Www.reimbursementspecialist.com



IntroductionProfessional Coding Certifications: CPC or CCS-P American Academy of Professional Coders AAPC (for profit)~1988CPC Certified Professional Coder CPC is doctors’ services codingCPC-AApprentice - ‘A’ represents Apprentice and signifies less than 2 years experienceNo experienceTakes ADDIN AudioMarker 8151 2 years experience to work off the ‘A’ ADDIN AudioMarker 8160 this class counts as one yearCOC Certified Outpatient Coder (OPPS) OutpatientFor example: ADDIN AudioMarker 2440 ER or hospital clinicsCIRCC Certified Interventional Radiology Cardiovascular Coder CPC Exam 150 questions5 hours 40 minutes Multiple choice 70% needed to pass$90 membership $325 examTwo tries Once one achieves the CPC credential18 CEUs must be accumulated every yearCEUs are submitted into the AAPC website every two years (36 CEUs) Membership must be renewed every year. AHIMA American Health Information Management Association (not-for-profit) ~AHIMA – taking care of records in acute care hospital AHIMA Credentials:RHIA Registered Health Information Administrator RHIT Registered Health Information TechnicianCCS Certified Coding Specialist (IPPS)CCS-P Certified Coding Specialist Physician Based CCA Certified Coding Associate CCS-P Exam 4 hours1 hr = 60 multiple choice (10 beta) 3 hrs = cases$300Only one try Possible Career Progression for a Coder: CPC → COC → CCS-P → CCS → RHIT → RHIA CPC → COC → CEMC → COSC →CIRCCThese are only a few among many possibilities. Conditions = diagnoses = ICD-10-CM ICD-10-CMCM = Clinical ModificationUSA onlyAcute Acute Care Hospital Acute care hospital exists to figure out problem and to stabilize patient by using resources (nurses, bed, etc.)Acute = Happening nowInpatient ADDIN AudioMarker 2427 a person who gets admitted ADDIN AudioMarker 3218 A coder in the hospital has to code all the diagnosis CCS credentialed coders work in the inpatient hospitalAHIMA CredentialChronic state of being conditionsFor example: diabetesDiagnostic Study ADDIN AudioMarker 2485 done on a patient in order to discover what the problem is ADDIN AudioMarker 2499 MRI, CT, U/S, Etc.Based on the ADDIN AudioMarker 2543 issues plaguing the patient the physician decides what kind of diagnostics are beneficialDifferential Diagnosis ADDIN AudioMarker 2652 Physician does not know what the actual problem isPresented as, for example: “COPD vs. URI vs. Asthma ADDIN AudioMarker 2660 ”Conclusive Diagnosis = Definitive DiagnosisPhysician ADDIN AudioMarker 2707 knows what the condition is and states what it is ADDIN AudioMarker 3270 office/outpatient visits are Evaluation and Management codesOutpatient vs. Inpatient vs. Doctors’ officesMedicare ADDIN AudioMarker 8256 Part AinpatientPart B ADDIN AudioMarker 8266 Professional and outpatientPart C (Medicare Advantage)Health planLike HMOAge-in after a certain age ADDIN AudioMarker 8759 Once a person has a chronic conditions, they are projected to have more expenditures in the futureFee for Service (FFS) ADDIN AudioMarker 8838 service delivered and paid for service ADDIN AudioMarker 8847 group similar conditions together ADDIN AudioMarker 8856 HCC ADDIN AudioMarker 8869 hierarchical category conditionsAcute Care FacilityPerson walks in with gallbladder problem another one walks in with stomach pain problem; stats show they utilized the same amount of resources and look a lot alike and are grouped together Group together is DRGDiagnosis Related GroupSimilar types of conditions are plopped together in one group with the same paymentWhen you read a doctor’s noteAssessment may be an ADDIN AudioMarker 8968 enumeration of conditionsdo not code just from the list of conditions; must review entire note and look at history PCP Primary Care Physician primary care physician ADDIN AudioMarker 12249 HMO makes you select one doctor ADDIN AudioMarker 12273 "gatekeeper" ADDIN AudioMarker 12278 required to order certain servicesreferralsContainment of costCan participate in Medicare program by signing agreement with Medicare that they will be a participating providerAgrees to accept Medicare Fee Schedule as full payment