Medical Coding and Billing

Question 1

Why to Care

Answer 1

It’s how you get paid!
No bill = no reimbursement = no salary for you
Coding/Billing shows:
Productivity
Complexity
Important if you have a bonus structure
Important for procedures

Question 2

Coding

Answer 2

Classifies diagnoses and reasons for visits in the US, in all settings

Uses International Classification of Diseases, 10th revision (ICD-10)
Classifies diagnoses and reasons for visits in the US, in all settings
CM = clinical modification, classifies morbidity
Adhering to ICD-10-CM guidelines falls under HIPAA laws
DSM 5 for mental disorders
Still assigned ICD-10 code

Question 3

Billing

Answer 3

Uses Current Procedural Terminology (CPT) Evaluation & Management (E/M) codes
Assigns a code (level of service) that quantifies what you have “done” in an encounter with a patient
Different codes for different care settings
Each code has different level of reimbursement
CMS documentation guidelines

Question 4

General Tips

Answer 4

Your practice type and setting narrows the scope of what you need to know
Some EHRs code and bill for you – some don’t
Be as specific as possible with diagnoses
Certain ICD codes cannot match with the billing code
If it’s not documented, it’s not done
So do a good job!
Can help in multiple ways
Don’t forget about procedures – even little/short ones

Question 5

ICD-10: The basics

Answer 5

Alphabetic Index: alphabetical list of terms and their corresponding code

Tabular List: structured list of codes divided into chapters based on body system or condition

Structure and Format
7 potential characters, can be letters or numbers (A12.45C3)
First 3 characters are the category
Next 4 are subcategories
Final level of subdivision is called the code
Also a placeholder, “X” – allows for further expansion at a later time

Abbreviations:
NEC: not elsewhere classifiable
NOS: not otherwise specified

Question 6

More ICD-10 Basics

Answer 6

Some diseases can fall in more than one category

Pick the underlying condition first, then the manifestation
“And” means “and” or “or”
“with” means “associated with” or “due to”

It’s okay to code a symptom if you don’t yet have the diagnosis

Code the laterality of the condition if possible

Question 7

Where to Find the Dx code

Answer 7

ICD10data.com

Question 8

Billing - What is CMS

Answer 8

Centers for Medicare and Medicaid

They decide all the documentation guidelines
New guidelines for 2021 outpatient billing!

They also set the values for reimbursement

Ensure that the service provided is medically necessary and appropriate – that’s where your documentation comes in

Question 9

How ti bill your visits

Answer 9

Outpatient/ambulatory practice vs inpatient care

Regular office visits, preventive care visits, procedure only visits, transitional care management, after hours, urgent care/same day visits

There are 2 components to billing
Medical decision making (MDM)
Time

History & Physical are no longer counted towards level of service but should be medically appropriate

Question 10

Hx - subjective

Answer 10

Chief complaint/concern
HPI
Past History (Medial, Family, Surgical, Social)
ROS

Question 11

Chief complaint/concern

Answer 11

Resean for the Visit

should accurately reflect the purpose of the visit

establish and suppots medical necessity

use quotations if in the Pt’s own words

DO NOT WRITE NO COMPLAINTS

Question 12

HPI

Answer 12

Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated s/s
OR status of chronic diseases

Question 13

History: PFSH

Answer 13

Past history: patient’s past experiences with illnesses, operations, injuries and treatments

Family history: a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient is at risk

Social history: an age-appropriate review of past and current activities

Note: For subsequent hospital and nursing facility E&M services, only an interval history is necessary. It is unnecessary to record information about the PFSH

TRy to include the pertinent Hx to the Problem and complete at least 2 of these areas

Question 14

ROS

Answer 14

Constitutional
Eyes
Ears, Nose, Throat
Cardiovascular
Respiratory
GI (Gastrointestinal)
GU (Genitourinary)
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/lymphatic
Allergy/Immunologic

Question 15

PE

Answer 15

Can be either body areas or organ system

Body Areas:
Head, including face
Chest, including breast and axillae
Abdomen
Neck
Back, including spine
Genitalia, groin, buttocks
Each extremity

