Friday, 28 April 2017

Understand the role of medical billers

As stated earlier, the job of the medical biller aligns closely with that of the medical coder, but there are other integral tasks that are unique to the medical biller. As you read in Course 2, the initial part of the medical billing process is the collection of data from the patient. Medical billing specialists must ensure they have all the relevant information from the patient and that this information is correct in order to proceed with a claim to the insurance company.
Once medical billers have the correct information regarding a patient’s history, contact information, and insurance policy (or policies), they then input that information into their medical claims software and begin the claims process. Upon translating the procedure notes into diagnostic and procedural codes (or upon receiving these codes from a third-party coder), the medical biller creates an insurance claim and sends this to an insurance company. Medical billers should be familiar with claim formats for each of the major payers, including Blue Cross/Blue Shield (and other private payers), Medicare, Medicaid, TRICARE, CHAMPVA, and various worker’s compensation and disability organizations.
When the claim is returned and the healthcare provider is properly reimbursed for services, medical billers must then bill the patient. This process involves following up with patients about late payments or arranging for a collections service in the case of notably delinquent bills. Medical billers are also responsible for interpreting the Explanation of Benefits (EOB) and explaining the general billing process to patients. Medical billers must be familiar with co-pays, coinsurance, and deductibles in order to bill patients correctly.
If a claim is returned to the healthcare provider as denied or rejected, the medical billing expert must determine why and correct errors if possible. If the claim was denied because of inaccurate or inappropriate coding, the medical biller must input the correct codes and resubmit the claim (or pass it back to the third-party coder who initially coded the procedure).
Medical billers must also prepare appeals to denied claims on behalf of patients or the healthcare provider. A denied claim may be due to a clerical error (as with a missed code), or it may come down to a discrepancy in the provider’s contract with a payer. Medical billers also have to help patients prove the necessity of their medical procedure. They must be prepared to research all of the elements of the appeals process. As with coding, the appeals process is time-sensitive, so medical billers handling claim appeals must work quickly and efficiently to ensure their appeal is filed in a timely manner.

See What Tools You Will Use as a Biller and Coder

Many professionals in the field rely heavily on billing and coding software. This software is especially important if you are planning on working from home. Software like Medisoft or MediTouch allow coders to look up specific codes for accuracy and create claims quickly. There are dozens of billing and coding software programs at various price points, and you will have to assess what your individual needs and preferences are when it comes to the coding software you use.
While medical billing and coding software is becoming an industry standard, some smaller practices still use paper hard copies for their coding and billing services. Paper is less efficient than electronic records, and can create problems such as duplicate data (in the case of there accidentally being two separate files for one patient), not to mention the massive amount of physical space needed for storage of paper claims. Coding and billing via hard copy also makes it difficult for different parties (like other insurance companies or healthcare providers) to access important health records. Still, despite the clear advantages of electronic health records for the purposes of billing and coding, professional billers and coders should familiarize themselves with hard copy billing and coding forms. Medical billers also have to refer to hard copies of a patient’s medical records and EOBs throughout the day when creating a claim.

Find Out What Regulations You Have to Follow

While there are no laws that apply exclusively to medical billing and coding, billers and coders must operate within the laws and regulations that govern the whole of the healthcare industry. Because the information they handle includes confidential patient medical histories, they must follow guidelines laid out in the Health Insurance Portability and Accountability Act (HIPAA), and the Correct Coding Initiative, which is a project of the Centers for Medicare and Medicaid (CMS).
Title II of HIPAA, also known as the Administrative Simplification Statute, ensures that the confidentiality of patients will be secure when their information is transmitted electronically. This applies to all entities that handle health information electronically, including health plans, healthcare providers, and healthcare clearinghouses. These rules also apply to any off-site or third-party entity (such as a freelance biller or coder) that handles sensitive healthcare information. The HIPAA Administrative Simplification Statute states, effectively, that all parties capable of accessing or transmitting sensitive health information have a set of rules in place that a) protect patient health and b) identify which employees or persons will have access to a particular level of private information. Privacy rules may vary from one practice to another, and HIPAA mandates internal audits as a primary method of ensuring adherence to the law. Audits may mean a routine review of protocol and procedure for the medical coder and biller.
Note that this part of HIPAA applies only to electronic transactions, including claims and encounter information (such as ICD-10-CM codes) and inquiries into claim status. Healthcare providers, coders and billers, clearinghouses, and insurance companies are not required to submit this information electronically, but if they do, they must follow HIPAA guidelines.
The Correct Coding Initiative provides detailed guidelines for professional coders and billers. Updated annually by CMS, the initiative ensures that the codes used for various medical transactions are uniform around the country. You are already familiar with certain initiative regulations: The initiative mandates that Current Procedural Terminology (CPT) be used to code medical procedures, and that ICD-10 be adopted by October 1, 2014 for all diagnostic reports. The Correct Coding Initiative also regulates which codes will be used in pharmacy and dental transactions. The medical biller and coder should be aware of these regulations and be able to research them whenever the need arises.

