Coding is the backbone of medical practices. Oncology facilities are no different, as well. If you need help on coding and billing for your oncology practice, check out this essential guide.
An Overview of Oncology
The field of oncology focuses on diagnosing, treating, and researching cancer. Oncologists are doctors who work in this field. However, some oncologists specialize in only a few types of cancer or treatments. Oncology therapy has three main components: medical, surgical, and radiation. Depending on the type, stage, and location of cancer, a patient may receive treatment from multiple oncology specialists.
Medical oncologists also develop treatment plans for cancer patients. The oncologist may recommend surgery, chemotherapy, targeted therapy, or hormone therapy while coordinating with other oncologists who play a role in the patient’s treatment.
Meanwhile, a surgical oncologist uses biopsies and other cancer-related procedures to remove tumors and the surrounding tissues.
Radiation oncologists also specialize in treating cancer with radiation therapy. Doctors can perform a procedure that shrinks or destroys cancer cells if a patient has cancer. They can also alleviate cancer-related symptoms.
Oncology subspecialists treat many types of cancer. For example, oncologists trained in gynecology treat cancers of the female reproductive system. Neuro-oncologists treat cancer of the brain, spine, and peripheral nerves.
What Makes Coding and Billing for Oncology Practices So Critical?
Correct coding practices are crucial to oncology coding and revenue payments. If there are coding errors, you are sure to lose revenue. Avoid it at all costs.
Moreover, billing and coding errors are a risk for healthcare professionals because oncology drugs are expensive. A lack of accurate and proper oncology coding will significantly impact revenue cycle management.
Every treatment course should be billed from the start and again as needed.
Current Procedural Terminology (CPT) Codes Used in Coding Oncology:
CPT code 77332:
CPT code 77332 corresponds to simple treatment devices, designs, and construction that include simple port blocks with one or two premade blocks that can be hand-positioned; simple prefabricated bolus that can be shaped for an individual patient; or independent jaw motion or asymmetrical collimation.
CPT code 77333:
Use CPT code 77333 if you need an intermediate treatment device that includes multiple port blocks, like corner pelvis blocks, beam splitter blocks, midline spinal cord blocks, stents, bite blocks, or a special multi-use bolus.
CPT code 77334:
The above CPT code is used for complex treatments, designs, and constructions. It includes customized, one-use bolus, for example, wax molds conforming to particular body parts, along with customized blocks of low alloy, customized compensators, wedges, molds, and casts, including customized immobilization devices and eye shields.
CPT code 77336:
The above code is used for continuous medical radiation physics consultation. These include the assessment of treatment parameters, assurance of quality in delivering perfect dosage, and review of patient documentation. A radiation oncologist reports for a week of treatment, including once every five treatments.
CPT code 77370:
During radiation therapy, use CPT code 77370 when a problem or a special situation arises. For this code, the requesting physician must provide a detailed description of the problem.
CPT code 77387:
Guidance for localization of target volume for radiation treatments, including intrafraction tracking, should use CPT code 77387. Only OPPS uses this code.
Important Note: These codes identify only the technical component of radiation treatment sessions and not any physician involvement.
Only treatment management codes are included in the professional component. In addition, insurance companies agree to pay for these terms and conditions for delivering radiation treatment under CPT codes 77401-77416.
CPT code 77401:
The above code is used for superficial/orthovoltage treatment delivery for a day. You cannot submit codes for clinical treatment planning – 77261, 77262, and 77263, for treatment devices with codes – 77332, 77333, and 77334, for isodose – 77306 and 77307, for physics consultation – 77336, and treatment management – 77427, 77431, and 77470 with 77401.
CPT code 77407
In the above code, any of the following criteria are met, but not all complex criteria. The criteria include two treatment areas, three or more ports, and three or more single blocks. Please note that OPPS is the only program that uses this code.
CPT code 77412:
When there is a need for complex treatment delivery, use the CPT code 77412. There are three or more separate treatment areas, custom blocking, tangential blocks, sedges, rotating beams, or tissue compensation that do not meet guidelines. OPPS uses this code exclusively.
CPT code 77295:
A three-dimensional radiotherapy plan that includes a dose value histogram is reported with this code, including procedures performed in coplanar therapy beams. Due to this, the below codes can’t be billed separately on the same date. The codes are 77280, 77285, and 77290.
CPT code 77300:
Based on the course of treatment, code 77300 is for radiation dosimetry, calculation, central axis depth, TDF, NSD, gap calculation, off-axis factor, tissue homogeneity factors, according to the order of treatment when prescribed by a health care provider.
Dosimetry recalculation may result from any changes in weight or birth at the time of radiation treatment. Moreover, daily performing this procedure every time a patient receives treatment is unnecessary.
Guidelines for Providing Proper Documentation:
Never attach any patient or treatment details to the original claim.
Ensure all services are billed with detailed information, itemization, and supporting documentation.
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
The Current Procedural Terminology (CPT) codes play a vital role in the medical billing process. The CPT functions as descriptions of the services provided. New CPT codes are added for everything a certified health care provider can do each year.
So, we will discuss what CPT codes mean for medical billing here.
Understanding CPT Codes in Medical Coding and Billing
Current Procedural Terminology (CPT) is a standard code set for reporting medical, surgical, and diagnostic procedures to healthcare providers, insurers, and organizations. In addition to this, CPT codes function in a multitude of ways in the medical field, such as
Setting guidelines for clinical care reviews and processing claims.
Documenting medical services and treatments provided to patients.
Providing an insurance company with the procedures the doctor wants reimbursement for.
Incorporating ICD codes into the medical processes provides payers with a complete picture of the operations.
Identifying the tasks and services that health care providers offer.
Tracking and billing of medical services.
A worldwide coding system for medical treatments.
The American Medical Association (AMA) streamlines the CPT manual every year. It also contains extensive requirements for service and procedure coding. Thus, providers are responsible for accurate reporting and documentation of the services.
A Brief Overview of CPT’s History
The American Medical Association manages CPT. In 1966, the AMA published the first edition of its manual of surgical procedures. At the time, terminology and reporting were standardized.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 set guidelines for transmitting and storing electronic health records. Also, these codes are required for coding medical terms and billing insurance companies. They provide information about the purpose of the CPT code treatment.
The Three Categories of CPT Codes
Depending on the category, CPT codes can be numeric or alphanumeric. Using CPT code descriptors, diverse users can understand clinical health care and use common standards.
Category 1: Medical procedures and practices
The first category covers widely performed procedures and medical practices. When coders talk about CPT, the Category 1 codes refer to FDA-approved services and procedures performed by healthcare providers nationwide. They are five-digit numeric codes that are proven and documented.
Six sections make up Category 1 codes, like:
Evaluation and Management: 99201 – 99499
Anesthesia: 00100 – 01999; 99100 – 99140
Surgery: 10021 – 69990
Radiology: 70010 – 79999
Pathology and Laboratory: 80047 – 89398
Medicine: 90281 – 99199; 99500 – 99607
Category 2: Services for Clinical Laboratories
Category 2 CPT codes provide supplementary tracking codes used for performance measurement. Moreover, these codes describe the quality of care your patients receive. However, medical codes are optional and do not replace Category 1 codes.
