Medical Coding and Billing Governance
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1 Medical Coding and Billing Governance Casper Venter HealthMan Director
2 Medical Coding in South Africa
3 Current Coding Structures Dilemma Lack of an Authoritative Source Reference for new codes & queries Code Manipulations and billing malpractice exist and on the increase Certain procedures in the past were described by one or two codes with a few additional codes for the complicated case. Now routinely being used and more codes added. Guidelines established are not freely available RPL does not exist Unilateral decision making process by Schemes and Providers Lack of transparency Not all providers support the structure in place Determination of RVU values Lacks transparency and outdated Review of existing RVU values- Top 300 review New technology/techniques Use of existing codes and adding others to make up fee Unnecessary motivations required No guidance
4 Agenda for Coding Governance 1. Statistical Overview 2. General Coding Governance 3. American Medical Association Processes for Guidance 4. South African Classification of Healthcare Interventions ( SACHI ) as a unique RSA Solution
5 Statistical Overview Let s look at some of the statistics that generate medical services invoices
6 Summary of Private Practitioners Category Practitioners Clinical Support Specialists 825 Complementary Medicine 860 Dental Professionals GP s Medical Specialists Supplementary & Allied Health Other Benefit Services 535 Group Practices 150 Unknown 574 Total
7 Medical Scheme Statistics: CMS Annual Report 2011/12 Patient Visits Cost per Visits (R) General Practice Medical Specialist Diagnostics - Radiology Pathology Anaesthetics Optometry Physiotherapy Patient Encounters
8 Specialist Coding Some Facts Code Analysis: Percentage by Value Specialist Payments Code Percentage (%) Consultations 28.98% Modifiers 6.75% Materials 3.12% Procedures & Equipment 61.15%
9 Top 12 Codes All Specialist Disciplines Rank Code Type Code % Utilised Consultation / 0111 Hospital Visit Consultation / 2614 Obstetrics Caesarean &NVD /5 Psychotherapy Consultation nd Surgeon Cons. Hospital /9 Cataract ICU Category Ultra Sound ICU Category
10 Top 12 Procedure Codes All Specialist Disciplines Rank Code Type Code % Utilised /5 Psychotherapy Obstetrics Caesarean /9 Cataract ICU Multiple Organ Failure Ultrasound ICU Category Total Colonoscopy Cardiac Examination Obstetric Normal Delivery Multistage treadmill Arthroplasty: Debridement Joints Upper Gastro Endoscopy 0.83
11 Specialist Coding Some Facts 24 Codes comprise 50.34% of claims 100 Codes comprise 74.92% of claims 200 Codes comprise 85.15% of claims 300 Codes comprise 90.26% of claims 490 Codes comprise 95.01% of claims Codes comprise % of claims
12 General Coding Governance
13 Coding in South Africa 2014 Virtually no progress since 2004 Unnecessary interference by the CC (2003/4?) DoH failed in the RPL process Constitutional Court Judgement on UPFS 2010 Coding is in the domain of Professional Societies Medical Schemes abuse the current position of uncertainty Certain Societies don t have skills or structures to deal with coding changes CMS interference in coding is unnecessary (complaints lodged with CC)
14 Objective of a Comprehensive Coding System To provide a uniform language that accurately describes medical, surgical and diagnostic services, and thereby serves as an effective means for reliable national private and public sector communication amongst all healthcare professionals, patients, funders and administrators, and other stakeholders SACHI
15 What is required in South Africa? To establish an independent multi-stakeholder NPO entity that will manage governance processes. It will not own codes, but will assist with and manage processes related to implementation and management of coding systems.
16 What is required in South Africa? Seek guidance from International experience American Medical Association ( AMA ) Establish a Corporate Governance Structure within a Company registered ito Companies Act 2008 Not-for-profit organisation South African Classification for HealthCare Interventions SACHI
17 AMA Processes 1. Developing Descriptors 2. Relative Value Scale Update Process 3. Practice Expense Review 4. Review and Introduce new Technology
18 Coding Advisory Committee Advises on procedure coding and specialist nomenclature; Documents appropriateness of medical and surgical procedures being considered for inclusion in Coding Manual; Suggests revisions to Coding. Committee meets 2-3 times p.a to discuss items of mutual concern and to keep abreast of current issues in coding and nomenclature; Assists in the review and further development of relevant coding issues and in the preparation of technical education material and articles pertaining to Coding; and Promotes and educates its membership on the use and benefits of accurate Coding.
