You might be a coding and payment geek if . . .
The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people. So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:
10. The first thing you associate with December is the arrival of the new CPT book.
9. You actually get excited when your new coding books arrive.
8. You wonder why the toy doctors bag you bought your kid doesn't include a claim form.
7. You worry your family physician is undercoding your visit.
6. You consider the Federal Register light reading.
5. You write to CMS more than to your own mom.
4. You actually understand Medicare's Sustainable Growth Rate formula.
3. You collect past issues of CPT Assistant on eBay.
2. When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.
And the number one sign that you might be a coding and payment geek:
1. You actually understood the humor in this blog post!
Posted at 01:10PM Oct 22, 2009 by Kent Moore | Comments[0]
Getting paid for H1N1-related services
Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?
Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.
Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.
Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.
Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.
Posted at 02:31PM Oct 02, 2009 by Cindy Hughes | Comments[0]
The trouble with consultations
In a rather surprising move, the Centers for Medicare and Medicaid Services (CMS) included in the proposed rule on the 2010 Medicare physician fee schedule a proposal to remove codes for consultations from the Medicare fee schedule. Physicians instead would report the office/outpatient, hospital, or nursing facility evaluation and management (E/M) visit codes as appropriate, and these codes would be awarded higher relative value units (RVUs) in the fee schedule, resulting in potentially higher payment. Whether these increased payments would make up for the elimination of the higher-paying consultation codes likely depends on each individual physician’s mix of consults and office/hospital visits and the percentage of established patients versus new patients.
Some physicians won't like this, as it redistributes payment for E/M services among all physicians. These physicians state that their work is always worth more money because of the additional education and training they have related to specific medical problems. What they may be missing is that Medicare is offering a carrot, an increase in RVUs for non-consult E/M codes and fewer of the coding and documentation burdens that were associated with consultation codes.
At the same time, the Medicare auditors are bringing out the sticks in the form of pre-payment and post-payment audits. Medicare's Comprehensive Error Rate Testing (CERT) Report for May 2008 specified a high "paid claims error rate" of 16.6 percent for consultation services, with a projected improper payment of $516,912,824. Incorrect coding accounted for 86.4 percent of the consultation coding errors. WPS, Medicare contractor for Iowa, Kansas, Nebraska and western Missouri is performing a widespread probe of all consultation claims submitted and requiring pre-payment submission of medical records to substantiate charges. Other Medicare contractors have also chosen consultations for review. Given the state of Medicare funding, can the administrators ignore these results and not attempt to collect (with interest) the money paid out for these consultation services? Will Medicare's Recovery Audit Contractors, who receive a percentage of all money returned to Medicare, ignore these findings? If it were me, I'd accept the carrot and hope the stick is eventually aimed elsewhere.
The proposed removal of consultation codes from the Medicare fee schedule is mostly positive for family physicians, since you seldom get the benefit of the higher payment associated with consultation codes despite doing extensive work-ups before referring patients to subspecialists for specific procedures. However, there could be a drawback in that the higher payment was an incentive for the subspecialists you refer to to promptly report back to you, as the consultation codes require. There is some danger that removal of the incentive will cause greater delays or failure of communication, making it more important than ever that your staff keep logs (automated or manual) to be sure that you are aware of all physicians caring for your patients and follow-up as needed to receive records or reports. If you don't have systems in place to help track referrals, lab tests, etc., consider downloading the AAFP's Road to Recognition guide. Though created to help physicians document the elements necessary for recognition under the National Committee for Quality Assurance's Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH), the simple tracking tools it includes may be useful in many practices. If you feel certain that you always receive timely written follow-up from consultants, using these tools will provide you with evidence of whether your feelings are matched by your results.
Posted at 04:52PM Aug 20, 2009 by Cindy Hughes | Comments[0]
Another urban myth about coding
Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved. He asked me if this was true.
As I have done with other callers asking the same question, I assured him that this was incorrect information. Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter). For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. In no case does CPT state that medical decision making, by itself, determines the level of E/M service.
Medicare policy supports this interpretation. Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.” That content includes the history and examination.
This particular urban coding myth grows out of confusion between medical decision making and medical necessity. As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance. In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service.
So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.
Posted at 04:47PM Apr 27, 2009 by Kent Moore | Comments[0]
For whom the bell curve tolls
As many family physicians, coders, and billers know, if your E/M coding pattern varies significantly from the norm of other physicians in your specialty, a Medicare audit can result. But what does the norm look like? According to national data from the Centers for Medicare & Medicaid Services for 2007 (the most recent data available), it looks like this for family physicians:
As one would expect, the norm is almost a bell-shaped curve. If your coding pattern is to the right of this curve (i.e., you code a significantly greater percentage of your encounters at higher levels than the norm), you may want to review the documentation for a sample of encounters to ensure that (1) the documentation supports the level of service and (2) the level of service seems medically reasonable or appropriate.
If your coding pattern is to the left of the curve (i.e., you code a significantly greater percentage of your encounters at lower levels than the norm), you may still want to review the documentation for a sample of encounters. In this case, the rationale for doing so is to ensure that you are not routinely undercoding and leaving money on the exam table in the process. If you're not sure of your coding pattern, you can download an Excel spreadsheet from the FPM Toolbox that will help you calculate it.
