Be an Attractive Candidate for a Hospital Coding Position

By Dorothy Steed, CPA, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC

Be ready if a hospital employment opportunity arises in a facility near you.

In our changing health care environment, there may come a time when you need to look beyond your physician practice and branch out in another direction. For example, based on the latest trend, your practice could be bought out by a hospital. If that happens, you’ll need to be able to prove you’re a viable candidate to hospital coding managers. However, many physician trained coders find hospital requirements very different and the transition difficult. You’ll have a much easier time if you are prepared, and a good place to start is by reviewing the hospital revenue cycle, which has significant differences from that of the physician office.

Review the Hospital Revenue Cycle

There will be differences between facilities in regards to the revenue cycle, depending on the size of the facility and whether they are for profit or not for profit. Typically, however, the chief financial officer looks at the hospital’s revenue producing departments and establishes certain monetary monthly goals for that department using service utilization, patient flow, and other data. The chief revenue officer typically determines a positive or negative outcome for each revenue-producing department using various reporting programs. If a department has an income deficit, this prompts a close look at why the deficit has occurred. There can be many reasons, but if the department does not produce expected revenue, particularly if the deficit occurs frequently, the department’s management must give an accounting of why and how he or she plans to improve the deficit.

The revenue cycle starts in Patient Access and moves to Benefits Verification. These are critical steps in obtaining correct demographic information, determining whether services will be covered, and calculating patient responsibility amounts. Errors in these steps usually have a ripple effect. If the patient is admitted as an inpatient or into observation, typically, case management is responsible for monitoring the stay and determining if the stay meets inpatient criteria and (if a Medicare patient) whether there is adequate inpatient days to cover the stay. If an observation patient is converted to inpatient status by the physician, this group will advise Benefits Verification that new authorization for inpatient services is necessary.

Understand Your Role in the Hospital Revenue Cycle

The next step in making yourself marketable in the hospital environment is to determine your role in the revenue cycle. The health information management (HIM) manager ensures that attending physicians complete the patient records in a timely manner and records are ready for the coders. Here is where a physician trained coder must be ready to shift gears. Regardless of what you are initially hired to do, you must realize that at some point, you will need to code inpatient records. This is where the money is for hospitals, so inpatient records take priority over outpatient encounters, even if outpatient coding is your normal assignment. To prepare for this new assignment and to stand out as a candidate for inpatient coding:

• Be proactive in showing an interest in learning inpatient coding.
• Take time to look at inpatient records coded by inpatient coders.
• Realize that inpatient and outpatient coding guidelines are somewhat different.
• Become very knowledgeable about coding conventions and guidelines in the front of your ICD-9-CM coding book. This is how hospital coders are expected to code the records. Encoders that are structured for hospital use will also assign codes based on these conventions. National Correct Coding Initiative (NCCI) edits are included in the encoder and generally flag the coder to look closely at two reported codes. Coding Clinic and CPT® Assistant are normally sources available within the encoder.
• Understand that CPT® is not reported on inpatient records. Procedures are coded using ICD-9-CM Volume 3, and there is not a direct crosswalk between CPT® and Volume 3. To assign codes from Volume 3, ask yourself: Is the procedure surgical in nature? Does it carry a surgical or anesthetic risk? Does it require specialized training to perform the service? If your answer is yes to any of these questions, a code is assigned. Using this information, take a look at some familiar CPT® codes and determine how the service might be reported using Volume 3. A reasonable rule of thumb is that if CPT® describes multiple steps, often more than one code from Volume 3 must be used to report the same service.
• Know that hospital coders report all conditions that the physician manages or affect the management of the patient. Inpatient records may require 10, 15, or even 20 diagnosis codes.
• Realize that sometimes there are different reporting protocols in CPT®, depending on whether you report for physician or facility services—infusions are a good example. Review the reporting hierarchy for facility infusions in your CPT® codebook to see how they differ from physician reporting.
• Be aware that facility evaluation and management (E/M) reporting is captured only in the emergency department and in facility clinics. History, exam, and medical decision making (MDM) are not factors in facility E/M; levels are determined based on use of resources and assigned based on a point system. Each facility typically determines their own point system; however, the service must be documented in the medical record, meet medical necessity, and be reasonable in the point assignments. Look at outpatient modifiers 73, 74, and 27, used by facilities, and know when these modifiers are applicable.

Understand How Charge Description Masters Are Used

In assessing your qualifications, hospitals may also look at your knowledge of charge description masters (CDM). Facilities establish services in the CDM that are charged to the patient’s financial record and are entered usually by the department performing the service. Hospital coders typically code for all diagnosis coding, surgical procedures, and infusions. They may code for other services, depending on if the service  is already embedded in the CDM. Your coding manager will advise of these services, but typically drugs, supplies, laboratory, radiology, and anesthesia are not coded by the hospital coder. Some clinics, such as pain management, may charge through the CDM or be coded by a coder, depending on how the hospital handles these functions.

