Medical Terminology
Presented by Harvey Richman, O.D.
Billing and Coding: Foundations for Beginners
Medical Terminology
Your presenter…
Harvey Richman, O.D.
Dr. Harvey Richman is a graduate of the New England College of Optometry where his education emphasized the evaluation of children with behavioral and perceptual difficulties. After several years of pediatric practice and research, Dr. Harvey Richman achieved the credentials of Fellow of the College of Optometrists in Vision Development. This was immediately followed by earning the credentials of Fellow of the American Academy of Optometry. In 2006, Dr. Richman was asked to join the American Optometric Associations Third Party Executive Committee to work on the Coding Committee due to his work for the state of New Jersey. Dr. Richman has lectured nationally on billing and coding, electronic health records, and PQRS. He has published work on Coding for Vision Therapy and Vision Rehabilitation for the AOA and COVD.
Billing and Coding: Foundations for Beginners
Medical Terminology
Topics to be covered:
• What is documentation, and why is it important?
• Coding systems
• Relevant terms
• Resources
Medical
Record
Documentation
The Medical
Record
• To record facts, findings,
and observations about
the patient’s health
history including past,
present illnesses,
examinations, tests,
treatments, and outcomes
• Chronologically
documents the care of
the patient and is an
important element
contributing to high
quality care
1.
•Accurate and timely claims review
and payment
2.
•Appropriate utilization review and
quality of care evaluations; and
collection of data that may be useful
in research and education
3.
•The diagnosis and procedure codes on
the health insurance claim form or
billing statement should be supported
by the documentation in the medical
record
•
Most payers are fully computerized
•
Computers process claims by:
1. Recognition of Codes
2. Matching procedures to diagnosis
3. Determining appropriateness of claim
•
Payers link diagnosis and services
CPT Procedure Codes
• What You Do
ICD-9 Diagnosis Codes
• What You Find
HCPCS II Codes
• What You Supplied
Modifiers
• What’s Different
Healthcare Common Procedure Coding System (HCPCS) code set
Level I of the HCPCS •
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Comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.
Level II of the HCPCS
•
Standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.
• Current Procedural Terminology
• Established in 1966
• CPT codes were adopted in 1983 by the Centers for Medicare/Medicaid Services • Listings of descriptive terms and identifying codes to report medical services and procedures
• Copyright held by the American Medical Association
• Five digit code
• FDA Approval
• Service or procedure performed by many providers across the USA
• Clinical efficacy well established and documented is US peer review literature
• Supplemental tracking codes used for performance measurement
• Use is optional. Not a supplement for category I codes
• Four digits followed with alpha character
• Reviewed by Performance Measures Advisory Group (PMAG) and the Health Care Professionals Advisory Committee (CPT/HCPAC) • Temporary tracking codes used for new and emerging technologies
• Codes consist of a numeric‐alpha identifier (eg, 1234T)
• NO RVU value assigned
• Payment subjected to carrier’s medical policy
Spectacle codes V2100‐V2799
•V2020 FRAMES, PURCHASES
•V2100 SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00, PER LENS
•V2103 SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D CYLINDER, PER LENS
•V2213 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS
Lens Options
V2715 PRISM, PER LENS
•V2718 PRESS‐ON LENS, FRESNELL PRISM, PER LENS
•V2730 SPECIAL BASE CURVE, GLASS OR PLASTIC, PER LENS
•V2744 TINT, PHOTOCHROMATIC, PER LENS
•V2745 ADDITION TO LENS; TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDES PHOTOCHROMATIC, ANY LENS MATERIAL, PER LENS •V2750 ANTI‐REFLECTIVE COATING, PER LENS •V2755 U‐V LENS, PER LENS •V2756 EYE GLASS CASE
Contact lens codes V2500‐V2599
• V2510 CONTACT LENS, GAS PERMEABLE, SPHERICAL, PER LENS
• V2521 CONTACT LENS, HYDROPHILIC, TORIC, OR PRISM BALLAST, PER LENS • V2522 CONTACT LENS, HYDROPHILLIC, BIFOCAL, PER LENS
• V2599 CONTACT LENS, OTHER TYPE
Low vision codes V2600‐V2615
• V2600 HAND HELD LOW VISION AIDS AND OTHER NONSPECTACLE MOUNTED AIDS • V2610 SINGLE LENS SPECTACLE MOUNTED LOW VISION AIDS • V2615 TELESCOPIC AND OTHER COMPOUND LENS SYSTEM, INCLUDING DISTANCE VISION TELESCOPIC, NEAR VISION TELESCOPES AND COMPOUND MICROSCOPIC LENS SYSTEM
Modify services and procedures when
primary code does not accurately reflect
what was done.
