DOCSLIB.ORG

Coding/Billing  Auditing/Compliance  Practice Management

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Coding/Billing  Auditing/Compliance  Practice Management June 2018 www.aapc.com 5 Questions Radiology Coders Should Ask: 32 The answers are not what you expect DOJ Reclaims Billions: 38 False Claims Act 2017 recoveries are surprising Get Back to Insurance Basics: 49 Better serve patients by knowing the options www.aapc.com June 2018 1 AAPC Members Save More Member savings are made just for you. Here are some ways you can save: • Buy 5 movie tickets to Cinemark or Regal theaters, save $20 • Buy a Papa John’s Pizza, save 25% • Stay in a Ramada, Days Inn or Super 8, save $15/night on average • Join Sam’s Club, get a $10 gift card • Eat at Arby’s, BOGO classic roast beef sandwiches By using these savings, you canAAPC save m Membershipore than the cost of your membership. Save more. Sign up for AAPC savings today. Learn more at: https://www.aapc.com/savings Healthcare Business Monthly | June 2018 AAPC Members Save More COVER | Added Edge | 34 Member savings are made just for you. Here are some ways you can save: Beyond Coding: Becoming a SME Loretta Jarrett-McDonald, BA, MPS, CPC, CPMA, CHI, • Buy 5 movie tickets to Cinemark or Regal theaters, save $20 CBCS, CMAA, CEHRS, NCICS, AAPC Fellow • Buy a Papa John’s Pizza, save 25% • Stay in a Ramada, Days Inn or Super 8, save $15/night on average • Join Sam’s Club, get a $10 gift card • Eat at Arby’s, BOGO classic roast beef sandwiches By using these savings, you can save more than the cost of your membership. [contents] Coding/Billing Auditing/Compliance Practice Management Save more. Sign up for AAPC savings today. 32 5 Questions Every Radiology 38 False Claims Act 2017 Recoveries 49 Refresh Your Understanding of Coder Should Ask May Surprise You Basic Health Insurances Stacy L. Shaw, CPC, CPMA, Robert A. Pelaia, Esq., CPC, CPCO Elizabeth Redman, CPC, COSC AAPC Fellow Amanda L. Govin, BS [continued on next page] Learn more at: https://www.aapc.com/savings www.aapc.com June 2018 3 Healthcare Business Monthly | June 2018 | contents 26 Coding/Billing 18 Two Best Practices to Improve Emergency Coding Gayathri Natarajan, CPC, COC 22 Clear Up Misconceptions About Transgender Coding Marcia Maar, MFA, COC, CPC, CRC, AAPC Fellow, AAPC MACRA Proficient Michelle A. Dick, BS 26 Alleviate RCVS Coding Headaches Brad Ericson, MPC, CPC, COSC, AAPC MACRA Proficient 28 Take the Right Approach to ICD-10-PCS Coding Kimberly Farley, CIC, COC, CPC, CHONC, AAPC Fellow 52 42 Decipher the Meaning of BRCA, ER/PR, and Her2 Frank Mesaros, DBA, MPA, MT(ASCP), CPC, CPCO 46 Get the Facts about Modifier QQ Mahalakshmi Vaithilingam, COC, CPC 48 Sequence Anemia in Order of Events Oby Egbunike, CPC, COC, CPC-I, CCS-P Auditing/Compliance 38 False Claims Act 2017 Recoveries May Surprise You Robert A. Pelaia, Esq., CPC, CPCO 56 Amanda L. Govin Practice Management 52 Nurses Are Perfect Candidates for Managed Care Positions Lisa Tevolini, LPN, CPC, CPCO Added Edge 54 Reach Milestones with Continuing Education after Certification Janine Duclos, CPMA, CCS-P Member Feature 56 HEALTHCON 2018: An Event Full of Fresh Starts David Blackmer, MSC COMING UP: DEPARTMENTS 60 Dear John • Coder Burnout 7 President’s Message 66 Minute with a Member • Auditor Checklist 8 Letters to the Editor EDUCATION • Turbinates 9 I am AAPC 61 Newly Credentialed Members • IPPE or AWV? 10 AAPC National Advisory Board • Urodynamic Testing 14 AAPC Chapter Association On the Cover: Loretta Jarrett-McDonald, BA, MPS, CPC, CPMA, CHI, 15 Chat Room CBCS, CMAA, CEHRS, NCICS, AAPC Fellow, explains how thinking outside Online Test Yourself – Earn 1 CEU of the medical coding box will help you to become a subject matter expert 16 Member Experience https://www.aapc.com/resources/publications/ (SME). Cover design is by Mahfooz Alam. 31 HBM News healthcare-business-monthly/archive.aspx 4 Healthcare