Chapter 17 Notes: Medical Coding

What is the procedure for completing a Medicare CMS-1500 (02-12) Claim Form?

1) Gather all of your necessary supplies or equipment and make sure that it is in good working order before beginning any procedure. For this particular procedure, you will need to have patient information, patient account or ledger card, copy of patient's insurance card, insurance claim form, computer, and printer. 2) The "Carrier" section of the CMS-1500 (02-12) is in the upper portion of the form. Use the blank space at the top right of the section marked "Carrier" to enter the name and address of the payer to whom this claim is being sent. The payer is the carrier, health plan, third-party administrator, or other payer who will handle the claim. The format for this information should be as follows: Key on line 4: first line--Name Key on line 5: second line--First line of address Key on line 6: third line--Second line of address Key on line 7: fourth line--city, state (2 letters) and zip code Do not use commas, periods, or other punctuation in the address. When entering a nine-digit ZIP code, you may include the hyphen. When printing page numbers on multiple-page claims (generally done by clearinghouses when converting the electronic claim form to the CMS 1500 claim form), print the page numbers in the "Carrier" block on line 8 beginning at column 32. Page numbers are to be printed as "Page XX of YY". The claims processor must know who the claim is from. 3) The "Patient and Insured Information" section asks for specific information related to the patient and his or her health insurance plan. The following information is required for this section. Complete each block as directed. These blocks must be accurately completed or the claim may be denied. Block 1: Indicate the type of health insurance coverage applicable to this claim by placing an "X" in the Medicare box. Only one box can be marked. Block 1a: Enter insured's ID number as shown on insured's ID card for the payer to whom the claim is being submitted. The insured's ID number is the identification number of the person who holds the policy. This information identifies the patient to the payer. (For Medicare beneficiaries, this appears as a nine-digit number followed by a letter). Block 2: Enter the patient's full last name, first name, and middle initial in this block Block 3: Enter the patient's eight-digit birth date (MMDDYYYY). Enter an "X" in the correct box to indicate sex of the patient. Only one box can be marked. If gender is unknown, leave blank. Block 4: Enter the insured's full last name, first name, and middle initial Block 5: Enter the patient's mailing address and telephone number Block 6: Enter an "X" in the correct box to indicate the patient's relationship to insured when block 4 has been completed. Only one box can be marked. Block 7: Enter the insured's address and telephone number. If block 4 has been completed, then this field should also be completed. Block 8: This is reserved for NUCC use. Leave blank. Block 9: If block 11d is marked "yes" (to indicate that the patient carries a secondary insurance plan), complete fields 9 and 9a through 9d with the patient's secondary insurance information; otherwise, leave blank. When additional group health coverage exists, enter other insured's full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in block 2. Block 9a: Enter the policy or group number of the other insured. Do not use a hyphen or space as a separator within the policy or group number. Block 9b: This is reserved for NUCC use. Leave blank. Block 9c: This is reserved for NUCC use. Leave blank. Block 9d: Enter the other insured's insurance plan or program name Blocks 10a to 10c: When appropriate, enter an "X" in the correct box to indicate whether one or more of the services described in block 24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked. The two-letter state abbreviation must be shown if "YES" is marked in 10b. Any item marked "YES" indicates there may be other applicable insurance coverage that would be primary. Block 10d: Refer to the most current instructions from the applicable public or private payer regarding the use of this field. Block 11: Enter the insured's policy or group number as it appears on the insured's health care ID card. If block 4 has been completed, then this field should also be completed. Block 11a: Enter the eight-digit date of birth (MMDDYYYY) of the insured and an "X" to indicate the sex of the insured. Only one box can be marked. If gender is unknown, leave blank. Block 11b: This is the other claim ID designated by NUCC. Leave blank. Block 11c: Enter the insurance plan or program name of the insured. (Some payers require an ID number of the primary insurer rather than the name in this field). Block 11d: When appropriate, enter an "X" in the correct box. If marked "YES", complete blocks 9, 9a, and 9d. Only one box can be marked. Block 12: Enter "Signature on File", "SOF", or legal signature. With a legal signature, enter the date signed in the proper eight-digit format. If there is no signature on file, leave blank or enter "No Signature on File". The patient's or authorized person's signature indicates there is an authorization on file for the release of any medical or other information necessary to process or adjudicate the claim. Block 13: Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File". The insured's or authorized person's signature indicates that there is a signature on file authorizing payment of medical benefits. 3) The "Physician or Supplier Information" section must be accurately completed or the claim may be denied. This is the bottom section of the form under the bolded red line. Block 14: Enter the eight-digit date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Leave blank if unknown. Block 15: Enter the first date the patient had the same or a similar illness. Enter the date in the eight-digit format. Previous pregnancies are not a similar illness. Leave blank if unknown. Block 16: If the patient is employed and is unable to work in his or her current occupation, an eight-digit date must be shown for the "from-to" dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage. Block 17: Enter the name (first name, middle initial, last name) and credentials of the professional who referred, ordered, or supervised the services or supplies on the claim. Do not use periods or commas within the name. A hyphen can be used for hyphenated names. Block 17a: The two-digit qualifier code is entered in the small box. Qualifiers are as follows: 0B: State license number 1B: Blue Shield provider number 1C: Medicare provider number 1D: Medicaid provider number 1G: Provider UPIN number 1H: CHAMPUS identification number E1: Employer's identification number G2: Provider commercial number LU: Location number N5: Provider plan network identification number SY: Social security number (the Social security number may not be used for Medicare) X5: State industrial accident provider number ZZ: Provider taxonomy The other ID number of the referring, ordering, or supervising provider is reported in the larger space. Block 17b: Enter the NPI number of the referring, ordering, or supervising provider. The NPI number refers to the HIPAA National Provider Identifier number. Block 18: Enter the inpatient eight-digit hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. Block 19: Refer to the most current instruction from the applicable public or private payer regarding the use of this field. Block 20: Complete this field when billing for purchased services. Enter an "X" in "YES" if the reported services was performed by an entity other than the billing provider. If "YES", enter the purchased price under charges. A "YES" indicates that an entity other than the entity billing for the service performed the purchased services. A "NO" indicates that no purchased services are included on the claim. Only one box can be marked. Block 21: Enter the patient's diagnosis/condition. You may list up to 12 ICD diagnosis codes. Use the highest level of specificity. Do not provide a narrative description in this field. Block 22: Enter the original reference number for resubmitted claims. Refer to the most current instruction from the applicable public or private payer regarding the use of this field. If it is not a resubmitted claim, leave this block blank. Block 23: Enter any of the following: prior authorization number, referral number, mammography precertification number, or CLIA number, as assigned by the payer for the current service. Do not enter hyphens or spaces within the number. Block 24A: Enter dates of service, from and to. If there is one date of service only (such as a clinic visit), enter that date within the "From" blank as well as the "To" blank. Both the "From" and "To" areas must be completed in order to comply with proper completion rules. Block 24B: Enter the appropriate two-digit code from the "Place of Service Code" list for each item used or service performed. "Place of Service Codes" are available at www.cms.hhs.gov/PlaceofServiceCodes/Downloads/POSDataBase.pdf. Block 24C: This block was originally titled "Type of Service" and is no longer used. Check with the trading partner to determine if an emergency indicator is necessary. If required, enter "Y" for "YES" or leave blank if "NO". The definition of emergency would be defined by either federal or state regulations or programs or payer contracts, or as defined in the electronic 837 Professional 4010A1 implementation guide. Block 24D: Enter the CPT or HCPCS codes and modifiers, if applicable, from the appropriate code set in effect on the date of service Block 24E: Enter the diagnosis code reference number as shown in block 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference number for each service should be listed first; other applicable services should follow. Enter the numbers left justified in the field. Do not use commas between the numbers. Block 24F: Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number. Block 24G: Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers right justified in the field. Block 24H: For Early and Periodic Screening, Diagnosis and Treatment-related services, enter the response as follows: If there is no requirement to report a reason code for EPDST, enter "Y" for "YES" if the service applies to EPDST. If "NO", leave blank. Block 24I: Enter the qualifier identifying if the number is a non-NPI. The other ID# of the rendering provider is reported in block 24J. The NUCC defines the same qualifiers as listed for Block 17a. Block 24J: Enter the non-NPI ID number in the top portion of the field if applicable. Enter the NPI number of the service provider in the lower area of the field. Block 25: Enter the provider of service or supplier federal tax ID or Social Security number. Enter an "X" in the appropriate box to indicate which number is being reported. Only one box can be marked. Do not enter hyphens with numbers. Enter numbers left justified in the field. Block 26: Enter the patient's account number assigned by the provider of the service's or supplier's accounting system. Do not enter hyphens with numbers. Enter numbers left justified in the field. Block 27: Enter an "X" in the correct box. Only one box can be marked. Block 28: Enter total charges for the services (total of all charges in block 24F). Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number. Block 29: Enter the total amount the patient or other payers paid on the covered services only (such as a copayment given on the date of service). Enter number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number. Block 30: This is reserved for NUCC use. Leave blank. Block 31: Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative, "Signature on File", or "SOF". Enter the eight-digit date the form was signed. The signature refers to the authorized or accountable person and the degree, credentials, or title. Block 32: Enter the name, address, city, state, and ZIP code of the location where the services were rendered. Providers of service must identify the supplier's name, address, ZIP code, and NPI number when billing for purchased diagnostic tests. When more than one supplier is used, a separate claim form should be used to bill for each supplier. Follow the previously outlined format for entering address information. Block 32a: Enter the NPI number of the service facility location Block 32b: Enter the two-digit qualifier identifying the non-NPI number followed by the ID number. Use the same qualifiers as listed in block 17a. Block 33: Enter the provider's or supplier's billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Follow the previously outlined format for entering address information. Block 33a: Enter the NPI number of the billing provider Block 33b: Enter the two-digit qualifier identifying the non-NPI number followed by the ID number as listed in Block 17a.

