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PubMed2003

Pulmonary function testing: coding and billing issues.

Clinicians who conduct pulmonary function tests should understand the principles and rules of the coding and billing system for pulmonary function testing. Certain billing codes will not be paid by most insurance payers. To ensure that your pulmonary function tests are appropriately coded, billed, and paid: (1) obtain a Current Procedural Terminology (CPT) coding book and an International Classification of Diseases 9th Revision (ICD-9) diagnosis book, and understand how they are used in setting coding and billing strategies, (2) know the people in your facility who do the billing and work with them to produce an appropriate coding and billing strategy, (3) make sure the physicians are involved in developing and implementing your coding and billing strategy, and (4) assure that your laboratory is set up properly to follows the Medicare rules for participation, that you have the appropriate testing supervision, that the appropriate administrative structure is in place to assure compliance with all regulations, and that you meet American Thoracic Society testing standards.

Fees and Charges↗

PubMed2000

Teen compliance with contraception. Analysis Of the ohio medicaid claims data

Background: Teen pregnancy is an important and costly issue for society and often commits the mother to a life of poverty. Physicians play an important role in preventing teen pregnancy by identifying teens at risk for pregnancy and prescribing contraception. This study examines for the first time, whether pharmacy data can be used to evaluate teens' compliance with contraception. Such a method may be useful to physician groups, health plans or state agencies to identify teens at risk for unwanted pregnancy and target interventions.Methods: Secondary analysis of the Ohio Medicaid Claims Data from 1998 was done identifying continuously enrolled young women ages 12-19 years, at high risk for pregnancy defined by ICD 9 codes for an STD, an abnormal pap smear, contraception, or a CPT code for a pregnancy test.Results: Between 1/1/98-3/31/98 we identified 4009 females, ages 12-19 years at high risk for pregnancy. During the study interval, 1084 (27%) became pregnant. 1732 (43%) used no prescription contraception and 1190 (30%) used a method at some time. Depo only (551) and OCP only (552) use was equal. Eighty-three combined the use of Depo and OCP. Compliance was poor. Only 20% of the contracepting group had coverage for the full year and approximately 30% used a method for 3 months or less. There was little difference in age or concurrent chronic physical or mental illness between the contracepting and non-contracepting groups. General practice physicians provided 40% of the OCP prescriptions to teens compared with 36% Ob/Gyn, 10% Pediatrics, and 6% Internal Medicine.Conclusions: Analysis of pharmacy data to evaluate the contraceptive compliance of teens at high risk for pregnancy demonstrated poor compliance. This may be a useful tool for identifying teens at risk for unwanted pregnancy and targeting interventions.

Journal Article↗

PubMed1992

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study.

OBJECTIVE: As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work. METHOD: A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods. RESULTS: The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.

Fee Schedules↗

PubMedDate not supplied

Practical tips on coding for diabetes care.

This article is designed to assist with the challenging effort to obtain reimbursement for health-care services to patients with diabetes. The basics of coding diagnoses and services are presented, including background information and specific examples of the use of codes that are particularly pertinent to the clinical endocrinologist's care of the patient with diabetes. The coding of diagnoses with use of the current International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM) classification system and the coding of outpatient and inpatient services by using current procedural terminology (CPT) codes and modifiers are outlined, including the use of the relatively new prolonged physician services codes. A discussion of reimbursement for diabetes education and pertinent revenue codes for hospital services is included, and resource references for further study are provided.

Journal Article↗

PubMed2001

Coding and billing in the pediatric intensive care unit.

Physicians need to be proficient in their use of CPT codes and ICD-9 codes. They must participate actively and be knowledgeable of their billing process. An organized approach to coding and billing has been suggested by the American Academy of Pediatrics, as outlined in the following box. Physicians are ultimately responsible for any bill submitted in their name. Therefore, close scrutiny of the coding and billing procedures is paramount. Even if mistakes are made in the billing process beyond physicians' input, physicians still may be held responsible. If physicians do their own coding, the bills become more accurate, which can result in higher reimbursement. Physicians also should have a functional compliance plan in place, whether practicing in a large faculty group practice or practicing solo, with the ability to audit the coding and billing process and respond to variances if they are found. By being more involved in the process, physicians can have a more efficient billing system that avoids the potential for fraud and abuse and improves collections.

