Reimbursement Issues
...coding systems that APNs will use for reimbursement. These are 1) International Classification of Disease, 9th edition (ICD-9-CM), 2) Physicians Current Procedural Terminology (CPT) guidelines and codes, 3) Health Care Finance Administration (HCFA) Common Procedure Coding System (HCPC) codes. The ICD-9-CM codes are diagnostic codes that identify the condition, illness, or injury to be treated. The ID-9 is a useful tool in the area of classification of morbidity data for indexing medical records, nedical care review, ambulatory and other medical care programs, and basic health statistics. The use of these codes is strongly recommended when billing insurance carriers because providers in any setting can use this diagnositic system. The HCFA has prepared guidelines for using ICD-9 codes and instruction on how to report them on claim forms. One can obtain a copy of the guidelines for using these codes from the Medicare intremediary. Each service or procedure performed for a client must be represented by a diagnosis that would substantiate those particular services or prodedures. For example a "dipstick urinalysis" would be substantiated by a diagnosis such as urinary tract infection. CPT codes are those listed in the Physician's Current Prodedural Terminology (CPT) manual published annually bu the American Medical Association (AMA). CPT specifies the prodedure or medical service provided. CPT lists over 7,000 descriptive terms used in coding medical services and procedures performed by APN's. All services or procedures paid for by third-party payers are listed in the CPT manual. Codes known as the Evaulation and Management (E/M) codes are part of the CPT system. Each code is assigned a procedural description which is referred to as the nomenclatore or medical practice performed by multiple providers in many locations. Medicare and state Medicaid carriers are required by law to use CPT coedes for the payment of health insurance claims; the majority of insurance carriers recognize and use CPT codes. Although there may be a CPT code that describes a current medical procedure, and insurance carrier is not obligated to reimburse the provider for that service. The CPT codes selected for reimbursement billing should accurately reflect the services or prodedures performed. HCFA Prodecure Coding System (HCPC) is used for reporting supplies and medical equipment. To receive full reimbursement, the APN needs to code both diagnosis and services to the greatest possible level of specificity. Inaccurate coding results in partial reimbursement, reimbursement delay, and possible prosecution for fraudulent billing. Medica...