Still Book-based? 22 Benchmarks for Picking the Right Physician Coding/Billing Online Reference Service

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(1)Sponsored by. Contents • Mountains of information .......... 1 • Denials research ...................... 2 • Online coding/billing reference services emerge....................... 3 • 22-point checklist for preferred online service features .............. 4 • Case Study 1: Phoenix medical practice..................... 10 • Case Study 2: Christie Clinic, Champaign, Ill. ...................... 11 • Final thoughts........................ 12 • About the Sponsor ................. 13 • Checklist summary table ......... 14. Executive Summary Comprehensive web-based coding, billing and reimbursement reference services help physician practices increase staff productivity and revenue while cutting costs and the clutter of too many books. These services provide searchable, online access to ICD-9 diagnosis, CPT and HCPCS code sets as well as dozens of other coding, billing and reimbursement references for physician services. This White Paper provides a checklist of 22 features for evaluating online services, plus 2 case studies of physician offices that have switched to them.. White Paper Program. physicianpracticewhitepapers .decisionhealth.com Posting of this white paper on any web site or intranet without prior written permission by DecisionHealth is prohibited. © 2008 DecisionHealth. © 2008 DecisionHealth®. Still Book-based? 22 Benchmarks for Picking the Right Physician Coding/Billing Online Reference Service Wouldn’t it be great to reduce the stacks of physician coding, billing and reimbursement references cluttering your desk? Think how wonderful it would be to push aside the piles in one grand gesture! Unfortunately, you’d lose access to information that’s critical to your medical practice’s compliance and reimbursement. What’s the ideal solution? That’s easy – it would be an expert sitting at the next desk with all those coding, billing and reimbursement facts, rules and guidance in her head. Ask your expert a question and in seconds she gives you the right answer – and then serves up the related information you’d probably ask for next! The odds of having that person nearby are slim to none, sorry to say. Another option: Some electronic medical records systems (EMRs) incorporate coding reference information. Many practices have found great value in digitizing clinical information about patients, so could an EMR kill two birds with one stone? While many EMR programs offer useful code look-up assistance, they don’t match the broad array of online coding and billing references. There also have been comprehensive references offered on CD-ROM. But CDs were superseded years ago by the speed and convenience of the Internet and its ability to provide always up-to-date information. In the search for an effective alternative, physician offices and ambulatory surgical centers (ASCs) are choosing online coding, billing and reimbursement references that provide fast, comprehensive and reliable information and guidance. There are several choices among online services, however. In evaluating them, what features will save your office time and money and help you pick the right ICD-9, CPT and HCPCS codes to file clean claims and obtain full, correct reimbursement? This white paper identifies 22 benchmarks (also provided in checklist format) for judging online reference services that seek to fulfill the needs of freestanding and hospital- or health system-affiliated medical practices. Mountains of information challenge physician offices There’s a lot at stake. The Centers for Medicare & Medicaid Services (CMS) estimates that Medicare Part B coding and billing errors cost the. Page 1.

