Archive for: Coding
CMS releases 2010 OPPS proposed rule
Changes for separately payable drugs, physician supervision
Outpatient facilities and pharmacies hoping to see an increase in reimbursement for separately payable drugs in CMS’ 2010 OPPS proposed rule didn’t get their wish, but they did see additional proposed guidance on physician supervision rules.
CMS also proposes to allow hospitals to bill Medicare for pulmonary and intensive cardiac rehabilitation services.
“My sense when I first looked at the proposed rule this year was that it seemed much shorter,” says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. One reason for that, Shah says, might be because CMS chose not to add any additional composite APCs or additional outpatient quality indicators.
That doesn’t mean CMS is abandoning its commitment to “value-based” purchasing principles, Shah says, but it does seem like CMS is taking some time to assess the impact of its current composite APCs before adding additional ones.
Reimbursement for separately payable drugs Providers and various stakeholders have repeatedly weighed in to CMS over the past four years that charge compression has a huge negative impact on how it computes payment rates for separately payable drugs. CMS acknowledges this as an issue, and in its discussion on how it calculated payment rates for 2010, CMS referred to the pharmacy stakeholders’ proposal.
Although CMS analyzed the pharmacy stakeholders’ proposal, the agency elected not to use that methodology nor did it follow the APC Advisory Panel’s recommendations. Instead, CMS introduced a new calculation method: the result is that CMS’ proposed payment for 2010 for all separately payable drugs of average sales price (ASP) plus 4% came as a total surprise, says Shah.
“The fact that the 2010 proposed payment rates for separately payable drugs remains the same as what we have today, despite the CMS’ new calculation methodology is truly disheartening,” says Shah.
CMS’ new methodology does shift some packaged drug costs to separately payable drugs, but falls quite short of covering what providers would consider their drug acquisition costs and pharmacy overhead/handling costs, says Shah.
Shah cautions that an in-depth reading of the information is required to analyze how CMS arrived at the payment rate.
“To the end user – hospitals paid under OPPS - if the proposed payment rate of ASP plus 4% is made final for 2010, then nothing will look different,” Shah says. She is hopeful that hospitals will weigh in on this and other CMS proposed changes.
“CMS’ proposal is far from what providers have been telling CMS they need for separately payable drug reimbursement to cover both acquisition and pharmacy overhead/handling costs,” Shah says.
Some estimates provided to CMS indicate that adequate coverage of drug acquisition costs and pharmacy overhead would result CMS paying closer to ASP plus 13% for separately payable drugs, Shah says. Alternatively, CMS could reimburse hospitals at ASP plus 6% and provide a separate add-on payment for pharmacy handling/overhead costs similar to what the pharmacy stakeholders group proposed and APC Advisory Panel supported.
“Unfortunately, CMS’ proposal for 2010 is far from what providers have been telling CMS they need for separately payable drug reimbursement to cover both acquisition and pharmacy overhead/handling costs,” Shah says.
Physician supervision and incident to
CMS proposes to allow physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and clinical psychologists to provide supervision of hospital outpatient therapeutic services when their license allows them to do so.
“The fact that they are going to be able to do the supervision is a huge benefit to hospitals,” says Kimberly Anderwood Hoy, Esq., CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA. Under last year’s clarification, hospitals were not be able to bill for services supervised by a nurse practitioner unless a physician was present.
“This really expands the number of people who can provide supervision, and that is really important in rural areas,” Hoy says.
However, Hoy cautions that the change, if finalized, would not go into effect until 2010, so hospitals must still follow the current rules for 2009.
“The fact that we see so much discussion in the 2010 OPPS proposed rule on this topic is a testament to providers and other industry organizations for a raising tough questions with CMS on its physician supervision and incident-to language over the past 12-16 months”, says Shah.
CMS added a discussion of its expectation that the supervising physician or nonphysician practitioner to be able step in and assume providing the service. In addition, the supervising practitioner can’t be occupied with any other procedure he or she can’t leave.
“That begs the question about whether the emergency physician is always appropriate to use to provide supervision,” Hoy says.
CMS did clarify its definition of what “in the hospital” means, which will be very helpful, Hoy says. Under the proposed change, “in the hospital” would mean areas in the main building(s) of the hospital that are under the ownership, financial, and administrative control of the hospital; are operated as part of the hospital; and for which the hospital bills the services furnished under the hospital’s CMS Certification Number.
“There are some very provider-friendly things . . . but those don’t go into effect until 2010,” Hoy says.
Hoy also recommended facilities carefully read the physician supervision requirements for cardiac and pulmonary rehabilitation services.
“There’s a nice opportunity for hospitals to expand those programs because it’s going to be a little easier to operate,” Hoy says.
Additional proposed changes
CMS proposes to evaluate surgically implantable biologicals that are not receiving pass-through payment before January 1, 2010, for pass-through status using the device category pass-through process. CMS has also proposed to increase the separately payable drug packaging threshold to $65 (it is currently $60) and to package 5HT3 antiemetics.
