Spotlight on Certification: Certified Interventional Radiology Cardiovascular Coder (CIRCC®)

Lately I've heard a lot of buzz about the AAPC's credential, Certified Interventional Radiology Cardiovascular Coder (CIRCC).  Interventional radiology (IR) coders are in demand because of the complexity of the field and the notoriously high error rates seen on audits. It may sound like a great credential to get, but before you make any sudden movements, here's what you need to know about the CIRCC exam.

Why this credential exists
I've been coding now for 22 years and I've seen quite a bit.  I helped train the workforce in ICD-10-CM and ICD-10-PCS. I've audited ICD-9, ICD-10, CPT and HCPCS codes.  I've read the Federal Register on DRGs and APCs.  But the hardest thing I've ever had to learn to code is IR and cardiology.  The coding rules are complicated, ever changing, and often inconsistent for different parts of the body.  Learning how to code IR and cardiology procedures by just looking at the CPT book is tough enough, but not all the rules are written there.  There are other societies that develop suggested guidelines and then there are the payer's rules and interpretations.  In a hospital setting, an understanding of IR and cardiology coding also usually requires an understanding of hospital charging and how departments are credited revenue.  This credential exists to show that you've mastered these areas of coding.  In my mind, this is the most difficult area of coding there is.

This is not an entry-level credential
I took the CIRCC exam four years ago with about 10 years of experience under my belt.  It was a tough exam.  As a matter of fact, it was the hardest multiple choice exam I've ever taken and I would put it up there with the Certified Coding Specialist (CCS) test as one of the toughest.  If you are thinking you will get the CIRCC and then land a job as an IR coder without any experience, think again.  This is the test you take after you've been coding those types of cases for a long time and feel confident in your abilities.  AAPC recommends, but does not require, at least two years of coding experience before taking the CIRCC exam.

What's on the test
The CIRCC exam is spotlighted for its focus on IR coding, but it also includes cardiology procedures.  The procedures we're talking about are surgical-type procedures done in a radiology suite or cardiac cath lab using radiological (fluoroscopic) guidance.  For IR, this can be vascular studies (angiograms) and interventions (e.g., angioplasty, stenting, thrombectomy) or nonvascular procedures (e.g., placement of biliary stents, nephrostomies, and fluoroscopically-guided biopsies).  For cardiology, this can be diagnostic cardiac catheterization, angioplasty and stenting, and cardiac electrophysiology studies and arrhythmia ablations.   If you don't know what any of that means, I don't recommend taking the test until you learn more!

What it costs
At the time of this writing, the cost to sit for the CIRCC exam is $400.  But the cost of taking the CIRCC doesn't end when you register and pass the exam.  Like other credentials, you need continuing education units (CEUs) to maintain the certification.  But unlike most other AAPC credentials, there are limited vendors from which you can get those CEUs.  Before you decide to take the test, look at the CEU requirements and visit the vendor websites (the AAPC has links) to see how much your CEUs will cost you and be very realistic about what you can afford.  If your primary job is coding these types of cases, check with your employer to see if they will reimburse you for any of the costs.  This is an expensive credential to maintain, but if it's valued by your employer, they may cover the costs.

Read all about it
I could regurgitate the contents of the AAPC's website about the CIRCC exam, but instead of doing that, I will direct you to their website with this simple instruction: Do your homework!  There is a plethora of information on the AAPC's website for this exam and it will tell you everything you need to know from the breakdown of the exam questions, approved manuals and materials (yes, you can bring anatomy cards showing selective vascular ordering), certification requirements, history of the exam, and FAQs.  If you were going to spend $400 on a new smartphone, you would probably read up on the different models before making a final decision.  Why wouldn't you also do this for a credential?  Don't take this exam until you've read all the fine print.

Preparing for the exam
Once you decide that you're ready to pull the plug and take the test, it's time to prepare.  Even if you've coded these cases for a long time, there is still preparation to be done.  Here is my list of recommendations:

