So Many Books, So Little Time - Part 3

Yes, it's true.  There are so many books and so little time, I haven't even had time to blog for the last two weeks because I had my nose in two of them.  Thank God for smartphones and long waits at the car wash, or who knows how much longer it would been before I posted again!

In my first post of this series, I gave one of my favorite quotes: "ICD is from Mars, HCPCS is from Venus."  So let's move on to Venus for a bit.  Don't worry, we'll be back to Mars, but I like to talk about the present before I talk about the future (ICD-10), so let's get on with it.  I apologize for the length of this post, but I have a lot to say today!

Three Levels of HCPCS
The Healthcare Common Procedure Coding System (HCPCS) has three different levels and just to make things more interesting, Level I is not usually called HCPCS, it's called CPT.  The Current Procedural Terminology (CPT) was developed and is maintained by the American Medical Association (AMA).

By Physicians for Physicians
What makes CPT so unique is that it is the only coding system in the HIPAA-approved code sets that is developed by physicians for physicians.  The codes you see in the CPT code book are the result of various medical and surgical societies coming together with the AMA to decide which procedures deserve their very own CPT codes.  Every year at the AMA's CPT Symposium, coders from around the country gather in Chicago to listen to these physicians present the coding updates for the coming year.  It's an expensive but valuable conference that I think every coder should experience at least once.  

CPT codes are primarily used by physicians to report procedures and services performed in every possible setting where a physician - or qualified health practitioner - may see  a patient: his office, the hospital, a clinic, a nursing home, etc. But it doesn't stop there.  CPT is also used to report hospital outpatient procedures. Of course, since there are still a lot of procedures that are performed solely as inpatient, hospital coders use a small number of CPT codes in comparison to pro-fee (physician) coders. 

Three within Three

So now that we know that CPT is one of three levels of HCPCS, let's delve a little deeper into this major code set. CPT has three categories of codes and this is still a pretty new concept for me because when I was learning, there were no categories, just CPT codes. 

Category I Codes

Category I codes are the original CPT codes they're what I like to call "grown-up" CPT codes. In order to get a grown-up CPT code, a procedure has to meet some pretty stringent criteria: 

• The procedure must have FDA approval
• The procedure must be commonly performed by practitioners nationwide
• The procedure must have proven efficacy

Once these criteria are met, a five-digit numeric code is assigned to the procedure and unlike ICD (different planet, remember?), these codes do not have decimal points. The codes are arranged in sections by type of procedure or service:

• Evaluation and Management (E/M) (codes beginning with 9)
• Anesthesia (codes beginning with 0)
• Surgery (codes beginning with 1-6)
• Radiology (codes beginning with 7)
• Pathology and Laboratory
• Medicine (the rest of the codes beginning with 9)

The Surgery codes are divided by specialty, for example, the cardiovascular codes begin with 3 and neuro codes begin with 6. After coding for a while, you should be able to look at a CPT code and have a general idea of what it is. A common newbie mistake is to look for the E/M codes in the back of the book. After all, they begin with 9!  But remember that CPT is a coding system that was developed by physicians for physicians and since physicians use E/M codes more than any others, they are in the front of the book for quick reference. 

Here are a few examples of Category I CPT codes:

• 99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity
• 12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.6cm to 7.5cm
• 75625, Aortography, abdominal, by serialography, radiological supervision and interpretation 

Category II CPT Codes

Category II CPT codes are located behind the Category I CPT codes in the book. These are the only CPT codes that are optional. They are used by physicians for tracking performance measures. The purpose of these codes is to decrease administrative burden on providers while collecting information on the quality of patient care. Category II codes are five-digit alphanumeric codes that end in "F."  Here are some examples:

• 1040F, DSM-5 criteria for major depressive disorder documented at the initial evaluation (MDD, MDD ADOL)1
• 3775F, Adenoma(s) or other neoplasm detected during screening colonoscopy (SCADR)12

Category II CPT codes are implemented throughout the year and may be implemented before they actually appear in the CPT book.  Code updates can be accessed on the AMA's website. 

