Edition: February 2003 - Vol 11 Number 02
Imagine running a business but not knowing for sure how much you’ll get paid for your services. That’s the quandary many physicians face every day, as they battle their way through the thickets known as Current Procedural Terminology (CPT) codes.
Developed by the American Medical Association in 1966, the CPT is the most widely accepted listing of descriptive terms and identifying codes for reporting medical services under public and private health insurance programs. CPT codes are revised, updated and modified by a panel of 16 members, 11 nominated by the AMA and one each from the Blue Cross and Blue Shield Association, the Health Insurance Association of America, Centers for Medicare & Medicaid Service, the American Hospital Association, and the co-chair of the Health Care Professionals Advisory Committee (HCPAC).
In June, the Denver-based Medical Group Management Association announced that coding expert Lisa Stravakas had joined the association’s Health Care Consulting Group as a senior consultant. She brought with her 15 years of CPT and Internal Classification of Diseases (ICD-9) coding experience. A Certified Professional Coder for both physicians and hospitals through the American Academy of Professional Coders, Stravakas focuses on the coding needs of MGMA’s medical group practice members.
Recently, Repertoire asked Stravakas to answer some basic questions about coding. Here is what she told us.
Repertoire: You are a member of the American Academy of Professional Coders. What is a professional coder? Do many physicians have professional coders in their offices?
Stravakas: A professional coder is one who has obtained certification through either the American Academy of Professional Coders or the American Health Information Management Association. Both organizations offer certification for physician coders, which allows an individual to uphold a better standard of coding and billing. We are seeing more and more physician offices require certification [of their coders] from either organization. If you look at the newspaper ads, they are looking for certification with experience.
Repertoire: How many CPT codes are there, and how do they differ from ICD-9 codes?
Stravakas: I don’t have an exact number, but it’s in the thousands. CPT codes describe procedures performed by a provider, and the ICD-9 codes describe the reason why a procedure is performed (such as the patient’s condition). There are also ICD-9 procedure codes, which a hospital uses for describing procedures performed in an inpatient setting, which is based on a DRG.
Repertoire: With so many different procedures being provided at physicians’ offices, how does the office keep on top of what CPT codes to assign them?
Stravakas: That’s where your certified coder comes in handy. Also, various coding companies publish newsletters, by specialty, regarding coding issues (for example, Ingenix, Coding Institute).
Repertoire: What are the most common questions you receive from MGMA members?
Stravakas: Common coding questions that I receive from members and non-members relate to Medicare rules and regulations, bundling issues and [questions like the one above] – “What code should I use.”
Repertoire: What are the most common mistakes?
Stravakas: Not understanding coding guidelines and Medicare regulations.
Repertoire: Most common misconceptions?
Stravakas: Providers [must] follow coding guidelines or Medicare regulations, but most payers can make up their own guidelines. This becomes difficult, as the coder follows coding guidelines, but payers have their own. [The result is] denied claims. When I give workshops, it always becomes a topic of discussion; I say one thing and someone questions me because their payer didn’t pay the claim according to what I instructed or [according to] what the guidelines say. I always have to come back and say, “These are the coding guidelines. However, payers may pay differently.”
Repertoire: How can a medical products distributor help their customers (for example, physicians’ offices) use codes correctly?
Stravakas: Know the Medicare rules and regulations. Get in touch with a certified coder on proper coding and reimbursement guidelines.