Revenue Cycle Institute » Coding

Region D RAC approved to audit modifiers -TC and -26

Andrea Kraynak, CPC-A — Tue, 17 Nov 2009 14:12:46 +0000

HealthDataInsights has been approved by CMS to audit for inappropriate billing related to the use of modifiers -TC and -26 on Part B claims in all RAC Region D states. The new issue is as follows: Global vs TC/PC. An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier [...]

Refresh your knowledge of core concepts for coding accuracy

HIM Connection — Tue, 17 Nov 2009 05:00:00 +0000

Clinical knowledge is an essential element for capturing severity and MS-DRG assignment, according to Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM at Kaiser Permanente in Oakland, CA. “When we’re talking about DRG changes and coding changes, it’s important to enhance clinical knowledge,” she said.

Additionally, refresh your knowledge of the following core concepts for coding accuracy:

Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.

“These are great actions to take to ensure accuracy in documentation, case-mix index, and certainly your MS-DRGs,” Bryant said.

Editor’s note: This tip is adapted from the November 2009 issue of Briefings on Coding Compliance Strategies.

Revenue Cycle Institute posts free coding tool

The RAC Report — Thu, 12 Nov 2009 05:00:00 +0000

Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. We hope you find this month’s tool—a chart of the new ICD-9 codes, including E and V codes—helpful in ensuring you’re on top of the code changes for 2010.

Editor’s note: Access the free tool via the Revenue Cycle Institute Web site by clicking on “Tools.” The chart originally appeared in the October issue of Medical Records Briefing.

Prepare for miscellaneous costs that may arise during the transition to ICD-10

HIM Connection — Tue, 10 Nov 2009 05:00:00 +0000

Despite an HIM director’s best efforts to prepare for a smooth transition to ICD-10, there may be unforeseen challenges along the way, says Tori Sullivan, RHIA, MHA, PMP, manager of Capgemini Government Solutions in Reston, VA. Having money in reserve is always a good idea. “Set aside money in case you don’t get reimbursed or can’t process claims for a period after go-live,” she advises. Use your hospital’s highest average daily reimbursement and multiply that amount by five. Set aside this amount for reserve in the event of claims submission errors or denials, she says.

One potential challenge for critical access hospitals is the likelihood that ICD-10 will require an encoder, an extra expenditure for hospitals that don’t have one, says Debbie

Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc., in Marblehead, MA. “[An encoder] will make things so much easier for coders who are trying to work out of books because it will do an automatic crosswalk for them,” she says.

Editor’s note: This tip is adapted from the December 2009 issue of Medical Records Briefing.

Q&A: Charging for behavioral therapy in the home setting

JustCoding News — Wed, 30 Sep 2009 04:00:00 +0000

QUESTION: I have a question regarding behavioral health treatment sessions. Can a physician or licensed therapist (e.g., LPC or LCSW) provide therapy to a client at the client’s home and then charge this service to the insurance company?

ANSWER: The answer depends on the third-party payer. For nonphysician professionals, coders would most often report HCPCS Level II codes. Refer to codes H0001–H2037 (Behavioral health/substance abuse services). Note that codes in this section cover a much wider scope of therapy than the heading implies. Report place of service code 12 (Home). Check with payers to determine whether they accept these codes. Also, note that CPT code 99510 (Home visit for individual, family, or marriage counseling) is used to denote services provided by a nonphysician healthcare professional.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

2009 JustCoding.com Coder Salary Survey

JustCoding News — Wed, 30 Sep 2009 04:00:00 +0000

JustCoding.com is conducting its annual coder salary survey, and we would appreciate your input. Please take a few moments to complete this survey. Only participate in the survey if you are a coding professional. If you are not a coding professional, please forward the survey to one of your coding colleagues. Note that the survey should take less than 5 minutes to complete. We appreciate your time! If the click-through does not work, please cut and paste this URL into the address bar of your browser: www.zoomerang.com/Survey/?p=WEB229JMJLMWKC

Thank you for your time and assistance.

Accurately assign POA indicators with the right info

HIM Connection — Tue, 29 Sep 2009 04:00:00 +0000

The present-on-admission (POA) indicator refers to conditions that are present at the time an order for inpatient admission occurs. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes.

To assign POA, coders must rely on a treating physician’s documentation. Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning a POA indicator:

Look in the history and physical, as well as the ER physician documentation and admitting progress notes and orders. The cut-off point in determining whether the condition was POA is when the admit order was written.
Look for confirming diagnoses. Perhaps the physician documented a sign or symptom on admission, but didn’t render a diagnosis until two or three days later. The physician may have documented a diagnosis as “possible” or “probable,” but didn’t confirm it until later in the progress notes. Only code a diagnosis listed as “possible” or “probable” when the condition is later confirmed or still qualified as uncertain at the time of discharge. Since the diagnosis is based on signs or symptoms that were POA, the coder would assign a “yes” indicator. Note that an uncertain diagnosis would be POA only when that diagnosis had related signs or symptoms that were present at the time of admission. Otherwise, if the signs and symptoms developed after the physician order, the diagnosis is not POA.

