Coding Made Simple
Yes, that seems to be a contradiction of terms: coding and simple. Coding is confusing because it changes quarterly, is regulated by all kinds of rules from seemingly all different sources, and more. It can be made simple, however.
HCPCS stands for "HCFA Common Procedure Coding System." This coding system was defined in 1983 by the Health Care Financing Administration (HCFA) for the purpose of standardizing the coding system currently in use. When people see "HCPCS," they immediately think of codes for healthcare supplies and materials, however, CPT codes (Current Procedural Terminology) are the major portion of the HCPCS coding system. CPT codes were designed by the AMA in 1966 and are the copyrighted material of the AMA.
The point?
"Industry standard" is the point. You will never know how to code or how to fight for denied payments unless you know the coding standard the industry uses. Prior to 1983, 120 different coding systems were in use. Today, there's only CPT, ICD-9, CDT (dental codes) and HCPCS (medical supplies).
Ohio state law mandates that "third-party payers" and providers shall, in connection with a claim, use the most current CPT code in effect, as published by the American Medical Association, the most current ICD-9 code in effect, as published by the United States department of health and human services, the most current CDT code in effect, as published by the American Dental Association, or the most current HCPCS code in effect, as published by the United States Health Care Financing Administration."
That's fine, but I don't live in Ohio.
That doesn't matter because even if you don't live in Ohio nor know your individual state law, federal judges have agreed with Ohio. They've ruled that "…the insurer has the duty to see to it that the promised protection is delivered when needed. It must act to facilitate the claims instead of searching for reasons not to do so" (Quote from Judge Rafeedie in the federal court case of: Kanne V. Connecticut General Ins. Co., 607 F. Supp. 899 (1985) on upholding $750,000 in additional damages for unreasonable delay in payment of medical claims.)
It doesn't hurt to know your individual state law, however. You can simply go online to your state Department of Insurance along with going online to research your state's current medical insurance laws. It takes time, but it's worth it.
Why is this important?
Medical insurance companies will always try to convince healthcare providers that the provider must live by the individual rules of the medical insurance company. That's not true at all. All medical insurance companies must abide by the "industry standard." Once you know this, you need three things:
- Good coding software that fully explains CPT codes
- Good coding newsletter that tackle problematic CPT codes
- Good review or appeal letters
that fight for denied CPT codes
Forget those huge CPT and ICD-9 books. It will cost you about the same to purchase good coding software (about $400), and it's much, much easier to use. Good coding software contains the current CPT, ICD-9 and CDT codes, along with the NCCI editing rules and AMA publication information. Software that also includes HCPCS information will cost a little more.
NCCI (National Corrective Coding Initiative) is the claims editing system that medical insurance companies implement to limit payment made to healthcare providers. NCCI was put out by CMS (Centers for Medicaid and Medicare Services). The purpose of the NCCI editing system?
CMS designed the NCCI editing system to make the claims review process easier. Unfortunately, the NCCI editing or "Claims Check" system has been implemented by medical insurance companies to limit payments made to healthcare providers.
CPT designed a system of coding whereby certain codes are NEVER allowed to be used together. They also ruled that certain codes could ONLY be allowed to be used together when a proper modifier is attached. The NCCI editing system is programmed to deny payment to ALL bundled codes whether or not a proper modifier is appended. Fortunately, HIPAA law mandates that medical insurance companies manually review those "kicked out" codes when the proper modifier is attached. Do they? Did you really need to ask? Of course not. They continue to deny these claims, without manual review, stating that the "editing system" or "Claims Check" system is solely to blame.
One of the major areas of denied payment is: E/M codes(evaluation/management)with modifiers.
Good coding software and coding newsletters along with a solid understanding of problematic codes and modifiers will help you obtain what is rightully owed you. Using the appropriate appeal letters and state and federal rulings letters will also help you fight for what is legally and ethically owed you.
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