Medical Billing in Facebook

Hello Everyone,

I'm inviting all you 'Medical Billing' professionals and enthusiasts, who are in Facebook, to become a fan of the service 'Medical Billing' in Facebook.

There was no proper page found previously for this service in Facebook, so I created one to promote its popularity and to bring together our Medical Billing friends in FB, in one page.

The homepage of the service 'Medical Billing' can be found at the following URL:
http://www.facebook.com/pages/Medical-Billing/43708806758

Please share this information with your friends, who are also 'Medical Billing' professionals or who's just interested in the domain and invite them to become fans of this service too.

Hope to have all your support...

Thanks,
Karna

'US Healthcare PM & RCM' - A LinkedIn Group

'US Healthcare PM & RCM' is a LinkedIn Group which was created to serve as a common platform to unite professionals involved with the US Healthcare Practice Management and Revenue Cycle Management, generally known as 'Medical Billing'.

It is a group that will include professionals at all levels from various processes like Appointment Scheduling, Patient Registration, Medical Documentation, Medical Coding, EMR/EHR, Patient Demographics and Charge Entry, Insurance Eligibility/Benefits Verification, Provider Credentialing, Claims Transmission, Accounts Receivable, Payment Posting, Accounts Payable, Insurance Follow-up, Patient Follow-up etc.

Injured By a Spacecraft? There’s a Diagnostic Code for That

July 15, 2008 @ 6:09 pm
By Jacob Goldstein | The Wall Street Journal Health Blog

So we’ve got this patient here who was injured in this spaceship accident. You know, just a routine, uh, orbital mishap. But how do we account for that? Oh, right, it’s ICD-9 code E845 — “Accident involving spacecraft.”

Apropos of nothing in particular, this billing code popped up on a couple of medical blogs last week (KevinMD and Dr. Secretwave101). Intrigued, we did a little reporting.

This extended definition notes that the code includes “launching pad accident,” but excludes “effects of weightlessness in spacecraft,” which has its own code (E928.0).

ICD (International Classification of Diseases) codes are the basic international health codes that exist for just about everything (as this spaceship thing suggests). They’re used both for billing purposes and for tracking trends in public health.

A spokesman for the Centers for Medicare and Medicaid, one of the key agencies that deals with the codes in this country, told us that E845 was in the current version of U.S. ICD-9 code when it was first published in 1979. The code was created by the World Health Organization as part of ICD-9, the spokesman said. Other places in the world use ICD-10, we’ve stuck with ICD-9-CM.

A little creative Googling turned up a citation of the same code all the way back in 1966.

Just because a code exists, it doesn’t mean anybody’s ever used it. “Whether someone was injured [by a spacecraft] or not was immaterial because somebody thought, ‘What If?’ ” Sheri Poe Bernard, a VP at the American Academy of Professional Coders told us.

It didn’t take much to get Poe talking about all the strange things that have their own codes. Bite of a non-venomous arthropod. Dog bite. Rat bite. Scorpion sting. “A centipede has its own code — E905.4,” she said. “Accident caused by paintball gun, E922.5 Accident by fireworks, explosion, E923.0″

If you can think of a way to be killed or injured, there’s a code for it. “Terrorism has all kinds of codes associated, involving marine weapons, aircraft, explosions, conflagration,” she said. “Terrorism involving nuclear weapons, E979.5; biological weapons E979.6; chemical weapons E979.7.”

Uh, thanks Sheri. If you need us, we’ll be huddling under our desk, fearing for our lives. What’s the ICD code for that?

Acute Cost and Growth Pressures to Drive Large-Scale BPO and ITO Outsourcing/Offshoring in Healthcare Sector over Next Three to Five Years

July 08, 2008 09:30 AM EDT | BUSINESS WIRE

HOUSTON -- The slumping economy may be slowing deal flow in some sectors, but it is accelerating adoption of outsourcing in the healthcare industry as it struggles to streamline its back-office and ramp up to meet increased demand for services as the U.S. population ages, according to EquaTerra, a leading business advisory firm. In its newly released poll of leading outsourcing service providers on the state of the healthcare outsourcing market, EquaTerra expects these competing macro economic trends to drive large-scale outsourcing and offshoring deals over the next three to five years, especially in business process and information technology outsourcing (BPO and ITO).

Half of the respondents to EquaTerra’s 2Q08 Healthcare BPO/ITO Service Provider Pulse Survey* report demand is up quarter over quarter and 70 percent expect an increase next quarter. The scope of healthcare outsourcing is expanding too as healthcare organizations attempt to gain efficiencies through greater automation, self-service capabilities and improved IT infrastructure and functionality.

Typically, healthcare companies that are currently outsourcing have already reduced labor costs. Now, they want to achieve business process improvements via technology, business process reengineering and implementation of Six Sigma methodologies. As a result, they are prioritizing their outsourcing goals and focusing on functions and processes core to healthcare front and back-office operations. Seventy percent of healthcare services providers polled cited vertical healthcare business service areas, like claims administration and revenue cycle management (RCM) as the top areas of outsourcing demand in the market today.

Outsourcing buying patterns also appear to be changing. There is an emerging trend toward consolidating work sourced to several providers (e.g. claims imaging, data entry and claims processing) to a single, large vendor that can handle the entire claims function. In addition to standard BPO services, the clear expectation from this single-source solution is overall business transformation plus value-added knowledge services, including claims analytics, collections and reserve forecasting.

The survey also indicates more healthcare industry work is moving offshore to both India-based and multinational service providers. IT infrastructure monitoring and support along with RCM were identified as the two functions using the highest levels of offshore talent. Cost reduction continues to be a major impetus, but there’s also a significant shift to more strategic activities, according to 65 percent of the survey participants. As a result, outsourcing buyers are migrating from a contract labor model to longer-term, project-based work and multi-year outsourcing efforts that require greater control over functions and processes. Service providers cited the top two drivers for the increased use of offshore resources as immediate access to expertise and talent (50 percent) and knowledge services (42 percent).

To compete for this upscale work, outsourcing providers are developing more compelling offerings, according to Mark Voytek, healthcare industry practice lead for EquaTerra. “Healthcare companies need tools that support effective fiscal management and IT applications that can automate clinical processes and assist in improving quality, especially reducing medical errors. The low upfront costs associated with outsourcing versus a total-cost-of-ownership model is especially attractive in the current economy.”

Voytek’s thoughts are echoed by an executive from a leading healthcare service provider who says escalating costs and cuts in Medicare and Medicaid payments coupled with the increased demand of an aging population threaten the solvency of many U.S. hospitals. “Sixty percent of U.S. hospitals are already unprofitable and rely on charity and donations for supplemental funding. Cuts in claims payouts will further shrink revenues just as more Americans will utilize health services. The number of hospitals that are highly unprofitable will grow unless they adopt large-scale outsourcing and offshoring to reduce overall cost levels.”

Top-line finds from the 2Q08 Healthcare Service Provider Pulse Survey:

• Outsourcing service providers (82 percent) said the healthcare payer industry exhibits the greatest demand for BPO and ITO services. The healthcare provider market ranked second (73 percent.)
• Costs savings are still paramount, but 75 percent of the service providers polled report buyers are putting greater emphasis on process improvement, innovation and transformation.
• EquaTerra estimates approximately 75 IT and BPO deals were initiated from 2004 through 2007 with a total contract value (TCV) of $50 million. Of these, 75 percent were ITO deals and 25 percent were BPO. To date, healthcare represents less than five percent of total outsourcing deals in the market, highlighting the relative immaturity of the healthcare outsourcing market as compared to other industries like banking, financial services and manufacturing. But the healthcare outsourcing market is expected to grow at close to 10 percent over the next five to seven years, faster than overall market growth of seven to eight percent.

