There currently is a broadening trend of physician practices changing forms within the auspices of healthcare systems. This includes outright sales of private practices as well as a variety of new affiliation agreements falling under the protective umbrella of individual health systems.

One of the most common aspects of these arrangements is the assumption by the anchor hospital that it will code services and diagnoses for its newly acquired physician practices. Different from facility inpatient and outpatient coding, coding for these services (termed professional or “pro-fee” services) quickly is becoming overseen by the medical records unit with a small contingent of HIM staff, the larger HIM department with ample coding support staff, and the facility’s central business office (CBO), which typically is replete with an army of on-site and remote coders. No matter the facility size, however, the potential problem areas remain the same.

Thoroughly and highly skilled in inpatient and/or outpatient coding, HIM coders are facing new challenges in assuming their roles as pro-fee coders. There are numerous differences between pro-fee coding guidelines and the various rules and regulations under which coders working in physician practices tend to labor. Steps in pro-fee coding also are markedly different than those followed in coding for inpatient cases – and coding two different types of work batches consecutively may cause confusion even for the usually stalwart, unflappable coder. At the other end of the coding spectrum, code assignments and guidelines for certain outpatient services tend to be quite similar to those used for physician services; in fact, the similarities can cause annoyance to surface, especially considering all of the outpatient prospective payment system (OPPS) rules and regulations. Have you ever heard “where is my pro-fee cheat sheet?” or “who has my pro-fee guidelines?” yelled at 300 gazillion decibels by a frenetic HIM coder?

Help is on its way! In terms of pro-fee coding, there are several “hot” audit and transitional areas of which HIM staff should be aware to ensure accurate coding within compliance standards: a) diagnosis coding and ICD-9-CM-to-ICD-10-CM code translation; b) evaluation and management (E/M) services coding; c) modifier assignment; and d) HCPCS Level II coding and units reporting for administered drugs and biologicals.

Let’s go over each:

a) Diagnosis coding and ICD-9-CM-to-ICD-10-CM code translation: Coding from diagnostic reports has been an area of difficulty in scenarios in which facility coders are tasked with coding pro-fee services. It also has been an area of perennial confusion among coders in the various other healthcare settings. The bottom line is this: in pro-fee settings, any test findings, impressions or abnormal test values provided in laboratory, radiology, pathology or other ancillary test reports are not coded as specific, confirmed diagnoses unless the treating physician has acknowledged and “data-bridged” those particular findings (thereby indicating their clinical significance to the patient in question).

Broadly speaking, the official reporting guidelines for pro-fee cases are the same as those for outpatient services, but certain portions of the guidelines tend to cause confusion for coders simultaneously performing inpatient and/or outpatient as well as pro-fee coding duties. One area typically cited in audits is the incorrect coding of “probable,” suspected,” “ruled out” and “versus” diagnosis code differentials listed as confirmed diagnoses. This mistake frequently is made by inpatient coders also tapped to code pro-fee cases (and who rarely code outpatient services), since under inpatient ICD-9-CM coding rules, the HIM coder can assign a “probable” or otherwise unconfirmed diagnosis with a code for a confirmed condition or illness.

In preparation for the transition to ICD-10-CM, and in the absence of confirmed diagnoses tied to abnormal diagnostic studies and labs, pro-fee coding often relies on appropriate selections listed in ICD-9-CM under “Chapter 16: Symptoms, Signs and Ill-Defined Conditions” (code range 780–799) for coding of a patient’s presenting symptoms or clinically ambiguous conditions. As with all diagnostic codes, these code assignments are driven by documentation in the medical record. In ICD-10-CM, however, this specific chapter has been moved and renamed “Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (code range R00–R99). It also might be a bit of an eye-opener for facility coders to discover that many primary care-level ICD-9-CM codes (and soon, ICD-10-CM codes) routinely are linked to signs- and symptom-related,, unspecified, and “not otherwise specified” (NOS) code assignments, because such codes are the only options for private-practice physicians in the early stages of patient evaluation and management.



As a refresher for facility coders, the aforementioned coding scenarios apply under both ICD-9-CM and ICD-10-CM when a) cases arise for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; b) signs or symptoms existing at the time of initial encounter prove to be transient, with causes that cannot not be determined; c) a provisional diagnosis is recorded for a patient who failed to return for further investigation or care; d) cases are referred elsewhere for investigation or treatment before a diagnosis is made; e) cases arise in which a more precise diagnosis is not available for any other reason; and f) certain symptoms for which supplementary information is provided are recorded, representing important problems in medical care in their own right.

