HCPro.com - Briefings on Coding Compliance Strategies

Continue preparations despite proposed delay

Fri, 01 Jun 2012 04:00:00 GMT

Continue preparations despite proposed delay

CMS has proposed delaying ICD-10 implementation until October 1, 2014, but coders shouldn't delay their preparations for the new code system, experts say.

"Coders should take this extra year to continue brushing up on their anatomy and physiology, medical terminology, and pathophysiology skills," says Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, director of professional practice at AHIMA in Chicago. "They can also continue to become familiar with the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, as well as learn the basics about assigning these new code sets, such as format and structure."

Coders who undergo ICD-10 training can assist with other aspects of ICD-10 readiness, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer in northern California with more than 30 years of HIM experience.

Coders with formal ICD-10 training can review and update query forms or work with CDI staff to create new queries that reflect ICD-10 terminology and indexing. Trained coders can inventory policies and procedures that will require review and updating, she says.

"Use your ICD-10-trained staff to assist with MS-DRG financial modeling efforts as well. All of these activities and tasks take time and effort," says Bryant. ICD-10-trained staff can conduct productivity studies to determine the impact the new coding system will have on their organizations, she says.

A delay equals additional costs, and a one-year delay could add an estimated 10%-30% to the total implementation cost for entities that have already spent or budgeted for the transition, according to the proposed rule.

The proposed one-year delay will increase costs because organizations must stretch their implementation preparation another year and try to maintain momentum, says Endicott.

The good news is that if CMS finalizes the 2014 compliance deadline, it's not likely that it will change again, says Sue Bowman, MJ, RHIA, CCS, senior director of coding policy and compliance at AHIMA in Chicago.

"CMS is aware of the importance of a firm date for this type of implementation," she says. "The healthcare industry has been engaged in various aspects of ICD-10 implementation for nearly 20 years now, so it is time to finish the process so that we can start to reap the benefits of ICD-10, stop increasing the implementation costs, and move on to other important initiatives."

Editor's note: Access the proposed rule, published in the April 17 Federal Register, at http://tinyurl.com/cl6brmn.

MAC prepayment reviews hit hospitals hard

Fri, 01 Jun 2012 04:00:00 GMT

MAC prepayment reviews hit hospitals hard

MACs have already begun prepayment reviews at hospitals nationwide, and Medicare Recovery Auditors aren't far behind.

MAC prepayment reviews denote a stark contrast from CMS' previous pay-and-chase methodology, says Monica Lenahan, CCS, coding education and compliance manager at Centura Health in Englewood, Colo. "It's a whole new ball game for us," she says.

TrailBlazer Health Enterprises, LLC (TrailBlazer), began auditing the 13-hospital health system in October 2011. The MAC issued 300 records requests systemwide in the first month alone, and that volume has continued to grow, says Lenahan.

Other hospitals are experiencing similar headaches.

"We're getting hit hard by [MAC prepayment audits] at this time," says Paul Belton, RHIA, MHA, MBA, JD, LLM, vice president of corporate compliance at Sharp HealthCare, an integrated seven-hospital healthcare system in southern California. Since Palmetto GBA began requesting records in October 2011, the MAC has audited several hundred records throughout the system, he says.

"For the first time ever, this is impacting our cash flow," says Belton. "We're seeing a tremendous amount of activity on the same DRGs that the Recovery Auditor has historically focused on." This includes pneumonia, chronic obstructive pulmonary disease, and heart failure and shock. The major difference is that MACs are reviewing claims before they're paid, he says.

Belton fears the Recovery Auditor prepayment demonstration program will mirror the MAC process with respect to volume. California is among the states included in the Recovery Auditor demonstration program slated to begin in June.

Neither rhyme nor reason seems apparent

One puzzling aspect of Centura Health's MAC prepayment reviews is the inconsistency with respect to the type or volume of DRGs reviewed at each of the system's 13 hospitals, says Lenahan.

Belton reports a similar experience, noting that one of the anchor hospitals in the Sharp HealthCare system received a very disproportionate share of requests-approximately 70%-during the first six months of the program.

