eBook_Definitive_Guide_to_Medical_Coding-120915
- 1. Medical Coding The Definitive Guide to
- 2. With the changeover to ICD-10-CM/PCS in full swing as of October 1, 2015 it is a crucial time in healthcare, as well as the future of numerous healthcare facilities and private practices. Whether physicians, healthcare providers, medical coders, and HIM support staff members sink or swim depends on how successful they navigate the new set of codes. The changeover comes at a time when several physicians and private practice groups are already in financial crisis; the significance of avoiding decline or disruption in reimbursements cannot be minimized. Envisioning the scope, magnitude, and cost of the changeover can paralyze a healthcare practice, which has led to deferment of adoption by many physicians and healthcare facilities. However, now that the ICD-10-CM/PCS is being utilized, failure to appropriately submit the claim forms using the new set of codes will eventually result in rejected claims and delayed or lost revenue. Medical coding began in its earliest form as an endeavor to evade the Black Death, otherwise, known as the Bubonic plague, which arrived in Sicily in 1937 via the ship’s rats. The plague spread quickly, reaching England by 1348. Over the next two years nearly half of London’s population of 70,000 people died as a result of the Black Death. Again, in 1629 the Bubonic plague returned to London this time killing roughly 25% of the popula- tion. Medical coding took another step forward when “The London Bills of Mortality” became a weekly publication; it included the cause of death and the geographic location in which the death took place. Reports were passed from parish to parish to help people avoid the plague.The publica- tions allowed people to avoid areas of infection. The history of Medical Coding will be discussed in more detail in the section A Brief History of Medical Coding. We will aslo cover What is a Medical Coder, The Revenue Cycle & Medical Coding, Who Participates in Medical Coding, In-House vs Outsourced Medical Coding, Domestic Coders vs International Coders, Financial Concerns & Pitfalls, and a special surprise at the end that will appeal to both physicians and medical coders. 01 Medical CodingThe Definitive Guide to
- 3. 01 What is a Medical Coder 02
- 4. What is a Medical Coder People often get confused about what medical coding is and what it is not. More times than not, you will see medi- cal coding and medical billing grouped together to appear as one. Coding and billing are two separate entities, how- ever, on occasion a coder and biller do work together. Although, the majority of the time, a medical coder and medical biller simply complement one another, each having their own job, but they do depend on each other to get the healthcare provider reimbursed for services rendered. Medical coding is a focused profession within the broader field of healthcare administration. Certified medical coders analyze the clinical documentation found in a patients’ medical record, then the medical coder translates the writ- ten documents into an industry standard, universally accepted, medical codes. The codes are then used to submit claims to third party payers, such as insurance companies so physicians can be reimbursed for their services. The codes also collect statistical information by tracking specific diseases, and by detecting developing tendencies in treatment practices. Correct medical coding is vital to the healthcare system. Medical coding is how claims for payment are reported for proper compensation of provided necessary medical services. In addition, the refined, specific information con- tained in the medical codes provide a picture of a patient’s medical history. When gathered in aggregate, an auditor can use the data to decide how to distribute assets for future medical needs. The medical coder reviews the patient’s medical records as physicians, nurses, technicians, therapists, and any other healthcare providers that participated in the patient’s care have documented them. After comparing the clinical doc- umentation to the principles vested by the Centers for Medicare and Medicaid Services, the American Medical Association, and predetermined contracts with commer- cial health insurance companies, the medical coders review the pages of written data, and then distil it into uniform codes. Medical procedures are converted into codes found in the directories of the Healthcare Common Procedural Coding System (HCPCS Level II codes), Current Procedural Terminology (CPT codes) and the codes found in Volume 3 of the International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM/PCS). The diagnosis codes that define a patient’s condition, at the time service was rendered, are transcribed into codes found in Volume 2 of the ICD-10-CM/PCS, or the medical coder then uses a computer software program to assign the patient to one of several hundred “diagnosis-related groups,”or DRGs. What is a Medical Coder 03 01
