medically necessary care for the given diagnosis, and bill accordingly Even if documentation is extensive, only bill for medically necessary care

Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statement “Medical necessity is determined based on the diagnosis submitted for that service or supply. Specificity and accuracy of diagnosis code and linkage on the claim form determine payment.”

ICD-9CM and CPT MAKE THE CONNECTION!!!