Inpatient Claims, Billing, Coding And More!

When a physician goes to the hospital to visit a patient, you have an inpatient claim for the hospital stay, services that are provided as part of that stay and in nursing homes and some inpatient rehab facilities. But you also have your professional services if the physician is not employed by the hospital. And CPT codes with the evaluation and management codes are used to bill for those professional services.

When the patient comes to the health centre or you go to your own provider or clinic, the CPT codes are used to identify what service you received. In these evaluation and management visits, there are different levels and there's criteria for each of those codes. And they're separated into general visits. There are preventive visits, there are psychological visits and there are established patients and new patients.

A patient is a new patient if they have not been seen in that facility by that provider or another provider of the same specialty for three years. The difference between those, between the not-so-established and a new patient, is reimbursement.

Often times, a new patient will require more time and expertise to go through their complete history, find out what's wrong with them, get to know them , et cetera, than non-established patient. So your new patients usually take longer and the reimbursement is usually higher for the new patient E/M codes than it is for the established.

In the CPT codes, there are usually 5-digit numeric codes. We also add modifiers to some of these. The index list services and procedures are in alphabetical order. The books are arranged in sections such as E/M, anesthesia, surgery, radiology, and laboratory. The laboratory are the 80,000 codes, radiology are the 70,000 codes and so on.

Each section provides an introduction with general guidelines like it does in ICD-9. Simple punctuation marks are used to assist with correct usage of this code. Some codes will be listed in there. They have a line through it. They'll have a symbol that will indicate it's no longer a valid code.

The reason you keep these valid codes in your system is if you're going to do some financial analysis, quality studies and you're going to go back a year. If you had deleted those codes, you would be removing information that you need for that analysis. So, you do not remove those codes from your system. If you have an electronic system, you only inactivate them.

So once they have been deleted by CMS or the American Medical Association, they are no longer valid to submit on current claim, if not in CMS. But you still keep that information in your system so that you could do study and analysis from previous fiscal years.

Modifiers are also used to further clarify what was done when the code does not specifically describe a procedure. You code to the highest level of specificity. But in CPT, there are modifiers that say one might be that you can only have one visit per day in a physician's office.