Pulmonology Coding Alert

n an effort to promote the highest levels of professional knowledge, service and ethics, the clinical coders and other health information management professionals who make up the American Health Information Management Association (AHIMA) have revised and released new Standards of Ethical Coding. In keeping with AHIMAs customary emphasis on extensive and continuing education, the new standards hold medical information professionals responsible not only for making moral decisions but also for keeping themselves, their colleagues, and even their employers abreast of the latest changes in coding regulations and practices. Now that governmental agencies are concentrating so heavily on uncovering fraud and abuse, physicians facing a random audit would do well to have on staff a coder who follows the AHIMA standards.

Greg Schnitzer, RN, CPC, CPC-H, CCS-P, vice president for coding compliance at CodeRyte Inc., a coding software firm in Bethesda, Md., says that AHIMAs guidelines are not legally enforceable, but they do provide a clear framework for professional comportment. Schnitzer observes that the standards are based on common sense. Their value is that they are an established, written document for professional conduct.

The complete set of 10 codes is available on the AHIMAs Web site at www.ahima.org.

Link Diagnosis Codes With Procedural Codes

AHIMA Guideline Number 2: Coding professionals in all healthcare settings should adhere to the ICD-9 coding conventions; official coding guidelines approved by the American Health Information Management Association, American Hospital Association, Health Care Financing Administration, and National Center for Health Statistics; the CPT rules established by the American Medical Association (AMA) and any other official coding rules and guidelines established for use with mandated standard code sets. Selection and sequencing of diagnoses and procedures must meet the definitions of required data sets for applicable healthcare settings.

Cynthia DeVries, RN, BSN, CPC, a coding coordinator with the Lee Physician Group, a 42-physician practice in Ft. Myers, Fla., teaches correct coding to physicians and their employees. She says standard number two demonstrates how important it is, with regard to securing appropriate reimbursement, to correctly link diagnosis codes with procedure codes.

DeVries illustrates, using the example of a patient diagnosed with pulmonary hypertension (416.0-416.9). The initial presentation constitutes an office visit (99211-99215, office or other outpatient visit for the evaluation and management [E/M] of an established patient). Suppose the patient also is having extreme shortness of breath due to a pleural effusion (511.9), DeVries says. The physician schedules a thoracentesis (32000). Both procedures should be reimbursed if the pleural effusion is linked with the thoracentesis and the hypertension is linked with the office visit. Append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Protect Your Reimbursement: Put It in Writing

AHIMA Guideline Number 6: Coding professionals should not change codes or the narratives of codes on the billing abstract so that the meanings are misrepresented. Diagnoses or procedures should not be included or excluded inappropriately because the payment or insurance policy coverage requirements will be affected. When individual payer policies conflict with official coding rules and guidelines, these policies should be obtained in writing whenever possible. Reasonable efforts should be made to educate the payer on proper coding practices in order to influence a change in the payers policy.

Don Self, CSS, BFMA, president of Don Self & Associates Inc., in Whitehouse, Texas, which assists physician practices with reimbursement and claims coding, says that fully understanding the implications of standard number six is critical because some insurance carriers make up their own coding rules, which can keep you from getting reimbursements to which youre ethically entitled.

For example, Self says, Neither Blue Cross/Blue Shield nor United Healthcare allows modifier -25. Yet, the HCFA standard coding rules, state that the -25 modifier is a valid modifier. The policy may vary by state. To be reimbursed, Self suggests that the provider get a written policy contract from the payer and internally publicize among employees the rules of the contract.

Cynthia Thompson, CPC, senior consultant at Gates, Moore & Co, a physician-practice management-consulting firm in Atlanta, concurs with Self. Thompson says standard number six is particularly relevant when it comes to code 99000 (handling and/or conveyance of specimen for transfer from the physicians office to a laboratory). She points out that some of the commercial carriers are paying this, but adds, Code 99000 for Medicare is not to be used unless you have to pay someone to pick up a specimen. She suggests you get a written agreement from the carrier stating whether it considers specimen handling/conveyance a covered service. Thats your protection, if the carrier comes back and says, We discovered we arent supposed to be doing this, and we want our money back. Youre protected in writing.

Proper Documentation Promotes Correct Coding

AHIMA Guideline Number 7: Coding professionals, as members of the healthcare team, should assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and the occurrence of events.

Thompson also sees a thorough understanding of the standards as vital to obtain the maximum allowable reimbursement As an example, a coder may receive a prepayment review request. While reviewing the request, the coder finds a certain pattern of physician coding errors. A common scenario is billing an office visit (99214) in addition to a procedure without sufficient documentation to support the office visit level of service. As part of a formal compliance program or to ensure that this physician understands what needs to be done, continues Thompson, the certified coder should sit down with that physician to review the problems and help the physician cover all the bases.

Develop Complementary Compliance Policies

AHIMA Guideline Number 8:Coding professionals should participate in the development of institutional coding policies and should ensure that coding policies complement, not conflict with, official coding rules and guidelines.

This standard calls for coding professionals to ensure that coding policies take official coding rules and guidelines into consideration. Thompson, who helps clients develop coding-compliance plans, says this standard means the professional coder is responsible for determining the validity of documentation and ensuring that any services billed actually were rendered. Such compliance, Thompson says, applies to federal and state rules and regulations, and carrier rules and regulations.

The best insurance for compliant billing is to employ a truly qualified, well-trained staff or a billing service that will review explanations of benefits (EOB) for recurring reasons that claims are being denied. The office manager, clinic administrator or billing service should reconcile the EOBs with the medical records. Multiple denials for reasons such as bundling or lack of medical necessity could indicate that a physician should check the coding and perhaps appeal the decision. Occasionally, payers may misinterpret codes or interpret them to fit their payment processing schedule, but payers who receive proper documentation and an explanation of their error usually will correct the problem.