Claim Basics

Medical Claims:

Medical claims are medical bills submitted to health insurance carriers for services rendered to patients’ by providers.

 

Diagnosis Codes:

(Commonly known as ISC-9 or Dx), are codes used as a tool to identify diseases, symptoms, injuries and disorders.

 

Invalid Diagnosis vs. Valid Diagnosis Codes:

Diagnosis codes are to be used at their highest level of specificity:

  • Assign three-digit code only if there is no four-digit sub classification for that category
  • Assign four-digit code only if there is no fifth-digit sub classification for that category
  • Assign the fifth-digit sub classification code for those categories where it exists

 

Procedure Codes:

(Commonly known as CPT codes), Procedure codes are developed by the American Medical Association and are used by doctors to describe and bill for services rendered to patients.

Evaluation & Management Coding:

  • Commonly known as E/M coding
  • E/M codes are a subset of CPT codes
  • E/M codes are grouped by location, type of care, and may have further subdivision such as a new patient and established patient visits.

 


 

 

E/M Groups:

 

1.)   Established patient complaint codes:

  1. 99215: ESTAB PT W/COMPLAINT HIGH COMPLEXITY
  2. 99213: ESTAB PT W/COMPLAINT LOW COMPLEXITY
  3. 99211: ESTAB PT W/COMPLAINT MINOR COMPLEXITY
  4. 99214: ESTAB PT W/COMPLAINT MOD COMPLEXITY
  5. 99212: ESTAB PT W/COMPLAINT STRAIGHTFORWARD

2.)   Established Patient Prevention Codes:

  1. 99394: ESTAB PT. PREVENTIVE VISIT AGE <18
  2. 99395: ESTAB PT. PREVENTIVE VISIT AGE 18-39
  3. 99396: ESTAB PT. PREVENTIVE VISIT AGE 40-60
  4. 99397: ESTAB PT. PREVENTIVE VISIT AGE 65+

3.)   New & Established Consult Codes

  1. 99245: NEW/ESTAB PT CONSULT HIGH COMPLEXITY
  2. 99243: NEW/ESTAB PT CONSULT LOW COMPLEXITY
  3. 99244: NEW/ESTAB PT CONSULT MODERATE COMPLEXITY
  4. 99242: NEW/ESTAB PT CONSULT STATIGHTFORWARD

4.)   New Patient Complaint Codes:

  1. 99205: NEW PT W/COMPLAINT HIGH COMPLEXITY
  2. 99203: NEW PT W/COMPLAINT LOW COMPLEXITY
  3. 99204: NEW PT W/ COMPLAINT MOD COMPLEXITY
  4. 99202: NEW PT W/ COMPLAINT STRAIGHTFORWARD

5.)   New Patient Prevention Codes:

  1. 99384: NEW PT, PREVENTATIVE VISIT AGE <18
  2. 99387: NEW PT, PREVENTATIVE VISIT AGE >65
  3. 99385: NEW PT, PREVENTATIVE VISIT AGE 18-39
  4. 99386: NEW PT, PREVENTATIVE VISIT AGE 40-64

6.)   Medicine | Path & Lab:

  1. 81000: URINALYSIS
  2. 80061: LIPID PANEL
  3. 84100: PHOSPHORUS INORGANIC

7.)   Medicine | PT & Rehab

  1. 97010: APPLICATION OF A MODALITY: HOT OR COLD
  2. 97001: PT EVAL
  3. 97140: MANUAL THERAPY TECHNIQUES

8.)   Hospital:

  1. 99221, 99222, 99223: INITIAL HOSPITAL VISIT
  2. 99218, 99219, 99220: OBSERVATION SERVICES
  3. 99234, 99235, 99236: HOSPITAL OBSERVATION OR INPATIENT CAER SERVICES (INCLUDING SAME DAY ADMISSION AND DISCHARGE)
  4. 99251, 99252, 99253, 99254, 99255: INPATIENT CONSULTATIONS

9.)   Surgery:

  1. 36415: COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE
  2. 17110: DESTRUCTION OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR