Beaverlog Tips: Volume 22 - January 5, 2005

2005 Procedure and Diagnosis Codes

Each year, the American Medical Association, World Health Organization, federal Centers for Medicare & Medicaid Services (CMS), and others add, change, and delete the codes used to identify diagnoses and procedures. CMS also updates the Relative Value Units (RVUs) for Medicare and Medicaid covered procedure codes. RVUs are numbers indicating the relative value and hence reimbursement rates on these procedure codes. Some other payers use RVUs as well for determining what they will pay for procedures on claims. Insurance payers also base their payment amounts on a patient's diagnosis so it is important to have and use the correct codes when you submit claims.

We are now offering a Codes Module update that will bring your procedure and diagnosis code lists up to date. The update is for all Windows versions of The THERAPIST starting with 1.0.009. The price is $60 for one installation and network user. Additional installations and/or network users are $20 each. You can download the update from If you want the update mailed to you on a CD, there is a $10 shipping and handling charge. Installing the update requires an unlock code that is specific to your installation of The THERAPIST. You can order the update and obtain your unlock code by calling customer service at (800) 895-3344.

Using Substitute Procedure and Diagnosis Codes

It's not just your imagination if it seems like insurance payers will do almost anything to avoid or delay paying a claim. Every payment denied or delayed means more money in their pockets. One of the ways they do this is to deny claims referencing particular diagnosis or procedure codes. Coding can be a complex process in is not an exact science. To make life even more interesting, sometimes, one insurance payer wants one code and rejects another while a second (secondary?) payer rejects the code required by the first while accepting a different code for a similar procedure or diagnosis. What is a responsible provider to do?

In The THERAPIST, you can tell the program to substitute one procedure or diagnosis code with another on claims to a particular carrier. Not only that, but it is easy to do and there are two ways to accomplish it. Open a Carrier record and look for the Codes tab. This tab has two lists, one for substitute diagnosis codes and one for substitute procedure codes.

Substitute Diagnosis Codes

Press the Insert button to add a code to the on subsitute diagnosis list on the left side of the scren. When you do, the diagnosis codes list screen pops up where you can select the code you want to replace. Once selected, a form opens where you can enter the substitute code that will be placed on claims to this Carrier. If you cannot remember the code, you can rght click or press F2 on this field to select a substitute code from the list.

Substitute Procedure Codes

Entering a substitute procedure code starts the same way when you press the Insert button on the right side of the screen. The procedure codes list comes up where you selec the code to replace. The subsequent form is a bit more complex than that for diagnosis codes. On this screen you can enter an Allowable Amount and an Obligated to Accept amount (don't ask) if the Carrier accepts this procedure code. If you check the "Procedure code is NOT accepted by this carrier" check box, you can enter a substitute procedure code or look one up from the list.

The second way to set up your code substitutions is from the entry screen for the desired procedure or diagnosis code. On the entry screen for either of these codes, go to the Carrier tab. This lists Carriers for whom substute codes (or allowable amounts for procedure codes) have been entered. Click the Insert button to add a substitution for a Carrier to the list.

When The THERAPIST creates a claim to the payer, it looks at these lists and makes the appropriate substitutions automatically.

Tip: Switch Tabs Using the Keyboard

Many screens in The THERAPIST are organized with a row of tabs along the top of the window. It is easy to select another tab by clicking on it with the mouse but how can you do it without taking your hands off the keyboard? That, too, is easy. The Alt+Right Arrow and Alt+Left Arrow keyboard combinations will rotate through the tab screens.

On the Money tab in services and when applying payments to services (in The THERAPIST Pro), there are tabs along the right side that let you select different payers (patient, responsible party, insurance). With these tabs, use the Alt+Up Arrow and Alt+Down Arrow keyboard combinations to cycle throught the payer tabs.