HCPro.com - Briefings on APCs

Injections and infusions continue to confuse coders

Fri, 01 Jun 2012 04:00:00 GMT

Injections and infusions continue to confuse coders

Consider this scenario: A physician orders three hours of hydration as well as a one-hour therapeutic antibiotic infusion for a patient. A nurse documents the hydration start time as 10 a.m. and the antibiotic start time as 11 a.m. Neither provider documents a stop time. What should coders report?

Without stop times, coders can't report much. An absence of start and stop times is one of the more frequent challenges that coders face when reporting injections and infusions, says Denise Williams, RN, CPC-H, vice president of revenue integrity services for Health Revenue Assurance Associates, Inc., in Plantation, Fla.

"Because CPT^® guidelines define infusions based on the amount of time involved, without specific time frame documentation for infusions, it is difficult to determine whether to report the infusion as an infusion or an IV push," Williams says.

If a provider documents giving a drug as an IV, the provider must also specify whether it is a push or document the start and stop time frame. Otherwise, the coder has no clear documentation regarding the administration.

Coders can't code from the physician order alone-they must also verify whether the service was performed at all, and if so, whether it was performed in its entirety, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C. This means that without documentation of stop times, coders can't assume the infusions took place or that they ran for a certain length of time.

In the scenario above, even though the physician ordered three hours of hydration and a one-hour therapeutic infusion, coders can't code the services at all because no stop time is documented.

Review the hierarchy

CPT guidelines include a hierarchy for coding injections and infusions. If coders aren't familiar with it or don't follow it, they can inadvertently end up either overcoding or undercoding the services, says Shah.

"What we find most often in situations where someone is struggling with reporting these services is that they don't have a solid understanding of the hierarchy and may not be aware of their FI/MAC's specific instructions on reporting drug administration services," Williams says.

Chemotherapy services are primary and should be selected as initial when provided in conjunction with therapeutic, prophylactic, or diagnostic services, says Shah. Remember, the hierarchy applies to all IV injection and infusion services, so in most cases, all of these would be selected as the initial service before hydration if hydration is provided during the same encounter as another IV injection or infusion service with the exception of two separate IV sites. Coders also need to remember that the order of the service delivery does not determine what's initial. Even if a patient receives hydration first, followed by a therapeutic infusion, and then finally chemotherapy, the chemotherapy would be reported as the initial service according to the hierarchy.

"If you refer back to the hierarchy," Shah says, "you'll never go wrong and will see why it's okay to report a service that was given last in the day as the initial service compared to the first thing that was done in that visit."

The hierarchy does not apply to physician reporting, nor does it apply to subcutaneous or intramuscular injections, Shah says.

Selecting the initial service

Typically, coders will only report one initial service per visit, unless the patient has more than one access site, Shah says. So if a patient receives hydration with IV pushes, with therapeutic infusions, or with chemotherapy, hydration can be reported but not as an initial service unless a separate IV line was started for it. Also remember that hydration that occurs concurrently with another infusion service cannot be reported per CPT rules. Typically hydration is only reported as an initial service when it's provided with no other drug administration services, or when it's provided with non-intravenous injection and infusion drug administration services.

Each category of IV infusion and injection codes designates one code as the initial service.

Coders should remember that the order of the service delivery doesn't determine what's considered the initial vs. subsequent services. If a patient receives hydration and then a therapeutic infusion followed by chemotherapy, coders should always report the chemotherapy first, Shah says.

Typically, coders only report one initial service per visit, unless the patient has more than one access site, Shah adds.

Coding subsequent and sequential infusions

The codes for subsequent and sequential infusions are add-on codes. Think of these infusions as one after another or an infusion that comes before or after the initial drug, Shah says.

Sequential infusions denote the administration of a new drug or substance. Coders can report these codes once per encounter for the same infusate, Shah says.

Coders can report sequential infusion codes for additional different drugs that are given. But if the same drug is given multiple times, then the additional hours code associated with the sequential therapeutic infusion, 96366, must be used. Keep in mind that the additional hours code 96366 is now used to report multiple things, including the following:

Additional hours of the initial service infusion
Additional hours of a sequential infusion, which means additional hours of an infusion of a new drug
Additional infusions of the same substance or drug

Coders can report 96366 (intravenous infusion, therapy, prophylaxis, or diagnosis; each additional hour) for additional hours of the initial infusion. For a sequential infusion of a new drug, coders should report 96367 (intravenous infusion, therapy, prophylaxis, or diagnosis; additional sequential infusion, [list separately in addition to code for primary procedure] up to 1 hour).

Consider this scenario: A patient receives antibiotic A for three hours. Coders should report a code for the initial hour, followed by 96366x2 for the remaining additional two hours, Shah says.

However, a different patient might receive two different drugs (antibiotic A and antibiotic B) during the same visit. In this case, coders should report the initial infusion for antibiotic A with 96365 and use 96366 for any additional hours of that infusion. For antibiotic B, coders would use 96367, and if this second infusion ran for two hours, then the additional hours of this sequential infusion would be picked up with 96366 as well. But if the physician ordered three separate one-hour infusions of antibiotic A, and the provider gave and documented them with separate start and stop times, then 96365 would be used to report the first and 96366 for the second and third infusions of the same drug.

Coders can report codes that include subsequent/sequential in their descriptions even if those codes are the first service in a group of services (e.g., first IV push subsequent to an initial one-hour infusion reported using the subsequent IV push code), Shah says.

"This is where we were saying the order doesn't matter. You have to follow the hierarchy," she says.

Reporting concurrent infusions

Unlike subsequent infusions that run after an initial infusion, concurrent infusions run at the same time as another infusion. Codes for concurrent infusions are add-on codes that denote multiple infusions running simultaneously through the same line, Shah says.

CPT doesn't include a code for concurrent administration of chemotherapy. If a patient receives concurrent chemotherapy infusions, coders should report the unlisted chemotherapy administration code 96549.

Substances mixed together in one bag are considered one infusion-not concurrent, Shah says. In addition, CPT doesn't include concurrent codes for hydration, and facilities don't receive separate payment for concurrent hydration.

Coders can assign the concurrent code when a patient receives chemotherapy and a therapeutic infusion simultaneously into the same line. They can also report it when the patient is receiving two different non-chemotherapy drugs, Shah says.

Deciding what to code

Coders can create a decision tree to help them determine what services to code and the order in which to report those services.

Start by determining whether the patient received any chemotherapy infusions during the visit. If yes, code the chemotherapy first.

Second, look at the route of administration. Is it IV infusion, IV injection, subcutaneous/intramuscular, or a combination? This is important because it also drives selection of codes, Shah says.

Next, determine the duration of each infusion. Was it fewer than 15 minutes, more than 15 minutes, one hour, or more than one hour? Time is critical for being able to code infusion services correctly, Shah says. "How can we ever get to additional hours if we don't know how long the service took? So this is very important in terms of time and time documentation."

Improving injection and infusion coding

Coders should reread the instructions in the CPT Manual each year, Williams says. Although CPT did not change the codes for injection and infusion services in 2012, it did significantly revise some of the guidelines.

The most significant changes occur in the instructions and parenthetical notes associated with the codes. CPT added new language regarding 96366 (intravenous infusion, for therapy, prophylaxis or diagnosis; each additional hour), which instructs coders to use this code for "each second and subsequent infusions of the same drug/substance."

"The positive part of this is that it works in tandem with the updated definition for CPT code 96367, which now specifies sequential infusion of a new drug," Williams says.

The introductory instructions also better define how to report a scenario in which a drug is given as a push injection and also as an infusion. The instructions now specifically state that both can be reported. Coders should report the infusion with the appropriate time-based code (infusion vs. push) and CPT code 96376 for the IV push (subsequent push of the same drug). "There were many iterations and opinions on how this should be reported in the past, so to have specific instructions is helpful," Williams says.

In addition, coders should read the OPPS update transmittals to determine whether CMS has changed any guidance. It is always a good idea to revisit this subject with everyone involved in providing/documenting the services so they understand what has changed, Williams says. "Knowledge and understanding is the key to documenting, coding, billing, and reporting services correctly to ensure and maintain revenue integrity."

Improving the documentation of start and stop times should not be an adversarial process, Williams says. Opening the lines of communication across departments ensures that everyone understands why accurate and complete documentation is a necessity.

"It is about complete and accurate documentation to reflect the details of the services provided," says Williams. "Complete and accurate documentation also has a quality of care impact that sometimes gets lost in the 'document it so I can bill it' discussion."

ICD-10 anatomy refresher: Get to know the skull

Fri, 01 Jun 2012 04:00:00 GMT

ICD-10 anatomy refresher: Get to know the skull

Editor’s note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month’s column addresses the anatomy of the skull.

Most coders know that the human body contains 206 bones, but what they may not realize is that more than 20 of them are in the cranium.

The skull is composed of the cranium and the mandible, which is better known as the jaw. The skull houses and protects the brain, eyes, ears, nose, and mouth, and it provides an attachment point for the muscles of the head and neck.

Physicians don't always specify which bone is fractured or which lobe of the brain is involved in an injury or illness. Coders can use their knowledge of the anatomy of the skull to determine where the physician is performing a procedure or where a patient suffered an injury.

Knowledge of the skull's anatomy will be even more important once coders begin using ICD-10-CM/PCS.

Bones of the skull

The bones of the cranium meet along joints called sutures. As a person ages, the sutures gradually fuse together. Let's look at the specific bones of the cranium.

These eight bones make up the skull itself:

Frontal bone: This bone comprises the forehead (squama frontalis) and the upper orbit of the eye (pars orbitalis). It joins the parietal bones at the coronal suture.
Two temporal bones: These bones are located at the sides and base of the skull, and they are the hardest bones in the body. Each one includes the ears, which comprise the auditory ossicles-the three smallest bones in the body.
Two parietal bones: These bones form most of the roof and sides of the skull. Each parietal bone consists of four borders (sagittal, squamous, frontal, and occipital) and four angles (frontal, sphenodial, occipital, and mastoid).
Ethmoid bone: This bone is located at the top of the nose and in between the two eye sockets. It differs from the other bones in the cranium because it's spongy instead of hard. It divides the nasal cavity from the brain.
The sphenoid bone: This bone is located behind the eyes at the base of the skull. Because of its shape, the sphenoid bone touches all the other cranial bones. It is divided into six portions: the body of the bone, two greater wings, two lesser wings, and the pterygoid processes.
Occipital bone: This bone forms the lower part of the back of the skull and the base of the cranium. The spinal cord exits the brain through a large oval hole, called the foramen magnum, in the occipital bone.

The face includes the following 14 bones:

Two inferior nasal conchae: These are two paired bones, each of which is individually known as a nasal concha or turbinate bone. The nasal conchae consist of the medial and lateral surfaces and the upper and inferior borders.
Two lacrimal bones: These bones are located in the middle wall of each eye socket between the ethmoid bone and the maxilla. Tears drain from the eye through a groove in the lacrimal bone and into the nasolacrimal duct.
Mandible: This bone forms the lower jaw. It is divided into the body, the two rami, the alveolar process, the condyle, and the coronoid process. The inferior alveolar nerve runs through the mandibular foramen (opening) and provides sensation to the teeth. The mandible is formed in two pieces that fuse together during early infancy.
Two maxillae: These bones are located above the mandible and below the orbits. The maxilla is divided into the body, the zygomatic process, the frontal process, the alveolar process, the palatine process, the infraorbital foramen, and the maxillary sinus. The alveolar process, known as the maxillary arch, holds the upper teeth in place.
Two nasal bones: These bones are located near the middle of the face and come together to form the bridge of the nose. Each nasal bone consists of an inner and outer surface.
Two palatine bones: These bones are located in the back part of the nasal cavity. Each palatine bone touches the ethmoid, the sphenoid, the maxilla, the inferior nasal concha, the vomer, and the other palatine.
Vomer: This is a thin, quadrilateral-shaped bone located at the base of the nasal cavity. It consists of the superior border, inferior border, anterior border, and posterior border.
Two zygomatic bones: These bones are also known as cheek bones. They're roughly triangular bones that connect the frontal bone, temporal bone, and the maxilla.

Other structures in the skull

The skull doesn't only consist of bones. It also includes three meninges, which are the protective membranes that cover the brain and spinal cord.

The dura mater, the outermost membrane, surrounds the brain and the spinal cord and is responsible for retaining the cerebrospinal fluid. It also carries blood from the brain toward the heart.

The dura mater has two layers referred to as lamellae: the superficial layer, which serves as the skull's inner periosteum (i.e., the endocranium), and a deep layer, which is the actual dura mater.

The arachnoid mater, the middle membrane, helps separate the hemispheres of the brain.

The pia mater is the deepest of the membranes and acts like protective Saran Wrap covering the brain. The subarachnoid space lies between the pia mater and the arachnoid mater and contains the cerebrospinal fluid.

If a physician documents an arachnoid hemorrhage, he or she likely found cerebrospinal fluid between the pia mater and the arachnoid mater.

The skull also contains various foramen, which are holes in the bone through which nerves and blood vessels pass. The most notable is the foramen magnum where the spinal cord exits.

The pituitary is located in the sella turcica, which is a saddle-shaped depression in the sphenoid bone. When a physician removes a patient's pituitary gland, he or she breaks through the sella turcica to reach the pituitary.

Coding for skull fractures

When coding for skull fractures in ICD-9-CM, coders reference the 800-804 series of codes. Each series specifies an area of the skull, such as the vault (800), base (801), and bones of the face (802). Other and unqualified skull fractures are included in the 803 code series. If a patient fractures multiple skull bones, coders should report the appropriate code from the 804 series.

All of the skull fracture codes require a fifth digit to denote loss of consciousness. The codes for a closed skull fracture with no loss of consciousness include:

800.01: Closed without mention of intracranial injury with no loss of consciousness
800.11: Closed with cerebral laceration and contusion with no loss of consciousness
800.21: Closed with subarachnoid, subdural, and extradural hemorrhage with no loss of consciousness
800.31: Closed with other and unspecified intracranial hemorrhage with no loss of consciousness
800.41: Closed with intracranial injury of other and unspecified nature with no loss of consciousness
800.51: Open without mention of intracranial injury with no loss of consciousness
800.61: Open with cerebral laceration and contusion with no loss of consciousness
800.71: Open with subarachnoid, subdural, and extradural hemorrhage with no loss of consciousness
800.81: Open with other and unspecified intracranial hemorrhage with no loss of consciousness
800.91: Open with intracranial injury of other and unspecified nature with no loss of consciousness

The ICD-10-CM skull fracture codes are constructed differently than ICD-9-CM codes. In ICD-10-CM, coders must know which specific bone of the skull is fractured. For example, if the patient suffered a closed fracture of the parietal bone, coders should report S02.0xxA for the initial encounter.

If, however, the patient suffered a fracture to the occipital bone, coders should choose a code from the following list and add the appropriate seventh character:

S02.110: Type I occipital condyle fracture
S02.111: Type II occipital condyle fracture
S02.112: Type III occipital condyle fracture
S02.113: Unspecified occipital condyle fracture
S02.118: Other fracture of occiput
S02.119: Unspecified fracture of occiput

Note that all of the ICD-10-CM fracture codes require a seventh character to denote whether the fracture is open or closed and whether the encounter is initial, subsequent (with type of healing), or sequela.

Coding for skull deformity

A patient may suffer from a skull deformity. In ICD-9-CM, coders will find only two choices: 754.0 (certain congenital musculoskeletal deformities of skull, face, and jaw) and code 756.0 (other congenital musculoskeletal anomalies of the skull and face bones).

In ICD-10-CM, coders must know whether the deformity is acquired or congenital. If the deformity is acquired, coders should report M95.2 (other acquired deformity of head).

For congenital deformities, coders should report one of the following codes from the Q75.- (other congenital malformations of skull and face bones) category:

Q75.0: Craniosynostosis
Q75.1: Craniofacial dysostosis
Q75.2: Hypertelorism
Q75.3: Macrocephaly
Q75.4: Mandibulofacial dysostosis
Q75.5: Oculomandibular dysostosis
Q75.8: Other specified congenital malformations of skull and face bones
Q75.9: Congenital malformation of skull and face bones, unspecified

Category Q75.- also includes the following Excludes1 notes:

congenital malformation of face NOS (Q18.-)
congenital malformation syndromes classified to Q87.-
dentofacial anomalies [including malocclusion] (M26.-)
musculoskeletal deformities of head and face (Q67.0-Q67.4)
skull defects associated with congenital anomalies of brain (Q00.0-Q03-)

The codes in this article represent diagnoses involving the skull. Refer to the CPT Manual, ICD-9-CM Manual (Vol. 3), or ICD-10-PCS Manual for procedure codes.

Note changes for skin substitutes, mental health codes

Fri, 01 Jun 2012 04:00:00 GMT

Note changes for skin substitutes, mental health codes

Facilities can't bill for skin substitutes unless they also bill for a skin substitute application procedure on the same date, according to the April update to the I/OCE. If facilities don't comply with this practice, they won't receive payment for the skin substitute. The April update includes a list of eight procedure codes (CPT codes 15271-15278) and 27 specific skin graft materials.

"You can't just bill the material by itself and expect to get paid for it," says Dave Fee, MBA, product marketing manager of outpatient products at 3M Health Information Systems in Murray, Utah. "You have to be very clear about what you did."

Three of the skin substitute codes have status indicator G, meaning CMS will reimburse facilities at average sales price (ASP) plus 6% when these codes are reported. Two of the skin substitute codes are packaged with status indicator N, and the remaining 22 codes have a status indicator K, meaning facilities receive ASP plus 4% reimbursement.

"This is the biggest issue [in the update] for any facility that does a lot of grafting, such as those that treat a lot of burn patients," Fee says. Facility coders may also see these skin substitutes applied to cancer patients who had skin removed or patients with certain infections that damage the skin. Every time coders report one of the 27 skin substitute codes, they need to make sure they also report an accepted procedure code.

