CPT 00170, 00190, 41899, D9220 - D9248 - Dental Anesthesia procedure

CPT Codes Description Modifiers Maximum Units

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified  U1 7Unit

00190 Anesthesia for procedures on facial bones or skull; not otherwise specified

41899 Other Procedures on the Dentoalveolar Structures (facility fees)

D9220 Deep sedation/general anesthesia, first 30 minutes

D9221 Deep sedation/general anesthesia, each additional 15 minutes

D9241 Intravenous conscious sedation/analgesia, first 30 minutes

D9242 Intravenous conscious sedation/analgesia, each additional 15 minutes

D9248 Non-intravenous conscious sedation

Background

Sedation and anesthesia for dental procedures performed on patients in nontraditional settings, such as acute inpatient facility or ambulatory surgery center, have increased over the past several years. Providers must be qualified and appropriately trained individuals in accordance with state regulations and professional society guidelines.

All locations that administer general anesthesia must be equipped with anesthesia emergency drugs, appropriate resuscitation equipment, and properly trained staff to skillfully respond to anesthetic emergencies. Locations covered under this policy are acute care inpatient facilities and ambulatory surgery centers.

General anesthesia allows for the safe and humane provision of dental diagnostic and surgically invasive procedures. General anesthesia is only necessary for a small subset of members but is an effective, efficacious, and safe way to provide necessary treatment. Those included in this subset are individuals who may be cognitively immature, highly anxious or fearful, have special needs, or medically compromised and unable to receive treatment in a traditional office setting.

Dental Anesthesia

Withholding of general anesthesia can result in less access to quality oral health care and long-term consequences. Less effective management of these members may increase avoidance behaviors of oral health professionals in the future and increase care being sought in the emergency department. Improved diagnostic yield and greater quality of procedures improves the cost-effectiveness of general anesthesia over local anesthesia in some individuals.

Local Anesthesia or conscious sedation (oral/inhalation) failed (V.A.)

Documentation provided must support/justify the need for the consideration of using IV Sedation or GA.

CLINICAL PAYMENT, CODING AND POLICY CHANGES

Dental services requiring general anesthesia must be coded as follows:

• Procedure code 00170 must be billed with modifier U3 and is for the anesthesiologist or certified registered nurse anesthetist (CRNA) to use on the claim form. Procedure code 00170 with modifier U3 will require prior authorization for all patients under the age of 21.

• Procedure code 41899 is for the facility to use on the claim form. Procedure code 41899 will require an authorization for all patients, regardless of age or modifier.

• An appropriate diagnosis code must be used on the claim form.

• The examining physician, anesthesiologist, hospital, ASC, or HASC must submit claims separately for the medical and facility components of their services.

Claims submitted for dental services requiring dental anesthesia with CPT code 00170, modifier U3, and a patient under the age of 21 will pend to our Claims Team who will review for a prior authorization. Claims with CPT code 00170, modifier U3, and a patient under the age of 21 that do not have a prior authorization will be denied. Claims submitted for dental services requiring dental anesthesia with CPT code 41899 will pend to our Claims Team who will review for a prior authorization. Claims with CPT code 41899 that do not have a prior authorization will be denied.


Dental Therapy under General Anesthesia

Modifier U3 will no longer be used with procedure code 00170 when billing for the appropriate reimbursement of dental general anesthesia. The new modifier to be used with procedure code 00170 for dental general anesthesia is EP.

For clients who are six years of age or younger, the following will change:

• All Level 4 sedation services provided by a dentist (procedure code D9223) must be prior authorized.

• Any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA) to be provided in conjunction with dental therapeutic services (procedure code 00170 with EP modifier) must be prior authorized.

• The dentist performing the therapeutic dental procedure is responsible for obtaining prior authorization for both services from TMHP and is responsible for providing the anesthesia prior authorization information to the anesthesiology provider.

• The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.



Procedure Code Updates

Procedure code 00170 with modifier EP and procedure code D9223 will be limited to once per six calendar months, any provider.

The following payable provider types will be added for procedure code 00170 with modifier EP, and procedure code D9223:


Procedure Code Place of Service Provider Types

00170 with modifier EP Office Physician providers

D9223 Inpatient hospital, outpatient hospital dentist, orthodontist, and oral maxillofacial surgeon providers

Procedure Code Limitations

Procedure codes D1110, D1120, D1206, D1208, D1351, and D1352 will be denied when submitted for the same date of service as any D4000 series periodontal procedure code, any provider.
Periodontal scaling and root planing (procedure codes D4341 and D4342) will be denied when submitted for the same date of service as other D4000 series codes, except D4341 and D4342, any provider.

Full mouth debridement (procedure code D4355) will be denied when submitted for the same date of service as the following procedure codes, any provider:


Procedure Codes

D4210 D4211 D4230 D4231 D4240 D4241 D4245
D4249 D4260 D4261 D4266 D4267 D4270 D4273
D4274 D4275 D4276 D4277 D4278 D4283 D4285
D4320 D4321 D4381 D4910 D4920 D4999

Dental hospital calls (procedure code D9420) are currently limited to twice per rolling year, per client, any provider. Procedure code D9248 will be denied when submitted for the same date of service as procedure code D9420, any provider.

Anesthesia procedure code D9243 will be limited to one and one-half hours per day. Oral maxillofacial surgeon providers will be added as a payable provider type for procedure code D9243 when services are provided in the outpatient hospital setting.

Procedure code D9230 currently denies when submitted for the same date of service as procedure code D9248, same provider.