“The use of offshore and global resources in healthcare outsourcing is accelerating,” said Stan Lepeak, managing director of research for EquaTerra. “In fact, deteriorating economic conditions will likely drive more outsourcing in the healthcare market over the next several quarters.”

*About the 2Q08 Healthcare Industry Pulse Survey

EquaTerra recently polled top outsourcing service providers in the healthcare market. Based on these findings and its own direct market experience, the company mapped the level of buyer demand across several sets of emerging BPO and ITO functions and processes specific to the healthcare space. The demand-level ranking is based on a 1 to 10 scale, with 1 equating to low buyer demand, 5.5 to moderate demand and 10 to high levels of demand. Service providers were asked to comment on current demand and projected levels for the balance of 2008. For more details or to obtain a copy of this survey, please contact Stan Lepeak.

About EquaTerra

EquaTerra sourcing advisors help clients achieve sustainable value in their IT and business processes. Our advisors average more than 20 years of industry experience and have supported over 2000 transformation and outsourcing projects across more than 60 countries. Supporting clients throughout the Americas, Europe, Middle East, Africa and Asia Pacific, we have deep functional knowledge in Finance and Accounting, HR, IT, Procurement and other critical business processes. EquaTerra helps clients achieve significant cost savings and process improvement with internal transformation, shared services and outsourcing solutions. For more information, please contact Lee Ann Moore at +1 713.669.9292; leeann.moore@equaterra.com; www.equaterra.com.

Billings Used Dead Doctors' Names

By Christopher Lee, Washington Post Staff Writer
washingtonpost.com | Wednesday, July 9, 2008

Medicare has paid as much as $92 million since 2000 to medical suppliers who billed the government for wheelchairs and other home equipment purportedly prescribed by physicians who, according to records, were dead at the time, congressional investigators said yesterday.

The Centers for Medicare and Medicaid Services (CMS) honored about 500,000 such claims despite pledging six years ago to correct the problem, which was identified by the Health and Human Services Department's inspector general in 2001.

In more than half the cases studied, the doctor listed as having ordered the equipment had died more than five years earlier, said a report by the Senate Homeland Security and Governmental Affairs Committee's permanent subcommittee on investigations.

"We discovered that some medical equipment suppliers have scammed the Medicare system -- and the American taxpayers -- out of massive amounts of money," Sen. Norm Coleman (Minn.), the panel's top Republican, said in a statement. "Using the ID numbers of dead doctors, these scam artists have treated Medicare like an ATM machine, drawing money out of the government's account with little fear of getting caught."

The report is part of the committee's ongoing investigations into waste, fraud and abuse in the fast-growing federal health program, which serves more than 43 million elderly and disabled Americans. Medicare pays annually more than $400 billion in benefits and is a fixture on the Government Accountability Office's "high-risk" list of troubled programs.

Last year, the government established a Medicare Fraud Strike Force to crack down on a problem that officials estimate costs taxpayers tens of billions of dollars annually. The program's durable medical equipment component, in particular, has been a frequent target of companies seeking to bilk the government. The subcommittee has scheduled a hearing on the problem today. When the system works properly, a physician writes a prescription for home medical equipment for a Medicare beneficiary. He takes the order to a supplier, who sells or rents the equipment to him. The supplier, in turn, submits a claim for payment to a Medicare contractor for processing. The claim includes a number issued by Medicare that identifies the prescribing physician.

Senate investigators obtained from the American Medical Association a computer file of physicians who had died between 1992 and 2002. They selected 1,500 at random and asked Medicare officials to turn over medical-equipment claims filed with those doctors' Medicare ID numbers between 2000 and 2007.

During that time, the review said, ID numbers for 734 deceased doctors were used to file 21,458 claims that totaled $3.4 million. Investigators counted the claims only if the equipment was bought more than a year after the doctor's death.

Extrapolating from the sample, investigators estimate that 384,730 to 572,238 such fraudulent claims were submitted during that period, and Medicare paid an estimated $60 million to $92 million. There are still active ID numbers in Medicare's system for as many as 2,895 dead physicians, investigators said.

They examined separate data for Florida, home to many retirees and a perennial leader in Medicare fraud. They found that more than a quarter of deceased Medicare doctors there still have active ID numbers in Medicare's system.

The ID for one doctor, who died in 1999, appeared on 83 claims submitted by Professional Gluco Services Inc., a Miami company, between November 2005 and September 2006. A federal grand jury indicted two of the company's owners last year on charges of defrauding the government of $1.3 million for equipment that had never been ordered or delivered. Both men pleaded guilty.

Medicare officials had promised to do a better job screening claims after the 2001 inspector general's report found that the agency had paid $91 million for medical supply claims with invalid or inactive physician ID numbers in 1999.

Medicare officials said several new steps should help, including a plan to match monthly Social Security Administration data about U.S. deaths against a revamped Medicare provider-identification system. They also pointed to new accreditation requirements for suppliers under a new program, opposed by the industry, that sets some equipment prices through competitive bidding.

"Fraud and abuse in the context of Medicare-covered durable medical equipment has been a focal point of ours in recent years," said CMS spokesman Jeff Nelligan. "Before this program, anyone could become a supplier, but now they must be fully accredited based on strict financial and quality standards."

Muscling in on Medicare

Legislative fight in Washington puts patients in midst of doc-insurer struggle

July 8, 2008 | Newsday.com

A Medicare tweak on the table in Washington is pitting doctors against insurers - with patients in the middle. Doctors are facing a steep cut in Medicare payments, and many say that if that happens, they'll reduce or end their participation in the program. And that will make it harder for elderly patients to get care.

The alternative is to trim what Washington pays private, Medicare Advantage plans. Insurers, some of whom underwrite those plans, are airing television commercials warning that will mean patients losing coverage or paying more.

For patients, this all sounds like heads you lose, tails you lose. But things aren't that bleak. Not if Medicare Advantage plans take the hit, as they should.

The problem is that doctor reimbursements will be slashed 10.6 percent unless Congress acts to stop it. A cut that deep is unrealistic. The House voted June 24 to increase payments to physicians by 1.1 percent. But the bill is stalled in the Senate and, should it pass, President George W. Bush has threatened a veto. The sticking point is cost.

The bill would take the money from those private plans - which is where it should come from. Medicare Advantage plans were pushed by private marketers who said they would save taxpayer dollars. But Washington pays the plans 13 percent more per beneficiary than it would cost to cover that same person under government-run Medicare.

Pitting private plans against traditional Medicare is a sound idea. Competition should make each better. But a fair contest requires a level playing field, and right now it isn't. Not with private plans being paid more per patient.

The pending legislation wouldn't end that disparity. But it would reduce it and free up money to pay doctors. That would be a win for most Medicare patients and taxpayers.

Healthcare groups use ads to lobby lawmakers on Medicare bill

July 03 2008 | McKnight's Long Term Care News

Congress may be on break this week, but two industry groups launched ads spurring the Senate to take action on a Medicare bill that affects nursing home residents and other older adults when it returns from the Fourth of July recess.

The American Medical Association unveiled an advertising campaign to encourage passing the bill, H.R. 6331. Targeted towards opponents of the legislation, the ads say the issue boils down to a choice: insurance company profits, or seniors and disabled vets who will lose their access to healthcare. Meanwhile, insurance lobbyists are working on their own anti-H.R. 6331 advertising blitz. They argue that the cuts to Medicare Advantage plans that would fund the bill would limit choices, reduce benefits and pass on higher costs to seniors.

This week, two harmful actions went into effect: the expiration of the exceptions process for Part B outpatient therapy caps, and a freeze on Medicare physician payments. Therapy caps, which affect nursing home residents, impose a $1,810 limit on physical therapy and speech therapy combined and $1,810 on occupational therapy for nursing home residents. Residents in Medicare-certified beds at a skilled nursing facility will not have therapeutic services covered past $1,810, according to a note from the Centers for Medicare & Medicaid Services. Others who exceed the cap, however, may obtain medically necessary therapy services at a hospital.