(2) White Paper: How to Pick the Right Online Service. Medicare program about $3.2 billion in overpayments for the 12 months ended Sept. 30, 2007. Those were due mainly to coding mistakes (57.7% of errors) and insufficient documentation (27% of errors). In 2006 (latest Medicare data available), physician services experienced an overall 12% claims denial rate, costing medical practices a whopping $25.5 billion for 642.6 million denied services, according to a recent Part B News analysis.. Paid claims error rate by medical specialty Anesthesiology. 1.1%. Cardiac Surgery. 5.0%. Cardiology. 4.9%. Dermatology. 2.0%. Emergency Medicine. 5.3%. Family Practice. 7.4%. Gastroenterology. 7.5%. General Surgery. 5.5%. Internal Medicine. 8.5%. Ob/Gyn. 4.5%. Ophthalmology. 1.9%. Orthopedic Surgery. 4.9%. Radiology (diagnostic). 1.7%. Urology. 4.8%. Source: CMS Comprehensive Error Rate Testing program, Table 10a, May 2008. % of paid claims error rate due to incorrect coding Anesthesiology. 61.5%. Cardiac Surgery. 22.2%. Cardiology. 57.3%. Dermatology. 59.4%. Emergency Medicine. 78.7%. Family Practice. 63.6%. Gastroenterology. 76.2%. General Surgery. 73.2%. Internal Medicine. 62.3%. Ob/Gyn. 90.9%. Ophthalmology. 36.0%. Orthopedic Surgery. 73.5%. Radiology (diagnostic). 14.0%. Urology. 66.7%. Source: CMS Comprehensive Error Rate Testing program, Table 14a, May 2008. © 2008 DecisionHealth®. Small wonder with 8,800 CPT codes, 12,000 ICD-9 codes and more than 1,300 HCPCS codes to choose from. Of course, that’s just the tip of the proverbial iceberg. There are plenty of references other than code books that you must consult to help you stay on the right side of coding, billing and reimbursement requirements. For example: • Bulletins from your Part B carrier or Medicare administrative contractor (MAC) • Local coverage determinations • National coverage determinations • Fee schedules • Prohibited Correct Coding Initiative code pairs – current and past • Newsletter articles providing breaking news of coding and payment policy changes and guidance from experts on how to stay in compliance • Reference books explaining rules and requirements in plain English • Federal Register notices of proposed and final regulations • Congressional legislative provisions setting policy for physician Medicare payments • Medicare Carrier Manual coding and billing requirements • E/M documentation guidelines • National Provider Identifier rules and Medicare enrollment requirements Just to name a few. Multiply these references times the number of staff that needs access to them. That’s a mountain of paper – so much for going “green”! – and substantial extra cost for your practice. Adding more doctors to your office also means more administrative staff and additional coding and billing reference material. For medical practices with multiple locations, the costs and headaches escalate. They have to worry about whether all staff members are in step – using code books for the current year and not from earlier years, for example. If the references aren’t all up to date, the lack of uniformity risks claims denials and compliance problems.. Page 2.

(3) White Paper: How to Pick the Right Online Service. Denials research strains resources Figuring out why a payer has denied your claim can consume a huge amount of your time or your staff’s – not to mention handing someone a tedious chore. How many books and other scattered references have you or others in your office spent hours digging through for evidence that your claim should have been paid or not downcoded? Part B paid claims error rate by type of service Hospital visit – initial. 17.6%. Consultations. 16.6%. Office visits – new. 15.5%. Nursing home visit. 14.2%. Hospital visit – subsequent. 12.2%. Ambulatory procedures. 7.6%. Minor procedures. 6.9%. Office visits – established. 6.0%. Emergency room visit. 5.3%. Hospital visit – critical care. 5.0%. Other drugs. 0.6%. Source: CMS Comprehensive Error Rate Testing program, Table 9a, May 2008. The task usually isn’t as simple as just looking up a code in the ICD-9, CPT or HCPCS manuals. You may have to correlate the denied procedure or service with the diagnosis, and then make sure there’s no carrier or national Medicare coverage restrictions or CCI prohibitions. Also, you should check newsletters for articles that give plain-English perspective and guidance on the problem and solutions that code books and payer documents don’t address. Some medical practices even have staff specifically dedicated to recovering denied or reduced reimbursement because of its resource-intensive work and potential payback. Online reference sites emerge As mentioned above, the ideal solution to stacks of reference books would be that coding/billing/reimbursement expert – who has comprehensive, up-to-date knowledge and instant recall – at your beck and call. Until that miracle happens, online resources are your best alternative. You can (and probably already do to some extent) pull some of the information you need from the web. A lot of it is online but scattered throughout dozens and dozens of web sites. Physician office staff easily can spend an hour or two everyday searching for the right web site and then drilling down many levels to find what they’re looking for. For example, have you ever tried to locate something on the Centers for Medicare & Medicaid Services (CMS) web site? Although the agency has improved it over the years, the site still can be tough going. There’s an even better solution than hunting and pecking your way through dozens of web sites for the key bit of information you need.. CodeManager is a registered trademark of the American Medical Assn. Encoder Pro is a registered trademark of Ingenix. Flash Code is a registered trademark of Medical Coding & Compliance Solutions.. © 2008 DecisionHealth®. A number of publishers have built online services (CodeManager®, CustomCoder, Encoder Pro®, Flash Code®) that pull together in one place key coding, billing and reimbursement information that medical practices need.. Page 3.

