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Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission.

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Presentation on theme: "Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission."— Presentation transcript:

1 Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Usual and Customary Medical Bill Reviewer Training Program Unit 1: Introduction and General Guidelines

2 Usual & Customary Training - Introduction July 2011 Overview Hi, Im here to guide you on a tour of our Workers Compensation Usual and Customary rules. Together, we can become more familiar with the unique aspects of these guidelines. Part I: Introduction to Usual and Customary Rules General Guidelines Client Rules Absent Client Rules Procedure Code Pricing Procedure Code Structure Modifiers Types of Service Codes

3 Usual & Customary Training - Introduction July 2011 Introduction to Usual and Customary Guidelines The Usual and Customary rates, also referred to as Usual, Customary and Reasonable (UCR) were established to control medical cost, when there are no assigned RV, RUV or scheduled fees for specific services. The phrase Usual, Customary, and Reasonable (UCR) refers to the base amount that third-party payers (including insurance carriers and employers) generally use to determine how much will be paid, on behalf of an enrollee, for services reimbursed under a policy or plan. Lets continue

4 Usual & Customary Training - Introduction July 2011 Introduction to Usual and Customary Guidelines Usual and Customary guidelines are used in place of State Reference Guides for any state that uses or refers to Usual and Customary when determining pricing. The states are Delaware, Iowa, Indiana, Missouri, New Hampshire, New Jersey and Virginia. Now lets take a look at the rules

5 Usual & Customary Training - Introduction July 2011 Client Rules Client Rules are specific policies or procedures unique to the business of a system user. These specifics are designed by and/or for a system user and may not apply to other users. Client Rules hold the highest authority in the hierarchy of the Usual and Customary Guidelines. However, when no Client Rules are provided, it is appropriate to utilize the UCR Reference Guide for processing guidelines. Client Rules Usual and Customary Billed Charges Keep in mind…

6 Usual & Customary Training - Introduction July 2011 Absent Client Rules When there are no client or state mandated rules, Usual and Customary guidelines are applicable. Although, all rules are not applicable to all states or services rendered. The following displays the general rules categories: Client Rules are silent on the subject The State Reference Guide is silent on the subject. The State Reference Guide refers to the UCR Guidelines.

7 Usual & Customary Training - Introduction July 2011 Procedure Code Pricing Values Procedure code pricing values are updated in the system continually in compliance with the Ingenix MDR pricing value updates. Services included are Medical pricing (CPT), Dental pricing, and HCPCS pricing. Technical documentation is distributed each time the system updates pricing based on new Ingenix MDR value pricing updates. There are some Usual and Customary states which also update pricing values for procedures. If the UCR state provides state specific pricing values for procedures, that pricing is primary.

8 Usual & Customary Training - Introduction July 2011 Procedure Pricing Code Values A few states utilize Usual and Customary guidelines because they have not adopted one or more of the Medical, Inpatient Hospital or Outpatient Hospital fee schedules. States where UCR is utilized in place of a Medical Fee Schedule are indicated in RED. States where UCR is utilized in place of an Inpatient or Outpatient Fee Schedule are indicated in BROWN The State Reference Guides and the Usual and Customary Guidelines provide instructions for those procedures with special handling requirements. AZ SD MO IA IN VA NH NJ CT DE DC HI OR UT WY ID

9 Usual & Customary Training - Introduction July 2011 Procedure Code Structures Level 1, CPT Codes: CPT codes make up the major portion of the HCPCS coding system. The services and guidelines not addressed in the CPT (specific supplies, materials and injections) are found in Level 2 and Level 3. Level 2, National Codes (HCPCS): These are five-character alphanumeric codes. The first character is alpha (A-V), followed by four numeric characters that more specifically represent supplies, materials, injections and other medical or related services. Level II of HCPCS also contains modifiers, which are either alphanumeric or two letters in the range from (AA-VP). Level 3, Local Codes: These are five-character alphanumeric codes. The first character is alpha (W-Z), followed by four numeric characters. Local codes are used to denote new procedures or specific supplies for which there is no national code listed. There are HCPCS codes developed by the Health Care Financing Administration (HCFA) to standardize Medicare billing. The system is used primarily to identify supplies, materials, injections, and other medical or related services. Providers may also use the HCPCS codes to identify procedures and/or services that are not defined in the CPT. HCPCS guidelines contain three levels of codes with a brief description of their uses. There are three level of codes, which include CPT codes, described as follows…..