Business Monthly 2019 Code Books Now Available For Pre-Order Order Now for the Best Price aapc.com/onlinestore Serving 175,000 Members – Including You! Go Green! HEALTHCARE Why should you sign up to receive Healthcare Business Monthly in digital format? BUSINESS MONTHLY Coding | Billing | Auditing | Compliance | Practice Management Here are some great reasons: June 2018 • You will save a few trees. Director of Publishing • You won’t have to wait for issues to come in the mail. Brad Ericson, MPC, CPC, COSC • You can read Healthcare Business Monthly on your computer, tablet, or [email protected] other mobile device—anywhere, anytime. Managing Editor • You will always know where your issues are. John Verhovshek, MA, CPC • Digital issues take up a lot less room in your home or office than paper [email protected] issues. Executive Editors Go into your Profile on www.aapc.com and make the change! Michelle A. Dick, BS [email protected] Renee Dustman, BS, AAPC MACRA Proficient Advertiser Index [email protected] HealthcareBusinessOffice, LLC ..................................... 27, 33 Graphic Design www.HealthcareBusinessOffice.com Mahfooz Alam ZHealth ............................................................................. 45 Advertising Sales www.zhealthpublishing.com Corey Stilson [email protected] (385) 207-2322 Address all inquires, contributions, and change of address notices to: Healthcare Business Monthly PO Box 704004 Salt Lake City, UT 84170 (800) 626-2633 ©2018 Healthcare Business Monthly. All rights reserved. Reproduction in whole or in part, in any form, without written permission from AAPC® is prohibited. www.aapc.com/medical-coding-jobs/project-xtern/ Contributions are welcome. Healthcare Business Monthly is a publication for mem- bers of AAPC. Statements of fact or opinion are the responsibility of the authors alone and do not represent an opinion of AAPC, or sponsoring organizations. CPT® copyright 2017 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components Need Help? are not assigned by the AMA, are not part of CPT®, and the AMA is not recommend- Visit our Frequently Asked Questions (FAQ) page at ing their use. The AMA does not directly or indirectly practice medicine or dispense www.aapc.com/master-faq.aspx. medical services. The AMA assumes no liability for data contained or not contained herein. FAQs are categorized under the following topics: The responsibility for the content of any “National Correct Coding Policy” included • Membership • ICD-10 Training • Project Xtern in this product is with the Centers for Medicare and Medicaid Services and no • Certification Exams • CEUs • Forums endorsement by the AMA is intended or should be implied. The AMA disclaims • Training • CEU Vendors • Books responsibility for any consequences or liability attributable to or related to any use, • ICD-10 • HEALTHCON • Practicode nonuse or interpretation of information contained in this product. CPT® is a registered trademark of the American Medical Association. Still not finding what you’re looking for? Search our entire database of FAQs (http://aapc.force.com/knowledgebase). Volume 5 Number 6 June 1, 2018 Healthcare Business Monthly (ISSN: 23327499) is published monthly by AAPC, For coding questions, please use our forums (www.aapc.com/memberarea/ 2233 South Presidents Drive, Suites F-C, Salt Lake City UT 84120-7240, forums/) or Ask an AAPC Expert service (www.aapc.com/resources/ask-an- for its paid members. Periodicals Postage Paid at Salt Lake City UT and at additional mailing office. POSTMASTER: Send address changes to: expert/ask-an-expert-purchase.aspx). Healthcare Business Monthly c/o AAPC, 2233 South Presidents Drive, Suites F-C, Salt Lake City UT 84120-7240. 