Medical Assistant Students Frustrated About Medical Coding Expectations

Can These Two CPT Codes Be Billed Together?

Medical assistant students enrolled in medical assistant courses often have difficulties understanding the medical billing claim form and have problems understanding evaluation and management codes. We often hear from frustrated students; many wind up venting on one of our active forums.
A medical assistant student recently posted that her instructor wasn't very helpful while teaching the administrative medical assisting module; she felt the instructor apparently wasn't well versed in the medical billing and coding process herself and therefore was unable to explain the process in a manner that made it clear to the class. The students are frustrated and overwhelmed. Another one posted in the forum: I work for a cardiologist. We are trying to get clarification on the following...

QUESTION:

Can these two codes be billed together if both of these services are performed?

• CPT 93454 (Catheter place in coronary arterty(s) for coronary angiography, imaging supervision, and interpretation.)
• CPT 93458 (with left heart catheterization including intraprocedural injection(s) for left ventriculogy, when performed.

Another question that is often raised in our medical assistant forum is why medical assistant students should have to learn medical coding and billing in the first place, and why it is such an extensive part of the medical assistant certification exams.

I have received emails from frustrated medical assistants who contacted me right after taking their certification exam, where they state that they were totally stumped on the many medical coding questions in the exam. They encountered questions that were multiple choice and asked about specific numeric codes, or modifiers for a given specific diagnosis, or procedure.

Now, ask any medical assistant to give you a specific code without any reference book/manual and he/she would be hard-pressed to give the right one, since there are so many, not to mention specific modifiers. There are codes for evaluation and management from 99201 - 99499, such as 99201 - 99215 for office and other outpatient services; codes for anesthesia from 00100 - 01999, such as 00100 - 00222 for the head; codes for surgery from 10021 - 69990, such as 10021 - 10022 for general, and 60000 - 60699 for the endocrine system, Category II CPT Code(s) – Performance Measurement (optional), Category III CPT Code(s) – Emerging Technology (Category III codes: 0016T - 0207T, to name just a few.

We also heard from a physical therapy instructor who teaches basic medical coding and billing as it pertains to PT because the majority of his students do their own billing and coding, who is equally frustrated at times, not knowing the exact codes and how to apply them.

Do Medical Assistants Really Need Medical Coding Skills?

I can see where medical assistants need to have an idea of medical practice financial management, such as banking deposits, accounting and bookkeeping, dishonored check processing, payroll - and even that is nowadays often outsourced. Nevertheless, in any profession you should get a picture of how the whole kit and caboodle functions to make it run.

I think, as far as medical assistant students are concerned, it is okay to briefly introduce them to the billing and collections process to give them a general understanding of how things work. The medical assisting instructor should also provide commonly used standard forms, such as laboratory requisition slips, which often already have CPT codes already printed on them, a Superbill, health insurance claim forms, medical history, and HCFA-1500 forms for the students to fill out, and practice. This way, they can better address patient questions and communicate with the medical billing and coding staff efficiently should certain issues arise.

However, as far as spending a great amount of time looking up CPT and  ICD-9 codes and drilling billing and coding procedures, and assigning specific codes from memory to procedures, diseases and injuries from memory in final exams, from my perspective as a former working medical assistant and medical assistant program instructor, it seems redundant.

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More at Medical Billing and Coding NET website.

Medical Assistant Information Technology (IT)

Gone are the days of clip boards and medical charts carried by the medical assistant, or nurse. Today's medical assistants, especially certified medical assistants, are headed toward the future and need to be prepared and well trained in Information Technology ( IT) and computer applications. Many are carrying iPads, smart phones, tablet PCs, and other high tech mobile devices that are directly linked to a central database, or are designed to upload into a central unit.  

A tremendous amount of medical centers, hospitals, ambulatory health clinics, and doctor’s offices are looking for medical assistants trained in computer applications which includes proficiency in appointment scheduling, electronic medical record (EMR) management, medical terminology,  understanding and managing computer databases,  medical transcription, and bookkeeping etc… Some medical assistants may be required to perform medical  billing and coding, medical insurance claims processing, and utilizing CPT and ICD-9 diagnostic codes (soon upgraded to the new ICD-10 already used in Canada and many European countries). 

Judy Jondahl, director of accreditation for the American Association of Medical Assistant (AAMA) who certify thousands of medical assistants year after year, reported that associate degree programs in medical assisting are now putting a bigger focus on information technology skills and requiring IT competency as part of the their curriculum. Two year degree or Associates Certified Medical Assistants programs can provide most of the up to date computer applications training you need to compete in today's computer tech world.  Having these skill will not only help you to get hired, but it would also allow you to earn more than the average or less qualified non-certified medical assistants. 

Don't Rely On Medical Billing Forums—Documentation Is The Key

All too often we receive questions regarding specific medical billing issues and matching medical codes in our forum; but that's not just our Medical Billing Forum alone, that's ANY medical coding and billing forum on the Internet is packed with questions regarding specific (CPT) codes and urgent requests for help. That way, if something goes wrong they have someone else to blame.

Medical Coding Questions Posted in a Forum

Unfortunately, this tells us that there are medical coders (and medical billers) who, quite frankly, have no clue; they are inadequately trained, or self-trained, and when they hit a wall, they post their question in a forum in hopes to get answers or find someone (anyone!!!) to give them approval of codes they have somehow come up with themselves. This could be a student with a test question, or homework assignment, or a medical coder, or biller already working but that is in over his or her head. One example of such requests posted to our medical billing forum is asking for help with a specific CPT code. It reads:

"I bill for a rheumatologist. I am familiar with most codes that he uses but last week he gave XYZ-medication (*brand name removed - not relevant for this example) to one of his patients who had a severe drug reaction. There was considerable disruption in the office and the direct observation lasted 2 hours. The doctor wants me to bill for his observation services but I am not sure which code to use. I was thinking may be 99058 will fit the bill, but the doctor insists that the code should be time specific since he spent two hours on the patient's care. Can someone please help?"

Medical coding must never be performed without first looking at the original documentation and the final decisions regarding coding issues rest with the provider. It must be clearly understood that a forum is not an official organization, agency, or anything else that provides a final decision regarding coding or billing issues. A forum is not here to code visits, to train a visitor how to code, or to recommend which codes to select. All a forum, its members and/or guests do is provide limited guidance.  Guidance is limited to what is presented by a poster, however, what is presented may, or may not be true, accurate or correct.

The CMS website, specifically at https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp states:

"Providers are responsible for the correct submission of claims and response to any remittance advice in accordance with current laws, regulations and standards."

The patient's medical record must show detailed entries as to time, who did what, when, for how long, was it the doctor who monitored the patient directly, or was it delegated to a nurse or a medical assistant, what directives were given, was emergency intervention provided, and if so, how much total direct hands on and face-to-face time from the doctor was involved? When it comes to accurate medical coding, any code selected must be:

1. medically necessary
2. documented as being rendered
3. the proper code for the documented services rendered.

Telling a patient to sit in the waiting room for 30 minutes before they can leave after an injection and direct face-to-face attention after an acute reaction can both be described as monitoring, but it doesn't always mean it can be billed it at a higher level.

The Doctor Makes the Final Decision

The provider knows what was done and everything must be coded as it was documented in the patient's records. A medical coder can research a subject, provide suggestions and present supporting documentation from the proper sources to to make a point, however, the final decision rests with the doctor.

Documentation is the key.