Now, we're at part 1, overview of CPT coding and definitions. If you're very familiar with this, you need not endure this part of the online learning. But it's good to have an overview if you're familiar but not so familiar. Anyway, let's proceed. 

So what is CPT? It's a registered trademark of the AMA, the American Medical Association, and it provides a common language, a language common to those that know how to speak it. 

And it's how CMS, Medicaid, other payers and coders and billers derive coverage. It is defined as a uniform language for coding medical services and procedures. All CPT codes are five digits and can be either numeric or alphanumeric, depending on the category. 

Now again, it says uniform language. It's really putting a code that represents a service that goes on to a billing form to be sent in to a payer. And the reason why the code set was derived was how can you really process millions, hundreds of thousands, hundreds of millions of invoicing, electronic invoicing that would be all free text? 

So this enables computers to grab the five codes and process the billing, simply. Hey, we have different categories, as the last slide intimated. Category 1, those are the codes you're most familiar with. They start from 00100 9499. 9499 is not payable, usually, and represents an undefined service that you have to fight for. 

I digress. Generally, ordered into subcategories based on procedure, service type, and anatomy. Category 2, alphanumeric tracking codes. It's optional, not required. These are for the MIPS, Medicare. It's what you get the bonus payments for. 

Yeah, bonus payments. It's going to be like we talked about the diabetes during this visit. We talked about maybe smoking cessation. And you get more money for that as a health provider or system. Category 3. Now, these are alphanumeric, and you don't get paid for them. 

They're teaser codes. Hey, use these, and we're still not going to pay you for services you're providing. But if you use them enough, maybe we'll pay for it. May sound a little sarcastic there. It usually results in people not really using them all that much. 

What are HCPCS then? Like that I put the pronunciation in there. It is a healthcare common procedure coding system. And that was the term that was the precursor to the CPT code. 

And it was derived by Medicare that really wanted to standardize billing and coding. These are things for all the drug payments, start with J, that goes into the book. It usually represents smoking cessation-- sensation-- cessation. 

We know what a smoke sensation is. It laughs in through a window. Other things. Testing for depression, stuff like that. So these are maybe claims just specific to Medicare, Medicaid. Medicaid's got its own too. Everyone's got their own system, but it's standard, and it's common, and we all understand it. 

Just being a little sarcastic. All right. What are these codes used for? Pro fees. What does pro mean? Professional, like a tennis pro or a golf pro. In this case, they're doctor pros. They're MPP pros. They're PA pros. 

Anything-- or in this case psychologist pros, psychiatrist pros, LCSW pros, marital family counselor pros. I wax on. I don't want to leave anyone out, but I'm running dry. So the CMS 1500 is what those in the biz call the pro fee invoice. 

It contains a lot of fields, as you can see. If you Google or not, to use a company name-- if you search on the internet using your favorite search engine for an explanation of what the fields mean and what goes in each field, on the CMS 1500, there are diagrams, detailed instructions. 

Here are a few of the fields that are filled. Patient and insured information, not the patient's. Not always the insured. Maybe they're the guarantor and provider details. All the people I referred to in that last diatribe about providers, the probes, place of service. 

Oh, that's our favorite in the last five, six, seven years. So 12? Oh wait, 10 was didn't come out until 2021, and then it confused everyone. How about 02? What about 12? What about 22, 19, 23, 32? All of our favorites. All of them. 

Service dates. Well, that's the date the service took place. Or if it's a 30-day code, it's the date range, perhaps like for hemodialysis. Got to use the date range. Procedures performed. Using what? 

Using the CPT code or a HIPPA code. Diagnosis code. I'll wax eloquent on ICD-10 the next slides. And signature certification information. Your providers don't have to sign every single one of these. Their signature is in the system-- in your system somewhere. 

It's with your office that credentials your providers. By putting their certification and signature information that this is their electronic signature, simply stating that they're ultimately the ones responsible for what is being billed out. Not the coder. Sometimes the coder. People like myself. 

Not the health system, not the office, not the front office staff. You, the provider, if you're the provider watching this, are ultimately responsible for what goes on that bill. So you want to make sure you document correctly. Make sure the key indicators are provided to coders if you're not coding by yourself. 