Documentation and billing

The anesthesia record must clearly define and document that portion of time that anesthesia is rendered by the provider of anesthesia services. Documentation must include an explanation of the service performed, the duration of the service and the length of time the rendering physician, resident, CRNA or anesthesia assistant was involved with the case. Submit a copy of the anesthesia record and the supporting documentation when you file a claim on the CMS-1500 form for anesthesia services.
BCBSM requires time to be reported in actual minutes of anesthesia care for anesthesia claims. Our claim system will round up the minutes to 15-minute time units. Report all appropriate modifiers to ensure accurate payment. If the same provider performs both dental surgery and anesthesia, the anesthesia is included in the billed dental surgical procedure.

General anesthesia and intravenous sedation are billable under the medical-surgical program in conjunction with procedures billed under the dental program. The dental procedures must meet medical criteria and must be performed in a hospital by a health care provider other than the surgeon. Dental procedures such as preventive services, restorations, endodontics, periodontics, extractions, etc., are not covered under the medical-surgical program and should be billed to the patient’s dental plan


Medical necessity criteria

• There are no medical contraindications to treatment.
• Documentation that more conservative treatment has been attempted and has not been successful must be provided.
• Totally edentulous mandible must have less than 20 mm in radiographic height from the inferior border to the crest of the ridge in the mandibular symphysis region.
• Documentation of the functional problem(s) associated with the mandibular deformity must be provided.



Local Anesthesia or conscious sedation (oral/inhalation) not feasible (V.B.)

Effective communicative techniques and the immobilization failed or is /was not feasible.
Requires extensive/complex dental treatment.
Patient has acute situational anxiety due to immature cognitive functioning .
Patient is uncooperative due to certain physical or mental compromising conditions.
Local anesthesia is/will be ineffective because of acute infection, anatomic variation, or allergy.
Local anesthesia is/will be ineffective or compromised because of oral-facial and/or dental trauma.
Dental Anesthesia Performed In Dental Offices
Effective July 1, 2018, a number of dental providers have opted to obtain a permit from the NH Board of Dental Examiners for providing general anesthesia and moderate sedation in their offices. These providers have been authorized by DHHS to allow either a dental anesthetist or a CRNA to provide such services to NHHF members. The service must be prior authorized by the Dental department at DHHS to be reimbursed by NHHF. The anesthesia charges must be billed separately on a CMS 1500 form using the specific coding in the table below, Dental Anesthesia Performed in Dental Offices.

Use CPT Codes to Determine Doctor Fees

CPT codes can be used to assess the actual costs of a procedure in terms of the doctor’s fees. While medical billers and coders have access to this information already, the AMA allows non-professionals and students the ability to use a free CPT lookup for one procedure at a time. This is done through the CodeManager system on the AMA website, which allows patients to enter an existing CPT code to determine the procedure or treatment or look up a CPT code by entering the procedure, which will allow you to assess the cost paid by Medicare for this procedure in your area. In addition, you can also determine the average cost of this service throughout the U.S.

Step-by-Step process for looking up CPT codes

The steps for looking up the cost of a treatment or procedure using the CodeManager system are simple.

1. Get Started. First, click the above link to enter the AMA CodeManager website.
2. Agree to play by the rules. You will have to read and click an agreement that stipulates that you do not sell the information you receive from the website, and that the number of times you can use this service are limited. To continue, hit the “Agree” button.
3. Specify your location. Next, the screen asks you to select the state and nearest city in which the procedure was performed,
4. Specify your procedure. Enter either the CPT code or keywords that describe the medical treatment or procedure you wish to look up.

Your query may not return anything right away, so use these tips to search successfully:

• Try a few different search terms. For example, if you were trying to determine the cost of surgery to remove a ruptured appendix, you could enter the keywords “appendectomy” or even just “appendix”, which would lead you to several possible procedures and their costs, including code 44960 for a simple appendectomy, as well as other codes describing unlisted procedures involving the appendix, examinations of that organ, and related surgical procedures.
• Use medical terminology. In most cases, procedures and body parts are described by their medical terms, so while a search for “hip replacement” will give you no hits, a search for “hip arthroplasty” will give you several options of possible procedures. Of course, if you have the CPT code you can enter it outright and it will take you straight to the relevant procedure.

Note that in the costs column, the medical payment listed can either be “non facility” or “facility”, depending on where the procedure was conducted. Facilities include hospitals, including emergency rooms, ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs), while non facility means any other setting, such as clinics or private practice offices. You may also notice that some procedures can only be conducted in a facility or non-facility setting, which means that the other column will have an “NA” or non-applicable label and no price.

Using RVUs to determine average costs

The medical payments listed are an average of the Medicare cost throughout the U.S. multiplied by the relative value amount (RVU) of a region, which may be higher or lower than 1.0. For example, the same procedure, such as an appendectomy (44950), is priced at $722.57 in Manhattan but only $642.29 throughout Arizona. This is due to the relative costs of goods and services in a region, and is reflected in CPU pricing.

It is also very important to note that the prices listed on the CodeManager website reflect the cost of a procedure paid by Medicare based on the Medicare Physician Fee Schedule (MPFS), which is very close to its actual cost, though the prices patients or insurance providers are typically charged more to account for the costs of the facility and its staff; This is particularly true of private medical institutions.

Convert CPT CODES to ICD-9 Codes for Medical Billing and Coding

Understanding Current Procedural Technology (CPT) Codes

Current Procedural Terminology (CPT) is a code set developed and maintained by the American Medical Association (AMA) that describes medical, surgical, and diagnostic procedures. CPT codes allow for uniform communication, research, and data analysis across local, regional, state, and national bodies. CPT Codes are updated annually on January 1.

Unlike ICD codes, CPT codes are trademarked by the AMA, making it impossible to find a comprehensive list of CPT codes online. But you should still know how to use them to look up procedures and understand their role in the medical billing and coding industry. These five-digit numeric codes identify medical procedures and services in a standardized manner, and are used by physicians, coders, health insurance companies, accreditation agencies, and patients. CPT codes can be used for financial, analytical, and administrative purposes, and are divided into three categories.

