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
The Business of Medicine
2
Objectives
– Regulations
• Health Insurance Portability and Accountability Act
(HIPAA)
• Compliance
• Office of Inspector General (OIG) Workplan
– AAPC
The Business of Medicine
3
The Business of Medicine
4
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.
The Business of Medicine
5
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
The Business of Medicine
6
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
The Business of Medicine
7
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 ofTheanBusiness
auditor
with
of Medicine
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
The Business of Medicine
9
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
The Business of Medicine
10
Hierarchy of Providers
Physician
Physician Assistant (PA)
Radiology Tech
Physical Therapist
Nurse Practitioner (NP)
Lab Tech
Nurses
The Business of Medicine
11
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
The Business of Medicine
12
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
The Business of Medicine
Medicare beneficiaries
13
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
The Business of Medicine
14
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.
The Business of Medicine
15
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
The Business of Medicine
16
Operative Report Documentation
• The body might include:
– Indication for the surgery
– Details of the procedure(s)
– Findings
The Business of Medicine
17
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.
The Business of Medicine
18
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
The Business of Medicine
19
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.
The Business of Medicine
20
Operative Report Coding Tips
4. Highlight unfamiliar words
– Words you are not familiar with:
•
•
•
Medical terms
Anatomic landmarks
Medical procedures
– Research for understanding
The Business of Medicine
21
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
The Business of Medicine
22
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.
The Business of Medicine
23
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
The Business of Medicine
24
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/policy/jh/l32614-r1.html
The Business of Medicine
25
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/policy/jh/l32614-r1.html
The Business of Medicine
26
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.
Source: Novitas Solutions https://www.novitas-solutions.com/policy/jh/l32614-r1.html
The Business of Medicine
27
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
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
Source: Novitas Solutions https://www.novitas-solutions.com/policy/jh/l32614-r1.html
The Business of Medicine
28
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:
252.08
252.1
268.0
268.2
268.9
275.3
275.41 - 275.42
HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NONRENAL
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
252.00 - 252.02
Source: Novitas Solutions https://www.novitas-solutions.com/policy/jh/l32614-r1.html
The Business of Medicine
29
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
The Business of Medicine
30
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.
The Business of Medicine
31
Health Insurance Portability and Accountability Act (HIPAA)
• National Standards ASCx12 for electronic
transactions
– 5010 (eff. Jan. 1, 2012)
The Business of Medicine
32
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.
The Business of Medicine
33
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
The Business of Medicine
34
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 exhusband. 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
The Business of Medicine
35
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
The Business of Medicine
36
OIG Compliance Plan
1.
2.
3.
4.
5.
6.
7.
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
The Business of Medicine
37
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
The Business of Medicine
38
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
The Business of Medicine
39
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
The Business of Medicine
40
AAPC
• 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
The Business of Medicine
41
Welcome to AAPC!
The Business of Medicine