Author Topic: Medical Billing  (Read 3002 times)

donmar313@gmail.com

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Medical Billing
« on: April 26, 2013, 08:03:58 PM »
Richard, you hit the nail on the head when you said I am not coding, but trying to ORGANIZE the codes on the CMS 1500 properly.
Let me clarify my question by explaining the reason for the visit: a 40 year old female pt was seen for her annual checkup and during the examination the physician finds a lump in her left breast.   The physician considers this a significant finding and performs a problem-focused E/M service.I was given the codes below and added modifier 25 to the office outpatient code to indicate that a significant separately identifiable evaluation and management service was provided by the same physician on the same day as the preventative medicine service.  Is the diagnosis and procedure code ORDER as well as the diagnosis pointer ASSIGNMENT for the CMS 1500 correct below?
Box#21 Diagnosis...                   Box#24DProcedures...              Box#24E Diagnosis Pointer
#1 V70.0                                   99396____________________1
#2 611.72                                 99212____________________2
« Last Edit: April 28, 2013, 06:35:20 PM by donmar313@gmail.com »

RichardP

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Re: Medical Billing
« Reply #1 on: April 27, 2013, 04:59:19 PM »
Why did your patient make the initial appointment to see the doctor?  What was the complaint?  Whatever it was, that should be the priority coding.  Any else would be additional work.

Is it likely your patient came in because they had a lump in their breast, and decided to stay for a complete general physical?  Or could it be that they came in for the physical, and the doctor decided to devote additional attention to something he found or the patient brought to his attention.


PMRNC

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Re: Medical Billing
« Reply #2 on: April 27, 2013, 05:15:41 PM »
NO chart, no documentation, can't code.
Linda Walker
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RichardP

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Re: Medical Billing
« Reply #3 on: April 28, 2013, 03:47:12 PM »
Linda, they are not trying to code.  They have been given the codes and want to know how to set them up on the CMS 1500 Form properly.

I assumed that the question came either from a billing student or a brand new biller.  That is why I gave them questions to help think through the logic of the situation.  That is what we do when we prepare codes given to us by the doctor for billing.  Some doctors number the order of the diagnosis codes for us, and some don't.  But all expect us to know (or be able to figure out) the order in which the procedures should be presented in order to get paid the maximum legitimately due, without having access to the chart.  That is what we get paid to know, and I assume that is true for many other billers.

PMRNC

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Re: Medical Billing
« Reply #4 on: April 28, 2013, 04:32:02 PM »
The Medical chart does not just provide the necessary info to code but also the proper order as well
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Billergirlnyc

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Re: Medical Billing
« Reply #5 on: April 28, 2013, 06:13:05 PM »
I was going to say what Linda did. Part of the OP's question DOES involve coding and the OP should be asking this question to the doctor/provider if they don't have access to the patient's medical records. The order of the DX code can found in the medical documentation. You can't just make assumptions about this, the medical documentation must support the order of DX codes, just as it must support the CPT and DX codes being billed, and any biller who doesn't have access to the medical chart should be getting that info directly from the rendering provider/doctor, not to mention any biller who doesn't know how to code from the patient's chart should also be getting that directly from the doctor/provider.

Again: The documentation must support everything billed and if you don't have access to that, then the doctor is the one responsible for indicating what goes with what, even if you know. Knowing is great, but it's not the biller's responsibility to place DX codes where they think they go without having the chart or confirming that documentation supports it. But hey those are the rules I play by and was taught to play by.

Let me also mention: A superbill/encounter form is NOT a part of the patient's medical records and serves no purpose outside of billing/coding functions, thus can't be used to SUPPORT any coding/and or billing of a service. The only thing that can support the billing/coding of a service is the medical documentation. As per CMS the superbill is NOT a part of the patient's record. Now, the superbill/encounter form is a part of the financial records and certain states require doctors to keep these records for a number of years, etc, but it's not what you use to code or determine where those codes go on the claim form. If the doctor has laid the CPT codes and the DX codes on a superbill/encounter form like below:

99212 25 DX: #1 724.2 #2 728.85
64405 RT DX #1 723.8

Then the biller will know exactly where all this goes on the claim form with no guessing involved or need to ask anyone where they go, and they don't need the chart to bill the above, because it's all coming from the doctor/provider. Even if the doctor wrote-out the DX codes like; lumbago, muscle spasm, or occipital neuralgia, as long as those numbers are there to show what order the DX should be placed in for said CPT code, then (to me) you're fine.

