Billing and Coding

What is the purpose of documentation in billing and coding?

Documentation is crucial for insurance reimbursement, proving services were performed, and avoiding audits and penalties.

What defines a procedure in medical billing?

A procedure is a service identified by a CPT (Current Procedural Terminology) code, including eye exams and various tests.

What is a 99 visit in medical coding?

A 99 visit refers to a follow-up appointment, typically coded with E/M codes.

How many digits are in a procedural code?

Procedural codes consist of 5 digits.

What is a diagnosis and how is it coded?

A diagnosis is identified by an ICD-10 code, which includes systemic diseases and causation codes for injuries.

What is vision insurance and what does it typically require?

Vision insurance is supplemental insurance providing benefits for routine examinations and eyewear, usually requiring a refractive diagnosis.

What is the difference between medical insurance and vision insurance?

Medical insurance covers sickness, injury, and disability, while vision insurance provides benefits for eye care and eyewear.

What are HMO, PPO, and EPO in health insurance?

HMO (Health Maintenance Organization) requires a primary care physician; PPO (Preferred Provider Organization) allows more flexibility; EPO (Exclusive Provider Organization) combines features of both.

What are common vision insurance providers?

Common providers include VSP, March Vision, Eyemed, Davis Vision, and Spectera.

What is the chief complaint (CC) in medical documentation?

The chief complaint is a concise statement describing the patient's symptom or reason for the visit, stated in their own words.

How do you differentiate between new and established patients?

A new patient has not received professional services from the same physician or specialty in the past 3 years, while an established patient has.

What is required for a comprehensive eye exam coding?

Comprehensive eye exam coding (92004 for new, 92014 for established) requires a detailed history, examination with dilation, and initiation of a treatment program.

What is the level of billing determined by in medical coding?

The level of billing is determined by the complexity of medical decision making or the total time spent during the encounter.

What are E/M codes and how do they relate to eye codes?

E/M codes (99 codes) are used for office visits, while eye codes (92 codes) are specific to ophthalmological services.

What is the significance of the final determination table in medical decision making?

It is used to assess the complexity of problems, data, and risk to determine the appropriate level of service.

What is required for billing with medical insurance?

A medical diagnosis is required, and while a refractive code can be added, it is generally covered only by vision plans.

What is the difference in billing for new patients using codes 99202 to 99205?

99202 is for straightforward MDM with 15 min spent; 99203 is low level with 30 min; 99204 is moderate with 45 min; 99205 is high level with 60+ min.

What is the billing for established patients using codes 99212 to 99215?

99212 is straightforward MDM with 10 min; 99213 is low level with 20 min; 99214 is moderate with 30 min; 99215 is high level with 40 min.

What are the three factors that E/M codes are based on?

E/M codes are based on the number and complexity of problems, the amount of data reviewed, and the risk of complications.

Why is coding and billing important in medical practice?

Proper coding and billing ensure reimbursement, compliance with regulations, and assessment of the practice's profitability.

What is the role of the Recovery Audit Contractor in billing?

The Recovery Audit Contractor recovers underpayments and reimburses a percentage of the dollars recovered.

Where can you find what insurance a patient has?

Patient insurance information can be found in the EHR (Electronic Health Record) and DAR (Daily Activity Report).

What is the significance of audits in medical billing?

Audits review claims and patient records to ensure documentation supports coding and compliance with billing regulations.

What is the importance of the History of Present Illness (HPI) in documentation?

The HPI provides a detailed account of the patient's current symptoms and should list at least 4 elements.