• Get the right CPT book.  The AAPC's website is very clear that they will only allow you to use the American Medical Association's (AMA) version of CPT.  If you have a CPT book from any other publisher, you cannot use it.  I recommend the AMA's Professional Edition of CPT for its color coding and pictures.  It's more expensive than the standard edition, but I think it's worth the money.
• Mark your CPT book.  Don't waste time writing in the things you already know, but I do recommend making cross-reference notes for any codes that have a one-to-one relationship.  For example, I wrote all of the C codes for drug-eluting stent placements next to their CPT counterparts so I didn't have to open another book during the test.  Sometimes CPT includes instructional notes in the Surgical section directing you to the Radiology component code.  And sometimes it doesn't, so I wrote those in too.  Especially if you are used to using an encoder, make sure you have your book set up so you can flip to different code sections fast.
• Get the exam prep book.  Yes, it costs more money and no, I am not being paid by the AAPC to push their products!  The exam prep book will go over what's on the test.  It will give you practice questions and show you the type of questions that will be on the exam.  The one thing I remember from the exam prep book is it said in several places that none of the questions are meant to be trick questions.  That might sound like a no-brainer, but when you really get into IR coding, you'll see why that's an important thing to remember.
• Spend your study time on your weak areas.  Don't waste your time studying things you already know.  If there is an area that is not your strongest, make notes on those CPT sections and find tricks to help you remember.  When I took the test, I was strong in vascular IR and cardiology, but not so much on nonvascular IR, so those sections of my book had the most notes.  Remember: you can write notes in your CPT book, you just can't put any loose pieces of paper in them.  
• Take a prep class.  If you can find a class that will cover part or all of the exam content, enroll now.  I am teaching a vascular interventional radiology class in October 2017 in Denver, which covers some of the trickiest IR coding.  I would love to see you there and chat about your CIRCC aspirations!

If you've ever considered taking the CIRCC exam, I hope you found this post useful.  Want to learn more about IR coding?  Stay tuned - more posts to come!

Evolution of the Coder

When I started the HIM program at the local community college in... ahem, a few years ago (sly smile), I split my time working as a file clerk in a doctor's office and a catch-all clerk in a physician's billing office. The doctor's office was a family practice managed by the owner of the billing office, which was located just next door. I remember my coworkers asking me why I was going to school to learn about medical records because I was already a file clerk. I also remember hearing one of the billers grumble about an insurance company denying claims for a male patient with pelvic pain and "can't men have pelvic pain?!"

Well, it didn't take me long to realize that the HIM field was more than filing - especially these days as hospitals and physicians move to electronic health records. And it didn't take me long to learn that, at least in the eyes of ICD-9-CM, men can't have pelvic pain - at least not the kind classified to code 625.9, Unspecified symptom associated with female genital organs (as evidenced by the word "female" in the code description and the little female symbol next to the code).

That was a long time ago and a lot has changed in the coding (and HIM) field since then. As a consultant, I work with hospitals to identify areas for coding education and then develop a curriculum and deliver training. It used to be as simple as telling my client to have all their coders at the training at a specific time and date. But not anymore. You see, the coders in a hospital aren't just sitting in the coding unit (physical or virtual) anymore. There could be coders all across a hospital. There could be people coding who don't even know they're coding. There could be nurses working with doctors to improve their documentation to ensure proper code-based reimbursement. There could be clinic coders coding the professional side for physicians working in hospital-based clinics. Finding coders in a facility is a challenge!

In short, coding has evolved.

And this is a great thing - this means that if you have the skill to be a coder - and it is a skill - there are many directions your career path can take you. So what's your passion? Do you relate to transactional work? Are you production oriented? Do you like the clinical puzzle involved in coding and secretly harbor fantasies of being Dr. Gregory House and solving the diagnostic dilemma in front of you? Do you like finance? Are you a data hound? Do you love to do research? If you answered yes to any of the above, there's a niche for you in coding.

The Transactional/Production Coder
I'll be honest. As a coder, my production, in general, stinks. At least it did the last time I did it. Some days I could concentrate very well and knock out a bunch of records. Some days it was like ADD kicked in and I just couldn't concentrate on the documentation in front of me. But there is a group of very special people who are production-based and enjoy transactional work. These are the people who are a coding manager's dream. They come to work, know how many accounts they need to code for the day, and they get it done. I have a lot of respect for those people. I wish that was me!

The Dr. House Coder
I use the TV show, House, a lot in my training sessions and blogs. I watch it and see if I can diagnose the patient before Dr. House. Usually not. But it's fun to try! Physicians and nurses alike are often surprised when they talk to coders to learn how much coders know about clinical practice and disease process. If you read enough medical records in your lifetime and see the treatment plans, it starts to rub off! If you love the clinical stuff like me, there's a lot of opportunity. Clinical documentation improvement (CDI) programs are popping up all over hospitals. The point: get the physician to document as specific as possible to ensure proper reimbursement for the hospital. Clinical documentation specialist (CDSs) are on the floor, looking at charts while the patient is in-house and talking directly with physicians. This is a job that can be done by a nurse or a coder who has been given proper clinical training. Some hospitals employ both coders and nurses as CDSs for a collaborative effort. I don't really have a desire to go back to working for a hospital, but if I did, I think I would like to be a CDS.