Medicare Payment Fiasco Causes Delay in Claims Processing

Action Should Not Mean Delayed Payments

By James Arvantes | AAFP News Now
7/1/2008

The Bush administration has announced it will delay the processing, but not necessarily the payment, of Medicare claims to give Congress more time to pass a bill blocking a 10.6 percent reduction in the Medicare payment rate. However, the administration's action should not result in delayed Medicare payments to physicians, said Kent Moore, the AAFP's manager of health financing and delivery systems.

CMS is required by law to hold Medicare claims it receives for 14 days before issuing payment on the claims. In normal circumstances, the agency starts to process claims within a few days of receiving them, paying them by the end of the 14-day time frame, Moore said. CMS now plans to hold Medicare claims for 10 business days before processing them to give Congress more time to pass Medicare payment legislation that is expected to negate a 10.6 percent payment cut effective July 1.

"CMS will use that 14-day window they have statutorily and refrain from processing the claim," Moore said. "Instead of processing (a claim) at the front end of that 14 days, they will process it 10 days later on the hope that Congress will act within the first days of July," said Moore. "Physicians should not see a delay in payment," he added.

In late June, the House overwhelming passed an 18-month Medicare physician payment bill that would have prevented the 10.6 percent reduction scheduled for the remainder of this year, along with a 5.4 percent cut scheduled for 2009. But the Senate failed to pass the legislation, allowing the 10.6 percent cut to take effect on July 1. Congress adjourned for a weeklong July 4 recess on June 27 and will return on July 7. Senate Majority Leader Harry Reid, D-Nev., in a prepared statement, said the Senate would address the Medicare legislation shortly after returning from the July 4 break.

Many physicians, meanwhile, are upset and angry, said Moore, thinking CMS will withhold Medicare payments, a perception that he characterizes as a misunderstanding.

"CMS is simply saying that they are going to take advantage of the 14-day payment floor they already have by law," Moore said. "They still intend to pay claims in a timely manner."

Although physicians will experience a reduction in their Medicare payment levels if Congress and the Bush administration cannot agree on a Medicare payment bill by mid-July, there is an expectation that they will agree on a payment bill by then and will make the legislation retroactive to July 1.

CMS has said that physicians should submit their Medicare claims for services on or after July 1 using the pre-July 1 scheduled amount. Claims submitted after June 30 that reflect the 10.6 percent reduction will be paid based on that amount, and "will likely require providers to resubmit a revised claim," said CMS in a June 30 press release.

Submitting claims with pre-July 1 amounts "will facilitate reprocessing of the claims by CMS, if needed, and will ensure that physicians are able to collect the full pre-July 1 allowed amount, when or if the cut is retroactively negated," said Moore.

However, noted Moore, "physician practices may only collect copayments and deductibles from Medicare beneficiaries based on the reduced (Medicare) rate, even if they are charging the pre-July 1 rate to Medicare."

Physician practices wishing to avoid confusion may choose to hold their Medicare claims in-house until it becomes clear that new legislation will be enacted or until cash flow becomes a problem, said Moore. "This will reduce the need for (physicians) to reconcile two payments -- the initial claim and the reprocessed claim -- and it will simplify physician billings of beneficiary co-insurance and payment calculations for payers that are secondary to Medicare," said Moore.

AMA launches campaign to cut waste from chaotic insurance claims process, unveils new health insurer report card

Delayed and inaccurate insurance payments add cost, inefficiency to health care system

June 16, 2008

CHICAGO — To help reduce the substantial administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association (AMA) today launched the Cure for Claims campaign to help heal the ailing system of processing medical claims with health insurers, and unveiled the first AMA National Health Insurer Report Card on claims processing.

"The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, and to educate and empower physicians so they are no longer at the mercy of a chaotic payment system that take countless hours away from patient care," said AMA Board Member William A. Dolan, MD.

The inefficient and unpredictable system of processing medical claims adds unnecessary cost to the health care system, estimated as much as $210 billion annually, without creating value. Physicians divert substantial resources, as much as 14 percent of their total revenue, to ensure accurate insurance payments for their services.

"Eliminating the inefficiencies of the billing and collection process would produce significant savings that could be better used to enhance patient care and help reduce overall health care costs," said Dr. Dolan. "To diagnose the areas of greatest concern within the claims processing system, the AMA has developed its first online rating of health insurers."

The AMA's new National Health Insurer Report Card provides physicians and the public with an objective and reliable source of information on the timeliness, transparency and accuracy of claims processing by health insurance companies. Based on a random-sample pulled from more than 5 million electronically billed services, the report card provides an in-depth look at the claims processing performance of Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.

Key findings include:

• Denials. There is wide variation in how often health insurers pay nothing in response to a physician claim (from less than 3 percent to nearly 7 percent), and in how they explain the reason for the denial. There was no consistency in the application of codes used to explain the denials, making it extremely expensive for physician practices to determine how to respond.
• Contracted payment rate adherence. Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. Additional analysis will be necessary to determine how often these errors were tied to inaccurate payment. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
• Transparency of fees and payment policies. More than half of the health insurers do not provide physicians with the transparency necessary for an efficient claims processing system.
• Compliance with generally accepted pricing rules. There is extremely wide variation among payers as to how often they apply computer generated edits to reduce payments (from a low of less than .5 percent to a high of over 9 percent). Payers also varied on how often they use proprietary rather than public edits to reduce payments (ranging from zero to as high as nearly 72 percent). The use of undisclosed proprietary edits inhibits the flow of transparent information to physicians, adding additional administrative costs to reconcile claims.
• Payment timeliness. Prompt pay laws appear to have been effective in ensuring a relatively quick response to physician's electronic claim. Further analysis will be necessary to determine the extent to which this response is accompanied by accurate payment if the claim.

The report card will be available for the first time today on the AMA Web site.

"Physicians want to focus on caring for their patients, not fighting health insurance red tape that may delay, deny or shortchanged payments for their services," said Dr. Dolan. "The report card provides a useful snapshot of how each of the nation's biggest health insurers can improve the process they use to pay their bills."

The report card demonstrates the inconsistency and confusion that results from each health insurer using different rules for processing and paying medical claims. This variability requires physicians to maintain a costly claims management system for each health insurer.

The report card also suggests that both physicians and health insurers can help reduce unnecessary administrative costs if electronic transactions and full transparency are widely adopted. The costs of re-submitting claims can also be reduced if health insurers make better use of voluntary fields and reason and remark codes in electronic transactions to communicate crucial information to physicians about their claims.

The AMA Cure for Claims campaign will empower physicians to create a systematic approach to claims management so they spend less time and resources on payment hassles with health insurers. To help physicians submit timely and accurate claims, the AMA has created the Practice Management Center, an easy-to-use online resource offering physicians and their staff members tools for preparing claims, following their progress and appealing them when necessary.

The Practice Management Center's library of education materials and practical tools are available online.

###

For additional information, please contact:

Robert Mills,
AMA Media Relations
(312) 239-4991 or (312) 464-5970

Last updated: Jun 16, 2008
Content provided by: Media Relations

Medical Fraud a Growing Problem

Medicare Pays Most Claims Without Review

By Carrie Johnson
Washington Post Staff Writer
Friday, June 13, 2008; A01

MIAMI -- All it took to bilk the federal government out of $105 million was a laptop computer.

From her Mediterranean-style townhouse, a high school dropout named Rita Campos Ramirez orchestrated what prosecutors call the largest health-care fraud by one person. Over nearly four years, she electronically submitted more than 140,000 Medicare claims for unnecessary equipment and services. She used the proceeds to finance big-ticket purchases, including two condominiums and a Mercedes-Benz.

