Be an Effective Coding Compliance Professional: Do You Have What It Takes?

By Ida Landry, MBA, CPC

Knowing coding and billing rules, and following them with integrity, is key to success.

Compliance is an important part of medical coding. Novice coders are instructed early on that “correct coding is the No. 1 objective,” and “if it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding and billing regulations and have a solid code of ethics.

Know How Compliance Fits into Today’s Coding and Billing

Payment is generated or denied by the guidelines, rules, and federal laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the Tax Relief and Health Care Act of 2006 and the Affordable Care Act of 2010 have mandated more oversight regarding documentation and coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808.

A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to meet the growing need for proper coding and documentation.

Key Compliance Principles

To understand fully coding compliance and be an effective medical coding compliance professional, you must have a commitment to the core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.

These core elements can be realized through successful instruction, education, and guidance of compliant coding and documentation requirements.

Compliance Means Trust, Not Opinion

As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on appropriateness of coding or documentation. If established guidelines, specifications, and/or legislation cannot provide validation, than any guidance given is considered opinion.

Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding community where trust is destroyed.

Trust also is abused when a compliance professional tells a coder one thing and the health care provider something different. This behavior can stem from provider pressure or a provider’s inability to comply with rules and guidelines. To prevent inconsistent information from being disseminated, present the same guidelines, rules, and regulations to all parties involved. Using information consistently also shows ethics and integrity. To maintain consistency throughout an organization, consider following a code of ethics.

Code of Ethics

AAPC has a code of ethics which addresses coding professionalism and compliance integrity. The eight components of AAPC’s Code of Ethics are:

• Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
• Respect the privacy of others and honor confidentiality.
• Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.
• Advance the profession through continued professional development and education by acquiring and maintaining professional competence.
• Know and respect existing federal, state, and local laws, regulations, certifications, and licensing requirements applicable to professional work.
• Use only legal and ethical principles that reflect the profession’s core values, and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
• Accurately represent the credential(s) earned and the status of AAPC membership.
• Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.

Other places to look for a code of ethics are your compliance or coding departments. Human Resource departments also may assist you if your company has a written code of ethics.

Use Compliance Tools at Your Fingertips

You can easily find useful tools to help you attain your goals. Here is a list of some typical resources you use:

• Office of Inspector General (OIG) website – On the “Compliance Guidelines” page, there are links to “Compliance 101 and Provider Education” and “Compliance Resource Material,” as well as other useful tools.
• Coding books -  CPT® codebook, CPT® Assistant, ICD-9-CM, HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor, DRG Expert, and the AAPC website
• Government coding/billing resources – Centers for Medicare & Medicaid Services (CMS) manuals; National Coverage Determinations; Medlearn Matters; the Federal Register; 1995 and 1997 Documentation Guidelines for Evaluation and Management Services; Medicare administrative contractors, Local Coverage Determinations, etc.
• Freedom of Information Act – Used to request federal agency records not publicly available.
• Federal acts -  Health Insurance Portability and Accountability Act (HIPAA); Health Information Technology for Economic and Clinical Health (HITECH) Act; the Affordable Care Act; Tax Relief and Health Care Act of 2006; False Claims Act; Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Stark law; anti-kickback statute, etc.
• Commercial payer resources – Look to company manuals, websites, webinars, and newsletters for guidance.
• Company compliance manuals – Your employer should be anxious to share its compliance manuals and plans with coding and billing staff.

Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines, and trust and validation at the core of its foundation. If you think you have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.

Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care industry since 1995. She acquired CPC® certification in 2004. Ms. Landry holds a Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge of coding.

March 1st, 2013

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Choose with Clarity Hearing Loss Supply Codes

With so many devices to choose from,
knowing what’s out there is key to proper reimbursement.

By Marita Cable-Camilleis, CPC

You would think that someone who has a vested interest in audiology would be an authority on the subject. While attending a four-day National Hearing Loss Association of America (HLAA) Convention in Providence, R.I., June 21-24, 2012, however, I quickly realized that there is no such thing as too much information, and that I had a lot more to learn. I’d like to share with you some valuable tips for reporting hearing-assistance technology supplies that I picked up at the convention so that you, too, may code hearing loss equipment with clarity.