Category III: Innovative Technologies, Services, and Procedures
Category III codes are temporary Alphanumeric codes for developing technologies, procedures, and services. These codes were created to collect, assess, and in some cases, pay for new services and processes that don’t meet the criteria for Category I codes.
What Are the Uses of Cpt Codes?
Patient costs are directly related to CPT codes. Due to this, offices, hospitals, and other medical facilities are extremely strict about coding. These facilities usually hire professionals to code services correctly.
The initial stage of coding
In most cases, the coding process will begin with your healthcare provider. They will list the CPT codes on paper forms for your visit. Likewise, you will receive a note in your Electronic Health Record (EHR) if they use one during your stay. Staff can often search for codes by service name.
Validation and Submission
Billers and medical coders look at your records after you leave the office. Indeed, these professionals ensure the correct codes for your records.
After all, your billing department sends a list of services to your insurance company. Medical providers often store and transmit this information electronically.
Processing of Claims
Your insurer or payer processes the claim using the codes. In this case, they decide how much to pay your healthcare provider and owe anything.
Research Purposes
In fact, data coding helps insurance companies and government officials predict future patient healthcare costs. Analyzing data coding by state and federal governments can provide insight into medical trends. It also assists with planning and budgeting for Medicare and Medicaid.
These are the CPT codes commonly used in medical billing and coding processes:
New Patient Office Visit Codes: 99201-05. These codes apply to patients who have not seen physicians within the same group in the past three years.
Established Patient Office Visit Codes: 99211-15. Patients are seen by a physician in the same specialty within the same group in the past three years;
Initial Hospital Care Codes: 99221-23
Subsequent Hospital Care Codes: 99231-23
Emergency Department Visit Codes: 99281-85
Office consultation codes: 99241-45. Often used to obtain a physician’s opinion on behalf of another physician.
Furthermore, the AMA has a complete list of medical billing codes here.
Summary
Medical providers submit claims for payment using CPT codes, which the AMA maintains. Therefore, following CPT process recommendations benefits physicians (and their patients).
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
How well do you know the No Surprises Act? What are the implications of the Act for healthcare providers? If these questions are on your mind, we can provide a comprehensive and friendly guide on the No Surprises Act (NSA).
COVID-19, on December 27, 2020. Moreover, the Act prevents healthcare consumers from being surprised by medical bills and shields them from insurance disputes. The Center for Medicare and Medicaid Services (CMS) has created a site for future updates on No Surprises Act implementation documents.
What Is a Surprise Medical Bill?
A “surprise medical bill” refers to unexpected higher charges after receiving care from an out-of-network provider. The out-of-network provider or facility may also bill you for the difference between the billed charge and what your health plan pays unless prohibited by state law. Balance billing also describes this situation. Surprise medical bills can also refer to unanticipated balance bills from out-of-network providers.
Furthermore, these protections are already available to those with Medicare or Medicaid.
Understand the “No Surprises Act” in Terms of Its Applicability
The No Surprises Act applies to all states without a law that prohibits balance billing. Whenever there is an existing law, it will take precedence over the Act. State or federal laws may apply to providers with a multi-state practice regarding insurance reimbursement. Billing companies and providers can benefit from this knowledge in dealing with reimbursements and perceived underpayments.
Surprise bills from healthcare providers must not exceed more than the in-network costs.
Providers cannot charge the patient more than the in-network cost-sharing amount covered by NSA, or a penalty of up to $10,000 may apply.
Nowadays, out-of-network doctors and hospitals are billing their patients directly for their total, undiscounted fees. Thus, the patient needs to submit a claim out-of-network to their insurance company and collect any reimbursement. The process starts this year. First, providers must verify the patient’s insurance status before submitting the surprise out-of-network bill. Providers are also “encouraged” to include information about NSA protections on the claim itself (e.g., whether the patient has waived his balance billing privileges).
On the other hand, the health plan must notify the provider of the applicable in-network cost-sharing amount within 30 days. Cost-sharing generally depends on the plan’s in-network rate and its pay for the service. Consumers will receive a notice that the health plan has processed the claim, along with the amount of in-network cost-sharing they owe to the out-of-network provider.Until then, the out-of-network provider may bill the patient no more than the in-network cost-sharing amount.
How the Act Impacts Physicians
The No Surprise Act prevents providers from surprisingly billing customers. Out-of-network providers must charge the in-network fee from their patient’s health plan.
If physicians are part of a smaller practice and do not have the resources to use the IDR process to ensure fair compensation, the No Surprise Bill law might pose financial difficulties. Physicians may face more financial stress, including the COVID-19 pandemic.
No Surprises Act: Does It Apply to Clinics?
Some of its rules do. However, many sources claim clinics are exempt from these rules.
First, it is helpful to think of the Act as having three prongs. The first prong deals with emergency services.
Secondly, it deals with patients undergoing treatment at a hospital or ASC.
The last prong considers estimates for patients who are not using insurance to cover their care. This is either because they are uninsured or refuse to use their insurance.
The third prong refers to clinics; you must provide estimates to patients without insurance. If physicians offer services in a hospital or an ASC, the first two prongs will apply.
What Is the Good Faith Estimate (GFE)?
From January 1, 2022, patients without insurance can get a good faith estimate (GFE) for any service scheduled within three business days in advance. All practices and facilities must comply with this rule. In addition, GFEs must include details such as diagnosis and procedure codes, as well as your NPI.
The three-day notice applies to every scheduled service, including office visits. If you plan the event between three and nine days ahead, you are required to submit the estimate within one business day after you schedule it. You get three business days to provide the estimate if the event is more than ten days away.
What’s Not Covered by the No Surprises Act?
There is no prohibition against surprise out-of-network billing under the No Surprises Act. However, there are two critical exceptions:
Ambulances: The Act covers air ambulances but not regular ground ambulances.
Facilities: Hospitals, emergency rooms, and outpatient surgery centers are covered by the Act. There are also plans to include clinics and urgent care centers in the future.
Medicare, Medicaid, TRICARE, Veterans Affairs Health Care, and Indian Health Services are not covered under these provisions since they are already protected against surprise medical bills.
Some of the notable provisions of the Act include:
It goes into effect on January 1, 2022, and abolishes balance billing, except in particular circumstances.
Balance billing laws apply to Employee Retirement Income Security Act (ERISA) plans and state-regulated plans in states without balance billing laws already in place.
Patient deductibles for out-of-network emergency care are the same as for in-network care, and deductibles must be printed on insurance cards.
Pay the provider directly or respond with a complete denial within 30 calendar days of receiving the claim.
Establishes an Income-driven Repayment (IDR) process for dealing with out-of-network payment disputes.
Throughout 2021, insurers will have to report to state-level all-payer claims databases. Also, rules for qualifying payments (defined as the median of contracted rates as of January 31, 2019, adjusted for inflation from 2019-2021) and the IDR process.
