Question

Please answer the following in your initial post:

What is the ICD-10-CM? How will it impact the coding of claims?

Describe at least one of the outpatient coding guidelines listed in your text.

What is the CPT?

What is one symbol that is used throughout the CPT coding book? Describe its purpose.

What is medical necessity, and how is it communicated to the insurance companies?

Should physicians be required to prove the medical necessity of the services they have provided? Why, or why not?

Answer 1

1.ICD-10CM is known as International Classification of Diseases and is used by health care providers to classify and code symptoms,possible diagnosis and procedures which is used in relation with hospital care.

ICD-10CM has changed the portraits of coding and it will be reflected in each and every section of the arena.The main reason is that ICD-10CM has many more codes than ICD-9-CM.When ICD-10-CM has been implemented it helped the coders to code an inpatient record with minimal time.The codesets have changed from numeric to alphanumeric and the definitions associated with it has also changed.Significant changes has happened regarding the costs as well as physical documentation and computer-assisted coding .

2 Out patient Services guidelines are classified into first listed diagnosis,Sequencingand finally Sequela. The out-patient coding guidelines listed here is taken from Fist listed diagnosis.Out patient Surgery-Incase of same day surgery code the reason for the surgery as the first listed diagnosis ie the possible reason for encounter even if the surgery is not performed.

3.CPT- Current Procedural Terminology is a medical code .It is used to report to the physicians ,insurance companies and other organizations about the medical,surgical and diagnostic procedures.This nomenclature allows the procedures to be transformed to numbers.

4.Triangle which means new or revised code,is the most frequently used symbol in the CPT coding book ,as changes are occuring frequently whenever a new diagnosis is made.It is especially used when the description of an older code is changed by its descriptor.

5.Medical Necessity-Based on the evaluation and treatment of a disease condition or illness with the applicable standard of care ,the acceptable health care services which is instituted by the health care providers is called Medical Necessity.

Most of the insurance companies have a list of criteria with which they interpret medical necessity.Since most of the providers do not have an accurate listing of qualifiers ,so a good documentation is necessary,inorder to communicate the medical necessity of services accurately to the payers.To avoid claim denials in the future,the physicians,clinical providers and coders should review the guidelines of what the payers have established and thoroughly scrutinize through it before agreeing upon a contractual relationship with a third party payer.

6 Yes Many people do not get the desired treatment they need ,merely because of insurance companies stating it is not of medical necessity.Insurance companies can restrict what type of services physicians can provide to a patient.So before filling up the authorization ,physicians need to scrutinize through the do's and dont's.Enquire whether the services which are required by the patients are covered.if not the physician need to write a letter of medical necessity.So it will help the patients and insurane company get the advantage of having to pay less.