The skills learned in this Medical Insurance Billing ...



MEDICAL BILLING EXERCISES

I. Career Opportunities

The skills learned in this Medical Insurance Billing Specialist class can apply to various career job descriptions, including:

• Reception-Appointments Desk,

• Patient Registration/Registrar,

• Insurance Verification, Authorizations,

• Front-Office,

• Insurance Biller,

• Insurance Clerk,

• Insurance Coder,

• Patient Accounts, Collections,

• Claims Adjuster-Examiner,

• Claims Auditor.

Some or all of these positions can be found in Physician/Doctor Offices, Acute Care Hospitals, Long Term Care Facilities, Outpatient Clinics, Chiropractic Offices, Physical Therapy Offices, Alternative Health Care Clinics, Freestanding Laboratories, Radiology Centers, Medical Equipment Vendors, Billing Services and Insurance Companies.

Of the bulleted job descriptions, which ones do you think would require the most contact with patients? ________________________________________________________.

When interacting with patients you need:

• A compassionate attitude and

• The desire to help the patient through medical, economic and insurance problems. This is called Patient Advocacy.

Using the job descriptions in bold type above, search the internet ( or ) and find at least five job listings nearest you. For each listing, note the:

• Job Title and Responsibilities.

• Hourly or Annual Wage.

• Amount of Education and Experience Required

• Whether it involves telecommute options.

• Attach the Job Description to this homework.

From the job listings, identify ten or more common job duties:

Print 10 job listings that give hours, wage, job description and minimum qualifications. You can go to individual job search sites or go to to search all sites. Turn in the print-outs.

II. Insurance Issues

1) When employees or members of the same organization or association obtain insurance together for a reduced rate, this is called __________ insurance.

2) When somebody does not have group insurance but buys health insurance directly from an insurance company or a broker, this is called _____________ insurance.

3) The person who took out the insurance policy is called the _________ holder or the __________ed or __________er. People added to the policy are dependents.

4) On government claims, the person receiving medical insurance coverage is called the Beneficiary (__________________) the Recipient (__________________).

5) The generic word that includes doctor, therapist, laboratory, clinic, hospital, equipment vendor, and any care-giver or supplier is: ________________.

6) In commercial insurance, the written agreement between the provider and the insured to allow the insurance to pay the provider is the ____________ of benefits.

7) The money the insured pays monthly to the insurance company for insurance coverage is called the _____________. The amount of covered medical expense the patient must pay out of pocket each year before insurance begins to pay is called the ______________.

8) The person responsible for payment of the medical bill (or any balances left after insurance payment) is called the _______________.

9) When determining the maximum dollar amount the insurance plan will pay for a particular CPT or HCPCS service code, you are requesting a _______________.

When determining whether the patient currently has insurance coverage you are checking _______________. Don’t forget to ask if there are pre-existing conditions.

When you are determining whether the CPT or HCPCS service code is covered under the insurance plan you are requesting _______________.

When determining whether the CPT or HCPCS service code must be authorized in advance by the insurance company, you are requesting _______________.

10) In Medicaid/Medi-Cal, Worker’s Compensation, Disability Evaluations, Pre-Employment or Pre-Insurance Physical Exams, the contract (obligation to pay) is between the provider and the _______________. It is not the patient’s obligation.

In nearly all other situations, the contract is between the provider and the _______________.

III. Medical Documentation Issues

In order to keep a record of the patient’s medical encounters, complaints, symptoms, test results, diagnoses and treatments, all health care providers must keep medical documentation. The documentation is either in the form of handwritten or typed notes in a hard-copy chart (file), or they may be directly input into a computer system as an Electronic Health Records (EHR). Most hospital records are electronic, and gradually HIPAA, Medicare and other government requirements are causing more and more healthcare providers to switch to EHR.

As the basic record of what a healthcare provider does, medical documentation is the source of all coding, all information for audits and all background for future treatment. It also can be the source of evidence of malpractice or fraud. So it is imperative that medical records be accurate and complete. They must also be confidential and disclosed only according to Health Insuranace Portability and Accountability Act (HIPAA) and any other applicable state or federal laws.

In coding, the rule of thumb is “not documented, not done,” so anything that is billed must be reflected in the medical record. Providers usually document in the SOAP format:

Subjective Information. This starts with the patient’s complaints, verbal descriptions of sensation or previous incidents. Examples include: “I feel dizzy,” “I felt like I would vomit,” “I was so feverish,” “I’m dead tired.”)

Objective Information. The next step is to gather information that the healthcare practitioner can see or measure. Examples: Vitals (blood pressure, temperature, pulse, respiration), Visible Condition (look yellow/jaundiced, look red, visibly in pain, bruise, laceration visible, etc.); Auditory or Auscultation (using the stethoscope to see if there is wheezing, rasping, heart murmur, abnormal bowel sounds, etc.). Touch or Palpation (swelling, tenderness, etc.). Smell (bacteria, alcohol, etc.). Taste (taste once was used in place of many of our current lab tests!). Laboratory, X-Ray and other diagnostic tests are examples of objective medical information.

Assessment. Conclusions drawn from the above subjective and objective information to form a diagnosis or a plan for further diagnostic work).

Plan. Treatment plans, such as dietary restrictions, prescriptions, exercises, surgery, hospitalization and any additional diagnostic work planned for the future.

Corrections for medical records. As a legal document, a medical record must be corrected as such. When we make corrections to a bank check, we always need to date the change, and initial or sign the changes. With a medical record you may not use white out correction fluid or obliterate the information changing. A single line through the incorrect information (corrected this way) with the corrected information above or beside and the date of the correction and the initials or signature of the person making the correction.

III. ICD-9-CM Coding Issues

1) Why do you think it was important to track disease and death (morbidity and mortality) statistics before there was such a thing as health insurance? _____________________________________________________________. The World Health Organization is responsible for ICD-9 and ICD-10 codes. Their purpose is not only for claims but to help identify health risks on a global level.

2) What will likely happen if I fail to put the ICD-9 code on the medical claim or fail to reference it to the procedure billed? Claims can be__________, or there may be a penalty or _________.

3) What are the two volumes of the ICD-9 book? Volume One, __________ _______ List, Volume Two, Alphabetic_______. Often, ICD-9 books may have Volume Two listed before Volume One.

4) NOS = “Not Otherwise Specified.” Use this when the ________________ does not specify any more information about the condition.

5) NEC = “Not Elsewhere Classified.” Use this when the ____________ does not classify the specific condition.

6) What coding system is scheduled to replace ICD-9 in 2013? __________.

7) If the your codebook indicates you need additional digits, is it a suggestion or a mandatory requirement?_________________________.

8) If you can’t find the fifth digits, can you just add numbers anyway? _Yes/No_.

9) Where are the fifth digit categories found in the book?________________.

10) What is an Eponym? When a disease is named after a _________or a _____.

11) What does Etiology mean? The disease process that is an underlying _______ of another disease. Slanted brackets [] indicate a manifestation code that is to be used after an etiology code.

12) You never code any diagnosis that is described as “likely” “suspected” “rule-out” “questionable” “probable.” Physicians only code what is known. If the diagnosis has not yet been made, you may code with the patient’s _____________.

13) Where do you find the Hypertension Table, the Neoplasm Table and the Table of Drugs and Chemicals? In or after the___________________.

14) You would use a “V” code to describe the reason for the health service when the patient is not currently ______ or presents for specific treatment.

15) You would use an “E” code to describe how a patient was injured or poisoned. Can an “E” code be a primary diagnosis? _Yes/No_.

16) The steps for finding an ICD-9-CM code are: Go to the Alphabetic _______ and look up the _____ term. Indented under that term you will find the Subterm. Write down the code(s) given and look them up in the _______ list. Read any special instructions such as “Excludes” or “Includes” or “See” and any symbols instructing you on how many digits you need to add to the code. Copy down the code and then _____-read it for accuracy.

17) Indentations: Any code description that starts with a small-case letter and is indented, includes the ___________ of the code that is not indented above it.

