• The Gist: Medical billing is a key to detect and discover related diagnoses, treatments and providers in a case.
© The Medical-Legal News 2007
By Kathleen Sesco, RN, BSN, MHA
Relevance: Medical billing and coding are dynamic specialty areas, with frequent changes in rules and regulations. Why are coding and billing important in a case? The accurate cost of medical services is the basis of the medical damages. The plaintiff seeks to calculate this number to its highest amount, in favor of the client. The defense calculates the medical damages to be less the adjustments in the billing and needs to know the accurate lien amount pending in the case.
A lien is a legal document that reserves part of the settlement amount for repayment of the cost of medical services related to the injury.
Each billing will list the cost of the service and the date the service was provided. The billing may also include an amount adjusted by contracts with an HMO, health insurance coverage, Medicare or worker’s compensation. This amount of the bill is “written off” and on the final billing is shown as a subtraction from the billed amount. Payments, made from private insurance, Medicare, Medicaid or the patient are shown as a credit on the billing.
Tip: In the case evaluation, compare the date of the injury with the dates of service on the billing. Dates billed before the date of injury cited in the complaint would not be considered related to the damages in the case. The billing will also indicate the patient’s billing address during the time the service was provided.
History: Diagnostic coding has its roots with record keeping in the 17th century in England. The numbers of deaths were documented in the London Bills of Mortality during this period. Much later, in 1937, the records became known as The International List of Causes of Death. In 1948 the World Health Organization (WHO) published a list to track both morbidity and mortality called the International Classification of Disease (ICD-9 C.M. 2001).
Before 1977, the ICD-9 had worldwide recognition. In 1988, the U.S. passed the Catastrophic Coverage Act which mandated the use of the ICD-9 for diagnostic codes on all Medicare billings. Today the ICD-9 is the benchmark for the classification of diseases. Understanding the Medicode International Classification of Disease 9th Revision Clinical Modification (ICD-9 C.M.) is a skill necessary to complete a case evaluation.
The ICD-9 is organized into coding conventions. There are three digits required for a primary diagnosis, such as 723 for spinal stenosis in the cervical region. The manifestation of the code further describes and specifies the diagnosis, e.g. 732.1 — Cervicalgia (pain in the upper cervical region). The code provides more detail as to the anatomical location of the symptoms treated. Codes also identify an adverse side effect such as 780.4 — vertigo. E-codes refer to external causes of an injury such as E815.0, Motor Vehicle Traffic collision on the highway. (ICD-9 C.M. 2001).
In the front of the book is the index to diseases, followed by a table of drugs and chemicals and then the index of external causes. The diseases are divided into sections under a three-digit number system. Chapter 1 is Infectious and Parasitic Diseases; chapter 2 is Neoplasm; chapter 3 is Endocrine, Nutritional and Metabolic Disease and Immunity Disorders; chapter 4 is Diseases of the Blood, and thusly each chapter is sectioned throughout the book.
Current Procedural Terminology (CPT):In 1966, The American Medical Association published the first CPT book.
While the ICD-9 provides the primary medical diagnosis for diseases, the CPT code describes those services performed related to the diagnosis. The purpose of the publication is to provide a uniform language to report medical services and procedures performed. This coding system provides a means to communicate and describe medical services provided by the physician, therapist, licensed medical person, hospital, etc., for the patient to the third-party payers.
The medical billing should clearly indicate the ICD-9 code for the disease or condition diagnosed and the CPT code — that is the service or procedure provided. The E-code indicates the external circumstance or cause of the injury.
Tip: Examine the billing for the E-code to confirm the location or external cause of the injury as cited in the complaint.
Medical Billing as an evaluation tool: The medical billing provides the name of the patient, his or her address, the diagnosis on that date, the date of the service and the services provided for the diagnosis. On physical therapy or chiropractic billing, the length of time of the service and the region of the body treated will be indicated. An office visit for a new patient, 99386, is coded differently from an established patient, 99396. This gives a clue if the patient has been treated by the same provider in the past.
Tip: Watch for codes listed as “unlisted service or Procedure,” 99199, and/or “ Special Reports.” Included should be notes to explain that service.
Terminology for coding: Coding has its own language. “Upcoding” refers to a practice of coding services at a higher or more complex level to increase reimbursement. “Unbundling services” is another unethical method to maximize reimbursement by billing individual testing instead of one unit for one price. An example is a thyroid profile, which usually is billed as one unit. Unbundling would bill each test individually as TSH, T3 and T4, which will cost more.
Radiology is billed in two parts, one for the technical taking of the film and another bill for the professional component with a modifier 26 — that is the reading of the film.
Technology: There are a number of medical coding software products on the market. Computers can aid, but not replace, the analytical eye of an expert. The medical records reviewer, such as a legal nurse consultant, can evaluate the medical billing to discover the dates of service that are related to injury, where the injury occurred, the procedures that relate to the treatment of the injury, the providers who billed the services, the location the service was provided and if the billing is usual. •
References: Current Procedural Terminology (CPT) is a registered trademark and copyrighted, American Medical Association, 4th Edition, 2003, Chicago.
ICD-9 C.M. 5th Edition, Medicode Inc., Salt Lake City, 2001.
Kathleen Sesco is a legal nurse consultant at Howell & O’Neal, PA in Jacksonville,firstname.lastname@example.org.
Tip: A defense move, when there is clear liability, and a large amount in damages, is to pay the subrogation amounts to the carriers before going into court. The plaintiff then cannot reveal to the jury all the “medical cost” the client has sustained because the defense has already settled the medical claim.