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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

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Providers see only minor productivity declines after ICD-10 implementation, according to survey

 By Steven Andrews

A decrease in staff productivity has been the top challenge for providers after ICD-10 was implemented, but relatively few organizations have seen a significant decrease in productivity, according to a recent survey from Navicure.
 
Despite nearly half of the participants (48%) noting a productivity decline as the top issue, only 13% of administrative staff and 15% of clinical staff saw a significant decrease. Another 46% of administrative staff and 42% of clinical staff didn’t see much of an impact, and the remaining respondents saw a minor impact or didn’t know of one.
 
The survey included 360 participants representing a broad range of specialties and sizes, with 60% from organizations with one to 10 providers.
 
Beyond productivity, 20% of respondents said revenue disruption was their top concern. However, 60% of organizations did not see any impact on monthly revenue following the transition. In terms of denial rates, 89% of respondents saw either no change or an increase of less than 10%.
 
All of these statistics are overwhelmingly positive for the industry, which was subject to constant fear mongering from organizations such as the AMA in the months before the transition, with predictions of massive productivity declines leading to insurmountable revenue problems for countless providers.
 
Predictions about how much providers would spend to get ready for implementation varied widely, depending on the source. An AMA-funded report from Nachimson Advisors estimated small physician practices would spend approximately $ 57,000-$ 200,000 to get ready. Even though this was already questioned, the actual results from the survey show a much different story.
 
Half of the respondents spent less than $ 10,000 on training and software updates, with another 14% spending between $ 10,000-$ 50,000. Only 5% spent more than $ 50,000, while 20% weren’t sure how much their organization spent.
 
And organizations are confident they’re coding correctly. Nearly all of the respondents (99%) reported sending the most specific ICD-10 code either all of the time or sometimes.
 
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Your current subscription to APCs Insider will be transferred to the Revenue Cycle Daily Advisor. The last issue of the APCs Insider is scheduled for today, January 22. Please watch for your issue of Revenue Cycle Daily Advisor starting next Monday, January 25. 

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Electronic Medical Record Implementation

EMR system implementation will increase over the next five years due to direct pressure from the United States government. A majority of health care providers are expected to be using some type of EMR system by 2014. As physicians become aware of EMR benefits, more clinics and hospitals will convert to a paperless system. The small percentage of health providers that have already made this change will agree that picking the wrong system, or choosing a system that is under supported can be catastrophic.

Finding an EMR system and understanding what it can provide is a confusing process. Knowing what your EMR system needs to be capable of will allow you to start identifying possible solutions. Good companies will let you demo their software. The company should offer template modification for a fee so their EMR is customized for your practice. Primary care providers typically have the easiest time finding a system to fit their needs because of their generic nature. There are many EMR systems that come tailored just for this type of environment. Practices that specialize in a certain area will have to narrow their search to systems created for that specialty.

It is important to select a system that is well supported by a strong IT and development team. These teams will make sure that the EMR system will interface with your appointment scheduling system and or billing system. They will be able to create and implement a custom interface for your EMR system so that it will work with your other systems. The IT team will let you know if local servers are needed in all practice locations so that there is not a decrease in system speed from remote sites. The vendor of the software will need to offer all of these premium support services in order for your EMR to be a success.

Interfaces for the EMR to communicate with other systems in the practice are vital. Your patient process needs to be as automated as possible. If you schedule an appointment with your scheduling software, your EMR software should create the patient record. Entering a diagnosis into the EMR should automatically update your billing system with the treatments prescribed for the patient. The coordination of these systems creates a true paperless environment.

A correctly implemented EMR system will save you time, money, and resources. It will increase your productivity and decrease error rates. The system will allow you to manage not just your practice, but the needs of your patients.

This article was provided as a courtesy of MyTech-net, a site dedicated to all IT needs.

Have coders typically been responsible for implementation of MU/PQRS/MIPS?

