Tools for Medical Coding
APRN’s may have medical coding delegated or outsource to other companies but it’s still good to have a general idea of how procedures or events are billed. Sometimes, practitioners are put in a situation that they have to do it on their own or overlook someone else doing the task. Therefore, it’s important to have a simple understanding of coding. Overall, coding is the universal language that helps organized and track medical care to appropriately compensate the provider.
The Main Point
With Medicaid and Medicare fraud it’s important to know not to upcode or downcode:
- Up code: to bill unnecessary and extra fees for something simple.
- Down code: to code down to cover expenses that are normally billable.
Stay current with the legalities of Health Care; Becker’s Hosptial Review
More Info:
“Upcoding” means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider’s documentation. For example, reporting a diagnosis of chronic bronchitis as if the patient has acute bronchitis qualifies as upcoding, as would billing a level 5 evaluation and management (E&M) service (e.g., 99215) for a minor patient problem, or coding for excision of a 2.5 cm skin lesion (e.g., 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm) when the lesion actually measured 1 cm (e.g., 11401 … excised diameter 0.6 to 1.0 cm).
Upcoding — whether intentional, or not — is a serious compliance risk that may lead to payer audits, reimbursement takebacks, and charges of abusive or fraudulent billing.
“Downcoding” is the opposite side of the upcoding coin. Typically, downcoding occurs because the provider fails to provide relevant documentation details to assign a service, procedure, or diagnosis to the optimal level of specificity. For example, diabetes is frequently undercoded. Many providers default to diabetes without complications. Whereas, correct coding requires that the provider document the type and method of control….
Here’s the bottom line: In every case, you should report and document diagnoses, services, and procedures to the optimal level demonstrated by provider documentation and medical necessity. Anything less is non-compliant.
–Physicians Practice
Tools to Help with Medical Coding
AAPC has created and offers free access to a variety of tools, including a Salary Survey Calculator, MACRA Calculator, E/M Utilization Tool, Health Plan/Provider Policy Search, Denied Claims Calculator, Risk Adjustment Search, and a CPT® RVU Calculator.
Government Websites
- Centers for Medicare and Medicaid
- Medicare Fee Schedule
- Physician Fee Schedule Search
- CERT program
- CLIA
- RAC program
- Department of Health and Human Services
- Food and Drug Administration
- Indian Health Services
- Archive Federal Register
- Office of Inspector General
- HIPAA
- Medicare Learning Network
- Medicare Utilization Statistics
- NPI
- NCCI
- CMS Internet-Only Manuals
OSHA Regulations (Practice Management)
Human Resources
Drug Enforcement Administration
Free Software
HIPAA
What is a Medical Coder?
A medical coder assigns numeric codes to represent diagnoses and procedures, describe the patient treatment, and delineate fees for health services, based on an official classification system (e.g., CPT-4, ICD-9/10, HCPC). Medical Coders are responsible for evaluating documentation to assure correct code selection for compliance with federal regulations and insurance requirements. Medical coders work in hospitals, insurance companies, and physician offices under the supervision of the health information manager or chief fiscal officer. Some medical coders are self-employed and contract for their services. Their work is used by risk managers, utilization reviewers, quality assurance experts, case managers, clinical managers, and other healthcare providers.
What is ICD?
ICD is the International Classification of Diseases and is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries, and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for:
– easy storage, retrieval, and analysis of health information for evidenced-based decision-making;
– sharing and comparing health information between hospitals, regions, settings, and countries; and
– data comparisons in the same location across different time periods.
Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines. They also include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease. ICD-10 is the most recent version, with ICD-11 expected in 2018.
What is CPT?
The CPT® (Current Procedural Terminology) coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency. For more than 5 decades, physicians and other health care professionals have relied on CPT to communicate with colleagues, patients, hospitals and insurers about the procedures they have performed.
CPT descriptive terms and identifying codes currently serve a wide variety of important functions. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
The uniform language is also applicable to medical education and research by providing a useful basis for local, regional and national utilization comparisons.
CPT® is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.
What is HCPCS?
The Healthcare Common Procedure Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS.
Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4), a numeric coding system maintained by the American Medical Association (AMA). The CPT-4 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. These health care professionals use the CPT-4 to identify services and procedures for which they bill public or private health insurance programs. Level I of the HCPCS, the CPT-4 codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.
Issues related to the application of Level I HCPCS codes (CPT-4) for physicians will be referred to the AMA. See Related Links Outside CMS below. CPT® is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items.
What is CDT?
The purpose of the CDT Code (Code on Dental Procedures and Nomenclature) is to achieve uniformity, consistency, and specificity in accurately documenting dental treatment. One use of the CDT Code is to provide for the efficient processing of dental claims, and another is to populate an Electronic Health Record.
On August 17, 2000, the CDT Code was named as a HIPAA standard code set. Any claim submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the version of the CDT Code in effect on the date of service. The CDT Code is also used on paper dental claims, and the ADA’s paper claim form data content reflects the HIPAA electronic standard.
What is NDC?
The Drug Listing Act of 1972 requires registered drug establishments to provide the Food and Drug Administration (FDA) with a current list of all drugs manufactured, prepared, propagated, compounded, or processed by it for commercial distribution. (See Section 510 of the Federal Food, Drug, and Cosmetic Act (Act) (21 U.S.C. § 360)). Drug products are identified and reported using a unique, three-segment number, called the National Drug Code (NDC), which serves as a universal product identifier for drugs. FDA publishes the listed NDC numbers and the information submitted as part of the listing information in the NDC Directory which is updated daily.
The information submitted as part of the listing process, the NDC number, and the NDC Directory are used in the implementation and enforcement of the Act.
–American Medical Billing Association
- Also check out: The Complexity of ICD10 Coding
- PMHNP Resources, Additional Links