Some of the skin substitutes are very costly, so facilities could lose significant revenue if coders don't report the skin substitute and the application procedure together, Fee says. For example, Q4114 (Integra flowable wound matrix, injectable, 1cc) reimburses approximately $1,090 per unit. When reported alone-and without the procedure-this error can have a large financial impact, he explains.

Coders and chargemaster coordinators must note two important caveats to the April update regarding skin substitutes. The first involves TRICARE, which is an insurance provider for military personnel and their families. TRICARE is following CMS' lead by requiring facilities to report skin substitutes and application procedures on the same date as a prerequisite for payment. However, TRICARE modified the list of skin substitute codes by adding two codes and removing five.

"They have 24 codes for the graft material instead of 27, and two of them are different," Fee says. "I thought that was interesting."

The second caveat involves ambulatory surgery centers (ASC). At this time, it's unclear whether ASCs will follow the same rules when billing skin substitutes and their application, Fee says. "I know there are two codes, Q4100 and Q4130, that are not on the list of skin substitutes for ASCs."

Coders must pay attention to the setting in which the procedure took place, what procedure the provider performed, and the third-party payer that will be processing the claim. These factors will affect how coders report the services.

Mental health diagnosis codes

CMS added the following six long-standing ICD-9-CM mental health codes to the list of codes that qualify patients for partial hospitalization programs:

291.89: Other alcohol-induced mental disorders
293.84: Anxiety disorder in conditions classified elsewhere
327.02: Insomnia due to mental disorder
327.15: Hypersomnia due to mental disorder
327.42: REM sleep behavior disorder
327.43: Recurrent isolated sleep paralysis

Bilateral CPT codes

CMS removed CPT code 36000 (introduction of needle or intracatheter, vein) from the conditionally bilateral list. In addition, CMS removed the following two codes from the inherently bilateral list and added them to the conditionally bilateral list:

64613: Chemodenervation of muscle(s); muscle(s) innervated by facial nerve
64614: Chemodenervation of muscle(s); cervical spinal muscle(s)

When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code.

New pass-through drugs and biologics

CMS granted pass-through status for these four HCPCS codes:

C9288: Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
C9289: Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (IU)
C9290: Injection, bupivicaine liposome, 1 mg
C9291: Injection, aflibercept, 2 mg vial

CMS published specific instructions regarding code C9291:

Eylea (aflibercept) is packaged in a sterile, 3 mL single use vial containing a 0.278 mL fill of 40 mg/mL Eylea (NDC 61755-0005-02). As approved by the Food and Drug Administration (FDA), the recommended dose for Eylea is 2 mg every 4 weeks, followed by 2 mg every 8 weeks. Payment for HCPCS code C9291 is for the entire contents of the single-use vial, which is labeled as providing a 2 mg dose of aflibercept. As indicated in 42 CFR § 414.904, CMS calculates an ASP payment limit based on the amount of product included in a vial or other container as reflected on the FDA-approved label, and any additional product contained in the vial or other container does not represent a cost to providers and is not incorporated into the ASP payment limit. In addition, no payment is made for amounts of product in excess of that reflected on the FDA-approved label.

Modifiers

CMS deactivated these two modifiers:

V8: Dialysis access-related infection is present (documented and treated) during the billing month
V9: No dialysis access-related infection, as defined for modifier V8, is present during the billing month

The complete April 2012 update to the I/OCE can be downloaded from the CMS website at www.cms.gov/Medicare/Coding/OutpatientCodeEdit/Downloads/FinalSumofDataChngsSpecCMSreport-.pdf.

HHS proposes one-year delay for ICD-10 implementation

Fri, 01 Jun 2012 04:00:00 GMT

HHS proposes one-year delay for ICD-10 implementation

Providers and payers may have an additional year to transition to ICD-10-CM/PCS if the Department of Health and Human Services (HHS) finalizes a proposed rule released April 9.

HHS had established October 1, 2013, as the ICD-10-CM/PCS compliance deadline, but in February said it would reconsider the date after some providers expressed concern about their ability to comply with that timeline. After additional consideration, HHS recommended a one-year delay and sought feedback from those in the industry.

"We're recommending it, but it's not [guaranteed]," said Denise Buenning, group director at the CMS Office of E-Health Standards and Services. Buenning delivered CMS' ICD-10 State of the Union report at the AHIMA ICD-10 Summit held April 16-17 in Baltimore. At presstime, HHS had not finalized the delay.

Length of the delay

CMS proposed a one-year delay for a variety of reasons, said Buenning. A longer delay (i.e., longer than two years) would result in a waste of resources for those providers that have already spent a lot of money toward the implementation, she said. A one-year delay gives certain providers more time to plan, but doesn't penalize those who have already begun implementation.

HHS considered a number of factors before deciding on the delay, including input from healthcare providers and the AMA.

Code freeze and Coding Clinic updates

The ICD-9-CM code freeze will remain in effect until ICD-10-CM/PCS is implemented, regardless of the timeline for the delay, according to Pat Brooks, RHIA, senior technical advisor at CMS. Brooks provided an ICD-10-CM/PCS update during the AHIMA ICD-10 Summit in April.

The next regular code update won't occur until one year after the eventual implementation of ICD-10-CM/PCS. This means that if HHS finalizes the proposed October 1, 2014, implementation deadline, the next update would be October 1, 2015. The 2013 code updates will only relate to new diseases and technologies.

It's unclear how or whether the delay will affect Coding Clinic, says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association (AHA) in Chicago.

Leon-Chisen told the audience at the AHIMA ICD-10 Summit that the AHA may need to review its timeline for releasing Coding Clinic for ICD-10-CM/PCS. Originally, the AHA planned to begin publishing ICD-10-CM/PCS-specific issues of Coding Clinic in the fall of this year.

However, the AHA has begun to review ICD-10-CM/PCS questions for inclusion in Coding Clinic and is currently accepting questions about coding scenarios using the new coding system, said Leon-Chisen.

This Month's Coding Q&A

Fri, 01 Jun 2012 04:00:00 GMT

This Month's Coding Q&A

Payment for items in OPPS Addendum B

Q Why does our MAC deny payment for certain items that include a payment amount listed in OPPS Addendum B? We reported the correct number of units as well as the correct HCPCS code, and the provider documented that he or she provided the item to the patient. Why didn't we receive payment for it?

A You don't specify the item(s) involved, so it's unclear whether a national or local coverage determination affects the claims processing. Addendum B describes the payment status for items, tests, procedures, and services provided under OPPS and the payment amount, if applicable, under OPPS.

Addendum B doesn't address the medical necessity of an item, test, procedure, or service. Payment decisions are based on medical necessity, which trumps a payable status indicator.

Transmittal 2418 reminds hospitals of the following:

Payment for skin substitutes

Q We don't always receive payment for skin substitutes that we report. These HCPCS codes appear in Addendum B as separately payable, but the line item indicates zero reimbursement. Do you have any information about this?

A The October 2008 update to OPPS (Transmittal 1599) instructed facility providers not to report the HCPCS code for skin substitutes when the substitute was used as a surgical implant or when it was inserted into the body. Remember that under APCs, supply items are packaged into surgical procedures and are not separately payable. CMS considers skin substitutes that are inserted or implanted as surgical supplies. Facilities were only to report the HCPCS code when an item was used as a skin substitute, which providers found difficult to operationalize.

Effective April 1, CMS instructed facility providers to report HCPCS codes for skin substitutes regardless of how they are used. New edits in the I/OCE will process the line item for payment only when providers report the HCPCS code with a CPT® code that describes the application of a skin substitute (specifically CPT codes 15271-15278).

In all other situations, the I/OCE will change the status indicator to N and package the item into the surgical procedure. CMS reminds providers to report the units based on the HCPCS description. Documentation should support the amount of product used to justify the units billed.

Providers should carefully review their remittance advices to ensure receipt of appropriate payment when skin substitutes are reported with CPT codes 15271-15278.

The April 2012 update appears in Transmittal 2418, which was published March 2. Details of the I/OCE edit appear in Transmittal 2423, which was published March 9.

Incomplete documentation for IV infusions

Q We have a problem with documentation that doesn't include start and stop times for medications that are given intravenously.

Consider this scenario: A physician times an order at 13:00 to give antibiotics via IV infusion. The nurse doesn't document a start or stop time for the infusion. Within the nurse's documentation it states that an IV access was already established at 12:00. An entry at 14:00 states the antibiotic is still running with no complication.

Our four questions are as follows:

1.Can we charge for the initial IV infusion code 96365 based on the nurse's documentation that the antibiotics were actually given and running at 14:00?

2.What, if anything, can we capture if the nurse had documented another entry stating the IV was running at 13:30 as well as an additional entry at 14:00 stating it was still running?

3.If the nurse had documented a start time of 13:10 but didn't document a stop time, can we charge for an IV push?

4.Can we capture the initial IV infusion code 96365 if the nurse had documented a start time of 13:10 and had also documented that the antibiotics were still running at 14:00, but didn't document a stop time?

A Regarding the first question, the nurse is the incidental provider, so you can report codes based on the nurse's documentation. However, you do need a stop time to be able to report the number of hours for an infusion. It's unusual that the physician would document this because the physician is not the professional providing the service.

Regarding your second question, code 96365 captures the initial "up to 1 hour" of infusion. Therefore, the half hour is reported with 96365. In my opinion, this is the same administration.

In answer to questions 3 and 4, an IV infusion and an IV push are two different services. Don't report a push unless it's documented. The IV access described in your question is established, the antibiotics are delivered via this IV, and this service matches the physician's orders for an infusion. Regardless of whether it was started as ordered (i.e., at 13:00) or whether it was started at 13:10 or 13:30 and was still running at 14:00, this all appears to be covered in one service captured by code 96365.

Coding for amputation of finger and aftercare

Q Can we assign codes V54.89 (other orthopedic aftercare) and 886.x (traumatic amputation of finger) when a patient has a healing traumatic finger amputation with concern of, but no diagnosis of infection at the amputation site? The physician prescribed Bactrim®.

A According to the ICD-9-CM Official Guidelines for Coding and Reporting, coders should report V codes in four primary circumstances, one of which relates to aftercare as follows:

These official coding guidelines also provide the following guidance regarding the appropriate use of aftercare codes:

Now let's consider the patient with a traumatic finger amputation who presents with an amputation stump and concern for infection at the amputation site.

There are no obvious signs and symptoms of infection at the amputation site, and the patient is receiving antibiotics presumably as a prophylactic measure for infection. In this case, the aftercare code V54.89 is the most appropriate ICD-9-CM code to report for this encounter.

The patient's status is post initial treatment of the traumatic amputation, and he or she is currently in the healing or recovery phase. The physician isn't directing the current treatment toward a current injury. Thus, it's inappropriate to assign a code from the 800 series to indicate a current injury for this encounter. Likewise, it's inappropriate to assign the V54.89 code along with an acute injury code, given the fact that aftercare codes shouldn't be assigned when treatment is directed at the current injury. Therefore, report only code V54.89.

By definition, codes from the 800 set and V54.89 shouldn't be reported together.

Facility codes for peritoneal dialysis

Q We work in a non-dialysis facility. When a patient is in observation for a non-kidney-related problem and must undergo hemodialysis, we report code G0257 (unscheduled or emergency dialysis treatments for an ESRD [end-stage renal disease] patient in a hospital outpatient department that is not certified as an ESRD facility). How should we code peritoneal dialysis when a patient is in observation or is an inpatient due to other conditions? I've received three different codes from three different coders. I can't really find any information on this anywhere.

A Code G0257 doesn't include any E/M services that a physician may provide related to the patient's renal condition.

Report codes 90935 (hemodialysis procedure with single physician evaluation) or 90937 (hemodialysis procedure requiring repeated evaluations) to denote the provision of hemodialysis along with E/M services provided by the physician on the same day. Per CPT guidelines, report these codes for the provision of inpatient hemodialysis to either an ESRD or non-ESRD patient as well as services for an outpatient non-ESRD patient.

Therefore, check the documentation to determine whether the physician provided E/M services in relation to the dialysis and whether the patient has ESRD. This answer should lead you to the correct code.

Contributors

We would like to thank the following contributors for answering the questions that appear on pp. 10-12:

Andrea Clark, RHIA, CCS, CPC-H

President

Health Revenue Assurance Associates, Inc.

Plantation, Fla.

Glenn Krauss, RHIA, CCS, CCS-P, CPUR

Independent HIM Consultant

Madison, Wis.

Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA

Safian Communications Services

Orlando, Fla.

Denise Williams, RN, CPC-H

Director of Revenue Integrity Services

Health Revenue Assurance Associates, Inc.

Plantation, Fla.

Briefings on APCs, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Injections and infusions continue to confuse coders

"Because CPT® guidelines define infusions based on the amount of time involved, without specific time frame documentation for infusions, it is difficult to determine whether to report the infusion as an infusion or an IV push," Williams says.

In the scenario above, even though the physician ordered three hours of hydration and a one-hour therapeutic infusion, coders can't code the services at all because no stop time is documented.

Review the hierarchy

The hierarchy does not apply to physician reporting, nor does it apply to subcutaneous or intramuscular injections, Shah says.

Selecting the initial service

Each category of IV infusion and injection codes designates one code as the initial service.

Typically, coders only report one initial service per visit, unless the patient has more than one access site, Shah adds.

Coding subsequent and sequential infusions

The codes for subsequent and sequential infusions are add-on codes. Think of these infusions as one after another or an infusion that comes before or after the initial drug, Shah says.

Sequential infusions denote the administration of a new drug or substance. Coders can report these codes once per encounter for the same infusate, Shah says.

Additional hours of the initial service infusion
Additional hours of a sequential infusion, which means additional hours of an infusion of a new drug
Additional infusions of the same substance or drug

Consider this scenario: A patient receives antibiotic A for three hours. Coders should report a code for the initial hour, followed by 96366x2 for the remaining additional two hours, Shah says.

"This is where we were saying the order doesn't matter. You have to follow the hierarchy," she says.

Reporting concurrent infusions

Deciding what to code

Coders can create a decision tree to help them determine what services to code and the order in which to report those services.

Start by determining whether the patient received any chemotherapy infusions during the visit. If yes, code the chemotherapy first.

Second, look at the route of administration. Is it IV infusion, IV injection, subcutaneous/intramuscular, or a combination? This is important because it also drives selection of codes, Shah says.

Improving injection and infusion coding

"The positive part of this is that it works in tandem with the updated definition for CPT code 96367, which now specifies sequential infusion of a new drug," Williams says.

ICD-10 anatomy refresher: Get to know the skull

Most coders know that the human body contains 206 bones, but what they may not realize is that more than 20 of them are in the cranium.

Knowledge of the skull's anatomy will be even more important once coders begin using ICD-10-CM/PCS.

Bones of the skull

The bones of the cranium meet along joints called sutures. As a person ages, the sutures gradually fuse together. Let's look at the specific bones of the cranium.

These eight bones make up the skull itself:

Frontal bone: This bone comprises the forehead (squama frontalis) and the upper orbit of the eye (pars orbitalis). It joins the parietal bones at the coronal suture.
Two temporal bones: These bones are located at the sides and base of the skull, and they are the hardest bones in the body. Each one includes the ears, which comprise the auditory ossicles-the three smallest bones in the body.
Two parietal bones: These bones form most of the roof and sides of the skull. Each parietal bone consists of four borders (sagittal, squamous, frontal, and occipital) and four angles (frontal, sphenodial, occipital, and mastoid).
Ethmoid bone: This bone is located at the top of the nose and in between the two eye sockets. It differs from the other bones in the cranium because it's spongy instead of hard. It divides the nasal cavity from the brain.
The sphenoid bone: This bone is located behind the eyes at the base of the skull. Because of its shape, the sphenoid bone touches all the other cranial bones. It is divided into six portions: the body of the bone, two greater wings, two lesser wings, and the pterygoid processes.
Occipital bone: This bone forms the lower part of the back of the skull and the base of the cranium. The spinal cord exits the brain through a large oval hole, called the foramen magnum, in the occipital bone.

The face includes the following 14 bones:

Two inferior nasal conchae: These are two paired bones, each of which is individually known as a nasal concha or turbinate bone. The nasal conchae consist of the medial and lateral surfaces and the upper and inferior borders.
Two lacrimal bones: These bones are located in the middle wall of each eye socket between the ethmoid bone and the maxilla. Tears drain from the eye through a groove in the lacrimal bone and into the nasolacrimal duct.
Mandible: This bone forms the lower jaw. It is divided into the body, the two rami, the alveolar process, the condyle, and the coronoid process. The inferior alveolar nerve runs through the mandibular foramen (opening) and provides sensation to the teeth. The mandible is formed in two pieces that fuse together during early infancy.
Two maxillae: These bones are located above the mandible and below the orbits. The maxilla is divided into the body, the zygomatic process, the frontal process, the alveolar process, the palatine process, the infraorbital foramen, and the maxillary sinus. The alveolar process, known as the maxillary arch, holds the upper teeth in place.
Two nasal bones: These bones are located near the middle of the face and come together to form the bridge of the nose. Each nasal bone consists of an inner and outer surface.
Two palatine bones: These bones are located in the back part of the nasal cavity. Each palatine bone touches the ethmoid, the sphenoid, the maxilla, the inferior nasal concha, the vomer, and the other palatine.
Vomer: This is a thin, quadrilateral-shaped bone located at the base of the nasal cavity. It consists of the superior border, inferior border, anterior border, and posterior border.
Two zygomatic bones: These bones are also known as cheek bones. They're roughly triangular bones that connect the frontal bone, temporal bone, and the maxilla.

Other structures in the skull

The skull doesn't only consist of bones. It also includes three meninges, which are the protective membranes that cover the brain and spinal cord.

The dura mater, the outermost membrane, surrounds the brain and the spinal cord and is responsible for retaining the cerebrospinal fluid. It also carries blood from the brain toward the heart.

