Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Practice Exam

CPC Practice Exam and Study Guide Package

Practice Exam

What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

CPC Exam Review Video

Laureen shows you her proprietary “Bubbling and Highlighting Technique”

Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page

Practice Exam

2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Primary Care Exception in Brief

Under the “primary care exception,” a medical resident may perform (and bill for) limited, specific evaluation and management services without the presence of a teaching physician. Here’s what you need to know when reporting these resident services. When the Primary Care Exception Applies Ordinarily, services furnished by medical residents are excluded from Medicare payment because […]

The post Primary Care Exception in Brief appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

CPT 96127- which is Brief emotional/behavioral assessment (depression inventory, ADHD

Hi,

Urgent Question:

For Mental Health/Behavioral Health/Substance Abuse Services- Nebraska Medicaid- will not allow this code to be billed but said to look for similar CPT codes that would service this purpose and are billable.

Does anyone know of other CPT codes that would cover the same type of service as 96127- for MDs, Nurse Practitioners, and Licensed Therapists?

Thanks.

Medical Billing and Coding Forum

CPT 96127- which is Brief emotional/behavioral assessment (depression inventory, ADHD

Hi,

Urgent Question:

For Mental Health/Behavioral Health/Substance Abuse Services- Nebraska Medicaid- will not allow this code to be billed but said to look for similar CPT codes that would service this purpose and are billable.

Does anyone know of other CPT codes that would cover the same type of service as 96127- for MDs, Nurse Practitioners, and Licensed Therapists?

Thanks.

Medical Billing and Coding Forum

CPT 96127- which is Brief emotional/behavioral assessment (depression inventory, ADHD

Hi,

Urgent Question:

For Mental Health/Behavioral Health/Substance Abuse Services- For Medicare- Both IA & NE- is this code billable or do we have to bill similar CPT codes that would serve this purpose and are billable?

Also, how many units are billable for this service?

If 96127 is not billable- does anyone know of other CPT codes that would cover the same type of service as 96127- for MDs, Nurse Practitioners, and Licensed Therapists?

Thanks.

Medical Billing and Coding Forum

Hospital Observation Services in Brief

If a patient has a condition that needs to be monitored to determine a course of treatment, they may be admitted to hospital observation status. For example, if a patient presents to the emergency department (ED) with acute abdominal cramping, the provider can admit the patient to observation status. After a period of monitoring, the […]

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AAPC Knowledge Center

Telemedicine Trends in Brief

Telemedicine allows patients who otherwise may not have access to specialized care to receive necessary services. Payers have begun to embrace telehealth services as a positive benefit for these patients, but providers must learn the telehealth coverage and billing requirements for their insurer and locale. Telemedicine Is Gaining Acceptance Many states have approved of, or […]
AAPC Knowledge Center

A Brief Overview of State and Private Medical Care in the UK

Some kind of medical services is can be sought in every nation in the world. The standard of care essentially depends on what location you find yourself in. This care can range from the very best to very simple. This piece looks at both private medical care and state-funded provision in Great Britain. Overwhelmingly, the NHS is the main care provider.

The majority of medical services in Britain are provided by the NHS. This service is paid for through taxation and is cost free at delivery point. While this medical care is widely thought of as good, waiting times can at times be significant for some operations and procedures.

One criticism of the state NHS is that some medications are not cost effective because to their pricing. Those who would benefit from private medical care might not to have this issue. They also get to enjoy faster service and more private surroundings or rooms.

Having said that, the NHS still remains extremely widely used – and it is considered generally that private medical care is only utilised as a ‘top up’ to what many people see as a dependable, and egalitarian system of medical care. A & E (or Accident and Emergency) and hospital care is free at the point of delivery, but some citizens (for the main part working people) are required to pay for prescriptions. People who are in full time education, and those of retirement age and other ones on benefits relating to incapacity get prescriptions for free.

