Welcome to the AASM Coding Education Program. Our first module will serve as an introduction to the program and will address the importance of proper coding and billing for sleep centers. Our learning objectives for this module are to review the purpose of coding and billing in the sleep center, to identify key terminology used in discussions about coding and billing, to identify the roles of staff within sleep centers related to coding and billing, and to discuss setbacks and roadblocks that sleep center coders and billers encounter. Ideally, all staff should have an understanding of the basic principles of coding and billing. However, it is most important that the staff specifically assigned to coding and billing tasks have a working knowledge of procedural and diagnostic coding. They should understand the requirements of insurance policies. Additionally, they should understand the claims process, including how to complete claims, submit claims, and appeal denied claims. Coding of services provided and diagnoses assigned by physicians is critical to any medical practice. Coding transforms documentation of a procedure or disorder into a number. These codes can then be transmitted to insurance companies to obtain reimbursement. Coding also standardizes data about diseases and procedures. Additionally, codes can be collected in registries and databases to establish statistics on disease prevalence and the health conditions of local populations. Billing for services provided is the way a sleep center obtains payment for those services. In order to bill, a sleep center submits either a paper or electronic claim to the patient's insurer. This is the sleep center's way of communicating about the service provided with the insurance company. Accuracy and timeliness of billing is how the sleep center can ensure appropriate and rapid payments, which helps keep the sleep center in business. Delayed billing or forgetting to bill means that the sleep center doesn't get paid for the work performed. In addition to coding and submitting claims for services, the coding and billing staff may have additional roles within a sleep center depending on a center's size and capabilities. Additional duties may include appealing denied claims, establishing contacts with insurance companies, and helping to prevent fraud and abuse in the sleep center. These additional roles are described in further detail in future modules. Coding and billing staff is typically responsible for appealing claims that are denied by insurance companies. There are a number of reasons why a claim may be denied, including typographical errors on the claim and lack of medical necessity for the service. In some cases, the coding and billing staff can simply correct errors on the claim in order to appeal the denied claim. This can include correcting the patient's name or birth date. In more complex cases, the coding and billing staff may need to provide the insurance company with documentation to justify why the service was provided. This may include portions of the patient's medical record. Providing the insurance company with this additional information is often the role of the coding and billing staff. Building relationships with insurance companies can be one of the most beneficial responsibilities of coding and billing staff. Coding and billing staff should establish contacts at insurance companies to provide assistance with appealing denials and to answer questions about policies. Additionally, by joining mailing lists and listservs, coding and billing staff can be kept up-to-date about changes to policies and or claims submission procedures. Understanding each insurance company's unique billing requirements helps coding and billing staff to minimize errors and make the claims submission process as smooth as possible. Coding and billing staff can play an important role in the prevention of fraud and abuse in the sleep center. By developing a compliance plan for the sleep center, coding and billing staff can standardize regular audits of claims and establish policies and procedures for claims submission. Additionally, sleep center coding and billing staff should be aware of state and federal laws as well as HIPAA, the anti-kickback and self-referral statutes. There are many terms and concepts used in discussions about coding and billing. These terms can sound like jargon to the unfamiliar listener. It is important that coding and billing staff feel comfortable using these terms and understand their meanings. Throughout each ASEP module, you will learn definitions of frequently used terms, concepts, and acronym definitions. Two main types of codes are used in sleep centers. Procedure codes describe the services provided by the physician. Typical procedure codes used in the sleep center include codes for sleep studies and office visits. Diagnosis codes describe the patient's condition as determined by the physician. Typical diagnosis codes used in the sleep center include codes for conditions such as obstructive sleep apnea and insomnia. Most procedure codes used in the sleep center can be found in the current procedural terminology or CPT codebook. Diagnosis codes can be found in the International Classification of Diseases Codebook. Both procedural and diagnostic codes and their respective codebooks and coding systems will be described in further detail in future modules. Physician and management codes, also referred to as E&M codes, are procedure codes that are used by sleep physicians to bill for office visits. E&M codes exist for new patients and established patients. The codes also vary based on the intensity of the service provided. For example, a blood pressure check for an established patient is coded differently than a new patient visit for suspected sleep apnea. There are also E&M codes for services provided in hospitals, nursing facilities, and