Forms and Records Control↗

PubMed2002

A data mining approach to characterizing medical code usage patterns.

This research describes a synthetic data mining approach to identifying diagnostic (ICD-9) and procedure (CPT) code usage patterns in two US. hospitals, with the goal of determining the adequacy and effectiveness of the current coding classification systems. We combine relative frequency measurements with measures of industry concentration borrowed from industrial economics in order to (1) ascertain the extent to which physicians utilize the available codes in classifying patients and (2) discover the factors that impinge on code usage. Our results partition the domain into areas for which the coding systems perform well and those areas for which the systems perform relatively poorly. The goal is to use this approach to understand how coding systems are used and to highlight areas for targeted improvement of the current coding

Data Interpretation, Statistical↗

PubMed1996

Penetrating hepatic trauma in children: operating room or not?

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

Adolescent↗

PubMed1996

Assessing mammography rates for Medicaid recipients age 50 to 65 years using claims data from a southeastern state.

A retrospective Medicaid claims data analysis for physician-submitted mammography procedure codes was performed for all continuously eligible female Louisiana Medicaid recipients in 1994. The study measured mammography screening and diagnostic radiology procedures, using CPT coding logic. The study population consisted of 19,688 female Medicaid recipients, age 50 to 65, comprising 55% of the total female Medicaid recipients within Louisiana. In this cohort, 18.3% received a mammogram, with approximately 50% being diagnostic mammography procedures. No significant racial difference in utilization of mammography was found for this population. This claims data analysis suggests that Louisiana's Medicaid population appears to be underserved with respect to mammography screening. The authors conclude that community, physician, and public health resources would be well served to place more emphasis on educational and other outreach programs. Louisiana has to increase its rates for Medicaid recipients by 50% to meet the goal of screening 60% of eligible women every 2 years as set forth in Healthy people 2000, by the United States Public Health Service.

Aged↗

PubMed2004

Reporting instruction for radiology residents.

RATIONALE AND OBJECTIVES: To determine the amount of formal instruction and evaluation about reporting given to radiology residents in the U.S.A., to document report generation methods and to quantify the performance of physician coding. MATERIALS AND METHODS: E-mail requests with links to a web-based, anonymous survey were sent to program directors of all accredited radiology residencies in the USA. Demographic questions included university or private affiliation, number of residents, geographic location, and number of hospitals covered. Subject-specific items covered the amount of didactic instruction, formal evaluation of reports, and use of structured reports. A didactic activity index (DAI) was calculated as the sum of answers to domain-specific questions and tested for relation to demographic variables. We also asked about dictation methods and International Classification of Diseases (ICD) or Common Procedural Terminology (CPT) coding of examinations by radiologists. RESULTS: Of the 191 active radiology residencies, 151 (79%) completed the survey. Responses for hours of didactic instruction in reporting given more than a 4-year residency were distributed as follows: 0-1 = 40%, 2-4 = 46%, >4 = 14%. The percentage of resident reports formally graded was distributed as follows: 0-1 = 82%, 2-4 = 8%, >4 = 10%. The extent to which faculty-designed, structured reports were used by residents was distributed as follows: none = 16%, minimal = 25%, few = 17%, some = 33%, most = 9%. The DAI was normally distributed with a mean of 14.8 and a standard deviation of 2.4. Military programs had higher DAIs than university residencies (P = .03). There was no significant relation between any other program demographic variables and the DAI (P > .05). A substantial number of programs reported that physicians performed coding for some or most studies: ICD-9 = 30%, CPT = 26%. The dominant method for report generation was human transcription in 79% followed by speech recognition at 19%. Speech recognition penetration (departments reporting use of the technology for at least some dictation) was estimated to be 38%. CONCLUSION: In 86% of sampled radiology residencies, trainees receive no more than one hour of didactic instruction in radiology reporting per year. An aggregate measure of didactic activity about interpretative reporting was identical across all program demographic variables except that military residencies seemed to do slightly more than those located at universities.

Data Collection↗

PubMed1999

Prospecting for gold in the data mine.

