ICD 10 & CPT Codes: Basic Overview

Navigating the Business of Medicine
12 Aug 202114:22
EducationalLearning
32 Likes 10 Comments

TLDRJennifer Globen-Smith from Integral Clinic Solutions discusses the importance of understanding ICD-10 and CPT codes in the medical field. She explains that CPT codes are used for billing medical services and that some have flat fees while others are unit-based, emphasizing the need for accuracy to avoid revenue loss. Globen-Smith also highlights the complexity and specificity of ICD-10 codes, which can influence reimbursement and require a strong billing team for proper implementation.

Takeaways
  • 📚 ICD-10 and CPT codes are essential for medical professionals and businesses in the healthcare industry.
  • 🔍 CPT stands for Current Procedural Terminology, used to report medical, surgical, and diagnostic procedures to insurance and other entities.
  • 💰 CPT codes determine reimbursement from insurance companies and may have a flat fee or be billed based on quantity of services provided.
  • 🕒 Evaluation and management CPT codes differentiate between new and established patients, with new patients often receiving higher reimbursement.
  • 📈 The quantity of services (e.g., allergy tests) must be accurately reflected in billing to avoid revenue loss or claim delays.
  • 🧪 It's crucial for practices to accurately record and bill for point-of-care testing like rapid strep tests and urinalysis.
  • 🩺 ICD-10 codes are the International Classification of Diseases, used to document health issues and can affect reimbursement.
  • 📚 ICD-10 transition from ICD-9 was challenging due to the significant increase in the number of codes and specificity.
  • 🔄 Modifiers can be added to ICD-10 codes to provide additional information to insurance companies about the services rendered.
  • 👥 Having a strong billing team or RCM (Revenue Cycle Management) team is vital for reviewing claims and ensuring accurate billing and reimbursement.
  • 💬 Providers should engage with resources and communities (like podcasts) to stay informed and find support in navigating the complexities of medical coding.
Q & A

  • What do CPT codes stand for?

    -CPT stands for Current Procedural Terminology. It is used to report medical, surgical, and diagnostic procedures and services to entities such as insurance plans, accreditation organizations, and physicians.

  • What is the purpose of CPT codes in the medical field?

    -CPT codes are used to inform insurance companies or other organizations about the specific services performed for a patient, which helps determine reimbursement amounts.

  • How do evaluation and management codes differ between new and established patients?

    -New patients receive a higher reimbursement because it takes longer to document their health history and create their charts. The codes for new patients are 99203 and 99204, while established patients have codes 99212-99213-99214-99215.

  • What is the significance of the face-to-face time with the patient in CPT coding?

    -The face-to-face time with the patient is crucial as it affects the reimbursement. It's not about the total time the patient is in the office, but specifically the time the provider spends directly with the patient.

  • How can errors occur when submitting claims with CPT codes?

    -Errors can occur if the quantity associated with a CPT code is not correctly updated, leading to underbilling or overbilling, and potential delays or denials in claim processing.

  • Why is it important for private practice owners to know their practice's CPT codes?

    -Knowing the CPT codes used in the practice helps private practice owners understand which codes have a flat fee and which are unit-based, ensuring accurate billing and avoiding missed revenue.

  • What is the role of staff in recording CPT codes for point-of-care testing?

    -Staff who perform and record the results of point-of-care testing are responsible for recording the associated CPT codes, which may be overlooked if not properly monitored.

  • What is the purpose of ICD-10 codes?

    -ICD-10 codes are the International Classification of Diseases, used to classify and report diseases and health conditions. They help determine reimbursement and provide a detailed health history for patients.

  • How have ICD-10 codes evolved compared to ICD-9?

    -ICD-10 codes have become more specific and detailed compared to ICD-9, with around 70,000 additional codes added in 2015, requiring medical professionals to learn a new coding system.

  • What is the impact of accurate ICD-10 coding on medical practices?

