Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Chapter 2 Basic Concepts of Coding and Insurance
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives Describe the main differences between fee-for-service plans and managed care plans. List the primary government healthcare programs and the basic eligibility requirements for each. Enter and change insurance carrier information in Medisoft.
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 Learning Objectives Describe the difference between CPT coding and ICD-9 coding. Explain the process used to identify Evaluation and Management (E/M) codes. Set up diagnosis and procedure codes in Medisoft. Create Medisoft cases.
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Chapter 2 Lesson 2.1
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Overview of Health Insurance Health Insurance Provides protection for patients against the financial consequences of illness, injuries, and disabilities. Payment for health insurance is referred to as a premium.
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Overview of Health Insurance Third-party payers: insurance companies Seven common insurance types include: Medicare Medicare Medicaid Medicaid Medi/Medi Medi/Medi TRICARE (managed care insurance for active and retired military) TRICARE (managed care insurance for active and retired military)
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Overview of Health Insurance CHAMPVA (Civilian Health and Medical Program of the Veterans Administration) Workers’ Compensation Managed Care - includes health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Overview of Health Insurance Medicare: federally administered insurance program retired people 65 & older on Social Security retired railroad or civil service workers 65 & older blind individuals
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Overview of Health Insurance Medicare: Disabled individuals eligible for Social Security of any age widows of disabled workers adults disabled before 18 whose parents are retired or eligible
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Overview of Health Insurance Medicare: Children/Adults with chronic kidney disease or kidney transplant with end-stage renal disease Kidney donors (all expenses related to kidney transplant are covered)
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Overview of Health Insurance Medicaid: insurance program to help families whose income is below a specific level, regardless of age Medi/Medi: patients who cannot afford to pay the portion of their bill received by Medicare, may qualify for both Medicare and Medicaid
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 TRICARE Formerly CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) Three choices: Standard: receive health care from military providers Prime: voluntary health maintenance organization (optional) Extra: patient does not have to enroll or pay fees, pays visit-by-visit basis at discounted rate
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 CHAMPVA Similar to TRICARE Available to spouses, dependent children of veterans who died of service-related injuries Veterans with permanent service disabilities, their dependents
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 Insurance Carrier Information Entry Used to bill insurance companies Occurs at List menu Four tabs: Address Options and Codes EDI/Eligibility Allowed By default, the Address tab displays
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Insurance Carrier Information Entry Address Tab: enter basic address and plan information Options/Codes Tab: some fields are referenced by Medisoft for billing and payments. Billing methods are set from this tab. EDI/Eligibility: used to submit claims electronically Allowed: enter allowed amounts for each procedure code
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Chapter 2 Lesson 2.2
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 ICD-9-CM Coding Overview ICD-9-CM: International Classification of Diseases-9th edition–Clinical Modifications System used to code patient diagnosis Developed by WHO (World Health Organization)
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 ICD-9-CM Coding Overview Three volumes: Volume 1: disease and condition codes (V codes) (V codes) (E codes) (E codes) Volume 2: alphabetic index for Volume 1 Volume 3: contains coding procedures for surgical, therapeutic, and diagnostic procedures used primarily in the hospital
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Each disease assigned three-digit number 4th digit: provides more detail to prognosis regarding site or symptom 5th digit: further classifies the disease (may be required) ICD-9-CM Coding Overview
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 ICD-9-CM Coding Steps Identify the main medical terms related to the diagnosis. Locate the main term in the alphabetical index, Volume 2. Verify the code number by reading the code’s description in the numerical index, Volume 1. Medisoft allows you to add as many diagnosis codes as needed.
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 CPT Coding Overview CPT Coding: Current Procedural Terminology System used to code services and procedures performed by providers Evaluation and management (E/M) codes classify patients with their level of service
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 CPT Coding Overview Components to determine E/M code: History of problem; provided by patient Examination of problem affecting the body Decision making: level of decision making involved in making a diagnosis New patient New patient Established patient Established patient
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 CPT Coding Overview Modifiers indicate special circumstances apply, often an alternation to procedure. Two-digit CPT codes -50: multiple or bilateral procedure -79: unrelated procedure -56: preoperative management only -53: discontinued procedure
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Diagnosis and Procedural Codes in Medisoft In Medisoft, transaction codes not only include the CPT codes, but also: Financial codes Managed care codes Finance charge codes From the Lists menu, click Procedure/ Payment/Adjustment Codes.
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Place of Service Codes Two-digit codes used to identify where the procedure or service was performed. 11: Office 12: Home 23: Emergency room – hospital 24: Ambulatory surgical center 25: Birthing center
Copyright © 2011, 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26 Case Information Entry Cases are situations or conditions for which a patient seeks treatment or services. Two main reasons for setting up cases: A case is set up whenever a patient is treated for a new and different condition. When a patient’s insurance carrier changes.