for services rendered to Medicare beneficiariesPhysicians’ profiles – old terminologyIncreased every year based on annual increases of doctors’ chargesWhen a doctor asks to change an audit score or tries to sway you to make coding changes; respond:“ ADDIN AudioMarker 11412 Let’s see the documentation”“ ADDIN AudioMarker 11394 let me check the references and resources”“ ADDIN AudioMarker 11435 let me ask my boss for coding guidance”CMS Centers for Medicare and Medicaid Services used to be referred to as HCFA Health Care Finance Administration Physician Payment Reform (PPR) Physician Fee Schedule Relative Value Units NCHS National Center for Healthcare Statistics Many years ago, a provider could raise his fees annually. Insurance maintained this information in PROFILES. A new MD might only charge a little bit. Case1990 Dr. Old was charging $80 for an office visit; Dr. New was charging $50 for an office visit. Medicare can send all patients to Dr. New or start paying both MDs the same amount. Medicare started PPR = Physician Payment Reform RBRVS Resource-Based Relative Value Scale Resources: 1. Practice Expense (overhead) 2. Work3. Malpractice 99213 = total RVU of 1.0 National Information PE RVU = .5 + Wk RVU = .4 + MP RVU = .1 Total RVU=1.0 * $35 = fee schedule amount of $35 RVU = Relative Value Unit Total RVUs times CF (conversion factor) = Medicare Fee Schedule Allowable Tuscaloosa, AL>>((PE RVU = .5 * .8 =.40) + (Wk RVU = .4 * 1 = .4) + (MP RVU = .1 * .9 = .09)) Total RVU = .89 * $35 = fee schedule amount of $31.15 GPCI = Geographic Practice Cost Index wRVU + PE RVU + MP RVU = Total RVUs Total RVUs * CF = National Fee Schedule Amount ((wRVU (wGPCI)) + (PE RVU (PE GPCI)) + (MP RVU (MP GPCI))) * CF = Local Fee Schedule Amount Participating Provider is one who accepts the fee schedule amount (MFS = Medicare Fee Schedule) as full payment. HCPCS Healthcare Common Procedural Coding System?Level I CPT = Current Procedural Terminology?Level II alphanumeric, supplies, drugs, DME (A-V)(durable medical equipment) Level III local (Medi-Cal) still use alphanumeric (W – Z) NCCI =National Correct Coding Initiative SYNONYM Column I Column II Prevents unbundling Edits When you reach this page, you will see ‘PTP’, this stands for Procedure To Procedure: CLIA Clinical Laboratory Improvement Amendment Waiver certificate for each doctor location where labs are done (POC=Point of Care) Then use a QW modifier with the lab CPT code. For a list of CLIA waived lab tests: {click OKAY} file will open Stark 1 prohibits kickbacks and self-referrals Prohibits physicians from referring patients for certain designated health services paid for by Medicare to any entity in which they have a “financial relationship.”Violation can result in civil action by the OIG.Stark 2 everything else too Anti-Kickback Statute applies to Medicare and any federal healthcare program False Claims Act any little thing that is not right on the claim causes it to be a false claim obamacare tripled the penalties for errorHIPAA Health Insurance Portability and Accountability Act Privacy Act OIG oig. Office of the Inspector General has an Annual Workplan on the website that should be reviewed on an annual basis. Sanctions Civil Monetary Penalties (CMP) Jail time Exclusion from the Medicare/ Medicaid program Industry basicsAMA American Medical AssociationAHA American Hospital AssociationJCAHO Joint Commission on Accreditation of Healthcare OrganizationsNCQA National Committee for Quality Assurance Four Cooperating Parties: AHIMACMS AHANCHS(Monitor the ICD10) Baseline AuditsUsually required for starting Compliance Programs Stark I & IICMS-1500 and CMS-1450 RBRVS RVUs3 components or resources: (1) work(2) Practice Expense (overhead)(3)malpractice GPCIs Conversion Factor Medical TerminologyLatin/Greek originComponents: PrefixSuffixroot wordscombining forms Prefix list Suffix list Medical Necessity : the diagnosis code (ICD-10-CM) must complement the procedure code (CPT/HCPCS) ADDIN AudioMarker 3478 Student students.htmlAnswers for textbook and workbook ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download