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OptumInsight Learning:Medical Billing Basics201411th edition
Ingenix NoticeAcknowledgmentsIngenix Learning: Medical Billing Basics is designed to be anaccurate and authoritative source regarding coding andevery reasonable effort has been made to ensure accuracyand completeness of the content. However, Ingenix makesno guarantee, warranty, or representation that thispublication is accurate, complete, or without errors. It isunderstood that Ingenix is not rendering any legal or otherprofessional services or advice in this publication and thatIngenix bears no liability for any results or consequencesthat may arise from the use of this book. Please address allcorrespondence to:Julie Orton Van, CPC, CPC-P, Product ManagerKaren Schmidt, BSN, Technical DirectorStacy Perry, Manager, Desktop PublishingLisa Singley, Project ManagerNichole VanHorn, CPC, CCS-P, Clinical/Technical EditorKelly V. Canter, BA, RHIT, CCS, Clinical/Technical EditorRegina Magnani, RHIT, Clinical/Technical EditorTracy Betzler, Desktop Publishing SpecialistHope M. Dunn, Desktop Publishing SpecialistRegina Heppes, EditorIngenix2525 Lake Park BlvdSalt Lake City, UT 84120Nichole VanHorn, CPC, CCS-PAmerican Medical Association NoticeCPT only 2010 American Medical Association. All rightsreserved.Fee schedules, relative value units, conversion factors and/orrelated components are not assigned by the AMA, are notpart of CPT, and the AMA is not recommending their use.The AMA does not directly or indirectly practice medicineor dispense medical services. The AMA assumes no liabilityfor data contained or not contained herein.CPT is a registered trademark of the American MedicalAssociation.The responsibility for the content of any “National CorrectCoding Policy” included in this product is with the Centersfor Medicare and Medicaid Services and no endorsement bythe AMA is intended or should be implied. The AMAdisclaims responsibility for any consequences or liabilityattributable to or related to any use, nonuse orinterpretation of information contained in this product.Our Commitment to AccuracyIngenix is committed to producing accurate and reliablematerials. To report corrections, please visitwww.ingenixonline.com/accuracy or emailaccuracy@ingenix.com. You can also reach customer serviceby calling 1.800.INGENIX (464.3649), option 1.Copyright 2012 OptumMade in the USAISBN 978-1-60151-424-0About the technical editorsMs. VanHorn has more than 15 years of experience in the health careprofession. Her areas of expertise include CPT and ICD-9-CMcoding in 16 specialties, auditing, and education. Most recently sheserved as Clinical Auditor for the Children’s Hospital Physicians atBlank Children’s Hospital, Des Moines, Iowa where she functionedas an auditor for a multi-specialty group. Ms. VanHorn wasresponsible for the oversight of the physician coding and educationsection of the Corporate Compliance Program and adherence topolicies. She has been an active member of her local AmericanAcademy of Professional Coders chapter for several years and servedas an officer.Kelly V. Canter, BA, RHIT, CCSMs. Canter is a clinical/technical editor for Ingenix with expertise inhospital inpatient and outpatient coding and reimbursement;ambulatory surgery coding; and ICD-9-CM, CPT, and HCPCScoding. Ms. Canters’ experience includes conducting coding auditsand coding staff education, revenue cycle management, andconcurrent review. Most recently she was responsible for auditing andcompliance of a health information management services company.She is an active member of the American Health InformationManagement Association (AHIMA).Regina Magnani, RHITMs. Magnani has over 30 years of experience in the health careindustry in both health information management and patientfinancial services. Her areas of expertise include facility revenue cyclemanagement, patient financial services, CPT/HCPCS and ICD-9CM coding, the outpatient prospective payment system (OPPS), andchargemaster development and maintenance. She is an activemember of the Healthcare Financial Management Association(HFMA), the American Health Information ManagementAssociation (AHIMA), and the American Association of HealthcareAdministrative Management (AAHAM).Karen Schmidt, BSNMs. Schmidt is Technical Director for Ingenix. She has more than 25years of health care experience beginning with a strong clinicalbackground in critical care nursing and later functioning as directorof case management including the components of quality assurance,utilization management, concurrent coding, case-mix analysis, anddischarge planning. Her areas of expertise include ICD-9-CM/DRGcoding, outpatient observation, billing compliance, implementationof concurrent coding methodology, and physician documentationeducation.
