Radiology

Laboratory

Medicine

Reports & Modifiers

ICD-9-CM Coding (Diagnostic Coding)

‘E’ Code Section

HCPCS/Level II Codes (Supplies Coding)

Charge Ticket/SuperBill

Medical providers, both inpatient and outpatient, communicate with insurance carriers by means of numeric codes. These codes describe both what was done to the patient (CPT Coding) and the medical necessity for treatment (ICD-9 Coding). Some carriers require another set of codes for billing supplies (HCPCS Codes). While occupational healthcare providers utilize national codes for reporting services, some states devise codes particular to those states, which may generate additional reimbursement. This section will explore the basics of medical coding, with particular attention to occupational health.

The CPT Manual is used nationally by all providers. It contains thousands of five-digit codes that describe what a medical practitioner does, including office visits, surgery, and physical therapy. Additionally, these codes may be used to determine fee schedules. Because each code has a unique descriptor, it is possible to assign relative value units to each code. These units will reflect the work done by the practitioner and the complexity of the procedure. Thus, a minor surgical procedure (simple laceration) would carry fewer units than a major procedure (repair of a fracture). States devise monetary conversion factors for each type of code, which are multiplied by the relative value units to determine fees.

The CPT contains six sections: Evaluation & Management (E&M), Anesthesia, Surgery, Radiology, Laboratory & Pathology, and Medicine. It is updated annually by the American Medical Association, which is responsible for these codes. Relative value units are assigned to new codes by the state office responsible for work injuries. But, not all state agencies use the current year’s CPT Manual, so occupational providers must verify which year is accepted by their state.

Evaluation & Management

The Evaluation & Management section may be used by any physician. The codes in this section start with the number 9. Office visits are the first codes in the Manual, and these are divided into New Patient visits and Established Patient visits. For occupational health providers, most workers’ compensation state laws apply a unique rule to these visits: whenever there is a new date of injury, the practitioner is instructed to use a New Patient code. This is important, since New Patient codes pay higher than Established Patient codes. While workers’ comp carriers are quick to recognize when a New Patient code has been applied incorrectly, the reverse is not true, so it is vital that dates of injury be properly captured and documented to alert the physician/coder.

Consultation codes are also found in Evaluation & Management. An office visit becomes a consult when the patient is sent from one physician to another for opinion/advice. This must be documented in the chart as "patient seen in consultation," not as a referral. Referral means something different to insurance carriers: a referral does not imply communication between two physicians. Besides documenting the need for the consultation, the physician seeing the patient generates a written report, which goes back to the original physician. Again, this is documented and supports the use of higher-paying consultation codes. If the consulting physician keeps and treats the patient instead of sending him/her back, Established Patient office visit codes are used when seeing the patient for return visits.

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Many occupational healthcare providers do consultations. They may choose from three sets of consult codes: inpatient, outpatient, and second opinions. Consult reports may be additionally billed in some states. (Report codes will be discussed in the Medicine section.) Many codes from the E/M section require the practitioner to choose a level of service that best describes the services provided. Office visits and outpatient consultations have five levels of service. By documenting the history taken and the examination performed, as well as the complexity of medical decision-making, the practitioner records a level ranging from problem focused to comprehensive. Relative value units, and thus reimbursement, increase as the level of service rises.

The importance of documentation cannot be overemphasized. All coding is based on documentation. When insurance carriers and/or review companies audit charges, documentation is closely scrutinized to be sure that code levels are justified. Conversely, if charges are reduced by "downcoding," documentation is the only defense. Review companies may routinely downcode, suspecting that higher-level codes cannot be supported.

Another useful set of codes from the E/M section is Prolonged Services. These codes are assigned on the basis of time. While private carriers link reimbursement of these codes to treatment of the patient, many carriers and state laws also recognize use of these codes when the practitioner is not with the patient but is spending time reviewing records, doing an ergonomic analysis, or detailing work limitations, so this is an area unique to occupational medicine where additional revenue may be captured.

The Surgery section of CPT contains those codes dealing with invasive procedures, from venipuncture to brain surgery. Codes in this section begin with numbers 1 through 6. There are rules unique to this section, as with all sections in CPT. Assignment of surgical codes depends on the surgical procedure performed, not on documentation of patient history or exam, as in the E/M section. Careful reading of notes in the Surgery section is necessary. Examples: repair codes require both the site of the repair and the size; when a physician reduces a fracture, any cast or splint is included at the time of initial treatment; lesion removal requires the physician to identify tissue as malignant or benign to properly code.

