Coding, Documentation, and Data Management

Coding, Documentation, and Data Management
Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs

Session Objectives Understand basic code systems and development of codes Understand basic organization and principles of procedure and disease coding Understand basic principles of coding and billing Understand basic principles of documentation

Topics for Discussion Coding systems Procedure codes Disease codes
Coding, billing, and compliance Documentation Referral guidelines and service agreements

How are codes used? Revenue generation (reimbursement)
Documentation of services Workload and utilization Productivity Cost analysis Provider profiles (privileging) Analysis, health research, and trending

Why is coding compliance so important in data management?
Critical to workload and data capture Critical to resource allocation Critical for health care planning Critical to third-party (insurance) reimbursement Must conform to uniform national standards (CMS compliance)

…and more importantly Demonstrates adherence to community standards of care Demonstrates accountability to patients and stakeholders Demonstrates to stakeholders that critical services and special programs are maintained Need to prove compliance with HCFA Medical Necessity guidelines Meet standards for Civil and criminal penalties for fraud and abuse

Basic Management Questions
How much work did my clinic do? What did it cost? Can I bill for it? If I can’t bill for it, does it affect my costs and productivity? How much revenue did I generate? Is my clinic a “value-added” service? Is my clinic efficient?

Basic Data Elements Patient demographics (name, SSN)
Diagnoses, conditions, symptoms, or problems Procedures or services Provider Successful capture of encounter data requires these basic elements.

Basic Data Flow AppointmentVisitEncounter
Encounter datadatabase=management reports, analyses, and trends Encounter databilling system=reasonable charges=revenue Important…accurate coding is essential because data management systems are linked. It all starts with the basic data elements.

The Manager’s Task Use various data systems to optimize workload, efficiency, utilization, costs, and revenue generation Benefits to the organization data-driven decision making maximized value quality improvement accountability justification of resources tracking of utilization, costs, and health care trends predictable, consistent health care delivery

Coding Systems

Topics for Discussion Coding Systems Procedure Codes Disease Codes
Coding and Billing Documentation

Procedure Coding Systems
Healthcare Common Procedure Coding System (HCPCS) Current Procedural Terminology (CPT) HCPCS Level II (National or HCPCS) ICD-9 PCS Future: ICD-10 and ICD-10 PCS

Disease Coding International Classification of Diseases, Ninth Edition, with Clinical Modifications (ICD-9-CM) Future: International Classification of Diseases, Tenth Edition (ICD-10-CM)

Future Code Systems ICD-10-CM Developed by World Health Organization
Clinical modification for U.S. developed by National Center for Health Statistics ICD-10 PCS developed by 3M under contract from CMS HIPAA mandates universal code system.

ICD-10-CM Ear and hearing problems found in Chapter 8
More descriptive than ICD-9-CM Examples: H90.3--bilateral SNHL H90.4--unilateral SNHL with unrestricted hearing on contralateral side

ICD-10 PCS Greatly expands procedures codes Not proprietary
Example: Pure tone audiometry-9C03Z1C 9=Rehabilitation and Diagnostic Audiology C=assessment 03=test method (pure audiometry) Z=body system (none) 1=equipment (audiometer) C=qualifier (individual)

HCPCS Codes Level I--Current Procedural Terminology (CPT-4)
Level II--National codes Level III-local codes used by Medicare intermediaries, no longer used Modifiers for Level I and Level II

CPT Codes Copyrighted and published by AMA
Five digit codes (e.g ) Revised annually by AMA Describes physician and non-physician services by specialty Complexity- or time-based Includes modifiers

Organization of CPT Codes
Evaluation & Management ( ) Anesthesiology ( , ) Surgery ( ) Radiology ( ) Pathology and Laboratory ( ) Medicine ( ) Miscellaneous Services ( ) CPT Modifiers (Appendix A)

Categories of CPT Codes
Category I--procedures and services (5 digits) Category II--performance measurement (4 digits followed by a letter) Category III--temporary codes (4 digits followed by a letter)

HCPCS Level II (National) Codes
Supplemental codes Updated annually by CMS Designated by letter and four digits (e.g. V5020) Ambulance services, dental services, durable medical devices, drugs and injections, home services, non-covered services, temporary and experimental codes