Tuesday, 25 April 2017

Running Your Own Medical Billing and Coding Service

Explore a Day in the Life of a Medical Biller and Coder

Any time a medical service is provided, whether it’s a routine checkup or a major surgery, information about that service is recorded and given to the medical billing and coding specialist. A doctor gives the medical biller and coder procedure documentation of the services provided, which the biller and coder must then translate into the proper code. Medical billing and coding specialists are responsible for correctly coding the diagnoses and procedures performed by the healthcare provider. This requires a thorough knowledge of both ICD-9-CM codes and ICD-10-CM codes for diagnostics, and CPT codes for procedures.
A procedure document includes relevant information like the date of the procedure, the patient’s name, and his or her date of birth. More importantly, a procedure document includes the doctor’s diagnosis and the procedure performed. For example, a doctor may provide documentation of a mole removed from the torso of a patient via cryoablation (essentially, freezing the mole). The medical biller and coder would look at the procedure documentation and decide which codes correspond to the diagnosis and procedure listed. In the case of this example, a coder would select the CPT code 11710 (destruction of benign lesions or skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure, and the ICD-9-CM code 216.5 (benign neoplasm of skin of trunk, except scrotum) for the diagnosis.
The bulk of the medical coding portion of the billing process involves turning procedure reports into correct medical code, then entering it into the system for the claims process. Medical coders spend their day taking procedure documentation, looking up the proper codes, and entering that information into their claims software. Most medical coding is relatively straightforward (for example, the CPT code 99213 corresponds to a routine visit to the doctor’s office), but even with common codes there are discrepancies or gray areas. Coders must consult their manual, professional associations, and periodicals to stay up-to-date on current professional best practices.

Learn about lag days

Like medical billing, medical coding is a time-sensitive operation. Any hiccup in the coding process can cause a ripple effect, which delays billing, the claims process, and ultimately the reimbursement of the healthcare provider from the insurance company. For this reason, most coders are asked to keep their operations within a number of “lag days.” Lag days refer to time between when a procedure note is given to the coder and when the claim for that procedure is filed. Most offices keep the number of lag days between two and five, so coders must stay on top of their work in order to ensure efficiency in the operation of the health-care provider.

Review crosswalking

In certain cases, a medical billing and coding professional has to perform a code “crosswalk” between these sets of codes. Crosswalking is covered in depth in courses 11 and 12. To briefly review, a crosswalk refers to an equivalency or translation between two code sets. A medical coder may have to use a crosswalk in order to track data between two different sets of code (as in the case of ICD-10-CM and ICD-9-CM) or translate between two sets to comply with certain form requirements (as with translating CPT codes into ICD-9-CM codes).

Avoid clerical errors to shorten reimbursement time

Coders should also make sure the procedural and diagnostic codes that they are entering on a claim make sense with one another. For example, you would not want to pair the procedure code for a tonsillectomy with the diagnosis code for a broken hand. Inaccurate, contradictory, or improperly crosswalked codes are just a few of the many reasons a claim may be denied, and it is up to the coding specialist to prevent as many of these clerical errors as possible.

Friday, 21 April 2017

A Guide to the Use of CPT MODIFIERS

CPT codes describe medical, surgical, and diagnostic procedures and services in five-digit numerical sequences. These codes are published and copyrighted by the American Medical Association (AMA). They allow for standardized documentation and communication between medical facilities and organizations, as well as between patients, healthcare providers, and insurance companies.

In order to describe the myriad number of different medical services, procedures, and factors accurately, CPT codes are divided into three Categories. Category I CPT codes describe medical, surgical, and diagnostic procedures (for instance, a routine checkup of low complexity is CPT code 99213). Category II CPT codes provide supplemental information to Category I CPT codes. The example used in Course 12 is the code for low-density lipoprotein cholesterol (CPT I code 80061) with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F). This test and its result would be coded as 80061-3048F.
Category II CPT codes supply information that streamlines administrative work and tracks the performance of certain tests or procedures. These Category II codes, however, do not always provide important information about the specifics of a procedure, like on which side of the body a surgery took place, or whether a surgery was discontinued due to concern for patient safety.