6 Healthcare Business Monthly President’s Message To Succeed, Be More Like Water Many members ask me after achieving their Becoming Protean credentials what else can they do to succeed. I wonder if Bruce Lee realized the parallels Our careers present many opportunities and between what he said and Proteus, the Greek obstacles. Changes inside our organizations, god of rivers and seas. Proteus was known for and disruptions outside, require us to evolve his shape-shifting. Mythology says he knew by learning and shifting roles. This can be the future, and when restrained by Menelaus accomplished when we become fluid as water. (Helen of Troy’s husband, ruler of Sparta), for example, he took the forms of several animals, Becoming Water water, and a tree. Proteus succeeded through Watch a stream to see what I mean. To move knowledge and flexibility. forward, water adapts — changing shape and To become Protean: direction to bypass rocks, slip around logs, • Be aware - Monitor and assess the job Finding success and pour over ledges. market. requires looking for Martial artist Bruce Lee once used water as an • See the future - Anticipate future example this way: developments, trends, and industry every opportunity If you put water in a cup, it becomes shifts. the cup. You put water into a bottle • Be water - Gain the skills and by learning new and it becomes the bottle. You put qualifications you need to flow over the it in a teapot, it becomes the teapot. industry’s changing needs. skills, trying new Now, water can flow or it can crash. • Change shape – Adapt quickly to an Be water, my friend. ever-changing industry environment. tasks, and accepting Finding success requires looking for every op- AAPC membership is one way to do this. portunity by learning new skills, trying new Your local chapter, the Member Forum, assignments tasks, and accepting assignments to improve Healthcare Business Monthly, the Knowledge our position. Sometimes stepping back or Center (www.aapc.com/blog), webinars (www.aapc. to improve our sideways is a step forward. Changing into a com/medical-coding-education/webinars), conferences new role or position, different from that with (www.aapc.com/medical-coding-education/conferences), position. which you’re comfortable, is the way to learn and credentialing training (www.aapc.com/certifi- valuable skills and earn wisdom you’ll use cation) are tools to help you anticipate changes, later.
Load more

Recommended publications
  • UB04 Hospital Billing Instructions & Revenue Code Matrix
    Maryland Department of Health Medical Assistance UB04 Hospital Billing Instructions & Revenue Code Matrix Revised 11/2017 Medical Assistance Problem Resolution Institutional Hotline: 410-767-5457 Nevis Smith, Division Chief, MAPR UB04 Hospital Instructions TABLE of CONTENTS Introduction 7 Electronic Verification System (EVS) 9 Sample UB04 11 UB04 FORM LOCATORS FL 01 Billing Provider Name, Address, and Telephone Number 12 FL 02 Pay-to Name and Address 12 FL 03a Patient Control Number 12 FL 03b Medical/Health Record Number 12 FL 04 Type of Bill 12 FL 05 Federal Tax No 17 FL 06 Statement Covers Period (From - Through) 17 FL 07 Reserved for Assignment by NUBC 17 FL 08 Patient Name – Identifier 18 FL 09 Patient address, city, State, zip code, and county code 18 FL 10 Patient Birth Date 18 FL 11 Patient Sex 18 FL 12 Admission/Start of Care Date 18 FL 13 Admission Hour 18 FL 14 Priority (Type) of Visit 19 FL 15 Source of Referral for Admission or Visit 19 FL 16 Discharge Hour 21 FL 17 Patient Status 21 FL 18-28 Condition Codes 23 FL 29 Accident State 32 FL 30 Reserved for Assignment by NUBC 32 FL 31-34 Occurrence Codes and Dates 32 FL 35-36 Occurrence Span Codes and Dates 36 FL 37 NOT USED 38 FL 38 Responsible party name and address 38 FL 39-41 Value Codes and Amounts 38 FL 42 Revenue Codes 42 FL 43 National Drug Code (NDC) Reporting 43 FL 44 HCPCS/Accommodation Rates/HIPPS Rate Codes 45 (HCPCS & HIV Testing Instructions) 45 FL 45 Service Date 46 FL 46 Units of Service 46 FL 47 Total Charges 46 FL 48 Non-Covered Charges 47 FL 49 Reserved for
    [Show full text]
  • Maryland PBHS Provider Billing Appendix
