Author Topic: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid  (Read 7343 times)

rferreira

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Hi!
I'm trying to get acquaintance with the US health care system with focus in Coding, Billing and what influences the hospital revenue and physicians payments, disregarding PQRI/PQRS or other Quality Reporting initiatives.

As far as I understood the physicians get paid based on the RBRVS prospective schema. Is this applicable only to physician private practices or physicians working for an hospital still get paid through this scheme instead of a periodic salary paid by the hospital?
what is taken into consideration for the RBRVS? all the procedures and services provided to the client? Or, just the E/M CPT code?
In case the RBRVS is also applicable to the physicians working for an hospital, specifically in the Inpatient setting, does that mean that all the procedures that were performed will have to be coded both in ICD and CPT? ICD for DRG computation for hospital reimbursement purposes and CPT for physician payment (RBRVS based) purposes?

Any thoughts/hints on these topics will be appreciated.
Thanks in advance

Ricardo

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Good luck because none of us still understand it. LOL

From the AMA
In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare and Medicaid Services). Payments are also adjusted for geographical differences in resource costs.

The physician work component accounts, on average, for 48 percent of the total relative value for each service. The initial physician work relative values were based on the results of a Harvard University study. The factors used to determine physician work include the time it takes to perform the service; the technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient. The physician work relative values are updated each year to account for changes in medical practice. Also, the legislation enacting the RBRVS requires the Centers for Medicare and Medicaid Services (CMS) to review the whole scale at least every five years.

The practice expense component of the RBRVS accounts for an average of 48 percent of the total relative value for each service. Practice expense relative values were based on a formula using average Medicare approved charges from 1991 (the year before the RBRVS was implemented) and the proportion of each specialty's revenues that is attributable to practice expenses. However, in January 1999, CMS began a transition to resource-based practice expense relative values for each CPT code that differs based on the site of service. In 2002, the resource-based practice expenses were fully transitioned.

On January 1, 2000, CMS implemented the resource-based professional liability insurance (PLI) relative value units. The PLI component of the RBRVS accounts for an average of 4 percent of the total relative value for each service. With this implementation and final transition of the resource-based practice expense relative units on January 1, 2002, all components of the RBRVS are resource-based.

Annual updates to the physician work relative values are based on recommendations from a committee involving the AMA and national medical specialty societies. The AMA/Specialty Society RVS Update Committee (RUC) was formed in 1991 to make recommendations to CMS on the relative values to be assigned to new or revised codes in Current Procedural Terminology (CPT®). Nearly 8,000 procedure codes are defined in CPT, and the relative values in the RBRVS were originally developed to correspond to the procedure definitions in CPT. Changes in CPT necessitate annual updates to the RBRVS for the new and revised codes.
Linda Walker
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rferreira

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"Good luck because none of us still understand it. LOL"
Phew!... I was starting to feel I'm a bit dumb by not figuring it out...  :)
I'm going to continue searching for all the answers.

BTW, there is a good example about how to compute the RBRVS-based payment at http://www.acs-inc.com/ov_rbrvs_based_payment_methods.pdf but no details are presented, for instance, about whether that is applicable to physician payments at inpatient setting.

RichardP

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If you haven't yet read through this link, it is a good read also.  Check out the references provided at the bottom of the article.  Googling on RBRVS also brings up other resources.

http://en.wikipedia.org/wiki/Resource-based_relative_value_scale

Is this applicable only to physician private practices or physicians working for an hospital still get paid through this scheme instead of a periodic salary paid by the hospital?

This question makes me think that you are asking for some foundational information about medicine financials in the U.S.  There are variations that I don't include here, but this will give you an understanding that you can build on.  If you already know this, then my appologies for misinterpreting your question.

* Who gets paid; the billing unit; Type 2 NPI Number:
    any legal entity (corporation, partnership; group; sole proprietor)

* Who did the work; the actual provider of the care; Type 1 NPI Number:
    only a real, live person

Any request for payment for medical services (billing) requires that the payor (insurance carrier) be told who the billing unit is and who the actual provider of care is.  I simplify that by saying who gets paid? and who did the work?.  This is done by providing the appropriate Type 1 and Type 2 NPI Numbers on the invoice submitted for payment.

