All the Insurance codes and strategies you could want

[Guest guest]

http://www.tacanow.org/health_ins_reimbursement_tips.htm

The purposes of this document/web link is to provide notes from our

February 2005 TACA Costa Mesa Meeting on Health Insurance Tips and

tricks. This information is presented by volunteer and health care

expert Kathy Ward. PLEASE REMEMBER – THIS INFORMATION SHOULD BE USED

AS A GUIDELINE. IT IS IMPOSSIBLE TO DOCUMENT ALL THE CAVEATS,

DIFFERENT PLANS AND ISSUES FOR EACH HEALTH INSURANCE COMPANY. PLEASE

CHECK WITH YOU INSURANCE PROVIDER FOR DETAILS.

Introduction

Finding your way around the health insurance process for typical

family needs can be confusing. Add in a special needs child with

special medical needs can complicate the matter and requires planning

and good record keeping. This process also requires a good amount of

diligent, consistent efforts to yield positive results.

First, the process starts and ends with paperwork. To a lay person or

a beginning health insurance bill " coder " the coding and

reimbursement process may appear at first to be simple and easy. Just

find out what the doctor did for a patient, take a CPT ( Current

Procedural Terminology) book, look up the procedure and get the CPT

code. Then find out the doctors diagnosis is, take an ICD 9 CM (

International Classification of Diseases – revision #9 ) Book, look

up the diagnosis and get the ICD-9 code. Type everything on the HCFA

1500 health insurance claim form – mail it in and GET PAID! What

could be easier than that??? (RIGHT!)

Not only does the biller select the correct CPT Code and the ICD-9

Codes to report medical services and procedures, they have to know:

How to interpret, decipher, and transfer medical acronyms, eponyms,

and abbreviations to get the correct reimbursement amount for that

provider.

When to use the HCPCS procedure codes instead of CPT procedure codes.

How to sequence multiple procedure codes properly.

When to use CPT code modifiers.

How to sequence multiple ICD-9 diagnosis codes.

When a medical report is required to support the procedures

performed.

If a procedure is covered by Medicare (becoming gold standard in

insurance processing and paying claims).

And IF there are special billing rules or payment policies for

Medicare, and a variety of other rules, regulations, policies and

procedures. THAT ALL VARY BY HEALTH INSURANCE PROVIDER! (and

remember, there are many plans by provider – which change

frequently!)

Bottom line: Phone calls, SUPER BILLS from your doctors' offices

(with signatures!) properly coding, submitting bills, and follow up

with your health insurance provider will provide better chance for

insurance reimbursements. However, even some of the most

knowledgeable and insurance experts get denied on medical claims. It

is important to do all your homework up front before you submit a

bill to health insurance for reimbursement.

DETAILS ON INSURANCE REIMBURSEMENT FOR AUTISM SPECTRUM & OTHER

MEDICAL DISORDERS

According to many treating physicians and DAN (Defeat Autism NOW)

doctors autism often is accompanied with other medical issues.

Medical issues are unique and different to each child and need to be

addressed to each individual.

Here are some important tips and information about medical care and

health insurance reimbursements:

A) Autism is also known as " Pervasive Development Disorder " . Most

medical books believe that the " goals of treatment are to:

Increase socially acceptable and pro-social behavior

To decrease odd behavioral symptoms

AND to aid in the development of verbal and non-verbal communications

Put simply, autism for medical and medical billing purposes is

treated as a psychiatric disorder and for which there is no cure.

(Diagnosis or DX codes are 299.00-299.80) Payments will typically be

paid for specific types of communication or occupational therapy.

The diagnosis codes 299.00 – 299.80 for Autism are RED FLAGS FOR

INSURANCE COMPANIES.

Click here for the American Academy of Pediatrics Standards of Care

for Autism and other medical information for additional resources and

information. These standards of care define the standards for

treatment and what treatments health insurance companies will pay for

and more importantly what they won't pay for.

There are both " Pros " and " Cons " for the medical diagnosis code of

Autism. Please keep track of the following funding resources for

behavioral, medical and other supports including:

Health insurance - WATCH LIFE TIME MAXIMUMS!!

