Billing and Coding Basics Flashcards
Why does correct billing and coding matter?
- It impacts how the patient or their insurance is billed
- It is a legal matter – especially with Medicare
* Incorrect billing practice is punishable by fines or legal action
* Billing too much or too little is considered fraud (saying you did not know is not a defense) - If you want to get paid and/or keep your job you need to be mindful of billing and coding
* Productivity pay is based of billing
* Bonuses are based of billing
* Yearly reviews often include a measure of billing
What is the current procedural terminology codes (CPT)?
The process of submitting and following up on
claims to insurance companies to receive
reimbursement for medical services rendered by a
medical provider as defined by Current Procedural
Terminology codes (CPT)
Evaluation & Management codes (E/M) are the CPT
codes for direct patient care
* They are a series of numbers that equate to the
intensity/complexity of a pt care visit
“How hard was it to treat”
What is coding and the international classification of disease (ICD)?
Is the transformation of healthcare diagnosis, procedures,
medical services, and equipment into universal medical
alphanumeric codes.
ICD (International Classification of Disease) and CPT codes to communicate with insurance companies regarding which diagnosis were managed and/or which procedures were completed at a given visit
“What was treated”
What is a “new patient” from documentation standpoint?
Someone who has not received any professional
services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years
professional services = face-to-face
What is an “established patient” from a documentation standpoint?
A patient who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years
professional services = face-to-face
Describe how billing works if it’s being based on time
Total time on the date of the encounter
For coding purposes, time for these services is the total time on the date of the encounter
* Does not include charting completed on other days
“It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff”
Qualifiers for billing based on time
Professional time includes the following activities, when performed
the same day:
* preparing to see the patient (eg, review of tests or outside records)
* obtaining and/or reviewing separately obtained history
* performing a medically appropriate examination and/or evaluation
* counseling and educating the patient/family/caregiver
* ordering medications, tests, or procedures
* referring and communicating with other health care professionals (when not separately reported)
* documenting clinical information in the electronic or other health record
* independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
* care coordination (not separately reporte)
Componens of medical decision making
- How many diagnoses did you address?
- How difficult was it for you to manage the condition(s)
- Did you prescribe or order anything? (such as meds, labs, imaging, or referral)
- This can include giving instructions to take OTC meds in greater doses than the bottle says, like ibuprofen
- How much patient education, shared-decision making, or review of external records did you need to utilize to make a treatment plan?
What is “incident to” billing?
When Medicare is billed “incident to” for non-physician
practitioner (NPP) services, the bill goes out under the physician’s NPI number, even though the midlevel has performed the work
Reimbursement for physician is 100% of the Medicare fee schedule, as opposed to 85% when the service is billed under the midlevel’s own number
APP services may be billed under the physician’s NPI when the service is part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment:
Example: patient seen for HTN by physician and told to come back in 2 weeks for f/u with the PA; the PA sees the patient and makes dose adjustments to the HTN meds - this can be Incident to
The physician does not have to be physically present in the patient’s treatment room while these services are provided, but must provide direct supervision; this means that the physician must be present in the office suite to render assistance if necessary
Other notes for incident to billing
- Many practices will attempt to use Incident to billing to recover the 15% lost for PA/NP billing - but the majority of visits do not meet the essential criteria
- Incident to billing needs special documentation in order to qualify
- There is no requirement to bill incident to
- A PA can bill for any visit of any Medicare patient - new or establishedunder their own NPI number
- Inappropriate use of incident to can subject a practice and the PA and/or physician to allegation of fraud and Medicare abuse prosecution and result in a practice being subjected to fines or payback penalties
What are some measures of productivity?
- Direct measures of reimbursable services
- Indirect measures of reimbursable services
- Measures of indirect clinical services
- Measures of non-clinical services
Examples of direct measures of reimbursable services?
Work RVU (wRVU), RVU, total changes/collections
Examples of indirect measures of reimbursable services?
Number of scheduled patients, number of documentations in the EHR, portion of global payments/RVUs, total practice revenue or RVUs
Examples of measures of indirect clinical services?
Hours worked, hours on-call, time spent providing patient education
Examples of measures of non-clinical services?
Participation in quality improvement or system processes, contribution to research