Although, I will say the original question sounds like something a billing school gives their students, lol.

To Linda: The AAPC and AHIMA both need more knowledgeable people like you. I know you don't need it, but I can certainly tell you know all aspects of this industry.  8)
« Last Edit: April 28, 2013, 11:20:42 PM by Billergirlnyc »
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RichardP

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Re: Medical Billing
« Reply #6 on: April 28, 2013, 11:43:45 PM »
the OP should be asking this question to the doctor/provider if they don't have access to the patient's medical records.

I agree.  But at some level of experience, the biller will come to recognize that certain combinations go together, and that certain procedures happen before others.

I ask some rhetorical questions:  out of all the solo practitioners who have not had EMRs over the past many years, what percentage do you suppose submit their billing to their billers in the manner you and Linda have expressed here?  What percentage do you suppose have the procedure codes and the corresponding diagnosis codes laid out in the correct order in the chart?  What percentage do you suppose chart the patient encounter hours, maybe days, after they filled out the fee slip?  I'm talking about doctors who work for themselves, and get paid based on their efforts.  I'm not talking about doctors who work for organizations, and who get paid regardless of their efforts.

... the superbill/encounter form is ... not what you use to code or determine where those codes go on the claim form.

It is, and always has been, for us.

We've been at this for about 17 years.  For all of those years, we have had a fee slip that has procedure codes (including in-house labs) on the front, and diagnosis codes on the back.  As our clients see their patients, they mark off which procedure codes and which diagnosis codes apply to that visit.  We normally get around 10-15 diagnoses codes checked off, 3-5 procedure codes checked off, and around 15 labs checked off - with the odd 3 or 4 immunization codes thrown in from time to time.  Only rarely in 17 years have any of these fee slips come to us with the procedure codes listed in the proper order and with the diagnosis codes pointed to the target procedure codes.  We get paid for knowing how to do that ourselves.  And we know when we don't know something and need to ask the doctor.  We also know when the doctor coded wrong and we send it back for him to correct.  We never put any codes into the computer that the doctor has not put onto the fee slip and signed off on.  But it has been rare that a client has ever told us the order of the procedure codes and what diagnosis codes go with what procedure code.

I know we do billing for doctors who practice complex medicine.  And we have a nurse on staff who sometimes has to remind our clients that, if they did A, they also needed to do B, but that they didn't put that on the fee slip.  I realize that not all billers do, or can do, what we can do (call it coding if you want, but we never see the chart).  But I cannot believe that all (any?) non-EMR doctors present their codes to the billers as you have laid out above.  For those who don't, their billers still deserve an answer that speaks directly to their real-life circumstances, rather than a theoretical answer that doesn't meet their immediate need.

I understand and applaud what you and Linda are doing by pointing to best practices.  But the rest of us out here work in the real world, and need to deal with life as it is lived by these doctors in the real world.  And these doctors, whose income is tied directly to their own efforts, are not as enamored of best practices as you and Linda are.  When provider behavior in the real world creates questions, real-world answers are sometimes more useful - even though it is also useful to point to best practices afterward.

PMRNC

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Re: Medical Billing
« Reply #7 on: April 29, 2013, 07:56:23 AM »
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But the rest of us out here work in the real world, and need to deal with life as it is lived by these doctors in the real world.  And these doctors, whose income is tied directly to their own efforts, are not as enamored of best practices as you and Linda are.  When provider behavior in the real world creates questions, real-world answers are sometimes more useful - even though it is also useful to point to best practices afterward.

Richard, what you are saying is that in the real world to which I don't live, we are supposed to just "go with the flow".  I've worked hard in this real world to get where I am and I've been doing this in the real world, with real doctors for over 25 years. I didn't get here by "bending rules" , going with the flow and most of all doing what "everyone else does".   Back to the coding ..

There's an UNFAIR advantage here since the ORIGINAL post was MODIFIED rather than a new post created to include the information left out (which was significant) of first post.

