Newman's Billing and Coding Technicians Study Guide

By xaiver newman

Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS. While the medical coder and medical biller may be the same person or may work closely together to make sure all invoices are paid properly, the medical coder is primarily responsible for abstracting and assigning the appropriate coding on the claims. In order to accomplish this, the coder checks a variety of sources within the patient’s medical record, (i.e. the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources) to verify the work that was done. Then the coder must assign CPT codes, ICD-9 codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency.
This text is intended to dispel any ambiguity prior to taking your national certification. This text contains over 400 preparatory examination questions, covering ICD-9, ICD-10, Revenue cycle, Medical report extrapolation assignments, HCPCS, UB04, and CPT.

• Language: English
• Publisher: xaiver Rauf newman
• Release date: Nov 8, 2013
• ISBN: 9781497759770

xaiver newman

Professor Newman has consulted with and advised hundreds of faculty and graduate students in the complexities of the competency based educational design. Along with his 15 years of combined civilian and military experience driven by a desire to provide top-notch Allied Health Education. Professor Newman has set a general academic canonical by prompting an allied health standardization analysis which has been adopted by propriety for-profit academia. Coupled with his dynamic presentation of the allied health subject theorem/practicum, Professor Newman has published numerous scholarly texts ranging from an interpretive series on the International Classification of Diseases 10 edition, to a medical laboratory assistant study series.

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Newman's Billing and Coding Technicians Study Guide

by xaiver newman

Published by xaiver newman, 2013.

While every precaution has been taken in the preparation of this book, the publisher assumes no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein.

NEWMAN'S BILLING AND CODING TECHNICIANS STUDY GUIDE

First edition. November 8, 2013.

Copyright © 2013 xaiver newman.

Written by xaiver newman.

Newman's

BILLING AND CODING SPECIALIST

STUDY GUIDE

By: Xaiver R.S. Newman NRCCS

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Kellie Guy NRCCS

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Yolanda Lewis NRCCS

48243-01-0148243-02-01

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Permission to reuse granted by Ingenix, Inc.

48243-19-0318

TABLE OF CONTENTS

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Billing & Coding Exam Structure: 7

Medical Billing and Coding as a Career 7

Medical Ethics 7

Legal Aspects of Medical Billing and Coding 7

Professional Liability 9

Medical Documentation 10

Medical Terminology 11

International Classification of Diseases, 9th Revision, 13

Clinical Modification:  ICD-9-CM 13

Supplementary Classification Codes 13

Health Care Financing Administration Common 16

Procedure Coding System – HCPCS Reference Manual 16

Types of Plans

Place of service and CPT specifics...............................................................................................20

Federal and State Programs

Disability and Liability Insurance

Types of claims

The Universal Claim Form

Insurance Terms

Billing and Coding Sample Test 42

Billing & Coding Exam Structure:

 Medical Terminology

 Insurance Principles

 Coding (Diagnosis and Procedures Codes)

 Law, Compliance & Ethics

 Claims Processing

 Analysis of Cases

Medical Billing and Coding as a Career

There are many different titles that fall under this particular specialty.  It is a diversified position and can be very broad or very narrow in the duties to be performed depending on the size of the office.

Listed below are some of the specialized job titles:

Claims assistant professional or claims manager

Coding specialist

Collections manager

Electronic claims processor

Insurance billing specialist

Insurance coordinator

Insurance counselor

Medical biller

Medical and financial records manager

Billing and Coding Specialist

Medical Ethics

Medical ethics are standards of conduct based on moral principles. They are generally accepted as a guide for behavior towards patients, physicians, co-workers, the government, and insurance companies.  Acting within ethical behavior boundaries means carrying out one’s responsibilities with integrity, decency, respect, honesty, competence, fairness and trust.

Legal Aspects of Medical Billing and Coding

Compliance Regulations: Most billing-related cases are based on HIPAA and False Claims

Act.

Health Insurance Portability and Accountability Act of 1996 (HIPAA):  Created the Health Care Fraud and Abuse Control Program  enacted to check for fraud and abuse in the Medicare and Medicaid programs, and private payers.

The Act contains two provisions:

Title I:  Insurance Reform

Primary purpose is to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs.

Limits the use of preexisting conditions exclusions.,

Prohibits discrimination for part or present poor health

Guarantees certain employees and individuals the right to purchase new health insurance coverage after losing a job.

Allows renewal of health insurance coverage regardless of an individual’s health condition that is covered under the particular policy.

Title II: Administrative Simplification

The goal is to focus on the health care practice setting to reduce administrative costs and burdens. It has two parts:

Development and implementation of standardized health-related financial and administrative activities electronically.

