Saturday, 27 July 2013

Medical Billing Code Changes - Keep up with updation.

Medical billing coding is used to claim from insurance companies, and change frequently, usually on an annual basis. When billing codes become obsolete, insurance companies do not accept them, and as a consequence, claims are rejected.

There are a few methods which one can employ to stay in touch with changes and maintain a current medical billing code. The Code Books like CPT give a definition for each billing code, and list each billing code alphanumerically, making it easy to follow. Billing codes recorded in the CPT Code Books are revised with each issue on annual basis. Within each book is an appendix of changes, which show how a service has been modified from the current procedural terminology while maintain the same definition. By following the changes in the CPT Code Book every year, one is able to maintain an up to date database of billing code changes.

Another possible method to handle billing code changes involves using the International Classification of Diseases (ICD9). This system is used primarily as a means of reporting statistical data, and works by grouping the procedures of the related diseases. Similar to the CPT Code Books, ICD9 Books sort their diseases and diagnoses alphanumerically, and are updated annually.

Having to cross-reference billing codes with two referencing systems can be very time consuming, and there can be an element of human error involved. Using Medical Billing Software is a worthwhile alternative for referencing code books, which is likely to be updated frequently. Another advantage is that one does not require cross-referencing or the need to refer a range of billing code books when coding any medical procedure. Electronic software completely removes this problem, and more importantly, online referencing features are available that cannot be matched by using code reference books.

With such distinct advantages, one can see that medical software for code billing is the most effective way to handle changes in billing codes. Apart from being more efficient in filing claims with the billing codes, offices that make use of online billing and coding software will have an easier migration from outdated billing codes and procedures to current items. All this is possible since the software itself can handle most of the comparison and referencing, providing there are regular updates to its database.

Maintaining an up to date billing code database not only streamlines administrative work, but it ensures that the billing practices used and the standard of service one can provide to consumers is improved, and a high standard maintained.
ICD 10 - Frequently asked question
1.  Q: What is ICD-10? 
A: ICD-10 is the International Classification of Diseases, version 10.  (ICD is the international standard for diagnostic classifications.) The current version, ICD-9, was adopted in 1979.

2.  Q: What changes are occurring in the ICD-10 version? 
A: The changes will impact ICD-9-CM diagnosis codes and ICD-9-CM procedure codes.  The changes are as follows:
** The diagnosis codes (ICD-9) are currently three to five digits that are alphanumeric in nature and combine to make around 14,000 unique diagnosis codes being used today. For ICD-10, the diagnosis codes will be seven digits that are alphanumeric in nature and combine to make around 68,000 unique diagnosis codes
** Currently, ICD-9 procedure codes are three to four digits that are numeric in nature and  combine  to  make  about  4,000  unique  procedure  codes.    For  ICD-10-PC  S (inpatient), the procedure codes will be 7 alphanumeric in nature and combine to make around 72,000 unique procedure codes.

3.  Q: What is the primary purpose of this change? 
A: The primary purpose of the change to ICD-10 is to improve clinical communication.  It allows for the capture of data about signs, symptoms, risk factors and comorbidities and better describes the clinical issues overall. It will also enable the United States to exchange information across country borders.

4.  Q: What is CarePlus’ plan for ICD-10 acceptance? 
A:  CarePlus  will  accept  ICD-9  codes  on  claims  w/  date  of  service  (DOS),  or  discharge  dates  of September 30, 2014 or prior.  CarePlus will accept ICD-10 codes on claims w/ DOS, or discharge dates of October 1, 2014 or after.

5.  Q: Do you plan to be ready to process ICD-10 codes submitted on claims forms by Oct 1, 2013? 
A: CarePlus will go live with the ICD-10 codes effective October 1, 2014.

6.  Q: How long will support for both ICD-9 and ICD-10 coding be provided? 
A:  CarePlus  will  process  correctly  coded  transactions  within  the  date  ranges  specified  in  the  answers above until the volume of ICD-9 submissions is diminished.

7.  Q: When will CarePlus begin testing transactions? 
A: CarePlus will begin testing ICD-10 transactions in the second quarter of 2014.
8.  Q: Do you have a communication plan and schedule for customers to keep them informed? 

A: The ICD-10 Program team is currently working on a communication plan and schedule with testing partners, trading partners, providers and internal departments.

9.  Q:  Will  your  claims  adjudication  processing  vary  by  contract  type  (e.g.,  hospital, professional provider, and/or ancillary services)? 
A: CarePlus does not foresee any issues with claims processing with the change to ICD-10.  Testing will begin in early 2013 to mitigate any such issues.

10. Q:  Will  CarePlus  purchase  any  new  technology  as  part  of  its  preparation  for  ICD-10 implementation? 
A: CarePlus is remediating the systems that are currently in place for claims reimbursement. 

11. Q: Will CarePlus be using GEMS as part of its process, or for creating files coming in or out? 
A:  CarePlus will process transactions in its “native” format and will not be using GEMS to crosswalk ICD-9 codes and ICD-10 codes for inbound or outbound v5010A1 transactions.

