Chapter 9

How do EHRs impact reimbursement?

EHRs produce more accurate documentation, leading to complete coding and accurate reimbursement.

What are some benefits of using EHRs in a medical practice?

Saving time, prompting clinicians for documentation, and improving consistency and completeness.

What replaces paper-based tasks when using EHRs?

Electronic processes replace tasks like pulling paper files and making photocopies.

What is the medical documentation and billing cycle?

A ten-step billing process integrated with EHR and practice management programs.

Who typically inputs vital signs and measurements into the EHR?

Medical assistants.

What information does the physician document in the EHR during the encounter?

Physical exam results, relevant history, and planned treatments.

Who assigns medical codes to diagnoses and procedures?

The physician or medical coder.

What does the biller/coder do after codes are assigned?

Reviews coding and billing compliance and checks out the patient.

Why might documentation be reviewed during claim adjudication?

To support medical necessity of the service billed.

Why should billers and coders understand the EHR billing cycle?

To access clinical info for claims and provide documentation supporting medical necessity.

Who is ultimately responsible for proper documentation and correct coding?

Physicians.

What role do administrative staff play in documentation and coding?

They audit medical coding to ensure codes are supported by documentation.

When does the audit process between documentation and coding occur?

After the patient encounter but before charges are billed.

What does documentation in medical records involve?

Organizing a patient’s health record in chronological, systematic, and consistent order.

Why is complete and comprehensive documentation important?

To show physicians followed medical standards of care and to legally protect them.

Why are patient medical records considered legal documents?

They provide evidence of who performed services and the rationale behind treatment decisions.

What is medical necessity?

The clinically logical link between a patient’s condition and the treatment or procedure provided.

What is the key tip about documenting services and coding?

If a service is not documented, it cannot be coded.

What is medical coding?

The process of applying HIPAA-mandated code sets to assign codes to diagnoses and procedures.

What are the three HIPAA-required code sets used in outpatient settings?

CPT, HCPCS, and ICD-10-CM.

What does CPT stand for?

Current Procedural Terminology.

What does HCPCS stand for?

Healthcare Common Procedure Coding System.

What does ICD-10-CM stand for?

International Classification of Diseases, Tenth Revision, Clinical Modification.

Why is accurate coding important for reimbursement?

Payers review codes to determine if services were appropriate and medically necessary for the diagnosis.

Give an example of a medically appropriate service related to an asthma patient.

A chest X-ray to rule out pneumonia.

What might happen if a service does not have a clear relationship to the diagnosis?

The insurance claim may be rejected.

How does documentation relate to coding and payment?

Accurate documentation supports proper coding, which affects whether physicians are reimbursed.

What is the purpose of procedure codes in medical billing?

To report medical, surgical, and diagnostic services provided, ensuring proper reimbursement and supporting best care practices.

What coding system lists common procedures and services performed by physicians?

CPT (Current Procedural Terminology), maintained by the American Medical Association (AMA).

What is HCPCS and how is it related to CPT?

HCPCS (Healthcare Common Procedure Coding System) includes CPT as Level I and adds codes for supplies/equipment as Level II.

How many categories of CPT codes are there?

Three: Category I, Category II, and Category III.

What are Category I CPT codes?

Five-digit codes with no decimals that describe commonly performed procedures.

Give examples of Category I CPT codes.

99204 - Office visit for a new patient evaluation and management; 00730 - Anesthesia for upper posterior abdominal wall procedures; 70100 - Radiologic exam of the mandible; 93000 - Routine ECG with report.

What is the mandated code set for physicians’ work under HIPAA?

CPT codes, which must be current as of the date of service.

What are Category II CPT codes used for?

Optional codes for tracking performance measures and quality of care (e.g., tobacco use assessment).

Give examples of Category II CPT codes.

0002F - Tobacco use, smoking, assessed; 0004F - Tobacco use cessation counseling.

What are Category III CPT codes?

Temporary codes for emerging technology, services, and procedures that may become permanent.

Give examples of Category III CPT codes.

0001T - Endovascular repair of abdominal aortic aneurysm; 0041T - Urinalysis infectious agent detection.

Why are three different CPT categories necessary?

Category I covers standard procedures for reimbursement, Category II supports quality tracking, and Category III tracks emerging technology.

Name the six main sections of Category I CPT codes.

1. Evaluation and Management (99201–99499); 2. Anesthesia (00100–01999); 3. Surgery (10040–69990); 4. Radiology (70010–79999); 5. Pathology and Laboratory (80047–89398); 6. Medicine (90281–99607).

What must be carefully followed when using CPT codes?

The section guidelines and rules for assigning correct codes.

What is the general process for assigning procedure codes?

Identify the service, locate the appropriate code section, apply guidelines, and assign the most specific code.

What are Evaluation and Management (E/M) codes used for?

Coding the thought process physicians use to collect, analyze patient info, and decide treatment.

What do E/M codes reflect in patient care?

Different levels of information gathering, analysis, and decision-making based on patient condition severity.

How many codes exist for office visits with new vs. established patients?

Four codes for new patients; five codes for established patients.

What determines the financial value assigned to an E/M code?

The level of complexity or time spent during the patient encounter.

How are E/M codes organized?

By place of service (office, hospital, home) and type of service, with different ranges for new and established patients.

Before January 1, 2023, what three components were used to select codes for observation, inpatient, consults, nursing facilities, and emergency services?

History documented, exam documented, and medical decision making documented.