Implementation of privacy and security procedures to prevent the misuse of health information by ensuring confidentiality.

False Claims Act (FCA):  Federal law that prohibits submitting a fraudulent claim, making a false statement, or representation in connection with a claim. It also protects and rewards persons involved in whistle-blower cases.

National Correct Coding Initiative (NCCI):  Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B health insurance claims.

Includes two types of edits:

Column 1/Column 2 (previously called  Comprehensive/Component) Edits: identifies code pairs that should not be billed together because one code (Column 1) includes all the services described by another code (Column 2). 

Mutually Exclusive Edits : identifies code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day.

Possible consequences of inaccurate coding and incorrect billing include:

delayed processing and payment of claims

reduced payments; denied claims

fines and/or imprisonment

exclusion from payer’s programs; loss of physician’s license to practice medicine

The Office of Inspector General (OIG) has the task to investigate and prosecute health care fraud and abuse.

Fraud:  Knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits is known as fraud.  Fraud is a felony and can result in fines and/or a prison sentence.  Claims are audited by state and federal agencies as well as by private insurance companies. Common forms of fraud are billing for services not furnished, unbundling, and misrepresenting diagnosis to justify payment.

Abuse: This is defined as incidents or practices, not usually considered fraudulent, that are inconsistent with the accepted medical business or fiscal practices in the industry.  Examples of abuse are submitting a claim for a service or procedure performed that is not medically necessary to treat the patient’s condition, and excessive charges for services, equipment, or supplies.

Patient Confidentiality: All patients have a right to privacy and all information should remain privileged.  Discuss patient information only with the patient’s physician or office personnel that need certain information to do their job.  Obtain a signed consent form to release medical information to the insurance company or other individual.

Under the HIPAA Privacy Rule, providers may use patient’s Protected Health Information (PHI) without specific authorization for treatment, payment, and operation (TPO) purposes.  Further defined:

Treatment:  primarily for the purpose of discussion of the patient’s case with other providers.

Payment:  providers submit claims on behalf of patients. 

Operations: for purposes such as staff training and quality improvement.

Professional Liability

Employer Liability:  Physicians are legally responsible for their own conduct and any actions of their employees (their designee) performed within the context of their employment.  This is referred to as vicarious liability, also known as respondeat superior, which literally means let the master answer.  This means that the employee can be sued and brought to trial.

Employee Liability:  Errors and omissions insurance is protection against loss of monies caused by failure through error or unintentional omission on the part of the individual or service submitting the insurance claim.  Some physicians’ contract with a billing service to handle claims submission, and some agreements contain a clause stating that the physician will hold the company harmless from liability resulting from claims submitted by the service for any account.  This means the physician is responsible for mistakes made by the billing service.  Thus errors and omissions insurance would not be needed in this instance.  If a physician asks the insurance biller to do the least bit questionable, such as write off patient balances for certain patients automatically, then make sure you have a legal document or signed waiver of liability relieving you of the responsibility for such actions.

Medical Documentation

Medical Records:  A medical record is documentation on the patient’s social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports, and correspondence to patient.

The connection between insurance billing and the medical record should be explained to better understand the importance of the medical record, the foremost tool of clinical care and communication. A medical report is part of the medial record and is a permanent legal document that formally states the consequences of the patient’s examination or treatment in letter or report form.  It is this record that provides the information needed to complete the insurance claim form. 

When billing the insurance company, the date of service (DOS), place of service (POS), type of service (TOS), diagnosis (dx or DX), and procedures must be recorded. This data is transferred as codes on the claim form for interpretation by the insurance company.  The key to substantiating procedure and diagnostic code selections for appropriate reimbursement is supporting documentation in the medical record.  Proper documentation can prevent penalties and refund requests should the physician’s practice be reviewed or audited. 

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Reasons for Documentation:  It is important that every patient seen by the physician has comprehensive legible documentation about the patient’s illness, treatment and plans for the following reasons:

Avoidance of denied or delayed payments by insurance carriers investigating the medical necessity of services. 

Enforcement of medical record-keeping rules by insurance carriers requiring accurate documentation that supports procedure and diagnostic codes.

Subpoena of medical records by state investigators or the court for review.

Defense of a professional liability claim.

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Retention of Medical Records:  Retention of medical records is governed by state and local laws and may vary from state–to–state.  Most physicians are required to retain records indefinitely; deceased patient records should be kept for at least five (5) years.

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Medical Terminology

International Classification of Diseases, 9th Revision,

Clinical Modification:  ICD-9-CM

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The ICD manual is divided into three (3) volumes:

Volume I – Diseases: Tabular List

contains the disease and condition codes and the descriptions

also contains the V codes and E codes

Volume 2 – Diseases: Alphabetic Index

this is the alphabetic index of Volume 1.

