Billing And Coding Flashcards
What do ICD (international classification of diseases) codes correspond to
Patients injury sickness
What do CPT (current procedure terminology) relate to?
What functions and services the HCP performed on or for the patient
What is ICD-10 CM
Clinical modification of the WHO standards of diagnosis
*diagnosis coding for all US health care settings
What is ICD 10 PCS
Inpatient procedure coding system for all US hospital settings
How are the ICD codes made
The codes have 3 to 7 characters
1. Digit 1 is alpha
2. Digit 2 is numeric
3. Digit 3-7 are alpha or numeric
*a decimal is used after the third character
What is the ICD-10-CM code structure
- Category (first three characters)
- Etiology, anatomical site, severity (fourth, fifth, sixth characters)
- Extension (seventh character)
What is a claim
Provider will select the most appropriate ICD code and take the information from the codes and bill the insurance company
What is the coding part
Select the ICD 10 code that best and accurately defines the diagnosis
What is the billing part
Select the best CPT E/M code based on the criteria given and supplied by the documentation
What is the evaluation and management coding (E/M or E&M coding) used for
It is a subset of CPT
1. A unique 5 digit code for procedures/services including office visits
*medical providers use to bill payers for reimbursement of services provided
What did the 2021 E/M coding changes apply to
New and established office patients
What classifies as a new office patient
Someone who has not been seen by you or someone in the exact same specialty in your group within the past three years
What classifies as an established office patient
Someone who has been seen by you or someone in the exact same specialty in your group within the three years
When did the new E/M (evaluation and management) guidelines take place
January 1 2021
What were the components of the Old EM guidelines
- History
- Physical exam
- Medical decision making
*new = 3/3 key components needed
*established = 2/3 key comments needed
How are the patients billed now according to the new 2021 EM guidelines
- Medically appropriate history and or examination
- Billing based solely on MDM or time
What else goes into consideration according to the new EM guidelines
- Total time includes face to face time plus non face to face time spent on the date of the encounter
What were the old rules based on time and what are the new rules based on time
Old = face to face time only
New = include face to face time, and non face to face time before and after the visit on the date of the encounter
What is including when adding up time spent on a patient
- Reviewing labs
- Counseling education
- Ordering medications, tests, or procedures
- Referring
*do not count travel time or teaching time
How many boxes are needed to qualify for any given level of MDM
2 out of 3
What is new in 2023 with initial hospital care
No more history or exam category
*replaced with medically appropriate history and or examination
*used for both inpatient and observation admission
What is new in 2023 with subsequent hospital care
Used for hospital progress notes for both inpatient/observation
* No more history or exam category
*replaced with medically appropriate history and or examination
What is new in 2023 with initial admission and discharge services
Used for both inpatients and observation patients
* No more history or exam category
*replaced with medically appropriate history and or examination
What is new in 2023 for outpatient consults and inpatient consults
- No more history or exam category
*replaced with medically appropriate history and or examination
What is new in 2023 with emergency department
Only device not coded based on time
*MDM
How to determine the level of MDM
Based upon three categories
1. Number and complexity of problems addressed
2. Amount and or complexity of data reviewed
3. Risk of complications and or morbidity
What is straight forward MDM
- Self limited or minor problem
What is low MDM (number and complexity of problems addressed)
- A chronic illness
- Acute uncomplicated illness or injury
- Stable acute illness
- One acute uncomplicated illness or injury requiring hospital inpatient or observation level of care
What is low MDM (amount and/or complexity of data reviewed )
- External notes, communications or test results are from an external physician or healthcare organization
- A unique test
*each unique test count as one element of data
*each unique test, order or document contributes to the combination of 2 elements needed in category 1 - Independent historian
What is the no double dipping rule
- You cannot order and interpret the same lab test to meet requirements
What is moderate MDM (number and complexity or problems addressed)
- Chronic illness with exacerbation or progression
*acutely worsening, poorly controlled or progressing
*does not require consideration of hospital care - Undiagnosed new problem with uncertain prognosis
- Acute illness with systemic symptoms
- Acute complicated injury
What is moderate MDM (amount and/or complexity of data reviewed )
- Independent interpretation
*must document your interpretation in the note
*no double dipping - Discussion
What is high MDM (number and complexity or problems addressed)
- Severe exacerbation of chronic illness
- Acute or chronic illness that poses a threat to life or bodily function
What is high MDM (amount and or complexity of data reviewed)
- Independent interpretation of tests
- Discussion
What is moderate MDM (risks of complications and/or morbidity)
- Drug therapy requiring intensive monitoring
- Decision regarding elective surgery
*may be yes or no - Decision regarding hospitalization
- Decision regarding escalation of level of hospital care
- Decision for DNR or to de-escalate care
- Parenteral controlled substances
How are prolonged services documented
99417 and G2212
*can be reported in conjunction with a level 5 (highest level of care)
*both codes are used to report each increment of 15 mixtures
How are 99417 codes reported
Reported the EM code + 99417
*99417 codes report additional 15 mins spent
1. Starts when the minimum time is reached
2. Medicare will not pay for the 99417 codes
What is code 993X0 used for
Used in conjunction with the highest level of care for hospital or nursing facility services
How are G2212 code reported
EM codes +G2212
1. Report for each additional 15 mins spent
2. Medicare will pay for the G2212 code
3. Time starts when the max time for the highest level of care has been reached
When are GXXX1 codes used
For hospital setting
*clock starts ticking when RUC time for the highest level of care +15 minutes
When are GXXX2 codes used
For nursing facility care
*clock starts when RUC time for the highest level of care has been reached
When are GXXX3 codes used
For home or residential setting
*clock starts ticking when RUC time for the highest level of care has been reached
