Modifier 52 Reduced services and Modifier 53 Discontinued services describe similar but distinct circumstances. To apply these modifiers appropriately, you’ll need to know why the provider stopped or otherwise “cut short” the procedure they were performing. Expected or Elected Calls for 52 If a provider plans or expects a reduction in the service, or electively cancels the […]
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A) The medical record should be complete and legible
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Tag Archives: between
MedPAC advises CMS to establish payment equity between postacute care settings
What is the different between account receivables and account revenues?
From my understanding, account receivables mean the account had been billed out but we haven’t received the payments. Account revenues mean we have received the payments. Is this correct?
Sample Contracts between Doctor and Coder
Hello, I am planning to code for a private doctor, does anyone have a sample of the contract that I can see or where to find one? I would want to include something about privacy, HIPAA, pay rate, confidentiality, etc. Please help asap. Thank you.
PLEASE HELP-discrepancy between name on id and name on insurance card
If a new patient comes in and their ID says their name is John Bob Doe and their insurance card says their name is Bob Doe, how do you handle this? I have always billed under the name that is on their ID as this is their legal name but I keep seeing posts that say offices change their demographics to match what is on the insurance card so that they will be paid. This seems wrong but I am surprised how many patients come into my office expecting me to do this. I tell patients that if their info is wrong with an insurance company they need to call them and correct it. Am I wrong? Really need some advice, I have looked everywhere I can think of and can’t find anything specifically dealing with this issue. Thanks in advance for any input you can give!
Know the Difference Between Medicare and Medicaid NCCI Edits
Follow the correct edit to promote payment and avoid denial. By Samantha Prince, BSHCM, COC, CPC, CPMA National Correct Coding Initiative (NCCI) edits for Medicare and Medicaid are not the same. If you’re following Medicare edits for Medicaid claims, you may have claims denying inappropriately. That’s missed revenue you could capture by applying the correct […]
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Question about Coordination of Benefits between Medical and Vision Insurances
Hello,
I am not extremely familiar with filing vision claims and I have tried to research this topic. Most instances it seems that it depends on why the patient is here as to who to bill to as primary, but my question comes in when the patient has a medical insurance and has either a copay, deductible, or coinsurance amount and if vision acts as a secondary to cover these amounts or if the patient is responsible.
The way it has "always been done" here at the clinic I work for is that when the patient’s medical insurance comes back, they file the remainder to any applicable vision policy. I understand that a refraction would be covered in this instance if not covered by the primary, but they have historically changed the diagnoses on the claim for to all vision codes and taken off all the medical. To me this seems incorrect. If the vision insurance acts as a true secondary on medical, then we should be filing the claim exactly the way we did to the medical insurance and not change any diagnosis codes. If their exam was billed as medical because their reason for visit was medical, then that should follow the claim form to the vision insurance company.
My co-worker who has been filing these claims stated that she called the vision company and explained my concerns and the vision company apparently told her it didn’t matter what diagnosis was on the claim. As long as they had the primary EOB, they would process the claim. Now I don’t trust what she is saying which is obviously why I am posting my question here.
Thanks in advance for helping me with this.
Amber
Communication – The bridge between providers and coders
This originally published in March of 2014… yet still has some GREAT information for all to use
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Communication – The bridge between providers and coders
March 11, 2014 (Revised and Updated 07 20 2017)
We have all heard the adage “if it wasn’t documented, it wasn’t done”. However, in the role of the medical provider, the fast pace of the job can get in the way of the accuracy of documentation. Unfortunately, in our current healthcare state, our practices have to be fiscally solvent. This is accomplished by accurate coding/billing, AND providing good patient care. Clinical Documentation is a fundamental piece of our total job function coupled with the challenge of providing good communication to our coders for accurate coding a billing.
The importance of good clinical documentation cannot be underestimated. Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care. Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream. If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster. Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.
Documentation will always be a “necessary evil” in the role of healthcare and reimbursement. The conversion to ICD-10 cm (Took place on 10.01.2015) will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system. Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.
Communication is the bridge between the provider of care, and the coder/biller. According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or is an especially skillful writer. As a providers and coders, think about this….. both fall into this category of expertise! The primary function of a coder is to apply that which is written by the provider, into a numeric format; such as ICD-9cm (ICD-10cm). However, once ICD-10cm is implemented, coders will need an excellent understanding of not only medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the written diagnoses per the documentation into the new alpha-numeric ICD-10cm format.
ICD-10 includes many new terms, and certain codes will now require documentation to be more precise and complete to give coders the best “picture” of the care received by the patient via a numeric format. Our challenge as good providers is to document and communicate this new criteria more effectively so we can all share the same understanding of the words needed to continue being fiscally solvent, but to also document the clinical course of care provided.
Unfortunately, most physician and clinical providers don’t have the “inside track” as to what criteria or “words” are needed to clearly document in ICD-9, much less for ICD-10. Both the coder and the providers are challenged even more by the specificity needed in ICD-10. A coder and the clinical documentation specialist are going to be looked up to as the expert. The ‘experts’ will now be looked to help educate and inform providers how to document more clearly and to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions. If we succeed in this endeavor, everyone benefits.
The coding query process can help. The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm training for the coder, clinical staff, physicians and mid-level providers will be a critical point for ICD-10cm and pcs coding success. Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.