What are the guidelines for using the computer to complete medical insurance claim forms?

1) The CMS-1500 (02-12) claim form is designed to accommodate optical scanning of paper claims. A scanner is used to convert printed characters into text that can be viewed by the optical character reader (OCR). This technology greatly increases claims processing productivity, with some claims being paid within 7 to 10 days. 2) Practice management software may require data to be entered using uppercase and lowercase letters and other data to be entered without regard to OCR guidelines. The computer program converts the data to the OCR format when the claim is printed or electronically transmitted to the carrier. Always use the software program's test pattern program to verify alignment of forms. Be sure the Xs are completely within the designated boxes. You may need to check this alignment each time a new batch of claims is inserted into the printer. 3) While completing the claim form on the computer, remember to not to interchange to zero (0) with the alpha character o. A substitute space should be used in place of the following keystrokes: 3a) Dollar sign or decimal in all charges or totals 3b) Decimal point in a diagnosis code number 3c) Dash in front of a procedure code modifier 3d) Parentheses surrounding the area code in a telephone number 3e) Hyphens in Social Security numbers 4) When a fee is expressed in whole dollars, always enter two zeros in the cent column. Birth dates should be entered using eight digits (MMDDYYYY). Two-digit code numbers are used for months (January 01, February 02, and so on). If the day of the month number is less than 10, add a zero before the day (i.e. 03 for the third day of the month). 5) The Administrative Simplification Compliance Act (ASCA), which went into effect July 5, 2005, specifies that no payment may be made under Part A or Part B of the Medicare program for any expenses incurred for items or servic3es for which a claim is submitted in a nonelectronic form. Simply stated, paper claims submitted to Medicare will not be paid. Some exceptions to this rule can be found in the Medlearn Matters article MM3440 available at the CMS website (www.cms.gov) by searching for "Medlearn Matters"