The dura mater has two layers referred to as lamellae: the superficial layer, which serves as the skull's inner periosteum (i.e., the endocranium), and a deep layer, which is the actual dura mater.

The arachnoid mater, the middle membrane, helps separate the hemispheres of the brain.

If a physician documents an arachnoid hemorrhage, he or she likely found cerebrospinal fluid between the pia mater and the arachnoid mater.

The skull also contains various foramen, which are holes in the bone through which nerves and blood vessels pass. The most notable is the foramen magnum where the spinal cord exits.

Coding for skull fractures

All of the skull fracture codes require a fifth digit to denote loss of consciousness. The codes for a closed skull fracture with no loss of consciousness include:

800.01: Closed without mention of intracranial injury with no loss of consciousness
800.11: Closed with cerebral laceration and contusion with no loss of consciousness
800.21: Closed with subarachnoid, subdural, and extradural hemorrhage with no loss of consciousness
800.31: Closed with other and unspecified intracranial hemorrhage with no loss of consciousness
800.41: Closed with intracranial injury of other and unspecified nature with no loss of consciousness
800.51: Open without mention of intracranial injury with no loss of consciousness
800.61: Open with cerebral laceration and contusion with no loss of consciousness
800.71: Open with subarachnoid, subdural, and extradural hemorrhage with no loss of consciousness
800.81: Open with other and unspecified intracranial hemorrhage with no loss of consciousness
800.91: Open with intracranial injury of other and unspecified nature with no loss of consciousness

If, however, the patient suffered a fracture to the occipital bone, coders should choose a code from the following list and add the appropriate seventh character:

S02.110: Type I occipital condyle fracture
S02.111: Type II occipital condyle fracture
S02.112: Type III occipital condyle fracture
S02.113: Unspecified occipital condyle fracture
S02.118: Other fracture of occiput
S02.119: Unspecified fracture of occiput

Coding for skull deformity

In ICD-10-CM, coders must know whether the deformity is acquired or congenital. If the deformity is acquired, coders should report M95.2 (other acquired deformity of head).

For congenital deformities, coders should report one of the following codes from the Q75.- (other congenital malformations of skull and face bones) category:

Q75.0: Craniosynostosis
Q75.1: Craniofacial dysostosis
Q75.2: Hypertelorism
Q75.3: Macrocephaly
Q75.4: Mandibulofacial dysostosis
Q75.5: Oculomandibular dysostosis
Q75.8: Other specified congenital malformations of skull and face bones
Q75.9: Congenital malformation of skull and face bones, unspecified

Category Q75.- also includes the following Excludes1 notes:

congenital malformation of face NOS (Q18.-)
congenital malformation syndromes classified to Q87.-
dentofacial anomalies [including malocclusion] (M26.-)
musculoskeletal deformities of head and face (Q67.0-Q67.4)
skull defects associated with congenital anomalies of brain (Q00.0-Q03-)

The codes in this article represent diagnoses involving the skull. Refer to the CPT Manual, ICD-9-CM Manual (Vol. 3), or ICD-10-PCS Manual for procedure codes.

Note changes for skin substitutes, mental health codes

"They have 24 codes for the graft material instead of 27, and two of them are different," Fee says. "I thought that was interesting."

Mental health diagnosis codes

CMS added the following six long-standing ICD-9-CM mental health codes to the list of codes that qualify patients for partial hospitalization programs:

291.89: Other alcohol-induced mental disorders
293.84: Anxiety disorder in conditions classified elsewhere
327.02: Insomnia due to mental disorder
327.15: Hypersomnia due to mental disorder
327.42: REM sleep behavior disorder
327.43: Recurrent isolated sleep paralysis

Bilateral CPT codes

64613: Chemodenervation of muscle(s); muscle(s) innervated by facial nerve
64614: Chemodenervation of muscle(s); cervical spinal muscle(s)

When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code.

New pass-through drugs and biologics

CMS granted pass-through status for these four HCPCS codes:

C9288: Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
C9289: Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (IU)
C9290: Injection, bupivicaine liposome, 1 mg
C9291: Injection, aflibercept, 2 mg vial

CMS published specific instructions regarding code C9291:

Catch up on what's new with injections and infusions

Poor documentation and a lack of clear guidance continue to cause coders to struggle with reporting injections and infusions.

CMS did not discuss drug administration services in the 2012 OPPS final rule, but the AMA did make significant additions to the CPT coding guidelines in the 2012 CPT Manual, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C.

CPT changes to drug administrationguidelines

The 2012 CPT Manual now includes instructions stating that coders should report a significant, separately identifiable office or other outpatient E/M service along with drug administration services when appropriate. This is the first time the AMA has included such a guideline in the CPT Manual.

The guidelines instruct coders to report the appropriate E/M service (i.e., 99201-99215, 99241-99245, or 99354-99355) with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in addition to drug administration codes 96360-96549.

“The litmus test again is, is it significant and separately identifiable, and under audit, would you be able to demonstrate this from the medical record documentation?” Shah says.

The 2012 CPT Manual also includes more information on what a concurrent infusion is; a concurrent infusion occurs when a new substance or drug is infused at the same time as another substance or drug. This is not a time-based code per CPT, which can be confusing because we have been told that infusions as time-based services, yet in this case we are being told that a concurrent infusion is not to be viewed as time-based Shah says.

This means current infusions (CPT add-on code 96368) are only reported once per day regardless of whether the concurrent infusion lasts for multiple hours or if additional drugs or substances are administered concurrently.

Clarifying the guidelines

The 2012 CPT Manual also includes guideline changes pertaining to sequential infusions. According to the CPT guidelines:

All sequential services require that there be a new substance or drug, except that facilities may report a sequential intravenous push of the same drug using 96376.

Coders should hone in on the terms 'sequential’ and ‘new substance ot drug,’ Shah says. Those are two key parts of what sequential means when it comes to using the sequential infusion CPT code 96367. In addition, providers should notethat sequential itself just means coming one after the other and what is key is knowing if the item being infused is the same or different as that will guide code selection, Shah says. If the provider is not infusing a new substance, coders should not report the sequential infusion code, but instead should follow the CPT instruction which points to using the additional hours code to report additional infusions of the same substance or drug.

Many facilities have inquired about how to handle scenarios in which a patient receives an infusion of a d

Coders may also feel uncomfortable about CPT's clarification involving multiple infusions because the add-on code is being used to report something other than “additional hours” of the same infusion. According to CPT guidelines:

When reporting multiple infusions of the same drug/substance on the same date of service, the initial code should be selected. The second and subsequent infusion(s) should be reported based on the individual time(s) of each additional infusion(s) of the same drug/substance using the appropriate add-on code.

Coders should focus on the terms ‘multiple infusions,’ and ‘same drug or substance,’ Shah says. Coders already know to report subsequent infusions of a different substance or drug using the sequential infusion code. In cases where the same drug is being infused multiple times, coders must examine the time of each individual infusion and report it using the additional hours infusion code.

Remember, add-on codes for drug administration services don’t necessarily follow the standard way that coders normally think about using add-on codes which usually involves the main code before using the add-on code. That is not the case for drug administration services, Shah says.

The CPT Manual provides an example to illustrate how the guideline is applied: In the outpatient observation setting, a patient receives hour-long intravenous infusions of the same antibiotic every eight hours on the same date of service through the same IV access. Coders should report CPT code 96365 for the first one-hour dose administered. They should then report add-on code 96366 twice (i.e., once for the second hour-long infusion and once for the third hour-long infusion of the same drug).

It might look to coders like CPT is adding up the times of the three infusions of the same substance or drug but that is not what is happening; it just happens to work, Shah says. CPT guidelines state, ‘the second and subsequent infusion should be reported based on the individual times of each infusion.'

“So what they’re saying is if you've got the same drug and it’s infused multiple times, each infusion must be reported according to its own time. Moreover, if one of the infusions is longer, then it would be reported with 96366 and the additional time of it would also be reported using the same 96366 add-on code. So coders need to remember to report additional infusions of that same substance or drug using the add-on code, not the sequential infusion code and they need to remember that the add-on code now has multiple uses,” Shah says

CMS vs CPT guidelines

Coders know to follow CPT codes, rules, and parenthetical notes but what is difficult is when CPT provides one instruction and CMS provides another. In these cases, questions often arise about what instruction should be followed. For example, CPT provides one set of guidance on how drug administration services that cross the midnight hour should be reported while CMS provides another. The difference here is that the CPT instruction is for physicians, while CMS’ instruction is for facility reporting and coders need to keep this straight.

CPT provides the following example: a patient receives intravenous hydration from 11 p.m. to 2 a.m. A coder reports 96360 once for the initial hour of hydration and 96361 twice for the additional hours.

The explanation for why this is the correct reporting according to CPT is because this is a continuous service. However, this is exactly the same reporting under CMS’ rules but the rationale is different. From CMS’ perspective this is the correct reporting because this is one single encounter in which case only one initial service code should be used unless two separate IV sites were accessed. The CPT guidelines go on to state:

However, if instead of a continuous infusion, a medication was given by intravenous push at 10 pm and 2 am., as the service was not continuous, both administrations would be reported with the initial service (96374).

“What we know from CMS is that this reporting instruction does not apply to hospitals because they are to report only one initial service per encounter regardless of whether services are continuous or not so in the above example, hospital reporting would dictate the use of 96374 and 96376. Hospitals should continue to follow Medicare Claims Processing Manual, section 230.2, Coding and Payment for Drug Administration, which states:

Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.

CMS notes in Transmittal 2386 that it has "subsequently become aware of new CPT guidance regarding the reporting of initial drug administration services in the event of a disruption in service; however, Medicare contractors are to continue to follow the guidance" in the Medicare Claims Processing Manual, Chapter 4, section 230.2.

Medicare is clearly aware of the CPT instruction, but is making it clear that hospital reporting must be done differently, Shah says. “It [Medicare] is going to continue following the rules that it has had in place now for drug administration where you have one initial service except in very specific instances, such as multiple vascular access sites or multiple separate visits.

In this example, coders would not follow the CPT instruction but instead would continue to follow CMS guidance. CMS states that for continuous services that extend beyond the midnight hour, such as hydration, hospitals should use the date on which the services begin and report the total units of time during which the services are provided continuously using the appropriate codes and time frames without being tempted to use another initial service code simply because the midnight hour was crossed. Don’t be confused by the example in the CPT Manual about the IV push, Shah says.

Coders may resist Medicare guidance because they generally adhere to CPT standards when coding, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, Mass. They may argue that they don't code according to payer policy; however, in some instances, they must, she says. "If they don't code to Medicare's policy, they may have overpayments that could be considered fraud."

Because Medicare is such a large governmental payer, it establishes some of its own rules, Hoy says. This allows CMS to set rules that are technically contrary to HIPAA standards.

Other payers may also default to the Medicare rules, so someone within the organization must identify the guidance that each third-party payer is following. "If you have it figured out for Medicare, and you know a limited number of your payers are using the Medicare rule, just follow the Medicare rule for them," Hoy says. "For everyone else, standard coding rules should be applied."

Organizations must also familiarize themselves with the rules that their individual MACs follow, Hoy says. Many of the differences between Medicare policy and CPT guidelines reside in local MAC guidance about how to document or use the codes. Although some national standards exist, CMS often defers to the MACs. Thus, not all MACs follow the same rules. Fortunately, most organizations must only learn the rules of one MAC.

HIM staff members should ensure that coding rules are reflected in the facility's coding software, Hoy says. This will help the facility track each of the different rules.

Fracture coding in ICD-10-CM requires greater specificity

Tue, 01 May 2012 04:00:00 GMT

Fracture coding in ICD-10-CM requires greater specificity

A 25-year-old woman presents to the ED for an initial visit for treatment of open displaced tibia and fibula fractures of the left leg. The injuries occurred in an automobile accident. In addition, she lost a significant amount of blood from her left leg.

Coders must know the following details to assign a correct ICD-10-CM code for this scenario:

Which leg and which specific bones were injured
Whether the fracture was open or closed
Whether the fracture was displaced
Whether this was an initial or subsequent visit

For open fractures, coders must also know what type of associated trauma the patient suffered. This information helps coders choose the appropriate character based on the Gustilo-Anderson classification system. (For more on the Gustilo-Anderson classification system, see the related article on p. 5. To learn more about the seventh character, used to denote the encounter, see the related artcile on p. 6.)

Type of fracture

Providers must document, in some form, whether the fracture is traumatic or pathologic.

A traumatic fracture is caused by some type of accident, fall, or other kind of force. For example, a traumatic fracture can occur after a car accident or when a person is struck with a heavy object.

A pathologic fracture is a broken bone caused by disease. In ICD-9-CM, coders must choose from only eight pathologic fracture codes. ICD-10-CM expands this code selection to more than 150 codes.

So how do coders tell the two types of fractures apart? Sometimes it's pretty obvious. For example, if a patient fractures his leg after falling off the roof while replacing the tiles, this is a clear example of a traumatic fracture.

However, if a patient leans over to pick up a glass and breaks a vertebra, this patient likely suffered a pathologic fracture, says Robert S. Gold, MD, CEO and cofounder of DCBA, Inc., an Atlanta-based consulting company. Leaning over generally does not produce enough force to break a healthy bone, he says.

If a patient suffers a fall or trauma that results in a fracture, don't assume the fracture is traumatic, says Sandy Nicholson, MA, RHIA, vice president of health information services for DCBA. If the force from a fall or trauma is insufficient to break a healthy bone, the fracture is pathologic, Nicholson says.

Site of the fracture

Coders must know the site of the fracture. This includes not only which bone is broken, but also the specific location of the fracture on that bone, Gold says. For example, a patient fractures his femur. Coders should look for documentation of which part of the femur he fractured. A physician may perform different procedures depending on the site of the fracture.

In addition, some ICD-10-CM codes include wording such as "distal end" or "proximal end"; coders should look for this information in the medical record.

For example, codes for fractures of the phalanx of the finger are divided into the proximal, medial, and distal phalanx. The codes are further divided by the specific finger fractured and whether the fracture is displaced or nondisplaced. Report code S62.655A for an initial encounter for a patient with a nondisplaced fracture of middle phalanx of left ring finger.

If more than one site is involved, coders can report multiple site codes, says Nicholson.

For example, if a patient presents with fractures to multiple ribs, coders should choose from among these codes and add the appropriate seventh character:

S22.41x, multiple fractures of ribs, right side
S22.42x, multiple fractures of ribs, left side
S22.43x, multiple fractures of ribs, bilateral
S22.49x, multiple fractures of ribs, unspecified side

If no multiple site code is available, report separate codes for each fracture. For example, coders should report separate codes (with the appropriate seventh character extension) when a patient fractures his or her tibia and fibula. Note that the codes also include mention of the specific area of the bone that is broken. For example, if the physician documented the displaced transverse fracture of shaft of left tibia and displaced comminuted fracture of shaft of left fibula, coders should report:

S82.222, displaced transverse fracture of shaft of left tibia
S82.452, displaced comminuted fracture of shaft of left fibula

ICD-10-CM pathologic fractures

Not all pathologic fractures are due to cancer. Unfortunately, most physicians don't call a fracture pathologic unless it is caused by a malignancy, Gold says.

As a result, insufficient documentation of pathologic fractures can be problematic for coders, says Nicholson. "It's up to the physician to document whether it is a pathologic fracture," she says.

If coders don't know whether the fracture is pathologic or traumatic, they won't be able to select the correct code or even the correct code series. The increased specificity of the codes and new documentation requirements in ICD-10-CM offer an opportunity to educate physicians about the importance of documenting whether fractures are pathologic, Gold says.

For example, physicians should document the following details for osteoporosis:

Whether the osteoporosis occurs with or without current pathologic fracture and history of pathologic fracture
The specific bone fractured and laterality, as appropriate
Whether the osteoporosis is age-related or due to some other specific cause (e.g., chronic steroid use or vitamin deficiency)

Coding for osteoporosis and fractures

ICD-10-CM code category M80- (osteoporosis with current pathologic fracture) denotes fractures caused by osteoporosis. Coders should only report a code from the M80- series when a patient has a current pathologic fracture at the time of the encounter.

When coding for the fracture, select the code based on the site of the fracture, not the location of the osteoporosis, Nicholson says. Consider the following examples of codes that denote a pathologic fracture with osteoporosis:

M80.011, age-related osteoporosis with current pathologic fracture, right shoulder
M80.022, age-related osteoporosis with current pathologic fracture, left humerus
M80.041, age-related osteoporosis with current pathologic fracture, right hand
M80.871, other osteoporosis with current pathologic fracture, right ankle and foot

As with other pathologic fracture codes, those that denote pathologic fractures with osteoporosis include laterality. Some codes do offer options for unspecified laterality, such as unspecified shoulder, humerus, ankle, or foot.

Note that codes for pathologic fractures with osteoporosis also require a seventh character to indicate episode of care.

Procedure coding for fractures

Not all coding will change after the switch to ICD-10-CM. Physicians will continue to use CPT® codes for outpatient procedures, Nicholson says.

In addition, medical terminology won't change, although physicians will need to document more specific information in some cases. That means complete and accurate documentation will continue to be important. Coders must continue to read the operative report and code only the services the physician actually performs.

For example, a physician may document that he or she performs an open reduction with internal fixation. Oftentimes, the physician actually performs a closed reduction and then makes the incision to perform the internal fixation, Gold says. In this case, coders should report a closed reduction with internal fixation instead of the open reduction.

Many times physicians don't perform a reduction if the fragment is aligned well, Gold says. "Read the operative report to see what the physician really did."

Use the Gustilo-Anderson classifications for open fractures

ICD-10-CM categories S52- (fracture of forearm), S72- (fracture of femur), and S82- (fracture of lower leg, including ankle) require additional seventh character extensions to identify open fractures using the Gustilo-Anderson classifications, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass.

The Gustilo-Anderson classifications are the most commonly used classifications for open fractures. The classifications identify the severity of the soft tissue damage.

