Diagnosis Codes - ICD10 and DSM IV Codes

Here's another question from our "Ask the Biller" page.

Hi again! I'm just wondering whether Diagnostic Codes, Line 21 on CMS 1500 are to be exclusively ICD 10 codes or are DSM IV codes also accepted?

Thank you, Carol

We answered:

You can use either ICD or DSM codes in box 21, as long as the codes are recognized by the individual insurance carrier that you are billing.

Question on Billing Sick Child Visit

Here's another question we received

I am the billing manager for a pediatric office. When we see a sick child for wheezing and/or tightness in the chest we usually bill 99213 for office visit and give them a inhalation breathing treatment under procedure code 94664 but we never get reimbursed for the treatment only the office visit. How do I get insurance companies to consider procedure 94664 am I billing this correctly?

Michele's answer

When you see the patient for the wheezing/tightness and you do the 94664, I would recommend trying a 25 modifier on the E&M code indicating that the E&M was a Significant, Separately Identifiable E&M Service by the Same Physician on
the Same Day of the Procedure or Other Service.

Also, if you have more than one diagnosis and if it is appropriate to use a different diagnosis for the E&M than you use for the 94664 that may help.
For example, if a child comes in with an upper respiratory infection, and you give him a breathing treatment for the wheezing/tightness, then you could bill the 99213 with dx URI and the 94664 with the wheezing/tightness diagnosis.

Hope that helps.

Question on Locum

We recently received this question

We have an anesthesia group and a pain clinic. We have two anesthesiologist on staff, one is permanent, the other is according to the permanent doctor, a locum. My dilemma is that the pain clinic is in the same building as the O/R, which means they are both in the same building, so is he actually covering for the permanent doctor while he is in the pain clinic, which would make him a locum, or is that not within locum guidelines. Both companies have seperate tax id's and NPI's but are on the same property.

Michele's response

I’m not completely sure I understand your question. Do both anesthesiologists (the perm & the locum) work in both the pain clinic & in the OR? A locum physician is just a temporary physician usually filling in for a permanent physician’s position. Some practices use locums more as a permanent position though. Since a locum is a licensed physician they do not have to work under a physician’s supervision, like a NP or PA. If this doesn’t answer your question, please email me with more details.

Can Your Business Get Too Big?

If you are a struggling new business I'm sure you wish your problem was that you were growing too large. But the reality is that when you are a growing business it can be difficult to see when you are growing too quickly.

For either the medical office or the medical billing service the same thing applies. When you grow too fast you risk not being able to take care of your customers the best possible way. We found an interesting example of this today.

We signed up a new account today. It was a small account, but his billing was important to him. He had signed up with a billing service in April 2007 and now in January 2008 had not yet received $.01 from an insurance company.

He inquired regularly to his service as to the status of his claims and was assured that everything was in place. Now nine months later he is questioning if he can stay in business.

How can you let nine months go by without a payment and not do something? That can only happen if you grow too quickly and can't take care of the details of your business. The details are critical.

Patients who must wait hours in a waiting room for the doctor are not happy patients. If this is happening in your office, you need to make changes and make them quickly before your practice suffers
If paperwork is required for patients to receive their workers comp checks, this paperwork needs to be completed asap. It is very important to this patient. These are the details I'm talking about.

If you already have too many patients to take care of the ones you have effectively, it is time to stop taking on new patients. If you don't, you will find you are loosing old patients as fast as you are gaining new ones.

This is also true of medical billing businesses. You must do a good job with the accounts you have. The details are critical. If you are too busy posting the payments to work your aging reports, you aren't paying attention to the details.

It's important to remember that whether it is a medical office or a billing service, it's still a business and needs to show a profit. So if you get too busy to take care of the details, you've grown too fast.