Question

Healthcare Insurance Coding, Billing, and Reimbursement

Introduction:
In order to properly code a bill for medical necessity, it is important to understand different plans and the requirements for billing each. It is true that they all use the ICD-10-CM diagnosis coding system, the CPT procedure coding system, and the CMS-1500 form, but each type of carrier has certain requirements for a clean bill.

Tasks:
Create a billing manual constructed of summaries of each type of insurance.
Include the major requirements for billing for each type.
Note inpatient or outpatient differences where appropriate.
Explain how to determine from the patient which type they subscribe to.

Answer 1

ICD-10-CM

Classification of Diseases, Tenth Revision, Clinical Modification is a system used by physicians to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care.

Format and Structure:

The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character. The ICD-10-CM uses an indented format for ease in reference.

Current Procedural Terminology (CPT) System :

It is a medical code set maintained by the Medical Association through the CPT Editorial Panel. CPT is currently identified by the Centers for Medicare and Medicaid Services as Level 1 of the Healthcare Common Procedure Coding System.

They fall into three categories:

• Category I – These five-digit codes have descriptors which correspond to a procedure or service. Codes range from 00100 - 99499.
• Category II – These alphanumeric tracking codes are used for execution measurement. Using them is often optional.
• Category III – These are provisional codes for new and developing technology, procedures, and services. The codes were created for data collection and assessment of new services and procedures.

CMS-1500 form

It is a form of medical insurance claim.