If a claim request has been submitted incorrectly, resulting in errors found before it is processed, the insurance company will reject the claim and not pay the bill as written. Upcoding can increase reimbursements. 12. downcoding A change in a code or codes for entries submitted for reimbursement. unbundled codes Codes in which the components of a major procedure are separated and reported separately. A upcoded bill can be sent to any payerwhether a private health insurer, Medicaid, Medicare, or the patient. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. Describe the process and steps for selecting the most accurate code based on clinical documentation. Prescriptions were issued in his name without adequate physical exams, proper diagnoses, or consideration of alternative treatment options. -Encounter form Consumers' frequently asked questions. The Alphabetic Index is a comprehensive, alphabetic listing of all procedures and services in the CPT manual. Good documentation practice helps ensure that your patients receive appropriate care from you and other providers who may rely on your records for patients' past medical histories. When a medical biller or coder makes a mistake, it can delay the claims process, cause a loss of revenue and/or affect a patient's care. Codes used on professional claims to specify the facility or location where the service or services were rendered. Administrators who run healthcare systems can benefit professionally when their profits are impressive, and upcoding is one way to make that happen by cheating the system. modifiers Terms that serve as the means to report or indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition or code. Category I codes that state specifically Exempt from modifier -63 do not require use of this modifier. Centers for Medicare and Medicaid Services. The process for coding procedures and services will prove to be similar to that of ICD-9-CM and diagnostic coding, except she will use a different coding manual, the Current Procedural Terminology (CPT), for most procedural and services rendered coding. While not a fraudulent practice like upcoding or undercoding, poor documentation can also negatively affect the claims process. inaccurate acceptable fraudulent Both A and C answers are correct The CPT manual is a list of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The subsection usually describes an anatomic site or an organ system, as in the following examples: Organ system: digestive, integumentary, or cardiology. Some special considerations and differences apply to the E/M and Anesthesia sections. In addition, they submit bills to insurance companies, which then pay claims. The modifiers for HCPCS are codes composed of two alphanumeric characters. If you think there is a problem with your bill, you can take action: Unfortunately, hospitals, healthcare providers, and diagnostic facilities have been caught upcoding. They can either explain to you why it is correct, they may offer to correct it, or they may be just as disturbed by the discrepancy as you are. The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. But physicians often inappropriately cut and paste data and services performed from previous patient visits. The subcategory is listed below the category and indented two spaces. A plus sign (+) indicates an add-on code. For tips you can share with your patients on how they can protect themselves from medical identity theft, see OIG's brochure entitled Medical Identity Theft & Medicare Fraud Brochure. The dermatologist admitted to falsifying lab tests and backdating letters to referring physicians to substantiate false diagnoses to make the documentation appear that his patients had Medicarecovered conditions when they did not. Consider the examples presented in Table 19-3. The state of a patient as either new or established; appears in the Evaluation and Management section of the CPT. Explain how to find codes in the Alphabetic Index of the CPT manual. The manual was developed after the AMA recognized a need for a standardized description of services that would be universally understood by physicians, hospitals, insurance companies, and all involved in the reimbursement or statistical data collection process. He paid $317,000 in restitution to the Government. In addition, these codes enable automated computer processing of claims, which also saves time and effort. In each section (and sometimes in subsections, categories, and/or subcategories), nonspecific codes have been provided. Code to the specificity based on the statements provided. The code ranges for the Pathology and Laboratory section are 80047 to 80076 for Organ or DiseaseOriented Panels and 80100 to 89999 for all other tests. While studying this chapter, think about the following questions: What will Sherald find similar to what she learned with the ICD-9-CM as she performs procedural coding? In one facility audit with more than 300 providers, Jimenez found that physicians coded correctly only 30% of the time. Sections are subdivided into subsections; subsections are further divided into categories; and categories can be subdivided into subcategories. Information pertinent to code selection is taken from a variety of medical documents. Sherald is beginning to fully understand the impact diagnostic and procedural coding has on reimbursement, and her responsibility to uphold ethical standards when coding to keep her employers, Dr. Shuman, Dr. Taylor, and Dr. Caddell, in compliance with federal and state guidelines. business math. What are the differences between coding for the CPT and coding for HCPCS? Code 15401 describes each additional 100 sq. This requires a solid understanding of medical terminology, anatomy, and physiology and a knowledge of how to use the CPT manual and its symbols, conventions, guidelines, and notes. If you knew or should have known that the submitted claim was false, then the attempt