Note the following Gustilo-Anderson classifications:

Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury). This is the result of low-energy trauma, caused by events such as falls from a sitting position or while standing.
Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury.
Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

Type III fractures are further divided into the following:

IIIA: Soft tissue coverage of the fractured bone is adequate.
IIIB: Extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture. After debridement and irrigation, a local or free flap is necessary for coverage.
IIIC: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

When coding open fractures in ICD-10-CM, select the appropriate seventh digit from these options:

B: Initial encounter for open fracture type I or II
C: Initial encounter for open fracture type IIIA, IIIB, or IIIC
E: Subsequent encounter for open fracture type I or II with routine healing
F: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
H: Subsequent encounter for open fracture type I or II with delayed healing
J: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
M: Subsequent encounter for open fracture type I or II with nonunion
N: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
Q: Subsequent encounter for open fracture type I or II with malunion
R: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Documentation should identify whether an open fracture is type III, McCall says. Otherwise, coders should assign a seventh character B for the initial care of all other open fractures.

Fractures are indexed by type in the Alphabetical Index (i.e., pathologic vs. traumatic). However, the index will only direct coders to the series of codes-not the specific code, McCall says.

Seventh character for closed fractures

The meaning of the seventh character for ICD-10-CM codes varies according to chapter and category. Fracture codes are an example of a category of codes for which the seventh character includes additional information about the type of encounter.

When coding a closed fracture, coders must add one of the following seventh characters to each code:

A: Initial encounter for fracture
D: Subsequent encounter for fracture with routine healing
G: Subsequent encounter for fracture with delayed healing
K: Subsequent encounter for fracture with nonunion
P: Subsequent encounter for fracture with malunion
S: Sequela

Report seventh character A (initial encounter) while the patient is receiving active treatment for the injury. This includes:

Surgical treatment
ED encounter
Evaluation and treatment by a new physician

Extensions for subsequent encounter (i.e., D, G, K, and P) denote encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. These types of encounters include:

Cast change or removal
Removal of external or internal fixation device
Medication adjustment
Other aftercare and follow-up visits

When a patient presents for a subsequent visit, physicians must document whether a fracture is considered routine or delayed healing, malunion, nonunion, or sequela. ICD-10-CM doesn't include an unspecified option for the seventh character extension, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass.

Don't report the ICD-10-CM aftercare Z codes for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate seventh character for subsequent encounter, McCall says.

Compare ICD-9-CM, ICD-10-CM coding for spinal conditions

Tue, 01 May 2012 04:00:00 GMT

Compare ICD-9-CM, ICD-10-CM coding for spinal conditions

Spinal conditions can be congenital, pathologic, or traumatic, and they can affect the vertebrae, spinal cord, muscles, nerves, discs, or a combination of the parts of the spine.

Many of the coding rules and guidelines pertaining to spinal conditions will remain the same in ICD-10-CM. However, physicians must document additional information for almost all spinal conditions.

Let's look at the coding similarities and differences for some common spinal conditions.

Congenital spinal conditions

Congenital anomalies of the spine may be simple (e.g., no spinal deformity) or complex (e.g., severe spinal deformity, cor pulmonale, or paraplegia), says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services in Orlando, Fla. The most common congenital spinal deformities are:

Hyperlordosis
Kyphosis
Scoliosis

In ICD-9-CM, coders report 754.2 (certain congenital musculoskeletal deformities of the spine) to denote all three conditions.

Not surprisingly, ICD-10-CM includes more detailed codes for reporting spinal conditions. For example, congenital conditions, such as kyphosis, are divided into separate code categories based on the specific location of the deformity. In ICD-10-CM, coders must choose from among the following codes for congenital kyphosis:

Q76.411, congenital kyphosis, occipito-atlanto-axial region
Q76.412, congenital kyphosis, cervical region
Q76.413, congenital kyphosis, cervicothoracic region
Q76.414, congenital kyphosis, thoracic region
Q76.415, congenital kyphosis, thoracolumbar region
Q76.419, congenital kyphosis, unspecified region

Physicians must document the specific region involved, which is not something they currently do in ICD-9-CM.

Acquired conditions

Patients can also acquire all three conditions (i.e., hyperlordosis, kyphosis, and scoliosis). In ICD-9-CM, coders choose from among the following codes that denote acquired conditions:

Kyphosis (737.1x), which is further divided into acquired (postural), due to radiation, postlaminectomy, and other
Lordosis (737.2x), which is further divided into acquired, postlaminectomy, other postsurgical, and other
Kyphoscoliosis and scoliosis (737.3x-), which is further divided into idiopathic, resolving infantile idiopathic, progressive infantile idiopathic, due to radiation, thoracogenic, and other

In ICD-10-CM, when a patient is diagnosed with acquired kyphosis, physicians must document whether the kyphosis is postural or secondary, as well as the specific site involved.

Coding for pathologic spinal conditions

Underlying diseases can cause a malfunction of the entire spine or a component of the spine and can lead to a variety of pathologic conditions, Safian says.

Examples of pathologic spinal conditions include rheumatoid arthritis of spine not otherwise specified (ICD-9-CM code 720.0) and Paget's disease (ICD-9-CM code 731.0).

Paget's disease, also referred to as osteitis deformans, says Safian, is a slowly progressing metabolic bone disease that is divided into two phases: osteoclastic and ostoblastic. When coding for Paget's disease, coders have two choices in ICD-9-CM:

731.0, osteitis deformans without mention of bone tumor
731.1, osteitis deformans in diseases classified elsewhere

ICD-9-CM code 731.1 includes a note directing coders to first code the underlying disease.

In ICD-10-CM, Paget's disease has its own series of codes (M88-) that specifies the site of the disease, including the specific bone involved and laterality. For example, coders can choose from among three ICD-10-CM codes for Paget's disease of the shoulder:

M88.811, osteitis deformans of right shoulder
M88.812, osteitis deformans of left shoulder
M88.819, osteitis deformans of unspecified shoulder

Coding for spinal stenosis

Spinal stenosis is another common pathologic spinal condition, and it's often age-related, Safian says. However, patients who suffer a spinal injury or who are born with narrow canal syndrome may seek treatment at a younger age.

In spinal stenosis, narrowing of the nerve cavities (i.e., spinal canal and intervertebral foramen) causes pressure to be placed on the spinal cord, cauda equina, and/or nerve roots. As a result, patients experience severe pain radiating down the extremities, numbness, cramping, and weakness.

When coding for spinal stenosis in ICD-9-CM, coders must know the site of the stenosis. Coders can choose from the following ICD-9-CM codes:

723.0, spinal stenosis of cervical region
724.0, spinal stenosis, other than cervical
724.00, spinal stenosis, unspecified region
724.01, thoracic region
724.02, lumbar region, without neurogenic claudication
724.03, lumbar region, with neurogenic claudication
724.09, other

In 2011, ICD-9-CM added the distinction for lumbar spinal stenosis with or without neurogenic claudication, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc., in Danvers, Mass. However, ICD-10-CM currently doesn't include this distinction, she says.

In ICD-10-CM, specific codes identify when the stenosis spans contiguous levels. For example, ICD-10-CM code M48.03 denotes stenosis, cervicothoracic, McCall says. In ICD-9-CM, coders assign separate codes for cervical and thoracic stenosis. In ICD-9-CM, lumbosacral is in the Alphabetical Index but is assigned to the lumbar stenosis code. ICD-10-CM includes a specific code for lumbosacral stenosis (M48.07).

Coding for traumatic spinal injuries

Traumatic injuries to the spine include traumatic fractures (ICD-9-CM codes 805-806), herniated discs (ICD-9-CM code 722.x), and whiplash (ICD-9-CM code 847.0). When coding for a traumatic fracture in ICD-9-CM, coders must know:

Which bone was fractured
Whether the fracture was open or closed
Which specific segment of the bone was fractured
How the patient was injured
The location at which the injury took place
Whether the spinal cord was injured

In ICD-9-CM, the codes for traumatic fractures of the spine are divided into two series: without mention of spinal cord injury (805) and with spinal cord injury (806).

All of the codes in the 806 series require a fifth digit for added specificity. Codes 805.0 (cervical, closed) and 805.1 (cervical, open) also require a fifth digit subclassification to identify the specific cervical vertebra involved.

For fractures of the cervical vertebrae using ICD-10-CM, coders don't need to add an additional character to specify the cervical vertebra involved. That's because this information is included in the code description. For a nondisplaced posterior arch fracture of first cervical vertebra, coders should report ICD-10-CM S12.031 with a seventh character to indicate encounter.

For a displaced lateral mass fracture of first cervical vertebra, coders would assign S12.040, again with the appropriate seventh character. If a patient suffers a posterior displaced Type II dens fracture of the second cervical vertebra, report code S12.111 with a seventh character.

Traumatic fractures of lumbar vertebrae are included in ICD-10-CM code category S32.0-. For these types of fractures, physicians must document the specific type of fracture, such as a wedge compression fracture, stable burst fracture, unstable burst fracture, or other fracture.

Codes in category S32.0 also cover fractures of the neural arch, spinous process, transverse process, vertebra, and vertebral arch. Coders should also code first any associated spinal cord and spinal nerve injury (S34-), according to the note.

For all codes in this subsection, coders must add a seventh character to specify the encounter. For example, add an "A" as the seventh character to denote an initial encounter. Without the seventh character, the code is invalid.

This Month's Coding Q&A

Tue, 01 May 2012 04:00:00 GMT

This Month's Coding Q&A

Coding for unsuccessful foreign body removal

Q I perform ED coding in my facility and have a question about a recent case in which a 3-year-old presented with a Q-tip® in his ear. The physician tried to remove the Q-tip with forceps and ear washer, but it wouldn't come out. Should I report CPT® code 69250 for a foreign body removal from the ear? Should I also add a modifier because the physician couldn't successfully remove the Q-tip? The provider did not document any information regarding follow-up care.

A CPT code 69200 (removal foreign body [FB] from external auditory canal; without general anesthesia) would be the correct code if your facility decides to report this service. CPT states that the success of a procedure doesn't dictate whether a coder can report a code to denote that procedure. However, you must consider several factors when deciding whether to report the code.

Regarding your particular question, more information is needed. For example, will the patient be sent to a specialist for removal of the Q-tip? If so, the specialist should bill for the FB removal. If the ED also bills, the family will receive a bill for more than one FB removal.

The payer (and parents) may question the medical necessity of reporting a procedure code in addition to an ED visit level if the provider could not remove the Q-tip in the ED. You might consider the procedure "work" in the calculation of the ED visit level, depending on your hospital's internal visit leveling guidelines.

On the other hand, facility CPT charges are billed based on facility resource utilization (e.g., equipment, supplies, and staff). If resources were expended, the procedure code for the unsuccessful procedure may technically be reported.

CPT code 69200 is paid under APC 0340 at $45.64. If reported, the procedure code for an unsuccessful procedure should, at a minimum, include a modifier. Payer policies vary widely regarding appropriate use of modifiers. Even CMS and CPT sometimes disagree, so be sure to ask your payer about its use of modifiers for unsuccessful procedures. Modifier -52 (reduced services) is approved for outpatient facility coding and may be the most appropriate choice (AMA, 2012 CPT Manual).

In general, a hospital's internal coding policy manual should clarify how to code unsuccessful procedures so all coders understand and apply the policy consistently.

Assigning modifier -52 for cancelled procedures

Q Our radiology department is billing for cancelled diagnostic procedures. For example, a provider cancels a test for a specific reason (e.g., the patient is in too much pain to undergo an x-ray). Radiology staff members are appending modifier -52 (reduced services). I thought modifier -52 indicates that a test performed is either partially reduced or discontinued as compared to what a particular CPT code describes when there isn't another code to report. Has something changed?

A CMS noted in the January update to OPPS, Transmittal 2386, that it updated its guidance regarding modifiers for discontinued services effective January 1. Since 2005, guidance concerning modifier -52 included "partial reduction or discontinuation of services for which anesthesia is not planned." The updated language for modifier -52 now includes this verbiage:

The guidance also states the following:

Documentation in the medical record must include specific information about medical necessity that led to cancellation or a reduced service. This documentation is crucial to support the resources being reported and to document the clinical/medical reason that necessitated cancellation of the service. Cancellation is elective, and the service is not reportable when a patient arrives but decides not to undergo the scheduled test or when a patient doesn't arrive at all for a scheduled test.

Refer to the Medicare Claims Processing Manual, Chapter 4, section 20.6.4.

New HCPCS codes for April

Q Did CMS establish any new HCPCS codes in the April update to OPPS?

A Yes, Transmittal 2418 establishes several new HCPCS codes that are effective April 1, 2012.

New procedure HCPCS code C9733 (non-ophthalmic fluorescent vascular angiography) is assigned to APC 0397 and has a status indicator Q2. Status indicator Q2 means that this will be a packaged service when reported on the same date of service as a procedure assigned a status indicator T.

CMS established four new codes for drugs and biologicals assigned status indicator G (i.e., pass-through status). The four codes are:

C9288, Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
C9289, Injection, asparaginase erwinia chrysanthemi, 1000 international units (I.U.)
C9290, Injection, bupivacaine liposome, 1 mg
C9291, Injection, aflibercept, 2 mg vial

Discuss these new codes with the appropriate departments in your facility and ensure that they are added to your chargemaster if performed or provided. Transmittal 2184 can be accessed in its entirety at www.cms.gov/transmittals/downloads/R2418CP.pdf.

Reporting vaccine administration codes

Q We have been reporting the CPT code for vaccine administration (90471) when administering the hepatitis B vaccine to patients. The Medicare Claims Processing Manual indicates this is appropriate. However, we have heard that a G-code should be reported instead. Which code is correct?

A HCPCS code G0010 (administration of hepatitis B vaccine) was reported on Medicare claims when providers administered the hepatitis B vaccine prior to January 2006. CMS changed the status indicator for G0010 from S (significant procedure, not discounted when multiple) to B (codes not recognized by OPPS when submitted on an outpatient hospital Part B bill type) in January 2007 and instructed coders to report the appropriate CPT codes (90471, 90472) for this service.

In March 2011, CMS published Transmittal 2174 in which it changed the status indicator for G0010 back to S. This change was retroactive to January 1, 2011.

CMS created a separate benefit category for the hepatitis B vaccine and waived the deductible and coinsurance. The status indicator change was necessary to identify the administration of the hepatitis B vaccine and enable the claims processing system to apply the waiver of the coinsurance and deductible to both the administration of the vaccine as well as the vaccine itself. Because these types of claims processing edits are based on reported codes, CMS cannot appropriately adjudicate claims without a specific HCPCS code for this service.

Transmittal 2390, published January 25, indicates that CMS did not update the instructions in the Medicare Claims Processing Manual to reflect the change when it released the original transmittal and reactivated the code under the OPPS.

CMS is updating the instructions in Chapter 18, section10.2.1 to reflect the appropriate billing instructions. The edit will be effective July 2, 2012, according to Transmittal 2390. Providers that are aware of any claims that were adjudicated inappropriately should bring these claims to the attention of their FIs/MACs for correction.

Providers should immediately update their CDMs to ensure that HCPCS code G0010 is reported for the administration of the hepatitis B vaccine.

New composite codes for 2012

Q What new composite codes, if any, did CMS create for 2012?

A CMS created a new composite for cardiac resynchronization therapy. The new composite affects the following CPT codes:

33249, Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
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)

When coders report these codes on one claim for the same date of service, CMS will process the claim as a composite service and make a single payment. When coders report these codes on different dates of service or only report one code of the pair, CMS will make a payment for the individual APC assignment for each code.

CMS assigned status indicator Q3 to both codes to indicate they may be part of a composite methodology. Based on information submitted on a UB-04, the I/OCE will apply composite guidelines and determine payment accordingly.

In a related matter, CMS implemented a claims processing edit to ensure that CPT code 33225 is billed with one of the procedure codes for implantation of a cardioverter-defibrillator or pacemaker. See the parenthetical note after the code in the CPT Manual for a listing of relevant codes. CMS has added section 10.2.2 to Chapter 4 of the Medicare Claims Processing Manual to reflect the new composite and claims processing edits for CPT code 33225. Refer to Transmittal 2386 for additional information.

Contributors

We would like to thank the following contributors for answering the questions that appear on pp. 10-12:

Andrea Clark, RHIA, CCS, CPC-H

President

Health Revenue Assurance Associates, Inc.

Plantation, Fla.

Candace E. Shaeffer, RHIA, RN, MBA

Chief Compliance Officer

LYNX Medical Systems, Inc.

Bellevue, Wash.

Denise Williams, RN, CPC-H

Director of Revenue Integrity Services

Health Revenue Assurance Associates, Inc.

Plantation, Fla.

Briefings on APCs, May 2012

Tue, 01 May 2012 04:00:00 GMT

Catch up on what's new with injections and infusions

Poor documentation and a lack of clear guidance continue to cause coders to struggle with reporting injections and infusions.

CPT changes to drug administrationguidelines

"The litmus test again is: Is it significant and separately identifiable, and under audit, would you be able to demonstrate that via the documentation and the record?" Shah says.

The AMA also included a statement defining concurrent infusion. A concurrent infusion occurs when a new substance or drug is infused at the same time as another substance or drug. This is not a time-based code, which can be confusing because coders generally think of infusions as time-based services, Shah says.

Concurrent infusions (CPT add-on code 96368) are only reported once per day regardless of whether an additional new drug or substance is administered concurrently.

Clarifying the guidelines

The 2012 CPT Manual also includes guideline changes pertaining to sequential infusions. According to the CPT guidelines:

Coders should hone in on the terms "sequential" and "new substance or drug," Shah says. Those are the two most important parts of the definition. If the provider is not infusing a new substance, coders should not report a sequential service.

Many facilities have inquired about how to handle scenarios in which a patient receives an infusion of a drug and then receives a separate IV push of that same drug, Shah says.

