Diagnosis and Procedure Codes

The U.S. Department of Health and Human Services (HHS) has made the final announcement regarding the rule that will ensure a smooth progression of the United States' ongoing transition to an electronic health care environment with the introduction of new healthcare code sets to be used in transactions for electronic healthcare.

The ICD-10 diagnosis and procedure codes are all set to replace the existing ICD-9 CM code set. The ICD-10 codes will be used on all HIPAA transactions which will also include outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. If this is not done then the claims and other transactions will be rejected and will require to be resubmitted again. So it's essential to start now to prepare for the change as delays may have a negative impact on provider reimbursements.

In today's healthcare industry 13,500 ICD-9-CM volume 1 & 2 codes are used to describe various diagnoses. ICD-9 diagnosis codes are 3-5 digits in length (e.g., 821.01 – Closed Fracture of shaft of femur) but with ICD-10 the length of diagnosis codes will increase to 3-6 alphanumeric characters plus a qualifier (e.g., S72.344 – Displaced spiral fracture of shaft of right femur). Moreover, there will be almost 69,000 codes that will increase specificity.

To report inpatient procedures around 4,000 ICD-9 CM volume 3 codes are used. ICD-9 procedure codes are 3-4 digits in length (e.g., 47.01 – Laparoscopic appendectomy). But in ICD-10 the length of inpatient procedure codes will increase to 7 alphanumeric characters (e.g., ODTJ4ZZ – Laparoscopic appendectomy). There will be 72,000 codes that will highlight greater detail than the existing procedure codes.

According to BCBSNC, in order to be compliant with the Federal ICD-10 regulations, only those claims will be accepted that will document ICD-10 diagnosis and procedure codes for services rendered on or after 10/1/2013. BCBSNC has also decided to change all the media like electronic, web, paper, FAX and telephonic communications to use ICD-10 codes .

If you are looking forward to maximize your reimbursements you need to take care of all the modifiers in medical billing that you are using. Sometimes, reporting a modifier can be tricky, especially when one needs to combine the CPT modifiers with Medicare's ever-changing regulations. If you are not updated with the proper usage of modifiers in medical billing, you are not only at the risk of losing deserved pay but also decrease your cash flow! Thus to avoid this situation we bring you top four tips that will help you report correct modifiers:

1) Modifier 26
By using modifier 26, it can be billed separately for an interpretation on a radiological service. The hospital or the imaging centre bills separately for the equipment, room, film and technician and the physician's interpretation is often not considered. If the interpretation is done by a physician who is not employed by the hospital and belongs to some other professional group, then he deserves a reimbursement. So if the service is reported with modifier 26, then this loss of reimbursement can be compensated.

2) Wondering what's the difference between modifier 58 and 78?
Modifier 78 should be used when there is any condition that is related to the initial surgery, for instance when there is a complication that requires a related surgery during postoperative period and requires a return to the operating room.

Important tip: When a postoperative procedure is performed unexpectedly then you should use modifier 78.

On the other hand, modifier 58 should be used when postoperative therapy is represented or when the procedure is planned at the same time of the original procedure, as per Medicare.

(It's important to check the op notes for clarification and the physician should report whether or not the procedure was planned).

3) Modifier 59
CCI does not allow two bundled codes to be billed on the same date. But sometimes modifier 59 is used to override an edit. Modifier 59 can only be used when the services are separate, distinct, and medically necessary or it can land you in serious compliance issues.

4) Modifier 50
If you use modifier 50 for certain surgical procedures it might vary the pay that you get from Medicare, because some procedures are unilateral and doesn't qualify for full reimbursement under the bilateral version. Column Z in Medicare Physician Fee Schedule will help you determine when to use this modifier in medical billing.