to collect unearned money constitutes a violation. determine the exact ethical issue involved. A upcoded bill can be sent to any payerwhether a private health insurer, Medicaid, Medicare, or the patient. They keep doctors and nurses on track and organized by carefully documenting patient procedures and treatments. Question text. Physicians should maintain accurate and complete medical records and documentation of the services they provide. CPT and HCPCS (discussed later in the chapter) are used in the claims submission process to obtain reimbursement from payers, to track physicians productivity, and to provide statistical data for research and other purposes. An invasive procedure is defined as any medical procedure in which a bodily orifice or the skin must be penetrated by cutting, puncture, or other method. Consequently, you should recognize that the issues discussed here may apply to your care of all insured patients. 10. The second, less common, way to obtain Medicare reimbursement is to bill as a nonparticipating provider. billing for services that you did not actually render; billing for services that were not medically necessary; billing for services that were performed by an improperly supervised or unqualified employee; billing for services that were performed by an employee who has been excluded from participation in the Federal health care programs; billing for services of such low quality that they are virtually worthless; and, billing separately for services already included in a global fee, like billing for an. What is upcoding? 90716 can be used for the administration of the chickenpox vaccine (varicella) 12002 can be used when a healthcare provider stitches up a 1-inch cut on your arm. Study with Quizlet and memorize flashcards containing terms like Ambulatory surgical centers are health care facilities focused on providing, Common ASC specialties include all but which of the following:, The accrediting body for ambulatory surgical centers is and more. Health Econ Rev. Participating providers receive the Medicare program's 80 percent directly from the Medicare program and bill the beneficiary for the remaining 20 percent. This booklet Hotline accepts tips and complaints provides the following tools to help protect the from all sources on potential fraud, Medicare Program, your patients, and yourself:waste, and abuse. Bundled codes indicate procedures or services that are grouped together and paid for as one procedure or service, as designated by the NCCI edits. Study with Quizlet and memorize flashcards containing terms like What should the assistant do when a code range is given in the CPT-4 index?, Which level of HCPCS does Medicare no longer use, An essential modifier, if available, must be included in the code and more. The Medicine section includes many and varied subsections, categories, and subcategories. In exchange for the fee, the physician offered: (1) an annual physical; (2) same- or next-day appointments; (3) dedicated support personnel; (4) around-the-clock physician availability; (5) prescription facilitation; (6) expedited and coordinated referrals; and (7) other amenities at the physician's discretion. Keep in mind that your healthcare provider is not in charge of billing you for services that you were referred toif a lab or diagnostic facility billed you for services that were not the same as the services you received, be sure to let your healthcare provider know, as he or she may stop referring to that facility. CPT (current procedural terminology). During residency, you probably are not focused on who pays for your patients' care. Examples of conventions include triangular and round symbols, which indicate that a code or description was revised, removed, or added. Lizzy came in for her 2-month-old well child (preventative) check. Upcoding: Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement. An official website of the United States government. What will Sherald find similar to what she learned with the ICD-9-CM as she performs procedural coding? Explain how to analyze and select codes using the CPT Main Text. These vaccines are listed in Appendix K and are identified in the Tabular Index of the CPT in various ways by different publishers. cm. If the medical assistant had not reviewed the medical record, a code with a lower reimbursement amount for the procedure would have been submitted to the insurance carrier, and the provider would have lost revenue. Upcoding is illegal, but there are hospitals and healthcare providers who have been caught doing it. Physicians must report UOS correctly. When multiple procedures are performed at the same session by the same provider, the primary procedure is reported, and the additional procedure or service is identified by appending modifier -51 to the procedure or service code. For more information on physician documentation, see CMS's Documentation Guidelines for Evaluation and Management Services . Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Official websites use .gov When practices say they cant afford to hire a coder, she says, I tell them they cant afford not to. If hiring a full-time coder isnt feasible, consider billing/coding contractors. b. respondeat superior. Like CPT codes 99417 and 99418, HCPCS codes G2212, G0316, G0317, and G0318 can only be used when time is used to select the level of service. For instance, modifier -50 adds the detail that a procedure was performed bilaterally, or on both sides of the body. A denied claim can be appealed, but such an appeal takes time and can be expensive. Unless the coder or biller is able to consult directly with the provider and clarify the situation, a claim request may be submitted incorrectly. Campus Medical Billing and Coding Training Program gives you the background you need to enter the exciting, busy world of healthcare. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients. Explain how to analyze and select codes using the CPT Main Text. Codes are included for the types of anesthesia administered (e.g., general, local, and sedation anesthesia); other support services, including the anesthesiologists preoperative and postoperative encounters with the patient, evaluation of the patients physical status, and the administration of anesthesia, fluids, and/or blood; and monitoring services, such as blood pressure, temperature, and electrocardiography (ECG). The symbols, guidelines, conventions, and other instructions found in the CPT manual contain all the information needed to select the correct code for the procedure or service documented in the medical record. Codes in which the components of a major procedure are separated and reported separately. Selecting a code without reading the guidelines will usually lead to selection of the wrong code. established patient (EP) A patient who has received professional services (face to face) from the physician, or from another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. The Medicare and Medicaid programs may review beneficiaries' medical records. Some of the procedures in the CPT are not printed in their entirety but refer back to a common portion of the procedure listed in a preceding entry. View instructional videos about the OIG Hotline operations, Medicare fraud and abuse examplesas well as reporting fraud to the OIG. A main term can identify a procedure or service performed; an organ or anatomic site; a condition, illness, or injury; or an eponym, abbreviation, or acronym. Explain how to analyze and select codes using the CPT Main Text. It generally refers to a specific procedure or service, but it can also indicate a more specific anatomic site: Procedures: esophagoscopy, incision and drainage, or cardiac catheterization, Specific anatomic site: mitral valve, distal femur, or occipital bone. Care provided to unstable, critically ill patients. Appendix B: Summary of Additions, Deletions, and Revisions: For easy reference, at each annual update of the CPT, this appendix lists all changes made from the previous year. cm. Rather, they bill their patients and the patients seek reimbursement from Medicare. You may have heard the saying regarding malpractice litigation: "If you didn't document it, it's the same as if you didn't do it." Just imagine, for example, if a billing department had to describe, in writing, every single one of the medical procedures and services represented by the codes in the CPT manual. Whether intentional or unintentional, overcoding is considered fraud and can trigger an audit. Conventions (Figure19-2) are special symbols used to provide additional information about certain codes. Professional Fees, Billing, and Collecting, Kinns The Administrative Medical Assistant An Applied Learning. In procedural coding, the outline or summary assists in ensuring that all procedures and services are included in an insurance claim submission and that nothing is omitted or added to the encounter form or charge ticket; as a verb form. If you are concerned that the hospital where you receive your medical care is guilty of upcoding, there are some steps you can take to make sure your payer has not been billed fraudulently. In procedural coding, an abstract is created to find all the procedures and services performed during a patient encounter and also to ensure that nothing has been omitted from or added to the encounter form or charge ticket that is not documented in the medical record. FDA Which of the following agency oversees CLIA? Phone and Online Service Codes on Your Medical Bill. A HCPCS/CPT code may be reported only if all services described by that code have been performed. Poor documentation. Many States also have adopted similar laws that apply to your provision of care under State-financed programs and to private-pay patients. Before continuing, consider this important fact: there are roughly 150,000 procedure and service codes in the CPT manual and thousands more in the HCPCS manual. The Alphabetic Index is like any other index in a textbook; it is simply a guide to finding data in the body of the textbook. Category II codes are optional; they cannot be used as a substitute for Category I codes, and they are not reported as part of the billing process. Explain how to find codes in the Alphabetic Index of the CPT manual. Once you start practicing, it is important to understand who the payers are. This is evident when an entry is followed by one or more indentations. Emergency Department Services (New/Established Patients) Appendix I: Genetic Testing Code Modifiers: Lists all modifiers, and their descriptions, unique to genetic testing. The abstracted data are then broken down into main terms and modifying terms. 5,6,7,8 quiz. 7 STUDY REVIEW Flashcards Learn Test Match Flashcards Learn Test Match Created by jerica727 Terms in this set (57) The practice of upcoding may be considered _____________ by government and private payers when they examine claims for payment. What will help Sherald in selecting the most specific and accurate CPT code? 13. If you receive Medicaid, you'll need to check withyour state's Medicaid officeto see how they want upcoding or other fraud reported. Two- or five-digit alphanumeric modifiers, included with the five-digit CPT code, can be used to supply additional information or to describe extenuating circumstances that affect the rendered procedure or service. occurs when healthcare providers or suppliers perform actions that directly . Thats problematic., EHRs frequently have integrated computer-assisted coding modules based on documentation. The following appendixes are found in the CPT manual. Non-participating providers do not receive direct payment from the Medicare program. cm. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). Center for Health Journalism. Each code has a description of the service or procedure performed. The physician allowed unauthorized and non-medical employees at his pain center to prescribe drugs using his pre-signed blank prescription forms. What is Overcoding? A .gov website belongs to an official government organization in the United States. What will Sherald learn about the legal and compliance implications of improper coding? For example, code 29999 is found in the Surgery section, Musculoskeletal subsection. Appendix L: Vascular Families: Lists the elements of the vascular system, grouped by families, beginning at the aorta and ending at the termination point of each vessel. abstract An outline or summary of the diagnostic statement and/or procedures and services performed. Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves: Lists each sensory, motor, and mixed nerve conduction study code. The codes for the Medicine section range from 90281 to 99199 and 99500 to 99607 (excluding the anesthesia code ranges described in the Anesthesia section). Sometimes, doctors, nurses, and advanced practice providers who are employed are unaware that their own services are being upcoded if malicious employers are secretive about billing. What is the result of upcoding? There is a lot of information to know. Tests frequently ordered together that are organ or disease oriented. An endocrinologist billed routine blood draws as critical care blood draws. 7. True- Upcoding can increase reimbursements but is considered an illegal practice. Category III codes are temporary codes assigned for emerging and new technology, services, and procedures that have not been officially added to the Main Text of the CPT manual. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Appendix M: Deleted CPT Codes: Provides a summary of crosswalked, deleted and renumbered codes and descriptors. Tabular Index The Main Text of the CPT manual; it contains the alphanumeric listing of all Category I procedure and service codes and their respective descriptions. Upcoding and unbundling are common types of healthcare fraud. Individuals qualified by education, training, licensure or regulation, and facility privileging who perform a professional service within their scope of practice and independently report that professional service. This appendix aids the accurate use of codes 95900, 95903, and 95904. Additional examples of improper claims include: Medicare pays for many physician services using Evaluation and Management (commonly referred to as "E&M") codes. Physicians also should ensure that the claims they submit for payment are supported by the documentation. Modifying terms affect the selection of appropriate codes; therefore, it is important to review the list of modifying terms when selecting a code or code range. the intent of the error What are the four elements needed in a negligence case? c. res judicata. by using add-on code 15401 (+15401). According to the Bureau of Labor Statistics, the employment rate for medical records and health information technicians (billers and coders) is growing much faster than the average for other occupations because people in these jobs are the ones who handle insurance and patient claims. This, too, is intentional and fraudulent. Modifiers are numeric supplements to a Category I code, whereas modifying terms are words that add to or modify the meaning of the main term. The psychiatrist also misrepresented that he provided therapy sessions when in fact a non-licensed individual conducted the sessions. National Health Care Anti-Fraud Association. Verified answer. Describe the steps for abstracting procedural data from clinical documentation. Add CPT codes, the five-character Current Procedural Terminology codes that are the U.S. standard for the way medical professionals document and report medical, surgical, laboratory, radiology, anesthesiology and E/M (evaluation and management) services, to the equation, and the coders job becomes even more complex, with a greater chance for making mistakes. Sedation may be billed as more complex anesthesia, or a procedure that was done by an assistant or nurse may be billed as if it was done by the doctor. Look-up tools and software for electronic codes can identify components of a procedure that should be bundled. Appendix C: Clinical Examples: Provides helpful narrative examples that aid selection of the correct and most specific level of E/M codes. List the six main sections of the CPT and describe their content. upcoding can result in: serious fines & penalties assigning a diagnosis code that does not match patient documentation for the purpose or increasing reimbursement through the DRG system is known as: upcoding When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. - Codes assigned for similar diseases and procedures. 99397 can be used for a preventive exam if you are over age 65. The Alphabetic Index is used as a guide to search for one or more codes or code ranges. c) a violation of the Medical Practice Acts. A physician was ordered to pay $50,000 in restitution to the Government for falsely indicating on his provider number application that he was running his own practice when, in fact, a neurophysiologist was operating the practice and paying the physician a salary for the use of his number. In the CPT manual, the subsection is listed below the section and indented two spaces. d. thoughts a person has. This, like undercoding, is a fraudulent practice, and should be noted and reported immediately. These errors are often intentional and considered to be fraudulent. c. Fraud involves intentional deception or misrepresentation while abuse does not. Physicians must avoid upcoding. The Drug Enforcement Administration (DEA) is a Department of Justice agency responsible for enforcing the Controlled Substances Act. Procedural coding is defined as the transformation of verbal descriptions of medical services and procedures into numeric or alphanumeric designations.
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