For example, a patient receives a therapeutic infusion of a drug for one hour. Coders should report CPT code 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour).

However, what happens when that same patient receives an IV push of the same drug? Coders know they should report an IV push code; however, they don't always know which one is appropriate, Shah says. Many coders are confused about whether to report CPT code 96375 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug) or 96376 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of the same substance/drug in a facility).

"What we know now is that we can use 96376," Shah says, noting that coders may feel uncomfortable reporting 96376 without reporting an initial push code. However, the key to understanding the guideline is to remember that it's the same drug-first as an IV infusion and then as an IV push. Coders may also feel uncomfortable about CPT's clarification involving multiple infusions. According to CPT guidelines:

Again, coders should focus on the terms "multiple infusions" and "same drug or substance," Shah says. Coders already know to report second and subsequent infusions based on the individual times of each additional infusion. However, add-on codes for drug administration services don't necessarily follow the standard thinking in CPT of using the additional hours code, Shah says. Thus, coders must become comfortable with this guideline.

It might look like coders are simply adding up all the times for three different infusions and it just happens to work, Shah says. However, CPT states in the guidelines, "the second and subsequent infusion should be reported based on the individual time of each infusion." "So what they're saying is if you've got the same drug and it's infused multiple times, that's fine. The way that you report the additional infusions of that same drug is using the add-on code, not the sequential infusion code," Shah says.

How to handle conflicting guidelines

CPT and CMS have both published guidelines regarding drug administration services that overlap the midnight hour and cross into the next day. Unfortunately for coders, each set of guidelines conflicts with the other, Shah says.

For example, a patient receives intravenous hydration from 11 p.m. to 2 a.m. A coder reports 96360 once for the initial hour of hydration and 96361 twice for the additional hours because it's a continuous service, Shah says. The CPT guidelines go on to state:

"What we know now is that hospitals should not follow this-meaning this IV push example instructing two initial services to be reported," Shah says. Instead, hospitals should continue to follow Medicare Claims Processing Manual, section 230.2, Coding and Payment for Drug Administration, which states:

Medicare is clearly aware of what CPT instructs hospitals to do; however, it disagrees with the guidance that CPT provides, Shah says. "[Medicare] is going to continue following the rules that it has had in place now for drug administration where you have one initial service except in very specific instances, such as multiple vascular access sites or multiple separate visits. And so in this example, we would not follow CPT."

For continuous services that extend beyond the midnight hour, such as hydration, OPPS hospitals should use the date on which the services begin and report the total units of time during which the services are provided continuously. Don't be confused by the example in the CPT Manual about the IV push, Shah says.

Because Medicare is such a large governmental payer, it establishes some of its own rules, Hoy says. This allows CMS to set rules that are technically contrary to HIPAA standards.

HIM staff members should ensure that coding rules are reflected in the facility's coding software, Hoy says. This will help the facility track each of the different rules.

Fracture coding in ICD-10-CM requires greater specificity

Coders must know the following details to assign a correct ICD-10-CM code for this scenario:

Which leg and which specific bones were injured
Whether the fracture was open or closed
Whether the fracture was displaced
Whether this was an initial or subsequent visit

Type of fracture

Providers must document, in some form, whether the fracture is traumatic or pathologic.

A traumatic fracture is caused by some type of accident, fall, or other kind of force. For example, a traumatic fracture can occur after a car accident or when a person is struck with a heavy object.

A pathologic fracture is a broken bone caused by disease. In ICD-9-CM, coders must choose from only eight pathologic fracture codes. ICD-10-CM expands this code selection to more than 150 codes.

Site of the fracture

In addition, some ICD-10-CM codes include wording such as "distal end" or "proximal end"; coders should look for this information in the medical record.

If more than one site is involved, coders can report multiple site codes, says Nicholson.

For example, if a patient presents with fractures to multiple ribs, coders should choose from among these codes and add the appropriate seventh character:

S22.41x, multiple fractures of ribs, right side
S22.42x, multiple fractures of ribs, left side
S22.43x, multiple fractures of ribs, bilateral
S22.49x, multiple fractures of ribs, unspecified side

S82.222, displaced transverse fracture of shaft of left tibia
S82.452, displaced comminuted fracture of shaft of left fibula

ICD-10-CM pathologic fractures

Not all pathologic fractures are due to cancer. Unfortunately, most physicians don't call a fracture pathologic unless it is caused by a malignancy, Gold says.

As a result, insufficient documentation of pathologic fractures can be problematic for coders, says Nicholson. "It's up to the physician to document whether it is a pathologic fracture," she says.

For example, physicians should document the following details for osteoporosis:

Whether the osteoporosis occurs with or without current pathologic fracture and history of pathologic fracture
The specific bone fractured and laterality, as appropriate
Whether the osteoporosis is age-related or due to some other specific cause (e.g., chronic steroid use or vitamin deficiency)

Coding for osteoporosis and fractures

M80.011, age-related osteoporosis with current pathologic fracture, right shoulder
M80.022, age-related osteoporosis with current pathologic fracture, left humerus
M80.041, age-related osteoporosis with current pathologic fracture, right hand
M80.871, other osteoporosis with current pathologic fracture, right ankle and foot

Note that codes for pathologic fractures with osteoporosis also require a seventh character to indicate episode of care.

Procedure coding for fractures

Not all coding will change after the switch to ICD-10-CM. Physicians will continue to use CPT® codes for outpatient procedures, Nicholson says.

Many times physicians don't perform a reduction if the fragment is aligned well, Gold says. "Read the operative report to see what the physician really did."

Use the Gustilo-Anderson classifications for open fractures

The Gustilo-Anderson classifications are the most commonly used classifications for open fractures. The classifications identify the severity of the soft tissue damage.

Note the following Gustilo-Anderson classifications:

Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury). This is the result of low-energy trauma, caused by events such as falls from a sitting position or while standing.
Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury.
Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

Type III fractures are further divided into the following:

IIIA: Soft tissue coverage of the fractured bone is adequate.
IIIB: Extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture. After debridement and irrigation, a local or free flap is necessary for coverage.
IIIC: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

When coding open fractures in ICD-10-CM, select the appropriate seventh digit from these options:

B: Initial encounter for open fracture type I or II
C: Initial encounter for open fracture type IIIA, IIIB, or IIIC
E: Subsequent encounter for open fracture type I or II with routine healing
F: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
H: Subsequent encounter for open fracture type I or II with delayed healing
J: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
M: Subsequent encounter for open fracture type I or II with nonunion
N: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
Q: Subsequent encounter for open fracture type I or II with malunion
R: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Documentation should identify whether an open fracture is type III, McCall says. Otherwise, coders should assign a seventh character B for the initial care of all other open fractures.

Fractures are indexed by type in the Alphabetical Index (i.e., pathologic vs. traumatic). However, the index will only direct coders to the series of codes-not the specific code, McCall says.

Seventh character for closed fractures

When coding a closed fracture, coders must add one of the following seventh characters to each code:

A: Initial encounter for fracture
D: Subsequent encounter for fracture with routine healing
G: Subsequent encounter for fracture with delayed healing
K: Subsequent encounter for fracture with nonunion
P: Subsequent encounter for fracture with malunion
S: Sequela

Report seventh character A (initial encounter) while the patient is receiving active treatment for the injury. This includes:

Surgical treatment
ED encounter
Evaluation and treatment by a new physician

Cast change or removal
Removal of external or internal fixation device
Medication adjustment
Other aftercare and follow-up visits

Compare ICD-9-CM, ICD-10-CM coding for spinal conditions

Spinal conditions can be congenital, pathologic, or traumatic, and they can affect the vertebrae, spinal cord, muscles, nerves, discs, or a combination of the parts of the spine.

Many of the coding rules and guidelines pertaining to spinal conditions will remain the same in ICD-10-CM. However, physicians must document additional information for almost all spinal conditions.

Let's look at the coding similarities and differences for some common spinal conditions.

Congenital spinal conditions

Hyperlordosis
Kyphosis
Scoliosis

In ICD-9-CM, coders report 754.2 (certain congenital musculoskeletal deformities of the spine) to denote all three conditions.

Q76.411, congenital kyphosis, occipito-atlanto-axial region
Q76.412, congenital kyphosis, cervical region
Q76.413, congenital kyphosis, cervicothoracic region
Q76.414, congenital kyphosis, thoracic region
Q76.415, congenital kyphosis, thoracolumbar region
Q76.419, congenital kyphosis, unspecified region

Physicians must document the specific region involved, which is not something they currently do in ICD-9-CM.

Acquired conditions

Patients can also acquire all three conditions (i.e., hyperlordosis, kyphosis, and scoliosis). In ICD-9-CM, coders choose from among the following codes that denote acquired conditions:

Kyphosis (737.1x), which is further divided into acquired (postural), due to radiation, postlaminectomy, and other
Lordosis (737.2x), which is further divided into acquired, postlaminectomy, other postsurgical, and other
Kyphoscoliosis and scoliosis (737.3x-), which is further divided into idiopathic, resolving infantile idiopathic, progressive infantile idiopathic, due to radiation, thoracogenic, and other

In ICD-10-CM, when a patient is diagnosed with acquired kyphosis, physicians must document whether the kyphosis is postural or secondary, as well as the specific site involved.

Coding for pathologic spinal conditions

Underlying diseases can cause a malfunction of the entire spine or a component of the spine and can lead to a variety of pathologic conditions, Safian says.

Examples of pathologic spinal conditions include rheumatoid arthritis of spine not otherwise specified (ICD-9-CM code 720.0) and Paget's disease (ICD-9-CM code 731.0).

731.0, osteitis deformans without mention of bone tumor
731.1, osteitis deformans in diseases classified elsewhere

ICD-9-CM code 731.1 includes a note directing coders to first code the underlying disease.

M88.811, osteitis deformans of right shoulder
M88.812, osteitis deformans of left shoulder
M88.819, osteitis deformans of unspecified shoulder

Coding for spinal stenosis

Spinal stenosis is another common pathologic spinal condition, and it's often age-related, Safian says. However, patients who s

Determine when to charge inpatient supplies separately

Sun, 01 Apr 2012 04:00:00 GMT

Determine when to charge inpatient supplies separately

Editor's note: In last month's issue of Briefings on APCs, we looked at how to separately charge for ancillary bedside procedures for inpatients in a compliant manner. This month, we switch our focus to billing separately for supplies provided to inpatients.

Coders and billers may not completely understand how to charge for inpatient supplies. One misconception is that the room rate incorporates all supplies used for every inpatient. Another misconception is that payers will not separately pay for inpatient supplies.

Facilities often refer to the following criteria when determining whether to separately bill for supplies used for inpatients. In order to separately bill for an inpatient supply, the supply must meet all three of these criteria:

Directly identifiable to a patient
Not generally provided to most patients
One of the following:
- Not reusable
- Represents a cost for each preparation
- Categorized as complex medical equipment

What CMS says

CMS derives the criteria referenced above from the skilled nursing facility (SNF) section of the definition of ancillary services for SNFs in section 22032 of the Medicare Provider Reimbursement Manual. Thus, the criteria are not actually related to hospitals, although they may be helpful when drafting a charging policy for supplies, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, MA.

Providers often cite a list of routine or stock items and say CMS prohibits charging for these items. This list of stock items is also derived from the SNF section of the Medicare Provider Reimbursement Manual, says Hoy. The list of stock items includes:

All general nursing services, including but not limited to administration of oxygen and related medications, hand feeding, incontinency care, and tray service
Items that are furnished routinely and relatively uniformly to all patients (e.g., patient gowns, paper tissues, water pitchers, basins, bed pans, deodorants, and mouthwashes)
Items stocked at nursing stations or on the floor in gross supply and distributed or utilized individually in small quantities (e.g., alcohol, applicators, cotton balls, bandages, antacid, aspirin [and other non-legend drugs kept on hand], suppositories, and tongue depressors)
Items used by individual patients that are reusable and expected to be available (e.g., ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, or other durable medical equipment)

Don't discard the list. Instead, consider including a cost for routine items in the room rate because facilities don't count these items or document their use for individual patients, Hoy says.

On the other hand, items such as antacid and aspirin, which are also included in the list, are supplies that hospitals could count and separately report, Hoy says. That's because they are supplies on the SNF list of stock items. CMS says charge structure should be consistent across inpatient, outpatient, and SNF settings; however, CMS also created the list of SNF stock items. The list raises the question of whether CMS believes the SNF definitions should apply across all settings, and if so, what this means for hospitals that commonly charge for items such as aspirin separately, Hoy says.

"I don't know that [the list was] put in the reimbursement manual to change that practice, but more as a way to say we need to see more consistency,” she says.

Keep in mind that each department within the hospital will likely have its own list of what it considers routine supplies, says Denise Williams, RN, CPC-H, vice president of revenue integrity services for Health Revenue Assurance Associates, Inc., in Plantation, FL. For example, the nursing department's list of routine supplies will likely differ from the list that the surgery department maintains.

Nursing supplies

Providers must understand that not all items kept on stock for a nursing floor are routine items. Bulk items, such as alcohol preps, iodine swabs, and gloves, are routine items because nurses use them with every patient.

However, other supplies-some of which may even be kept on the same shelf within the supply closet-may not be routine items, says Williams. These nonroutine items, such as Foley catheters and IV solutions, are kept on the shelf for easy access. They are not used for every patient, and they are separately identifiable to a specific patient, Williams says.

Nursing staff or other hospital personnel keep these nonroutine items on hand so when a physician writes an order, they can quickly retrieve the item instead of waiting for it to arrive from central supply or another department, Williams says.

Surgery supplies

Most, if not all, of the items routinely required for surgery are included in a facility's surgery charge. Some facilities set up their charges for minor, intermediate, and major surgeries, Williams says. Other facilities may divide surgeries by specialty, such as general, vascular, or orthopedic. Facilities generally include a set charge for the supplies used based on the level of surgery or the specialty.

Routine items, such as gowns, drapes, gloves, sheets, and basins, are included in the procedure, and the charge amount varies depending on the surgery.

Items must be disposable in order to charge separately for them. Some may argue that gowns, drapes, and gloves are disposable; however, they are also required to perform the procedure, Williams says.

Instead of thinking "routine,” think "required,” she suggests. Is the item required to perform the surgery? If so, it's not separately billable. Facilities that set up charges based on the surgical specialty can be more specific in terms of determining what items are required. For example, an item required for a vascular surgery may not be used routinely for an orthopedic surgery. Thus, the facility would include the item in the vascular surgery charge; however, the facility could consider billing the item separately if a surgeon uses it for an orthopedic procedure.

What about reprocessed items? Are they routine? Williams and her associates at Health Revenue Services spoke with a number of FIs several years ago when facilities first started using reprocessed supplies. The FIs agreed that facilities could separately charge for reprocessed supplies because they sent the supply to a company to reprocess it, then paid to get the item back, Williams says.

"You have a cost related to the second time you use that item,” she says. "So you may have a charge.”

Some facilities charge for reprocessed supplies and others don't. It's a decision that each facility must make on its own, Williams says.

Other supplies

Always consider what is required for a particular service before separately billing for inpatient supplies, says Williams. A laboratory can't perform tests without using specimen containers, butterfly needles, and Vacutainers. As a result, facilities should not separately bill for these items. The cost should be included in the cost of the test.

If the cost associated with tracking an item exceeds the item's value, build the cost of the item into the charge for the test or procedure, Williams says. "Again, this is an internal decision, and it is a balancing act based on what your methodology is and how much staff time you are using to sticker and track that item.”

Many facilities have an internal cost threshold, says Williams. For example, if a supply costs less than $5 to purchase, the facility won't charge for it. "Regardless of which caveat you use or steps you take along the way, consistency is the most important thing,” she says.

Creating a billing policy

Remember that CMS requires facilities to charge all patients consistently. However, the agency provides little guidance regarding how to bill for inpatient supplies. This means each hospital must create its own internal charging policy, Hoy says.

When creating a billing policy, consider the SNF criteria of whether an item is identifiable to an individual patient. If it is, consider charging separately because it's easy to audit these items. If an item is generally provided to most patients, it's easier to include the charge for that item in the room and board rate rather than bill separately for the item, Hoy says.

Don't forget about specialty bandages that may only be used in certain areas. Although bandages are on the SNF list of stock items, not all types of bandages are used for every patient. Consider separately charging for these specialty items because they can be identified to a specific patient, Williams says.

"SNF is lending us some rules here that are good to use across all settings,” Hoy says. "Because charging has to be consistent across all settings, these are some good rules to use.”

This Month's Coding Q&A

Sun, 01 Apr 2012 04:00:00 GMT

This Month's Coding Q&A

Reporting HCPCS codes for drugs that aren't separately payable under OPPS

Q Our CFO wants us to restructure our pharmacy chargemaster to report HCPCS code for drugs that are not separately paid under OPPS. Is there a reason to add the HCPCS codes to the chargemaster?

A In the early days of OPPS, facilities reported HCPCS codes to reflect pass-through status for supplies and drugs. When pass-through status expired, codes were deleted and no longer reportable under the OPPS.

However, as CMS began to base its payment calculation on claims data, the agency had no specific information to identify items that were reported on a claim. All supplies would be categorized under the same supply revenue code that didn't identify the specific item.

A similar situation arose with pharmacy items reported under revenue code 025x. Over the past few years, it has become apparent that many drugs are categorized under the same revenue code (0250). No HCPCS code is reported. CMS has also noted in past OPPS final rules that if a HCPCS code is reported on a line item with revenue code 0250, the HCPCS code is not recognized in the data used for rate setting. This means that information related to drugs and biologicals that are reported without a HCPCS code is not identified and therefore not included in the APC payment calculations.