Circle main term, underline subterm, list *complete* ICD-9 code:

Hip fracture _________

Corneal abrasion _________

Abscess in left axilla region _________

Acute cerebrovascular accident (CVA) _________

Bell’s palsy facial paralysis _________

Insulin dependent diabetes mellitus (IDDM) _________

Acute Myocardial Infarction MI), First Episode _________

Chronic serous otitis media (OM) _________

Duodenal ulcer with hemorrhage _________

Abnormal blood level of iron _________

Acute upper respiratory infection (URI) _________

Foreign body, eye _________

Secondary carcinoma lung, lower lobe _________

Urinary tract infection (UTI) _________

Benign essential hypertension _________

Coronary arteriosclerosis _________

Primary carcinoma, face _________

Malignant hypertensive renal disease

with renal failure _________

Abdominal pain LLQ _________

Diabetes mellitus, juvenile type,

uncontrolled _________

Diverticulosis, small intestine with hemorrhage _________

Spontaneous fracture, vertebra (collapse) _________

North American blastomycosis _________

Complication due to transplanted bone marrow _________

Laceration elbow with tendon involvement _________

Calcification of shoulder joint _________

Cleft lip with cleft palate _________

Anaerobic septicemia _________

Christmas disease _________

Dysplasia of cervix (uteri) _________

Pitting edema of bilateral ankles _________

Gastrojejunocolic fistula _________

Nun’s Knee _________

Tennis Elbow _________

Abnormal weight loss _________

Dislocated shoulder _________

Contusion of upper arm _________

Fracture, right tibial shaft _________

Fracture, right knee _________

Advanced Concepts and Problems

Colles' Fracture _________

Cervical stenosis, (C3 – C4 spine vertebra) _________

Follow-up exam for Myocardial Infarction (MI)

of 6 week duration, posteriolateral _________

ECG on patient with history of MI a year ago: _________

AIDS (symptomatic) _________

HIV positive, non-symptomatic _________

Arteriosclerosis of

coronary artery bypass graft (CABG) _________

West Nile encephalitis _________

Malignant neoplasm of ovary _________

Diabetes Mellitus (DM), adult onset, on insulin _________

Multiple Code Situations

Diabetes Mellitus (DM), juvenile onset,

with complication of glaucoma: _________ and _________

Kyphosis due to tuberculosis of spine _________ and _________

Familial cardiomyopathy due to Chagas’ disease _________ and _________

Normal vaginal delivery,

with episiotomy and single live-born baby _________ and _________

Vaginal delivery complicated by prolonged labor

with unknown outcome _________ and _________

Kaposi’s Sarcoma due to AIDS _________ and _________

Mal-union fracture, right tibia shaft _________ and _________

Traumatic arthritis

following fracture of right knee _________ and _________

Fetal eye damage due to forceps delivery _________ and _________

Burns

First and second degree burns of face (1%), hands (3%) and trunk (5%)

_________ and _________ and _________ and _________

V Codes

Screening for alcoholism _________

Special screening exam for heavy metal (chemical) poisoning _________

Special screening for sickle cell anemia _________

Routine infant well baby health check-up _________

Routine laboratory exam (adult) _________

Hemodialysis treatment encounter _________

E Codes

Motor vehicle accident (MVA),

collision with horse-carriage, injuring carriage occupant _________

Accidental fall from elephant _________

Burn by boiling soup _________

Legal execution – capital punishment _________

Accident while aboard spaceship _________

IV. CPT Coding Issues

CPT/HCPCS codes are for services. They are like invoice numbers for a catalog of things a doctor or provider can bill to an insurance company. There are CHARGES for CPT/HCPCS codes. ICD-9 codes are illnesses, and illness is free of charge! The CPT/HCPCS code answers the question, “What treatment or service is the doctor charging for?” Remember, ICD-9 codes simply answer the question, “Why did the patient go to the doctor?”

HCPCS Level One is _________. These codes are maintained by _____________.

HCPCS Level Two is _________. These codes are maintained by _____________.

HCPCS Level Three is _________. These codes are maintained by _____________.

How often are the CPT/HCPCS codes updated? _______________.

How often are the CPT/HCPCS code books revised? _____________.

What does CPT stand for? _____________________________.

What are the names of the seven major sections of the CPT codebook?

1) _____________. These codes start with ________ and end with _________.

2) _____________. These codes start with ________ and end with _________.

3) _____________. These codes start with ________ and end with _________.

4) _____________. These codes start with ________ and end with _________.

5) _____________. These codes start with ________ and end with _________.

6) _____________. These codes start with ________ and end with _________.

Additionally, there are two more sections: Category II codes (use is optional) and Category III codes (mandatory temporary codes for services not in sections 1-6).

CPT codes have an indented code rule just like the ICD-9 rule. However, the indented code *only includes the description of the non-indented code above up to the SEMICOLON (;).

Another convention of CPT is the ADD-ON code. Add-on codes are designated with a plus symbol (+) to the left of the code. Add-on codes may NEVER be billed alone. They are always in addition to another code. Examples would be the Prolonged Services codes in E/M, or the Lesion Destruction codes (17000 and +17003) in surgery.

When using the CPT book, you should start by looking up the description of the service in the index. The index will usually give you a range of codes. If they are separated by a dash (like 99201-99205) it is a range of all the codes. If they are separated by a comma (like 99201,99205) it is sending you only to those two codes and not the full range in between. Write down the codes from the index and look them up in the appropriate section. The book is in numerical order, except for Evaluation and Management, which is in the front when it numerically would be expected to be at the end.

It is always necessary to read the guidelines for the section, and the additional guidelines for the subsection you are working with. Read the description of all codes in the indexed range before choosing one, and read any parenthetical notes as well.

EVALUATION AND MANAGEMENT (“VISITS”)

An established patient has seen the doctor OR a doctor of the same specialty in the same practice within the last three years.

A new patient – hasn’t!

At what point does a patient previously seen become a “new patient” all over again?

If they have not been seen by this doctor or another doctor of the same _______ in the group for ___ years.

Circle the correct answer.

Jane was seen at the hospital for a consult with Dr. Williams. Two weeks later she was seen for treatment at Dr. Williams’ office.

New patient Established patient

While Dr. Halibut was on a fishing vacation, his partner, Dr. Bass, saw Dr. Halibut’s patient in the office for a sore throat. Dr. Bass was acting as Locum Tenens.

New patient Established patient

John and his family have just moved into town. John has asthma and requires medication to control the problem. Dr. Yokohama has received his records from the previous doctor back in John’s old neighborhood.

New patient Established patient

Tom was in the army for two years. During that time he did not see Dr. Teacup. The office policy is to place any inactive files on microfilm after 18 months of inactivity.

After Tom finished his tour of duty and returned home, he made an appointment to see Dr. Teacup again.

New patient Established patient

How many of the key components (history, physical exam, medical decision-making) must be met or exceeded for new patient services? ______ How many for established patient services? _________.

For evaluation and management, you need to first consider the ________ where the service occurred. Was it Office or Outpatient Hospital Clinic? Inpatient Hospital? Nursing Home? Hospital Emergency Department? Or is it a Consultation situation where one doctor is asking your doctor to examine the patient and write a report advising the requesting doctor how to treat the patient?

Once you have selected your location/situation, you are often need to know if your patient is New or Established (seen by the doctor or another doctor of the same specialty in the same practice within the last three years) and approximately how much time the doctor spent with the patient and what kind of medical history and physical examination were done as well as something about how complicated the doctor’s decision making process was. Most services are at the first three levels of service.

Levels of service 4 and 5 should only be used after reviewing medical documentation and looking at the clinical examples in the back of the CPT book to verify you are not “up-coding” or overcharging the insurance, as this can be considered fraudulent billing.

Let’s practice looking for the proper section in the E/M section.

1) The patient was seen in the doctor’s office for abdominal pain. The patient was last seen two months ago. Subsection/Location _____________. Category/Patient Status______________.

2) A doctor has referred his patient to your office. The doctor wants your doctor to evaluate the patient and send him a report advising him how to treat the patient’s condition. Subsection/Location _____________. Category/Patient Status ______________. Notice there is no special new patient vs. established patient category for Consultations.

3) The doctor sees the patient in the Hospital Emergency Room for sudden shortness of breath. Subsection/Location _____________. Category/Patient Status ______________. Notice there is no special new patient vs. established patient category for Emergency Department.

