How2Day: Problems in Billing & Coding

Billing an x-ray requires proper CPT coding and modifier use. ballyscanlon/Stockbyte/Getty Images
Medical codes are the stepping stones between medical facilities, physicians and insurance companies. Medical coders use documents, such as medical records and lab reports, and create claim forms for billing insurance companies. The insurance companies review the codes and charges, making a determination regarding the payment. Errors in coding cause problems with the medical billing, resulting in non-payment or reduced payment.

Billing services and procedures is done by using a correlation Current Procedural Terminology (CPT) code. The American Medical Association (AMA) provides a list of codes that correlate with procedures and services performed in clinics and hospitals. These codes are updated annually.

Not using the most current CPT code is a common problem in medical billing, since insurance companies recognize and pay claims based on the CPT codes provided by the most current manual from the AMA.

The Centers for Disease Control and Prevention (CDC) provides a list of diagnosis or International Classification of Diseases (ICD) codes. These codes are used in conjunction with CPT codes and provide medical necessity, the deciding factor for insurance companies regarding payment of claims, according to the American Academy of Family Physicians.

Using a diagnosis code that does not show medical necessity generally results in denial of a claim. For instance, a physician performing an X-ray on a patient's hand and using a diagnosis code for diabetes screening, V77.1, does not denote medical necessity and results in non-payment of the claim.

In addition to the proper CPT code, a medical coder often adds a modifier to ensure the insurance company receives additional information necessary for accepting and processing a claim. A modifier provides details, such as extenuating circumstances, regarding the procedure or service. For instance, a modifier of RT used on an X-ray code tells the insurance company it was done on the right side of the body. Additionally, if a procedure takes longer than usual, a modifier of 22 is added. Not adding a modifier when necessary may result in a denial or a reduced payment of the claim.

How2Day