Demystifying Billing and Coding for Market Access Leaders: A Quick Guide ????

Navigating the world of medical coding can be daunting, but it doesn't have to be intimidating! As a Market Access leader, it's essential to get a handle on the basics of key codesets and processes to understand how to optimize billing and reimbursement while maintaining regulatory compliance. Having the right billing and coding strategy is an essential component of a successful market access launch.

Here’s a succinct guide to help you master the essentials.

Codes for Diagnosis ????

ICD-10-CM Codes (International Classification of Diseases, 10th Revision)

What They Are: Codes describing diagnoses and reasons for patient encounters, used in both inpatient and outpatient settings. ICD-10-CM codes range from three to seven characters long. The first character is always a letter, followed by numbers. The more characters, the more specific the diagnosis. In the US, Centers for Medicare & Medicaid Services and other payers may require the most detailed level of code for a product or service to be reimbursed. Using a less specific code can result in claim denials or reduced reimbursement. The ICD-10 is governed by the World Health Organization (WHO), with the CDC's National Center for Health Statistics (NCHS) maintaining and updating the ICD-10-CM codes in the United States

Examples of increasing coding specificity for a Melanoma disease state: Top-Level (3 Characters): C43 – Malignant melanoma of skin... More Specific (4-5 Characters): C43.0 – Malignant melanoma of lip or C43.1 – Malignant melanoma of eyelid, including canthus... Even More Specific (6-7 Characters): C43.11 – Malignant melanoma of right eyelid, including canthus... C43.12 – Malignant melanoma of left eyelid, including canthus.

Applying for a new code: In most cases, manufacturers will be operating in an established disease area with an existing diagnosis code. However, if a new code is required, submit proposals in March or September to the ICD-10 Coordination and Maintenance Committee for the next update cycle.

Codes for Procedures and Activities ????

(1) CPT Codes (Current Procedural Terminology)

What They Are: Codes for medical, surgical, and diagnostic services. They are primarily used for outpatient billing; CPT codes are crucial for billing Medicare patients via the the Medicare Hospital Outpatient Prospective Payment System (OPPS) as well as private payers. They are subcategorized into Category I codes (Common procedures and services), Category II (Performance tracking codes), and Category III (Emerging technologies and services), and are governed and published by the American Medical Association . Medicare's Physician Fee Schedule (PFS) establishes relative value units (RVUs) for each service described by a CPT code, which payers use to determine reimbursement amounts that can vary by payer and geographic location.

Applying for a new code: Applications for new CPT codes can be submitted to the AMA's CPT Editorial Panel, which typically meets three times per year. Getting a new CPT code can potentially be a lengthy process from preparation through submission and approval, and once approved, it will be available in January of the following year. Note, however, that not all categories of CPT codes are reimbursed, and achieving a new code does not automatically lead to reimbursement.

(2) HCPCS Codes (Healthcare Common Procedure Coding System)

What They Are: HCPCS codes represent products, supplies, and services not covered by CPT. These include two types of codes that are frequently important in coding for drug products, particularly those that are physician administered: C-codes and J-codes. Both of these categories are considered HCPCS Level II codes. Centers for Medicare & Medicaid Services governs HCPCS Level II codes. Prior to a drug receiving a designated HCPCS code, it is often billed using an "unspecified" code of which there are several.

Applying for a new code: Anyone can apply for a new HCPCS code using CMS's electronic application. For drugs and biologics, applications must be submitted by the first business day of each quarter (January, April, July, and October) of the year. Ensuring that HCPCS II code applications are done in a timely fashion is a key component of Billing & Coding Operations for Market Access leaders!

(3) ICD-10-PCS Codes (Procedure Coding System) ?? ??

What they are: ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System) codes are used to describe inpatient procedures. They are essential for hospital billing and reporting, particularly under the Medicare Inpatient Prospective Payment System (IPPS). These codes are highly detailed and structured to provide specific information about the procedures performed during an inpatient stay. ICD-10-PCS codes are exclusively used for inpatient hospital billing. Each code consists of seven characters, with each character representing a specific aspect of the procedure, such as the section of the system, body system, root operation, body part, approach, device, and qualifier. CMS maintains and updates the ICD-10-PCS codes.