The Code-Based Reimbursement Coder
More and more I see coders being placed in the billing departments of hospitals. Or certified coders being given the role of charge description master (CDM) analyst. As Medicare and other code-based payers get really sticky with their billing requirements, it gets more difficult to get a clean claim out the door. Coders working on the revenue side are typically ensuring hospital systems that incorporate the use of codes are updated and interfacing/functioning properly.

A CDM analyst maintains the hospitals list of charges. If you're looking for a picture of what a CDM looks like, it's a massive spreadsheet for each department in the hospital with a line item for everything they could possibly charge for along with prices for those services and supplies. And some of those line items are attached to codes. CDM analysts work with clinical department heads to make sure charges are set up for all their services and supplies. They also make sure CPT and HCPCS codes in the CDM are updated according to regulatory standards. They might be called into a clinical department to assist in training personnel who are responsible for charging.

For lack of a better title, the code-based reimbursement analyst (an aptly named title I borrowed from a former employer where I was responsible for training code-based reimbursement analysts), is a catch-all before a claim goes out the door. Or someone who audits claims and makes corrections. This person may be responsible for working NCCI edits to get claims through the hospital scrubber and may also work closely with the coders, educating them on the latest Medicare reimbursement changes.

Code-based reimbursement analysts may also be placed in departments prone to frequent coding and charging errors, like interventional radiology, wound care, or injections and infusions. These specialty coders often work not only with documentation, but also with nurses entering charges and physicians regarding their documentation. They may also have a link to billing so they can see how their coding is translating to claim denials and errors.

If you like the revenue and compliance side of coding, there are lots of opportunities for you. Students and recent grads interested in this area often ask me where they can get training or certification for this type of job. Well, there really isn't a specific type of training for it. The best thing you can do is try to get your foot in the door and learn on the job. The coding piece of this is probably the hardest - the rest you learn from your employer. Revenue cycle is part of what I do as a consultant and I like it. I particularly like trying to figure out the complex changes Medicare has put into effect and walking that tightrope between ensuring the provider is getting paid as much as possible while maintaining revenue compliance. Let's just call this code-based coder the "Goldilocks" coder - don't code too much, don't code too little, code just right!

The Data Coder
Maybe you like analyzing data. I for one, find it dull after about 15 minutes. But I've had the joy of working with people who love doing that so we can leverage our skills for the greater good. There are many opportunities for the data-oriented coder. Of course, we should all be concerned about data integrity and coding what was done. But there are positions for people who want to slice and dice and interpret coded data. Registry programs (e.g., cancer, trauma, cardiac) often incorporate the use of codes and then some. The plus to being a registrar is that you usually become an expert in one particular area. For example, I know a cancer registrar who has been to enough tumor board meetings where cancer cases are discussed among physicians, she can effectively diagnose skin cancers most of the time (of course, the real diagnosis comes from a physician!).

Coded data is used by many - health departments, clearinghouses, universities, state hospital associations - and the list goes on. As the government becomes more concerned about outcomes of care and pay-for-performance in hospitals, there is a heavier reliance on accurate coded data. Independent companies like HealthGrades rely on coded data to compare the quality of healthcare among providers and report it to consumers. Someone is behind that data ensuring it's accuracy and interpreting it's impact and meaning. That could be you!

The "Why" Coder
I saved the best for last - well, in my opinion anyway. The "why" coder is the one who loves research and wants to know why. Why will Medicare not pay for a biopsy and an excision of a lesion done at the same time? Why does Medicare pay less for certain patients who have been discharged to a nursing home rather than home? What's the difference between two codes that at first glance appear to have identical code descriptions? Why can't men have pelvic pain?! And this is why I have trouble being a production coder. It's hard to produce when you keep asking why. Luckily, I am able to put my investigative skills to work and do research to build training materials for other coders - like production coders - so they can do their jobs efficiently. The best thing about the "why" coder is that it's free. You can learn just about anything you ever wanted to know about Medicare and their why's and not pay a cent. Of course, the price for accessing public domain information is the sheer amount of information you need to paw through to answer a single question - it can be several hundred pages.

So what's your passion? What kind of coder will you be? The opportunities are endless and we need all kinds!

Two Track Mind: ICD-10 and Vascular CPT Coding

Do I seem like a stranger? Because I feel like a stranger. These days I have two things on my mind: ICD-10 and the CPT coding changes for vascular procedures. And pretty much anything outside of these two topics isn't getting much of my attention lately - including blogging. So in an effort to provide you with a recent blog post - and to keep my attention focused on the tasks at hand - I figured I would blog about what I've been up to recently. This will give some insight into the challenges that existing coding professionals are facing today.