CPT Category I Codes

CPT is organized into three distinct categories. The first category, which is by far the largest of the three, contains codes for six subtypes of procedures. Much like ICD-9 and ICD-10, these procedural codes are organized into clusters, which are then subdivided into more specific ranges. For instance, codes for radiology fall in the number range of 70010 to 79999, and codes for a diagnostic ultrasound procedure fall into the range of 76506 to 76999. Within that number range, procedures have a designated code, ensuring healthcare payers record exactly which procedure a patient has undergone. For example, the codes 99213 and 99214, which you may have seen on your medical bill following a checkup, correspond to routine doctor’s visits (of simple and medium complexity, respectively).

As is the case with ICD-9 or ICD-10, the goal of CPT codes is to condense as much information as possible into a uniform language. CPT codes are designed to cover all kinds of procedures and are therefore very specific. For example, the code for a 45-minute session of psychotherapy with a patient and/or family member is 90834, while the code for a 60-minute session with a patient and/or family member is 90837.

CPT Category II Codes

The second section of CPT (Category II, or CPT II) consists of optional supplemental tracking codes. These codes are formatted with a letter as their fifth character, and are coded after the initial CPT code. These Category II codes include information on test results, patient status, and additional medical services performed within the larger Category I procedure. Like Category I codes, they are divided into clusters. CPT II codes for Patient Management, for example, fall into the 0500F-0575F range. While optional, these codes reduce the need for record abstraction and chart review, and lower the administrative burden on healthcare professionals. In addition to increasing efficiency, Category II CPT codes facilitate research and the collection of data related to the quality of patient care. Some codes also relate to state or federal law, as in the case of the codes 3044F-3046F, which document the blood alcohol level of a patient.

These codes are a supplement, not a substitute, for the codes in Category I, and therefore must always be attached to an existing Category I code. An example of a CPT code with a Category II code attached is 80061-3048F, which describes a test of low-density lipoprotein cholesterol (CPT I code 80061), with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F).

CPT Category III Codes

The third section of the CPT code is devoted to new and emerging technologies or practices. Note that this code does not indicate that the service performed is ineffectual or purely experimental. A Category III code simply means the technology or service is new and data on it is being tracked. Like Category II codes, Category III CPT codes are numeric-alpha, meaning the last digit is a letter. After a predetermined period of time (typically five years of data tracking), a procedure or technology described by a Category III code may move into Category I, unless it is demonstrated that a Category III code is still needed.

Understand How CPT and ICD-9-CM Codes Interact

CPT codes work in tandem with ICD-9-CM codes to create a comprehensive picture of medical services rendered. ICD-9-CM codes, discussed in detail in Course 10, are numeric (and in certain cases alphanumeric) diagnostic codes that describe the symptoms, area, and type of injury or disease in a patient. When listed together, ICD-9-CM and CPT codes present a picture of both the diagnosis of an injury or disease and the type of service provided to the patient by the healthcare provider.

In some cases, it may be necessary to convert CPT codes to ICD-9-CM codes. ICD-9-CM’s alphanumeric codes describe the services, tests, consultations, and any other way that that a healthcare provider has interacted with a patient. There is often significant overlap between this set of codes and CPT. For instance, the CPT code for two doses of Hepatitis A vaccine, of pediatric or adolescent dosage, for intramuscular use is 90633. The ICD-9-CM code for that same vaccine is V05.3. In general, CPT codes provide more specificity than their ICD-9-CM counterparts. For instance, three doses of the above vaccine is coded in CPT as 90634, while in ICD-9-CM it is still coded as V05.3. Medical coders should familiarize themselves with the equivalencies between these two code systems, and be able to freely translate one into the other.

In addition to converting between these two codes, medical coders must ensure that the code they enter for a medical procedure (the CPT code) makes sense with the diagnosis code (ICD-9-CM). The two codes work in tandem to show which procedure was done for what reason. By confirming that the codes correspond correctly, coders ensure that a claim will not be denied and returned by a health insurance company. For instance, if you submitted a claim for a Human Papilloma Virus vaccine (CPT code 90650), but list the diagnosis as acute appendicitis with generalized peritonitis (ICD-9-CM code 540.0), a health insurance company would catch this error, deny the claim, and return it to you for correction. Lastly, the upcoming switch to ICD-10-CM on October 1, 2014, means that coders should also be able to convert CPT codes into ICD-10-CM codes.

ICD-9 to ICD-10 Medical Coding Crosswalk

The United States healthcare system will discontinue its use of ICD-9-CM diagnostic codes and upgrade its entire system to the next revision of the code: ICD-10-CM. Because ICD codes are integral to the medical billing process, the changes are taking place at every level of the patient-provider-payer relationship. As the person who interacts with diagnostic codes on a daily basis, the medical coder must be prepared for this transition. A medical coder must be fluent in both ICD-9-CM and ICD-10-CM in order to make the switch as seamlessly as possible.

This change was originally planned for October 1st, 2014 , however, the U.S Senate  introduced a bill on March, 26th, 2014 that will delay the change of ICD-9-CM to ICD-10-CM until October 1st, 2015.

A process called crosswalking is used to translate from one code to another. Crosswalking means mapping or translating a code from one set to another. Use the AAPC tool below to crosswalk between the different coding systems.

Learn Why the Change Will Happen

In order to understand this important shift in health informatics, it’s important to first look at why the change is occurring. ICD-9-CM is being phased out because it is outdated (published in 1978) and not flexible enough to deal with changes and expansions to medical procedures and diagnoses. To put it another way, ICD-9-CM is out of room. As new methods, diseases, and diagnoses are discovered, ICD-9-CM has been unable to find space in its code to accurately report these advances in medicine. ICD-9-CM caps out at around 13,000 codes, while ICD-10-CM has roughly 68,000.