ContentsChapter 1: Introduction . 1Welcome to the Career of Medical Coding .1The Nature of Medical Coding.1Coding and the Financial Picture.2Supporting Organizations .3Opportunities in Coding .5Knowledge Assessment Chapter 1 .6Chapter 2: Medical Terminology and Anatomy . 9Introduction .9History .9Spelling.10Approaches to Medical Terminology .10Introduction to Human Anatomy.12Integumentary System .14Musculoskeletal System .17Respiratory System .25Cardiovascular System .30Lymphatic System .35Digestive Tract .38Urinary System .48Endocrine System .54Nervous System .56Eye—Ocular—Auditory .59Planes .63Summary .64Knowledge Assessment Chapter 2 .65Chapter 3: Insurance Basics . 75Introduction .75History .75Medicare and Medicaid.75Health Insurance Today.76Health Care Reform.76Payer Comparisons .77The Reimbursement Process .85Coverage Issues .85Payment Methodologies.86Fee Schedules and Relative Values .86Capitation.87Inpatient and Ambulatory Systems .87Claim Submission .87Common Insurance Terminology .88Fraud and Abuse Issues .89Summary .89Knowledge Assessment Chapter 3 .90Chapter 4: Coding Physician Services and Procedures . 95Introduction .95CPT History .95 2012 OptumCPT only 2011 American Medical Association. All Rights Reserved.Who uses CPT codes?. 97Documentation and the CPT Code Book:Reviewing the Source Document. 97CPT Coding Conventions . 99Guidelines . 100Code Changes . 101Resequencing of CPT Codes . 102Modifiers . 102Modifier Impact on Reimbursement. 103Types of Modifiers. 103Add-on and Modifier 51 Exempt Codes . 105Unlisted Procedures. 105The CPT Code Book Index . 106The 10 Steps to Basic CPT Coding . 107Evaluation and Management Services . 108E/M Service Guidelines . 109Evaluation and Management Service Levels . 111Selecting a Visit Code . 111New and Established Patient Services . 112SOAP Note . 112Key Components to E/M Selection . 114Chart Authentication . 119Main Categories of the Evaluationand Management Section . 119Anesthesia. 123Surgery . 126Surgery Section Guidelines . 129Minor and Endoscopic Surgical Procedures . 130Major Surgical Procedures . 130Ancillary Services . 132Technical and Professional Components . 133Radiology . 134Pathology and Laboratory. 136Medicine . 140Summary . 141Knowledge Assessment Chapter 4 . 142Chapter 5: Diagnosis Coding and ICD-9-CM .153Introduction . 153History . 153Data Collection . 154ICD-9-CM Diagnosis Coding . 155Organization. 155Coding Guidelines. 156Documentation and Diagnosis Coding. 157ICD-9-CM, Volume 2 . 158ICD-9-CM, Volume 1 . 161Supplemental Classification: V Codes. 163Appendixes to Volume 1. 164i
Ingenix Learning: Medical Billing BasicsConventions.165Assigning Diagnosis Codes.170Etiology Differences.173Clinical Applications of Coding Guidelines .176ICD-10 Coding System .177Summary .181Knowledge Assessment Chapter 5 .182Chapter 6: HCPCS Level II Coding .189Introduction .189HCPCS Level I /CPT Coding System .189HCPCS Level II National Codes .190The HCPCS National Codes in Detail .190HCPCS Codes .191Use of HCPCS .192How to Use HCPCS.192Color-Coded Coverage Instructions.192Modifiers .193Unlisted HCPCS Codes.194Practicing the Principles.195Hospital Outpatient Services.195Physician Office Services.196DMEPOS .196The HCPCS Level II Codes.198Summary .199Knowledge Assessment Chapter 6 .199Chapter 7: Medical Coding and Practice Management .203Introduction .203Registration.203Encounter Forms .204Precertification and Preauthorization .204Claims Submission and Processing.206Problem Claims .207Advance Beneficiary Notice of Noncoverage .207Charge Amounts .208Physician Reimbursement Methodologies .208Inpatient Reimbursement Methodologies .209Diagnosis-Related Group .210Medicare Severity DRGs.212Postpayment Process .213Red Flags Rule .215The Medical Record and Documentation .216Inpatient Charting .221Compliance and Legal Considerations .223Summary .225Knowledge Assessment Chapter 7 .226Chapter 8: Inpatient Coding .231Introduction .231The Coding Process .
Ingenix Learning: Medical Billing Basics is designed to be an accurate and authoritative source regarding coding and every reasonable effort has been made to ensure accuracy and completeness of the content. However, Ingenix makes no guarantee, warranty, or representation that this publication is accurate, complete, or without errors. It is