Volumes 1 & 2 are used in the inpatient and outpatient settings

Volume 3 – Procedures: Tabular List and Alphabetic Index

contains codes for surgical, therapeutic, and diagnostic procedures; used primarily by hospitals.

To ensure that you have chosen the correct code, first locate the code in the alphabetic index (Volume II), and then cross-reference this code in the Tabular List (Volume I).

Supplementary Classification Codes

Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V Codes) are supplementary classification codes used to identify health care encounters that occur for reasons other than illness or injury or to identify patients whose illness is influenced by special circumstances or problems.  The codes can be found in both Volumes I and II.

The following are circumstances under which V Codes are used:

When a person who is not currently sick encounters the health services for some specific reason such as to act as an organ donor or receive a vaccination. (e.g. V59.3 is the code for a donor of bone marrow.)

When a person with a resolving disease or chronic condition presents for specific treatment of that disease or condition. (e.g.., V56.0 is the code for extracorporeal dialysis.)

When a circumstance may influence a patient’s health status but is not a current illness or condition. (e.g.., V16.3 is the code for family history of coronary artery disease.)

To indicate the birth status of a newborn. (e.g.., V30.01 is the code for a newborn male born in the hospital by cesarean section.)

Supplementary Classification of External Causes of Injury and Poisoning (E Codes) are supplementary classification codes used to describe the reason or external cause of injury, poisoning and other adverse effects.  These codes can be found in both Volumes I and II.  E codes are used to classify environmental events, circumstances, and conditions as the cause of injury, poisoning and other adverse effects and capture how the injury or poisoning happened, the intent, and the place where the event happened.

* The ICD manual is updated every year, usually in October.

Tabular List  (Volume 1): consists of 17 chapters based on either body system or cause or type of disease. The codes range from 001-999.

Chapters are the main division in the ICD-9-CM; they are divided into sections. e.g.., 3.  Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders (240-279).

Sections are composed of a group of three-digit categories representing a group of conditions or related conditions; they are divided into categories.  e.g. ., Disorders of Thyroid Gland (240 – 246).

Categories are composed of three-digit codes representing a single disease or condition.

The three-digit code is used only if it is not further subdivided.  There are about 100 category codes and most requires a fourth digit (subcategory code). e.g.  242 Thyrotoxicosis with or without goiter.

Subcategories provide a four-digit code (one digit after the decimal point) which is more specific than category code (3-digit) in terms of cause, site, or manifestation of the condition. This must be used if available. From subcategory, specificity moves to another level which is the subclassification.  e.g.  242.0 Toxic diffuse goiter.

Subclassification provides a five-digit code which gives the highest specificity of description to a condition. Use of it is mandatory if it is available. A code not reported to the full number of digits required is invalid.  e.g.  240.01  Toxic diffuse goiter with thyrotoxic storm

Level of detail in coding

A category code is used only if it is not further subdivided. Where subcategory and subclassification codes are provided, their assignment is mandatory.  A code is invalid if it has not been coded to the level of specificity required for that code.

Sequencing the diagnosis

The diagnosis, condition, or other reason for the encounter or visit shown in the medical record to be chiefly responsible for the services provided is listed first. Coexisting conditions that were treated or medically managed or influenced the treatment of the patient during the encounter are listed as additional codes. (Conditions that were previously treated and no longer exist are not coded.) If personal history or family history has an impact on current care or influences treatment, history code may be assigned as secondary code.

Alphabetic Index  (Volume 2): The main term in the index may by followed by terms within parenthesis.  These parenthetic terms are called nonessential modifiers because their presence or absence does not have an effect on the selection of the code listed for the main term.

There are also terms indented two spaces to the right below the main term called subterms.  These subterms are essential modifiers because they have bearing in the selection of the right code.  Everything in the Index is listed by condition – that is, diagnosis, signs, symptoms, and conditions such as pregnancy or admission.

Hypertension Table:  found in the Index under the main term Hypertension, and it contains a list of conditions that are due to or associated with hypertension. The table classifies the conditions as:

Malignant – An accelerated, severe form of hypertension with vascular damage, and a diastolic pressure of 130mmHg or greater.

Benign -  Mild or controlled hypertension and no damage to the vascular system or organs.

Unspecified - This is not specified as benign or malignant in the diagnosis or medical record.

Neoplasm Table: this is located in the Index under the main term Neoplasm and is organized by anatomic site. Each site has six columns with six possible codes determined by whether the neoplasm is malignant, benign, of uncertain behavior, or of unspecified nature.

Malignant - further