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Resource Coder Toolbox

Coding Resources:

There are many resources available.

Bookmark these for future reference when you need help coding.

Best advice I was given was make Google your new BFF.

But BEWARE know your source & always check dates as coding changes frequently & a good coder needs to stay current in their knowledge to stay relevant in the field.

Being here is your first step, welcome!

Toolkit.jpg
 
P&T Committee -Pharmacy & Therapeutics Committee. Committee, appointed by the Governor, which conducts in depth evaluations of selected drug therapies for the DOM.

Paid Claim -A claim that has resulted in the provider being reimbursed for some dollar amount. The amount may be less than the amount which the provider billed DOM.

Parallel Testing -Testing based upon comparison of old and new system results. Requires a period of parallel operation where both systems operate and use the same data.

Part D -Prescription drug program under the Federal Medicare Modernization Act (MMA).

Patient Liability -Monthly income, of a beneficiary in a long-term care or inpatient setting for more than 30 days, which must be applied to cost of care before Medicaid payment is made.

Pay and Chase -A term denoting the practice of paying a claim on behalf of a beneficiary with third party resources and then recovering from the responsible parties. This is done when the third party resources are not known at the time of payment. Pay and Chase is most common with recovery claims involving casualty cases.

Payment Cycle -The processing of claims from adjudication to payment. A payment cycle includes the updating of financial history and the preparation of provider payments and remittance advices.

Peer Review -An activity performed by a group or groups of practitioners or other providers by which the practices of their peers are reviewed for conformance to generally accepted standards.

Pending Claim -A claim that is in the process of adjudication.

Pharmacy Claim -A Claim for pharmacy services.

Pharmacy Services -The dispensing of drugs listed on the Medicaid Formulary.

Physician Claim -A claim filed for payment of Physician Services. A claim is filed: (1) for one or more services given on the same date, or (2) upon completion of services for a treatment. The claim is filed on a CMS-1500 form.

Physician Services -Services provided by a licensed physician. Services include physician visits, laboratory and X-ray services, family planning, etc.

Plan -A subset of beneficiaries in a program eligible to receive a specific subset of medical services.

Postpayment Review -Process to review specific beneficiaries, providers, procedure codes, or provider types, as determined by the DOM, after payment.

Predictive modeling -Predictive modeling is the process by which a model is created or chosen to try to best predict the probability of an outcome. In many cases, the model is chosen on the basis of detection theory to try to guess the probability of a signal given a set amount of input data, for example given an email determining how likely that it is spam.

Prepayment Review -Process to suspend and review specific beneficiaries, providers, procedure codes, or provider types, as determined by the DOM, prior to payment.

Primary Contractor -The vendor with whom the DOM will contract for the services outlined in this RFP.

Primary key -See Key.

Procedure Code -The coding structure for all medical procedures covered by Medicaid. (See HCPCS).

Processed Claim -A claim that has been adjudicated.

Production -Describes the setting in which software and other products are put into operation for their intended uses by end users. A production environment is considered a real-time setting where programs are actively running and hardware setups are installed and operational for daily operations.

Profile -An outline of the most outstanding characteristics of a provider practice in rendering health care services or of beneficiary usage in receiving health care services.

Program -A group of beneficiaries eligible to receive medical services paid by State and/or Federal funds by virtue of the beneficiaries’ demographic or other characteristics.

Provider -A person, organization, or institution certified to provide health or medical care services.
 
Query (n.) -A request for information from a database. (v.) To make a request for information from a database.

Queue -A queue is the holding point for a number of calls or interactions that are waiting to be answered by an agent.
 
Real-time -Occurring immediately. The term is used to describe a number of different computer features. For example, real-time operating systems are systems that respond to input immediately. They are used for such tasks as navigation, in which the computer must react to a steady flow of new information without interruption. Most general-purpose operating systems are not real-time because they can take a few seconds, or even minutes, to react.

Recipient -An individual eligible for medical assistance in accordance with a state's Medicaid Program and who has been certified as eligible by the appropriate agency and has received services. This term is used interchangeably with beneficiary for the purposes of this RFP.

Referential integrity -A feature provided by relational database management systems (RDBMSs) that prevents users or applications from entering inconsistent data. Most RDBMSs have various referential integrity rules that you can apply when you create a relationship between two tables.

Refund -A repayment made by a provider, usually needed because of an error in billing, receipt of a late insurance payment or a duplicate payment which resulted in an overpayment by Medicaid for services rendered.

Reimbursement Rate -An amount calculated for the reimbursement of providers, usually based on costs.

