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PROCEDUREDIAGNOSIS CODE OVERVIEW. Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations.

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Presentation on theme: "PROCEDUREDIAGNOSIS CODE OVERVIEW. Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations."— Presentation transcript:

1 PROCEDUREDIAGNOSIS CODE OVERVIEW

2 Participants will interpret basic medical codes and assess how to use them when conducting provider fraud investigations. Learning Objective

3 Medical coding is a uniform language that allows a reliable means of communication among physicians, patients and third parties. Medical “Code Speak”

4

5 HCPCS Codes Healthcare Common Procedure Coding System (HCPCS) is maintained by the Centers for Medicare and Medicaid Services (CMS). Provide a system for reporting the medical services provided to Medicare beneficiaries.

6 HCPCS Code Ranges A-codes: Transportation, Medical & Surgical Supplies, Miscellaneous & Experimental B-codes: Enteral and Parenteral Therapy C-codes: Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures E-codes: Durable Medical Equipment G-codes: Temporary Procedures & Professional Services H-codes: Rehabilitative Services J-codes: Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes: Temporary Codes for Durable Medical Equipment Regional Carriers L-codes: Orthotic/Prosthetic Procedures M-codes: Medical Services P-codes: Pathology and Laboratory Q-codes: Temporary Codes R-codes: Diagnostic Radiology Services S-codes: Private Payer Codes T-codes: State Medicaid Agency Codes V-codes: Vision/Hearing Services

7 CPT codes enable healthcare providers to effectively and efficiently communicate with government or private insurance companies about medical, surgical and diagnostic services rendered to a patient. The CPT Coding System

8 The Current Procedural Terminology (CPT) is a five digit coding system first published by the American Medical Association (AMA) in The Procedure / Service

9 1 1 ToFrom Medicine Surgery Radiology Pathology Evaluation & Management Hospital DRG CodeDRG-001DRG-999 Anesthesia CPT Code Ranges

10 Health Insurance Claim Form 1500

11 Page 2

12 Medical Record Documentation Cycle DOL/OWCP Review Claim Documents are Coded & Submitted to DOL/OWCP Doctor Examines Claimant Doctor Renders Treatment & Documents Diagnosis Claimant Goes to Doctor Payment Sent Most provider offices use “superbills” for billing purposes.


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