65 terms

Training Day 6- Billing and Coding

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Terms in this set (...)

superbill
a bill, submitted to the insurance company, that reflects the services provided to the patient
ICD
international classification of diseases
V-code
a billing code for preventative care
CPT
current procedural terminology
E&M
evaluation and management
LOS
level of service
problem-focused
a visit, history, or exam that focuses solely on the chief complaint
in-house study
a study (usually a lab test) that can be done in the clinic, during an appointment- typically results in a few minutes
6.1: what distinguishes a new patient from an established patient?
NEW- a patient who has had no care by any member of the billing physician's specialty or practice group within 3 years
ESTABLISHED- a patient that has been seen in the clinic within the last 3 years
New
*no previous records
*longer visit
*detailed chart
established
*previous records available
*shorter visit
*concise chart
alice has an orthopedic visit with Dr. Smith whose partner, Dr. Roy, saw alice 18 months ago for a wrist sprain. Is alice considered a new patient during her appointment with Dr. Smith?
no, established
which type of patients (new or established) typically have a longer and more detailed visit?
new patients
what is the cutoff for a patient to be considered established at a particular clinic?
3 years
check-up
3 month diabetes maintenance visit
6.2: how is a billable chief complaint documented?
The chief complaint is the primary reason(S) that brought the patient to the clinic. ALWAYS include a chief complaint. EVERY level of billing requires a chief complaint to be documented
follow-up
HTN management evaluation
lab results
discuss treatment options for elevated TSH
medication refill
evaluation of medication management for HTN
Why is it important to include a chief complaint on every chart?
ALWAYS include a chief complaint. EVERY level of billing requires a chief complaint to be documented
Fix the following chief complaints to make them billable:
1. results of bloodwork (low hemoglobin)
2. HTN follow-up
3. refill of lisinopril
4. check-up- HLD
1. discuss treatment options for low hemoglobin
2. HTN management evaluation
3. evaluation of medication management for HTN
4. 3 month HLD maintenance visit
6.3: what are the five E&M levels and why focus on a level 4?
level 1: minimal
level 2: problem-focused visit
level 3: expanded problem-focused
level 4: detailed
level 5: comprehensive
What is the most commonly used E&M level?
The most commonly used E&M levels are 3 and 4. We encourage you to always aim for level 4 charts, even though some visits are more simple and may actually be a level 3
LEVEL 4- New patient
HPI elements
ROS elements
PMHx
PE
Assessment/plan
4
10
3
10
1
LEVEL 4- Established patient
HPI elements
ROS elements
PMHx
PE
Assessment/plan
2
2
1
2
2
T/F: Level 4 is a "Comprehensive" E&M level
F- detailed
Why is it important to memorize the elements needed for a level 4?
b/c it will allow you to bill for that level
Do new patients require more or less documentation than established patients in order to bill for the same level?
more
How many HPI elements are needed for a new patient level 4?
4
How many ROS elements are needed for an established level 4?
2
6.4: how is a level 4 visit documented?
History
Physical exam
Assessment and plan
Low risk
*two or more minor problems
*one stable chronic illness
*acute uncomplicated illness or injury
Moderate risk
*one or more chronic illness with mild exacerbation or progression
*two or more stable chronic illnesses
*undiagnosed new problem with uncertain prognosis
*acute illness with systemic symptoms
*acute complicated injury
*prescription drug management
high risk
*one or more chronic illness with severe exacerbation or progression
*acute or chronic illness or injuries which pose a threat to life or bodily function (e.g. acute MI,)
T/F: every patient whether new or established must have a complete 10-system ROS.
false. Only new patients
Based on what you have learned so far, how many systems need to be documented on the physical exam for a new patient? Established patient?
New- 18(9)
established- 12(2)
LEVEL 4- new patient
HPI elements
ROS elements
PMHx
PE
Assessment/ plan
4
10
3
10
1
LEVEL 4- new patient
HPI elements
ROS elements
PMHx
PE
Assessment/ plan
2
2
1
2
2
6.5: how are E&M codes assigned?
Problem/ health risk + counseling = E&M level
(RISK) No PMHx, here for an ankle sprain
low risk
Check-up for HTN and DM
moderate risk
Asthma was recent exacerbation
moderate risk
HTN well controlled with UTI symptoms
moderate risk
No PMHx; blood pressure has been high recently
low risk
What percentage of the patient encounter must be spent face-to-face to bill for counseling time?
>50%
Level 3- New patient
History
*HPI (<4 elements)
*ROS (<9 systems)
*PMH/FH/SH (<1 element per section)
Physical exam
*(<9systems or 18 bullets)
A & P
*missing either problem, data or risk
Level 4- New patient
History
*HPI (4 elements)
*ROS (9 systems)
*PMH/FH/SH (3 sections needed)
Physical exam
*(9systems or 18 bullets)
A & P
*needs to include: problem, data or risk
Level 3- established patient
History
*HPI (<2 elements)
*ROS (<2 systems)
*PMH/FH/SH (<1 element per section)
Physical exam
*(<2 systems or 12 bullets)
A & P
*missing either problem, data or risk
Level 4- established patient
History
*HPI (2 elements)
*ROS (2 systems)
*PMH/FH/SH (1 element per section)
Physical exam
*(< systems or 12 bullets)
A & P
*needs to include 2 or the following: problem, data, and risk
6.6: what is a superbill?
a superbill is a bill that details the services provided to the patient during a single visit
*the healthcare provider generates the superbill
*the superbill is submitted to the insurance company (or patient) for reimbursement
*insurance company reimburses provider for services performed
*any remaining balance is billed to the patient
What information does the superbill contain?
the superbill contains:
*provider's name and information
*patient's name and information
*visit date and information
*items to be billed
A superbill is generated by the provider after the patient's visit. what are two items that must be marked on every superbill?
ICD-10 codes
E&M code
6.7: what are ICD-10 codes and how are they assigned?
ICD stands for International Classification of Diseases
ICD-10 codes range from general to specific
More specific codes are better and result in higher reimbursement
What are the types of ICD-10 codes?
*newly diagnosed diseases
*established but ongoing diseases
*symptoms
T/F: every superbill must have at least one ICD-10 code.
T
T/F: it is best to assign the most general ICD-10 code for the disease because general codes bill higher.
F
6.8: What are V-codes and why are they important?
codes for preventative care. Examples include:
*check-ups for children V20.2
*annual gynecological exams V72.31
*vaccinations V03-V06
T/F: V-codes are reimbursable.
F. v-codes are NOT reimbursable. You must always have an ICD-10 code with the V-code. V-codes allow for reimbursement of other services that are not otherwise authorized
6.9: What are CPT codes and how are they assigned?
CPT = current procedural terminology. CPT codes include:
*E&M codes
--> every superbill must have an E&M code
*procedures codes
*medication codes
*counseling codes
E&M codes for new patients
Level 1
2
3
4
5
99201
99202
99203
99204
99205
E&M codes for established patients
Level 1
2
3
4
5
99211
99212
99213
99214
99215
T/F: you must always have an ICD-10 code with the CPT code.
T. The ICD-10 code should fit together with the CPT code
List 5 examples of modifiers?
In house lab examples:
1. pregnancy test
2. INR check
3. finger-stick blood glucose
4. rapid strep test
5. urine dip
When is a modifier needed?
if a procedure is performed or an in-house lab obtained, we must have a modifier- 25 to bill for the service. this can sometimes be found in a drop down menu next to the E&M code in the superbill
If the physician verbalizes an E&M code for 99214, does this pertain to a new patient or an established patient?
established