Tuesday, July 24, 2012

Coding Neoplasms

Neoplasms - The first step in choosing the correct code.

The word "neoplasm" is often used interchangeably with the word "cancer" despite this inaccuracy. Neoplasm, which literally means "new growth," is an abnormal mass of tissue, and can be benign (not cancer) or malignant (cancer).

Understanding the differences in primary, secondary, in-situ, benign and undetermined behavior neoplasms is the first step in choosing the correct neoplasm code. A primary neoplasm is cancer (malignant), and designates the location (its origin) of where the cancer started. A secondary neoplasm (metastases) is cancer (malignant) that designates where the cancer spread. In-situ is cancer (malignant); however, it is confined to a specific area of origin, such as in the cervix or breast. A benign neoplasm is not cancer and is a localized tumor that has well-differentiated cells that do not metastasize or invade surrounding tissues. Some examples of benign neoplasms include lipoma, adeoma and hemangioma. A neoplasm of undetermined behavior is a diagnosis that can only be utilized if the pathologist notes in his pathology report that the behavior of the tumor is undetermined.

The general guidelines for neoplasms include first determining if a neoplasm is benign, in-situ, malignant or of uncertain histological behavior. In addition, if the neoplasm is malignant, determination needs to be made if there are any secondary (metastatic) sites involved. 

The guidelines for neoplasm are divided into nine separate categories to help with assigning the appropriate neoplasm code(s).

1. Treatment directed at the malignancy

If the treatment is directed at the malignancy, assign the malignancy code as the principal diagnosis. (An exception to this rule is when the patient is admitted for chemotherapy, radiation therapy or immunotherapy for the malignancy. In this situation, utilize the V58.x code as the principal diagnosis followed by the code for the malignancy.) An example of this would be a patient with sigmoid colon cancer admitted for a colectomy. The principal diagnosis would be the sigmoid colon cancer (primary site), as opposed to the patient being admitted for chemotherapy for the sigmoid colon cancer. In this situation, the chemotherapy code would be used as the principal diagnosis (V58.11), with an additional code for the sigmoid colon cancer.

2. Treatment directed at the secondary site 

If a patient is admitted with metastatic cancer, and the treatment is directed toward the secondary (metastatic) site, utilize the metastatic cancer code as the principal diagnosis followed by the primary cancer site (if still present) or a V code for a history of the primary neoplasm. An example of this would be a patient with prostate cancer who is currently undergoing chemotherapy admitted for a severe headache. After an MRI of the brain, it is determined that the patient has metastatic cancer of the brain from his prostate cancer. The principal diagnosis would be the metastatic (secondary) brain cancer and an additional code would be added for the prostate cancer.

3. Coding and sequencing of complications 

Anemia is often a result of neoplasms, as well as, therapy directed toward the neoplasm. When a patient is admitted for anemia due to a neoplasm and the treatment is directed toward the anemia, utilize the code 285.22, Anemia due to neoplasm as the principal diagnosis followed by the code for the neoplasm. Anemia due to a neoplasm, 285.22, can also be utilized as a secondary diagnosis if the patient suffers from anemia and is being treated for the malignancy.

When a patient is admitted for anemia due to chemotherapy, immunotherapy or radiation therapy, and the treatment is directed at the anemia, the anemia code should be the principal diagnosis. An additional code should be used to capture the neoplasm.

When anemia due to a neoplasm (285.22) and anemia due to chemotherapy (285.3) are both documented on the same encounter, both 285.22 and 285.3 can be coded. If both are documented as the reason for admission, based upon coding guidelines, either can be chosen as the principal diagnosis.

When a patient is admitted due to dehydration due to a malignancy or therapy directed at the malignancy, and only the dehydration is being treated, the dehydration is sequenced as the principal diagnosis followed by a code for the malignancy.

When a patient is admitted due to complications that resulted from a surgical procedure, code the complication as the principal or first-diagnosis if the treatment is directed toward the complication.

4. Primary malignancy previously excised

When a primary neoplasm has been excised and no further treatment (i.e., chemotherapy, immunotherapy, radiation therapy) is being directed toward that neoplasm, and there is no evidence of any existing primary neoplasm, utilize a code from V10.x for a personal history of a malignant neoplasm. Should an extension, metastases or invasion to another site be documented, code a secondary malignancy to that site. The secondary malignancy can be utilized as the principal or first-listed diagnosis followed by a V10.x code for the personal history of a malignancy.

5. Admission/encounter involving chemotherapy, immunotherapy and radiation therapy

When a patient is admitted for the administration of chemotherapy, immunotherapy or radiation therapy, the appropriate V58.x code is used as the first-listed or principal diagnosis followed by the code for the neoplasm(s) that is being treated.