Many Aid Choices, Many Code Choices

Most familiar hearing aid HCPCS Level II codes are classified to V5030–V5267, but many prosthetic implant/hearing assist supply codes also fall into categories L8613–L8629 and L8690–L8693.

For example, new sound processor devices for cochlear implants and cochlear bone-anchored hearing aid (BAHA) implants are reported with L8614 Cochlear device, includes all internal and external components and L8690 Auditory osseointegrated device, includes all internal and external components, respectively. Replacement implants are reported with L8619 Cochlear implant, external speech processor and controller, integrated system, replacement and L8691 Auditory osseointegrated device, external sound processor, replacement.

Bonus tip: Report surgical implantation of cochlear implants with CPT® 69930 Cochlear device implantation, with or without mastoidectomy. For BAHA, 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy or 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy. When implants are placed in both ears, you may append modifier 50 Bilateral procedure. A child under the age of five would wear a headband for BAHA (or Ponto Pro) without surgery.

In other examples for different body locations, HCPCS Level II code V5095 Semi-implantable middle ear hearing prosthesis is for Vibrant Soundbridge® (VSB), a semi-implantable electromagnetic hearing aid. Another middle ear implant, called Envoy Esteem®, is fully implantable with no external components. This implant is also coded like the VSB semi-implant with CPT® 69799 Unlisted procedure, middle ear. For an in-the-mouth (ITM) device called SoundBite, used for bone conductive loss, report L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code.

According to Consumer Reports (“How To Buy a Hearing Aid,” July 2009), you cannot truly “compare” hearing aids because no two people have the same kind of hearing loss (type, severity, and configuration). With so many hearing aids—classified as monaural, binaural, and bilateral—it is easier to keep track of them using a chart, like the one shown in Table A. If a patient is diagnosed as having unilateral hearing loss and one deaf ear, a choice of bilateral contra-lateral routing of signals (BICROS) may be appropriate. Contra-lateral routing of signals (CROS) is used when a patient has one ear with normal hearing and one deaf ear.

One side of chart has the body-location variable and the other side lists hearing loss diagnosis variables mixed with manufacturers’ variables. Some hearing aids may be adjusted for high and/or low frequency hearing losses.

V5298 Describes Aids NOC

Several increasingly popular hearing aids are not yet specifically described by HCPCS Level II codes, such as receiver-in-the-canal or receiver-in-the-ear (ITE) devices. A small version of ITE is called half shell. Slim-tubing behind the ear (BTE) devices without ear molds are called open fit or over the ear; they are also called mini-BTE aids. These new hearing aids have microphones located in the ear, rather than on the hearing aid itself, and create a more natural sound and less wind noise. The newest, smallest completely in-the-canal (CIC) devices are called mini-CICs or invisible in the canals. If these new hearing aids are not classified, they could be coded as V5298 Hearing aid, not otherwise classified.

Alternate Hearing Assistance Technologies

Not all assistive listening devices are specifically coded because of multi-functionality. Captioned telephones such as CapTel® and CaptionCall® may be included in the HCPCS Level II code V5274 Assistive listening device, not otherwise specified, or simply reported with V5268 Assistive listening device, telephone amplifier, any type. These codes may also include hearing aid compatible smartphones. A modern digital hearing aid may have the ability to be controlled remotely by the patient’s cell phone.

Some assisted listening devices have not yet been coded because they are geared more toward groups, rather than individuals. One example is the increasingly popular “looping” system that is more common in Great Britain and Scandinavia. In this setting, an electromagnetic wire is looped around a room (or a ticket booth) to the speaker microphone, so anyone nearby can turn on the telecoil (t-coil) switch of his or her custom-made hearing aid (or cochlear implant) to hear the speaker more clearly. Approximately 69 percent of all hearing aids have a t-coil, which can be turned on for hearing-aid compatible phones with optional neck loops plugged in. T-coils (including related batteries, feedback-suppression capability, and directional microphones) are not currently specified in HCPCS Level II codes for hearing aids.

Even a non-deaf person can hear better with a headphone and inductive loop receiver, which picks up signals from a loop system while cutting off background noise. There are also personal loops just for television, which may be reported with V5270 Assistive listening device, television amplifier, any type.

