Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.
by James S. Kennedy, MD, CCS, CDIP
For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :
- Standardize the definition and documentation of severe sepsis first. Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
- Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
- A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
- Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.
No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:
- Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
- Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
- Be on the lookout for Coding Clinic advice clarifying this issue. Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.
Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.
Note: This post is part one of four, excerpted from an article originally published in JustCoding. Click here to read the original. The comments and opinions represent those of Kennedy
by James S. Kennedy, MD, CCS, CDIP
There are a number of coding compliance challenges with sepsis-3 and with sepsis or severe sepsis in general. In this article, I’ll review my top four concerns.
First, sepsis-3 states that patients with an infection meeting the new sepsis criteria should be coded as R65.20, severe sepsis. This is impossible in the United States, given that ICD-10-CM code R65.20 can only be assigned if the physician documents “severe sepsis,” not sepsis alone, or if the physician documents that an acute organ dysfunction is associated with sepsis, though many coders fail to assign R65.20 when these links are made. Its apparent that the sepsis-3 authors are not familiar with Coding Clinic for ICD-10-CM/PCS, the Department of Justice, or our friendly neighborhood recovery auditors (RA).
Secondly, ICD-10-CM still has a multitude of codes for sepsis without organ dysfunction (e.g., A40-A41). The 2017 ICD-10-CM Official Guidelines for Coding and Reporting states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. It states:
“The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (Emphasis added.)
Recent advice from Coding Clinic supports the concept that if an individual physician documents sepsis using his or her own criteria (that may differ from sepsis-3 or that of a RA), coders are obligated to code it. Therefore, if a physician documents sepsis, can we still defend the coding of an A40-A41 code if there is no documented organ dysfunction? I believe that the Guidelines and Coding Clinic say that we can, even if the RA doesn’t like it.
Thirdly, the ICD-10-CM table instructions for code R65.20, severe sepsis, tell us to use an “additional code to identify specific acute organ dysfunction.” If a physician documents severe sepsis based on the sepsis-3 criteria of a lactate over 2 milliequivalent per liter (mEq/L), or sepsis-3’s changes in the Glasgow Coma Scale, what is the organ dysfunction that should also be coded or queried for? Without an organ dysfunction documented and coded, a RA may claim that the severe sepsis code is invalid.
Finally, in my own personal review of the CMS 2015 MedPAR, approximately 45-55% of MS-DRGs 871 or 872 (septicemia or severe sepsis) do not have a code for severe sepsis, yet a number of patients have acute organ dysfunctions present on admission which I believe should have been linked to the patient’s sepsis to render the severe sepsis code.
RAs look at sepsis DRGs without R65.20, severe sepsis, or R65.21, septic shock, as opportunities to take money away from facilities who coded sepsis (e.g., A40-A41) as present on admission and sequenced it as a principal diagnosis without an additional R65.20 or R65.21 code. To take these records out of the RA data mining pool, CDI professionals must make every effort to query providers if the clinically valid indicators of organ dysfunction due to sepsis are present but the record does not have the documentation interpreting these indicators as to report R65.20 and R65.21 and their associated organ dysfunctions. This effort, however, must be coordinated with the SEP-1 or quality manager, given that any coding of R65.20 or R65.21 subjects the record to the SEP-1.
Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at firstname.lastname@example.org.
by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro
While many providers are still digesting the IPPS Final Rule, muddling through how the OPPS Proposed Rule might impact their bottom line, and kicking rocks because the 2-midnight rule was not chucked, President Obama signed a bill into law on August 6, 2015—and it’s one providers should note. Unanimously approved by both the House and Senate earlier this year, the Notice of Observation Treatment and Implication for Care Eligibility Act, otherwise called the NOTICE Act, will not take effect until August 2016, but will certainly add one more layer to the administrative burden associated with outpatient observation services when it does.
Public Law 114-42 will amend the Social Security Act and require a hospital or critical access hospital (CAH) to provide the beneficiary with a written notice when they receive outpatient observation services for more than 24 hours. The notice must be provided within 36 hours of the start of observation, which would coincide with the order for such service, or prior to discharge or transfer, whichever occurs first after the initial 24 hours has been reached.
