Many healthcare billing and coding experts employ a wide range of knowledge on various conditions and service lines. At hospitals and family practices; this work could be anything and everything in the book! But sometimes it’s nice to dive deeply into a certain medical specialty and find someone with a wealth of knowledge to have a chat with.
Nephrology is definitely a worthy specialty to spend some time discussing. Chronic Kidney Disease (CKD) is a very common issue in our country, with around 37 million Americans dealing with this illness. Add to this the instances of renal failure and other kidney conditions, and we can see why it’s imperative to have experts in specialties like this. It’s definitely good to have someone around who knows their N17, N18, and N19 codes!
Kristen Poat, RHIT, sits down with our host, CJ Wolf, MD, in this episode of “Compliance Conversations.” Kristen manages auditing and compliance for a nephrology clinic in Illinois and was gracious enough to join our podcast guest family.
In this podcast, Kristen and CJ discuss many nephrology-related topics, including:
- Common billing and coding errors in nephrology
- Important medical record documentation activities with nephrology
- Coding with practice staff versus relying on an external coder
- Compliance risks worth noting in nephrology
Interested in being a guest on the show? Email CJ directly here at firstname.lastname@example.org.
*Note: this text is provided by a transcription service and may not be 100 percent accurate to the recorded conversation.
CJ: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity, and we are so excited today to be talking to a nephrology billing and coding expert, Kristen Poat. Welcome Kristen.
Kristen: Hello CJ, thank you so much for having me today. I’m so excited to be here.
CJ: I’m excited to talk to you and kind of pick your brain a little bit on coding and billing with nephrology. It’s a really unique specialty and I think there are some unique things that our listeners will love to hear. There’s probably some also common themes that are common across a lot of specialties, too, so.
Kristen: Absolutely, absolutely.
CJ: Kristen, one thing that we like our guests to do is just briefly, you know, maybe tell us a little bit about yourself and maybe how you got into coding and billing, how long you’ve been doing it and anything else you’d feel comfortable sharing.
Kristen: Sure. So I graduated with an RHIT, which is registered health information technology certification. I kind of started low man on the totem pole with just data entry stuff. Once they caught on that I was a quick learner and really loved what I do and am a hard worker and everything, I moved up pretty fast. I went from data entry to coding to auditing to leadership, between two different companies. So as far as nephrology goes, though, nephrology was a new specialty to the company that I had been working for previously, and nobody really knew much about it or the ins and outs of what was going on. I knew it had some funky little billing nuances, so it was kind of just thrown at me, like, ‘Hey Kristen, figure this out. You’re good at this kind of thing.’ So that’s exactly what I did. I built really good relationships with the MDs and with the staff leadership there and really grew that specialty auditing at that company, and so after that I had an actual nephrology company approach me and say, ‘Hey, we like what you do. We really want you here,’ and the rest is kind of history. I have been at this company now for a little over two years, and I’m growing their auditing and compliance program, totally revamped it from what it was when I first started, and it has just really given me even more experience in nephrology, learning the ins and outs and just all the crazy things that come up, you know, I really learned to tackle them.
CJ: Yeah, absolutely. One of the things that I was thinking about in preparation for today, maybe we can start here before we get into some specific questions, is Medicare was created so long ago. A lot of us think of Medicare as for people over 65, which is true, but there were early provisions in the Medicare program for coverage for individuals suffering from end stage renal disease. And so I’m just kind of curious: do most of the scenarios that you’re working with, are they almost all Medicare patients, or — is that an accurate statement? Tell us a little bit about that.
Kristen: Yeah, I would say that’s an accurate statement. We have a pretty high population of Medicare, Medicaid patients. We do have some private payers, but most of the time when we’re auditing, doing anything related to that, coding, billing, it’s mostly related to CMS, following CMS guidelines. We’re very familiar with CMS.(laughs)
CJ: Yeah, I bet, I bet, absolutely. That’s cool. So maybe we can — you know, a lot of our listeners are coders and compliance folks, and I thought I would ask you: in your vast experience, what are some of the most common coding and billing errors that you see in nephrology and in that specialty?