When a patient is admitted for chemotherapy, immunotherapy or radiation therapy, and develops complications, such as dehydration or uncontrolled nausea and vomiting, code the appropriate V58.x code as the principal diagnosis followed by codes for the complications.

When a patient is admitted for the surgical removal of a neoplasm and receives chemotherapy, immunotherapy or radiation therapy after the surgery, the appropriate neoplasm code should be listed as the principal diagnosis.

6. Admission/encounter to determine extent of malignancy

When a patient is admitted to determine the extent of a primary or secondary malignancy, the malignancy is coded as the principal diagnosis.  

7. Symptoms, signs and ill-defined conditions listed in Chapter 16 associated with neoplasms

Should any signs, symptoms or ill-defined conditions listed in Chapter 16 be related with a primary or secondary neoplasm, the neoplasm is listed as the principal diagnosis.  

8. Admission/encounter for pain control/management

When a patient is admitted for pain control due to pain related to a neoplasm, utilize the code 338.3 as the principal diagnosis followed by a code for the neoplasm. In addition, 338.3, pain related to neoplasm can be utilized as the principal or a secondary diagnosis dependent on the reason for admission, and is used if the pain is acute or chronic.  

9. Malignant neoplasm associated with transplanted organ

When a patient is admitted for a malignant neoplasm in a transplanted organ, the principal diagnosis will be a complication of a transplant (996.8x) followed by the code 199.2, malignant neoplasm associated with transplanted organ. Also, utilize a code for the specific neoplasm.

To obtain the correct neoplasm code, the coder should carefully read over the documentation, determine the type(s) of neoplasm(s), assess the reason for admission, and then review the coding guidelines.  

This month's column has been prepared by Meredith McCollum, MBA, RHIA, CCS, ICD-10-CM/PCS AHIMA Certified Trainer, a coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Meredith's position is dedicated to providing ICD-9 and ICD-10 education to both internal colleagues, as well as clients based across the United States. She also is an adjunct professor for DeVry University where she not only teaches ICD-9 and ICD-10, but also develops classes for their nationwide Health Information Technology Program. 

Want to test your knowledge?


1. A patient with small cell carcinoma of the right lower lobe of the lung is admitted for a 7-day treatment of chemotherapy. The chemotherapy is administered, and the patient is discharged. How would this case be coded?

2. A 63-year-old male is admitted with a severe headache and backache. The patient has a history of malignant melanoma 6 years prior with no reoccurrence. An MRI is performed of the brain, spinal cord and vertebrae. The scan notes metastatic disease of the brain, spinal cord and the vertebrae. Radiation therapy is administered prior to his discharge. How would this be coded?

3. A 7-year-old female with acute lymphocytic leukemia (ALL) is admitted with severe anemia due to her ALL. The patient is transfused two units of packed red blood cells and discharged. What would the codes be for this encounter?

4. A 55-year-old male is admitted for pain control due to severe pain related to metastatic bone cancer from a primary lung carcinoma. How is this encounter coded?


1. The chemotherapy code will be listed as the principal diagnosis (V58.11), followed by a code for the neoplasm of the lower lobe of the lung (162.5). In addition, a procedure code for the administration of chemotherapy can be added (99.25).

2. The secondary neoplasm code for the brain and spinal cord (198.3) will be the principal diagnosis with additional diagnoses for secondary neoplasm to the vertebra (198.5), and V10.82 for personal history of melanoma of the skin. A procedure for the radiation therapy can also be added (92.29).

3. The anemia due to a neoplasm is assigned as the principal diagnosis (285.22) with an additional code for ALL (204.00). In addition, the procedure code for the transfusion of the packed cells can be added (99.04).

4. The code for the pain due to a neoplasm (338.3) is used as the principal diagnosis followed by a code for the metastatic bone cancer (198.5) and primary lung cancer (162.9).

Wednesday, July 11, 2012

Glossary Of Medical Billing Terms

Medical Billing Terms

AMA - American Medical Association. The AMA is the largest association of doctors in the United States. They publish the Journal of American Medical Association which is one of the most widely circulated medical journals in the world.

Aging - One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software's have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.

Ancillary Services - These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations - such as surgery, tests, counseling, therapy, etc.

Appeal - When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the
process and associated forms can be found on the insurance providers web site.

Applied to Deductible - You typically see these medical billing terms on the patient statement. This is the amount of the charges, determined by the patients insurance plan, the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.

Assignment of Benefits - Insurance payments that are paid to the doctor or hospital for a patients treatment.

