Answers to common coding questions for practice management.

- Fee & Coding

How long should I wait to check claim status?

How do I select the appropriate diagnosis code?

What is the difference between an assigned and a non-assigned claim?

Is documentation required for a Modifier 22 claim?

Even when I send in additional documentation to support medical necessity, the services are still sometimes denied because requested information was not provided or was insufficient or incomplete. What am I doing wrong?

Does Medicare have guidelines for required documentation?

What can I do to be sure my documentation supports the services I bill?

How many services should be listed on the claim when using the modifier 50?

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How do I check the status of a claim?

Effective October 1, 2003, the Centers for Medicare and Medicaid Services (CMS) required that all claim status inquiries be performed by the carrier's automated Interactive Voice Response (IVR) System.

Our IVR system is fast and convenient. Enhancements to the IVR have improved functionality and ease of use. Shortcuts have been added for entering provider numbers and beneficiary Health Insurance Claim (HIC) numbers. The IVR also provides information about the last three checks on file, how to request a duplicate remittance advice notice, and fee schedule allowances.

The IVR is toll-free at 1 877 567-7271. You will need to have the beneficiary's HIC number, the date(s) of service, total amount billed and your provider identification number available.

The Carrier has 30 days to process a claim. Providers should wait 30 days after submitting their claims before contacting the Carrier for a claim status check.

The full ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) system consists of three volumes. For Medicare purposes, providers should only use the first two volumes.

ICD-9-CM codes contained in the two-volume set are designed to be used together. The third volume of ICD-9-CM contains procedure codes and is not to be used. Providers should continue to report the procedures using the Physicians' Current Procedural Terminology (CPT).

The portion of the ICD-9-CM book to be used by providers consists of codes within two general ranges:

Diagnosis coding is a three-step process. First, review the medical record to extract the pertinent written descriptions of the disease or symptoms. Second, look up the disease, signs and symptoms, or condition in Volume 2, Diseases Alphabetic Index and locate the corresponding code. Third, look up the corresponding code in Volume 1, Diseases Tabular List and choose the most specific code that accurately describes the patient's condition.

Because Volume 2 contains many diagnostic terms not used in Volume 1, and Volume 1 uses more descriptive terms, it is important to use both books when finding the most accurate code. In general, it is best not to code directly from the alphabetic index.

For patients who receive only ancillary diagnostic services during an encounter, report the diagnosis and symptoms or signs for which the services are being performed.

Codes must be used at their highest level of specificity and must not be truncated.

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ICD-9-CM is composed of codes with three, four, or five digits. Codes with three digits are included in ICD-9-CM as stand alone codes or as the heading of a category of codes that are further subdivided by the use of fourth or fifth digits, which provide greater specificity. A truncated diagnosis code is an ICD-9-CM code not reported to the highest level of specificity, e.g., claims submitted with a 3-digit diagnosis code where a 4- or 5-digit code exists. Diagnosis codes must be submitted to the highest level of specificity. The ICD-9-CM manual also gives the complete codes and their descriptions. Remember:

Physicians may report a maximum of four unique diagnosis codes per claim when billing for their services. For each line of service, the physician must indicate which of the reported diagnosis codes relates to the service(s) reported on that line (diagnosis code pointer). Of the diagnosis codes reported, the physician must select the diagnoses which best describes the reason for the procedure.

In instances where the patient has more than four conditions present at the time of treatment, the primary diagnosis code that is chiefly responsible for the services reported on the claim is to be listed in the first position, followed by the secondary, tertiary and quaternary. Procedures that cannot be related to any of the four diagnoses must be reported on a separate claim with the appropriate diagnosis.

Please note: ICD-9 codes should never be reported to Medicare with decimal points. For example, ICD-9 743.06 would be reported to Medicare as "74306".

An assigned claim means the provider will accept the Medicare allowed amount as full payment for a given service. Medicare will make payment directly to the provider. The patient is responsible for the co-insurance, which is the difference between the Medicare allowed amount and the amount Medicare paid directly to the provider. The co-insurance is usually 20% of the allowed amount.

For example, if Medicare approves payment to the provider for $100.00, Medicare would pay 80% ($80.00). It is the patient's responsibility to pay the difference between what Medicare allowed and what Medicare paid. In this case, the patient would pay $20.00 (20% of the Medicare allowed amount), unless the have a secondary or supplemental insurance.

A non-assigned claim means the provider will not accept the Medicare allowed amount as full payment. Medicare will make payment to the patient. Most services are subject to "limiting charge" regulations. The provider cannot charge the patient more than 115% of the Medicare allowed amount for services subject to limiting charge. It is the patient's responsibility to pay the full billed amount to the provider for services that are not subject to limiting charges (such as non-covered Medicare services).

Yes. Modifier 22 signifies an unusual procedural service; therefore, when submitting a surgical claim, documentation must be submitted with the claim (i.e., operative note) indicating the medical necessity for the unusual procedural services.

When you receive an Additional Documentation Request (ADR), you must return the documentation within in thirty (30) days, you claim will be subject to a denial. Also make sure you are submitting the appropriate documentation.

Remember when sending in supporting documentation, send the actual contemporaneous record (progress note, report of diagnostic tests, session note, procedure note). A narrative of the services that was rendered would be considered insufficient documentation

"No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period".

There must be sufficient documentation in the medical records to substantiate the services being performed and to verify the services being billed. If there is no documentation, there is no justification for the services. If there is insufficient documentation to support claims that have already been paid by Medicare, the reimbursement made may be considered an overpayment and the funds may be recouped.

An appropriately documented medical record will give a clear picture of a patient's health history and affords Medicare the ability to determine the medical necessity of a billed service upon review. The general principles of medical record documentation are applicable to all types of medical and surgical services. The article published in the June 2004 Medicare News, "Critical Importance of Adequate Documentation", provides recommendations intended to assist physicians with adequate coding and documentation. Remember, if it is not documented, it is not done.

The modifier 50, bilateral services, is used when the service being provided is being provided bilaterally. Remember when you use the modifier 50 the number of services should be "1", not "2". The modifier 50 means both sides (Right and Left). There is no need to use modifier 50 and the modifiers RT and LT.

20601- Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g. shoulder, hip, knee joint, subacromial bursa)