This tip was adapted from the HCPro book, The MS-DRG Training Handbook. For ordering information, visit the HCMarketplace.

Q&A: Coding conditions as “acute” versus “chronic”

HIM Connection — Tue, 29 Sep 2009 04:00:00 +0000

Question: A patient came into the ER with complaints of a headache and facial pain. The ER physician gave a final diagnosis of sinusitis. This patient had no history of sinusitis. After a coding review, the reviewer said we were wrong to use “acute” and told us to use “chronic.” She told us never to use “acute” unless the physician documents the condition as “acute.” We were previously under the impression that when coding ER accounts, coders should always report conditions as “acute.” Do you know of any ER coding guidelines or publications that would clear this up?

ANSWER: Coders assign codes based on physician documentation. In order to assign a code for an acute condition, the coder should see clearly that the physician documented it as acute. Many ICD-9-CM codes, like sinusitis, default to a chronic status without further specification by the physician.

Sinusitis (accessory) (nasal) (hyperplastic) (nonpurulent) (purulent) (chronic) 473.9

Coders should not assign codes based on the setting in which the physician provided the services. Patients could present to the ER for care related to a chronic condition as well as an acute condition.

Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS, director of HIM and coding for HCPro, Inc., in Marblehead, MA answered this question in the October issue of Briefings on Coding Compliance Strategies.

Effectively research your ICD-9-CM coding questions

HIM Connection — Tue, 22 Sep 2009 04:00:00 +0000

Follow these steps when researching an ICD-9-CM coding question:

Start with the ICD-9-CM Manual. You can resolve many ICD-9-CM coding questions by carefully studying the ICD-9-CM Manual itself, paying particular attention to typographical conventions and the various notes included throughout the Manual.
Review the official guidelines. The Public Health Service and CMS jointly publish the Official ICD-9-CM Guidelines for Coding and Reporting. The following organizations helped develop and approve these guidelines:
- American Hospital Association (AHA)
- AHIMA
- CMS
- National Center for Health Statistics
Review Coding Clinic. Coding Clinic is a newsletter published by the AHA. Representatives from the four organizations listed above review and approve each issue of Coding Clinic. You can order a subscription or back issues of Coding Clinic from the AHA by calling 800/AHA-2626.

This tip was adapted from the handbook, Coding and You: What Every Healthcare Professional Should Know. For ordering information, visit the HCMarketplace.

Q&A: Medically Unlikely Edits and Once in a Lifetime codes

The RAC Report — Thu, 17 Sep 2009 04:00:00 +0000

Q: Several RACs are looking for once in a lifetime procedure coding errors. Wouldn’t Medically Unlikely Edits (MUE) help prevent a large number of these errors?

A: According to CMS, an MUE is a unit of service edit for a HCPCS/CPT code for services provided by a single provider to a single beneficiary on the same date of service. The ideal MUE is the maximum unit of service reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. Examples include:

Code 23405 (Tenotomy, shoulder area; single tendon) has an MUE of 2
Code 43600 (Biopsy of stomach; by capsule, tube, peroral (one or more specimens) has an MUE of 1
Code 58260 (Vaginal hysterectomy, for uterus 250g or less) has an MUE of 1

(Click here to see CMS’ published list of MUEs. Note: CMS has not published all MUEs.)

A once in a life time code refers to codes for services or procedures generally performed only once during a patient’s lifetime. Examples include code 87902 (Genotype, hepatitis C), code 90989 (Dialysis training, completed course) or code 47600 (Cholecystectomy).

There are several differences, but one major issue relates to the timing. MUEs refer to services unlikely to occur on the same date of service, whereas once in a lifetime codes are unlikely to occur more than, well, once in a lifetime.

So an MUE may catch a once in a lifetime coding error if, for example, a computer glitch causes a provider to rebill all of the claims for a certain date—one of which contained a once in a lifetime code—a second time. However, if a once in a lifetime code is reported for a patient on different dates of service, the MUE would not catch the error.

Note that there are occasions when it may be appropriate to bill a once in a lifetime code on separate days, in which case a modifier should also be used. For example, a physician may begin a procedure but not be able to finish it due to problems with the patient’s blood pressure. The physician may then perform the same once in a lifetime procedure on a different day, in which case it is correct to bill for both procedures. However, modifier -73 or -74 would need to accompany the code for the uncompleted procedure.

