Do I Have the Right Credential? AAPC National Conference April 2013 Judy Wilson CPC,CPC-H,CPCO,CPC-P,CPPM,CPCI,CANPC,CMRS Jaci Johnson CPC,CPC-H,CPMA,CEMC,CPC-I
Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and regulations. However, application of the information in this text does not guarantee claims payment. Payers interpretation may vary from those found in this text. Please note that the law, applicable regulations, payer instructions, interpretations, enforcement, etc., may change at any time. Therefore, it is crucial to stay current with all local and national regulations and policies.
So Why Are We Here? What are the goals? From a work perspective Identify some basic differences in the CPC and CPC-H credential Identify some basic similarities
CPC-H Exam 150 questions 5 hours, 40 minutes Open Book CPT, ICD-9 (Volumes 1 and 2), HCPCS Level II Tests knowledge of coding for the outpatient hospital and ASC facilities, ICD-9-CM, revenue codes, and APCs.
CPC-H Exam Format Medical Terminology (10) Anatomy (10) Coding Concepts (10) Payment Methodologies (15) Compliance (5) ICD-9-CM (30) CPT Coding (20) HCPCS Level II (10) Surgery and Modifiers (40)
CPC-H Overview The CPC-H credential recognizes expertise in the area of outpatient hospital, hospital-based ambulatory surgical center coding, and independent ambulatory surgery centers (ASC). In most hospitals, coding is performed in several different areas including: Provider based clinics HIM department CPT, ICD-9-CM, HCPCS Level II surgical coding, etc. Ancillary clinical departments Through CDM
Overview The CPC-H credentialing examination will cover general billing questions for a facility as well as general code assignment for all areas of CPT, with emphasis on outpatient surgery coding and ICD-9-CM coding. Understanding the use of revenue codes along with the chargemaster is part of this examination, but memorizing the revenue codes and their assignment will not be necessary.
CPC Exam 150 questions 5 hours, 40 minutes Open Book CPT, ICD-9 (Volumes 1 and 2), HCPCS Level II The CPC examination consists of questions regarding the correct application of CPT, HCPCS Level II procedure and supply codes and ICD-9-CM diagnosis codes used for billing professional medical services to insurance companies.
CPC Exam Format Medical Terminology Anatomy Coding Concepts ICD-9-CM CPT Coding (all six sections and modifiers) HCPCS Level II
CPC Overview Expertise in reviewing and assigning accurate medical codes for diagnoses, procedures, and services performed by physicians and other qualified health care providers Proficiency across a wide range of services, including evaluation and management, anesthesia, surgical services, radiology, pathology and medicine A sound knowledge of medical coding rules and regulations including compliance and reimbursement allowing a CPC to better handle issues such as medical necessity, claims denials, bundling issues and charge capture
CPC Overview Knowing how to integrate medical coding and reimbursement rule changes into a practice's reimbursement processes Knowledge of anatomy, physiology and medical terminology necessary to correctly code provider diagnosis and services
How to Think Facility Differences The service The claim The payment structure
How to Think Facility Same CPT codes ICD-9 codes HCPCS codes Compliance and Documentation Standards
Lets Compare a Typical Surgical Intervention All names have been changed to protect everyone.
A typical day in surgery The day begins at Our Lady of a Better Day Hospital. Ms. Tan (Tough as Nails) has jut arrived to check in for her outpatient surgery. Ms. Tan will undergo a Lap Cholecystectomy possibly with grams under the competent hands of Dr. Gag (Good as Gold).
A typical day in surgery Ms. Tan is sedated, scrubbed and prepped and is now in the OR. Dr. Gag makes the incision and inserts the laparoscope. The gallbladder is not a pretty sight and it is thought best to have a look at the common bile duct as well and a cholangiography is performed.
A typical day in surgery CPC-H Coding Lap Chole with grams - 47563 Status Indicator CPC Coding Lap Chole w grams -47563 RVU
A typical day in surgery Sadly Ms. Tan has had some issues in her past and it is showing up now. The damage to the bile duct as seen on the choliangiogram is caused from severe cirrhosis. Further inspection reveals a mass in the left lateral segment of the liver which requires resection.
Oh My!! Just as an incision is made to access the liver and begin the resection Ms. Tan becomes extremely hypotensive.
A typical day in surgery Alas, she stands by her name and Ms. Tan is stabilized and Dr. Gag requests a central line and arterial line placed.
A typical day in surgery CPC-H Coding Central Line - 36556 CPC Coding Central Line - 36556 Arterial Line - 36620 Arterial Line - 36620
A typical day in surgery Dr. Gag decides based on the messy state of affairs that perhaps a roux en y bypass would be the best course of action for this patient.
A typical day in surgery CPC-H Coding Roux-en-Y 47740 CPC Coding Roux-en-Y 47740
A typical day in surgery Our patient is stable, closed, and is in recovery. When Ms. Tan awakes a tad later, she is feeling exceptionally well and feels strongly that she must go home totally disregarding Dr. Gag s pleas to have her committed oops admitted. Ms. Tan feels is most important to get on home and feed the cats.
So, then what happens? UB Our Lady of a Better Day Surgery which ones? Modifiers? Status Indicators? Anesthesia? CMS 1500 Dr. Gag Surgery which ones? Modifiers?
So, then what happens? UB Diagnosis Coding Our Lady of a Better Day Pre Operative Post -Operative CMS 1500 Diagnosis Coding Dr. Gag Pre Operative Post Operative
So. Most of the differences will be in understanding a payment methodology. Which CPT codes are allowed? Which modifiers should be used? How will payment determinations be made? A thorough understanding of correct CPT code application and diagnosis coding will be vital with either credential.
So what if? What if Dr. Gag and the anesthesia team were not able to stabilize Ms. Tan and the surgery did not continue? Modifier for Dr. Gag Modifier for Our Lady of Better Day
Thank you!!