Medical Coding and Billing PDF Spring 2024

Medical Coding and Billing ASHLEY NORDAN, MHPE ,MSCR, MPAP, PA-C CAMPBELL PA PROGRAM SPRING 2024 Why we’re talking about this now….  Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)  Accreditation Standards  Section B: Curriculum and Instruction  Subsection B2: D...

Medical Coding and Billing ASHLEY NORDAN, MHPE ,MSCR, MPAP, PA-C CAMPBELL PA PROGRAM SPRING 2024 Why we’re talking about this now….  Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)  Accreditation Standards  Section B: Curriculum and Instruction  Subsection B2: Didactic Instruction  B2.14 – The curriculum must include instruction about the business of health care to include:  Coding and billing  Documentation of care  Health care delivery systems; and  Health policy Objectives 1. 2. 3. 4. 5. Discuss the reimbursement by Medicare for services rendered by a physician assistant (PA). Compare and contrast ICD-10, CPT, and HCPC in terms of documentation for coding and billing. Understand the key components of E/M coding and learn to select the correct level of care, including MDM and complexity of the visit and how this relates to Electronic Health/Medical Records. Discuss the two ways that a medical provider may bill for the service(s) provided. a. Billing based on complexity b. Billing based on time Describe “Incident To” billing and when it may be utilized. Need to know Nice to know ICD, HCPC and CPT (OH MY) Types of Codes ICD 10 code = diagnosis code service codes = HCPCS, CPT  Diagnosis Codes   International Classification of Diseases 10th Revision (ICD-10) Service Codes  Health Care Financing Agency’s Common Procedural Coding System (HCPCS) like the difference between medical device bill and procedure bill (ex. nexplanon)  Current Procedural Terminology (CPT) – Published and owned by the AMA   National HCPCS Codes – Published by CMS   Includes evaluation and management (E&M), surgical procedures (CPT), and other services Supplies and other services Local HCPCS Codes – getting rid of these Diagnosis Codes International Classification of Diseases (ICD) codes  Created by the International Statistical Institute in 1893 as a way to collect epidemiologic data  Adopted in US in 1898  Ownership by WHO as of 1948  10th revision (ICD-10) endorsed by World Health Assembly in 1990   Implemented in the US in October 2015 Benefits over ICD-9 ICD10 is more specific  Classified by body part/system as opposed to condition  More specific and detailed  Related medical conditions, causes and location of condition/injury ICD-9 versus ICD-10 kinda skipped this, fyi Code structure ICD-9 ICD-10 3,284 Codes 14,025 Codes 71,924 codes 69,823 codes -3-5 characters -First character is numeric or alpha -Characters 2-5 are numeric -3-7 characters Character 1 is alpha Character 2 is numeric Character 3-7 is alpha or numeric Specifies R vs. L, initial vs. subsequent encounter, complexities ICD-10 Code Structure Z is prevention M is MSK stuff ICD-10 Code Examples more complex ICD-10 codes = more billing rights - more specific Code Description E08 Diabetes mellitus E08.3 Diabetes mellitus due to underlying cause E08.32 Diabetes mellitus due to underlying cause with mild proliferative diabetic retinopathy E08.321 Diabetes mellitus due to underlying cause with mild proliferative diabetic retinopathy with macular edema E08.3211 Diabetes mellitus due to underlying cause with mild proliferative diabetic retinopathy with macular edema, right eye ICD-10 Code Examples no ICD-10 code for differential diagnosis list - only code for the actual diagnosis!!! in the assessment area Code Description S82 Fracture of lower leg S82.1 Fracture of upper end of tibia S82.12 Fracture of lateral condyle of tibia S82.124 Non-displaced fracture of lateral condyle of right tibia S82.124A Non-displaced fracture of lateral condyle of right tibia, initial encounter Service Codes HCPCS Codes for supplies “Hick picks”  5 digit code specific to a particular item  Some places may have a list of commonly used supplies in that particular setting  For example…  Nexplanon – J7307  Depo Provera – J1050  Crutches – E0114  Compression stockings – A6501-A6550 Current Procedural Terminology (CPT) CPT = E&M codes = billing code for the evaluation and patient management!!  