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.

Transcript

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