Hospital Billing tools offer many solutions to support hospital billing processes as well as auditing, payers' pricing, life planning and more....
Use the DRG Grouper to determine how much Medicare will pay, further group DRG's into Major Diagnostic Categories (MDCs), and use the ICD-10-PCS official guidelines to ensure compliance.
Select the title to see a summary and a link to the full article.
August 21st, 2019
So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 21st, 2019
You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from? It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems. One of the ...
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
By Find-A-Code | Published March 20th, 2019 - Last Review/Update March 25th, 2019
The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form.
Type of bill codes are four-digit codes that describe the type of bill a ...
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
By BC Advantage | Published November 26th, 2018 - Last Review/Update November 29th, 2018
This article will focus on the Present on Admission (POA) indicator which is used as a method of reporting whether a patient’s diagnoses are present at the time they are admitted to a facility. We’ll look at a few scenarios to determine the correct reporting of POA and the impact...
By Christine Woolstenhulme, QMC, QCC, CMCS, CPC, CMRS | Published October 2nd, 2018
Life Care Planners play a vital and underappreciated including understanding the progression of a disease and lifetime clinical treatment options, research, delete (I combined this into the paragraph above) compiled into one easy-to-use resource. a unified providing a single destination for procedure coding coding to find information on...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 27th, 2018
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
By BC Advantage | Published March 27th, 2018 - Last Review/Update April 12th, 2018
From internal reviews to external inpatient coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind....
The Coder as the Last, Best Hope for the Right DRG
By Dr. Erica Remer | Published February 12th, 2018 - Last Review/Update April 12th, 2018
f the story doesn't make sense, there is probably something missing. There are a variety of reasons why the DRG might not tell the story of the patient encounter....
When coding surgical procedures, the approach is the technique you use to reach the site of the procedure, or how you get in to do the operation. The fifth character of PCS code is used to indicate the approach when using.
There are seven approaches. They are listed below with their ...
Escharotomy Procedural Cross-Walking CPT to ICD-10-PCS
By Brandon Dee Leavitt QCC, CMCS, CPC, EMT | Published November 10th, 2017 - Last Review/Update November 17th, 2017
An Escharotomy is used for "local treatment of burned surface" per the AMA Guidelines, when incisions are performed on the burn site. Notice, when cross-walking 16035 or 16036 to inpatient codes, Find-A-Code crosswalks lead to Body System H, Operation 8 - Division of the skin, and Operation N - Release of the skin.
A division or release of the skin would be a ...
By Shannon Cameron, MBA, MHIIM, CPC | Published September 29th, 2017 - Last Review/Update January 31st, 2018
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
Definitions for Character #3 of PCS Codes Medical and Surgical Root Operations
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 12th, 2017
Character #3 of PCS codes Medical and Surgical Root operations definitions
Alteration
Modifying the anatomic structure of a body part without affecting the function of the body part
Bypass
Altering the route of passage of the contents of a tubular body part
Change
Taking out or off a device from a body part, and putting back an ...
The 2017 ICD-10-CM and ICD-10-PCS code updates, including a complete list of code titles, are available on the 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages.
By Wyn Staheli, Director of Research | Published August 3rd, 2016
The Centers for Medicare & Medicaid Services (CMS) recently released the Proposed Rule regarding the updates to the ICD-10-CM and ICD-10-PCS code sets for Fiscal Year 2017 which begins October 1, 2016. Comments regarding the proposed ICD changes are due May 6th and CMS has stated that the Final Rule ...
Procedure code set for Procedures ICD-10-PCS to ICD-9-CM
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 13th, 2016
There are some PCS codes that have a GEMS mapping and is available on Find-A-Code, such as ICD-9-CM Vol 3. 02.11, the GEMS mapping can be found in out Map-a-code tool.
See this code mapping to the following PCS codes
CodeDescription00Q20ZZ
Repair Dura Mater, Open Approach
00Q23ZZ
Repair Dura Mater, Percutaneous Approach
00Q24ZZ
Repair Dura Mater, Percutaneous Endoscopic ...
The final version of the 2017 ICD-10- PCS codes has been released by the Center for Medicare and Medicaid Services. Beginning on October 1, 2016, the first day of the federal fiscal year, the use of these codes will become mandatory for hospital inpatient services. The updates for the 2017...
When reading through documentation in an operative report for a hysterectomy, for the ‘Procedure Performed’, a ‘TAH-BSO, and Omenectomy’ is performed. As with all operative reports, there are guidelines that should be followed when determining the appropriate ICD-10-PCS codes. The first is identifying ‘TAH-BSO’. These are common abbreviations that are...
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
By Codapedia | Published December 11th, 2015
Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple...
CEO - stop "Making decisions." If the data and metrics are correct, the decisions are self evident. Spend time instead developing your team, your culture of communication, and ensuring that you are measuring the right activities. Stop managing departments and start managing patients. The silos...
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and...