4) The doctor makes a house call to an established patient’s apartment. Subsection/Location ____________. Category/Patient Status_____________.

5) The doctor visits the patient’s hospital room after they have been admitted as an inpatient. Subsection/Location _____________. Category/Patient Status______________. Note: Inpatient services do not have New or Established patient status, but there is the Initial services (billed once by the doctor who admits the patient and by no other doctor) and subsequent inpatient services that are billed by all doctors once the patient is admitted.

OFFICE OR OTHER OUTPATIENT SERVICES

1. New patient, office, expanded problem focused history and exam, straightforward decision making. (Example: 16 year-old male with severe cystic acne.) ____________________.

2. Established patient, office, detailed history and exam, decision making moderate complexity. (Example: 28 year-old female with regional enteritis, diarrhea and low grade fever. ____________________.

3. An established patient presents in Dr. Seth O’Scope’s office stating she needs emergency treatment because she cannot breathe. She is taken back to the treatment area and Dr. O’Scope makes several other patients who have appointments wait while he does an evaluation involving a detailed history and physical examination with low complexity medical decision-making. _________ and _________.

4. When is time a factor in choosing the correct E&M code? When counseling and/or coordination of care is more than ___% of the total encounter time and when selecting P________Services, C________ Care Services, or Hospital _________ services.

OBSERVATION SERVICES

A pregnant patient (28 weeks’ gestation) with a long history of premature labor began having contractions and called Dr. Forceps, her obstetrician. The doctor recommended that she be placed in an observation unit in the hospital. His care included a comprehensive history and physical with low-level medical decision-making. The patient was discharged on the same day _________. Observation care discharge code 99217 may only be billed when the discharge is NOT the _______ date of observation status. Otherwise, use codes _________.

HOSPITAL SERVICES

1. Initial hospital care is the same as hospital _________ and may only be billed by the Admitting doctor.

2. Are there different codes for new and established patients for hospital services? ___.

Find the following codes:

3. Initial hospital care, detailed comprehensive history & exam, low-level decision-making __________.

4. Subsequent hospital care, detailed history and exam, high-complexity decision-making __________.

5. Hospital discharge day management, more than 30 minutes ____________.

CONSULTATIONS

To qualify as a consultation, there must be a ________ doctor who is sent a ______.

1. Dr. Dwight Coates calls Dr. Cleaver and asked Doctor Cleaver to perform a gastrointestinal inpatient consultation on Miss Hurt. The consultation involved detailed history and detailed physical exam and low complexity medical decision-making _________.

2. Two days later Dr. Dwight Coates got results for Miss Hurt’s test results and called Dr. Cleaver to review the test results and see Miss Hurt again and write a report giving his recommendations for treatment. The visit involved a expanded problem-focused interval history and examination and moderate complexity decision making _________.

3. A patient was sent for consultation to Dr. Pharmer C. Rex’s office by the patient’s primary care physician, Dr. Seth O’Scope. The patient had a long history of urinary and kidney problems which required a comprehensive history and physical examination with moderate complexity medical decision-making _________.

4. Dr. Fibula, an orthopedic surgeon, saw Dr. Dwight Coates’s long-time patient in his office for a consultation regarding the patient’s amputated leg. The amputation was due to diabetic related gangrene some eight years previously. The patient’s below the knee prosthesis had fallen off of the patient’s right leg when the patient stepped off a curb on a busy downtown intersection, causing the patient to fall. There was a stress fracture in the tibial plateau. A cast was applied, but the fracture was not healing well due to the patient’s osteoporosis and diabetes. Surgery was inevitable, but the patient’s high deductible on their insurance and work obligations made them hesitant to set a surgery date, and the patient wanted to delay or avoid surgery if possible. Dr. Fibula sent the patient to Dr. Sawbones for a second opinion regarding the need for surgery and the best surgical procedure to perform. Dr. Sawbones took a comprehensive history, performed a comprehensive examination and high complexity medical decision making to evaluate the patient. He sent a report to Dr. Fibula recommending immediate surgical fixation with percutanious fracture reduction. Code Dr. Sawbones’ service _________. (This is a good exercise in extracting necessary information from long narratives containing confusing information not necessary for coding.)

5. Initial inpatient consultation, detailed history and exam decision-making low. (Example: diagnosis/management of fever following abdominal surgery) __________.

EMERGENCY ROOM

How does the CPT book define emergency department?

Code the following:

1. Emergency department visit, comprehensive history and exam, high decision-making (Example: patient with new onset of rapid heart rate requiring IV drugs) _______.

2. Dr. Dwight Coates is called to the hospital emergency room by the ER physician to evaluate and treat one of his established patients who has a broken hip. He takes and expanded problem-focused history and physical exam and makes medical decisions of low complexity _________.

3. Dr. Ron Call sees an established patient in the hospital emergency room. The patient has chest pain and a history of cardiomyopathy. Dr. Ron Call evaluates the patient with a detailed history and physical exam and then he calls Dr. Dwight Coates who also evaluates the patient with a comprehensive history and physical and high complexity medical decision-making and Dr. Dwight Coates admits the patient to the hospital (as an inpatient with room and board). Code the services first for Dr. Ron Call _________ and for Dr. Dwight Coates _________.

CRITICAL CARE

1. Dr. Ron Call saw a critically ill patient in the intensive care unite of the hospital and provided constant bedside care for 45 minutes _________.

2. Dr. Dwight Coates saw a critically ill new patient in the morning of January 8 in the cardiac care unit of the hospital. He provided constant bedside care for 1 hour 12 minutes. That afternoon, Dr. Dwight Coates returned to the hospital and spent an additional hour and ten minutes _______ Box 24 G (times:)x__ and _______ Box 24 G (times:)x__.

NURSING FACILITY

How does the CPT book define the types of facilities covered under “nursing facility services” codes?

1.

2.

3.

and 4.

A nursing facility provides medical services, but rest home, domiciliary, custodial care services have no ____________ care component at all.

Code the following:

1. Comprehensive nursing facility assessment with detailed history and exam, low complexity decision-making. (Example resident with non-insulin dependent diabetes, stable angina and chronic obstructive pulmonary disease, one year after previous comprehensive exam) __________.

2. Subsequent nursing facility care expanded problem focused exam and history, moderate complexity decision making (Example: skilled nursing facility patient who is six months post stroke and now has fever and mild cough) ____________.

3. A hospital inpatient was discharged to a nursing facility_________.

4. Dr. Dwight Coates went to the Holiday Hamlet Rest Home to see a patient of his who has chronic urinary problems and an occluded urostomy catheter. His visit included an extended problem-focused history, detailed physical and moderate-level medical decision-making _________.

PROLONGED SERVICES

Prolonged services are add-on codes and cannot be used by themselves. They are for additional time added to other Evaluation and Management service codes. Prolonged services can be face to face with the patient or not face to face.

1. Refer to #4 above. Before seeing the patient, Dr. Coates spent 14 minutes reviewing extensive patient records. After leaving the patient’s room, Dr. Coates spent an additional hour and 92 minutes while he gave instructions to the patient’s family about catheter use and problem prevention, second code is: _________ Box 24 G (times:)X___ and ___________ Box 24 G (times:)X___ (Note: there are TWO Prolonged Care sections, face to face and not face to face!)

HOME SERVICES

1. New patient home visit, expanded problem focused hx and px, moderate mdm _________.

2. Established patient home visit expanded problem focused hx and px, low mdm _________.

PHYSICIAN STANDYBY SERVICES

3. Dr. Ferney Forceps spent 2 hours standing by for a high-risk cesarean delivery _______ Box 24 G (times:)x__.

CARE PLAN OVERSIGHT

4. Care plan oversight by physician of a patient referred by a home health agency, requiring complex care involving physician development of care plans 30 minutes within a one month period ___________.

PREVENTIVE VISITS

5. Preventive medicine services for a 5-year-old established patient _________.

6. A 19-year-old established female patient presented in Dr. Dwight Coates’ office for a yearly physical examination. A comprehensive history and physical exam were performed and the doctor discussed sexually transmitted disease prevention and birth control _________.

7. A 4-year-old new patient was brought to Dr. Dwight Coates’ office by his mother. He received a pre-kindergarten examination _________.

