Billing and coding

9


Billing and coding





Objectives


Upon completion of this chapter, the reader will be able to:


• Understand the relevant coding systems for billing: ICD, CPT, HCPCS Level II.


• Understand that coding and billing rules may vary based on benefits and payer.


• Understand the structure of evaluation and management codes in CPT and the Centers for Medicare and Medicaid Services (CMS) documentation guidelines.


Whether you are in solo practice, pay all your own practice expenses, and earn only what you bill, or whether you are an employee of a large group or institution, you are generating income based on billing. Although there are some payment methods that are not fee-for-service systems, most medical care provided by professionals in the United States is paid for using a fee-for-service payment methodology. This means you, or someone on your behalf, is submitting a bill to the patient or insurance company for the services you perform. Because it is a fee-for-service system, you will need to state the name of the service you performed and your charge for that service. An orderly payment system requires a set of rules so that you are aware of your required behavior and the payers are aware of their requirements. The first rule of order is that there is a nomenclature system for every service. Use of this system is referred to as “coding.”


The rules of coverage, payment, coding, and billing can seem daunting. Further stress is added by the knowledge that your livelihood may be on the line or that billing performed incorrectly can have adverse legal and financial repercussions. If you do not bill personally, you are still responsible for the work of your agents. Try to remember that if you are able to care effectively for the complex geriatric patient, you have more than adequate brain power to handle billing and coding processes. As with patient care, a team approach is useful. When available, seek out the expertise of people who regularly perform billing functions.


This chapter is not intended to be a treatise on all important aspects of practice management and does not include topics such as when to refer patients to a collections agent for unpaid bills, accounting methods for tracking accounts receivables, or claims appeals. Nor will the chapter explain details of payment systems and delivery systems such as capitation and accountable care organizations, even though the type of system will affect coding and billing practices. However, the chapter is intended to provide a solid foundation and educational resources for issues related to billing and coding.



Coding systems


There are three key coding systems. The first is the diagnostic classification system known as International Classification of Diseases, Clinical Modification (commonly called ICD-9). This system will be replaced in the United States with ICD-10 on October 1, 2014. The World Health Organization creates ICD versions, but the clinical modifications are from the U.S. National Center for Health Statistics; thus ICD-CM versions do vary by country. ICD also includes ICD-PCS, a procedural code set. Hospitals use ICD-PCS for inpatient procedure coding but professionals use the American Medical Association’s Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid’s Healthcare Common Procedure Coding System, Level II (known as HCPCS). Hospitals also use CPT and HCPCS for outpatient procedure reporting.


CPT is the backbone of professional procedure reporting, but HCPCS is used to supplement CPT because CPT does not maintain a drug or device (e.g., durable medical equipment) classification system; also, Medicare may need codes that are very specific to its benefits as defined in law. Unfortunately, none of the systems use the terminology that clinicians use when communicating with each other in conversation. With the advent of electronic records, problem lists are now in “ICD speak” and finding the official term for a condition can be frustrating at times. Fortunately, few medical professionals will need to memorize the entire coding lexicon; the key is to understand and be familiar with high-volume codes.


ICD is organized by types of diseases (e.g., infection, cancer, cardiovascular) and has codes for symptoms or reasons for an encounter that are not diagnoses (e.g., V70.0 is the diagnosis code for a routine general medical examination, and 786.0 is the code for dyspnea). CPT is arranged by major categories and then subdivided by body system and anatomically. Major sections are evaluation and management (the office and facility visits often called cognitive services), anesthesia, surgery, radiology, pathology and laboratory, and medicine. The last category actually is a broad mix of services and includes diagnostic tests such as electrocardiograms and codes for immunization administration and the vaccine itself. Evaluation and management services, commonly referred to as E and M (or E/M), are usually the bulk of services performed by geriatric providers who may report them. Physicians, nurse practitioners, clinical nurse specialists, and physician’s assistants may use E/M, but physical therapists and nutritionists have their own evaluation and treatment codes in the medicine section. The medicine section also includes the procedures used by mental health professionals, whether physician or nonphysician, and includes psychological testing codes.


All sections are relevant to professionals and it is important to gain familiarity with the range of codes. For example, although a bladder volume scan is not technically imaging and is certainly not surgery it is in the urodynamics subsection of CPT, which is within the surgery/urinary system section. If a code for a common service cannot be located, one should not conclude that a code does not exist; it is more likely that it simply has not been found yet. However, there are some important exceptions. For example, removing sutures that were placed by a clinician from another practice would be considered E/M; there is no suture removal code. A mental status exam is part of E/M, and not in the neuropsychologic testing sections. HCPCS codes are used for drugs administered, such as a steroid injection. Medicare also uses HCPCS codes for specific benefits. For example, a flu shot administration has CPT codes, but Medicare requires that HCPCS G code G0008 is reported. This is because the CPT administration code is agnostic to the vaccine given and not all vaccines are covered by Medicare (outside of a Medicare Part D drug benefit). It is strongly advised that all medical professionals maintain access to current editions of these coding resources. CPT changes annually and HCPCS changes quarterly.



