The document discusses medical billing and coding. It explains that physicians generate revenue through CPT and ICD coding of medical services which are then billed to insurance companies. Claims can be rejected for reasons like missing information, duplicate claims, or non-covered services. Maintaining accurate and timely coding and thorough medical documentation can help lower rejection rates and expedite insurance approval and payment.

2.  Understand
 How physicians generate revenue
 How medical billing works
 Become familiar with
 CPT coding
 ICD coding

5. Dependent on
adequate and
appropriate
medical
documentation

8. Document encounter
Pertinent positive and negative findings in history and exam
Differential diagnoses
Treatment options
Risks and benefits to patient of treatment options

9. Rejected by Insurance

10. Accepted
90%
Rejected
10%
Physicians Practice, 5 Common Medical Practice Denials, May 2014
http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014

11. Physicians Practice, 5 Common Medical Practice Denials, May 2014
http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014
 Duplicate Claim
 Missing Required Information
 Service Included In Service Previously Paid
 Non-Covered Service
 Late Claim Filing

12. Rejected by Insurance

13. High Rejection Rate
Slow Submission
Of Claims
Inaccurate or
Incomplete claims
Delayed
Coding
Inaccuracy
Slow approval
Of claims
Slow payment
Audits
Inadequate
documentation

14. Low Rejection Rate
Fast Submission
Of Claims
Accurate and
Complete Claims
Prompt
Coding
Accuracy
Good
Documentation
Timely Billing
Prompt approval
Prompt Payment

15. Business in Medicine

16.  Current Procedural Terminology (CPT)
Codes
 Code for services provided
 Hospital admission
 Follow up visit
 Procedure
 Code for level of service
 Ranked 1-3 or 1-5 for some services
 Higher levels result in higher payment

17. = Service
Codes

18.  Current Procedural Terminology (CPT) codes
 Developed by the American Medical Association
 Describe medical services
 Patient visits
 Procedures
 Tests
 Used by Medicare since 1978, other insurers quickly followed

19.  Medical documentation
 H&P
 Progress Note
 Operative note
 Order for a test or imaging study
 Diagnosis (ICD) Codes

20. = Diagnosis
Codes

21.  Diagnosis codes!
 International Classification of Diseases (ICD)
 ICD-9 - 17,000 codes
 ICD-10 - 155,000 codes
 ICD-10 will be required starting in 2015

23. Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level 1 99221 $102 1.92
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
Three levels for this service
1997 E&M Documentation Guidelines
Used by physician to determine what level to bill

24. Procedure CPT Code Medicare Allowable
Charge
Arthroplasty, knee,
(TKA)
27447 $1,682
No levels for this service
This is for the physician’s component of the
service
Hospital and device costs are billed separately

25. OR
Insurance
Claim #1
Insurance Claim #2

26. Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level 1 99221 $102 1.92
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed

27. Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level 1 99221 $102 1.92
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed

28. Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare Allowable Fee $204 $204
Medicare Responsibility $163 $163
Supplemental
Responsibility
$0 $41
Patient Responsibility $41 $0 $0 $392
Total Payment $204 $204 $67 ?
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014
Illinois Medicaid Fee Schedule, Accessed 7/29/2014

29. Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare Allowable Fee $204 $204
Medicare Responsibility $163 $163
Supplemental
Responsibility
$0 $41
Patient Responsibility $41 $0 $0 $392
Total Payment $204 $204 $67 ?
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014
Illinois Medicaid Fee Schedule, Accessed 7/29/2014
The Medicare Allowable Charge may
not cover the cost of providing the
medical service and is independent of
what a physician might charge (bill) for
these services.
Physicians are prohibited from
collecting the difference between the
charge and the Medicare Allowable
Charge.

30. Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare Allowable Fee $204 $204
Medicare Responsibility $163 $163
Supplemental
Responsibility
$0 $41
Patient Responsibility $41 $0 $0 $392
Total Payment $204 $204 $67 ?
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014
Illinois Medicaid Fee Schedule, Accessed 7/29/2014
Many practices report
the cost of providing
services to patients with
Medicaid for healthcare
coverage exceeds
reimbursement.
Payment from patients
without insurance is
variable, but they are
charged at the highest
rate.

31. Rejected by Medicare
Rejected by Supplemental
Only Eligible for payment if
Claim Accepted by Medicare
80%
20%
Portion of
Charges

32.  Complex and Lengthy Process
 Influence factors you can control
 Timeliness of coding
 Accuracy of coding
CPT
ICD
 Quality of medical documentation