Any billing also requires that the payor (insurance carrier) be told what the complaint was and what the solution was.  Or, what was the diagnosis, and what were the procedures done to provide relief from the diagnosis.  This is done by providing the appropriate diagnosis/ICD-9 and procedure/CPT codes on the invoice submitted for payment.

Payment is always provided by the payor (insurance carrier) based on the diagnosis (ICD-9) and procedure (CPT) codes supplied with the payment invoice.  This is true whether the work was done in the private doctor's office of a sole proprietor, or in a clinic, or in a hospital.  Therefore, a hospital gets paid in the same way a doctor in private practice gets paid - based on the diagnosis and procedure codes they submit to the payor.

To repeat: the basis for payment for medical care, regardless of where that care is performed, is the combination of diagnosis (ICD-9) and procedure (CPT) codes supplied with the payment invoice.

Assume that I split my foot open with an axe.  I am are wheeled into the examining room, bleeding vigorously from my foot.  Q:  What is my complaint?  A:  My foot is split open.  Q:  What procedure must be done?  A:  Put my foot back together.  The doctor will not get paid for noticing that my foot is split open (the diagnosis; ICD-9 code).  He will get paid for putting my foot back together (the procedure; CPT code).  If the doctor is in private practice, he is both the entity who did the work and the entity that will get paid (even if he did the work in a hospital).  If the doctor has been hired by the hospital, he is the entity who did the work, so he will be paid a salary by the hospital.  But the hospital is the billing entity, and is therefore the entity that will get paid by the insurance carrier - based on what diagnosis (ICD-9) and procedure (CPT) codes are submitted.
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Payment to the billing entity is based on the procedure performed, regardless of whether the procedure was performed in a private doctor's office, a clinic, or a hospital (remember that the billing entity can be a private person or a corporation such as a hospital).  Payment is based on the procedure code submitted to the payer (insurance carrier) on the payment invoice.  The RBRVS you talk about are connected to each individual CPT code.  The RBRVS are not connected to the place of service.  The RBRVS determines what payment/reimbursement will be for each individual procedure/CPT code - regardless of where that procedure was performed (private office, clinic, hospital, etc.).

The fundamental information provided above is complicated just a bit by the following.  Level I and Level II HCPCS Codes http://patients.about.com/od/costsconsumerism/a/hcpcscodes.htm .  And - the amount of reimbursement can vary depending on which CPT/HCPCS Code is listed first on the billing invoice; reimbursement can also vary depending on the order in which diagnosis codes are linked to a given CPT Code on the billing invoice.  There are also such things as facility fees, the professional component vs. the technical component, etc. that figure into this.  But the first thing to know is that the RBRVS schema is attached to the CPT/HCPCS codes that providers of care use to bill for their services / supplies / equipment.  In turn, these CPT/HCPCS codes are used whenever payment is sought for services / supplies / equipment provided - regardless of the location where these things were provided (although some CPT/HCPCS codes will indicate the type of location where the services / supplies / equipment were provided).

Remember that there are variations on the foundational information I provided.  For clarification, let me make this point again, and again I'm leaving out some detail.  A doctor in private practice would be both the billing entity and the one who did the work.  The insurance company will pay the doctor, regardless of whether he repaired my foot in his private office or in the hospital.  If the doctor who repaired my foot is employed by the hospital, he is the one who did the work, but he gets paid by receiving a salary from the hospital.  The hospital is the billing entity, and would therefore get paid by the insurance carrier.  In either case, private practice or employed by hospital, the insurance carrier pays the billing entity based on what diagnosis and procedure codes the doctor provided to describe his encounter with me.  And the dollar value attached to the CPT/HCPCS Codes is determined through the RBRVS process.
« Last Edit: May 09, 2013, 02:16:34 PM by RichardP »

rferreira

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Richard,
Thank you very much for your clear and thorough explanation.

Now the only doubt that remains in my head concerns the DRG based payment used to reimburse the billing entity (Type 2 NPI).
May I assume that DRG based payment is an alternative to RBRVS based payment and DRGs are used mainly for reimbursement in Inpatient settings while RBRVS is the main reimbursement basis when not using DRGs?

