At Med-Certification, we monitor the industry trends and flag any problems. With the 25 years experience in training and certifying coders, we know the problems in order to provide appropriate solutions. Here’s the latest:

Emerging problems: Hospital coders are often now required to provide CPT coding which they have not been trained to do. Medical codes include the diagnosis codes (ICD) and physician- provider codes (CPT). Providers in private practice use the CPT codes to describe the service performed in their offices. They use the diagnosis codes to describe the disease, injury or symptom. Hospitals use the ICD codes as well, but until recently, had no application for CPT codes since they are institutional providers.

With the growing trend of physician private practices being acquired or controlled by various health care systems (hospital groups), the hospital entity now is providing the coding and billing of professional (CPT) services and in many cases is becoming centralized, taken out of the physician practice and brought to the responsibility of facility coders. However, the fact has become apparent that in most cases there is a lack of physician-oriented coding experience in the facility setting where the skilled coders in inpatient and/or outpatient services are typically found. Those coders are feeling the pinch, too. They face the challenges of learning to code the physician services. Coding errors on the CPT codes can certainly impact the practice’s bottom line as well as create potential compliance problems, especially in the tangled virtual environment of transmittals, “Change Requests” and official guidelines issued by the Centers for Medicare and Medicaid Services (CMS) for federal claims.

Some of the features of the CPT coding are markedly different than coding for inpatient care, and even though coding for CPT services is somewhat similar to outpatient services, the differences between the two are still numerous, especially considering all of the outpatient prospective payment system (OPPS) rules/regulations. A few simple steps may help the private practice physician to alleviate selected aspects of the transitional stress such as sharing charge  capture documents (e.g., superbills), transferring electronic code tables, and so forth. This data will be immensely beneficial to the facility’s coding staff. But what are the major points of CPT coding that physicians should be aware of before and during practice migration? There are four major audit areas that providers should know to ensure the CPT services are coded accurately and within compliance standards:

  1. ICD CODES: Aspects of ICD-9-CM diagnosis coding and the new ICD-10 codes
  2. CPT CODES: Evaluation and Management (E/M) services coding
  3. CPT CODES: Modifiers used with the codes
  4. HCPCS Level II codes and their respective units reporting for drugs and biologicals.

ICD-9 and 10 Code official reporting guidelines for private practice are the same as those for outpatient services, but certain areas of the guidelines tend to cause confusion for the hospital coders simultaneously performing inpatient, outpatient and the provider CPT coding duties. One area typically found on audit is the incorrect coding of “probable,” suspected,” “rule out” and “versus” diagnosis code differentials as confirmed diagnoses. This mistake is frequently made by inpatient coders also tapped to do periodic outpatient and/or the CPT services, since under inpatient ICD-9-CM coding rules, the inpatient coder can assign a “probable” or otherwise unconfirmed diagnosis with a code for a confirmed condition or illness.

Coding from diagnostic reports has also been an area of difficulty in scenarios where facility coders are tasked with coding these professional fee services. It is an area of perennial confusion between coders in the various health care settings. The bottom line: in professional fee settings any test findings, impressions or abnormal test values provided in laboratory, radiology, pathology and other ancillary test reports are not coded as specific, confirmed diagnoses unless the treating physician has acknowledged those particular findings, impressions or results, thereby indicating their clinical significance (in the absence of confirmed diagnoses for abnormal labs, there are appropriate code selections from Chapter 16 “Symptoms, Signs and Ill-Defined Conditions” of Volume 1, ICD-9-CM). This can be achieved by the treating physician in a variety of ways but typically is found when the physician signs/initials the test report and frequently adds patient-specific comments or – in the optimal documentation scenario – the physician documents the test results in a confirmatory way in the patient’s progress notes, or other report data, together with commentary or assessment on the test findings.

Evaluation and Management (E/M) services such as office visits, inpatient hospital visits, observation services and other such cognitive services tend to have CPT codes assigned based on the extent of the case documentation and the degree of “key component” fulfillment under professional fee coding. This approach differs significantly from facility E/M coding wherein tally or point systems are utilized, grading the various services and items not separately billable to account for resource expenditures, and adding up the points into a facility level E/M code.