Kristen: Sure. Well I’ve got three, mainly. First one is medical decision-making, which is kind of funny to me. I run across this quite frequently, and even though I’ve been here for 2.5 years I’m still running into this problem. It’s medical decision-making. I find that our nephrologists very often undervalue their services due to repetition. They’re doing this day in and day out. They’re consistently managing highly complex medical conditions like end stage renal disease and acute kidney injury which, on the medical decision-making chart, actually equate out to organ failure, obviously. So that’s just — it’s so routine to them that they kind of end up undervaluing their services and bill lower because they just think that they see this day in and day out, it’s not that complicated. It actually is in the billing and coding world. So yeah, making those high-complexity decisions in conjunction with patients, caregivers, families — all the work that goes into prepping patients for dialysis and for transplants and everything, that’s high-level stuff. So I feel like nephrologists, again, quite often undervalue themselves as far as medical decision-making goes.
CJ: Yeah, you know, on medical decision-making, that’s a good point because, as you mentioned, organ failure, and then there’s a lot of complications that often go with kidney failure. These other things that are common complications with those kinds of patients. But let me ask on that a little bit: are there some visits that are maybe more routine? For example, I use an example that I’ve used from oncology a lot: people who have cancer — that’s a pretty severe condition. However, some of them, it may be controlled at the moment you’re seeing them and it might not be as acute as you get closer to end of life or you’re trying to diagnose things, and that. Do you see any of those kind of parallels, even though these are high-risk patients, some might be more controlled, and so the medical decision-making might not always be super high, or is that not the case?
Kristen: No, I absolutely agree. It’s very much in line with patients who have cancer. With end stage renal disease in particular, when the patient is progressing from four to five to end stage renal, when they make that end stage renal disease diagnosis, then they’re looking at the long-term options. They’re looking at transplants. They’re looking at dialysis. When they have that main visit to make all those big decisions and do all that extra management and everything, all the phone calls, all the outreach, that’s when I consider that visit to be high-level medical decision-making. But if you’re just following up on an end stage renal disease patient who is overall stable, they may have end stage renal disease and they may have complications, but nothing is exacerbated at the moment — no, that’s not high-level billing. Same with AKI. AKIs can come and go. They can be more acute. Acute kidney injury, AKI. They can be acute, but they can also linger a little bit, so when they’re lingering, I don’t necessarily count them as high medical decision-making. Especially an office follow up, patients are usually admitted to the hospital when they have AKIs, and by the time they’re seen in the office, they may still have that AKI, but it’s not, for lack of a better term it’s not as fresh. It’s not as acute.
CJ: Yeah, no, I get it. That’s helpful. I didn’t mean to kind of cut you off from your other areas. You mentioned potentially three different things. You mentioned medical decision-making. Any others that you wanted to talk about?
Kristen: Dialysis billing, which is — this is where it gets kind of hairy, and this is where I hit the learning curve. I’m still hitting the learning curve. I’m always going back to my guidelines and trying to figure out what I’m doing wrong, because sometimes I feel like I’m missing the mark, but the most common codes that are used in nephrology, mainly adult nephrology, are 90960, 90961 and 90962, which are bundled monthly payments for end stage renal disease services based on how many times the patient is seen by the physician or the APP. So without tight documentation turnaround and savvy billing staff and coders, and even reliable systems to help aid in keeping track of visits, dialysis services can get messy very quickly.
CJ: Yeah. Yeah absolutely. I remember before I went to medical school, students are always trying to volunteer and get exposure to the clinical world, and I volunteered at the dialysis center. This is many, many years ago. But I just found it so fascinating, those services. Could you maybe tell us a little bit about — so, some of our listeners may know, there’s some different kinds of dialysis. Maybe you know which ones are more common, but there’s hemodialysis where, essentially, and I’ll simplify and you can fill in the details, the blood is taken out, it’s sent through a machine to clean and it’s put back in. And that’s usually done at a center or some sort of clinic. But then there’s also peritoneal dialysis. I don’t know if that’s as common anymore nowadays, but that is something that you typically do at home. Could you talk about those two, or maybe just clarify if one is not even really done anymore?
Kristen: Yeah, so both of them are done. There are different billing codes for each. They’re the same type of dialysis, but as far as billing and everything goes, they are a little separated. There’s — we go by PD or HT. Sometimes the PD they call CCPD, which is continuous renal replacement therapy. Mostly we see the HT, though. That is the dialysis that’s done in the centers, and that’s only a few hours at a time versus the PD, which is a more continuous — you’re hooked up to the machine longer, continuously. So we see HT much more commonly than PD.
CJ: That’s good to know. But there are separate codes for each of those types of —
Kristen: Yes, there are separate codes. Especially for inpatient, there’s 90935, 90937 for HT and 90945, 90947 for PD. And again, the interchanges in the codes are just based on how many times the patient is seen while on dialysis.
