Physician office and hospital coding are sometimes two different worlds.
By Dorothy Steed, CPC-H, CHCC, CPC-I, CPUM, CPUR, CPHM, CCS-P, CEMC, CFPC, ACS-OP, RCC, RMC, PCS, FCS, CPAR
When physician coders/billers transition to a hospital environment, they frequently encounter difficulty without a clear understanding as to why. Hospital managers have positions to fill, but the required skill levels of hospital coders are often different from that expected of physician coders.
Know What Skills Hospital Coding Requires
To prepare for a physician coder/biller hospital position, you need to know the following 10 differences in the two work environments:
1. Physician coders are proficient in coding and billing specific services their physician group provides whereas hospital coders need reasonable proficiency in multiple specialty areas.
2. Hospital coders have to identify the principal diagnosis and properly sequence codes. In the hospital arena, the principal diagnosis is determined as the “reason, after study, that occasioned the admission.” When a patient has multiple co-existing conditions, the coder needs to identify the condition requiring inpatient admission.
3. Hospital coders must be able to select co-morbidities and major co-morbidities correctly. Medicare reimburses most hospitals based upon Medicare Severity Diagnosis-Related Groups (MS-DRG) methodology. Detailed physician documentation is critical in capturing these co-morbidities, which affect the hospital’s reimbursement. Very general statements regarding conditions without further details often do not equate to a complication/co-morbidity (CC) for reimbursement purposes. Other payers may reimburse on a slightly different methodology, depending upon the current contract, but the expectations of the coder are the same regardless of the payer. When diagnosis statements are lacking detail, the coder should query the physician for clarification.
4. The physician billing form contains only four fields for diagnosis codes; whereas a hospital coder commonly selects 10, 15, or 20 diagnosis codes. Whether all will fit onto the UB-04 is not relevant. Due to the collection of disease data reported by hospitals, it is necessary for hospitals to capture all codes for applicable conditions that require physician management or affect the physician’s management of the patient.
5. Inpatient coders must report the correct Present on Admission (POA) indicator for conditions managed during the inpatient admission. The purpose of the POA indicator is to report whether a condition was present at the time of the inpatient admission order. Conditions such as catheter-related infections that occur during the admission may not generate additional revenue for the hospital even though they use additional resources to treat the hospital-acquired condition.
6. CPT® codes are not reported on hospital inpatient claims. Procedures are reported using codes from ICD-9-CM’s Volume 3. These codes are not a direct crosswalk to CPT®; often, when a CPT® code describes multiple steps, more than one code from Volume 3 are required to describe the procedure adequately. For example, 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) describes both cataract extraction and intraocular lens implant. Volume 3 will require that two codes be reported; one for the cataract extraction (13.3 Extracapsular extraction of lens by simple aspiration (and irrigation) technique; Irrigation of traumatic cataract, 13.41 Phacoemulsification and aspiration of cataract, or 13.43 Mechanical phacofragmentation and other aspiration of cataract, depending upon technique), and a second code for the lens implant (13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage).
7. In general, hospital coders are required to meet both productivity and accuracy standards. For example, they may be required to process inpatient records in an average of 18 to 20 minutes each; ambulatory surgery records, eight-10 cases per hour; emergency department (ED) records, 20 per hour; diagnostic referrals such as lab and radiology, 30 per hour. Standards for accuracy are likely to be in the 92 to 95-percent range (this is up to the coding manager, but most require accuracy well into the 90 percent range).
8. Charges are entered onto a hospital claim through a charge master, which is a large file containing all services, supplies, and drugs the hospital uses to treat the patient. Departments providing services to the patient are responsible for their services’ charges, and these appear on the UB-04 under the revenue codes applicable to the area in which the service was provided.
Hospital billers need to view the charges, determine if errors are present, and have any errors corrected prior to releasing the claim to the payer. Common errors include incorrect units reporting and missed charges.
Operation room (OR) time and anesthesia time are typically reported in 15 minute increments by the hospital. For example, reporting of 4 units = patient in OR for one hour. The number of units for OR and anesthesia should either be the same, or there should be no more than one anesthesia unit more than OR units (to allow for sedation to begin a few minutes prior to the start of the surgical procedure). More than one unit should be considered an error requiring the biller to correct the charges.
9. Although similarities exist between physician coding and hospital outpatient coding, hospital staff needs to understand and correctly use the facility modifiers:
- 27 Multiple outpatient hospital E/M encounters on the same day
- 73 Discontinued outpatient procedure prior to anesthesia administration
- 74 Discontinued outpatient procedure after anesthesia administration
Medicare outpatient reimbursement for most hospitals is based on Ambulatory Payment Classifications (APC) rather than the physician fee schedule or Resource-Based Relative Value Scale (RBRVS), and managed care payers also may reimburse on a form of APCs.
10. Understand that hospital coding managers may not have the option to staff based on just outpatient coders. Although it is relatively common for the most experienced coders to handle the inpatient claims, when short staffed or during vacation time, all staff is expected to assist in completing the work. Likely, there will be a time when you need to code inpatient claims.
Weigh Your Skills Against Hospital Expectations
If your goal is to transition into the hospital environment, review your skills against these requirements and determine your readiness for change. Many coding/billing managers in large urban markets hire only those applicants who demonstrate skills in at least some of the 10 listed areas. Be realistic as to what your current skill level is and how it can be utilized by a hospital. When you think you are ready to take that leap, consider the fact that there are generally more employment opportunities in rural locations due to the shortage of qualified coders in remote areas. Also, consider that managers will usually require you to take a pre-employment test applicable to their needs, regardless of geographical location. If you score well, you have a good chance of being the selected candidate.