Relational database -See RDBMS.

Resource -Any property, stock, bond, or item of value owned by an individual.

Response Time -The time a system or functional unit takes to react to a given input.

Retroactive -Refers to “back dated” coverage or service date in which a person was determined to be eligible for a period prior to the month in which the application was initiated.

Returned Claim -A claim which is returned to the provider prior to entry into the system due to lack of clean claim data or a claim which is returned after deletion.

Router -A device that forwards data packets along networks. A router is connected to at least two networks, commonly two LANs or WANs or a LAN and its ISP’s network. Routers are located at gateways, the places where two or more networks connect.

Routing -The intelligent determination of what to do next with a given interaction. Routing is not limited to traditional interactions like voice calls and e- mails but can also be utilized to decide what to do with workflow items, scheduling items and any other type of business activity that involves a decision process.

Rural Health Clinic -Claim A claim filed for payment of Rural Health Clinic Services.

Rural Health Clinic Services -Services provided in a rural health clinic that participates in the Medicaid program.
 
Same Family -The people that are considered to be in the ‘same family’ include spouse, parents, grandparents, step-parents, step-grandparents, siblings, step-siblings, half-siblings, brother-in-law, sister-in-law, mother-in-law, and father-in-law.

Schema -The structure of a database system, described in a formal language supported by the database management system (DBMS). In a relational database, the schema defines the tables, the fields in each table, and the relationships between fields and tables.

Script -The written words and logic to be followed in the handling of a situation. Used for testing, call centers, etc.

Server -A computer or device on a network that manages network resources. For example, a file server is a computer and storage device dedicated to storing files. Any user on the network can store files on the server. A print server is a computer that manages one or more printers, and a network server is a computer that manages network traffic. A database server is a computer system that processes database queries.

Service -A covered medical benefit under the Medicaid Program performed by a provider for a beneficiary, usually indicated by a service or treatment code.

Service Level Agreement -Performance objectives reached by consensus between the user and the provider of a service (e.g., DOM and the Contractor), or between an outsourcer and an organization. A service level agreement specifies a variety of performance standards.

Service Limitation -A maximum amount of services allowable for a beneficiary for a given time period, such as 12 physician visits per fiscal year.

Single sign-off -Single sign-off is the reverse property of single sign-on, whereby a single action of signing out terminates access to multiple software systems.

Single sign-on -A property of access control of multiple, related, but independent software systems. With this property, a user logs in once and gains access to all systems without being prompted to log in again at each of them.

Single State Agency -The department of a State that is legally authorized and responsible for the statewide administration of the State's plan for medical assistance.

Specialty -The specialized area of practice for a physician, such as Pediatrics, Pathology, etc.

Specialty Certification -Certification or approval by a National Professional Academy, Association, or Society, which designates that a provider has demonstrated a given level of training or competence and is a “fellow” or specialist.

Spend-down -A periodic, usually six month, “deductible” amount that must be incurred by medically needy beneficiaries in order to reduce their income to Medicaid eligibility levels through payments to providers.

State -Refers to any State in the United States.

State Plan -The document by which the State outlines to CMS the amount, duration, and scope of Medicaid services to be provided and the reimbursement mechanism utilized in servicing specified groups of eligible.

Subcontractor -Party contracting with the Primary Contractor to perform services for the DOM.

Surveillance -Activities designed to monitor the expenditure of Medicaid funds and services.

Suspended Claim -A claim that is taken from the processing flow for additional information, correction or review.

System -All of the subsystems/modules collectively and referred to as the MMIS.

System Testing -A test of all functions within a subsystem of the MMIS, ensuring that all data and functions are handled correctly. In addition, the functions within the system are then tested to ensure interaction from system to system and outside the MMIS (i.e., BUY-IN, BENDEX, etc.)
 
Taxonomy -The Health Care Provider Taxonomy code set is a collection of unique alphanumeric codes, ten characters in length, maintained by the NUCC Code Subcommittee. The code set is structured into three distinct "Levels", including Provider Type, Classification, and Area of Specialization. Allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them.

Title IV-D -Title of the Federal Social Security Act. The Child Support and Establishment of Paternity program refers to state-run child support enforcement programs which are funded through grants to States for the purpose of providing aid and services to needy families with children and for child-welfare services.

Title IV-E -Title of the Federal Social Security Act. The Federal Foster Care Program helps to provide safe and stable out-of-home care for children until the children are safely returned home, placed permanently with adoptive families or placed in other planned arrangements for permanency.

