1. Reporting, Coding and Billing Just the facts and where to find them
Back to the Basics
Reporting, Coding and Billing
Just the facts and where to find them

2. Presenter Pamela Pully
30+ years billing/coding/auditing of most disciplines and specialties
CPC - Certified Professional Coder
CPMA – Certified Professional Medical Auditor
AAPC Fellow-granted by AAPC in June of 2017
Certified in ICD-10-CM
Member of American Academy of Professional Coders (AAPC), Past officer of local chapter in Flint, MI. Member of National Alliance of Medical Auditing Specialist (NAMAS)

3. Goals of the presentation
Inform, review and remind everyone of the facts for reporting, coding and billing of services.
Where the source documents can be found with links to information.
Understanding the information and the federal and state laws. Help that could save you from recovery of funds.
Focus will be on Medicaid and Medicare as these are the most common payers for the population served.
Other payers and rules related to what order should you bill, credentialing and enrollment rules.

4. Coding rules of CMS, AMA and HIPAA
Centers for Medicare and Medicaid services (CMS)
Federal laws, rules and National Coverage Determinations (NCD)
Medicare Administrative Contractor (MAC) for Michigan this is J-8 region. The MAC sets the rules for each region creates Local Coverage Determinations (LCD)
When your consumer/client/patient has a primary insurance carrier or Medicare you have to follow those rules first. Required by law and the famous statement “Medicaid is the payer of last resort”
American Medical Association (AMA)
Owners of CPT codes and the documentation requirements of each code
These codes are patented and can’t be change in meaning or definition
HIPAA law requires you to only code and bill using approved codes, rules and guidelines. CPT, HCPCS and ICD-10 approved.

5. Coding rules for CPT Current Procedural Terminology
Standardized code set to bill outpatient & office procedures.
Patented by the American Medical Association (AMA)
By rule these codes are used first for procedures.
There are specific documentation requirement for all these codes.
procedural-terminology

6. Coding rules of HCPCS
Healthcare Common Procedure Coding System (HCPCS)
Standardized coding system used primarily for products, supplies and services not included in the CPT codes
These codes are used only when there is not a CPT that meets the service provided
ACTP
Targeted case management
Injectable medications
Vocational services
All the services that start with letters
These codes have documentation guidelines that can be based on Fed., State, or Payer specifications guidelines
More flexibility then a CPT code
SCODINGPROCESS.html

7. Coding rules for ICD-10 You must code to highest specificity.
You must follow the coding guidelines for all diagnostic coding.
You must put in proper order for billing.
Jargon has changed for ICD-10 no longer use term primary diagnosis. Must code for all conditions related to the visit.
New verbiage is code first. Usually the first code is the primary diagnosis, however, there will be times you will have to code by rule.
/2018-I CD-10-CM-Coding-Guidelines.pdf

8. State of Michigan Scope of Practice
When deciding who can perform a behavior health service in the state of Michigan you need to be aware of the states scope of practice laws.
Just because a payer allows it doesn’t mean it’s ok in this state.
This information can be found on the state of Michigan web site
For a client with dual insurance (both Medicare and Medicaid) or someone who has a primary payer you need to consider both payers rules, the scope of practice for the state, the payers enrollment rules and the PIHP qualification chart.
Billing with an understanding and knowledge of only one payer will lead to improper coding and errors in documentation. This lack of knowledge (which the OIG states as unacceptable) could lead to false claims and possible pay backs. Big Risk Area for anyone who bills this way.

9. Cost per Code Listing for PIHP/CMHSP
The final word for all codes reported or billed to the state through the PIHP/CMHSP systems.
Best place for information on allowable codes under the PIHP.
Allowable modifiers and the meaning when billing to PIHP.
Location or place of service codes (POS) and usage.
Review often and read appendix for better detail.
All billers and payers of claims should read and understand this document.
rt_554443_7.pdf

10. Qualification chart
Place where you can find out the PIHP requirements for who can provider the service.
Required qualifications can be different for each payer. This includes commercial insurance, Medicare, Medicaid and the PIHP.
Some payers have a “no exceptions” for specific qualifications requirements. When there is a primary payer you may have to use different codes based on law, rule or policy.
MHSP_Provider_Qualifications_530980_7.pdf

11. Rules for those with more then one payer
You need to insure you are billing the primary payer.
Some systems call this water falling but it is a matter of billing in the proper order.
Understand the codes they do and do not cover. Understand the credentialing and enrollment requirements of payer.
If the primary payer (example Medicare) has a retro-active effective date you need to insure you go back and bill all services within that date range. Medicare gives you 60 days, after notice of retro-active effective date, to bill for Medicare for allowable dates.
If you wait for a payer to take back funds it maybe to late to recover that billing.

12. Billing/Reporting
Have policies that insure you stay up to date for coding, billing and reporting.
New ICD-10 codes and rules effective October first. There are updates every year.
New CPT and HCPCS codes effective January first.
New documentation requirements when there is a new or changed codes. Can happen anytime usually in line with books
New provider qualification requirements. This can change anytime good to review payers rules yearly.
Insure you are documenting and coding your diagnosis's to the highest specificity.

13. FYI----WPS Medicare e-News
Billing Medicaid Patients for Co-Insurance and Deductible A provider may not collect any applicable deductible or co-insurance from a patient who has both Medicare and Medicaid. When Medicare approves a service, Medicare pays the physician 80% and the patient is responsible for the remaining 20%. In addition, Medicare will apply the appropriate deductible amounts for the allowed services. Patients are generally responsible for payment of the deductible and co-insurance. However, when a patient also has Medicaid, the patient is not responsible for any applied deductible or the co-insurance. The provider's enrollment status with Medicaid does not change this requirement. The patient is responsible for any co-pay determined by Medicaid. If you have further questions, please access the CMS MLN Matters article, Prohibition of Balance Billing Qualified Medicare Beneficiaries (QMBS) (SE 1128)

14. Clinical documentation
Clinical documentation requirements must be met.
Clinical Documentation Improvement (CDI) or Clinical Documentation Excellence (CDE) are terms that used to be associated with inpatient services now it includes outpatient.
All clinical providers should go through at least one CDI training and have yearly reviews.
Certified auditors should review a percentage of claims quarterly. Not only for quality but for content, for proper coding based on the documentation, CDI.
A query practice should be established.
CDI and all it in tales is best way to reduce the risk of take back.

15. Questions