Another important thing to remember: The physician is not available to clarify documentation; and you will not be able to use charge tickets, encounter forms, or super bills for coding assistance.

Meet Productivity and Accuracy Standards

Accuracy and meeting quota also may factor into whether you are a good candidate for hospital coding. When the coding department experiences a backlog of records for coding, the manager must take action to bring the records current. This is a good example of when an outpatient coder may be asked to code inpatient records, and why hospital coders are held to productivity and accuracy standards. You will be held to these same productivity standards.

Although there may be slight differences, depending on expectations of the coding manager, typical coding time is approximately:

• Inpatient records: 18-20 minutes. This includes all diagnosis codes, Volume 3 codes, assigning the present on admission (POA) indicator, and abstraction of the record.
• Ambulatory surgery records: 7-10 per hour
• Emergency department records: 20 per hour
• Referral encounters (example: patients coming for lab, X-ray): 30 per hour

These numbers translate to three minutes for emergency department records and two minutes for referral encounters.

If you are given a pre-employment coding test, the coding manager will not only look at accuracy, but whether there is reasonable expectation you can reach these production standards by the end of the normal 90-day probationary period. When records are not coded quickly, the entire revenue cycle is affected, in billing, insurance follow up, and other collection efforts. Accounts receivable days are closely monitored by hospitals, and are a primary measure used to determine their financial health. Slowdowns and backlogs of the revenue cycle directly affect the revenue stream. Time spent collaborating with other coders must be kept to a minimum if you intend to meet your productivity requirements.

Seek Training

When I speak with physician coders about transitioning to hospitals I am asked, “Where can I obtain this type of training?” Here are some ideas that may be helpful:

• Invite someone from your hospital to present at a chapter meeting. If a coding professional is not available, use someone from the billing or revenue cycle department.
• If there is a community college in your area that has a HIM program, invite someone from that program to speak at a chapter meeting.
• Use Quality Improvement Organizations (QIO) as a resource. They review disputes between Medicare and hospitals about correct Medicare Severity Diagnosis Related Groups (MS-DRG) assignments and necessity of inpatient admissions. They may send coding disputes to a contracted coder for supporting opinions, but they have already done an in-house review prior to that step.
• If you have a hospital-based member in your chapter, ask that person to help you get training underway.

Interested in implementing physician-to-hospital coder training in your chapter? Based on the three-day workshops I present, training might begin with an overview of hospital coding and billing on day one. On days two and three, activities might include hands-on coding of sample hospital records—reviewing accuracy and looking at how quickly coders can determine codes and POA indicators. Consider holding sessions on three consecutive days or on three separate Saturdays. Something else to consider: This is a good opportunity to collaborate with another chapter to arrange a group session.

Sell Yourself Using Knowledge and Adaptability

Through my experience when speaking with hospital managers about an ideal candidate, they often mention the need for coders to be able to code multiple types of records, meet productivity standards, and be familiar with hospital encoders. You may not have an opportunity to use encoders unless you are actually in a hospital, but you can focus on building efficiency in multiple encounters, being open minded, and knowing that you will need to meet productivity standards.

Take advantage of opportunities to learn the facility side of coding. Realize hospitals provide many more services than physician offices. If general surgery is your specialty, it’s likely you’ll need to code for many other types of services. Hospitals in smaller towns may be more lenient when using a physician coder, but you should still sell yourself in an interview by showing you are ready for the challenge. If you welcome the opportunity and are proactive in learning about the facility world, doors that are not easily opened will open for you.

March 1st, 2013

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New POS Rules Get Sticky for 21 and 22 E/M Services

Although it may mean denials, stay compliant when reporting inpatient transports to outpatient settings.

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC

Be sure your place-of-service (POS) code matches the setting where the patient received the service (for face-to-face services), or the setting where the technical portion of the service was delivered (for non-face-to-face services, such as diagnostic test result interpretation). Although this may sound easy in theory, new Medicare guidance can make POS assignment tricky.

In recent transmittal 2563, change request (CR) 7631, the Centers for Medicare & Medicaid Services (CMS) clarified guidance for assigning POS codes on Medicare claims. That guidance has posed new questions that should be addressed regarding these claims.

One of those questions came to light through Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P, when she used the following coding scenario to point out discrepancies when reporting in compliance to the new POS reporting rules:

“An inpatient is transported to an outpatient provider office for an evaluation and management (E/M) service and a procedure. The patient is still a registered inpatient and will return to the hospital at the conclusion of the visit. Should the outpatient provider report his or her E/M service using the outpatient E/M codes (99201-99215) or can they use the subsequent inpatient E/M codes? Applying the new POS code reporting rule, where an outpatient E/M service is reported with POS 21 or 22, the service will be denied.”

