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Coding and Billing For Maximum Return

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... a patient who presents to the office with an ear infection and cerumen impaction. ... to both diagnosis and include the ear wash (69210 removal impacted cerumen. ... – PowerPoint PPT presentation

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Title: Coding and Billing For Maximum Return


1
Coding and Billing For Maximum Return
  • A Closer Look at Coding for Medical Necessity

2
What You Put In Is What You Get Back -
  • Far too often the person coding the services
    provided to the patients visiting the practice
    never sees the corresponding insurance response.
  • Just because you place a service on a claim form
    DOES NOT mean the service will be paid.
  • In many cases the data entry person does not have
    a medical back ground
  • Sadly, many offices hire inexperienced medical
    billers to save money……

3
Terms
  • E.O.B. Explanation of Benefits. This is the
    response from an insurance company when a medical
    claim has been filed.
  • Bundled Service These are services that have
    been grouped together as one service and are not
    paid separately.
  • Example Suture removal will not be paid as a
    separate service since removal is included in the
    price of the original service.
  • Medicare Healthcare coverage for the elderly
  • Medicaid Healthcare coverage for the indigent
  • Commercial Insurance coverage for the working
    population and their dependents if included.
    Typically has a co-payment per visit.
  • Indemnity Plan Sometimes known as catastrophic
    coverage. Typically has a deductible, once met
    insurance payment is a ratio of the covered
    amount such as 80/20 (80 paid by ins. 20 paid
    by the patient)

4
Elements of a Clean Claim
  • CMS1500 this is the standardized form created by
    the Center for Medicare Service (formerly HCFA
    1500 from the Health Care Finance Administration)
    for the purpose of submitting claims for payment
  • Each box on the form contains a number and
    description of the information required in that
    box.
  • Example 1

5
Elements of a Clean Claim
  • Each box should have the required information
    being requested.
  • Match the patient demographics to the information
    on their insurance information. See Example 2.1
  • Primary, secondary and tertiary insurance should
    be in the proper order. Example 2.2
  • Current and relevant ICD9 Diagnosis codes should
    be used and linked to the specific CPT code they
    correspond to. Example 2.3
  • Some CPT codes such as those for Laboratory blood
    work panels are bundled and will not be paid
    separately. Example 3
  • Make sure to use any insurance specific codes for
    that insurance only examples include special
    Medicare codes, CHiP codes.

6
Avoid these Common Mistakes
  • HCFA Box 14 Date of current illness, accident
    or pregnancy (LMP). When coding for a physical
    exam other than a well woman, record the date of
    the visit and leave the remainder blank. Example
    4
  • When coding a well woman, use the date of the
    visit and LMP.
  • When you are seeing a patient to confirm her
    pregnancy be sure NOT to use the diagnosis code
    for pregnancy unless your office will be seeing
    her for the duration of her pregnancy, since this
    is a global care code. You can use amenorrhea
    or other appropriate code.

7
Avoid these Common Mistakes
  • HCFA Box 24, A,B,C,D,E,F,H,G,I,J
  • This is where diagnosis codes are linked to CPT
    codes. Try not link every CPT code to every
    diagnosis code unless it is appropriate to do so.
  • Consider a well child exam (V20.2) where 4
    vaccines were given in addition to the exam. Be
    sure to link the physical exam to V20.2 and each
    individual vaccination CPT coding to its
    corresponding individual ICD9 code. In the
    majority of cases there is only one correct code.
    Example 5 and 6

8
Avoid these Common Mistakes
  • For Laboratory testing the CLIA number should
    appear in box 23 of the HCFA 1500 form (even
    though it asks for prior authorization number!)
  • Box 32 should show the name and address of the
    facility where the services took place
  • Box 33 should show the name and address of the
    physician or provider of service.

9
Coding for Ancillary Services
  • Patient presents for a chief complaint of
    shortness of breath, wheezing and cough
  • Upon examination the patient is diagnosed with an
    upper respiratory infection and is found to be
    asthmatic.
  • The prescribed treatment includes a nebulizer
    treatment in addition to the office visit.

10
Coding for Ancillary Services
  • 1. 465.8 Upper Respiratory Infection
  • 493.12 Asthma, Intrinsic, with acute exacerbation
  • 786.05 Shortness of Breath
  • 786.2 Cough
  • 99213 Office visit, established patient, low to
    moderate severity. Linked to all 3 diagnosis
  • 94640 Inhalation Treatment linked to Asthma and
    Shortness of Breath ONLY
  • J7613 Albuterol linked to Asthma and SOB ONLY

11
Coding for Ancillary Services
  • Patient presents to the office complaining of
    intermittent chest pain, upper back pain and
    shortness of breath.
  • Upon examination of the patient an EKG and Lipid
    Test is ordered. The diagnosis are chest pain,
    thoracic spine pain and shortness of breath.

12
Coding for Ancillary Services
  • 786.59 Chest pain, other including discomfort,
    pressure tightness in chest
  • 724.1 Pain of Thoracic Spine
  • 786.05 Shortness of breath
  • 99214 Office visit, established patient of
    moderate to high severity linked to all 3
    diagnosis
  • 93000 EKG linked to Chest pain
  • 80061 Lipid Panel (this is a bundled service
    which includes 82465-Total Serum Cholesterol,
    83718 Lippoprotein, 84478 Triglycerides).