Linda Walker
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Dede19

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Re: Medical Billing
« Reply #8 on: April 29, 2013, 09:12:22 AM »
I am lost in this trail, but from what I have gathered, the patient was probably scheduled for a physical.  In the midst of performing the physical, a mass (lump) was discovered upon breast exam.  Therefore, I would code the 99396-25, followed by the E/M code.  You will be paid 100% of the preventative, and the E/M code will most likely be paid at 25-50%, depending upon the carrier.

It would be great if doctor's were trained, or even knew a tad about coding and the order in which to place codes, but reality says that THEY DO NOT!  That is what they have us for; to take their notes, be it via paper or EMR, and put the codes into order for them.  With this situation, it really doesn't matter what the patient was scheduled for, but that a physical was performed and a mass in the breast was discovered upon examination.  So long as documentation covers both, there should be absolutely no problem. 

It is not uncommon that a patient come into our office for something totally unrelated to what they were scheduled for.  Insurance companies do not have access to our schedules to see what the patient was scheduled for, therefore just code according to the documentation.

Billergirlnyc

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Re: Medical Billing
« Reply #9 on: April 29, 2013, 11:02:40 AM »
I am lost in this trail, but from what I have gathered, the patient was probably scheduled for a physical.  In the midst of performing the physical, a mass (lump) was discovered upon breast exam.  Therefore, I would code the 99396-25, followed by the E/M code.  You will be paid 100% of the preventative, and the E/M code will most likely be paid at 25-50%, depending upon the carrier.

Why are you putting a modifier on the the physical if it was scheduled? The physical (according to you) was the reason for the visit. And based on what you're saying the patient came in for a physical 1st and the E/M was second once the doc discovered the lump and or mass in the breast, so mod 25 goes on the E/M to identify that it's separate from the physical. There is no need to put modifier 25 on the physical since it was already scheduled and done. So if it was by itself and the E/M never happened you wouldn't put a modifier at all. But since there is an E/M now, the modifier goes on it not the physical. And every carrier is different either the E/M code will get paid completely, partially, or not at all, based on the member's benefits and plan rules. 


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It would be great if doctor's were trained, or even knew a tad about coding and the order in which to place codes, but reality says that THEY DO NOT!  That is what they have us for; to take their notes, be it via paper or EMR, and put the codes into order for them.  With this situation, it really doesn't matter what the patient was scheduled for, but that a physical was performed and a mass in the breast was discovered upon examination.  So long as documentation covers both, there should be absolutely no problem.

It doesn't matter what a patient was scheduled for? This is wrong. It absolutely matters what the patient was scheduled for in the scenario described here and it's imperative that the biller know this too when entering charges. If the patient was scheduled for a physical and received it that matters, especially if an E/M was done right after this, but I've already answered why this matters above. Also I don't know what doctors you work with that don't know what order to place DX codes, but I've never met one who didn't understand what a chief complaint or a secondary complaint is, since it's medical school 101. And if I code from notes and that's not there then I need to have a serious talk with the doctor.

And while we're on this so it's very clear: A biller is very different than a coder and vice verse. So when you say "us" who do you mean? In a setting where a coder is present then the certified CODER would code the chart and pass that info to the biller to enter charges (either via charge slip signed by the MD or in the system some place the biller can look to see what the coder put for CPT/DX. A biller shouldn't be doing coding if they aren't trained and or certified, because it doesn't help the doctor if and when he's audited. When I code and sign my name to that I'm responsible for what's been billed just as much as the doctor AS A CODER, not as a biller. I'm held to standards and ethics placed on me by my certification outfits (AHIMA AND AAPC). Now, I know how to bill (charge entry, payment posting, follow-ups, etc), but because I'm also a certified coder and RHIT through 2 associations respectfully, I have to be careful and ensure that I can verify the charges I'm entering. When I was a biller only, and didn't have access to the charts, then my clients superbill was very detailed and there was NEVER a question of where DX codes go on the claim form, because they were taught how to properly mark-up the superbills, as it's all we had to bill with. This way no one ever question us on why we billed this way, if I saw an error or mismatch in DX codes or CPT codes, then I would always confer w/my client (the doctor) and they'd correct and resend the superbill. It's also my job to TEACH my clients what they don't know. I've worked in huge hospital systems who REQUIRE the doctor's to know how to code and audit them every six months, so saying doctor's don't is a cop-out (to me) and on the part of the doctor and any billers part if they see issues. For me doctors must understand the basics. They don't have to be a coding wiz, but they must understand what a level 3 E/M means for documentation. There is no reason to hold info from a client, because if they don't know then how can they support the charges they're billing? If a doctor doesn't know about the codes he's billing for and how they work, etc, then he or she should hire someone who can either teach them or does, and preferably someone who is certified through AHIMA or the AAPC. A good biller will ensure their clients know the basics of what constitutes what they're billing and will have no problem deffering certain skills (like coding) to a CCS or CPC. I did this all the time before I was a coder and still kept my clients. I'd outsource stuff to coders and have them make cheat sheets (for E/M and certain procedures so they understood what documentation was required etc) for my clients, but now that I'm a certified coder I no longer outsource and offer it to my clients. Doctors don't know all the nuances and I don't expect them too, but a good biller and coder will know, and teach their client and or boss so they're all on the same page. And if ever audited the documentation will stand up.