Health-care experts say the simplicity of Campos Ramirez's scheme underscores the scope of the growing fraud problem and the need to devote more resources to theft prevention. Law enforcement authorities estimate that health-care fraud costs taxpayers more than $60 billion each year.

A critical aspect of the problem is that Medicare, the health program for the elderly and the disabled, automatically pays the vast majority of the bills it receives from companies that possess federally issued supplier numbers. Computer and audit systems now in place to detect problems generally focus on overbilling and unorthodox medical treatment rather than fraud, scholars say.

"You should be able to spot emerging problems quickly and address them before they do much harm," said Malcolm Sparrow, a Harvard professor and author of "License to Steal," a book about health-care fraud that advocates for greater federal vigilance. "It's a miserable pattern, a cycle of neglect followed by a painful and dramatic intervention."

Fallout from the Campos Ramirez case continues. After pleading guilty to filing false claims, she has helped authorities win indictments against more than half a dozen doctors and patients who allegedly accepted kickbacks for pretending to receive costly HIV drug therapy. With cooperation from Campos Ramirez, FBI agents this week arrested three Miami-area men who, the government alleges, financed sham clinics that billed the government more than $100 million.

Daniel R. Levinson, the inspector general of the Department of Health and Human Services, has warned repeatedly that the Medicare program is "highly vulnerable" to fraud, particularly in South Florida, where schemes center on expensive, infusion-based HIV medications and on equipment such as wheelchairs, walkers, canes and hospital beds.

Officials from the Centers for Medicare and Medicaid Services (CMS), which oversees federally funded health programs, say they have stepped up their efforts to combat fraud over the past year by working closely with investigators, removing the requisite billing numbers of nearly 900 companies and imposing new standards in high-fraud areas that would prevent people convicted of felonies from ever receiving a Medicare number.

"There's always more fraud than we have resources to combat," said Kimberly L. Brandt, director of program integrity at CMS. "We have done a much better job of realigning our resources to attack this problem."

Investigators and prosecutors trained their focus on Miami after noticing two troubling patterns:

· HHS investigators discovered that nearly half of 1,581 medical equipment companies they visited in the Miami area did not comply with basic Medicare requirements to be open during scheduled hours and to have a telephone number. The inspector general and the Government Accountability Office have flagged weak oversight of these kinds of suppliers for a dozen years, according to congressional testimony.

· The South Florida region bills Medicare more than $2 billion each year for injectable HIV medications. That figure is 22 times as high as the amount of similar claims in the rest of the country, and is far out of line with demographic data in a population of 2 million people in Miami-Dade County, HHS statistics show.

Justice Department officials moved to freeze money in suspicious bank accounts controlled by medical equipment company owners and they created a Washington-based strike force to handle the issue. The strike force, in concert with a small group of U.S. attorney's offices, has in the past year opened nearly 900 criminal investigations and convicted 560 defendants in health-care fraud offenses throughout the country.

Authorities say the strategy is working. They point to a $1.75 billion drop in Medicare claims in Miami since the operation began a year ago. But even government officials hope for a more comprehensive solution.

Christopher Dennis, the special agent in charge of the HHS inspector general's office in Miami, said fraudulent medical equipment companies appear to have shifted gears since the strike force arrived. After a crackdown in South Florida, at least some corporate owners moved to the north, he said. Investigators dubbed one initiative "Operation Whack-a-Mole," after the carnival game in which a creature pops up in different places after being hit with a hammer.

"The sheer number of zeroes following the dollar sign is irresistible to crooks and con men," Attorney General Michael B. Mukasey said last month during a Miami visit. "For every crooked company we bust, there is another one to replace it before the ink on the indictment is dry. . . . The money and the temptation are simply too big."

The strike force recently established a base in Los Angeles, another area rife with fraud. Prosecutors announced criminal charges last month against two medical equipment company owners who are accused of falsely billing Medicare more than $2 million. Plans call for a similar rollout this fall in Houston, another potential fraud hot spot.

"You can see how these frauds spread through communities," said Kirk Ogrosky, who is deputy chief in the Justice Department's fraud section and helps lead the strike force. "Family members and friends just get sucked into it. It's really rags to riches on the backs of the American taxpayer."

Officials who oversee the Medicare program say they are vigilant despite time pressure and limited resources. Employees review fewer than 5 percent of the nearly 1 billion claims filed each year. The vast majority of claims shuttle through computer systems that are tweaked when authorities notice fraud patterns. This year, CMS is working to finalize a rule that would prevent convicted felons from obtaining Medicare billing numbers. At present, that regulation applies only in a few high-fraud regions.

"It's a big volume," Brandt said. "No matter how hard we try to get people trained, there's always going to be a margin of error."

Sentenced to 10 years, Campos Ramirez, 60, may yet reduce her prison term by helping authorities unwind "the large web of medical clinics, doctors, nurses, money laundering companies and HIV clinic financiers who participated in this massive fraud," prosecutors wrote earlier this year in court papers. Her lawyer did not return calls seeking comment.

By many accounts, Campos Ramirez was unusually successful. Prosecutors say that corrupt medical clinic owners anticipate that Medicare will cover a quarter of their phony claims. But Campos Ramirez persuaded authorities to cover 60 percent of all the bills she submitted on behalf of 75 HIV clinics in South Florida, according to court filings.

As the owner of R and I Medical Billing, Campos Ramirez advised clinic owners how to justify the costly HIV treatments and manipulated Medicare claims to make sham clinics appear to be legitimate health-care facilities, prosecutors said. She personally collected more than $5 million with which she bought property and luxury items. Over the past year, however, Campos Ramirez has met repeatedly with law enforcement agents to unravel the scheme, which ran from 2002 to 2006.

At the time of her sentencing in March, Campos Ramirez had amassed a net worth of $1.5 million, including one of the condominiums where her son, an employee of her billing company, had lived.

State proposes ban on HMO billing practice

June 1, 2008 | By LORA HINES | The Press-Enterprise

State officials, hospitals and doctors are locked in a dispute over whether some patients can be charged if they are taken to an emergency room outside of their health care network. For some, that bill can be a couple of hundred dollars, but for others it can reach into the thousands.

The ban proposed by the California Department of Managed Health Care would affect members of HMOs, such as Kaiser Permanente, not members of other kinds of insurance plans. The department only regulates HMOs. Administrators and hospital-based doctors say the state should be targeting insurance companies.

Statewide, thousands of people get pressed for payment by doctors and hospitals, typically after they are taken to an emergency room outside their insurance plan. Doctors and hospitals that think health care plans and insurance companies have shortchanged them on payment for treatment then try to make up the difference by going after patients who already paid their share. It's called balance billing.

Karla and William Gledhill, of Chino Hills, understand the practice well.

The couple got hit with a $53,000 bill from Arrowhead Regional Medical Center in Colton after their insurance company, Anthem Blue Cross, paid about $25,000. Their 16-year-old son, Ryan, was flown to the hospital after a serious dirt bike crash in Lucerne Valley.

Karla Gledhill said she racked up late-payment fees and bill-collection threats as she repeatedly wrote letters and made telephone calls to the hospital and insurance company. Last week, the insurance company agreed to pay the bill.

Gledhill said she thought she would have to hire an attorney, which sometimes is a patient's only recourse, hospital officials say.

The hospital and insurance company said privacy laws prevented them from commenting on the family's claim.

"You don't know anything about balance billing until you're stuck in the middle, trying to hammer out what's right," Gledhill said.

Balance Billing

More than 1.75 million insured Californians who visited emergency rooms in the past two years were asked to pay more, even after their co-payments and deductibles, according to the California Association of Health Plans. The professional organization represents 40 health care plans that cover an estimated 21 million Californians.