The Critical Role Of Hospital CFOs: A Data Driven Answer [Infographic]
By Codapedia | Published December 3rd, 2015
We know the evolving role of CFOs in the healthcare industry. There are situations which have forced the executives to make such decisions like changing the vendor, attritions and outsourcing one or more of their processes. There could be ample reasons like transition to value-based model, slow payer procedures, low...
DRIP Line ICD-10-CM Did you know... ICD-10-CM/PCS consists of two parts
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 8th, 2015 - Last Review/Update August 9th, 2017
ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all United States health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 17th, 2015
Documentation assessment and gap analysis is important in ICD-10-CM/PCS. Clinical documentation will also affect code assignment and relative weight associated with payment. To read more information on problem areas with documentation issues read AHIMA's article.
...
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015 - Last Review/Update August 7th, 2017
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech - language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy ...
Levels of Care Data Required on the Institutional Claim to Medicare Contractor
By Find-A-Code | Published August 3rd, 2015
With the exception of payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 17th, 2015
ICD-10-PCS has a seven character alphanumeric code structure. Each character contains up to 34 possible values. Each value represents a specific option for the general character definition (e.g., stomach is one of the values for the body part character). The ten digits 0-9 and the 24 letters A-H,J-N and P-Z ...
10 Things to Know About Turning a Surgery Center Into a Hospital Outpatient Department
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2015 - Last Review/Update February 16th, 2016
Hospitals are investing more in outpatient services, and wisely so. The migration of procedures from inpatient to outpatient settings is steadily increasing, as is the demand — from payers, physicians and patients — for outpatient care. The Agency for Healthcare Research and Quality reported that in 1980, 16 percent of ...
Aligning the Way Providers are Paid to Reward Value Rather than Volume (Value Based Modifiers)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS is aligning the way providers are paid to reward value rather than volume.
Paying providers for quality, not quantity of care. In 2015, Medicare is continuing to phase in the Value-based Payment Modifier, which adjusts traditional Medicare payments to physicians and other eligible professionals based on the quality and ...
Patient Discharge Status Codes and Hospital Transfer Policies - Clarification
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter or at the end time of a billing cycle. It belongs in Form Locator 17 on a UB-04 claim form or its electronic equivalent in the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
To group diagnoses into the proper DRG, CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Use the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator ...
Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions. CMS has titled the provision “Hospital-Acquired Conditions and Present on Admission Indicator Reporting” (HAC & POA).
Read more about it here: Medicare learning network fact sheet, ICN 901045 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
For a list of HACs and Codes
Medicare learning network ICN 901045 October 2012
(This list was current with Medicare when published October 2012)
Affected Hospitals
The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision:
Critical Access Hospitals (CAHs)
Long-Term Care Hospitals ...
#2 DRIP Line ICD-10 -CM Did you know... ICD-10-CM/PCS Examples: Structural Differences
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 8th, 2014 - Last Review/Update August 9th, 2017
The examples below show the structural differences between ICD-9-CM and ICD-10-CM/PCS.
ICD-9-CM Diagnoses Codes:
3–5 digits
First digit is alpha (E or V) or numeric
Digits 2–5 are numeric; and Decimal is after third digit
Examples:
496 – Chronic airway obstruction, Not Elsewhere Classified (NEC)
511.9 – Unspecified pleural effusion
V02.61 – Hepatitis B carrier
ICD-10-CM Diagnoses Codes:
3–7 digits
Digit 1 is ...
Hospital Medical Coders Must Switch To The ICD-10-PCS Codes For Billing Purposes
By David Berky | Published July 16th, 2014 - Last Review/Update January 25th, 2017
For numerous years, United States doctor's offices, medical clinics and hospitals have been using the standard ICD-9-CM on medical forms for inpatient procedures. This code, developed by the World Health Organization (WHO - the "ICD-9") and modified by the use (the "CM"), is used by medical professionals for billing and ...
By | Published May 2nd, 2014 - Last Review/Update January 25th, 2017
On the evening of April 30th, the release of the 2015 Inpatient Prospective Payment System Proposed Rule included three separate references to the implementation of ICD-10:
1. "The ICD-10-CM/PCS transition is scheduled to take place on October 1, 2015. After that date, we will collect non-electronic health record-based quality measure data coded only in ICD-10-CM/PCS." - page 648
2. "ICD-10 will officially be implemented on October 1, 2015." - page 1065
3. "ICD-10-CM/PCS will officially be implemented on October 1, 2015." - page 1074
Today, May 2, 2014, CMS released the following statement:
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January 15th, 2019
Coding Auditing Inpatient Evaluation and Management — A Hands-On Experience
Do your providers perform and report Evaluation and Management (E/M) services in the inpatient setting? Does the documentation match with the services being billed, or does it fall short? Join Aimee for a hands-on audit of an inpatient E/M service and get an idea of the information and documentation needed to correctly code inpatient E/M services.
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