Place Of Service (POS)

Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes.

Place of Service Code(s)	Place of Service Name	Place of Service Description
00-10	Unassigned	N/A
11	Office	Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
12	Home	Location, other than a hospital or other facility, where the patient receives care in a private residence.
13-20	Unassigned	N/A
21	Inpatient Hospital	A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical)and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22	Outpatient Hospital	A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23	Emergency Room - Hospital	A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24	Ambulatory Surgical Center	A free-standing facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
25	Birthing Center	A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.
26	Military Treatment Facility	A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
27-30	Unassigned	N/A
31	Skilled Nursing Facility	A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32	Nursing Facility	A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
33	Custodial Care Facility	A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34	Hospice	A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.
35-40	Unassigned	N/A
41	Ambulance - Land	A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42	Ambulance - Air or Water	An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
43-49	Unassigned	N/A
50	Federally Qualified Health Center	A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51	Inpatient Psychiatric Facility	A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility Partial Hospitalization	A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53	Community Mental Health Center	A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54	Intermediate Care Facility/Mentally Retarded	A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
55	Residential Substance Abuse Treatment Facility	A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56	Psychiatric Residential Treatment Center	A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57-59	Unassigned	N/A
60	Mass Immunization Center	A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.
61	Comprehensive Inpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
62	Comprehensive Outpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
63-64	Unassigned	N/A
65	End-Stage Renal Disease Treatment Facility	A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or care givers on an ambulatory or home-care basis.
66-70	Unassigned	N/A
71	State or Local Public Health Clinic	A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.
72	Rural Health Clinic	A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
73-80	Unassigned	N/A
81	Independent Laboratory	A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.
82-98	Unassigned	N/A
99	Other Unlisted Facility	Other service facilities not identified above.

Convert CPT CODES to ICD-9 Codes for Medical Billing and Coding

Understanding Current Procedural Technology (CPT) Codes

Current Procedural Terminology (CPT) is a code set developed and maintained by the American Medical Association (AMA) that describes medical, surgical, and diagnostic procedures. CPT codes allow for uniform communication, research, and data analysis across local, regional, state, and national bodies. CPT Codes are updated annually on January 1.

Unlike ICD codes, CPT codes are trademarked by the AMA, making it impossible to find a comprehensive list of CPT codes online. But you should still know how to use them to look up procedures and understand their role in the medical billing and coding industry. These five-digit numeric codes identify medical procedures and services in a standardized manner, and are used by physicians, coders, health insurance companies, accreditation agencies, and patients. CPT codes can be used for financial, analytical, and administrative purposes, and are divided into three categories.

CPT Category I Codes

CPT is organized into three distinct categories. The first category, which is by far the largest of the three, contains codes for six subtypes of procedures. Much like ICD-9 and ICD-10, these procedural codes are organized into clusters, which are then subdivided into more specific ranges. For instance, codes for radiology fall in the number range of 70010 to 79999, and codes for a diagnostic ultrasound procedure fall into the range of 76506 to 76999. Within that number range, procedures have a designated code, ensuring healthcare payers record exactly which procedure a patient has undergone. For example, the codes 99213 and 99214, which you may have seen on your medical bill following a checkup, correspond to routine doctor’s visits (of simple and medium complexity, respectively).

As is the case with ICD-9 or ICD-10, the goal of CPT codes is to condense as much information as possible into a uniform language. CPT codes are designed to cover all kinds of procedures and are therefore very specific. For example, the code for a 45-minute session of psychotherapy with a patient and/or family member is 90834, while the code for a 60-minute session with a patient and/or family member is 90837.

CPT Category II Codes

The second section of CPT (Category II, or CPT II) consists of optional supplemental tracking codes. These codes are formatted with a letter as their fifth character, and are coded after the initial CPT code. These Category II codes include information on test results, patient status, and additional medical services performed within the larger Category I procedure. Like Category I codes, they are divided into clusters. CPT II codes for Patient Management, for example, fall into the 0500F-0575F range. While optional, these codes reduce the need for record abstraction and chart review, and lower the administrative burden on healthcare professionals. In addition to increasing efficiency, Category II CPT codes facilitate research and the collection of data related to the quality of patient care. Some codes also relate to state or federal law, as in the case of the codes 3044F-3046F, which document the blood alcohol level of a patient.