Category III CPT Codes

Category III CPT codes, or "baby codes," as I like to call them, are for emerging technologies that do not meet the criteria of a grown-up Category I CPT code. The Category III codes are found behind the Category II codes in the CPT book. For procedures that are not commonly performed, lack FDA-approval, or don't yet have proven efficacy, Category III codes are assigned. These are temporary codes for a period of 5 years. It has become common practice to see Category III codes reach Category I status with each annual update. For 2015, one of those procedures that was moved was transcatheter mitral valve repair with a prosthesis. The MitraClip uses this relatively new technology to treat mitral regurgitation and it received FDA approval in 2013. 

These are five-digit alphanumeric codes that end in "T." The codes are added throughout the year and may be implemented before they are published in the CPT book. Here are some examples of some Category III codes:

• 0387T, Transcatheter insertion or replacement of permanent lead less pacemaker, ventricular
• 0274T, Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

Updates to Category III codes can also be found on the AMA's website throughout the year.  

Staying Updated

Back in the day, it was important just to make sure that you had the most recent year's CPT book to ensure you were using valid codes. However, with the Internet, now it's also important to monitor the CPT updates and errata on a regular basis since changes are made throughout the calendar year. I find it easiest to put a reminder on my calendar the first of each month to check the AMA's website for updates to the errata, which is a list of corrected errors in the CPT code book, as well as changes in Category III codes. Since I don't use Category II codes, I forego that update, but if you are coding them, be sure to look for those updates too. 

By the way, the errata is on the list of approved materials for the AAPC exams. The year I took the CIRCC exam (Certified Interventional Radiology and Cardiology Coder), there were a lot of errors in the electrophysiology code notes and the errata was something I really needed.  Be sure to check it out!

Modifiers

HCPCS codes have a concept specific to HCPCS codes only: modifiers. Think of modifiers like moons that are specific to a planet (and please forget for a moment that Venus doesn't have any moons!). Modifiers apply to HCPCS codes only, not ICD-9-CM codes. They are added to HCPCS codes to provide additional information, such as a bilateral procedure or an unusual service or to indicate that a procedure was discontinued. CPT modifiers are two numeric digits that are appended to a HCPCS code with a dash (e.g., 75710-59). 

All CPT Coders are not Created Equal

The people who assign CPT codes are just as complex as the coding system. Since hospital coders code only a subset of CPT codes, they don't have the same skill set that a pro-fee coder has. Remember that hospital inpatient coders use volume 3 of ICD-9-CM to code procedures. Hospital outpatient coders assign CPT codes for procedures that are found in the outpatient setting. So while the pro-fee coder coding for the cardiologist will code everything from a clinic visit in the physician's office to an angioplasty in the hospital cardiac cath lab to a full blown coronary bypass in the hospital's OR (all using CPT, of course), the outpatient hospital coder would only use CPT to code the angioplasty. Hospitals don't follow conventional E/M rules and coronary bypass is an inpatient procedure that gets coded using ICD-9.   In addition, many of the modifiers used by hospitals are different than those used by physicians. 

These differences are one of the reasons it's so difficult to make the crossover from hospital to pro-fee coding and vice versa. I personally hate E/M coding but I know people who love it. So if you find that one area of coding is not really your cup of tea, fear not!  You may find another area very rewarding. 

I also really can't talk about CPT without bringing up a little tiny thing from the hospital side called a charge description master (CDM), or as it's more commonly called, the charge master.  It's as masterful as it sounds: a line-item listing of everything a hospital department charges for.  Each line item has a description of the charge, charge amount, and sometimes a CPT code.  One of the most difficult transitions I see in pro-fee coders crossing over to the hospital side is not understanding that the coder doesn't code everything.  There are many codes that are assigned automatically by the charge master when a charge is applied to the bill.  This is the case when the CPT code doesn't require a lot of subjective reasoning (e.g.,  lab test or x-ray).  For those procedures and services, such as operative procedures, that require subjective reasoning, a real-live coder will assign the code.  It may sound counter intuitive, but this actually increases the amount of coding-related jobs in a hospital.  The charge master analyst requires coding knowledge as he/she works with hospital departments to set up charges, research appropriate CPT codes for the procedure or service, and determine if it will be hard coded (by the charge master) or soft coded (by a person in coding).  

CPT Made (Too?) Simple
This posting really oversimplifies the CPT code set (that's right, it gets more complex!), but it's a start if you're still finding your way in the coding field.  I have a love-hate relationship with CPT because I find it both challenging (love!) but also frustrating when I hear conflicting coding advice between CMS, the AMA, and medical/surgical societies (hate!).  If you find that you love all aspects of CPT, then you can have a very lucrative career in either the pro-fee or facility coding arenas.

Stay tuned to this series...  Next up is HCPCS Level II.

So Many Books, So Little Time - Part 1

What's Your Idea of a Best Seller?
Every once in a while I page through a magazine taking keen interest in the best seller and "must read" book lists that everyone is talking about.  I usually tear out the pages for books that are interesting so I can download them later.  And then I rarely read them.  Or it takes me literally months to finish a book.  I love to read, but frankly, after a day of reading code books, and spending a lot of time writing, I just don't have the eye or mental energy to crack a book for fun.

My idea of a best seller is a string of code books that I use every day.  Don't worry though, I find other ways to have fun that have nothing to do with coding!

The last time I moved, I had lots of friends helping me lug boxes and it didn't take long for them to zone in on the heaviest ones: they were labeled "code books."  I have code books for various coding systems going back several years and yes, they are heavy.  And it's hard to explain to the layman why I need so many books in such an electronic age.  I've found it can also be challenging to explain the different code sets to novice coders.  But alas, I am going to give it a try in a series of blog posts because you may not be exposed to all coding systems in coding school, but depending on the setting you work in, you may find you have to become familiar with something new.

I Don't Hate Encoders
Let's get one thing out of the way first, though.  I have no issues with computers or encoders.  In fact, I use a computer for almost everything and, like so many people, I am pretty addicted to my iPhone and iPad.  But as a coding trainer, I learned by the book and I teach by the book and will always default to the book when I have a question.  Encoders are only useful when the user understands the logic behind the program and that logic is based on the book.

ICD is from Mars, HCPCS is from Venus
In healthcare, we deal with two major planets of coding systems: the International Classification of Diseases (ICD) and the Health Care Common Procedure Coding System (HCPCS).  And as if that wasn't enough, those coding systems are divided into further classifications with different uses. Coding for a physician practice?  Then you'd better brush up on different parts of the coding spectrum than what you'd see in a hospital. Coding outpatient services for a hospital? Then you need to know something different than what you would need to know if you were coding hospital inpatient services.  Want to know how to code everything?  Then it's time to become familiar with your new best seller list.  This post will start with the basic coding system that everyone uses.

ICD-9-CM Volumes 1 and 2: Everyone Does it 

You probably aren't surprised to hear that the government determines which codes we use in the U.S.  But you may be surprised to hear that the law that defines those coding systems is a little law called HIPAA. Yes, the same law that addresses privacy and security of medical information also tells us which codes we must use to report healthcare services.  This is why some code books boldly state on the cover that they support HIPAA compliance.  In order to make health information portable and comparable,the Healthcare Portability and Accountability Act of 1996 (HIPAA) makes sure we're all speaking a common language, expressed in codes, before we exchange data electronically. The privacy and security provisions are simply byproducts of making sure health care data can be shared electronically. 

Every health care case, regardless of provider and setting, has one code set in common: ICD diagnosis codes. This coding system was developed by who?  That's right - it was developed by WHO: the World Health Organization. Here in the U.S. we currently use an adaptation of WHO's ICD, which is currently the ninth version. We call the U.S. version a clinical modification. And thus, we have ICD-9-CM: the International Classification of Diseases, 9th Revision, Clinical Modification.

ICD-9-CM has three volumes. The first two volumes include the diagnosis codes.  This includes the tabular (Volume 1) and index (Volume 2). I'll address volume 3 in part 2 of this series. Bottom line here: every HIPAA-covered entity, which includes hospitals and physicians (and excludes workers' compensation and car insurers) utilizes ICD-9-CM codes to report diagnoses on a claim.