ASP - Application Service Provider. This is a computer based services over a network for a particular application. Sometimes referred to as SaaS (Software as a Service). There application service providers that offer Medical Billing. The appeal of an ASP is it frees a business of the the need to purchase, maintain, and backup software and servers.

Beneficiary - Person or persons covered by the health insurance plan.

Blue Cross Blue Shield (BCBS) - An organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the association's brands (Blue Cross or Blue Shield). Many local BCBS associations are non-profit BCBS sometimes acts as administrators of Medicare in many states or regions.

Capitation - A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patients health care services. This payment is not affected by the type or number of services provided.

CHAMPUS - Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.

Charity Care - When medical care is provided at no cost or at reduced cost to a patient that cannot afford to pay.

Clean Claim - Medical billing term for a complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.

Clearinghouse - This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is compliant with the strict HIPPA standards (this is one of the medical billing terms we see a lot more of lately).

CMS - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPPA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration). You'll notice that CMS it the source of a lot of medical billing terms.

CMS 1500 - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500's. The form is distinguished by it's red ink.

Coding - Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment.

COBRA Insurance - This is health insurance coverage available to an individual and their dependents after becoming unemployed - either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It's typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986. 

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.

Co-Insurance - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%.

Collection Ratio - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total amount of money owed on the providers accounts.

Contractual Adjustment - The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company.

Coordination of Benefits - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.

Co-Pay - Amount paid by patient at each visit as defined by the insured plan.

CPT Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot.

Credentialing - This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance company networks.

Credit Balance - The balance thats shown in the "Balance" or "Amount Due" column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund.

Crossover claim - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid.

Date of Service (DOS) - Date that health care services were provided.

Day Sheet - Summary of daily patient treatments, charges, and payments received.

Deductible - amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.

Demographics - Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

DME - Durable Medical Equipment - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.

DOB - Abbreviation for Date of Birth

Downcoding - When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment.

Duplicate Coverage Inquiry (DCI) - Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists.

Dx - Abbreviation for diagnosis code (ICD-9 or ICD-10 code).

Electronic Claim - Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.

Electronic Funds Transfer (EFT) - An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

E/M - Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.

EMR - Electronic Medical Records. This is a medical record in digital format of a patients hospital or provider treatment.

Enrollee - Individual covered by health insurance.

EOB - Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.

ERA - Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.

ERISA - Employee Retirement Income Security Act of 1974. This law established the reporting, disclosure of grievances, and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.

Fee For Service - Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital. Some policies require the patient to pay provider directly for services and submit a claim to the carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.

Fee Schedule - Cost associated with each treatment CPT medical billing codes.

Financial Responsibility - The portion of the charges that are the responsibility of the patient or insured.

Fiscal Intermediary (FI) - A Medicare representative who processes Medicare claims.

Formulary - A list of prescription drug costs which an insurance company will provide reimbursement for.

Fraud - When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

GPH - Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).

Group Name - Name of the group or insurance plan that insures the patient.

Group Number - Number assigned by insurance company to identify the group under which a patient is insured.

Guarantor - A responsible party and/or insured party who is not a patient.

HCFA - Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

HCPCS - Health Care Financing Administration Common Procedure Coding System. (pronounced "hick-picks"). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a
procedure code in the medical billing glossary.

The three HCPCS levels are:

  • Level I - American Medical Associations Current Procedural Terminology (CPT) codes.
  • Level II - The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures.
  • Level III - Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.
Healthcare Insurance - Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family policy which covers the beneficiary's family members. May include coverage for disability or accidental death or dismemberment.

Heathcare Provider - Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

Health Care Reform Act - Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.

HIC - Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

HIPAA - Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care. HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.

HMO - Health Maintenance Organization. A type of health care plan that places restrictions on treatments.

Hospice - Inpatient, outpatient, or home healthcare for terminally ill patients.

ICD-9 Code - Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.

ICD 10 Code - 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10.

Incremental Nursing Charge - Charges for hospital nursing services in addition to basic room and board.

Indemnity - Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital.

In-Network (or Participating) - An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

Inpatient - Hospital stay of more than one day (24 hours).

IPA - Independent Practice Association. An organization of physicians that are contracted with a HMO plan.

Intensive Care - Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.

MAC - Medicare Administrative Contractor. Contractors who process Medicare claims.

Managed Care Plan - Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area.

Maximum Out of Pocket - The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses.

Medical Assistant - A health care worker who performs administrative and clinical duties in support of a licensed health care provider such as a physician, physicians assistant, nurse, nurse practitioner, etc.

Medical Coder - Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD-9 codes (soon to be ICD-10) and corresponding CPT treatment codes and any related CPT modifiers.