What are the basic components of a superbill/encounter form?

1) The date of service 2) The visit or consultation code 3) Diagnoses for this visit 4) Procedures done and laboratory tests ordered 5) If necessary, the date the patient is to return

What are the five coding systems that are used within the United States?

1) Current Procedural Terminology: The Current Procedural Terminology (CPT) system was developed by the American Medical Association (AMA) to convert commonly accepted descriptions of medical procedures into five-digit numeric code with two-digit numeric modifiers when required. CPT guidelines instruct the coder to add more codes. Symbols are used to visually represent instructions. Modifiers are important because they can impact the charge that is associated with the code. This system is used to code medical procedures such as clinic visits, x-rays, laboratory tests, and professional fees for providers who have performed surgery. Each CPT code has a fee schedule which is used to request reimbursement. The American Medical Association publishes the CPT manual annually. The first edition was published in 1966. The six sections of the CPT coding system include: -Evaluation and Management: 99201 to 99499 -Anesthesiology: 00100 to 01999, 99100 to 99140 -Surgery: 10021 to 69990 -Radiology (Including Nuclear Medicine and Diagnostic Ultrasound): 70010 to 79999 -Pathology and Laboratory: 80047 to 89398 -Medicine (Except Anesthesiology): 90281 to 99199, 99500 to 99607 To determine the CPT code, turn to the Category I section of the CPT code book and select one of the sections that constitutes the general classification of the procedure being coded (i.e. Surgery, Radiology). Then select the name of the procedure or service that accurately identifies what you are looking for. Read all of the codes that are indented below the main code. Indented codes provide greater specificity. Do not select a CPT code that only approximately defines the service performed. If you cannot find a name that exactly defines the service provided, report the service using the appropriate unlisted code. Unlisted codes are found at the end of each subsection in the CPT code book, and are also listed within the gudelines that precede each of the main sections. Most unlisted CPT codes end in 99. When using an unlisted code, a special report must be submitted with an insurance claim form to avoid denial or rejection. A special report will contain the nature, extent, and need of the procedure performed. An example of a special report would be the provider's operative note. Unlisted codes should not be used if a Category III code is available. This section is found in the back of the code book and gives temporary codes for emerging technologies, services, and procedures. 1a) Evaluation and Management: The Evaluation and Management section takes every possible combination of visits into consideration and assigns each its own number. For instance, Mary O'Keefe, a new patient, is seen for a period of 45 minutes during which the provider takes a detailed history, examines the patient, and makes a medical decision of moderate complexity. The CPT code for this visit (99204) is found by looking under Office and Other Outpatient Services, New Patient. In another instance, Abigail Johnson, an established patient, is seen in the hospital for several days. These visits (99231, 99232, or 99233) would be found under Hospital Services, Subsequent Hospital Care. Codes for any type of evaluation and management are found in this section. In many clinics, the provider determines the level or charge for visits; however, the medical assistant must be familiar with all of the codes to make certain that billings are correct and that codes match the provider's documentation. 1b) Anesthesiology: The anesthesiology section includes all codes for anesthesia required for any procedure (with the exception of local anesthesia). The codes listed begin with the head and continue down the body to the legs and feet, concluding with anesthesia for radiologic procedures. If you want to find the correct code for anesthesia during a total hip replacement (arthroplasty), you will find Anesthesia in the index, look for the subterm "hip", and refer to the range of codes listed: 01200 to 01215. When you refer back to the Anesthesia section, you find: 01200: Anesthesia for all closed procedures involving hip joint 01202: Anesthesia for arthroscopic procedures of hip joint 01210: Anesthesia for open procedures involving hip joint; not otherwise specified 01212: Hip disarticulation 01214: Total hip arthroplasty 01215: Revision of total hip arthroplasty As you read through the codes, you see that the correct code is 01214. Please note that this CPT code represents only the services provided by the anesthesiologist, not the surgical procedure itself. 1c) Surgery: The section on surgery divides the codes according to body system. It begins with the integumentary system, and continues through subsequent systems ending with the ocular and auditory systems. The codes are very specific in this section, and care must be taken at all times to ensure the selection of the correct code. For example, a simple laceration repair of the neck is found as: 12001: Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet): 2.5cm or less 12002: 2.6cm to 7.5cm 12004: 7.6cm to 12.5cm 12005: 12.6cm to 20.0cm 12006: 20.1cm to 30.0cm 12007: over 30.0cm Thus, the exact length of the laceration and complexity of the repair can be found and coded correctly on the claim form. However, the aforementioned code description illustrates three important points. First, the code selected must represent the site of the laceration. Second, the code must represent the correct level of complexity for the repair. Third, the code must specify the correct length of the repair. If the medical assistant selects a code that is off by even one digit, there would be a delay in reimbursement. The insurance claim would have to be corrected and resubmitted to the insurance company 1d) Radiology: Coding in the Radiology section covers each procedure done and each specific alteration to the procedure. For instance: 75889: Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision, and interpretation 75891: Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision, and interpretation Radiologic procedures are not often done in the provider's clinic, although they may be in larger urgent care centers. Occasionally, chest x-rays are done or, in an orthopedic specialty, many skeletal x-rays may be done. More often, though, radiologic studies are ordered by the provider through a local facility that bills the insurance company directly, using the diagnosis the provider has provided. 1e) Pathology and Laboratory: The Pathology and Laboratory section includes every test and combination of laboratory tests that can be ordered, as well as a section on surgical pathologic evaluation. This latter section includes specimens sent for examination, such as Pap smears, analysis of biopsy tissue from surgical sites, and tissue typing. Following is an example of a laboratory procedure code for hepatitis B that illustrates the complete selection of tests that may be ordered: 87340: Hepatitis B surface antigen (HBsAg) 86704: Hepatitis B core antibody (HBcAb); total 86705: IgM antibody 86706: Hepatitis B surface antibody (HBsAb) 87350: Hepatitis Be antigen (HBeAg) 86707: Hepatitis Be antibody (HBeAb) Once again, it is very important that the code for the exact service be selected. The medical assistant should be aware of laboratory codes because when a laboratory test is ordered, the laboratory may call to clarify the order. If the coding is correct, the laboratory should have no questions. For surgical pathologic evaluation, the codes are different. The level of examination (gross and microscopic) for the item determines the code. The provider usually determines these levels or the charge for these services based on the type of tissue obtained, and the reason for the service. 1f) Medicine: The section of the CPT entitled Medicine includes codes for immunizations, injections, dialysis, allergen immunotherapy, and chemotherapy, as well as ophthalmologic, cardiovascular, pulmonary, and neurologic procedures, to name a few. Some of the procedures are considered invasive, although others are not. As in the earlier sections, there is a comprehensive breakdown of each procedure. For example: Cardiography 93000: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005: Tracing only, without interpretation and report 93010: Interpretation and report only Chemotherapy Administration 96409: Intravenous, push technique, single or initial substance/drug 96413: Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug +96415: Each additional hour (list separately in addition to code for primary procedure) 96416: Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump The plus symbol (+) before the CPT code indicates that the procedure is an add-on to a previously described procedure. For example, 96413 would be used to describe the service and the time administered up to 1 hour. Use +96415 for each additional 1 hour of administration 1g) Index: The final portion of the CPT code book is a comprehensive index listing every procedure alphabetically. The proper use of the CPT code book involves looking for the procedure in the index by its main term and then checking the number given to determine the precise code. Category I codes found in the CPT have five numeric digits. This is the level of codes that are used the most to describe procedures and other professional services. Category II and Category III codes are made of four numeric digits and are followed by an alpha character. These codes would be used when no specific Category I code is available. Note that there are no decimal points in any of the codes. Each five-digit code stands for a specific procedure not duplicated elsewhere. 1f) Modifiers: Occasionally, a service or procedure needs to be modified or altered in a certain way. In that case, there are two-digit numeric modifiers that can be applied to the five-digit CPT code. These modifiers can indicate unusual procedural services (-22), bilateral procedures (-50), multiple procedures (-51), two surgeons (-62), surgical team (-66), or repeat procedure by the same provider (-76). The modifiers are listed in the inside front cover of each of the CPT code books as well as Appendix A of the book to alert the coder to use modifiers available for that code. In addition, there are other modifiers of an alpha or alphanumeric nature that are also listed in the front of the CPT code book, and are commonly used with CPT codes. Review the following examples that illustrate the use of modifiers: Surgical arthroscopy of the right shoulder with rotator cuff repair: 29827-RT Bilateral otoplasty, protruding ear, with or without size reduction: 69300-50 Blepharoplasty of the lower right eyelid; extensive herniated fat pad: 15821-E4 2) Healthcare Common Procedure Coding System (HCPCS): HCPCS was developed by Medicare as a supplement to the CPT system for procedures not defined with sufficient specificity. This system uses a five-digit alphanumeric code (one letter followed by four numbers) with an additional two-digit alphanumeric modifier if required. This code set includes supplies, durable medical equipment, and other medical services. HCPCS codes can be located by finding the main term or subterm in the alphabetical index. The name of the item, the type of service, the anatomical site, or abbreviation can also be used to look up the code. Modifiers are used to provide additional information about a service, item, or procedure. The code consists of a letter followed by four numbers. The Table of Drugs provides codes for the generic and brand names of drugs. Verify the code in the tabular list. You can also locate the code range and search the code that is needed. 3) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM): The ICD-9-CM system was developed by the World Health Organization in 1979 to classify all known diseases and disorders to assist in maintaining statistical records of morbidity (sickness) and mortality (death). Until October 2015, this system was used for both diagnostic coding (for all health care settings) and procedure coding (for inpatient services only). The ICD-9-CM code consists of a three-digit code (called a category) with one or two numeric digits following a decimal point. The ICD-9-CM coding manual was revised periodically and was updated yearly. 4) International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): ICD-10-CM was developed by the World Health Organization in 1992. The official version is called the International Classification of Diseases (ICD-10). The WHO is responsible for revisions every 10 years. The United States implemented ICD-10-CM in October 2015 to replace ICD-9-CM. The National Center for Health Statistics is responsible for maintaining the diagnostic codes. The Centers for Medicare and Medicaid is responsible for maintaining the procedure codes for ICD-10-CM. Revisions in ICD-10-CM from ICD-9-CM include the use of six and seven characters. In addition, the codes have laterality and greater specificity. There were thousands of codes added from version ICD-9-CM. There are 1,943 new codes; 351 revised codes; and 313 deleted codes for the 2017 ICD-10-CM as published by CMS. Revisions to the ICD-10-CM include codes that specify laterality such as the right arm or the left arm. Chapter 19, "Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)," has been expanded to include additional codes. There has been an increase of combination codes in which the code defines both a diagnoses and symptoms, reducing the need to record additional codes. The use of a sixth and seventh character contributes to greater specificity and validity for diseases, injuries, conditions, procedures, and so on. The official coding guidelines appear at the front of the coding manual as well as at the beginning of each chapter. In addition, there are two types of Excludes notes. Tools used to convert ICD-9 to ICD-10 codes are called guide maps. These maps are published on the CMS website. It is important for many reasons to know how to convert the codes. One reason is to research and compare statistical data from the codes. Another reason is for claims resolution and processing of older claims. Because there are more codes in ICD-10, many of the codes do not directly convert from ICD-9. The intent of the International Classification Disease system is to record morbidity and mortality. Morbidity is defined as conditions, injuries, or diseases that are not considered normal health. The physician documents changes in morbidity in the health record for each patient encounter. HIPAA mandates the recording of the various ICD-10-CM classifications as a standard in the electronic health care transactions for reporting purposes. Data generated from the reporting process are used to track diseases, injuries, and impairments in the population. Mortality means death. There are 21 chapters in ICD-10-CM. ICD-10-CM uses conventions, instructional notes, punctuation marks, and abbreviations to help the coder select the appropriate code. Selecting the correct code is necessary in order for the code to be complete, correct, and accurate. The coding guidelines define the use of each convention. Examples include code also, code first, excludes 1, excludes 2, in disease classified elsewhere, includes, not elsewhere classified (NEC), not otherwise specified (NOS), see, see also, and use additional codes. Examples of symbols include brackets, colon, parentheses, and a-point dash. The coding guidelines are located at the beginning of the ICD-10-CM book as well as at the beginning of each chapter. The guidelines reference the appendices and sections. The coder must be familiar with these coding guidelines. How to Find an ICD-10-CM code: Using the main term, subterm, or synonym, search in the alphabetic index at the beginning of the code book. Find the code in the tabular section of the code book making sure to follow any instructions or directions described by symbols or coding guidelines. 5) ICD-10-PCS: ICD-10-PCS codes have seven alphanumeric characters. Each character has a specific meaning and/or value. The 16 sections of ICD-10-PCS include Medical and Surgical, Obstetrics, Placement, Administration, Measurement and Monitoring, Extracorporeal Therapies, Osteopathic, Other Procedures, Chiropractic, Imaging, Nuclear Medicine, Radiation Oncology, Physical Rehabilitation and Diagnostic Audiology, Mental Health, and Substance Abuse Treatment. These sections each have a number, which represents the first character of the PCS code. The remaining characters represent the following: 5a) The second place character represents the body system. There are 31 body systems that range from the central nervous system to the anatomical regions, lower extremities. 5b) The third place character represents the root operations. There are 31 root operations for the Medical Surgical section. Additional root operations are assigned for the other sections. 5c) The fourth place character represents the specific part of the body system on which the procedure is performed. 5d) The fifth place character for the Medical and Surgical codes is the approach used in the procedure. For example, an open approach means a cutting through of the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. 5e) The sixth character indicates a device and specifies the device that remains after the procedure is completed. An example of one of the four types of devices is a cardiac pacemaker. 5f) The seventh character in the Medical Surgical section is a qualifier that has a unique value for an individual procedure. How to Use the ICD-10-PCS code book: Use the index at the beginning of the book. Using terms or general types of procedures, locate the correct PCS table which identifies the seven characters of the PCS code. Each code has a row that identifies the details of the procedure.