Hello all,

I am curious if in the other physician practices out there, who typically is responsible for the implementation and participation of Meaningful Use, PQRS and now MIPS? Our practice has been participating in these programs (including eRx) since 2011. At the beginning way back in 2010 the office manager we had decided that I would be responsible for all things PQRS which made sense since we were reporting via Claims. She would take on Meaningful Use. About 6 months later she began handing over the Meaningful Use to me ("since it was really more about coding") and then she left the practice. I just attested for the 6th year for MU. I was told before our new administrator joined the group that this would be one of their responsibilities – sure I would be involved but she was going to take over. I am the only coder in our group of 4 providers, a mid-level and 2 techs, so needless to say I have my hands full.
Now that we have begun our transition to MIPS it has become quite evident that this will continue to be my responsibility. I am curious because I am coming up on my yearly evaluation and was told last year that I had "topped out" at the salary for a coder in our area and would not be eligible for a raise this year.
I really feel like I am much more than a coder – something to which I’m certain any coder in a small physician practice can relate. I believe my job title would more accurately be described as Coder/Biller/MIPS/Receptionist/Financial Counselor/Operations Manager/New Hire Trainer.

Has anyone out there been through a similar experience? I am curious if this is the norm at most physician practices?

Thanks!

Medical Billing and Coding Forum

Physician Orders for Lab, Radiology Services, and Other Services after ICD-10 Implementation


CMS is not requiring the ordering provider to rewrite the original order with the appropriate ICD-10 code for lab, radiology services, or any other services after ICD-10 implementation on October 1, 2015, including Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

Products and services that require a diagnosis code on the order will use ICD-9-CM codes if written prior to October 1, 2015. If the order is for a repetitive service that will continue to be delivered and billed after October 1, 2015, providers have the option to use the General Equivalence Mappings (GEMs) posted on the 2016 ICD-10-CM and GEMs web page to translate the ICD-9-CM codes on the original order into ICD-10-CM diagnosis codes.


Coding Ahead

Chronic Care Management codes – post implementation… Are you missing out?

Chronic Care Management codes – post implementation… Are you missing out?

December 4, 2016

In January of 2015 CMS developed codes for chronic care management.  This was based on the premise that more careful oversight would result in better care and reduced spending in regard to patients with chronic conditions.  The (CPT) code 99490, for non-face-to-face care coordination services was developed for this reason.

As a time-based code there are some criteria that need to be met, but the amazing part of this code implementation is it does not require face to face time with the patient.  This is all done as “non” face to face time.    CPT and CMS both require these specifics to be met :

At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month,  Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions must  place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
A comprehensive care plan is to be established, implemented, revised, or monitored.

Some practitioners were concerned with the comprehensive care plan, but this list below from CMS helps with the clinical documentation of establishing and implementing this care plan.

Problem List
Expected Outcome and Prognosis
Measurable Treatment Goals
Symptom Management
Planned Interventions and Identification of those services/individuals responsible/needed for each intervention
Medication management
Community/Social Services Ordered
A description of how the services/agencies outside of the practice will be coordinated
A Schedule for periodic review and revision of the care plan

However, there are some down-side items that have been discovered over the last 18 months.   One of the findings is that CPT code 99490 cannot be billed during the same service period as CPT codes 99495–99496 transitional care management;  HCPCS codes G0181/G0182 home health care supervision/hospice care supervision;  or CPT codes 90951–90970 End-Stage Renal Disease services.  If you are unsure if a code can/cannot be billed with the 99490 CCM code,  always run a CCI edit scrub or review the CCI bundling edits to ensure that you can bill the CPT code 99490 with a specific code.  This will also confirm if the codes are truly bundled, or if they can be over-ridden with a modifier added to the claim.

Another issue of concern from coders is what place of service (POS) should be reported on the physician claim.  Physicians/Practitioners must report the POS for the billing location as the same place where a face-to-face office visit with the patient would take place.  (eg POSs 11-office etc.)  Again, if the care is furnished in the hospital outpatient setting, (eg  provider-based locations) then they should be reported as the appropriate place of service for a hospital outpatient setting.   In addition, Medicare and CPT allow billing of E/M visits during the same service period as CPT 99490.  If an E/M visit or other E/M service is furnished on the same day as a CCM service, the clinical documentation  needs to clearly define  the allocation of total time between the CCM CPT 99490 code and the E/M code(s).

Medicare guidelines state that only one E/M service can be billed per day unless the criteria is  met for the usage of modifier -25, and the designation of “time”  cannot be counted twice, regardless if the time denoted from the provider is  face-to-face or  non-face-to-face time.

