so you think you know profee coding?2016 (an 11% increase). hospital employed physicians increased...

So, You Think

You Know

ProFee Coding?Vanessa Youmans, MA, RHIA, CCS, CPC

YES HIM Consulting, Inc.

www.YES-HIMconsulting.com

Learning Objectives

2 CONFIDENTIAL AND PROPRIETARY

1) The Industry

2) Facility versus ProFee Coding and Billing

3) Denials Management

My hosptial just

acquired a large

physician group.

3

Now what?

Part 1.

The Industry –

Physician Group

Acquisitions

Hospital Acquisition Trends

5

The last decade has seen a remarkable increase in hospitals

acquiring private physician groups – aiming to broaden

service lines and increase their market share.

Over 5,000 physician practices

acquired between July 2015 and July

2016 (An 11% increase).

Hospital employed physicians

increased by over 63% from 2012 to

2016.

83% - 205% range increase in

hospital owned practices across all

regions from 2012 to 2016.

What have you seen in the industry?

A. I no longer have a personal doctor that is completely independent/in private practice

B. I have experienced a physician group acquisition either in a personal or professional capacity

C. I have seen hospital systems extend their reach in new capacities in my area

D. All of the above

E. None of the above

Common Challenges

Physician Group Acquisitions

1. Coding Quality

2. Physician Discrepancies/Coding Communication

3. Coder Turnover

4. Merging Facility and Former Independent

Practices’ Policies, Procedures and Level of Quality

5. Lack of Resources

6. Lack of ProFee Expertise

7. Denials Management


Part 2.

Facility vs. ProFee

Coding

Professional “ProFee” Coding


▪ Professional Fee Portion

▪ Completely separate from facility bill

▪ ProFee is for personal

▪ Physicians are typically paid by work RVUs

▪ Coders are usually divided by specialty

▪ CPT coding can be different from the facility-based CPT

▪ Physician and Coder discussions/questions are common

▪ Manual coding/systems

Facility and ProFee coding and billing aren’t that different…right?

A. Facility and ProFee coding and billing are exactly the same

B. Facility and ProFee coding and billing are very similar

C. Facility and ProFee coding and billing do not share any similarities

D. Facility and ProFee coding and billing do share some similarities, but also many, many differences

Differences in

Facility vs. ProFee Billing


▪ APCs vs RVUs

▪ OPPS

▪ Outpatient Code Editor

▪ NCCI edits and NCCI Manual

▪ Medically Unlikely Edits (MUEs)

▪ Global Surgery Edits

▪ E/M Levels

▪ Modifiers

▪ Status Indicators

Similarities in Facility vs. ProFee


▪ ICD-10-CM Diagnostic coding

▪ CPT

▪ NCDs/LCDs

Differences in Facility vs.

ProFee Coding


▪ Medicare Part B Physician Fee Schedule (PFS) for

appropriate assignment of coding

▪ NCCI manual

▪ Provider discussions/questions

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Physician Fee Schedule

Physician Fee Schedule Reference


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How_to_MPFS_Booklet_ICN901344.pdf

NCCI Manual vs. CCI Edit


17

wRVU Differences

Tips for Physician Discussions

1. Stay one step ahead

2. Keep it “official”

3. Use your resources: consulting firm, colleagues,

AMA, CPT assistant, etc.

4. Escalate when needed:

We recommend not including coders in tense

discussions – instead designate a department or

team for physician relations/education.

5. Communication is key!


Part 3.

Denials

Management

PFS Status Indicators: Indicator B


PFS Status Indicators: Indicator T


PFS Status Indicators: Indicator I


Part 4.Summary

What is an example of a difference between professional fee billing and facility?

A. CPT coding accuracy can make a bigger impact on professional fee reimbursement than facility

B. Coding edits, status indicators for payment reimbursement, medical necessity requirements, etc. can differ between professional fee and facility

C. Professional fee billing systems tend to be more manual than facility systems

D. All of the above

Common Challenges

Physician Group Acquisitions

1. Coding Quality

2. Physician Discrepancies/Coding Communication

3. Coder Turnover

4. Merging Facility and Former Independent

Practices’ Policies, Procedures and Level of Quality

5. Lack of Resources

6. Lack of ProFee Expertise

7. Denials Management


Example ProFee Audit


Summary


▪ Personal

▪ Provider and coder/coding mgmt. interaction

importance

▪ Differences between facility and professional fee

▪ Denials

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Consulting

• Trending Reports

• Management Support

• Query trending & Analysis

• CDS & Coder Mismatch Review

Denials

Remediation

• Coding-related Process for Revenue

Recovery

• Identify Coding-related Error Trends

• Remediation Plan

• Ensure that Appropriate Payment is

Received for Services Provided.

Auditing

• Inpatient Coding Compl. Audits

• Outpatient Coding Compl. Audits

• ProFee Coding Compl. Audits

• PSI/HAC Reviews

Education

• ICD-10, CPT, CDI Academies

• Refresh With YES customized

Webinars

• 2019 Hot Topics

• CPT Updates

• ICD-10 Updates

Inpatient Coding Outpatient & ProFee CodingCoder Mentoring

• Online Assessments

• New Hire mentoring

• Secondary Quality Reviews

• Compliance Audits

• Coding Accuracy Reviews for APC’s

• Coding Accuracy Reviews for Dx,

CPT, Code Assignment & RVU’s

• Quarterly, Semi-Annual, and Annual

coding accuracy reviews for:

• MS-DRGs, discharge disposition,

PDx, procedures, and POA

References


▪ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

▪ https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/

▪ https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

▪ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/

https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html

30

Questions?

31

What is HFMA?

THE LEADING MEMBERSHIP ORGANIZATION FOR

FINANCIAL MANAGEMENT EXECUTIVES & LEADERS

HFMA’sVISION

HFMA IS:

TO BE THE INDISPENSABLE

RESOURCE FOR HEALTHCARE

FINANCE

Demographics

32

40,000+MEMBERS

8.3%MEMBERSC

ER

TIF

IED

63%PAYERSPROVIDERS

21AVG

YEARS IN

HEALTHCARE

CHAPTERS6811REGIONS

HFMA Florida Chapter

33

1,572MEMBERSLARGEST CHAPTER

IN T

HE

US

FALL3STATE CONFERENCES

EACH YEARSPRING WINTER

37REGIONAL

MEETINGS

Early Careerist Overview

• HFMA created the Early Careerist committee to support and develop future leaders in healthcare finance/accounting.

• Who are Early Careerist? Young Professional under the age of 35 or 40, who have chosen a profession in or related to healthcare finance.

• Develop strategies to engage the young professional demographic in the local Tampa Bay area.

• Articulate the needs and preference of the early careerist market, particularly in terms of learning styles, participation, networking, and communication.

34

Questions about membership?

Contact:

Brian McNally

Director of Interactive Learning

O:813-513-3790

Email: [email protected]

so you think you know profee coding?2016 (an 11% increase). hospital employed physicians increased...

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