CJ: Ah, OK. So if a patient is actually doing, does a lot of PD, or peritoneal dialysis, patients do that at home, maybe overnight or something?
Kristen: I don’t want to speak out of turn, but I don’t really see that as commonly. It’s more HT.
CJ: OK, gotcha. I was just curious: so these codes are more the number of visits the doctor sees a patient who’s having that kind of dialysis. It’s not necessarily, ‘We did dialysis on this day, and so we report that code,’ or is that not correct? Kristen: It’s usually when the physician or the APP must see the patient while on dialysis. In the inpatient setting, if they do not see the patient while on dialysis, they have to bill just a regular hospital visit code: 09922 — oh God. (laughs)
CJ: OK, that’s helpful. That clarifies things for me. Awesome, and then you said there may be a third one with common coding and billing.
Kristen: Yes, This is transitional cure management, which is not something that you usually think of when you think of nephrology, but due to changes in CMS guidelines that took place in 2020, TCM is now a billable service for end stage renal disease patients. It used to bump up against the dialysis codes. They weren’t able to be billed together, but now they can be. So this opens up a huge window of opportunity for nephrology billing, but it also comes with compliance risks. The most prevalent errors we’re seeing with this is that the patients are often readmitted to the hospital, especially being end stage renal disease patients. They’re very sick, they are in and out of the hospital frequently. That kind of throws a wrench in billing, as TCM comes with a 30-day time period to work with. It’s a transition, pun intended, for nephrology, learning how to bill for TCM compliantly, making sure that we’re keeping all the guidelines in mind when we’re billing, but it’s also a really great opportunity for us, because a lot of times it — transitional care management, you have to see the patient within seven or 14 days after discharge from the hospital. Usually the patients are going to dialysis the day after being discharged, maybe two, three days after. So it’s a really good chance for nephrology to catch the patient while in the center, and get on top of that TCM billing first, before any other specialty is able to get to it.
CJ: Gotcha. Yeah, that’s really interesting. You mentioned centers and places where dialysis and these other things occur. Are those typically billed with a place of service 11, with the outpatient clinic, or are these hospital outpatient departments, or maybe both?
Kristen: For the dialysis clinics?
Kristen: Those are places of service 65.
CJ: OK so there’s a unique place of service for dialysis?
CJ: OK, great. Good to know. OK so I appreciate that. I also wanted to ask — in our world as coders and billers and compliance, right, we often focus on what’s in the medical record, right. That’s kind of our foundation for reviews and compliance and those sorts of things. Do you have any tips or thoughts on some of the most important medical record documentation activities to be cognizant of with nephrology?
Kristen: Yeah, yeah, definitely. This is just in any scope, in the practice that I worked with previously, I was doing mostly specialty coding, auditing, whatnot, and it rings true for nephrology, too: just practice defensible documentation. It goes back to the coined phrase in our field, “If it wasn’t documented, it wasn’t done.” Nephrology is no exception. I always encourage our physicians to become allies with their billers, coders, auditors, because they’ll give you a leg up when it comes to documentation tips and tricks that will not only save you time but can save you a headache in case of an audit. So defensible documentation is the number one tip. Second one would be to clearly state diagnoses and dialysis notes. It’s kind of funny — which, it makes sense, outside of a compliance person’s mind, but many nephrology providers think that it’s implied when you’re seeing a patient on dialysis that they have end stage renal disease, which is not necessarily true. The diagnosis must always be clearly stated in the documentation for that date of service, regardless of whether it’s common knowledge.
CJ: Yeah, go ahead.
Kristen: Oh, sure. The last one is just to clearly identify whether the patient was seen while on dialysis, which is something that we talked about just a few minutes ago. This would relate to the end patient setting. This is another kind of silly one, but it’s very common. There aren’t very many documentation requirements for 90935 and 90937, which is the hemodialysis... But it’s crucial to clearly communicate that the patient was seen while on dialysis. Otherwise we have to bill for those other hospital codes.
