Medical Coding 101

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Dr. Lander's presentation on basic coding concepts for residents and new doctors

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Medical Coding 101

  1. 1. Coding 100Richard Lander MD FAAP
  2. 2. Why is coding important to me?
  3. 3. Coding tells the insurers & auditorswhat the patient’s problems were andwhat you did for them so that you can get paid.
  4. 4. Coding is how you will make your living.
  5. 5. What is a CPT and where do they come from?
  6. 6. CPT codes stands for CurrentProcedural Terminology. It is owned by the AMA. It is revised yearly and it is the standard for all medical billing.
  7. 7. What is a RBRVU?
  8. 8. RBRVU stands for Resource Based Relative Value Units.
  9. 9. RBRVU Developed at Harvard by Dr. Hsai to make Medicare payments more equitable, it is now the standard of payment for many private insurers.
  10. 10. What is an ICD?
  11. 11. ICD tells whatillness wasdiscovered in yourexaminations
  12. 12. ICDs have “severity” scoring systems in existence that look to see that physicians are paid appropriately for the work they deliver
  13. 13. Well visits
  14. 14. With well visits you only need to know if thepatient is “new” or “established. New patients – one not seen by you or the practice in 3 years
  15. 15. Well visitsAge CPT Code New CPT Code EstablishedUnder 1 year 99381 993911 – 4 years 99382 993925 – 11 years 99383 9939312 – 17 years 99384 9939418 – 39 years 99385 99395
  16. 16. Evaluation and Management Codes
  17. 17. E&M codes are for sick visits. They arebased on the severity of the illness and work done.
  18. 18. Note: If more than 50% of visit is counseling, then time is an element
  19. 19. New patient codes require all 3 elements New Patients Patients onlyEstablished require 2 out of 3 elements Doesn’t require the presence of a 99211 physician
  20. 20. 99212 Expanded problem focused history Expanded problem focused exam Straightforward medical decision making
  21. 21. 99213 Detailed history Detailed examination Medical Decision making of low complexity
  22. 22. 99214 Comprehensive history Comprehensive examination Medical decision making of moderate complexity
  23. 23. 99215 Comprehensive history Comprehensive examination Medical decision making of high complexity
  24. 24. Why is this important?
  25. 25. Most doctors (pediatricians, actually) under code
  26. 26. What does this cost?
  27. 27. If you increase from 5% 99214 to 20% , you can increase your net income by $20,000 without doing any more work
  28. 28. You don’t want to over code becauseMedicaid and private health insurers canand will audit you. If the documentation doesn’t equal the code billed, they will penalize you
  29. 29. Evaluation requested by an appropriate professionalwith a report back to that person 99243 - Consult 99213 – E/M 3.17 x 36.79 1.39 x 36.79 $116.62 $51.14
  30. 30. Pediatricians do many procedures
  31. 31. If you don’t bill for the procedures you do, you cheat yourself out of the many dollars
  32. 32. Subluxation of elbow 24640 99213 4.85x 36.79 1.39 x 36.79 $178.43 $51.14
  33. 33. What does this tell you?
  34. 34. It is critical to know the codes for all the procedures you do,since obviously procedures pay better than E/M codes
  35. 35. Where can you learn more?
  36. 36. Decide if the practice you are looking at has someone who knows codingThe Academy offers coding courses – at the NCE and as stand alone courses
  37. 37. Other Steps
  38. 38. Be sure you have a current CPT and ICD coding books in your office
  39. 39. USEThem

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