Then, I believe that in the situations where we have DRG based reimbursement, the procedures have to be reported in ICD (ICD-9-CM Vol.3 or ICD-10-PCS) instead of CPT/HCPCS. Is this true?

RichardP

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rferreira - we don't do hospital billing, so my knowledge of DRG issues is limited.  Others may chime in with a more detailed response.  The links below provide a good overview of the subject.

Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use. ... There is more than one DRG system being used in the United States, but only the MS-DRG (CMS-DRG) system is used by Medicare.

DRGs are assigned by a "grouper" program which gathers claim information based on ICD diagnoses, procedures, age, sex, discharge status and the presence of complications or comorbidities. All these factors are used to determine the appropriate DRG on a case by case basis.

From the first link.  You might glance through the other links as well, if you haven't already.

http://www.findacode.com/drg/drg-diagnosis-related-group-codes.html
http://en.wikipedia.org/wiki/Diagnosis-related_group
http://www.smainformatics.com/pdfs/IPPS_FY2012MSDRG.pdf

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I believe that in the situations where we have DRG based reimbursement, the procedures have to be reported in ICD (ICD-9-CM Vol.3 or ICD-10-PCS) instead of CPT/HCPCS. Is this true?

Based on the words quoted above, it appears that DRGs are assigned after-the-fact (someone please correct me if I am wrong).  That is, the DRG selected to describe the current case is based on the diagnosis code (ICD-9) and the procedure code (CPT/HCPCS) used for that encounter.  Codes from both of these code groups must first be provided before the DRG code can be assigned.

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May I assume that DRG based payment is an alternative to RBRVS based payment

Yes.  DRGs are an attempt to describe a product, such as an appendectomy or heart surgery or childbirth.  Over time, the total costs for a given product are assumed to be approximately the same each time that product is "produced"; e.g., the cost of labor, supplies, overhead assigned, etc. for each appendectomy, heart surgery or childbirth would approach some constant figure over time.

DRG payment is based on the total cost to provide a given product.  RBRVS payment is based on a cost/payment for each procedure performed, where total cost/payment becomes a function of how many procedures the doctor can justify for a given encounter.

Quote
DRGs are used mainly for reimbursement in Inpatient settings while RBRVS is the main reimbursement basis when not using DRGs?

Yes.  But note that diagnosis codes (ICD-9) and procedure codes (CPT) are used in both reimbursement situations.  When using RBRVS, reimbursement is tied directly to the codes.  When using DRGs, reimbursement is tied to the specific DRG identified - but the codes are used to help determine which DRG should be used for that encounter.
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Finally, note that we are using two different and distinct code sets.  rferreira, the words you used make me think you maybe don't realize this.  Diagnosis Codes (ICD-9 or 10) are different from procedure codes (CPT)  As described above, both sets of codes must be used to ensure proper payment, whether you are using the RBRVS method or the DRG method.

http://en.wikipedia.org/wiki/List_of_ICD-9_codes
http://en.wikipedia.org/wiki/Current_Procedural_Terminology
« Last Edit: May 13, 2013, 11:49:44 AM by RichardP »

PMRNC

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Completely not relevant to the question, but I used to do DRG reviews when I worked at the insurance companies.. LOVED it.. such a high taking a 200K hospital bill and taking it down to a $60K bill. We had a formula we used to do this.
Linda Walker
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RichardP

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Linda - doctors can be participating providers or not with a given carrier.  If they are selected to participate, they should get a list of prices the carrier will pay for various procedures.  Can hospitals also elect to participate or not, as individual doctors do?  And if the answer is yes, do participating hospitals get a list of prices the carrier will pay for DRGs, the way that doctors get a list of prices the carrier will pay for CPT codes?

Billergirlnyc

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Ugh, I just had a long reply and lost it, so it's shorter than the original, lol.  :o

I do Hospital billing and coding so a few basics here: The ICD-9 codes directly affect DRG assignment. CPT codes play no role in DRG assignments -- this doesn't mean they aren't used, just that they don't affect how DRGs (diagnosis related groups) are assigned.