What is the key component for coding counseling or coordination of care before 2023?

Time spent by the physician.

After January 1, 2023, how are observation, inpatient, and nursing facility services coded?

By medical decision making or time, with medically appropriate history and exam documented.

How are emergency room services coded after January 1, 2023?

By medical decision making only (time not used).

Why were the 2023 changes to E/M coding guidelines implemented?

To streamline coding and let providers focus on patient care documentation.

In outpatient/office settings, how is the E/M code selected?

By time spent or complexity of medical decision making.

What is the first step in selecting an E/M code for office visits?

Determine if the patient is new or established.

Are emergency room patients considered new or established?

All emergency room patients are considered new.

What factors determine whether coding is done by time or medical decision making complexity?

Office compliance plan and revenue cycle leaders’ decision.

What must the provider document when coding by time?

Time spent with the patient along with history, exam, assessment, and plan to support medical necessity.

What activities count toward the documented time for E/M coding?

Face-to-face exam, history taking, assessing, managing, reviewing tests, ordering meds/tests, documentation, care coordination.

Give an example of time-based coding: 99213 corresponds to how many minutes?

20–29 minutes of total time spent.

What does coding by medical decision making complexity involve?

Number of diagnoses considered, amount of data reviewed, and risk of complications or death.

What are the four levels of medical decision making complexity?

Straightforward, Low, Moderate, High.

What is an example of an E/M code for a new patient with low medical decision making?

99203 (30–44 minutes of time documented).

What documentation is required to assign an E/M code?

Clinical details supporting medical necessity, including history, exam, and medical decision making or time.

Why might new patient E/M codes be reimbursed higher than established patient codes?

New patients typically require more time and effort to gather comprehensive history and perform exams.

What is the purpose of diagnosis codes in physician practices?

To report patients’ conditions on claims, including primary and secondary diagnoses.

Who may assign diagnosis codes?

Physicians, medical coders, insurance/billing specialists, or medical assistants.

What coding system has the US used since October 1, 2015?

International Classification of Diseases, 10th Revision (ICD-10).

What is ICD-10-CM?

A clinical modification of ICD-10 that provides more detailed codes for morbidity from medical records.

How long can ICD-10-CM codes be?

Three to seven alphanumeric characters.

What do the 6th and 7th characters in an ICD-10-CM code represent?

Additional specific info about the condition; must be used when available.

What is the example of a detailed ICD-10-CM code for a fracture?

S82.111A = Displaced, closed fracture of right tibial spine, initial encounter.

What are the two major parts of ICD-10-CM?

1) Alphabetic Index to Diseases and Injuries, 2) Tabular List of Diseases and Injuries.

What additional coding resources are part of ICD-10-CM?

Neoplasm Table, Table of Drugs and Chemicals, and Index to External Causes.

What is the primary rule when assigning ICD-10-CM codes?

Use Alphabetic Index first to locate code, then verify with the Tabular List.

What does a hyphen after a code in the Alphabetic Index mean?

It indicates the code is incomplete and must be fully specified using the Tabular List.

What are ICD-10-CM Official Guidelines for Coding?

Rules developed by CMS, AHA, AHIMA, and NCHS for consistent and compliant coding.

Name the main sections of the ICD-10-CM Official Guidelines.

Section I: Conventions and guidelines; Section II: Principal Diagnosis; Section III: Additional Diagnoses; Section IV: Outpatient coding.

What are the three key outpatient coding points in the Official Guidelines?

1) Code primary diagnosis first, 2) Code highest level of certainty, 3) Code highest level of specificity.

What is Step 1 in diagnosis code assignment?

Review complete medical documentation including the chief complaint and physician diagnosis.

What is Step 2 in diagnosis code assignment?

Abstract the medical conditions documented in the visit.

What is Step 3 in diagnosis code assignment?

Identify the main term for each condition (e.g., ulcer, paralysis).

What is Step 4 in diagnosis code assignment?

Locate the main term in the Alphabetic Index using supplementary terms and notes.

What is Step 5 in diagnosis code assignment?

Verify the selected code in the Tabular List by reading includes/excludes notes and checking for additional digit requirements.

What is Step 6 in diagnosis code assignment?

Check compliance with Official Guidelines and list codes in the appropriate order.

Why is it important to not include suspected conditions in outpatient coding?

Because outpatient coding guidelines require coding only confirmed diagnoses.

What should be listed first when coding multiple diagnoses?

The primary diagnosis (first-listed code).

What must be logically connected in a patient’s medical record to show medical necessity?

The diagnosis and the medical services documented.

What does "code linkage" mean?

Connection between a procedure code and the related diagnosis code.

What are the general conditions that codes must meet to support medical necessity?

• In accordance with accepted medical standards

• Clinically appropriate in type, frequency, extent, site, and duration

• Not for convenience of patient, physician, or provider

• CPT procedure codes must match ICD-10-CM diagnosis codes.

Give an example of code linkage showing medical necessity.

Procedure to drain an abscess of external ear must be supported by diagnosis of disorders of external ear or ear carbuncle/cyst.

Are elective or experimental procedures considered medically necessary?

No, they are not considered medically necessary.

When might cosmetic nasal surgery be considered medically necessary?

When performed to repair accidental injury or improve function of a malformed body part (e.g., deviated septum, nasal obstruction).

What must support a high-level E/M office visit code (like 99204/99205)?

A serious, complex condition such as sudden unexplained large weight loss.