Optimizing Coding in Primary
Care, Part 1
Bill Dacey, MHA, MBA, CPC The Dacey Group, Inc.
Palm Harbor, FL
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Learning Objectives
• Understand the financial impact of poor coding • Correct common primary care coding errors
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Today’s Agenda
• The Role of Coding in Reimbursement • Errors
• Bundling (Light) • Modifiers
• General Considerations
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Urban Coding Myth #1
• Correct coding equals reimbursement =NOT • Reimbursement is a function of your
understanding and response to third-party payer reimbursement policies
• You are far more likely to get paid based on what
you know rather than simply by what you do
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Federally Identified Risk Areas
• Per the Final OIG Compliance Guidance the
Specific Risk areas outlined are:
- Coding and Billing
- Reasonable and Necessary Services - Documentation
- Improper Inducements, Kickbacks, and Referrals
Within each category further detail is provided.
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Coding and Billing
• The elements specified in the plan are:
• Billing for items or services not rendered
• Reasonable and necessary service
• Double billing – duplicate payments
• Non-covered services
• Incorrect provider ID numbers
• Unbundling
• Modifiers
• Clustering
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What Are Your Risk Areas?
• In the absence of fraud, all of the areas addressed are likely process or education issues with the exception of unbundling, clustering, and upcoding
• Many of these can be addressed via data audits and attendant process reviews, typically with good result
• Unbundling is a coding error, and the solution depends on who creates it
• Clustering and upcoding are E/M issues (next session)
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Current Risk Areas/Opportunities
• EHR/EMR cloning/over-use (more next session) • The trend towards technological solutions versus
“medical necessity”
• Quality reporting – Category II codes
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Top 6 Errors (payer perspective)
• Duplicate claims
• Claims not covered by this payer
• Bundled services
• Beneficiary eligibility
• Medical necessity
• Non-covered services
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You May Get Paid for What Is Payable
• It is your obligation to know how each payer
processes claims and covers services
• It is highly likely that each contract you sign
assigns this responsibility to you
• In Health Care Claims submission and processing
what you don’t know will likely hurt you financially
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Submitting the Claim
• You may submit a claim for services, but that does not
necessarily mean you will be paid
– (i.e. preventive/cosmetic) – Just plain NOT COVERED
• Professional MD services are reported on the CMS-1500
(some still call it the “HCFA”)
– New CMS-1500 (Went into effect June 2007) – This change is primarily to allow for the 10-digit NPI #s
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CPT
®Coding
• YOU NEED TO OWN THIS • You need to KNOW this
• Codes range from head to toe in each coding section of CPT®
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Category II Codes
• These are tracking codes; they are designed to facilitate data collection for performance measurement.
• These codes are released in January and again in July each year.
• They are optional BUT now are part of Medicare’s Quality Reporting Initiative – no individual payment – but part of the quality reporting system.
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Surgical Coding
• When can one report procedures and visits on
the same date?
• When does a coder need to utilize a modifier to
obtain accurate payment?
• What impact does the National Correct Coding
Initiative have on coding?
• What role does the RBRVS play?
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The Surgical Package
Preop Intraoperative Postop
Global Period determined by payer [Not CMS]
Intra – OP Bundling determined by payer
Minor – day of surgery (Modifier 25 is applicable) Major – day of and day before surgery
(Modifier 57 is applicable)
Minor – 0 or 10 Major – 90 day post-op
+1 day pre-op 91 global days
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Items NOT Included in the Surgical
Package
• Initial decision for surgery
• Other MD services (diff. spec./diff. group) • Visits unrelated to surgical diagnosis (24) • Treatment for underlying conditions • Complications following surgery (78) • Unrelated surgical procedures (79) • Unrelated critical care services (24/25) • Staged/related/distinct procedures (58/59)
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National Correct Coding Initiative (CCI)
• Commonly referred to as “bundling”
• Created under CMS contract with Adm. Federal – early in
1996
• Saved $96 million in the 1st 6 months. • Updated quarterly
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CCI Status Indicators
• 0 – This code is ALWAYS included in the Comprehensive code. Knowing this fact will reduce denial rates and lower aged insurance receivables.
• 1 – There may be a chance to unbundle. Only add modifiers on this component code if appropriate. Use caution, reviews are possible – are you certain you should be paid?
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Bundling
• Two main types of bundling:
- Incidental: The relationship between one service and another, and
- Integral Component: One of the services is generally considered an integral part of a larger more comprehensive service - This is payer-specific – you need to find out
how each one does it
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Selecting E/M Codes…
• E/M is far and away the most important group of
codes for regulatory liability concerns
• Depending on specialty – potential high revenue
impact as well
• Coding correctly requires documenting it
correctly – there is no other safe harbor…
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Chart Audit or Pattern Monitoring
• Scope is all payers – look ahead • Triage by risk – payer mix, profile
• Focus chart intensive reviews on High Risk • Pattern monitor low-risk areas or reduce audit
size or frequency
• Customize reviews to performance 22
Documentation Issues
• Coding By Time:
– Document Counseling and Coordination of care versus Prolonged Services coding
– If 50% or more of an encounter is c/c, time can be used as a driving factor to support a higher level of service of the original code
– Just state the time and the purpose
– For prolonged – just state the nature of the extra time
– Critical Care – requires total time that day
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Improve Processes…
• Establish Compliance and Correct Coding rates
for providers: CPT and ICD-9
• Develop “thresholds” of compliance geared to
specific educational activities
• Verify all “no bill” determinations
• Establish correct coding/reviewing rates for
coders and reviewers
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Effective Tools
• One set of rules: Don’t forget about the other 55%
of private payers
• The Template – bridge to electronic record • Real time and the prospective review: The best
opportunity for MD education – use their own work product
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Templates and Forms
• CMS allows but is concerned about “cloning” and
repetitive documentation
• They don’t want stamps – but rather that the MDs
will write what they did
• Don’t over-rely on these – they support
documentation – they don’t replace it
• If forms are used – avoid total repetition – mix it
up – they should reflect your patients!
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The E/M Modifiers
• -21 – Use rarely if ever – prefer prolonged CPT codes • -24 – Unrelated E/M in a global (that you performed) • -25 – Separate, Significant, Identifiable, etc. • -32 (sometimes) – Mandated
• -57 – Initial decision to perform surgery (+10 global)
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The Surgical Modifier
• For most providers the big issues here are: • Modifier 51 – Same site, same incision • Modifier 59 – separate site, separate incision • Modifier 58, 76, and 78
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Own the Work, the Codes,
and the Payment Process
• Know your codes