- 5. 01 04 Medical coders generally work 40 hours a week. Overtime may be occasionally necessary. Medical coders who work in environments such as a hospital, where the health informa- tion department is often open around the clock, may work the day shift, evening shift or even the night shift. Coders, who work in outpatient surgical centers, clinics, and doctors offices that have set hours, will work during the facility or office's normal business hours. Medical coders work in a quiet and comfortable office because accuracy is of the upmost importance. Medical coders are some of the few people who work in the healthcare field which do not deal directly with patients. What A Medical Coder Is Not A medical coder is not the same as a medical biller. While some physicians’ offices only have a medical biller that performs both roles, this occurs on a much smaller scale. A dermatologist, podiatrist, or small office that sees a limited number of patients may have a medical biller that also does the coding. It is very rare to find a medical biller acting as a medical coder because they are simply not qualified or certi- fied to fill the role to the fullest extent. What is a Medical Coder
- 6. 02 A Brief History of Medical Coding 05
- 7. Origin The medical coding system originated in England during the 17th century. Statistical data was collected from a system called the London Bills of Mortality, and the data was organized into numerical codes. The codes were then used to estimate the most recurrent causes of death. Fast-forward a few centuries… The statistical examination of the Mortality Rate (causes of death) was then organized into the “International List of Causes of Death.”Over the years, the World Health Organi- zation (WHO) used the list increasingly to help in tracking the mortality rates and the international health develop- ments. The list was later developed into the International Classifi- cation of Diseases, which is now in it’s 10th edition, also known as the ICD-10-CM/PCS. In 1977, the global medical community accepted the ICD system, which compelled the National Centers for Health Statistics (NCHS) to expand their reach to contain clinical information. In other words, the ICD system was extended to include cause of death and clinical diagnoses, such as injuries and illnesses. By including the clinical diagnoses, further statistical infor- mation also became available. Once the ICD system was implemented to include the new additions, there was a way to catalog the medical records, make medical evalua- tions quicker and easier to complete, and offer additional insights into medical care. The ICD-10 version is much more specific than previous editions, for example, in ICD-9 there were only 13,000 codes and the "other" and "non-specified" codes were used for numerous diseases, conditions, and injuries. The ICD-10 has 68,000 codes, which eliminate a lot of the "other" and "non-specified" codes. As ICD-10 is updated, more and more codes will be added, which will greatly help with the reimbursement process. There will be a lot fewer denied claims and physicians and healthcare provid- ers will be paid for specific services instead of generic cases. There were numerous changes made between ICD-9 and ICD-10. Aside from the number of codes and the elimina- tion of most of the "other" and the "non specified" codes, and the inclusion of combination codes for symptoms and diagnoses, less codes are needed to report and fully describe a patients condition. "The code set has been expanded from five positions (first one alphanumeric, others numeric) to seven positions. The codes use alpha- numeric characters in all positions, not just the first posi- tion as in ICD-9, when using a modifier the codes expands to 6 or 7 positions. 02 06 A Brief History of Medical Coding
- 8. 02 07 Why the Change from ICD-9 to ICD-10? The question on a lot of physicians, coders, and healthcare information specialists minds was why the change? Many of these people believed the change would only confuse everyone and make things worse; if it is not broken why fix it? What they didn’t realize is that the "system" was not only broken, but also old and in need of some serious upgrades. If hospitals, healthcare facilities, and private practice physicians were going to "stay in business" these changes were necessary and long over due. "The practice of medicine has changed dramatically in the last 25 years or so. There have been many new conditions discovered, many new treatments developed, and many new types of medical devices have been placed into service. The ICD-9 code set was not designed to capture all of this progress, and as such, has become bogged down with many types of modifications to attempt to capture information. The ICD-10 code set is much better at describing the current practice of medicine, and has the flexibility to adapt as medicine changes. Diagnosis codes and procedure codes permeate almost every business process and system in both health plan and provider organi- zations. Diagnosis codes are key for determining coverage and are used in treatment decisions. From plan design to statistical tracking of disease, these codes are a crucial part of the way health plans — including State Medicaid agencies — run their programs." — Medicaid.gov A Brief History of Medical Coding