The average balance bill was $300, which added up to about $528 million that patients spent in addition to their co-payments and deductibles, the association said. More than half of the patients who were balance billed paid.

"The practice needs to be banned, period," said association spokeswoman Nicole Kasabian Evans. "The patient shouldn't be placed in the middle. That's what the insurance companies and health care providers are doing."

In July 2006, Gov. Schwarzenegger ordered an end to balance billing after he realized many residents were being charged for medical expenses they didn't owe, said Cindy Ehnes, director of the state Managed Health Care Department. But the department couldn't come up with a suitable solution to HMOs and providers, she said. So, the department decided to merely ban the practice.

"We have tried many other approaches to solve this problem," Ehnes said. "We have decided to go back to our first job, which is to protect consumers."

Ehnes said she had hoped lawmakers would have passed legislation regulating balance billing. At least seven states have balance billing laws, including Colorado and Florida. Meanwhile, state Sens. Don Perata, D-Oakland, and Leland Yee, D-San Francisco, have introduced balance billing legislation.

HMO Vs. Hospital

The ban comes as Kaiser, the state's largest HMO, got a temporary restraining order earlier this month from Los Angeles County Superior Court against Prime Healthcare Services Inc., of Victorville, to stop it from collecting money from thousands of Kaiser patients or reporting them to credit agencies. A hearing is set for Thursday.

"This has been an ongoing dispute for a year or year and a half," said Dr. Ben Chu, president of Kaiser's Southern California region. "... They threatened to trash their credit ratings if they didn't pay."

Earlier this year, Prime Healthcare sued Kaiser, claiming that Kaiser owes $25 million for its patients who were treated at eight of Prime Healthcare's hospitals, including Desert Valley Hospital in Victorville, Chino Valley Medical Center and Montclair Medical Center.

Prime Healthcare attorney Michael Sarrao couldn't be reached for comment.

Prime Healthcare has accused Kaiser of delaying payments by repeatedly demanding patient medical records, claiming that care provided was unnecessary and requiring transfer of members to Kaiser hospitals.

Chu disputed the claims.

"It's not about delaying payment," he said. "It's about substantiating claims."

Calculating Health Cost

Dr. Richard Frankenstein, president of the California Medical Association, said the organization, which represents 35,000 doctors, will fight the state Managed Health Care Department's ban.

"They ought to be regulating the insurance companies, not the doctors, which it does not have the authority to do," he said. "We see this as a $500 million transfer from patients to insurance companies, and the insurance companies aren't paying the bill."

On average, Frankenstein said, insurance companies pay all but about $30 of a doctor's bill.

"If that doctor sees 50 to 60 patients, that $30 does add up," he said.

Some specialists may not work on-call emergencies if insurance companies refuse to pay and they can't bill patients, Frankenstein said.

Frank Arambula, Arrowhead Regional Medical Center's chief financial officer, said the hospital compares its costs to those of other facilities, which are reported to the California Office of Statewide Health Planning and Development. The data are posted on the agency's Web site.

"We set our rates based on market-driven prices," he said. "We think it's a fair assignment and the payer is going to pay those charges."

Conversely, insurance companies rarely show patients and health care providers how they determine what to pay for service, Arambula said.

In a written statement, Anthem Blue Cross spokeswoman Peggy Hinz said the company reimburses out-of-network hospitals for what it considers reasonable and customary costs. It is changing its reimbursement policy to protect members who require emergency care, she wrote.

"It was not the intent of our reimbursement policy to increase out of pocket expenses for our members, who do not have a choice in selecting the place where health care services are performed, such as in the case of an emergency," Hinz wrote.

Anthem Blue Cross bases its reimbursement rates on factors including submitted charges for payment, comparisons of charges for services offered at other hospitals, and service costs that are reported to the state, Hinz wrote.

Fighting the Bill

The Gledhills didn't care whether Arrowhead Regional Medical Center was in their Anthem Blue Cross preferred provider organization network. Their son needed surgery on his pancreas.

"Worst case, we thought we would owe $6,000," said Karla Gledhill, whose husband owns a small Anaheim business.

Anthem Blue Cross first determined the Gledhills owed the hospital $53,273.17 after it paid $25,121.28, according to a claim recap. It paid another $12,606.15 after Karla Gledhill complained to the California Department of Insurance.

The Gledhills still faced a $40,667.12 bill and no explanation of how Anthem Blue Cross determined what it would pay.

"How could I fight a fair fight if I didn't have all the information?" Karla Gledhill asked. "I didn't think Arrowhead's charges were exorbitant for the care my son received."

On May 21, Anthem agreed to pay the rest of Ryan Gledhill's hospital bill after the company "made a one time administrative decision to remit payment," according to the letter the Gledhills received.

The letter did not include further explanation, and Hinz said privacy laws prevented her from offering one.

Reach Lora Hines at 951-368-9444 or lhines@PE.com

---

Online Help

California Office of Statewide Health Planning and Development: www.oshpd.ca.gov

California Department for Managed Health Care: www.hmohelp.ca.gov

California Department of Insurance: www.insurance.ca.gov

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Why Does Your Practice Employ You? - For Physician Assistants

By Abby Jacobson, MS, PA-C

Why does your practice employ you? Can you answer this question? Employing PAs has many benefits, but of course, patient access to care always should be the primary objective when a practice or a hospital decides to start utilizing PAs. Improved physician quality of life is another reason. Nevertheless, the financial benefits of employing PAs cannot be overlooked. Besides offering high-quality patient care, you are a financial asset to the practice.

But how much of an asset are you? The easiest way answer this is to know how much money you bring into the practice. Here are tips to remember when determining how much of a financial benefit you are to your employer.

Ask for Your Data

You need to know how much you bill each month and how much is collected from those charges each month. I strongly recommend your physician assistant employment contract state that you will receive monthly (or at least quarterly) reports of your billings and collections. Ask for this data now. Don't wait until it's time for contract negotiations.

Be careful to not appear greedy or selfish when asking for this information. If you say you want the data to see how much you are making for the practice, implying that you will use the data during your next contract negotiation, you are already creating an adversarial situation and setting the stage to be denied access to the data.

Instead, explain that you want this information to review for consistency, to ensure that the practice is getting paid fairly from insurance companies, to review for compliance with reimbursement rules, to evaluate worthwhile contracts with particular insurance companies and to see whether your productivity for the practice is comparable with your colleagues.

Have you asked for this data in the past and been denied? You have a few options. A number of formulas are available to help you try to track collections, or you can calculate some average per-patient charges. Or you could use information collected from other PA colleagues who practice in a setting similar to yours. It's more difficult, but it can be done. But consider that if a practice is keeping this data from you, what else are they hiding? If your practice won't share this information, I think you need to ask whether this is the right practice to stay in.

Ask for Colleagues' Data

It's very helpful to know what other providers in your office are billing and collecting. This includes the physicians, PAs or nurse practitioners in your practice. Some professional societies, such as the Society of Dermatology Physician Assistants and the Medical Group Management Association, track average billing and collections as part of their salary surveys. If you are under-producing compared with your colleagues, you need to fix the problem. Are you not seeing enough patients? Do you need more support staff? Are you undercoding or overcoding? Do you need to start offering more procedure-based services?

Code and Bill Properly

The most important step in being a financial benefit to your practice is proper coding. As boring and difficult as it seems, you have to know when and how to use the proper codes to bill for the services you provide. You need to know everything from the appropriate level of evaluation and management visits (what makes a 99213 different from a 99212?) to when and how to use a modifier. Unfortunately, this stuff changes regularly, and you need to make it a priority to review it at least yearly.