Explore How the Change Will Happen

Being able to perform translations between ICD-9-CM and ICD-10-CM codes is a vital skill for a professional coder. One way in which translation is useful is that you can crosswalk codes back to ICD-9-CM if you are tracking or analyzing data. For example, if you are creating a report on the 2014 calendar year (which, again, will see the use of both ICD-9-CM and ICD-10-CM codes), it may be easier to crosswalk ICD-10-CM codes back to ICD-9-CM to create a standard set of data. Crosswalking will also help you update your records and programs.

There are, however, a number of difficulties in this process. Because ICD-10-CM expands so significantly on the body of codes in ICD-9-CM, there are a number of discrepancies and inaccurate or incomplete translations between the two code sets. It’s the medical coder’s job to watch out for these discrepancies and become familiar with crosswalking procedure as the deadline to switch from ICD-9-CM to ICD-10-CM approaches. Note that it is impossible in most cases to perform a 100 percent accurate translation from one code set to the other, as ICD-10-CM is significantly different from ICD-9-CM in terms of the format, concept, and structure.

One resource that will help you learn to crosswalk between the two code sets is the National Center for Health Statistics’ General Equivalence Mappings, or GEMs. These GEMs find and list equivalencies between the code sets, and they are considered the authoritative source for mapping between both sets. The GEMs allow you to map forward and backward between ICD-9-CM and ICD-10-CM. Coders should be familiar with both processes.

Understanding Different Code Matches

There are different types of matches that occur between the ICD-9-CM and ICD-10-CM code sets. The AMA identifies four types of matches between the two code sets, and an additional type that is reserved for “no match.”

One-to-one exact matches

In one-to-one matches, a coder is able to identify an exact match between the two code sets. These are relatively rare; only 5% of codes translate exactly from ICD-10-CM to ICD-9-CM, and just over 24 percent map directly in the opposite direction. One example is the ICD-9-CM code 416.0 (primary pulmonary hypertension) and the ICD-10-CM code I270 (primary pulmonary hypertension).

One-to-one approximate matches with one choice

A significantly more common occurrence in ICD code crosswalking is a one-to-one approximate match. In fact, 82.6 percent of ICD-10-CM codes can be backward-mapped this way, while 49.1 percent of ICD-9-CM codes can be forward-mapped to a similar degree of accuracy. It should be noted that this is not a direct translation, but more of a “close enough” approximation. For example, the ICD-9-CM code 422.91 (idiopathic myocarditis) is an approximate match for ICD-10-CM code I401 (isolated myocarditis).

One-to-one approximate matches with multiple choices

Exact and approximate matches with one choice make up the majority of ICD code crosswalking, but there are still a large number of codes that do not translate with the same level of accuracy. Approximate matches with multiple choices put much more responsibility on the coders, as they must pick the best fit from a number of similar choices. In certain cases, different diagnoses may fall under one code in the other set. For example, ICD-10-CM codes C220 (liver cell carcinoma) and C22 (hepatoblastoma) both correspond to ICD-9-CM code 155.0 (malignant neoplasm of the liver, primary). Each code set has instances of different diagnoses corresponding to only one code in the other. Coders must pay attention to these areas, as a miscoded diagnosis could affect the status of a claim.

One-to-many matches

By far the most difficult instance of crosswalking, one-to-many matches involve one code in a code set corresponding to several codes in the other. For instance, the ICD-9-CM code 80010 (closed fracture of vault of skull with cerebral laceration and confusion, state of consciousness unspecified) corresponds to two different codes in ICD-10-CM: S02.0xxA (fracture of the vault of the skull, initial encounter for closed fracture) and S06.339A (contusion and laceration of the cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter). Essentially, the diagnosis code in one set must be created out of multiple codes in another set. The groups of codes that translate to a single code in another set are called “clusters.” Clusters are always between two and four codes in size. Some single codes may correspond to multiple clusters. All codes in a cluster need to be listed in order to fully represent its corresponding translation. This process of translating one-to-many matches requires diligence and constant review, as a code missing from a cluster creates fundamental inaccuracies in your report.

Preparing for the Change to ICD-10

The ICD-9-CM will be replaced by the updated ICD-10 in late 2014. In order to comply with this change, healthcare providers, insurance companies, and clearinghouses must all be prepared to fully adopt ICD-10-CM by October 1, 2014. All claims filed with ICD-9-CM after that date will be rejected as non-compliant. Procedures arranged or completed before that date may still be filed with ICD-9-CM.

This switch is happening for a variety of reasons. For one, the ICD-9-CM is out of room. ICD-9-CM is set up so every category can only have 10 subcategories. As it currently stands, the ICD-9-CM can only classify around 13,600 diagnoses, compared to ICD-10-CM’s estimate of 69,000. As diagnoses continue to expand, the system can no longer support the breadth of medical study. The ICD-10 is also better suited for modern technological advances in the field, allowing for more optimized analysis of disease patterns and treatment outcomes.

There are similarities between the two code sets. The conventions and guidelines for assignment codes are largely the same, as is the organization of both sets. For instance, the first chapter, or category cluster, in both ICD-9-CM and ICD-10 is “Certain infectious and parasitic diseases,” so any professional qualified to manage ICD-9-CM should not have a problem with ICD-10. However, there are also key differences between the ICD-9-CM and ICD-10 systems, requiring a conversion on the part of the medical coder.

The composition of codes in the ICD-9-CM is primarily numeric, with limited alphanumeric additions, as discussed above. Valid ICD-9-CM codes are three, four, or five digits. In ICD-10-CM, all codes are alphanumeric and may be anywhere from three to seven digits, depending on the need for specificity. For instance, in ICD-9-CM, the cluster for “Certain infectious and parasitic diseases” is 001-139. In ICD-10 that same cluster would be labeled A00-B99.