The majority of the Britain’s private medical care is offered to the general population by BUPA (British United Provident Association). In 2008 the group acquired the Cromwell Hospital in the middle of London – creating its principle medical facility in the country’s capital city, which many say is indicative of their aspirations.

There are also various other private medical care hospitals available across the nation, be it in Leicester, Glasgow, London or Birmingham. This sort of care is frequently thought to need medical insurance, but in reality lots of hospitals provide the possibility of one-off payments for single procedure. As has been well documented, private health care can lower or indeed get rid of the need to wait for operations.

In situations where individual people are waiting for procedures which have a substantial waiting list on the National Health Service, private health care can be an option – the big reason for selecting it is frequently the pain involved in the ailment remaining without treatment.

Whatever the kind of health insurance a patient has – medical services in Britain are good, catering for all pockets and all needs. Whether you are in the ninety-two percent of people who use the always-present NHS, or 1 of the eight percent who decide to top up their options with a faster private scheme, quality medical care is available for everyone.

Gino Hitshopi is highly experienced in the realm of both state and private medical care, having worked in the medical industry for many years. For more information please visit: http://www.claremont-hospital.com/

A Brief Introduction to Medical Answering Services

Medical answering services provide the ideal solution for the medical practitioners who get huge influx of calls from their patients. It is not possible for doctors to attend every call especially during the working hours and therefore several medical practitioners outsource this requirement to companies engaged in providing call-handling services to doctors.

The main function of answering services is to answer the generic queries of patients and to schedule their appointments with the doctor. Thus, the doctor and his staff are freed from the hassle of doing day to day routine jobs. If there are some issues that the doctor should personally look into, the same is communicated to the doctor so that he can do the needful.

The main benefit of medical answering services is that they help the doctors perform effectively. Also, the patients feel good, as they do not have to wait for long to get appointments and answers to their queries. The patients can also communicate through emails as the service provider also answers the e-mails of the patients. If there is something critical then the executive will forward the mail to the doctor or the concerned staff. Another benefit is that the company providing such services takes responsibility for maintaining all database regarding the incoming calls and e-mails. Also, these companies take utmost care in taking regular backup of the data so that the data remains secure even if the server breaks down.

These services are better than the automated answering machines as in case of automated machines patients get sometimes frustrated when they have to dial several digits to reach the doctor’s assistant or to schedule the appointments or to get an answer to a simple query.

Some companies providing these services have fixed working hours while others operate 24 X 7. The medical practitioner can choose the type of services he wants depending upon the volume of calls he receives and the type of his medical practice.

In short, the virtual answering service helps medical practitioners to stay connected to their patients while they are away for work, study, a conference, or enjoying a short vacation. Visit medical answering services for more information.

Brief Mental Health Consultation Code

I have a provider (LISW) who saw a patient for basically a brief mental health consultation and was only in there for around 7 minutes. I am trying to find the CPT Code that would best fit that description but I can’t really find "BRIEF CONSULT". Does anyone have any suggestions as what might be close to this for us to bill correctly. Thanks in advance for any help!

Medical Billing and Coding Forum

AHIMA practice brief addresses clinical validity and coding compliance

AHIMA practice brief addresses clinical validity and coding compliance

We as coders, clinical documentation specialists, and compliance officers, are actively invested in coding compliance, aren’t we? AHIMA and ACDIS emphasize coding compliance in their codes of ethics. If we aren’t interested in coding compliance, why are we reading newsletters named Briefings in Coding Compliance Strategies and other similar publications?

Many coders I know code solely on what a doctor documents, claiming not to be physicians, nor having the authority to challenge a diagnosis or documented treatment by a provider.

In fact, AHIMA’s 2008 practice brief, Managing an Effective Query Process, emphasized that we should not query physicians if the clinical indicators do not support a provider’s documented diagnosis. This practice brief stated:

Providers often make clinical diagnoses that may not appear to be consistent with test results. Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed?legibility, completeness, clarity, consistency, or precision.