Title XIX -The provisions of the Federal Social Security Act, including any amendments, authorizing the Medicaid Program.

Title XVIII -The provisions of the Federal Social Security Act, including any amendments, authorizing the Medicare Program.

Title XXI -The provisions of the Federal Social Security Act, including any amendments, which established the child health care programs for the uninsured.

Transaction Types (EDI): 276/277/277U -- EDI Healthcare Claim Status Request (276) and EDI Healthcare Claim Status Notification (277) 278 -- EDI Healthcare Service Review Information (278) 820 -- EDI Payroll Deducted and other group Premium Payment for Insurance Products(820) 834 -- EDI Benefit Enrollment and Maintenance Set (834) 835 -- EDI Healthcare Claim Payment/Advice Transaction Set 837 P/D/I -- EDI Healthcare Claim Transaction Set (837), Professional (P), Dental (D), and Institutional (I).

Transition -The system conversion from the Contractor to the State or successor Contractor.

TRICARE -Military Health Benefits.

Turnover -The transfer of the MMIS to the State and/or a successor Contractor.
 
UB-04 -The latest version of the uniform hospital billing form approved by the American Hospital Association. This claim form is usually used by hospitals for inpatient, outpatient, and swing-bed services.

User Acceptance Testing
-The last phase of MMIS testing prior to final acceptance of the system.

Usual and Customary Charges -Charges made by a provider for a given medical service or procedure.

Utilization Review -The process of monitoring and controlling the quantity and quality of health care services delivered under the Medicaid Program.
 
View -In database management systems, a view is a particular way of looking at a database. A single database can support numerous different views. Typically, a view arranges the records in some order and makes only certain fields visible. Note that different views do not affect the physical organization of the database.
 
Waiver -An exception requested of or granted by CMS in response to a request from a State, usually regarding some required aspect of Medicaid regulations in order to implement a new program or system.

Web services -A standardized way of integrating Web-based applications using the XML, SOAP, WSDL and UDDI open standards over an Internet protocol backbone. XML is used to tag the data SOAP is used to transfer the data. WSDL is used for describing the services available UDDI is used for listing what services are available Used primarily as a means for businesses to communicate with each other and with clients, Web services allow organizations to communicate data without intimate knowledge of each other's IT systems behind the firewall.

Wholesale Income -Changes Mass changes performed by computer program that detail how to process need standards and income increases for the designated group of beneficiaries covered by Medicaid. Wholesale Income Changes include COLA updates to SDX or BENDEX.

WINASAP -Provider claims submission software.

Workers’ Compensatio
n -A type of third-party coverage for medical services rendered as the result of an on-the-job accident or injury to a recipient for which his employer’s insurance company may be obligated under the Workmen’s Compensation Act.

Workstation -For purposes of this RFP includes, but is not limited to: laser printers, microcomputers, terminal cabinetry, and site-specific communications devices that shall be installed in the offices for the purpose of providing access to the MMIS database. It shall also include any upgrades to existing LAN equipment and software, including bridges, servers, cables, and printers.
 
AAPC suggests Free Resources to Improve Your Accuracy and Efficiency.

Committee members share their favorite coding tools & resources.

Learn about who are the MACS:

The following CMS web page provides current MAC maps and lists. But remember — more than one MAC may be assigned to an area, depending on whether they are contracted for Medicare Parts A/B (see Figure A) or durable medical equipment (DME) (see Figure B).

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Get NCCI Medicare FAQs here.
Billing & Coding advice.
National Correct Coding
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NCCI
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Modifiers

 

Medicare Provider Compliance Tips List​


  • Ambulance Services
  • Annual Wellness Visits
  • Anticancer Drugs
  • Bacterial Cultures
  • Blood Counts
  • Canes & Crutches
  • Cataract Services
  • Chiropractic Services
  • Commodes
  • CORF Services
  • CPAP Devices
  • Diabetic Shoes
  • Diabetic Supplies
  • Echography & Sonography
  • Enteral Nutrition
  • Enteral Nutrition Pumps
  • ESRD Clinic Services
  • Home Health Services
  • Hospital-Based Hospice Services
  • Hospital Beds
  • Immunosuppressive Drugs
  • Infusion Pumps
  • Inpatient Rehabilitation Services
  • Lenses
  • Lipid Panels
  • Lower Limb Orthoses
  • Lower Limb Prostheses
  • Manual Wheelchairs
  • Nebulizers & Drugs
  • Negative Pressure Wound Therapy
  • Ostomy Supplies
  • Other Lab Tests
  • Oxygen
  • Parenteral Nutrition
  • Patient Lifts
  • Physical Therapy
  • Podiatry
  • Pressure Reducing Support Surfaces
  • Psychiatric Care
  • Sleep Studies
  • SNF Services
  • Spinal Orthoses
  • Surgical Dressings
  • TENS Units
  • Tracheostomy Supplies
  • Urinalysis
  • Urological Supplies
  • Venipuncture
  • Ventilators
  • Walkers
  • Wheelchair Options