Because many key provisions of the new law are still unclear, how should a practice prepare for such changes?
Be familiar with the law in the state(s) in which the practice is located.
Establish a method that identifies current out-of-network payment trends. Next, compare them with payments received after January 1, 2022.
Prepare to file underpaid claims in the IDR process.
Thus, the NSA may continue to modify its standards and procedures as implementation proceeds (and federal courts consider legal challenges to the regulations).
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
As fall approaches, not only do the leaves change but healthcare practices should also be prepared for ICD-10 changes, which take effect every October 1. The Big Question: Is Your Practice Already Prepared for the New ICD-10 2022 Guidelines? Worry no more! With this article, you can adhere to the New ICD-10 Coding Guidelines FY 2022.
So, what are ICD-10 Guidelines?
In every healthcare setting, ICD-10-CM guidelines are used to classify diagnoses, morbidities, and reasons for patient visits. Healthcare providers and coders must use these guidelines and reporting requirements as companion documents to the official version of the ICD-10-CM. ICD-10-CM and the ICD-10 code set under the new guidelines, including new, revised, and retired codes, are updated. Also, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) implement the newly updated International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and the ICD-10 code set. A total of 72,748 codes are available this year including 159 new codes, 32 deleted codes, and 20 revised codes.
New Codes for COVID-19 Infection
New codes are available for FY 2022 to report conditions secondary to COVID-19 infection (sequelae):
J12.82: Pneumonia due to Coronavirus disease 2019 (MCC)
M35.81: Multisystem inflammatory syndrome (CC)
M35.89: Other specified system involvement of connective tissue (CC)
Z11.52: Encounter for screening for COVID-19
Z20.822: Contact with and (suspected) exposure to COVID-19
Z86.16: Personal history of COVID-19
Below is the latest code in a series of six codes added on January 1, 2021:
U09.9: Post COVID-19 condition, unspecified
New codes for conditions affecting the nervous system
The ICD-10 now includes 10 new codes in this category, with many of them classified as MCC or CC codes (please see above). Some of these new codes include:
ICD-10-CM coding guideline changes for 2022 include a number of corrections to spelling errors, as well as significant changes to diseases and conditions. Code additions and deletions are also major areas of change. The table below is a high-level breakdown of additions and deletions to the ICD-10-CM coding guidelines for 2022.
Chapter
Action
2022 Codes
2022 Code Descriptions
1
New Code
A79.82
Anaplasmosis [A. phagocytophilum]
2
New Code
C56.3
Malignant neoplasm of bilateral ovaries
2
New Code
C79.63
Secondary malignant neoplasm of bilateral ovaries
2
New Code
C84.7A
Anaplastic large cell lymphoma, ALK-negative, breast
3
New Code
D55.21
Anemia due to pyruvate kinase deficiency
3
New Code
D55.29
Anemia due to other disorders of glycolytic enzymes
Sjögren syndrome with peripheral nervous system involvement
13
New Code
M35.07
Sjögren syndrome with central nervous system involvement
13
New Code
M35.08
Sjögren syndrome with gastrointestinal involvement
13
New Code
M35.0A
Sjögren syndrome with glomerular disease
13
New Code
M35.0B
Sjögren syndrome with vasculitis
13
New Code
M35.0C
>Sjögren syndrome with dental involvement
13
New Code
M45.A
Non-radiographic axial spondyloarthritis
13
New Code
M45.A0
Non-radiographic axial spondyloarthritis of unspecified sites in spine
13
New Code
M45.A1
Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region
13
New Code
M45.A2
Non-radiographic axial spondyloarthritis of cervical region
13
New Code
M45.A3
Non-radiographic axial spondyloarthritis of cervicothoracic region
13
New Code
M45.A4
Non-radiographic axial spondyloarthritis of thoracic region
13
New Code
M45.A5
Non-radiographic axial spondyloarthritis of thoracolumbar region
13
New Code
M45.A6
Non-radiographic axial spondyloarthritis of lumbar region
13
New Code
M45.A7
Non-radiographic axial spondyloarthritis of lumbosacral region
13
New Code
M45.A8
Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region
13
New Code
M45.AB
Non-radiographic axial spondyloarthritis of multiple sites in spine
13
New Code
M54.50
Low back pain, unspecified
13
New Code
M54.51
Vertebrogenic low back pain
13
New Code
M54.59
M54.59
16
New Code
P00.82
Newborn affected by (positive) maternal group B streptococcus (GBS) colonization
16
New Code
P09.1
Abnormal findings on neonatal screening for inborn errors of metabolism
16
New Code
P09.2
Abnormal findings on neonatal screening for congenital endocrine disease
16
New Code
P09.3
Abnormal findings on neonatal screening for congenital hematologic disorders
16
New Code
P09.4
Abnormal findings on neonatal screening for cystic fibrosis
16
New Code
P09.5
Abnormal findings on neonatal screening for critical congenital heart disease
16
New Code
P09.6
Abnormal findings on neonatal screening for neonatal hearing loss
16
New Code
P09.8
Other abnormal findings on neonatal screening
16
New Code
P09.9
Abnormal findings on neonatal screening, unspecified
18
New Code
R05.1
Acute cough
18
New Code
R05.2
Subacute cough
18
New Code
R05.3
Chronic cough
18
New Code
R05.4
Cough syncope
18
New Code
R05.8
Other specified cough
18
New Code
R05.9
Cough, unspecified
18
New Code
R35.81
Nocturnal polyuria
18
New Code
R35.89
Other polyuria
18
New Code
R45.88
Nonsuicidal self-harm
18
New Code
R63.30
Feeding difficulties, unspecified
18
New Code
R63.31
Pediatric feeding disorder, acute
18
New Code
R63.32
Pediatric feeding disorder, chronic
18
New Code
R63.39
Other feeding difficulties
18
New Code
R79.83
Abnormal findings of blood amino-acid level
19
New Code
S06.A
Traumatic brain compression and herniation
19
New Code
S06.A0
Traumatic brain compression without herniation
19
New Code
S06.A1
Traumatic brain compression with herniation
19
New Code
T40.71
Poisoning by, adverse effect of and underdosing of cannabis (derivatives)
19
New Code
T40.711
Poisoning by cannabis, accidental (unintentional)
19
New Code
T40.712
Poisoning by cannabis, intentional self-harm
19
New Code
T40.713
Poisoning by cannabis, assault
19
New Code
T40.714
Poisoning by cannabis, undetermined
19
New Code
T40.715
Adverse effect of cannabis
19
New Code
T40.716
Underdosing of cannabis
19
New Code
T40.72
Poisoning by, adverse effect of and underdosing of synthetic cannabinoids
19
New Code
T40.721
Poisoning by synthetic cannabinoids, accidental (unintentional)
19
New Code
T40.722
Poisoning by synthetic cannabinoids, intentional self-harm
19
New Code
T40.723
Poisoning by synthetic cannabinoids, assault
19
New Code
T40.724
Poisoning by synthetic cannabinoids, undetermined
19
New Code
T40.725
Adverse effect of synthetic cannabinoids
19
New Code
T40.726
Underdosing of synthetic cannabinoids
19
New Code
T80.82
Complication of immune effector cellular therapy
20
New Code
Y35.899
Legal intervention involving other specified means, unspecified person injured
21
New Code
Z55.5