Surgical codes are subject to a "global" billing rule, which says that when a surgery is performed, the patient’s pre-operative visit, the supplies used, and a certain number of follow-up days are included in the reimbursement and may not be separately billed. Codes in the Surgery section followed by a star or asterisk fall outside this rule for many carriers or state law, and allow additional billing for a New Patient visit, supplies used, and return visits for suture removal. Knowing which carriers or states recognize the starred procedures can make a measurable difference in reimbursement. Scattered throughout the CPT, but of particular note in the Surgery section, are add-on codes. These codes contain the word(s) "each" or "each additional" in the descriptor. An example is "each lesion," which is a direction to the physician/coder that if more than one lesion is removed, each lesion is coded separately when billing. Missing one word in the descriptor can have dire consequences for charge capture.

The Surgery section contains 16 subsections, most of which are arranged anatomically. Subheadings further divide by the procedure performed. Guidelines and notes particular to each subsection are found throughout, and require careful scrutiny.

Radiology codes comprise the next section of CPT, where codes begin with the number 7. Here are found x-rays, CT scans, MRIs, and ultrasounds. Many codes from this section may be coded in one of three ways, depending on the work performed. The professional component, which identifies radiological interpretation, can be broken out of the main code by use of a modifier, and will be paid at a percentage of the total fee. Likewise, the technical component, which describes the technologist’s services, can be broken out and billed separately. This allows for billing in the event the occupational health practitioner is reading a film brought in from another source. If the office or clinic has an x-ray machine and technologist on site, the code may be billed without being broken down, allowing reimbursement for both components.

Laboratory procedures are coded from the next section, where the codes begin with 8. This section contains codes for urine drug screens, breath alcohol tests, and blood tests, among others. Drug or HIV/Hepatitis B testing may be required as part of work injury treatment but may or may not be billable, depending on state rules. Guidelines will direct the physician/coder to the type of test performed and if it is billable to the carrier or employer.

The final section of CPT is called the Medicine section, and here again, codes start with a 9. This section contains mainly non-invasive diagnostic and therapeutic services. There are several specialized types of testing found here, including EKGs, audiologic function tests, nerve conduction studies, spirometry, and oximetry. The section begins with coding for therapeutic injections and immunizations. It is important to know the year of the CPT being used by the state, since changes made to some of the codes in 2001 may not be state-approved.

A distinction is made between immunizations, which are prophylactic in nature (tetanus, Lyme disease), and injections of medications given for treatment of illness/injury. Immunization codes contain the name of the vaccine in the descriptor and are coded along with an administration code. Injections, on the other hand, are coded from the HCPCS manual. Only the code identifying the route of administration is found in CPT. This is an often-overlooked source of revenue. Many physicians/coders are unaware that two codes should be billed every time an injection/immunization is given: the substance given and its administration. Since tetanus shots are frequently given to injured workers, missing the accompanying administration code can be costly.

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Physical medicine and rehabilitation codes are also found in this section, but the codes found here are used mainly by private carriers. This is an area where state-specific codes are of vital importance. Most states have expanded, and in some cases almost totally replaced, physical therapy codes for use by occupational health providers. Ground rules will vary by state and often increase revenue beyond what can be coded in the national CPT manual. Physical therapists need to be informed of both sets of codes and when it is appropriate to use each set.

CPT has only one report code, which is inadequate for the range of reports required in occupational medicine. Here again, the state-specific codes take precedence when billing for required services. Some of the reports involve specialized knowledge and are reimbursed accordingly. Careful perusal of ground rules may reveal additional opportunities to recoup payment for physicians’ services, including use of Prolonged Services codes (found in the E/M section) for lengthy review of documentation, x-rays, etc. Special services, such as seeing patients after hours and/or Sundays/holidays are allowed in some states in addition to E/M visits and procedures. There are codes in the CPT that may be expanded upon in the state manual.

Besides the five-digit codes, CPT and some state manuals contain two-digit modifiers. These digits modify or change the meaning of the code to which they are appended. Some modifiers are explanatory and describe bilateral x-rays or multiple surgical procedures. Others allow billing for E/M services at the same time as a procedure, even though the procedure has no star. State manuals may provide modifiers for unique situations, such as an interpreter or services legally exceeding ground rules. In any case, modifiers allow the practitioner to notify the insurance carrier that an unusual circumstance exists for which additional payment must be made.

The other aspect to coding involves the ICD-9, an international coding manual, containing diagnostic information or why the patient was treated. This manual is used throughout the United States, with no other state-specific manual required. Codes may have three, four, or five digits indicating the level of specificity. Three-digit codes are assigned if the coding category does not contain four-digit codes; four-digit codes are assigned if no five-digit codes exist; five-digit codes must be used where available. Claims will be denied if five-digit codes are not assigned when present in ICD-9. Most frequently the denial will indicate "lack of medical necessity," a sure sign that the diagnostic coding is incomplete.

