COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html