    -Accurate ICD-10 coding is crucial as it can influence reimbursement based on the complexity of the diagnosis, and it provides a comprehensive health history for retrospective reviews.

  • Why is it beneficial to have a strong billing team or RCM management team?

    -A strong billing team or RCM (Revenue Cycle Management) team can review claims before submission to ensure accuracy, avoid missing funds, and maintain the practice's financial health.

Outlines
00:00
📚 Introduction to CPT and ICD-10 Codes

Jennifer Globen-Smith introduces the video by discussing the importance of understanding CPT and ICD-10 codes in the medical field. She explains that CPT stands for Current Procedural Terminology, which is used to report medical, surgical, and diagnostic procedures to insurance plans and other entities. CPT codes determine reimbursement for services provided, with some having a flat fee and others billed based on quantity. The video emphasizes the need for accurate billing practices to avoid missing revenue and the significance of face-to-face time with patients in determining the appropriate CPT code.

05:03
🩺 Billing and CPT Code Specifics

The second paragraph delves into the specifics of billing with CPT codes, highlighting the importance of understanding unit-based billing versus flat fee codes. It discusses the potential for errors in billing, such as forgetting to enter a CPT code for certain tests or not updating the quantity for unit-based services. The paragraph stresses the importance of having a knowledgeable staff who can review claims and ensure accurate billing to avoid revenue loss. It also touches on the challenges of adapting to ICD-10 codes, which are more specific and complex than their ICD-9 predecessors.

10:05
🌟 Navigating the Complexity of ICD-10 Codes

In the final paragraph, Jennifer Globen-Smith discusses the intricacies of ICD-10 codes, emphasizing their importance in influencing reimbursement based on the complexity of the diagnosis. She mentions the addition of 70,000 new codes in 2015 and the need for specificity, especially in specialties like orthopedics. The paragraph also introduces the concept of modifiers in ICD-10 coding and shares a humorous example of an ICD-10 code for catching on fire while water skiing. The video concludes with advice for medical providers and business owners on the importance of having a strong billing team to review claims and ensure accurate and complete reimbursement.

Mindmap
Keywords
💡ICD-10
ICD-10 stands for the International Classification of Diseases, 10th Revision. It is a coding system used by healthcare professionals to classify, track, and manage diagnoses and treatments. In the video, Jennifer discusses the importance of ICD-10 codes in influencing reimbursement and providing accurate health histories for patients. The transition from ICD-9 to ICD-10 was noted as challenging due to the significant increase in the number of codes.
💡CPT Codes
CPT Codes, which stands for Current Procedural Terminology codes, are standardized codes used by healthcare providers to report medical, surgical, and diagnostic procedures and services to insurance companies and other entities. These codes are essential for billing and reimbursement purposes. In the video, Jennifer explains that CPT codes can be either flat fee or unit-based, and it's critical for providers to understand which codes require changing the quantity to avoid revenue loss.
💡Reimbursement
Reimbursement refers to the payment made by insurance companies or other organizations to healthcare providers for the services rendered. In the context of the video, Jennifer emphasizes the importance of accurate ICD-10 and CPT coding for proper reimbursement from insurance companies. She notes that the specificity of ICD-10 codes can influence the amount of reimbursement a provider receives.
💡Evaluation and Management Codes
Evaluation and Management (E/M) codes are a subset of CPT codes that describe the range of services provided by physicians in evaluating patients, formulating a diagnosis, and developing a treatment plan. These codes are crucial for billing and are differentiated based on the complexity of the service and whether the patient is new or established. In the video, Jennifer explains that new patients receive higher reimbursement due to the additional time required for documentation and history-taking.
💡Flat Fee
A flat fee refers to a fixed amount charged for a service or procedure, regardless of the time or resources used. In the context of medical billing, some CPT codes have a flat fee associated with them, meaning the provider receives a set amount from the insurance company for that service. Jennifer explains in the video that certain CPT codes, like evaluation and management codes, have a flat fee, while others are billed based on quantity or units of service.
💡Unit-Based Billing
Unit-based billing is a method of charging for medical services where the cost is determined by the number of units of a particular service provided to the patient. This is in contrast to a flat fee, where a set amount is charged regardless of the quantity. In the video, Jennifer discusses the importance of understanding which CPT codes require unit-based billing and accurately recording the quantity of services to avoid underbilling or overbilling.
💡Modifiers
In the context of medical billing, modifiers are additional codes added to a primary CPT or ICD-10 code to provide further information about the service or diagnosis. They can indicate a variety of circumstances, such as a service being performed under special conditions or the presence of a secondary diagnosis. Jennifer explains that modifiers are used to help insurance companies understand that more than one code may be billed for the same service encounter.
💡Claim Form
A claim form is a document used by healthcare providers to submit a request for payment to an insurance company for services rendered to a patient. It includes various details such as patient information, provider details, and the specific CPT or ICD-10 codes for the services performed. In the video, Jennifer emphasizes the importance of accurate completion of claim forms to ensure proper billing and reimbursement.
💡Private Practice Owner
A private practice owner refers to an individual who owns and operates their own healthcare practice, often taking on responsibilities beyond direct patient care, such as business management, financial oversight, and compliance with regulations. In the video, Jennifer addresses private practice owners specifically, discussing the nuances they face in understanding and managing CPT and ICD-10 codes for their businesses.
💡Retrospective Chart Review
Retrospective chart review is the process of examining a patient's medical records after the fact to ensure that all services provided were accurately documented and billed. This can help identify missed charges or errors in coding, leading to corrected claims and improved revenue collection. In the video, Jennifer suggests that having a team to perform retrospective chart reviews can help healthcare providers catch errors and ensure they are reimbursed for all services provided.
💡Revenue Cycle Management (RCM)
Revenue Cycle Management (RCM) refers to the processes and administrative efforts undertaken by healthcare providers to manage and optimize the revenue stream from patient services. This includes patient registration, scheduling, billing, and collections. In the video, Jennifer emphasizes the importance of having a strong RCM team to review claims before submission to avoid missing out on potential revenue and to ensure accurate billing practices.
Highlights

Jennifer Globen-Smith introduces the topic of ICD-10 and CPT codes, emphasizing their importance in the medical field.

CPT stands for Current Procedural Terminology, which is used to report medical, surgical, and diagnostic procedures and services.

CPT codes are essential for reimbursement, informing insurance companies and other organizations about the services performed for a patient.

Evaluation and management codes are flat fee CPT codes used across all specialties, with different amounts for new and established patients.

The 2021 changes simplified the requirements for E&M codes, focusing on the time the provider spent face-to-face with the patient.

Some CPT codes are associated with a flat fee, while others are billed based on quantity, requiring attention to detail when submitting claims.

Errors in submitting claims can lead to missed revenue, emphasizing the importance of understanding CPT codes for medical practice owners.

ICD-10 codes are part of the International Classification of Diseases and are crucial for accurate diagnosis and reimbursement.

The transition from ICD-9 to ICD-10 was challenging due to the significant increase in the number of codes and the need for specificity.

Modifiers can be added to ICD-10 codes to provide additional information to insurance companies about the services rendered.

ICD-10 codes reflect real-life medical situations, even if they seem absurd, such as the example of catching on fire while water skiing.

The podcast 'BS Free MD' provides comic relief and discusses the frustrations of ICD-10 codes from a doctor's perspective.

Having a strong billing team or RCM management team is essential for reviewing claims and ensuring accurate billing and reimbursement.

Providers should bill for all services provided, even if some insurance companies do not reimburse for certain procedures.

Jennifer Globen-Smith encourages providers to seek information on CPT and ICD-10 codes and to ask questions for further guidance.

The video provides a comprehensive overview of CPT and ICD-10 codes, their significance, and practical tips for medical practice owners.

Transcripts

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