The second step is to communicate with your billing department staff. Make sure they know how to submit claims properly, that they do it in a timely manner and that current information is collected on your patients. Ask them how rejected or bundled services are handled, and what is done for outstanding patient balances.

For example, one of my PA clients just found out her practice has been writing off charges when a patient's insurance has a deductible, regardless of whether the patient can pay or not. Her billing staff never even asks the patients for their portion! So the practice is losing hundred of thousands of dollars each year, and the PA is providing free care 25% of the time to a population that could pay at least a portion of their deductibles. You must be involved in the office coding, billing and collections from A to Z.

Know Your Billing-to-Collection Ratio

I recently was working with a client on her contract negotiations and we figured out that her accounts receivable (AR) rate was 48%, meaning that of everything she billed, less than half was ever collected! That's far below the average benchmarks for a strong practice with a good billing department.

To calculate your practice's AR rate, divide your collections by your billings and then multiply by 100 to get a percentage. So, for example, if you billed $300,000 and collected $215,000, your AR rate is 71.67%. Compare your rate to the other providers in your office and to other similar practices.

Are Charges and Collections Tracked?

With today's computers and electronic medical billing, there's no excuse for a practice not to keep track of your charges and collections. Even if services are billed out under your physician, you can put an internal code on them to track them. If your billing department or office manager doesn't know how to do that, offer to call the computer software company yourself to find a solution.

It does become more complex if you never see patients directly or if you spend at least part of your time doing things that won't result in a charge, such a pre-rounding, taking call or assisting during procedures. In this situation, you need to attempt to calculate whether these duties enable your supervising physician to bill more. For example, if you help the physician pre-round, does this save him an hour a day? And if he uses that hour to see patients, how much more has he collected? Or if he can perform two more surgeries a day because you speed the procedures, how much more money do those two surgeries a day bring in?

Start with a strong, ironclad contract, and pay attention to your gut-if you sense red flags, beware! Before accepting a position, find out about the practice's reputation. Seek opinions from former employees (especially PAs) and from referring clinicians in the community. Research the salaries of other PAs in similar settings. If you're being abused, look elsewhere. Change can be scary, but sometimes it's necessary.

By becoming involved with the billing and coding in your office, you can help your physician navigate the confusing and complicated work of running a medical practice. Doing this will give you an advantage in contract negotiations, and you'll also help your physician in yet another way that PAs can benefit their physician partners in medicine.

Abby Jacobson practice dermatology in Lancaster, Pa. She has held numerous leadership positions in the American Academy of Physician Assistants, the Pennsylvania Society of Physician Assistants and the Society of Dermatology Physician Assistants. She is owner of Strategic Medical Consulting LLC.

Copyright ©2008 Merion Publications

Who Benefits From Billing In Healthcare?

Posted in The Huffington Post on May 29, 2008
By Dr Deane Waldman

Have you ever been a patient? If so, you know how incredibly complex, user-unfriendly and inefficient the whole billing/insurance system is. Do you know a doctor, nurse or hospital administrator? Ask them and they will say the same thing, louder and angrier: billing is exceedingly cumbersome, under-paying, always late, and inefficient. If the doctors don't benefit from this mess and the patients certainly do not, then who does benefit? Good question, and is it really "inefficient?"

Pictured above is one of last year's medical billing code books, containing 8805 five-digit or longer codes - more than the number of identified human diseases. Typically, it is "updated" (expanded) at least once a year. This book gives information required for just one of the 57 (!) different steps used to submit a medical bill.

Efficiency is usually defined as the least resources used for the most money gained. In health care billing, who gets the gain? The people who make profit are not the doctors or hospitals: the profit-makers are the insurance companies.

How do insurance companies make money? The formula is simple: collect lots of premiums and avoid spending the money. That means the more they delay payments; the more they reduce the amount paid; the more they deny payment altogether, the more profit they make. In other words, delaying, paying less or not paying at all for your medical care...generates profit.

And before you blame the big bad heartless insurance companies, remember that they are behaving just the way their stockholders - which probably includes YOU - want them to act. Your pension plan does not hold stock in HCA, United Health, or Blue Cross because they lose money. Your insurance company is not the culprit. The dastardly villain smirking while twirling his handlebar moustaches is the system.

PS. If - a big if - so-called universal health care saves money, it will do so by simplification. This means three things: 1) The middleman profit will go away; 2) Reducing the bureaucracy and red tape will put thousands out of work; and 3) The value of your insurance stocks will end up in the toilet.

Dublin Doctor Defrauds Medicare, Medicaid, Gets Four Years Probation For Health Care Fraud

Source: rockbridgeweekly.com

Acting United States Attorney Julia C. Dudley announced today that Dr. Linda Sue Cheek, age 59, of Dublin, Virginia, was sentenced yesterday in United States District Court for the Western District of Virginia in Roanoke for defrauding Medicaid and Medicare.

“These taxpayer-funded health care programs are designed to allow our friends and neighbors who are in need of medical care, the opportunity to obtain it,” Acting United States Attorney Julia C. Dudley said today. “When physicians like Dr. Cheek take advantage of these programs in order to get rich, it is our job to hold them responsible for their actions.”

Cheek was sentenced to serve four years of probation for her role in a scheme to knowingly and willfully defraud the Medicaid and Medicare health care programs for her own personal, financial gain. In February Cheek pled guilty to one count of health care fraud, admitting that she had been stealing from the two programs from January 2002 to March 2006.

In addition, Cheek was ordered to pay a total of $24,210.37 in restitution to Medicare and Medicaid and will be required to serve 600 hours of community service in a non-medical field. As part of her sentencing, her license to practice medicine was also revoked.

The defendant, who was a licensed physician by the Commonwealth of Virginia, operated New River Medical Associates, Inc. located in Dublin, Virginia. The facility operated primarily as a pain management and alternative medicine practice.

Cheek previously admitted that between January 2002 and March 2006 she submitted a series of false Medicare and Medicaid claims relating to her medical practice, including the practice of billing Medicaid and Medicare for services she had not performed.

In addition, Cheek admitted to billing Medicaid for services she claimed to perform herself that were, in fact, performed by one or both of the two nurse practitioners employed by New River Medical Associates. Cheek admitted that during many of these procedures she was out of the office and, at times, out of the country.

Finally, Cheek admitted to billing Medicaid and Anthem Blue Cross Beneficiaries for individual treatments called “cleansing sessions,” an investigational service. These “cleansing sessions” were performed and billed as regular, individual office visits but were carried out in a group setting. Medicaid, Medicare and other insurance providers do not allow medical professionals to bill for group sessions.

This case was investigated for the United States Attorney’s Office, Western District of Virginia by the Virginia Attorney General’s Medicaid Fraud Control Unit, the Internal Revenue Service, the U.S. Department of Health and Human Services, Office of Inspector General, the Virginia State Police Drug Diversion Unit and the Financial Investigation Unit of Anthem Blue Cross Blue Shield.

Assistant United States Attorneys Patrick Hogeboom and Charlene Day prosecuted the case for the United States.

Now doctors jump into BPO bandwagon

18 May, 2008, 1410 hrs IST, PTI
Source: The Economic Times

NEW DELHI: After engineers and lawyers, now doctors are also gearing up to join the BPO brigade, with the outsourcing firms opening up alternative career options for medicos.

With more and more outsourcing firms moving into healthcare sector and medical transcription, the job opportunities for doctors and nurses in the country are getting widened, an industry expert said.

In a BPO firm, the job of a doctor can include medical billing, transcription and coding for the US hospitals.

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format.

However, some companies like the Patni also provides high-end knowkledge process outsourcing where a doctor is required to study the reports of elderly patients and do risk assessment and prepare reports for health Insurance companies in the US.

At present, the IT services and business outsourcing company has 10 doctors in its team who does insurance claim processing, claim and long-term care management.