Medical Billing Specialist - Processes insurance claims for payment of services performed by a physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance information are entered correctly and submitted to insurance payer. Enters insurance payment information and
processes patient statements and payments. Performs tasks vital to the financial operation of a practice. Knowledgeable in medical billing terminology.

Medical Necessity - Medical service or procedure that is performed on for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental.

Medical Record Number - A unique number assigned by the provider or health care facility to identify the patient medical record.

MSP - Medicare Secondary Payer.

Medical Savings Account - Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a Medical Spending Account.

Medical Transcription - The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.

Medicare - Insurance provided by federal government for people over 65 or people under 65 with certain restrictions. 

There are 2 parts:
  • Medicare Part A - Hospital coverage
  • Medicare Part B - Physicians visits and outpatient procedures
  • Medicare Part D - Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B.
Medicare Coinsurance Days - Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters "Lifetime Reserve Days."

Medicare Donut Hole - The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs.

Medicaid - Insurance coverage for low income patients. Funded by Federal and state government and administered by states.

Medigap - Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, co-insurance and balance bills, or other services not covered by Medicare.

Modifier - Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or "modified" in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.

N/C - Non-Covered Charge. A procedure not covered by the patients health insurance plan.

NEC - Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available.

Network Provider - Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.

Nonparticipation - When a healthcare provider chooses not to accept Medicareapproved payment amounts as payment in full.

NOS - Not Otherwise Specified. Used in ICD for unspecified diagnosis.

NPI Number - National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through theNational Plan and Provider Enumeration System (NPPES).

OIG - Office of Inspector General - Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices.

Out-of Network (or Non-Participating) - A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider.

Out-Of-Pocket Maximum - The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.

Outpatient - Typically treatment in a physicians office, clinic, or day surgery facility lasting less than one day.

Palmetto GBA - An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina.

Patient Responsibility - The amount a patient is responsible for paying that is not covered by the insurance plan.

PCP - Primary Care Physician - Usually the physician who provides initial care and coordinates additional care if necessary.

POS - Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance.

POS (Used on Claims) - Place of Service. Medical billing terminology used on medical insurance claims - such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.

PPO - Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.

Practice Management Software - software used for the daily operations of a providers office. Typically used for appointment scheduling and billing.

Preauthorization - Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.

Pre-Certification - Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn't guarantee the benefits will be paid.

Predetermination - Maximum payment insurance will pay towards surgery, consultation, or other medical care - determined before treatment.

Pre-existing Condition (PEC) - A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).

Pre-existing Condition Exclusion - When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective.

Premium - The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.

Privacy Rule - The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments.

Provider - Physician or medical care facility (hospital) who provides health care services.

PTAN - Provider Transaction Access Number. Also known as the legacy Medicare number.

Referral - When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).

Remittance Advice (R/A) - A document supplied by the insurance payer with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits).

Responsible Party - The person responsible for paying a patients medical bill. Also referred to as the guarantor.

Scrubbing - Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.

Self-Referral - When a patient sees a specialist without a primary physician referral.

Self Pay - Payment made at the time of service by the patient.

Secondary Insurance Claim - claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Secondary Procedure - When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard - Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.

Skilled Nursing Facility - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.

SOF - Signature on File.

Software As A Service (SAAS) - One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.

Specialist - Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some heathcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.

Subscriber - Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.

Superbill - One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance - Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare.

TAR - Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered.

Taxonomy Code - Specialty standard codes used to indicate a providers specialty sometimes required to process a claim. 

Term Date - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.
Tertiary Insurance Claim - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.

Third Party Administrator (TPA) - An independent corporate entity or person (third party) who administers group benefits, claims and administration for a selfinsured company or group.

TIN - Tax Identification Number. Also known as Employer Identification Number (EIN).

TOP - Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.

TOS - Type of Service. Description of the category of service performed.

TRICARE - This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

UB04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.

Unbundling - Submitting several CPT treatment codes when only one code is necessary.

Untimely Submission - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.

Upcoding - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor. 

UPIN - Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Usual Customary & Reasonable(UCR) - The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.

Utilization Limit - The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit.

Utilization Review (UR) - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.

V-Codes - ICD-9-CM coding classification to identify health care for reasons other than injury or illness.

Workers Comp - Insurance claim that results from a work related injury or illness.

Write-off - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms.

    Friday, July 6, 2012

    Continuing Education Unit Guidelines and Information

    Continuing Education Unit (CEU)
    Guidelines and Information
    Definition of CEU
    One CEU = ten contact hours of participation in organized continuing education/training experience under responsible, qualified direction and instruction.

    Definition of Contact Hour
    One contact hour = one 60 minute clock hour of interaction between learner and instructor or between learner and materials which have been prepared to bring about learning.