School IEP's (Individualized Education Program)

Regional Center assistance

Other federal and state agencies and funding

C) Physiological issues that may be contributing to, or as some

medical professionals believe, causing your child's autistic symptoms

(but most of all are paid for by your insurance company) may include:

Gut & Brain related codes:

Diarrhea CPT Code 787.91 (must be coded to FIFTH digit!)

Constipation CPT Code 564.00 (must be coded to FIFTH digit!)

Food allergies CPT Code 693.1

Yeast overgrowth CPT Code 112.85

Nutritional deficiencies CPT Code 227.9

269.2 Vitamin Deficiency

269.3 Mineral Deficiency

579.8 malabsorotion

136.9 Inf & Parasitic Disease

569.9 Intestinal Disorder

314.01 ADD/Hyperactivity

348.3 Encephalopathy

784.0 Headache NOS

Hyperbaric Oxygen Codes:

diagnosis code 348.30

CPT codes 99183 with 1,2,3,4 as diagnosis

Metal toxicity and related issues:

High mercury or lead CPT Code 963.8

985.9 Heavy Metal Toxicity

277.9 has been used frequently -metabolic disorder

348.3 Encephalopathy

348.9 Unspecified condition of the brain

279.3 Immune Dysfunction

277.9 Neurotransmitter Disorder

Auditory / Listening & Speech therapy codes:

338.40 Abnormal Auditory Perception

388.42 Hyperacute Hearing

388.43 Impairment of Auditory Discrimination

92507 Speech/Language Therapy

92510 Aural Rehabilitation

It is often noted that individuals suffering from autism can also

suffer from other disorders such as; apraxia, central auditory

processing disorder, gut disbyosis, chronic diarrhea or constipation,

speech delays, and other medical conditions. It is recommended to

code the diagnosis and treatment issues that reflect all the

disorders an individual may have for the procedure and treatments

they require --- in other words, not just Autism.

D) Coding Medical Receipts for Reimbursement:

You need to make sure you have the PAYMENT FORM or SUPERBILL from

your medical provider showing the CPT Codes, ICD-9 Codes, with

procedures and treatments provided during the visit. IMPORTANT: this

is needed to include correct diagnosis and miscellaneous codes when

appropriate.

In your cover letter to the health insurance provider make sure to

note that payment has been made and requested reimbursement to the

health insurance carrier (i.e. your family) is requested. Be sure to

send to the correct ACCOUNTS PAYABLE / REIMBURSEMENT ADDRESS.

If you have ANY PRE-APPROVAL DOCUMENTS OR NOTES FROM A PHONE CALL,

DOCTORS PRESCRIPTION & DOCTORS REFERRAL – please include this for

your reimbursement purposes. (Note: THIS IS HIGHLY RECOMMENDED.)

Many health insurance companies need to see dates of services –

especially for continuous treatment over time – for reimbursement

review purposes.

Always make a copy of paperwork for your records. DO NOT SEND YOUR

ORIGINALS. Always, always keep your originals and send copies. Be

sure to document the claim process with who you spoke to, the date,

and items discussed for future reference.

Call on your health care reimbursements requests and make notes who

you spoke to and items discussed. Payments from your health insurance

provider should be processed in a timely fashion typically in 30-60

days or less. Each company has a different reimbursement policy and

this would be explained in your Explanation of Benefits (EOB.)

If the insured has paid the vendor for services and seeking

reimbursement for previous payment it is recommended to obtain a ZERO

BALANCE due invoice. This demonstrates it has been paid and insurer

is seeking reimbursement.

If this is not provided sometimes insurance companies make the

mistake of paying the doctor or treatment facility versus

reimbursement the insurer. Please make this clear in your request.

E) The Appealing Claim Process

Families can appeal a claim if the claim is unpaid or partially paid

(more than what the family was expecting.)

Bills and paperwork can be re-submitted for payment if CPT or ICD-9

Codes were accidentally omitted by the health care provider.

Ask your health care insurance company how the appeal process works

and for assistance in this process. Each health insurance company

should have an 800# with help available on the appealing process.\

The insurer will have some responsibility of payment for procedures

according to the policies of the health insurance provider. This

varies by provider and can change regularly.

SOME GOOD ARTICLES:

Assigning codes based on symptoms or findings

Answers to your questions

Q: Should we assign a diagnosis code based on the symptoms that a

patient presented with, or based on what the physician determined is

the cause of the symptoms? For instance, if a child comes in with

fever and I conclude the fever is caused by an ear infection, which

code would I assign?

