Medical Billing and Coding PDF

The Business of Medicine Angela Weifenbach, CPC Revenue Cycle Manager/Privacy Officer Medical Billing and Coding Medical billing and coding is Topics Covered: complicated. What coding looks like There are many pe...

The Business of Medicine Angela Weifenbach, CPC Revenue Cycle Manager/Privacy Officer Medical Billing and Coding Medical billing and coding is Topics Covered: complicated. What coding looks like There are many people involved. Clinic staff, providers, office staff, Overview of the billing process etc. Why your documentation matters Lots going on. Claim entry, claim follow-up, Types of insurance payment posting, filing appeals, monitoring payments, compliance, etc. HIPAA Reminder Details matter, a lot. Audits 2 Medical Billing and Coding Coders translate your documentation into codes used to bill for services and supplies. Coders can be certified or non-certified. Coders can be as specialized as providers. Cardiology, orthopedic, neurology, etc. Auditor, compliance, practice manager CPC, CPMA, CPB, CPCO, CPPM Billers are usually not certified but can be certified. Continuing education credits are required for all certifications to maintain credentials. 3 Types of Codes Billing codes are how we tell the insurance company what happened and why during the appointment: services, issues, etc. Types of codes used for billing: CPT – Procedure codes (what did you do?) ICD-10-CM – Diagnosis codes (why did you do it?) HCPCS – Supply codes (did you give/use anything?) Other codes include place of service, modifiers, and service type codes. 4 Types of Codes - CPT CPT – Current Procedural Terminology Tells the payer “what” was done. Procedures, office visits, labs and pathology, diagnostic testing 5-digit codes 00100 – 99999 Some alphanumeric Update yearly on January 1st Per AMA, there are over 10,000 CPT codes Detail in documentation is vital to assigning the correct code. 5 Types of Codes - CPT 6 Types of Code - CPT CPT I Sections: Surgery: 10021-69990 10000-10022 General Evaluation and Management (E/M): 10040-19499 Integumentary 99201-99499 20000-29999 Musculoskeletal 30000-32999 Respiratory Anesthesia: 00100-01999, 99100-99140 33010-37799 Cardiovascular Radiology: 70010-79999 38100-38999 Hemic & Lymphatic 39000-39599 Mediastinum & Diaphragm Path and Lab: 80047-89398 40490-49999 Digestive Medicine: 90281-99199, 99500-99607 50010-53899 Urinary 54000-55899 Male Genital 55920-55980 Reproductive & intersex 56405-58899 Female Genital 59000-59899 Maternity Care & Delivery 60000-60699 Endocrine 61000-64999 Nervous 65091-68899 Eye & Ocular Adnexa 69000-69979 Auditory 7  Types of Codes – ICD 10 ICD-10 – Internal Classification of Diseases, 10th Edition 2 Types of ICD-10 codes CM – Clinical Modification (used by practitioners) PCS – Procedure Coding System (used by facilities) Diagnosis codes – tells insurance “why” services were performed. 22 chapters 6–7-character alphanumeric codes: L97.312 = Non-pressure ulcer, right ankle, fat layer exposed T25.222A = 2nd-degree burn, left foot, initial encounter Updated every year on October 1st Per AMA, there are over 69,000 codes Again, detail is important to assign the most accurate diagnosis code Insurance companies will deny a claim if an “unspecified” diagnosis is used, ie: ulcer of unspecified foot of unspecified depth L97.909, or unspecified pain R52. 8  Types of Codes – ICD 10 - CM 1) A00–B99 Certain infectious and parasitic diseases 13) M00–M99 Diseases of the musculoskeletal system 2) C00–D48 Neoplasms and connective tissue 3) D50–D89 Diseases of the blood and blood-forming 14) N00–N99 Diseases of the genitourinary system organs and certain disorders involving the immune 15) O00–O99 Pregnancy, childbirth and the puerperium mechanism 16) P00–P96 Certain conditions originating in the 4) E00–E90 Endocrine, nutritional and metabolic perinatal period diseases 17) Q00–Q99 Congenital malformations, deformations 5) F00–F99 Mental and behavioral disorders and chromosomal abnormalities 6) G00–G99 Diseases of the nervous system 18) R00–R99 Symptoms, signs and abnormal clinical 7) H00–H59 Diseases of the eye and adnexa and laboratory findings, not elsewhere classified 8) H60–H95 Diseases of the ear and mastoid process 19) S00–T98 Injury, poisoning and certain other consequences of external causes 9) I00–I99 Diseases of the circulatory system 20) V01–Y9 External causes of morbidity and mortality 10) J00–J99 Diseases of the respiratory system 21) Z00–Z99 Factors influencing health status and 11) K00–K93 Diseases of the digestive system contact with health services 12) L00–L99 Diseases of the skin and subcutaneous 22) U00–U99 Codes for special purposes tissue 9 Types of Codes – HCPCS HCPCS – Healthcare Common Procedure Coding System Supply codes: medications, cast supplies, DME given in clinic 5-character alphanumeric codes: J1100, Q4038 Updated January 1st There are roughly 7,000 HCPCS codes Often added to the claim by the coder 10 Modifiers Modifiers give the insurance company E/M code modifiers: additional information about the service. 