Here is the relevant language from transmittal 2563, effective Oct. 11, 2012:

“In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.”

And here is the specific provider instruction added to the Medicare Claims Processing Manual:

Special Considerations for Services Furnished to Registered Inpatients

“When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.”

According to this provision, I see the issue where a physician performing an E/M service in an office setting for a patient who is currently a registered inpatient at a facility (and transported to the office location) would be required to report POS 21 for any physician service or procedure performed.

The problem this instruction potentially creates is that while there is a facility payment rate for an outpatient E/M service, some carriers may not process a payment for an outpatient E/M service (e.g., 99201-99215) when billed with POS 21 consistent with this rule. Where payment is denied, the provider is forced to appeal and validate that reporting is accurate under the above rule, consistent with the following revised instructions to the Medicare administrative carrier (MAC):

10.6 – Carrier Instructions for Place of Service (POS) Codes

(Rev.2563, Issued: Oct.11, 2012, Effective: April 1, 2013)

For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. For example, if the physician’s face-to-face encounter with a patient occurs in the office, the correct POS code on the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 24B on the claim Form CMS-1500) will match the address and ZIP entered in the service location (Item 32 on the 1500 Form) – the physical/geographical location of the physician. However, there are two exceptions to this general rule – these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code — regardless of where the face-to-face service occurs — is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 22) as discussed in section 10.5 of this chapter. So, if in the above example, the patient seen in the physician’s office is actually an inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS code reflects a different setting than the address and ZIP code of the practice location (the physician’s office).*

* Medicare Claims Processing Manual, Internet Only Manual (IOM), pub 100-4, chapter 26, section 10.6 (emphasis added).

Although it is time consuming to appeal such denials, I have to assume that Medicare administrative contractors will eventually fix their payment systems to comply with this instruction, which is not yet updated in the processing manual on the CMS IOM website.

The other option would be for the physician to go to the hospital to do the E/M and procedure work. Then, and only then, could the physician bill the inpatient code—because only in that case is an “inpatient” E/M service provided.

A word of caution: Nothing in the above instruction suggests or implies that it would be reasonable to interpret the change as instructing a provider to report an inpatient E/M code for an E/M service performed in an outpatient setting. It merely instructs the provider to use POS code 21 (or a more specific code, where the exact facility status is known) when the outpatient E/M service or other procedure is performed on a patient that is a current registered inpatient at a hospital. Note that the location of the service in block 32 would be the physician’s office and ZIP code.

I suspect carriers will reprogram their claims processing systems soon to deal with this payment problem, where it exists. Attempting to avoid the denial by reporting an inpatient E/M service that was not performed, especially where that code results in the physician obtaining additional reimbursement, is not recommended. Even if paid, the provider would have to disclose and refund the overpayment within 60 days, consistent with the reverse false claims provision of the False Claims Act and the draft implementing regulations.

February 1st, 2013

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Get Ready: The RACs are Coming!

By Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA 

December 1st, 2012

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EHR Warning: Under-documenting Is as Harmful as Over-documenting

By Erin Andersen CPC, CHC 

November 1st, 2012

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Salary Survey 2012: Trends Show Growth and Diversification

Five-year comparison indicates consistent progress in this health care sector.

By David Blackmer, BA, and Brad Ericson, MPC, CPC, COSC

Download the PDF of this article

Snapshots are instant slices of our lives. Compare them from year to year while placing them side by side and our lives become stories.

Every year, Coding Edge presents AAPC’s Salary Survey as an annual slice of data about our members’ welfare. This year, we decided to show you how the information trends through the years because it tells a very interesting story about our profession’s growth.

The 2012 AAPC Health Care Salary Survey, which was open to health care business professionals online this summer, confirms coders, billers, practice managers, auditors, and educators are in a dynamic environment. It is obvious the recession affected our industry, and for most members things are improving. But the unpredictable impact of market forces provides surprises.

A lot has happened since 2008, when our trend lines begin. A deep recession, beginning in December 2007, ended in 2009 with a slow recovery and rippling effect throughout the country. Changes to the mix of practice size and affiliation occurred. Major changes to the way federal and commercial payers could pay physicians evolved and were mandated. And, as AAPC grew from 60,000 members in 2008 to nearly 120,000 now, our professional roles, expertise, locations, and education diversified unimaginably.

A significant nod to the importance of our craft is that more than 25 percent of respondents said they have decision-making power in their work places, compared with less than 20 percent in previous years. This means AAPC members are gaining more credibility for knowledge and expertise.