Face-to-face time that can be/or is used to calculate the E/M service that was provided by the physician cannot be counted towards CPT 99490.   However, the time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 has to be reported, and appended on the CCM claim.

The other issue of concern from coders is if the provider spends greater than 20 minutes of non-face to face time, that there is not a code or an “add on” code to designate the additional non-face to face time spent.  The CPT code criteria and verbiage are very specific in regard to code 99490.  The CPT criteria state “Code 99490 is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities.”   This means that even if a practitioner spends more than 20 minutes, there is no additional reimbursement or coding option for more “units” or the addition of an “add on” code for additional time based reimbursement.

Another concern from  medical billers and coders, is repayment for the physician providers within their practice, if another physician practice or specialty practice have billed for this code within the same month.  Medicare will only pay for this code once per calendar month.  If more than one provider/specialty submits a claim on the patient, the first claim to be received by the insurance carrier will be paid.  Any other claims for code 99490 will be denied reimbursement.  The code 99490 can be billed by any provider of care; however, again only 1 provider will be paid for the claim.    This can be problematic if the patient is being cared for by multiple providers and specialties.  Communication between the providers is necessary to provider not only good care, but to ensure that each provider is coding and billing appropriately.

As billers and coders, it is our job to code and bill appropriately for the care being provided.  Code 99490 was implemented to incentivize providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions.  Unfortunately, as a biller/coder, it may be hard to “find” this care documentation within the chart.  In addition to charting the “time” the diagnosis for the two (or more) chronic conditions must  be documented and clearly connected as medically necessary  for this oversight care.

In the last 18 months, since code 99490 has been implemented in the CPT code set, one of the biggest issues that has come to the forefront is physician reluctance to document and bill for the 99490 CCM code.  Many providers have implemented the basic criteria into their electronic health records, yet are not utilizing this method to document and bill for cod 99490.  The EHR is the most effective way to meet and guarantee that the fulfillment of all criteria for billing of this code is met.  However, the usage of a basic “table” format into a hard-copy chart or file can be just as effective and easy to use.  With either system, it still allows the biller/coder to easily audit and bill for this code.  (see end of article for a template for hard copy documentation)

Another “bonus” of this code, is if the practice utilizes mid-level providers of care (as listed below) those providers can provide this care management without a huge amount of impact to the physician providers of care.
Physician Assistants
Nurse Practitioners
Certified Nurse Midwives
Clinical Nurse Specialists

For those physician providers that have been billing for this code, for 20 minutes of work time, the national Medicare payment amount on this code for fiscal year is  $ 40.82, and the proposed payment for 2017 is $ 42.21.  According to CMS, in the fiscal year of 2015, only 275,000 Medicare beneficiaries received (and CMS paid for)  this service under code 99490.  Considering how many Medicare beneficiaries are enrolled and receiving Medicare services (approx. 54 million)  275,000 services provided with code 99490 is a very small percentage of total Medicare beneficiaries that could have received these services.  At first glance, it seems that $ 40.82 as the reimbursement for this service is small, however, this can add up quickly if you have a large Medicare population.  Code 99490 can  easily be provided, documented and billed for to increase the revenue stream into the practice.

It remains, however, the area of continued concern from providers is they must also allow the patient to “Opt in” and consent to have oversight for this care.  This can be problematic, as this is a non-face to face coordination of care, and patients may view this as a “charge” for a service not rendered appropriately, as they did not physically “see” the provider.  Patients have complained to their providers for having to pay for this “invisible” service.  Again, it is imperative that the physician provider communicate clearly to the patient regarding this service and allow the “opt in”  or “opt out”.  Physicians also stated concern, if they would be able to ensure or maintain a 24-hour-a-day, 7-day-a-week (24/7) access to care management services as required by the CMS guidelines.