Outpatient coding in ICD-9 uses Volume I and Volume II. Volume I is the Tabular Index, the section of the book where the numeric codes are found. Volume II is the Alphabetic Index, where all diagnostic coding begins. Identification of the main term in the physician’s diagnostic statement leads the coder from Volume II to Volume I and the actual code used in billing the insurance carrier.

Here again, as with CPT, documentation in the medical record provides the basis for coding. Written diagnostic statements may include specific diagnoses, signs/symptoms, or other complaints that are converted to ICD-9 codes. Diagnoses noted as "probable," "suspected," "questionable," or "rule out" may not be coded in the outpatient setting, leaving the signs or symptoms to be used.

Whatever diagnostic code is assigned, it must support the service or procedure performed. Linking CPT and ICD-9 correctly results in payment; failure means denial and subsequent rebilling. For example, when a patient receives physical therapy on one body area, with one date of injury, linking the treatment to the diagnosis is straightforward. However, when a patient receives treatment on two body areas, with two separate dates of injury and a different diagnosis for each body area, matching treatments to diagnoses becomes more complex. Documentation must clearly guide the coder and be able to support treatments in each case. Data entry personnel must be alert and may benefit from access to the chart notes.

Volume I (Tabular Index) consists of 17 chapters that classify diseases and injuries, plus two sections that contain supplementary codes. Codes in the supplemental sections are alphanumeric, starting with either V or E. Codes in the V code range describe reasons for encounters, not necessarily for an illness or injury. Examples include screening for TB (V74.1), observation following an accident at work (V71.3), and testing for blood alcohol (V70.4).

The E code section is of major value to occupational health providers. These codes, while never primary codes, "complete the picture" for the workers’ comp carrier in describing what caused the injury or illness. For example, category E919 details accidents caused by machinery; E920.5 codes an accidental needlestick; categories E880-E888 describe accidental falls. Use of supplemental E codes can help move a claim through the process without providing additional chart notes. Of the 17 chapters of numeric codes in Volume I, those most useful in occupational health are chapters 16 (Symptoms, Signs, and Ill-Defined Conditions) and 17 (Injury and Poisoning).

Thorough understanding of the complex rules of these chapters, use of appropriate fifth-digit codes assigned extensively in Chapter 17, and judicial use of E codes are vital in the billing process. For example, when coding multiple injuries, the most severe injury is the principal diagnosis. Many injury codes require fifth digit assignment to provide information regarding level of consciousness, specific anatomical sites, and severity of injuries. Fractures can be coded as "open" or "closed;" if a dislocation is diagnosed with a fracture, only the fracture is coded. Correct code assignment can mean the difference between prompt payment and endless delays, denials, and rebillings.

CPT codes do not cover all services provided to patients, particularly supplies. The HCPCS five-digit alphanumeric codes allow for continuity and specificity in billing. Each code has a unique descriptor so that braces, crutches, casting supplies, surgical trays, and the myriad of other supplies can be tracked, assigned specific pricing, and billed. Codes for injectable materials are found in this manual and, combined with the CPT code identifying the route of administration, are used to bill when the patient receives an injection as part of the treatment. A Table of Drugs is found in this manual as well, but in some states, drugs may require additional billing formats and information such as dosage, NDC numbers, and/or invoices to reimburse. As the cost of supplies continues to rise, the HCPCS manual and knowledge of its use become more important to recouping revenue.

How do the practitioner and coder make sense of the coding rules and adequately record what is done to the patient, as well as explain medical necessity? The use of a charge ticket or SuperBill is vital; it should be particular to the physician office and/or clinic. Sections for each set of codes (CPT, ICD-9, and HCPCS) should be accurate and current. Mnemonics such as the stars on starred procedures, sites and sizes for repair codes, and fifth-digit alerts on ICD-9 codes can mean a measurable difference in revenue. The charge ticket brings all relevant information to one useful piece of paper. Annual updates keep the practitioner apprised of code changes necessary to avoid denied claims. Design of any charge ticket should be a joint venture between the practitioner and the coder/reimbursement analyst.

Medical coding is complex and requires the use of three manuals, each with its own codes and rules. Occupational health billing for workers’ compensation may require an additional, state-specific manual. Coding is as important to the overall reimbursement process as the required reports, and is likely to increase as computerization of data expands and the financial margins of providers shrink. Providers and billers who are continually trained in the nuances of workers’ compensation billing and coding are essential to the occupational clinic’s financial success, which is predicated on optimal billing and coding procedures. 

Part 1 of this two part series is also available on-line.

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