8. New patient, age 14, initial preventive medicine exam and MMR vaccination? _________ and _________

9. What would you bill if the patient in the last question also has a problem found in the examination and that problem is evaluated (detailed hx and px, mdm moderate complexity? ________ and _________ (as above) and additionally __________ with modifier ___ to indicate significant, separate service. (Don’t forget! If there are additional services, you will need additional justifying ICD-9 diagnosis codes linked to the additional services.)

COUNSELING RISK FACTOR SERVICES

1. Mrs. Plumb was concerned about her 16-year-old daughter losing weight and constantly working out at the gym, and possibly being anorexic. The daughter refused to be examined by Dr. Coates, but she did consent to sit down for 45 minutes to talk with the doctor about diet and exercise _________.

2. Mrs. Plumb’s daughter agreed to return to a one-hour long group counseling session the following week. About eight young adults and teens discussed body image and eating disorders___________.

SURGERY SERVICES (INVASIVE PROCEDURES)

Global services and Bundled Services are services that are paid in a “Combo Package.” Evaluation and Management within 24 hours of surgery is usually packaged or “bundled” into the surgery code. Follow-up visits for the surgery are also “bundled” into the surgery code and shouldn’t be billed separately. An analogy would be ordering a dinner combo (let’s say the Big Mac #1 with drink and fries) and getting charged for each item separately “a la carte.” CPT code billing this way is sometimes called “a la carte medicine”, unbundling, or “exploding” charges, and it is considered fraud if intentionally billed that way on government claims.

Where can you find the global surgery follow-up days listed? On the Medi____________ fee schedule websites or print-outs.

A minor surgery that usually requires no return visits (for example, a small wart removal) generally has how many follow- days under the global surgery rules? ____. Same day decision for surgery visit modifier___.

A major surgical procedure or a fracture reduction generally as how many follow-up days under the global surgery rules? _____. Same day decision for surgery visit modifier___.

A minor surgery that usually has dressing changes or suture removals usually has how many follow-up days under the global surgery rules? _____. Same day decision for surgery visit modifier___.

Modifier -51 is for __________ surgery procedures on the same date, same session. It is not put on the ______st procedure (the most expensive one), nor is it put on _____-on procedures (marked with the + symbol) or on procedures marked with the Ө symbol.

When multiple surgery procedures are billed with modifier -51, the first procedure (the most expensive) does not have modifier -51 and receives 100% fee schedule allowance, and second surgical procedure (with modifier -51) is paid at a reduced rate of 50% of the fee schedule allowance. The third procedure (with modifier -51) would usually receive only 25% of the fee schedule allowance and the fourth procedure (with modifier -51) would usually receive only 10% of the fee schedule allowance.

On Medicare modifier -51 is not used. Medicare will automatically give a 100% fee schedule allowance to the most expensive procedure, and 50% of the fee schedule allowance to all covered subsequent procedures.

Multiple endoscopies are an exception to the percentage rules. You use a single endoscopy for the insertion of an endoscope from a point of entry to it’s farthest destination (think of airline tickets, you but from origin to destination, not from layover to layover). You do, however, bill an additional code if the endoscope is either removed and reinserted through another point of entry or if it is backed up and changes it’s course (example: bronchoscopy where the scope goes down the trachea into one lung, then backs up and goes into the other lung).

Endoscopies are generally considered diagnostic procedures if there is no biopsy taken, and they become surgical procedures if a biopsy (tissue sample) is taken during the procedure.

Modifier -50 is for bilateral procedures, that is, they are done twice when there are a pair of organs. Identify which of the following will take a modifier -50:

1. Cataract (Eye) surgery? Yes/No

2. Nephrotomy (Kidney) surgery? Yes/No

3. Uterine surgery such as hysterectomy with removal of ovaries? Yes/No

4. A procedure with a description, “multiple or bilateral.” Yes/No

5. Cochlear Implant (ear) surgery? Yes/No

6. Lung surgery? Yes/No?

7. A procedure with a description, “separate procedure.” Yes/No

8. Integumentary is a fancy word for _______.

9. A lesion is any ________ of the skin.

10. An ecchymosis, contusion or hematoma is a __________.

11. A laceration is a __________.

12. Always add up the total lengths of laceration repairs when the type of the repair and the __________ category are the same.

13. A coder needs to code lesion excision or destruction measurements from which report? The Pathologist or Surgeon report?

14. If a biopsy is performed and a surgical excision (removal) follows on the same date/surgery session, can you bill for a needle or excisional biopsy with an excision? Yes/No

15. Can you bill for bandages or gauze used on a patient? Yes/No

16. Can you bill for cast material such as plaster or fiberglass? Yes/No

17. Modifier -58 is for __________ procedure. Use it when replacing a cast or in the rare situations where a surgery has to be done in more than one session.

Add-On Codes and Lesion Removal

A code with + next to it is an add-on code. These codes are “in addition” to another code and therefore cannot ever be billed by themselves. Alone they are unpayable, invalid orphan codes that need their parent!

Code the following:

Destruction of three premalignant lesions from the face using laser treatment:

1. Line 1, Box 24 D__________Box 24 G (times:)X ____.

2. Line 2, Box 24 D__________Box 24 G (times:) X____.

Remember the first code is for a certain number of lesions, and the add-on code is for the remaining or additional lesions. NOTE: for all codes, read the special instructions for the section, and for the subsection and for the code itself.

Repair of wounds/lacerations:

Repair (suturing) can be:

• Simple (single, surface-layer) repair/closure or

• Intermediate (surface-layer plus the first layer below the surface) or

• Complex (closure of layers all the way through to the muscle tissue and/or including debridement or foreign-body removal).

Code the following:

1. Simple repair of superficial wound of the lip; 2.3 cm __________.

2. Repair of complex wound of the scalp; 5 cm ___________.

For surgical excisions (removal, cutting-out), a simple repair is included in the code and not billed separately. However, if the repair is intermediate or complex you would bill the additional “repair” code for the appropriate intermediate or complex repair done.

1. Excision of benign lesion from the neck; 4 mm __________ (4 mm = 0.4 cm)

2. Excision of malignant lesion from the ear (2.6 cm) requiring complex closure:___________ and ___________.

What does a + next to a code mean? ______________ code.

Code the Following:

1. Excision, lesion right arm, benign 4.5 cm _________.

2. Simple wound closure, superficial wound dehiscence ________.

3. Repair layer closure of wound, hand, 12.8 cm _________.

4. Five-year-old presents in the ED with following lacerations for simple repair with 4-0 vicryl sutures in upper layer of skin: 1.2 cm, right index finger and 0.8 cm right middle finger: ___________ F6 F7.

What are the three methods that may be used to treat closed fractures?

1.

2.

3.

NOTE: A closed fracture diagnosis may have open treatment CPT. The treatment method and the type of fracture are two different things not to be confused.

VARIOUS SURGERIES AND ANESTHESIA

Code the following:

1. Incision of soft tissue abscess, superficial ___________.

2. Treatment, closed nasal septal fracture __________.

3. Closed reduction, fracture radius and ulna _________.

4. Reconstruction, tendon pulley, hand __________.

5. Surgical arthroscopy of elbow synovectomy, complete _________.

6. Tonsillectomy, patient under 12 years _________.

7. Diagnostic laparoscopy _________.

8. Appendectomy, emergency due to rupture _________.

9. Normal vaginal delivery of first baby __________.

10. Cesarean delivery of first baby _________.

NOTE: Delivery of baby includes all prenatal and postnatal care. Do not bill E/M codes for prenatal or postnatal visits. Bill delivery after delivery!

Many surgical procedures have several possible components: Surgeon (no modifier), Assistant Surgeon (modifier -80), Two-surgeons (modifier -62 on both bills), Surgical Team (modifier -66) and Anesthesia (normally billed with an anesthesia section code, but sometimes billed as the surgery code with modifier -30 or modifier -36 on worker’s compensation).

Code the following:

Coronary artery bypass graft (CABG), vein only, 5 venous grafts ________.