For CY 2012, CMS strongly encourages hospital providers to report HCPCS codes for all drugs if a specific HCPCS code is available. In Transmittal 2386, CMS notes:

More complete data from hospitals on the drugs and biologicals provided during an encounter would help improve payment accuracy for separately payable drugs and biologicals in the future. … CMS realizes that this may require hospitals to change longstanding reporting practices. … CMS notes that it makes packaging determinations for drugs and biologicals annually based on charge information reported with specific HCPCS codes on claims, so the accuracy of OPPS payment rates for drugs and biologicals improves when hospitals report charges for all items and services that have HCPCS codes under those HCPCS codes, whether or not payment for the items and services is packaged or not. It is CMS' standard rate-setting methodology to rely on hospital cost and charge information as it is reported to CMS by hospitals through the claims data and cost reports. Precise billing and cost reporting by hospitals allow CMS to most accurately estimate the hospital costs for items and services upon which OPPS payments are based.

Providers should review and update their chargemasters to include the HCPCS codes for all drugs and biologicals regardless of whether they are separately payable. This will ensure that CMS can calculate correct and specific cost from claims data. Doing so will lead to more accurate payment for specific procedures and services. Otherwise, this cost cannot be allocated to the procedure into which the cost is supposedly bundled.

Coding for diabetes in ICD-10-CM

Q How will coding for diabetes change in ICD-10-CM?

A In ICD-10-CM, the diabetes mellitus codes are combination codes that include the following information:

Type of diabetes
Body system affected
Complications affecting that body system

These combination codes make coding diabetes mellitus less confusing, and they decrease the number of codes necessary to describe diabetic complications. Coders may report as many combination codes as needed to completely describe all complications. Coders should sequence the codes based on the reason for a particular encounter.

In ICD-10-CM, the diabetes mellitus codes are no longer classified as controlled or uncontrolled. If provider documentation includes words such as "uncontrolled,” "out of control,” or "poorly controlled,” coders should report the type of diabetes with hyperglycemia.

In ICD-10-CM, diabetes mellitus falls under these ?five categories:

E08-Diabetes mellitus due to underlying condition
E09-Drug- or chemical-induced diabetes mellitus
E10-Type 1 diabetes mellitus
E11-Type 2 diabetes mellitus
E13-Other specified diabetes mellitus

Category O24 identifies diabetes mellitus in pregnancy, childbirth, or the puerperium.

Deducting push time from infusions

Q If a nurse administers an IV push without a stop time at the same time hydration is running, how many minutes should we deduct from the hydration time?

A Nothing in the CPT guidelines or from CMS requires start and stop times for pushes. Pushes are typically short duration and last for only a few seconds.

In my opinion, you don't need to deduct push time from hydration or from an infusion because there's no requirement for start and stop times for pushes.

However, a Q&A in CPT Assistant alluded to the fact that providers would deduct some time for the push from either the hydration or the infusion. This means providers should make a decision regarding whether they're going to follow this notion that pushes need a start and stop time and then deduct accordingly.

The best solution is to continue to pose the question to CPT Assistant.

Average time for CPT initial observation codes

Q Observation care codes 99218, 99219, and 99220 in the 2012 CPT Manual include the average time physicians spend at the bedside and present on the patient's hospital floor or unit for initial observation care. Do these codes only apply when the counseling and/or coordination of care support the respective minutes of time?

A As of January 1, CPT guidelines state that these time measurements have not been revised. The measurements provide general guidance regarding the approximate time a physician may spend physically present on the floor in the patient's unit and at the patient's bedside while adding to or reviewing the patient's chart. The physician's time may also be spent performing a physical examination on the patient, writing or dictating notes, and spending time communicating with other healthcare professionals, the patient, and the patient's family.

The times are not part of the code description. Instead, they are simply a general guide for each level. Report the code that most accurately represents the tasks performed-not the time spent.

Reporting molecular pathology codes

QAddendum B of the APC updates for 2012 lists the new molecular pathology codes as status indicator E (noncovered service, not paid under OPPS). Our laboratory director said we should report the new codes in addition to the codes that are payable. Can you explain why?

A Providers use molecular pathology tests to detect the presence of specific genes. Currently, coders report these tests with multiple CPT® codes to describe the specific testing that providers perform. When reported in this way, codes are referred to as being "stacked.”

In CY 2012, the AMA created new CPT codes for these tests to reflect each test with a single code. However, claims data reflects the stacked codes that historically have been reported for these services. No one-to-one relationship maps the old codes to new codes. No easy crosswalk between them exists.

Multiple current CPT codes will map to one new code, and one current CPT code will map to several new codes because they are reported for several types of testing. CMS must consider this multiple-to-one and multiple-to-multiple mapping before determining payment rates.

CMS depends on providers to report both sets of codes to facilitate mapping the new CPT codes to the current cost/pricing information. Assignment of status indicator E should allow this line item to pass through the I/OCE without delaying claims. CMS will not reimburse providers for the new codes. Reporting in this manner will put the new code on the same claim with current codes for the service and allow CMS to analyze the claims with the individual codes and the combination of codes that were reported for future rate-setting under the Clinical Diagnostic Laboratory Fee Schedule. Transmittal 2386 provides the following guidance:

Effective January 1, 2012, under the hospital OPPS, hospitals are advised to report both the existing CPT "stacked” test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active.

Use of the word "advised” suggests this reporting is voluntary. However, providers must carefully consider the future impact of failing to report both sets of codes. If providers don't report both codes, CMS will use incomplete and insufficient claims data to determine the payment amount for these services. These molecular pathology tests are complex; if providers don't report both sets of codes, the resulting payment determination could be insufficient for the services provided. Providers should read the entire section of the transmittal pertaining to reporting these codes.

Contributors

We would like to thank the following contributors for ?answering the questions that appear on pp. 10-12:

Andrea Clark, RHIA, CCS, CPC-H

President

Health Revenue Assurance Associates, Inc.

Plantation, FL

Shannon McCall, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS

Director of Coding and HIM

HCPro, Inc.

Danvers, MA

Jugna Shah, MPH

President, Nimitt Consulting

Washington, DC

Denise Williams, RN, CPC-H

Director of Revenue Integrity Services

Health Revenue Assurance Associates, Inc.

Plantation, FL

Take a trip through the digestive system

Sun, 01 Apr 2012 04:00:00 GMT

Take a trip through the digestive system

by Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer

The digestive system consists of two parts: the alimentary canal and the accessory organs. The alimentary canal is the direct path through the body from the mouth to the anus. This pathway includes:

Mouth
Pharynx
Esophagus
Stomach
Small intestine
Large intestine
Rectum
Anus

The digestive accessory organs play a role in the way the body processes food and water so that each tissue and organ system has the fuel to function. These organs secrete enzymes, alkalines, and other substances that are required for the digestive process and include:

Salivary glands
Liver
Gallbladder
Pancreas

Start at the top-the mouth

Virtually all nourishment enters the body at the mouth, or oral cavity, which includes the:

Lips
Cheeks
Tongue
Lingual tonsils
Hard and soft palates
Uvula
Palatine tonsils
Pharyngeal tonsils
Teeth

Lips form the entranceway into the oral cavity and the alimentary canal. Their mobility and flexibility aids in the formation of sounds to enable speech.

Cheeks form an area as they meet the gingiva known as the buccal cavities. The inner lining of the cheek is made up of moist, stratified squamous epithelium cells.

The tongue does more than help you form the sounds of speech. It helps rotate food particles into position so the teeth, particularly the molars, can grind the food to enable swallowing safely. The tongue meets with the hyoid bone in the posterior of the mouth and has a surface of lymphatic tissue masses known as the lingual tonsils. When you touch the roof (hard palate) of your mouth with your tongue, you can see a membrane below that appears to connect your tongue with the sublingual gland along the bottom of your mouth. This is called the lingual frenulum.

On each side at the back of the tongue are collections of lymphatic tissue known as the palatine tonsils-so called because of their location at the back of the mouth where the soft palate begins to curve into the throat. The drop-shaped appendage hanging in the posterior of your throat, called the uvula, also helps modulate tones during speech.

The pharyngeal tonsils (adenoids) sit on the posterior wall of the pharynx and are also made of lymphatic tissue.

As the teeth and tongue break down food in preparation for the journey down the alimentary canal, three major salivary glands (the parotid, submandibular, and sublingual glands) secrete saliva to moisten and bind the food particles. This begins the chemical digestion of carbohydrates by dissolving foods so you can appreciate their flavor. It also makes swallowing food particles easier. In addition, saliva helps clean the teeth and mouth after the particles leave the oral cavity.

Moving down the throat

The pharynx is an open cavity posterior to the nose and mouth leading down to the esophagus. This section of the human anatomy serves two important systems: the respiratory system when inhalation is in process, and the digestive system when food and drink are ingested. The pharynx is subdivided, for reference only, into three sections:

Nasopharynx
Oropharynx
Hypopharynx, also called the laryngopharynx

At the superior end of the larynx is the epiglottis, a flap that closes the path to the larynx and trachea, thereby directing food and liquid down the esophagus to the stomach.

The esophagus is a tubelike structure that connects the hypopharynx to the stomach. It lies parallel and posterior to the trachea. At the lower end of the esophagus, the upper esophageal sphincter restricts the entrance of air into the stomach.

A second esophageal sphincter is located at the juncture between the esophagus and the stomach (the lower esophageal sphincter). It is designed to prevent the contents of the stomach from splashing back up into the esophagus. When this sphincter does not function properly, a person might experience chronic heartburn, nausea, and possibly a sore throat.

Now entering the stomach

The next organ along the alimentary canal is the stomach. As stated earlier, the stomach connects to the esophagus at the lower esophageal sphincter in the cardiac region of the stomach, also known as the cardia. To the left, the stomach curves upward creating the fundic region, or fundus. The fundus of the stomach is located superior to (above) the opening to the esophagus.

The lining of the stomach, a mucous membrane, contains gastric glands that secrete gastric juices. Similar to the function of saliva in the processing of food in the mouth, the gastric juices support the extraction of nutrients from the contents that entered from the esophagus. Mucous cells coat the internal wall of the stomach to prevent the gastric juices from digesting the stomach itself. When this coating is flawed, a person might develop a gastric (peptic) ulcer, where the acids in the stomach actually eat a hole in the lining and wall of the stomach.

As the stomach curves downward, the inside of the curve on the cardiac side is referred to as the lesser curvature. The outside curve, coming down from the fundus, is referred to as the greater curvature. The lower portion of the stomach narrows as it nears the duodenum and connects to the small intestine. The pyloric sphincter is located here to control the emptying of the stomach contents forward into the lower half of the digestive system.

Welcome to the lower GI

The gallbladder is an oblong-shaped pouch lying atop of the duodenum. This sac stores bile, a yellow-green liquid that is used by the body to assist in digestion. When required, the gallbladder contracts to release bile into the duodenum via the common bile duct.

Tucked right below the diaphragm and above the gallbladder, on the right side of the superior aspect of the abdominal cavity, sits the liver, a triangular-shaped organ. The liver is subdivided in two sections by a ligament. The left lobe of the liver is equal to about one-third of the total size with the right lobe making up the remaining two-thirds.

The liver helps metabolize proteins, carbohydrates, and lipids. In addition, it stores glycogen, iron, and vitamins A, D, and B12; removes damaged red blood cells, foreign matters, and toxins by filtering the blood; and secretes bile into the common bile duct by way of the common hepatic duct.

The inferior aspect of the pyloric sphincter is the duodenum, the first segment of the small intestine. The duodenum curves around like the letter "c,” with the pancreas tucked in the center. The hepatopancreatic sphincter, also called the sphincter of Oddi, is the connection point between the duodenum, the pancreatic duct, and the common bile duct that comes from the gallbladder and the liver.

The pancreas provides pancreatic juice, via the pancreatic duct into the duodenum, to assist with proper digestion. The pancreatic islets (the islets of Langerhans) are responsible for secreting hormones, including glucagon and insulin.

As the duodenum trails into that last portion, at the bottom of the "c,” it curves around and becomes the jejunum, the segment of the small intestine that twists and turns throughout the abdomen. The mesentery membrane connects to the jejunum like a spiderweb filled with blood vessels, nerves, and lymphatic vessels to provide nourishment to the intestine. The greater omentum, a double-fold of the peritoneum, looks like a protective curtain on the anterior side of the abdominal cavity from the greater curvature of the stomach down to the anterior of the jejunum.

The ileum is the last segment of the small intestine. It connects to the cecum, the bridge to the large intestine, via the ileocecal sphincter. This sphincter controls the passage of material from the small intestine to the large intestine. At this point, one will find the vermiform appendix, a rounded tubular appendage, protruding from the end of the cecum.

And then into the colon

The colon is also known as the large intestine and the two terms are used almost interchangeably. Actually, the large intestine consists of the cecum, the colon, the rectum, and the anal canal. The colon represents the majority of the large intestine, but the two are technically not the same thing.

Starting at the cecum, the colon frames the abdomen and is referred to in four segments. The ascending colon stretches upward from the cecum to just below the liver in the superior aspect of the abdomen. At this point, this tubular structure makes a left turn, known as the hepatic flexure, and stretches directly across the abdomen to the left side. This is named the transverse colon because it traverses the abdomen. Here on the left side, the colon turns downward at a curve known as the splenic flexure. This downward segment, known as the descending colon, continues down until it slightly curves, just above the pelvis, and becomes the sigmoid colon.

The large intestine turns downward again into the rectum, which leads directly into the anal canal. At the distal end of the anal canal, the internal and external anal sphincters form the anus, the opening to the outside-the end … literally.

ICD-10-CM coding: Start with the structure

Sun, 01 Apr 2012 04:00:00 GMT

ICD-10-CM coding: Start with the structure

The transition to ICD-10-CM is coming. The only question is when. CMS is currently reviewing the implementation date that was originally set for October 1, 2013. As of presstime, CMS had not published a revised implementation date.

Despite the delay, coders and other HIM professionals must continue to prepare for the transition.

Coders must remember that the diagnostic conditions won't necessarily be new, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, MA. Instead of relying on memory for the appropriate codes, coders will need to manually look up codes (or use an encoder) to choose the correct code. This step will be necessary until coders become accustomed to the new system, says McCall.

To locate an ICD-10-CM code, coders should look up the main term in the Alphabetic Index or Table of Drugs and Chemicals, then verify the code assignment in the Tabular List, says McCall. Coders should also consider any instructional notes pertinent to the category of codes they assign.

Learn the structure of the new codes

Coders will need to adjust to the appearance of ICD-10-CM codes, as it differs significantly from ICD-9-CM codes.

Currently, ICD-9-CM codes consist of three to five digits. For example, ICD-9-CM code 490 denotes bronchitis, not specified as acute or chronic.

If a physician documents simple chronic bronchitis, coders can assign a four-digit code (491.0) that reflects the added specificity. If a physician documents obstructive chronic bronchitis with acute exacerbation, coders can report a five-digit code (491.21) to reflect the added severity.

ICD-10-CM codes, on the other hand, contain three to seven characters, where the first character is always a letter, the second is numeric, and characters three through seven can be alpha or numeric. As in ICD-9-CM, the first three characters of an ICD-10-CM code designate a category, McCall says.

The decimal point is used after the third character. The seventh character is used in certain chapters to provide information about the characteristics of the encounter.

For example, when a physician documents bronchitis, not specified as acute or chronic, coders should report ICD-10-CM code J40. Simple chronic bronchitis becomes J41.0.

Chronic obstructive bronchitis codes fall within the J44.- series in ICD-10-CM. For chronic obstructive pulmonary disease with acute exacerbation, coders should report ICD-10-CM code J44.1.

Some ICD-10-CM codes include greater detail and additional characters.

When looking at injuries and diseases of the musculoskeletal system, codes become even more specific. Codes for pneumococcal arthritis of the hand require seven characters, with the seventh character indicating laterality (i.e., which hand is affected).

Laterality is a new convention in ICD-10-CM, McCall says. "It's something that is pretty easy to incorporate into the documentation. If a physician documents a fracture, it's not uncommon for the physician to include right or left in the documentation,” she adds.

Understand the role of characters 4-7

The fourth through seventh characters can vary by chapter and by disease. As an example, consider the meaning of characters four through seven in Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue (M00-M99).

Characters four through six of codes within this range denote the etiology, anatomic site, and severity. The seventh character represents the visit, encounter, or sequelae for injuries and external causes. The meanings of the seventh character for ICD-10-CM codes vary across chapters and categories, says Sandy Nicholson, MA, RHIA, vice president of health information services for DCBA, Inc., a consulting firm in Atlanta.

Do not use the ICD-10-CM aftercare Z codes for aftercare for injuries, Nicholson says. Assign the acute injury code with the appropriate seventh character for subsequent encounter for this purpose.

Get to know the placeholder

Not every ICD-10-CM code with a seventh character has a sixth character-or even a fifth or fourth character for that matter. This frequently occurs with poisonings and injuries. The letter "x” serves as a placeholder when a code contains fewer than six characters and a seventh character applies, says Nicholson. The "x” also allows for future expansion of the codes.

When reporting ICD-10-CM codes, coders must add a placeholder so the seventh character is in the correct position. Without this placeholder to ensure characters appear in the correct positions, codes are invalid.

For example, a patient presents with an accidental poisoning by an antiallergic drug. For the initial encounter, coders should report ICD-10-CM code T45.0x1A. In this case, the x in the fifth position serves as a placeholder so that the sixth and seventh characters are in the correct position. If a coder inadvertently omits the placeholder, the resulting code would be T45.01A, which is invalid.

Coders should also note that an ICD-10-CM code can start with an X (i.e., codes X00-X99), McCall says. For example, in code category X78.0, the X denotes the intention of an injury, exposure, etc. The X series of codes is part of Chapter 20: External Causes of Morbidity.

Note that the location of the X within a code matters. When x is in the fourth, fifth, and/or sixth character, it appears lowercase and is a placeholder. When X is at the beginning of the code, it is uppercase and indicates the chapter.

Not everything is changing in ICD-10-CM

The ICD-10-CM coding system includes some considerable changes from ICD-9-CM; however, some aspects will remain the same.