Organ System:
Constitutional
Eyes
Ears, nose, mouth, throat
Respiratory
GI
GU
Cardiovascular
MSK
Skin
Neuro
Psych
Hem/lymph/imm

Question 16

Medical Decision Making

Answer 16

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and analyzed

Risk of Complications and/or morbidity or mortality of patient management

Question 17

Low MDM (Level 3)

Answer 17

2 or more self-limited or minor problems
OR
1 stable chronic illness
OR
1 acute, uncomplicated illness or injury

Low risk of morbidity from additional diagnostic testing or treatment

Question 18

Moderate MDM (Level 4)

Answer 18

1 or more chronic illnesses with exacerbation,
progression, or side effects of treatment;
OR
2 or more stable chronic illnesses;
OR
1 undiagnosed new problem with uncertain prognosis;
OR
1 acute illness with systemic symptoms;
OR
1 acute complicated injury

Moderate risk of morbidity from additional diagnostic testing or treatment

Question 19

High MDM (Level 5)

Answer 19

1 or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment;
OR
1 acute or chronic illness or injury that poses a threat to life or bodily function

High risk of morbidity from additional diagnostic testing or treatment

(Examples: drug therapy requiring monitoring for toxicity, decisions about hospitalization)

Question 20

Billing for Time Includes (occurring on the same day as visit):

Answer 20

Preparing to see the patient (review of tests)

Obtaining and/or reviewing separately obtained history

Performing a medically appropriate exam and/or evaluation

Counseling and educating the patient/family/caregiver
Ordering medications, tests, procedures

Referring and communicating with other HCP (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 reported)

Question 21

Preventive Visits

Answer 21

Codes are by age group

Can also bill for early and periodic screening and diagnostic treatment (EPSDT) for kids

Behavioral and developmental screening questionnaires

Separate screening codes for breast/pelvic cancer

Preventive counseling
Can be billed separately, not with a preventive visit
Medicine counseling or behavior change interventions

Medicare Wellness
Initial vs annual initial vs subsequent

Question 22

Telehealth (modifier 95)

Answer 22

If audio only, use special telehealth codes based on time
If audio and video, bill for time, or use MDM and regular E&M codes

Question 23

UC Visits

Answer 23

Can be billed if visit disrupts other scheduled office services

Question 24

Transitional Care Management

Answer 24

Starts on day of discharge
Specifics:
Must have phone call documented within 2 days of discharge
Not for elective admissions or ED visits
Can be within 7 days or 14 days of discharge

Question 25

Procedures

Answer 25

Can be billed as part of a regular outpatient visit

Can also be billed as separate, procedure only visit

Documentation tools/templates are helpful

Question 26

After Hours Billing

Answer 26

Outside of regularly scheduled hours

During regularly scheduled evening, weekend, or holiday office hours

Question 27

Modifiers

Answer 27

Must be used for significant, separately identifiable evaluation and management service by the same provider on the same day of the procedure or other service

Also for distinct service – like for 2 injections, 2 excisions

Question 28

RVU: Relative Value Unit

Answer 28

A way to quantify your work for budgeting, determining productivity, allocating expenses

Developed in the 80s to try and level the playing field among specialties

3 types: physician work, practice expense,malpractice liability

Each billing code equates to “work RVUs”
Level 4 outpatient established patient = 1.5 RVU*

You may have a “target” for the year

How it translates to money depends on lots of factors
Type of practice, physical location, etc

Question 29

Medicare Fraud

Answer 29

What is it?

Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of facts to obtain a Federal health care payment

Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs

Making prohibited referrals for certain designated health services

Examples
Billing for services not furnished or supplies not provided, including billing Medicare for appointments patients fail to keep
Altering claim forms, medical records, or receipts to receive a higher payment

Question 30

Medicare Abuse

Answer 30

Practices that result in unnecessary costs to Medicare

Includes services that aren’t medically necessary, don’t meet standards, or aren’t fairly priced

Both fraud and abuse can expose providers to liability (criminal and civil)