Coding and Billing For Maximum ReturnA Closer Look at Coding for Medical Necessity

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……

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)

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

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.

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.

Avoid these Common Mistakes HCFA Box 24, A,B,C,D,E,F,H,G,I,JThis 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

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.

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.

Coding for Ancillary Services 1. 465.8 Upper Respiratory Infection 493.12 Asthma, Intrinsic, with acute exacerbation 786.05 Shortness of Breath 786.2 Cough99213 Office visit, established patient, low to moderate

severity. Linked to all 3 diagnosis94640 Inhalation Treatment linked to Asthma and

Shortness of Breath ONLYJ7613 Albuterol linked to Asthma and SOB ONLY

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.

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 breath99214 Office visit, established patient of moderate to

high severity linked to all 3 diagnosis93000 EKG linked to Chest pain80061 Lipid Panel (this is a bundled service which

includes 82465-Total Serum Cholesterol, 83718 Lippoprotein, 84478 Triglycerides).

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 childDuring the physical exam the child receives a urinalysis and hearing screen.Diagnosis V20.299392, Preventive care visit, established patient ages 1-481002 urinalysis92551 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.

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 exam389.00 Hearing Loss, conductive, unspecified

99392, Preventive care visit, established patient ages 1-4Linked to both diagnosis81002 urinalysisLinked to well exam only92551 hearing screenLinked 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

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.

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.

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)

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

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?

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.

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

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/

consumer/complform/complform.html Standardized Credentialing Form for Texas http://www.tdi.state.tx.us/company/hmoqual/

crform.html

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 EOB’s to make sure your claims are being paid

Many things can be delegated – but fiscal responsibility is not one of them.