(4) White Paper: How to Pick the Right Online Service. 22-item checklist for preferred online service features As you know, many elements come into play when you code a service and bill a payer to receive the reimbursement you’re due. Use this checklist, organized into convenient categories, as an aid in evaluating comprehensive online coding services for the features and capabilities that will meet your practice’s needs. Coding & Billing. Ambulatory Surgical Centers. 1. Code sets: First, everyone would agree that an online reference for coding/billing/reimbursement should include the entire ICD-9 diagnosis, CPT and HCPCS code sets and modifier definitions. CPT codes aren’t freely available on the web because they are copyrighted material; the public domain ICD-9 and alphanumeric HCPCS code lists may be found online but searching the files and using them can be cumbersome. Code sets are the “basic cable” of online services; everyone offers them.. ASCs operate under many policies and rules specific to the facilities – an important issue for hospitals and medical practices affiliated with any of the 5,300 Medicare-certified ASCs.. ASC note: If your organization is a freestanding ambulatory surgical center or includes an ASC, make sure the online service offers an option for identifying the 2,500+ codes that are on Medicare’s ASC-covered list. Also look for other crucial ASC data such as the:. Check to see whether an online reference service recognizes the unique coding, billing and reimbursement information needs related to the $4 billion in procedures and services provided by Medicarecertified ASCs.. 9 Facility version of the Correct Coding Initiative used in the ASC setting. 9 Payment groups and rates with projected fees during the fouryear transition of the new APC-based ASC payment method 9 Payment indicators showing whether a code is subject to multiple procedure fee reductions 9 Easily accessible Medicare documents with ASC codes and other data you can import into your own systems for further use. Example: Medicare payment policies for use of P-C and A-C intraocular lenses. 2. Plain-English definitions: Unless you have a deep understanding of anatomy or keep an anatomy book at hand, making sense of some code definitions can be a challenge. Example: 20610 is billed to Medicare about 5 million times a year. The CPT definition: “Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa).” Easier, faster to understand in plain English: “The physician administers local anesthesia and inserts a needle into a joint or bursa. Fluid is aspirated and/or injected.” A drawing illustrating the procedure is a valuable bonus.. © 2008 DecisionHealth®. Page 4.

(5) White Paper: How to Pick the Right Online Service. 3. Correct Coding Initiative (CCI) edits: Make sure your online coding resource provides access to Medicare’s latest list of CCI edits and mutually exclusive code pairs (many private payers screen claims with the CCI code lists, too). Knowledge of CCI helps avoid inadvertently billing two codes that are prohibited for services furnished to the same patient on the same day. It’s also important to have earlier versions of the CCI at your fingertips when you have to research a claims denial and fight a payment recoupment effort. That’s because CMS adds, deletes and revises hundreds of CCI code pairs every quarter; the Medicare program applies the CCI version in effect at the date of service. Example: Carriers and private payers sometimes audit claims going back as far as three years. Let’s say a payer audits your claim paid a year earlier but uses the latest CCI version. The claim bills lung procedures 32442 and 32998 together but the payer denies the claim because its auditors checked the code pair against the current CCI version. In researching the denial, your online coding reference shows that the CCI version in effect on the date of service didn’t include the code pair. That fact gives you concrete grounds for disputing the denial and overpayment recoupment demand.. ICD-9 ⇔ CPT Avoid claims denials by quickly and easily cross-checking CPT and HCPCS codes against diagnosis codes your Medicare carrier says are acceptable for showing medical necessity (when appropriately documented). Carrier lists of acceptable I-9 codes change frequently – but online reference services make it easy to stay current with them and related local and national coverage determinations (LCDs, NCDs).. 4. CPT Guidelines: CPT coding guidelines, scattered throughout the CPT manual, offer valuable insight into correctly matching the right code to a clinical service. You always can thumb through the CPT manual to find the guidelines but having them one click away from other types of code information is a substantial timesaver. Example: When you review search results for rhythm ECG 93040, you’d want to see cardiography procedures guidelines explaining when it’s appropriate to order the test. 5. Coverage determinations by code: Because your local Part B carrier sets limits on when it pays for certain services, having an updated list of its “local coverage determinations” (LCDs) is crucial to proper billing and denials research. Similarly, you must have access to the “national coverage determinations” (NCDs) that CMS imposes nationwide. Example: When billing diagnostic test 93025 to assess heartbeat rhythm problems, it’s good to know before submitting your claim that a Medicare NCD allows coverage of the spectral analysis method but not the modified moving average method. When billing cardiac stress testing codes 93015 to 93018 performed in Highmark’s Philadelphia metro carrier locality, it’s also crucial to know a Highmark LCD says that 90325 can be paid when supported by ICD9 codes 414.2 (Chronic total occlusion of coronary artery) and 440.4 (Chronic total occlusion of artery of the extremities). 6. Medical necessity: What’s the correct diagnosis code to support the. © 2008 DecisionHealth®. Page 5.