In the end, it is not important that you conform to the norm. Rather, it is important that you know where you stand relative to the norm and be able to explain and defend your position, if called upon to do so.
Posted at 04:43PM Mar 03, 2009 by Kent Moore | Comments[2]
ICD-10: Y2K all over again?
People often see things differently. Two neighbors may call their county government offices, one to ask that weeds be sprayed along the road and another asking for a no-spray ordinance. Health care is not immune to such conflicting priorities.
Some are anxiously counting the days until the Oct. 1, 2013, deadline for adoption of the ICD-10-CM codes and the "granularity" they promise. I doubt many practicing physicians are among that group. A letter to the Centers for Medicare & Medicaid Services from Jim King, MD, chairman of the AAFP Board of Directors, left no doubt the AAFP did not support this change. That said, I hope you are not losing sleep, hoarding canned goods or preparing to duck for cover. The transition from ICD-9 to ICD-10 will create some challenges but will not likely result in widespread calamity.
Don't get me wrong. This is not your average annual code update. As reported by the American Academy of Professional Coders, when the Blue Cross Blue Shield Association converted the 164 ICD-9 codes included in FPM's model superbill to ICD-10, the resulting mess was seven pages longer than the original list. (The FPM Superbill has been updated for 2009; you can download it from the FPM Toolbox.) Clearly the ICD-10 code set is cumbersome compared to ICD-9, but it's not as difficult as learning to diagnose and manage the 68,105 conditions that may be reported with ICD-10. You can handle this.
Here are some things to consider as the Oct. 1, 2013, implementation deadline approaches:
1. You will no doubt soon receive ads for ICD-10 products and educational resources. Please don't waste your money. Learning a complex coding system that you will not use for nearly five years isn't productive, and changes could be made to the code set before 2013. Keep reading FPM and plan to learn more when implementation is closer.
2. Don't let ICD-10 overshadow another change with the potential for significant financial impact, especially for solo and small practices -- the conversion to the HIPAA 5010 electronic transaction standards, which must be completed by Jan. 1, 2012. Version 5010 is an extensive revision and paves the way for submission of ICD-10-CM codes. If your software vendor charges for upgrades or floundered during prior changes, now is the time to start asking questions about implementation plans and considering your options (e.g., upgrade or change vendors).
3. If you think you might need to change your software, consider a combined EHR/practice management system. A combined system may relieve some of the ongoing burdens and costs of transitioning to ICD-10. Imagine having an ICD-10 look-up tool similar to the FPM ICD-9 Look-Up Tool built into your EHR and integrated with your billing system, or a system that automatically converts standardized nomenclature to codes.
Most of you have endured the Medicare enrollment process, so you are combat-tested. And you are not alone. The AAFP and FPM will continue to provide you with the best resources that we can find or create to help you make the transition to ICD-10.
Posted at 03:50PM Jan 29, 2009 by Cindy Hughes | Comments[1]
The future of diagnosis coding
The Centers for Medicare & Medicaid Services (CMS) announced the future of diagnosis coding for physicians last week. Specifically, on Jan. 16, CMS published a final rule specifying that by
The good news is that you have almost five years to get ready, which is two years longer than CMS originally proposed. The bad news is that you will still have to make systems changes and train yourself and your staff to use the new codes.
In the meantime, you and your practice will also have to comply with an updated X12 standard, Version 5010, for certain electronic health care transactions, including claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Version 5010 accommodates the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1, the current X12 standard. The compliance deadline is
They say that “forewarned is forearmed.” Please consider yourself “forewarned” and anticipate that Family Practice Management, the
Posted at 05:15PM Jan 21, 2009 by Kent Moore | Comments[0]
Injection rejections
It’s annoying. You’ve submitted your claims for subcutaneous injections with code 90772 for a couple years now and all of a sudden, rejections! The code has been changed to 96372. Who's responsible for this disruption to your cash flow? It was the insurance companies, wasn’t it?
No. Insurance companies do have some influence on CPT code changes but really not that much. CPT code changes can be proposed by anyone who identifies a problem or gap in existing codes. Many originate from physician complaints made to specialty societies about payment policies that don’t align with CPT or current practices. All proposed changes are vetted and recommended for approval, modification or rejection by physician volunteers from each of the medical specialty societies that participates in the AMA's CPT process. Proposals are then approved, postponed or rejected by the AMA's 17-member CPT Editorial Panel. Most of the panel members are physicians nominated by their specialty organization and appointed by the AMA Board of Trustees. David Ellington, MD, of Lexington, Va., and the AAFP Board of Directors is a member of the panel. A handful of the panel members represent payers.
So what else has changed in CPT 2009 and how are you, a busy physician, supposed to care for your patients and your practice and keep up with all of this? You can look to Appendix M of your 2009 CPT book for a summary of the deleted codes and their replacements. Also, watch for an article in the January/February issue of FPM on the code changes most affecting family medicine. And finally, don’t hesitate to contact me (chughes@aafp.org) or join the AAFP e-mail discussion list for coding issues to find help with coding questions and keep up-to-date. (The discussion list is also open to non-members so that your coding and billing staff can take advantage of this free resource.)
Posted at 05:15PM Jan 14, 2009 by Cindy Hughes | Comments[1]