What is New for 2003? New Evaluation and Therapeutic Section in the Otolaryngology Section (92500-series) Cochlear implant codes Major changes for Speech Pathology New unlisted ENT service code (92700)

How are CPT Codes Developed?
Developed and copyrighted by AMA CPT Editorial Panel--16-member panel meets quarterly to revise, update or modify CPT codes Health Care Professionals Advisory Committee (HCPAC)--14-member non-physician advisory panel. ASHA represents Audiology and Speech Pathology with AAA as an observer

Resource-based Relative Value System Update Committee (RUC)--29-member panel assigns reimbursement value RUC HCPAC Review Board--recommends reimbursement for non-physician codes Practice Expense Advisory Committee (PEAC)--being phased out

Application to Editorial Panel--must be FDA approved, proven benefit in peer-reviewed literature, widely used, standard of care (category I codes) Application sent to RUC or RUC HCPAC for review and value determination CMS generally follows AMA recommendations

Calculating RVU Physician work (55%) Practice expense (42%)
Medical liability insurance (3%) RUC determines only the physician work and practice expenses Global RVU x Medicare conversion factor=dollar reimbursement value

Practice Expenses Most Audiology procedures do not involve physician work. Resource-based relative values (RBRVU) include practice expenses (e.g. clinic labor, equipment, supplies). Sources of data: Socioeconomic Monitoring Survey (SMS) and Clinical Practice Expert Panel (CPEP)

Practice Expenses SMS data is used to calculate physician practice expense per hour (PE/HR) SMS includes clinical staff time but does not include independent audiologists. CMS created “zero work pool”, now called the Non-physician Work Pool (NPWP)

Practice Expense Data Where do Audiology practice expenses come from?
All physician PE/HR average (SMS) and clinical staff time (CPEP) for procedure CMS calculates an expense pool (e.g. clinical labor) using “all-physician” PE/HR and the CPEP average clinical staff time Data may not be accurate for audiologists.

How Does this Affect Audiologists?
70% of Audiology codes are in the NPWP 90.6% of Audiology revenue comes from NPWP, highest of any clinical specialty NPWP does not accurately reflect true practice expenses Options: obtain survey data or continue to use physician data

Pros and Cons Are audiologist practice expenses more than physician expenses? All-physician average: $69.00 per hour ENT: $ per hour Many physician specialties are included in NPWP (e.g. oncology, radiology, internal medicine, cardiology) If some physician groups leave the NPWP, the remaining groups will be paid less.

Professional & Technical
Codes may not have physician work value Some codes have technical (TC) and professional (26) components. Professional component=physician work (May be billed by audiologists.) Technical component=practice expense Most Audiology codes do not have physician work.

RVU Example 1--92585-TC Technical procedure without interpretation
Physician work--0.0 Practice expense--1.18 Malpractice--.10 Non-facility RVU--1.26 Medicare fee (unadjusted)--$44.28

RVU Example 2--92585-26 Professional component Physician work--0.50
Practice expense--.22 Malpractice--.02 Non-facility RVU--.74 Medicare fee (unadjusted)--$25.60 Notice how small the professional fee is compared the technical fee.

RVU Example 3--92585 Global Physician work--.50 Practice expense--2.06
Malpractice--.14 Non-facility RVU--2.70 Medicare fee (unadjusted)--$93.40 Global can be billed by audiologists.

Complexity-based Codes
Unless otherwise specified, procedures are based on complexity Enter one code per procedure regardless of time spent Most CPT codes are complexity-based.

Time-based Codes Time period is specified (e.g. 15 minutes)
Enter one code for each time period Total volume=total time Example: 2 units=30 minutes for a 15-minute procedure Few Audiology codes are time-based. Time must be documented.

Audiology Services CPT codes in the 92500-series
Technical and professional services Do not require supervision by a physician Performed by qualified audiologists Must be ordered by a physician to be billed.

General Purpose Codes evaluation of auditory processing and/or aural rehabilitation status treatment of auditory processing disorder (includes aural rehabilitation) group treatment Often used (and abused) for hearing evaluation and treatment, not elsewhere classified

Audiology Treatment Codes
Audiologists cannot be reimbursed for treatment services under Medicare foreign body removal cerumen management vestibular rehabilitation

Implant Services Cochlear implant evaluation: Use audiological assessment codes Post-op analysis and fitting: Diagnostic analysis of CI, <7 yoa Subsequent programming, < 7 yoa Diagnostic analysis of CI, >7 yoa Subsequent programming, > 7 yoa Billable as diagnostic services CI Rehab (treatment) or 92507?

