Clinical Billing - Basic Science

definitions
- Overview
  - coding and billing involves a system of rules and guidelines by which orthopedic surgeons can describe what was treated and in what manner it was treated
- Definitions
  - Common procedural terminology (CPT®)
    
    a 5 digit alphanumeric code used by insurers to help determine the amount of reimbursement that a practitioner will receive for services provided
    
    Category I codes
    
    five-digit codes have descriptors which correspond to a procedure or service (range from 00100 - 99499)
    
    Category III codes
    
    provisional or temporary codes for emerging procedures
  - Relative Value Units (RVU)
    
    a unit value assigned to each CPT code derived by four factors
  - International Classification of Disease -10 (ICD-10)
    
    a clinical cataloging system developed by the World Health Organization (WHO) used to define and classify diagnoses

ICD-10
- ICD-10 provides coding structure to diagnosis
  - alphanumeric seven-digit codes utilized
    
    allows description of:
    
    chronicity
    
    from acute to chronic
    
    phase of care
    
    initial, subsequent, sequela
    
    effects
    
    routine, complications,
    
    laterality
    
    left, right, unspecified

Current Procedural Terminology (CPT)
- CPT codes
  - are assigned to specific services including operative procedures, nonoperative care, and minor procedures (injections/aspirations)
    
    operative procedures codes are all-inclusive and include approach, procedure, closure, splinting, etc.
    
    codes are associated with a global period (0, 10, or 90 days) during which all associated services are considered within the package of care
- Modifiers
  - a 2-digit code used to indicate a special situation
    
    -22 modifier
    
    unusually complicated due to increased technical difficulty, patient condition, time, effort
    
    -24 modifier
    
    unrelated E&M during the postoperative period
    
    -25 modifier
    
    significant or separate E&M performed on the day of the procedure

Evaluation and Management (E&M)
- Location of service and level of service
  - location
    
    outpatient
    
    new patient
    
    has not received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years
    
    established patient
    
    has received professional services from the physician or any other providers in the same practice group and specialty within the last 3 years
    
    there is a 90-day post-operative period where all follow-up services are considered part of the global fee and cannot be billed separately
    
    consultation
    
    service requested by another physician
    
    advice must be the object of the request, not a transfer of care
    
    a request must be documented in the chart
    
    level of visit must be documented
    
    written response to requesting physician must be provided by consulting physician
    
    emergency department
    
    hospital
    
    initial care, continued care, consultation
  - level of service (1-5)
    
    component-based
    
    history, examination, and medical decision making
    
    levels include problem focused, expanded problem focused, detailed, comprehensive
    
    billing level is limited to the lowest level of history, examination, or medical decision making
    
    time-based
    
    when visit consists mainly of counseling and coordination of care
    
    amount of time must be documented
- Documentation
  - detail in note must match requirements for location and level of services that are billed for

Global Period (90-Day)
- Overview
  - single payment for care associated with a surgical procedure
- What is included
  - preoperative care
    
    preoperative visits and work
    
    OR preparation (patient marking, positiong, prep, drape)
  - operative care
    
    skin to skin work
  - immobilization and bracing
    
    application of immobilization or bracing in the OR
  - postoperative care
    
    inpatient visits (postoperative progress notes)
    
    postoperagive visits for up to 90 days
    
    whether performed by physician or physician extender
- What is not included
  - postoperative care
    
    diagnostic tests and procedures (e.g., CBC on postop day #1)
  - immobilization and bracing
    
    application of immobilization outside of the OR
  - different conditions
    
    visits for separate problems
    
    evaluation by physician part of a different group
  - additonal operations
    
    reoperation for complications from initial procedure (e.g., infection)
    
    staged procedures (e.g., front-back spine surgery)

Coding errors
- ICD-10 diagnosis code should support and justify the corresponding E&M and CPT codes for services provided
- Errors
  - seen as fraud regardless of whether intentional or unintentional
    
    services billed were not provided at all
    
    services billed were not provided by billing physician
    
    services billed were provided but not supported in documentation
  - responsibility ultimately falls on the billing physician

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T