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Unusual Procedure (‐22)
Significant/Separate Procedure on Same Day (‐25)
Professional Component (‐26)
Bilateral Procedure (‐50)
Reduced Service (‐52)
Pre‐op or Post‐op Management (‐56, ‐55)
Decision for Surgery (‐57)
Multiple Modifiers (‐99)
• E1‐ Upper left eyelid
• E2‐ Lower left eyelid
• E3‐ Upper right eyelid
• E4‐ Lower right eyelid
• LT – Left side
• RT – Right side
• TC – Technical component
• GA ‐ Wavier of Liability on File
• GB ‐ Claim resubmitted
• GO ‐ OP Occupational therapy service
• GV – Attending physician not hospice
• GW – Service unrelated to term condition (hospice)
• GY‐ Statutorily excluded procedure
• QW‐Therapeutic procedure
• International Classification of Diseases, 9th Revision, Clinical Modification
• Identify diagnoses for purposes of medical records and reimbursement • Overseen by the World Health Organization • Changes effective October 1 every year
• International Classification of Diseases, 10th Revision, Clinical Modification
• US is currently obligated by world treaty to classify morbidity statistics with ICD‐10
• October 1, 2014
Physician Quality Reporting System Pay for Reporting –
Voluntary for 20072014
The Affordable Care Act
(ACA) of 2010
• Created a 1.0% bonus in
2011 and a 0.5% bonus in
2012-2014. For those who
do not report, reduces
Medicare payments by 1.5%
in 2015 and by 2.0% in 2016
Medicare Improvements for
Patients and Providers Act
of 2008 (MIPPA)
• Expanded bonus payments
through 2010 - 2% bonus
Tax Relief and Health Care
Act of 2006 (TRHCA)
• Authorizes financial
incentive for professionals
by reporting quality data
Medicare, Medicaid, and SCHIP
Extension Act of 2007 (MMSEA)
• Continued authorization for
PQRI in 2009-2010
Reported with Quality Data Codes (QDCs)
HCPCS G codes used:
• Measures without published CPT II codes
• Measures required to share CPT II codes CPT II codes
• Performance codes developed by CPT
• If implemented before published in CPT book –
posted online
• Not all published CPT II codes utilized for PQRI
Centers for Medicare & Medicaid Services (CMS)
• Previously known as the Health Care Financing Administration
(HCFA)
• Federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare
program and works in partnership with state governments to
administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards. • Clinical laboratory quality standards under the Clinical Laboratory
Improvement Amendments
• Administrative Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Health Insurance Portability and Accountability Act
• Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. • Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.
• The Administrative Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system.
http://www.hhs.gov/ocr/privacy/
HCFA
Health Care Finance Administration
• Changed name to CMS
• Timely/untimely filing of claims
• Redetermination/appeals
• Fifteen months is the absolute maximum
• End of calendar year of year following service date to submit
• 10% reduction if over 12 months delay
CMS 1500 Form
• Completion guidelines
• Example form
National Correct Coding Initiative (NCCI) (also known as CCI) • Implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment
• NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B‐covered services
Medically Unlikely Edits (MUEs)
• A MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single HCPCS/CPT code billed by a provider on a date of service for a single beneficiary.