Hospitals and CAHs currently provide many “notices” to the patient, including a financial consent, consent to treatment (procedure, anesthesia, blood transfusion, etc.), release of information, Important Message from Medicare (IM), Detailed Notice of Discharge (DND), Advance Beneficiary Notice (ABN), and the Hospital Issued Notice of Noncoverage (HINN)—just to name a few. The regulation clarifies that this notice will not be in “hit and run” form, as it requires hospital staff to provide an oral explanation of the implications of remaining in outpatient status.
As hospitals begin to draft the notice and develop a process for issuing it, they should also consider who will be responsible to eloquently explain the situation to the patient. Key elements of the notice must include a written and oral explanation stating:
- The patient is an outpatient and not an inpatient of the hospital and the reasons why;
- The implications of remaining in outpatient status, primarily the related financial issues including deductible, coinsurance, and items or services not covered by Medicare, such as self-administered drugs; and,
- All time spent as an outpatient, including observation services provided on the inpatient floor, will not count towards the 3-day acute care qualifying stay required for coverage of a subsequent skilled nursing facility (SNF) stay, if appropriate.
The notice must be written in easy-to-understand language and available in “appropriate languages.” This requirement is not further specified in the law, although the IM, DND and ABN notices can only be provided in English or Spanish versions, so more clarification will be needed. At this point in time, it is unclear if CMS will provide standardized language similar to that used to inform the beneficiary and the provider about the financial liability protections under the Fee-for-Service (FFS) Medicare and, in certain cases, the Medicare Advantage (MA) Programs.
The notice must also be signed by the patient or the person acting on behalf of the patient and the hospital staff member who presented the notice. If the patient or his or her authorized representative refuses to sign the notice acknowledging their outpatient status, the hospital must indicate on the refusal on the form and include the name, title, and signature of the staff member issuing the notice, as well as the date and time of the refusal. This procedure is similar to recommendations CMS has provided when a patient refuses to sign an ABN. However, refusing to sign the new notice does not release the beneficiary from any financial obligation.
As hospitals incorporate the new regulation into their current processes, they should also be acutely aware of the 2-midnight benchmark and the implications of keeping patients in outpatient status receiving observation services for more than 24 hours. CMS has stated that they do not expect a Medicare patient receiving medically necessary hospital care to pass a second midnight without an order for inpatient care. Providing the new notice to the patient should not only serve to inform them of their potential financial liability as an outpatient but also to put the hospital and the attending physician on notice regarding the correct application of the 2-midnight rule.
Editor’s Note: This article originally published in HCPro’s Medicare Insider eNewsletter.
By Karen Newhouser, RN, BSN, CCDS, CCS, CCM
Quality. If we had a dollar every time that word is used, we would be wealthy. But money isn’t everything. Just consider the evolution of the CDI profession.
True, the CDI profession was built on a financial platform – it’s how CDI programs got in the door in the early years. Now, the focus in healthcare is quality. Quality is the common theme in many healthcare initiatives. It may seem that quality just surfaced, but it has been on the scene for decades.
Pay-for-performance (P4P) is the umbrella from which all modern-day quality indicators stem since its emergence in the early 2000s—after deficiencies in quality were highlighted on two major reports by the Institute of Medicine, To Err is Human: Building a Safer Health System, in November, 1999, and Crossing the Quality Chasm—A New Health System for the 21st Century, in March, 2001. These reports recommended a sweeping redesign of the health care system to improve quality of care.
In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so will also reduce costs. The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. P4P programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings.
P4P programs can be broken down into both private sector and public sector initiatives. The largest and longest running (2001) is the California’s program. Within the public sector, CMS established a Value-Based Purchasing (VBP) program to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration.
P4P evolved and grew and the Affordable Care Act further encouraged improvements in quality of care while addressing the subject of cost. Due to CMS’ continuous updates in its IPPS proposed and final rules, a few of the P4P programs worth paying attention to include:
- Hospital Value Based Purchasing Program
- Hospital Readmission Reduction Program
- Hospital Acquired Condition (HAC) Reduction Program
As with most quality measures, establishing present on admission (POA) status is crucial. If one looks at POA with a widely general view, if the patient did not come into the hospital with a particular condition, then they acquired it in the hospital. One element to remember is that POA is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure/unable to determine/doesn’t know if the diagnosis was POA. This POA indicator of “W” is considered to be equivalent to an indicator of “Y” and will exempt the condition from being identified as a HAC.
