You have received, or are waiting on provider numbers for the various health plans for which you plan to participate. How do you identify the services you performed, notify the health plan and receive payment for those services?

A standardized set of codes have been developed, and continue to be updated and modified to reflect the type(s) of services performed, the location where the services were performed, who performed the service, the reason(s) why the service was performed and how a health provider should be paid.

1. CPT codes
• The type of service provided for a health provider is denoted and managed in a list of codes called the Current Procedure Terminology (CPT) which is administered by the American Medical Association (AMA). Over 18,000 codes specify every activity from “A” (Anesthesia) to “Z” (Ziconotide injection) in most every setting from office to hospital. CPT codes can be further “modified” to detail the body location of service, what components to include (professional services only, facility or total) or who participated in the service. CPT codes are regularly updated with new codes defining new services, deletion of obsolete codes as well as modification of use and description of existing codes.

  Development of the Medicare payments for CPT codes include a comprehensive Resource-Based Relative Value Scale (RBRVS) enacted by the Federal government in 1992. The RBRVS system assigns Relative Value Units (RVUs) for provider work, practice expense, and malpractice costs. Multiplying total RVUs (work, practice expense and malpractice), for each CPT, against a conversion factor produces the Medicare payment for each CPT code. Medicare payments, in many instances, are the unofficial benchmark on which commercial and other insurers base their payments structure.

  To search the current CPT codes information, register, log in and go to the Practice Preparations section behind our secure firewall.




2. Diagnosis codes
• Every medical service provided and enumerated by a CPT code must be justified with a (or multiple) valid medically necessary reason(s) for performing the service. Description of a medical diagnosis or multiple diagnoses supporting the necessity of a medical service is an essential component to medical billing.

  The officially accepted standard for coding diagnoses and disease is the International Classification of Disease (ICD) as published by the World Health Organization, sponsored by the United Nations. The most recent version is ICD-11. For purposes of health care billing in the United States, ICD-10CM is the current version utilized.

  Click here to browse a listing of ICD-10CM diagnosis codes.
  




3. Place of Service
• For each medical service performed, the location where the service was performed is required for billing. The “Place of Service” (POS) determines where a billable service may be performed and the limitations on reimbursement. The Centers for Medicare and Medicaid Services (CMS) maintains and updates the list of two digit numeric codes which designate a place of service. Specific POS examples include: 21 – Inpatient Hospital; 11 – Office; and 31 – Skilled Nursing Facility.

  Click here to go to CMS and view the list of current POS codes.