(6) White Paper: How to Pick the Right Online Service. CPT or HCPCS code you’re billing? If you’re not sure, diagnosisprocedure code crosslinks will guide you to the right answer. Example: When you enter 20610, you should be no more than a screen away from the scores of ICD-9 codes associated with the procedure. Reimbursement. 7. Fees by CPT or HCPCS code: Medicare’s physician fee schedule, with fees automatically adjusted for your locality, is bottom-line necessary. It also helps to have the Medicare fees for all of Medicare’s 89 carrier payment localities in case your service area extends beyond one locality. 8. Resource-based relative value units: RVUs are a must-have for medical practices that use them to calculate profit/loss per code and/or use RVUs to measure physician productivity for compensation purposes. (You also need RVUs at hand when billing services subject to the multiple-procedure discount.) Medicare’s resource-based relative value scale (RBRVS), launched in 1992, has become the national gold standard for medical practice financial management and analysis. Injectable drug prices Because of frequent changes in prices, look for fast access to the latest Medicare payment amounts for drugs administered in physician offices. Medicare reimburses about $10 billion a year for these drugs.. 9. Drug prices by code: Medicare Part B pays physicians about $10 billion a year for drugs they administer in their offices. Not only is it important to bill the right J- or Q-code to get reimbursed, it’s also important to know what you will be paid. CMS revises drug prices quarterly, resulting in big fluctuations in payments for some drugs. Having current pricing data helps you compare your purchase price to your peers’ and determine whether your practice is making or losing money on the drugs you buy. Government Rules & Private Guidance. 10. Rules and requirements: Your coding, billing and reimbursement are affected by a steady stream of Federal Register regulations, carrier program memoranda, claims processing revisions and additions, updates on specific programs such as the Physician Quality Reporting Initiative (PQRI), provider enrollment and National Provider Identifier requirements. Plus there are many other reference documents you may need to check at any time, such as E/M documentation guidelines, place of service codes, explanations of acronyms and abbreviations, or a crosswalk of drug codes and NDC numbers. There’s a treasure trove of these documents spread all over the Internet but having them in one place makes the difference in usability. 11. Guidance: No matter how many government or payer documents you read in your quest for coding/billing/reimbursement answers, you. © 2008 DecisionHealth®. Page 6.

