1. Coding, How it all Connects Lesvia O Millican, CPC AETC Coding Consultant

2. Overview Basic understanding of coding Application of code sets according to providers How this translates to workload reporting

3. Glossary of Terms Coding Systems  ICD – International Classification of Diseases  CPT – Current Procedural Terminology  HCPCS – Healthcare Common Procedure Coding System

4. Where does it begin? The initial appointment Patient presents for visit Physician provides treatment

5. Where does it all begin? “A” = Inpatient  AAAA = Internal Medicine “B” = Outpatient  BAAA = Internal Medicine “C” = Dental “D” = Ancillary  DBAA = Laboratory “E” = Support  EBCC Meetings “F” = Special  FCDA Other Mil Facility “G” = Readiness  GDAA Deployment  GFAA Fitness

6. Who are the players? Privileged providers  Residents, fellows, and interns  PA, NP IDMT, IDC Nurses  Social workers, Techs  PT/OT, nutrition, etc.

7. How do you identify? Skill type I Skill type II Skill type III Skill type IV

8. Tools of the Trade CPT – procedures and services  Category III Codes HCPCS – procedures, services,& supplies  Optional in some cases ICD-9 CM – signs, symptoms, disease, etc.  E codes  V codes

9. ICD-9-CM The assignment of 3rd, 4 th and 5 th digits codes to fully describe:  Signs  Symptoms  Diseases  factors influencing health  external causes of injury and poisoning ICD-9 determines IF you get “paid”….

10. HCPCS The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS.  Level I of the HCPCS is comprised of CPT (Current Procedural Terminology)  Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes.

11. CPT – Level I AMA’s Physicians’ Current procedural Terminology coding system is the nation’s official HIPAA compliant code set for procedures and services provided by:  physicians  ambulatory surgical centers  Hospital outpatient services  Laboratories  Imaging centers  Physical therapy clinics  Urgent care centers  Others CPT determines WHAT you get “paid”.

12. HCPCS – Level II Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as:  ambulance services  durable medical equipment  prosthetics, orthotics, and supplies  Other services Specific to carriers needs

13. Making the Connection Skill type I  evaluation and management services  procedures Skill type II  limited evaluation and management services Skill type III  services Skill type IV  services  limited procedures

14. Systems and their part AHLTA CCE CHCS ADM TPOCS M2

15. Where does it end? Providers close out encounters  Privileged providers  Nurses  Techs Coders/auditors review data EOD DQ MEPRS

16. Who drives the bus? MEPRS? Coding? Billing? DQ?

17. Erroneous data Clinic “A”  4 providers  2 techs  1 nurse 30 appts-all listed under provider Indicates no support staff needed Incorrect code(s) assignment Inflated “Business Plan Metrics” }

18. Correct data Clinic “B”  4 providers  2 techs  1 nurse 10- appts provider 10- appts tech 10- appts nurse Cost per visit per RVU Correct coding Base line “Business Plan” metrics }

19. What to look for Count vs non-count Outpatient services performed on inpatients Administrative services Ancillary services Other

20. What to look for Count vs non-count  Immunizations under Allergy Clinic  Staff encounters in nurse/tech run clinic  Tele-health clinic  Multi discipline clinics  Other

21. What to look for Outpatient services performed on inpatients  PT/OT  Speech  Nutrition  Wound care  Other

22. What to look for Administrative services  Flight line  Records review  Staff meetings  Command initiatives  Other

23. What to look for Example: Nurse/tech sees patient, transfers encounter to Staff, codes – 99211 Reflects ineffective use of resources Deflates RVU per provider Reflects poorly on the business plan

24. What to look for Example: Procedure performed for air sickness desensitization: returning the flier back to the chair to get used to the sensation of flying If the docs are observing the pilots on the flight line

25. What to look for Example: Clinical pharmacists provide patient care independently outside the pharmacy environment.  Internal Medicine  Coumadin Clinics  Diabetic Clinics Service-specific guidance for privileging procedures

26. Common issues “The clinic has been under the impression that there would be no “count” if any services were appointed under technicians, even though services are provided solely by the technician and no provider services are rendered. They stated that the technicians are not profiled to have appointments made under their names. How should services performed by technicians only be correctly appointed?”

27. Common issues Services performed by staff/tech outside the clinic setting.  Flight lines  Ambulance runs  Downtown care  Security services  Other

28. Patient Access Appt Booking Patient Calls for Appt Coding Record of Encounter Credentials Provider Profile MEPRS Template PAS/ Managed Care Appt Template Facility Process Encounter Direct MEPRS Impact How it all connects Example Provider MEPRS Template Category MEPRS Time IP AAAA 40 Clinic BAAA 60 Mtgs EBCC 13 Teach EBEA 40 MURT GBAA 6 Fitness GFAA 12 Leave “LV” 20 Total 191 Available clinic time = 31% Critical for Business Planning Business Plan Developed based upon expected demand and production capability derived from available clinic time.

29. GOAL Quality data on which to base sound decisions  For you  For your Commander  For your Service  For the Military Health System (MHS)

30. Questions?