Distinguish between routine, non-routine nursing supplies

Editor’s note: This tip originally appeared in “Briefings on APCs.”

Not everything kept in stock for nursing floors is a routine item.

Bulk items, such as alcohol preparations, iodine swabs, and gloves, are routine items because nurses use them with every patient. For this reason,—and because these items generally are not noted on patient charts, facilities may not  separately bill for them.

However, other supplies—some of which may even occupy the same shelf in the supply closet—may not be routine items. Non-routine items, such as Foley catheters and IV solutions, are on the shelf for easy access. They are not used for every patient, and they are separately identifiable to specific patients. Consequently,  facilities may bill inpatients for them.

Nursing staff and other hospital personnel keep these non-routine items on hand to ensure they’re readily available when a physician writes an order. This facilitates quick retrieval and eliminates  waiting for items  to arrive from central supply or another department.

Note new guidelines for molecular pathology codes

Editor’s note: This tip originally appeared in “Briefings on APCs.”

Molecular pathology procedures are laboratory procedures that analyze nucleic acid to detect variations in genes that may indicate constitutional disorders or somatic (e.g., neoplasm) conditions. These tests may also be used to test for histocompatibility antigens.

The codes are based on the analyte or the gene-to-gene variant and not on the technology or the methodology used to determine the result.

The CPT^® Manual uses the Human Genome Organization-approved gene names. The code descriptors also include proteins or diseases associated with the genes. For example, code 81228 denotes cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g. Bacterial Artificial Chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis.

When an abbreviation denotes a gene name, the abbreviation appears first in the code description, followed by the complete gene name in parentheses. One example is code 81240, F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant.

Molecular pathology guidelines state that coders should separately report any procedures performed prior to cell lysis, such as microdissection.

Some tests require a physician or other qualified healthcare professional to interpret results. When ­providers only perform the interpretation, coders should append modifier -26 (professional component) to the specific pathology code.

The CPT^® Manual also includes an extensive list of definitions for molecular pathology that can assist coders. Coders will find additional instructional parenthetical notes and cross-references throughout the section.

Differentiate integral, non-integral self-administered drugs

Editor’s note: This tip originally appeared in “Briefings on APCs.”

In 2002, CMS provided specific guidelines for understanding which self-administered drugs are considered integral to a procedure. Transmittal A-02-129, p. 30, states: “Certain drugs are so integral to a treatment or procedure that the treatment or procedure could not be performed without them.” The transmittal provided the following examples of drugs that are integral to  performing a procedure:

• Sedatives administered to patients in the preoperative area being prepared for a procedure
• Mydriatic drops instilled into the eye to dilate the ­pupils, anti-inflammatory drops, antibiotic ointments, and ocular hypotensives  are administered to a patient immediately before, during, or immediately following an ophthalmic procedure
• Barium or low-osmolar contrast media used for diagnostic imaging procedures
• Topical solutions for photodynamic therapy, local ­anesthetics, and antibiotic ointments

Drugs that are not directly related and integral or packaged supplies include the following, according to 67 FR 66767 and Transmittal A-02-129:

• Drugs given to a patient for his or her continued use at home. An example is starting a patient on an oral antibiotic in the ED, and then providing a prescription for continuing doses.
• Drugs related to the procedure or treatment. An example is supplying a patient with aspirin for a headache during  chemotherapy treatment.
• Drugs the patient normally takes at home. An example is a daily supply of insulin or hypertension medication for a patient undergoing outpatient surgery.

Identify potential Medicaid RAC target areas

Editor’s note: This tip originally appeared in “Briefings on Coding Compliance Strategies.”

The Medicaid RAC program kicked off January 1, and experts say that although the program got off to a slow start, activity will likely ramp up in the next few months.

This means that if your hospital hasn’t experienced an audit yet, it probably will soon. As audits get under way, specific target areas will begin to emerge as well.

These Medicare Recovery Audit focus areas could also become potential Medicaid RAC focus areas:

• DRG code validation denials (i.e., RACs allege that the record documentation doesn’t support the coding)
• Medical necessity denials for inpatient settings

Inpatient settings could experience medical necessity denials in the following specific areas:

• Syncope. Many of these cases, in retrospect, turn out to be vasovagal in etiology rather than having a more serious cardiac cause.
• Transient ischemic attack (TIA). TIA by its nature is a self-limited condition, but it may be a precursor to stroke and therefore be of more concern.
• Pain (i.e., abdominal pain and back pain). Auditors frequently question whether outpatient treatment was attempted prior to ­admission. Documentation should reflect the nature and extent of that treatment, he says.
• Short-stay surgery. Laparoscopic procedures (e.g., appendectomies and cholecystectomies) aren’t elective. However, RACs may deny payment if the patient suffers no complications and is treated in fewer than 24 hours. RACs also may target coronary ­artery stent procedures if there are no complications, the ­procedure is ­elective, and the patient is in the ­hospital for ­fewer than 24 hours. They may also target genitourinary procedures, such as nephrolithotripsy.

Respiratory coding guidelines similar in ICD-9-CM, ICD-10-CM

Editor’s note: This tip originally appeared in “Briefings on APCs.”

Coders need to understand the intimate details of the upper and lower respiratory systems to report diseases and conditions of the respiratory system in ICD-9-CM (Chapter 8, codes 460–519).

For patients diagnosed with acute sinusitis, physicians must document which specific sinus is infected or inflamed so that coders can report the correct required fourth digit. Coders working with ear, nose, and throat specialists should focus on the upper tract; those working with pulmonologists should focus on the lower tract.

Diseases of the respiratory system appear in Chapter 10, codes J00–J99. Currently, ICD-10-CM guidelines are the same as those for ICD-9-CM with additional guidance for the proper reporting of ventilator-associated pneumonia.