13
Coding for Ancillary Services
  • Scenario 1 a 3 year old child presents to the
    office for a well child exam, the parent reports
    no problems with the child
  • During the physical exam the child receives a
    urinalysis and hearing screen.
  • Diagnosis V20.2
  • 99392, Preventive care visit, established patient
    ages 1-4
  • 81002 urinalysis
  • 92551 hearing screen
  • In this scenario, the office can expect to be
    paid for the visit alone, in some cases the
    urinalysis may be paid or not depending upon
    whether it is considered a bundled service
  • The hearing screen for no other diagnosis besides
    a well exam is generally not paid separately.

14
Coding for Ancillary Services
  • Scenario 2- A 3 year old child presents to the
    office for a physical examination, the parent
    reports that the child is slow to respond when
    spoken to and watches television with the volume
    turned up.
  • During the physical exam the child receives a
    urinalysis and hearing screen.
  • Diagnosis V20.2 well child exam
  • 389.00 Hearing Loss, conductive, unspecified
  • 99392, Preventive care visit, established patient
    ages 1-4
  • Linked to both diagnosis
  • 81002 urinalysis
  • Linked to well exam only
  • 92551 hearing screen
  • Linked to hearing loss only
  • In this scenario, the office can expect to be
    paid for the visit, perhaps the urinalysis as
    well as the hearing screen

15
In Office Surgeries
  • In most cases, when a patient presents with a
    skin lesion to be removed, the office visit will
    not be paid on the same day as the surgery.
  • If the office visit and the surgery are done on
    the same day, use a modifier 57 (decision for
    surgery) with your office visit.
  • It is more likely to have the office visit paid
    if there was a SEPARATE reason for the visit such
    as in the case of a medication refill or an
    illness
  • In this case, code your office visit with a
    modifier 25 (separate, identifiable service
    performed on the same day) being sure to link the
    visit to ONLY the codes not dealing with the
    reason for the surgery.

16
Is it a Surgery?
  • The CPT coding manual considers any invasive
    procedure to be surgical
  • Consider a patient who presents to the office
    with an ear infection and cerumen impaction.
  • If you code the office visit to both diagnosis
    and include the ear wash (69210 removal
    impacted cerumen. This code is included in with
    other codes for removal of foreign body and is
    considered an invasive (surgical) procedure the
    office can expect to be paid for ONLY the ear
    wash as the least expensive of the two billed
    codes.

17
Other in Office Surgeries
  • Destruction of Skin Lesions- those which are not
    considered suspicious are considered cosmetic
    by many insurance companies and are not a covered
    benefit such as 702.0 actinic keratosis.
  • A patient having 5 actinic keratosis removed-
    702.0
  • 17000 Destruction benign or pre-malignant
    lesion, first lesion. (bill 1 unit).
  • 17003 lesions 2-14. (bill 4 units)

18
Other Office Surgeries
  • Other Skin Lesions that are not benign or are
    suspicious in nature such as are included in
    diagnosis codes 170 176.9 for reporting
    malignant neoplasms and melanomas
  • A patient presents to the office with a 2 cm
    malignant melanoma of the upper arm (173.6)
  • 11302 Shaving of Eipdermal or Dermal Lesions of
    trunk, arms, legs 1.1 2.0 cm

19
Showing Medical Necessity
  • Sadly in our changing healthcare climate there
    are many offices who are attempting to supplement
    their practice income by offering as many
    services as possible.
  • This is great as long as the services provided
    are substantiated and documented!
  • Does every single patient who comes in for a
    respiratory complaint need the test for both
    Strep A and B?
  • Does the patient who comes in for Diabetes and
    Hypertension management really need a Carotid
    Doppler Study?

20
Wrapping Up Great Resources
  • Every office should have an ICD9 and CPT code
    book and KNOW how to use them.
  • There are several CD rom programs such as Medical
    Manager that have ICD9, CPT, HCPCs and Dorlands
    all on one program. This particular program will
    also give the Medicare rules for any CPT code
    when you double click it.
  • This can be invaluable when trying to determine
    why your code was not paid.

21
Wrapping Up Great Resources
  • Become familiar with the Trailblazer (Medicare)
    website at www.trailblazerhealth.com
  • There are educational resources for physicians
    and staff, there is training available, forms,
    newsletter and much more.
  • Medicare is the insurance industry standard and
    their rules are closely followed by most other
    insurance companies

22
Wrapping Up Great Resources
  • The Texas Department of Insurance
  • You can file a complaint on line against an
    insurance company on unpaid medical claims ()
  • https//wwwapps.tdi.state.tx.us/inter/perlroot/con
    sumer/complform/complform.html
  • Standardized Credentialing Form for Texas
  • http//www.tdi.state.tx.us/company/hmoqual/crform.
    html

23
Summary-
  • Make sure that claims are properly coded.
  • Consider cross training front office personnel
  • Keep yourself and staff updated on new
    developments by attending training sessions.
    This is an investment in your practice
  • Periodically review the office payments and EOBs
    to make sure your claims are being paid
  • Many things can be delegated but fiscal
    responsibility is not one of them.
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