Basics of Billing and Coding & Understanding Pre-Authorization

DayneAlonso, MMS, PA-C
Miami Cancer Institute

 Concise documentation is critical to providing
patients with quality care and to ensure accurate
and timely reimbursement.
 Medical records are used by payers to validate
that the services provided were medically
necessary and were consistent with the
individual’s insurance coverage.
 Evaluation and Management (E&M) Services is
the service that is provided by a provider (PA/NP
or physician) introduced in 1993 by the AMA and
CMS.

 CMS has developed the requirements for
provider documentation since 1995
 Collaborated with reimbursement for all
services
 All commercial and other payers follow CMS
rules

 A provider can bill or code for a number of
different types of patient encounters.
 Evaluation and Management Services (E&M)
codes include:
- office/outpatient visits
- outpatient consultations
- Inpatient hospital visits
- inpatient consultations
- Management of observation/critical care
patients

 Current ProceduralTerminology code set
used for insurance billing.
 The American Medical Association created
and maintains the CPT code set.
 Listing of descriptive terms and identifying
codes for reporting medical services and
procedures
 Uniform language for processing insurance
claims

Determined by several factors:
 New, established, or seen for consultation services.
 Type of facility where care is provided.
 Level of service – determined by the History, PE, medical
decision making
Time spent face to face with the patient, time spent reviewing
records, and the complexity of the case are other factors.
All of these factors are taken into account when finding the
right CPT code.

Determined by:
 History
 Physical Exam
 Medical Decision Making

 International Classification of Diseases – 10th
edition
 Reason for the services (i.e. diagnosis)
 Classifies diseases and injuries and is used to
track mortality and morbidity statistics.
 Use by national and international agencies to
forecast healthcare needs, evaluate facilities
and services, review costs, and conduct studies
of trends in diseases.
 ICD 9 (17,000) vs. ICD 10 (155,000)

 When billing for each patient encounter, the
provider must include a CPT and ICD-10 code.
Example: 99213 – CPT code (established
patient)
F50.00 - Anorexia

 Any tests ordered must correlate with an ICD 10 code
assigned to the visit.
 Pregnancy test ordered –What is the ICD 10 code
 Assign an ICD code that reflects the most specific
diagnosis that is known at the time
 The primary code should reflect the patient’s chief
complaint or the reason for the encounter.
Ex: has a hx of Diabetes, HTN but presented for abdominal
pain - primary code should be abdominal pain.

Do not use “rule out..” as a diagnosis –There is
no code for this. Instead, use a diagnosis,
symptoms, condition, or problem
Signs and symptoms that are routinely
associated with a disease process should not
be coded separately.
When the same condition is described as both
acute and chronic, code both and use the
acute code first.
ie. Acute on chronic renal failure

 Others may do the billing and coding for you
however, your documentation must be intact.
 Downcoding refers to the process by which an
insurance company reduces the value or procedure or
encounter and resulting reimbursement. Either due
to the CPT code mismatch or ICD 10 code does not
justify the level of service.
 The quality and accuracy of the medical record are
vital to the reimbursement process, which in turn is
vital to the delivery of health care.

 Insurance company representatives
 State Federal payers (reviewing for fraud and
abuse)
 Peer review organizations
 Researchers
 Hospital peer review committees
 Medical professionals involved in the active
care of the patient
 The PATIENT and their FAMILIES

 Center for Medicare and Medicaid Services (CMS) is an agency
of the US Department of Health and Human Services (HHS).
www.cms.gov
 Nation’s largest payers for health care services
 Developed specific guidelines for documentation – 1995 and
1997
 1995 Guidelines - https://www.cms.gov/outreach-and-
education/medicare-learning-network-
mln/mlnedwebguide/downloads/95docguidelines.pdf
 Evaluation and management guide 2009 -
https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-
serv-guide-ICN006764.pdf

 The medical record should be complete and
legible
 Each patient encounter should include:
 Reason for the encounter
 Relevant history (pertinent negatives and positives)
 Physical examination
 Diagnostic test results (labs, imaging)
 Diagnosis (also called Assessment or Impression)
 Plan of Care
 Include a date, time, and provider signature

 Rationale for ordering diagnostic and other
services should either documented or easily
inferred.
(i.e. Chest X-ray will be ordered to evaluate
patient’s cough which is unresponsive to
treatment)
 Past and present diagnoses should be
accessible to the treating and consulting
providers
(i.e. history of Rheumatoid Arthritis, HTN, )
 Heath risk factors should be identified
(i.e. morbid obesity)

 Patient’s progress, response to and changes in
treatment, revision of diagnoses should be
documented
(i.e. Diagnosis: UrinaryTract Infection - Plan:
Patient continues to experience dysuria despite
current antibiotics after reviewing the culture
and sensitivity report, the patient will benefit
from Levaquin 500mg PO daily x 5 days, will re-
evaluate after tx)
 CPT and ICD-10 codes should be supported by
the documentation in the medical record.

 Date,Time (military time), and Provider
Name/Signature
 Never chart in advance of seeing the patient
 Make appropriate corrections
 If record is dictated and then transcribed, you
should read and edit before signing.
 Avoid medical abbreviations (facilities have
own list)

 A decision by a health plan that a health care
service, treatment, prescription drug or
durable medical equipment is medically
necessary.
 Complete the process prior to the service
being reimbursed.
 Ex: PET/CT scan, chemotherapy

Basics of Billing and Coding & Understanding Pre-Authorization

Basics of Billing and Coding & Understanding Pre-Authorization

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Basics of Billing and Coding & Understanding Pre-Authorization