- 9. 03 Revenue Cycle & Medical Coding 08
- 10. How Medical Coding Fits into the Revenue Cycle The revenue cycle refers to all of the administrative and clinical tasks that contribute to the“capture, management, and collection of patient service revenue," as defined by the Healthcare Financial Management Association (HF- MA.)The revenue cycle includes the complete life cycle of a patient’s medical account from when the first appoint- ment is made to the payment receipt. Each phase has a pending effect on the revenue cycle. Phy- sicians and healthcare providers must diligently take steps to guarantee that superlative management practices are being applied. The first stage of the revenue cycle begins when the patient makes an appointment to see the physician or healthcare provider. The receptionist or secretary starts the process by collecting data from the patient to start his/her medical chart for the office. When the physician sees the patient they update or add to the medical chart of each patient’s diagnoses. The next step of the revenue cycle is the medical coding process. Deciding who will be accountable for the coding process is one of the most vital decisions within the reve- nue cycle. A medical coder should always be certified and 03 Revenue Cycle & Medical Coding 09 have at a minimum two to three years of experience in several medical fields, especially if the physician specializ- es in family medicine or general medicine. The medical coder is responsible for making sure the codes they use are correct, to ensure that the physician is reimbursed correct- ly, and no revenue is lost.
- 11. Where mdical coding impacts the revenue cycle 03 10 Revenue Cycle & Medical Coding Receive Payment 8 Eligibilty Confirmation3 Claims Submission6 Retrospective Audit 9 Chart Sent to Coder4 Coding Processed5 Appointment With Physician 1 Physician Updates Chart2 Physician/Group/ Facility/Surgical Ctr Healthcare Revenue Cycle Denial Management 7
- 12. 04 Who Participates in Coding 11
- 13. Who Participates in Coding? Coding is a team effort, with the certified medical coder leading the way. Front Desk/Receptionist Medical coding starts with a patient making an appointment to see their physician. The receptionist makes the appointment – without the appointment the coding process would fail to start. Physician or Healthcare Provider Next, is the physician, or healthcare provider. They diagnose the patient based on their symptoms (com- plaints), and in some cases blood tests, x-rays, or any number of other test(s). Certified Medical Coder Then the medical record makes its way to the certified medical coder. The coder translates the written clinical documents into codes. This coding process allows the physician or healthcare provider to receive payment for the services they have provided to the patient. Certified Professional Medical Auditor Certain instances (not always) require the medical record to be reviewed by a certified auditor. If the coder is new then the auditor, to ensure the coding is 04 12 Who Participates in Coding
- 14. correct, will review the charts. The auditor also checks random charts – this helps the coder stay on their toes, never knowing when one of their charts will be audit- ed. An auditor also reviews and corrects if necessary the medical record when the claim is denied for pay- ment. Clinical Documentation Assessment If the auditor finds an error or several errors that may become a repeat problem with the coder, then Clinical Documentation Assessment Services are clearly needed. Medical records are reviewed and may be corrected by this third party service. Clinical Documen- tation Services also offer refresher courses in medical coding, or a specific area of medical coding, to help the coders learn how to correct the errors they are making. Certified Compliance Officer The compliance officer has several roles; the most important role is the investigation of incidents of fraud or abuse. A common problem is “upcoding”, meaning the physician receives more money from the payee for services they did not perform. The auditor calls in the compliance officer when a coder continually codes in a manner that is not compliant with the government laws, guidelines, rules and regulations that have been put in place for medical coding. Who Participates in Coding 13 Denial Management Specialist The denial management specialist is a certified medi- cal coder who is extremely knowledgeable and has years of experience. This coder goes through the denied medical chart and determines the reason(s) why the claim was denied and then rectifies the claim and resubmits the claim to the insurance company. 04
