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The Business of Medicine

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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-10-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-10-CM 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-10-CM codes
ICD-10-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
Role of a coder may become more of an auditor with the advancement of EHRs

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Technicians who specialize in coding are called medical coders or coding specialists. Medical coders assign a code to each diagnosis and procedure by using a classification system. Coders may use several reimbursement systems, such as those required for ambulatory settings, physician offices, or long-term care. Most coders specialize in coding patients' medical information for insurance purposes.

Physician based coders review charts, assign CPT, HCPCS and ICD-10-CM codes for insurance billing. This is tied directly into physician reimbursements and careful thought to assigning the correct codes is essential for physician livelihood.

Technicians who specialize in coding for hospitals are called health information coders, medical record coders, coder/abstractors, or coding specialists. These technicians assign a code to each diagnosis and procedure, relying on their knowledge of disease processes. Coders then use classification systems to assign the patient to one of several hundred “Medicare severity diagnosis-related groups," or MS-DRGs. The MS-DRG determines the amount for which the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system.

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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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The coding profession is unique and, once mastered, continuing education must be ongoing. Code updates and policies are changed as often as quarterly. It remains important to stay abreast of these changes to insure proper coding and payments.

The increasing use of electronic health records (EHR) will continue to broaden and alter the job responsibilities of coders. For example, with the use of EHRs, coders must be familiar with EHR computer software, maintaining EHR security, and analyzing electronic data to improve healthcare information.

Coders also may assist with improving EHR software usability and may contribute to the development and maintenance of health information networks. The role of a coder may also become more of an auditor as they review the documentation in the encounter and how the code was assigned.

In addition to mastering anatomy and terminology, coders must be very detailed oriented. Simple words such as “if” “and/or” can completely change a code selection. Special attention to the many guidelines when learning the codes is necessary.

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Hospital vs. Physician Services

Physician-based medical coding

Bill for physician’s work and overhead
CPT®, HCPCS, ICD-10-CM
CMS-1500 claim form

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Hospital vs. Physician Services

Hospital-based medical coding

Bill for the technical component of services provided
ICD-10 CM, ICD-10-PCS, MS-DRGs, APCs
UB-04 claim form

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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

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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

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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PREOPERATIVE DIAGNOSIS: Right knee lateral discoid meniscus. �

POSTOPERATIVE DIAGNOSIS: Right knee lateral discoid meniscus. �

PROCEDURES PERFORMED: Right knee arthroscopy, lateral meniscus saucerization, lateral meniscal repair. �

SURGEON: T. Smith M.D.

ASSISTANT: M.D., Resident. �

ANESTHESIA: General. ��ESTIMATED BLOOD LOSS: Minimal.

There are regulations that govern medical necessity found in the Social Security Act. CMS develops policies based on items or services that are covered by the Act. CMS is not allowed to cover any items or services unless it has been put through the legal requirements.

The statutory and policy framework within which National Coverage Decisions are made may be found in title XVIII of the Social Security Act, and in Medicare regulations and rulings.

National Coverage Determinations, or NCDs, describe whether specific medical items, services, treatment, procedures, or technologies can be paid for under Medicare.

Medicare Administrative Contractors are responsible for interpreting national policies into regional policies. These are called Local Coverage Determinations, or LCDs. LCDs only have jurisdiction within their regional area.

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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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PROCEDURES PERFORMED: Right knee arthroscopy, lateral meniscus saucerization, lateral meniscal repair. �

SURGEON: T. Smith M.D.

ASSISTANT: M.D., Resident. �

ANESTHESIA: General. ��ESTIMATED BLOOD LOSS: Minimal. �

COMPLICATIONS: No complications noted. The patient was taken to the recovery room in stable condition. ��TOTAL TOURNIQUET TIME: 57 minutes. � �INDICATIONS: The patient is a 15-year-old female with right knee painful popping. She has a lateral discoid meniscus. After discussions of options, risks and benefits, it was elected to proceed with surgical management. ��DESCRIPTION OF PROCEDURE: The patient was taken to the operating suite, placed on the operating table in the supine position. She was administered preoperative antibiotics, general anesthetic, followed by intubation by the anesthesia team. The standard 3-portal knee scope was performed. On evaluation of the intraarticular space, cartilage throughout the knee looked in great condition. The medial meniscus looked in good condition as well. ACL was intact. We turned our attention to the lateral meniscus where it was noted to be a complete tear. We saucerized the meniscus out to a rim of 8 mm. The anterior horn was noted to be detached. So we roughened up this area and placed two number 2 Fiber wires using the spectrum technique. These were tied down with SMC knots. She was also noted to have a horizontal cleavage tear of the posterior horn, which was roughened with the shaver and the rasp and a single Fast-Fix was placed to close the space down. The instruments were then removed. Portals were closed using 3-0 Monocryl followed by Steri-Strips, 0.25% Marcaine with epinephrine was injected around the portal sites. Sterile dressing was placed. The patient was awoken, taken to the recovery room in stable condition.

