Medical Billing & Coding

Medical Billing and Coding

These conventions can include special rules, abbreviations, or symbols.

NEC

Not Elsewhere Classifiable - no code is specific for that condition

NOS

Not Otherwise Specified - used when a condition is not completely described in the medical record.

Code Also

may be found in the instructional notes indicating that a second code may be required

Category

Three-character alphanumeric code that covers a single disease or related condition

Subcategory

Four or five character alphanumeric subdivision of a category.

Inclusion Notes

Headed by the word "includes" and refine the content of the category appearing above them.

Exclusion Notes

Headed by the word "excludes" and indicates conditions that are not classifiable to the preceding code.

{ } Brackets (square)

enclose synonyms, alternative wording or explanatory phrases. Brackets identify manifestation codes.

( ) Parentheses

are used in both the index and tabular list to enclose supplementary words - non-essential modifiers

: Colons

are used in the Tabular List after an incomplete term which needs one or more of the modifiers

Sequelae

Are conditions that remain after a patient's acute illness or injury has ended - could be called residual effects or late effects

A bullet (solid circle)

indicates a new procedure code. The symbol appears next to the code only in the year that it is added

A triangle

indicates that the code's descriptor has changed. The symbol appears next to the code only in the year that it is added.

Facing triangles (two triangles that face each other)

enclose new or revised text other than the code's descriptor

A plus sign

next to a code indicates an add-on code.

A bullet inside a circle

indicates that moderate sedation is part of the procedure.

The lightning bolt symbol

is used with vaccine

CPT codes

are five-digit numerical codes that were developed by the American Medical Association (AMA)

Category I codes

have 5 digits, each code has a descriptor, which is a brief explanation of the procedure

Category II codes

used to track performance measures for a medical goal such as weight loss

Category III codes

temporary codes for ermerging technology, services, and procedures

Evaluation and Management (E/M)

99201-99499

Anesthesia

00100-01999

Surgery

10021-69990

Radiology

70010-79999

Pathology and Laboratory

80047-89398

Medicine

90281-99607

Level I codes

contain five numerical characters

Level II codes

are alphanumeric still containing five characters but starting with a letter.

Encounter forms, also referred to as superbills

are used by medical practices to outline the services there were provided to a patient for insurance processing.

The CMS-1500 insurance claim form

This form is a uniform document that ensures all providers and insurers use the same format regarding insurance claims

CMS-1500/837P forms to be completed

It is a good idea for billing professionals to refer to the specific guidelines on how each entity wants to be billed.

The UB-04 (CMS-1450) insurance claim form and its electronic equivalent known as 837I

are used in reimbursement for medical services provided by institutional healthcare providers

Payer payment policies

a certified staff member that is responsible for the collection of copayments

Usual, Customary, and Reasonable (UCR)

individual doctors' charge profiles and customary charge screens for similar groupings of physicians within a geographic area with similar expertise

Usual

fee normally charged for a given service

Customary

fee in the range of usual fees charged by physicians of similar training and experience for same service within the same specific and limited socioeconomic area

Reasonable

fee that is considered justifiable by responsible medical opinion considering special circumstances of the particular case in question

Relative Value Studies (RVS)

a list of 5-digit procedure codes for services with unit values that indicate the value for each procedure

How to identify fraud and abuse as it pertains to coding

Compliance in this area can enhance operations, reduce waste and fraud, and foster ethical practices that improves the overall delivery of patient care.

External Audits

Conducted by an outside entity; Private payers or government agencies can review selected records of a practice for compliance

Internal Audits

Conducted by the medical office staff or a hired consultant; these types of audits can be great for leadership to get a glance at the accuracy of their practice; can also give good feedback without the risk of a third party's consequences

Retrospective audits

conducted after the claim has been sent and the remittance advice has been received

There are many reasons that claims may be denied or rejected

Incorrect patient or policy information; Missing documentation; Coding errors; Benefits not matching procedures/services; Duplicate claims