Billing Billing BackgroundBackground

Diagnosis (ICD) versus Service (CPT)Diagnosis (ICD) versus Service (CPT)

ICD codes are diagnosis codesICD codes are diagnosis codes–Describe new and established Describe new and established

diagnoses diagnoses –Also include symptom codesAlso include symptom codes–headache (symptom code), vs headache (symptom code), vs

migraine (diagnosis code)migraine (diagnosis code)

Diagnosis (ICD) versus Service (CPT)Diagnosis (ICD) versus Service (CPT)

CPT codes are service codesCPT codes are service codes–Describe performed services, both Describe performed services, both

procedures and procedures and evaluation/management (E/M)evaluation/management (E/M)

–Service codes must be based on Service codes must be based on necessity determined by necessity determined by diagnosis/ICD-9 codesdiagnosis/ICD-9 codes

ICD or Diagnosis/Disease ICD or Diagnosis/Disease CodesCodes

IInternational nternational CClassification of lassification of DDiseasesiseasesDeveloped by the WHODeveloped by the WHOFacilitates classification of morbidity and Facilitates classification of morbidity and mortality data and international disease mortality data and international disease standardizationstandardizationRevised periodicallyRevised periodically

ICD-9 CM ICD-9 CM

ICD-9 CM: International Classification of ICD-9 CM: International Classification of Diseases, 9Diseases, 9thth Revision, Clinical Revision, Clinical ModificationModification

System modified from ICD, includes more System modified from ICD, includes more specificity for clinical and billing purposes specificity for clinical and billing purposes

Revised annuallyRevised annually

ICD-10 CM has an in use deadline of ICD-10 CM has an in use deadline of

1 OCT 151 OCT 15

ICD-9 CM Cont…ICD-9 CM Cont…

ICD-9 CM diagnosis codes range from general to ICD-9 CM diagnosis codes range from general to specificspecificMore specific codes may better support billing i.e. justify More specific codes may better support billing i.e. justify why higher level of service was deemed necessarywhy higher level of service was deemed necessary

ICD-9 CMICD-9 CM DiagnosisDiagnosis

427.9427.9 Arrhythmia, NOSArrhythmia, NOS

427.31427.31 Atrial fibrillationAtrial fibrillation

250.01250.01 Diabetes type IDiabetes type I

250.03250.03 Diabetes Type I, UncontrolledDiabetes Type I, Uncontrolled

595.0595.0 UTI -cystitisUTI -cystitis

590.10590.10 UTI – pyelonephritis, acuteUTI – pyelonephritis, acute

428.1428.1 CHF, leftCHF, left

428.30428.30 CHF, diastolic unspecifiedCHF, diastolic unspecified

V Codes (sub set of ICD-9 CM codes)V Codes (sub set of ICD-9 CM codes)

Code for preventative careCode for preventative care

Usually not reimbursable themselves, but…Usually not reimbursable themselves, but…

May allow for reimbursement of other May allow for reimbursement of other services not otherwise authorizedservices not otherwise authorized– HIV, asymptomatic (v08) allows for payment of HIV, asymptomatic (v08) allows for payment of

vaccines not otherwise reimbursedvaccines not otherwise reimbursed– Family history, breast cancer (v16.3) allows for Family history, breast cancer (v16.3) allows for

reimbursement of early screening or genetic reimbursement of early screening or genetic testingtesting

CPT Codes/Service CodesCPT Codes/Service Codes

CCurrent urrent PProcedural rocedural TTerminologyerminologyDescribe performed services, both procedures and Evaluation and Management (E/M)Describe performed services, both procedures and Evaluation and Management (E/M)Service codes must be based on necessity determined by diagnosis/ICD-9 codesService codes must be based on necessity determined by diagnosis/ICD-9 codes

CPT Codes Cont…CPT Codes Cont…

Currently the national standard for almost all Currently the national standard for almost all health insurers (Medicare, Medicaid and health insurers (Medicare, Medicaid and private insurers)private insurers)

1960’s 1970’s 1983

Developed by AMA to standardize

billing/coding for Surgical Specialties

Expanded to include medical procedures and

services

Adopted and standardized by

federal government to include all

subspecialties

CPT Codes Cont…CPT Codes Cont…

5 digit codes5 digit codes

Cover all billable services and proceduresCover all billable services and procedures– Anesthesia 00100-01999Anesthesia 00100-01999– Surgery 10040-69999Surgery 10040-69999– Radiology 70010-79999Radiology 70010-79999– Pathology and Laboratory 80001-89399Pathology and Laboratory 80001-89399– Medications (ie meds administered) 90700-99199Medications (ie meds administered) 90700-99199– Evaluation and Management (E/M) 99201-99499Evaluation and Management (E/M) 99201-99499

CPT Codes – an exampleCPT Codes – an example

An 65 yo man visits his PCP for his annual checkup and An 65 yo man visits his PCP for his annual checkup and incidentally complains of 2 days of knee pain. On exam incidentally complains of 2 days of knee pain. On exam his knee is erythematous, warm, tender and swollen. his knee is erythematous, warm, tender and swollen. You perform a joint aspiration, and he also receives a You perform a joint aspiration, and he also receives a Pneumovax as part of his routine preventative care.Pneumovax as part of his routine preventative care.

3 codes apply (and can all be used for the single visit)3 codes apply (and can all be used for the single visit)– Evaluation and management codeEvaluation and management code– Medication code (for vaccine)Medication code (for vaccine)– Surgery code (for joint aspiration)Surgery code (for joint aspiration)

Medical Necessity RuleMedical Necessity Rule

There must be a connection between the There must be a connection between the diagnosis and the corresponding service diagnosis and the corresponding service CPT codeCPT code

MD must decide what is medically MD must decide what is medically necessary care for the given diagnosis, necessary care for the given diagnosis, and bill accordinglyand bill accordingly

Even if documentation is extensive, only Even if documentation is extensive, only bill for medically necessary carebill for medically necessary care

Medical Necessity Rule: CMS (centers for Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statementMedicaid and Medicare Services) official statement

““Medical necessity is determined based on Medical necessity is determined based on the diagnosis submitted for that service or the diagnosis submitted for that service or supply. Specificity and accuracy of supply. Specificity and accuracy of diagnosis code and linkage on the claim diagnosis code and linkage on the claim form determine payment.”form determine payment.”

ICD-9CM and CPTICD-9CM and CPT

MAKE THE CONNECTION!!!