Here is a broader example of the tabular breakdowns in ICD-9-CM and ICD-10:

ICD-9-CM

• Certain infectious and parasitic diseases (001-139)
  • Intestinal infectious diseases (001-009)
    • Cholera (001)
      • Cholera due to vibrio cholerae (001.0)
      • Cholera due to vibrio cholerae eltor (001.1)
      • Unspecified (001.9)

ICD-10

• Certain infectious and parasitic diseases (A00-B99)
  • Bacterial infections, other intestinal infectious diseases, and STDs (A00-A79)
    • Intestinal infectious diseases (A00-A09)
      • Cholera (A00)
        • Cholera due to vibrio cholerae (A00.0)
        • Cholera due to vibrio cholerae eltor (A00.1)
        • Unspecified (A00.9)

As you can see, the two code sets are largely similar, but with key differences. The alphanumeric numbering system of ICD-10 follows the same tabular tree as the numeric system in ICD-9-CM, adding a new subcategory within the A00-A79 cluster. As medical coders prepare for the shift, plenty of resources will be made available to translate ICD-9-CM into ICD-10.

Because ICD-10 and ICD-10-CM have a significantly larger set of codes than ICD-9 and ICD-9-CM, direct translation between the two code sets is impossible. The translation of ICD-9-CM codes into ICD-10-CM codes using a “crosswalk” program will be discussed in Course 11.

Watch for Coding Notes

In many cases, codes will have notes attached to them that prevent redundancies or inaccurate coding. These notes help medical coders accurately translate the diagnosis into code, and may include instructions like:

• “Code first,” in which case the coder must list an underlying condition or prior procedure
• “Includes,” which tells the coder which symptoms or afflictions the code contains
• “Excludes” or “excludes1,” which are especially important. Unique to ICD-9-CM, the “excludes” note instructs the coder that there is another, more appropriate code for a certain diagnosis. “Excludes1” indicates that the term listed under the “excludes1” field cannot occur simultaneously with the term listed above it. For example, systemic inflammatory response syndrome (SIRS) is coded as R65.1, but excludes severe sepsis (R65.2).

Those these notes can be complicated, they are essential for coding accurately. Even the smallest mistake can cause a medical claim to be denied, creating more work for the office and possibly delaying vital payments from the insurance company to a patient.

ICD-9-CM and ICD-10-CM Codes

The International Classification of Diseases (ICD) code is one of the most essential pieces of the medical billing and coding process. Created by the World Health Organization (WHO) as a way of standardizing healthcare classification, ICD codes are diagnostic codes that represent all aspects of a medical diagnosis, including symptoms, social circumstances, cause of injury or disease, and more.

ICD-9-CM Tool

To use the ICD-9-CM tool, simply type the name of a disease or injury in the search field. The search engine should then give you the corresponding ICD-9-CM code. You can look up that code in the ICD-9-CM index, available through the CDC. You will have to download a copy and open it as an RTF file.

ICD-10-CM Tool

Use the ICD-10 -CM Tool to search by the name of the disease or injury, or by the code itself. You can then take your search results and use them to find more information on the World Health Organization’s version of ICD-10-CM. Click on the chapter title (like “diseases of the respiratory system”) in the drop-down menu on the left to get a list of code blocks that chapter contains. You can also click the arrow button to the left of the chapter title to navigate the drop-down menu from the sidebar.

Background on the ICD

ICD-9—the ninth revision of the International Classification of Diseases—was published in 1978 by the WHO and adapted for use in America by the NCHS. ICD codes were originally intended to be used for epidemiological purposes, but in the United States these codes are used by healthcare providers and insurance companies for billing and reimbursement.

In America, “CM” stands for “Clinical Modification,” which was instituted in the United States by the National Center for Health Statistics (NCHS) to provide additional information related to diagnosis and procedural codes. The CM allows for a much wider spectrum of specific information. ICD-9-CM is updated annually on October 1st in order to reflect new diagnoses, practices, and procedures in the healthcare industry.

How the ICD-9-CM Works

ICD codes create a standard vocabulary for identifying causes of illness, injury, and death around the world.

Physical copies of the ICD-9-CM codes are divided into volumes. Volume 1 contains a tabular list of codes (codes listed by number with the diagnosis following the number) and Volume 2 contains an alphabetical list of symptoms and diagnoses. The third volume for each of these contains procedure codes, which are only used by hospitals to report surgeries performed in their facility. Healthcare providers and insurance companies only use the first two volumes. For the purposes of this course, you will be looking up ICD codes entirely online, but it is still helpful to understand the organization of the ICD manuals.

The 5-digit numeric ICD-9-CM codes are organized from 000 to 999 according to the type of disease or injury they describe. For instance, codes in the 320-359 range represent diseases of the nervous system, such as encephalitis or meningitis. Codes 800-999 correspond to injury and poisoning, like dislocation (codes 830-839) or poisoning by drugs, medications, or other biological substances (codes 960-979).

Those first three digits in an ICD-9-CM code describe the general type of injury or disease, and are called the “category.” The category can be followed by a decimal point and up to two other digits, which provide more specific information about the type, location, and severity of the disease or injury. These last two digits are called the subcategory, and allow coders to increase the level of specificity of their report on a disease or injury.

Example:

The code 722.52 corresponds to degenerative disc disease of the lumbar, where:

• The 3-digit code, or category, “722” corresponds to “intervertebral disc disorders” in the list of diseases and injuries
  • The two-digit sub-subcategories refers to degenerative disc disease, lumbar

Generally speaking, the more digits in a code, the more specific the type, cause, and/or area of injury or disease.

There are also two sets of alphanumeric codes in ICD-9-CM. E-codes describe external causes of injury, while V-codes describe factors that influence health status and/or describe interactions with health services. An example of an e-code would be E905.2, which describes a scorpion sting causing poisoning and toxic reactions. An example of a V-code is V30.00, which describes a single live infant (V30) born in a hospital (V30.0) without mention of caesarean section (V30.00). Like the numeric codes in ICD-9-CM, each of these codes has varying degrees of specificity based on the incident.

