Survey of Medical Insurance pp ch06

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 6.1 Discuss the purpose of the HCPCS code set. Page: 218 Teaching Notes:   Ask students to name some situations that would require the use of HCPCS codes.
  • Learning Outcome: 6.2 Define durable medical equipment. Pages: 218-221 Teaching Notes:   Have your students think of examples of durable medical equipment.
  • Learning Outcome: 6.2 Define durable medical equipment. Pages: 218-221 Teaching Notes:   Look over the HCPCS Level II code ranges and examples (as seen in Table 6.1) with your students.
  • Learning Outcome: 6.3 Compare permanent national codes and temporary national codes. Pages: 221-222 Teaching Notes:   Examine the different types of temporary national codes with your students. (C codes, G codes, Q codes, K codes, S codes, H codes, and T Codes.)
  • Learning Outcome: 6.4 Explain how to locate the periodic updates to HCPCS. Page: 222 Teaching Notes:   Instruct your students to look at the updates to the HCPCS codes on the CMS HCPCS website. (www.cms.gov/HCPCSReleaseCodeSets/)
  • Learning Outcome: 6.5 List the steps for assigning correct HCPCS codes and modifiers. Pages: 222-224 Teaching Notes:   Ask your students to cite three cases when the Medicare and Medicaid programs administered by CMS will not cover a surgical or other invasive procedure to treat a medical condition due to a practitioner error. ((1) The correct procedure but on the wrong body part; (2) The correct procedure but on the wrong patient; (3) The wrong procedure on the wrong patient.)
  • Learning Outcome: 6.6 Discuss the tools used to verify Medicare billing rules for specific HCPCS codes. Pages: 224-226 Teaching Notes:   Look over the HCPCS Level II modifiers found in Table 6.2 with your students.
  • Learning Outcome: 6.7 State the purpose of the Certificate of Medical Necessity. Pages: 227-228 Teaching Notes:   Have your students discuss the advantages offered by the CMN.
  • Survey of Medical Insurance pp ch06

    1. 1. 6 Procedural Coding: Introduction to HCPCS
    2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>6.1 Discuss the purpose of the HCPCS code set. </li></ul><ul><li>6.2 Define durable medical equipment. </li></ul><ul><li>6.3 Compare permanent national codes and temporary national codes. </li></ul><ul><li>6.4 Explain how to locate the periodic updates to HCPCS. </li></ul><ul><li>6.5 List the steps for assigning correct HCPCS codes and modifiers. </li></ul><ul><li>6.6 Discuss the tools used to verify Medicare billing rules for specific HCPCS codes. </li></ul><ul><li>6.7 State the purpose of the Certificate of Medical Necessity. </li></ul>6-2
    3. 3. Key Terms <ul><li>Certificate of Medical Necessity (CMN) </li></ul><ul><li>CMS HCPCS Workgroup </li></ul><ul><li>Coverage Issues Manual (CIM) </li></ul><ul><li>durable medical equipment (DME) </li></ul><ul><li>durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) </li></ul>6-3 <ul><li>Durable Medical Equipment Medicare Administrative Contractor (DME MAC) </li></ul><ul><li>Healthcare Common Procedure Coding System (HCPCS) </li></ul><ul><li>Level II </li></ul><ul><li>Level II modifiers </li></ul><ul><li>Medicare Carriers Manual (MCM) </li></ul>
    4. 4. Key Terms (Continued) <ul><li>never event </li></ul><ul><li>permanent national codes </li></ul><ul><li>Pricing, Coding Analysis, and Coding (PDAC) contractor </li></ul><ul><li>temporary national codes </li></ul>6-4
    5. 5. 6.1 Overview of HCPCS <ul><li>The Healthcare Common Procedure Coding System (HCPCS) was set up to give health care providers a coding system that describes specific products, supplies, and services that patients receive </li></ul><ul><li>HCPCS is technically made up of two sections of procedural codes: </li></ul><ul><ul><li>Level I, the CPT (from Chapter 5) </li></ul></ul><ul><ul><li>HCPCS Level II Codes —national codes that identify supplies, products, and services not in Level I </li></ul></ul>6-5
    6. 6. 6.2 Level II Codes <ul><li>Level II codes are five characters, beginning with a letter and followed by four numbers </li></ul><ul><li>Durable medical equipment (DME)— reusable physical supplies ordered by the provider for home use </li></ul><ul><ul><li>Can withstand repeated use </li></ul></ul><ul><ul><li>Primarily and customarily used for a medical purpose </li></ul></ul><ul><ul><li>Generally not useful to a person in the absence of an illness or injury </li></ul></ul><ul><ul><li>Appropriate for use in the home </li></ul></ul>6-6
    7. 7. 6.2 Level II Codes (Continued) <ul><li>CMS has four Durable Medical Equipment Medicare Administrative Contractors (DME MAC)— contractors that process Medicare claims for DMEPOS </li></ul><ul><li>Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)— category of HCPCS services </li></ul>6-7
    8. 8. 6.3 Permanent versus Temporary Codes <ul><li>CMS HCPCS Workgroup: government committee that maintains the Level II HCPCS code set </li></ul><ul><ul><li>Maintains the permanent national codes— HCPCS Level II codes </li></ul></ul><ul><ul><li>Temporary national codes— HCPCS Level II codes available for use but not part of the standard code set; may become permanent codes </li></ul></ul><ul><li>Pricing, Coding Analysis, and Coding (PDAC) contractors— contractors responsible for helping to determine which HCPCS code describes DMEPOS items </li></ul>6-8
    9. 9. 6.4 HCPCS Updates <ul><li>Annual updates to HCPCS codes are released on the CMS HCPCS website, effective for use January 1 of each year </li></ul><ul><ul><li>Interim updates for temporary codes are also found on the CMS HCPCS website </li></ul></ul><ul><li>Annual HCPCS code books are published as a code reference </li></ul>6-9
    10. 10. 6.5 HCPCS Coding Procedures <ul><li>Correct HCPCS coding follows the same general guidelines as ICD-9-CM and CPT coding: </li></ul><ul><ul><li>Begin by locating the item to be coded in the index (or the Table of Drugs) </li></ul></ul><ul><ul><li>Then verify the probable code in the main sections </li></ul></ul><ul><ul><li>Assign appropriate modifiers </li></ul></ul><ul><li>Level II modifiers— HCPCS national code set modifiers </li></ul><ul><ul><li>Provide additional information about services, supplies, and procedures </li></ul></ul>6-10
    11. 11. 6.6 HCPCS Billing Procedures <ul><li>Medicare billing rules for specific HCPCS codes are shown by references in the main sections next to the codes </li></ul><ul><li>Medicare Carriers Manual (MCM)— guidelines established by Medicare about coverage for HCPCS Level II services </li></ul><ul><li>Coverage Issues Manual (CIM)— information about Medicare-qualified clinical trials, treatments, therapeutic interventions, diagnostic testing, durable medical equipment, therapies, and services </li></ul>6-11
    12. 12. 6.7 The Certificate of Medical Necessity <ul><li>Certificate of Medical Necessity (CMN)– document used to assist DME MACs in gathering information </li></ul><ul><ul><li>Useful for providing medical necessity information in a concise manner formatted for efficient claims processing </li></ul></ul><ul><li>The following DMEPOS items require a CMN: </li></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Pneumatic Compression Devices </li></ul></ul><ul><ul><li>Osteogenesis Stimulators </li></ul></ul><ul><ul><li>Transcutaneous Electrical Nerve Stimulators (TENS) </li></ul></ul><ul><ul><li>Seat Lift Mechanisms </li></ul></ul>6-12

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