Perspective Analysis of ICD Codes and the Relationship to Procedural Coding in the USA
ICD codes have been a part of the medical procedure arena for quite some time. Attention to the guidelines offered by these codes, and the subsequent drop down CPT codes that are derived from them, which are updated and provided to institutions, are the basis to new pathways for medical treatments and institutional growth and success.
These are especially evident in the treatment of diseases provided by medical specialists in Oncology, Imaging and Cardiology. The introduction of new procedures provided to these services by the advancements in medicine for the treatment of diseases and the improvement of quality of life for patients is truly immeasurable!
2. Education and Updates
With the advent of the every new year, clinical CPT code changes, which include additions and subtractions of, will need to be scrutinized, reviewed, and the departmental code books of every department that uses CPT codes for billing under the guidelines and parameters be updated to provide the current new codes as provided by the ICD manuals. It is then imperative that these be implemented to current and new procedures to ensure compliance with the guidelines provided.
It is important to identify the individuals familiar with procedures and empower them to be the points of contact for necessary changes that would affect the order of business, whether it be in a lab, clinic, surgical center, or hospital.
3. Change is Inevitable and Services Affected
For immediate perspective, beginning in 2020 in the United States, Interventional Radiology, formerly an offshoot of a residency in Radiology, has blossomed into its own residency program. This is due to the phenomenal expansion of procedures these specialists have implemented and the structured growth by the Imaging industry geared to the interventional area of Imaging services medicine. The procedures performed by the Interventionist drove the market and vice versa.
How does this affect the Imaging Centers, Universities, clinics and hospitals? By providing an avenue for departmental renovation, updating and addition of new equipment to provide Interventional procedures and in order to attract Interventional radiologists as a positive addition to their staff. This will in turn attract patients and provide referrals for the services they can bring to the hospital and department, while giving a competitive edge to them over their hospital peers and competitors for patients and services. A substantial benefit to this addition is the enhancement of the institutions reputation within the medical community, not only in which they practice but the medical community as a whole.
The positive upside by the introduction of CPT codes designed for the IR Radiologists will be measured through multiple channels, as their expertise will save hospital admissions, inpatient surgical procedures, readmission’s, etc. which all translate to better care for patients, less recovery times for the procedures performed, along with dollars saved through higher reimbursements for their procedures.
The CPT codes traditionally on new procedures, ie; kryoablative therapies, outpatient biopsy procedures, and those such as fistulagrams and peripheral stents, will allow for the greater flexibility in performance and coding, while treating the patient as a whole, and ultimately, all the while extending a quality of life existence for the patients. Additionally, proper use of correct billing for reimbursement of new procedures (as well as existing) will improve the viability of the institution and enhancing its reputation.
Oncology services benefit from any new CPT codes through the parameters of ICD guides through the utilization of imaging through PET/CT, kryoablative therapies with imaging agents used in PET/CT (fluorodeoxiglucose (FDG) flourine 18) under the guide of the IR specialist and oncologist, to which reimbursements and are available.
With the advent of new FDG F18, there will be additional CPT codes provided for subsequent procedures associated for treatment, and again, offer improved recovery times for the patients while offering alternatives for disease treatment, saving surgical times,admissions and readmission’s, recovery times, etc. These types of reimbursements point to a continued financial stream for the health of the institution and a successful path of progression forward to new medical developments and treatments meaning success for the patients, departments, and ultimately the institution.
One other successful procedural implementation for Imaging and Oncology, was that of low dose imaging and the introduction of lung cancer screenings through CT, This allowed radiologists to identify early stage one lung cancers, leading to less costly treatments before they could advance, which again, provides a substantial savings of treatment dollars expended the discovery of an early cancer, and save the patient a better course of action and outcome for the treatment of the disease, along with shorter recovery times for the patient.
Interventional Cardiologists have been opportunities to introduce new procedures that combine CT built models for Trans Aortic Valve Replacements (TAVR), and Watchman procedures, again with CT built models, that will potentially eliminate the need for invasive surgical procedures (open heart) which would require longer hospital stays, recovery, etc. while the Watchman would help the elimination of medicines prescribed by the cardiologist normally that the patient relied upon for cardiac and overall stroke prevention before these procedures were offered.
As with any procedure, new or established, success both for the patient and the institutional health depends upon having a clear chain of command, beginning with the Provider and the order. Familiarity to the procedure requested and the success of and acceptance for the study rely on basic criteria, ie; necessity, correctness in the requested order, pre-certification of the requested study or procedure, and proper documentation of the diagnosis and reason for the request.
This is where the knowledge and familiarity of the CPT codes (and ICD codes) are needed to ensure that there will be no delays in service or treatment provided to the patient, and that the procedure will not be denied, and/or that the procedure will be reimbursed, basically that the insurance provider will be satisfied and provide reimbursement for the procedure that is requested. The introduction to the new procedures and their familiarity of the CPT and ICD codes to the points of contact will lead to proper CPT coding for the procedures and financial health of the organization.
This starts at the top of the pyramid, the provider, and works its way down through to the base, which is routed through the clerks, nurses, techs, and RNs involved in processing and entering orders correctly to the departments, and they in turn, accepting the orders.
Oftentimes, the first pitfall is as simple as adding a sentence providing justification for the procedure, or the lack of a communicated suspected diagnosis in the order. Another is an improper transfer of a verbal order by a provider to a clerk or nurse, which is then misinterpreted and not documented by the provider or one who is authorized to accept a verbal order, and hence the break occurs.
Another important pitfall to be aware of is imperative importance that in the provider know what to order.Oftentimes, the provider is not aware of what studies allow for an avenue to confirm a diagnosis, and this works the other way as well, in that the Cardiologist or Radiologist or their Administrative Officers provide an update or provide educational in-services or how to steps for the ancillary providers to order the studies or procedures and to what is available for the provider to treat the patient as a whole. The Imaging and Cardiology specialists must work with the providers to educate and participate in either Medical Morbidity Reviews, Grand Rounds, and Tumor Board discussions and patient case treatment plans as a pathway for the exchange of information and communication is a necessary step in order to achieve success. In my opinion, Radiologists need to insert themselves in the total care from beginning to end of the patients hospital or clinic journey.
Issues along this path that can lead to delays are, again, miscommunications, misinterpretations of orders, improper requested orders, wrong studies ordered, and pre-certifications not granted by insurance companies for the studies or procedures requested, along with the . A possibility that the requested study is not the wrong study needed. As with any failures or delays, proper communications between providers and specialists, along with open lines of communication between departments and clinics need to be cultivated and continued for success.
How does this Affect You?
The overall success of proper procedures and subsequent codes, along with the introduction and acceptance of new CPT codes for new procedures provide avenues of growth that enhance not only the quality of life for the patient, but the financial growth of the hospital to keep on the cutting edge of research and technology while growing the reputation in the community or region in which they are located. Successful implementation of coding can keep new equipment on schedule, additions to the departments involved not only in treatments, but upgraded to computer systems, departmental remodeling, functional equipment replacement (carts, zero lift facilities) etc.
I appreciate your time and attention and wish you a very successful 2020 and beyond.
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