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FAQ for Medical Coders

Q: What kind of product is referenceWizard Pro and who is it for?
Q: What data and features does referenceWizard Pro include?
Q: What kind of product is claimWizard Pro and who is it for?
Q: Why should I use your software and how can it help me with my medical claims?
Q: OK, so what does claimWizard include?
Q: What is the difference between "inpatient" and "outpatient" coding?
Q: Is the use of 9-digit zip codes mandatory for submitting claims?
Q: Is it necessary for the provider to obtain permission of the subject of protected health information (i.e. the patient) before a record is released to a health oversight agency for survey and certification work?
Q: What modifiers are allowed with the CCI edits?
Q: How should modifier "-25" be reported under the CCI?
Q: In what instances can I use the modifier -59 to designate a separate, different site?
Q: How should modifier -59 be reported under the CCI?

Answers:

Q: What kind of product is referenceWizard Pro and who is it for?
A: referenceWizard Pro is a medical coding software tool for referencing medical codes, medical necessity, medical coding edits including NCCI, and medical cross-referencing. referenceWizard Pro is a must for every medical coder, medical biller, medical auditor, or medical insurance compliance professional.
Please visit referenceWizard Pro page for more information.


Q: What data and features does referenceWizard Pro include?
A: Here is a brief list of the innovating and unmatched features presented by referenceWizard:
  • CPT Codes and modifiers
  • HCPCS Codes and modifiers
  • ICD-9-CM Codes, Volume 1 and 3
  • ICD-10-CM and ICD-10-PCS Codes
  • ICD-9 to ICD-10 (Forward) Conversion
  • ICD-10 to ICD-9 (Backward) Conversion
  • User-friendly and easy to use interface
  • Extensive code information including Short and Long Description
  • User notes saved for each code which could be private or shared with other professionals from the same group
  • Medical Necessity and LCD
  • Medical Coding Edits including NCCI
  • Code-specific library information
  • Favorite Codes
  • Medicare Fee Schedule and RVU
  • Procedural Modifiers, Crosswalk for Allowed Modifiers


Q: What kind of product is claimWizard Pro and who is it for?
A: claimWizard Pro is a web-based code-editing software for validating medical claims. claimWizard seamlessly integrates with other coding and billing programs in order to provide you with the functionality. Visit our How it works page for more detailed information.
Our software targets software vendors of medical coding/billing programs for physicians’ offices who want to make sure their medical claims are always correct and compliant and at the same time boost their payment process.


Q: Why should I use your software and how can it help me with my medical claims?
Our excellent medical coding team prepared a list of edits that can make your medical claims correct and compliant up to the latest changes from the government agencies with no effort from your side. At the same time it allows you to find hidden potentials for revenue and accelerate your payment cycle. It also helps you increase your medical coding knowledge and save time.
Visit this link for more information: More reasons to subscribe


Q: OK, so what does claimWizard include?
Please go to this page for the list of claimWizard SDK Features and Updates currently applied to the system.
Our commitment is to keep current with every major update from the government agencies so we can make sure your medical claims are always compliant up to the latest changes.


Q: What is the difference between "inpatient" and "outpatient" coding?
An outpatient is a patient who only comes to a hospital or doctor for diagnosis and/or therapy and then leaves again.
An inpatient on the other hand is 'admitted' to the hospital and stays overnight or for an indeterminate time, usually several days or weeks (though some cases, like coma patients, have stayed in hospitals for decades).


Q: Is the use of 9-digit zip codes mandatory for submitting claims?
A: CMS has become aware that some ZIP codes cover more than one payment locality; in some cases, while the service may actually be rendered in one county, because of the ZIP code it may be assigned into a different county. This causes a payment issue when each of the counties is associated with a different payment locality and therefore a different payment amount.
Effective for dates of service on or after October 1, 2007, for services rendered in the ZIP code areas displayed in Table 1, if a valid full nine-digit ZIP code is not present on the Provider Master File Address ZIP code, services paid by the FIs/MACs under the MPFS and for anesthesia services, your claim will be treated as unprocessable.
Exceptions
There are two instances in which you do not need to submit the nine-digit ZIP code in claims for services payable under the MPFS and for anesthesia services:
  • You may continue to submit claims with five-digit ZIP codes if you provide these services in ZIP code areas that do not cross payment localities;
  • There is no current requirement for the submission of a ZIP code when the place of service (POS) is “Home” or any other places of service that your Medicare contractor currently considers to be the same as “Home.”
As necessary, CMS will provide quarterly updates of the list of the ZIP codes that cross localities.
More: http://www.cms.hhs.gov/Transmittals/downloads/R1193CP.pdf


Q: Is it necessary for the provider to obtain permission of the subject of protected health information (i.e. the patient) before a record is released to a health oversight agency for survey and certification work?
A: The HIPAA Privacy Rule provides that protected health information (PHI) may be used and disclosed without the authorization of the subject of that information for health oversight activities that are authorized by law. Examples are inspection, licensure and other activities necessary for the appropriate oversight of entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards. The HIPAA Privacy Rule also provides that PHI may be used and disclosed without the authorization of the subject of that information to the extent a law requires the submission of that information.


Q: What modifiers are allowed with the CCI edits?
A: The following modifiers are allowed with the CCI edits:
Anatomical ModifiersGlobal Surgery ModifierOther Modifiers
-E1-F6-T1-25-78-59
-E2-F7-T2-58-79-91
-E3-F8-T3   
-E4-F9-T4   
-FA-LC-T5   
-F1-LD-T6   
-F2-RC-T7   
-F3-LT-T8   
-F4-RT-T9   
-F5-TA    



Q: How should modifier "-25" be reported under the CCI?
A: Modifier "-25" should be appended to an evaluation and management (E/M) code when reported with another procedure on the same day of service. Appending modifier -25 to the E/M code indicates to the carriers or fiscal intermediaries that as a result of the patient's condition, the physician performed a significant, separately identifiable E/M service above and beyond the other service provided.


Q: In what instances can I use the modifier -59 to designate a separate, different site?
A: If none of the anatomical modifiers can be used appropriately to describe the different site, then the modifier -59 can be attached to indicate the separate location.


Q: How should modifier -59 be reported under the CCI?
A: Modifier -59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier indicates to the carriers or fiscal intermediaries that the procedure or service represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries). When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters.


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