CMS is also considering paying rural providers for kidney disease education services furnished on or after January 1, 2010, to Medicare beneficiaries diagnosed with Stage IV chronic kidney disease.
CMS will accept comments on the proposed rule until August 31, and will respond to comments in a final rule to be issued by November 1.
Q&A: Billing infusion hours when there is an order to admit
Q: A patient in the ED is receiving infusion services. A physician writes an order to admit that patient as an inpatient to the regular floor. However, the patient sits in the ED for three hours waiting for a bed. Should the ED continue to bill for hours of infusion while the patient waits for a bed and as the service is provided, or does time stop when the admit order is written?
A: A patient becomes an inpatient at the time the physician writes an order for inpatient admission, regardless of whether the patient is still located in the ED. For this reason, although ED staff members continue to provide the infusion service for the patient, this service is part of the inpatient care for the patient. Providers should not bill infusion hours as an outpatient service under the outpatient prospective payment system by the ED after the time the inpatient admission order is written.
Editor’s note: Kimberly Anderwood Hoy, JD, CPC, regulatory specialist at HCPro, Inc., answered this question that appeared in the June issue of Briefings on Coding Compliance Strategies.
June 8-15 Issuances: ICD-9-CM documents available
ICD-9-CM October 2009 update available
The fiscal year 2010 ICD-9-CM index to diseases addenda, tabular addenda, and new code conversion table are now available. These are effective October 1, 2009.
View the ICD-9-CM index to diseases addenda.
View the ICD-9-CM tabular addenda.
View the ICD-9-CM new code conversion table.
Frequently asked questions
CMS issued several new/updated frequently asked questions (FAQ) last week.
View a listing of recently updated FAQs.
2010 ICD-9 code updates now available online
On June 3, the National Center for Health Statistics (NCHS) posted its ICD-9-CM index addenda and ICD-9-CM tabular addenda. As part of the 2010 addenda, NCHS has expanded code category 488 to add two new codes:
- 488.0 (Influenza due to identified avian influenza virus)
- 488.1 (Influenza due to identified novel H1N1 influenza virus)
In addition, coders and others can reference an ICD-9-CM code conversion table at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdcnv10.pdf.
On June 10, CMS posted the new, revised, and invalid diagnosis and procedure codes on its Web site.
Each of these changes, many of which pertain to new E codes, will take effect October 1.
May 25-June 1: Transmittals and MLN Matters articles: CMS updates OPPS, NCCI, and more
CMS updates interpretive guidelines for EMTALA
On May 29, CMS issued a transmittal to the State Operations Manual (SOM) in which it updated Appendix V of the SOM to include information previously released via the Survey and Certification Memoranda issued to State Survey Agency Directors from April 22, 2005, through March 6, 2009.
Effective date: May 29, 2009
Implementation date: May 29, 2009
CMS updates MPFS database
On May 29, CMS issued a transmittal to update the Medicare physician fee schedule database for July 2009.
Effective date: January 1, 2009
Implementation date: July 6, 2009
CMS updates OPPS
On May 22, CMS issued two transmittals to the Benefit Policy Manual and the Claims Processing Manual, updating the outpatient prospective payment system (OPPS) for the quarter.
Effective date: January 1, 2009
Implementation date: July 6, 2009
View the transmittal to the Benefit Policy Manual.
View the transmittal to the Claims Processing Manual.
View a related MLN Matters article.
CMS updates IPF PPS for RY 2010
On May 22, CMS issued a transmittal updating the inpatient psychiatric facilities prospective payment system (IPF PPS) for rate year (RY) 2010.
Effective date: January 1, 2009
Implementation date: July 6, 2009
CMS issues quarterly NCCI update transmittal
On May 22, CMS issued a transmittal to update the NCCI edits for the quarter.
Effective date: January 1, 2009
Implementation date: July 6, 2009
View a related MLN Matters article.
Master wound care coding to prepare for RAC audits
Coders should arm themselves with as much wound care and coding knowledge as possible to prepare for anticipated RAC audits, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco.
That means understanding the clinical difference between excisional and nonexcisional debridement, knowing what documentation is required to support each procedure, and proactively educating physicians and other staff members who perform these procedures about what they need to document in the medical record.
Bryant also offered a few suggestions on how to prepare for the RACs that may target this area of coding:
- Reviewing all Coding Clinic guidance dating back to the 1980s. Guidance regarding wound care coding has changed many times since Coding Clinic offered initial advice in 1988. Since then, it has published nine more clarifications. The most recent guidance came in Coding Clinic, in the third and fourth quarters of 2008.
- Implement standardized processes for documenting debridement. Pay particular attention to excisional debridement, as it typically falls under a higher-paying MS-DRG. During the demonstration project, the RACs focused on insufficient terminology in documentation.