IPPS (inpatient prospective payment system) which was implemented in 1983 (I believe) is what Medicare uses to reimburse hospitals for inpatient hospital services according to a predetermined rate for each discharge. Each DISCHARGE is categorized into DRG (diagnosis related groups), which is based on the patient's PRINCIPLE and SECONDARY diagnosis (including comorbidities and complications), as well as PRINCIPLE and SECONDARY procedures (if performed). The DRG determines how much payment the hospital receives. DRG's are organized in mutually exclusive categories called MDC's (major diagnostic categories). Each DRG has a payment weight assigned to it based on the average resources used to treat say a Medicare patients in that DRG, and reimbursements can be adjusted according to: DSH (disproportionate share hospital adjustment - say if the hospital treats a high number of low-income Medicare patients), IME (indirect medical education adjustment - usually approved teaching hospitals and the adjustment varies based on residents-to-beds (calculating operating costs) or residents-to-average daily census (to calculate capital costs), or Outliers (hospitals who treat an unusually higher number of costly cases and the additional payment here designed to protect hospitals from large financial losses due to these expensive cases - I work with a few Outliers in Florida and 2 here in NY.

There are several DRG systems used in the US, but Medicare uses the MS-DRGs (medical severity diagnosis related groups) and they have very large PDFs that list the CC/MCC so it's not as convoluted to understand despite how COMPLEX this all may seem. The other 2 major ones are AP-DRGs (all patient diagnosis related groups), and APR-DRGs (all patient refined diagnosis related groups) <-- as an example NY Medicaid uses this (well last I checked they did) my staff does all our billing for our hospital clients but I try to be sufficiently aware of who uses what system. The pdf's MC has helps anyone decide what DX code would affect a certain DRG.

Under the PPS (prospective payment systems) there is the: OPPS (outpatient prospective payment system), and under this is APC (ambulatory payment classification)-used by medicare/other govt programs for hospital outpatient services including ambulatory surgery performed in a hospital outpatient dept and is where a a outpatient hospital is paid a fixed fee based on PROCEDURE performed. The DRG used by Medicare/other govt programs for hospital inpatient cases is where the hospital is paid a fixed fee based on the patients CONDITION and RELATIVE treatment. The RBRVS - used by Medicare/other govt programs for Physician and outpatient services where a unit value is assigned to each PROCEDURE and includes/and or represents things like physician time, skills, practice overhead, and malpractice, etc).

Hospitals are often paid by 3rd party payers either on a case rate, contract rate, flat rate, or per diem - each one you can look up to see what they mean in terms of how a hospital is paid. If the hospital has a contract with a certain payer then they've negotiated and know the fee schedule. Is the same for all these really, even the flat rate, it's all payer determined and hospitals know in terms of commercial payers. But most 3rd party payers will usually use a mix of the aforementioned w/fee-for-service and percentage of accrued charges thrown in, well based on my experience.

I think you also asked about doctors in hospitals. Remember there are PROFESSIONAL and TECHNICAL components with billing of some services. If a Radiologist isn't employed by the hospital and he reads a Bone Scan then he/she bills for the PROFESSIONAL component (interpretation of said scan) and if the hospital owns the equipment, they bill for the TECHNICAL component. The Radiologist would then submit his charges  on the 1500 not the UB form. The doctor is usually paid using the RBRVS system and sometimes their fee can be reduced. The reasoning is often they didn't buy or provide supplies, equipment, etc. If the doctor is employed or under contract w/the hospital then the hospital would bill for both components.
« Last Edit: May 13, 2013, 09:38:41 PM by Billergirlnyc »
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RichardP

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Thanks for the response.

Quote
Ugh, I just had a long reply and lost it, so it's shorter than the original, lol.

I've done that myself, so I know the feeling.

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Medicare uses the MS-DRGs (medical severity diagnosis related groups) and they have very large PDFs that list the CC/MCC ...

I linked to this in my response above.  Is this the type of list you are talking about?

http://www.smainformatics.com/pdfs/IPPS_FY2012MSDRG.pdf
« Last Edit: May 13, 2013, 08:48:11 PM by RichardP »

Billergirlnyc

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #10 on: May 13, 2013, 10:21:38 PM »
Thanks for the response.

Quote
Ugh, I just had a long reply and lost it, so it's shorter than the original, lol.

Quote
I've done that myself, so I know the feeling.

No problem and it sure does.

