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5 years and let me tell you, I dont know how many times a client would get upset because of incorrect codes being used. I worked n both the benefits department as well as the claims department so here is a little insight.
As a general rule ICD9 codes are used for diagnosis. If there is a V in the ICD9 code then that signifies a routine/preventative office visit. No V in code then signifies the actual diagnosis. These codes determine how the claim gets paid. Either under preventative or sick benefit.
CPT4 codes are the actual PROCEDURE codes that are primarily used by
doctors. They state what was done during the visit.
HCPCS(hickpicks) codes are primarily used by hospitals for services rendered. The room charge is a hcpc. A MRI has its own hcpc.
THe most common problem with coding would be whn diagnostic work is done such as xray or lab work. When these services are done then there is a professional fee and a technical fee. What commonly happens is that both the doctor administering the xray bills for the xray and the radiologist bills for reading the xray. Now both providers will use the exact same code but what happens is they forget or dont add the modifier code which is what is needed in order to pay both parts of the xray charge. When the claims system gets the claim for that xray it pays it then when the other provider bills for service then claim gets denied because it has already been paid to the other provider. So what is needed is a corrected claim with the correct modifier attached in order to pay both parties.
Im not privy to your situation but you can call (505-681-1339)me if you would like and I would be more than willing to give you some insight into what needs to be done to get this paid. you have many rights such as appealing the denial. I know united health had a website where you could actually see copies of the claims recvd from providers.
Robert
, Fri, 30 Nov 2007 19:56:15
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