Consider the big picture before querying physicians

Editor’s note: This tip originally appeared in “Briefings on Coding Compliance Strategies.”

Coders work under the constant stress of needing to determine whether to query physicians for codeable conditions.

When reported, these conditions affect data quality. They may also affect DRG assignment as well as severity of illness and risk of mortality scores. Although ­querying to obtain a patient’s true clinical picture is ­important, ­coders must think about whether patients could conceivably have certain conditions before approaching physicians. Otherwise, they run the risk of frustrating and annoying the individuals from whom they seek information.

Physicians are particularly offended when coders query regarding the significance of a number when the query itself is totally inappropriate. Examples include querying for the significance of a specific body mass index (BMI), patient weight, hemoglobin level, brain ­natriuretic peptide, troponin I, or creatinine level.

Don’t react to abnormal values and ask medical staff inappropriate questions. They’ll either ignore you because they feel insulted or they’ll write what you want (even though the patient doesn’t have it) to get you off their backs. Exercise due diligence. Determine what’s wrong with the patient first. If there’s a valid reason to query, get your ducks in a row before doing so.

Note new edits in I/OCE

Editor’s note: This tip originally appeared in “Briefings on APCs.”

CMS has added two new edits to the Integrated Outpatient Code Editor (I/OCE):

• 84 (Claim lacks required primary code [RTP])
• 85 (Claim lacks required device code or ­required procedure code [RTP])

Edit 84 creates an interesting interplay between two CPT^® codes:

• 33225 (Insertion of pacing electrode, ­cardiac venous system, for left ventricular pacing, at time of ­insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [including upgrade to dual chamber system])
• 33249 (Insertion or repositioning of electrode lead[s], for single or dual chamber pacing cardioverter-­defibrillator and insertion of pulse ­generator)

These codes have Q3 status (codes subject to ­payment as part of a composite), but they are not truly ­composites. Code 33225 is an add-on code, so ­facilities must bill it with the appropriate primary code. If a ­facility bills codes 33225 and 33249 together, CMS will pay only for 33249 and it will package 33225 into the payment. If a facility bills code 33225 with a different primary code, CMS will pay for both.

Edit 85 applies mainly to HCPCS codes C9732 (insertion of ocular telescope prosthesis including removal of crystalline lens) and C1840 (telescopic intraocular lens). Facilities should report these codes together. Billing one without the other will trigger the edit and prevent payment.

The only exceptions occur when the following ­modifiers are appended:

• -52 (Reduced ­services)
• -73 (Procedures discontinued prior to ­anesthesia)
• -74 (Procedures discontinued after anesthesia administration or after the procedure has begun)

Planning can maximize benefits of internal coding audits

Editor’s note: This tip originally appeared in “Briefings on Coding Compliance Strategies.”

If you’re going to spend time and resources to conduct a coding audit, you want to ensure effective and informative results.

Start by defining the purpose and scope of audits. You need to go into the audit with a clear understanding of why you are performing the audit. You also need to audit the same volume of per coder. Volume should be consistently based on the ­average number of discharges at the facility. Approximately 20-30 records per coder per quarter is typical.

Make sure senior leadership buys-in to the audits. Obtaining buy-in from senior leadership is a crucial part of creating an effective audit. This is especially important when audits reveal unfavorable findings related to physician documentation. Chief medical officers must be on board to ensure that all physicians-even those who bring in the most business for the hospital-are held to the same standards with respect to sanctions.

Obtaining buy-in also involves helping senior leadership establish realistic expectations for audits.

Don’t allow dollars to drive an audit. Too many audits are based purely on financial performance. Hospitals should not perform coding audits solely to increase revenue in a particular area. This could raise a red flag for auditors and might not even yield anticipated results. CFOs often incorrectly assume that incorrect coding causes decreased revenue, but the decrease could be due to other factors.

The frequency of coding audits-whether annual, quarterly, monthly, or some other frequency-should be based on associated risk. Conducting random audits at random intervals is not helpful.

Determine what your room rate includes

Editor’s note: This tip originally appeared in “Briefings on APCs.”

Before deciding which ancillary bedside services can be billed separately to inpatients, facilities must understand and define what their room rates include. Generally, the room rate includes:

• Housekeeping and maintenance services
• Electricity
• Water
• Trash and biohazard disposal
• Administrative services

Consider avoiding the term “overhead” because this is a generic word that is open to interpretation.

Facilities must also define their standard nursing services. Consider whether any nurse can provide a particular service within his or her scope of practice.

Other nursing services, such as specialized wound care, fall outside this definition. Specialized wound care is not a service that every nurse may perform, and it is not a service provided to all patients.

Also, determine whether you charge for a service separately to all patients regardless of whether they are inpatients or outpatients. Remember that you must apply charges uniformly to every patient.

Recent CMS transmittals

CMS issues transmittal on quarterly update to CCI edits, version 18.2

On March 29, CMS issued a transmittal containing the normal update to the CCI procedure to procedure edits.

Effective date: July 1, 2012

Implementation date: July 2, 2012

View MLN Matters article MM7802:

http://www.cms.gov/MLNMattersArticles/downloads/MM7802.pdf

CMS issues April 2012 I/OCE specifications version 13.1

On March 9, CMS issued a transmittal that informs FIs, A/B MACs and the FISS that the I/OCE was updated for April 1, 2012. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE which eliminates the need to update, install, and maintain two separate OCE software packages on a quarterly basis.

Effective date: April 1, 2012

Implementation date: April 2, 2012

View transmittal R2423CP:

http://www.cms.gov/transmittals/downloads/R2423CP.pdf

View MLN Matters article MM7751:

http://www.cms.gov/MLNMattersArticles/downloads/MM7751.pdf