Recently, there’s been talk that medical necessity is the “first issue to emerge in ICD-10.” This has sparked both questions and concerns, specifically in regards to whether or not CMS’s ICD-10 guidance about not auditing or counting errors for the specificity of an ICD-10-CM code. CMS is not going to count the code as an error as long as the first three digits are correct. Many have asked if this guidance applies to medical necessity.
Here’s the deal. CMS did issue guidance that stated it will not deny or audit claims based on the specificity of diagnosis codes (fourth through seventh characters), as long as the codes on these claims are from the correct “family of codes.” However, this applies only to physician and practitioner claims that are billed under the Part B physician fee schedule for the first 12 months after implementation only. Further, this guidance does not apply to facility providers.
CDI specialists must note that CMS never said it wouldn’t deny or audit claims for medical necessity.
The need to specify medical necessity, as defined by National Coverage Determinations and Local Coverage Determinations, is not changed by the guidance, says Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, in a recent Q&A with APCs Insider. If there is a specific code required to support medical necessity, then all characters of the code must be accurate to meet medical necessity. This overrides the family code guidance, says Williams.
This means that CDI staff need to work especially hard to make sure documentation is as specific as possible, and clearly supports why the patient required the treatment they received. With specific, detailed documentation, coders will be able to report the most specific code. The new code set does not give anyone a free pass when it comes to capturing the most accurate clinical picture possible. Medical necessity matters, period.
For more information, check out CMS’ FAQs related to the guidance.
Editor’s Note: This post was compiled using a variety of ACDIS and HCPro resources. For more information, check out:
Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at an article from the April 2014 CDI Journal, “Watch for these ICD-10 coding and documentation traps,” by Robert S. Gold, MD.
Let’s take a look at cardiomyopathy, another subject that has disturbed me when it comes to advice on how to assign the various ICD-9 codes in the 425 series. All of the listed conditions are causes of diseases of the heart muscle or codes that are assigned for cardiomyopathy of other specified diseases with 425.8—and I think that’s a good thing. Even though advice on when to assign 425.4 has been horribly wrong, at least the code set did what it was supposed to do—allow the physician to define the case of the patient’s sick heart, regardless of whether there was heart failure.
With ICD-10, unfortunately we go back to the dark ages. Now we have two codes that describe what the heart looks like and provide no indication as to the cause of the patient’s sick heart muscle—and that’s just plain wrong.
In ICD-9, we had 425.4 and 425.9, which addressed that the physician, in fact, didn’t know which primary or secondary cardiomyopathy a patient had. The rest of the codes were all specific causes or were tied to specific causes.
Now, with I42.0 dilated cardiomyopathy, we seem to be happy that the patient has a dilated heart from whatever the cause, and there’s no need to question the physician as to what the cause was because we have a code that looks like it’s a specific disease—but it isn’t specific. Conditions that can lead to dilated hearts include the following:
- Ischemic heart disease (now I25.5)
- Peripartum cardiomyopathy (now O90.3)
- Cardiomyopathy due to coxsackie viral myocarditis, that happens in children (now B33.24)
- Toxicity from chemotherapeutic drugs (now included in I42.7)
- Alcoholic cardiomyopathy (now I42.6)
- Cocaine use (also I42.7 as a toxin)
- Takotsubo syndrome, stress cardiomyopathy (now I51.81)
With so many possible choices, so long as we get I42.0, you might ask: Who cares? Well, the data cares. The patient cares. Work with your physicians to get these conditions clarified.
As ICD-10-CM/PCS implementation takes place, CDI teams will need to work to obtain ever more specificity to capture the clinical picture of the patient’s treatment. Type, treatment, and causative organism for the pneumonia. Linking language such as “sepsis due to Foley catheter and urinary infection.” Laterality.
The good news for CDI specialists is that although the code set may be new, the concept of querying for greater specificity is not. All CDI specialists need to worry about is to keep doing the amazing work you do. If you need additional go-live advice, we’ve got it for you throughout the latest edition of CDI Journal.
If you haven’t seen the Sept./Oct. edition here’s a look at some of the articles you’ll find inside:
- Implementation Advice: Picking last-minute ICD-10-CM/PCS priorities
- Last-minute ICD-10 training tips for documentation
- Ask ACDIS: Non-treating physician responses to queries
- In the News: CCDS certification set to receive an ICD-10 update
- Meet a member: Foreign Medical Grad finds CDI home in California
- Ask ACDIS: Escalation policies and clinical validation queries
- Clinically Speaking: Adding venous thromboembolism to the CDI checklist
- Coding Clinic for CDI: Defining root operations
- Outpatient Efforts: One system’s efforts to address physician practice documentation improvement needs
And we want to hear your go-live journey stories and tales of how your documentation improvement efforts helped improve patient care. Email them to me at firstname.lastname@example.org.
Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Would you please clarify the correct ICD-10-PCS code for a second degree obstetrical (perineum) laceration that includes muscle?
A: This is a challenging area of ICD-10-PCS coding. Repair of obstetric lacerations documentation can often lead to miscoding, so we need to clearly document perineal lacerations and related treatments.
There is conflicting guidance online regarding this procedure, but the Coding Clinic, Fourth Quarter 2013, p. 120 does provide a definitive example to clarify appropriate code assignment. It discusses the case of a 25-year-old patient who had a normal spontaneous vaginal delivery at 39 weeks gestation and suffered a second degree perineum laceration. The repair involved suturing of the muscle.
In this instance, Coding Clinic says to assign code 0KQM0ZZ, repair perineum muscle, open approach. In ICD-10-PCS, an “open” approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. In this case, “open approach” is assigned because the laceration has cut through the external body layers, exposing the muscle (i.e. site of the procedure).
Although the laceration occurred spontaneously, it is nevertheless the means by which the procedure site is exposed. The same principle would apply for a laceration repair caused by other means, such as a knife wound that lacerates the liver.
Editor’s Note: Mark Morsch, MS, AHIMA-Approved ICD-10-CM/PCS Trainer, vice president of technology for Optum360, and Tom Darr, MD, chief medical officer for Optum360, answered this question. To access their free webcast, “Beyond the Planning: Post-Implementation Strategies for CDI and ICD-10,” presented by Optum360 and hosted by ACDIS, click here.
A couple of weeks ago, CMS and the American Medical Association (AMA) released a series of questions and answers regarding the July 6, 2015 joint announcement on ICD-10-CM/PCS implementation flexibilities. CMS answered 13 questions that a lot of CDI specialists and coders had been asking.
For the first year of ICD-10 use, CMS will not deny or audit physician claims based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family of codes. What is family of codes, you ask? According to CMS, a “family of codes” means any code from the same ICD-10 three-character category.
Here’s an example: Take category H25 (age-related cataract): this category, according to CMS, is a family. The family contains a number of specific codes that capture information on the type of cataracts, as well as information on the eye involved.
If a coder were to report H25.9 (Unspecified age-related cataract) when the patient really suffered H25.031 (Anterior subcapsular polar age-related cataract, right eye), CMS would not audit or deny this claim because a valid code was reported within the correct family.
What does this mean for CDI? Well, for one, CMS never said it wouldn’t deny claims for medical necessity. Additionally, this “deal” with the AMA only pertains to private physician practice, not hospital claims. This means CDI needs to work especially hard to make sure the documentation is as specific as possible, and clearly supports why the patient required the treatment they received. Some things you can do to ensure specific and accurate documentation include:
- Make sure the documentation includes all conditions that were clinically evaluated, that were therapeutically treated, that were studied, that extended the length of stay, or that increased nursing care or monitoring.
- Ask questions and query—if something isn’t clear to you, or if you think it can be documented to a higher specificity, do not hesitate to get a second opinion from a CDI or coding peer, and/or query the physician.
- Try to review every piece of the record, including, but not limited to, physician assessments and orders, ER nursing assessments, EMT records, history and physical, other physician orders, nursing admission assessments, consulting physician documentation, operation reports, diagnostic testing, ancillary staff reports, and progress notes.
- Confirm the principal and any secondary diagnoses, symptoms relating to these diagnoses, surgeries or treatments, and any change in care level.
- Take the time to verify the correct code assignment/sequencing and clinical indicators.
With specific, detailed documentation, coders will be able to report the most specific code. While this may seem basic, these tips could help your facility defend against denials, which are still very possible even if the code is within the correct family.
Editor’s Note: This post was compiled using a variety of ACDIS and HCPro resources. For more information, check out:
- The Clinical Documentation Improvement Specialist’s Guide to ICD-10
- The Clinical Documentation Improvement Specialist’s Complete Training Guide
- family,” originally published on the JustCoding ICD-10 Trainer blog
- “CMS clarifies ’family of codes,’” originally published in CDI Strategies
The location of a character has meaning as well as the value of the character. Some codes require a character in the 7th position that provides additional information, such as the episode of care. A 7th character is typically used with injuries—most fractures will require a 7th character to define the episode of care—and pregnancies.
The most common 7th characters are as follows:
A – Initial encounter
D – Subsequent encounter
S – Sequelae, treatment for condition that arises as a direct result of the acute illness or injury
Not only are codes that require a 7th character invalid without it, but the 7th character can be found only by using the tabular list, since the possible value of the 7th character can vary with the type of code.