- Track debridement cases at your facility. Especially focus on cases for which coders assign ICD-9 procedure code 86.22. Bryant said she started doing this in a homegrown spreadsheet within her system and continues to use coding compliance software to track this procedure information.
- Audit a random sample of patients coded with 86.22. Look for coding errors and fix any inaccurate claims. However, don’t change documentation in a medical record to prove excisional debridement, Bryant said. During a CMS RAC Open Door Forum in 2008, Bryant asked for clarification about how far back hospitals can change medical records. CMS responded that hospitals may amend documentation “in a timely manner,” but did not provide more information. Bryant urged caution here.
- Suggest the need for a standardized appeal letter. If the RAC claims that documentation in a medical record does not support ICD-9-CM procedure code 86.22, but you believe it does, “go back, look at the policy, look at the documentation, and appeal that case,” Bryant said.
Editor’s note: This tip was excerpted from the article “Understand inpatient wound care coding for RAC audits,” published in the May issue of Briefings on Coding Compliance Strategies. For more information on the audio conference, “ICD-9-CM Procedural Coding for Wound Care and Debridement: Confront Compliance and RAC Challenges,” visit HCMarketplace.
New modifiers for outpatient never events; billing for hospital acquired conditions
By Kimberly Hoy, regulatory specialist for HCPro
This week, CMS published the July Integrated Outpatient Code Editor (I/OCE). Although there were relatively few changes, CMS did introduce three new modifiers for use with the occurrence of three never events identified by the National Quality Forum (NQF) that were recently the subject of National Coverage Analyses by CMS. The new modifiers are: PA for surgical or invasive procedure on the wrong body part, PB for surgical or invasive procedure on the wrong patient, and PC for wrong surgery or invasive procedure on patient. The modifiers were added to the list of valid modifiers effective January 1, 2009.
As many of you are aware, earlier this year CMS published three national coverage decision memos related to the never events of wrong patient, wrong body part and wrong procedure surgeries and invasive procedures. The decision memos, not surprisingly, detailed Medicare’s non-coverage of these procedures. This distinguishes them from the Hospital Acquired Conditions (HACs) in the inpatient environment, which remain covered even though they are excluded for DRG assignment purposes.
This is an important distinction. For wrong patient, wrong body part, wrong procedure surgeries, the services are not covered and therefore either not billed to Medicare or billed as non-covered with the appropriate modifier if circumstances dictate (i.e. the need for a denial). However, because services related to HACs continue to be covered, these services are billed as covered services on the inpatient claim. The CMS explained this policy in the FY2008 IPPS Final Rule (see 72 Federal Register page 47201). In that same section, they also go on to clarify that the HAC provisions do not affect outliers and therefore any charges related to HACs could potentially push a hospital over the outlier payment threshold.
This is a shock to many providers who assumed that the HACs were non-covered conditions because of CMS’ statements about not paying for hospital errors that resulted in conditions acquired at the hospital but that could have reasonably been prevented. However, as CMS points out, the provision of the Deficit Reduction Act requiring adoption of the HACs only requires that the DRG assignment not be higher because of the HAC, but does not make the services related to the HAC non-covered.
Additionally, this highlights the difference between CMS’ list of HACs, which they deem to be “reasonably preventable” but not always avoidable and the NQF’s never events which should not occur if proper practices are adopted. While some never events are on the HAC list, such as blood incompatibility or objects left during surgery, the two lists are very different. The HAC list contains conditions such as infections and pressure ulcers that may develop despite best practice, due to some compromise in the patient’s system. Nevertheless, CMS considers them reasonably preventable in most cases and therefore has designated them on the HAC list.
For more information on the difference between the NQF’s never event list and CMS’ HAC list provider may wish to review a Fact Sheet CMS published in 2008. While some of the specific conditions have been updated since then, the basic distinctions described there remain the same. Additionally hospital may wish to review the NCAs for wrong body part procedures, wrong patient procedures, and wrong procedure on patient.
Construct and maintain a hospital-specific coding manual
Every hospital should develop and maintain its own internal coding manual. It’s an essential tool to ensure good coding quality and compliance. Although your department must have all the official manuals (i.e., the CPT Manual, the ICD-9-CM Manual, and the HCPCS Manual), an internal coding manual provides much more information, including the following:
-
Reference guide for coders
- Backup in case of a compliance audit
- Source for policies and procedures
- External/internal audit information
- Definitions of coding terminology
The following is a checklist you can use as a guide to help develop your own coding manual:
- Coding scope of service and ethical standards
- Coding protocols (use of coding manuals, encoder, and medical record as the source document)
- Coding accuracy
- AHIMA’s standard of ethical coding
- Definitions of coding terms
- Coding classification systems
- Use of outside consultants
- Orientation checklist
- System-wide corporate compliance
- Rebill policy
- Job descriptions
- Other policies
- Tips for the medical staff
- Resources
Editor’s note: This article was adapted from HCPro’s book, The HIM Director’s Handbook, by Jean S. Clark, RHIA. For more information, visit the HCPro Web site.