(5) MS-DRG Codes (Medicare Severity-Diagnosis Related Groups) ?? ??

What They Are: MS-DRG codes are part of the Medicare Severity-Diagnosis Related Groups system, which classifies inpatient stays for the purpose of determining reimbursement rates under the Medicare Inpatient Prospective Payment System (IPPS). These codes group inpatient hospital services into categories based on the principal diagnosis, secondary diagnoses, procedures performed, patient demographics, and discharge status. They are used exclusively for inpatient hospital billing. They help standardize payment rates by categorizing cases that are clinically similar and expected to use similar hospital resources. Each MS-DRG code represents a specific category of inpatient stay, factoring in the severity of the condition and the intensity of the resources required for treatment.

Applying for a new code: CMS is responsible for maintaining and updating MS-DRG codes. They review and revise the DRG definitions annually to reflect changes in technology, practice patterns, and resource use. Proposals for new codes are reviewed by the Medicare Payment Advisory Commission (MedPAC) and other advisory groups. Review includes public comment periods and is finalized in the annual IPPS final rule in a Fiscal Year (FY) cycle. New MS-DRG codes, if approved, are published in the IPPS final rule and become effective on October 1 of the following year.

(6) NTAP Codes (New Technology Add-on Payment) ?? ??

What They Are: NTAP codes are part of the New Technology Add-on Payment program, which provides additional reimbursement under the Medicare Inpatient Prospective Payment System (IPPS) for new medical technologies and services that offer substantial clinical improvement over existing treatments. These payments are designed to support the adoption of innovative technologies that may not yet be fully accounted for in the standard MS-DRG payment rates. NTAP codes are used in inpatient hospital billing to provide supplementary payments for new technologies used during inpatient stays. To qualify for NTAP, a technology must meet three criteria: Newness, High Cost, and Substantial Clinical Improvement. CMS oversees the NTAP program in terms of both applications and determining eligibility and reimbursement level.

Applying for and achieving an NTAP can be extremely important for reimbursement confidence for products that are delivered on an inpatient basis, such as cell and gene therapies, but that would "break the DRG" by being more expensive than hospital economics would support under a MS-DRG based bundled payment.

Applying for a new code: Like some of the other codesets maintained by CMS, NTAP can be applied for on an annual basis. CMS reviews these applications as part of its annual IPPS rulemaking cycle and determines whether to award the NTAP designation. This schedule does, admittedly, cause some headaches for manufacturers when their launch date and the NTAP dates don't coincide, leading sometimes to months where reimbursement is less than optimized while waiting for an NTAP decision to be made, issued, and implemented on the IPPS/Fiscal Year cycle.

(7) Value Codes ????

What They Are: Value codes are a set of codes used in medical billing to convey additional information on institutional claims, such as monetary amounts, units of service, or other specific details necessary for billing purposes. They provide context for the amounts billed and can include information like the number of covered days in a hospital stay, the value of certain medical supplies, or patient responsibility amounts. Value codes are primarily used on the UB-04 billing form, the standard claim form used by hospitals and other institutional providers to bill Medicare and Medicaid, as well as many private insurance companies, for services. They ensure that detailed and specific information is included on claims to support accurate billing and reimbursement. They are governed by the National Uniform Billing Committee (NUBC) which sets standards for billing practices and ensures that value codes are used consistently across the industry. The NUBC includes representatives from major healthcare industry stakeholders, including providers, payers, and government agencies.

The UB-04 Billing Form ????

What It Is: The UB-04 form, also known as the CMS-1450 form, is the standard claim form used by hospitals and other institutional providers to bill Medicare, Medicaid, and private insurance companies for. It captures comprehensive information about the patient, services provided, charges, and billing codes, ensuring that claims are processed accurately and efficiently. The form includes fields for patient information, diagnosis codes, procedure codes, revenue codes, value codes, and other relevant details needed to process a claim.

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