Less than a high school diploma
21
New Code
Z58
Problems related to physical environment
21
New Code
Z58.6
Inadequate drinking-water supply
21
New Code
Z59.00
Homelessness unspecified
21
New Code
Z59.01
Sheltered homelessness
21
New Code
Z59.02
Unsheltered homelessness
21
New Code
Z59.41
Food insecurity
21
New Code
Z59.48
Other specified lack of adequate food
21
New Code
Z59.81
Housing instability, housed
21
New Code
Z59.811
Housing instability, housed, with risk of homelessness
21
New Code
Z59.812
Housing instability, housed, homelessness in past 12 months
21
New Code
Z59.819
Housing instability, housed unspecified
21
New Code
Z59.89
Other problems related to housing and economic circumstances
21
New Code
Z71.85
Encounter for immunization safety counseling
21
New Code
Z91.014
Allergy to mammalian meats
21
New Code
Z91.51
Personal history of suicidal behavior
21
New Code
Z91.52
Personal history of nonsuicidal self-harm
21
New Code
Z92.85
Personal history of cellular therapy
21
New Code
Z92.850
Personal history of Chimeric Antigen Receptor T-cell therapy
21
New Code
Z92.858
Personal history of other cellular therapy
21
New Code
Z92.859
Personal history of cellular therapy, unspecified
21
New Code
Z92.86
Personal history of gene therapy
22
New Code
U09
Post COVID-19 condition
22
New Code
U09.9
Post COVID-19 condition, unspecified
The deleted codes:
19
Deleted Code
T40.7X
Poisoning by, adverse effect of and underdosing of cannabis (derivatives)
19
Deleted Code
T40.7X1
Poisoning by cannabis (derivatives), accidental (unintentional)
19
Deleted Code
T40.7X2
Poisoning by cannabis (derivatives), intentional self-harm
19
Deleted Code
T40.7X3
Poisoning by cannabis (derivatives), assault
19
Deleted Code
T40.7X4
Poisoning by cannabis (derivatives), undetermined
19
Deleted Code
T40.7X5
Adverse effect of cannabis (derivatives)
19
Deleted Code
T40.7X6
Underdosing of cannabis (derivatives)
Note: There was no change or deletion to chapters not listed above.
Implementing Diagnosis Code Changes
To ensure your claims are paid, healthcare practices should integrate the 2022 ICD-10-CM coding guideline changes into their system.
Billing/medical records software systems are a huge risk for your practice (if you use them). It can be disastrous if you blindly rely on your software system to implement ICD-10-CM updates in a timely manner. If there is a problem with your system, the software company is not responsible. The responsibility lies with you. Thus, you should compare the current year’s diagnosis code changes with those added to your software system to identify errors as soon as possible.
Lastly, you must teach your staff and providers about the key changes to the 2022 ICD-10-CM coding guidelines – based on your specialty. By doing so, you will be improving efficiency and accuracy when choosing diagnosis codes – either electronically or on paper.
Key Takeaway
To enhance the quality of reported data, the continuity of care, and patient outcomes, we endeavor to improve ICD-10 codes and clinical documentation throughout the process.
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
The American Medical Association (AMA) has released the latest version of the Current Procedure Terminology (CPT) code set for 2022. AMA made 405 changes to the current procedure code set in 2022, including 249 new codes, 63 deletions, and 93 revisions. These changes will take effect on January 1.
What is a CPT® code?
Current Procedural Terminology (CPT®) codes provide doctors and healthcare professionals a uniform language to code medical services and procedures to simplify reporting, improve accuracy, and increase efficiency. CPT codes are also used to manage administrative tasks like claims processing and medical care reviews. Electronic medical billing utilizes CPT codes as well as ICD-9-CM or ICD-10-CM numerical diagnostic coding. Throughout the country, CPT terminology is used to report medical, surgical, radiology, laboratory, anesthesia, genomic sequencing, evaluation, and management (EM) services under public and private health insurance programs.
The following AMA CPT codes were announced for new vaccine-specific immunizations against the novel coronavirus.
With the help of the Centers for Disease Control and Prevention (CDC), the AMA’s CPT editorial panel approved unique immunization codes for two coronavirus vaccines — as well as administration codes unique to each vaccine. In a press release, the AMA stated that the new CPT codes differentiate each coronavirus vaccine for better tracking, reporting, and analysis for data-driven planning and allocation.
The new Category I CPT codes and long descriptors for the vaccine products are:
91300
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative-free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use (Report 91300 with administration codes 0001A, 0002A, 0003A, 0004A) ◄ Do not report 91300 in conjunction with administration codes 0051A, 0052A, 0053A, 0054A, 0071A, 0072A)
November 10, 2020 July 30, 2021
September 3, 2021 October 6, 2021
0001A, 0002A, 91300: December 11, 2020 0003A: August 12, 2021 0004A: September 22, 2021 0071A, 0072A: October 29, 2021 0051A, 0052A, 0053A, 0054A: Effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration (FDA)
CPT® 2022/2023
91301
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative-free, 100 mcg/0.5 mL dosage, for intramuscular use (Report 91301 with administration codes 0011A, 0012A, 0013A)
November 10, 2020
August 16, 2021
0011A, 0012A, 91301: December 18, 2020 0013A: August 12, 2021
CPT® 2022/2023
Here are the new Category I CPT codes and long descriptors for vaccines:
To comply with new CPT codes for vaccine-specific products, the CPT editorial panel collaborated with the Centers for Medicare & Medicaid Services. Their purpose is to develop vaccine administration codes that are distinct for each Coronavirus vaccine and the specific dose used in the schedule.
According to AMA, the level of specificity is a first for vaccine CPT codes. However, it allows tracking all vaccine doses, even when the vaccine product is not reported, like when a vaccine may be given free to the patient. Moreover, these CPT codes report the actual act of administering the vaccine and all counseling needed to the patient or caregiver. They also update the electronic records.
The AMA site provides a number of resources regarding the new vaccine administration CPT codes and long descriptors. As soon as each newly developed Coronavirus vaccine receives Emergency Use Authorization or FDA approval, all the new vaccine-specific CPT codes will be available for use.
AMA’s website offers short and medium descriptors for these new vaccine-specific CPT codes. They also provide recent changes to the set of CPT codes that have streamlined the public health response to SAR-CoV-2 and COVID-19 disease.
In addition to releasing the standard code descriptor PDF of SARS-CoV-2-related CPT codes, we are also providing an easy-to-use Excel file of SARS-CoV-2-related CPT codes. It contains all the SARS-CoV-2 CPT codes, some may not be included in the 2022 CPT data file, and it includes:
CPT code descriptors (long, medium, and short)
Published date
Effective date
Type of change.