24 – Unrelated E/M during post op 25 – Separate E/M from procedure Modifiers can also help us “unbundle” 57 – Decision for surgery procedures for further reimbursement. Procedure code modifiers: Types of Bundling: 22 – Increased procedure services Procedure-to-procedure 58 - Staged/related procedure during post-op Surgical global period (post-op period) 59 – Distinct procedural service 76 – Repeat procedure, same provider Informational modifiers: 77 – Repeat procedure, other provider Laterality/site: RT, LT, TA-T9 (toes), FA-F9 78 – Unplanned return to OR (fingers) 79 – Unrelated procedure by same provider 11 Types of Billing Evaluation and Management (E/M) – Procedure billing – Performed in the These are office visit codes office or a facility setting E/M guidelines: Some can be performed in the office, In 2021 AMA/CMS changed the guidelines for office/out-patient visit E/M others must be performed in a facility codes Office – biopsy, lesion removal, In 2023 AMA/CMS changed the debridements, labs, etc. guidelines for in-patient/facility E/M codes Facility – bunionectomy, joint reconstruction/replacement, etc. Can E/M and procedures be billed together? Sometimes… New patient visit, most likely Other codes in this category include labs, Established, maybe testing, and therapy codes. Was the procedure planned? Should the provider have expected to perform the procedure? 12 E/M Billing Evaluation and Management (E/M) There are 4 levels of new and 5 levels of established office and outpatient E/M codes New Patient: 99202-99205 (99201 was deleted1/1/21) Established: 99211-99215 99211 is used for nurse visits ONLY Do not use consult codes. Insurances won’t pay them Hospital E/M codes typically have 3 levels: 99221-99223 Initial inpatient, 99231-99233 subsequent visit inpatient 13 14 Per the AMA E/M Guidelines: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management. * You can find the AMA guidelines here *You can find the AMA Table of Risk here 15 Table of Risk 16 Social Determinants of Health 17 Time Based Billing New Patient Minimum Time Established Patient Minimum Time 99202 15 minutes 99212 10 minutes 99203 30 minutes 99213 20 minutes 99204 45 minutes 99214 30 minutes 99205 60 minutes 99215 40 minutes *99211 reserved for nurse/cma visits IP – Initial Minimum Time IP – Subsequent Minimum Time 99221 40 minutes 99231 25 minutes 99222 55 minutes 99232 35 minutes 99223 75 minutes 99233 50 minutes 18 Time Based Billing Total time of activities per encounter Does not include: Preparing to see patient Separately reported tests/procedures Obtaining and/or reviewing history Staff time Exam Slow charting Counseling/education Any element performed on a different date Ordering tests, medications, or procedures Document the exact time spent; no time Charting ranges. Independently interpreting results (if not billing CPT) Prolonged service code 99417 is for Communication of results each (whole) 15 minutes spent over the Care coordination level 5 caps. 19 Procedure Billing Who – Patient information Provider information When – Date of service Where – Location – Facility (in/outpatient, ASC) Location – What body part What – Procedure(s) to be performed Why – Diagnosis/diagnoses How – The procedure, in detail, including patient status afterward. 20 Procedure Billing 21 Procedure Billing 2 Categories: Minor and Major Procedures All procedure codes have surgical global periods, also called post-op periods. Global periods are 0, 10 or 90 days. Zero &10 days global is considered minor, and 90 days is considered major. Global means that we cannot bill an office visit (coding posts 99024 = $0); however, we can bill for tests and procedures (x-rays, I&D, cast application, etc). We can only bill an office visit for a new/separate problem Procedures are “unbundled” with modifiers Rounds in the hospital are also included in the post-op period if related to the surgery (including complications) 22 Documentation Pointers **IF IT’S NOT DOCUMENTED, IT DIDN’T HAPPEN!!!!** Document “why” a diagnosis or treatment options is risky, or not. Especially important for problems usually considered self-limited/minor but the patient’s history establishes higher risk. New callus in a diabetic with a history of ulcers. Document problems in HPI and Exam. Chief complaint, HPI, ROS, and Exam all go towards establishing condition risk as well as treatment risk While we’re not counting bullet points or body parts/organ systems, you still need to establish medical necessity that supports billing. Document time spent on the patient’s visit. Exclude time for any procedure(s) being billed with the E/M “Itemizing time” is not a bad idea, but currently not required. 23 The Process Provider performs services Coder translates the note into codes and sends a claim to insurance. The insurance company processes and pays the claim Insurance tells us what adjustments to take and what to bill the patient When everything goes right, we can expect payment 10-30 days after claim submission. 