What is coding? What is the purpose of coding?

1) Coding is the application of alphanumeric characters selected from standard terms used to describe a condition, disease, or service in health care. Medical codes come from complex nomenclature systems comprised of a detailed organization of information based on body systems. Health care staff need to use their knowledge about medical terminology, anatomy and physiology, pathophysiology, and pharmacology when performing medical coding tasks. 2a) Coding is done in order to process demographic, insurance, and coded medical diagnoses and procedures in order to request reimbursement for services and supplies used in health care. The coded information is analyzed to improve quality of medical care through the development and use of quality indicators, which provides information for public health and safety. This includes processes to decrease outbreaks of contagious diseases. 2b) Another use of coded information includes the identification of risk factors used to develop standards for treatment and prevention of diseases. In addition, the purpose of coding includes the improvement and development of new treatments, supplies, and medications and technology. Payers use coded data to determine that the appropriate level of services are provided for specific conditions in order to make payment determinations. Health care costs are controlled through the combination of medical codes and documentation guidelines which are necessary to justify medical necessity for the services provided to the patient. 2c) Medical necessity is required to ensure that services or procedures for a specific diagnosis or specified frequency are in order for consideration for reimbursement by the patient's insurance covered benefits. This is directed by 42 CFR 405.500 1995. The provider of services is responsible for documenting that the service is necessary and is covered by the insurance plan. 2d) The HIPAA Administrative Simplification Act provision of 1996 ruled that electronic transmission of health care data complies with legal standards. It mandated the use of standardized code sets for submission of health care data.

