A CPT code (Current Procedural Terminology) is the standard billing code that is used when billing a payer. Sometimes it is referred to as a HCPCS code (Healthcare Common Procedure Coding System). You are familiar with the three letter code used by DDD to bill. In order for DDD to be reimbursed by the state for those services they have to translate the 3 letter code to the CPT code internally. They will now require you use the industry standard for biling codes. They have provided a translation document so you understand how to map the 3 letter code to the CPT/HCPCS code.

You can find the rate conversion chart and other documents here.

Some CPT codes require you bill by 15 minute or 30 minute increment. We call this a multiplier. The reason we call this a multiplier is so that you can still pay someone for an hour of service and bill by the multiplier. Otherwise employees would need to be paid by 15 minute rates on some services and 60 minute on other services.  Keep in mind that authorizations are given out by the "unit". Which means that if someone gets 100 hours of service and it has a multiplier of 4 then they would have 400 unites of that service.  You will still pay the employee by the hour regardless of what the payer multiplier is. SpokeChoice will calculate the amount of auths against the time that the member is served. Keep in mind the rates for a given CPT will be by the UNIT. Which means you can calculate the hour amount by multiplying the multiplier times the rate. You will ALWAYS put in the unit price into SpokeChoice and not the hourly amount.

835 files are EDI files but contain remittance information for payment (or denials). These files are used to mark claims as paid and be uploaded to SpokeChoice.

TA1 files is an acceptance file that indicates if the 837 file you've uploaded was accepted or not. Using the EDI Analyzer within Spokechoice you can easily decode the information and it is not necessary to learn how to read it.

999 Files are syntax EDI files that indicate what was wrong with the 837 file that was uploaded. Again, you can use the SpokeChoice EDI analyzer to read these files and do not need to guess or learn how to read them, which is almost impossible.

A diagnosis code pointer is called such because of how it was entered on the old 1500 form. Below you'll see that there are 12 places for diagnosis codes

Then on each claims within the 1500 form you will see a column called diagnosis pointer

If you were to enter F89 as a diagnosis code in 21A then the diagnosis pointer in 3 would be "A". This is to say that the claim you are billing for is for the diagnosis of the patient of F89 found in box A.

The good news with all this mess is that SpokeChoice handles it but it has to know based on the "billing code", ie: S5152, you are billing with a certain diagnosis code. This means that every client has to have a billing code pointer to each diagnosis code the member might have.  Understand that certain billing codes go with certain diagnosis codes. It is up to you to ensure you have assigned the proper billing code to the proper diagnosis code or run the risk of denial when the claim is submitted. This only has to be setup once per member/diag/CPT code and not each time you are billing a claim.