ICD-9-CM codes have 3-5 digits with a decimal point after the first three digits. All codes are numeric except for V codes, which start with a V and then have two numeric digits and may have up to two more digits after the decimal point; and E codes, which start with an E and have three numeric digits and may have an additional digit after a decimal point. E and V codes are actually "supplementary" codes that are not included in the main part of the ICD-9-CM volumes 1 and 2 code set.

Here are some examples of ICD-9-CM codes:

• 486, Pneumonia, organism unspecified
• 401.9, Essential hypertension, unspecified
• 250.00, Diabetes mellitus without mention of complication, Type II or unspecified type, not stated as uncontrolled

Examples of supplementary codes:

• V08, Asymptomatic HIV infection status
• V27.0, Outcome of delivery, single liveborn
• V76.51, Screening for malignant neoplasm of colon
• E961, Assault by corrosive or caustic substance, except poisoning
• E885.3, Fall from skis

Regardless of who you plan to code for, you will be using ICD-9-CM diagnosis codes for billing.  As such, this is likely the first coding system you learn.  

Frozen

You may notice in my picture that my most recent ICD-9-CM code book is from 2012.  That's because that was the last year that we had updates to the coding system.  ICD-9-CM is under a permanent code freeze as we optimistically await ICD-10 implementation.  Don't worry, I will address ICD-10 in future posts.  For now, you are safe using an ICD-9-CM code book from 2012 or newer, but I wouldn't waste money on a new book if (heaven forbid), ICD-10-CM is not implemented this year.  ICD-9-CM remains forever frozen and is no longer being maintained.  If you want to bone up on ICD-9-CM coding guidelines, they are printed in the front of your code book.  Or you can do what I do and download the PDF document so you can easily search the document for something specific.  Here is a link to the last version of the ICD-9-CM Official Guidelines for Coding and Reporting.  

Next up: ICD-9-CM Volume 3...

It's HIPAA, not HIPPA

Just for the record, it's HIPAA, not HIPPA. The actual legislation is called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), not the Health Information Patient Privacy Act (HIPPA). I can't tell you how many times I've seen the latter referred to. As a matter of fact, a colleague of mine once emailed a company after seeing HIPPA repeatedly displayed on their website. Once she educated them, they offered her a job!

Privacy and Security
It's true - when most of us think HIPAA, we think privacy of health information. And that's a huge part of it. We may even think, as coders, that we are only impacted by HIPAA when it comes to keeping the medical record information we read during the coding process confidential. But HIPAA is much bigger than keeping health information from falling into the wrong hands. The true intent of the law was the make sure people retained insurance coverage as they changed jobs. It includes several provisions for sharing data electronically and in order to enact this sharing of information, it was prudent that privacy and security provisions be built into the infrastructure of HIPAA.

As coders, we will likely be required to sign confidentiality agreements with employers. We will be subjected to criminal background checks and possibly credit checks. We will be forbidden from discussing that interesting ER case in the elevator. We won't be able to look up medical record information for friends and family. Well, I suppose you could, but make no mistake - there is very little to no tolerance for HIPAA violations. I've seen people dismissed immediately for violating patient confidentiality. I saw this most at a celebrity-frequented hospital where people tweeted or posted on Facebook when someone famous was admitted or they released specific protected health information (PHI). In this day and age, it's not uncommon for employers to have a social networking policy that addresses Facebook and Twitter.

And while privacy of PHI is a coder's concern, there are other provisions within HIPAA that impact us. I meet a lot of people who want to code so they can work from home. But setting up a home office as a coder means more than getting a computer and internet connection. Along with ensuring patient privacy comes security of PHI as well. The home workstation must be secure from breaches including hacking of computer systems and stolen computers. It's a natural concern when setting up a home office - who will have access to the work computer and if there are multiple people living in the household, what provisions are being taken to ensure that the workstation is secure? Some home coders may be subjected to a home evaluation by an employer to ensure the workspace is secure.