 

While AHIMA told us then not to query to ascertain clinical validity of documentation, the United States Department of Justice (DOJ), or Health and Human Services, must not have gotten the memo.

In June 2009, Johns Hopkins Bayview Medical Center, in Baltimore, Maryland, settled a False Claims Act case for $ 2.75 million. This happened after the DOJ said that the hospital’s "employees allegedly focused on lab test results which might indicate the presence of a complicating secondary diagnosis such as malnutrition or respiratory failure, and advised treating doctors to include such a diagnosis in the medical record, even if the condition was not actually diagnosed or treated during the hospital stay."

Baptist Healthcare Inc. and its affiliated hospitals near Louisville, Kentucky, paid $ 8.9 million in 2011 to settle a case involving the documentation, coding, and clinical validity of respiratory infections and inflammations, pulmonary edema, respiratory failure, and septicemia. These do not include the costs of attorneys, expert witnesses, and other intangibles expended in legal defense. Visit the DOJ’s website to learn more of these settlements: www.justice.gov.

The Medicare Provider Quarterly Compliance Newsletter then emphasized in July 2011 that providers and facilities are to determine the validity of documented acute respiratory failure, and when the clinical indicators are not present and emphasized, Recovery Audit Contractors had leeway to change a principal diagnosis based on provider documentation. This would happen if Recovery Audit Contractors believed that the clinical indictors did not support the documented diagnosis. Read the newsletter at http://tinyurl.com/jb5aauu, page 2.

AHIMA has since changed its tune. In its 2013 Query Practice Brief, AHIMA stated that a query is appropriate when the health record documentation "provides a diagnosis without underlying clinical validation."

The article adds the additional statement, "when a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation process." Their sample escalation policy is available at http://tinyurl.com/2013AHIMAescalationpolicy.

AHIMA recently stepped this up a notch by publishing a clinical validation practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members at http://tinyurl.com/2016AHIMAclinicalvalidation. I encourage you to get a copy from an AHIMA member or from your local medical library and to discuss this document with your compliance officer or attorney.

Given that AHIMA is one of the ICD-10-CM/PCS Cooperating Parties, their practice briefs are often quoted by the DOJ, and thus must be read closely, and if agreeable, incorporated into one’s compliance plan. Several points are made in this practice brief, most of which I agree with, but some of which I do not. These include:

 

Compliance

AHIMA states:

Compliance, whether it’s a formal compliance department that understands compliant coding or coding management performing quality audits, can support the clinical validation process. Compliance can assist in developing a standardized query policy that applies to all who perform the query process within the organization regardless of the department in which they are located.

 

I wholeheartedly agree; however, AHIMA does not articulate under what circumstances, or how, a facility can omit an ICD-10-CM code for a documented diagnosis that is re-authenticated by an authorized provider.

I personally believe that if recovery auditors can deny codes for documented diagnoses based on their clinical judgment, then facilities should be able to do the same, particularly if they believe that the code would not survive reasonable scrutiny. I wish that they had discussed this.

 

Clinical validation

AHIMA states, "it appears clinical validation may be most appropriate under the purview of the CDI professional with a clinical background," emphasizing that it is the coder’s role to become more clinically astute as to refer cases to a nurse or physician advisor as necessary.

I disagree to some extent. The ICD-10-CM Official Guidelines state that ICD-10-CM code assignment is a joint effort between the provider and the coder, not the provider and the CDI specialist or the CDI specialist and the coder. So, I believe that a properly trained and certified coder who is well versed in clinical terminology and definitions should be able to have the conversation with the provider alone and not have to delegate this to another individual that may not be as experienced. That said, if the coder is insecure with the situation, he or she should have a lifeline for clinical support as to ensure the validity of the documented diagnosis or treatment.

 

Referencing clinical criteria

AHIMA and Coding Clinic for ICD-10-CM both say that the Coding Clinic should not be referenced as a source for clinical criteria supporting provider documentation. I wholeheartedly agree, except in cases where no definition of a clinical term is available in the physician literature, such as with functional quadriplegia or acute pulmonary insufficiency following surgery or trauma.