What is the procedure for applying third-party guidelines?

1) Gather all of your necessary equipment or supplies and make sure that it is in good working order before beginning any procedure. For this particular procedure, you will need to have a patient chart and CMS-1500 (02-12) claim form. 2) When the patient signs in at the reception desk, check his or her chart to ascertain whether an authorization to release medical information form has been signed and is currently valid. PHI cannot be released without written authorization from the patient. 3) If there is no record of signature on file, have the patient sign block 12 of the CMS-1500 (02-12) claim form or the offices' customized authorization to release medical information form. PHI cannot be released without written authorization from the patient.

What is the procedure for coding with ICD-10-CM?

1) Gather all of your necessary equipment or supplies and make sure that they are in good working order before you begin any procedure. For this particular procedure, you will need to have an ICD-10-CM code book for the current year, a copy of the encounter form and access to the patient's chart, a pencil, and paper. Case Scenario: Mary O'Keefe, a new patient, presents at the clinic today reporting painful, frequent urination. She is seen for 10 minutes, during which time the provider takes a focused history and completes a problem-focused examination. A routine urinalysis, nonautomated and without microscopy, is performed and a straightforward medical decision is made. Mary's preliminary diagnosis is painful urination. The urinalysis confirms a urinary tract infection. The provider writes her a prescription for an antibiotic and asks her to make an appointment in 10 days for another urinalysis to confirm the infection has cleared. 2) Using the ICD-10-CM code book, the alphanumeric Index to Diseases, look up the main symptom or condition that brought the patient to the facility or the specific diagnosis confirmed by test results. In this case, the laboratory results confirmed a urinary tract infection. Code N39.0. This uses the alphanumeric index to choose urinary tract infection. 3) Using the tabular section, look up code N39.0. Read through al of the N39 listings to determine the appropriate code having the highest level of specificity. This establishes the most appropriate code: urinary tract infection, site not specified

What is the procedure for coding with Current Procedural Terminology (CPT)?

1) Gather all of your necessary supplies or equipment and make sure that it is in good working order before beginning any procedure. For this particular procedure, you will need to have a CPT code book for the current year, a copy of the encounter form and access to the patient's chart, a pencil, and paper. Case Scenario: Jane Smith, a new patient, is seen for 10 minutes, during which the provider takes a focused history and completes a problem-focused examination. A routine analysis, non-automated and without microscopy, is performed and a straightforward medical decision is made. Mary's preliminary diagnosis is painful urination. The urinalysis confirms a urinary tract infection. The provider writes her a prescription for an antibiotic and asks her to make an appointment in 10 days for another urinalysis to confirm the infection has cleared 2) Using the CPT code book, look in the Evaluation and Management section, Office or Other Outpatient Services, New Patient. Carefully read through the options until the code matching the described scenario has been found. This section of the CPT code book provides codes used to report evaluation and management services provided in the provider's clinic or in an outpatient or other ambulatory care facility. You should have selected 99201 3) Continue with the CPT code book, turn to the Index again, and look up Urinalysis, Routine. The code given is 81002. This provides you with a code to investigate and determine its appropriateness. 4) Continue in the CPT code book and turn to the Pathology and Laboratory section. Follow the codes until you locate code 81002. When verifying the code, 81002 is an indented code and specifically states that the test is nonautomated, without microscopy. Be sure the description provided there matches what the provider has documented in the patient's chart. This helps verify that the code is correct and matches documentation

What are the legal issues associated with medical coding? What are the ethical issues associated with medical coding?

1) Issues of insurance fraud and abuse must be understood before accurate codes can be assigned to medical procedures, services, and diagnosis of disease. 2) The Omnibus Budget Reconciliation Acts of 1986 and 1987 state that providers can be assessed civil penalties if they "know of or should know that claims filed with Medicare or Medicaid on their behalf are not true and accurate representations of the items or services actually provided." This means that providers can be held responsible not only for negligent mistakes they make but also for mistakes made on their behalf by their medical assistants or administrative staff who complete insurance claim forms. The penalties assessed are usually in the form of a monetary fine and may also involve exclusion from Medicare and Medicaid programs for a specified period of time. 3) Compliance programs based on guidelines issued by the Office of the U.S. Inspector General are not mandatory; however, they help prevent violations that can be financially costly and that may carry criminal penalties for the provider and clinic personnel. Participation in a compliance program demonstrates that the practice is making a good-faith effort to submit claims appropriately and is considered equivalent to practicing preventative medicine. The following are basic elements of a compliance program: a) Have a designated compliance officer b) Develop and use written standards and procedures for coding c) Develop a plan for communicating coding standards and procedures d) Train personnel in standards and procedures e) Conduct periodic audits f) Respond to detected violations and notify appropriate government agencies g) Make personnel aware that they have an ethical duty to report suspected or observed fraudulent or erroneous coding practices so that they can be corrected. Publicize and enforce disciplinary standards on coding violations

What are the guidelines for following up on medical insurance claims?

1) Occasionally, claims are denied because the claim form was incomplete. However, if there is no payment from the carrier and no other notification after a period of 1 to 6 weeks, it is necessary to follow up on the claim. The claim register will enable the clinic to keep track of the progress of claims. 2) To follow up, a toll-free number is provided by most carriers. The necessary information to have on hand before making the call includes a copy of the claim form and the patient's name and insurance identification number. The carrier should be able to give the status of the claim. If payment is delayed, the carrier should be able to give the date when it can be expected. It is possible that payment was sent to the insured person, in which case a statement should be sent to the patient. If there is a problem with the claim, the medical assistant may need to investigate the cause of the error and submit a revised claim.

