Need a crash course in coding!

[EtherBunny]

I'm about to finish my fellowship and I've started looking at coding for procedures. It seems incredibly convoluted and confusing, with multiple seemingly identical codes that pay out differently. Can somebody please explain some of this nonsense to me? We don't get any guidance in fellowship and every time I ask my attendings a coding question, it's pretty obvious that they have no idea.

A cross-section through my confusion...

**ICD-9 codes: My understanding is that ICD-9 codes are mostly for diagnoses but on the Medtronic website there are ICD-9 codes for procedures (e.g., 03.90 for "Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances"). Will I ever have to know the ICD-9 codes for procedures? I've only used them in fellowship for documenting diagnoses.

**HCPS II device codes and Device C codes: what the hell are these things? I have literally never even heard of them before.

**CPT codes: What's the difference between CPT codes and ICD-9 codes? Do the CPT codes only apply to the professional fees or do they apply to facility fee billing too? Can you use more than one CPT code for a procedure?

**HOPD, ASC, vs. physician fee schedules: The thing I don't understand is the difference between HOPD and physician fees. Is the physician's fee lumped into the HOPD fee or are they separate? Also, do the HOPD fees cover the costs of hospitalization? For example, if a patient gets an intrathecal pump implant and stays in house for one day, is the hospitalization billed separately or does the HOPD reimbursement for an intrathecal pump implant (roughly $14000) cover the ENTIRE cost of the encounter (OR time, cost of the implant itself, PACU care, 1 day of inpatient stay, etc.)?

This crap is so incredibly confusing! I feel like I need to take a course on billing. For example, there are 6 different codes for a pump refill and interrogation. Why? They all seem the freakin same!

Any help would be greatly appreciated. Sorry if these are stupid questions but I've been so focused on learning medicine that I haven't really learned a lot of the practice management stuff.

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[SSdoc33]

I'm about to finish my fellowship and I've started looking at coding for procedures. It seems incredibly convoluted and confusing, with multiple seemingly identical codes that pay out differently. Can somebody please explain some of this nonsense to me? We don't get any guidance in fellowship and every time I ask my attendings a coding question, it's pretty obvious that they have no idea (the billing is handled by our administration).

**My understanding is that ICD-9 codes are mostly for diagnoses but on the Medtronic website there are ICD-9 codes for procedures (e.g., 03.90 for "Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances"). Will I ever have to know the ICD-9 codes for procedures? I've only used them in fellowship for documenting diagnoses.

**Also on the Medtronic site: "HCPS II device codes" and "Device C codes." What the hell are these things? I have literally never even heard of them before.

**Then we have all the lovely physician billing codes (the "CPT codes" right?). Why are there 6 different codes for a pump refill and interrogation? They all seem the freakin same!

**On the ASIPP site they have tables for HOPD, ASC, and physician fees. The thing I don't understand is the difference between HOPD and physician fees. Is the physician's fee lumped into the HOPD fee or are they separate? Also, do the HOPD fees cover the costs of hospitalization? For example, if a patient gets an intrathecal pump implant and stays in house for one day, is the hospitalization billed separately or does the HOPD reimbursement for an intrathecal pump implant (roughly $14000) cover the ENTIRE cost of the encounter (OR time, cost of the implant itself, PACU care, 1 day of inpatient stay, etc.)?

This crap is so incredibly confusing! I feel like I need to take a course on billing.

Any help would be greatly appreciated. Sorry if these are stupid questions but I've been so focused on learning medicine that I haven't really learned a lot of the practice management stuff.

ICD 9 or 10 codes are for diagnoses.
CPT codes are for procedures

some CPT codes are only reimbursed with certain ICD codes. this is payor-specific and region specific.

your attendings are a joke if they dont know this or cant teach you the basics.

dont worry about the HOPD/ASC/physician's fees yet. this might be important depending on which type of job you end up in.

focus on appropriate billing level (as directed by CMS on their website) and CPT coding with procedures.

it is daunting, but becomes wrote after a while

 

[Ducttape]

first things first - attendings at academic institutions usually dont do that much coding. there is a reason they are in academics, and its not because they are financial wizards.

there will be a coder for the department, and you need to arrange a sit down with that coder before you leave the fellowship.

every patient you see will get a diagnosis code (ICD-9/10) and a procedure code (CPT - follow ups and evaluations have CPT codes 992xx)

second, ICD 10 codes are for diagnoses. learning mostly ICD 10 codes will save you some time and effort as ICD 9 might get phased out soon (next year).

fees do depend on the type of job you get. figuring out the rest is sometimes why it is best to join a practice, so you get time to learn the ropes on coding.


im sure ppl will be more than happy to correct me if im wrong, but here is an example or two:

for example, you see a patient with postlaminectomy syndrome of the lumbar spine and you do a follow up, 15 or so minutes, moderate complexity, expanded problem focused history, problem focused exam, ie level 3
ICD-9: 722.83
CPT: 99213

same patient, but on Nucynta 50 mg qid, and you do a 2 level transforaminal injection on the patient. you have to review meds, review side effects, do a detailed history (inc UDS, PMP, etc.), a detailed PE, and moderate to detailed medical decision making, so a level 4 visit (or 25+ minutes in time based billing).

ICD-9: 722.83 and v58.69 (long term use opiate analgesic)
CPT: 99214 + 64483 (first TF level) +64484 (second TF level, nowadays pays nothing), + 25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. )

(note that what makes this a separately identifiable item is the opioids - if you just see him for 722.83 and decide to do an injection, you cant use 25 modifier, only the TF codes).