AMA will update these files as new CPT codes are approved by the CPT Editorial Panel:
CPT code set for 2022 includes five new codes (98975, 98976, 98977, 98980, 98981) for reporting therapeutic remote monitoring. These codes reflect the rise of digital care during the pandemic. In a news release, the AMA referred to codes 99453, 99454, 99457, and 99458 as “codes that expand upon the remote physiologic monitoring codes created in 2020.”
According to the AMA, the new code set includes a taxonomy that supports “increased awareness and understanding of approaches to patient care through diverse digital medicine services available for reporting.”
As of 2020, new CPT codes also apply to the principal care management program. Patients with a single chronic condition can receive reimbursement under that policy. Whereas before, only patients with multiple chronic conditions were eligible.
The AMA wrote that the new codes – 99424, 99425, 99426, 99427 – and changes to existing codes, “better align with Medicare guidelines.” Thus, a data file can be used to download the codes and descriptors into a provider’s software solution.
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
Billing and coding for general surgery include a wide range of procedures, from gastrointestinal (GI) tract surgery, kidney, pancreas, liver, and thoracic and abdominal surgery to breast surgery and elective surgery. The coding and billing of general surgery can be challenging due to numerous guidelines. Moreover, the general surgeons in 2019 faced 135 changes to ICD-10 codes and more than 69 changes to CPT codes.
The Health Common Procedure Coding (HCPCS) describes medical devices, supplies, products, and services and aids Medicare and other insurance companies in processing health claims. Physician billing companies should be up to date with all the latest changes in CPT, ICD, and HCPCS codes to submit accurate claims to payers.
In this article, we’ll discuss billing and coding guidelines for general surgery.
CPT Codes 20000-29999: Top Surgical Procedures
Surgery CPT Codes
Description
20610
DRAIN/INJECT, JOINT/BURSA
29581
APPLY MULTLAY COMPRS LWR LEG
29125
APPLY FOREARM SPLINT
29515
APPLICATION LOWER LEG SPLINT
20552
INJ TRIGGER POINT, 1/2 MUSCL
29105
APPLY LONG ARM SPLINT
29881
KNEE ARTHROSCOPY/SURGERY
20680
REMOVAL OF SUPPORT IMPLANT
29126
APPLY FOREARM SPLINT
23430
REPAIR BICEPS TENDO
25605
TREAT FRACTURE RADIUS/ULNA
23650
TREAT SHOULDER DISLOCATION
23350
INJECTION FOR SHOULDER X-RAY
20553
INJECT TRIGGER POINTS, =/> 3
29826
SHOULDER ARTHROSCOPY/SURGERY
29877
KNEE ARTHROSCOPY/SURGERY
26055
INCISE FINGER TENDON SHEATH
20605
DRAIN/INJECT, JOINT/BURSA
29823
SHOULDER ARTHROSCOPY/SURGERY
22513
PERQ VERTEBRAL AUGMENTATION
29824
SHOULDER ARTHROSCOPY/SURGERY
26010
DRAINAGE OF FINGER ABSCESS
24640
TREAT ELBOW DISLOCATION
29882
KNEE ARTHROSCOPY/SURGERY
28485
TREAT METATARSAL FRACTURE
27096
INJECT SACROILIAC JOINT
29505
APPLICATION, LONG LEG SPLINT
28291
CORRJ HALLUX RIGIDUS W/IMPLT
26605
TREAT METACARPAL FRACTURE
23515
TREAT CLAVICLE FRACTURE
28285
REPAIR OF HAMMERTOE
22514
PERQ VERTEBRAL AUGMENTATION
29888
KNEE ARTHROSCOPY/SURGERY
27792
TREATMENT OF ANKLE FRACTURE
27093
INJECTION FOR HIP X-RAY
25608
TREAT FX RAD INTRA-ARTICULAR
27570
FIXATION OF KNEE JOINT
29822
SHOULDER ARTHROSCOPY/SURGERY
27447
TOTAL KNEE ARTHROPLASTY
29806
SHOULDER ARTHROSCOPY/SURGERY
25565
TREAT FRACTURE RADIUS ULNA
25607
TREAT FX RAD EXTRA-ARTICUL
25115
REMOVE WRIST/FOREARM LESION
26770
TREAT FINGER DISLOCATION
Coding updates for Surgery Section 2021:
Integumentary System-Breast Repair and Reconstruction
In the breast repair and reconstruction subsection (19316-19499) of the Integumentary System, 15 codes were updated, and two were deleted (19324 and 19366) in 2021. Moreover, this subsection includes new instructions for each code and new fundamental guidelines for coders.
Breast Reconstructions
The following code descriptions were updated:
Code
Descriptions
19357–
Tissue expander placement in breast reconstruction, including subsequent expansion(s)(previously stated breast reconstruction, immediate or delayed, including subsequent expansion) The subsequent expansions of the tissue expander are included in code 19357.
19361–
Breast reconstruction; with latissimus dorsi flap (had said the same plus “without prosthetic implant”) The extensive notes for this code explain what not to report. If there is the insertion of an implant in addition to latissimus dorsi flap on the same day, additionally code 19340 to 19361. If it is on a separate day, use 19342.
Codes 19364-19369 cover breast reconstruction using different types of flaps, such as fTRAM, DIEP, SIEA, bi=pedicled TRAM, TRAM with and without separate microvascular anastomosis or “supercharging.” The supercharging procedure increases blood flow in TRAM flaps with marginal circulation to ensure flap survival. All of these procedures are the same as in 2020. The only difference is that they now all mention: “including the closure of donor sites.” Of course, this is just part of the code. Notes before each code explain what each type of flap entails.
Revisions for Breast Procedures
In the past, coders found it difficult to distinguish between breast reconstruction and revision. The descriptions of the three codes were revised:
Code
Descriptions
19370–
Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy (had stated open periprosthetic capsulotomy, breast) In most cases, this is done to fix a displacement of an implant.
19371–
Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (had stated open periprosthetic capsulectomy, breast) Complete capsulectomy with implant removal is the key here. This was added for clarity. A partial capsulectomy is 19370. Physicians must document clearly.(Do not report 19371 with 19328, 19330, or 19370 in the same breast. For removal and replacement with a new implant, use 19342)
19380–
Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction (had stated revision of reconstructed breast). In terms of revisions, this code description has been revised extensively. There is a full listing of codes not to report this within the CPT tabular, so coders must refer to it.
Indeed, the documentation of all breast procedures codes is crucial. It may be good to discuss with surgeons to review the changes above so the documentation needed for coders will be included in operative reports.
Thus, we encourage coders to use the Breast Reconstruction in CPT Action Plan and to look at photos of the various breast reconstruction techniques online. Visualizing these can sometimes make it easier to understand what should be done.
On the other hand, the guidelines clarify which reconstruction method should be used for each breast. Codes have been updated: mammary is now known as breast, and language has been added that indicates whether a breast implant was inserted simultaneously or after a significant mastectomy.
Respiratory System: The Nose
Code
Descriptions
30468–
Unique, and was created to explain the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants. Furthermore, a code was also required to recognize the opening of the nasal collapse using minimally invasive methods and absorbable lateral wall implants.