Another doctor was assisting the surgeon, and there was anesthesia administered with pump and oxygenator. Patient is 83 years old and has a mild systemic disease:

1. Surgeon (Dr. Cutler): __________.

2. Assistant Surgeon (Dr. Cleaver): ___________.

3. Anesthesiologist (Dr. Zonk): _________-P__ and 99_____.

NOTE: READ the introduction to the Anesthesia Section. There are modifiers to indicate the patient’s status and “Qualifying Circumstance” codes from the Medicine Section that often need to be added to anesthesia billing. Medicare has a completely different set of HCPCS modifiers to be used with anesthesia.

RADIOLOGY PROCEDURES

When a radiology code is billed without the modifiers –26 or –TC, it means that the bill is for the technical and professional services together – the technician/film and the reading/report.

When a facility bills for the TECHNICAL COMPONENT of a radiology procedure, they are billing for the services of the technician and the film only. This is billed using the radiology code with the modifier –TC added.

When a doctor bills for the PROFESSIONAL COMPONENT of a radiology procedure (X-Ray, CT Scan, MRI, etc.), he is billing only for the “reading” or looking at the X-Ray and writing a report of his findings. This is billed using the radiology code with modifier –26 added.

Modifiers –RT and –LT help identify and separate radiology procedures on hands, feet, etc. that might otherwise look like they are the same view being done twice.

UNTANGLING DESCRIPTIONS

Sometimes the description of the service may need to be separated out into multiple codes and might need some thought in order to be coded. Here’s a radiology example.

Code the following:

Spiral CT scan of abdomen without contrast material and spiral scans of abdomen and pelvis using Isovue contrast injection. __________ and __________.

Bundled Services are services that are paid in a “Combo Package.” X-Ray services also have the Bundled Services concept.

1. One service: Radiological examination, chest, single view, (front) _________

2. One service: Radiological examination, chest, single view, (lateral) ________

3. BOTH views, same day: _________ ONLY!!!!

Code the following:

1. Chest X-Ray PA and lateral (2 views), technical component only _______ ___

2. X-Ray hand, 3 views, professional interpretation only _________ ___

3. X-Ray hand, 3 views (no split component) ____________

Diagnostic procedure is when there is a problem, such as a breast lump that needs to be diagnosed. Screening is a preventive service to make sure there is no lump or abnormality. Screening would have a V code ICD-9. Diagnostic would have 611.XX or some ICD-9 code indicating there was a mass or pain or some symptom or diagnosis.

1. Unilateral Diagnostic Mammography ____________

2. Bilateral Screening Mammography ____________

PATHOLOGY AND LABORATORY SERVICES (Clinical Lab/Chemistry)

Bundled Services are services that are paid in a “Combo Package.” Laboratory Panel services also have the Bundled Services concept.

Code the following:

1. One service: Cholesterol ___________

2. One service: Lipoprotein, direct measurement, high-density (HDL) __________

3. One service: Triglycerides ____________

4. ALL THREE tests, same day: bill __________ ONLY!!!!

Remember that you need to have enough detailed information to select a correct code. A good example is that Hepatitis B can refer to testing for the disease by more than one method, or it can refer to giving a vaccination for the disease.

Code the following:

1. Hepatitis B (core antibody) __________.

2. Hepatitis B (Virus antigen, direct probe) __________.

3. Hepatitis B (vaccine, adult) _________ (not a lab service at all!).

Under Clinical Laboratory Improvement Amendment (CLIA) rules, it is very important only to bill for laboratory services for which your office or laboratory is certified. For example, if you do not have a microscope or a technician capable of using the microscope, you would not bill codes involving microscope services.

1. Code: UA (urinalysis), non-automated, without microscopy __________.

PATHOLOGY (Anatomical Lab - Biopsies)

Most laboratory services are not divisible into technical and professional components. However, Pathology Services (codes starting with 88) involve a physician taking a tissue sample (receiving biopsy sample) and looking at it through a microscope and writing a report of what he sees. The physician’s pathology service is a professional service that may be billed with modifier –26.

LAB-RELATED COLLECTION/VENIPUNCTURE (not Lab/Path codes)

Many insurances pay for blood collection OR handling/conveyance, but not both.

Code blood collection venipuncture (surgery section) ___________;

Code collection and handling of specimen for conveyance (medicine section)__________

MEDICINE SERVICES

The Medicine Section of the CPT book is a jumble of services that do not fit into other sections. They may be diagnostic services, treatments, reports, or other special circumstances or services.

Code the following:

1. Therapeutic injection, subcutaneous _________.

2. Hemodialysis, single physician evaluation ________.

3. Esophageal motility study ___________

4. Electrocardiogram, 12 lead with interpretation and report ________.

5. EKG 12 lead tracing only _________.

6. EEG, extended monitoring, greater than one hour ________.

7. Chemotherapy administration, subcutaneous _________.

8. Service rendered on Sunday or Holiday __________.

9. Medical Testimony _________.

10. Ophthalmological service, new patient, medical examination with initiation of diagnostic and treatment program, comprehensive ___________.

11. Individual psychotherapy, approximately 20-30 minutes with medical evaluation and management services ___________.

12. Miss Zorba Tall was recently diagnosed with diabetes. Because of this, she attended a special instructional group session with noted diabetologist, Dr. Mel Saccharine. At the session, he explained insulin control measures such as use of glucose monitors and lancets, medications and adherence to a diabetic diet _________.

13. Mechanical traction modality __________.

14. Chiropractic manipulation, spinal, 4 regions __________.

15. Post-operative follow-up visit that is part of the global surgery (no charge)_____.

16. Acupuncture, 1 or more needles, without electrical stimulation ________.

17. Allergy testing, percutaneous, with allergenic extracts, 10 tests _______24G x__.

18. Hemodialysis with single physician evaluation _________.

19. Supply of plaster cast material, adult long arm cast __________.

20. Supply of wheelchair, heavy-duty, detachable arms, elevating leg rests _______

21. Supply of Vincristine sulfate, 4 mg, IV (chemotherapy drug) ___________ x__.

Please review the HCPCS below and recode the 99070 services.

Some Samples of HCPCS – Medicare Alpha-Numeric Codes (bill to most insurers):

• Cast supplies, long arm cast, adult, plaster = Q4005

• Cast supplies, long arm cast, adult, fiberglass = Q4006

• Wheelchair, heavy-duty, detachable arms, elevating leg rests = E1280

• Vincristine sulfate 1 mg IV = J9370

• Vincristine sulfate 2 mg IV = J9375

• Vincristine sulfate 5 mg IV = J9380

V. DATA FOR CMS 1500 FORM COMPLETION

|Claim A |GLOBAL SURGERY | |Claim B |COB BILLING |

| |SOLO PRACTICE | | |SOLO PRACTICE |

|Patient Account Number |GATEGLO | |Patient Account Number |GATEGUI |

|Patient Name |Gloria Gates | |Patient Name |Guillermo Gates |

|Address |2579 Los Angeles Avenue | |Address |2579 Los Angeles Avenue |

| |Simi Valley, CA 93065 | | |Simi Valley, CA 93065 |

|Patient Home phone # |(805) 555-1212 | |Patient Home phone # |(805) 555-1212 |

|Date of Birth |January 4, 1998 | |Date of Birth |August 12, 1930 |

|Relationship to Insured |Child | |Relationship to Insured |Self |

|Martial Status |Single | |Martial Status |Married |

|Sex |Female | |Sex |Male |

| | | | | |

|Insured Name |Guadalupe Gates | |Insured Name |Self |

|Insured ID Number |VC155 45 5555 | |Insured ID Number |BP764190 |

|Insured Address |Same | |Insured Address |Same |

|Insured phone number |Same | |Insured phone number |Same |

|Insured Date of Birth |December 1, 1950 | |Insured Date of Birth |Self |

|Insured Sex |Female | |Insured Sex |Male |

|Insured Employer name |ABC Corporation | |Insured Employer name |WalFed Corporation |

|Group Number |R7786 | |Group Number |AE700 |

| | | | | |

|Insurance Company |Blue Cross of California | |Insurance Company |AETNA PPO |

|Insurance Co. Address |P.O. BOX 60007 | |Insurance Co. Address |P.O. BOX 2700 |

| |Los Angeles, CA 90060 | | |El Quattro, CA 94106 |

|Rendering Provider |Sally Sawbones, MD | |Rendering Provider |George Weber, MD |