 

[lobelsteve]

Failure to teach at institution. This is inexcusable. That said there are people in and out of your delt that do this and can help. Ask for your cpc contact. CPC = certified professional coder.

 

[hyperalgesia]

I'm about to finish my fellowship and I've started looking at coding for procedures. It seems incredibly convoluted and confusing, with multiple seemingly identical codes that pay out differently. Can somebody please explain some of this nonsense to me? We don't get any guidance in fellowship and every time I ask my attendings a coding question, it's pretty obvious that they have no idea.

A cross-section through my confusion...

**ICD-9 codes: My understanding is that ICD-9 codes are mostly for diagnoses but on the Medtronic website there are ICD-9 codes for procedures (e.g., 03.90 for "Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances"). Will I ever have to know the ICD-9 codes for procedures? I've only used them in fellowship for documenting diagnoses.

**HCPS II device codes and Device C codes: what the hell are these things? I have literally never even heard of them before.

**CPT codes: What's the difference between CPT codes and ICD-9 codes? Do the CPT codes only apply to the professional fees or do they apply to facility fee billing too? Can you use more than one CPT code for a procedure?

**HOPD, ASC, vs. physician fee schedules: The thing I don't understand is the difference between HOPD and physician fees. Is the physician's fee lumped into the HOPD fee or are they separate? Also, do the HOPD fees cover the costs of hospitalization? For example, if a patient gets an intrathecal pump implant and stays in house for one day, is the hospitalization billed separately or does the HOPD reimbursement for an intrathecal pump implant (roughly $14000) cover the ENTIRE cost of the encounter (OR time, cost of the implant itself, PACU care, 1 day of inpatient stay, etc.)?

This crap is so incredibly confusing! I feel like I need to take a course on billing. For example, there are 6 different codes for a pump refill and interrogation. Why? They all seem the freakin same!

Any help would be greatly appreciated. Sorry if these are stupid questions but I've been so focused on learning medicine that I haven't really learned a lot of the practice management stuff.

Reimbursement is based on CPT procedure codes and justified by ICD diagnosis codes.
My favorite handy CPT resource: Physician Fee Schedule at http://www.asipp.org/feeschedules.html
My favorite ICD 9/10 resource: Google
It is a learning process. There are forums like this for coding professionals and all they do is debate how to code. So don't expect to be an expert over night. You can always google any code and often find a vigorous debate about it.

 

[NOSfan]

My favorite ICD 9/10 resource: Google

ICD: http://icd9cm.chrisendres.com/index.php
CPT: https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do

Note the AMA CPT website used to also show the breakdown of the CPT (wRVU, etc.); however, you need to sign-in now in order to see it

 

[geauxg8rs]

I would contact program director or chair of dept and ask to set up some time with the coder/biller and tell them you want insight into making sure you are documenting correctly. These people need to show that their dept is collecting money and this might show some initiative on your part.
In the end you need your notes to reflect the correct documentation and diagnoses for both progress and procedure. Then need correct coding and billing. The billing/coding will love to talk to you.
This was required at our fellowship

 

[clubdeac]

Here is an excellent resource (thank you Dr. Faubel!). Just click on the billing/coding tab on the top right. I used this when setting up my superbill. These ICD-9/10 and cpt codes should cover about everything you do. I've also attached the ASIPP website which has all the cpt codes and corresponding reimbursements according to site of service - HOPD/office. The only thing you'll need to learn now is when to use the appropriate modifiers: -25, -50, -59, -53, -52 etc. It'll come pretty quickly. And just some advice, stay away from pumps Your life will be a lot simpler

http://thepainsource.com/
http://www.asipp.org/feeschedules.html

 

[emd123]

. And just some advice, stay away from pumps Your life will be a lot simpler

True enough that it should be considered near biblical advice

 

[geauxg8rs]

True enough that it should be considered near biblical advice

11th commandment

 

[bedrock]

Here is an excellent resource (thank you Dr. Faubel!). Just click on the billing/coding tab on the top right. I used this when setting up my superbill. These ICD-9/10 and cpt codes should cover about everything you do. I've also attached the ASIPP website which has all the cpt codes and corresponding reimbursements according to site of service - HOPD/office. The only thing you'll need to learn now is when to use the appropriate modifiers: -25, -50, -59, -53, -52 etc. It'll come pretty quickly. And just some advice, stay away from pumps Your life will be a lot simpler

http://thepainsource.com/
http://www.asipp.org/feeschedules.html

Agree with deac. Those two sites are the best, most concise references you'll need for 95% of what we do.

 

[Pacman27]

Learn your Medicare LCDs

Local coverage determination

Go to asipp billing course

 

[emd123]

Agree. Know your LCDs

Agree, to keep the ASIPP fee schedule handy. That's going to have 95% of your CPT codes you need.

Learn the modifiers (-25, -50)

Learn e & m's (most patients will be a level 3 or 4, 10% or less should be 5's)

Learn multilevel codes (facets, rf, etc)

Learn what's bundled and what isn't.

Finally, if you have a specific question, ask it here. You'll probably get it answered in 10-15 min.

 

[Ducttape]

Finally, if you have a specific question, ask it here. You'll probably get it answered in 10-15 min.

the correct answer but not what the coders tell you

 

[emd123]

the correct answer but not what the coders tell you

Yeah, I know. The coders can't agree on how to code stuff half the time. The CPT system is a nebulous mess, with gray areas.