30468–
Report for a bilateral system Add modifier 52 to the process if it is performed unilaterally.
Respiratory System: The Lungs and Pleura
Code
32408–
For 2021, to report core needle biopsy of the lung or mediastinum using all imaging guidance types, including, but not restricted to, CT, MRI, ultrasound, and fluoroscopy. The current guidelines for 32408 state that imaging guidance is not to be listed separately, and the code is only used once per lesion tested in a single session. If multiple lesions are tested on a corresponding day, select 32408 for each lesion examined simultaneously, including modifier 59.
Male Genital System: Prostate
Code
Description
55880–
Code is used to report transrectal, high-intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue.
Before 2021, coders were following an unrecorded code to communicate that method.
Female Genital System: The Cervix Uteri
Code
Description
57465–
A unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy.
57465–
Used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461).
57465–
The specification states that it combines optical dynamic spectral imaging that aids in the mapping of abnormal measures for biopsy.
Auditory System—Other Procedures:
There are new codes designed to practice the nasopharyngoscopy technique for the dilation of the eustachian tube. Eustachian tube balloon dilation (ETBD) is the name of this procedure. In the past, coders reported this procedure using unlisted code 69799 because no specific code was available.
Code
Description
CPT
69705–
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); unilateral (effective 1/1/2021)
69706–
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); bilateral (effective 1/1/2021)
69799–
Unlisted procedure, middle ear HCPCS C9745 Nasal endoscopy, surgical; balloon dilation of the eustachian tube
Notice: CPT codes, descriptions, and materials are the property of the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) owns the copyright to HCPCS codes, descriptions, and materials.
Therefore, the following surgery coding guidelines 2021 have been updated recently. For more accurate billing and coding for general surgery, refer to this website.
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
In simple terms, substance abuse refers to the pattern of harmful use of any substance to change one’s mood. Furthermore, the term “substances” can encompass not only alcohol and drugs ( legal or illegal) but also substances that do not technically qualify as drugs. On the other hand, “abuse” involves using a substance in a way that is not intended or recommended or when you consume too much of it.
The substance abuse medical billing process is only one element of revenue cycle management, which begins with gathering accurate patient information. In this guide, we’ll guide you all you need to know about the Medical Billing and Coding Guide for Substance Abuse.
This table shows Outpatient SUD Services:
HCPCS or CPT® Code
Modifier
Description
Service
Taxonomy
H0001
HD
Alcohol and/or drug assess
Substance use disorder assessment, Pregnant and Parenting Women (PPW)
261QR0405X
H0001
HF
Alcohol and/or drug assess
Substance use disorder assessment
261QR0405X
H0004
HF
Alcohol and/or drug services
Individual therapy, without family present, per 15 minutes
261QR0405X
H0038
HF
Selfhelp/peer svc
SUD Peer Services
261QR0405X
H0020
HF
Alcohol and/or drug services
Opiate Substitution Treatment, methadone administration See the Opioid Treatment Programs (OTP) section of this guide for more information about Opioid Substitution Treatment.
261QM2800X
T1017
HF
Targeted case management
Case management, each 15 minutes
251B00000X
96164
HF
Health behavior intervention, group, face-to-face; initial 30 minutes
Group/ Face to face
261QR0405X
96165
HF
Health behavior intervention, group, face-to-face; each additional 15 minutes
Group/ Face to face
261QR0405X
96167
HF
Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
Family w/ patient present/ face to face
261QR0405X
96168
HF
Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes
Family w/ patient present/ face to face
261QR0405X
96170
HF
Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
Family without patient present, face to face
261QR0405X
96171
HF
Health behavior intervention, family (without the patient present), face-to-face; additional 15 minutes
Family without patient present, face to face
261QR0405X
This table shows Residential SUD Services:
HCPCS or CPT® Code
Modifier
Description
Service
Taxonomy
H0010
HA
Alcohol and/or drug services
Youth subacute withdrawal management
3245S0500X
H0010
HF
Alcohol and/or drug services
Adult subacute withdrawal management
324500000X
H0011
HA
Alcohol and/or drug services
Youth acute withdrawal management
3245S0500X
H0011
HF
Alcohol and/or drug services
Adult acute withdrawal management
324500000X
H0018
HA
Alcohol and/or drug services
Youth recovery house
3245S0500X
H0018
HF
Alcohol and/or drug services
Adult recovery house
324500000X
H0018
HV
Alcohol and/or drug services
Adult intensive inpatient residential, w/o room and board, per diem
324500000X
H0019
HA
Alcohol and/or drug services
Youth intensive inpatient residential, w/o room and board, per diem
3245S0500X
H0019
HB
Alcohol and/or drug services
Residential treatment, Pregnant and Parenting Women (PPW) w/Children, w/o room, and board, per diem
324500000X
H0019
HD
Alcohol and/or drug services
Residential treatment, Pregnant and Parenting Women (PPW) w/o Children, w/o room and board, per diem
324500000X
H0019
TG
Alcohol and/or drug services
Residential treatment, long term recovery
324500000X
H2036
HA
A/D Tx program, per diem
Youth room and board*
3245S0500X
H2036
HF
A/D Tx program, per diem
Adult Room & Board*
324500000X
H2036
HD
A/D Tx program, per diem
PPW room and board*
324500000X
For more assistance on the billing guide, refer to this site.
Substance Abuse Diagnosis
Psychiatrists, psychologists, and licensed drug counselors are often involved in the evaluation process for diagnosing alcoholism, drug addiction, or other substance use disorders. Testing blood, urine, or other tests can assess drug use but not a diagnostic test for addiction. These tests can help monitor recovery as well as treatment.
Mental health professionals diagnose substance abuse using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
How to identify correct substance abuse ICD-10-CM codes?
ICD-10-CM uses the format F1x.xxx for substance use codes. In ICD-10-CM, the letter F indicates that the code belongs to Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders. Furthermore, the number 1 represents a mental or behavioral disorder due to the use of psychoactive substances. The first x, the next digit, indicates the problematic substance (see table below in Step 1). After the decimal point, all numbers indicate the severity and nature of the problem (see Table in Step 2 below). For example, F10.121 refers to alcohol abuse with intoxication delirium. Not all specifiers are used for every substance (primarily perceptual disturbance), so users should refer to the complete ICD-10-CM code set.
