Coding

Physicians and other practitioners are required to justify the amount of money they charge for an patient interactions they bill as services. Medical billing coding is one way that this is monitored. Following a visit, the provider must document the extent of the medical attention needed. They will record the review of the patients history, the list of problems that the patient presents with, their physical findings, medical necessity and acuity or difficulty level of visit. Through an evaluation of these items a provider will then assign a CPT codes to the visit. Each and every service or procedure that is provided will be assigned a code.

In addition to the CPT codes, a provider will assign another code to the visit. This additional code will also help support medical billing coding. At some point in the visit, the provider will attach a diagnosis , or multiple diagnoses, to the visit. This is the actual reason for the visit, like hypertension, diabetes or hyperlipidemia. Each diagnosis has its own ICD - 9 code. So, the diagnosis is then translated in to its ICD - 9 code for billing purposes. Then, through a billing office, these codes along with necessary supporting office notes will be sent to the patients insurance company for reimbursement.

Dec 16 2007

Evaluation and Management - Healthcare by Intimidation

CPT, Coding, Healthcare IT, Healthcare Policy

Most Primary Care Physicians are more then familiar with CPT coding, or the Current Procedural Terminology (CPT) code set which is maintained by the American Medical Association.

These codes, mostly 5 digit numbers, represent the procedures that doctors, and other practitioners perform. These codes and are the basis on which payments from insurance and the Medicare are made.

This arcane system is normally reduced to a simple nomenclature based on the last digit in the CPT code. For example the CPT codes for new patient in-office visit are:

  • 99201
  • 99202
  • 99203
  • 99204
  • 99205

These numbers go from 1 to 5 so they are normally referred to a Level number exam. The higher the number the more complete the examination will be. Healthcare professional will use the verbal shortcut and say “It’s a Level 3 exam”

But let’s look at what happens when its time to get paid for these services. The insurance carriers gather E&M codes on a per practice basis. They gather these statistics and then they establish ratios that they expect a doctor to maintenance for the higher coded exams. This is quota system, nothing more and nothing less.

It is not usual to our staff to establish a solid working relationship with their counterparts at the insurance company. As a large processor of claims we will often be given “advice” when a physician is getting too near the “quota” for the higher level exams.

What does this means? It means that a PCP has to be concerned with towing the carriers’ line or expect a request for further documentation or even an audit.

The Journal of the American Board of Family Medicine study, Accuracy of CPT Evaluation and Management Coding by Family Physicians study done in 2001 was quite through but came to the wrong conclusions. Physician under-code old patients because they are afraid that they will be punished for spending too much time on each patient, which is what the higher level codes actually represents.

Further, they “over-code” new patients because the higher codes are extremely restrictive. The Evaluation and Management Services Guide issued by the The Centers for Medicare & Medicaid Services (CMS) is a confusing document. Even the AMA’s CPT coding book has a section towards its back that tries to breakdown the different levels and explain them in plain English with specific examples.

Correct coding will decrease claims denials and speed up payments, as a billing company that’s what Preferred Health assists our practices to do. But if CMS and the major carriers want to move towards preventive medicine they need to move away form intimidation by CPT code.

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