- 16. In-House vs Outsourced Medical Coding There are pros and cons to both employing an in-house coder and using an outsourced coding company. In gener- al outsourced coding is less expensive and done as equally well as in-house coding. Let’s explore the two options in more depth below. In-House Medical Coding Whether hiring an in-house coder or an outsourced coder, there are plenty of pros and cons. Depending on your situ- ation, one might be more favorable than the other. Let’s touch on some important points. Pros of an In-House Medical Coder With an in-house coder, if there are any questions about a patient’s medical chart, the coder can ask the doctor for clarification in-person, and receive a quick answer. Physicians and administrators like retaining medical coders who are executing RCM duties and coding. This allows the administrators and physicians to have more control over what the medical coder is doing, how it is being done, and provides a sense of security. Cons of an In-House Medical Coder Employing an in-house medical coder increases the cost of running the office. As a general rule paying the medical coders salary, health benefits, paid time off, and the neces- sary technology and software needed for a medical coder to do their job is a considerable amount more than what is commonly paid to a third-party coding company. 05 15 In-House vs Outsourced
- 17. 05 16 Having a fully burdened coder employed can be a lot more expensive than most people realize. The nice thing about outsourcing is your work is guaran- teed.You only pay the medical coder when they are actual- ly coding, not taking sick days, extended lunches, office gossip, water cooler talk, or staff meetings, etc. Outsourced Medical Coding As with In-house coding, outsouced coding has it’s pros and cons as well. Let’s look at some of the most evident. Pros of Outsourcing Using an outsourced medical coding company increases your financial bottom line. This is important all the way around whether you are opening your first private practice or going into practice with a group of physicians. In addi- tion, if your medical coder has resigned, outsourcing makes financial sense. A medical coding company will be able to provide the phy- sician with a comprehensive performance report automat- ically or as requested. This report grants the physician increased visibility into their medical coding operations without requiring them to micromanage, or even super- vise any of the offices medical coders. Most outsourced In-House vs Outsourced coding companies will bill at an extremely reliable fixed rate, leaving no guesswork when it comes to accounting. The physician will also receive enhanced consistency. The outsourcer is most likely contractually obligated to exe- cute certain services, such as auditing services, denial management, and clinical documentation assessments. Plus, there is no need to be concerned with staffing, since it is the outsourcing company’s job to support your office’s coding needs year-round. Cons of Outsourcing When using an outsourced coding service, often times, there are hidden fees. Be sure to read any contract very carefully and closely. Some things to look for while review- ing the contract include; startup charges, fees for printing, sending the statements or reports, postage, and if you cancel your membership/contract will you be fined. It’s important to make certain that the money you are saving by using an outsourced medical coding company is not being offset by several fine-print charges.
- 19. Domestic Coders vs International Coders There is really only one positive benefit of choosing to work with an international medical coding company over a domestic company; the inexpensive price. However, the potential negative aspects out way the single positive one. That is not to say that all international coding companies are bad or that the coders are not experienced enough to do a good job. There are some companies that send their coding manager to the United States to work in a hospital HIM department, in order to learn how medical coding is done in the US. The coding manager also gets to see first- hand how important it is to build a solid working relation- ship with the hospital(s) or physicians’offices that they will be coding for, especially if the international company will be working in a supporting role, helping with the overflow. These managers are then able to return to their country and teach their coders what they have learned. The time difference can be a disadvantage. While some would also argue that it can be an advantage, because the coding is being done around the clock. What happens though when a physician’s documentation is not clear and a question needs to be answered, and possibly other types of management tasks need addressing, the coding can be delayed until the reply is received. By nature, international coders use a more conservative 06 18 Domestic vs International coding pattern because they are fearful of mis-coding a medical record. The coder’s ability to self-interpret medical record documents may be lacking, which causes addition- al levels of quality assurance reviews, and can add to the cost of coding. An international coder may not think outside of the box, which makes their coding ability limited. They code strictly by the coding guidelines, which is perfect for coding com- pliance, however, it generally has a negative effect on reimbursement. Therefore, if a hospital, medical facility, or private practice physicians is looking to use international coders they should do their homework first and know the drawbacks.