12. Q: Will there be any changes in payment with the change to ICD-10? 
A: CarePlus’ plan is to be reimbursement neutral. There should be no change to the way a claim is paid with  ICD-10  and  ICD-9  codes  unless  an  MS-DRG  change  has  taken  place  or  a  contract  has  been rewritten to incorporate a change of reimbursement.
13. Q: What claim-processing issues does CarePlus anticipate with the preparation for ICD-10? 

A:  CarePlus is investing in remediation of systems and processes to support the ICD-10 requirements. CarePlus  does  not  foresee  any  issues  with  claims  processing  with  the  change  to  ICD-10,  although rejection due to misuse of new codes is possible. Testing will begin in early 2013 to mitigate any such issues.

14. Q: What key information should providers to keep in mind as they develop their own ICD-
10 implementation plans? 

A:  CarePlus  suggests  that  providers  stay  up-to-date  on  any  changes  by  CMS  regarding  the  ICD-10 implementation.  This  can  be  done  by  monitoring  the  CMS  website.  If  providers  have  questions  or concerns, they may contact their CarePlus provider associate.

Websites offering additional information on 5010 and ICD 10 are:

changes in reimbursement - Billing professional and technical component -
Modifier 26

Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number.

Modifier TC

Technical Component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians.

However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.

Global service

Unmodified CPT codes are intended to describe both the technical and professional components of a service. The professional and technical components together are
referred to as the "global service."

“If the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components of the service separately.”

When the service is furnished to a hospital outpatient or inpatient, the facility bills the technical component, which includes the cost of equipment, supplies, technician salaries, etc.

If the interpreting physician is not paid by the facility for services but will instead be billing the carrier separately, the physician may bill only for the professional component.

“Hospitals must provide directly or under arrangements all services furnished to hospital outpatients. Therefore, if a specimen (e.g., tissue, blood, urine) is taken from a hospital patient, the facility or technical component (TC) of the diagnostic test must be billed by the hospital. Only in cases where the patient leaves the hospital and obtains the service elsewhere is the hospital not required to bill for the service…At the request of the industry, the implementation of this rule was delayed to allow independent laboratories and hospitals sufficient time to negotiate arrangements…through February 29, 2012.”

 Reimbursement Guidelines

Procedures that are comprised of both a technical and professional component are identified on the National Medicare Physician Fee Schedule Database (MPFSDB) in Field 20 with a Professional Component (PC)/Technical Component (TC) Indicator of “1”. It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims).  When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC or 26.


If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.

If the clinic has not obtained a separate TIN (and a separate contract with Insurance to be participating), then the global service must be billed by the interpreting clinic physician. The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.

When the technical and professional components of a procedure are unbundled and billed to Insurance under the same TIN, the Insurance claims processing system will process the component procedures in a variety of ways (due to system constraints).

• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit.

Insurance requires a corrected claim with the procedure billed as a global service(without -TC or -26 modifier) for any adjustment or additional reimbursement to be

• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines. If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.

• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service.

Only the components that have been actually performed by the billing provider may be billed to Insurance. If only one of the components has been performed, charges may not be submitted to Insurance for the component that has not been performed. The instructions in CMS Transmittal 1892/CR6733 are both optional and conditional, and do not apply to claims submitted to Insurance.

While CMS does sometimes instruct providers to re-bill the service as separate professional and technical component procedure codes, our research indicates this is specifically related to the calculation of CMS bonus payments in a health professional shortage area (HPSA), and does not apply to billing to commercial carriers such as Insurance. Submitting Only the Professional Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1, 6, or 8 (see field 20 on the MPFSDB) will be allowed with modifier 26 appended.

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 7, or 9 will be denied when submitted with modifier 26 appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Submitting Only the Technical Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Services Reported in a CMS POS 24 (Ambulatory Surgical Center) 

CMS guidelines, UnitedHealthcare Community Plan will not reimburse physicians or other health care professionals for the Technical Component of services included in the Ambulatory Surgery Center Fee Schedule (ASCFS) Addendum BB and reported with a CMS POS 24 as the ambulatory surgical center (ASC) is reimbursed for the Technical Component.

The Technical Component of services reported on a CM-1500 claim form with an SG modifier (Ambulatory surgical center [ASC] facility service) is not reimbursed as a professional claim.

 Claim lines reported with modifier SG indicate a facility charge and are reimbursed as a facility claim. PC/TC Indicator 1 Codes For codes included in the ASCFS Addendum BB PC/TC Indicator 1 Codes list, only the Professional Component (PC, modifier 26) will be reimbursed.

 When reported globally (no modifier), the Technical Component of the code will not be reimbursed.

  When reported with modifier TC, the code will not be reimbursed. PC/TC Indicator 3 Codes

Codes included in the ASCFS Addendum BB PC/TC Indicator 3 Codes list will not be reimbursed as they represent Technical Component services only.


  1. Another set of codes will indicate the doctor's diagnosis and what medication, if any, was prescribed.

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