How Much We Make

The 2012 average salary is $47,870, based on responses. This includes credentialed and non-credentialed members; but, when broken down by credential, the averages this year look like this:

• Certified Professional Coder (CPC®) – $47,796 (up nearly $900 from 2011)
• Certified Professional Coder – Hospital Outpatient (CPC-H®) – $56,466 (up nearly $1,800 from last year)
• Certified Professional Coder – Payer (CPC-P®) – $55,255 (up nearly $3,800 from last year)
• Certified Professional Medical Auditor (CPMA®) – $59,365 (up more than $3,200 over last year)
• Specialty credentials – $54,145
• All AAPC credentials, avg. – $48,033

Taking all of the credentialed respondents’ salaries and averaging them, we see that in the last two years salaries are slowly growing.

Salary by Workplace

Average salary by workplace has increased from last year by 9.7 percent or more for those in smaller groups or practices. Those working in facilities made more, but received less in raises comparatively, averaging between 4 and 5 percent. For example, as shown in the Salary by Workplace table, the average salary at a solo practice was $40,290 in 2010, $41,301 in 2011, and $45,312 in 2012 compared to the average salary in an outpatient hospital: $43,685 in 2010, $43,751 in 2011, and $45,399 in 2012.

Salary by Job Responsibility

As you can see in this next table, Salary by Job Responsibility, salaries are indeed affected by job responsibility, and educators are making the most money.

Credentials, Education, and Benefits

Credentials and education impact our salaries. How much education and what certifications we hold factor in to where we sit financially.

Credential Required

While slow, there is a definite trend toward employers requiring credentials. As you can see in the Credential Required table, 54 percent of employers require certification today, compared to 47 percent in 2008.

Salary by Experience

We know now that the average years of experience of credentialed members are significant. In our survey, CPCs® have 12; CPMAs® and CPC-Hs® have 14; and Certified Professional Coder—Instructors (CPC-Is®) have 19 average years of experience. As shown in the Salary by Experience table, salary reflects experience over the years, and salary increases follow suit.

It is discouraging to note that beginning coders’ salaries have not changed much in five years, while those with significant experience are seeing larger increases.

Education

Our education is less predictable from year to year. For example, salaries are larger depending on how much education a member has, but higher levels of education did not always see an increase in average salary in past years. Fortunately, as shown in the Education table, this year showed improvement for everyone, especially for those with a master’s degree or higher.

Those with an associate degree or some college make 9 percent more on average than those who have not attended college. Those who have a bachelor’s degree make 21 percent more on average than those with an associate degree or some college experience. Those who have a master’s degree or greater make 46 percent more on average than those who have a bachelor’s degree. Clearly education pays.

Education Breakdown

We are an educated group, according to the breakdown of respondents’ education level in 2012, as shown in the Education Breakdown table.

Unemployment

We’ve seen growth in members with bachelor’s and master’s degrees. We believe that much of this gain is based on an increasing number of providers becoming certified and members who are choosing this field as a second or third career. This led us to look at unemployment rates. As shown in the Unemployment table, the unemployment rate is up for CPCs® and those with AHIMA credentials, but still well below the national average of 8 percent. For apprentices (CPC-As®, CPC-H-As®, and CPC-P-As®) who are breaking into the field, employment has improved, but remains difficult, with rates close to 25 percent.

Workplace

We are seeing an upward trend towards facility employment, as shown in the Workplace table. This may be a reflection of many providers’ decision to sell their practices to facilities.

Benefits

What sort of benefits we receive fluctuates from year to year, as does the number of hours we work per week. More than half of respondents work an average of 31 to 40 hours a week. Around 40 percent work more than 40 hours per week. As shown in the Benefits table, employer-sponsored perks appear to be little changed over the past four years.

Where Do We Go from Here?

Interestingly, most of us are alright staying exactly where we are. The highest percentage of respondents (44 percent) indicate coding/billing was their long-term career goal. Auditing and practice management were the next top choices (about 16 percent each), with compliance and health information technology (HIT) trailing behind at 7 and 6 percent respectively.

Salary by Region

One of the most interesting year-to-year comparisons is of average salary by region. It is easy to see how the recession has moved through regions and when. Most heartening, though, is that for respondents in 2012 in all regions, salaries are up. Only 19 percent of us work in a rural area, while 37 percent work in a suburban location, and 44 percent work in an urban setting.

Salary by Region

Overall, since the advent of the recession of 2008, members have slowly grown their compensation and continue to do so.

David Blackmer, BA, is a marketing specialist at AAPC; Brad Ericson, MPC, CPC, COSC, is director of Publishing and Warehouse at AAPC.

September 20th, 2012

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