See Examples of CPT Modifiers

In order to communicate this extremely detailed information in an efficient, standardized way, the AMA created CPT modifiers. CPT modifiers are two-character suffixes that healthcare providers or coders attach to a CPT code to give additional information about the procedure documented. CPT modifiers are always two characters in length. They may consist of two numbers from 21 to 99, two letters, or a mix (alphanumeric). These modifiers are appended to the initial CPT code by a hyphen.
Some examples of common CPT modifiers include:
  • -53 (discontinued procedure)
  • -59 (distinct procedural service)
  • -79 (unrelated procedure or service performed by the same physician during the postoperative procedure).
Some common letter-based modifiers include:
  • -LT (denotes a procedure on the left side of the body)
  • -RT (denotes the right side of the body),
  • -GC (identifies that a service has been performed by residents or students under the guidance of a teaching physician).
If you had to code a partial mastectomy of the left breast, you would use the CPT code 19302 for the procedure, with the modifier –LT to describe on which side of the body the procedure took place. Our code would read 19302-LT. If, however, the procedure had to be stopped because of a concern for the well-being of the patient, you would add another modifier: -53. The new code would read 19302-LT-53. Note that this is a simplified example, and that a procedure as complex as a mastectomy often has numerous additional codes).
Certain CPT modifiers are only used with a particular type of procedure or service. For instance, the modifier –LT used above is only valid when describing a procedure on an appendage or organ paired in the body, such as the lung, kidney, leg, or breast. The modifiers, -21, -24, -25, and -27 are only used for evaluation and management. Also, note that unlike CPT codes and ICD codes, CPT modifiers are not necessarily grouped into related procedures.

Monday, 17 April 2017

Use CPT Codes to Determine Doctor Fees

CPT codes can be used to assess the actual costs of a procedure in terms of the doctor’s fees. While medical billers and coders have access to this information already, the AMA allows non-professionals and students the ability to use a free CPT lookup for one procedure at a time. This is done through the CodeManager system on the AMA website, which allows patients to enter an existing CPT code to determine the procedure or treatment or look up a CPT code by entering the procedure, which will allow you to assess the cost paid by Medicare for this procedure in your area. In addition, you can also determine the average cost of this service throughout the U.S.

Step-by-Step process for looking up CPT codes

The steps for looking up the cost of a treatment or procedure using the CodeManager system are simple.
  1. Get Started. First, click the above link to enter the AMA CodeManager website.
  2. Agree to play by the rules. You will have to read and click an agreement that stipulates that you do not sell the information you receive from the website, and that the number of times you can use this service are limited. To continue, hit the “Agree” button.
  3. Specify your location. Next, the screen asks you to select the state and nearest city in which the procedure was performed,
  4. Specify your procedure. Enter either the CPT code or keywords that describe the medical treatment or procedure you wish to look up.
Your query may not return anything right away, so use these tips to search successfully:
  • Try a few different search terms. For example, if you were trying to determine the cost of surgery to remove a ruptured appendix, you could enter the keywords “appendectomy” or even just “appendix”, which would lead you to several possible procedures and their costs, including code 44960 for a simple appendectomy, as well as other codes describing unlisted procedures involving the appendix, examinations of that organ, and related surgical procedures.
  • Use medical terminology. In most cases, procedures and body parts are described by their medical terms, so while a search for “hip replacement” will give you no hits, a search for “hip arthroplasty” will give you several options of possible procedures. Of course, if you have the CPT code you can enter it outright and it will take you straight to the relevant procedure.
Note that in the costs column, the medical payment listed can either be “non facility” or “facility”, depending on where the procedure was conducted. Facilities include hospitals, including emergency rooms, ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs), while non facility means any other setting, such as clinics or private practice offices. You may also notice that some procedures can only be conducted in a facility or non-facility setting, which means that the other column will have an “NA” or non-applicable label and no price.

Using RVUs to determine average costs

The medical payments listed are an average of the Medicare cost throughout the U.S. multiplied by the relative value amount (RVU) of a region, which may be higher or lower than 1.0. For example, the same procedure, such as an appendectomy (44950), is priced at $722.57 in Manhattan but only $642.29 throughout Arizona. This is due to the relative costs of goods and services in a region, and is reflected in CPU pricing.
It is also very important to note that the prices listed on the CodeManager website reflect the cost of a procedure paid by Medicare based on the Medicare Physician Fee Schedule (MPFS), which is very close to its actual cost, though the prices patients or insurance providers are typically charged more to account for the costs of the facility and its staff; This is particularly true of private medical institutions.

Thursday, 13 April 2017

Convert CPT CODES to ICD-9 Codes for Medical Billing and Coding

Understanding Current Procedural Technology (CPT) Codes

Current Procedural Terminology (CPT) is a code set developed and maintained by the American Medical Association (AMA) that describes medical, surgical, and diagnostic procedures. CPT codes allow for uniform communication, research, and data analysis across local, regional, state, and national bodies. CPT Codes are updated annually on January 1.
Unlike ICD codes, CPT codes are trademarked by the AMA, making it impossible to find a comprehensive list of CPT codes online. But you should still know how to use them to look up procedures and understand their role in the medical billing and coding industry. These five-digit numeric codes identify medical procedures and services in a standardized manner, and are used by physicians, coders, health insurance companies, accreditation agencies, and patients. CPT codes can be used for financial, analytical, and administrative purposes, and are divided into three categories.

