The Easy Fix for 10% of Denied Claims

Better’s Guide to Codes & Coding Resources for Providers

Coding mistakes can be costly to both individuals and healthcare providers. Up to 10% of claim denials are due to coding errors. Here’s our guide to help providers avoid the most common issues!

The US healthcare system uses procedure codes and diagnosis codes to help healthcare providers communicate to insurance companies what treatment they are providing to patients and why it is necessary. The procedure code explains the “what” and the diagnosis code explains the “why”.

Codes change frequently and codes providers have been using for years may not be billable today. If a code is no longer valid, any claim using that code will be automatically denied.

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According to a recent study, up to 90% of hospital bills contain errors. As a patient, any issue with a bill can result in substantial delays when your claim is processed by your insurance company. When patient’s submit out-of-network bills with Better, we review them for any coding errors or missing information. We often encounter out-of-date codes, missing modifiers, or other material errors, and work with the healthcare provider, patient, and insurance company — as necessary — to ensure each claim is processed correctly.

Codes Come in Many Flavors

While CPT codes (the “what” codes) and ICD-10 diagnosis codes (the “why” codes) are the most commonly used codes when billing insurance, there are a range of coding standards. Not all are accepted by insurance companies and it is important to use the correct coding system when billing insurance.

Below is a brief overview of common US coding standards:

CPT

CPT (Current Procedural Terminology) describes current medical procedures or treatments in response to a diagnosis, created by the American Medical Association.

HCPCS

HCPCS (Healthcare Common Procedure Coding System) has two levels. Level 1 codes are numeric codes identical to the AMA’s CPT code system. Level 2 describes alpha-numeric codes for items not covered by CPT codes such as durable medical equipment, prosthetics, ambulance rides, and certain drugs and medicines.

Modifiers

Modifiers are two digit add-on codes used with a corresponding CPT or HCPCS code to provide additional details concerning a procedure or service. Modifiers can be crucial to supplying health insurance companies with the necessary information to process a claim and should be used when necessary.

ICD-10

ICD-10 (International Classification of Diseases) describes diagnoses of diseases and injuries. ICD-10 has replaced the now obsolete ICD-9 system.

NDC

NDC (National Drug Code) is a universal product identifier for all drugs sold in the US and is published by the FDA. All drug products are identified using a unique, three-segment number.

CDT

CDT (Current Dental Terminology) is used by dental professionals to accurately document dental care on claims.

DSM-5

DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is the taxonomic and diagnostic tool published by the American Psychiatric Association. While this is broadly used by mental health professionals to classify psychiatric diagnoses, when submitting claims to insurance the corresponding ICD-10 code for the diagnosis must be included on the claim.

V Codes

V Codes were part of the ICD-09 system and were used to describe reasons other than a disease or injury that resulted in an encounter with a healthcare professional. Although some healthcare providers do still include these codes on claims, they are no longer billable and the correct ICD-10 code should be used instead.

Changes to each coding system in use occur regularly, which is a headache and can be difficult for healthcare providers and patients to keep up with. It’s incredibly important to be aware of coding changes because insurance companies will not process claims with codes that are out of date. Any claim with the wrong code will automatically be denied.

How to Check Your Codes

For healthcare providers that use an EHR (Electronic Health Record) system, your system will typically indicate if a code is out of date when you are creating a superbill or claim. In many cases, the system will automatically provide the current coding options.

If you create your superbills or claim by hand, it can be useful to routinely search online to determine whether a code is still in use, and we’ve shared some resources at the end of this article. If a code is no longer billable, there are many online coding resources that can help you find the current coding options. For example, the obsolete CPT therapy code 90801 (diagnostic evaluation without medical services) was retired in 2013. We searched for CPT 90801. This was the result:

The “old system” of CPT codes (using CPT codes 90806, 90804, 90801), etc. changed as of 2013 and was revised again for clarification by the American Medical Association in January 1, 2017. 90791 is the code for diagnostic evaluation/assessment.

90791 is the new billable CPT code that must be used on all claims.

Resources for Keeping Up

US healthcare codes are in a constant state of evolution and all providers should expect updates on at least an annual basis. For example, major updates to ICD-10 are released each October 1st, the beginning of the federal fiscal year. CMS also releases coding changes on January 1st of each year.

Even today, many healthcare providers are still using ICD-9 codes or other coding systems that are not accepted by insurance on their patient superbills. Claims including non-billable codes will be automatically denied.

It is important to be aware of upcoming coding changes. ICD-11 has been in development since 2007 and, although the release date has been pushed back several times, the latest information available suggests it will be phased in by 2023.

It can be really hard to keep on top of these things. In addition to our articles about the recent 2016 and 2017 changes, here are some of our favorite online resources:

ICD-10 Data

ICD-10 Data describes all ICD-10 codes in details and makes it easy to determine whether a diagnosis is currently billable. They also have a handy tool for translating from ICD-09 to ICD-10.

CMS

Center for Medicare and Medicaid Services provides the full list of coding changes

AAPC

The American Academy of Professional Coders offers a CPT code look-up tool as well as Coding Forums to ask specific questions of their coding community.

Navigating The Insurance Maze

Navigating The Insurance Maze provides a series of articles answering common coding questions for mental healthcare providers

Visit our provider page to request brochures for your private-pay patients so they can get paid back by their health insurance for care!

If you ever have questions or need coding resources, please reach out to us at support@getbetter.co. We’re here to help.