Basics of Billing and Coding & Understanding Pre-Authorization
- 1. DayneAlonso, MMS, PA-C Miami Cancer Institute
- 2. Concise documentation is critical to providing patients with quality care and to ensure accurate and timely reimbursement. Medical records are used by payers to validate that the services provided were medically necessary and were consistent with the individual’s insurance coverage. Evaluation and Management (E&M) Services is the service that is provided by a provider (PA/NP or physician) introduced in 1993 by the AMA and CMS.
- 3. CMS has developed the requirements for provider documentation since 1995 Collaborated with reimbursement for all services All commercial and other payers follow CMS rules
- 4. A provider can bill or code for a number of different types of patient encounters. Evaluation and Management Services (E&M) codes include: - office/outpatient visits - outpatient consultations - Inpatient hospital visits - inpatient consultations - Management of observation/critical care patients
- 6. Current ProceduralTerminology code set used for insurance billing. The American Medical Association created and maintains the CPT code set. Listing of descriptive terms and identifying codes for reporting medical services and procedures Uniform language for processing insurance claims
- 7. Determined by several factors: New, established, or seen for consultation services. Type of facility where care is provided. Level of service – determined by the History, PE, medical decision making Time spent face to face with the patient, time spent reviewing records, and the complexity of the case are other factors. All of these factors are taken into account when finding the right CPT code.
- 8. Determined by: History Physical Exam Medical Decision Making
- 13. International Classification of Diseases – 10th edition Reason for the services (i.e. diagnosis) Classifies diseases and injuries and is used to track mortality and morbidity statistics. Use by national and international agencies to forecast healthcare needs, evaluate facilities and services, review costs, and conduct studies of trends in diseases. ICD 9 (17,000) vs. ICD 10 (155,000)
- 16. When billing for each patient encounter, the provider must include a CPT and ICD-10 code. Example: 99213 – CPT code (established patient) F50.00 - Anorexia
- 17. Any tests ordered must correlate with an ICD 10 code assigned to the visit. Pregnancy test ordered –What is the ICD 10 code Assign an ICD code that reflects the most specific diagnosis that is known at the time The primary code should reflect the patient’s chief complaint or the reason for the encounter. Ex: has a hx of Diabetes, HTN but presented for abdominal pain - primary code should be abdominal pain.
- 18. Do not use “rule out..” as a diagnosis –There is no code for this. Instead, use a diagnosis, symptoms, condition, or problem Signs and symptoms that are routinely associated with a disease process should not be coded separately. When the same condition is described as both acute and chronic, code both and use the acute code first. ie. Acute on chronic renal failure
- 19. Others may do the billing and coding for you however, your documentation must be intact. Downcoding refers to the process by which an insurance company reduces the value or procedure or encounter and resulting reimbursement. Either due to the CPT code mismatch or ICD 10 code does not justify the level of service. The quality and accuracy of the medical record are vital to the reimbursement process, which in turn is vital to the delivery of health care.
- 20. Insurance company representatives State Federal payers (reviewing for fraud and abuse) Peer review organizations Researchers Hospital peer review committees Medical professionals involved in the active care of the patient The PATIENT and their FAMILIES
- 21. Center for Medicare and Medicaid Services (CMS) is an agency of the US Department of Health and Human Services (HHS). www.cms.gov Nation’s largest payers for health care services Developed specific guidelines for documentation – 1995 and 1997 1995 Guidelines - https://www.cms.gov/outreach-and- education/medicare-learning-network- mln/mlnedwebguide/downloads/95docguidelines.pdf Evaluation and management guide 2009 - https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt- serv-guide-ICN006764.pdf
- 22. The medical record should be complete and legible Each patient encounter should include: Reason for the encounter Relevant history (pertinent negatives and positives) Physical examination Diagnostic test results (labs, imaging) Diagnosis (also called Assessment or Impression) Plan of Care Include a date, time, and provider signature
- 23. Rationale for ordering diagnostic and other services should either documented or easily inferred. (i.e. Chest X-ray will be ordered to evaluate patient’s cough which is unresponsive to treatment) Past and present diagnoses should be accessible to the treating and consulting providers (i.e. history of Rheumatoid Arthritis, HTN, ) Heath risk factors should be identified (i.e. morbid obesity)
- 24. Patient’s progress, response to and changes in treatment, revision of diagnoses should be documented (i.e. Diagnosis: UrinaryTract Infection - Plan: Patient continues to experience dysuria despite current antibiotics after reviewing the culture and sensitivity report, the patient will benefit from Levaquin 500mg PO daily x 5 days, will re- evaluate after tx) CPT and ICD-10 codes should be supported by the documentation in the medical record.
- 25. Date,Time (military time), and Provider Name/Signature Never chart in advance of seeing the patient Make appropriate corrections If record is dictated and then transcribed, you should read and edit before signing. Avoid medical abbreviations (facilities have own list)
- 26. A decision by a health plan that a health care service, treatment, prescription drug or durable medical equipment is medically necessary. Complete the process prior to the service being reimbursed. Ex: PET/CT scan, chemotherapy