CPT Category I Codes

CPT is organized into three distinct categories. The first category, which is by far the largest of the three, contains codes for six subtypes of procedures. Much like ICD-9 and ICD-10, these procedural codes are organized into clusters, which are then subdivided into more specific ranges. For instance, codes for radiology fall in the number range of 70010 to 79999, and codes for a diagnostic ultrasound procedure fall into the range of 76506 to 76999. Within that number range, procedures have a designated code, ensuring healthcare payers record exactly which procedure a patient has undergone. For example, the codes 99213 and 99214, which you may have seen on your medical bill following a checkup, correspond to routine doctor’s visits (of simple and medium complexity, respectively).
As is the case with ICD-9 or ICD-10, the goal of CPT codes is to condense as much information as possible into a uniform language. CPT codes are designed to cover all kinds of procedures and are therefore very specific. For example, the code for a 45-minute session of psychotherapy with a patient and/or family member is 90834, while the code for a 60-minute session with a patient and/or family member is 90837.

CPT Category II Codes

The second section of CPT (Category II, or CPT II) consists of optional supplemental tracking codes. These codes are formatted with a letter as their fifth character, and are coded after the initial CPT code. These Category II codes include information on test results, patient status, and additional medical services performed within the larger Category I procedure. Like Category I codes, they are divided into clusters. CPT II codes for Patient Management, for example, fall into the 0500F-0575F range. While optional, these codes reduce the need for record abstraction and chart review, and lower the administrative burden on healthcare professionals. In addition to increasing efficiency, Category II CPT codes facilitate research and the collection of data related to the quality of patient care. Some codes also relate to state or federal law, as in the case of the codes 3044F-3046F, which document the blood alcohol level of a patient.
These codes are a supplement, not a substitute, for the codes in Category I, and therefore must always be attached to an existing Category I code. An example of a CPT code with a Category II code attached is 80061-3048F, which describes a test of low-density lipoprotein cholesterol (CPT I code 80061), with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F).

CPT Category III Codes

The third section of the CPT code is devoted to new and emerging technologies or practices. Note that this code does not indicate that the service performed is ineffectual or purely experimental. A Category III code simply means the technology or service is new and data on it is being tracked. Like Category II codes, Category III CPT codes are numeric-alpha, meaning the last digit is a letter. After a predetermined period of time (typically five years of data tracking), a procedure or technology described by a Category III code may move into Category I, unless it is demonstrated that a Category III code is still needed.

Understand How CPT and ICD-9-CM Codes Interact

CPT codes work in tandem with ICD-9-CM codes to create a comprehensive picture of medical services rendered. ICD-9-CM codes, discussed in detail in Course 10, are numeric (and in certain cases alphanumeric) diagnostic codes that describe the symptoms, area, and type of injury or disease in a patient. When listed together, ICD-9-CM and CPT codes present a picture of both the diagnosis of an injury or disease and the type of service provided to the patient by the healthcare provider.
In some cases, it may be necessary to convert CPT codes to ICD-9-CM codes. ICD-9-CM’s alphanumeric codes describe the services, tests, consultations, and any other way that that a healthcare provider has interacted with a patient. There is often significant overlap between this set of codes and CPT. For instance, the CPT code for two doses of Hepatitis A vaccine, of pediatric or adolescent dosage, for intramuscular use is 90633. The ICD-9-CM code for that same vaccine is V05.3. In general, CPT codes provide more specificity than their ICD-9-CM counterparts. For instance, three doses of the above vaccine is coded in CPT as 90634, while in ICD-9-CM it is still coded as V05.3. Medical coders should familiarize themselves with the equivalencies between these two code systems, and be able to freely translate one into the other.
In addition to converting between these two codes, medical coders must ensure that the code they enter for a medical procedure (the CPT code) makes sense with the diagnosis code (ICD-9-CM). The two codes work in tandem to show which procedure was done for what reason. By confirming that the codes correspond correctly, coders ensure that a claim will not be denied and returned by a health insurance company. For instance, if you submitted a claim for a Human Papilloma Virus vaccine (CPT code 90650), but list the diagnosis as acute appendicitis with generalized peritonitis (ICD-9-CM code 540.0), a health insurance company would catch this error, deny the claim, and return it to you for correction. Lastly, the upcoming switch to ICD-10-CM on October 1, 2014, means that coders should also be able to convert CPT codes into ICD-10-CM codes.

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