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

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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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5 Skills All Healthcare Business Professionals Should Have

Do you have the skills employers are seeking most in 2023? Every profession in the medical field has its unique set of requirements. But one thing all healthcare employers have in common is that they’re looking for employees at the top of their game. Physician practices and hospitals could not function without medical coders, billers, […]

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AAPC Knowledge Center

Q&A: Should we hardcode modifier -CT?

Q: Our radiology department is requesting that we add a new modifier to their charge description master (CDM), modifier –CT (computed tomography [CT] services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard). They want this added to the CT scan line items, but they are not sure if it is for all of the items or only certain ones. Can you provide more information that might help us know how to proceed?
 
A: Each facility needs to have a discussion before you hardcode the modifier to the CDM. Modifier –CT is a new modifier for 2016 and the NEMA standard has to do with dose optimization and management. For CT scans that are performed on equipment that is non-compliant with this standard, the modifier must be reported on specific codes. The specific CPT codes are listed in Transmittal 3425 and the Medicare Claims Processing Manual, Chapter 4, section 20.6.12.
 
A discussion is warranted if you have more than one CT scanner in use at your facility. This modifier is only applicable to scanners that don’t meet the requirement, and a payment reduction is involved when the modifier is reported. For CY 2016, CMS instituted a 5% reduction in payment when the modifier is reported, but the percentage increases for CY 2017 and beyond. So, if you have multiple scanners in use, you want to be sure that the modifier is only applied to those services provided on the non-compliant scanner/equipment.

 

Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Revant Solutions,in Fort Lauderdale, Florida, answered this question.
 

HCPro.com – APCs Insider

Should Long-Term Care Facilities Outsource Compliance?

If long-term care (LTC) facilities want to save a bundle and ensure compliance with federal regulations, the answer is obvious. On Dec. 24, 2003, the Securities and Exchange Commission (SEC) promulgated new investment compliance rules. Pursuant to these rules, effective Oct. 24, 2004, investment companies and investment advisers are required to adopt written compliance procedures, […]

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AAPC Knowledge Center

ICD-10 Remix: What the Heck is a DRG and Why Should I Care About Case Mix?

I originally penned this blog post in 2011 and while the essence of DRGs hasn’t changed much, the coding system has.  So here is the ICD-10 update to one of my most popular blog posts of all time.  Enjoy!

So you want to be a coder. And not just that, you want to be a hospital coder because, on average, they make more money than physician coders. And you don’t just want to be a hospital coder, you want to be an inpatient hospital coder because then you get to look at the whole chart and piece together the patient’s clinical picture. If this is your goal, then everything you need to know you will not learn in school. And that’s mainly because there is so much to learn and practical experience is key.

Most of all, if you want to be an inpatient coder, you need to know diagnosis-related groups (DRGs) because in hospitals, it’s all about DRGs and case mix – and compliance. If you have no idea what I’m talking about, fear not – here’s a primer on DRGs! I wish I could say I cover it all here, but this is just a beginning!

What is a DRG?
The ICD-10-CM coding systems contains over 72,000 codes. Imagine trying to determine a payment amount for each individual condition. And that doesn’t include accounting for procedures (over 78,000 ICD-10-PCS codes). The most logical solution is to create a system that allows for broader classification of conditions and services for easier comparison and assignment into payment categories. DRGs were created for this purpose. I look at DRGs as a way to “organize the junk drawer” where patients are grouped into different categories based on similar conditions and cost to treat the patient.

History
DRGs were first developed at Yale University in 1975 for the purpose of grouping together patients with similar treatments and conditions for comparative studies. On October 1, 1983, DRGs were adopted by Medicare as a basis of payment for inpatient hospital services in order to attempt to control hospital costs. Since then, the original DRG system has been changed and advanced by various companies and agencies and represents a rather generic term. These days, we have various DRG systems in use – some proprietary and some a matter of public record – all of which group patients in different ways. Two of the main DRG systems currently in use are the Medicare Severity DRG (MS-DRGs) and 3M’s All Patient Refined DRGs (APR-DRGs). Different DRG systems are used by different payers.

How to Get a DRG
All DRG systems are a little different, but the basic premise is the same. DRGs are based on codes. In effect, DRGs are codes made up of codes. The following elements are taken into consideration when grouping a DRG:

  • ICD-10-CM diagnosis codes
  • ICD-10-PCS procedure codes
  • Discharge disposition
  • Patient gender
  • Patient age
  • Coding definitions as defined by the Uniform Hospital Discharge Data Set (UHDDS) – in other words, the sequence of codes on the claim

Back in the 80s, DRGs were grouped manually using decision trees. These days, DRGs are grouped with the touch of a button and DRG groupers are a big part of encoding software. But I would be doing you a disservice if I didn’t at least give you an idea of the grouper logic. As I mentioned, there are different DRG systems and probably the most popular is the MS-DRG system, so I will explain how MS-DRG grouper logic works.

