Medical coding standards are set forth by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which identifies coding standards and acceptable entities. Following medical coding standards is important when billing insurance companies, since it allows for the need of medical necessity to be met. Using the correct codes and modifiers could mean the difference in a claim being paid or denied.
Current Procedural Terminology (CPT)
The American Medical Association (AMA) uses the Current Procedural Terminology (CPT) manual to set medical coding standards for procedures. The services performed in medical offices, labs, diagnostic centers and hospitals are represented by CPT codes. The codes consist of five numerical digits. Each code represents a service such as an office visit, surgical procedure or lab test.
Health Care Common Procedure Coding System (HCPCS)
The Centers for Medicare and Medicaid Services (CMS) set the standard codes for the Health Care Common Procedure Coding System (HCPCS). These codes represent non-medical items and supplies not represented by the CPT. They include prosthetics, orthotics and medical supplies. National Drug Code (NDC) codes are used to identify the product, vendor and package size of all medications.
International Classification for Diseases (ICD)
A medical coding standard set forth for representing diagnosis and conditions is the International Classification for Diseases (ICD). It is a list of codes that are three digits, plus additional digits up to two places. The ICD code is used in conjunction with the CPT code to establish medical necessity for a procedure rendered.
Modifiers
On an insurance claim form, modifiers are added to CPT codes to make the code more precise. It gives the insurance company more information. For example, when an X-ray is performed on the right hand, an "RT" modifier is added to the CPT code to follow coding standards.
Correcting Claims
Coding standards allow for insurance claim forms to be corrected and rebilled. If a CPT or ICD code is incorrect and the insurance company denies the claim, it is standard for the coder to correct the codes to meet medical necessity and mark the claim as a "corrected claim." The insurance company then reviews the claim for payment.
Tags: coding standards, insurance company, medical necessity, Care Common, Care Common Procedure, Classification Diseases, Coding System