These codes are a supplement, not a substitute, for the codes in Category I, and therefore must always be attached to an existing Category I code. An example of a CPT code with a Category II code attached is 80061-3048F, which describes a test of low-density lipoprotein cholesterol (CPT I code 80061), with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F).

CPT Category III Codes

The third section of the CPT code is devoted to new and emerging technologies or practices. Note that this code does not indicate that the service performed is ineffectual or purely experimental. A Category III code simply means the technology or service is new and data on it is being tracked. Like Category II codes, Category III CPT codes are numeric-alpha, meaning the last digit is a letter. After a predetermined period of time (typically five years of data tracking), a procedure or technology described by a Category III code may move into Category I, unless it is demonstrated that a Category III code is still needed.

Understand How CPT and ICD-9-CM Codes Interact

CPT codes work in tandem with ICD-9-CM codes to create a comprehensive picture of medical services rendered. ICD-9-CM codes, discussed in detail in Course 10, are numeric (and in certain cases alphanumeric) diagnostic codes that describe the symptoms, area, and type of injury or disease in a patient. When listed together, ICD-9-CM and CPT codes present a picture of both the diagnosis of an injury or disease and the type of service provided to the patient by the healthcare provider.

In some cases, it may be necessary to convert CPT codes to ICD-9-CM codes. ICD-9-CM’s alphanumeric codes describe the services, tests, consultations, and any other way that that a healthcare provider has interacted with a patient. There is often significant overlap between this set of codes and CPT. For instance, the CPT code for two doses of Hepatitis A vaccine, of pediatric or adolescent dosage, for intramuscular use is 90633. The ICD-9-CM code for that same vaccine is V05.3. In general, CPT codes provide more specificity than their ICD-9-CM counterparts. For instance, three doses of the above vaccine is coded in CPT as 90634, while in ICD-9-CM it is still coded as V05.3. Medical coders should familiarize themselves with the equivalencies between these two code systems, and be able to freely translate one into the other.

In addition to converting between these two codes, medical coders must ensure that the code they enter for a medical procedure (the CPT code) makes sense with the diagnosis code (ICD-9-CM). The two codes work in tandem to show which procedure was done for what reason. By confirming that the codes correspond correctly, coders ensure that a claim will not be denied and returned by a health insurance company. For instance, if you submitted a claim for a Human Papilloma Virus vaccine (CPT code 90650), but list the diagnosis as acute appendicitis with generalized peritonitis (ICD-9-CM code 540.0), a health insurance company would catch this error, deny the claim, and return it to you for correction. Lastly, the upcoming switch to ICD-10-CM on October 1, 2014, means that coders should also be able to convert CPT codes into ICD-10-CM codes.

Use CPT Codes to Determine Doctor Fees

CPT codes can be used to assess the actual costs of a procedure in terms of the doctor’s fees. While medical billers and coders have access to this information already, the AMA allows non-professionals and students the ability to use a free CPT lookup for one procedure at a time. This is done through theCodeManager system on the AMA website, which allows patients to enter an existing CPT code to determine the procedure or treatment or look up a CPT code by entering the procedure, which will allow you to assess the cost paid by Medicare for this procedure in your area. In addition, you can also determine the average cost of this service throughout the U.S.

Step-by-Step process for looking up CPT codes

The steps for looking up the cost of a treatment or procedure using the CodeManager system are simple.

1. Get Started. First, click the above link to enter the AMA CodeManager website.
2. Agree to play by the rules. You will have to read and click an agreement that stipulates that you do not sell the information you receive from the website, and that the number of times you can use this service are limited. To continue, hit the “Agree” button.
3. Specify your location. Next, the screen asks you to select the state and nearest city in which the procedure was performed,
4. Specify your procedure. Enter either the CPT code or keywords that describe the medical treatment or procedure you wish to look up.