CJ: Yeah. Yeah, you know, and I’m thinking with documentation, tell me if — maybe this isn’t a large percentage, but there are end stage renal disease, which is typically kind of a progressive disease, right, and it’s usually the result of some other condition like somebody might have diabetes for many years or they might have lupus, which is an autoimmune condition, or other conditions that damage the kidneys over time. So there’s probably a staging criteria. But then there’s also work that I’m assuming nephrologists are doing, is you mentioned acute kidney injuries. Sometimes people go on dialysis temporarily, right, like if they had some sort of trauma, some sort of issue, they might be in the hospital, they might be getting dialysis, and then occasionally they don’t need long-term dialysis and they might not be end stage renal disease patients. So I think, to your point about talking about, ‘What’s the diagnosis?’even though people might be assuming it’s clear, is really important. Is what I described kind of accurate? Do you see that type of thing in the medical record?
Kristen: Absolutely. Yeah, whether the patient is acute, air quotes, or whether they’re end stage renal disease, that’s how we differentiate between the two. The AKIs and the end stage renal disease patients. There’s different codes. There’s different processes. It’s really important to specify which one in the documentation, even though it is kind of implied. But as far as documentation goes, it has to be flat out stated by the provider.
CJ: Do you see a lot of, like from a practice standpoint or efficiency standpoint, do most nephrologists, and this probably just varies depending on the practice, but do most nephrologists choose their own codes or do they rely on coders, or does that just vary depending on the practice?
Kristen: I’m sure that it varies depending on the practice. The two practices that I’ve worked for, the nephrologists have picked their own codes, but again it’s, especially for dialysis billing, it’s just based on how many times you see the patient, so it’s not too much work that you have to put into it. You just have to count how many times you see the patient, or your systems will count for you. There were four notes this month, three notes this month. It’ll equate to what code needs to be filled out for the month.
CJ: Yeah, you know, and we — all of us in the coding and compliance profession are aware of the E&M guidelines that recently changed for a certain subset of codes, right, for some of those office-based codes, and we’re preparing for those similar kind of changes in other E&M codes. Did you see any major issues as nephrologists made those transitions through those new E&M guidelines while still needing to be thinking of, ‘Oh, the guidelines may be different for my inpatient population’?
Kristen: Not really. Actually it was kind of funny, because when I came to this new practice it was right when all the guidelines changed, so I had to educate all these physicians that I wasn’t totally familiar with on all these new guidelines and everything. It ended up being fine, but I really feel like there weren’t too many new changes that we had to get used to in nephrology. I feel like it was a little bit easier to get to a level four in the outpatient setting. I think that’s been our biggest hurdle, is just defining what a level three is versus a level four in the outpatient center.
CJ: Yeah, especially like you were saying before, if physicians are prone to kind of undervalue their services to begin with, because in their minds it’s routine to them, but it’s — in reality, these are probably more complex patients, so I see that a lot in other specialties, too. With that leap from three to four, sometimes people are a little uncomfortable with it.
Kristen: Yes, yes. I also see the same. Yep.
CJ: Yeah. Interesting. So I’ve spent a lot of my time as a compliance officer and so I — though my initial background was in coding and billing and from a clinical background, so I did spend some time there, but when you’re not doing it every day, you lose some of those details. That’s why I was so excited to talk to you, because I knew you’d know the details off the top of your head. But as a compliance officer we’re always looking at — we’re trying to manage risks and compliance risks and understand, ‘Where should we look? What should we do?’ and we can’t always do super deep dives into everything. So I’m curious if you have any thoughts on, in the nephrology world, are you seeing, maybe nationally, certain compliance risks that are more common than others in this specialty?
Kristen: The biggest one that I can think of off the top of my head, and I don’t know if I want to necessarily label this as a compliance risk, but value-based care is new to nephrology within the past few years. It’s a kind of — actually it isn’t kind of, it is an initiative that was pushed forward by CMS. There have been nephrology practices across the nation that then adopted it to either mandatory or even voluntarily enlisted in value-based care models with CMS. So the whole purpose is to make sure that nephrologists, dialysis facilities, transplant providers form end stage renal disease-focused account with care organizations to manage care for beneficiaries with end stage renal disease. I’m reading straight from CMS, here, by adding financial incentives for health care providers to manage care for beneficiaries that have either CKD four or five and end stage renal disease, and this is meant to delay the onset of dialysis and to incentivize kidney transplantation. So this is a whole new approach to kidney care, and, where am I going with this? In my mind, as a compliance and auditing professional, anything that’s new means that we have a lot of room for mistakes. New things kind of scare me a little bit (laughs). So we run into lack of clarity overall from CMS, CMMI about requirements and expectations and taking part of these models, so I really feel like that’s the biggest compliance risk that we’re facing right now. Not necessarily — I lost my train of thought there.