HIPAA Compliance

Title II: Preventing Medical Healthcare Fraud and Abuse, Administrative Simplification, and Medical Liability Reform

Title II addresses many more concerns relevant to the medical billing and coding field, namely, security and privacy requirements for handling a patient’s medical records and methods to simplify the billing and processing of claims. In addition, it establishes guidelines for electronic recordkeeping and electronic transactions between parties in the healthcare system.

Title II also stipulates how healthcare providers and insurance companies should avoid fraudulent activity. The law puts the Officer of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) in charge of investigating and if necessary prosecuting those who commit fraud. Your responsibilities as a medical billing specialist will be discussed in the next section of this lesson.

The Privacy Rule

Title II expands security and privacy measures within the healthcare system with the creation of the Privacy Rule and the Security Rule. The Privacy Rule addresses how insurance companies and providers can handle patient information by regulating how they disclose the information to each other and to other entities that may require medical data. Under the Privacy Rule, medical billing and coding specialists must be careful not to share a patient’s Protected Health Information (PHI) with parties that aren’t covered entities (providers, insurance companies, etc.) as stipulated by Title II. A patient’s PHI includes the following data:

• The patient’s medical record, including present and past medical conditions or illnesses and treatments received for them
• The location and type of healthcare provider wherein the patient received care
• Any and all fees paid by the patient or a patient’s insurance company to cover healthcare expenses rendered by a provider

The Security Rule

The Security Rule, on the other hand, establishes the rules for protecting a person’s information and also explains how those rules can be enforced if necessary. The security rule explains how covered entities must collaborate to protect patient medical information. Part of this collaboration involves the creation of computerized physician order entry (CPOE) systems and electronic healthcare records (EHRs) that medical billing and coding specialists use everyday to file and process claims. The Security Rule also requires that any technologies developed by covered entities to facilitate their administrative work must be secure and up to standards established by HIPAA.

Title II also creates unique identifiers for providers, employers, and patients in an attempt to optimize communication between entities in the healthcare system and universalize the billing process. This is done in accordance with the Electronic Data Interchange (EDI) Rule set forth in Title II. The unique identifiers created for the EDI are either individual numbers or code sets assigned to covered entities for the use of electronic transactions and should have equal value and meaning for any medical billing specialist. Some of the unique identifiers include the following sets:

• The National Standard Employer Identifier Number (EIN) for tracking employers
• The National Provider Identifier Number (NPI) for tracking providers such as private clinics, hospitals, and nursing facilities
• The National Health Plan Identifier Number (HPID) for tracking participating health insurance companies

For medical billing and coding purposes, the standards set forth under Title II are important because they optimize the claims process. The format and transaction of electronic claims in particular is simpler and more secure now than ever before thanks to Title II of HIPAA.

Medical Billing Guidelines

Medical billing and coding specialists deal with sensitive information on a daily basis. As a medical billing and coding specialist, you will handle provider, patient, and insurance information that must be kept secure at all times. You will also be responsible for facilitating the secure electronic and physical transference of sensitive medical information between these parties. Failing to perform your duties within the guidelines may result in a federal investigation.

An overview of guidelines and compliance requirements set by the Health Insurance Portability and Accountability Act (HIPAA), the Office of the Inspector General (OIG), and the Healthcare Reform Act of 2010 follows. The guidelines set forth by these entities comprise some of the most important privacy, security, and filing-related rules you will need to know as a medical billing specialist.

HIPAA Compliance

HIPAA was passed by Congress and signed into law by President Clinton in 1996. Chief among the goals set forth by HIPAA was increased security and accountability when it comes to patient medical information. Specifically, HIPAA established guidelines that healthcare providers and health insurance companies must follow in order to keep a patient’s information secure.

These HIPAA guidelines apply to the gathering, cataloging, and transferring of any and all patient information. For the purposes of medical billing and coding, HIPAA serves to curb fraudulent activity before, during, and after the claims process as well as establishing standards for transferring patient information electronically.

HIPAA is divided into five Titles.

Title I: Healthcare Access, Portability, and Renewability

Title I of HIPAA addresses health insurance policies within the confines of a person’s employment. Under Title I, HIPAA sets guidelines for what an employer can and cannot do with an employee’s healthcare plan as provided by the employer. Specifically, Title I protects health insurance coverage for employees and their dependents by making healthcare plans available to those who have either lost their job or those who are in the process of switching employers.

Title I protects employees by modifying and improving the Consolidated Omnibus Reconciliation Act of 1985 (COBRA). Title I of HIPAA extended healthcare benefits already offered by COBRA, including extending the duration of benefits of disabled persons eligible for COBRA from 18 to 36 months. Title I also allowed dependents of a person covered under COBRA to continue to receive the same healthcare coverage as they did when that person was employed with health benefits.

Title I also addresses how health insurance companies treat patients with pre-existing conditions. Before HIPAA, a person with a pre-existing condition might have trouble finding a healthcare plan that covers their medical expenses because commercial insurance companies would consider them too risky to cover. Under Title I, insurance companies are limited in how many restrictions they can put into place in their healthcare plans for people with pre-existing conditions.

For medical billing and coding professionals, Title I is important because it ensures that more people are eligible for health insurance. Because of the laws set forth in Title I, you will process claims that involve patients covered by COBRA or those with pre-existing conditions that still receive coverage thanks to this act.

Medical Billing Terminology - D & E

D

Date of Service (DOS): The date when a provider performed healthcare services and procedures.

Day Sheet: A document that summarizes the services, treatments, payments, and charges that a patient received on a given day.

Deductible: The amount a patient must pay before an insurance carrier starts their healthcare coverage. Deductibles range in price according to terms set in a person’s health plan.