Your query may not return anything right away, so use these tips to search successfully:

• Try a few different search terms. For example, if you were trying to determine the cost of surgery to remove a ruptured appendix, you could enter the keywords “appendectomy” or even just “appendix”, which would lead you to several possible procedures and their costs, including code 44960 for a simple appendectomy, as well as other codes describing unlisted procedures involving the appendix, examinations of that organ, and related surgical procedures.
• Use medical terminology. In most cases, procedures and body parts are described by their medical terms, so while a search for “hip replacement” will give you no hits, a search for “hip arthroplasty” will give you several options of possible procedures. Of course, if you have the CPT code you can enter it outright and it will take you straight to the relevant procedure.

Note that in the costs column, the medical payment listed can either be “non facility” or “facility”, depending on where the procedure was conducted. Facilities include hospitals, including emergency rooms, ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs), while non facility means any other setting, such as clinics or private practice offices. You may also notice that some procedures can only be conducted in a facility or non-facility setting, which means that the other column will have an “NA” or non-applicable label and no price.

Using RVUs to determine average costs

The medical payments listed are an average of the Medicare cost throughout the U.S. multiplied by the relative value amount (RVU) of a region, which may be higher or lower than 1.0. For example, the same procedure, such as an appendectomy (44950), is priced at $722.57 in Manhattan but only $642.29 throughout Arizona. This is due to the relative costs of goods and services in a region, and is reflected in CPU pricing.

It is also very important to note that the prices listed on the CodeManager website reflect the cost of a procedure paid by Medicare based on the Medicare Physician Fee Schedule (MPFS), which is very close to its actual cost, though the prices patients or insurance providers are typically charged more to account for the costs of the facility and its staff; This is particularly true of private medical institutions.

ICD-9 to ICD-10 Medical Coding Crosswalk

The United States healthcare system will discontinue its use of ICD-9-CM diagnostic codes and upgrade its entire system to the next revision of the code: ICD-10-CM. Because ICD codes are integral to the medical billing process, the changes are taking place at every level of the patient-provider-payer relationship. As the person who interacts with diagnostic codes on a daily basis, the medical coder must be prepared for this transition. A medical coder must be fluent in both ICD-9-CM and ICD-10-CM in order to make the switch as seamlessly as possible.

This change was originally planned for October 1st, 2014 , however, the U.S Senate  introduced a bill on March, 26th, 2014 that will delay the change of ICD-9-CM to ICD-10-CM until October 1st, 2015.

A process called crosswalking is used to translate from one code to another. Crosswalking means mapping or translating a code from one set to another. Use the AAPC tool below to crosswalk between the different coding systems.

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Learn Why the Change Will Happen

In order to understand this important shift in health informatics, it’s important to first look at why the change is occurring. ICD-9-CM is being phased out because it is outdated (published in 1978) and not flexible enough to deal with changes and expansions to medical procedures and diagnoses. To put it another way, ICD-9-CM is out of room. As new methods, diseases, and diagnoses are discovered, ICD-9-CM has been unable to find space in its code to accurately report these advances in medicine. ICD-9-CM caps out at around 13,000 codes, while ICD-10-CM has roughly 68,000.

Explore How the Change Will Happen

Being able to perform translations between ICD-9-CM and ICD-10-CM codes is a vital skill for a professional coder. One way in which translation is useful is that you can crosswalk codes back to ICD-9-CM if you are tracking or analyzing data. For example, if you are creating a report on the 2014 calendar year (which, again, will see the use of both ICD-9-CM and ICD-10-CM codes), it may be easier to crosswalk ICD-10-CM codes back to ICD-9-CM to create a standard set of data. Crosswalking will also help you update your records and programs.