As a coder, billing code 99490  is one way to help your physician actually get paid for time spent performing this care management service.  This service can include telephone calls, coordination of continuing services, and collaboration with specialty physicians which are services that are not normally paid for, or bundled in traditional E&M services.  In addition to providing good patient care, the billing/coding of CCM code 99490 that can also help the practice revenue stream and enhance the patients overall care.  It is your expertise of you, the coder/biller that can pull this all together with your providers.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Lori-Lynne’s Coding Coach Blog

Sterilization forms and coding: documentation tips post ICD-10 implementation

Sterilization forms and coding:  documentation tips post ICD-10 implementation
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
Originally published: March 25, 2016
Coding and reimbursement for sterilization has more to it than simply applying the CPT code, diagnosis code, submitting the claim and “voila”  having the reimbursement dollars  magically appear in the revenue stream. 
The Federal Government has regulations in place that need to be followed for those providers that perform sterilizations and accept reimbursement from federally funded payers.    These mandates are found within U.S. Code: Title 42 – The public health and welfare  and are contained in the laws within Title 42.  The sterilization consent form requirements can be officially found  within; Title 42; Chapter I, Subchapter D, Part 50, Subpart B,  Section 50.205.  This is commonly referred to as  “42 CFR 50.205 – Consent form requirements”
If you are a provider who performs sterilization procedures on a frequent basis, you are probably well versed in the process of getting this form filled out correctly and getting reimbursement.  Many providers who only occasionally provide sterilization services are unaware of this mandated form, and either get the form filled out incorrectly, or don’t get the form filled out at all.  This creates issues for the entire practice, and impacts the revenue you rightly deserve for providing this care.   The requirement of this form is non-discriminatory, in the fact that it has to be filled out and utilized for those who perform sterilization procedures on men as well as those sterilization procedure performed on women.
50.205 Consent form requirements
“42 CFR 50.205” contains these parameters to be fulfilled
(a)   Required consent form. The consent form appended to this subpart or another consent form approved by the Secretary must be used.   link to federal form HHS-687
(b) Required signatures. The consent form must be signed and dated by:
(1) The individual to be sterilized; and
(2) The interpreter, if one is provided; and
(3) The person who obtains the consent; and
(4) The physician who will perform the sterilization procedure.
(c) Required certifications.

(1) The person obtaining the consent must certify by signing the consent form that:

(i) Before the individual to be sterilized signed the consent form, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

(ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

(iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

(2) The physician performing the sterilization must certify by signing the consent form, that:

(i) Shortly before the performance of the sterilization, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

(ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

(iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized. Except in the case of premature delivery or emergency abdominal surgery, the physician must further certify that at least 30 days have passed between the date of the individual’s signature on the consent form and the date upon which the sterilization was performed. If premature delivery occurs or emergency abdominal surgery is required within the 30-day period, the physician must certify that the sterilization was performed less than 30 days but not less than 72 hours after the date of the individual’s signature on the consent form because of premature delivery or emergency abdominal surgery, as applicable. In the case of premature delivery, the physician must also state the expected date of delivery. In the case of emergency abdominal surgery, the physician must describe the emergency.