24 The Process Electronic Claims – All claims are filed electronically to insurance. Exceptions: Work Comp and MVA Claim scrubbed by provider clearinghouse. It will kick back claims with errors Claims scrubbed by payer clearinghouse It will kick back claims with errors Currently there is no way to submit notes electronically with a claim. 25  How Does Insurance Process Claims? Charge Master – This is the amount we bill everyone for services. Fees are set above the highest payer. Fee Schedule – The insurance company’s list of procedure codes and how much they allow for each code. The most $ we can expect to receive. Contractual Adjustment – The difference between our charge amount and the insurance company’s allowed amount Patient copay, coinsurance, and deductible are subtracted from the provider’s payment. (to be collected from the patient) 26 Copay, Coinsurance, Deductible and Out of Pocket Maximum Copay vs Co-insurance vs Deductible: Copay is the set rate the patient pays for medical visits. Coinsurance is the % of medical costs the patient pays after the deductible is met. Deductible, this of this like car or home insurance deductible. Patients must meet deductible before insurance pays. This is determined by the patient’s plan, type of service, and the place where service(s) were provided. Individual vs Family Deductible: Individual deductible applies to the subscriber. Family deductible applies to other covered members on the plan. 27  Claim Issues and Denials Insurance companies will delay/deny payment for any reason All i’s dotted and t’s crossed Timely follow-up is important There are time limits set on claim submission and on appeals Claim filing limits run 90 – 365 days There are only 2 payors who allow for 365 days. We have 90 to 180 days to submit an appeal This is determined by the insurance company’s appeals policy. Appeals can take 60-90 days to process There are multiple appeal levels for all payers 28 Claims Issues and Denials Insurance companies have coverage limits for some types of care: Nail care and/or callus care every 61 days Walking boot/CAM boot, ankle braces and other DME every 3-5 yrs (depending) Authorization limitations on services (i.e.: skin grafts) 29 Types of Insurance Coverage Government – Medicare and Medicaid, TriCare/TriWest, Veteran’s Administration These are our lowest payers – they “keep the lights on” Commercial – BCBS, UHC, Aetna, Cigna, etc Pays double, or more, than what government payers do Liability – Auto accident, slip and fall These pay between government and commercial rates Can be long and drawn out Work Comp – People hurt at work Highly involved: multiple people involved, special reports, work status reports, authorizations and referrals, etc. State of Iowa – Employer/Work Comp directs care Some other states allow employees to direct care 30  Insurance Audits Audits will happen. (Most audits the providers never see because staff and the business office take care of them.) All payers, all types Pre-service review – authorization requirements Post-service review – insurance has the claim and wants to audit before paying RAC – Recovery Audit Contractor, Medicare’s post-payment audits Multiple contractors across the US, designated by carrier regions Payment audits – insurance companies audit their claim processing Don’t see these unless payment is incorrect – insurance company issues refund request Can happen years later Usually centered around a specific issue: procedure, diagnosis, modifier use or even patient information (coordination of benefits) Just because there is an error, does not mean you’re going to jail!! Fraud = intent, not mistake/misinformation The payer’s first steps are provider education and recoupment of incorrect payment 31 Protecting PHI in Clinic Be aware of your surroundings and who could be listening to your conversations. Do not discuss health information in the lobby with patients. Do not leave PHI lying around. Flip document(s) over. Lock your computer when you’re away from it. Double check the name on documents handed to the patient. Only view records that you have a legitimate reason to be in. Do not access a friend, colleague, or family member chart. Do not access your own medical record. Do not discuss patient, diagnosis, treatment, etc. with your friends, family, or colleagues. Report any potential breaches to the clinic Privacy Officer. Angela Weifenbach, x1417, [email protected] Also report on Pulse>Departments>Compliance>Privacy & Cyber Security Incident Reporting 32 That’s a wrap! That’s a LOT to remember! Thank goodness for the internet! Insurance companies publish their fee schedules, claim edits, authorization requirements, and more on their websites. Billing staff should have sound knowledge of basic payer guidelines and the ability to research others. Codes are updated annually – staff, and then provider, education should happen yearly. Ask questions! We all learn from each other. Teamwork makes the dream work! 33 Coding and Billing Resources www.aapc.com www.ama-assn.org Angela Weifenbach, CPC Revenue Cycle Manager & Privacy Officer www.encoderpro.com DMU, Clinic Tower, Clinic Admin, Rm 103 [email protected] www.emuniversity.com 515-271-1417 www.cms.gov 34