Code1
Mental and Behavioral Disorders due to…
F10
…use of alcohol
F11
…use of opioids
F12
…use of cannabis
F13
…use of sedatives, hypnotics, anxiolytics
F14
…use of cocaine
F15
…use of other stimulants, including caffeine
F16
…use of hallucinogens
F17
…use of nicotine
F18
…use of inhalants
F19
…use of other psychoactive substances and multiple drug use
Specifiers for Substance Coding
Code1
Abuse
.1
Uncomplicated
.10
With intoxication
.12
…uncomplicated
.120
…delirium
.121
…with perceptual disturbance
.122
…unspecified
.129
With [insert substance] – induced mood disorder
.14
With [insert substance] – induced psychotic disorder
.15
…with delusions
.150
…with hallucinations
.151
…unspecified
.159
With other [insert substance] – induced disorder
.18
…anxiety disorder
.180
…sleep disorder
.182
…other [same-substance] – induced disorder
.188
With unspecified [insert substance] – induced disorder
.19
Dependence
.22
Uncomplicated
.20
In remission
.21
With intoxication
.22
…uncomplicated
.220
…delirium
.221
…with perceptual disturbance
.222
…unspecified
.229
With withdrawal
.23
…uncomplicated
.230
…delirium
.231
…with perceptual disturbance
.232
…unspecified
.239
With [insert substance] – induced mood disorder
.24
With [insert substance] – induced psychotic disorder
.25
…with delusions
.250
…with hallucinations
.251
…unspecified
.259
With [insert substance] – induced persisting amnestic disorder
.26
With [insert substance] – induced persisting dementia
.27
With other [insert substance] – induced disorders
.28
…anxiety disorder
.280
…sexual dysfunction
.281
…sleep disorder
.282
…other [same-substance] – induced disorder
.288
With unspecified [insert substance] – induced disorder
.29
Use, unspecified
.9
With intoxication
.92
…uncomplicated
.920
…delirium
.921
…with perceptual disturbance
.922
…unspecified
.929
With withdrawal
.93
…uncomplicated
.930
…delirium
.931
…with perceptual disturbance
.932
…unspecified
.939
With [insert substance] – induced mood disorder
.94
With [insert substance] – induced psychotic disorder
.95
…with delusions
.950
…with hallucinations
.951
…sleep disorder
.959
With [insert substance] – induced persisting amnestic disorder
.96
With [insert substance] – induced persisting dementia
.97
With other [inset substance] – induced disorders
.98
…anxiety disorder
.980
…sexual dysfunction
.981
…sleep disorder
.982
…other [same-substance] – induced disorder
.988
With unspecified [insert substance] – induced disorder
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
The ongoing battle against COVID-19 has left doctors, nurses, medical assistants, and other frontline hospital staff members exhausted and overwhelmed — adding to the burnout that has long existed before the pandemic even began. In an article published by NPR, many healthcare professionals offered insights on solving this crisis, often by focusing on smaller details of the work. One thing that bothers many healthcare workers is the paperwork that sucks up their after-hours and weekends.
Managing insurance forms and billing statements is a frustrating reality of clinical experience. As time-consuming and tedious it may be, however, handling the bills is a vital part of operations. The financial success of any healthcare institution depends on translating patient visits into actual reimbursements, which is why streamlining medical billing through automation is necessary. Here are three ways automated billing can greatly assist healthcare providers:
Reduces billing errors
Medical billing is a complex process that involves monitoring, calculating, and evaluating bills for each patient. As many as 250 people may be involved in this process, from nurses to medical coders, and manual data entry can result in errors. Even the most competent employees are not above an occasional mistake, more so if every member of the staff is stretched thin by administrative tasks. With an estimated 80% of medical bills containing mistakes, professors from John Hopkins University are campaigning to standardize metrics for billing quality. They argue that financial difficulties patients encounter in medical care is also a medical complication, and healthcare institutions should provide care for the patient’s entire person — not just their body.
Automating the billing process ensures each bill is prepared correctly every time. Bots can accurately calculate the total amount patients have to pay, and take into account costs for tests, medications, doctor fees, and insurance claims. The billing software can automatically notify patients and collect payments to speed up account settlements, opening up enough resources for activities and tasks which can’t be automated.
Minimizes overall workload
One study from the peer-reviewed journal Nursing Open revealed that many healthcare workers take on multiple roles to reduce gaps in primary care. Nurses, in particular, are in charge of paperwork related to assessments, admissions, and evaluations. They also work as relationship builders, patient outreach professionals, program facilitators, and care coordinators; Maryville University’s outlook for doctor of nursing practice graduates points out that advanced nurse practitioners are often called to provide services in health assessment, pathophysiology, and pharmacotherapeutics on top of their general nursing duties.
Juggling all these tasks can cause burnout, even for the most experienced of nurses, so automated billing can lessen their workload and allow them to focus on patient outcomes. Instead of entering data by hand, an automated billing system manages information between systems, saving healthcare workers administrative time and improving overall efficiency.
Improves budgeting and resource management
In our blog post on ‘5 Signs You Need to Call a Medical Billing Specialist’, we discussed how being focused on day-to-day patient duties can leave you to neglect a dwindling revenue stream. Payment problems cause revenue cycles to slow down quickly, especially as medical billing deals with multiple payers at a time. The unpaid bills slip through the cracks, and incorrect reimbursements cause your organization to lose money.
An automated billing system can follow up on outstanding claims and reduce the administrative workload, which can cut overtime staffing costs so you can funnel additional funding into areas like patient care. Automation enriches data collection and reporting as well. With more accurate and organized information, you can make strides in closing any financial gaps. The automated process delivers a continuous feedback loop, so you can optimize your practice and scale-up.
If you’re interested in an automated medical billing and coding solution, call us at 5 Star Billing Services today.
Specially written for drbillingservice.com by Josephine Hawkins
The term cardiovascular disease (CVD) refers to conditions that affect the heart or blood vessels. Also, the World Health Organization (WHO) estimates 17.9 million people died from cardiovascular diseases in 2019, representing 32% of all global deaths. A majority of these deaths resulted from heart attacks and strokes. Overall, CVD is the most severe disorder afflicting the majority of Americans.
Before discussing CVD in further detail, let’s examine documentation and diagnosis coding for cardiac conditions to ensure accurate and compliant practices.
The table below shows the ICD-10 diagnosis codes for common cardiac conditions.
COMMON DIAGNOSES
ICD-10 DIAGNOSES CODES
DEFINITION
Arch obstruction
Q25.1
Coarctation of the aorta
Q25.21
Interrupted aortic arch
Arrhythmias
I47.0-I47.9
Re-entry ventricular arrhythmia
I47.1
Supraventricular tachycardia
147.2
Ventricular tachycardias
147.9
Paroxysmal tachycardia, unspecified
Cardiac arrest
I46.2
Cardiac arrest due to underlying cardiac condition
I46.8
Cardiac arrest, due to other underlying condition
I46.9
Cardiac arrest, due to unspecified condition
Cardiomyopathies
I42.0
Dilated cardiomyopathy
142.1
Obstructive hypertrophic cardiomyopathy
142.2
Other hypertrophic cardiomyopathy
142.3
Endomyocardial (eosinophilic) disease
142.4
Endocardial fibroelastosis
142.5
Other restrictive cardiomyopathy
142.6
Alcoholic cardiomyopathy
142.7
Cardiomyopathy due to drug and external agent
142.8
Other cardiomyopathies
142.9
Cardiomyopathy, unspecified
Source: Extracorporeal Life Support Organization 2021
Heart failure includes systolic, diastolic, and combined heart failure as well acute heart failure, chronic heart failure, and acute chronic heart failure.