As a transaction based industry, health care is data rich. A new generation of business-supporting information technology is emerging that can transform such data into knowledge critical to sustain value in health care. In order to adopt successfully this new information technology, physicians and other health care leaders must come to understand the value of complete, accurate and consistent coding of clinical activities. The clinical laboratory has a pervasive role in health care. With its recent federally assigned responsibility to assure clinically relevant testing through ICD-9-CM and CPT coding, and its experience with computerized information systems, the clinical laboratory is in an ideal position to become a champion of the new information technology.

Clinical Laboratory Information Systems↗

PubMed1992

Coding and reimbursement of primary care biopsy and destruction procedures.

Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.

Abstracting and Indexing↗

PubMed2004

Medicare's bundling of trauma care codes violates relative value principles.

BACKGROUND: Physician payment by Medicare is based on a Resource-Based Relative Value Scale (RBRVS). The Correct Coding Initiative (CCI) was introduced to counter unbundling by pairing component procedures with more comprehensive procedures. We hypothesized that Medicare's rebundling process ignored relative value concepts. METHODS: CCI tables were downloaded from Medicare's website. Each comprehensive code's Relative Value Units (RVUs) were compared with component RVUs. Trauma, Burn, and Critical Care (TBC) surgeon charges were analyzed to determine whether component services had higher RVUs than the comprehensive charge. RESULTS: 2,990 component CPT codes had total RVUs exceeding the RVUs of their paired comprehensive codes. If the undervalued comprehensive codes had been valued at their highest component's value, the minimum additional revenue would have been $211,600.59 per surgeon per year. CONCLUSION: A relative value scale depends upon equity in value units. Disregarding RVUs when bundling services and procedures results in severe physician underpayment.

Current Procedural Terminology↗

PubMed2006

How clean are your bills?

An audit of the UB-92 should address the following questions: Are all current procedural terminology codes assigned by health information management transferred to the bill? Are all services and medications being correctly captured? Are services being "double charged" by departments that do not understand the complexity of the billing process? Are all CPT codes in the chargemaster appearing on the claims?

Accounts Payable and Receivable↗

PubMed2004

Determining benchmarks for evaluation and management coding in an academic division of general surgery.

BACKGROUND: Academic divisions of general surgery are facing ever-increasing financial pressures. Cost-cutting is a common approach to maintaining profitability, but strategies to increase revenue should not be ignored. One specific avenue for enhanced revenue generation in general surgery is that of coding for evaluation and management (E&M). Although this is the financial life-blood for many of the consultative services in departments of medicine, E&M coding is an often neglected and misunderstood component of surgical care. STUDY DESIGN: The financial records for the Division of General Surgery were reviewed for the period of January 2001 to June 2003. Specifically, charges and receipts for inpatient procedures and hospital visits (CPT codes 99231, 99232, and 99233) were determined. The analysis was limited to surgeons with a primary clinical focus based at the University hospital rather than the neighboring community or Veteran's Affairs hospitals. In addition, ICD-9 and All Patient Refined Diagnosis Related Groups (APR-DRG) data were analyzed to determine the surgeon-specific number of inpatients and inpatient-days with more than one ICD-9 code or secondary ICD-9 codes, or both, or an APR-DRG severity of illness score of 2, 3, or 4. These categories were defined to determine the number of inpatient-days for which E&M coding could be billed for management of secondary medical diagnoses. RESULTS: Analysis demonstrates that actual E&M charges were 40% to 47% of predicted minimums for E&M charges for the period under study. In theory, this result translates into an annual gain in receipts of 400,000 dollars to 600,000 dollars. CONCLUSIONS: We conclude that the ICD-9 and APR-DRG models may serve as benchmarks to determine the limits for E&M revenue stream, and E&M coding may represent an underutilized source of revenue among academic departments of surgery.

Academic Medical Centers↗

PubMed2005

Interpretation of dermatopathology specimens is within the standard of care of dermatology practice.