Placeholder use [more]
Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we took a look at an ICD-10 article from our April 2014 CDI Journal, “Watch for these ICD-10 coding and documentation traps.” by Robert S. Gold, MD. Contact him at DCBAInc@cs.com.
“Hypostatic pneumonia” represents one of these problem areas. I have written about it previously in other publications. The code for this condition was developed to describe an expired patient found lying in one position for weeks or months, often severely malnourished and with no protein stores to hold fluid in the bloodstream. Frequently these patients’ lungs have turned to the consistency of liver (called hepatization of the lungs) due to settling of fluid in the dependent portions of the lungs.
In ICD-9, the code for this condition was found under pulmonary edema, or congestion of the lungs, as the lungs became severely congested with blood and debris. This led coders to group the diagnosis along with pulmonary edema and respiratory failure. Some consultants taught this as the right code to assign when there was documentation of “pulmonary congestion.” [more]
An experienced CDI specialist should have an average daily census of 12-15 new patients and five to 10 established/follow-up cases. A good rule of thumb is one CDI specialist for every 1,200-1,500 discharges per year. The more functions a CDI specialist is expected to perform, the higher the staff ratio should be. Smaller CDI staff should focus on condition clarification only. However, many CDI programs are understaffed—some only employ one CDI specialist. Such staffing will become even more problematic once ICD-10 implementation begins.
Reviews are going to take more time and require more resources. While CDI staff ratios and productivity expectations depend on the program’s mission, CDI programs need to evaluate whether or not their program’s focus is realistic for their staff size. More importantly, they must start considering whether or not they need to bring on additional staff to bridge those anticipated productivity gaps.
Most programs query to identify incomplete, vague [more]
Those following the episodic turns of the ICD-10-CM/PCS implementation saga witnessed another dramatic plot twist in the narrative this week when the American Medical Association (AMA) and CMS made a joint announcement essentially prioritizing physician ICD-10 education and allowing some flexibility in claims auditing and quality reporting.
“ICD-10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD, in a joint statement with CMS Monday morning, July 6.
Stack’s statement not only marks a sea change in opinion from the AMA. Yet those hoping the agreement might also resolve years of debate and back-room political attempts to delay ICD-10 implementation may just have to keep on hoping until the actual implementation date comes to pass. Last week (July 10) Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-N.C., introduced H.R. 3018, the Code-FLEX Act, to allow submission of ICD-9-CM and ICD-10-CM codes for 180 days after implementation.
W. Jeff Terry, MD, a Mobile, Alabama, urologist, sounded off on the problems of ICD-10-CM/PCS implementation in a HealthLeaders Media article, “AMA Delegate Blasts ICD-10 Implementation Requirements,” on Friday, July 1. And previous AMA leaders described ICD-10-CM/PCS’ detriments in Star Wars terms, Healthcare IT News pointed out this week, recalling that past-AMA President Robert Wah, MD, indicated the group wanted to essentially freeze the code set in carbonite.
Despite the new Code-FLEX Act proposal, the AMA and CMS seem to be moving forward with ICD-10 education. Although the details of their agreement seem simple enough, many news headlines seems to state that CMS gave physician practices permission to code incorrectly. When actually, CMS for its part said Medicare review contractors “will not deny physician… claims …based solely on the specificity of the ICD-10 diagnosis code as long as the physician used a valid code from the right family.” (Emphasis added.)
The problem comes, as Michelle Leppert points out in an an article on the ICD-10 Trainer Blog, that CMS does not define a family of codes. Is it a category of codes, such as 500, superficial injury of head? “That could be interesting,” Leppert writes, since the category includes nine subcategories which each also have further subsections.
While those entrenched in ICD-10-CM/PCS drama may say that these concessions read more like snip-its from the Official Guidelines for Coding and Reporting, getting the AMA to effectively bury its opposition is, for once, a welcome shift in the ICD-10-CM/PCS implementation storyline.
Editor’s Note: Portions of this article originally published in eNewsletter CDI Strategies. Subscribe now, for free.
By Michelle A. Leppert, CPC
Ah, the Fourth of July, picnics, parades, and pryotechnics. What could be better? Well, not having your family and friends end up at Fix ‘Em Up Clinic the next day would be a good start. Alas, holidays here in Anytown never go off without a hitch, so let’s see who has wandered in with a holiday malady.
Doug was running around with a lit sparkler and one of the sparks flew into his eye. So what kind of injury does Doug have? If the little metal shaving from the sparkler is still in his eye, he may have a foreign body in the cornea (T15.0-) or a foreign body in the conjunctival sac (T15.1-). Alternately, he could have a corneal abrasion without a foreign body (S05.0-).
The code we choose will ultimately depend on the physician’s documentation [more]