Coding and billing in a nephrology practice

What is medical coding?

Medical coding is the process of converting a medical diagnosis, symptom or procedure into universal medical code numbers. These codes are utilized by insurance providers to compensate physicians and other health care providers. Medical coding aids in identifying insurance claims and displays the entire history of the patient and the services performed.

In nephrology, the codes are quite complex and require a thorough understanding of federal guidelines and requirements.

What is medical billing?

Medical billing is the process of billing insurance companies and patients for procedures and office visits. The staff members in a nephrology practice who handle medical billing are called coders. They perform a vital behind-the-scenes billing support activity by interacting daily with health care professionals to ensure that payments and reimbursements are optimized.

The role of a medical coder

Medical coders work with medical records and patient charts. They are responsible for identifying diagnostic and procedural information and converting this information into simplified numerical codes that can be electronically processed for payment by third-party payers, such as insurance companies and Medicare.

Coders analyze and review medical records to generate the most appropriate code, which can be CPT^®, ICD-9-CM, and HCPCS. The diagnoses and procedures are usually drawn from a variety of sources within the medical record, such as the transcription of the doctor's notes, laboratory results, radiologic results, and other sources.

The advantages of medical coding

Although it may seem time-consuming and tedious to learn how to code, it offers the following benefits to a nephrology practice. Accurate coding helps you:

• Easily determine fees for your specialty practice and reinforce consistency in the charges
• Document for procedures and services such as ESRD, hemodialysis, E/M services, kidney biopsy, and others
• Increase claims transaction process efficiency with connectivity and automation
• Prevent common and costly coding mistakes
• Avoid claim denials and/or audits
• Improve efficiency and accuracy of medical underwriting processes with proactive risk mitigation and forecasting
• Control costs and improve health through data-driven disease prevention and avoidance
• Locate information faster

Keeping up-to-date on codes

The Federal government mandates the use of medical codes in the health care industry for insurance processing, reimbursement and statistical data gathering. Being familiar with codes makes the coding process easier and more efficient. Accurate coding ensures that a nephrology practice is compliant, streamlines the reimbursement process and reduces reimbursement time.

Each year, the CPT^® and ICD-9-CM codes change specific to nephrology. The government does not allow a grace period for annual code sets. The new HIPAA Transaction and Code Set Rule requires providers to use national medical code sets that are valid at the time that a service is provided. That’s why it’s so important to keep up-to-date on billing and coding in nephrology.

ICD-9-CM code revisions become effective October 1 each year while CPT and HCPCS code revisions become effective January 1. In order for you to meet this requirement, you must have the revised CPT, HCPCS, and ICD-9-CM codes in your possession before the implementation dates. The best way to do this is to order your code books early through a source such as the Renal Physicians Association (RPA).

Proper coding is key to reimbursement

Many critically ill patients with acute renal failure are unable to withstand the rigors of intermittent conventional hemodialysis. Thorough documentation and correct coding for alternate dialysis procedures performed in the critical care unit are essential for timely and appropriate reimbursement.

With a growing number of compliance plans and Medicare’s heightened vigilance about fraud and abuse detection, it is imperative that nephrologists correctly distinguish between payable services and those that are not payable through Medicare Part B.

How to avoid common nephrology billing errors

Insufficient or unclear documentation can result in costly errors, especially if a nephrologist fails to review the note before placing it in the patient’s chart.  Although errors differ with each practice, the most common billing and documentation errors that nephrology practices find are:

• Lack of specificity in the chart or unsubstantiated comments
• Failure to chart secondary or multiple diagnoses
• Failure to document ancillary services, such as lab work or injectables
• Failure to distinguish which labs provide tests covered by the composite rate
• Billed consults for established patient visits.

Sometimes nephrologists face coding challenges when examining multiple systems in a patient, such as in the case when a renal patient comes in with a sore throat. To prevent undercoding, a one-line note in the chart stating that “all other systems are negative” (if all system areas are examined) is sufficient to flag the need for a higher-level examination. Ideally, a chart audit should be performed each month to ensure accurate documentation and coding.

Coding for hypertension and kidney disease

Recent changes in the diagnosis codes for hypertension will affect the billing for chronic kidney disease (CKD) patients. Coding for patients with both hypertension and kidney disease presents unique problems. It is not enough to determine whether the patient has “benign,” “malignant” or unspecified hypertension or to question the stage of CKD. Coding when both conditions are present requires careful consideration by the coding professional.

By coding the hypertensive kidney disease correctly, the provider can justify billing for higher levels of service as the patient’s renal disease and hypertension progress. Because it is clinically more difficult to care for a hypertensive renal disease patient at stage 4 CKD than at stage 2 CKD, billing for higher levels of service is justified. In this case, bill for the level of service, not the diagnosis.

By understanding the presumed relationship between hypertension and CKD, the provider and coder can more accurately code the patient’s condition, which will ultimately support the level of service provided by the physician. Such correct coding will result in more equitable and appropriate reimbursement.

Continuing education for coders

Coding professionals must have adequate knowledge in medical terminologies, treatment procedures and other details that are needed for nephrology coding. Coding rules are continually changing, and even the best coders must strive to stay on top of all the new coding and payment rules affecting your practice. By investing in their continuing education each year, your practice will see a difference in accuracy and in reimbursements.

There are numerous seminars held at various locations across the United States at different times of the year. It is worth the dollar investment to send your medical coders to seminars to keep them in the know. 

Doctors need coding education, too

Coders, billers and administrators who attend specialty coding seminars often wonder where the physicians are. Few physicians attend, even though more physicians are coding than ever before.

Without a coding education, physicians who assign codes and submit them without verification from certified professional coders may expose their practices to audits and charges of fraud and abuse. In addition, physicians who know little about coding risk denials from payers. Whether using professional coders or performing the coding themselves, physicians are liable when medical coding does not accurately reflect the services rendered.

Most physician practices do not employ a professional coders; the physician is often primarily responsible for all coding and billing. It is in the best interest of the nephrology practice to ensure that individuals who are directly involved with billing, coding, or other aspects of the federal health care programs receive extensive education in order to perform their function accurately.

Physicians also would be wise to check into purchasing nephrology billing software that is specifically designed to expedite the claims processing and follow-up process in a nephrology practice.

Cheat sheets

There are one-stop resources that consolidate the coding process exclusively for those who code for nephrology. They provide a comprehensive guide, including complete 2008 CPT^® and ICD-9-CM code sets specific nephrology in an easy-to-use, one-page format. Each page has the CPT^® code with its official description, a detailed illustration, and the one-page format includes lay descriptions, coding tips, terminology, cross coding and national Medicare relative value units.

With a special “cheat sheet,” coders have 300 of the most commonly reported codes and descriptions for nephrology. Using this type of reference guide helps coders access the correct information easily and rapidly.  In the complex world of coding, every available tool helps a nephrology practice be complaint, and expedite claims and receive reimbursement as quickly and painlessly as possible.

Web Resources

• CPT® coding information — American Medical Association
• ICD-9-CM coding information —  American Hospital Association
• CMS ESRD Center — Centers for Medicare and Medicaid Services
• Coding Seminars — Renal Physicians Association