Editor’s note: Thanks to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro and Stacey Levitt, RN, MSN, CPC, Director of patient care management at Lenox Hill Hospital, for assistance answering the previous question. To hear more from Kimberly and Stacey on RACs and once in a lifetime procedures, consider attending the "Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status, and the Role of Physician Advisors" in Atlanta October 26-27.

Q&A: Coding acute blood loss anemia due to patient noncompliance

HIM Connection — Tue, 15 Sep 2009 04:00:00 +0000

QUESTION: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood loss anemia with hemorrhage and low hematocrit and hemoglobin caused by Plavix®. A physician had instructed the patient to discontinue this medication 10 days before surgery. However, the patient admits after surgery that he or she stopped taking the drug only two days before surgery.

What ICD-9 code(s) should I report for this scenario? I considered reporting the following:

964.8 (Poisoning by other specified agents affecting blood constituents)
998.11 (Hemorrhage complicating a procedure)
285.1 (Acute posthemorrhagic anemia)
E858.2 (Accidental poisoning by agents primarily affecting blood constituents)
E878.8 (Surgical operation and other surgical procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at the time of operation)
E849.7 (Place of occurrence; hospital)

I was also considering these options:

ICD-9 codes 998.11 and code E934.8 (Other agents affecting blood constituents)
ICD-9 codes 998.11 and 285.1

ANSWER: This is not an adverse reaction because the patient did not follow the instructions for dosage.

Plavix® is the brand name for anticoagulation medication. The generic name is clopidogrel bisulfate. Report code 964.2 (Poisoning by agents primarily affecting blood; anticoagulants) first. ICD-9 code 964.8, which you mentioned, is for blood substitutes and plasma expanders, not anticoagulants such as Plavix®.

In addition to reporting code 964.2, report the following codes:

285.1 (Acute posthemorrhagic anemia)
998.11 (Hemorrhage complicating a procedure)
E858.2 (Accidental poisoning by agents primary affecting blood constituents)
E878.8 (Surgical operations and procedures as the cause of abnormal reaction of patient or of later complication, other)

Be sure to sequence code 964.2 first.

Do not report code E849.7 (Place of occurrence, hospital) because the accidental overdose took place at the patient’s home. This code might imply that the hospital—not the patient—made the dosing error.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question in the August 26 issue of Justcoding.com.

Ensure compliant coding for ARF

HIM Connection — Tue, 08 Sep 2009 04:00:00 +0000

The following ICD-9-CM codes denote acute respiratory failure (ARF):

518.81, ARF
518.82, other pulmonary insufficiency, not elsewhere classified (includes acute respiratory distress, acute respiratory insufficiency, and adult respiratory distress syndrome NEC)
518.84, acute and chronic respiratory failure

Check out Coding Clinic, fourth quarter 1998 and first quarter 2005, for more information about when ARF should be the principal diagnosis, as well as documentation requirements.

The sequencing of respiratory failure depends on the reason for admission. When respiratory failure from an underlying condition causes the inpatient admission, the failure becomes the principal diagnosis; when the patient develops respiratory failure after admission, it is the secondary diagnosis and should be coded as such.

Remember to refer to ER notes for much-needed information that may not appear elsewhere in the chart, says Kathy DeVault, RHIA, CCS, manager of professional resources at the American Health Information Management Association in Chicago.

ARF can be resolved fairly quickly in the ER, so it’s possible that the physician will write it once in the chart and it won’t appear again anywhere in the documentation. That doesn’t mean the physician didn’t diagnose or treat it, she notes.

In general, coders need an awareness of each chart in its entirety, DeVault says, adding that this will help them focus on strong documentation and accurate reimbursement, rather than increased reimbursement.

Editor’s note: This tip was adapted from the August issue of Briefings on Coding Compliance Strategies.

Coding incidental versus ectopic pregnancy

HIM Connection — Tue, 08 Sep 2009 04:00:00 +0000

Q: What does an incidental pregnancy (code V22.2) mean? Is it related at all to an ectopic pregnancy (code 633.11)? Should I report the two together?

A: Coding Clinic, fourth quarter 1996, p. 50–51, states that code V22.2 is a secondary code only for use when the pregnancy is in no way complicating the reason for the visit. Otherwise, coders should report a code from the obstetric chapter.

For routine outpatient prenatal visits when no complications are present, report codes V22.0 (supervision of normal first pregnancy) and V22.1 (supervision of other normal pregnancy) as the first-listed diagnoses. Do not report these codes in conjunction with Chapter 11 codes. For more information, see Chapter 11 (Pregnancy/Childbirth) of the ICD-9-CM Official Guidelines for Coding and Reporting that took effect October 1, 2008.

Editor’s note: Alison Stangeby, RHIA, CCS, CPC, senior consultant at BKD, LLP in Little Rock, AR, answered this question that originally appeared in the August 2009 issue of Briefings on Coding Compliance Strategies.