Outpatient coders will continue to use CPT codes the same way they do currently, says Robert S. Gold, MD, CEO of DCBA, Inc., a consulting firm in Atlanta. The only aspect that will change is how the diagnosis is reported.

The terms that physicians use to document diagnoses and procedures won't change either, Gold adds. Coders will continue to see the same terminology in the medical record. The language that physicians use won't change to accommodate for the new codes, although coders should be prepared to query for additional information when necessary.

Most of the coding guidelines will also remain the same. The challenge for coders will be to apply the new guidelines when they contradict those that have been in place for many years, cautions Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist with HCPro, Inc., in Danvers, MA.

"Coders are very structured people and they don't like it when guidelines change,” Avery says. "That's going to be a struggle [for some coders].”

Coders who code both inpatient and outpatient records will still need to remember which hat they're wearing, Avery says. As with ICD-9-CM, some of the ICD-10-CM guidelines vary depending on setting.

Note other similarities

Coders and other HIM professionals generally focus on the ways in which ICD-10-CM is different from ICD-9-CM. This includes the number of codes, their length and appearance, the level of specificity, and the increased documentation requirements.

However, not everything is changing. For example, the index in ICD-10-CM will be structured similarly to the index in ICD-9-CM. ICD-10-CM indexes will include the Alphabetic Index of Diseases and Injuries, Alphabetic Index of External Causes, Table of Neoplasms, and Table of Drugs and Chemicals. The Alphabetic Index will be divided into two parts:

Index to Diseases and Injuries
Index to External Causes

The ICD-10-CM Tabular Index will retain the same hierarchical structure as ICD-9-CM. The chapters are structured similarly to ICD-9-CM with minor exceptions. For example, the sense organs (i.e., eye and ear) will move from the nervous system chapter to their own specific chapters.

In addition, many conventions (e.g., abbreviations, punctuation, and symbols) will retain the same meaning. Even though ICD-10-CM generally provides more detail, nonspecific codes (i.e., those that are unspecified or not otherwise specified) are available to use when providers don't include enough detail in the documentation to support more specific code assignment.

Parentheses will continue to enclose supplementary terms that may be present or absent in the statement of a disease or procedure. These are otherwise known as nonessential modifiers, says Kim Felix, RHIA, CCS, director of education with MECA, LLC, in Holland, PA.

Inclusion terms and includes notes carry the same meaning in ICD-10-CM as they do in ICD-9-CM (i.e., to clarify the content of the chapter, subchapter, category, or subdivision to which the terms apply), Felix says.

Throughout the ICD-9-CM tabular listing, notes describe the general content of the succeeding categories and provide instructions for assigning these codes. The same is true for ICD-10-CM.

In ICD-10-CM, "code first” notes will continue to alert coders that two codes are necessary to completely classify the condition. The term "and” will continue to mean "and/or” in both the Alphabetic Index and the tabular listing for ICD-10-CM.

Briefings on APCs, April 2011

Sun, 01 Apr 2012 04:00:00 GMT

Determine when to charge inpatient supplies separately

Directly identifiable to a patient
Not generally provided to most patients
One of the following:
- Not reusable
- Represents a cost for each preparation
- Categorized as complex medical equipment

What CMS says

All general nursing services, including but not limited to administration of oxygen and related medications, hand feeding, incontinency care, and tray service
Items that are furnished routinely and relatively uniformly to all patients (e.g., patient gowns, paper tissues, water pitchers, basins, bed pans, deodorants, and mouthwashes)
Items stocked at nursing stations or on the floor in gross supply and distributed or utilized individually in small quantities (e.g., alcohol, applicators, cotton balls, bandages, antacid, aspirin [and other non-legend drugs kept on hand], suppositories, and tongue depressors)
Items used by individual patients that are reusable and expected to be available (e.g., ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, or other durable medical equipment)

Don't discard the list. Instead, consider including a cost for routine items in the room rate because facilities don't count these items or document their use for individual patients, Hoy says.

"I don't know that [the list was] put in the reimbursement manual to change that practice, but more as a way to say we need to see more consistency,” she says.

Nursing supplies

Surgery supplies

Routine items, such as gowns, drapes, gloves, sheets, and basins, are included in the procedure, and the charge amount varies depending on the surgery.

Items must be disposable in order to charge separately for them. Some may argue that gowns, drapes, and gloves are disposable; however, they are also required to perform the procedure, Williams says.

"You have a cost related to the second time you use that item,” she says. "So you may have a charge.”

Some facilities charge for reprocessed supplies and others don't. It's a decision that each facility must make on its own, Williams says.

Other supplies

Creating a billing policy

"SNF is lending us some rules here that are good to use across all settings,” Hoy says. "Because charging has to be consistent across all settings, these are some good rules to use.”

Take a trip through the digestive system

by Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer

The digestive system consists of two parts: the alimentary canal and the accessory organs. The alimentary canal is the direct path through the body from the mouth to the anus. This pathway includes:

Mouth
Pharynx
Esophagus
Stomach
Small intestine
Large intestine
Rectum
Anus

Salivary glands
Liver
Gallbladder
Pancreas

Start at the top-the mouth

Virtually all nourishment enters the body at the mouth, or oral cavity, which includes the:

Lips
Cheeks
Tongue
Lingual tonsils
Hard and soft palates
Uvula
Palatine tonsils
Pharyngeal tonsils
Teeth

Lips form the entranceway into the oral cavity and the alimentary canal. Their mobility and flexibility aids in the formation of sounds to enable speech.

Cheeks form an area as they meet the gingiva known as the buccal cavities. The inner lining of the cheek is made up of moist, stratified squamous epithelium cells.

The pharyngeal tonsils (adenoids) sit on the posterior wall of the pharynx and are also made of lymphatic tissue.

Moving down the throat

Nasopharynx
Oropharynx
Hypopharynx, also called the laryngopharynx

At the superior end of the larynx is the epiglottis, a flap that closes the path to the larynx and trachea, thereby directing food and liquid down the esophagus to the stomach.

Now entering the stomach

Welcome to the lower GI

And then into the colon

ICD-10-CM coding: Start with the structure

Despite the delay, coders and other HIM professionals must continue to prepare for the transition.

Learn the structure of the new codes

Coders will need to adjust to the appearance of ICD-10-CM codes, as it differs significantly from ICD-9-CM codes.

Currently, ICD-9-CM codes consist of three to five digits. For example, ICD-9-CM code 490 denotes bronchitis, not specified as acute or chronic.

The decimal point is used after the third character. The seventh character is used in certain chapters to provide information about the characteristics of the encounter.

For example, when a physician documents bronchitis, not specified as acute or chronic, coders should report ICD-10-CM code J40. Simple chronic bronchitis becomes J41.0.

Chronic obstructive bronchitis codes fall within the J44.- series in ICD-10-CM. For chronic obstructive pulmonary disease with acute exacerbation, coders should report ICD-10-CM code J44.1.

Some ICD-10-CM codes include greater detail and additional characters.

Understand the role of characters 4-7

Do not use the ICD-10-CM aftercare Z codes for aftercare for injuries, Nicholson says. Assign the acute injury code with the appropriate seventh character for subsequent encounter for this purpose.

Get to know the placeholder

Not everything is changing in ICD-10-CM

The ICD-10-CM coding system includes some considerable changes from ICD-9-CM; however, some aspects will remain the same.

"Coders are very structured people and they don't like it when guidelines change,” Avery says. "That's going to be a struggle [for some coders].”

Coders who code both inpatient and outpatient records will still need to remember which hat they're wearing, Avery says. As with ICD-9-CM, some of the ICD-10-CM guidelines vary depending on setting.

Note other similarities

Index to Diseases and Injuries
Index to External Causes

Correctly bill ancillary �bedside procedures in �addition to the room rate

Thu, 01 Mar 2012 04:00:00 GMT

Correctly bill ancillary bedside procedures in addition to the room rate

As technology evolves, providers can perform more procedures at the patient's bedside than they ever could in the past. Previously, they could only perform these procedures in another department of the hospital, and they had to charge separately for them.

As charges become more specific to provide additional concrete and transparent cost data, providers must consider what procedures they routinely provide to patients and what procedures are specifically related to the patient's condition.

In some cases, hospitals may charge for certain services when the provider performs the service in an ancillary department, but not at a patient's bedside. The facility's staff may believe they are not permitted to charge for a service provided at the bedside of an inpatient or may think the cost is already accounted for in the regular room rate.

"If we're going to charge them in the ancillary department, why can't we charge them when they are done at the bedside?" says Denise Williams, RN, CPC-H, vice president of revenue integrity services for Health Revenue Assurance Associates, Inc., in Plantation, FL. "They are the same procedures and they are done for the very same indications."

Charging for inpatient services

CMS provides very little guidance regarding how hospitals should bill inpatient services, including ancillary bedside procedures. This lack of guidance confuses facilities because it's unclear what they can bill for in addition to the room rate.

Although it would be helpful if CMS provided additional guidelines, the agency does allow latitude so facilities with different needs can make things work for their structure, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, MA.

Individual payers also add to the confusion by stipulating that facilities cannot bill for certain ancillary bedside procedures or invoking Medicare coverage rules that don't exist, Hoy adds.

So instead of having actual guidelines, many consultants and payers are creating best practices based on Medicare's recommendations, Hoy says. Sometimes these individuals or entities inaccurately cite those recommendations as actual CMS guidance. As a result,third-party payers incorrectly deny items billed separately from the room rate. (For more on what CMS actually says, see the related article on p. 4.)

Apply charges uniformly

CMS specifically says facilities must apply charges uniformly to inpatients and outpatients. This becomes important when providers render ancillary services to inpatients, Hoy says.

Facilities often question whether they can bill something as an ancillary service for an inpatient. In many cases, facilities would absolutely bill those services separately for outpatients, Hoy says.

"What we see is a disparate application of charges between inpatients and outpatients, and it isn't really clear that this is what Medicare intends," she says. CMS seems to intend that facilities separately bill the same services for inpatients and outpatients, she adds.

Each facility has its own charging methodology, so the staff has to look at that methodology as an individual facility or system, Williams says. Then weigh the pros and cons of the decision you're going to make, she adds.

Some providers include everything in the room rate. As a result, these providers have a really high room rate because they believe it's too difficult operationally to list out all of the separate charges. Other providers find it easier to delineate the separate items, resulting in a lower room rate, Hoy says.

"That philosophy of how am I going to set my charges is really up to you, and you need to establish that," Hoy says. "However, facilities should also follow the common practices of other hospitals in the same area."

Determine what's in the room rate

So how should a facility's staff initiate the discussion about what to bill separately? Start by determining and defining what's included in the room rate, Williams says. 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, Williams says. "If you use that term, you want to specify exactly what your definition of overhead is," she says.

Facilities must also define what they consider standard nursing services. Think about whether any nurse can provide a particular service within his or her scope of practice. "You may decide that something is standard nursing care and happens for most of your patients," Williams says. "Therefore, you're going to include that in your room rate."

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

Also, determine whether you charge a service separately to any patient in your facility regardless of whether the patient is an inpatient or outpatient. Remember that you must apply charges uniformly to every patient.

"You have to sit down and have a discussion and get away from the idea that everything for an inpatient is included in the room rate," Williams says.

Create a policy for the room rate

Once a facility decides to charge for ancillary bedside procedures, staff must then create a policy definition to describe what is included in the facility's room rate, Williams says. "It's probably a good idea to do it anyway, whether you decide to proceed down the path now or you think you might do it later. It really is important to know for now and for the future exactly what is included in your room rate," she says.

For example, hospital XYZ defines its room rate to include the following services:

Nursing care provided by any RN without additional certification or training required, such as vital signs and routine postoperative care
All dietary requirements eaten or provided via the gastrointestinal tract (meals, snacks, enteral nourishment)
Housekeeping services
Electricity, water, and other systems required to operate the facility
Disposal of trash, biohazard materials, etc.
Supplies that are available to the general patient population and not specifically ordered by a physician
Alcohol, Betadine®, and other skin cleansing products
Cotton balls and cotton tip applicators

All other items/services not defined by the above categories are considered to be nonroutine and patient-specific services. When provided for an individual patient, hospitals should report these services as a separate line item on the patient's bill.

Once a facility creates its policy, it will be able to demonstrate to CMS and to other auditors that it is charging all patients in the same way, Williams says.

"If you don't have some of these things defined, you can tell CMS what you think is happening," she says. "If I'm CMS or a CMS entity that is auditing, and I ask six different people this question and I get six different answers, I'm going to start to wonder if all patients really are being charged the same."

In addition to serving as defense during an audit, the written policy will document the decision-making process and provide guidance for the future, says Williams.

Define bedside procedures

After defining what is included in the room rate for the inpatient room, review what services remain, and determine whether a line-item charge is appropriate and/or feasible, Williams says. Define bedside procedures the facility does not currently report on inpatient claims. The trick is to actually create the definition, Williams says, because the phrase "bedside procedures" is similar to the term "overhead" in that its meaning is somewhat subjective.

"We've coined that phrase for things done for the patient at the bedside and they are an inpatient," Williams says. When patients are in observation, facilities often already capture many of these charges.

Consider using outpatient procedures as a guide to determine whether a service meets the facility's definition of what is and isn't included in the room rate. Consider procedures such as:

Lumbar punctures
Insertion of Foley catheter
Declotting of implanted vascular access device

Also, consider ICD-9-CM procedure codes that providers don't perform in the OR. "Surgeries are charged so the cost is captured for the individual patient," Williams says. "We are interested in those procedures that are not currently line item reported."

Charging methodologies

Facilities can use a variety of methods to charge for ancillary procedures.

Consider establishing a line-item charge for bedside procedures using a revenue code that HIM coders report (e.g., 0369). HIM can then report the appropriate CPT code based on the documentation in the record. The data is then stored internally for costing and trending purposes, Williams says.

Even though facilities don't report CPT codes on inpatient bills, some hospitals have decided to put the CPT code on the bill for their internal information and to ensure they capture every service, Williams says.

Not every bedside procedure results in an identical charge, she says. Facilities must consider what to charge for each procedure, or they can choose to bill the same amount they would in the outpatient setting.

For inpatient claims, report the service with revenue code 0230. Most payers consider revenue code 0230 to be a "routine service" revenue code and an extension of the room rate.

For outpatient claims, report the service with an ancillary revenue code (e.g., 0361, 0761, or 0260).

Effect on payment rates

CMS has determined that billing for ancillary services affects APC and MS-DRG payment rates. CMS uses cost reporting to set these payment rates, and when facilities don't appropriately report ancillary charges, CMS does not account for those charges in the reimbursement.

When facilities group a large number of services into a category that is not well defined, CMS cannot easily determine the differential costs between patients. "If your room rates include a lot of different things that only a few patients receive, then it's very hard to tell which patients are more expensive and need more services compared to ordinary patients," says Hoy.

CMS' inability to distinguish each of the different nursing services across multiple types of patients presents a large challenge when it comes to setting PPS payment rates because the agency can't tell which patients require more expensive services.

By separating specialized nursing services and reporting more detailed incremental charges, facilities provide CMS with additional data that it can use to set appropriate payment rates.

Providers also need more specific cost information to ensure the reimbursement they negotiate with third-party payers is commensurate with their costs, Williams says. "So we have to consider what procedures are routinely provided to patients and which ones are patient-condition specific," she explains.

The bottom line is facilities must charge all patients the same way, Hoy says. Facilities must also establish a charge structure that is separate from the one in the chargemaster. They need a way to consistently mark up charges as well as a plan for how they will structure their charges, Hoy says.

Look at one example

In the 2009 IPPS final rule, CMS discusses charging for blood transfusions. This service is not specifically mentioned in the list of routine services or the list of ancillary services. Transfusions are arguably a specialty service, Hoy says. So providers must consider the common charging practices of hospitals in the same state as well as charging practices in their own subunits or other settings.

Facilities must separately bill transfusions in the outpatient setting because they are separately paid. In general, facilities bill transfusion ancillary cost centers (i.e., OR or ED) separately. In fact, facilities cannot bill for the blood itself without reporting the transfusion code as well.

In some ancillary areas, such as the ED, facilities also normally bill blood transfusions separately. It may be inappropriate to not bill transfusions separately for inpatients, Hoy says.

Determining which procedures to include in the room rate and which to charge separately is not an easy process, says Williams.

"This is definitely an Olympic-sized exercise," she says. "Decisions will not be made overnight. This is going to take some work."

What CMS actually says about billing ancillary procedures

When considering what guidance CMS provides regarding billing ancillary procedures, hospitals must understand how CMS defines charges. In §2202.4 of the Provider Reimbursement Manual, CMS states:

Charges refer to the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient. All patients' charges used in the development of apportionment ratios should be recorded at the gross value; i.e., charges before the application of allowances and discounts deductions.

CMS makes it clear in §2203 that although it cannot dictate a facility's charges or charge structure, it can determine whether the charges are allowable for use in apportioning costs, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, MA. Apportioning refers to how a facility allocates costs between Medicare and nonMedicare patients.

Apportioning can be traced back to when CMS reimbursed hospitals based on costs, Hoy says. Even though this is no longer the case, CMS still relies on this guidance to build rates, among other things. "So they are still concerned about what costs are appropriate to Medicare and what costs are appropriate to other payers," Hoy says.

To qualify for apportioning, facilities should establish a charge structure and apply it uniformly to all patients. The charge structure should be reasonably and consistently related to the costs of the services, Hoy says. "If you have a cost for a service, it should be represented in some reasonable and consistent way somewhere on your claim."

A facility must follow the same method of charge setting regardless of the setting in which the services take place (e.g., inpatient, outpatient, distinct part units, or skilled nursing facility). A facility must also follow that charging practice for Medicare and nonMedicare patients. The consistent application is what makes the costs apportionable, which is the ultimate goal, Hoy says.

In some instances, facilities may choose to incorporate the cost as part of a routine rate and consider other costs as ancillary. Either way, those charges should relate to costs. If a payer denies the charges, it is not allowing certain costs, Hoy says. As a result, facilities will have an imbalance between costs and charges. That's because the payer has taken away the charge even though the facility still incurs the costs.