    Maryland PBHS Provider Billing Appendix 1. Billing Appendix Overview This Maryland PBHS Provider Billing Appendix (Billing Appendix) is included in the Optum Maryland Provider Manual by reference in section 13 Claim Submission. Note: Information contained in this Billing Appendix may be periodically updated or further explained through Provider Alerts. 2. General Claim Submission Guidelines Claims may be submitted online using Incedo Provider Portal (formerly known as Provider Connect), through a clearinghouse using Electronic Data Interchange (EDI) with 837batch files or by U.S. Mail. Online and Electronic Claim Submission For Incedo Provider Portal: After logging into Incedo Provider Portal, use the Incedo Provider Portal User Guide for instructions on entering a claim or for submitting an electronic file of claims. The link to the Incedo Provider Portal guide is found at maryland.optum.com > Behavioral Health Providers. For EDI/Electronic claims: Electronic Data Interchange (EDI) is the exchange of information for routine business transactions in a standardized computer format; for example, data interchange between a practitioner (physician, psychologist, social worker) and a payer. You may choose any clearinghouse vendor to submit claims using EDI. For PBHS claim submissions, use Payer ID OMDBH. The link to the 837i and 837p companion guides is maryland.optum.com Paper Claim Submission For U.S. Mail (paper claims): Optum Maryland will accept paper CMS-1500 forms for practitioner/professional services or Uniform Billing (UB)-04 forms for inpatient and outpatient facility claims. The mailing address for completed claim forms and required attachments is: Optum Maryland P.O. Box 30531 Salt Lake City, UT 84130 1 | P a g e BH2536_Billing Appendix 122019 Optum Maryland Please see the section on Paper claim submission for more specific instructions for use of CMS-1500 and UB-04 claim forms.
    [Show full text]
  • MHSUDS Information Notice No.: 16-051
    State of California—Health and Human Services Agency Department of Health Care Services JENNIFER KENT EDMUND G. BROWN JR. DIRECTOR GOVERNOR DATE: October 7, 2016 MHSUDS INFORMATION NOTICE N O.: 16-051 TO: COUNTY BEHAVIORAL HEALTH DIRECTORS COUNTY BEHAVIORAL HEALTH DIRECTORS ASSOCIATION OF CALIFORNIA CALIFORNIA COUNCIL OF COMMUNITY BEHAVIORAL HEALTH AGENCIES CALIFORNIA ALLIANCE OF CHILD AND FAMILY SERVICES SUBJECT: IMPLEMENTATION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-5), FIFTH EDITION REFERENCES: MHSD INFORMATION NOTICE 13-22 MHSUDS INFORMATION NOTICE 14-040 MHSUDS INFORMATION NOTICE 15-003 MHSUDS INFORMATION NOTICE 15-030 PURPOSE The purpose of this Information Notice is to direct Mental Health Plans (MHPs) to use the American Psychiatric Association (APA) DS M-5 to make diagnostic determinations for the purposes of determining if beneficiaries meet medical necessity criteria for Medi-Cal specialty mental health services (SMHS). This Information Notice updates information previously provided in Mental Health Services Division (MHSD) Information Notice 13-22. BACKGROUND The APA issued the DSM-5 on May 20, 2013. The DSM-5 provides diagnostic criteria and codes as well as corresponding International Classification of Diseases-10 (ICD-10) codes. Since March 2013, the Department of Health Care Services (DHCS) has collaborated with internal and external stakeholders and partners to address implementation issues specific to SMHS related to the DSM-5. Mental Health & Substance Use Disorder Services 1501 Capitol Avenue, MS 4000, P.O. Box 997413 Sacramento, CA 95899-7413 Phone: (916) 440-7800 Fax: (916) 319-8219 Internet Address: www.dhcs.ca.gov MHSUDS INFORMATION NOTICE N O.: 16-051 October 7, 2016 Page 2 DHCS has issued previous MHSUDS Information Notices1 that instruct MHPs to report only ICD-10 codes for claiming and diagnoses reporting purposes and provide ICD-10 procedural and diagnosis crosswalk documents f or SMHS.