There are, however, a number of difficulties in this process. Because ICD-10-CM expands so significantly on the body of codes in ICD-9-CM, there are a number of discrepancies and inaccurate or incomplete translations between the two code sets. It’s the medical coder’s job to watch out for these discrepancies and become familiar with crosswalking procedure as the deadline to switch from ICD-9-CM to ICD-10-CM approaches. Note that it is impossible in most cases to perform a 100 percent accurate translation from one code set to the other, as ICD-10-CM is significantly different from ICD-9-CM in terms of the format, concept, and structure.

One resource that will help you learn to crosswalk between the two code sets is the National Center for Health Statistics’ General Equivalence Mappings, or GEMs. These GEMs find and list equivalencies between the code sets, and they are considered the authoritative source for mapping between both sets. The GEMs allow you to map forward and backward between ICD-9-CM and ICD-10-CM. Coders should be familiar with both processes.

Understanding Different Code Matches

There are different types of matches that occur between the ICD-9-CM and ICD-10-CM code sets. The AMA identifies four types of matches between the two code sets, and an additional type that is reserved for “no match.”

One-to-one exact matches

In one-to-one matches, a coder is able to identify an exact match between the two code sets. These are relatively rare; only 5% of codes translate exactly from ICD-10-CM to ICD-9-CM, and just over 24 percent map directly in the opposite direction. One example is the ICD-9-CM code 416.0 (primary pulmonary hypertension) and the ICD-10-CM code I270 (primary pulmonary hypertension).

One-to-one approximate matches with one choice

A significantly more common occurrence in ICD code crosswalking is a one-to-one approximate match. In fact, 82.6 percent of ICD-10-CM codes can be backward-mapped this way, while 49.1 percent of ICD-9-CM codes can be forward-mapped to a similar degree of accuracy. It should be noted that this is not a direct translation, but more of a “close enough” approximation. For example, the ICD-9-CM code 422.91 (idiopathic myocarditis) is an approximate match for ICD-10-CM code I401 (isolated myocarditis).

One-to-one approximate matches with multiple choices

Exact and approximate matches with one choice make up the majority of ICD code crosswalking, but there are still a large number of codes that do not translate with the same level of accuracy. Approximate matches with multiple choices put much more responsibility on the coders, as they must pick the best fit from a number of similar choices. In certain cases, different diagnoses may fall under one code in the other set. For example, ICD-10-CM codes C220 (liver cell carcinoma) and C22 (hepatoblastoma) both correspond to ICD-9-CM code 155.0 (malignant neoplasm of the liver, primary). Each code set has instances of different diagnoses corresponding to only one code in the other. Coders must pay attention to these areas, as a miscoded diagnosis could affect the status of a claim.

One-to-many matches

By far the most difficult instance of crosswalking, one-to-many matches involve one code in a code set corresponding to several codes in the other. For instance, the ICD-9-CM code 80010 (closed fracture of vault of skull with cerebral laceration and confusion, state of consciousness unspecified) corresponds to two different codes in ICD-10-CM: S02.0xxA (fracture of the vault of the skull, initial encounter for closed fracture) and S06.339A (contusion and laceration of the cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter). Essentially, the diagnosis code in one set must be created out of multiple codes in another set. The groups of codes that translate to a single code in another set are called “clusters.” Clusters are always between two and four codes in size. Some single codes may correspond to multiple clusters. All codes in a cluster need to be listed in order to fully represent its corresponding translation. This process of translating one-to-many matches requires diligence and constant review, as a code missing from a cluster creates fundamental inaccuracies in your report.

ICD-9-CM and ICD-10-CM Codes

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.


The International Classification of Diseases (ICD) code is one of the most essential pieces of the medical billing and coding process. Created by the World Health Organization (WHO) as a way of standardizing healthcare classification, ICD codes are diagnostic codes that represent all aspects of a medical diagnosis, including symptoms, social circumstances, cause of injury or disease, and more.

Exploring the ICD-9 and ICD-10 with Easy Lookup Tools
On this page are two tools for investigating ICD-9-CM and ICD-10-CM codes. They are a good place to get started with your education in medical billing and coding.