Before I let you in on what's been on my plate, I should mention that there is no crossover between these two topics. They are two very different aspects of coding that use two entirely different parts of the human brain. Or at least, they use two very different parts of my brain! When asked why I am so deeply involved in two areas that are so vastly different, all I can say is, I love a challenge. And challenged I've been!

CPT Code Changes

I know what you're thinking. "It's March, Kristi, the CPT code changes were effective January 1 so that's old news." Well, the reality is, it takes some time to get used to new codes. Since I spend a significant amount of time as a subject matter expert (SME) for my clients in the realm of cardiac catheterization and peripheral vascular interventional radiology coding and charging, I can tell you that 2011 has presented my clients with some significant challenges. First of all - the deletion and nearly complete overhaul of the cardiac catheterization section of CPT. If you have a chance to look at a 2011 CPT codebook (I recommend the Professional Edition since it shows all code changes in color-coded fashion), and compare it to a 2010 book, you'll see what I mean.

My biggest challenge? They changed the code descriptions and code numbers, but in many cases used the same digits - just in a different order. A dyslexic's nightmare and yes, yours truly is dyslexic. There are a couple of perks now - we no longer have to worry about coding left ventriculography separately, it's bundled into the left heart catheterization code, and for the most part, supervision and interpretation (S&I) codes are a thing of the past.

The peripheral vascular coding is getting really interesting. This year the American Medical Association (AMA) decided that leg revascularization procedures could be more effectively reported using bundled codes. This new Wal-Mart approach to coding is becoming more commonplace in interventional radiology (IR) coding. What do I mean about Wal-Mart codes? Well, vascular IR coding has historically involved the separate reporting of all procedure codes, including the catheterization or approach, which is typically a no-no in coding. The end result is often a list of 4 or 5 codes to describe one procedure. Wal-Mart coding is "one stop shopping" where everything is included in a single code. Maybe I should call them Ragu codes for those who remember the old Ragu pasta sauce commercials. You know - "It's in there!" This Wal-Mart or Ragu concept of coding means unlearning many complex IR coding guidelines that have been ingrained in our brains over the past few years.

The new leg revascularization codes are set up based on a heirarchy - angioplasty followed by atherectomy followed by stenting - with newly established vascular territories. The iliac territory consists of three vessels. The femoral-popliteal territory is treated as a single vessel. And the tibioperoneal territory as three vessels. To make things more confusing, the AMA deleted all of the atherectomy codes from Category I in CPT and moved them to Category III.

And because IR is arguably the most difficult area of CPT coding (as an IR SME I may be biased), someone has to research all this and educate coders on the changes. Thus, I find myself updating training materials with these changes and presenting the changes. If the areas of cardiac catheterization and IR interest you, I suggest you acquire a solid foundation on basic medical coding first. These 2 areas are difficult for even the most seasoned coders.

ICD-10-CM and ICD-10-PCS

Well if you're a coder, a coding student, or have done any research at all about the coding field, you know we're in for a huge change with the implementation of ICD-10-CM and ICD-10-PCS in 2013. I would like to say that all organizations are in full swing and getting ready for the transition. What I'm hearing as I talk with organizations, though, is that they are just getting started - a full 1-2 years behind the recommended schedule.

In recent weeks I've taken my ICD-10-CM/PCS trainer recertification through AHIMA and kicked off a Task Force through the Colorado Health Information Management Association (CHIMA). As chairperson of the ICD-10 Task Force here in Colorado, I've had the chance to meet with providers and organizations who will be impacted by the ICD-10 code sets. And I am also embarking on a project through AHIMA to get ensure that Colorado Medicaid is ready for the transition.

In addition to that, I'm preparing presentations for the spring conference season and developing ICD-10 tools and training programs for my company. Here's a shameless plug for The Wilshire Group - just in case you're looking for some additional ICD-10 references! My favorite part is the ICD-10 countdown. I've set this as one of my home pages so I can feel the urgency every time I open my browser!

Prepare for Your Challenge

If you really have a passion for coding, then this commentary got you really excited to learn more. I wish I could properly convey how much more difficult coding is than simply looking up a code in a book. And I wish you could get an accurate depiction of what your daily work will look like as a coder. But the truth is, you don't really "get it" until you get into it and although I know so many are frustrated because they can't get the required experience to get hired, I've said it time and again - keep trying to find an angle to get the experience you need to get your foot in the door. And once you're in, I hope you're ready for the challenge because it's a constant learning experience.