What is the insurance carrier's role?

1) The claims processor at the insurance carrier checks the codes to confirm that the procedures and accompanying diagnoses link properly with one another. The processor then analyzes the information to confirm that: a) The coverage was in force at the time of treatment b) The provider has contracted with the insurance carrier c) There are no exclusions or restrictions on the policy for payment of the diagnosis, service, or procedure d) There are no preexisting condition restrictions e) The diagnosis and procedures done are reasonable and meet medical necessity The processor also checks to make sure that the billed amount falls within the usual, customary, and reasonable fee that the insurance carrier has developed for that specific procedure CPT code. 2) On completion of the processing of the claim, the insurance company sends an explanation of benefits (EOB) letter to the insured person. This form includes the dates; charges; amounts applied toward the deductible; amounts not covered either because of an exclusion or excess over the usual, customary, and reasonable charge; and the amount the company is paying for this claim. Some EOB letters even serve as a "bill" or "notice" in that they indicate the amount the insured must forward to the provider for payment of the account in full

What are the three primary reasons why down-coding happens?

1) The coding system used on the claim form does not match the coding system used by the insurance carrier. Failure to routinely update the charge master contributes to this problem. The carrier's computer will convert the submitted claim code to the closest recognized code. In most cases, the reimbursement amount will be less because each CPT code is assigned a fee schedule 2) If a Workers' Compensation claims examiner has to convert a CPT code to a relative value scale (RVS) code, the examiner will select the lowest-paying code. When billing Workers' Compensation, always use the RVS system used by that carrier and match the code to the best description of the CPT code. 3) When attached documentation does not match the written description of the procedure, the reimbursement will always be the lowest-paying code that fits the written description. Denial of payment may occur due to a lack of documentation for medical necessity. As stated earlier, medical necessity is required to ensure that services or procedures for a specific diagnosis or specified frequency are in order for consideration for reimbursement by the patient's insurance covered benefits

What is the general rule for coding? Why is it important for medical insurance claim forms to be accurate and complete?

1) The general rule for coding is do not guess. The code becomes a permanent part of the patient's health record with the insurance carrier. If an incorrect code is used, that coded diagnosis will stay with that patient. This can be a difficult problem for insured persons if they change insurance carriers or if other health problems occur. Examples of protected diagnosis of health condition include HIV, AIDS, substance abuse, mental health conditions, and sickle cell anemia. 2a) Accuracy and completeness in coding is vitally important. Imprecise coding affects how quickly the provider is reimbursed and the correct amount of the reimbursement. Codes must be appropriate to the documentation. Insurance carriers always down-code if documentation or codes are ambiguous and reimburse for the provider for the lowest possible fee. 2b) The more accurate the coding on the claim form, the less chance there is for error, the more quickly the provider is reimbursed, and the better the chance that the provider's reimbursement will reflect the actual charge. Many insurance carriers keep a fee profile of each provider's charges. This profile reflects the amount of each charge for each service and can affect the provider's reimbursement for those services 2c) Incorrect coding can be a problem with ruling out a diagnosis. For instance, a patient presents many symptoms of peptic ulcer disease. Do not immediately code that patient as having that disease (which would be assumptive coding) until the diagnosis is confirmed. Instead, code the symptoms. When the tests come back and a specific diagnosis of peptic ulcer can be made, then code the disease as: K27.7 chronic peptic ulcer, site unspecified, without hemorrhage or perforation

What are the ICD-10-CM code ranges and descriptions?

A00 to B99: Certain infectious and parasitic diseases C00 to D49: Neoplasms D50 to D89: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism E00 to E89: Endocrine, nutritional, and metabolic diseases F01 to F99: Mental, behavioral, and neurodevelopmental disorders G00 to G99: Disease of the nervous system H00 to H59: Diseases of the eye and adnexa H60 to H95: Diseases of the ear and mastoid process I00 to I99: Diseases of the circulatory system J00 to J99: Diseases of the respiratory system K00 to K95: Diseases of the digestive system L00 to L99: Diseases of the skin and subcutaneous tissue M00 to M99: Disease of the musculoskeletal system and connective tissue N00 to N99: Diseases of the genitourinary system O00 to O9A: Pregnancy, childbirth, and the puerperium P00 to P96: Certain conditions originating in the perinatal period Q00 to Q99: Congenital malformations, deformations, and chromosomal abnormalities R00 to R99: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified S00 to T88: Injury and poisoning and certain other consequences of external causes V00 to V99: External causes of morbidity Z00 to Z99: Factors influencing health status and contact with health services

How are HCPCS codes organized?