(7) White Paper: How to Pick the Right Online Service. won’t get the whole story. For that, you need additional perspectives from newsletter articles which contribute understanding and improve your ability to make the best decisions. Through exclusive interviews with knowledgeable sources, newsletters bring the guidance of: • CMS officials who explain how to comply with their agency’s rules, providing insight above and beyond what’s in the rules themselves. • Congressional staff and lobbyists for physician organizations who analyze the impact on medical practices of coming legislation that will change how you operate or what you’ll get paid. • Private sector experts who share their experience and recommendations derived from working with multiple physician practices on resolving coding and billing problems. • Your colleagues in physician offices around the country who share their daily challenges and solutions they’ve found.. Stay current with alerts Seek web-based reference services that send notices to you identifying changes in coding, billing and reimbursement requirements. Don’t try to figure out what’s been revised yourself. Require that the service customizes alerts to your geographic, medical specialty and subject matter interests.. Example: You search your online reference for code 93015 (cardiac stress test). The results include a newsletter article in which one consultant relates encountering confused coders who believe that billing a stress test by its components would violate unbundling rules. She and another consultant advise that it’s completely legitimate for different entities to bill 93016, 93017 and 93018 when they furnish different components of the stress test. Filtering Content. 12. Geographic & specialty customization: Avoid the extra work of (1) having to adjust national information to your geographic area and (2) having to filter out information unrelated to your medical specialty (or specialties). Look for an online reference service that allows you to designate your area and specialty in advance so that information displayed – such as Medicare payment rates, payer coverage and medical necessity policies and news articles – is automatically adjusted for your geographic locality and targeted to your specialty. 13. Alerts for changed content: There’s a never-ending stream of additions, deletions and revisions in codes, coding rules, billing policies and procedures, coverage criteria, reimbursement rates and more. It’s tough to stay on top of all these changes. Look for an online service that offers a daily e-mail that alerts you to changes in key subject areas – but only those that you designate! Bringing it all together. 14. Comprehensive integration: Even though you are looking for one online service, you don’t want to have to click through multiple, disjointed. © 2008 DecisionHealth®. Page 7.

(8) White Paper: How to Pick the Right Online Service. screens within that service when trying to find key coding and billing information related to a code. Look for a service that lets you enter a code and then gives you a “one-stop-shop” of relevant information that you can use every day in your practice. Example: When you enter arthrocentesis code 20610, wouldn’t you like to see one screen showing where to click for:. The web-based advantage Quick updates of content represent one of the big advantages of an online service. Require that your service incorporate new information within 24-48 hours.. • The 65 Column 2 codes for which CCI allows modifiers to override the edit, the 3 codes where no modifiers are allowed and the 1 mutually exclusive code pair. Then have an ability to flip the list to see the same information when 20610 is the Column 2 code. • The 74 ICD-9 diagnosis codes that may support the medical necessity of the procedure. • Crosslinks to the 16 other procedure codes that may support the medical necessity of the billed procedure. • The appropriate primary and 4 alternate anesthesia codes. • The 42 CPT and HCPCS modifiers that are appropriate to use with 20610. • Definitions of any of the more than 150 codes or 42 modifiers referenced above. • A dictionary of key terms associated with 20610 (example: Bursa is a sac or saclike cavity filled with a viscid fluid…). • National Coverage Determinations • Local Coverage Determinations • Physician office and in-facility Medicare allowable fees and all relative value units (RVUs) for 20610 (example: $75.73 physician office fee for Philadelphia in 2008). • Payment indicators for 20610 showing the applicability of the Medicare global surgical period (0 days) and payment policy limits for multiple procedures (yes), bilateral procedures (yes), assistant at surgery (not allowed), plus the applicability of other payment indicators. • Relevant news articles about this code or code ranges in which it falls as published in CMS rules, carrier bulletins, CPT Assistant and independent coding/billing/reimbursement newsletters and references. 15. Daily updates of content: With the vast amount of information that applies to physician office coding, billing and reimbursement, there are changes every day. If your web-based service doesn’t swiftly incorporate those changes within 24 hours, its value quickly becomes impaired by placing you at risk of relying on out-of-date or missing information. 16. Print summary option: After reviewing information on 20610 or any other codes, look for a handy way to create and print a summary of. © 2008 DecisionHealth®. Page 8.