MS-DRG Grouper Logic
The first step in assigning an MS-DRG is to classify the case into one of the 25 major diagnostic categories (MDC). These MDCs are based on the principal (first) diagnosis and, with a few exceptions, are based on body systems, such as the female reproductive system. Five MDCs are not based on body systems (injuries, poison and toxic effect of drugs; burns; factors influencing health status (V codes); multiple significant trauma; and human immunodeficiency virus infection). Organ transplant cases are not assigned to MDCs, but are immediately classified based on procedure, rather than diagnosis. These are called pre-MDC DRGs.

Once a case has been assigned into an MDC (with the exception of the transplant pre-MDCs), it is determined to be either medical or surgical. Surgical cases require more resource consumption (that’s industry speak for “costs more!”), so they must be separated from the medical cases. If there are no procedure codes on the case (e.g., a patient with pneumonia may have no procedure codes), then it’s simple – it’s a medical case. But if the patient had a procedure, that procedure may or may not be considered surgical. For example, an appendectomy is quite clearly a surgical procedure. But something like suturing a laceration is not. It’s all based on resource consumption – the cost of performing the procedure. For the most part, anything requiring an operating room is surgical.

Okay, so now that we have our MDC and a designation as medical or surgical, we need to look at the other diagnoses on the claim. Right now, Medicare is able to process the first 18 diagnoses on the claim. These other diagnoses, depending on their severity, may be designated as complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Medicare maintains lists of CCs and MCCs and updates them annually. CCs and MCCs are conditions that have been identified as significantly impacting hospital costs for treating patient with those conditions. For example, it’s been determined that congestive heart failure without further specification does not significantly impact costs and it is not a CC/MCC. However, patients with chronic systolic or diastolic heart failure do have slightly higher costs, so those conditions are CCs. More so, patients with acute systolic or diastolic heart failure have even higher costs, so they are designated as MCCs. Are you beginning to see how slight changes in a physician’s diagnostic statement impact coding and thus payment?

DRG Weights
Now that we know the MDC, whether the case is medical or surgical, and whether or not there are any CCs or MCCs, how does that translate into reimbursement? Well, if you’re using an encoder (and if you code for a hospital, you will), you hit a button and presto! You have a DRG with a relative weight. Now if only you knew what that relative weight meant. The DRG relative weight is the average amount of resources it takes to treat a patient in that DRG. Huh?

Let me demonstrate. The baseline relative weight is 1 and represents average resource consumption for all patients. Anything less than 1 uses less than average resources. Anything above 1 uses more than average resources. So let’s compare some respiratory MS-DRGs:

  • MS-DRG for lung transplant has a relative weight of 10.7863
  • MS-DRG for simple pneumonia (no CC/MCC) has a relative weight of 0.6821
  • MS-DRG for chronic obstructive pulmonary disease with an MCC has a weight of 1.144

You can see how different combinations of codes lead to different MS-DRGs with different relative weights. In order to convert that into monetary terms, we multiply the relative weight by the hospital base rate. Now I’m sure you want to know how to get that hospital base rate. Me too. Well, up to a point. The base rate is exclusive to each hospital and takes a lot of historical, facility-specific data into account, like what they’ve been paid in the past, whether they are an urban or rural hospital, and how much the hospital pays out in wages. That’s just more math than my poor little head can comprehend! So for the purposes of this exercise, let’s pretend like this hospital – we’ll call it Happyville Hospital – has a base rate of $ 5000. So if we multiply the relative weights above by $ 5000, our reimbursement for those cases, respectively, is $ 53,932, $ 3,411, and $ 5,720.

Case Mix
You just might be asked in an interview if you understand case mix. It’s a good indication of whether someone really understands DRGs. And I have to admit, in my sometimes sadistic manner, I like seeing that look of glazed-over confusion on someone’s face when I bring up case mix. But case mix is simple. It’s the average relative weight for a hospital. So get out a big piece of paper for your hospital and start writing down the relative weights for every single case and then divide to get your average. Okay, so it’s computerized now. But that’s all case mix is – an average.

In the industry, we officially refer to case mix as the type of patients a hospital treats. Let’s say at Happyville, we have a high volume of transplant cases plus a trauma center and a well-renowned cardiac program. These are all highly weighted types of cases and our overall case mix will be higher than say, Anytown Hospital down the street that has no trauma center, no transplant program, and basic cardiac services (they transfer all their serious cardiac cases to Happyville!). Happyville’s case mix will be higher than Anytown’s.

