Evaluation and Management

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

The E/M code's is a big important part in this process. Being a health care professional, using the medical code's. like medicare, medicaid, other private insurance to be reimbursement. If not using the right code, the doctor office, hospital, and urgent care. Will lose a lot of money. So using the right cpt code's insurance companies, office, hospital, and urgent care can be reimbursement correct. Cause CPT code's are formed with 5 digits.

HCPCS (Healthcare Common Procedure Coding System) Level II codes are updated by the Centers for Medicare and Medicaid Services. HCPCS Level II codes are revised annually with implementation in Jaunary of each year. This means that coders have to stay up to date on all changes. Some of the ways coders can stay up to date include: getting updates from the CMS website; consulting with the ASCA website; network with other coders; and consulting local coverage determinations. There are also monthly newsletters published by the AMA called HCPCS Assistant that are considered an official coding resource by the CMS. The medical management software must be kept up to date to ensure the proper codes are being used. A coder should never use an older

One of the greatest milestones in the United States health system is the use of electronic health records codes to ensure consistency in diagnosis and treatment procedures provided by physicians (Romano & Stafford 2011). The purpose of the case scenario of the sixteen year old female who visits the emergency department is to show how electronic health record coding is done and its impact on health reimbursement. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) codes are brought out well in the case study showing how they help in ensuring physician consistency in coding diagnosis and treatment procedures for the purpose of health reimbursement.

Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92.

The Current Procedural Terminology (CPT) codes, are codes a medical biller uses to report healthcare procedures and services. Both medical billers and providers use CPT codes as a way to communicate with insurance companies. Proper coding and documentaition is essential for reimbursement. Proper coding and documentation also makes the difference between full reimbursement and reduced reimbursement or even a denial. Each code that is sent to a payer on a claim, has to have supporting documentation. For example, if a patient is seen for a urianary tract infection and during the visit the patient receives a urianalysis, you would expect to see an order, the correct CPT code, and the results for a urinalysis in the patients chart. I have always

The Centers for Medicare and Medicaid Services (CMS) requires all providers to implement ICD-10 coding system begin on October 1st, 2015 so the U.S. healthcare system can communicate in the same language as with other countries’ systems. The transition from ICD-9 to ICD-10 had big changes from 14,000 diagnostic codes to more than 68,000 and 4,000 procedure codes to 87,000. The transition affected the reimbursements of hospitals. Medicare requires all patients’ procedures and services to be coded using ICD-10 system while they are charged in CDM using CPT codes. However, there is no direct link between ICD and CPT codes (Jensen, Ward, & Starbuck, 2016). The CDM committee had to work together to prepare for this event. Switching from numerical

The EHRs have an automated system which may result in a suggested E/M code. Coders have to make sure this code is accurate because the clinicians are responsible for the submission of this code for the reimbursement of the facility. If the code is accurate then it could result in an increase up to tens of thousands of dollars in revenue. The common pitfalls of coding E/M services are down coding the level of care that is given to the patient. They do this because they are afraid of the risk because they do not know what code they are actually supposed to use and it is their natural instinct to do so. They don’t think about the documents that support what they have done. Another thing that is done is tied to the level of complexity of the visit. The hardest part of not knowing which code to pick is the medical decision making because it is not always so easy to pick out and hard to express in writing. Documentation is crucial to figuring out the code. If it is incomplete then the coder cannot properly decide which code to use. The doctors don’t usually think about writing the complexity of the visit, they forget to put in specific things like the images they have reviewed and the info gathered from people other than the patient. One other than that can happen is that the EHR will generate a code through the E/M calculator and it may generate one that causes an upcoding incident.

The CPT code set is used to describe medical, surgical, and diagnostic services and is designed to communicate information about procedures with coders, accreditation organizations, and physicians, patients. The purpose of the codes is for financial, and administrative and analytical purposes. For example, if a physician performs a total abdominal colectomy Cpt code (44159) should be used. However, Cpt code (49000) exploratory laparotomy should not be used because it is included with code (44159) it is incorrect to bill for both. Medicare and Medicaid identify CPT codes as level 1 of the Healthcare Common Procedure Coding Systems. When using Category II codes the 5th character is identified by an alphabetical character. The CPT section includes information about modifiers, measures and the source, there is currently 11 CPT Category II codes. CPT Category III codes are used for data collection services and procedures. These codes are intended to be used in the approval process by the Food and Drug Administration

In society today patient encounters take place in a variety of different settings. Evaluation and Management codes (E/M) describe a patient encounter with a physician and are the most frequently used codes that adhere to unique criteria. The criteria are to identify the settings, patient type and level of service. In the CPT Manual E/M codes are located in the front of the book and are broken down by divisions which are known as categories and subcategories. The categories are the first level of division because they identify the location of where the service took place such as a hospital visit, office visit and consultation. The subcategories identify the type of service rendered depending on the patient type if they are new or established, age and frequency. Also the subcategories are classified into levels of services that are identified by specific codes. It is by utilizing this classification that one is able to determine the nature of the work by the service type as well as place and patient status.

The AMA-AMERICAN MEDICAL ASSOCIATION is responsible for the CPT manual since 1966. The reason why was to give physicians an orderly system to process medical services that link reports that is more accurate and efficient throughout the country. These services has made it easy for healthcare professions to communicate with each other, along with hospitals, insurers, and patients about services rendered. In addition, the CPT Editorial Panel was assign to keep CPT codes up-to-date reflecting new procedures given to patients.

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Evaluation and management coding is a medical coding process in support of medical billing. The health care providers must use the evaluation management coding system in order to be reimbursed by Medicare, Medicaid, and private insurance. The medical record documentation is critical to providing patients with quality care and is required for the providers to receive accurate and timely payments for furnished services. The six different steps of the evaluation management section are: Step 1: Identify the Category and Subcategory of Service. Step 2: Review the Reporting Instructions for the Selected Category and Subcategory. Step 3: Review the Level of E&M Service Descriptor Examples. Step 4: Determine the Extent of History Obtained Step 5: Determine

The outmoded coding professional’s role was to describe and apportion diagnosis, procedure, and other medicinal service codes using ICD-9-CM and HCPCS/CPT coding classifications while referencing the Coding Clinic for ICD-9-CM, Coding Clinic for HCPCS,

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