Durable Medical Equipment
• DMEPOS
• Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
• DMERC‐Regional Carrier
Fraud:
Intentional deception or misrepresentation resulting in unauthorized benefit
Abuse:
Practices, directly or indirectly, resulting in unnecessary costs
• Services performed for excessive frequency are not medically necessary
• Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation
YOU SHOULD KNOW:
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Contractor published the requirements
Previous review, hearing decision, or other notice informed of requirements
Physician reasonably expected to know requirement based on standard medical practice
Physician received denial/reduction for same or similar service
Office of Inspector General
• Federal agency responsible for enforcing DHHS regulations
OIG:
• “Voluntary” compliance procedures • Self policing
Self‐referrals
Self policing your practice in the areas of: • Coding and billing • Providing services: reasonable and necessary
• Improper documentation • Improper inducements • Kickbacks • Self‐referrals
Fines, prison, exclusion
Comprehensive Error Rate Testing
• Carriers contract outside auditors
• Outside auditors paid by amount recouped
• Many difficulties
• Poor training
• No incentive to allow claims
• Every incentive to deny claims
• Recoupment go beyond claims audited
Progressive Corrective Action
• Medical review activities:
• Targeted at identified problem areas
• Corrective actions are appropriate for infraction
• Education
• Policy development
• Prepayment review
• Post‐payment review
Progressive Corrective Action
• Data analysis
• Unusual billing patterns
• General surveillance or complaint specific
• Probe review
• 20‐40 claims: physician‐specific problems
• <100 claims: physicians for general problems
GET IT. SHARE IT. USE IT. • Fully implemented now
No legacy identification numbers accepted
No Medicare provider number
No UPIN number
• Never expires
• 10 digit NPI
Individuals
Organizations
• NPI Registry Online
Advanced Beneficiary Notice • In writing
• Approved ABN form • In advance Notice must include: • Patient’s name, date • Description of service/item
• Reason(s) the service/item may be denied • Patient must sign and date the ABN
• Patient assumes financial liability
When a beneficiary goes for an eye examination with no specific complaint, the expenses are not covered even if the exam discovered a pathologic condition.
Explanation of benefits • A statement sent by a health insurance company to covered individuals explaining what medical treatment and/or services were paid for on their behalf
•An EOB typically describes:
• The service performed—the date of the service, the description and/or insurer's code for the service, the name of the person or place that provided the service, and the name of the patient
• The doctor's fee, and what the insurer allows—the amount initially claimed by the doctor or hospital, minus any reductions applied by the insurer
• The amount the patient is responsible for.
• There will normally be at least a brief explanation of any claims that were denied, along with a point to start an appeal.
Resource‐Based Relative Value Scale (RBRVS)
• Mechanism used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs)
• Assigns procedures performed by a physician or other medical provider a relative value which is adjusted by geographic region. This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment
• Determines prices based on three separate factors: physician work (52%), practice expense (44%), and malpractice expense (4%)
Relative Value Scale Update Committee
• AMA/Specialty Society • Makes annual recommendations regarding new and revised physician services to the CMS • Performs broad reviews of the RBRVS every five years
• RUC is a separate agent from the CPT Editorial Panel
• RUC surveys physicians and recommends values to CMS
• Final recommendations are announced in the Medicare Physician Payment Schedule Evaluation and Management Coding (commonly known as E/M Coding or E&M Coding) • Medical billing process that practicing doctors in the
United States must use to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters
• E/M standards and guidelines were established by Congress in 1995[1] and revised in 1997. It has been
adopted by private health insurance companies as the
standard guidelines for determining type and severity of
patient conditions. This allows medical service providers
to document and bill for reimbursement for services provided
• E/M codes are based on the CPT codes established by the AMA
• In 2010, new codes were added to the E/M Coding set, for prolonged services without direct face‐to‐face contact
A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words.
Review of Systems
• An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. For the purposes of the CPT codebook the following elements of a system review have been identified:
•Constitutional symptoms (fever, weight loss, etc.)
•Eyes
•Ears, nose, mouth, throat
•Cardiovascular
•Respiratory
•Gastrointestinal
•Genitourinary
•Musculoskeletal
•Integumentary (skin and/or breast)
•Neurological
•Psychiatric
•Endocrine
•Hematologic/lymphatic
•Allergic/immunologic
• The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options
History of Present Illness
A chronological description of the development of the patient's present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s).
Past, Family, Social History
• A review of the patient's past experiences with illnesses, injuries, and treatments that includes significant information about:
• Prior major illnesses and injuries
• Prior operations
• Prior hospitalizations
• Current medications
• Allergies (eg, drug, food)
• Age appropriate immunization status
• Age appropriate feeding/dietary status
Past, Family, Social History
• A review of medical events in the patient's family that includes significant information about:
• The health status or cause of death of parents, siblings, and children
• Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review
• Diseases of family members that may be hereditary or place the patient at risk
Past, Family, Social History
• An age appropriate review of past and current activities that includes significant information about:
• Marital status and/or living arrangements
• Current employment
• Occupational history
• Use of drugs, alcohol, and tobacco
• Level of education
• Sexual history
• Other relevant social factors
• AOA Third Party Executive Center
• WWW.AOACODINGTODAY.COM
• WWW.AOA.REIMBURSEMENTPLUS.COM
• http://www.aoa.org/x6167.xml
• Ask The Codeheads
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