Implant Services No specific codes for brainstem implants
Use codes for cochlear implant With diagnosis of vestibular schwannoma (225.1) or NF-2 (237.72)

Vestibular Function Tests
With electrical recording spontaneous nystagmus test positional nystagmus test caloric vestibular test, each irrigation optokinetic nystagmus test oscillating tracking test (pursuit) sinusoidal vertical axis rotation test

use of vertical channel recording Add-on code--usually limited to and 92542 No specific code for saccades (use 92700)

Observation without electrical recording No reimbursement value spontaneous nystagmus positional nystagmus caloric vestibular test optokinetic nystagmus

Audiological Assessment Codes
screening test, air only pure tone audiometry, air only pure tone audiometry, air/bone SRT SRT and speech recognition No code for PI/PB (use modifier 22)

Audiological Assessment Codes
comprehensive audiometry Bundled code (includes and 92556) Do not code separately if all component tests are performed group audiometric test

Middle-ear Function Tests
acoustic immittance (tympanometry) acoustic reflexes acoustic reflex decay

Site of Lesion Tests 92571--filtered speech test 92572--SSW
SSI (ICM or CCM) tone decay test SISI pure tone Stenger test speech Stenger test central auditory function test

Less Commonly Used Procedures
Lombard test SAL loudness balance test (ABLB) Bekesy screening test Bekesy diagnostic test

Electrophysiological Tests
electrocochleography auditory evoked potentials, screening auditory evoked potentials (ABR, MLR, late potentials), diagnostic otoacoustic emissions, screening otoacoustic emissions, diagnostic intraoperative monitoring (added on to primary procedure, e.g )

Hearing Aid Services 92590--HAE, monaural 92591--HAE, binaural
hearing aid check, monaural hearing aid check, binaural V5014--hearing aid repair electroacoustic test, monaural electroacoustic test, binaural

Hearing Aid Services Programming--Use 92594 or 92595
Ear impression--V5275 Real-ear measurement--V5020 Otoscopy is part of examination and is not coded separately. Video-otoscopy is diagnostic and is coded as

Hearing Aid Services 97703 (each 15 min)--hearing aid orientation
outcome measures 92507-aural rehabilitation (except implant) Considered to be part of fitting*: device ordering/handling (99002) special supplies (99070) patient education materials (99071) group patient education (99078) *not billable by audiologists

Evaluation & Management
Level of care determined by complexity Time determines level only for counseling and coordination of care Office visits, inpatient services, consults, case management, prevention, disability assessment

Evaluation & Management
Cannot be billed Medicare, Medi-gap, and many third-party payers but may be billed to some HMOs Controversy: use E&M? 99499? 99211? 99211 is allowed but does not describe level of service is unspecified service and may not pass through billing system. Not appropriate when more specific codes are applicable.

Balance Treatment Audiologists treat vestibular disorders including BPPV. Peripheral vestibular rehab (canalith repositioning) is within the audiologist’s scope of practice. Code PT/OT treats global balance problems (sensory integration, proprioception). Dynamic posturography (92548) is within the PM&R scope of practice. Global vestibular rehabilitation (97112).

Audiology: HCPCS Codes
V5008-hearing screening V5010-V5298--hearing aid services V5299--miscellaneous hearing service L8614--cochlear implant device/system L8619--speech processor replacement L7510--repair of prosthetic device (not hearing aid)

CPT Modifiers

CPT Modifiers 31 CPT modifiers 6 Anesthesia modifiers
13 Ambulatory Surgery modifiers

Why Use Modifiers? To indicate that a service was more or less complex than typical To indicate that a service was repeated or discontinued To add more information regarding the purpose or anatomic site of the procedure To help to eliminate the appearance of duplicate billing To help to eliminate the appearance of unbundling (fragmentation).

CPT Modifiers Not all modifiers are appropriate for use by audiologists Modifiers should be used when appropriate to describe or clarify the service provided. Not all modifiers may be applicable to all codes.

