Articles tagged with cpt
Over the past few weeks, we’ve talked a lot here about medical coding — what it is and how it’s done. At a fundamental level, hospitals and clinics code diagnoses and procedures so that they can get paid by a third-party payer or the patient.
That all-important “getting paid” part is where the charge master, also known as the chargemaster (one word) or the charge description master (CDM), comes in. The CPT (procedure) code of 97810 tells us that a patient received basic acupuncture, and the ICD-9-CM (diagnosis) code of 784.0 tells us it was related to the patient’s headaches, but nowhere does it tell us anything about cost.
A charge master is essentially a big list of every service, procedure, or item that could be billed to a patient — and its price. Each hospital or clinic develops its own charge master and formats vary. Charge masters allow health care providers to match services rendered with their appropriate charges. In some states, providers must make their charge masters available to the public.
Let’s look at the acupuncture example. Before generating a bill, the health care provider must find out what price is attached to CPT code 97810 (defined as “acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient”).
Think of the charge master as a spreadsheet. In the first column is a list of CPT codes. You’ll scroll down to the row representing 97810. In that row, you’ll find columns containing:
- The CPT code for that procedure (of course)
- A written description of the procedure
- The revenue code, a four-digit code indicating where the procedure took place (e.g., emergency department, outpatient clinic) or the general type of procedure performed
- The procedure price
- Organization-specific information (e.g., hospital/clinic department that performs the procedure)
For our acupuncture example, you might see: 97810; acupuncture, one or more needles …; 2101; $41.00; internal medicine. Depending on the organization, you might find additional information as well.
This data is then entered into a CMS 1450 (for institutional providers such as hospitals and outpatient clinics; form is also known as UB-04) or CMS 1500 (for physicians) claim form and sent off to the third-party payer. (You can look up examples of both forms on the Centers for Medicare and Medicaid Services website.)
For medical centers, an optimized charge master means increased revenue. If legitimate, chargeable items are missing from the charge master, the health care provider is missing out on that revenue. For example, a charge master might be missing a line item for the second part of a three-part procedure.
Or, a new procedure or service may not yet be included in the charge master, meaning it could be given to patients without them being billed for it. Likewise, a mistakenly billed charge — due to an outdated CPT code in the charge master — delays insurance reimbursements.
To remedy these issues, health care organizations should better educate their coding staff and physicians about the importance of charge capture. They can also perform audits — by manually comparing physician documentation with what was ultimately charged to the patient — to check for inconsistencies.
Software solutions can also add value by searching for out-of-date CPT codes or by applying logic to charges, sniffing out cases where you couldn’t perform procedure X without using supply/device Y, and yet X was billed while Y was not.
Do you know what’s in your charge master?
Don’t miss out on charges or take compliance risks. pmFAQtory can help. Please contact us to discuss your needs.
As we’ve discussed, medical coding is the process of assigning standardized numbers to diagnoses/diseases, causes of death, and inpatient and outpatient medical procedures. The primary reason for medical coding is to ensure consistent classification and billing, as it enables physicians, medical centers, and third-party payers to “talk” in the same language.
So where do these codes come from? There are four major “code sets” in the medical coding world, each with a different use:
- International Statistical Classification of Diseases and Related Health Problems (ICD), maintained by the World Health Organization
- International Statistical Classification of Diseases and Related Health Problems, Clinical Modification (ICD-CM), maintained by the Centers for Medicare and Medicaid Services and the National Center for Health Statistics
- Healthcare Common Procedure Coding System (HCPCS), maintained by the Centers for Medicare and Medicaid Services
- Current Procedural Terminology (CPT), maintained by the American Medical Association
Here’s how they fit together:
ICD-9: The ninth revision of the ICD code set, ICD-9 was used to classify mortality (death) in the U.S. until Jan. 1, 1999, and is now obsolete (replaced by ICD-10).
ICD-9-CM: The ninth revision of the ICD code set with “clinical modifications,” ICD-9-CM is used today in the U.S. to classify morbidity (diagnoses/diseases) and inpatient medical procedures. It consists of three volumes: volume one (tabular listing of diagnosis codes), volume two (index of diagnosis codes), and volume three (procedure codes). An ICD-9-CM code has between three and five characters, such as 560, 553.3, or 560.81.
ICD-10: The 10th revision of the ICD code set, ICD-10 replaced ICD-9 for classifying mortality in the U.S. as of Jan. 1, 1999.
ICD-10-CM: The 10th revision of the ICD code set with “clinical modifications,” ICD-10-CM is an expanded and revised version of ICD-9-CM, and will be put into use in the U.S. as of Oct. 1, 2013, to classify morbidity. An ICD-10-CM code has between three and seven digits; examples are M05.339 and S26.020D.
When you hear rumblings that medical centers are anxious about planned ICD changes, it’s this forthcoming implementation of ICD-10-CM across the U.S. that’s causing the angst.
HCPCS: A two-level code set used to classify outpatient medical procedures. Level one consists of CPT codes (see below), while level two classifies non-physician services and supplies, such as ambulance transportation and medical equipment.
CPT: Serves as HCPCS level one and is used in the U.S. today to classify all outpatient medical and surgical procedures (ICD-9-CM volume three is used to classify inpatient procedures). A CPT code has five digits, such as 39520 or 00756.
A subset of CPT codes, called evaluation and management (E&M) codes, are used to classify non-surgical physician visits/consultations.
Put another way, in the U.S. today …
- ICD-9-CM volumes one and two are used to classify morbidity
- ICD-9-CM volume three is used to classify inpatient hospital procedures
- ICD-10 is used to classify mortality
- HCPCS level one (CPT) is used to classify outpatient procedures
- HCPCS level two is used to classify medical equipment, supplies, and drugs
The intersection of medical coding and health care information technology — pmFAQtory’s field — is pretty clear-cut. For humans, sorting through various code sets and tens of thousands of individual medical codes, while at the same time ensuring compliance with payer regulations, is about as much fun as doing taxes by hand.
That’s why numerous technological solutions have surfaced to help medical centers more efficiently assign codes and ensure accuracy. pmFAQtory specializes in guiding health care organizations as they implement these systems, which sit within a complex health IT landscape. We’ll examine that landscape in more detail in the next few weeks.
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