ICD-9-CM Tool

To use the ICD-9-CM tool, simply type the name of a disease or injury in the search field. The search engine should then give you the corresponding ICD-9-CM code. You can look up that code in the ICD-9-CM index, available through the CDC. You will have to download a copy and open it as an RTF file.

ICD-10-CM Tool

Use the ICD-10 -CM Tool to search by the name of the disease or injury, or by the code itself. You can then take your search results and use them to find more information on the World Health Organization’s version of ICD-10-CM. Click on the chapter title (like “diseases of the respiratory system”) in the drop-down menu on the left to get a list of code blocks that chapter contains. You can also click the arrow button to the left of the chapter title to navigate the drop-down menu from the sidebar.

Background on the ICD

ICD-9—the ninth revision of the International Classification of Diseases—was published in 1978 by the WHO and adapted for use in America by the NCHS. ICD codes were originally intended to be used for epidemiological purposes, but in the United States these codes are used by healthcare providers and insurance companies for billing and reimbursement.

In America, “CM” stands for “Clinical Modification,” which was instituted in the United States by the National Center for Health Statistics (NCHS) to provide additional information related to diagnosis and procedural codes. The CM allows for a much wider spectrum of specific information. ICD-9-CM is updated annually on October 1st in order to reflect new diagnoses, practices, and procedures in the healthcare industry.

How the ICD-9-CM Works

ICD codes create a standard vocabulary for identifying causes of illness, injury, and death around the world.

Physical copies of the ICD-9-CM codes are divided into volumes. Volume 1 contains a tabular list of codes (codes listed by number with the diagnosis following the number) and Volume 2 contains an alphabetical list of symptoms and diagnoses. The third volume for each of these contains procedure codes, which are only used by hospitals to report surgeries performed in their facility. Healthcare providers and insurance companies only use the first two volumes. For the purposes of this course, you will be looking up ICD codes entirely online, but it is still helpful to understand the organization of the ICD manuals.

The 5-digit numeric ICD-9-CM codes are organized from 000 to 999 according to the type of disease or injury they describe. For instance, codes in the 320-359 range represent diseases of the nervous system, such as encephalitis or meningitis. Codes 800-999 correspond to injury and poisoning, like dislocation (codes 830-839) or poisoning by drugs, medications, or other biological substances (codes 960-979).

Those first three digits in an ICD-9-CM code describe the general type of injury or disease, and are called the “category.” The category can be followed by a decimal point and up to two other digits, which provide more specific information about the type, location, and severity of the disease or injury. These last two digits are called the subcategory, and allow coders to increase the level of specificity of their report on a disease or injury.

Example:

The code 722.52 corresponds to degenerative disc disease of the lumbar, where:

• The 3-digit code, or category, “722” corresponds to “intervertebral disc disorders” in the list of diseases and injuries
  • The two-digit sub-subcategories refers to degenerative disc disease, lumbar

Generally speaking, the more digits in a code, the more specific the type, cause, and/or area of injury or disease.

There are also two sets of alphanumeric codes in ICD-9-CM. E-codes describe external causes of injury, while V-codes describe factors that influence health status and/or describe interactions with health services. An example of an e-code would be E905.2, which describes a scorpion sting causing poisoning and toxic reactions. An example of a V-code is V30.00, which describes a single live infant (V30) born in a hospital (V30.0) without mention of caesarean section (V30.00). Like the numeric codes in ICD-9-CM, each of these codes has varying degrees of specificity based on the incident.

Preparing for the Change to ICD-10

The ICD-9-CM will be replaced by the updated ICD-10 in late 2014. In order to comply with this change, healthcare providers, insurance companies, and clearinghouses must all be prepared to fully adopt ICD-10-CM by October 1, 2014. All claims filed with ICD-9-CM after that date will be rejected as non-compliant. Procedures arranged or completed before that date may still be filed with ICD-9-CM.

