Lesson 14 Discussion Board 1818 unread replies.1818 replies. This week, you will post a discussion on one of the topics below by Wednesday at 11:59 PM. Please post your original reply no later than...

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Lesson 14 Discussion Board

1818 unread replies.1818 replies.

This week, you will post a discussion on one of the topics below by Wednesday at 11:59 PM.


Please post your original reply no later thanWednesday at 11:59 pm.



  • Please participate at least 2 additional times during the week. Weekly participation must be completed no later thanSunday at 11:59 pm.


  • This is a graded forum.



Choose and explainoneof these topics and discuss the process steps involved in the Medical assistant or other health care provider with the task. Respond to two students who posted a discussion on a topic different from the one that you selected. Responses must be substantial. Read all discussion.




  1. Preventing upcoding and down coding.

  2. Securing a Prior authorization

  3. Obtaining an ABN

  4. Justifying a Medical Necessity for a billing code

  5. Referring a patient to a specialist.




CPT Curretn proceual terminology These codes are five characters long and may be numeric or alphanumeric. Medical Billing and Coding and Managed Care CPT-HCPCS- ICD-10CM Standardized Coding Set are used to facilitate Medical Billing When Billing the appropriate code must be assigned and the documentation must be in the medical record to support that code assignment. One encounter may generate more than one billable code. Medical necessity is the justification of medical services as reasonable, necessary. Medical necessity is often “proven” using ICD codes. For example, a coder would use the ICD code for a broken leg bone (tibia) to justify the medical necessity of an X-ray and the application of a cast. Precertification, preauthorization, or prior authorization are a terms that refers to the process to obtain approval by the insurance plan for coverage of a specific medical procedure or prescription drug before it can be performed/dispensed. Certain criteria may need to be documented in the medical record gain coverage of the service. Advance Beneficiary Notice (ABN) is a notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service and Medicare does not pay for it, then you probably do not have to pay for it. If the doctor or supplier does give you an ABN that you sign before you get the service, and Medicare does not pay for it, then you will have to pay your doctor or supplier for it. ABNs only apply if you are in the Original Medicare Plan. They do not apply if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan. CPT Current Procedural Terminology Published, copyrighted, and maintained by the American Medical Association Each code has 5 characters which may be alphanumeric or numeric only. The CPT code set is divided into three Categories. Category I describes medical procedures, technologies and services.(most commonly used) Category II is used for performance management and additional data. Category III codes for emerging and experimental medical procedures and services. Evaluation and Management (CPT): Evaluation and Management, or E&M, is a section of CPT codes used to describe the assessment of a patient’s health and the management of their care. The codes for visits to doctor’s office so the Medical Assistant will be part of the documentation and assignment for these codes. A Modifier is a two-character code that is added to a procedure code to demonstrate an important variation that does not, by itself, change the definition of the procedure. For example to designate left arm or right arm. CPT codes have numeric modifiers after the 5-digit code and separated with a hyphen. HCPCS “Hick-Picks” Healthcare Common Procedure Coding System The main procedural code set for reporting procedures to Medicare, Medicaid, and a large number of other third-party payers. Maintained by CMS HCPCS is divided into two levels. Level I is identical to CPT and is used in the same way. Level II describes the equipment, medication, and outpatient services not included in CPT. HCPCS codes have alphanumeric modifiers. These are added at the end of a code with a hyphen to provide information about the procedure itself when needed. Example, the HCPCS modifier –LT describes a bilateral procedure that was performed only on the left side of the body. World Health Organization (WHO) publishes the International Classification of Diseases 10th Revision (ICD-10), ICD-10-CM has 68,000 codes and growing....the classification system is updated regularly. ICD-9 was the ninth revision, and it is no longer used for billing. Codes from ICD-9 in medical record documents can be mapped to ICD-10. ICD-11 is scheduled to be adopted by member countries in 2022. Adoption into the US will be after that date. ICD-10 CM –CM=clinical modifications. This coding set is used by physicians and other healthcare providers to classify and code all diagnoses, symptoms. ICD-10 PCS PCS=Procedural Coding System This coding set is used to code procedures in the inpatient and hospital settings. ICD-10 CM codes are used in the ambulatory and inpatient setting to code disease/symptoms so a medical assistant will need to identify the format and know how to lookup these codes. ICD-10-CM Code Structure 6 Category first three characters Etiology, anatomic site, severity, fourth, fifth, sixth characters (if applicable) Extension seventh character (if applicable) decimal ICD-10 CM CODE STRUCTURE FORMAT Format 3 - 7 Characters alphanumeric Character 1 is alpha (all letters except U are used) Character 2 is numeric Characters 3 - 7 are alpha or numeric For codes longer than three characters, use of decimal after 3 characters Use of dummy placeholder “x” when a code is needed in the 7th space, but not in 4,5,or 6 M1A.00X0 Idiopathic chronic gout, unspecified site, without tophus ICD-10 CM Structure They have a three-character category which describes the injury or disease This is followed by a decimal point and two-to-four more characters which give more information about the disease or location. Examples: E05 Thyrotoxicosis [hyperthyroidism] E05.3 Thyrotoxicosis from ectopic thyroid tissue The additional characters give greater specificity or “granularity” Z-codes: describe circumstances outside of the injury or disease that cause a patient to visit a health professional. This may include a patient visiting a doctor because of family medical history such as: Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system Codes can be looked up in Coding Books They are arranged by: The Alphabetical Index of diagnostic terms The Tabular Index is organized in chapters based on the body’s parts or systems. CAC is computer assisted coding which allows coders to use the computer to search the correct code. Most EHRs have billing modules with CAC functions. Payment for services: Managed Care System Integrates the financing and delivery of appropriate health care services to covered individuals Contract arrangements with selected providers to furnish a comprehensive set of health care services to members, Significant financial incentives for members to use providers and procedures associated with the plan. (in-network vs. out-of-network which results in higher copays) Managed care plans typically are labeled as HMOs Health maintenance organization with per capita payments PPOs A preferred provider organization (PPO) is a network of medical professionals and facilities that are contracted to provide services to subscribed clients at reduced rates.  Point of Service plans.  It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO). Managed care services are reimbursed via a variety of methods including capitation, fee for service, and a combination of the two. National Health Spending Explorer - Peterson-Kaiser Health System Tracker. (2019). Peterson-Kaiser Health System Tracker. Retrieved 8 August 2019, from https://www.healthsystemtracker.org/health-spending-explorer/?display=U.S.%2520%2524%2520Billions&s Overview and Trends for Payers for Healthcare Types: Government: Medicare, Medicaid, CHIPS, and for military (Department of Defense-Tricare) and VA Private Insurance (employers and self pay) No insurance (out of pocket)
Answered Same DayDec 08, 2021

Answer To: Lesson 14 Discussion Board 1818 unread replies.1818 replies. This week, you will post a discussion...

Sumita Mitra answered on Dec 09 2021
140 Votes
2
Justifying a Medical Necessity for a billing code:
Coding is an important process needed to subm
it the medical claims and bills internally in the health care unit and also for used for medical reimbursements through third party insurance. Medical coding takes the information regarding the patient in terms of his diagnosis, treatment, medication and procedures to be done and is represented through alphanumeric codes. Medical coding professionals transfer these codes from the sources to medical billing systems and patient records. These codlings...
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