19 Application and Adjudication Editorial Panel meets 4 times a year to discuss New and emerging technologies Difficulties with procedures and services (esp. relating to codes) Interested parties may submit applications for changes to CPT. Either applicants advised of panel s recommendations if issue has previously been dealt with; or application is referred to the Advisory Committee if a new issue or offering significant new information If no Advisory Panel support, can be withdrawn, otherwise becomes an Agenda item for Editorial Panel discussion at next meeting.
20 Editorial Panel Meetings Schedule allows 3 months for preparation and processing before issues are ready for Panel review. Agenda material prepared for Panel at least 30 days in advance (incl. original application, commentary by Advisory Committee members, ballot for decision) 4 possible outcomes: Addition or revision (will reflect in forthcoming volume of Coding Manual), referral to workgroup for further study, postponement to a future meeting; or rejection. A multi-step process naturally means that deadlines are very important.
21 Category 1 Code Status Category 1 codes (5-digit code & descriptor nomenclature) provide a detailed description of a medical procedure or service Panel requires evidence that the service/procedure: has FDA or EUapproval (for devices and drugs) is distinct and performed by many practitioners nationwide [ s] clinical efficacy is well established and documented in U.S. peer review literature doesn t have an existing code, nor fragments one that does doesn t report extraordinary circumstances related to an existing code
22 AMA Governance Processes Relative Value Scale Update Process Suggestions from physicians, medical specialty societies, state medical associations, and those who deal regularly with health care information are the only way to ensure that CPT reflects current practice.
23 Resource-Based Relative Value Scale and Update Committee AMA advocates for fair and accurate valuation for all physician services, hence Resource-Based Relative Value Scale ( RBRVS ) CPT has 8,000 defined procedure codes, with relative values in the RBRVS corresponding to the procedure definitions AMA/Specialty Society Relative Value Scale Update Committee ( RUC ) ensures physician services across all specialities are wellrepresented Acts as an expert panel to make annual recommendations re. new and revised services to CMS Performs a broad review of the RBRVS every 5 years
24 Five-Year Reviews of RVUs Updating and maintaining the RVU is a clinical & scientific activity that must remain in the hands of the medical profession Each review is an opportunity to improve the accuracy of the physician work component (1 of 3) of the RVUs physician work (52%), practice expense (44%), and malpractice expense (4%) All of the codes on the Scheme Payment Schedules must be open for public comment In addition, the Relativity Assessment Workgroup (5-Year Review Identification Workgroup) identifies potentially misvalued services using objective mechanisms for re-evaluation during the upcoming Review 300 Services as a Benchmark.
25 South African Classification of Healthcare Interventions ( SACHI )
26 Committee Structure CUSTODIAN SOUTH AFRICAN CLASSIFICATION FOR HEALTH INTERVENTIONS ( SACHI ) DIAGNOSTIC CODING PROCEDURAL CODING DRG S ICD -10 ADVISORY COMMITTE EDITORIAL PANEL RELATIVITIES COMMITTEE COST COMMITTEE POLICY COMMITTEE DESCRIPTORS STANDARDS, STATISTICAL IMPACT CODING AND CLINICAL RULES TIME PRACTICE COST LIAISON, STATE LIAISON, OUTCOMES CODING CONSULTANT RESPONSIBILITY FINANCIAL CONSULTANT HEALTH TECHNOLOGY ASSESSMENT CODING CONSULTANT COMPLEXITY GEOGRAPHICAL FACTOR ACTUARIAL CONSULTANT SCARCE SKILLS
27 The Way Forward Maintenance of current coding structures lacks a governance structure Involve all Professions and Stakeholders Set up a Section 21 Company SACHI Take control of the governance process Maintain custody of coding structures within professional societies Urgency!
28
Annexure E PRINCIPLES AND GUIDELINES FOR ESTABLISHING AND MAINTAINING AN EFFECTIVE MEDICAL CODING SYSTEM IN SOUTH AFRICA
Unit 16, Northcliff Office Park, 203 Beyers Naude Drive Northcliff, Johannesburg, 2115, South Africa Tel: (+27)(11) 340 9000, Fax: (+27)(11) 782 0270 Email: [email protected] PO Box 2127, Cresta,
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