Facility coders taking on pro-fee coding services should take steps to familiarize themselves with the ICD-10-CM codes that will be assigned regularly by primary-care physician practices (for example, codes for essential hypertension, diabetes mellitus, hypercholesterolemia, osteoarthritis, and hyper/hypothyroidism, as well as ICD-10-CM codes expected to be assigned by specialty practices such as orthopedics, cardiology, OB/GYN, neurology, otolaryngology, and medical/surgical oncology, just to name a few). In an effort to ascertain which codes will be applicable in ICD-9-CM and which will be transitioned under ICD-10-CM, the HIM coding staff of every facility should obtain copies of current practice fee tickets or superbills and translate those documents from ICD-9-CM to ICD-10-CM. In the months leading up to the implementation of ICD-10-CM/PCS on Oct. 1, 2014, these code assignments can be reviewed and discussed at HIM department meetings. Often, provider executives themselves like to be included in a meeting or two for assurance that their diagnoses and services will be captured accurately.

b) Evaluation and management (E/M) services: Office visits, inpatient hospital visits, observation services and other such “cognitive” services tend to have CPT codes assigned based on the extent of the medical record documentation and the extent of “key component” fulfillment under pro-fee coding parameters. This differs greatly from facility E/M coding, wherein tally or point systems are utilized, with coders grading various services and items not separately billable to account for facility resources and adding up the points to a facility E/M level. For example, emergency department visits can vary in terms of recorded facility E/M assignments based on which nursing and other assistive services are provided to the patient, as well as various interventional efforts. Assignment also can hinge on other considerations such as the patient’s age (an infant might require more intensive staff triage effort than an older patient), the nature of the presenting problem (a myocardial infarction automatically engages certain facility responses accounted for at a specific assessment point value), and whether special care is required. While these are also considerations factored into the final pro-fee assignment of E/M codes, ultimately, for physicians and non-physician practitioners alike, such assignment is only reflective of the degree, quality and content of the documentation of three key components for the E/M service: a) history, b) physical examination and c) medical decision-making. These distinct E/M components all mesh together for final appropriate code selection under the 1995 or 1997 E/M documentation guidelines. Those distinct E/M guideline sets establish the appropriate basis and approach to coding E/M visits appropriately, based on medical record documentation. Again, facilities do not follow such E/M documentation guideline sets, but instead utilizes their own E/M facility-level, point-based gradations. The differences between these two approaches to E/M coding are numerous and significant.

c) Modifier assignment: Being incorporated into CPT Level I and HCPCS Level II classifications, pro-fee modifiers may differ from facility outpatient modifier assignments in several ways. Generally speaking, the number of modifiers available and applicable to pro-fee coding is much greater than the number of modifiers for facility outpatient services. CPT Level I modifiers reported by outpatient facilities include -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, and -81. Pro-fee coding allows for nearly all of those particular Level I modifiers except -73 and -74 as well as -27 (the -27 modifier is not accepted at this time by the Centers for Medicare & Medicaid Services, or CMS, as a payment modifier for facility outpatient services; however, certain state Medicaid and commercial payors might accept it). Pro-fee coding also allows for such modifiers as -22, -23, -24, -53 and numerous others, including a recently added preventive services CPT modifier, -33. Of the HCPCS Level II modifiers, about 40 are applicable to facility outpatient services, while many more are applicable to pro-fee coding, including the recently added preventive services HCPCS II modifier “-PT.” Therefore, familiarity among facility coders of the various pro-fee coding choices, in terms of modifiers, may be limited by virtue of the lower number of modifiers they have dealt with in the past.

d) HCPCS Level II codes and units for drugs/biologicals: a great deal of confusion typically surrounds the assignment of HCPCS II codes for drugs and biologicals by facility coders not typically responsible for coding such items. In many cases, items such as J0696 Rocephin IM, 250mg at the facility level are “dropped” or “pushed” through the charge capture system to the claims processing module via the charge description master (“chargemaster” or “CDM”) of various outpatient clinics, and such services may not be coded directly from provider documentation. This operational issue accounts for numerous HCPCS Level II code and unit errors found during outpatient clinic audits. Unit(s) reporting is an area of focus in many federal auditing levels Miscoding these data elements can compromise revenue as well as burden providers with avoidable compliance issues. To help avoid this situation, the private practice staff can supply the HIM coding staff with its “cheat sheets” and/or superbills (if these documents are thorough and up to date) to apprise the facility coders of the full complement of HCPCS Level II codes and the typical unit counts reported by the practice prior to integration.

Aside from coding education and training centering on pro-fee services, there are a few simple steps HIM coding staff and department managers can take to help alleviate some of this transitional stress. Such steps include sharing charge capture processes and documents (superbills or fee tickets), transferring or exporting electronic code tables, and spotlighting and discussing potential complication points of pro-fee coding that physician coders struggle with themselves. This active exchange of information will be immensely beneficial to any facility’s coding and management staff. By following a few simple but common-sense steps, HIM staff can avoid coding errors that might cause pro-fee revenue compromise and stay clear of fraud, waste and abuse issues after physicians have brought their practices into the fold of an affiliated health system.

About the Author

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metro area, specializing in compliance, revenue cycle management, CDI, and coding/billing in the facility inpatient/outpatient and physician arenas.

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