Medical Coding & Claims Flashcards
ICD-9-CM stands for:
International Classification of Diseases , Ninth Revision, Clinical Modifications.
What is a Claim?
A bill sent to the insurance carrier for payment of professional services.
What is the CMS 1500?
Universal health care insurance form.
3 types of claim submission:
- paper
- electronic
- digital fax
What do the CMS 1500 abbreviations look like?
Only capital letters and no punctuation.
- SSN - social security number
- EIN - employer identification number
- PIN - provider identification number
- NOI - national provider indentifier
What are Dirty Claims?
Claims held or rejected by the insurance carrier because of problems or errors.
Examples of Dirty Claim errors:
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- Incorrect data
- Missing data
- Diagnosis not supporting procedure
- Coding errors
- patient ineligible for services
- Claim to wrong carrier
- Coding/Dates do not match documents
Common fraudulent claim terms :
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- unbundling
- upcoming
- phantom billing
- ping-ponging
- yo-yoing
- gang visits
- split billing
What is “unbundling”?
Using several CPT codes to identify procedures normally covered by a single code
What is “upcoding”?
Deliberately using an incorrect code to be you at a higher rate
What is “Phantom Billing?”
Billing for services for supplies not provided
What is “Ping-Ponging”?
Unnecessary or excessive referrals of patients to other providers and back to primary office
What is “Yo-yoing?”
Scheduling the patient for unnecessary follow-up visits.
What is the meaning of the term, “Gang visits”?
Billing for individual visits when not all the patients present during the visit receives services
What is “Split billing”?
Billing for several visits one services were performed and one visit
What are the 5 levels of CMS appeals?
- Predetermination
- Reconsideration
- Administrative Judge
- Appeals Review Board
- Federal Court Review
Etiology
Cause of a disease.
Appeal
A resort to a higher authority for decision
Super bill
(Also) called and “encounter form”;
A charge form custom designed for the specific medical practice
What are V Codes?
ICD-9 codes identifying health care visits for reasons other than illness
CPT coding was established by the…
AMA in 1966.
What are the 6 CPT code sections?
- Evaluation & Management (E&M)
- Anesthesia
- Surgery
- Radiology
- pathology
- Medicine
Evaluation & management code ranges:
99200-99499
Anesthesia code ranges:
00100-01999
Surgery code ranges:
10000-69999
Radiology code ranges:
70000-79999
Pathology & Lab code ranges:
80000-89999
Medicine code ranges:
90000-99199
What is a “modifier”?
In addition to the initial CPT code that identify certain circumstances
Common Modifiers are:
Identified by the initial CPT code followed by a dash & 2 numbers
What are the 6 common modifiers?
- -24: unrelated E&M service
- -50: bilateral procedures
- -54: surgical care
- -55: postoperative care only
- -56: preoperative care only
- -80: assistant surgeon
Common HCPCS modifiers:
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- -E1: upper left eyelid
- -E2: lower left eyelid
- -E3: upper right eyelid
- -E4: Lower right eyelid
- -FA: left thumb
- -F1 to -F4: left fingers, digits 2 through 5
- -F5: right thumb
- -F6 to -F9: right ringers, digits 2 through 5
- -TA: left great toe
- -T1 to -T4: left toes, digits 2 through 5
- -T5: right great toe
- -T6 to -T9: right toes, digits 2 through 5
HCPCS level 2 provides:
Coding for services not covered in the CPT codes: supplies, pharmaceuticals, ambulance etc.
HCPCS level 2 sections:
- A0000-A0999 =Medical Supplies
- A4000-A8999 =Transportation & ambulance
- A4000-A8999 =Medical supplies
- E01000-E9999 =Durable medical equipment
- J0000-J89999 =Drugs administered other than oral
General steps for ICD coding.
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1) Locate the term in the alphabetic index.
2) Refer to the notes under the main heading.
3) Read the terms in parentheses
4) Note indented subterms
5) proceed to tabular index &a instructional terms.
6) Assign code