Similarly, a fourth indicator of “U,” or the documentation is insufficient to determine if the condition was present at the time of inpatient admission, is equivalent to an indicator of “N” in a POA determination where a HAC is identified. It is important to note the words “documentation is insufficient…” in the above indicator explanation. These words should be an indication that a query is warranted in an attempt to obtain sufficient documentation to make a POA determination.
The most important point to understand about these initiatives is that they are risk-adjusted. Reporting agencies have their own risk-adjusted methodologies and most are proprietary; it is not necessary to know the methodology. What is relevant is these methodologies use factors such as chronic and co-morbid conditions to determine the degree of risk. The greater the number of, and/or the more significant, the chronic and co-morbid conditions, the higher the risk.
We all realize that the patient entering the hospital today is much sicker than the patient entering the hospital 20 years ago. That is the role of the CDI specialist—to ensure that the record identifies an appropriate principal diagnosis and reflects all significant reportable secondary conditions to match the care delivered and resources consumed.
We are charged with carrying forward the story of the patients’ encounter. We are, in essence, the editors of a non-fiction story. As we move towards a personal health record in our mobile age, it is imperative that we advocate for the patient and appeal for a complete, accurate account of their health status.
Yes, this is the fuss about quality. Our patients are depending on us. We won’t let them down.
And while it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above; however, I leave you with this thought…
Quality doesn’t follow money; money follows quality.
Editor’s note: Newhouser is the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. Contact her at KarenMPU@medpartnershim.com. This article originally appeared in the CDI Horizons newsletter.
Healthcare organizations spent approximately $471 billion on paperwork related to billing and insurance in 2012, with 80% of that potentially wasted, according to the study “Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence,” published in BMC Health Services Research.
Using a standard definition of “billing and insurance-related costs” (BIR), researchers found that physician practices spent approximately $70 billion, hospitals spent roughly $74 billion, and other institutions (e.g., nursing homes, home health care agencies, prescription drug, and medical supply companies) spent approximately $94 billion. Private insurers spent approximately $198 billion on BIR compared to $35 billion spent by government-sponsored health insurance programs.
Adopting a simplified, single-payer insurance system similar to Medicare could save the U.S. approximately $375 billion annually or more than $1 trillion in three years.
Editor’s Note: This article originally published in the HIM-HIPAA Insider.
The legibility of physician documentation continues to be a concern. Even as facilities implement electronic health record systems, many others continue to struggle with paper records, printed attestation sheets, and other hard copy medical record reports. One of the principal concerns of the printed/paper world comes from famously illegible physician handwriting and perhaps most troublesome illegible physician signatures.
CDI professionals still battling this one out with their physicians, do have some supportive tools from CMS.
So when physicians challenge you, and ask “where does it say that my signature has to be legible?” (Let’s hope you never actually have to hear that said out loud, geez!) you can quickly print out these regulations and show them
The last link brings you to a page of related articles at the CMS.gov website. To find these links I simply accessed CMS.gov, clicked the tab for Medicare and then searched for information related to physician legibility.
This is a hot topic as we do not wish to lose reimbursement because we can’t read the handwriting or identify the signature. That is just lost money for no good reason.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the July 2012 edition of the CDI Journal.
by Trey La Charité, MD
We all agree: Better medical record documentation helps the patient, the physician, and the hospital. So why do we have so much trouble getting physicians to implement suggestions made by the CDI staff ? If your facility is anything like mine, provider compliance varies greatly. What always amazes me and our CDI specialists here is which physicians participate and which do not. Let’s look at some reasons why physicians choose not to adopt CDI goals and what remedies we might implement to gain wider acceptance of CDI principles.