Demographics: The patient’s information required for filing a claim, such as age, sex, address, and family information. An insurance company may deny a claim if it contains inaccurate demographics.

Durable Medical Equipment (DME): This refers to medical implements that can be reused such as stretchers, wheelchairs, canes, crutches, and bedpans.

Date of Birth (DOB): The exact date a patient was born.

Downcoding: Downcoding occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed coded medical services and so they reduce or remove those codes. Downcoding usually reduces the cost of a claim.

Duplicate Coverage Inquiry (DCI): A formal request typically submitted by an insurance carrier to determine if other health coverage exists for a patient.

Dx: The abbreviation for diagnosis codes, also known as ICD-9 codes.

E

Electronic Claim: A claim sent electronically to an insurance carrier from a provider’s billing software. The format of electronic claims must adhere to medical billing regulations set forth by the federal government.

Electronic Funds Transfer: A method of transferring money electronically from a patient’s bank account to a provider or an insurance carrier.

Evaluation and Management (E/M): E/M refers to the section of CPT codes most used by healthcare personnel to describe a patient’s medical needs.

Electronic Medical Records (EMR): EMR is a digitized medical record for a patient managed by a provider onsite. EMRs may also be referred to as electronic health records (EHRs).

Enrollee: A person covered by a health insurance plan.

Explanation of Benefits (EOB): A document attached to a processed medical claim wherein the insurance company explains the services they will cover for a patient’s healthcare treatments. EOBs may also explain what is wrong with a claim if it’s denied.

Electronic Remittance Advice (ERA): The digital version of EOB, which specifies the details of payments made on a claim either by an insurance company or required by the patient.

ERISA: Stands for the Employee Retirement Income Security Act of 1974. This act established guidelines and requirements for health and life insurance policies including appeals and disclosure of grievances.

Medical Billing Terminology - B and C

Beneficiary: The beneficiary is the person who receives benefits and/or coverage under a healthcare plan. The beneficiary of an insurance plan may not be the person paying for the plan, as is the case for young children covered under their parents’ plans.

Blue Cross Blue Shield: Blue Cross Blue Shield is a federation of 38 health insurance companies in the U.S. (some of which are non-profit companies) that offer health insurance options to eligible persons in their area. Blue Cross Blue Shield offers healthcare plans to over 100 million people in the U.S.

C

Capitation: A fixed payment that a patient makes to a health insurance company or provider to recoup costs incurred from various healthcare services. A capitation is different from a deductible or co-pay.

Civilian Health and Medical Program of Uniform Services (CHAMPUS): CHAMPUS (now known as TRICARE) is the federal health insurance program for active and retired service members, their families, and the survivors of service members.

Charity Care: This type of care is administered at reduced or zero cost to patients who cannot afford healthcare. Providers may offer charity care at their discretion.

Clean Claim: This refers to a medical claim filed with a health insurance company that is free of errors and processed in a timely manner. Some providers may send claims to organizations that specialize in producing clean claims, like clearinghouses.

Clearinghouse: Clearinghouses are facilities that review and correct medical claims as necessary before sending them to insurance companies for final processing. This meticulous editing process for claims is known in the medical billing industry as “scrubbing.”

Centers for Medicare and Medicaid Services (CMS): The CMS is the federal entity that manages and administers healthcare coverage through Medicare and Medicaid. CMS coordinates with providers and enrollees to provide healthcare to over 100 million Americans.

CMS 1500: The CMS 1500 is a paper medical claim form used for transmitting claims based on coverage by Medicare and Medicaid plans. Commercial insurance providers often require that providers use CMS 1500 forms to process their own paper claims.

Coding: Coding is the process of translating a physician’s documentation about a patient’s medical condition and health services rendered into medical codes that are then plugged into a claim for processing with an insurance company. Medical billing specialists must be familiar with many code sets in order to perform their job duties.

COBRA Insurance: A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.

Co-Insurance: The percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in a health plan. Co-insurance percentages vary depending on the health plan.

Collection Ratio: This refers to the ratio of payments received relative to the total amount owed to providers.

Contractual Adjustment: This refers to a binding agree between a provider, patient, and insurance company wherein the provider agrees to charges that it will write off on behalf of the patient. Contractual adjustments may occur when there is a discrepancy between what a provider charges for healthcare services and what an insurance company has decided to pay for that service.

Coordination of Benefits (COB): COB occurs when a patient is covered by more than one insurance plan. In this situation one insurance company will become the primary carrier and all other companies will be considered secondary and tertiary carriers that may cover costs left after the primary carrier has paid.

Co-Pay: A patient’s co-pay is the amount that must be paid to a provider before they receive any treatment or services. Co-pays are separate from a deductible, and will vary depending on a person’s insurance plan.

Current Procedural Technology (CPT) Code: CPT codes represent treatments and procedures performed by a physician in a 5-digit format. CPT codes are entered together with ICD-9 codes that explain a patient’s diagnosis. Medical billing specialists will enter CPT codes into claims so insurance companies understand the nature of healthcare a patient received with a provider.

Credentialing: The application process for a provider to coordinate with an insurance company. Once providers have become credentialed with an insurance company, they have the opportunity to work with that company in providing affordable healthcare to patients.

Credit Balance: Refers to the sum shown in the “balance” column of a billing statement that reflects the amount due for services rendered.

Crossover Claim: When claim information is sent from a primary insurance carrier to a secondary insurance carrier, or vice versa.

Medical Billing Terminology - A

Allowed Amount: The sum an insurance company will reimburse to cover a healthcare service or procedure. The patient typically pays the remaining balance if there is any amount left over after the allowed amount has been paid. This amount should not to be confused with co-pay or deductibles owed by a patient.