BACKGROUND: Laws have been passed in New York, California, New Jersey, Nevada, Louisiana, and Rhode Island and were recently tabled in South Carolina to prohibit providers from billing for pathology services provided by other physicians. The Ohio proposal included language stating that only board-certified pathologists be able to directly bill for anatomic pathology services. Dermatologists, however, have extensive training in dermatopathology and frequently bill anatomic pathology codes. OBJECTIVE: To determine if interpretation of cutaneous pathology falls within the standard of care of dermatology practice. DESIGN: We used Medicare part A and B claims data from the Medicare Current Beneficiary Survey, 1992 to 2000. We identified surgical pathology claims by Current Procedural Terminology (CPT) code 88305 and those related to skin disease by the associated International Classification of Disease, 9th Revision (ICD-9), code. Weights were applied to obtain nationally representative estimates. The number of physicians in each specialty was obtained from American Medical Association estimates. RESULTS: Pathologists, independent laboratories and group practices, and dermatologists submitted 59%, 26%, and 13% of total claims, respectively. For skin-related diagnoses, pathologists, dermatologists, and independent laboratories and group practices performed 34.5%, 31.2%, and 32.8% of cases, respectively. Assuming that independent laboratory and group practice claims were performed entirely by pathologists, dermatologists and pathologists submitted 1,047 and 1,154 cases/physician, respectively. CONCLUSION: Dermatologists have extensive training in dermatopathology and interpret a large proportion of cutaneous specimens. Interpretation of anatomic pathology, in particular, skin and subcutaneous pathology specimens, falls within the scope of dermatology practice.

Adult↗

PubMed2003

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Aged↗

PubMed2002

Evaluating outpatient versus inpatient costs in endophthalmitis management.

PURPOSE: To assess the cost savings that would result from 1) implementing the treatment guidelines of the Endophthalmitis Vitrectomy Study (EVS) and 2) performing procedures on an outpatient rather than an inpatient basis, and to compare the savings to the cost of conducting the EVS. METHODS: The coding algorithms for four endophthalmitis treatment groups were obtained from Patient Financial Services at the Anne Bates Leach Eye Hospital (ABLEH) and national Medicare averages were consulted for reimbursements in 2000 dollars. The four groups were: 1) inpatient pars plana vitrectomy (PPV) with intravenous antibiotics; 2) outpatient PPV; 3) inpatient vitreous tap with intravenous antibiotics; and 4) outpatient vitreous tap. Physician reimbursements were calculated using International Classification of Diseases-9 (ICD-9) diagnoses and Current Procedural Terminology (CPT) codes. Facility reimbursements were calculated using ICD-9 diagnoses and Diagnosis-Related Group codes for inpatient procedures versus Ambulatory Payment Classification codes for outpatient procedures. The annual savings in reimbursements were estimated for a range of annual incidence rates of endophthalmitis assuming ABLEH financial data across all patients in the United States, and the savings into the future as well as the total expenses of conducting the EVS from 1989 to 1995 were summed in 2000 dollars using a net present value analysis based on the Bureau of Labor Statistics consumer price indices. RESULTS: Facility reimbursements are significantly higher for procedures performed on an inpatient compared to an outpatient basis (P < 0.001). Treating endophthalmitis according to the EVS guidelines on an outpatient basis would be associated with an estimated $1.5 to $7.8 million reduction in reimbursements per year. The cost of the EVS in 2000 dollars was $4.0 million. CONCLUSIONS: Implementing the treatment guidelines of the EVS on an outpatient basis may result in significant cost savings--savings that may cover the entire cost of the EVS in 3 years.

Ambulatory Care↗

PubMed2005

Physician documentation in support of appropriate billing with modifier '-25'.

What is one of the surest ways for a practice to lose revenue and invite the unwanted attention of government auditors? By failing to select and document the appropriate use of modifiers to code for services provided. For example, the Office of Inspector General (OIG) has made it known that they will closely review professional billing with the use of modifier '-25.' The use of this particular modifier appeared on their radar screen, because in one recent year Medicare paid approximately 1.7 billion dollars for Evaluation and Management (E/M) services billed with modifier '-25'. The OIG feels an increase of this amount warrants further investigation to determine if these claims were billed and reimbursed appropriately. Additionally, Oklahoma Medicaid auditors are actively scrutinizing the use of modifier '-25' to a degree even more stringent than Medicare and the CPT code book's description allow. Therefore, it is important that physicians be knowledgeable in determining when it is appropriate to bill using this modifier.

Current Procedural Terminology↗