Gender Specific Diagnose Coding

of 7 4/28/2018 Medical Necessity Diagnosis Coding

EXAMPLE 1 – CLAIM EDIT FOR INVALID DX

 BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE IF THE MEDICAL RECORD DOCUMENTATION SUPPORTS MEDICAL NECESSITY AS STATED IN THE LCD.

of 7 4/28/2018 EXAMPLE 2 – CLAIM EDIT FOR INVAILD DX

 BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE IF THE MEDICAL RECORD DOCUMENTATION SUPPORTS MEDICAL NECESSITY AS STATED IN THE LCD.

CODE PAIR & LCD ID NUMBER L28300 SUMMARY

of 7 4/28/2018 Gender Specific Diagnosis Coding EXAMPLE - CLAIM EDIT INVALID DX FOR PATIENT GENDER

Note: Placenta is an organ that develops within all female mammals during pregnancy.

 BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE THE GENDER SPECIFIC DIAGNOSIS PER MEDICAL RECORD.

Note: The prostate is a gland found in the male reproductive system.

of 7 4/28/2018 Payer Specific CPT Coding

EXAMPLE - CLAIM EDIT CPT NOT RECOGNIZED BY PAYER

 Note: Change Request (CR) 6740, which alerts providers that effective January 1, 2010, the Current Procedural Terminology (CPT) consultation codes (ranges 99241–99245 and 99251–99255) are no longer recognized for Medicare Part B payment. Effective for services furnished on or after January 1, 2010, providers should code a patient evaluation and management visit with E/M codes that represents where the visit occurs and that identify the complexity of the visit performed. Only applies to billing for physician services under the Medicare fee-for-service program. It does not revise existing policies or rules governing Medicare Advantage or non-Medicare insurers.

Additional Information If you have any questions, please contact toll-free J1 Provider Contact Center. For Part A call (866) 931-3906 or for Part B call (866) 931-3901. The official instruction, CR6740, issued to Medicare MACs and carriers regarding this change may be viewed at www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf on the CMS Web site. You may also want to review the related article SE1010 (Questions and Answers on Reporting Physician Consultation Services), which may be found at www.cms.hhs.gov/MLNMattersArticles/downloads/SE1010.pdf on the CMS Web site.

of 7 4/28/2018 The E/M documentation guidelines are available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp on the CMS Web site. CPT Modifiers - CPT APPENDIX A

EXAMPLE - CLAIM EDIT MISSING CPT MODIFIER

REFERENCE CPT MANUAL APPENDIX OF A - MODIFIERS

of 7 4/28/2018 EXAMPLE OF A CMS 1500 HEALTH INSURANCE CLAIM FORM (PATIENT DATA IS FICTIOUS)

Note: For CMS 1500 CLAIM FORM INSTRUCTIONS REFERENCE

of 7 4/28/2018