This switch is happening for a variety of reasons. For one, the ICD-9-CM is out of room. ICD-9-CM is set up so every category can only have 10 subcategories. As it currently stands, the ICD-9-CM can only classify around 13,600 diagnoses, compared to ICD-10-CM’s estimate of 69,000. As diagnoses continue to expand, the system can no longer support the breadth of medical study. The ICD-10 is also better suited for modern technological advances in the field, allowing for more optimized analysis of disease patterns and treatment outcomes.

There are similarities between the two code sets. The conventions and guidelines for assignment codes are largely the same, as is the organization of both sets. For instance, the first chapter, or category cluster, in both ICD-9-CM and ICD-10 is “Certain infectious and parasitic diseases,” so any professional qualified to manage ICD-9-CM should not have a problem with ICD-10. However, there are also key differences between the ICD-9-CM and ICD-10 systems, requiring a conversion on the part of the medical coder.

The composition of codes in the ICD-9-CM is primarily numeric, with limited alphanumeric additions, as discussed above. Valid ICD-9-CM codes are three, four, or five digits. In ICD-10-CM, all codes are alphanumeric and may be anywhere from three to seven digits, depending on the need for specificity. For instance, in ICD-9-CM, the cluster for “Certain infectious and parasitic diseases” is 001-139. In ICD-10 that same cluster would be labeled A00-B99.

Here is a broader example of the tabular breakdowns in ICD-9-CM and ICD-10:

ICD-9-CM

• Certain infectious and parasitic diseases (001-139)
  • Intestinal infectious diseases (001-009)
    • Cholera (001)
      • Cholera due to vibrio cholerae (001.0)
      • Cholera due to vibrio cholerae eltor (001.1)
      • Unspecified (001.9)

ICD-10

• Certain infectious and parasitic diseases (A00-B99)
  • Bacterial infections, other intestinal infectious diseases, and STDs (A00-A79)
    • Intestinal infectious diseases (A00-A09)
      • Cholera (A00)
        • Cholera due to vibrio cholerae (A00.0)
        • Cholera due to vibrio cholerae eltor (A00.1)
        • Unspecified (A00.9)

As you can see, the two code sets are largely similar, but with key differences. The alphanumeric numbering system of ICD-10 follows the same tabular tree as the numeric system in ICD-9-CM, adding a new subcategory within the A00-A79 cluster. As medical coders prepare for the shift, plenty of resources will be made available to translate ICD-9-CM into ICD-10.

Because ICD-10 and ICD-10-CM have a significantly larger set of codes than ICD-9 and ICD-9-CM, direct translation between the two code sets is impossible. The translation of ICD-9-CM codes into ICD-10-CM codes using a “crosswalk” program will be discussed in Course 11.

Watch for Coding Notes

In many cases, codes will have notes attached to them that prevent redundancies or inaccurate coding. These notes help medical coders accurately translate the diagnosis into code, and may include instructions like:

• “Code first,” in which case the coder must list an underlying condition or prior procedure
• “Includes,” which tells the coder which symptoms or afflictions the code contains
• “Excludes” or “excludes1,” which are especially important. Unique to ICD-9-CM, the “excludes” note instructs the coder that there is another, more appropriate code for a certain diagnosis. “Excludes1” indicates that the term listed under the “excludes1” field cannot occur simultaneously with the term listed above it. For example, systemic inflammatory response syndrome (SIRS) is coded as R65.1, but excludes severe sepsis (R65.2).

Those these notes can be complicated, they are essential for coding accurately. Even the smallest mistake can cause a medical claim to be denied, creating more work for the office and possibly delaying vital payments from the insurance company to a patient.

Medical Billing for Medicaid/Medicare

The Difference Between Medicaid and Medicare

Medicaid and Medicare are often mentioned in the same breath, but the two programs perform completely separate functions in the American healthcare system.