|Rendering Provider License Number|A4559 | |Rendering Provider |C65987 |

| | | |License Number | |

|Rendering Provider NPI |1358432769 | |Rendering Provider NPI |4765413687 |

|Provider SSN |556 66 7755 | |Provider SSN |443 22 4987 |

|Billing provider information |Sally Sawbones, MD | |Billing provider |Weber Dermatology |

| |2215 Gander Grove | |information |4488 Brand Blvd |

| |Simi Valley, CA 93065 | | |Glendale, CA 91244 |

|Billing provider ID |A4559 | |Billing provider ID |C65987 |

|Billing provider NPI |1358432769 | |Billing provider NPI |2641534544 |

|Service facility location |Santa Susana Medical Center | |Service facility location information|(No Facility) |

|information Address |10 Boxwood Boulevard | |Address | |

| |Santa Susana, CA 93063 | | | |

|Service Facility NPI |3667144551 | |Service Facility NPI |(NONE) |

|Date of Service |September 7, 2007, | |Date of service |October 1, 2007 |

| |September 14, 2007 | | | |

| | | | | |

|Dr. Sawbones at Santa Susana Medical Center (POS 22) found the patient to | |Dr. Weber performed a complex repair of 5.1 centimeter lesion (CPT 13132) |

|have a cystic lesion of the left upper eyelid (ICD-9 374.84) and performed | |($950.00) in the office (POS 11). |

|outpatient surgery of excisional biopsy of lesion with flap reconstruction | |Diagnosis: Neck Lesion (ICD-9 739.1). |

|eyelid (CPT 67961-E1) ($500.00) on 09/07/07. The doctor A follow-up exam | |Patient has *secondary* insurance through his spouse, Guadalupe Gates (see |

|problem focused (**HINT: CPT_global 99024 can’t be billed) was done in the | |Insured/Insurance information on claim A or claim C). |

|office (POS 11) on 9/14/2007. | |Authorization to Release Information is on file. Assignment of benefits on|

|Authorization to Release Information is on file. Assignment of benefits on| |file. |

|file. | | |

|Claim C |E/M ON SURG DAY | |Claim D (1 and 2) |TOTAL OB CARE |

| |GROUP PRACTICE | | |GROUP PRACTICE |

|Patient Account Number |GATEGUI | |Patient Account Number |68 9430 |

|Patient Name |Guadalupe Gates | |Patient Name |Barbara Butler |

|Address |2579 Los Angeles Avenue | |Address |1111 E. Birmingham |

| |Simi Valley, CA 93065 | | |Bayport, CA 90020 |

|Patient Home phone # |(805) 555-1212 | |Patient Home phone # |(999) 456-2233 |

|Date of Birth |12/1/1950 | |Date of Birth |May 15, 1985 |

|Relationship to Insured |Self | |Relationship to Insured |Spouse |

|Martial Status |Married | |Martial Status |Married |

|Sex |Female | |Sex |Female |

| | | |LMP Date |02/15/2007 |

|Insured Name |Same | |Insured Name |Branford Butler |

|Insured ID Number |VC155 45 5555 | |Insured ID Number |000 00 0000 |

|Insured Address |Same | |Insured Address |Same |

|Insured phone number |Same | |Insured phone number |(999) 456-2233 |

|Insured Date of Birth |12/1/1950 | |Insured Date of Birth |March 12, 1980 |

|Insured Sex |Female | |Insured Sex |Male |

|Insured Employer name |ABC Corporation | |Insured Employer name |XYZ Corporation |

|Group Number |R7786 | |Group Number |GP002 | | | |

| | | | | |

|Insurance Company |Blue Cross of California | |Insurance Company |Blue Cross of California |

|Insurance Co. Address |P.O. BOX 60007 | |Insurance Co. Address |P.O. Box 60007 |

| |Los Angeles, CA 90060 | | |Los Angeles, CA 90060 |

|Rendering Provider name |George Gilroy, MD | |Rendering Provider name |Brian Brown, MD |

|Rendering Provider License Number |A07854 | |Rendering provider License Number |G45000 |

|Rendering Provider NPI |2347511764 | |Rendering Provider NPI |2275433176 |

|Employer ID number |95-1442899 | |Employer ID number |33-1557669 |

| | | | | |

|Service facility location |(No Facility) | |Service Facility Location |Bayport Hospital |

| | | | |4957 Nursery Lane |

| | | | |Backdoor, CA 90120 |

|Service Facility NPI |(NONE) | |Service Facility NPI |0674156999 |

|Billing provider information |Gavner Orthopedic | |Billing provider information |Babies R US |

| |5900 Gathic Avenue | | |4440 Bobsey Way |

| |Huntington park, CA 91311 | | |Backdoor, CA 90120 |

|Billing provider ID |W874534 | |Billing provider ID |W45689 |

|Billing provider NPI |0684936649 | |Billing Provider NPI |0649378140 |

|Date of Service |6/16/2007 | |Patient Hospitalized |October 21-23, 2007 |

|Date of First Visit |6/16/2007 | |Date of First Visit |May 15, 2007 |

| | | | | |

| | | | | |

|Dr. George Gilroy performed a new patient minimal visit of straightforward | |Patient complaint of abdominal pain (ICD-9 789.00) Detailed established |

|decision-making (CPT 99201-25) ($50.00) in the office (POS 11) on 6/16/2007. | |patient office (POS 11) visit (CPT 99214) ($70.00) was performed, along with |

|An injection of tendon sheath (CPT 20550-RT) ($70.00) was also performed on | |a urine pregnancy test (CPT 81025) (for $12.00) on 5/15/2007. Patient is |

|6/16/07. On 7/15/2007 the patient came back to the office (POS 11) and Dr. | |found to be pregnant (ICD-9 V22.2). Prenatal visits on 6/16/07, 7/20/07, |

|Gilroy performed arthrocentesis on the right elbow (CPT 20605-RT) ($150.00) | |8/15/07, 9/20/07. A UA dip with micro (CPT 81000) ($10.00) was performed on |

|Diagnosis: Neuralgia/neuritis (ICD-9 729.2) | |9/20/07. SPLIT NEW FORM FACILITY POS: Patient vaginally delivered a baby |

|A co-payment of $50.00 was made by patient. | |girl on 10/21/07 (total OB care) (CPT 59400) ($2500.00) at Bayport Hospital |

|Authorization to Release Information is on file. Assignment of benefits in | |(POS 21). Diagnosis: Vaginal Delivery, Single Life-born (ICD-9 650 and |

|file. | |V27.0). Patient paid $200.00. Authorization to Release Information is on |

| | |file. Assignment of benefits in file. |

|Claim E |NON-ASSIGNED | |Claim F |BILATERAL-UNILATERAL |

| |UNRELATED TO SURG | | | |

|Patient Account Number |88901 | |Patient Account Number |4356 098 |

|Patient Name |Brielle Butler | |Patient Name |Branford Butler |

|Address |1111 E. Birmingham | |Address |1111 E. Birmingham |

| |Bayport, CA 90020 | | |Bayport, CA 90020 |

|Patient Home phone # |(999) 456-2233 | |Patient Home phone # |(999) 456-2233 |

|Date of Birth |April 2, 1997 | |Date of Birth |March 12, 1980 |

|Relationship to Insured |Child | |Relationship to Insured |Self |

|Martial Status |Single | |Martial Status |Married |

|Sex |Female | |Sex |Male |

| | | | | |

|Insured Name |Branford Butler | |Insured Name |Branford Butler |

|Insured ID Number |000 00 0000 | |Insured ID Number |000 00 0000 |

|Insured Address |Same | |Insured Address |Same |

|Insured phone number |(999) 456-2233 | |Insured phone number |(999) 456-2233 |

|Insured Date of Birth |March 12, 1980 | |Insured Date of Birth |March 12, 1980 |

|Insured Sex |Male | |Insured Sex |Male |

|Insured Employer name |XYZ Corporation | |Insured Employer name |XYZ Corporation |

|Group Number |GP002 | |Group Number |GP002 | | | |

| | | | | |

|Insurance Company |Blue Cross of California | |Insurance Company |Blue Cross of California |

|Insurance Co. Address |P.O. BOX 60007 | |Insurance Co. Address |P.O. BOX 60007 |