Nishikant Kadam, Head of HR of medical BPO CBay said: "We generally hire doctors for training our workforce. The doctors in our firm also works as quality analyst for our medical transcription work."

CBay currently has 11 doctors on its roll. The doctors are also enjoying this corporate job which comes with fat pay-packet.

"It takes at least three to four years for a fresh medical graduate to establish a successful medical practice. In this period a person can work in a medical BPO and earn good cash," a doctor working with a Noida-based BPO said.

"Salaries are lucrative compared to regular medical job. A senior doctor with three-five years experience could earn about Rs 8-20 lakh per annum in KPO," Patni Senior Vice- President Sanjiv Kapur told PTI.

As more medico-related work comes to India, the opportunity for more doctors in the business is rising.

The concept of the "greying of America" is widely accepted today. By 2020, the US population over the age of 65 is projected to grow to 55 million and 42 per cent of them would enter a nursing home in their lifetime. This has opened alternative career options for Doctors in KPO," Kapur added.

"By outsourcing these jobs, the hospitals and clinics in the US aim to reduce your administrative burden," Kadam said.

Are MTs Necessary?

This column explores the realm of the medical language specialist. This week, read about "Are MTs Necessary?"
By Rebecca A. McSwain, PhD, CMT, CPC-H-A

Experienced transcriptionists spot mistakes or inconsistencies in a medical report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high-quality patient care. US Department of Labor, Bureau of Labor Statistics, www.bls.gov/oco/ocos271.htm

The above paragraph, at the US Department of Labor's Bureau of Labor Statistics Web site, mentions an aspect of our job that seems underappreciated: quality assurance. Patient by patient, report by report, for every one of the millions of files that pass through our hands every day, the MT is closely scrutinizing the medical record for accuracy, our own and others'. Currently, there is no one else, and no machine, doing this job. Health care providers, though ultimately responsible for the content of records they create, do not have the time or inclination to control quality at this level of detail in their documents. Health care institutions can (and do) conduct random assessments of medical record quality in various ways. But it is literally impossible for such programs to scrutinize every narrative record. Fortunately, medical transcriptionists are doing it. Unfortunately, various systems that eliminate or drastically reduce the role of the MT are also getting rid of this quality assurance (QA) function, thus throwing a pretty important baby out with the bathwater.

Anyone who honestly assesses documents currently created by voice recognition systems, and those created through self-entry by health care personnel, must acknowledge that these documents today pose a major quality risk. It's likely that in the future--and, by the way, after extensive feedback training provided to the machines by human MTs--VR systems will improve. But will it be enough?

As for self-entry: there may come a day when health care providers can evaluate, diagnose and treat patients while at the same time writing and keyboarding accurately and efficiently--with a mastery of spelling (even in areas outside their expertise) and grammar (even if English is their second language)--but I suspect that day is not now dawning. I think it may arrive about the same time that all health care providers are capable of doing their own coding accurately and efficiently.

And the medical transcriptionist brings something else to the creation of the medical narrative: a global understanding of language (medical and secular) and medical practice, combined with a comprehension of relevant community, provider, technology and individual patient circumstances for each of millions of encounters. This wide knowledge base, of course, grows bigger and better the longer an MT works in a particular context. But an experienced MT brings a store of information into any clinical situation, even an unfamiliar one. This specific kind of knowledge is not really held anywhere else in the health care system. Individual providers don't have it--they have pieces of it, but not the whole picture. Electronic data bases don't have it. I won't assert that computers will never be capable of this level of value, but they are far from it now. And this MT knowledge is a source of quality in the medical narrative for which there is currently no substitute.

If this QA function is, in fact, important, then HIM managers, administrators, planners, need to consider how to preserve it, whatever the mode of record-creation may be in the future. If not MTs, then who?

Rebecca A. McSwain is currently working as a production MT for a national service. She has worked as an MT supervisor, business owner, instructor and QA manager. She's a member of AHDI and the American Medical Writers Association. She has a PhD in anthropology and continues to work on anthro-related writing projects in her spare time. She can be reached at rmcswain_985@fuse.net.

Copyright ©2008 Merion Publications

Coding Multiple Conditions

Coders must be familiar with combination codes, multiple codes and manifestation coding guidelines.
Prepared by Ingenix Staff

A coder with any experience knows that coding involves more than merely looking up words and selecting corresponding codes on a one-to-one basis. Coding also requires that the coder review the clinical relationship between the multiple conditions that a patient may have and make code selections based upon that clinical relationship. Many medical conditions are inter-related, and the ICD-9-CM coding system allows the capture of these relationships through the use of several different types of diagnosis codes: combination codes, multiple codes (whether mandatory or discretionary) and the related manifestation codes. Each will be discussed.

A combination code is used to report two diagnoses or one diagnosis that is associated with a secondary condition. Combination codes are located in the ICD-9-CM alphabetic index as subterms that follow connecting words such as "due to," "with," "associated with" or "in." The coder may also be able to locate combination codes by reading inclusion and exclusion notes in the tabular list. The new coder may ask, "How do I know when to assign a combination code?" The answer is through thorough coding and paying attention to all coding instructions. The coder then becomes familiar with the types of conditions that require combination codes. Some are more readily apparent than others: acute cholecystitis with cholelithiasis should be assigned to code 574.00 instead of reporting separate codes of 575.0 and 574.20. The combination code is present in the alphabetic index as follows:

Cholelithiasis

with

cholecystitis

acute 574.0

The fifth digit of 0 is added after ascertaining that no obstruction was present.

But some combination codes are not so straightforward and may involve conditions that are clinically and inherently related. For instance, when chronic renal failure and hypertension are both documented on a patient record, the coder may be tempted to assign the very common codes 585.X and 401.9. But the ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.7.a.3) indicates:

"Assign codes from category 403, Hypertensive chronic kidney disease, when conditions classified to categories 585 - 587 are present. Unlike hypertension with heart disease, ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease (CKD) with hypertension as hypertensive chronic kidney disease."

Note that this guideline involves chronic renal failure only, and if acute renal failure and hypertension are present without documentation of co-existing chronic kidney disease, the conditions are reported separately with codes from the 401 and 584 categories.

Another example of the appropriate assignment of a combination code in lieu of separate, more commonly reported codes involves chronic obstructive pulmonary disease (COPD) and asthma. Coding Clinic, 2^nd Quarter, 1990, page 20 includes the following:

"The new code 493.2x, Chronic obstructive asthma, was developed because of the need to distinguish between non-obstructive and obstructive asthma (that in chronic obstructive lung disease), within the classification. When a patient has COPD with asthma, there is continuous obstruction to airflow on expiration, unlike a patient with non-obstructive asthma, where the patient wheezes during an asthma attack, but then returns to normal breathing once the attack subsides. When a diagnosis of asthma is documented with COPD, 493.2x is assigned whether or not the physician states 'chronic obstructive' asthma."

Multiple coding involves the use of more than one code to fully describe the components of a particular disease process or complex diagnostic statement. When combination codes are not available, but the documentation includes terms such as "due to," "with, "secondary to" or "incidental to," multiple codes should be assigned to most fully describe the conditions.

Multiple coding can be considered mandatory or discretionary. Mandatory multiple coding is designated in the alphabetic index by the use of the second code in brackets, which designates the manifestation code. The first code reflects the main underlying condition, and the second code identifies the manifestation of that main condition. Both of these codes must be assigned, and they must be sequenced in the order specified. In the tabular list, the coder will know that another code is required because the terminology "use additional code" appears with the main code and "code first underlying condition" appears with the manifestation code. Regardless of the circumstances of the admission, a manifestation code can never be sequenced as a principal or first-listed diagnosis. If submitted to a Medicare fiscal intermediary, or to another payer that follows national coding guidelines, the case will not be reimbursed until another code is sequenced as the principal or first-listed diagnosis.

