General Coding Compliance Test Review

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General Coding Compliance TestReview

• Presented by Joan Benham, CPC, CPCH
• Institutional Compliance Program

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Things to know

• General Coding Compliance
• Medicare/Medicaid Teaching Physician Supervision
  Documentation guidelines
• General Reimbursement Issues
• CPT, ICD9CM, HCPCS, Abbreviations
• Medical Terminology

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Medicare

• Federally funded program
• Not limited to people 65 years or older
• Has specific rules for billing professional and
  hospital services
• HCFA changed their name to Center for Medicare
  Medicaid Services (CMS)

Medicaid

• State funded and administered program
• Must qualify to be eligible for program
• May have different rules from Medicare for
  billing professional and hospital services

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Coding Compliance includes.

• Using the current CPT, ICD9CM, HCPCS books
• Abstracting medical records to verify the
  documentation supports the service
• Continuing education
• Avoiding Fraud and Abuse

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Class Exercise 1General Compliance
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Medicare Teaching Physician Guidelines

• Only apply to supervision of residents
• Teaching physician must see patient
• Do not apply to PAs and NPs
• Can only use the ROS and PFSH of the medical
  student
• Must provide a proper linking statement and
  note when the resident is involved
• GC modifier is needed when part of the service is
  rendered by the resident under the direction of
  the teaching physician

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Important Medicare Rules to remember for E M
Services.

• The teaching physician must confirm or revise the
  key portions that determine the level of
  service billed.
• When the teaching physician does not link their
  documentation to the resident note it is
  considered to be a stand alonenote.
• If the teaching physician is not present when the
  resident examines the patient, he/she must
  repeat the key portions of the exam.
• The teaching physician should always, sign,
  date, and time the note

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Medicare Teaching Physician Evaluation
Management Scenarios..

• Teaching Physician sees the patient
• Alone
• Before the resident
• Along with the resident
• After the resident

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Teaching Physician sees an established Medicare
patient along with the resident
I interviewed and examined the patient along with
Dr. Resident. I agree with the history of fluid
in both ears. Patient is to continue Amoxicillin
and return if pain in ears persist. Dr. Teaching
Physician, 1/4/02, 800 am
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Teaching Physician sees an established Medicare
patient after the resident
I personally interviewed and examined the patient
and discussed findings with Dr. Resident.
Patient complains of ear pain. Both ears have
fluid. I agree with the diagnosis of bilateral
otitis media. Continue to take Amoxicillin and
RTC in 2 weeks. Dr. Teaching Physician, 1/4/02,
800 AM
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Class Exercise 2Writing a Linking
StatementandNote
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Exercise 2 Answer 1I have personally seen
and examined Ms. Doe along with Dr. Resident . I
agree with the exam and the finding of the
nodule. Discussed treatment options with patient
and patient elected observation.Dr. Teaching
Physician, 1/15/02,1000 am
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Exercise 2- Answer 2I personally saw and
examined patient Ms. Doe and discussed findings
with the resident. On examination I found a
nontender nodule on her neck. Discussed treatment
options with patient, but she elected
observation.Dr. Teaching Physician 1/15/02
1030 am
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Medicare Rules for Surgeries...

• Global Package may apply
• Different global periods for minor and major
  procedures
• Teaching Physician may determine which
  post-operative visits are considered to be key
  and require his/her presence
• May not supervise more than two overlapping
  surgeries at one time

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Reimbursement issues.

• Medicare Part B does not reimburse for Residents
  in a GME program or for Medical Students.
• Medical students are not licensed physicians.
• For Medicare the incident to rules do not
• apply to a provider based clinic.
• Correct Coding Initiative edits
• Unbundling

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Medicaid rules to remember

• For outpatient services the Teaching Physician
  needs to be in the building where the service is
  being provided and immediately available to
  provide assistance.
• The global days for surgeries may be different
  than Medicare

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Class Exercise 3 Teaching PhysicianSupervision
Documentation Guidelines
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CPT

• Developed by the AMA
• Appendix A Modifiers
• Symbols
• Guidelines
• Diagnostic/Therapeutic Procedures
• Separate Procedure
• Each Each Additional

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Evaluation Management

• Three key components
• Levels of History Exam
• Levels of Medical Decision Making
• Consults vs. Referrals
• Critical Care
• Billing on time
• New vs. Established

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E M ModifiersModifier 25

• Use when a separately identifiable
  procedure/service is performed on the same day
  as an E M visit.
• Can only be appended to an E M service.
• Is not recognized by Medicaid.

Modifier 24

• Use when a unrelated E M service is provided by
  the same physician during a postoperative
  period.

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Other Modifiers

• 52- reduced services
• 22- unusual services

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ICD9CM

• Developed by the WHO to track signs, symptoms,
  and diseases
• Updated once a year
• Can be 3-5 digits
• For the professional side you do not code rule
  out or probable

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HCPCS National Level 2

• All codes begin with a letter
• Were developed to report services that are not in
  the CPT book
• Are updated as needed in the book or newsletters
• Modifiers are two alpha or alpha-numeric
  characters
• Screening procedure codes

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APCs

• Ambulatory Payment Classifications
• Are used to reimburse the facility outpatient
  services
• Only for Medicare

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Reimbursement Issues..

• Professional services are billed on a HCFA 1500
  insurance form
• Hospital services are billed on a UB92 form
• Advance Beneficiary Notice

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Class Exercise 4CPT, ICD9CM, HCPCSEvaluation
Management Services APCs
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Exercise 5 Medical Terminology
Abbreviations
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Suffix Examples -ectomy excision -tomy incision
-stomy create an opening -rrhage burst
forth -plasty plastic repair -scopy examine
with a scope -itis inflammation -oma tumor
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Medical Term Examples dermatoplasty surgical
repair of the skin nephritis inflammation of
the kidney cardiomyopathy disease of the muscle
of the heart gastrology study of the
stomach arthroscopy examination of the
joint lymphadenoma tumor of the lymph
gland leukocyte white blood cell tibia large
inner bone of the lower leg fibula the outer
smaller bone of the lower leg adenoma tumor of
the gland ateriosclerosis hardening of the
arteries neoplasm new growth mandible lower
jaw bone
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Abbreviation Examples CPT Current Procedural
Terminology ICD9CM International Classification
of Diseases 9th Revision Clinical
Modification HCPCS HCFA Common Procedural Coding
System IDDM Insulin Dependent Diabetes
Mellitus APC Ambulatory Payment
Classification WHO World Health
Organization EOMB Explanation of Medicare
Benefits AMA American Medical Association R S
Report Remittance Status Report RA Remittance
Advice UTI Urinary Tract Infection CCI Correc
t Coding Initiative