I50.41
Acute systolic (congestive) and diastolic (congestive) heart failure
I5.43
Acute on chronic systolic (congestive) and diastolic (congestive) heart failure
I50.9
Heart failure, unspecified
Hypoplastic left heart syndrome
Q23.4
HLHS includes all combinations of mitral stenosis/atresia and aortic stenosis/atresia
Q21.0
Ventricular septal defect
Atrial septal defect
Q21.1
Includes PFO, Secundum ASD, coronary sinus ASD, and sinus venosus ASD. Does not include ostium primum ASD
Atrioventricular septal defect
Q21.2
Includes all forms of AVSD or endocardial cushion defects including primum ASD
Tetralogy of Fallot
Q21.3
Includes TOF, TOF with pulmonary atresia, and TOF with absent pulmonary valve
Q21.4
Aortopulmonary septal defect
Q21.8
Other congenital malformations of cardiac septa
Q21.9
Congenital malformation of the cardiac septum, unspecified
Total anomalous pulmonary venous connection
Q26.2
Includes cardiac, supra cardiac, and infra cardiac TAPVC
Source: Extracorporeal Life Support Organization 2021
Through this guide, ordering physicians can ensure accurate ICD-10 diagnostic codes for cardiac conditions.
Coronary Artery Disease (CAD)
The other term for coronary artery disease (CAD) is sometimes called ischemic heart disease. CAD is the narrowing and hardening of the coronary arteries (the blood vessels that supply oxygen and blood to the heart). According to the Centers for Disease Control and Prevention (CDC), coronary artery disease (CAD) is the most common form of heart disease in the United States.
The table below shows ICD-10 codes for CAD:
ICD-10 CODES CAD
DESCRIPTION
I25
Chronic ischemic heart disease
I25.1
Atherosclerotic heart disease of native coronary artery
I25.10
Atherosclerotic heart disease of native coronary artery, without angina pectoris
I25.11
Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110
Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111
Atherosclerotic heart disease of native coronary artery with unstable angina pectoris, with documented spasm
I25.118
Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119
Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
Tap Into Our Expertise
For professionals in the healthcare industry, knowledge of ICD-10 codes is essential in reporting common cardiovascular diseases. Our team can ensure accurate medical billing and coding for optimal reimbursement, as well!
Medical coding is essential in medical practice. In this area, accuracy is crucial, as it will impact patient care, clinic operations, and revenue for your practice. The American Academy of Professional Coders (AAPC) describes healthcare coding as translating diagnoses, treatments, and even equipment into universal alphanumeric codes. In simple terms, it is the process of translating crucial medical information into codes to maintain accurate medical records and billing. The coding process assigns numerical or alphanumeric codes to every healthcare data element—outpatient and inpatient. It is essential to identify whether a patient is an outpatient or an inpatient as part of the hospital coding and billing process.
Let’s first understand the definition of Outpatient and Inpatient Coding:
What is Inpatient Coding?
Inpatient coding refers to the formal admission of a patient to a medical facility for a prolonged stay. It specifies the diagnosis of the patient and the services provided to them during their extended stay.
Inpatient coding allows accounting departments to determine the correct billing and reimbursement from insurers by providing a detailed overview of patients’ treatments during their extended stay. It has two standard coding guidelines: ICD-9/ICD-10-CM and ICD-10-PCS. But inpatient coders prefer to utilize ICD-10-PCS as the basis for procedural Coding. Furthermore, inpatient coding requires an admission status indicator (POA), distinguishing between a patient’s health status upon admission and new symptoms that develop throughout their stay.
What is Outpatient Coding?
In contrast, outpatient Coding is for patients who receive treatment but do not remain in a facility for an extended period. Outpatient Coding refers to a patient’s stay lasting less than 24 hours. Patients can still be classified as outpatients even after staying for 24 hours.
The outpatient coding system uses ICD-9/10-CM diagnostic codes but utilizes CPT or HCPCS for procedural Coding. Outpatient services and supplies fall under the latter category. CPT and HCPCS codes for services rely on documentation as well.
Outpatient settings do not allow the use of words such as “likely” or “probable” to describe a patient’s diagnosis. Instead, they must code conditions with certainty for signs, symptoms, or abnormal test results. In a single outpatient visit, the physician has limited time to observe the patient. A physician’s job is not to search for a comprehensive explanation of a patient’s health condition; instead, it is to form an educated conclusion based on the medical evidence at hand.
The Difference Between Inpatient and Outpatient Coding
Outpatient Coding differs from inpatient Coding by the length of the patient’s stay. The outpatient Coding is done for patients who do not stay for long and can leave within 24 hours of admission, while under the doctor’s prescription, the inpatient coders handle patients admitted for several days with a thorough diagnostic report.
The Medicare Part B program covers outpatient services, while Medicare Severity-Diagnosis Related Groups (MS-DRGs) cover inpatient services. Both types of services are eligible for Medicare reimbursement, but they use different plans.
The Outpatient Prospective Payment System (OPPS) manages reimbursements for outpatients. For inpatients, the Inpatient Prospective Payment System (IPPS) seeks reimbursement.
The inpatient coding process stays longer and has greater complexity of care. For instance, patients who remain in the hospital for several days may receive medical care from an ER physician, nurses, a surgeon, an anesthesiologist, and others, which should be recorded in their medical records.
Outpatient Coding requires the coders to know codes and guidelines of ICD-10-CM and HCPCS Level II, whereas an inpatient coder should be proficient in ICD-10-PCS and ICD-10-CM.
The coders should have enough knowledge of the outpatient coding guidelines, including ICD-10-CM and HCPCS Level II. On the other hand, the inpatient coders should be an expert in ICD-10-PCS and ICD-10-CM.
The inpatient and outpatient coding guidelines for treatment also differ in numerous ways. Both settings use different codes and guidelines for reporting services. Refer to the table below:
Facility/ Inpatient Coding Guidelines for Treatment
Physician/ Outpatient Coding Guidelines for Treatment
ICD-10-CM for diagnoses
ICD-10-CM for diagnoses
Coding for “probable,” “suspected,” or “rule-out” conditions are allowed
Coding for “probable,” “suspected,” or “rule-out” conditions are NOT allowed
Medical/Surgical procedures: ICD-10-PCS
Medical/Surgical procedures: CPTⓇ and HCPCS Level II
The basis of reimbursement is on the diagnosis-related group (DRG)
The reimbursement basis is on physician fees, insurance contracted rates, ambulatory surgical center rates, etc.
Require a hospital stay (usually with a two-day minimum)
It does not require a hospital stay.
The basis of code assignment is on the entire admission (length of stay)
The basis of code assignment is on the encounter/visit
By understanding the differences between inpatient and outpatient coding, health care providers can reduce overhead costs. These medical codes are both essential for billing and for outpatient billing services. Coders must therefore have an in-depth understanding of medical coding to perform their duties efficiently.
Tap Into Our Expertise
It may take some time for your medical practice to adjust. So, you can also hire a medical coding company with mastery of the official coding guidelines!
At 5 Star Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
