Smarter Coding in Gastroenterology

Chris Cole

Coding issues remain a moving target in gastroenterology, and one must rely on other sources to remain up to date.

According to Daniel C. DeMarco, MD, FACG, when it comes to smarter coding in gastroenterology, one must look at communication, coder education, documentation, consistency, transparency, and possibly the use of an EHR system in their practice.

For optimum communication, the physician should write legibly, document everything he or she does, take note of times spent on procedures/tasks, and remember that if you charge for more than one service per day that you can expect to be paid less.

Coder education can be obtained through seminars, coding courses, webinars, periodicals, the coding primer by Glenn Littenberg, and CPT advisors.

When documenting, says DeMarco, be as specific as possible, don’t rely on mind reading or precedent, and adopt a user-friendly and idiot-proof system. And be consistent, as doing so will protect you against errors and make it easy for charges and codes to be entered. Also, allow for transparency, which can protect you in the case of an audit, facilitates smooth transition when resources change, and helps with call coverage.

As far as EHRs, the presenter says “Good luck with this. Be patients, and find a system that works for you, and let me know when you do!”

Other things in your practice that can help with better coding, according to DeMarco, include turning in charges promptly and regularly, making corrections promptly, submitting test cases, performing and internal audit, don’t allow coders to sit at desks with drawers (they shouldn’t need them, and if they do, that means things are getting backed up), and watch out for the EHR transition.

A number of CPT 2010 issues face gastroenterologists, says DeMarco, including what category to give for a partial exam for colonic motility, whether HREPT is category 3 or 1, the inability of the panel to distinguish pressure measurement from GI tract transit time, and the lack of a code for large volume therapeutic vs. small volume diagnostic when it comes to paracentesis.

The audience had a nice chuckle when DeMarco began discussing the Mergener/Ganz Rules of Medicare:

  1. Just because it has a code, doesn’t mean it’s covered.
  2. Just because it’s covered, doesn’t mean you can bill for it.
  3. Just because you can bill for it, doesn’t mean you’ll get paid for it.
  4. Just because you’ve been paid for it, doesn’t mean you can keep the money.
  5. Just because you’ve been paid once, doesn’t mean you’ll get paid again.
  6. Just because you’ve been paid in one state, doesn’t mean you’ll get paid in another
  7. There are thousands of rules, and they change every year.
  8. You must know every rule.
  9. Not knowing every rule can land you in the slammer.
  10. You’ll never know every rule.

Then the chuckles ended.

ICD-10 and RAC are coming down the pike, says DeMarco. So, why the move to ICD-10-CM? Because ICD-9-CM badly needs replacing. It’s 30 years old, the terminology and classification of some conditions are outdated and obsolete, outdated codes produce inaccurate and limited data, there is an increasing lack of specificity, comparison with international data is hindered, and it cannot support the transition to interoperable health data exchange.

How does ICD-10-CM/PCS overcome these shortcomings? The up-to-date classification systems provide much better data for measuring the quality, safety, and efficacy of care; designing payment systems and processing claims for reimbursement; conducting research, epidemiological studies, and clinical trials; setting health policy; operational and strategic planning and designing health care delivery systems; monitoring resource utilization; improving clinical, financial, and administrative performance; preventing and detecting health care fraud and abuse; and tracking public health and risks.

When it comes to structure, ICD-9 and ICD-10 differ in the following ways. ICD-9 uses 3-5 character, the first character is numeric or alpha (E or V), characters 2-5 are numeric. With ICD-10, codes are 3-7 characters, character 1 is alpha, character 2 is numeric, characters 3-7 are alpha or numeric, all letters are used except U. The two coding systems are the same in that both use codes that are always at least 3 characters, have a decimal used after 3 characters, and both use alpha characters that are not case-sensitive.

Implementing ICD-10 will be dependent on system issues, notes DeMarco, specifically the degree of automation, number of software vendors, EHRs, planned future upgrades, and the use of in-house vs. commercial software. Physicians will need to contact and collaborate with current software vendors, health insurance payers, clearinghouses or billing services if currently used, and trading partners. Practitioners will also need to discuss awareness, plans for support, readiness, and the testing of their practice prior to the compliance date to ensure everything will work smoothly. Staff training needs will need to be identified, implementation costs will need to be budgeted for, and post-implementation review will need to be planned for to ensure successful implementation.

Key points to keep in mind regarding ICD-10, according to the speaker, are that you cannot use ICD-10 codes until October 1, 2013; ICD-9 codes will be rejected for services rendered after October 1, 2013, with older claims continuing through the system with ICD-9 codes; and don’t expect a delay in the compliance date.

Workflow will be drastically changed because of ICD-10. Because fee ticket ICD-10 pick lists are inadequate, according to DeMarco, e-lookup will most likely be forced, meaning hassles and time spent for look-ups (visits, lab orders, preauthorization requests). For example, if a gastroenterologist makes four diagnoses during a visit, spends 45 seconds to look up each code, and sees 25 patients in a day, that’s 75 minutes per day looking ups codes. Other workflow issues come in the form of claim submissions, including whether all payers will be up to speed, the fact that many submissions will likely be denied and need reworking, and the problem of accuracy faced by some physicians who use staff to turn narrative into codes.

When implementing ICD-10 codes from the CPT Assistant Bulletin Vol. 20, Issue 1, DeMarco gives the following advice:

  1. Identify your current systems and work processes, either electronic or manual, which use ICD-9 codes
  2. Talk to your current practice management system vendor
  3. Talk to your clearinghouses, billing services, and payers
  4. Talk to your payers about potential changes to your contracts as a result of implementing ICD-10 codes
  5. Identify potential changes to existing practice workflow and business processes
  6. Identify staff training needs
  7. Perform testing with your trading partners (eg, payers and clearinghouses)
  8. Budget for implementation costs, including expenses for system changes, process changes, resource materials, consultants, and training.

The speaker next switched gears to discuss RAC, or regional audit contractors, noting that if you bill fee-for-service programs, your claims will be subject to review by the RACs. The RAC program mission is to detect and correct past improper payments so that CMS and carriers can implement actions that will prevent future improper payments, providers can avoid submitting claims that don’t comply with Medicare rules, CMS can lower its error rate, and taxpayers and future Medicare beneficiaries can be protected. The RAC legislation is a 3-year demonstration, with a permanent and nationwide program to be in place not later than the end of the year and CMS given the authority to pay the RACs on a contingency basis.

When it comes to RACs, providers can pay them by check, allow recoupment from future payments, request or apply for an extended payment plan, or appeal.

So, what can providers do to prepare for ICD-10 and RACs? DeMarco suggest providers know where previous improper payments have been found, look to see what improper payments have been found in OIG and CERT reports, know if you are submitting claims with improper payments, and prepare to respond to RAC medical record requests.