Quote
Medicare uses the MS-DRGs (medical severity diagnosis related groups) and they have very large PDFs that list the CC/MCC ...

I linked to this in my response above.  Is this the type of list you are talking about?

http://www.smainformatics.com/pdfs/IPPS_FY2012MSDRG.pdf

Yes, the link above gives all the MS-DRG's but below is a list to the of MCC from about page 883 on.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads/cms-1533-p.pdf - may be old. I have them loaded on my office computer, but it's just to give you an idea of how the MCC's look.

Here is a link to the CC/MCC's list for ICD-10 - it's a bit convoluted but if you know the ICD-9 code you shouldn't have  a problem looking up the ICD-10 version or you could just search the sickness itself. https://www.cms.gov/icd10manual/fullcode_cms/P0031.html

When coding for DRG (say if you didn't want to search through MC's list: Must remember that when assigning codes to comorbities (co-existing condition) and complications (conditions that develop DURING the inpatient admission) a coder must be sure to carefully review the patient record documentation to assign the MOST SPECIFIC code possible. This is why hospitals are BIG on ensuring their doctors know about proper documentation, another reason is the revisions to the MS-DRG's comorbidities and complications CC list got rid of many diagnosis that were considered CC's in the past. To give you an example: An example of a DX that wouldn't be a CC is CHF (congestive heart failure), but chronic systolic heart failure is a CC and acute heart failure is a MCC. I should also mention that the POA indicator (present on admission) is required to be reported on all claims for acute care hospitals and other facilities subject to law or mandating the collection of this info. You pretty much need to tell them if a condition was present at time of admission or not and this affects payments as well.


Don't worry. Be happy.
~Dalia, CPC, CPC-H, RHIT.

rferreira

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #11 on: May 14, 2013, 08:18:18 AM »
Dalia,
Thank you very much for your valuable insights.

In what concerns the CC/MCC, isn't it somehow overlapped by the POA indicator? If a diagnosis is marked as a complication (=acquired inside the hospital) doesn't it necessarily mean that its POA=false?

Based on the words quoted above, it appears that DRGs are assigned after-the-fact (someone please correct me if I am wrong).  That is, the DRG selected to describe the current case is based on the diagnosis code (ICD-9) and the procedure code (CPT/HCPCS) used for that encounter. 

DRGs are assigned based on the diagnosis and procedure codes (after-the-fact and after coding). However, the procedures are not coded in CPT/HCPCS. For DRG grouping purposes, procedures are coded in ICD-9-CM Vol.3 or ICD-10-PCS.

Finally, note that we are using two different and distinct code sets.  rferreira, the words you used make me think you maybe don't realize this.  Diagnosis Codes (ICD-9 or 10) are different from procedure codes (CPT)  As described above, both sets of codes must be used to ensure proper payment, whether you are using the RBRVS method or the DRG method.

My statements were based on the fact that for DRG assignment one has to provide diagnosis and procedure codes both in ICD (ICD-9-CM Vol.1&2/ICD-10-CM and ICD-9-CM Vol.3/ICD-10-PCS, respectively, for Dx or Procedure codes) and I was assuming that it was applicable to all groupers (MS-DRG, APC, TRICARE, ...) - which now I realise it is not true. As we usually see/hear procedures coded in CPT/HCPCS code set, it was not clear in my head how we reached to ICD coded procedures to compute the DRG (dual coding?! ICD<->CPT cross-mappings?!...).

Now, based in your contribution and what I have investigated I reached the conclusion that DRGs are used mainly in inpatient where procedures are coded (almost) only in ICD, while outside inpatient usually CPT/HCPCS come into the game. In the situations that we have grouping-based reimbursement it seems that the groupers are already expecting the code set usually used on those environments. For instance, the APC grouper expects to receive procedures coded in CPT/HCPCS, while MS-DRG grouper expects ICD procedures.

Ricardo Caetano Ferreira

rferreira

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #12 on: May 14, 2013, 08:25:24 AM »
The RBRVS - used by Medicare/other govt programs for Physician and outpatient services

This may seem a silly question... but I often see refering to "Physician and outpatient services". Shouldn't it be enough to say "outpatient services" or "physician" is added because in an outpatient environment the physician can charge separately from the outpatient service itself? Or is it used to distinguish between hospital and non-hospital services?