As a coder, you don’t need to know what your specific hospital’s case mix is at any given time. But knowing what impacts case mix is an indication that you know your stuff. First and foremost, case mix fluctuates. Most hospitals monitor case mix on a monthly basis because changes in case mix are a precursor to changes in reimbursement. Of course your CFO wants case mix to continue to rise, but that could be a red flag. And he certainly doesn’t want case mix to fall. If case mix begins to decrease, the first place hospital administration usually looks is coding – after all, case mix is based on DRGs, which are based on codes. But there are lots of things that can impact case mix and many of them have nothing to do with coding, such as:

  • The addition or removal of a heavy admitting physician – especially specialty surgeons
  • Opening or closing a specialty unit
  • Changes in a facility’s trauma level designation
  • Movement of cases from the inpatient setting to outpatient, and
  • Anything else that impacts the type of services the hospital provides

Your Life as an Inpatient Coder
As an inpatient coder your job is to make sure you get all the codes on the claim in the correct order so that the accurate DRG is assigned and the hospital gets paid appropriately. When I put it that way, it sounds so easy! The reality is, with more and more patients being treated as outpatients, those who are admitted as inpatients are sicker than they’ve ever been. And sicker means harder to code. For instance, the patient comes in with shortness of breath and the final diagnosis is acute exacerbation of COPD, staphylococcal pneumonia, and respiratory failure. How you code and sequence the case will determine the appropriate DRG and reimbursement. The good news is, you’ll have an encoder to help you model the DRGs and see what pays what. The bad news is, you have to paw through the medical record to determine the true underlying cause of that shortness of breath.

So are you ready for the challenge? Are you ready to apply DRGs?
Coder Coach

Should we code borderline to mild? paging demitchell

Trying to referee a coding debate here.

Coding echo reading for primary physicians.

Junior coder doesn’t code "borderline to mild left atrial enlargement" as cardiomegaly since query with doctor says that it’s not clinically relevant.

Senior coder says that’s wrong and it should be coded.

1. Which one is right?
2. Senior coder says that well, if the report goes back to primary care follow up and primary care office codes the left atrial enlargement as cardiomegaly – upon chart review for HEDIS, Risk Adjustments, etc. we would run risk "undercoding" bec it would look weird to the insurance that the "codes don’t match".
Question: Do insurances match codes and audit you ?
3. Most of the carotids we read are due to carotid occlusive disease , bilateral so we code I65.23 for all of them. Would that get us in "trouble"?

Our coder keeps on saying oh if we don’t do this, if we don’t do that we will get in trouble. We are all just trying to make an honest living of saving lives, helping people. Are the insurances that unreasonable as to try to "get us" with a code that’s missed or an overlooked diagnosis that was coded from HPI and past medical but not in assessment?

Thanks for suggestions and advices.

Medical Billing and Coding Forum

7 Reasons You Should Use AAPC Code Books for Your Exam

Using the right code books is essential to your success on your AAPC exam. Among all the code books out there, we recommend AAPC’s. Here are seven reasons why using AAPC’s ICD-10-CM, ICD-10-PCS, and HCPCS Level II code books will help you on your certification exam: Made for Your Examination – AAPC’s code books are […]

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AAPC Knowledge Center

Should I wait until the pt is discharged from hospital to create and send the claim?

Hello everyone,

I need your help… I am working in a practice that have been doing the hospital billing the same way for the last couple of decades. They are very fortunate to have the same employee for almost 40 years. Now that I involved in the hospital billing I have been informed that they wait until the patient is discharged from the hospital to create the claim. I have never heard of such rule and I cannot find any documentation to prove it right or wrong either. From previous experience, this rule was not recommended. I have always created the claims on a daily basis if possible, but at the end of the month all visits were counted as part of the monthly financial report therefore all hospital claims were created and sent to the insurance companies by the last day of the month.

My questions is: How do you do it in your practice, your experience? What is your recommendation? Should we wait until the patient is discharge from the hospital to create and send the claim>

In advance, thank you for your help and the learning experience.

Isvel Bacallao CPC

Medical Billing and Coding Forum

How is this should be coded? (OB/GYN OUTPATIENT)

Hi guys!

Can you please help me to code this ob encounter?

Scenario:
An established patient visited the clinic for her initial antenatal care. She is currently 15 weeks pregnant (G2,P1) with previous cesarean section due to breech presentation. This is a spontaneous pregnancy. Patient has currently no complaints. No nausea, no vomiting, no abdominal pain, no vaginal bleeding. She is a known case of Uterine Fibroid, and Iron Deficiency Anemia. Patient is taking oral iron replacement. No surgical history, negative family history. The physician requested dating scan and booking investigation for the patient.

I hope you can help me with this.

Thank you!!!
:):)

Medical Billing and Coding Forum