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DMEPOS General Documentation Requirements​

Documentation requirements apply to certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items.
All claims billed to Medicare require a written order or prescription from the treating practitioner as a condition for payment. The written order or prescription must meet Standard Written Order (SWO) requirements.
To justify payment, suppliers must meet these requirements:
  • SWO
  • Medical record information (including continued need and use if applicable)
  • Correct coding
  • Proof of delivery (POD)
Note: Section 5.10 of Medicare Program Integrity Manual, Chapter 5 states that suppliers must keep POD in their files for 7 years, starting from the date of service, and must provide documents to their Durable Medical Equipment Medicare Administrative Contractor (DME MAC) upon request.
The treating practitioner must communicate a SWO to the supplier before submitting a claim. For certain DMEPOS items, we require a Written Order Prior to Delivery before delivering the item(s) to the patient.
A SWO must have:
  • Patient’s name or MBI
  • Order date
  • General item description
    • Description can be a general description (for example, wheelchair or hospital bed), an HCPCS code, an HCPCS code narrative, or a brand name or model number
    • For equipment: Besides description of a base item, the SWO may include all concurrently ordered options, accessories, or other features that are separately billed or require an upgraded code (list each separately)
    • For supplies: Besides description of a base item, the SWO may include all concurrently ordered supplies that are separately billed (list each separately)
  • Dispensed quantity, if applicable
    • Prescriptions may be refillable
  • Treating practitioner name or NPI and signature
Signature and date stamps aren’t allowed, with a few exceptions. You must follow our signature requirements in section 3.3.2.4 of Medicare Program Integrity Manual, Chapter 3.
Complying with Medical Record Documentation Requirements and Complying with Medicare Signature Requirements fact sheets have more guidance.
Note: Local Coverage Article (LCA): Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) has more information about these requirements.
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Lab Test Order Requirements​

  • You, the physician, practitioner, or NPP who’s treating the patient (and who provides a consultation or treats them for a specific medical problem and uses the results to manage their specific medical problem) must order the tests. Tests you haven’t ordered for treating the patient aren’t reasonable and necessary.
  • Document medical necessity in the patient’s medical record when ordering the service.
  • The entity submitting the claim must keep documentation from you, which includes:
    • Documentation of the order for the service billed (including information which allows us to find and contact the ordering provider)
    • Documentation showing accurate order processing and claim submission
    • Diagnostic or other medical information you provided to the lab (including any ICD-10-CM code or narrative description)
Diagnostic lab test orders require 1 of these:
  • Signed order or signed requisition listing the specific test
  • Unsigned order or unsigned lab requisition listing specific tests done and an authenticated medical record that supports your intent to order the tests (for example, order labs, check blood, or repeat urine)
  • Authenticated medical record that supports your intent to order specific tests
Note: Section 6.9.1 of Medicare Program Integrity Manual, Chapter 6 has more information on order requirements.
You can deliver an order through:
  • Written and signed document that’s hand delivered, mailed, or faxed to the testing facility. We don’t need your signature on orders for clinical diagnostic tests paid based on the clinical lab fee schedule, physician fee schedule, or for physician pathology services.
  • Call from you or your office to the testing facility.
  • Email from you or your office to the testing facility.
Section 80.6 of Medicare Benefit Policy Manual, Chapter 15 has more information.
Note: If you communicate the order by phone, you or your office staff and the testing facility must document the call in the respective patient’s medical record. We don’t require a signed order, but you must clearly document in the medical record your intent to do the test.
Complying with Medical Record Documentation Requirements and Complying with Medicare Signature Requirements fact sheets give more guidance.
Medical record documentation should include enough information to show the ordered or provided tests are reasonable and necessary, per 42 CFR 410.32.
Signature and date stamps aren’t allowed, with a few exceptions.
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“Other” Errors​

“Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.


 

AAPC suggests these resources​

Medical Coding Links​

Links, guides and information related to coding, billing, audit and physician groups.


CPT®
ICD-10-CM
HCPCS Level II codes

EMR Resources

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Ambulatory EHR
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OSHA Regulations
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Specialty Societies

Anesthesia
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