RichardP

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #13 on: May 14, 2013, 11:28:39 AM »
(This has been revised from my original post made about 45 minutes ago.)

I just learned something from this discussion.  I didn't know that ICD-9 contained procedure codes for hospital inpatient billing.  Thanks for that info.

While most professional medical coders and medical billers use the diagnosis codes in ICD-9-CM every day, the code manual also contains a series of codes used to describe medical procedures. All editions of ICD-9-CM contain Volume 1 and Volume 2. Expert editions of ICD-9-CM, designed for use by hospitals and payers, also contain Volume 3, which is dedicated to procedural coding.

From here:  http://www.medicalbillingandcodingu.org/icd-9-cm-procedure-codes/

However - we need to make a distinction here between private physicians who have privileges at the hospital versus staff physicians who are employed by the hospital.  We bill for private physicians who do procedures on patients admitted to the hospital (inpatient status).  We use the procedure codes (CPT) from the AMA - not the procedure codes from ICD-9, Ver. 3.  It must be that procedure codes from ICD-9, Ver. 3 are used by hospital staff doctors.  Perhaps you know this already?

So - can an inpatient who is treated by a private physician have a DRG(s) assigned to them?  If this previous comment of yours is true, then probably not.

Now, based in your contribution and what I have investigated I reached the conclusion that DRGs are used mainly in inpatient where procedures are coded (almost) only in ICD ...

... I often see refering to "Physician and outpatient services".

You don't state the context in which you see that phrase, so I don't know if this response is appropriate to your question.  But physicians seeing patients in their private offices as well as at a hospital in an outpatient setting would use the AMA Procedure/CPT Codes in both situations.  Hence, both physician and outpatient are designated.  But maybe the physician in your phrase is supposed to be private physician - because private physicians also use AMA CPT procedure codes on inpatient as well as outpatient procedures.  Contrasted with the hospital staff doctor, where the procedure codes would always come from ICD-9/10, Ver. 3.

Interesting discussion.
« Last Edit: May 14, 2013, 01:11:24 PM by RichardP »

Billergirlnyc

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #14 on: May 14, 2013, 10:39:40 PM »
Dalia,
Thank you very much for your valuable insights.

No problem. I'm always learning and re-learning with these topics, so thank you for asking.

Quote
In what concerns the CC/MCC, isn't it somehow overlapped by the POA indicator? If a diagnosis is marked as a complication (=acquired inside the hospital) doesn't it necessarily mean that its POA=false?

One of the reason MC started requiring POA indicators from IPPS hospitals is to help distinguish between pre-existing conditions and complications and to add precision to the ICD-9-CM coding in administrative data, aka to reduce payment as we say in my office, because regardless if it's overlaps or not it must be answered if a hospital falls under the IPPS system, because IPPS hospitals are required to utilize the Present on Admission (POA) indicator for all primary and secondary (2-9 not 10/beyond) diagnoses for all inpatient admissions. Remember POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. Based on the POA indicator assignment, CMS/Medicare determines whether the patient had an HAC (hospital acquired condition). If it overlaps or is a "N" for POA indicator on one of conditions doesn't change that it must be answered and can affect payment. For example if a patient came in and they have asthma, then the POA indicator for this would be "Y" because they had this condition diagnosed before inpatient admission, but say they were admitted for coronary artery bypass surgery and postoperatively they developed a pulmonary embolism. The pulmonary embolism would be assigned a POA of “N", and in this case Medicare won't pay for the CC/MCC DRG HACs codes as "N" for the POA indicator, but they'll pay the CC/MCC DRG HACs for the POA indicator with "Y".  There are other POA indicators which explain if MC will pay or not. But sometimes it's not so cut and dry and payment ends up being higher or not affected but that's a whole other topic. The point is if the hospital falls under the IPPS sytem they must report the POA indicator and they must understand how each indicator affects their payments and of of course consult the POA exempt list for the codes that are, so they know how to code those as well to show exemption.

I hope I helped and didn't complicate w/my response. I know what you're asking but I just couldn't give an out and out answer without going into the above (for me).
« Last Edit: May 14, 2013, 11:06:33 PM by Billergirlnyc »
Don't worry. Be happy.
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