CPT Modifiers 22--unusual procedural service
26--professional component (interpretation) 51--multiple procedures during same encounter 52--reduced service. Example: unilateral procedure when bilateral is assumed.

CPT Modifiers 53--discontinued procedure
59--distinct procedural service on same day 76--repeat procedure by same provider 77--repeat procedure by other provider 99--multiple modifiers

CPT Modifiers The following modifiers are restricted:
50--bilateral procedure 76 and 77--not used for quality control or verification Other modifiers clearly identified as medical or surgical (21, 23, 24, 25, 27, 32, 47, 54, 55, 56, 57, 58, 62, 66, 73, 74, 78, 79, 80, 81, 82, 90, 91) Physical status modifiers (P1, P2, P3, P4, P5, P6)

HCPCS Modifiers TC--technical component CC--procedure code change
RP--repair/replace prosthetic device RR--rental or lease of DME or prosthetic device

ICD-9 PCS Used mainly for inpatient procedures
CPT used exclusively in U.S. for outpatient procedure coding Surgical procedures ( ) Diagnostic and therapeutic procedures ( ) Hearing tests ( )

ICD-10-CM Replaces ICD-9-CM Disease and procedure sections
ICD-10 PCS proposed as replacement for CPT AMA opposes ICD-10 PCS and is developing a new system, CPT-5

Disease Coding

Structure of ICD-9-CM 3-, 4-, and 5-digit codes indicating levels of specificity Updated annually by working group Diseases and injuries ( ) Factors influencing health status and contact with health services (V-codes) External causes of injury or poisoning (E-codes)

Principles of Disease Coding
General rule: code to the highest degree of medical certainty. Use the most specific code possible. Avoid NOS and NEC codes. Non-physicians may code symptoms. Choice of disease code has a great affect on reimbursement.

NEC and NOS Codes NEC--not elsewhere classified (xxx.x8)
NOS--not otherwise specified (xxx.x9) NEC means that no appropriate code was found in the tabular list based on the information provided. NOS means that the condition was not adequately described by the provider. NOS codes are usually not accepted

Inpatient Disease Coding
Principal diagnosis (DXLS)--condition established after study that occasioned the admission V-codes are rarely used as principal diagnoses and rarely stand alone. Exception: rehab services

“possible”, “probable”, “suspected”, or “rule out” diagnoses are coded as confirmed. “rule out”--diagnosis is possible “ruled out”--diagnosis is not possible If condition is ruled out, it is not coded. Abnormal findings are not coded unless the clinic significance is indicated.

Conditions that have no bearing on current stay are not coded. All conditions observed during evaluation are coded. Only conditions treated or that have direct bearing on the condition being treated are coded during treatment. Conditions that are integral to a disease process are not coded separately.

Outpatient Disease Coding
Condition that is chiefly responsible for the patient’s visit is the primary diagnosis. Primary diagnosis may be a disease, condition, problem, symptom, injury, or reason for encounter. Secondary diagnoses may describe co-existing conditions, symptoms, or reasons Do not code conditions previously treated and no longer exist.

Outpatient Disease Coding
Do not code “probable”, “suspected”, “questionable”, or “rule out” diagnoses. Code to the highest degree medical certainty. If unsure, code symptoms or reasons. Symptoms may be coded as primary if a confirmed diagnosed has not been assigned. As a general rule, follow outpatient rules

Primary and Secondary Primary Diagnosis: disease, symptom, condition or reason that is chiefly responsible for the visit. Secondary Diagnosis: other diagnoses (e.g. relevant chronic conditions), conditions that have impact on care, or other conditions found after study.

Primary and Secondary For treatment services:
Primary Diagnosis: reason that is chiefly responsible for the visit. Secondary Diagnosis: Condition treated and other diagnoses (e.g. relevant chronic conditions) or other conditions found after study.

Routine or Administrative Exams
Primary Diagnosis: appropriate V-code to indicate the reason for the exam Secondary Diagnosis: any diagnoses, conditions, or symptoms found after study

Organization of V-codes
Health hazards related to communicable diseases (V01-V06) Health hazards related to personal or family history (V10-V19) Reproduction and development (V20-V29) Classification of live births (V30-V39) Conditions influencing health status (V40-V49) Specific procedures and after-care (V50-V59) Other circumstances (V60-V68) Persons without diagnosis (V70-82)

V-codes Do not confuse ICD-9-CM V-codes with HCPCS Level II V-codes.
ICD-9-CM codes are diseases, conditions, symptoms, or reasons. HCPCS Level II codes are procedures.

V-codes Some V-codes must be coded as primary; others are coded as secondary Consult your ICD-9-CM guide or your local registered health information specialist

Audiology: ICD-9-CM V-codes
V19.2 (family history of hearing loss) V41.2 (problems with hearing) V53.2 (fitting/adjustment of hearing aid) V65.2 (non-organic condition) V71.8 (observation for suspected condition) V70.5 (disability exam)

Normal Function There is no ICD-9-CM code for normal function. Normal function is not coded as a disease. V65.5 when there are no risk factors. V71.89 when there is clinical reason to suspect a problem.

Coding and Billing

Caveats Every insurance carrier has its own rules.
Coding is not the same as billing. Coding errors may lead to billing errors Even accurate coding may lead to errors. Not all billed codes are reimbursable. Not all encounter codes are appropriate or billable. Billing errors, however innocent, may be viewed insurance fraud.

Coding Rules Coding must conform to uniform coding standards.
CMS has the right to audit medical records, levy fines, and file claims for false and fraudulent billing. Insurance carriers may also audit medical records and file civil claims for fraud and abuse. May lead to civil and/or criminal penalties

What is Required to Assure Accuracy (compliance)?
Billing codes must match documentation. Documentation must support the scope and level of service (complexity or time). CPT codes must match diagnosis. Services must be appropriate by provider type. Services must be ordered by a physician (in writing)

What will Medicare audit?
Eligibility processes, identification and verification of insurance Medical record documentation, legibility, and accuracy of medical terms Medical record completeness Consistency of descriptive and decision-making terms in the medical record Accuracy of encounter forms Matching of medical terms in the record with encounter codes Accuracy of codes on claim form and bill sent

Reasons for Fraudulent Billing
Inadequate documentation Improper coding Services not provided Fragmentation (unbundling) Lack of medical necessity

Role of the Provider Fully document clinical care
Provider is responsible documentation Use accurate encounter forms Encounter form is a tool. Documentation is what is important. Follow applicable coding and documentation guidelines Assist in verifying claims

Coding Dilemma: Data Capture vs. Billing
Data capture: enter codes that appropriately describe the service provided. Purpose: workload reports, costing, staffing, efficiency, health care trends, research

Billing: enter codes that is appropriately describe the service provided Purpose: revenue generation

Problems: Not all codes entered for data capture purposes are appropriate for billing. Exceptions: codes entered into non-billable clinics, codes without charges High probability of errors if data capture and billing systems are linked. Concerns: Codes may be eliminated if they are not appropriate by provider type. Problematic codes may be restricted or removed from encounter forms or software.

Lesson Provider must know the reason for coding:
Data capture (workload, costing, etc.) Reimbursement (revenue generation) Define the purpose of coding up front. Coding rules are different for each purpose.

What Can Be Done to Improve Coding?
Coding handbooks and guidelines Standard encounter forms (super bills) Education Good dialogue with coding and billing officials Electronic aids (templates, code filters, prompts, taxonomies, e.g. CHCS-2)

Provider Billing Providers may bill for services (e.g. physician services). Non-providers: Other types of practitioners may provide services but procedures are billed as ancillary or facility charges. Facility decides who is a provider.

Billing by Non-providers
Audiologists may bill for global (TC + 26 components). Audiologists may not bill Medicare for physician (E&M) services. Technical services may be billed as facility charges if the procedure has technical (TC) and professional (26) components. Technical services are facility charges regardless of who provides the service.

Professional and Technical Services
Some CPT codes have both technical and professional components. Technical component includes the time of the ancillary staff. Professional component includes the physician’s work and expertise. Technical services are billed as facility charges. Professional services are billed as physician services.

Medicare Charges Hearing aid services are not covered services.
Routine services are not be covered. Treatment services by audiologists are not covered. All services must be ordered by a physician.

Medicare Charges Most procedures are billed as facility charges.
ENG, ABR, and OAE have TC and 26 components. Cerumen management is a physician charge. Intraoperative monitoring has TC and 26 components. Miscellaneous services ( ) are physician charges.