And just do it right. Do it right. OK. They also are used pick picks. CPT codes. They're used for technical fees, tech fees. Not a computer tech, not your phone tech, not the AT&T tech, the Verizon tech. 

The people that perform diagnostics at a place of service, such as radiology suite. A person that positions your poor broken shoulder. How many years am I going to milk this reference out to my shoulder? Your broken shoulder onto a plate while you're wincing in pain. That is the technician. 

Their service gets loaded onto this UB-04 form. And that is your facility fee. It's also used by places like FQHCs, RHCs, critical access hospitals. And there's no place of service. 

You're either in or you're out. And I always think of Ken Kesey. You're off the bus, or you're on the bus? The bus called further. We are on the West Coast. Actually. So there's no place of service. 

But there is a patient status. You're admitted. You're outpatient. You're on the bus, or you're off the bus? And also revenue codes are used. So 780 is for telehealth. 250 is for general office. Those are the two I know. I sound so smart when I just rattle them off. I know two. 

All right. So there are also modifiers that can go on the CMS 500 and the UB-04. The two characters. They're not always the same characters used between payers. Sometimes, they are. 

A lot of times, they are. I mean, most of the time, they are. Sometimes, they're not. So I want to tell you a little bit more about this 99215 that I performed the other day. I also did some behavioral health therapy. 

I'm going to put a 25 on that 99215, where I prescribed you a new medication. And I'm a psychiatrist. And I also did behavioral health. I want to get paid for both of these. But guess what, we're going to go down to the lowest paid CPT code. 

If you're a payer, pay that one and the other. Because I didn't really prove electronically that the evaluation and management service was separate and identifiable. Simple, right? 

So here's another code we love, 95. Used to be GT. Some people still want GT. People, ensures. Audio video. It's a video visit. 93 is an audio only visit performed on an audio visit. Audio, video telecommunication system or telephone. 

OK. Place is-- place of service codes. All of a sudden I thought, didn't I just-- yeah, I did just talk about place of service codes. My favorite ones are used on trophies. Trophy. Where do the trophies get entered? On the CMS 1500. 

See this tangled web of knowledge and information getting in there. 02. That used to be our favorite. It was the only-- it was the only place of service code for us in our hearts as telehealth providers, builders, coders, payers. 

But CMS came up with place of service 10, which is a telehealth service provided in a patient's home. Home is everywhere else other than a place of service that has its own place of service code. So if it's 02, that means your patient, I'm the provider. 

Let's just suspend disbelief for a minute here and believe I'm the provider. My patient's in a facility, like a hospital, or an outpatient department, or an RHC and FQ. Where else? A sniff. 

And they're admitted there. That's their status for that moment in time. I'll admit it. That's where they are. They're not at home. They're not in their car. They're not on the street, which is a place of service 27. 

They're in a facility, so that's 02. 10 is everywhere else. The patient feels that they're at home. Assisted living facility. Oh, wait, that says facility. But guess what? It's the patient's home. 

How to parse these things down? Gotta talk to your friends about what really is the correct place of service when you indicate 10. Where is that patient sitting? If they're in step up unit, they've gone into dementia care. 

And you want to assess how they're doing. That is no longer their home. They're admitted there. That is now an 02 place of service. Good times. All right. Briefly talked upon on ICD-10 codes. 

The World Health Organization has moved on, my friends. They're on 13. I don't know. 15. They're years ahead. They're episodes, issues, whatever ahead in classifying diseases. 

US we're still on 10. Took us a couple of maybe a decade to catch up with that one. And now, the world's moved on anyway. The whole purpose is to track disease. Where's disease happening? 

Where are the pockets of disease? Where did COVID-19 go during that pandemic we all experienced? Where was it the most documented? Where is Ebola right now? 

Well, probably somewhere not the United States. Probably somewhere in that massive continent of Africa. Oh, where are measles right now. Measles tracked by ICD-10 codes, and anecdotes, and the news, obviously. But we submit those ICD-10 codes to document where measles is traveling so that we know where to wear a face mask, where not to go, where to take extra precautions, where to start considering events to mitigate this disease called measles. 

Anyway. So there are other things. Measure outcomes and care provided to patients. Those are our favorites, right. We got to have the ICD-10 code to its greatest specificity, to be able to support the medical necessity of that CPT code going on that HCPCS. 

Wait, not the HCPCS, going on that CMS 1500 or the UB-04, especially UB-04. Got a patient admitted to inpatient. They've exhibited social determinant of health. Z code described process. State of life. 

Homelessness is one that is being reimbursed at a higher rate if you are billing for inpatient services, that that increases the payment on the DRG, the diagnosis related group code. I'm not going to talk about those today. But just letting you know, the ICD-10 codes are very useful. 

We use them everywhere. Use them-- use them to mostly support medical necessity for payment and track disease. Some general definitions that come up that people in the biz use all the time, that maybe others don't know what they're talking about, which is pretty much 100% of the time when you talk to anyone who's not a health worker, such as ourselves. 

Copay. It's what you pay, the dollar figure on your health insurance card. But my insurance has gone up to $30 per service copay. I remember when it was $5. 

The deductible. That is the level of payment that you and/or your family will reach before the insurance plan kicks in on something like an inpatient stay, or emergency department, or any other amount of services that will-- it's a portion. 

You're not going to pay 100% of each visit, but you're going to be chipping away at that deductible until insurance will kick in at 100%. It's tiring, I know. What's an EOB? 

I didn't even know what that was when I first started working in healthcare. It is-- it's an explanation of benefits. It's the statement, Like the charges. Oh, my God. I owe so much money. 

Yeah, if you don't have insurance, which is that happens. People can't afford insurance. That's your case. Talk to your provider of how lowering that cost or setting up a payment plan. Hopefully, not to the point of losing a lot of things. 

But the EOB, it's the charge amount. It says the allowed amount, yeah, it's going to indicate what CMS is covering, what your insurance carrier is covering. And then what your liability is. They call it your liability or risk. 

Liability is anything that affects your pocketbook. And it usually does detail what you got. You were inpatient, got stitches. You had your shoulder fixated. Incident two. That's one. That's a big one. We love that, right. 

So it's a service or supply provided integral, though incident two. Part of a physician or NPP. Professional services during diagnosis and treatment. This is for established patients in a non-facility location. 

What did I say about facilities? What did I say? Place of service. 1119. No, it's not 11. Gotcha. It is 19, 22, 21, 23. Anything that is not a non-facility location, like a non-facility place of service. Place of service 11. 

So you've established a care plan. And these are things that although integral but also maybe not so noticed type of things, like you don't-- maybe not your-- maybe you don't think you know you're getting charged for something. 

Well, the nurse just gave me the vaccine. Why do I have a copay? Well, they did that incident to a care plan established by provider at a prior visit, or maybe even the same day. So anyway, it's part of a care plan. 

You know what it means, though. It means you can bill-- you get paid at 100% from CMS. Not all providers recognize incident two services. Check with your health plan. General definitions continued. 

What's an MP? Military Police? No, it's a nurse practitioner. What's a CNM, CNS PA, what? These are people that can provide incident to services if they don't have their national provider identifier number enrolled with CMS. 

So if they do it under a physician, get 100% of payment. If these folks are billing individually, usually get 85%. So there's a whole lot of incentive to doing things incident too. These people services are very important and integral. 

They're not incidental. I don't like that word. They're integral to a physician's office and making sure that the provider is overseeing the staff, paying their salaries, paying their insurance, their malpractice insurance. Everyone's getting a paycheck that they get paid at 100%. All right. 

So we're talking about behavioral health. Let's start seeing stuff about behavioral health other than little off hand comments that I make. This could apply to coverage for psych services. If-- let's see. I'm going to read this. 

A furnished incident to the pro services. Those on the CMS 1500. A certain non-physician practitioners, including a clinical psychologist, MP, CNS. So if you're providing services, incident too, any of these providers. 

You know what, let's look it up in that medical policy article. I'm going to go into it here. But there are ways to compliantly make sure you get paid the maximum amount of reimbursement you are owed by an insurer, primarily Medicare. 

People often talk about, I want to maximize reimbursement. Well, know what you can bill and sit-in too. Know what you can legally bill for. You don't like that word maximize reimbursement, but you can get what you're owed.