Additional CMS guidance

CMS provided additional information as part of the 2009 IPPS final rule. In the IPPS rule, CMS provides information about common practices among providers in a state. CMS seems to say that facilities should base their decisions regarding whether to classify a service as routine or ancillary on what other facilities are doing, Hoy says.

As stated in the 2009 IPPS final rule, CMS requires facilities to follow the "common or established practice of providers of the same class in the same state" (73 Federal Register 48466). When no common or established classification of an item or service as routine or ancillary exists, CMS will recognize a provider's customary charging practice as long as the facility consistently follows the practice for all patients, and as long as the practice does not result in an inequitable apportionment of cost to the program.

"As long as you are consistent about it, CMS is going to let you determine what your charging practices are going to be," Hoy says.

Common charging practices will vary; however, CMS defines routine and ancillary services in §2202.6 of the Provider Reimbursement Manual as follows:

Inpatient routine services in a hospital or skilled nursing facility generally are those services included by the provider in a daily service charge-sometimes referred to as the "room and board" charge. Routine services are composed of two board components; (1) general routine services, and (2) special care units (SCUs), including coronary care units (CCUs) and intensive care Units (ICUs). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made.

Many ancillary services are not regular nursing services and are not specified in CMS' list of routine services, Hoy says.

Contrasting with routine services, CMS defines ancillary services in §2202.8 as follows:

Ancillary services in a hospital or SNF include laboratory, radiology, drugs, delivery room (including maternity labor room), operating room (including postanesthesia and postoperative recovery rooms), and therapy services (physical, speech, occupational). Ancillary services may also include other special items and services for which charges are customarily made in addition to a routine service charge.

According to these two definitions, regular nursing services are routine and should be included in the room rate. Specialty nursing services are ancillary services that are not included in the room rate and that facilities customarily charge separately.

ICD-10 anatomy refresher: Respiratory system

Thu, 01 Mar 2012 04:00:00 GMT

ICD-10 anatomy refresher: Respiratory system

by Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I

The respiratory system, responsible for inspiration (carrying oxygen into the body) and expiration (the expulsion of carbon dioxide), is composed of two tracts: the upper respiratory tract and the lower respiratory tract.

Upper respiratory tract

The upper respiratory tract begins at the nose, followed by the nasal cavity and paranasal sinuses, then culminates with the pharynx.

Respiration begins with the intake of air through the two nostrils (the openings of the nose). While air can be brought in through the mouth, the mouth and oral cavity are considered part of the digestive system. The air continues to flow through the nasal cavity, which is composed of the nasal septum (bone and cartilage) and the nasal conchae (bone).

The paranasal sinuses, air-filled cavities within the skull above and behind the nose, are lined with a mucous membrane and include the maxillary, frontal, ethmoidal, and sphenoidal sinuses.

The pharynx, commonly known as the throat, begins behind the nose (the nasopharynx) and continues down behind the oral cavity (the oropharynx) to the larynx. This enables the air to travel from the nasal cavity to the larynx, where the lower respiratory tract begins.

Lower respiratory tract

The epiglottis is a flap that opens to permit air to travel into the larynx or closes to prevent food particles and liquids from traveling into the larynx and ultimately the lungs. Food particles in the lungs can create severe breathing problems. The epiglottis tops the larynx, which includes the thyroid cartilage and the cricoid cartilage.

The air continues through the larynx into the trachea. At a point approximately at the center of the chest (thoracic cavity), the trachea forks into two parts, identified as the left and right primary bronchi.

The bronchi enter the left and right lungs, respectively, and continue to branch out into smaller bron-chioles. The bronchioles branch out into smaller tubelike structures called alveolar ducts that end with alveolar sacs. The sacs are surrounded by a fishnetlike network of capillaries from the pulmonary vein and artery to enable the exchange of gases (oxygen and carbon dioxide)-the purpose of the respiratory system.

This structure is similar to the branches of a tree. The trachea is like the trunk of a tree, branching out its limbs (the bronchi). Each limb then has its branches (the bronchioles) whose twigs (the alveolar ducts) blossom with buds (the alveolar sacs).

The lungs, located in the lower respiratory tract, are within the thoracic cavity and represent the largest portion of the respiratory system. The ribs form a protective cage around the lungs, meeting at the sternum in the anterior medial (front center) of the thorax. The diaphragm sits distally to the lungs.

Structure of the lungs

The lungs are composed of two hemispheres: the right lung and the left lung. The right lung is subdivided into three segments: the superior lobe, the middle lobe, and the inferior lobe. The superior lobe is located posterior to the first rib and the top of the sternum, the middle lobe approximately at the fifth rib. The seventh rib protects the distal end of the inferior lobe.

The left lung only has two lobes: the superior and the inferior. The oblique fissure (an angular crack) separates the lobes.

The exterior surface of the lungs is covered by the visceral pleura, a lubricated membrane. This slippery fluid, contained in the intrapleural space, hinders friction between the internal surface of the ribs and the lungs when they expand after inhalation.

ICD-9-CM: What you need to know

Coders need to understand the intimate details of the upper and lower respiratory systems to report diseases and conditions of the respiratory system (Chapter 8, codes 460-519). For a patient diagnosed with acute sinusitis, the physician must document which specific sinus is infected or inflamed so the coder can report the correct required fourth digit. If working with an ear, nose, and throat specialist, coders should focus on the upper tract; coders working with a pulmonologist will focus on the lower tract.

ICD-10-CM: What you need to know

Diseases of the respiratory system are listed in Chapter 10, codes J00-J99. At this point in time, the guidelines are the same as ICD-9-CM with additional guidance for the proper reporting of ventilatorassociated pneumonia.

CMS adds new modifier -PD, two edits, additional APCs

Thu, 01 Mar 2012 04:00:00 GMT

CMS adds new modifier -PD, two edits, additional APCs

Modifier -PD (diagnostic or related nondiagnostic item or service provided in a wholly owned or wholly operated entity to a patient who is admitted as an inpatient within three days or one day) is now included in the I/OCE, according to January updates detailed in Transmittal 2370.

"This is one of the real sleepers in this release," says Dave Fee, MBA, product marketing manager of outpatient products at 3M Health Information Systems in Murray, UT. "When you think of a new modifier, you don't think of it as a big deal."

That's not the case with modifier -PD, he says. Here's why: A hospital wholly owns or wholly operates a clinic or an ambulatory surgery center (ASC). A patient receives services at the clinic or ASC.

So far, so good.

However, if the patient is admitted to the hospital within three days, the services provided by the other entity must be included as part of the inpatient stay.

A problem arises when the clinic or ASC is wholly owned by the hospital but not provider-based. Provider-based clinics bill through the hospital, and both information management systems are tied together. A non-provider-based clinic or ASC is freestanding and has its own information management system and billing practices. The freestanding clinic or ASC also submits bills on its own. "They're really almost independent, but they happen to be wholly owned," Fee says.

Because the freestanding facility doesn't share information systems with the hospital, the hospital may not know when the three-day rule applies unless the patient mentions that he or she had previously received services at the freestanding facility.

"How do you know if they had a minor service provided somewhere else unless they mention it?" Fee says. "It really speaks to the need to have an enterprisewide [electronic health record]."

Providers should expect additional guidance about modifier -PD to clarify some of this confusion, Fee says. "I think all of the rules are still settling out, so we need to keep a close eye on this," he says.

New edits

CMS added two new edits to the I/OCE: edit 84 (claim lacks required primary code [RTP]) and 85 (claim lacks required device code or required procedure code [RTP]).

Edit 84 creates an interesting interplay between 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]) and 33249 (insertion or repositioning of electrode lead[s], for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator), Fee says.

The codes have Q3 status (codes subject to payment as part of a composite); however, 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 only pay for 33249 and package 33225 into the payment. However, if a facility bills code 33225 with a different primary code, CMS will pay for both.

"They are like composites, but they are not actually composites" Fee says. "They are conditionally paid, but the composite flag is not set."

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 two codes together. If a facility bills one without the other, it will trigger the edit and prevent payment.

The only exceptions occur when certain modifiers are appended. These include modifiers -52 (reduced services), -73 (procedures discontinued prior to anesthesia), and -74 (procedures discontinued after anesthesia administration or after the procedure has begun), Fee says.

APC changes

CMS added only 28 new APCs to the list, which is not an extensive number, Fee says. It does, however, bring the total number of APCs to 850. Many of the new APCs are related to pharmaceuticals, which seems to be a trend, he says.

CMS reassigned 15 APCs from status indicator G (pass-through drugs and biologicals) to status indica-tor K (non-pass-through drugs and biologicals). In addition, APC 00668 moved from status indicator S (significant procedure, not discounted when multiple) to status indicator T (significant procedure, multiple reduction applies).

Codes that require two devices

Codes 0238T (transluminal peripheral atherectomy, including radiological supervision and interpretation; iliac artery, each vessel) and 33249 now require two device pairs to satisfy edit 71 (claim lacks required device code). This is important to note because codes rarely require two devices to bypass the edit, Fee says.

Code 0238T requires both a PERM device and the leads, while code 33249 requires both the implantable cardioverter-defibrillator and the leads. "We just need to make sure both devices are coded," Fee says.

Reimbursement changes

Although CMS intended to lower the fixed dollar threshold for outlier payments from $2,025 to $1,900, it did not because of an error it made in calculating the update to the 2012 OPPS. The threshold is currently $2,025. "That's one of the changes that came out well after the fact," Fee says. (For more information, see 77 Federal Register 218.)

However, CMS did change the reimbursement rate for drug codes having status indicator K to average sales price plus 4%.

Code changes

CMS added four codes to the list of male procedures:

G8822, male patients with aneurysm minor diameter > 6 cm
G8828, aneurysm minor diameter <= 5.5 cm for men
G8829, aneurysm minor diameter 5.6-6.0 cm for men
G8830, aneurysm minor diameter > 6 cm for men

CMS added 15 codes to the list of female procedures:

81266, Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (e.g., pre-transplant recipient and donor germline testing, post-transplant non-hematopoietic recipient germline; each additional specimen)
G8802-G8805, pregnancy test, urine or serum
G8806-G8809, transabdominal or transvaginal ultrasound
G8810, Rh-immunoglobulin (Rhogam) not ordered for reasons documented by clinician
G8811, documentation Rh-immunoglobulin (Rhogam) was not ordered, reason not specified
G8823, female patients with aneurysm minor diameter > 6 cm
G8824, female patients with aneurysm minor diameter 5.6-6.0 cm
G8827, aneurysm minor diameter <= 5.5 cm for women
G8831, aneurysm minor diameter > 6 cm for women
G8832, aneurysm minor diameter 5.6-6.0 cm for women

CMS added 11 codes to the conditionally bilateral list, meaning coders can now append modifier -50, when applicable:

0282T-0238T, percutaneous or open implantation of neurostimulator electrode array(s)
20527, injection of an enzyme
26341, manipulation of the palmer fascial cord
29582-29584, application of multi-layer compression system
64633-64636, destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance

CMS also added two codes for central motor evoked potential studies (95928 and 95929) to the inherently bilateral list. Coders should not report modifier -50 with these codes.

Reordering blood products

Certain blood products cost more than others, and each Medicare patient has a blood deductible amount in his or her benefit, says Fee. When all of the new APC weights and rates are released, CMS reorders the blood products to ensure the most expensive ones are processed first, he says. This priority processing satisfies patients' deductibles. This isn't a big issue, but it is something facilities should be aware of, Fee says.

This Month's Cding Q&A

Thu, 01 Mar 2012 04:00:00 GMT

This Month's Cding Q&A

Reporting molecular pathology codes

Q Addendum B of the APC updates for 2012 indicates the new molecular pathology codes have status indicator E (noncovered service, not paid under OPPS). Our laboratory director said we should report these new codes in addition to the codes that are payable. Can you explain why?

A Providers use molecular pathology tests to detect the presence of specific genes. Currently, coders report these tests with multiple CPT® codes to describe the specific testing the provider performs. Codes reported in this manner are sometimes referred to as "stacked" codes.

The AMA created new CPT codes for these tests to reflect the service with a single code for CY 2012. Claims data reflects the stacked codes that have historically been reported for these services. No one-to-one relationship maps the old codes to new codes. Therefore, no easy crosswalk between them exists.

Multiple current CPT codes map to one new code, and one current CPT code will map to several new codes because they are reported for several types of testing. The result is multiple-to-one and multiple-to-multiple mapping that must be considered before payment rates can be determined.

CMS relies on providers to report both sets of codes to facilitate mapping the new CPT codes to the current cost and pricing information. Assignment of status indicator E should allow this line item to pass through the I/OCE without delaying claims. CMS will not reimburse providers for the new codes; however, reporting in this manner will result in claims that include both the new code and the current codes for the service. This will allow CMS to analyze the claims with the individual codes and the combination of codes that were reported for future rate setting under the Clinical Diagnostic Laboratory Fee Schedule. Transmittal 2386 provides the following guidance:

Effective January 1, 2012, under the hospital OPPS, hospitals are advised to report both the existing CPT "stacked" test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active.

The word "advised" suggests this reporting is voluntary. However, providers must carefully consider the future impact of not reporting both sets of codes. If providers don't report both sets of codes, incomplete and insufficient claims data will be used to determine the payment amount for these services.

These molecular pathology tests are complex. If providers don't report both sets of codes, the resulting payment determination could be insufficient for the services provided. Providers should be sure to read the entire section of the transmittal pertaining to reporting these codes.

Note that Transmittal 2386, which was published January 13, replaces Transmittal 2376.

Correct use of modifiers -FB and -FC

Q Our billing office is concerned about reports that the OIG is auditing for appropriate use of the following modifiers:

-FB (Item provided without cost to provider, supplier or practitioner, or credit received for replacement device [examples, but not limited to, covered under warranty, replaced due to defect, free samples])
-FC (Partial credit received for replaced device)

We know these audits may be related to pacemaker recalls. Our billing office doesn't typically know whether pacemakers are replaced due to a recall or because the battery simply needed replacement. No one seems to know at the time of the procedure whether the cost is discounted and whether modifier -FC is applicable. Billing office staff members say they know this information only when the invoice arrives.

Can you help us sort this out?

A CMS has required hospitals to append modifiers -FB and -FC since 2007 and 2008, respectively, to reflect the reporting of a device that the provider obtains at no cost (modifier -FB) or at a discounted cost (modifier -FC).

The modifiers are appropriate for reporting devices related to a recall, among other situations. Append modifier -FB when a facility incurs no cost for replacing a device or receives full credit for the cost of a device. For example, a patient has a previously placed pacemaker in 2009 and the device's battery is failing based on tests done in the physician's office. The manufacturer is required to provide a new device free of charge since the battery is covered under warranty for five years. The hospital will get paid to replace the device; however, the vendor should supply the device free of charge since it is under warranty.

Append modifier -FC when a facility receives a manufacturer credit of 50% or more of the cost of a device. For example, a patient has a previously placed dual-chamber pacemaker and presents to have it removed due to a recent recall. The physician decides at the time of implantation that, due to other symptoms, he or she will place an automatic implantable cardioverter-defibrillator (AICD) instead of replacing the dual-chamber pacemaker. In this scenario, the hospital has to identify what the upgraded cost is due to the AICD versus the original dual-chamber pacemaker.

When CMS packaged the cost of devices into the APC payment for the procedures, the total APC payment is largely due to the cost of the device. In the 2007 and 2008 OPPS final rules, CMS stated it believes a facility should receive reduced payment when it obtains a device at a decreased cost.

CMS believes that the Medicare program or a beneficiary should not pay for something that a facility receives at a substantially discounted cost. As a result, the agency created these modifiers for use in these instances. Report the appropriate modifier with the HCPCS code for the procedure-not the device. Appending the modifier triggers a reduced APC payment.

Establish a communication process to ensure that the appropriate parties know how to identify situations in which one of these modifiers is applicable.

We suggest that the hospital develop an internal strategy for identifying these situations before they are scheduled. Have the staff ask at the time of scheduling whether the procedure being scheduled is due to a recall or warranty issue. If so, is it considered an upgrade to the previously placed model? Additionally, since the modifier can be placed by different people in each institution, you should create a sticker that flags this situation and is in the permanent record so the coder or other person can easily identify when this type of scenario occurs. After placing the -FB or -FC modifier, e-mail a chain notification to materials management and billing so they can manually adjust the cost/charge based on the appropriate charge scenario described above.

CMS realized providers may not know information about partial discounts at the time a procedure is performed, so it published the following instructions in the January 2008 update to OPPS in Transmittal 1417:

Because hospitals may not know at the time the device replacement procedure takes place whether or how much credit the manufacturer will provide for the device, hospitals have the option of either: (1) submitting the claims immediately without the FC modifier and submitting a claim adjustment with the FC modifier at a later date once the credit determination is made; or (2) holding the claim until a determination is made on the level of credit.

The modifiers do not apply to every scenario in which a facility receives an item at a discounted cost. CMS provides a specific list of devices and APCs for which the cost of a device accounts for the majority of the APC payment and for which these modifiers are applicable based on the percentage of payment related to the device at www.cms.gov/HospitalOutpatientPPS/HORD/list.asp. Select the Final Changes to the Hospital Outpatient Prospective Payment System and CY 2009 and then the file titled "OPPS Final Without Cost or With Credit Device Information."

CMS provides additional instructions in the Medicare Claims Processing Manual, Chapter 4, §§20.6.9, 20.6.10, and 61.3 for reporting the modifiers and charges.

Contributors

We would like to thank the following contributors for answering the questions that appear on pp. 10-12:

Andrea Clark, RHIA, CCS, CPC-H

Health Revenue Assurance Associates, Inc.

Plantation, FL

Denise Williams, RN, CPC-H

Health Revenue Assurance Associates, Inc.

Plantation, FL