even in the emergency room. E&M codes will be discussed in detail in the procedure coding module. Like other procedure codes, E&M codes can be found in the CPT codebook. Modifiers are two-digit codes that are added to a procedure code to modify or change it. The modifiers can indicate that something unusual happened during the procedure. For example, in most sleep services, modifier 52 is added to a code if the recording time is less than 6 hours. Some modifiers are added to procedures to attest that all documentation for the procedure is present and on file. Some modifiers are listed in the CPT codebook, but they can also be found in other coding manuals and online. Different insurers use different modifiers, though many frequently used modifiers are standard across most insurers. Modifiers are discussed in further detail in the procedure coding module. A claim is the way in which a sleep center communicates with an insurance company about the service provided. The insurance company reviews a claim to determine whether or not to pay the sleep center for a service. There are two ways in which claims are submitted, on paper or electronically. The 1500 Claim Form is a standardized paper form for claim submission. It requires patient and physician information, insurance information, and coding information. When claims are submitted electronically, they must be submitted in a standardized format. Version 5010 is the current required standardized format for electronic claims transactions. It is important for all sleep center staff to understand their key role in the coding and billing process. Front office staff, clinical and professional staff, and coding and billing staff all play a part in this process. As the initial information gatherers, front desk staff members play a huge part in the coding and billing process. Front desk staff perform scheduling and registration duties that, when performed accurately, help ensure that the claims process is as smooth as possible. Insurance information, spelling of names, birth dates, and other personal information must be collected accurately by well-trained front desk staff. Clinical and professional staff members perform the services and assign the diagnoses that must be coded and eventually billed for. In some offices, clinical and professional staff assign codes based on their services. Depending on the office structure and technology, the clinical and professional staff either enter the codes into an electronic medical record system or write them on a patient encounter form, which is also known as a super bill. Coding and billing staff are responsible for confirming the coding of the clinical and professional staff. They can do this by reviewing the medical record to ensure that the documentation matches the coding. Coding and billing staff will then submit claims and interact with insurance companies to obtain reimbursement for services. If claims are denied, coding and billing staff work with the insurers to appeal the denial if appropriate. As the key staff responsible for claims submission, coding and billing staff have to regularly interact with clinical and professional staff as well as front desk staff. This can be challenging, especially because coding and billing staff may need to question the accuracy of the coding decisions made by clinical and professional staff. Coding and billing staff need to know how to politely address potential errors with clinical and professional staff. In addition, coding and billing staff may need to interact with front desk staff to discuss issues of information accuracy. Front desk staff should have standardized information collection policies to minimize errors though this may not resolve all issues. Respecting colleagues while still promoting accurate information and correct billing is a difficult balance to maintain. There are a number of additional challenges to coding and billing in the sleep center. Because of the small number of procedure codes for sleep services, it is often thought that procedural coding for sleep is easy, but this is not the case. Additionally, diagnostic coding for sleep disorders can be complex because the Diagnostic Coding Manual, the ICD-10 codebook, includes sleep disorders throughout many sections. Because sleep is a relatively new field, and because sleep physicians often work in small practices, the responsibilities of sleep center staff can be varied. It is often the responsibility of the front office staff to perform coding and billing, but this staff is often left untrained due to limited resources. It is the nature of all small offices that employees are required to multitask and hold many responsibilities that would, in a larger setting, be the responsibility of many individuals. With many responsibilities, coding and billing staff are pulled in many directions and may not get to focus on coding education and preventing fraud and abuse, issues that are important to the successful functioning of the sleep center. Wearing many hats and learning how to handle many tasks is a skill that coding and billing staff must learn, especially in the sleep center. In conclusion, coding and billing in the sleep center can be very challenging but also rewarding. Coding and billing staff are responsible for a wide variety of tasks within the sleep center as well as communicating effectively with various sleep center staff. These tasks are critical to the financial viability of the sleep center. In addition to claims submission, coding and billing staff may be responsible for other duties, including appealing denied claims, developing relationships with insurers, and preventing fraud and abuse. You are now ready to move on to Module 2, which will address procedural coding for sleep medicine.

AASM Coding Education Program

proper coding and billing

sleep centers

key terminology

staff roles