    [Show full text]
  • Section 4 Procedure Codes
    Home Health Services Provider Manual Manual Updated 06/01/18 SECTION 4 PROCEDURE CODES TABLE OF CONTENTS PROCEDURE CODES 1 PROCEDURE CODES .............................................................................................................. 1 MODIFIERS ............................................................................................................................ 1 DIAGNOSIS CODES ................................................................................................................. 1 INCONTINENCE SUPPLIES PROCEDURE CODES ......................................................................... 2 i Home Health Services Provider Manual Manual Updated 06/01/18 SECTION 4 PROCEDURE CODES PROCEDURE CODES PROCEDURE CODES The following procedure codes will be used for home health visits: T1030 Nursing care by a Registered Nurse T1030 Pediatric Home Health nursing care T1031 Nursing care by a Licensed Practical Nurse T1031 Nursing Visit – Stabilized Patient T1021 Home Health Aide Visit T1028 Assessment Visit DME Evaluation A9900 Supplies S9127 Social Work Services to Enhance the Effectiveness of Home Health S9128 Speech Therapy S9129 Occupational Therapy S9131 Physical Therapy 36415 Venipuncture MODIFIERS Two nursing care visits, medically justified, for the same date of service shall be allowed under procedure code T1030 with a modifier 76 (repeat procedure or service by same physician or other qualified health care professional). Modifier 76 shall be recorded for the second visit only, and reflected on the CMS-1500
    [Show full text]
  • ICD-10 International Statistical Classification of Diseases and Related Health Problems
    ICD-10 International Statistical Classification of Diseases and Related Health Problems 10th Revision Volume 2 Instruction manual 2010 Edition WHO Library Cataloguing-in-Publication Data International statistical classification of diseases and related health problems. - 10th revision, edition 2010. 3 v. Contents: v. 1. Tabular list – v. 2. Instruction manual – v. 3. Alphabetical index. 1.Diseases - classification. 2.Classification. 3.Manuals. I.World Health Organization. II.ICD-10. ISBN 978 92 4 154834 2 (NLM classification: WB 15) © World Health Organization 2011 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
    [Show full text]
  • Clinical Vocabularies for Global Real World Evidence (RWE) | Evidera
    Clinical Vocabularies for Global RWE Analysis Don O’Hara, MS Senior Research Associate, Real-World Evidence, Evidera Vernon F. Schabert, PhD Senior Research Scientist, Real-World Evidence, Evidera Introduction significant volume of real-world evidence (RWE) analyses continue to be conducted with data A repurposed from healthcare administrative Don O’Hara Vernon F. Schabert databases. The range of sources represented by those databases has grown in response to demand for richer description of patient health status and outcomes. information for improved quality and coordination Data availability, including the range of available data of care, often using standardized messaging systems sources, has grown unevenly across the globe in response such as Health Level 7 (HL7). These messages are to country-specific market and regulatory dynamics. only as good as the standardization of codes between Nonetheless, as demand globalizes for RWE insights from message senders and receivers, which motivates the databases, those demands increase pressure on analysts encoding of facts using common code sets. The second to find ways to bridge differences between local data is the increased availability of common data models to sources to achieve comparable insights across regions. standardize the extraction and analysis of these data for RWE and drug safety purposes. While common data One of the challenges in bridging differences across models make compromises on the structure of tables databases is the codes used to represent key clinical and fields extracted from healthcare systems such as facts. Historically, RWE database studies have leveraged electronic medical records (EMR) and billing systems, local code sets for cost-bearing healthcare services they can improve consistency and replicability of analyses such as drugs, procedures, and laboratory tests.