For example, a patient with bleeding esophageal varices is admitted to a hospital for treatment of the varices. The documentation indicates that the varices are due to cirrhosis of the liver. The alphabetic indexed entry appears below:

Varix

esophagus

bleeding

in

cirrhosis of liver 571.5 [456.20]

This indicates that the code for the cirrhosis (571.5) must be sequenced first and the manifestation (the varices, code 456.20) must be sequenced as a secondary condition. This is considered mandatory multiple coding.

Discretionary multiple coding involves assigning multiple codes only if the additional condition is documented as actually being present. The coding instruction in the tabular list is "use additional code," which then instructs the coder to look for the presence of the condition in the medical record documentation before assigning an additional code.

A common example is a urinary tract infection due to E.coli infection. Under code 599.0 in the tabular list, the following appears: "Use additional code to identify organism, such as Escherichia coli [E.coli] (041.4)." This specific type of organism will not be present on all cases, but the coder is alerted to look for documentation of an underlying organism that is causing the infection and assign a separate code accordingly.

Another common coding scenario involves guidelines for cases in which terminology for both "acute" and "chronic" are documented. Whether or not both are coded depend upon the alphabetic indexed entries for that term. For example, a coder may commonly see "acute and chronic bronchitis" documented. The indexed entry appears below:

Bronchitis

acute or subacute 466.0

chronic 491.9

If separate subterms for acute or subacute and chronic are listed at the same indentation level in the index, both conditions are coded, with the code for the acute condition sequenced first. In this particular example, both the acute and the chronic conditions appear at the same indentation level so both would be assigned, with code 466.0 sequenced first. Conversely, if a patient has acute and chronic poliomyelitis, the indexed entry appears as below:

Poliomyelitis (acute) (anterior) (epidemic) 045.9

chronic 335.21

When only one term is included in the index as a subterm, and the other is in parentheses as a nonessential modifier (after the main term), only the code listed for the subterm is assigned. In this case, only code 335.21 would be assigned.

Multiple coding is also required for cases involving patients with late effects, which are residual conditions that remain after the end of the acute phase of an injury or illness. There is no time limit for when a late effect code can be assigned, but coders should review documentation carefully to ensure that the physician makes the connection between the current condition and the fact that it is due to the previous, but now healed, original condition. The nature of the late effect is sequenced first, with the code for the late effect sequenced second.

Many conditions related to previous trauma are inherently late effects, such as fracture nonunion or malunion. Others may not be as readily apparent, such as neural deafness from childhood measles. The vast majority of late effects require two codes for appropriate coding, unless the alphabetic index or tabular list directs otherwise. Also, when the late effect code has been expanded to the fourth- or fifth-digit level that includes the specific late effects for the residual conditions, only the cause of the late effect code is assigned. A good example of this is the late effect of cerebrovascular disease (438.0 - 438.9) category.

It should be noted that although reporting multiple codes to fully describe an episode of care is necessary, indiscriminate multiple coding is not appropriate. An example involves assigning secondary codes for signs and symptoms that are an inherent part of a definitive diagnosis that has already been coded. If a patient is admitted for treatment of congestive heart failure (CHF) and has an associated pleural effusion that is not addressed during the admission, it would not be appropriate to assign a secondary diagnosis for pleural effusion on the same case. Likewise, assigning codes solely on the basis of lab or other tests that have not been substantiated by a physician is not allowed. This is especially crucial when assigning codes under the new MS-DRG system, whereby finding CC or MCC conditions may be more difficult than it was under the previous CMS DRGs.

Coders should not assign codes for conditions that are considered incidental findings and have no significance for the current episode of care. For example, atelectasis on a chest X-ray or right bundle branch block on an EKG is not unusual, and unless the physician documents the significance of the finding and how it relates to the current episode of care, it should not be coded.

To brush up on the ICD-9-CM Official Guidelines for Coding and Reporting that are referenced above, please review the following:

A. Conventions for the ICD-9-CM

6. Etiology/manifestation convention ("code first," "use additional code" and "in diseases classified elsewhere" notes)

B. General Coding Guidelines

9. Multiple coding for a single condition

10. Acute and Chronic Conditions

11. Combination Code

12. Late Effects

* * * * * * *

After you've completed your review, check yourself with the quiz below.

1. A patient is seen in the physician's office with a diagnosis of chondrocalcinosis of the shoulder due to calcium pyrophosphate. Which of the following would be the appropriate diagnosis code(s) selection?

a. 275.49, 712.21

b. 712.11, 275.49

c. 712.21, 275.49

d. 275.49, 712.81

2. A patient is admitted to the hospital with an admitting diagnosis of GI bleeding. Underlying chronic conditions include hypertension, S/P MI, COPD, atrial fibrillation and asthma, all of which are currently treated. After GI endoscopy, diverticulitis of the colon is diagnosed as the cause of the bleeding. Which of the following would be the appropriate diagnosis code(s) selection?

a. 578.9, 562.11, 401.9, 412, 496, 427.31, 493.90

b. 562.13, 401.9, 412, 496, 427.31, 493.90

c. 562.13, 401.9, 412, 493.20, 427.31

d. 578.9, 562.11, 401.9, 412, 493.20, 427.31

3. The patient is seen in the ambulatory surgery center for treatment of a scar contracture of the left hand secondary to a burn that was suffered during the previous year. Which of the following would be the appropriate diagnosis code(s) selection?

a. 944.00, 709.2

b. 709.9, 944.00, 709.2

c. 709.2, 906.6

d. 906.6, 709.2

4. An elderly patient is admitted to the inpatient unit of the hospital with shortness of breath and fever. She is found to have influenza and pneumonia and is treated accordingly. She also has flaccid hemiplegia due to an old CVA. Which of the following would be the appropriate diagnosis code(s) selection?

a. 487.1, 486, 438.20

b. 486, 487.1, 438.20

c. 487.0, 438.20

d. 487.0, V12.59

5. A patient was admitted with a diagnosis of subacute and chronic pyelonephritis. He has underlying conditions that include diabetic retinopathy, COPD and a traumatic arthritis of the ankle, S/P ankle fracture two years ago. Which of the following would be the appropriate diagnosis code(s) selection?

a. 590.00, 590.80, 250.50, 362.01, 496, 716.17, 905.4

b. 590.10, 590.00, 250.50, 362.01, 496, 716.17, 905.4

c. 590.80, 250.51, 362.01, 496, 716.17, 824.8

d. 590.10, 590.00, 250.51, 362.02, 496, 716.17, 905.4

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.

Answers:
1. a: The underlying condition (the calcium pyrophosphate problem) is sequenced first, and then the chondrocalcinosis is sequenced second. The instruction note in the tabular list under cde 712.2X indicates, "Code first underlying disease (275.4)."

2. c: Combination codes are assigned for the colon diverticulitis with bleeding (562.13) and for the COPD and asthma (493.20).

3. c: Following the late effect guidelines, the code for the residual condition (the scar) is sequenced first, and the code for the late effect itself is sequenced second. The burn happened during the previous year and is no longer considered acute; it should not be coded separately.

4. c: Combination codes are assigned for the influenza with pneumonia (487.0) and the hemiplegia late effect of a CVA (438.20).

5. b: Both subacute and chronic pyelonephritis codes are listed at the same indentation level in the index and so both are coded, with the acute code sequenced first. The diabetes is not specified as Type I, nor is the retinopathy specified as proliferative, so codes 250.50 and 362.01 should be assigned. The ankle fracture is no longer acute, so code 824. 8 should not be assigned at this time. Assign codes 716.17 for the traumatic arthropathy and 905.4 to represent a late effect of an ankle fracture.

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