For example, Emergency Department visits can vary in facility E/M levels based on nursing and other assistive services provided to the patient, as well as various interventional efforts and other considerations such as the patient’s age (e.g., an infant might require more intensive staff triage effort), the nature of the presenting problem (e.g., a myocardial infarction presentation will automatically engage certain facility responses accounted for at a specific assessment point value), special care, etc.

While these are also factors in the professional fee assignment of an E/M code, for physicians and nonphysician prorviders, the final code assignment for E/M services is only reflective of the degree, quality and content of documentation of three key components:

  • History, physical examination and medical decision making.

These distinct E/M components all mesh together for appropriate code selection under either the E/M Documentation Guidelines which establish the basis of the service and in the chart documentation for E/M codes. Facilities do not follow these E/M documentation guidelines but use their own (internal and rarely formal) E/M facility level point-based gradations. The differences between these two approaches to E/M coding, then, are numerous and significant.

The private practice physician must be knowledgeable enough about the coding process to ensure the EM (cognitive) services will be coded accurately.

Modifier assignment, including both CPT Level I and HCPCS Level II modifiers, differ from facility outpatient modifiers in several ways. The number of modifiers available and applicable to provider coding is much greater than the gamut of modifiers for facility outpatient services.

CPT Level I modifiers reported by outpatient facilities include -25, -27, -50, -52, -58, -59, -73, – 74, -76, -77, -78, -79, and -81. Provider coding allows for nearly all of those particular Level I modifiers except -73 and -74 as well as -27 (note: the -27 modifier is not accepted at this time by

CMS as a payment modifier for facility outpatient services; other commercial payers may accept it) Of the HCPCS Level II modifiers, about 40 modifiers are applicable to facility outpatient services while many more are applicable to provider-fee coding. Therefore, the familiarity by facility coders in terms of modifiers may be limited by virtue of the fewer number of modifiers they have dealt with on a regular basis.

Physicians should also ask in which manner modifiers are assigned to cases by the facility; many facilities have moved from hard-coded protocols (via the chargemaster or “CDM”) to soft-coded protocols (via the HIM Department coders or assigned clinic coders) because of compliance concerns, such as indiscriminately appending modifier -59 (Distinct Procedural Service) on line items regardless of the scenario or supporting documentation. A compliance-oriented health system must ensure that modifiers affecting payment and/or enabling the claims to bypass system edits will be appropriately assigned by coders per the documented case circumstances, not by an automated system. For pro-fee coding this is of paramount importance.

A great deal of confusion typically surrounds the assignment of HCPCS-II codes for drugs/ biologicals (with the related units) by facility coders not typically responsible for coding such items (they are most often done with an automated process). In many cases the items such as J0696 Rocephin IM 250mg are “dropped” through the charge capture system to the claims processing module via the CDM from various outpatient clinics, and may not be coded directly from provider documentation. This operational issue accounts for numerous HCPCS Level II code and unit errors found on outpatient clinic audits. Miscoding these products/services can compromise revenue as well as burden the provider with compliance issues. A good solution is to use the provider’s superbill or a workable “cheat sheet.” If these elements are employed and are thorough and up-to-date, it would assist the facility coders of the full complement of HCPCS Level II codes typically engaged by the practice. The facility representatives can then decide if these services should be added to any particular CDM subset in an automated fashion, or if they should continue to be soft-coded by coders.

Transitioning from a private practice into a health system or network setting can bring both rewards and compromises, but in the conversion certain coding and billing issues must be addressed as early as possible. If centralized coding and billing are part of that transition, one of the due diligence issues to address is the level of expertise the health system’s coders have with provider-fee coding. The private practice physician and the facility will avoid revenue compromises and compliance issues by assuring the coders learn the facts on the CPT codes.

If your hospital organization needs help with in service coding training, contact us for fast-track training for CPT coding. If you haven’t yet made it up to speed with ICD-10, we’ve got a great program for that. ICD-10 TRAINING