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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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DESCRIPTION OF PROCEDURE: The patient was taken to the operating suite, placed on the operating table in the supine position. She was administered preoperative antibiotics, general anesthetic, followed by intubation by the anesthesia team. The standard 3-portal knee scope was performed. On evaluation of the intraarticular space, cartilage throughout the knee looked in great condition. The medial meniscus looked in good condition as well. ACL was intact. We turned our attention to the lateral meniscus where it was noted to be a complete tear. We saucerized the meniscus out to a rim of 8 mm. The anterior horn was noted to be detached. So we roughened up this area and placed two number 2 Fiber wires using the spectrum technique. These were tied down with SMC knots. She was also noted to have a horizontal cleavage tear of the posterior horn, which was roughened with the shaver and the rasp and a single Fast-Fix was placed to close the space down. The instruments were then removed. Portals were closed using 3-0 Monocryl followed by Steri-Strips, 0.25% Marcaine with epinephrine was injected around the portal sites. Sterile dressing was placed. The patient was awoken, taken to the recovery room in stable condition.

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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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DESCRIPTION OF PROCEDURE: The patient was taken to the operating suite, placed on the operating table in the supine position. She was administered preoperative antibiotics, general anesthetic, followed by intubation by the anesthesia team. The standard 3-portal knee scope was performed. On evaluation of the intraarticular space, cartilage throughout the knee looked in great condition. The medial meniscus looked in good condition as well. ACL was intact. We turned our attention to the lateral meniscus where it was noted to be a complete tear. We saucerized the meniscus out to a rim of 8 mm. The anterior horn was noted to be detached. So we roughened up this area and placed two number 2 Fiber wires using the spectrum technique. These were tied down with SMC knots. She was also noted to have a horizontal cleavage tear of the posterior horn, which was roughened with the shaver and the rasp and a single Fast-Fix was placed to close the space down. The instruments were then removed. Portals were closed using 3-0 Monocryl followed by Steri-Strips, 0.25% Marcaine with epinephrine was injected around the portal sites. Sterile dressing was placed. The patient was awoken, taken to the recovery room in stable condition.

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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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Example of extra time documented in an operative report:

Once this was identified, there was an obvious hernia, and this was incised. Two hours were spent in lysis of adhesions and to identify the point of obstruction, and the limits of the hernia. After the hernia defect had been identified in its entirety, there was no gross evidence of ischemic bowel, however, there was obvious obstruction, which went beyond on what was visible.

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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

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Source: Novitas Solutions https://www.novitas-solutions.com

Providers should use an ABN when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. The ABN is a standardized form that explains to the patient why Medicare may deny the particular service or procedure. Additionally, an ABN protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure.

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 in any way other than to put the practice information in the header area.

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Sample LCD

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Sample LCD

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Source: Novitas Solutions https://www.novitas-solutions.com

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Sample LCD

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Source: Novitas Solutions https://www.novitas-solutions.com

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Sample LCD

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Source: Novitas Solutions https://www.novitas-solutions.com

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Sample LCD

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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-10-CM (ICD-9-CM Prior to October 1, 2015) – International Classification of Diseases, 10th 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-10-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.

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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

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.

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

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Office of Inspector General (OIG) Workplan

Published twice per year
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 – 2016

Physical Therapists – High Use of Outpatient Physical Therapy Services

We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary. Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.”

(Social Security Act, §1862(a)(1)(A) Documentation requirements for therapy services are in CMS's Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 220.3. (OAS; W-00-11-35220; W-00-12-35220; W-00-13-35220; W-00-14-35220; W-00-15-35220; various reviews; expected issue date: FY 2016)

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OIG Work Plan – 2016

Sleep Disorder Clinics – High Use of Sleep-Testing Procedures

We will examine Medicare payments to physicians, hospital outpatient departments, and independent di-agnostic testing facilities for sleep-testing procedures to assess the appropriateness of Medicare payments for high utilization sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY2010 Medicare payments for Current Procedural Terminology (CPT) codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedures. Medicare will not pay for items or services that are not “reasonable and necessary.”

(Social Security Act, §1862(a)(1)(A).) To the extent that repeated diagnostic testing is performed on the same beneficiary and the prior test results are still pertinent, repeated tests may not be reasonable and necessary. Requirements for coverage of sleep tests under Part B are in CMS’s Medicare Benefit Policy Manual, Pub.No.100-02, ch.15, §70.

(OAS;W-00-10-35521; W-00-12-35521; W-00-13-35521; W-00-14-35521; various reviews; expected issue date: FY2016)

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