Volume 2, #2

April 2005

In this issue:

• Coding News
  • Monitoring for Coding Quality
  • The Bundling of Conscious Sedation into Procedure Codes in 2005
  • Who Performed that Procedure?
• Compliance Corner
  • Supervision and Compliant Documentation of Procedures Performed by Medical and Other Healthcare Students

Coding News

Monitoring for Coding Quality

By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

In order to ensure coding quality, LYNX coding managers and Quality Management staff monitor several parameters of professional coding practice (as well as the hospital coding) every two weeks. They employ the tools built into our E/Code coding system to check your E/M and procedural frequencies. They compare the actual coded visit level frequency distribution to prior months and to the typical frequencies for the presenting problems seen in your ED. This latter comparison tells us if there are variations from what we would expect to see. If a significant variation is found, an audit of the records is performed. The E/M frequency distribution is also assessed relative to the admit rate for the period. If the admit rate increases, your frequency distribution is expected to shift commensurately to the right or toward the higher acuity levels.

Several other data points are compared, analyzed and trended. Managers look at the average charge and RVUs compared to previous months, the percentage of levels 4 and 5 relative to the full volume of patients, and the number of procedures coded per 100 visits. In addition, coders provide their managers with a weekly report containing any unusual circumstances that the manager should be aware of and that might change the distribution of visits and procedures.

Coding is not an exact practice. Coding guidelines are vague in some areas and can vary by payer. There are also many factors that contribute to the determination of the final visit level in a given record. We employ credentialed or credential - eligible coders and all of them undergo an extensive training program of didactic learning and auditing. We also provide continuing education on a monthly basis. This is all part of our commitment to you to deliver the highest possible quality of coding.

Despite the very best efforts, in any coding practice, coding can get off track. The monitoring described above is one of the best methods to detect and correct errors early. LYNX views coding as a partnership with each of our clients and if you have questions about any aspect of coding, your feedback and input are welcomed. We provide you with reports so you can review coding performance and also compare coding results to what you expect based on your and your group’s clinical practice. If you ever need more information, your LYNX coding manager can assist you.

The Bundling of Conscious Sedation into Procedure Codes in 2005

Appendix G of the 2005 CPT book, lists the 257 CPT codes that include conscious sedation (where it will not be paid separately). The affected procedures most commonly performed in the ED are listed below. In addition, conscious sedation can not be coded with intubations or RSI because an intubated patient is no longer managing his or her own airway. Prerequisite conditions for coding Conscious Sedation are the patient’s airway, protective reflexes and ability to respond to stimulation or verbal commands are maintained. LYNX coders will not code conscious sedation, 99141 or 99142 when performed with any of the following:

Who Performed that Procedure?

Many physicians have received feedback from LYNX coders asking them to document who performed a procedure noted in the ED record. We continue to see records where it’s impossible to tell who did what. When physicians, medical students, residents and mid-level providers work together, it is not always easy to determine who performed the actual procedure. When it is unclear, coders suspend the record and ask the physician to clarify. This takes extra time for physicians and causes delays in the billing process. A quick “performed by me” with an initial or signature will solve this problem and expedite the coding and billing processes.

Compliance Corner

Supervision and Compliant Documentation of Procedures Performed by Medical and Other Healthcare Students

By Ann Florer, RN, CCS-P
Coding Compliance Manager

The supervision of medical procedures performed by students is a common ED practice and is an important part of a medical student’s (or other healthcare student’s) education.

A health care “student” is defined by the Center for Medicare and Medicaid Services (CMS) as an individual who participates in an accredited educational program (such as a medical school, paramedical program, nursing school or PA school) that is not part of an approved graduate medical education (GME) program. A student is never an intern or a resident. Under Medicare, services by students are not billable.

CMS has confirmed, following a clarification sought by The American College of Emergency Physicians (ACEP), that when the teaching physician personally supervises a student there is no prohibition against the teaching physician billing for the procedure.

Documentation criteria required to code the service to the teaching MD:

• The Emergency Department Clinician (EDC) must personally document their presence and direct supervision of the procedure performed by the student.
• The EDC must document the procedure (student documentation of a procedure with a physician co-signature is not sufficient).

When a student is supervised by a resident while performing or providing a service, the teaching physician can bill for the service only when he/she is present throughout the critical or key portion (see clarification below) of the procedure providing direction. If the teaching physician is not present when the resident is supervising the student then the teaching physician cannot bill for the service.

Current Medicare policy requires teaching physicians to be present during minor procedures (requiring five minutes or less to complete, e.g.; simple suture) performed by a resident. It is not sufficient to document a review of the outcome after the procedure has been completed. For other procedures (requiring more than five minutes), the teaching physician must document their presence during the key portion(s) of the procedure, as determined by the teaching physician.

This information is the result of ACEP’s request for CMS to provide clarification regarding the supervision of medical students and the definition of a student in Medicare Carrier Manual Section 15016 A.2, which states “Medicare does not pay for any services furnished by a student.” For additional information and a review of Section 15016 of the Carriers manual, please click here.