6/30/2015. Physician Revenue Cycle: Basics and Beginnings. Today s Agenda. Codes by Setting

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1 Revenue Cycle: Basics and Beginnings Leigh Williams CPC, CPHIMS AHIMA Approved ICD-10-CM/PCS Trainer Director, Revenue Cycle/HIM Today s Agenda Terminology for code sets ICD Modifier RVU What about ICD-10? fee billing Coding scenario Hospital fee billing by Setting Procedure vol. 3 1

2 International Classification of Diseases (ICD) Code set used to classify diseases, conditions, injuries, congenital abnormalities, symptoms, poisonings, and external causes of injury Governed internationally by the World Health Organization Modified in the U.S. by the National Center for Health Statistics called the Clinical Modification or CM Examples of Unspecified hemiplegia - nondominant side Acute Respiratory Failure 430 Subarachnoid Hemorrhage Current Procedural Terminology () Code set used to describe physician services Published by the American Medical Association Describes services provided by physicians and hospital outpatient services Six main categories: Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine 2

3 Examples of Decompression; unspecified nerve(s) Arthrodesis, sacroiliac joint (including obtaining graft) Modifiers Reports that the service or procedure has been altered in some way Used to communicate special circumstances to payors May increase or decrease reimbursement Examples of Modifiers 22 Increased procedural services 24 Unrelated E&M service by the same physician during the post-op period 50 Bilateral procedure 62 Two surgeons 78 Unplanned return to the operating room by the same physician following initial procedure 3

4 Work Relative Value Unit (WRVU) Assigned to a The standard relative values per procedure include the following elements: 1. work (technical skill, effort) 2. Practice expense (facility overhead) 3. Malpractice expense (insurance) Updated annually in the Federal Register Used to provide a standard value to the work performed Examples of wrvus Decompression; unspecified nerve(s) is worth 4.82 wrvus Arthrodesis, sacroiliac joint (including obtaining graft) is worth wrvus What about ICD-10? Tenth revision of the International Classification of Diseases Compliance date will be October 1, 2015 Training will commence this summer Focus on complete and timely documentation 4

5 by Setting - Today Procedure vol. 3 by Setting - Future ICD-10-CM ICD-10-CM ICD-10-CM Procedure ICD-10-PCS What about ICD-10-CM? Unspecified hemiplegia - nondominant side becomes G81.93 Hemiplegia, unspecified affecting right nondominant side or G81.94 Hemiplegia, unspecified affecting left nondominant side 5

6 What about ICD-10-CM? Acute Respiratory Failure becomes J96.ØØ Acute respiratory failure, unspecified whether with hypoxia or hypercapnia or J96.9Ø Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia And ICD-10-PCS? 36 new root operations the coders must use to classify all procedures 03VG0CZ Root Operation: Restriction Restriction, Artery, Intracranial (03VG) Rationale: Section: Medical and Surgical 0 Body System: Upper Arteries 3 Root Operation: Restriction V Body Part: Intracranial Artery G Approach: Open 0 Device: Extraluminal Device C Qualifier: No Qualifier Z Billing for a Fee fees require a procedure/service code () and a diagnosis (ICD) code to compile a claim Tells what you did () and why you did it (ICD) Payors assess medical necessity by pairing the ICD and code they have to make sense together 6

7 Billing for a Hospital Fee Hospital fees require the same for outpatient services Inpatient services use DRGs (next session!) A diagnosis related group does the same: tells the story about why the patient was admitted and what services were performed Uses the same documentation as charted for the physician fee, but also allows for charges and supplies billed by other clinicians by Setting - Today Procedure vol. 3 Time for Your Questions 7

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