The idea that a doctor leans so heavily on a biller to the point that they can't be educated it odd to me, it doesn't happen that way in my world and or in the world of all the billers and coders I know. The doctor is responsible for ensuring the documentation supports whats being billed, because at the end of the day there is only rule when a doctor is being audited and that's the documentation must support what was billed and if someone doesn't have access to that then they need to figure out a system that ensures they bill exactly what the doctor states on the superbill/encounter form.

As to Richard -- I'm going to say this once. I live and work in the real world, what other world can I live in? See Linda's response if you need better explanation. Also please state what I said CORRECTLY. I never mentioned anything about putting the CPT codes in the right order (also important). I said the DX codes and where they go on the claim form absolutely is coding because it can be found in the chart, and it's not something a biller should be guessing on, let alone a coder. The only way to determine the manner in which DX codes should be listed if there is NO CHART to confirm, is through the doctor/provider. How your clients get that to you is on you. How my clients get that to me who I don't code for is on me. And these are REAL WORLD practices. I don't have phantom experiences, so yeah. The End.
« Last Edit: April 29, 2013, 12:06:49 PM by Billergirlnyc »
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Billergirlnyc

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Re: Medical Billing
« Reply #10 on: April 29, 2013, 11:04:35 AM »
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There's an UNFAIR advantage here since the ORIGINAL post was MODIFIED rather than a new post created to include the information left out (which was significant) of first post.

Thank you very much for saying this, Linda. Now others won't get to see what was originally posted since they've modified their original post.
Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

PMRNC

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Re: Medical Billing
« Reply #11 on: April 29, 2013, 11:51:41 AM »
I NORMALLY completely skip over coding questions for this very reason, I probably shouldn't have commented to begin with. This is why I respect the heck out of coders because I def don't want their job. I have an EXTENSIVE coding background FROM the other side which is completely different. A lot of people want to know why I don't go and become a CPC.. that's why! LOL

As for the reason of the visit.. yeah I can't get why that would NOT be important. Just to point something out.. you can see how ONE word omitted or added can change an entire course of a post when dealing with coding. Billerglnyc picked up something in regards to the modifier 25 just from seeing the word "scheduled" which translated from this part of the post:
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Let me clarify my question by explaining the reason for the visit: a 40 year old female pt was seen for her annual checkup
    I'm not a coder so I wouldn't have picked that up..   But that's the point.. that's why the medical chart is what is supposed to be used to code. And also like Billergirlnyc said, the superbill and fee slip are NEVER a part of the patient's medical record.

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We normally get around 10-15 diagnoses codes checked off, 3-5 procedure codes checked off, and around 15 labs checked off - with the odd 3 or 4 immunization codes thrown in from time to time.  Only rarely in 17 years have any of these fee slips come to us with the procedure codes listed in the proper order and with the diagnosis codes pointed to the target procedure codes.  We get paid for knowing how to do that ourselves.
 

Now see, I only really deal with multiple diagnosis/procedure codes for my peds clients and in hospital physician visits but I have never worked off a coding fee slip that did not have EVERY single aspect of coding properly. If I took on a client where I saw that would be a problem, it wasn't difficult to revamp the fee slips to make the job easier for the physician. ULTIMATELY the physician is responsible and if I felt a client of mine was lacking that VERY important element .. then I suggest a CPC in the office or available as consultant. That is my real world. The clients fee slips do indeed have ordering cpt/diagnosis
« Last Edit: April 29, 2013, 11:53:16 AM by PMRNC »
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com