- 20. 07 Financial Concerns & Pitfalls 19
- 21. Financial Impact The complexity of revenue cycle management in medical coding has immensely amplified and will continue to become even more multi-faceted with the introduction of ICD-10. The key to a positive financial impact is a stable and profit- able revenue cycle, which requires eliminating healthcare abuse and fraud. Most physicians, healthcare providers, hospitals, healthcare facilities, medical billers, and medical coders are all too familiar with the words abuse, fraud, unbundling, upcoding, and compliance because these issues are often in the media. The federal government has made it a top priority to elimi- nate healthcare fraud and abuse. Investigations are rapidly increasing and everyone involved in the management of the revenue cycle shiver at the idea of becoming one of the investigative targets. The Office of Inspector General (OIG) shared an investiga- tion report that clearly shows why investigations are a nec- essary part of medical coding and billing. The financial impact was astounding. The audit was done back in 1996, on the Health Care Financing Administration (HCFA) it exposed errors in 30% of all claims paid by the HCFA.These errors are responsible for nearly $23.3 billion dollars a year. Approximately half of the errors found resulted from inad- equate or lack of documentation by the physicians and healthcare providers. As you can see, errors can be extremely costly. Common Pitfalls of Medical Coding The potential for errors starts as soon as the patient walks through the office door – with the registration and health insurance verification. Incorrect personal or insurance information documented at the front desk leads to a sub- stantial number of denied claims. Often times, the following issues can occur which cause coding mistakes as well; typing in the wrong policy num- bers, failing to have the services authorized services and even entering or misspelling the patient’s name, address, gender, or guarantor. If the receptionist writes down the patient's name as ‘Jan Smith’ because that's the name she told the receptionist, but the insurance company knows the patient as Jane Smith, the claim is not going to get paid when the coder codes a chart for someone who does not technically exist. 20 07 Financial Concerns & Pitfalls
- 22. Misusing Modifiers Another very common coding mistake is the misuse of modifiers, specifically modifier 25 this modifier indicates that the physician or healthcare provider executed a sepa- rate evaluation and management (E&M) service on the patient the same day as a minor surgical procedure was performed. Claims are usually denied when coders use modifier 25 to code for the decision-making part of the visit, when it is actually supposed to be included in Medi- care's payment for the procedure. “Consider the following example offered in the January 2013 update to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services:” If a physician decides that a new patient that has a head trauma needs sutures, he/she confirms the patient’s immunization and allergy statuses, gets the informed con- sent signed, and then performs the procedure, a medical coder cannot code an E&M (Evaluation and Management) service separately. Although, if the physician also performs a medically necessary and reasonable complete neurological exam, an E&M may be reported separately. The majority of minor surgical procedures have a global grace period of 10 days, which means that any follow up services with the physician or healthcare provider that are related to the surgical procedure such as the removal of sutures within the 10 day time period cannot be coded as a separate service. A situation such as this would fall under the category of upcoding. With major surgeries, a similar rule applies for a global period of 90-days, however the decision to do the surgical procedure can be coded separately using modifier 57. Errors occur more frequently in the post-operative period, because of miscommunication between the physician/- surgeon and the medical coder. One of the most common coding errors occurs with the global surgical packages, partly because CMS (Medicare/- Medicaid) uses very strict guidelines and insurance com- panies tend to follow suit. Global surgery can apply in any type of setting, including a hospital, outpatient services facility, ambulatory surgical center (discharged same day as surgery), and a physician’s office. The guidelines also apply when a physician or surgeon sees a patient in the intensive care unit or critical care unit, before or after surgery. These are all included in the Medicare global surgical packet. In addition, the following services are all included in the surgical global packet and cannot be coded separately. They must all be coded as a global surgical packet. If each item that follows were coded separately, it would be a 21 07 Financial Concerns & Pitfalls
