Medical Coding and Reimbursement

(Medical Coding and Reimbursement)

Medical coding questions.

the following procedures:

Endometrial biopsy
Pelvic ultrasound
TDAP immunization
Maxillofacial prosthetics, unlisted procedure
X-ray of stomach
Coombs test
Intracapsular lens extraction

Choose correct CPT codes and type the code next to its corresponding procedure. Also, within the Word document, underline the key term utilized to locate the code.

Create a scenario where HCPCS Level I and Level II are used together. Explain how the HCPCS level determines payer responsibility and why documenting this information accurately is directly linked to reimbursement from the insurance company.

CPT Codes for Procedures

Endometrial biopsy – 58100
Key term: Biopsy, endometrium
Pelvic ultrasound – 76856
Key term: Ultrasound, pelvis
TDAP immunization – 90715
Key term: Immunization, TDAP
Maxillofacial prosthetics, unlisted procedure – 21089
Key term: Prosthetics, maxillofacial
X-ray of stomach – 74022
Key term: X-ray, stomach
Coombs test – 86880
Key term: Test, Coombs
Intracapsular lens extraction – 66920
Key term: Extraction, lens, intracapsular

Scenario Using HCPCS Level I and Level II

Scenario:
A patient presents for a TDAP vaccination (CPT: 90715) and requires the use of an immune globulin product (HCPCS Level II: J1670) to address an allergy concern related to the vaccine.

Explanation of HCPCS Levels and Payer Responsibility:
HCPCS Level I includes CPT codes for services and procedures performed by healthcare providers, such as the administration of the TDAP vaccine (90715). HCPCS Level II includes codes for supplies, medications, and other products not included in CPT, such as the immune globulin product (J1670).

Payer responsibility is determined by the type of HCPCS code used. For example:
- Level I (CPT codes): Covers professional services and procedures.
- Level II: Covers supplies and medications, often reimbursed under durable medical equipment (DME) or drug formularies.
Documenting this information accurately ensures proper reimbursement. Errors in coding or omissions (e.g., failing to include the Level II code for immune globulin) could result in claim denial or underpayment. Correct documentation ensures compliance with payer guidelines, mitigates audit risks, and improves revenue cycle management.

Medical Coding and Reimbursement