(3) If an interpreter is provided, the interpreter must certify that he or she translated the
information and advice presented orally, read the consent form and explained its contents and to the best of the interpreter’s knowledge and belief, the individual to be sterilized understood what the interpreter told him or her.
Critical verbiage and procedures
As you can see from the above, there are a lot of “rules” to be followed.  However, the government has given us a standardized form to use and be implemented by the providers.  They have even given us an electronic type version that can be downloaded and filled in, or even filled in on-line.  This form can be found at  http://www.hhs.gov/opa/pdfs/consent-for-sterilization-english-updated.pdf.   This government form is currently valid for use though 12/31/2018.  
The critical verbiage that must be followed closely is the mandate that “at least 30 days have passed between the date of the individual’s signature, and the date for when the sterilization is performed”.   If this is not followed closely, the physician and the facility/hospital will not be paid. 
This form is used across the United States, however, some State funded Medicaid programs may use their own form, but it has to contain the minimum information that has been outline in 42 CFR 50.205.  
When implementing the procedure to get this form completed correctly, all staff, and especially the physician/provider,  should be aware of its content and ensure that it is filled out correctly.   This seems like more government buracracy  however, if you are a Medicare/Medicaid provider this is part of the process we must perform to ensure the patient fully understands the implications of sterilization, and that as a patient they consent to the procedure.
ICD-10 diagnosing –  ICD-10 procedure – CPT procedure
In the post ICD-10cm and ICD-10pcs world things have changed for the coding and reimbursement for sterilization codes. 
In ICD-9cm we used code V25.2; Sterilization
In ICD-10cm we now use code Z30.2; Encounter for Sterilization
The codes are very similar, but in ICD-10cm they expanded the description to state that the usage of the code was for the encounter  for sterilization –  not just stating the word “sterilization” .    So for the diagnosing of sterilization procedures it remains straightforward for the diagnosis of the sterilization procedure.
However, that is not the same for ICD10pcs.  In ICD10pcs, the procedure of “vasectomy” is found in the index, and you’re referred to the code tables that provide the codeset for   a procedure performed on the male reproductive organ system.    The same can be said for the term  “tubal ligation”   as when you go to look it up the ICD-10pcs system as a tubal ligation, it refers you to the term “occlusion”  where as you view the index, you find  “Occlusion; Fallopian Tube; Left, Right, Bilateral”  and refers you to the table sections that are appropriate.   (see attached pages)  
CPT procedures have many different codes that can be used for “sterilization procedures”  so careful review of the operative reports to determine the correct code is a vital piece to ensuring your smooth reimbursement of sterilization procedures.
If you look in the CPT manual index, you will find the term for the “vasectomy”procedure, and CPT refers you to the numeric code of 55250.  In the CPT codeset the code 55250 is found in the surgery/male genital system section under Vas Deferens; Excision; then the code 55250 is the only code that appears in this subset.  If your provider does the traditional vasectomy procedure this is the correct code to use.  However, there have been newer and less invasive techniques for “vasectomy”  so code 55250 may not be the correct choice.   It is this new technology that requires coders to carefully review the operative note(s) to ensure the correct CPT code goes with the correct diagnosis. 
The same can be said for coding of sterilization for female patients.  In the CPT manual sterilization codes for female patients can range from a very simple to extremely complex invasive procedures.  CPT includes sterilization procedures that range from simple “incision” type procedure, and include codes for sterilization procedures that utilize  laparoscopic technique, hysteroscopic technique,  percutaneous incision, to abdominally open surgical procedures.  CPT even includes codes that factor in a sterilization performed at the time of delivery (with a cesarean section)  or even performed shortly after a vaginal delivery.
Diagnosis beyond “encounter for sterilization”
In cases where a sterilization is being performed, not all sterilization procedures are performed strictly for birth control.  Providers, clinical personnel, and coders all need to ensure that the coding and documentation for a sterilization procedure is clearly reflective of why the procedure is being performed.  Sterilization procedures may be required for a medically necessary or medically indicated diagnosis. 
If a sterilization procedure is needed by the patient, this does not absolve us from not getting the proper paperwork filled out. (eg the federal sterilization form, appropriate consents, pre-authorizations, and referrals)   In the case of a female patient requiring an emergent type of sterilization procedure, the 42 CFR 50.205 federal form allows for this circumstance in which the form still needs to be filled out, but the caveat of “emergency abdominal surgery” is noted on the form, and in the patients’ medical record.
When filling out the claim form for sterilization procedures that are not for contraceptive reasons, the medically necessary diagnosis would be appended first;  then any additional medically indicated symptoms or diagnoses, with the final code of  Z30.2; Encounter for Sterilization.  When sequenced, this paints the picture of a medically indicated procedure, and denotes that the patient is also rendered sterile.
Prior to sending your claim, take the time to review the sterilization form and review it has been filled out correctly,  all signatures and dates are correct and within the mandated guidelines.  If the form is incomplete, or incorrect take the time to make all necessary corrections, and get all necessary signatures. 
As you submit your claim, if it is an electronic claim, you may be required to submit a copy of the signed sterilization form, the operative report and also supporting medical records with your claim.  If you are still submitting your claim as hard copy, you will need to include these documents as hard copy.  
Final thoughts – wrap it up neatly
As a coder, you now have the unique opportunity to connect with your providers, clinical back office personnel, and your first line patient representatives to ensure that all the appropriate forms are filled out.  You can provide the education and the importance of the sterilization form,  and the importance of clear documentation to determine the reasons for the sterilization procedure. (eg, if done for “contraceptive or birth control” or “medically necessary/medically therapeutic” ).
If the sterilization procedure is denied for payment by the insurance carrier, review the denial code carefully, and if needed, contact the carrier to fully determine the cause of the denial.   If warranted, appeal your denial. 

For “male sterilization “ procedures performed in ICD-10 PCS

 … for female sterilization “tubal ligation” procedures in ICD-10 pcs



Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.   

Lori-Lynne’s Coding Coach Blog