A0000 to A9999: Transportation services such as ambulance; medical and surgical supplies, including supplies for urinary incontinence, ostomy, respiratory, and dialysis; and radiopharmaceuticals B4000 to B9999: Supplies, equipment, and nutritional products for enteral and parenteral nutrition C1300 to C9899: New technology procedures, drugs, biologicals, radiopharmaceuticals, magnetic resonance angiography (MRA), and devices for outpatient hospitals to report D codes: Dental services--the ADA holds the copyright to D codes; they usually do not appear in the HCPCS manual E0100 to C8002: Durable medical equipment (DME) for patient's activities of daily living, including crutches and oxygen equipment G0008 to G9360: Procedures and services that may or may not have equivalent CPT codes, such as screening exams. H0001 to H2037: Mental health services, including treatment for alcohol and drug use J0120 to J9999: Drugs that the patient does not self-administer K00014 to K0900: DME for which there are no other HCPCS codes available, such as power wheelchairs L0112 to L9900: Orthotics (devices that help to regain function) and prosthetics (replacement body parts), including cervical collars, lumbar support, artificial limbs, and male vacuum erection systems M0064 to M0301: Codes represent an office visit for prescription drugs and miscellaneous therapies P2028 to P9615: Pathology and laboratory services and blood products Q0035 to Q9968: Temporary codes for drugs and supplies R0070 to R0076: Transportation of portable diagnostic radiology equipment to provider locations S0012 to S9999: Drugs, services, and supplies for Medicaid and other non-Medicare payers T1000 to T5999: Medicaid services and supplies V2020 to V564: Vision supplies, such as eyeglasses; hearing services and supplies; and speech language pathology services

How must medical assistants manage the medical insurance claims process?

Once the claim form has been completed, a series of events take place. The medical assistant or administrative staff, who may have used a referral number generated by a point-of-service device, enters the claim into the office register (or practice management software) of submitted claims; the insurance carrier processes the claim; an explanation of benefits letter is sent to the insured person and the medical provider; and, if necessary, follow-up procedures are instituted if payment is not received from the carrier within a specified time period. Each of these events is discussed in detail in the following sections: 1) Documentation of Referrals: Many insurance plans require that a referral be preapproved by the plan before scheduling an appointment with someone other than the primary care provider. This is particularly true for managed care plans, especially HMOs. The medical assistant working in both the primary care facility and specialist facility must make sure that when an approval is required, the necessary authorization has been obtained and the referral number is recorded in the patient's file. The referral number must be submitted as part of the claim submitted to the carrier by the specialist. This piece of information would be entered in block 23 of the CMS-1500 (02-12). 2) An electronic device available to some health care providers is a point-of-service (POS) device. This device provides immediate and direct access to patient eligibility information and managed care functions through an electronic network connecting the medical clinic and the health plan's computer. The POS device is a small card-swipe box similar in design and function to a credit card terminal. It allows medical clinic personnel to: -Record a patient visit -Check eligibility for patients in the health plan -Enter referrals for patients in managed care plans -Verify referral information -Check authorization status -Enter inpatient authorization requests -Enter outpatient authorization requests After the necessary information is entered by the medical assistant, the POS device communicates with the health plan's computer system. The computer then returns an acknowledgment to the medical clinic confirming the transaction or giving an error message code. For example, when visits are recorded accurately, a reference number is generated that is used as the medical clinic's confirmation that the transaction is complete. On successful entry of a referral, a referral number is generated. Specialists may use this number on claims they submit for services they render under the referral. 3) Maintaining a Claims Registry or Claims Tracking System: When claim forms are sent to the appropriate insurance carrier, it is wise and necessary for the medical clinic personnel to keep a diary or register of submitted claims. This claim register, created with a spreadsheet or software, should include the patient's name, the insured's name if it is different from the patient's name, the dates of service for which the claim is being made, the amount of the claim, and the date the claim is submitted. When payment is received, the date of payment should be entered. When aging and reconciling accounts, the bookkeeper then can check the diary to note where the claim is in the process. 4) Following Up on Claims: Occasionally, claims are denied because the claim form was incomplete. However, if there is no payment from the carrier and no other notification after a period of 1-6 weeks, it is necessary to follow up on the claim. The claim register will enable the clinic to keep track of the progress of claims. To follow up, a toll-free number is provided by most carriers. The necessary information to have on hand before making the call includes a copy of the claim form and the patient's name and insurance identification number. The carrier should be able to give the status of the claim. If payment is delayed, the carrier should be able to give the date when it can be expected. It is possible that payment was sent to the insured person, in which case a statement should be sent to the patient. If there is a problem with the claim, the medical assistant may need to investigate the cause of the error and submit a revised claim.

What are the common errors in completing medical insurance claim forms?

Once the claim form has been completed, it should be proofread for accuracy and to make certain that all information has been filed in correctly. The following list provides common errors: 1) The patient name must match the name on the insurance card 2) Eliminate typographic errors. Check all numbers carefully to be sure they have not been transposed or entered incorrectly 3) Eliminate incorrect information. The name of the patient and the name of the policyholder must be the same (unless a wife is covered under a husband's insurance, a child under a parent's insurance, etc) 4) Verify that all blanks have been completed accurately. Specifically check that units of service are entered, hospital admission and discharge dates are included, and the procedure service date is provided. 5) Verify that each procedure links correctly with the correct diagnosis (block 24E) 6) Verify that the procedure was medically necessary 7) Include the patient's name and policy identification information on each page 8) Do not use staples when submitting paper claims because the form cannot feed through the OCR if it is defaced or creased 9) Verify that the printer alignment was properly set and that all claim information is contained within its proper field 10) Be sure the claim form is signed appropriately

What are the benefits of submitting medical insurance claim forms electronically?

Submitting claims electronically has many benefits including: 1) Standardized electronic claim format ensures consistency, reducing errors 2) Submitters can exchange electronic data with multiple payers using the same data format 3) Supplies required (i.e., paper, postage) and administrative costs are reduced 4) Cash flow can be significantly improved because Medicare pays 14 days after receipt of complete and accurate electronically submitted claims (paper claims may take a minimum of 29 days to process)