New Receivers, Transmitters, and Microphones

For 2013, the descriptor for V5267 Hearing aid or assistive listening device/supplies/accessories, not otherwise specified was revised and new codes V5281–V5290 were added to accommodate personal FM/DM auditory devices, which are most often used with hearing aids to improve the signal-to-noise ratio. This allows the listener to better hear in the presence of background noise.

FM/DM auditory devices direct sound from a transmitting device (FM/DM transmitter) via a frequency or digitally modulated signal to a receiving device (FM/DM receiver), which may be coupled to a hearing device. A complete FM/DM system typically consists of a transmitter and a receiving device. If the receiver is built into a new hearing aid, you may report V5288 Assistive listening device, personal FM/DM transmitter assistive listening device for the transmitter only.

Another system creates a “public address-type” system with a wireless microphone, transmitting sound to receivers attached to loudspeakers and/or to those attached to hearing aids. For example, Inspiro® is an FM transmitter for teachers to wear in the classroom, and the DynaMic is a cordless microphone designed to be used with it. To combine all three components (receiver(s), transmitter, and microphone), use V5281 Assistive listening device, personal FM/DM system, monaural, (1 receiver, transmitter, microphone), any type for one receiver or V5282 Assistive listening device, personal FM/DM system, binaural, (2 receivers, transmitter, microphone), any type for two receivers (one for each ear).

Personal amplifiers (V5274), such as Pocketalkers®, are useful when FM systems, infrared systems, and hearing loop (or induction loop) systems are not available.

February 1st, 2013

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2013 Picks for HCPCS Level II

Effective Jan. 1, 2013, there are 150 changes, plus lots of quality performance measurement G code updates.

By G.J. Verhovshek, MA, CPC

Since April 1, 2012, the HCPCS Level II code set has undergone approximately 150 individual changes, not counting those G codes used for reporting to the Physician Quality Reporting System (PQRS) or Medicare demonstration projects (more on those below).

New Modifiers

Among the changes are seven new modifiers for Medicare reporting, which must be appended to HCPCS Level II codes G8978-G9176 (new for 2013) to describe a functional limitation (e.g., G8981-G8983 Changing and maintaining body position functional limitation …). The modifiers describe the extent of the functional limitation.

CH     0 percent impaired, limited or restricted

CI       At least 1 percent but less than 20 percent impaired, limited or restricted

CJ      At least 20 percent but less than 40 percent impaired, limited or restricted

CK     At least 40 percent but less than 60 percent impaired, limited or restricted

CL      At least 60 percent but less than 80 percent impaired, limited or restricted

CM     At least 80 percent but less than 100 percent impaired, limited or restricted

CN     100 percent impaired, limited or restricted

The G codes with modifiers must be reported at regular intervals for Medicare patients who receive outpatient therapy services, including:

• At the outset of therapy episode
• On or before every 10 treatment days throughout the course of therapy
• At the time of discharge from therapy
• At the time the beneficiary’s condition, changes significant enough to clinically warrant a re-evaluation such that a HCPCS/CPT® code for a re-evaluation or a repeat evaluation is billed

Also new are two modifiers that may be used to “break” National Correct Coding Initiative (NCCI) edits, when appropriate. Modifiers LM Left main coronary artery and RI Ramus intermedius coronary artery alert the payer that two procedures occurred at separate sites and may be reimbursed separately, similar to modifiers LT Left side and RT Right side.

Modifiers V8 and V9, previously used with dialysis revenue code lines for all end stage renal disease (ESRD) claims and all ESRD hemodialysis claims, were deactivated April 1, 2012.

New Supply Codes

As always, there has been plenty of action when it comes to drug supply codes as temporary codes transition to permanent status and new drugs are added. See Table 1 for details.

And as shown in Table 2, there has been a lot of movement in codes used to describe skin substitutes.

Matching HCPCS and CPT^® Changes

The Centers for Medicare & Medicaid Services (CMS) designated several new HCPCS Level II codes to take the place of CPT® codes for Medicare reporting.

For example, since 2003, CMS has assigned coronary stent placement procedures to separate ambulatory payment classifications based on the use of nondrug-eluting or drug-eluting stents. To enact this policy, CMS created G0290 and G0291, which corresponded to CPT® codes 92980 and 92981. For 2013, CPT® deleted 92980 and 92981, replacing them with new, more granular codes describing coronary therapeutic services and procedures.

To maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, CMS designated new HCPCS Level II C codes to parallel the new CPT® codes:

HCPCS = CPT^®

C9600 = 92920

C9601 = 92921

C9602 = 92924

C9603 = 92925

C9604 = 92937

C9605 = 92938

C9606 = 92941

C9607 = 92943

C9608 = 92944

Consult Table 3 on the next page for a list of other new HCPCS Level II codes, some of which were created to take the place of CPT® codes for Medicare reporting.

Another interesting code is Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose, which is newly established to report Tc-99m from non-highly enriched uranium (HEU) sources. TC-99m is the most widely used radioisotope for diagnosing diseased organs. For 2013, CMS will make an additional payment of $10 to cover the marginal costs associated with non-HEU Tc-99m production.

In some cases, newly-created CPT® codes have taken the place of now-deleted HCPCS Level II codes. For example, Category III CPT® code 0308T Insertion of ocular telescope prosthesis including removal of crystalline lens replaced C9732 for ocular telescope prosthesis with removal of crystalline lens, while many pathology procedures in the range S3711-S3860 have been deleted and replaced with new CPT® codes describing molecular pathology and multianalyte assays with algorithmic analysis (e.g., 81200-81408, 81500-81512, 81599, and 86152-86153).

Finally, V5267 has been revised to specify Hearing aid or assistive listening device/supplies/accessories, not otherwise specified, and 10 new codes have been added to describe personal FM/DM auditory devices, which are used with hearing aids to improve the signal-to-noise ratio, allowing the listener to hear better in the presence of background noise.

Table 1

*Medicare does not accept S codes.

Table 2

Table 3

Physician Quality Reporting and Medicare Demonstration Projects

G codes in the range G8000–G8999 are designated PQRS codes. Since April 1, 2012 there have been 114 code additions, 48 code deletions, and 122 code revisions to the G codes used to report quality performance measurements.

Eligible professionals (EPs) who successfully report on quality measures in the PQRS are eligible for a 0.5 percent Medicare payment incentive for years 2012-2014. In 2015, EPs and groups that do not report quality data successfully will face a 1.5 percent payment reduction in Medicare payments, and a 2 percent reduction for 2016. For additional information about PQRS, visit the CMS website.

G codes in the range G9000–G9999 are applied for Medicare Demonstration Project reporting. Since April 1, 2012, there have been 21 new codes and two code deletions in this section. For more information on Medicare Demonstration Projects, visit the CMS website.

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Know Your Payer to Make the Most of Modifier 24

Successful coding often means knowing what a payer wants.

The CPT® codebook instructs you to append modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period for an unrelated evaluation and management (E/M) service during the global period of a previous procedure. CPT® and the Centers for Medicare & Medicaid Services (CMS) agree the global surgical package includes routine, related postoperative care. But CMS and CPT® differ on what they include in the global surgical package.

To cut through the confusion, determine if your payer follows CMS or American Medical Association (AMA) guidelines (get the reply in writing, if possible). Then, apply the following rules.

Under CMS policy, modifier 24 applies for a:

• Visit for a new problem unrelated to surgery (must be supported by a different ICD-9-CM code)
• Visit for treatment of the underlying condition (not wound care, pain management, or a repeat procedure) that is not part of normal recovery from surgery.

Under AMA guidelines, modifier 24 applies for a:

• Visit for a new problem unrelated to surgery — supported by a different ICD-9-CM code;
• Visit for treatment of the underlying condition; and
• Visit for treatment of complications, exacerbations, or recurrence.

Here’s the Difference

CMS bundles into the global surgical package any complications arising from the original surgery, unless the complication requires a return to the operating room (OR). The Medicare Claims Processing Manual (chapter 12, section 30.6.6.A) instructs carriers, “Do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the surgeon is treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.” For Medicare payers, if the physician treats a patient for a post-operative infection during the global period, and the treatment does not require a return to the OR, the physician could not report a separate E/M service to Medicare.

AMA has stated that post-operative infection during the global period would qualify as a “new” (i.e., unrelated) problem because the diagnosis for the follow-up visit would be different from that which prompted the original procedure. Private payers who explicitly follow AMA guidelines may allow you to report a separate E/M service with modifier 24 if the physician tends to postoperative complications in the office.