As the transition to ICD-10 marches forward, the documentation and support for ‘medical necessity’ remains. The clinical documentation is always the first thing requested for a payment audit or review. Not only as providers are we having to make the leap to ICD-10, but the healthcare payers are also challenged to be proficient at this new documentation system also. We have substantial challenges for payment at this point in time. Concern is are the payers going to be ready also, and how will they respond, if there is a question regarding documentation, payment for your services.
Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.
Documentation for each encounter should include:
§Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;
§Assessment, clinical impression or diagnosis
§Plan of care
§Time spent (eg face to face/counseling-coordination of care)
o Documented time in
o Documented time out
o Documented total time spent (eg at bedside, on monitor(s), etc)
§Date and Signature
§The rationale for ordering diagnostic and other ancillary services
§Past and present diagnoses (If pertinent to the encounter)
§Appropriate health risk factors should be identified (if pertinent to the encounter)
§Patient’s progress, response to and changes in treatment and/or revision of diagnosis
B) Avoid Ambiguous Language
Eg.. “Non-contributory” : The term “non-contributory” is good example of ambiguous documentation. In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed… while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported. Be clear, concise and relevant by avoiding using the term “non-contributory”.
Another term that can be misconstrued is “abnormal” be sure to clarify, qualify, or quantify what is “abnormal”.
C) Clarify your diagnosis
“For a presenting problem with an established diagnosis the documentation should reflect whether the problem is:
a) improved, well controlled, resolving or resolved;
b) inadequately controlled, worsening, or failing to respond/or change as expected
“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)
“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)
c) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)
D) Ordering of Tests and Procedures
Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures
§document ‘what’ test/procedure is being ordered. (i.e. Fetal NST, fetal fibronectin)
§document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)
E) Omitted Information
In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however, should be used infrequently.
Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:
•Create a new entry for the additional information
•Do not annotate in the margins to add information
•Keep all entries chronological and in record sequence
•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”
•Use the actual date of the addendum, amendment or late entry
•Reference the original entry or document by indicating the date of the service
•Always sign the additional entry or document
The need for good communication and documentation brings us back to the term “wordsmith”. Again, both the coder and the physician/provider will need to add this to their job proficiencies. Getting the conversation started is the first step. A quick way to begin is to conduct a mini review of the current physician/provider documentation. The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice. If the coders’ are currently struggling with appending these “difficult” diagnoses now utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes which will be mandatory in October of 2014. Have the coder document and analyze what they’ve found. This quick analysis will help define where better communication and documentation is needed for both the coder and provider.
Here’s a quick process to help enhance communication processes for both the coder and the physician/provider of care.
- Ask the coder(s) and provider(s) for the top 5 mis-coded or difficult to code diagnoses
- Pull the operative/procedure notes that were associated with these diagnoses
- Cross-code the documentation with both ICD-9 and ICD-10 codes
- Identify areas that need to be clarified for the coder with the physician or provider
- Schedule a meeting (face to face) with the coder and the provider and include
- The actual provider notes
- The ICD-9 codes (using the code -book)
- The ICD-10 codes (using the code-book)
Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.
Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
What is the Difference Between Medical Billing, Medical Coding and Medical Transcription?
It can be confusing when talking about medical billing, medical coding and medical transcription. People often use them interchangeably when in fact they’re all separate functions. They’re all areas of medical assisting job expertise and many people have successful careers or own work at home businesses in these fields.
All three medical professions or careers are hot healthcare information fields right now and that will not change. As more and more people need health care, there will be more and more jobs available in this market.
The nice thing about two of these fields is that you can combine them easily. In fact you may want to learn medical coding along with medical billing and be able to offer both to prospective employers or be able to offer both if you work from home or start your own business.
Medical coders and medical billers work in doctor’s offices and clinics, in hospitals or for dentists. All three fields require a background or knowledge of medical terminology, anatomy and physiology and you’ll be using special billing or coding or other software.
If you’re a medical biller you’ll be submitting claims to insurance companies, Medicare and Medicaid. In some cases to the patients on behalf of clients they may have or their employers. If you choose this field you’ll need to be detail-oriented and accurate. Mistakes can cause problems both for patients and employers. Medical billing jobs usually require you to have medical billing training and certification as a Medical Billing Specialist. You’ll also need to know the rules of the HIPAA.
Medical coders provide codes to medical inpatient and outpatient procedures and services – billing public and private insurance companies. If you’re a medical coder you’ll read patient charts and assign the right code based on established codes derived from the standard classification manuals.
A medical transcriber transcribes medical records. These are usually the doctor’s notes, progress notes, etc. or those of other health professionals such as dentists. You need to be proficient in typing as you’d be doing a lot of it. Many people work from home as medical transcribers too.
So this is the difference between medical billing, medical coding and transcription. Make sure you get fully informed before you sign up for any training or enroll in schools, take online courses or programs. There are many scams to be aware of. Also there is money available from the government for both online and on-campus training. Make sure to check this out too to save yourself a lot of money.
For secrets and tips on how to start a medical billing business or as a career, choosing the best medical billing training, finding the best medical billing business schools, online courses, college, work at home and financing go to a nurse’s website: http://www.MedicalBillingTrainingInfo.com
Clarification between o36.011 and o36.091
If the patient is Rh- which is the most correct code to use?