Back to Basics – Applying Coding to Payment Policy
Back to Basics – Applying Coding to Payment Policy
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Q: [Back to Basics- Applying Coding to Payment Policy] – Please explain CPC coding and payment policy.
A: That’s a question that’s asked all the time even when I’m speaking to students about coding, they always bring in the billing components in that and it’s really important for coders to understand this because first of all when we study in for the CPC exam, first of all we always have to remember that we’re using the guidelines from the CPT manual only. That’s very important particularly for students, or CPCs who are already working with insurance companies and observe the reimbursement policies on a daily basis. It’s just that the way CPT presents and the way what insurance companies adopts certain information, it’s all relative.
In my own experience, even when I was studying for the exam, I always got inpatient E/M code questions wrong because I thought in the Medicare mindset as opposed to the CPT and it really makes a difference once you get that CPC and you get a real job in some healthcare facility or a doctor’s office or whatever, you have to start paying attention and go to the next level. That’s just very important.
One of the most important factors associated with the CPC coding and insurance payment is the Place of Service code, and that is so important. For example, I can have one podiatrist who will bill for a surgical procedure in an outpatient setting, while another podiatrist can bill for the exact same procedure in an office setting. That podiatrist that performs the surgery in the office will receive more money based on the Relative Value Units, which is basically the office overhead expenses. When a procedure is performed in the outpatient setting, the outpatient department of the hospital will collect that portion of the overhead, paying the doctor less money.
I know for a fact because I worked with the OIG on one of these investigations where they were performing audits on physicians in rural areas who were coding the wrong place of service in order to get more money, and it’s really fraud in its purest form because a lot of doctors in rural areas will get a stipend if they’re on call in the emergency room or something and they’re supposed to be billing with the emergency department’s place of service because their patients come in, they automatically bill it as an office visit and that’s double dipping and that’s really not good.
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