First, the inescapable elephant in the room that must be effectively and decisively crushed is money. Unfortunately, the gut reaction of most doctors is that CDI is something that benefits only the hospital through an increased profit margin. While CDI professionals know this is not true, this initial reaction is understandable. After all, from where does the impetus for most CDI programs originate? The chief financial officer’s (CFO) office, of course! And, frequently, the CFO has jumped onto the CDI bandwagon because he or she learned how another facility improved their case-mix index (CMI) by implementing CDI initiatives. Although the CMI is merely a reflection of how sick the patients are in a hospital, to a CFO, a higher CMI simply equals greater revenue.
Unfortunately, this means that your fledgling CDI program may have a public relations problem before it ever gets off the ground.
How do we remedy this problem? Education, education, education! The majority of doctors do not understand the increasing availability of their performance data to the general public, the insurance companies, and our government. Why is this important? Our government (via new Medicare payment rules) has embarked on a strategy of healthcare reform through forced competition between healthcare providers. The theory is that patients will choose the doctors and facilities that have better outcomes and fewer complications at a lower cost.
Additionally, insurance companies and employers will intentionally steer their beneficiaries and employees toward the providers who display these same qualities. The ultimate question becomes whether new patients will want (after reviewing performance data on the Internet) or be able (through reduced copays to see the better providers) to be treated by your physicians in your hospitals. Yes, the probable short-term goal of any new CDI program is increased revenue at the CFO’s behest. The long term goal of all CDI programs is to ensure the flow of new patients through your doors through better performance data.
By Vicki Sullivan Davis, RN
Doesn’t it burn you up when someone says that CDI programs are all about reimbursement? I can feel my face get red when I hear that statement! Of course, I remain composed, smile, and provide politically correct education to the individual. But deep down I have always wanted to say, “You are darn right CDI is about reimbursement! I work hard every day to make sure you and everyone else continue to have a place to work. I make sure our patients have the most updated equipment for imagining, the most advance surgical suites, a bigger emergency department, adequate nurses on the units, food to prepare, patients to see and E/Ms to bill!”
I want to say, “Yes, my job is to help make money for hospital and so is yours!” Every person in this industry needs be concerned with reimbursement; our survival depends on having money to provide resources for our patients! We provide for our futures through cost containment, efficiency monitoring, billing, staffing to volume, charging for supplies, and even decreasing the number of linens stocked in each room. All staff should be concerned with cost containment and revenue growth. CDI specialists are no different! Reimbursement is reimbursement, we just call it different things in different departments. Budgets, staffing, billing levels, supplies, etc.
Without bringing in adequate reimbursement, the hospital would have to close their doors despite anyone’s best efforts to control efficiency and quality. If we are not worried about reimbursement, we would not have the resources to provide services that are important to the community. We would not be able to sit and hold the hand of a dying patient. We would not be able to give out teddy bears to a scared child getting a chemo treatment. We would not be able to provide a warm blanket for a frail, confused, and aging patient. The impact of healthcare reform is so significant that we all must worry about the almighty dollar if we truly care about people.
But just because I say my job has an impact on reimbursement, doesn’t mean that I only focus on reimbursement.
The heart of our program focuses on the patient. As CDI specialists, making sure we capture severity of illness and risk of mortality (SOI/ROM) is essential, and the outcome of capturing SOI/ROM correctly happens to equate to reimbursement. CDI specialists are just charged with finding innovative ways to perpetuate our hospital’s future (for the patient’s sake!) So next time the next someone rants that your CDI program is “all about the money,” be proud he or she took time to notice your program, then smile and hand them a teddy bear.
Editor’s Note: Vicki Sullivan Davis is CDI manager at Cone Health System at Alamance Regional in Burlington, North Carolina, and past-speaker at ACDIS National Conference. Contact her at email@example.com.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the August 2010 edition of the CDI Journal.
By Laura Legg, RHIT, CCS
Some MS-DRGs are more complex and prone to error than others. What can facilities do to identify and manage these MS-DRGs that are prone to error?
- Short stays
- Three-day stays
- Error-prone DRG assignments
- Put PEPPER to proper use
- Tip: Use PEPPER reports to search for CDI targets
- Back to Life: Let SOI/ROM/PEPPER Invigorate Your CDI Program