| |Los Angeles, CA 90060 | | |Los Angeles, CA 90060 |

|Rendering Provider Name |Benjamin Blood M. D. | |Rendering Provider Name |Bobby Brown |

|Rendering Provider License Number |A38877 | |Rendering Provider License Number |G56782 |

|Rendering Provider NPI |1140276510 | |Rendering Provider NPI |0919367415 |

|Employer ID number |94-4446749 | |Employer ID number |95-4336712 |

| | | | | |

|Service facility location |Mercy Medical Hospital | |Service facility location information |Mercy Medical ASC |

|information Address |2400 Polar Avenue | |Address |2445 Polar Avenue |

|Out Patient ER |Brighton, CA 90129 | | |Brighton, CA 90129 |

|Service facility NPI |0614422200 | |Service facility NPI |212423770 |

|Billing provider information |Emergency Medical Group | |Billing provider information |Sight for Sore Eyes |

| |1232 Boston Blvd. | | |1501 Bass Drive |

| |Brighton, CA 90129 | | |Brighton, CA 90132 |

|Billing Provider ID |W98723476 | |Billing Provider ID |W762533 |

|Billing provider NPI |2655541367 | |Billing Provider NPI |3367410921 |

|Date of Service |6/30/2007 | |Date of Service |4/30/07 |

| | | |Authorization Number |133374 |

| | | | | |

|Patient was brought into the emergency room (POS 23). Patient fell from a | |Patient was scheduled for out patient surgery at Mercy Medical Ambulatory |

|horse today (ICD-9 E828.2). A problem-focused emergency room visit of | |Surgical Center (ASC POS 24). On 4/30/07, Dr. Bobby Brown performed removal |

|moderate complexity (CPT 99283-57) ($250.00) and open treatment of distal | |of lens, intracapsular for cataracts, bilaterally (CPT 66980-50) ($2500.00). |

|radius with internal fixation (CPT 25620) ($2500.00) was performed by Dr. | |On 7/10/07, Dr. Bobby Brown performed photo-coagulation scleral buckling for |

|Benjamin Blood, MD. (NOTE: E CODES ALWAYS LAST!) | |retinal detachment of the right eye (CPT 67107-RT) ($5500.00) at Mercy. |

|Diagnosis: Fracture of distal radius, open (ICD-9 813.52). Patient returned | |Diagnosis: Cataract (ICD-9 366.9) |

|to Emergency Room on 07/02/07 and a problem-focused ER visit of low | |Retinal Detachment (ICD-9 361.9) |

|complexity (CPT 99284-24) performed by Dr. Blood. | |Authorization to Release Information is on file. |

|Diagnosis: Acute asthma attack (ICD-9 493.92) | |Assignment of benefits in file. |

|Authorization to Release Information is on file. | | |

|Benefits not assigned. | | |

|Claim G |DECISION FOR SURG | |Claim H |AUTHORIZATION |

| |MULTIPLE SURGERY | | |MULTI SURGERY |

|Patient Account Number |22222 7 | |Patient Account Number |66666-7 |

|Patient Name |Tony Thompson | |Patient Name |Terry Thompson |

|Address |222 Tamarack Lane | |Address |222 Tamarack Lane |

| |Tomahawk, TN 37308 | | |Tomahawk, TN 37308 |

|Patient Home phone # |(999) 444-4444 | |Patient Home phone # |(999) 444-4444 |

|Date of Birth |7/10/50 | |Date of Birth |8/21/54 |

|Relationship to Insured |Self | |Relationship to Insured |Spouse |

|Martial Status |Married | |Martial Status |Married |

|Sex |Male | |Sex |Female |

|Insured Name |Same | |Insured Name |Tony Thompson |

|Insured ID Number |999 99 9999 | |Insured ID Number |999 99 9999 |

|Insured Address |Same | |Insured Address |Same |

|Insured phone number |Same | |Insured phone number |(999) 444-4444 |

|Insured Date of Birth |7/10/50 | |Insured Date of Birth |7/10/50 |

|Insured Sex |Male | |Insured Sex |Male |

|Insured Employer name |XYZ Corporation | |Insured Employer name |XYZ Corporation |

|Group Number |GP003 | |Group Number |GP003 | | | |

| | | | | |

|Insurance Company |Blue Cross of California | |Insurance Company |Blue Cross of California |

|Insurance Co. Address |P.O. BOX 60007 | |Insurance Co. Address |P.O. BOX 60007 |

| |Los Angeles, CA 90060 | | |Los Angeles, CA 90060 |

|Rendering Provider Name |Terrence Tew, MD | |Rendering Provider Name |Tamara Teeson, MD |

|Rendering Provider License Number |A8273 | |Rendering Provider License Number |C873332 |

|Rendering Provider NPI |6631334759 | |Rendering Provider NPI |4498470012 |

|Employer ID number |22-222222 | |Employer ID number |22-2222238 |

|Service facility location |Tomahawk Memorial Hospital | |Service facility location information |Tomahawk Women's Hospital |

|information Address |222 Hawk Street | |Address |228 Hawk Street |

| |Tomahawk, TN 37308 | | |Tomahawk, TN 373708 |

|Service facility NPI |9974237419 | |Service facility NPI |6740193320 |

|Billing Provider Information |Terrence Tew, MD | |Billing provider information |Tamara Teeson, MD |

| |7643 Lakeview Ln | | |Tomahawk Women's Clinic |

| |Tomahawn, TN 37308 | | |229 Indiana Street |

| | | | |Tomahawk, TN 373708 |

|Billing Provider ID |A8273 | |Billing Provider ID |W678823 |

|Billing Provider NPI |6631334759 | |Billing Provider NPI |449847001 |

|Referring provider information |Tamara Teeson, MD, UPIN OTH822 | | | |

|Referring provider NPI |4498470012 | |*******Authorization******** |A2007170017 |

| | | | | |

|Date of Service |9/9/2007 | |Date of Service |7/21/07 |

|Date of First Visit | | |Hospitalized |7/21-22/07 |

| | | | | |

| | | | | |

|A comprehensive consultation of moderate complexity (CPT 99244-57) ($200.00) | |While inpatient at Tomahawk Women's Hospital (POS 21), authorization was |

|was performed and it was it was determined the patient should have a bone | |obtained (NOTE AUTH #!) and a laparoscopy for visualization of pelvis viscera|

|cyst excised from the humerus (CPT 23150) ($1600.00) and excision of | |(CPT 49320) ($600.00) was performed. A D&C was also performed (CPT 58120-51)|

|olecranon bursa (CPT 24105-51) ($500.00). These services were performed on | |$150.00) with laparoscopic lysis of adhesions (CPT 58660-51) ($200.00). |

|09/09/07 at Tomahawk Memorial Hospital Outpatient (POS 22). Patient was | |Diagnosis: Menorrhagia (ICD-9 626.2) |

|referred by Dr. Tamara Teeson. | |Pelvic Pain (ICD-9 625.9) |

|Diagnosis: Tennis Elbow (ICD-9 726.32) | |Cyst Ovarian (ICD-9 620.2) |

|Authorization to Release Information is on file. | |Authorization to Release Information is on file. |

|Assignment of Benefits on file. | |Assignment of Benefits on file. |

|Claim I |ANESTHESIA | |Claim J |ANESTHESIA |

| | | | | |

|Patient Account Number |GH5246 | |Patient Account Number |485478 |

|Patient Name |Ned Norton | |Patient Name |Nancy Norton |

|Address |34578 Navaho Lane | |Address |34578 Navaho Lane |

| |Nampa, NV 80462 | | |Nampa, NV 80462 |

|Patient Home phone # |(999) 334-4443 | |Patient Home phone # |(999) 334-4443 |

|Date of Birth |May 5, 1955 | |Date of Birth |June 10, 1956 |

|Relationship to Insured |Self | |Relationship to Insured |Spouse |

|Martial Status |Married | |Martial Status |Married |

|Sex |Male | |Sex |Female |

|Insured Name |Ned Norton | |Insured Name |Ned Norton |

|Insured ID Number |77-44-3333 | |Insured ID Number |77-44-3333 |

|Insured Address |Same | |Insured Address |Same |

|Insured phone number |(999) 334-4443 | |Insured phone number |(999) 334-4443 |

|Insuredl Date of Birth |May 5, 1955 | |Insured Date of Birth |May 5, 1955 |

|Insured Sex |Male | |Insured Sex |Male |

|Insured Employer name |ABC Corporation | |Insured Employer name |ABC Corporation |

