Submiting claim - Common coding requirments

 Diagnosis Codes

All claims must include the proper ICD-9-CM diagnostic code.

The Centers for Medicare and Medicaid Services (CMS) provides specific guidelines to aid in standardizing U.S. coding practices. The guidelines for outpatient facilities, physician offices and ancillary care are summarized below:

• Identify each service, procedure or supply with an ICD-9-CM code to describe the diagnosis, symptom, complaint, condition or problem.

• Identify services or visits for circumstances other than disease or injury, such as follow-up care after chemotherapy, with V codes provided for this purpose.

• Code the primary diagnosis first, followed by the secondary, tertiary and so on. Code any coexisting conditions that affect the treatment of the patient for that visit or procedure as supplementary information. Do not code a diagnosis that is no longer applicable.

• Code to the highest degree of specificity. Carry the numerical code to the fourth or fifth digit when available. Remember, there are only approximately 100 valid three-digit codes; all other ICD-9-CM codes require additional digits.

• Code a chronic diagnosis when it is applicable to the patient’s treatment or when follow-up on the condition is requested during the visit.

• When only ancillary services are provided, list the appropriate V code first and the problem second. For example, if a patient is receiving only ancillary therapeutic services, such as physical therapy, use the V code first, followed by the code for the condition.

• For surgical procedures, code the diagnosis applicable to the procedure. If, after the procedure has been done, the condition necessitating the surgery is more specifically identified, or even determined to be different than the preoperative diagnosis, code the most specific diagnosis determined to be the reason for the surgery.

Procedure Codes
Common Procedure Terminology

CPT is a standardized system of five-digit codes and descriptive terms used to report the medical services and procedures performed by physicians or health care professionals. It was developed and is updated and published annually by the American Medical Association (AMA). CPT codes communicate to physicians, health care professionals, patients, and payors the procedures performed during a medical encounter. Accurate CPT coding is crucial for proper
reimbursement from payors and compliance with government regulations.

The AMA revises and publishes the CPT Book on an annual basis. Appendix B always consists of a summary of additions, deletions and revisions to the current edition. Of these three types of changes, only the descriptions of revised codes appear in Appendix B, so you must refer to the manual itself to look at the descriptors of the new codes.

All physicians and health care professionals must use the appropriate procedure codes from the most recent HCPCS and CPT coding manuals. Claim processing cannot be completed without accurate procedure codes which reflect the services provided to enrollees.

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