HIPAA-Defined Code Sets
Still not convinced that HIPAA impacts you greatly as a coder? How about the codes you use? Those are also intertwined into HIPAA legislation. Electronic exchange of information between two different parties requires specific transactions. For example, the submission of an insurance claim by a provider to a payer is one such HIPAA transaction. There is another for communication from the payer back to the provider about what was paid on each account. These HIPAA transactions require a common language between the parties. And that language is often codes. As such, HIPAA defines which code sets are approved for reporting diagnoses and procedures in order to ensure uniformity.

There are six code sets approved for various uses and time periods as defined by HIPAA:

• HCPCS (Healthcare Common Procedural Coding System, Level II)for ancillary services and procedures
• CPT-4 (Current Procedural Terminology) for hospital outpatient and physician services
• CDT (Current Dental Terminology) for dental services
• NDC (National Drug Codes) for over-the-counter and prescription medications
• ICD-9 (International Classification of Diseases, 9th Revision) for diagnoses and hospital inpatient procedures - currently used
• ICD-10 (International Classification of Diseases, 10th Revision) for diagnoses and hospital inpatient procedures - effective October 1, 2013

The HIPAA Version 5010 Standard
Most coders and coding students are aware of the massive effort currently under way to migrate from ICD-9 to ICD-10 in 2013. Many are not aware, though, of the updates to the HIPAA transactions that must occur in order to make ICD-10 data electronically exchangeable. We currently operate under the HIPAA version 4010 and as of January 1, 2012, we will use HIPAA version 5010. This upgrade includes many other updates besides those to get us ready for ICD-10. The impact of 5010 implementation is currently being felt by payers and providers as they gear up for testing these new transactions beginning in July. As of January 1 of next year, CMS will not accept any electronic data in the old format. And that means failure to comply will hold up claims submission and payment.

The 5010 upgrade is probably invisible to most coders in an organization. It's very much an information technology (IT) initiative and involves inventorying systems and working with vendors and payers to ensure everyone has updated to the 5010 standard. In addition to updating the number of bytes available to report ICD codes and allowing for alpha-numeric entry (instead of mostly numeric with ICD-9), it also includes updates to allow for reporting the present on admission indicator, eliminates the release of superfluous PHI for insurance certification and verification, and eliminates numerous other inefficiencies in reporting data electronically.

So keep an eye out for the acronym HIPAA - it will come into play a lot in your career as a coder. As for HIPPA, I still can't figure out what that is. There is no Health Information Patient Privacy Act, so as best as I can tell, a hippa is a baby hippo!

It's Coding Season!

I'm sometimes asked if there's a busy time of year for coders or if it's pretty much status quo. As a matter of fact, there is a busy time of year for coders and this is it!

Every year, we gear up for all the upcoming year's coding changes. That means letting coders know which codes have been deleted, expanded, and added and letting coders, physicians, administrators, and revenue cycle personnel know how code-based reimbursement will be affected in the coming year. This may seem rather straightforward, but since we work with more than one code set with different implementation dates, fourth quarter of each year can be pretty crazy!

ICD-9-CM Codes
The ICD-9-CM diagnosis and procedure codes are updated annually with the Center for Medicare and Medicaid Services' (CMS) fiscal year (FY), which begins October 1. These codes are used to report diagnoses for all health care settings and procedures for hospital inpatients. Right now, you will find coders acquiring their FY 2011 ICD-9-CM code books and attending seminars on the code updates. Some of this year's highlights include:

Diagnosis Codes:

• A new code for obesity hypoventilation syndrome
• Expansion of fluid overload code to differentiate between transfusion-associated fluid overload and other causes
  
• Expansion of the avian flu codes to include manifestations of the disease
• Expansion of the blood transfusion incompatibility codes to differentiate between ABO and Rh incompatibility
• Additional personal history codes
• Expansion of the body mass index (BMI) codes up to allow for classification of BMI in varying increments up to 70 and over
• A new section of V codes to report retained foreign body fragments
• A new section of V codes to report the number of placentae associated with multiple fetal gestations

ICD-9-CM diagnosis codes are within the public domain and the 2011 revisions can be found on the National Center for Health Statistics' (NCHS) website.