    Please Note: Contact implies a connection between a learner and a learning source. For the purpose of the CEU, that connection is two-way. The instructor or learning source must monitor the learner’s progress and provide some form of feedback to the learner. This definition and requirement apply to face-to-face interaction as well as distance learning programs.

    Minimum Hours
    NSGC does not grant CEUs for learning programs that are less than a total of one hour in length. Sessions within a learning program may be of any length.

    Calculation of Contact Hours for Distance Education/Training and Other Alternative Delivery Methods
    Self-paced programs include learning programs in which learners progress at their own pace. Program developers should establish a standard number of contact hours based on an average number of hours required by several representative learners to complete the program. Program developers desiring to introduce a new self-paced learning program might select a representative sample from the intended audience – the larger the audience, the better – to complete the learning program. Each member of the sample records the actual amount of time spent completing the learning program. The number of hours spent by all members of the sample is totaled, averaged, and divided by the number of representatives in the sample. Please note that NSGC requires a minimum of 3 learners to be considered a representative sample. Program developers should continue to monitor the amount of time it takes learners to complete the learning program. The standard should be adjusted, if necessary. This continuing validation provides credibility to the NSGC’s established standards.

    What CAN be Counted
    The following learning activities are examples of types of activities to include when calculating
    contact hours for CEUs:
    • classroom or meeting session time led by instructor and/or discussion leader;
    • activities in which a learner is engaged in a planned learning program in which the learner’s progress is monitored and the learner receives feedback. (Examples include, but are not limited to, independent study, computer-assisted instruction, interactive video, web site learning, and planned projects.)
    • projects and assignments which are an integral part of a learning program; and/or
    • learner assessment and learning program evaluations

    What CANNOT be Counted
    While unplanned and unsupervised activities may produce worthy learning and are occasionally recognized by other the professions and licensing boards, they do not meet NSGC’s requirements for CEUs.

    The following activities do not qualify for CEUs:

    • Academic credit courses
    • Association membership and leadership activities
    • Committee meetings.
    • Entertainment and recreation
    • Individual scholarships
    • Mass media learning programs (i.e., through television, radio, newspaper)
    Specific activities that promote professional development may meet the requirements for Professional Activity Credits (PACs) as defined by the American Board of Genetic Counseling (ABGC).

    NSGC requires that learning source/sponsoring organizations adhere to the following guidelines when planning activities that will be submitted for CEU approval.