American Medical Association (AMA): The AMA is the largest organization of physicians in the U.S. dedicated to improving the quality of healthcare administered by providers across the country. The current procedural technology (CPT) code set is maintained and revised by the AMA in accordance with federal guidelines.

Aging: A formal medical billing term that refers to insurance claims that haven’t been paid or balances owed by patients overdue by more than 30 days. Aging claims may become denied if they aren’t filed in time with a health insurance company.

Ancillary Services: Any service administered in a hospital or other healthcare facility other than room and board, including biometrics tests, physical therapy, and physician consultations among other services.

Appeal: Appeal occurs when a patient or a provider tries to convince an insurance company to pay for healthcare after it has decided not to cover costs for someone on a claim. Medical billing specialists deal with appeals after a claim has been denied or rejected by an insurance company.

Applied to Deductible (ATD): This term refers to the amount of money a patient owes a provider that goes to paying their yearly deductible. A patient’s deductible is determined by their insurance plan and can range in price.

Assignment of Benefits (AOB): This term refers to insurance payments made directly to a healthcare provider for medical services received by the patient. Assignment of benefits occurs after a claim has been successfully processed with an insurance company.

Application Service Provider (ASP): ASP is a digital network that allows healthcare providers to access quality medical billing software and technologies without needing to purchase and maintain it themselves. Providers who use ASP typically pay a monthly fee to the company that maintains the billing software.

Authorization: This term refers to when a patient’s health insurance plan requires them to get permission from their insurance providers before receiving certain healthcare services. A patient may be denied coverage if they see a provider for a service that needed authorization without first consulting the insurance company.

Is your claim reimbursement in line with your contracted fees?

This type of analysis is invaluable to any medical practice.  Once you have signed on that dotted line with the payer, you are wise to ensure that you are receiving the proper reimbursement based on the agreed upon contractual rates.  In the daily whirlwind of activity in the medical office, office staff seldom has the time to comb over the detail of every paid line item.  

A monthly report that compares the payments received to the payer’s fee schedule will indicate payments that are below (as well as above) the payers contracted fees.  Payments that are below should immediately prompt a call the Provider Relations Department.  For payments above the contracted fees, research has to be done on the accuracy of the fee schedule you are using, for instance, perhaps the payer has updated its schedule and you have not.  

This type of report could also make you aware of overpayments. If those are pre-emptively refunded to the payer, it will show your practice to be following proper procedures in the eyes of the payer.

These two reports are just a small sampling of the extensive selection of practice management reporting options built into the Report Center module of Iridium Suite Medical Billing Software.

Be sure to watch for the upcoming publication of Part 3:  Temperature.

Check the Vital Signs of Your Medical Practice-Part 1

A Medical Practice is a unique business in many ways, but it is still a business and must be treated as such.  Checking the health of your practice is similar to checking the health of your patients.  In this three part series, we will look at these Vital Signs, pulse, blood pressure and temperature, to help you assess the financial well-being of your medical practice.

We will begin in Part 1 with the Pulse -     

How many new patients are you seeing each month?

By analyzing the trends month over month, you will be able to calculate your current growth rate and estimate the potential need for increased staffing and other infrastructure changes.  If close monitoring of your patient numbers shows a progressive decline or steep increase, it can give you the opportunity to research the reason why.  One reason could lie in the next item on our list, referrals.

Who is referring those patients to you?

With the almighty internet, physicians have been able to reach out much more easily and cost effectively to a wider range of patients.  While many people with basic medical needs may feel comfortable doctor-shopping online, there are many who have complicated issues.  These referrals generally come from colleagues and satisfied patients.  Know which providers in your area are referring patients to your office and always keep the lines of communication open in regards to those mutual patients.  

A happy, well-taken-care-of patient is the best advertising.  Many times less than stellar office staff can scare away patients who “love” their doctor, and those unpleasant episodes can make their way back to the referring colleague.  Watch for trends that would show a reduction in referrals from a particular source and take the time to reach out personally.   

These two reports are just a small sampling of the extensive selection of practice management reporting options built into the Report Center module of Iridium Suite Medical Billing Software.

Be sure to watch for the upcoming publication of Part 2:  Blood Pressure.

Inaccurate or non-specific diagnosis coding can adversely affect your reimbursement of medical claims.

Many categories of the ICD-9 contain codes that represent the non-specified site of a certain neoplasm. The are typically indicated with a “9” as the last digit of the code.

Even though all of these codes are viable, accepted diagnoses, many payers, especially Medicare, highly encourage the use of the more “site specific” codes. Failure to be specific can in some instances cause Medical Necessity denials as the non-specific codes may not be listed as acceptable in the payers' Medical Policies. 

Also, if audited, a discrepancy between the treating diagnosis in the medical chart and the diagnosis submitted on a claim, could cause payment reversals and money due back to the payer. 

In all medical specialties, the patient medical record should dictate what services are billed and the diagnoses used.

One specialty example is Radiation Oncology. The prescriptions for Radiation Therapy Treatment Courses are very site specific, so this information is one of the most helpful tools in proper diagnosis coding when used in conjunction with patient data the medical staff has entered into the medical record.

In any specialty, but quite frequently in Radiation Oncology, a patient can have numerous diagnoses that require treatment. In these instances, it is especially important to indicate the proper diagnosis priority on your services. The priority one diagnosis should always be the current treating diagnosis for the service you are billing.

Another frequent situation in Radiation Oncology billing arises when treating a patient for metastatic disease. The metastatic treatment site will be listed as the priority one diagnosis with the primary original site diagnosis listed as the second.

Other specialties would follow a similar scenario if they were treating a complication diagnosis, billed as priority one, from an initial diagnosis, billed as priority two.

Billing and coding software with comprehensive ICD -9 and ICD-10 code files, as well as an ICD 10 conversion crosswalk, such as Iridium Suite can assist your office in accurately billing the most specific diagnoses for the patients in your practice.