Get Your Paint Brush

I've been painting a lot lately. I recently had the intense urge to splash bold color on my bathroom walls. And I have to say, that while I love making drastic changes to a room and gazing admiringly at the finished product, the actual process of getting there drives me a bit nuts. While I was prepping and painting, it gave me a lot of time to think about... well, everything - including coding, mentoring, and blogging. And it struck me how much painting is like coding.

Maybe you don't paint the way I do, but as a typical perfectionist coder-type, I'm pretty picky about the end result. I always tell people that should this coding thing not work out for me, I'll go into interior design (LOL!). Finally, I've found a way to tie two of my passions together! At any rate, I hope you enjoy the analogy.

It's All in the Prep Work
First of all, I hate blue tape. Not because I have an aversion to the color blue, but it stands in the way of what I'm really looking forward to - the transformation that comes with brushing and rolling a new color onto the walls. And in an effort to paint the wall a dark purple with bright white trim while avoiding getting paint on the floor, it meant either a very steady hand or the use of blue tape.

While I was taping, my mind wandered to the people I've talked to who are trying to get into the coding field and how I often hear complaints about the education piece of coding. I liken taping off a room to getting a coding education. No one is going to recommend my painting skills if there is paint slopped all over the place. Likewise, no one is going to recommend me as a coder if I'm not educated.

Do You Have the Right Paint Supplies?
I wish I could say that my project took only one trip to the store to get the paint and the few supplies I needed (since I have the desire to paint something every year or two) -but it took three. The first trip resulted in a gallon of purple paint, ceiling paint, a tarp, blue tape (!), and a couple of other essentials that I couldn't remember if I had or not. The second trip garnered me a few more paint brushes for trim.

I thought I was set.

If only. At 6:00 pm on Sunday, I started going through paint cans of redecorating sessions past trying to remember which subtle shade of white was the right one for the trim. When I eventually found it, I opened the can and it was dried solid (when did I paint last anyway?!). I thought of using another white for trim, but while it wasn't dried out, it was in a sad state and ready to be retired. I thought about forgetting it and worrying about it next weekend. But I know me - it would probably never get done. So I headed back out for one last trip to get some trim paint.

Then I was set with another decision - which color of white should I get? If you've ever chosen white paint, you know there are about 5000 different shades of white. The old colors I had previously used were either a little two yellow or a little too green. So I selected a shade in the same color family as the purple and soon I was back home, painting the trim.

So how is this like coding? Well, if the prep work is the education, then your supplies are the educational institution you select. A higher quality institution means a higher quality you. I could have painted the trim with the yucky, rotten back up paint, but it wasn't the shade of white I really wanted and I knew the end result would not hold up to my standards. You can select an education based on cost, time, or promises the institution makes to you. But is it really a quality institution? There's a reason some educational institutions are more expensive. The only real answer to this is to get references from people in the industry. If you are working with a school, ask them to provide references from graduates. Make sure that the education you're seeking will set you up for the job you want, which means preparing you for the right certifications.

If you select the wrong educational institution only to find out later that it's an issue with hiring managers, be prepared to go back. Trust me. I was not happy that I had to go back to the paint store. But I am very happy with the end result. If you can't get anywhere with the education you received previously, find out what you need to do to get the education that will get you somewhere.

Don't Forget to Accessorize
Since I have fantasies of making a living transforming people's living spaces, for me no room is complete until it's been redesigned down to the last accessory. I've had this bathroom remodel planned for months, inspired by some personal stationary. I searched in stores and online for the perfect (and affordable) shower curtain, wall hangings, light fixture, and other room accessories. The end result was a complete cosmetic overhaul - the only thing I kept in the room besides the existing plumbing fixtures were the towel bars and soap dispenser. These final touches make all the difference. Let's face it - without them, this room is just a giant grape.

I always recommend that people accessorize their coding careers by picking up a specialty (or two). It's going to make the difference between you as a coder and you as a highly skilled coder. Specialties such as interventional radiology, cardiac catheterization, pain management, and radiation oncology are very difficult areas in coding. If you can code any of those specialties - and keep up with the frequent changing in coding rules and regulations - you will be highly marketable. But be careful. Unless you are willing to relocate to get a job, make sure you are seeking a specialty that is in demand in your geographic area.

When is the Painting Done?
I would like to tell you that the bathroom is done and it's beautiful and I will never change it. The truth is, I still need to replace the broken light fixture, hang the vanity mirror, and do a couple of touch ups. In another few years I will probably be sick of the color and want to change it again.

Likewise, once you complete your coding education, you won't be done. Coding requires continuous education to maintain your certification and keep up with medical technologies. And just when you get that most difficult area of coding down, Medicare will change the rules and you'll have to learn it all over again.

So keep up those painting skills and best of luck on your career remodel!