A: It depends. For an office visit, practices traditionally assign a

diagnosis codereflecting the findings. However, if the physician

orders further tests to determine the cause, the signs and symptoms

are used most often to determine the coding. For example, report ICD-

9-CM code382.9 (unspecified otitis media) with the E & M service

provided to the child above rather than the codefor high fever

(780.6). If an elderly man presents with shortness of breath, and an

X-ray determines the cause to be pneumonia, report 786.05 (shortness

of breath) as the primary reason for the study.

Increasing numbers of local Medicare carriers and private payers are

accepting findings—in the case of the X-ray above, 485

(bronchopneumonia, organism unspecified)—as the reason for further

tests. The idea behind this change is that patient encounters should

be coded to the highest degree of specificity possible. Because payer

policies vary greatly, coders should determine local requirements and

assign the ICD-9-CM codesthat comply with guidelines.

Time-based coding

Article Web link: www.aafp.org/fpm/20040200/coding.html

Q: How do I code based on time spent counseling patients, and what

needs to be documented?

A: E/M services can be coded based on the time spent counseling the

patient when that time constitutes more than 50 percent of the

encounter (i.e., more than 50 percent of the face-to-face time you

spend with the patient in the office or other outpatient setting or

more than 50 percent of the floor/unit time you spend in the facility

setting). To choose the correct CPT code, compare the total time

spent with the patient with the typical times listed in CPT. For

example, if you spend 15 minutes of a 25-minute office visit

counseling an established patient, you could code that service using

99214 since the total time spent with the patient (25 minutes) meets

or exceeds the typical time listed in CPT for 99214.

Documentation of these visits should include a description of the

counseling provided and the total length of the visit. It should also

specify that over half of the time was spent in counseling to make it

clear that you are coding the encounter based on time rather than

other key components (i.e., history, exam and medical decision

making). (For more information on time-based coding, see " Time Is of

the Essence: Coding on the Basis of Time for Physician Services, "

FPM, June 2003, page 27.)

BOOK RESOURCES

AMA CPT 2005 - Professional Edition (or the current year)

Color enhanced illustrated Current Procedural Terminology Official

CPT developed by the CPT Editorial Panel

*****

Lexi-Comp's Clinical Reference Library Laboratory Test Handbook

Concise with Disease Index by: S. s MD, Wayne R. DeMott

MD, Harol J. Grady PhD, T. Horvat PhD, W. Huestis MD,

Bernard L. Kasten, Jr., MD 4th Edition - over 786 Clinical Lab Tests

********

The Coder's Handbook 2000 PMIC

( " ...is a comprehensive coding compliance and terminology reference

designed for medical office, hospital, and health insurance company

personnel involved in the coding and reimbursement process. " )

WEB RESOURCES

What are CPT Codes & other valuable info

Standard Health & Dental Insurance forms

Medicare & Medicaid Information

Insurance Help for Autism

GLOSSARY OF TERMS & Additional details:

Appealing Claim Every health insurance provider has a process for

appealing claims for reimbursements. It is estimated approximately

90% of the claims submitted to health insurance companies are

rejected for some reason. Many insurers stop there and do not move

forward on getting reimbursed. It is important to check with the

appealing claim process and follow this all the way thru for proper

reimbursement. Organization and complete documentation of this

process is highly recommended.

CPT Code Current Procedural Terminology. Multiple codes are

acceptable to use for an appointment with multiple procedures.

EOB Explanation of Benefits is a document outlining all health

insurance benefits, life time caps, reimbursement policies and other

important information. This document is typically supplied by the

health insurance provider.

HCFA 1500 Health insurance Claim Forms – standard forms used by the

industry.

ICD 9 CM International Classification of Diseases – revision #9.

ICD's define all the diseases currently coded and treated.

Medicare Medicare is the federal funded health insurance initiative

which many of the privately funded health insurance providers follow

for what claims are paid and which ones are not.

Superbills: Typically are the receipt you receive from an office

visit with all the standard CPT & ICD-9 codes that doctor typically

uses.

Special thanks to volunteer Kathy Ward for helping TACA families

navigate the health insurance maze!

©2000-2007 Talk About Curing Autism