September 26th, 2012

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No Hard, Fast Rule Setting Up Your Fee Schedule

By Terry Leone, CPC, CIRCC, CPC-P

Physician fee schedules are the “usual and customary” fees a physician or group charges for services. Depending on the services provided, you may have multiple fee schedules.

For example, if the group owns the equipment and interprets diagnostic studies, it may charge global fees for the entire service. If the group does not own the equipment, but does interpret the studies (as radiologists working in hospitals do), it may bill for the professional component of the service by reporting the appropriate CPT® code with modifier 26 Professional services appended. Or, if the group owns the equipment but does not interpret the studies, it may bill for the technical portion of the service by reporting the appropriate CPT® code with modifier TC Technical component appended. Or, the group may bill surgical fees based on the facility in which they provide the services.

Hospitals refer to fee schedules as the “charge master.” Charge masters are as complex as the various reimbursement methodologies they embrace. Inpatient care is reimbursed via Diagnostic Related Groups (DRGs). Some departments—such as the Emergency Department—are reimbursed by negotiated rates from various payers, while their ambulatory outpatients are generally paid by a fee schedule, similar to that of physicians. Due to hospital charge master complexities, out discussion here will stick to the physician fee schedule.

There is no hard, fast rule on setting your fee schedules; however, there are two methods the majority of physician offices and billing companies generally use.

The first method typically uses three separate fee schedules:

1. A workers’ compensation/no fault (WC/no fault), which is usually your highest reimbursement. Using just WC/no fault reimbursement rate for the fee schedule would inflate accounts receivable dramatically for all of the patients with general health insurance.

2. A Medicaid fee schedule, which is often the lowest reimbursement rate. If you use a WC/no fault rate based on local reimbursement rate, there would be no inflation of the fee schedule over the reimbursement rate. Setting these two fee schedules at the exact reimbursement rates will help to prevent over-inflated accounts receivable.

3. A third rate for all remaining payers, including all other insurances and any self-pay patients. This rate is the same for all patients and all insurances, with the fee schedule being higher than the highest payer of this group of carriers. This third group of charges will inflate your accounts receivable.

Using this methodology allows you to change a wrong insurance company without changing the charge rate for the service. Your physicians and billing company clients need to understand there will be payer adjustments (write offs) for each patient, which is the part of the charge that is higher than the carrier-allowed amount.

For example, if you charge $100 for a service of a participating carrier, but the payer allows $80, you have to write-off the $20 as a contractual disallowance because the charge was higher than the carrier allowed.

The second methodology is to load into your billing system the exact reimbursement rate of every payer you charge. The individual payers’ reimbursement rates become your fee schedule.

Although this method probably sounds better than the first, there are difficulties with this method.

For example, I have one HMO in my area with 42 separate lines of business, each having its own fee schedule. I would load all 42 fee schedules, plus the fee schedules of every carrier I send claims to. But the patient’s insurance information downloaded from a hospital does not tell you which line of business this patient belongs to. Even if your staff is registering the patient, the insurance card may not indicate which line of business. This means your staff doesn’t know which fee schedule to use, which can force a change to the charge amount and insurance company. Some managers don’t like staff-changing fees after the patient has been initially charged. Managing all of the different fee schedules is a large task—especially because payers often make throughout the year.

After you decide which charge methodology you are going to use, you need to set your “usual and customary” fees.

In the first methodology, it is best to use a percentage of the Medicare fee schedule to set up your general insurance fee schedule, use the workers’ compensation/no fault fee schedule for your specific area, and use the state Medicaid fee schedule for your Medicaid fees.

To set up your general insurance fee schedule, know your local payer reimbursement rates. For example, one of my local Health Maintenance Organizations (HMOs) uses 125 percent of our Medicare fee schedule for their reimbursement rate, while another local payer reimburses at 115 percent. After finding out the highest reimbursement rate for local payers, most offices generally set general insurance fees 15 to 25 percent higher to assure they are charging over the highest reimbursement rate. This assures physicians that no money is being left on the table.

No matter how you set it, your fee schedule should be logical, reasonable for your region, created using a set formula, and defensible during an audit.

July 23rd, 2012

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