Medicare

Medicare is a federal healthcare program created in 1965 with the passage of the Social Security Amendments to ensure that citizens 65 and older as well as younger persons with certain disabilities have access to quality healthcare. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). CMS manages Medicare programs by selecting official Medicare administrative contractors (MACs) to process the Medicare claims associated with various parts of Medicare. Medicare as a healthcare plan is divided into different parts, each of which cover a specific healthcare service:

• Part A (Medically necessary services): Part A of Medicare covers basic healthcare necessary to treat a pressing medical condition. Covered services may include hospital care, skilled nursing care, nursing home care, hospice care, and other support deemed essential to treating an illness or a condition.
• Part B (Preventive Care): Services covered in Part B include services or supplies needed to treat or prevent a medical condition. Part B of Medicare also covers some preventive care services such as inpatient/outpatient mental health, clinical research, and ambulance services.
• Part C (Medicare Advantage Plan): Part C of Medicare covers all healthcare services through a provider organization such as a hospital or a private practice. Patients must be enrolled in Medicare Parts A and B to qualify for Part C.
• Part D (Prescription Drugs): Part D was created in 2003 with the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. It covers many prescription drug costs and is paid for by monthly premiums of Medicare enrollees.

For more information regarding Medicare, check out the federal government’s official page for Medicare.

Medicaid

Medicaid is a program that provides healthcare coverage for low-income families and individuals, for persons with disabilities, and in some cases the elderly. For medical billing purposes, the most important difference between Medicare and Medicaid is the organization of each program. Medicare is a program provided by the federal government through CMS and has universal applications across state boundaries. Medicaid is a program funded by both state governments and the federal government. States provide Medicaid benefits in cooperation with CMS and federal guidelines. Medicaid programs differ from state to state, though they must all meet certain standards established by the federal government.

Medicaid coverage plans can change from state to state. Some states have extended their Medicaid programs to cover comprehensive healthcare issues for recipients, while other states only meet the minimum program requirements as mandated by the federal government. The following are some of the minimum Medicaid services covered:

• Inpatient/outpatient hospital services
• Family planning care
• Pediatric services
• Prescription drug costs
• Dental healthcare and services
• Mental health services
• Occupational, physical, and speech therapy

Rules of Medicaid eligibility also vary by state. Some states have stricter rules for eligibility, while others are more relaxed. As a medical billing specialist you should understand Medicaid eligibility in your state. You can visit the official Medicaid site in addition to the Medicaid page for your state to learn more.

Medical Billing for Medicaid

Medical billing for Medicaid is more complicated than medical billing for Medicare simply because Medicaid programs differ from state to state. Some citizens eligible for care in one state may not be eligible for care in another state, or they may receive a more or less benefits depending on the state in which they receive care. Billing codes, claim submission protocols, reimbursement rates, and other billing information will vary by state.

You will start the medical billing process for Medicaid by filling out a state claim form for the services and procedures covered. Most state Medicaid claim forms will be divided into main two parts: information regarding the patient and/or the insured person and information regarding the healthcare provider. As you complete the Medicaid form you will input codes from the following code sets:

• International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes: ICD-9-CM is the system by which official codes are assigned to medical diagnoses and procedures relating to hospital use in the U.S. The ICD-9-CM lists the official disease codes for relevant medical conditions and procedures. ICD-9-CM codes are a series of alphanumeric digits followed by a decimal point followed by one or two numeric digits.
• Place of Service Codes: Place of service codes specify where the patient received their medical care or supplies. Place of service codes are ascribed to medical facilities such as inpatient hospitals, nursing facilities, and hospices. Place of service codes are typically two digits long.
• Healthcare Common Procedure Coding System (HCPCS) Level II Codes: HCPCS Level II codes are used to identify and categorize supplies, services, and products not included in CPT codes. HCPCS Level II codes may include ambulance services and prosthetics. HCPCS Level II codes have a single letter followed by four numeric digits.
• Current Procedural Terminology (CPT) Codes: CPT codes (also known as Level I HCPCS codes) are a subset of the HCPCS and they are used for identifying and categorizing medical procedures and services. CPT codes are created and revised as necessary by an official editorial board in conjunction with the American Medical Association. CPT does are five numeric digits long.

You can check the format of the Medicaid claim form in the state where you live in addition to state Medicaid policies on the official Medicaid webpage.

