Planning Notes for Combined Financial and Coding Workshop on Apgs

Planning Notes For Combined Coding and Billing Workshop on APCs

Planning Notes for Combined Coding and Billing Workshop on APCs

Title: Coding & Billing For APCs

Objective: To provide a comprehensive assessment of both the coding and billing considerations surrounding the implementation and utilization of CMS’s APC Payment System. The importance of proper coding and modifier utilization along with the implementation parameters affecting billing and reimbursement along with the financial impact will also be addressed.

Upon Completion the Participants Will:

1. Understand the APC payment system and the extreme importance of coding for APCs.

2. Appreciate the role of CPT, HCPCS, modifiers and ICD-9-CM for APCs.

3. Recognize the interface between the coding process, the charge master and the final generation of the UB-92.

4. Understand the need for making changes to the charge master in order to better accommodate coding and billing under APCs.

5. Knowledge of the use of encoding programs for CPT and ICD-9-CM and the use of the APC grouper in understanding APC reimbursement.

6. Review all of the modifiers that are used for hospital coding.

7. Appreciate the differences between modifier utilization for physicians and hospitals.

8. Review of CPT E/M coding and surgical coding.

9. Appreciate CMS’s coding guidelines including CMS’s Correct Coding Initiative (CCI) and its use by coding and billing staff.

10. Understand the various edits to which claims will be subjected by CMS’s OCE (Outpatient Code Editor).

11. Appreciate the complexities of the various co-payment issues under APCs.

12. Understand the importance and role of the APC grouper pricing capabilities and

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the need for a claims adjudication tracking system (CATS).

13. Recognize the need to develop various coding and billing policies and procedures to meet compliance concerns under APCs.

14. Appreciate the need to develop documentation systems that will provide the necessary information to properly code and bill under APCs.

15. Appreciate the need for carefully organizing the coding and billing functions within the hospital setting to accommodate various points of service.

16. Recognize the importance of Service Mix Indexes and other financial data relating to coding.

17. Appreciate the need for on-going training and the need to develop an APC integrity program.

18. Knowledge of additional sources of assistance.

Audience: Coding Staff, Hospital Business Office personnel, Health Information Management personnel, data processing personnel, outpatient coders, insurance clerks and administrative staff and other involved in the billing and coding aspects of outpatient services. Team attendance representing both financial and health information management personnel is highly encouraged!

Prerequisites: Participants MUST have a basic knowledge of the APG-Type Payment Systems and/or equivalent knowledge of Outpatient Payment Reform and APCs.

Method of Presentation: The primary method is Lecture-Recitation with the use of case studies. Interaction and questions from the audience are HIGHLY encouraged. Exercises and examples in the form of financial scenarios will be used.

Course Materials: Extensive Class Notes (including copies of Overhead Transparencies). Class Notes will include copies of selected readings and special materials as appropriate.

Student Materials: None.

Suggested Class Limit: Due to the somewhat limited interactive nature of this program, class size is suggested to be limited to 100 participants.

Course Times: 9:00 a.m. to 12:00 noon, 1:00 p.m. to 4:00 p.m.

Outline:

I. Introduction A. Overview APCs B. APCs Versus APGs C. APCs, DRGs, and RBRVS D. Importance of Coding Under APCs E. Coding Systems For APCs F. CMS’s CCI – Correct Coding Initiative G. Claim Adjudication and The OCE – Outpatient Code Editor H. CATS – Claims Adjudication Tracking System

II. E/M & Outpatient Surgical Coding Using CPT Codes A. Physician-Hospital CPT Coding Differences B. CPT Coding Process C. CPT Coding Guidelines D. E/M Coding Documentation Guidelines E. Coding Exercises & Case Studies

III. Charge Master Interface For Coding & Billing A. Overview of Charge Master B. Dynamic versus Static Coding C. Proper Use of Revenue Center Codes (RCCs) D. Billable, Non-Billable and Overhead Items E. Placement of Modifiers on the Charge Master F. CMS’s Transitional Pass-Through Items

IV. Modifiers For Outpatient Services A. Physician Modifiers Versus Hospital Modifiers B. Types Of Modifiers – CPT Versus HCPCS C. Anatomical Modifiers D. Payment Modifiers E. Surgical Versus E/M Modifiers F. Ancillary Services Modifiers G. Coding Exercises & Case Studies

V. ICD-9-CM Ambulatory Coding for APG/APCs A. ICD-9-CM Coding Process

B. ICD-9-CM Outpatient Coding Guidelines C. Primary Versus Encounter Diagnoses D. Diagnosis Coding & APCs

V. Billing System And Associated Interfaces A. Proper Generation of UB-92s B. Using the APC Grouper/Pricer C. Addressing CMS’s CCI D. Understanding CMS’s OCE E. Addressing Co-payment Issues F. Addressing Secondary Payer Issues G. Developing A Reimbursement Feedback Loop

VI. Special Billing and Coding Areas A. Observation Services B. Cardiac Catheterization/Vascular Laboratory C. Clinic Services D. Emergency Department E. Oncology And Cancer Services F. Wound Care/Pain Management

VII. Management/Organization Of The Billing & Coding Processes A. Centralized Versus Decentralized B. Insuring Uniformity And Consistency C. Point Of Service Coding and Billing D. Interfaces Of Computer Systems E. Assessing the Overall Coding And Billing Flow

VIII. Compliance Issues A. APC Coding And Billing Policies And Procedures B. Medical Necessity Requirements C. Utilization Of Non-Physician Providers (NPPs) D. Significance Of Modifier Utilization E. Post-Payment Audits For Outpatient Coding F. Using A Team Approach For Internal Compliance Auditing G. Education and Training Requirement for APCs

IX. Informational Tools With APCs A. Service Mix Indexes B. Cost Per APC C. Frequency Analyses D. Code Distribution Analyses

X. Sources For Additional Information

Notes: 1. This is an intensive one-day workshop emphasizing practical applications relative to the coding and financial aspects of the APC Payment System. 2. Questions submitted prior to the class are encouraged! 3. Reference materials will be made available to class participants as a part of their notes.

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