    System for Awarding CEUs: The provider must have a system in place to identify learners who meet requirements for satisfactory completion.
    • Satisfactory completion requirements are established prior to the beginning of the learning program.
    • Requirements for performance levels are based on the intended learning outcomes.
    • For conferences and live events, NSGC requires that attendance within a given session be part of the satisfactory completion requirements.
      • Attendance requirements should be set high and documented on rosters, sign-in sheets, self-report forms, or other methods for tracking attendance.
    • Learners are informed of satisfactory completion requirements prior to their participation in the learning program and are informed that only those who meet the requirements will earn CEUs.
    • Whether each learner has (or has not) met the specified requirements for satisfactory completion and is (or is not) awarded CEUs Is verified.
    • The criteria for successful completion are compatible with the learning outcomes of each learning program.
    • When partial credit is awarded to learners who do not attend the entire learning program, the provider has a system to track, calculate, and award variable credit.
    Learning Environment and Support Systems: Learning environment and support services,
    appropriate to the continuing education or training goals and learning outcomes, are provided.
    • The design and use of facilities should facilitate teaching and learning. For example, lighting, sound, seating, visuals, reference materials, and other needed resources should be appropriate and available to enhance learning.
    • In distance learning formats, such as correspondence study and computer-assisted instruction, the instructor or learning source may not be able to control the learning environment. In such cases, the instructor or learning source should include ways to support learners and facilitate learning in the planning process.
    • The instructor or learning source makes available convenient, efficient, and responsive learner support services (e.g., scheduling, registration, technical support, advising, and counseling, etc.) appropriate and sufficient for the ongoing success of the learning program
    Planning and Instructional Personnel: Qualified personnel are involved in planning and conducting each learning program.
    • Qualified individuals must be directly involved in determining the learning program purpose, and planning, designing, developing, conducting, and evaluating each learning experience.
    • The quality of a continuing education program and its value to the learner rests heavily on the competence of the planners and the instructor(s) in the subject matter, and their ability to communicate and facilitate learning. It is the joint responsibility of the learning source, the planner(s), and the instructor(s) to ensure that the learning experience results in the learners achieving the learning outcomes.
    • NSGC defines “qualified personnel” as those who:
      • Are competent in the subject matter;
      • Understand the learning program’s purpose and learning outcomes; and
      • Have knowledge and skill in instructional methods and learning processes
    • NSGC requires that short biographical sketches and/or CVs for instructors and planning personnel be provided at the time an application is submitted for CEU approval.
    • Instructors should demonstrate high standards of professional conduct and should not discriminate against learners on the basis of gender, age, socioeconomic or ethnic background, sexual orientation, or disability.
    • Individuals who participate in a continuing education/training program have the right to know of any commercial interest an instructor may have in a product or service mentioned during a program. Therefore, NSGC requires that the learning source disclose each instructor's proprietary interest in any product instrument, device, service, or materials discussed in the program, as well as the source of any compensation related to the presentation.
      • NSGC recommends that learning sources and planning personnel require instructors to complete a Conflict of Interest agreement at the time they are selected/contracted to present.
      • This information must be made available to the learners prior to the program and may be conveyed through promotional materials, a written handout, or an announcement prior to the commencement of the training. Disclosure statements are not necessary if there is no commercial interest.
    • The learning source/sponsoring organization must provide completed Conflict of Interest agreements to NSGC at the time an application is submitted for CEU approval.
    • Instructors should be provided feedback on their performance.
    Learning Outcomes: The instructor or learning source has clear and concise written statements of intended learning outcomes, commonly referred to as participant behavioral or performance objectives, based on identified needs for each continuing education and training learning program.
    • The learning outcomes (performance objectives):
      • Provide a framework for learning program planning;
      • Are the basis for selection of content and instructional strategies;
      • Describe to learners exactly what knowledge, skills, and/or attitudes they are expected to accomplish/demonstrate as a result of the learning program;
      • Are the basis for providing periodic feedback, measuring progress, and final assessment of learning.
    • The learning outcomes (performance objectives) must be clear, concise, and measurable.
      • NSGC recommends using the suggested list of behavioral verbs when developing learning outcomes (performance objectives).
      • Each learning outcome (performance objective) should contain no more than one behavioral verb.
    • For large events such as conferences or conventions:
      • Overall learning outcomes must be established
      • Each session within the event must have its own learning outcomes (performance objectives) or be keyed to one or more of the overall program outcomes.
    • The number of planned outcomes is appropriate for the learning program.
      • For conferences or conventions, NSGC requires a minimum of three overall learning outcomes
      • For individual sessions or smaller activities NSGC recommends a minimum of two learning outcomes (performance objectives) be established per sixty minutes of educational content
    • Learners should be informed of these intended learning outcomes (performance objectives) prior to and during the learning program.
    Content and Instructional Methods: Content and instructional methods are appropriate for the learning outcomes of each learning program and provide opportunities for learners to participate and receive feedback.
    • Subject matter and content are directly related to learning outcomes. NSGC requires that learning sources/sponsoring organizations track this relation by completing an Educational Activity Overview form.
    • Content should be organized in a logical manner, proceeding from basic to advanced levels.
    • Instructional methods are consistent with learning outcomes regardless of delivery method.
    • Instructional methods accommodate various learning styles.
    • Learning experiences should be designed to promote relevant interaction between learner and learning resources to achieve the stated learning outcomes
    Assessment of Learning Outcomes: Formal processes or procedures established during program planning are used to assess achievement of the learning outcomes. 
    • In every learning program for which CEUs are awarded, the learning source/sponsoring organization must require learners to demonstrate that they have attained the learning outcomes
    • Assessments may take diverse forms, such as performance demonstrations under real or simulated conditions, written or oral examinations, written reports, completion of a project, self-assessment, or locally or externally developed standardized examinations.
      • NSGC recommends utilizing self-assessment tools for conferences or live programs and the sessions contained within the conference. Please click here to see a sample self-assessment form.
      • NSGC recommends using multiple choice examinations for distance learning programs.
        • A passing score of 80% or higher should be required.
        • NSGC recommends including approximately 5-7 questions per sixty minutes of educational content.
      • The way that learners will demonstrate their attainment of the outcomes should be an integral part of the program planning
      • Assessments may be made at the conclusion of the learning program, or after some elapsed time following the learning experience.
    • Learners must be informed in advance that learning outcomes will be assessed.
    Post-Program Evaluation: Each learning program is evaluated.
    Program evaluation is a measurement of the quality, or determination of the worth, of the learning program as a whole, examining all parts of the planning and delivery process.
    • The evaluation process should examine the needs assessment, logistical and instructional planning and execution, selection and preparation of instructors, operations, and the extent to which learning outcomes were achieved.
    • The evaluation process should ask the following questions (amongst others determined by the learning source/sponsoring organization):
      • Did the learning experience and the instructional methods used accomplish the learning outcomes?
      • Did the learners indicate that the learning outcomes were appropriate for the stated program purpose and for the learners involved?
      • Was learning program execution effective and efficient?
      • Distance learning programs should be evaluated periodically by comparing the degree of learner achievement to the intended learning outcomes, by assessing the appropriateness and effectiveness of the technology used, and by determining the cost effectiveness of the program
    • Evaluation results are incorporated into learning program improvements.
    Submitting Your Program for CEU Approval
    For consideration of Continuing Education Units (CEUs) for genetic counselors, please complete the CEU application and submit it with the required supporting material. Applications and supporting material must be received in the NSGC Executive Office no later than 6 weeks in advance of the printing of your general information brochure in order to be considered. Programs using only online announcements may submit the application up to 4 weeks in advance of the online posting of the announcement.