    [Show full text]
  • Non-Interventional (Ni) Study Report
    Apixaban B0661018 NON-INTERVENTIONAL STUDY REPORT FINAL, 20 May 2015 NON-INTERVENTIONAL (NI) STUDY REPORT PASS information Title Post-approval safety study (PASS) of the utilization pattern of apixaban in the Netherlands Protocol number B0661018 Version identifier of the final study report 1.0 Date of last version of the final study 20 May 2016 report EU Post Authorisation Study (PAS) ENCEPP/SDPP/5177 register number Active substance B01AF02 apixaban Medicinal product Eliquis -2016 15:22 y Product reference EU/1/11/691/001-015 Procedure number EMEA/H/C/002148 Marketing Authorisation Holder (MAH) Bristol-Myers Squibb/Pfizer EEIG roved On: 23-Ma Joint PASS No pp Research question and objectives This is a descriptive study using roved\A retrospectively collected data from pp electronic health record databases. The study describes the utilization pattern of apixaban in the Netherlands (01 Dec 2011 through 31 Dec 2014). The study aimed 1) to estimate the proportions of apixaban users who receive the drug for the approved indications at the time of the first apixaban dispensing and 2) to describe the characteristics of the patients who were prescribed apixaban for 090177e188105755\A PFIZER CONFIDENTIAL Page 1 Approved v 1.0 930102376 1.0 Apixaban B0661018 NON-INTERVENTIONAL STUDY REPORT FINAL, 20 May 2015 on-label and off-label indications. Country(-ies) of study The Netherlands Author Marketing Authorisation Holder(s) Marketing Authorisation Holder(s) Bristol-Myers Squibb/Pfizer EEIG -2016 15:22 y MAH contact person roved On: 23-Ma pp roved\A pp This document contains confidential information belonging to Pfizer.
    [Show full text]
  • 1 the Business of Medicine
    Chapter 1 The Business of Medicine Coding as a Profession language, a patient’s condition, or the care provided can change code selection completely. Each time you receive health care, a record is maintained of the resulting observations, medical or surgical inter- Technicians who specialize in coding are medical coders ventions, and treatment outcomes. This medical record or coding specialists. Medical coders assign a code to includes information concerning your symptoms and each diagnosis, service/procedure, and (when applicable) medical history, the results of examinations, reports of supply, using classification systems. The classification X-rays and laboratory tests, diagnoses, and treatment system determines the amount health care providers plans. will be reimbursed if the patient is covered by Medi- care, Medicaid, or other insurance programs using the At its most basic, coding is the process of translating system. this written or dictated medical record into a series of numeric or alpha-numeric codes. There are sepa- If the medical record is inaccurate or incomplete, it rate code sets to describe diagnoses, medical and will not translate properly to the language of codes and surgical services/procedures, and supplies. These reimbursement for services may be lost. The coder must code sets serve as a common “shorthand” language to evaluate the medical record for completeness and accu- ease data collection (for example, to track disease), to racy and communicate regularly with physicians and evaluate the quality of care, and to determine costs and other health care professionals to clarify diagnoses or reimbursement. to obtain additional patient information. Coders may use computer programs to tabulate and analyze data to Coders may use several coding systems, such as those improve patient care, better control cost, provide docu- required for ambulatory settings, physician offices, mentation for use in legal actions, or use in research or long-term care.
    [Show full text]
  • (Child Core Set) Technical Specifications and Reso
    Core Set of Children's Health Care Quality Measures for Medicaid and CHIP (Child Core Set) Technical Specifications and Resource Manual for Federal Fiscal Year 2019 Reporting February 2019 Center for Medicaid and CHIP Services Centers for Medicare & Medicaid Services This page left blank for double-sided copying ii ACKNOWLEDGMENTS For Proprietary Codes: CPT® codes copyright 2018 American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004-2018 The International Health Terminology Standards Development Organisation. All Rights Reserved. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the World Health Organization (WHO). ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. The International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-PCS) is published by the World Health Organization (WHO). ICD-9-PCS is an official Health Insurance Portability and Accountability Act standard. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is published by the World Health Organization (WHO). ICD-10-CM is an official Health Insurance Portability and Accountability Act standard. The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) is published by the World Health Organization (WHO). ICD-10-PCS is an official Health Insurance Portability and Accountability Act standard. This material contains content from LOINC® (http://loinc.org).