Describes what you did for the patient  Codes go from 00100 to 99607  Evaluation & Management (E&M) Codes:  Type of code depends on setting (out pt office, inpatient hospital, nursing home, emergency department, etc.)  Billable visit level of service decided by total time or complexity of this is why it is important to pick a detailed ICD-10 code - so we can pick a higher billing code E&M Codes used in Outpatient Practice new patients $$$$$ > established $$ annual exams are based on AGE - not time/complexity New Patient 99202 99203 99204 99205 Established Patient 99212 99213 99214 99215 99202 < 99205 in billing Billed based on time/complexity Annual Preventive Exam New patient 99381 ( reviewed 3 tests Risk of Complications and/or Morbidity or Mortality of Patient Management —> Low What CPT code would you use to bill this encounter based on MDM? moderate (bill for the highest category —> 2nd one!) Bundling and Modifiers  Bundling   examples - I&D procedure (bill for materials used) Billing of multiple CPT codes to include the subordinate procedures and the supplies necessary to complete a procedure or “visit” Modifiers   bundling - billing multiple CPT code ex. fracture patient that needs casting (supplies for casting - lots of stuff for this) Codes that justify “bundling” when appropriate Global Period/Package Ex- vaginal discharge but also wants nexplanon (two separate things at the same appointment), provides justifcation for two things  Billing of services that occur over a period of time as one “package” instead of billing visits/services individually  Ex. Prenatal care Ex. All prenatal care and 2 postpartum visit so patient does not need a copay for EVERY visit but is insurance based Another example - I&D patient comes back for packing removal - do not bill again for this something that requires follow up later (I&D, pregnancy), BUT this is NOT a f/u thing (like not if patient is f/u on diabetes) post-operative visits are also a good example Modifier examples  24 – unrelated E&M service during a postoperative period  25 – significant, separately identifiable service by the same provider on the same day of the procedure or other service example nexplanon or having a complaint on a annual exam!  33 – preventive service  50 – bilateral procedure  58 – staged or related procedure or service during the postoperative period PA Billing “Incident to” Billing need to know this rule and how to use the loophole (called “incident to”)  Under CMS rules, PA’s get 85% of the fully reimbursable amount   Loophole = “incident to” In order to bill “incident to” the following must be met:  Use collaborating physician’s NPI and name  PA must be employed/under contract with physician or physician practice  Physician must treat the patient at the first visit  Physician must be on site for subsequent visits if we bill under our name and license number, we are reimbursed 85% of what a MD would make so the loophole is using the incident to - this means you are able to bill under the physician (using their NPI) to get 100% you must be emplyed and under contract with physician or practice, the supervising MD must treat the patient at the first visit (you cannot be the first visit!!!) and MD must be on site for extra visits = so its a pain! most PAs will just bill for the 85% Questions? ICD-10 Consult App Resources  https://www.cms.gov/Medicare/Coding/ICD10/ Downloads/032310_ICD10_Slides.pdf  https://www.cms.gov/Medicare/MedicareContracting/ContractorLearningResources/ downloads/ICD-10_Overview_Presentation.pdf  https://accessmedicine.mhmedical.com/ content.aspx? sectionid=138889722&bookid=1872&Resultclick=2#11 37606953  Millette K. “Countdown to the E/M Coding Changes”. American Academy of Family Physicians. 2020.  Self C, Moore K, Church S. “The 2021 Office Visit Coding Changes: Putting the Pieces Together”. American Academy of Family Physicians. 2020.  Millette K. “Coding Leve; 4 Office Visits Using the New E/M Guidelines”. American Academy of Family Physicians. 2021.