    Once Your Program has been Approved
    Organizations whose applications are approved will receive notification of the number of CEUs approved, as well as the exact verbiage that much appear in the program announcement or brochure. 

    Issuing of CEUs
    NSGC requires learning sources/sponsoring organizations to collect, track and provide various information of an approved learning program or activity in order to issue CEUs to genetic counselors:
    • Payment of $25.00 per individual claiming CEUs will be required at the time the learning source/sponsoring organization files for CEUs on behalf of its participants.
    • The learning source/sponsoring organization must provide NSGC with a spreadsheet containing the following information for each individual claiming CEUs:
      • Full Name (first, middle, last)
      • Company
      • Street Address
      • City, State and Zip
      • Email Address
      • Number of CEUs & Contact Hours to be issued
    • For live events, copies of sign-in sheets and/or self-report forms (tracking learner attendance)
    • For live events distance learning activities, summaries of learner assessments

    At Home Medical Billing Jobs

    Working From Home
    You’ve probably seen the ads for at home medical billing jobs. Can you really sit at home and make a good living as a medical biller or coder? The short answer is yes you can but it’s not as simple as some of those ads make it sound. The only way this is possible is if you have a very flexible and accommodating employer or have your own billing or coding business. If you are really good at what you do and have proven
    yourself trustworthy, your boss may not care where you work – as long as you can be as productive at home as you are in the office.

    In order to succeed at medical coding jobs from home, you should be result oriented and self-disciplined, able to work independently, and manage your time. You also should have the required work space or office at home, be OK with little or no social interaction, and be able to separate family and work.

    Due to the nature of the work, medical billing and coding jobs from home are more feasible now than ever. Most practices billing systems are server based and accessible remotely from any PC – either via web or remote desktop. You do have to be in touch with insurance companies, patients, and healthcare providers.
    However most of this can be done by phone, fax, and email. 

    A lot of the medical coding and billing work I do at home can be done on any schedule as long as it's done promptly. A medical biller bears a lot of responsibility as the financial health of a practice is dependent on our performance.

    The benefits of medical billing from home and medical coding from home are the flexibility to set your own hours and the tax advantages of having a home office (consult with your accountant). It’s also nice not to have to deal with the daily commute. When working from home it’s very important to make sure your office complies with HIPAA privacy practices and all patient information is handled as such.

    The drawbacks are that you have to be disciplined not to let it interfere with your home life. If you don't set boundaries, work can really interfere with your home life. 

    If you have employees they need to have access to your home. Depending on how your home is laid out this can be intrusive to your privacy. I employ other stay at home moms who work from their home part time as contractors. I just give them an assignment and they can perform on their own schedule. Our medical billing software allows access to our server via Remote Desktop from any other PC.

    Demand may Create Flexible Work Options
    According to the U. S. Department of Labor’s latest Occupational Outlook, the prospects for medical records and health information technicians (under which medical coders fall), employment is expected to increase by 18% through 2016. This means there will be a strong demand for medical coders.

    For employers having difficulty attracting qualified coders, they are more likely to offer more flexibility to accommodate productive employees. One of the best benefits is remote medical coding. Larger more progressive employers typically have the information technology systems and HIPAA procedures in place to allow remote medical coding jobs.

    For motivated employees, working from home results in improved morale and productivity. Offering such a benefit makes it easier to attract and retain good employees. Especially in large cities, municipalities may offer incentives for telecommuting to business to ease traffic congestion.

    Medical Coding and Billing Jobs

    Finding Medical Coding and Billing Jobs

    A good place to start is the local classified listings - online classified is probably the easiest. Although local newspapers aren't the only source in searching for medical billing and coding jobs like there used to be, they are a good starting point when looking locally. Don't forget CraigsList - many employers are discovering this is a great way to advertise medical coding and billing jobs because it's free, quick, and easy.

