Taking the Mystery Out Of the CPT Coding Process

Taking the Mystery Out Of the CPT Coding Process Robert McDonald, MD, MBA President, Aledo Consulting, Inc. Dr. Grant Bagley, MD, JD Chairman, HillCo Partners Health Practice April 14th 2010

Overview: Why Is Coding A Mystery In The First Place?

CODING IS A TRANSPARENT PROCESS OPEN TO ALL TRUE? FALSE?

In 1994, HIPPA Created Standard Code Sets That Must Be Followed • CPT-4 – Physician Procedures • HCPCS – Things (DMEPOS) • ICD-9-CM – Diagnoses • ICD-9-CM – Inpatient Procedures • NDC – Pharmaceuticals • CDT – Dental Procedures

Each Code Set Has An Organization That Maintains It • CPT-4 – Physician Procedures (AMA) • HCPCS – Things (DMEPOS) (HHS/CMS) • ICD-9-CM – Diagnoses (HHS/CMS) • ICD-9-CM – Inpatient Procedures (HHS/CMS) • NDC – Pharmaceuticals (HHS/FDA) • CDT – Dental Procedures (ADA)

CPT CODES MANAGED BY THE AMA • Regularly Communicating All Codes • Adding/Deleting/Separating/Collapsing Codes • Changing Categories of Codes (Level I/III) • Changing Definitions of Codes • Providing Definitive Answers to Interested Parties About Coding

“It’s All About The Money”

SPECIALTY SOCIETIES, THIRD PARTY PAYORS AND CMS CONTROL CPT: HOW DO THEY VIEW THE THE ADDITION OF NEW CODES?

HOW WILL PROTECT OURSELV ES FROM THE WOLF (AKA DRUG AND DEVICE INDUSTRY)?

WE CAN REQUIRE MEDICAL NECCESSITY,. BUT THAT TURNED OUT TO BE A HOUSE OF STRAW.

WE CAN USE MEDICAL POLICY DEVELOPMENT AND PRACTICE GUIDELINES THAT TURNED OUT TO B E A HOUSE OF WOOD EASILY CHALLENGED BY PROVIDERS.

WHY NOT USE CODES? AND SO THEY DID AND IT BECAME THE HOUSE OF BRICKS

AMA CPT CODES • 3 MEETINGS PER YEAR • DECISIONS BY THE CPT EDITORIAL PANEL-17 MEMBERS • ALL SPECIALTIES HAVE ADVISORY INPUT • PAYOR INDUSTRY, AHA HAVE INPUT

CODE CREATION TIME LINE • APPLICATION CAN BE AT ANY TIME • APRIL, OCTOBER AND FEB MEETINGS CREATE CODES FOR THE FOLLOWING YEAR • CODES BECOME ACTIVE ON JAN 1 • CMS VALUES NEW CODES IN PFS

V ARIETIES OF CPT CODES • CATEGORY I-USED FOR CLAIMS FOR SERVICE • CATEGORY II-USED TO REPORT PERFORMANCE • CATEGORY III-USED FOR NEW AND EMERGING TECHNOLOGY TO TRACK UTILIZATION

CATEGORY III CODES IN PRACTICE • MOST INSURANCE DENIES COVRAGE • MEDICARE USUALLY DOES NOT PAY • CONSIDERED INVESTIGATIONAL • OFTEN USED AS “PROBATIONARY” BY SPECIALTY SOCIETIES • SUNSETS AFTER 3 YEARS • ALTERNATIVE TO USE OF A MISC. CODE

KEYS TO SUCCESS • EVIDENCE TO SUPPORT THE CODE • SUPPORT FROM MEDICAL SPECIALTY SOCIETIES • AVOID DISRUPTION IN PRACTICE PATTERNS OR SPECIALTY MIX • REALIZE THAT IT IS ALL ABOUT ECONOMICS—KEEP EXPECTATIONS REALISTIC

NOT VERY LIKELY TO BE IN THE NEWS THIS YEAR 2010 AMA CREATES NEW USER FRIENDLY CPT PROCESS

THE REAL USE OF CODES NEEDS TO BE THE AGREGATION OF THINGS THAT ARE THE SAME AND THE SEPERATION OF THINGS THAT ARE DIFFERENT

Thank You!! Robert C. McDonald, MD, MBA, President Aledo Consulting, Inc 8395 Keystone Crossing, Suite 206 Indianapolis, IN 46240 Website: www.aledoconsulting.com Phone: 317-453-2004 E-mail: bmcdonald@aledoconsulting.com Grant Bagley, MD, JD HillCoHealth LLP 610 10th St. NW Washington, D.C. 20001 Website: www.hillcohealth.com Phone: 202 509 0760 E-mail: gbagley@hillcohealth.com

Taking the Mystery Out Of the CPT Coding Process