|Group Number |GP004 | |Group Number |GP004 | | | |

| | | |LMP Date |04/01/2007 |

|Insurance Company |Blue Cross of California | |Insurance Company |Blue Cross of California |

|Insurance Co. Address |P.O. BOX 60007 | |Insurance Co. Address |P.O. BOX 60007 |

| |Los Angeles, CA 90060 | | |Los Angeles, CA 90060 |

|Rendering Provider Name |Nathan Navarro, MD | |Rendering Provider Name |Norma Nelson, MD |

|Rendering Provider License Number |A87843 | |Rendering Provider License Number |C2343 |

|Rendering Provider NPI |0143755921 | |Rendering Provider NPI |8374659578 |

|Employer ID number |88-8754449 | |Employer ID number |88-8778493 |

| | | | | |

|Service facility location |Nampa Medical Center | |Service facility location information |Nampa Medical Center |

|information Address |1226 Nampa Avenue | |Address |1226 Nampa Avenue |

|Out Patient |Nampa, NV 89462 | | |Nampa, NV 89462 |

|Service facility NPI |2224351420 | |Service facility NPI |2224351420 |

|Billing provider information |Navarro Anesthesia Assoc | |Billing provider information |Norma Nelson, MD |

| |1234 Nampa Avenue | | |475 Nancy Lane |

| |Nampa, NV 89462 | | |Nampa, NV 89462 |

|Billing Provider ID |W6574 | |Billing Provider ID |C2343 |

|Billing Provider NPI |6735295837 | |Billing Provider NPI |8374659578 |

|Referring Provider Name |Bart Simpson, MD, UPIN OTH765 | |Referring Provider Name |Maria Enceinte, MD, UPIN OTH245 |

|Referring Provider NPI |0143755921 | |Referring Provider NPI |6463211077 |

|Date of Service |May 5, 2007 | |Date of Service |December 28, 2006 |

|Time under Anesthesia |Start 20:20, Stop21:40 | |Time under anesthesia |Start-10:30, Stop 17:56 |

| | | | |7 Hours, 26 mins (actual time in |

| | | | |attendance 2 hours, 4 mins) |

|***Anesthesia Units*** |( _6_ ) Units | |Hospitalized |December 28-31, 2006 |

| | | |***Anesthesia Units*** |( _8_ ) Units |

| | | | | |

|Dr. Nathan Navarro administered anesthesia for a colonoscopy with biopsy | |Dr. Norma Nelson administered continuous epidural analgesia for labor and |

|beyond splenic flexure (CPT00810-P1) ($350.00) at outpatient department of | |vaginal delivery (CPT 01967 -P1) ($1950.00) inpatient at Nampa Medical Center|

|Nampa Medical Center (POS 22). | |(POS 21). |

|Diagnosis: Excessive Gas (ICD-9 787.3) | |Diagnosis: Normal Vaginal Delivery without forceps or breech, single live |

|Authorization to Release Information is on file. | |born (ICD-9 650 and V27.0). |

|Assignment of Benefits on file. | |Authorization to Release Information is on file. |

| | |Assignment of Benefits on file. |

California Medical Association

AB 1455 Regulations: Unfair Payment Practices

Summary

Plans may not impose a deadline for claims submission that is less than 90 days for contracting physicians and less than 180 days for non-contracting physicians. An unfair payment pattern exists if a plan imposes a filing deadline that is inconsistent with the above in three (3) or more claims over the course of any three- month period.

Plans are required to forward misdirected claims to the appropriate medical group/IPA and medical groups must forward misdirected claims to the appropriate health plan. An unfair payment pattern exists if a plan fails to forward at least 95% of misdirected claims over the course of any three-month period.

Plans must accept a late claim if the physician files a formal physician dispute with the payor and demonstrates “good cause” for the claim filing delay. An unfair payment pattern exists if a plan does not accept late claims at least 95% of the time for the affected claims over the course of any three month period.

Plans must appropriately request refunds for claims that have been overpaid. An unfair payment pattern exists if a plan fails to request reimbursement of an overpayment of a claim at least 95% of the time for the affected claims over the course of any three-month period.

Plans must acknowledge receipt of all physician claims, whether or not complete, electronically, by post, phone or website. An unfair payment pattern exists if a plan fails to acknowledge the receipt of at least 95% of claims over the course of any three-month period.

Plans must provide an accurate and clear written explanation of the specific reasons that each claim has been denied, adjusted or contested. An unfair payment pattern exists if a plan fails to provide specific reasons for denying, adjusting or contesting a claim at least 95% of the time for the affected claims over the course of any three-month period.

Plans may not include a provision in a provider contract that requires a physician to submit medical records that are not reasonably relevant to the adjudication of a claim. An unfair payment pattern exists if a plan makes an unreasonable/unnecessary request for medical records on three or more occasions over the course of any three-month period.

Plans must justit to DMHC that requests for medical records more frequently than in three-percent (3%) of the claims submitted over any 12-month period for non-emergency services and twenty percent (20%) of the claims submitted for emergency services were reasonably necessary. An unfair payment pattern exists if a plan fails to justify to the DMHC the reasonableness of its requests.

Plans must reimburse claims with the correct payment including the automatic payment of all interest and penalties due. An unfair payment pattern exists if a plan fails to reimburse claims correctly at least 95% of the time during the course of any three-month period.

Plans must contest or deny claims within 45 days (HMO) or 30 days (PPO) of receipt. An unfair payment pattern exists if a plan fails to contest or deny affected claims within the required time period at least 95% of the time over the course of any three-month period.

Plans must contractually require its claims processing organizations and/or its capitated providers to comply with the requirements of these regulations. An unfair payment pattern exists if a plan fails to do so with three (3) or more of its contracts over the course of any three-month period.

Plans must provide Information for Contracting Providers, the Fee Schedule and Other Required Information disclosures to all contracted providers on or before January 1, 2004, initially upon contracting and upon the contracted physician’s request. Plans must fully disclose fee schedules and the payment rules used to adjudicate claims to physicians as well as a description of the plan’s provider dispute process. An unfair payment pattern exists if a plan fails to provide this information to three or more contracted providers over the course of any three-month period.

Plans must provide contracted physicians with 45 days notice of any modifications to the Information for Contracting Physicians, to the Fee Schedule or Other Required Information. An unfair payment pattern exists if a plan fails to provide appropriate notice to 3 or more contracted physicians over the course of any three-month period.

Plans may not require physicians to waive protections or assume any plan obligations pursuant to the Knox-Keene Act. An unfair payment pattern exists if a plan does so on 3 or more occasions over the course of any three-month period.

Plans must provide physicians with a Notice to Provider of Dispute Mechanisms whenever a plan contests, adjusts or denies a claim. An unfair payment patterns exists if a plan fails to provide physicians with the appropriate notice at least 95% of the time for the affected claims over the course of any three-month period.

Plans must acknowledge the receipt of a provider dispute within two (2) working days of the receipt of an electronic provider dispute and within fifteen (15) days of the date of receipt of a paper provider dispute. An unfair payment pattern exists if a plan fails to acknowledge at least 95% of the affected claims over the course of any three-month period.

Plans may not impose a provider dispute filing deadline of less than 365 days from the date the plan denied the claim. An unfair payment pattern exists when a plan fails to comply with the Time Period for Resolution and Written Determination requirements at least 95% of the time over the course of any three-month period.

Plans must resolve physician disputes within 45 days of receipt of the physician dispute. An unfair payment pattern exists if a plan fails to resolve at least 95% of the disputed claims during the specified time period over the course of any three-month period.

Plans cannot rescind or modify an authorization for services after the physician renders the services pursuant to a prior authorization. An unfair payment pattern exists if a plan rescinds or modifies a prior authorization for services on three or more occasions over the course of any three-month period.

For assistance with your reimbursement related problems, call CMA’s Reimbursement Help Line at 1-888-401-5911

(AB 1455 applies to Health and Safely Code §1371.37.38.9)

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