Keep up to date with annual changes to procedure coding and Medicare benefits.




Knowing payer, benefits, medicare contractor, specialty/licensure, and group rules


Geriatrics professionals tend to think Medicare. However, there are Medicare Advantage plans (Medicare Part C) and many retirees have commercial insurance. These payers may cover more than Medicare or require participating providers to report services differently. This is usually because of benefits differences (i.e., what is covered by the plan). Generally speaking all payers follow the same basic coding rules. The most common example of variation can be seen with the “annual physical.” Even with the Medicare Wellness Visit benefit, there is no annual physical per se and for years a major point of differentiation for Part C plans was coverage of preventive services that Medicare did not cover. A Medicare Advantage or commercial plan will typically require use of the CPT Comprehensive Preventive Medicine services codes such as 99397. This code will be denied when submitted to traditional Medicare. However, this service is in fact covered, almost entirely, when reported using the correct HCPCS II G codes; thus, practically speaking, it is not truly a noncovered service. Therefore one cannot charge the beneficiary.


Medicare Part B, the part that covers professional services, is administered by multiple contractors (companies Medicare pays to process claims and enforce rules). The rules of different contractors tend to be consistent, but in some cases where national rules have not been promulgated or there is potential for variable interpretation, there can be differences. Even if the policies are the same, enforcement may be divergent. These disparities can occur in some high-volume services. A contractor may define E/M medical decision-making level of complexity as requiring a change in the medication regimen, whereas another may not have such a requirement. The contractor’s website is a good source of information concerning these issues.


A health care professional’s specialty or license type will dictate both coding and coverage rules. For example, physical therapists and physicians in most cases will not be using the same codes. One may specify E/M whereas the other uses 97001 for assessments. However, a physician who performs a timed “get up and go” test may meet criteria to report it as a physical performance test 97750 if it takes at least 8 minutes and a separate report is created; otherwise the test is considered to be part of a physical examination. In mental health coding there is a great deal of overlap between the various professions. At times very similar services are reported differently by different professions. Physicians do not report the CPT medical nutrition therapy services when counseling a patient on obesity; they report E/M as specified in CPT guidelines, and for certain patients in Medicare, physicians may use G codes for intensive behavioral therapy for obesity. Specialty type as well as license type is relevant. In E/M, a new patient is one who has not received a reported face-to-face service from a professional in the exact same specialty and subspecialty within the same group. Therefore, if an internist refers a patient to a geriatrician within his or her group for an opinion or assistance in management and a joint medical record is used, the patient is nonetheless a new patient to that geriatrician; this means that a new patient code E/M is used as compared to the established patient code. However, if the geriatrician sees the internist’s patient in the role as covering physician in the office, the geriatrician is acting on behalf of his or her colleague and the patient is therefore considered an established patient. It is important to be aware of specialty classification listings by payer and also to be aware of Tax Payer Identification numbers and National Provider Identification (NPI) numbers that define groups.



Claims, claims edits, and modifiers


Billing usually means submitting a claim to a payer. The claims-processing systems use edits, though not all payers use the same edits. Some edits are in place to prevent coding errors. For example, if two skin lesions are removed and the same code is reported twice, it will be assumed this was an erroneous duplicate entry unless a modifier code is appended to the second procedure code to designate that two separate services were performed. The most common modifier relevant to geriatrics professionals is modifier 25, which indicates that the E/M was distinct and not part of a simultaneous surgical service. For example, if a patient with osteoarthritis is seen for an intraarticular steroid injection and no significant separate assessment was performed, no E/M should be reported. However, if another condition was treated, or the patient required a distinct history and examination to determine the condition and to determine if the injection was warranted, modifier 25 is appended to the E/M code.


Edits also exist for a medical necessity match for services such as laboratory tests. A claim for a thyroid-stimulating hormone test may be paid if the diagnosis is hypothyroidism, but denied for a diagnosis of migraine. The edit may determine the benefit. A diagnosis code that designates a service as preventive may result in no patient cost sharing, whereas the same service with a different diagnosis may have cost sharing such as with lipid testing in Medicare. These claims-processing rules/edits have greater variability among payers and are often the source of a bill not being paid as expected.


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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on Billing and coding

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