(9) White Paper: How to Pick the Right Online Service. the information produced by your online reference service. The summary should include: 9 9 9 9 9 9 9 9. The code’s official definition Plain-English explanation RVUs and fees Payment indicators Appropriate modifiers CCI edits Appropriate anesthesia codes Other procedure codes and ICD-9 diagnosis codes supporting medical necessity, and 9 Special national and local coverage parameters (NCDs, LCDs).. Annual annotation challenge Using multiple code books also means lots of notes. You’ve probably seen code books festooned with sticky notes and annotated with hand-written scribbles in the margins. If you indulge in this practice, do you laboriously transfer your key notes into each year’s pile of new code books? Do your colleagues do the same or are they procrastinators? The notational information is certainly valuable but what a hassle – something online services can help you avoid.. Just think of the convenience of finding that summary sheet in a patient’s file when doing a chart audit! Assistance. 17. Electronic sticky notes: As noted at left, there are coders and billers who pack their books with sticky notes and handwriting in the margins and have to transfer these reminders each year to new books. That chore goes away thanks to online coding reference services that offer an electronic version of sticky notes. Users open small pop-up windows in which they type their notes and attach them to specific information. Make sure the electronic reference service’s notes are searchable and available for retrieval at any time, any year and by any member of your staff. 18. Bookmarks: Got a few pages on your favorite web sites that you go back to time and again? Then you understand the value of bookmarks. Seek an online service that offers a bookmarking feature that takes you straight to your most-used codes, pages, etc. and avoid those extra clicks. 19. Easy to learn: You are busy and don’t have hours to spare for initial training and refresher courses on how to use an online service. Demand an intuitive design and short learning curve. 20. Dictionary: Here’s a way to eliminate yet another book from your desk – select an online service that comes with a built-in medical dictionary that’s also supplemented by illustrations. 21. Ask Questions: Let’s face it – no online service’s reference information can answer every question under the sun. So when your research efforts leave you stumped, who do you ask? Go for a service that lets you e-mail your question to an expert coder/biller, with a prompt response guaranteed. Make sure the feature includes a keyword searchable database of questions posed by your colleagues and the answers they’ve. © 2008 DecisionHealth®. Page 9.

(10) White Paper: How to Pick the Right Online Service. received. It may have just what you’re looking for! 22. Discussion forum: Your colleagues who use the same online service as you can offer a wealth of experience in dealing with the same coding, billing and chart auditing challenges that you face. Tap into that knowledge through a forum limited to fellow users where you can pose your queries (and share your experiences) in a secure area. In a similar vein, you also may have a question about how the online service operates, its content sources or how to perform a specific function. Seek a service that allows you to ask such questions of its operator and other users, who may have their own tips and shortcuts for using the service. BONUS: To use the above 22 benchmarks in a convenient summary format, see the table at the end of this white paper.. Case Study 1: Phoenix medical practice. With a few key strokes, the online service eases the process of creating a clean claim for codes subject to the multiple procedure discount policy. Coding and Billing Manager Susan Ward enters the codes and sees them instantly ordered by relative value so they can be listed on the claim in proper order for proper reimbursement.. When researching claims denials, Susan Ward spent more time than she felt should be necessary to accumulate information to support an appeal. The coding and billing manager for a Phoenix plastic/reconstructive surgeon used the usual line-up of coding manuals, a cross-coder plus multiple web sites by CMS, her Medicare carrier and professional societies. Now when asked, it takes a minute for her to recall many of the references she consulted because “it’s been so long since I’ve used them.” (Ward, however, still keeps her CPT book at hand out of habit.) Since March 2007, she’s been using an online coding reference service, which she calls a “wonderful tool” that substantially cuts down her research time for new as well as denied claims. For example, while preparing a claim for services subject to the multiple procedures payment reduction policy, she enters all the codes into the reference service and sees with a quick click which one has the highest RVU count so she can list it first on the claim form to obtain the full, correct reimbursement. Ward also runs codes through the program’s CCI checking feature that tells her in a second what’s part of another procedure and what’s not. Similarly, she obtains instant answers to whether the carrier will allow modifier 78 for a return to the OR, modifier 58 for a staged procedure or whether the payer will reimburse for an assistant at surgery. In her. © 2008 DecisionHealth®. Page 10.