Case Management Services
Case management services such as team management ( ) are physician charges. These codes are considered as evaluation & management codes which are not appropriate for use by audiologists.

Advanced Billing Issues
Physician charges are billed on HCFA 1500. Facility charges are billed on UB-92. It is not appropriate to put a physician charge on a UB-92 and then attach a TC modifier to indicate it is a “technical” (non-physician) service.

Medical Necessity Physicians determine medical necessity.
All orders, consultations, and referrals must be signed and dated by physician. All orders, consultations, and referrals must indicate why the care is medically necessary. Referrals for evaluation must be medically necessary and pose a diagnostic question.

Reasonable and Necessary
“reasonable and necessary for the diagnosis or treatment of an illness, injury, or to improve the function of a malformed body member.” To be reimbursable, all services must be reasonable and necessary.

Covered Audiology Services
ordered by a physician reasonable and necessary used by the physician for evaluating appropriate medical or surgical treatment not covered when the diagnosis is known to the physician therapeutic services by audiologists are not covered

Documentation

Principles of Documentation
Documentation must be: Accurate--describes the care provided Codable--supports CPT, ICD, DRG codes Understandable--clear to reader Timely--written at time patient was seen Error free--stands alone as a legal document

If ain’t documented, it weren’t done! All care must be documented. Anecdotal or historical events (patient not present) should be documented. All documentation must be dated and signed.

Assessments must address: chief complaint or reason for the visit pertinent medical, social, and family history examinations, diagnostic tests diagnosis or diagnostic impressions plan of care

Treatment plans are derived from assessments. Treatment plans must address: diagnoses, conditions, or problems objectives or goals of treatment expected outcomes treatment modalities duration of treatment

To be reimbursable, all treatment services must be ordered by a physician. Ongoing treatments (e.g. AR) must be re-certified by the referring physician at least every 30 days during and at the termination of treatment. All documentation must include: patient’s name, SSN referring physician

Progress notes must address: goals or objectives of treatment progress toward stated treatment goals documented, measurable outcomes alterations to treatment plan patient and/or family education

Service Agreements and Referral Guidelines

Service Agreements Bilateral agreement (contract)
Usually between Audiology and Primary Care but can be with ENT or any other referring source.

Service Agreements Defines scope of services available
Referral criteria (specific, pre-work) Timeliness agreements Roles defined for both parties Criteria for co-management or return Communication methods Measuring effectiveness

Referral Guidelines Operational version of service agreement
Electronic template Examples: cerumen, sudden hearing loss, routine repair/adjustment for hearing aid, disability or fitness exam, non-visit consult Ensures appropriate, efficient, and timely referrals

Example: Sudden Hearing Loss
Patient reports sudden hearing loss in one or both ears. Time of onset and precipitating factors are important in diagnosis. Treatment must be started early to be effective. Send STAT consult to Audiology and ENT followed by phone call to Audiology for appointment

Consult Template Are ear canals clear of cerumen? Y/N
Does patient have associated dizziness? Y/N Is there evidence of middle-ear effusuon or otitis with exudate? Y/N Hearing loss in RE, LE, Both ears

Patient Education

What is Patient Education?
Preventive care & wellness programs? What about... advance directives informed consent objectives, benefits, risks, alternatives to treatment community resources test results, health status, medical findings treatment and discharge plans patient and/or family responsibilities

JCAHO Requirements Required patient education:
rehabilitative & compensatory techniques safe and effective use of medical devices safe and effective use of medications food/drug interactions nutrition, modified diets, food consistency test results, health status, medical findings treatment options and alternatives

JCAHO Requirements risks and benefits of treatment
awareness of community resources obtaining additional care, entitlements, access to care issues informed consent and advanced directives patient and family responsibilities self care skills and personal hygiene

Documentation of Patient Education
assess patients ability & readiness to learn assess motivation assess barriers and special need assess preferred mode of learning document educational content, medium document educational outcomes and level of understanding

Coding, Documentation, and Data Management

Similar presentations

Presentation on theme: "Coding, Documentation, and Data Management"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Coding, Documentation, and Data Management

Similar presentations

Presentation on theme: "Coding, Documentation, and Data Management"— Presentation transcript:

Similar presentations

About project

Feedback