    [Show full text]
  • Inappropriate Primary Diagnosis Codes Policy, Professional
    Commercial Reimbursement Policy CMS 1500 Policy Number 2020R0122C Inappropriate Primary Diagnosis Codes Policy, Professional IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, the enrollee’s benefit coverage documents and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.
    [Show full text]
  • G11.11: New Icd-10-Cm (Diagnosis) Code for Friedreich's Ataxia
    G11.11: NEW ICD-10-CM (DIAGNOSIS) CODE FOR FRIEDREICH’S ATAXIA EFFECTIVE OCTOBER 1, 2020 CALL TO ACTION – PROVIDE THIS INFO TO YOUR CLINICIANS Starting on October 1, 2020, at your next appointments with any clinician, ask that your ICD-10 diagnosis code for FA be updated to G11.11 (previous code for FA was G11.1 > add a “1” > G11.11). Your clinician can use multiple ICD-10 diagnosis codes based on your need for medical care (e.g. G11.11 – FA, I49.9 - cardiac arrhythmia, Z13.1 – encounter for screening for diabetes mellitus). Please email [email protected] if you or your clinician has questions regarding use of G11.11 PREVIOUS CODING FOR FRIEDREICH’S ATAXIA ICD-9 system had a specific code for FA: 334.0 In conversion to ICD-10, the code for FA became less specific because it covered a group of conditions described as “early-onset cerebellar ataxias”. The previous FA ICD-10 diagnosis code was G11.1. BENEFITS OF THE NEW FA-SPECIFIC ICD-10-CM CODE G11.11 • Fewer rejected health insurance claims • Payer coverage determinations without need for direct access to patients’ medical records for review of medical necessity • Monitor adherence to clinical management guidelines and track care outcomes • Evaluate symptom progression of FA; additional ICD-10 codes can be applied to reflect context of FA diagnosis, such as for falls, surgeries, medications, and co-morbidities • Enhanced ability to track disease prevalence BACKGROUND ON ICD CODING SYSTEM ICD = International Classification of Diseases The ICD coding system was established by the World Health Organization; currently used by ~100 countries for reporting cause of death and epidemiology statistics.
    [Show full text]
  • Development of the ICD-10 Procedure Coding System (ICD-10-PCS)
    Development of the ICD-10 Procedure Coding System (ICD-10-PCS) Richard F. Averill, M.S., Robert L. Mullin, M.D., Barbara A. Steinbeck, RHIT, Norbert I. Goldfield, M.D, Thelma M. Grant, RHIA, Rhonda R. Butler, CCS, CCS-P The International Classification of Diseases 10th Revision Procedure Coding System (ICD-10-PCS) has been developed as a replacement for Volume 3 of the International Classification of Diseases 9th Revision (ICD-9-CM). The development of ICD-10-PCS was funded by the U.S. Centers for Medicare and Medicaid Services (CMS).1 ICD-10- PCS has a multiaxial seven character alphanumeric code structure that provides a unique code for all substantially different procedures, and allows new procedures to be easily incorporated as new codes. ICD10-PCS was under development for over five years. The initial draft was formally tested and evaluated by an independent contractor; the final version was released in the Spring of 1998, with annual updates since the final release. The design, development and testing of ICD-10-PCS are discussed. Introduction Volume 3 of the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) has been used in the U.S. for the reporting of inpatient pro- cedures since 1979. The structure of Volume 3 of ICD-9-CM has not allowed new procedures associated with rapidly changing technology to be effectively incorporated as new codes. As a result, in 1992 the U.S. Centers for Medicare and Medicaid Services (CMS) funded a project to design a replacement for Volume 3 of ICD-9-CM.
    [Show full text]