Questions Requiring External Assistance Related to ICD-9-CM Diagnosis Or Procedure Codes
PAGE: 1 of 3 / REPLACES POLICY DATED:
APPROVED: July 21, 1999 / RETIRED:
EFFECTIVE DATE: October 1, 1999 / REFERENCE NUMBER: HIM.PHY.004
SCOPE:
All personnel responsible for performing, supervising or monitoring coding/claims processing of physician services including, but not limited to:
Regional Service CentersHealth Information Management Services
Management Services OrganizationsInternal Audit & Consulting Services
Owned Outpatient Clinical Office Administration
Owned Physicians/Providers Physician Practice Management
Physician Practice Operations SupportEthics and Compliance Officer
Physician Practice Compliance Consultant
PURPOSE:
To provide guidelines for using the Coding and Billing Help Line for Physician Practices to provide consistent answers/advice for questions related to ICD-9-CM /CPT-4/HCPCS Level II code assignments and billing requirements. The Coding and Billing Help Line for Physician Practices, operated by QuadraMed Corporation, is available to all HCA Physician Services (HPS) providers to provide quality advice for complete, accurate and consistent coding and billing.
POLICY:
The Coding and Billing Help Line for Physician Practices should be utilized to provide consistent answers and/or advice for Physician Practices provider coding and billing questions.
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PROCEDURE:
- Questions requiring external assistance related to ICD-9-CM diagnosis or procedure codes, CPT-4/HCPCS Level II procedure codes or sequencing/linking questions, will be referred to the Coding and Billing Help Line operated by the QuadraMed Corporation staff at 1-800-373-5620, extension 132.
- The call will then be directed to a member of the QuadraMed Corporation staff. The caller should be prepared to provide their name, the provider/practice/Regional Service Center/Managed Services Organization name, COID#, city, state, and telephone number including area code. The caller should record the incident number assigned by QuadraMed. The caller should then discuss the coding/billing question.
- If a QuadraMed Corporation staff member is not available the call will be forwarded to extension 320, which is a voice mailbox dedicated for use by the Company. When leaving a message, the caller should leave their name, the provider/practice/Regional Service Center/Managed Services Organization name, COID Number, city, state, and telephone number including area code.
5.The QuadraMed Corporation staff member and the caller will discuss the coding or billing question. This may include, but is not limited to, reading documentation from the chart to the QuadraMed Corporation staff member. The QuadraMed Corporation staff member will provide coding/billing advice in response to the question. This coding/billing advice should contain any reference to Coding Clinic, CPT Assistant, Medicare Carrier’s Manual, HCFA Transmittal or other references used by the QuadraMed Corporation staff member to respond to the question.
6.If the question cannot be answered immediately over the phone, the question can be typed and faxed, (patient name must be removed from document) along with corresponding information, to (610) 882-3084, “attention help desk” or recorded by QuadraMed’s staff member. If the question is recorded by QuadraMed’s staff member, it will be read back so that accuracy is verified. The question, as verified by the requestor, will be the question that will be researched with a response formulated.
7.Within 24 hours of the faxed question, or the following business day, the professional staff at QuadraMed will call the individual submitting the question to provide a response. If a response is not available, the professional staff will, at a minimum, acknowledge receipt of the faxed question. QuadraMed will estimate turn-around time to adequately answer the question, but do not expect it will exceed 5 business days.
8.If the caller does not agree with the advice received from the QuadraMed Corporation staff member, express the reason for disagreement with the answer and ask that the representative to obtain another opinion on the subject.
a.Conclude the call but retain the incident number; conduct additional research; return a call to the QuadraMed Corporation staff member citing the incident number and discuss further. If the caller still disagrees with the QuadraMed Corporation staff member’s advice, ask to speak with a QuadraMed Corporation supervisor.
b.If there is still disagreement with the advice being proposed by the QuadraMed Corporation staff member, contact one of the HIMS Physician Practice Coding Consultants at (615) 344-1896.
c.The Physician/Provider has the responsibility for final decision. The physician query form should be generated, completed and maintained. Documentation of the final decision should be maintained and accessible.
9.For CPT coding questions that QuadraMed Corporation is unable to answer, contact one of the HIMSPhysician Practice quality control consultants at 615-344-1896. Discuss the question and let them know that QuadraMed Corporation was unable to provide an answer. The HIMS quality control consultant will either provide an answer or submit the question to the AMA for clarification.
10. The HIMS Department and HPS will conduct quarterly quality control reviews of the printed coding advice logs provided by the Coding and Billing Help Line for Physician Practices and the response times for recorded questions.
11.Any coding advice from the Coding and Billing Help Line for Physician Practices that requires further clarification will be discussed with the QuadraMed Corporation staff. If the HIMS Department and/or HPS and QuadraMed Corporation agree that inappropriate advice was provided to a provider/entity, QuadraMed Corporation will contact the entity. This will be recorded by the HIMS Department for future reference.
12.Recurrent coding and billing questions will be addressed in the Physician Office Coding Update for continuous coding and billing education to support complete, accurate, and consistent coding and billing.
12/2000