Every healthcare claim, regardless of specialty, is submitted to third-party payers through the language of industry-standard medical code. Every physician uses the same code books to submit claims for payment after services have been provided. Current Procedural Terminology (CPT) is used to describe outpatient procedures. Healthcare Common Procedure Coding System (HCPCS) Level II codes are used to report specific procedures and quality measures to Medicare. The International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) is used to describe the reasons procedures are performed.
While every physician utilizes the same basic coding standards, an experienced medical billing company knows that no two medical specialties are alike when it comes to seeking compensation for medically necessary services. A look at the code books shows the reason. CPT codes are divided by medical specialty. HCPCS Level II codes are divided by type of service. Procedure coding and diagnosis coding are two different aspects of the same healthcare claim, and each system has its own requirements. A certified professional medical biller, medical coder, or documentation specialist knows how to use procedure codes to accurately report services and conditions to maximize timely reimbursement while reducing the need for costly appeals of denied claims.
Firstly, the medical record must be a reliable and unequivocal record of what occurred during a patient encounter. Unclear documentation results in unsubstantiated coding. While EHR and medical coding software has advanced to provide a rough draft of a CMS-1500, that claim still needs to be reviewed by an experienced, human, billing professional to ensure that it is accurate according to the contractual obligations between a medical practice and an insurer.
A professional medical biller needs to be familiar with the medical specialty for which he or she is crafting bills. For instance, surgical billers need to be aware of the global billing periods associated with specific procedures. Some procedures have a global billing period of 10, 30, or 90 days. This means that follow-up care related to a surgery is considered part of the original surgical package within a set time frame. Services are still reported, but the procedure code is modified in order to indicate what occurred while not expecting further reimbursement.
There are times, however, when a patient presents with an unrelated condition. A patient who visits his orthopedist for a cast check complains of a sinus infection. As a medical doctor, the orthopedist evaluates the patient’s upper respiratory tract for signs of infection and prescribes an antibiotic. Checking the cast is part of the surgical package. Evaluating and treating a URI is not. The examination of the patient and the following treatment is coded separate from the surgical package. A professional medical coder knows to submit a claim containing 99212 with the appropriate modifier for the unrelated service with the justification of the diagnosis 461.1, acute frontal sinusitis. This claim will result in accurate reimbursement for extra services performed for the patient’s benefit unrelated to the fracture that necessitated the cast.
Surgical billers are not the only documentation specialists who need to be aware of global billing periods. Any rearrangement of tissue falls within the surgical chapters of CPT, meaning that procedures internists or non-surgical physicians perform in their offices in the outpatient setting also fall under global billing rules. The CPT codes for biopsies or wound repairs are also associated with surgical packages. Professional medical billers, cognizant of the requirements of individual payers, know when to modify procedure codes to reflect bundled services for which reimbursement is not expected, and to modify procedure codes that fall outside the surgical package model with the associated diagnosis code.
The healthcare reimbursement system is a complex thicket of individual guidelines issued by payers and government legislation. Professional medical billig company will always be current on these guidelines. They utilize the contents of the medical record to submit clean claims that accurately reflect services performed in order to ensure legitimate, timely cash flow for a private medical practice.