the business of medicine. –coding as a profession how the coder fits in hospital vs. physician...

The Business of MedicineThe Business of Medicine

The Business of Medicine


– Coding as a profession• How the coder fits in• Hospital vs. physician services• Hierarchy of providers

– Coding and billing aspects• Payers• Documentation in the medical record• Medical necessity• ABN

Objectives

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– Regulations• Health Insurance Portability and Accountability

Act (HIPAA)• Compliance• Office of Inspector General (OIG) Workplan

– AAPC

Objectives

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The Business of MedicineThe Business of Medicine 44


• What is coding?– Coding is the process of translating a written or

dictated medical record into a series of numeric or alpha-numeric codes.

– Assign CPT®, ICD-9-CM, and HCPCS codes to convey services and the reason they are performed.

• Why is it important?– Provides the medical biller with information

necessary to process a claim for reimbursement.

Coding As A Profession

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• Physician-based coders (medical coders, coding specialists)– Assign CPT®, HCPCS and ICD-9-CM (Volumes 1

& 2) codes for insurance billing– Codes are tied directly to physician

reimbursement


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• Hospital-based coders (health information coders, medical record coders, coder/abstractors, coding specialists)– Assign CPT®, HCPCS and ICD-9-CM codes– ICD-9-CM (diagnosis) codes are used to assign

a Medicare severity diagnosis-related group (MS-DRGs) for reimbursement


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• Rapidly changing profession– updates and policies are changed as often as

quarterly – increasing use of electronic health records (EHR) will

continue to broaden and alter the job responsibilities • Role of a coder may become more technical as they

contribute to the development and maintenance of EHRs• Role of a coder may become more of an auditor with the

advancement of EHRs


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• Master anatomy and terminology

• Must be detail oriented– Words such as “if” and “and/or” can completely

change a code selection– Attention to guidelines


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• Physician-based medical coding– Bill for physician’s work and overhead– CPT®, HCPCS, ICD-9-CM Volumes 1 & 2 – CMS-1500 claim form

• Hospital-based medical coding– Bill for the technical component of services

provided– ICD-9-CM Volume 1, 2, & 3, MS-DRGs, APCs– UB-04 claim form

Hospital vs. Physician Services

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Hierarchy of Providers

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Physician

Radiology Tech

Physician Assistant (PA) Nurse Practitioner (NP)

Physical Therapist Lab Tech Nurses


• Self-pay• Insurance

– Private (commercial) insurance• BCBS (Blue Cross/Blue Shield)• Aetna• Cigna• Etc

– Government insurance• Medicare – for persons ≥ age 65, blind, disabled, and people with

permanent kidney failure or end-stage renal disease , federal• Medicaid – for low-income people, sponsored by state and federal• TriCare – for active duty service members, National Guard and

Reserve members, retirees, families and survivors worldwide

Payers

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• Part A - inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home health care

• Part B – medically necessary physician services, outpatient care, and other medical services not covered by Part A

• Part C – managed by private insurers and may include a combination of Part A, Part B and sometimes Part D services

• Part D – prescription drug coverage program available to Medicare beneficiaries

Medicare

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• Recording of pertinent facts and observations about an individual’s health

• Chronologically documents patient care to:– Provide continuity of care between providers– Facilitate claims review and payment– Serve as a legal document

The Medical Record

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• S— Subjective—The patient’s statement about their health, including symptoms.

• O— Objective—The provider assesses and documents the patient illness using observation, palpation, auscultation, and percussion.

• A— Assessment—Evaluation and conclusion made by the provider.

• P— Plan—Course of action.

Evaluation and Management Documentation

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• The header might include: – Date and time of the procedure – Names of the surgeon, co-surgeon, assistant

surgeon – Type of anesthesia and anesthesiology provider

name – Pre-operative and post-operative diagnoses – Procedure performed – Complications

Operative Report Documentation

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• The body might include:– Indication for the surgery– Details of the procedure(s)– Findings

Operative Report Documentation

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1. Diagnosis code reporting– Use the post-operative diagnosis for coding

unless there are further defined diagnoses or additional diagnoses found in the body or findings of the operative report.

– If a pathology report is available, use the findings from the pathology report for the diagnosis.

