Medical Coding and Billing Flashcards
Why to Care
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
Coding
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
Billing
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
General Tips
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
ICD-10: The basics
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
More ICD-10 Basics
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
Where to Find the Dx code
ICD10data.com
Billing - What is CMS
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
How ti bill your visits
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
Hx - subjective
Chief complaint/concern
HPI
Past History (Medial, Family, Surgical, Social)
ROS
Chief complaint/concern
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
HPI
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated s/s
OR status of chronic diseases
History: PFSH
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
ROS
Constitutional
Eyes
Ears, Nose, Throat
Cardiovascular
Respiratory
GI (Gastrointestinal)
GU (Genitourinary)
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/lymphatic
Allergy/Immunologic
PE
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
Medical Decision Making
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
Low MDM (Level 3)
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
Moderate MDM (Level 4)
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
High MDM (Level 5)
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)
Billing for Time Includes (occurring on the same day as visit):
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)
Preventive Visits
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
Telehealth (modifier 95)
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
UC Visits
Can be billed if visit disrupts other scheduled office services
Transitional Care Management
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
Procedures
Can be billed as part of a regular outpatient visit
Can also be billed as separate, procedure only visit
Documentation tools/templates are helpful
After Hours Billing
Outside of regularly scheduled hours
During regularly scheduled evening, weekend, or holiday office hours
Modifiers
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
RVU: Relative Value Unit
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
Medicare Fraud
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
Medicare Abuse
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)