    According to a recent CNNMoney article, most people looking for a job look in a variety of different sites. The average web sites used in most job searches is 5. For larger employers such as hospitals, large practices, and medical research facilities, you'll do better going directly to the web site for job listings. But it really helps to have someone you know on the inside pulling for you (and looking out for your resume) at these larger employers.

    Most Popular Web Sites

    There's two types of online job sites - general purpose job boards catering to a wide variety of professions, industries and locations. General purpose sites are CareerBuilder, Monster, or Yahoo! HotJobs. In the latest survey by Weddle's which prints a guide to internet job hunting, the most popular job sites are:

    • CareerBuilder
    • CareerJournal
    • Indeed.com
    • Job.com
    • Monster
    • SimplyHired
    • HotJobs (Yahoo!)
    • SnagAJob
    After trying several of these sites to search for a medical billing and coding job, I really liked the Indeed Jobs site the best. It's one of the best sites to search for online medical billing jobs. Indeed compiles job listings from thousands of different job website sources from large and small local companies. The job results are relevant, unlike other job sites who send you jobs in a completely different field when you sign up for email alerts. Indeed allows you to save your searches and sign up for email alerts.

    Online sites also have a lot of tools to help in the job search like advice, example resume's, and preparing for the interview. They allow you to set up a profile and receive email notification when there's there's an opening that matches your criteria. Monster even offers resume writing and interview coaching services for a fee.

    I notice there's a lot of jobs listed in both the local and online boards for temp and hiring agencies. What an employer will do sometimes is have the employment agency screen potential applicants and present the most qualified candidates as they don’t want to dedicate the time for this.

    A lot of job openings don't even get posted online. That's why its so important to network and speak with as many people as possible. Every year, a number of job openings are filled even before they can be advertised. Your friends, relatives, ex-coworkers, and neighbors may have inside information about a vacancy for the right job. If there is a certain hospital or physicians office you want to work for, try to get to know someone who works there.

    Most of the people that I have hired for my Medical Billing business have not been through ads or postings, but from friends and referrals. Knowing that an employee is trustworthy counts for a lot even if they don’t have a lot of experience.

    Medical Billing and Coding Employment

    Outlook for Medical Billing and Coding

    Medical Billing Employment
    The U. S. Department of Labor - Bureau of Labor Statistics projects an annual increase of 14.4% in health care office and administrative support occupations. Although the Department of Labor does not specifically categorize the medical billing specialist, they do project a 20.9% increase in those performing bookkeeping and accounting functions and a 21.5% increase in general office clerical functions - which is where the medical billing employment functions best fit.

    This corresponds to a projected increase of 21.3% for professional and related occupations - or health care providers which will need billing services. Especially considering the increasing complexity of the billing process brought on by changes in health care reimbursement (like HIPAA).

    In summary the outlook is very good for medical billing employment. And this is based on the most credible source available - the U.S. Department of Labor. Reference the Bureau of Labor Statistics Career Guide to Industries - Health Care.

    Medical Coding Job Opportunities

    The DOL projects a faster than average growth for medical coding jobs with those having a good  background being in especially high demand. Through the year 2016, medical coding positions are estimated to increase by 18%. 

    This higher than average demand is due to the increased need for medical treatments, procedures, and tests due to an aging population. Also driving the demand is greater scrutiny placed on health care services by insurance companies, consumers and their employers, and regulatory agencies.

    Medical coding jobs will also be abundant for those with good computer skills. There is an increasing movement by the health care industry to electronic medical records. DOL projects opportunities in physician offices, outpatient and home health services, and nursing facilities. Not only will new positions be created but many opportunities will be created by retirements.

    Experienced medical coders with credentials will be in particularly high demand. Health care providers and facilities are challenged to attract and retain good coders. The Occupational Outlook anticipates job prospects to be especially good for medical coders through temporary job agencies and professional services firms.

    The U. S. Department of Labor (DOL) creates the Occupational Information Handbook which gives the outlook for various professions in the United States. The medical coder job falls under the classification of Medical Records and Health Information Technicians. According to their latest report, approximately 2 out of 5 jobs (or 40%) of jobs are in hospitals. The remaining 60% are in provider offices, nursing facilities, outpatient centers, and home health services.

    Work Schedule

    Most medical coding positions work a typical 40 hour work week with occasional overtime. Hospitals which are open 24/7 may require coverage during evening, night, and weekend times. Because of the increased demand of medical billing coding jobs, employers may be more accommodating of flexible work schedules. In their attempts to attract good employees, employers will probably be more accommodating by offering
    more flexible work hours and work-at-home options.