Operative Report Coding Tips

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2. Start with the procedures listed– One way of quickly starting the research process is

by focusing on the procedures listed in the header– Read the note in its entirety to verify the

procedures performed• Procedures listed in the header may not be listed

correctly• Procedures documented within the body of the report

may not be listed in the header at all


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3. Look for key words– Locations and anatomical structures involved– Surgical approach– Procedure method (debridement, drainage,

incision, repair, etc.)– Procedure type (open, closed, simple,

intermediate, etc.)– Size and number– Surgical instruments used during the procedure.


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4. Highlight unfamiliar words– Words you are not familiar with:

• Medical terms• Anatomic landmarks• Medical procedures

– Research for understanding


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5. Read the body– All procedures reported should be documented

within the body of the report– The body may indicate a procedure was:

• Abandoned• Complicated• Extensive• Extra time


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Services or supplies that: • are proper and needed for the diagnosis or treatment

of your medical condition, • are provided for the diagnosis, direct care, and

treatment of your medical condition, • meet the standards of good medical practice in the

local area, and • aren’t mainly for the convenience of you or your

doctor.

Medical Necessity

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• National Coverage Determinations (NCD) help to spell out CMS policies on when Medicare will pay for items or services– Each Medicare Administrative Carrier (MAC) is

then responsible for interpreting national policies into regional policies

– LCD’s only have jurisdiction within their regional area

National Coverage Determinations

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Contractor Information:• Contractor Name: Novitas Solutions, Inc.• Contractor Number(s):

04911, 07101, 07102, 07201, 07202, 07301, 07302, 04111, 04112, 04211, 04212, 04311, 04312, 04411, 04412

• Contractor Type:MAC Part A & B

Sample LCD

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Source: Novitas Solutions https://www.novitas-solutions.com/policy/jh/l32614-r1.html



Indications and Limitations of Coverage and/or Medical NecessityNotice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Medicare generally considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non-covered. Similarly, assays for micronutrient testing for nutritional deficiencies that include multiple tests for vitamins, minerals, antioxidants and various metabolic functions are never necessary. Medicare reimburses for covered clinical laboratory studies that are reasonable and necessary for the diagnosis or treatment of an illness. Many vitamin deficiency problems can be determined from a comprehensive history and physical examination. Any diagnostic evaluation should be targeted at the specific vitamin deficiency suspected and not a general screen. Most vitamin deficiencies are nutritional in origin and may be corrected with supplemented vitamins.

Most vitamin deficiencies are suggested by specific clinical findings. The presence of those specific clinical findings may prompt laboratory testing for evidence of a deficiency of that specific vitamin. Certain other clinical states may also lead to vitamin deficiencies (malabsorption syndromes, etc).

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Limitations:

For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861(nn)). Vitamin or micronutrient testing may not be used for routine screening.

Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors.

Assays of selenium (84255), functional intracellular analysis (84999) or total antioxidant function (84999) are non-covered services. Assays of vitamin testing, not otherwise classified (84591), are not covered since all clinically relevant vitamins have specific assays.

The following are pertinent laboratory tests for which frequency limitations will be specified [note this should be all the CPT codes in the list below, except for those that are non-covered]:Vitamins and metabolic function assays: 25-OH Vitamin D-3, Carnitine, Vitamin B-12, Folic Acid (Serum), Homocystine, Vitamin B-6, Vitamin B-2, Vitamin B-1, Vitamin E, Fibrinogen, High-Sensitivity C-Reactive Protein and Lipoprotein-associated phospholipase A 2 (Lp-PLA 2); Vitamin A; Vitamin K; and Ascorbic acid.

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82180 Assay of ascorbic acid

82306 Vitamin d 25 hydroxy

82379 Assay of carnitine

82607 Vitamin B-12

82652 Vit d 1 25-dihydroxy

82746 Blood folic acid serum

83090 Assay of homocystine

CPT/HCPCS CodesNote: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

Note:Code 82306 includes fractions, if performed.Code 82652 includes fractions, if performed.

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252.00 - 252.02HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NON-RENAL

252.08 OTHER HYPERPARATHYROIDISM252.1 HYPOPARATHYROIDISM268.0 RICKETS ACTIVE268.2 OSTEOMALACIA UNSPECIFIED268.9 UNSPECIFIED VITAMIN D DEFICIENCY275.3 DISORDERS OF PHOSPHORUS METABOLISM275.41 - 275.42 HYPOCALCEMIA - HYPERCALCEMIA

585.3 - 585.6 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) - END STAGE RENAL DISEASE

ICD-9 Codes that Support Medical NecessityNote: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT codes 82306 and 82652:Covered for:

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• Providers are responsible for obtaining an ABN prior to providing the service or item to a beneficiary. – The form must be filled out in its entirety as

well as the cost to the patient and the reason why Medicare may deny the service

– Only the approved Form CMS-R-131 is valid and the forms may not be altered

Advance Beneficiary Notice

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• Title II: Administration Simplification:• National standards for electronic health care

transactions and code sets;• National unique identifiers for providers,

health plans, and employers;• Provides federal protection for the privacy

and security of personal health information.

Health Insurance Portability and Accountability Act (HIPAA)

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• National Standards ASCx12 for electronic transactions– 5010 (eff. Jan. 1, 2012)


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• Code Sets– HCPCS – Healthcare Common Procedure Coding System– CPT® - Current Procedural Terminology– CDT - Dental Procedures and Nomenclature– ICD-9-CM (ICD-10-CM eff. Oct. 1, 2014) – International

Classification of Diseases, 9th revision, Clinical Modification

– NDC – National Drug Codes• Although HIPAA mandates the use of the specified

code sets, it does not mandate the use of its conventions or guidelines, except for the ICD-9-CM.


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• The Health Information Technology for Economic and Clinical Health Act– Promote the adoption and meaningful use of

health information technology– Strengthened HIPAA rules by addressing

privacy and security concerns associated with electronic transmissions of health inforamtion

– Patient audit trail

HITECH

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Large Health Care Provider Restricts Use of Patient RecordsCovered Entity: Multi-Hospital Healthcare ProviderIssue: Impermissible Use

A nurse practitioner who has privileges at a multi-hospital health care system and who is part of the system’s organized health care arrangement impermissibly accessed the medical records of her ex-husband. In order to resolve this matter to OCR’s satisfaction and to prevent a recurrence, the covered entity: terminated the nurse practitioner’s access to its electronic records system; reported the nurse practitioner’s conduct to the appropriate licensing authority; and, provided the nurse practitioner with remedial Privacy Rule training.

Violation of Privacy Act (HIPAA)

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http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html#case1


• Benefits of a compliance plan:– Faster, more accurate payment of claims– Fewer billing mistakes– Diminished chances of a payer audit– Last chance of running afoul of self-referral and antikickback statutes– Increased accuracy of physician documentation that may result from a

compliance program actually may assist in enhancing patient care– Show the physician practice is making a good faith effort to submit

claims appropriately– Sends a signal to employees that compliance is a priority while

providing a means to report erroneous or fraudulent conduct, so that it may be corrected

Need for Compliance

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1. Conduct internal monitoring and auditing. 2. Implement compliance and practice standards. 3. Designate a compliance officer or contact. 4. Conduct appropriate training and education. 5. Respond appropriately to detected offenses and develop

corrective action. 6. Develop open lines of communication with employees. 7. Enforce disciplinary standards through well-publicized

guidelines.

OIG Compliance Plan

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http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp


• Published yearly• Outlines priorities for the Centers for

Medicare & Medicaid Services; the public health agencies; the Administrations for Children & Families; and Administration on Aging

• Targets areas for improvement

Office of Inspector General (OIG) Workplan

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OIG Work Plan – FY 2013

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Evaluation and Management Services—Use of Modifiers During the Global Surgery Period

We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment. includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.) Guidance for the use of modifiers for global surgeries is in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 30.

(OAS; W-00-13-35607; various reviews; expected issue date: FY 2013;new start) Source: https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WP01-Mcare_A+B.pdf


OIG Work Plan – FY 2013

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Sleep Testing—Appropriateness of Medicare Payments for Polysomnography

We will identify questionable billing patterns for Medicare sleep study services provided in 2009 and 2010. Medicare payments for polysomnography increased from $62 million in 2001 to $235 million in 2009, and coverage was also recently expanded. Sleep studies are reimbursable for patients who have symptoms such as sleep apnea, narcolepsy, or parasomnia in accordance with the CMS’s MedicareBenefit Policy Manual, Pub. 102, ch. 15, § 70.

(OEI; 05-12-00340; expected issue date: FY 2013; work in progress)

Source:https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WP01-Mcare_A+B.pdf


• Founded in 1988 to provide education and professional certification to physician-based medical coders

• Over 110,000 Members Worldwide• Over 78,000 Certified Members• Over 440 local chapters across the United

States

AAPC

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the business of medicine. –coding as a profession how the coder fits in hospital vs. physician...

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