(11) White Paper: How to Pick the Right Online Service. speaking and training engagements around the country, she logs into the service and easily summons information adjusted for the audience’s locality. Her practice has an EMR with a code look-up feature but it lacks CCI code bundling and other information. In addition, the EMR’s code information isn’t formatted the way it is in the familiar CPT manual. But that’s not the case with CustomCoder, the online reference service she uses. It’s organized the same way “you would look up information in your book. There’s no having to retrain your brain. I’ve been doing coding for close to 20 years and I’m used to one way of looking at codes. I also teach that same way. If I’m going to use a program online, I want to search the same way” – by index or tabular search. Ward is an approved PMCC instructor and holds CPC credentials for physician, E/M and hospital outpatient coding through the American Academy of Professional Coders. She tried other online coding/ billing/reimbursement services but they didn’t satisfy her desire to have all information “just a click or two away.” When she tried CustomCoder during a free trial, “it didn’t take but probably an hour or two before I said ‘I need to have this program, doctor, will you pay for it?’” Case Study 2: Christie Clinic. Christie Clinic Champaign, Ill.. How would you like to see – with one click – whether the codes representing a physician’s services for the day comply with each other and the Correct Coding Initiative edits? Amy Schaffer, CPC, compliance and coding educator for her practice, likes that ability. She praises this kind of “validation” assistance in preparing clean claims as big benefit of the online coding/billing service used by Christie Clinic, a 106-physician multispecialty group practice headquartered in Champaign, Ill. Example: The clinic’s radiation oncology practice sometimes bills 12 to 15 codes for a patient for one day. “We’re able to put in all of those codes, hit one button and know whether we have any bundling issues…it tells us everything we need to know for billing.” The validation feature verifies combinations of CPT, HCPCS and ICD-9 diagnosis codes and modifiers against CCI edits. After entering the relevant codes, the feature displays a green box indicating no problems, a yellow one noting CCI bundling issues that may be overridden by an appropriately documented modifier, or a red box warning the code combination won’t be reimbursed under any condition. Validation is a feature of CustomCoder, which the clinic has used since September 2006. “It looks at the whole picture and tells you whether any of your CPT codes are bundled per CCI, any diagnosis codes are. © 2008 DecisionHealth®. Page 11.

(12) White Paper: How to Pick the Right Online Service. nonpayable per Medicare, whether your modifiers are correct, and whether there are other issues like a Medicare frequency-of-service limit on a particular code. It looks at your whole day and says this looks really good or you need to do some tweaking on the front end rather than waiting for the denial to happen,” Schaffer says. Non-coders benefit, too Staff members don’t have to be coders to use the online service, Christie Clinic’s Schaffer says. When nurses or medical office assistants are new to the clinic, they’re encouraged to use the online reference to learn about the medical specialties they work with. When they enter codes from their physician’s charge ticket, they see plainEnglish definitions of the procedures or services. “That one paragraph (in layman’s terms) explains it a little bit clearer, gives them a better idea of what their physicians are doing. It’s a good way to learn what’s going on in the practice. So we actually use it [CustomCoder] not only as a coding tool but as an educational tool.”. Much of the data, rules and other content in all online services come from Medicare because nearly all of Medicare’s coding, billing and reimbursement policies are in the public domain. That’s not a problem, Schaffer notes, because most of the clinic’s private payers use Medicare as the basic template for their coverage and payment policies. “We actually find it (the online service) helpful for all our payers.” In denials research, the service helps figure out why private payers rejected a claim. Their denial notices will simply state “bundled” with no further explanation, she says. A single coder can research the denial in the online service without involving others. “They’re able to figure it out themselves and get the claim resubmitted if possible. It just cuts a lot of people out of the process.” Recalling when cumbersome stacks of code books had crowded her desk space, Schaffer says she was “a book girl but I was up for something better.” She and the clinic looked at other electronic information resources. CD-ROM-based coding tools were rejected because of the need to manually install updates with each new CD and the fear that if the update wasn’t done, the clinic unknowingly would use out-of-date information. An online service was considered but lacked the nuances the clinic wanted. Then one of the clinic coders saw an ad for a 90-day freetrial for CustomCoder. She figured it couldn’t hurt to try it and loved it. “Then she got me to sign on to it and I fell in love with it” as did other clinic coders, Schaffer says. However, she and the other coder were wary of giving up their “bookfirst security blanket.” So after using CustomCoder for 30 days of the free-trial period, they made a pact to try going the next 30 days coding book free. “We promised each other we wouldn’t open our books and in 30 days neither one of us had even grabbed them.” Final thoughts Physician coders and billers see it everyday – the overwhelming convenience of the Internet pushes more information to the web everyday. However, just having volumes of coding, billing and reimbursement information online isn’t good enough by itself. To save hours of work and hassle as well as boost their chances of finding the right answer, they favor a comprehensive, web-based reference service that puts in one place all the relevant codes, definitions, government. © 2008 DecisionHealth®. Page 12.