For these two conditions, Coding Clinic and/or the ICD-10-CM Official Guidelines are the only sources for definitions as to ensure their validity. The most recent high-impact physician literature or textbooks should be referenced when defining other clinical conditions, or when defending claims of clinical invalidity. A physician advisor can point out which references are highly respected.

 

Coders and CDI defining diagnoses

AHIMA states:

Although it is tempting for CDI and coding professionals to define diagnoses for providers, doing so is beyond their scope. For example, it is not appropriate for a CDI or coding professional to omit the diagnosis of malnutrition when it is based on the patient’s pre-albumin level rather than American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. Many practicing physicians have not adopted ASPEN criteria and there is no federal or American Medical Association (AMA) requirement stating that ASPEN criteria must be utilized by a physician in making the diagnosis of malnutrition.

While this is technically true, given that CDI and coding professionals are not licensed to practice medicine, nor are involved with direct patient care under most circumstances, they still should be their facility’s representatives to encourage the medical staff, as a whole, to adopt facilitywide definitions of challenging clinical terms (e.g., sepsis, malnutrition, acute respiratory failure). They should also monitor and encourage individual providers as they adopt these definitions in their documentation and escalate noncompliance with these definitions to physician advisors, compliance officers, or medical staff leadership.

While one physician may not use ASPEN, or the Academy of Nutrition and Dietetics criteria, to define and diagnose malnutrition, I challenge readers to find any support for pre-albumin or albumin as a current clinical indicator for malnutrition, or a more authoritative criteria than that of the nation’s premier association of dietitians and nutritional support teams in defining, diagnosing, and documenting malnutrition in the adult and pediatric population.

 

Multiple-choice queries

AHIMA appears to have changed the language for multiple-choice queries with this practice brief, especially when clinical validity is an issue. In an example for validating documented sepsis without apparent clinical indicators, they offered the following multiple-choice options:

  • Sepsis was confirmed
  • Sepsis was ruled out
  • Sepsis was without clinical significance
  • Unable to determine
  • Other ______________

Given that this is AHIMA’s query format, we’re obligated to consider it; however, this does cause some difficulties. What can a coder do with "sepsis was without clinical significance" or "unable to determine," if that’s the option the provider selects? If "sepsis was without clinical significance" is selected, do we not code it with the belief that the documented condition doesn’t qualify as an additional diagnosis as defined in the ICD-10-CM guidelines? How many of us have run into physicians who document "unable to determine" as a way of avoiding the question?

I believe that if any of these two options are chosen, then the record should be escalated to a physician advisor or coding manager who implements the facility’s policy of coding the documented diagnosis without defendable clinical indicators.

 

Clinical validation auditing

AHIMA states, "auditing a small sample (e.g., 15 records per year) of coded records by each coding professional (both contract and employed) is one way to ensure that each coding professional is given some education on clinical validation."

While true, I believe that these audits should include CDI specialists, given that many are not members of AHIMA and may not read AHIMA practice briefs, much less believe that they apply to them. AHIMA does emphasize their position as one of the four Cooperating Parties for ICD-10-CM/PCS and that this brief is "relevant to all clinical documentation improvement professionals and those who manage the CDI function, regardless of the healthcare setting in which they work or their credentials."

 

Summary

In conclusion, please be sure to read this practice brief and consider how this affects your organization. Given that there are no standard definitions for at-risk ICD-10-CM/PCS terminology published by any of the Cooperating Parties or payers, and given that medical terminology used in documentation should be defined by physicians and their professional organizations, I encourage all facilities to engage with their medical staff to provide indicators for the clinical terminologies most often challenged by payers.

I also would encourage facilities to develop and implement policies that ensure their validity prior to any submission of HIPAA transactions sets with appropriate boundaries and limits.

 

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at [email protected]. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at [email protected]. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

HCPro.com – Briefings on Coding Compliance Strategies