CJ: No worries. To your point about value-based care, that’s new for a lot of people in health care, right, so for years and decades we’ve been living through this feature service model, the way you increase revenue is you do more stuff and do more procedures or more visits or whatever. Now we’re in the midst of transitioning, we’re not there yet, and who knows where it’s really going to take us, but these value-based models are kind of a new paradigm. It’s a new way of thinking.
CJ: And sometimes the measures are not what the docs want, and the principles and the concepts I think most people can agree with, but the devil’s in the details, and it’s like, ‘How do we actually measure that, and what does that actually mean?’ and to your point about not feeling like there’s really good clarifying regs or clarifications, that can be really frustrating.
Kristen: It can be, especially when everything that we’ve been doing previously — there’s always educational material out there. There’s always something that you can reference and say, ‘This is what happened, this is the outcome and this is the rule or guideline or regulation that was made because of it.’ This is just all so new, we don’t have that content yet. We’re making the content ourselves, so that’s kind of a scary world for compliance people to be in, but that’s just coming from a compliance mind.
CJ: Yeah, exactly. No I totally get it. One thing I wanted to ask: we kind of started, I kind of prefaced that end stage renal disease and a lot of these services have been around in Medicare for a long time. I talk to a lot of people across the country, and you’re probably familiar with the difference between an NCD and an LCD for Medicare. And NCD, for our listeners, is national coverage determination, so it’s some sort of policy of what’s covered by Medicare and what’s not, maybe certain codes or certain diagnoses, at a national level. And the local MAC cannot really change if there’s an NCD in place. They can’t really come out with an LCD, or local coverage determination, that contradicts that NCD. And so I’m curious, because many of these services have been such a core part of the Medicare program for decades, are there really NCDs that define a lot of this versus LCDs, or do you know of a lot of local coverage determinations that may vary from jurisdiction to jurisdiction?
Kristen: Oh. CJ, I wasn’t prepared for this one (laughs).
CJ: Yeah, no, basically what I’m asking is — you mentioned CMS as not having a lot of clarity. I was just curious if you knew — what policies are you following? So when you go to CMS, are you going to your local mac, or —
Kristen: It’s not even on that level yet. It’s so new that it’s just coming straight from CMS CMMI. It hasn’t even trickled down yet, I feel, as far as resources and references and everything. If we have a question, we have to ask CMS directly. There’s no further clarification from the macs or anything, as far as value-based care goes.
CJ: Yeah. What about non value-based care? If we’re looking at the traditional stuff, when you’re referencing these codes and what Medicare will cover and won’t, what you have to document, are those in more maybe national CMS manuals or national policies, or do you see a mix of national plus local?
Kristen: It’s more national.
CJ: I thought so. I thought that would be the case. So I do a lot of reviews where somebody — maybe it’s a high-cost drug, right, and there is maybe a local policy, and in Florida that policy may be a lot different than what it is in California. I suspected that with nephrology types of services, because it’s a core qualifying condition to have Medicare, even if you’re not 65, and so I figured they would have some pretty specific manual or regs at the national level.
Kristen: Yeah, Yeah definitely more national than local. Yep, agree.
CJ: Cool. Well this has just been fascinating. We’re getting a little bit close to the end of our time. I always like to ask the guests: what things did we leave off? Is there anything maybe that as we were discussing that came to mind, of last-minute thoughts from your perspective on this really interesting topic of nephrology coding and billing?
Kristen: I can’t think of anything offhand. This has been a great conversation. I really appreciated you listening and just asking these really animated and vibrant questions. I don’t get this very often, so I’m happy to answer them.
CJ: Yeah, absolutely. Some coders — there are some coding societies that can specialize in certain areas, like I know you can get a certification in cardiology. Are there those types of things if people are interested in learning more about nephrology coding? Are there some more formalized classes or certifications that people get, or is that not really there yet?
Kristen: Not that I’m aware of. I wish that there was, because I feel like it’s complicated enough (laughs).
CJ: Yeah exactly, right.\
Kristen: But yeah not that I’m aware of.
CJ: Yeah, OK. Well good. Well Kristen, it’s been fascinating to get your insights into nephrology coding and billing ins and outs. We really appreciate your expertise and your time. Thank you so much for participating.
Kristen: Yes, thank you.
CJ: And thank you to all of our listeners for listening to another episode. Until next time, be safe and hopefully you’ll listen to our next episode. Take care everyone.