CMS posts ICD-10 fact sheet

HIM Connection — Tue, 08 Sep 2009 04:00:00 +0000

CMS recently posted a fact sheet regarding ICD-10 that summarizes structural differences between the new system and its predecessor, ICD-9. It also explains how organizations and facilities should plan for the change and provides a list of helpful Web sites.

IPPS 2010 final rule available in Federal Register

Medicare Weekly Update — Tue, 01 Sep 2009 04:00:00 +0000

IPPS final rule published in Federal Register

On August 27, the inpatient prospective payment system (IPPS) final rule for FY 2010 was published in the Federal Register (74 FR 43754). It was previously available as a display copy.

View the IPPS final rule.

CMS announces next Hospital Open Door Forum

Medicare Weekly Update — Tue, 25 Aug 2009 04:08:00 +0000

The next Hospital & Hospital Quality Open Door Forum (HODF) is scheduled for Wednesday, August 26, 2009, at 2 p.m. Eastern. To participate, dial 800/837-1935 and reference conference ID 22153872.

MedicareFind subscribers and free trial users can access transcripts and audio of past HODF conference calls.

Improve documentation with strong CDI specialist, program

HIM Connection — Tue, 11 Aug 2009 04:00:00 +0000

By now, most coders are aware that ICD-10 will usher in expanded codes that will require additional specificity and more detailed documentation. A single diagnosis or procedure code in ICD-9-CM may be expanded to multiple codes in ICD-10-CM or PCS.

More hospitals will likely develop clinical documentation improvement (CDI) programs as ICD-10 takes center stage. Those programs that are already in place will likely need to grow, expand, and mature, says Heather Taillon, RHIA, manager of coding compliance at St. Francis Hospital in Beech Grove, IN, and a board member of HCPro, Inc.’s Association for Clinical Documentation Improvement Specialists (ACDIS). CDI programs will become commonplace, Taillon says, adding that this is something she’s already seeing on a national level.

Editor’s note: For more information about CDI programs and to purchase a copy of this article for $10, visit the HCPro Web site. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the August issue.

Providers may need four years to implement ICD-10

HIM Connection — Tue, 11 Aug 2009 04:00:00 +0000

Industry experts have repeatedly said that ICD-10 implementation must begin immediately for hospitals, health plans, and vendors to meet the October 1, 2013 compliance deadline. But now there is detailed evidence to prove it.North Carolina Healthcare Information and Communications Alliance, Inc., (NCHICA) and The Workgroup for Electronic Data Interchange (WEDI) released a timeline that quantifies each ICD-10 preparation task in terms of the number of days it will take to complete.

On July 20, the NCHICA and WEDI estimate it will take providers nearly 1,286 work days to implement ICD-10. For vendors, it will take nearly 1,521 work days to complete. And the clock is ticking.

"The NCHICA-WEDI timeline shows graphically that the full time from now to October 2013 will be required to successfully meet the compliance deadline. We cannot continue to delay this effort," said Holt Anderson, executive director of NCHICA in a press release.

To read more, click here.

August 3-10 Transmittals and MLN Matters articles: CMS maintains noncoverage of CTC for colorectal cancer and more

Medicare Weekly Update — Tue, 11 Aug 2009 04:00:00 +0000

CMS continues noncoverage of CTC for colorectal cancer

On August 7, CMS issued transmittal R105NCD to implement its decision to maintain noncoverage of computed tomography colonography (CTC) for colorectal cancer.

Effective date: May 12, 2009
Implementation date: September 8, 2009

View the transmittal.

CMS updates travel allowance fees for collection of specimens for CY 2009

On August 7, CMS issued transmittal R1790CP to update the Medicare travel allowance fees for collection of specimens for CY 2009.

Effective date: January 1, 2009
Implementation date: October 5, 2009

View the transmittal.

CMS issues annual update for HPSA bonus payments

On August 7, CMS issued transmittal R1789CP to provide new ZIP codes files for contractors to use when making Health Professional Shortage Area (HPSA) bonus payments.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

CMS revises selection criteria for RAC adjustment crossover claims and fully reimbursable Part B claims

On August 7, CMS issued transmittal R1793CP to modify one aspect of the logic that the Part A shared system uses in marking claims as RAC adjustment claims for crossover purposes. CMS also modified the Common Working File logic used in association with 100% reimbursable Part B claims that contain denied service lines.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

MLN Matters article

CMS released MLN Matters article MM6587, related to a transmittal previously outlined in Medicare Weekly Update.

Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 15.3, Effective October 1, 2009

CMS releases fiscal year 2010 IPPS Final Rule

Andrea Kraynak, CPC-A — Mon, 03 Aug 2009 20:10:45 +0000

Documentation and coding adjustment on hold; hospitals to receive a 2.1% increase in payments By Kristen Kohrt, CPC-A Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and [...]