Procedure Codes:

• New code for placement of a central venous catheter under imaging guidance
• New codes for carotid sinus stimulation components and devices

Changes to the ICD-9-CM procedure codes are within the public domain and are available on CMS' website.

IPPS and MS-DRGs
The inpatient prospective payment system (IPPS), the system used for Medicare payments for inpatient hospitalizations, is also updated each year on October 1. This includes recalibration of the relative weights for the classification system used under IPPS - the Medicare severity diagnosis related groups (MS-DRGs). This year, the major changes to the MS-DRGs include:

• A documentation and coding adjustment of -2.9%, wherein CMS will discount payments in FY 2011 to hospitals by 2.9% in order to remain budget neutral. The attempt to remain budget neutral is to counteract the financial impact of implementing a severity-based DRG system 3 years ago.
• The addition of 12 new quality measures to be reported by hospitals under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
• A revamping of Medicare's 3-day rule, which bundles payment for outpatient services provided within 3 days of inpatient admission into the inpatient payment.

Changes to the IPPS and MS-DRGs are available in the public domain through CMS' website as well as the Federal Register.

CPT Codes
Changes to CPT codes become effective with each calendar year on January 1. These codes are used to report procedures and services for physicians and hospital outpatients. Because CPT codes are owned and maintained by the American Medical Association (AMA), they are not available in the public domain. As such, finding a list of upcoming CPT code changes is often a closely guarded secret until the CPT book is published, generally around November or December each year.

The best way to get updates on upcoming CPT codes is to attend either the AHIMA's Annual Clinical Coding Meeting (September 25 and 26, 2010 in Orlando) for the national code update or the AMA's CPT and RBRVS Symposium (November 10-12, 2010 in Chicago). After the AMA's Symposium, it's common to see articles appearing in coding journals and publications discussing the upcoming coding changes.

HCPCS Codes
HCPCS codes are developed and maintained by CMS to report services, supplies, and procedures that are not found in CPT. They are utilized by physicians and hospital outpatient reporting. HCPCS codes are potentially updated quarterly, although an update isn't always required that frequently. HCPCS codebooks may be purchased on an annual basis with the calendar year and quarterly updates are found on CMS' website. HCPCS codes are in the public domain and general information about their use can also be found on CMS' website.

OPPS and APCs
The outpatient prospective payment system (OPPS) is the payment system utilized by Medicare to pay for hospital outpatient claims. This is updated on January 1 each year, along with the CPT and HCPCS codes. The proposed rule was published in the Federal Register on August 3 and CMS accepted public comment on that proposed rule through August 31. CMS will review the comments, make final determinations, and finalize the rule by November 1.

OPPS changes include recalibration of the relative weights for ambulatory payment classifications (APCs), the categories used to group similar procedures for payment.

Some highlights of the proposed rule include:

• Two areas that have undergone frequent changes or requested changes will remain static for 2011: drug and substance administration and hospital outpatient evaluation and management visit guidelines
• Establishment of a list of services that must be performed under physician supervision
• Removal of three orthopedic codes from the inpatient-only list, making them reimbursable as outpatients under Medicare
• A new method of paying for separately payable drugs
  

Information about OPPS and APCs can be found on CMS' website.

Physician Fee Schedule and RVUs
Physician payment, as outlined in the physician fee schedule, is updated annually on January 1 by Medicare. The proposed rule was published in the Federal Register on July 13 and the comment period ended on August 24. The physician fee schedule outlines the relative value units (RVUs) for each CPT code based on the amount of work the physician performs. Information on the Medicare physician fee schedule and RVUs is within the public domain and can be found on Medicare's website.

Too Much Information?
It sounds like an awful lot of information, but remember this - not every coding professional needs to learn the ins and outs of every coding and payment system. Because I work with hospital clients, I will be focusing on everything but the physician fee schedule. And those who work in physician offices will focus on ICD-9-CM diagnosis code changes, CPT/HCPCS code changes, and the physician fee schedule only. Even so, it's enough of an impact to call fourth quarter "coding season!"