(13) White Paper: How to Pick the Right Online Service. coding and payment rules, and expert guidance. The cost of these services pales in comparison to the cost of claims denials and noncompliance. Not only do all-in-one reference sites offer better access to critical information, through multi-user site licenses they offer better access for more of your staff, providing a substantial savings in purchase of duplicate code books and other references. Add in an intuitive web site design and good customer support, online reference services that meet the checklist above may come as close as you can get to having a coding/billing/reimbursement expert (with total recall) at the next desk. About the White Paper Sponsor CustomCoder™ is the online reference service where users simply type in a code or keyword to gain instant access – all in once place – to code definitions, coding and billing rules and expert guidance that will help ensure physician practices receive all the reimbursement they have earned. Comprehensive and customizable to the user’s locality and medical specialties, CustomCoder has been accepted by the Medical Group Management Association’s AdminServe® Partner Program as the best-inclass online coding reference application. CustomCoder aggregates thousands of policies, bulletins, regulations, newsletters (including DecisionHealth’s Part B News and the specialty Coder’s Pink Sheets), and news articles from dozens of government and private sources into a single web site. Because it’s web-based, there’s nothing to install – making CustomCoder’s coding, billing, reimbursement and compliance information always current due to daily online updates. CustomCoder is available in three levels of service to suit the needs of users in freestanding and hospital- or health system-affiliated physician practices. For more information on CustomCoder: • Go to www.customcoder.net or call 877-652-9093. • To request a free, live demo viewable from the convenience of your desk, call Gene Kraemer at 877-652-9093 or e-mail gene@customercoder.net. • MGMA members should go www.customcoder.net/mgma for more information or to request a demo.. © 2008 DecisionHealth®. Page 13.

(14) White Paper: How to Pick the Right Online Service. 22 Preferred-Features Checklist For Comprehensive Online Coding/Billing/Reimbursement Reference Services Yes/ No. Key Features. Benefits Summary. All code sets. Searchable, electronic alternative to ICD-9 diagnosis, CPT, HCPCS code books. Option for ASC codes, payment and other data. Plain-English definitions. Faster understanding of the service or procedure represented by a code. Correct Coding Initiative prohibited code pairs – past and present. Avoid claim denials; research and refute payer overpayment demands. CPT Guidelines. Quick access to guidelines to facilitate selection of correct code. National, local coverage determinations (NCDs, LCDs). Code and bill correctly according to coverage limits set by CMS nationally and your specific Medicare carrier. Medical necessity. Ensure claims meet this standard by billing the correct diagnosis code. Physician fees by CPT, HCPCS codes, adjustable for any locality. Know ahead of time what you’ll be paid by Medicare or any non-Medicare payer using an RBRVS-based fee schedule. Relative value units (RVUs). Calculate cost per code, measure physician productivity, list codes in correct order for multiple-procedure payment. Drug prices by code. Monitor profit/loss for injectable drugs furnished in your office. Federal rules and requirements. Ensure your compliance with rules for coding, billing situations. Guidance. Expert, independent guidance on the meaning of official rules to further your compliance with coding, payment changes. Geographic & Specialty Customization. Save time by automatic adjustment of fees, coverage and payment rules and other information for your locality and medical specialty(ies). Alerts for changed content. Receive timely word of changes but only in subject areas you designate. Comprehensive integration. Save time, cover all coding/billing bases by having access to all relevant information from one screen. Daily updates of online reference information. Avoid wasting time, mistakes due to obsolete information. Print coding/billing summary. Save in one paper document all relevant coding, billing, payment data for any code. Electronic sticky notes. Customize information to your practice’s operational needs; avoid transferring handwritten notes to new code books and other references each year. Bookmarks. Set up quick access to the information you use most often. Easy to learn service. Faster to learn, faster to realize the benefits. Look for training that takes no more than 30 minutes to get the basics down.. Dictionary. Built-in searchable dictionary avoids having to dig out and thumb through a print dictionary. Question submission. Ability to ask a coding/billing/reimbursement question directly of the online service’s content experts. Discussion forum. Benefit from knowledge, experience of other online service users by posting questions to them via listserve in a secure environment. © 2008 DecisionHealth®. Page 14.

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