Medical Billing for Medicare

Medicare functions as a single-payer healthcare system that pays insurance companies on behalf of people enrolled in its various programs. It’s up to medical billing officials to submit claims to appropriate MACs for processing after a person has received care covered by their Medicare plan.

Your duties as a medical billing specialist include inputting information from a provider’s superbill into compatible medical billing software. This includes provider information, patient information, information regarding treatment the patient received, and any relevant medical codes. Once you’ve input the necessary information into the medical billing software, you will either print out a CMS-1500 claim form for submission via mail or you will submit another claim form electronically to MAC for processing. As you file claims associated with Medicare, you will need to input medical codes similar to those you would use for Medicaid claim forms including CPT, ICD-9-CM, and place of service codes.

In order to properly understand how to file claims associated with Medicare coverage, consider the separate parts of the Medicare healthcare program.

Part A: medically necessary services

You will process claims associated with Part A of Medicare (medically necessary services) if you’re a medical billing specialist working with hospitals, clinics, and other facilities that offer inpatient care. You file Part A claims on behalf of your provider using the UB-04 medical claim form (also known as the CMS-1450 form). The UB-04 is the uniform institutional provider hardcopy claim form accepted for billing third-party providers. It is also the only hardcopy claim form that CMS accepts from institutional providers such as hospitals or skilled nursing facilities. When filing the UB-04 form, you should note that not all payers are required to complete the same data fields. Do your research to determine what fields are appropriate for each claim.

Part B: preventative care

As a medical billing specialist working for an outpatient healthcare provider, you will usually process claims associated with Part B of Medicare (preventative care). You file Part B claims using the CMS-1500 form, which is the standard claim form used by healthcare providers to billing Medicare carriers.

These forms must be purchased from legitimate sources other than the CMS, like the National Uniform Claim Committee (NUCC), which is responsible for updating and maintaining the CMS-1500. Be sure to check the guidelines for printing and preparing CMS-1500 forms before you process any claims. Note that the CMS-1500 form can also be used to bill some state Medicaid programs.

Parts C and D: to be filed separately

Claims related to Parts C and D of Medicare are relayed through a private insurer and should never be filed through Medicare. You won’t file Medicare claims with Parts C and D because private health plan carriers have agreements with Medicare to receive a certain amount per member every month. Part D of Medicare coverage may change depending on the person receiving care because coverage depends on the drugs involved. Some drugs aren’t covered by Part D at all. Thus claims filed through Parts C and D of Medicare should be treated like any other claim handled through a private health plan carrier.

Check out the Centers for Medicare and Medicaid Services for detailed information about medical billing and coding procedures related to Medicare.

Processing Claims for Medicare and Medicaid

Know how to handle claims through these government healthcare programs.

Medicare claims

As a medical billing specialist, Medicare claims you file on behalf of the provider are sent directly to nearby MACs for processing. MACs typically take around 30 days to process each claim they receive.

Part A claims: Medicare pays the provider directly. Any deductibles, co-pays, or other fees that apply after Medicare pays the provider must be satisfied by the patient.

Part B claims: Medicare pays either the provider or the patient for care covered by the plan, which depends on who accepts assignment of the claim. If the provider accepts assignment of the claim, Medicare will pay them for 80% of the approved amount. The remaining 20% will be paid to the provider by the patient. If the provider does not accept assignment of the claim Medicare will pay the patient the approved amount for care received, and they will then pay the provider.

Medicaid claims

Processing billing for Medicaid claims can be trickier than those filed under Medicare because Medicaid claims must adhere to both federal and state guidelines. Providers who participate in Medicaid must meet these guidelines, and as a medical billing specialist you should be aware of any discrepancies between federal and state guidelines as you process claims. For example, a provider must adjust the remaining balance once meeting any applicable charges for a co-payment or deductible and after Medicaid has paid what they are allowed to pay under the Medicaid fee schedule.

Note also that Medicaid is officially the payer of last resource for a claim, meaning that if a person has any other health coverage for services rendered, those institutions should be billed before Medicaid.