General Category > General Questions
ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
Billergirlnyc:
--- Quote from: RichardP on May 13, 2013, 11:43:37 PM ---Thanks for the response.
--- Quote ---Ugh, I just had a long reply and lost it, so it's shorter than the original, lol.
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--- Quote ---I've done that myself, so I know the feeling.
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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 ...
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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
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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.
rferreira:
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?
--- Quote from: RichardP on May 13, 2013, 02:38:05 PM ---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.
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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.
--- Quote from: RichardP on May 13, 2013, 02:38:05 PM ---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.
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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:
--- Quote from: Billergirlnyc on May 13, 2013, 09:24:47 PM ---The RBRVS - used by Medicare/other govt programs for Physician and outpatient services
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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:
(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.
--- Quote from: rferreira on May 14, 2013, 11:18:18 AM ---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 ...
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--- Quote from: rferreira on May 14, 2013, 11:25:24 AM ---... I often see refering to "Physician and outpatient services".
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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.
Billergirlnyc:
--- Quote from: rferreira on May 14, 2013, 11:18:18 AM ---Dalia,
Thank you very much for your valuable insights.
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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?
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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).
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