- 23. severe case of upcoding that would require an audit and may even be viewed as fraud. Experienced medical coders are well aware of how and what is included in the global surgical packet, however new and unexperienced coders often run into a tremendous amount of issues with the surgical packet. So, the items included in the global surgi- cal packet are pre-op visit after the decision to move forward with surgery has been made, any pre-op testing, all intra-operative services, the actual surgery, and all instruments and equipment used before, during, and immediately following the surgery, recovery care, post-op care by the surgeon and nurses including dressing chang- es, pain medication, removal of all surgical equipment including staples, sutures, catheters, pumps, wires, IVs, rectal tubes, etc. The items not included in the global surgical packet can also cause confusion and be coded as part of the packet, when they should be coded separately. Items not included in the global surgical packet include the following services provided by another surgeon, physician, or healthcare provider, any tests not related to the surgery, any type of treatment or consultation that is not directly related to the surgery, or complications caused by the surgery. It is also important to remember that if two surgeons from a differ- ent office perform the surgery together each surgeon must be reimbursed for his/her services. In this case the 22 07 Financial Concerns & Pitfalls
- 24. medical coder is coding the same exact surgical packet for two or more surgeons. Often times the physician/surgeon marks the visit as an encounter, but the medical coder is unaware that the visit is for a surgical follow-up. So, the coder codes for a visit and the claim is denied. Other common modifier mistakes include confusing modi- fier 51 (multiple procedures) with modifier 59 (distinctive procedures). For example, modifier 59 would be used if the same procedure was performed on several sites of the body, such as removing lesions on different areas of the body, requiring each lesion to have there own incision, or to specify that two separate procedures were done on the same day. Modifier 51 is for reporting multiple procedures that are commonly performed together, such as an upper endos- copy and a colonoscopy, and do not qualify for any NCCI edit allowances as defined by modifier 59. Using modifier 51, when the condition authorizations the use of modifier 59, may result in lost revenue. Mixing up the modifiers is often caused by poor documentation or lack of coding training. These mistakes happen frequently in small offices. Many offices miss out on potential revenue by failing to do a follow up on denied claims or by not correcting coding errors and resubmitting the claim. Raemarie Jimenez, Director of education for the American Academy of Professional Coders (AAPC), the national coding training and certifying organization says, "The way you find out about major problems is by looking at your denials. Many practices don't have anyone doing it because no one ever has time. But without someone dedi- cated to looking at denials, it will be a large source of loss for the practice." Tendencies, such as the receipt of several denials at one time, can reveal problems such as new employees that need more training. If you discover these mistakes within an appropriate time, the claims can be resubmitted and possibly approved. In addition to reviewing denied claims, offices should do periodic audits on the coded files. Medical coding is a difficult and rewarding career. All med- ical coders should be certified and have a few years of experience working in small private offices before moving to large facilities. Many medical coders decide to select a specialty such as emergency care, surgical, oncology, pedi- atrics, or one of the current 20 specialties available to med- ical coders. 23 07 Financial Concerns & Pitfalls
- 25. As promised a special Surprise Aviacode has nearly 1,000 experienced ICD-10-CM Certi- fied Medical Coders. Utilizing its proprietary coding work- flow platform ProCoder10, Aviacode has emerged as one of the top medical coding companies in the world. As one of the leading authorities on the implementation ICD-10-CM, Aviacode has the resources and experience to help train, assist, or perform fulltime production coding for healthcare professionals across the United States. To learn more about Aviacode and our products and services please visit us online at www.Aviacode.com 24 Aviacode Medical Coding Services for more information, call or email: 1-855-438-2634 | contact@aviacode.com The Definitive Guide to Medical Coding Source news.aapc.com/ jblearning.com/samples/0763727393/Aalseth_Chapter_01.pdf library.ahima.org/xpedio/groups/public/documents/ahima/bok2_000382.hcsp?dDocName=bok2_000382 medicalbillingandcollection.com/news/how-do-medical-practices-maximize-revenue-cycle-management-in-coding medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/ICD-Coding/ICD-10-Changes-from-ICD-9.html cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf