Transcript The Business of Medicine - Network Learning Institute
The Business of Medicine
The Business of Medicine
Objectives
– 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
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Objectives
– Regulations • Health Insurance Portability and Accountability Act (HIPAA) • Compliance • Office of Inspector General (OIG) Workplan – AAPC
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Coding As A Profession
• 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.
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Coding As A Profession
• 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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Coding As A Profession
• 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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Coding As A Profession
• 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 the advancement of EHRs 8
Coding As A Profession
• 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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Hospital vs. Physician Services
• 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
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Hierarchy of Providers
Physician Physician Assistant (PA) Nurse Practitioner (NP) Radiology Tech Physical Therapist Lab Tech Nurses
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Payers
• 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
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Medicare
• • • •
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
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The Medical Record
• 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
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Evaluation and Management Documentation
• • • •
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.
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Operative Report Documentation
• 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
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Operative Report Documentation
• The body might include: – Indication for the surgery – Details of the procedure(s) – Findings
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Operative Report Coding Tips
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.
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Operative Report Coding Tips
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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Operative Report Coding Tips
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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Operative Report Coding Tips
4. Highlight unfamiliar words – Words you are not familiar with: • • • Medical terms Anatomic landmarks Medical procedures – Research for understanding
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Operative Report Coding Tips
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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Medical Necessity
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.
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National Coverage Determinations
• 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
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Sample LCD
• • •
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 Source: Novitas Solutions https://www.novitas-solutions.com
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Indications and Limitations of Coverage and/or Medical Necessity Notice: 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).
Source: Novitas Solutions https://www.novitas-solutions.com
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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.
Additional inclusion of Vitamin D (with limited coverage not otherwise specified).
Source: Novitas Solutions https://www.novitas-solutions.com
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CPT/HCPCS Codes Note: 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.
82180 82306 82379 82607 Assay of ascorbic acid Vitamin d 25 hydroxy Assay of carnitine Vitamin B-12 82652 82746 Vit d 1 25-dihydroxy Blood folic acid serum 83090 Assay of homocystine Source: Novitas Solutions https://www.novitas-solutions.com
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ICD-9 Codes that Support Medical Necessity Note:
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:
252.00 - 252.02
252.08
252.1
268.0
268.2
268.9
275.3
275.41 - 275.42
HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NON RENAL OTHER HYPERPARATHYROIDISM HYPOPARATHYROIDISM RICKETS ACTIVE OSTEOMALACIA UNSPECIFIED UNSPECIFIED VITAMIN D DEFICIENCY DISORDERS OF PHOSPHORUS METABOLISM HYPOCALCEMIA - HYPERCALCEMIA 585.3 - 585.6
CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) - END STAGE RENAL DISEASE Source: Novitas Solutions https://www.novitas-solutions.com
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Advance Beneficiary Notice
• 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
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Health Insurance Portability and Accountability Act (HIPAA) • 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.
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Health Insurance Portability and Accountability Act (HIPAA) • National Standards ASCx12 for electronic transactions – 5010 (eff. Jan. 1, 2012)
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Health Insurance Portability and Accountability Act (HIPAA) • 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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HITECH
• 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
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Violation of Privacy Act (HIPAA)
Large Health Care Provider Restricts Use of Patient Records
Covered Entity: Multi-Hospital Healthcare Provider Issue: 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.
http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html#case1
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Need for Compliance
• 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
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OIG Compliance Plan
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Conduct internal monitoring and auditing. Implement compliance and practice standards. Designate a compliance officer or contact. Conduct appropriate training and education. Respond appropriately to detected offenses and develop corrective action. Develop open lines of communication with employees. Enforce disciplinary standards through well-publicized guidelines. http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp
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Office of Inspector General (OIG) Workplan
• 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
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OIG Work Plan – FY 2013
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
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OIG Work Plan – FY 2013
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
Medicare Benefit 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
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AAPC
• Founded in 1988 to provide education and professional certification to physician-based medical coders • Over 124,000 Members Worldwide • Over 90,000 Certified Members • Over 500 local chapters across the United States
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Welcome to AAPC!
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