10 Usual & Customary Training - Introduction July 2011 Procedure Code Structures Lets continue….. The Physicians Current Procedural Terminology (CPT) is the procedure code reference guide. Procedure codes provide both a means for providers to bill for the services they provide and the means for others to review those bills for appropriate treatment plans and reimbursement levels. In determining pricing and what codes are proper for treatment and reimbursement, codes are listed in categories. Categories appear as follows…. Category I, II and III Codes Category I - Main body of the CPT procedures. ( ) Ex: – Intermediate Office Visit. Category II - Allow data collection for these services/procedures. Example: #4015F, (description). Category III -Emerging technologies, services, and procedures. Example: #0055T (description). Category III codes used significantly, may be assigned a permanent Category I code.

11 Usual & Customary Training - Introduction July 2011 Procedure Code Structures CPT Appendices and Index: Appendix A - Modifiers Appendix B - Summary of Additions, Deletions and Revisions Appendix C - Clinical Examples Appendix D - Summary of CPT Add-on Codes: Appendix D is a summary of all CPT add-on codes. Appendix E - Summary of CPT Codes Exempt from Modifier 51 Appendix F - Summary of CPT Codes Exempt from Modifier 63 Appendix G - Summary of CPT Codes That Include Moderate (Conscious) Sedation. Appendix H - Alphabetic Index of Performance Measures by Clinical Condition or Topic Appendix I - Genetic Testing Code Modifiers Appendix J - Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves Appendix K - Product Pending FDA Approval: Some vaccine products have been assigned a CPT Category I code in anticipation of future approval from the Food and Drug Administration (FDA). Finally, Appendices and Index are additional aids in billing services and reviewing bills for appropriate treatment plans and reimbursement levels. The following is an example of how they are listed in the CPT guide book.

12 Usual & Customary Training - Introduction July 2011 Procedure Code Modifiers Procedure code modifiers are supplementary codes. When billed with a procedure code they further define the service provided. These guidelines address the following types of modifiers: CPT code modifiers: CPT modifiers provide physicians with a method of indicating whether a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code (performance specific) HCPCS modifiers: HCPCS modifiers provide physicians with a method of indicating a service or procedure that has been performed and has been altered by some specific circumstance but not changed in its definition or code (body part specific). Internally created modifiers: Internally created modifiers are designed to alter service values, or to print messages on the EOR. Internally created procedure code modifiers may be valid for some usual and customary states. Pricing/Informational modifiers: A pricing modifier affects the value of the procedure code. A modifier is referred to as informational, when it provides proper payment insight or prints a specific EOR message, but does not affect the value of the service.

13 Usual & Customary Training - Introduction July 2011 Types of Service Codes (TOS) Each procedure code in the system has a corresponding type of service (TOS) classification code that is a one-byte alphanumeric code. The type of service code identifies the kind of service for which the provider is billing. The system defaults the TOS code based on the procedure code or service keyed. Example such as… Ambulance: Key ambulance procedure codes and charges as billed using type of service B'. Usual and Customary pricing for ambulance procedures are updated on a continual basis. TOS Service Descriptions 9 Administrative Procedure Codes and system default for type of service/procedure code mismatch. B Ambulance / Transportation Services 7 Anesthesia Services T Dental Services

14 Usual & Customary Training - Introduction July 2011 Summary Introduction to UCR Guidelines. Established to control medical cost, when there are no assigned RV, RUV or scheduled fees for specific services. Usual and Customary States. The states are Delaware, Iowa, Indiana, Missouri, New Hampshire, New Jersey and Virginia Client Rules. Specific policies or procedures unique to the business of a system user. These specifics are designed by and/or for a system user and may not apply to other users. Pricing. Values are updated to be in compliance with the Ingenix MDR pricing for Medical (CPT), Dental and HCPCS. Procedure Structure. HCPCS codes developed by the Health Care Financing Administration (HCFA) to standardize Medicare billing. Modifiers. Supplementary codes, when billed with a procedure code, further define the service provided. Types of Services. The type of service code identifies the kind of service for which the provider is billing. Great Job! Youve completed the introduction to UCR guidelines. This Summary will aid in reviewing the other units. Now, go forth and conquer the remaining units.


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