MACs are targeting services and items that "pose the greatest financial risk to the Medicare program and that represent the best investment of resources," according to the Medicare Program Integrity Manual, Chapter 3-Verifying Potential Errors and Taking Corrective Actions. This includes services with significant potential for noncoverage or incorrect coding. CMS encourages MACs to use prepayment and post-payment screening tools or natural language coding software to identify these targets.

MAC prepayment audits have prompted Centura Health to examine high-dollar DRGs (e.g., those for joint replacements) and high-volume DRGs (e.g., DRG 392 [gastroenteritis and miscellaneous digestive disorders without MCC]) more closely, says Lenahan.

Sharp HealthCare has been placing greater emphasis on medical necessity and determining whether documentation in the medical record tells a patient's entire story to support outpatient services and inpatient admission, says Belton. HIM staff members ask these two questions when reviewing documentation prior to releasing claims:

Is there an accurate physician status order?
Does the physician demonstrate his or her complex medical judgment by documenting the patient's current symptomatology, past medical history, CC conditions, and ancillary studies with interpretation?

"All of this reinforces the fact that case management must work with HIM more than ever before," he says.

Sharp HealthCare will provide CDI education to physicians to prepare for MAC prepayment reviews and Recovery Auditor prepayment reviews, says Belton. Education will proactively target hospitalists, intensivists, and ER physicians.

Understand the process

So how do MAC prepayment reviews actually work?

Hospitals must respond to Additional Documentation Requests (ADR) for MAC prepayment reviews within 30 days of receiving a request from a MAC. If a MAC doesn't receive this documentation within 45 days, it will automatically deny the claim. If a MAC receives documentation in a timely manner, it must make and document its determination within 60 calendar days. It must also enter its payment decision into the Fiscal Intermediary Shared System, Multi-Carrier System, or the VIPS Medicare System within this same time frame.

Lenahan hasn't yet tracked the average time it has taken TrailBlazer to make prepayment determinations. However, Centura Health is tracking the money it would have received had prepayment reviews not been triggered. The dollar amount is significant, says Lenahan. "It really is a huge payment burden," she says.

Identify operational challenges

In addition to cash flow disruption, MAC prepayment reviews have also caused operational challenges. Centura Health created a flag in its billing system to identify claims selected for prepayment review.

Logging these claims internally has been challenging, says Lenahan. Currently, a billing manager performs this function. However, ADRs are sometimes sent directly to facilities rather than a centralized billing office, which makes logging and tracking requests difficult. Lenahan hopes the hospital's Recovery Auditor tracking software eventually will be able to track MAC prepayment requests as well.

Belton agrees that operational challenges exist. Sharp HealthCare's Recovery Auditor/MAC coordinator tracks all requests systemwide. The coordinator logs each request and sends the request to the medical records department at the hospital to which the request pertains. Requests are monitored based on the following reason codes provided by the MAC:

Denied (MAC conducted a prepayment review and denied the claim)
Paid (MAC conducted a prepayment review and agreed to pay the claim)
Pending (MAC prepayment review is pending)
Withdrawn (MAC is in the process of reviewing the claim, payment is pending, but the review is taking longer than anticipated)

When claims are denied, the Recovery Auditor/MAC coordinator sends records to a case manager at each hospital to determine whether the hospital can appeal the denial. Approximately 20% of the claims reviewed during the first six months were denied immediately upon prepayment review, says Belton. Approximately 75% of the claims reviewed during the first six months had a "withdrawn" status at some point during their review.

TrailBlazer notifies Centura Health of its payment decision via a reason code as well (e.g., no payment is forthcoming), says Lenahan.

Encourage physician involvement

Physicians at Centura Health have become more involved in documentation improvement efforts since the onset of MAC prepayment audits, says Lenahan. This is because TrailBlazer reviews Part A hospital claims as well as Part B claims for services rendered in place of service 21 (inpatient hospital). The MAC looks specifically at the history and physical completed by the surgeon, operative reports, imaging reports, and any other pertinent information in the record on Part A claims, says Lenahan. The MAC examines Part B claims for the same dates of service as hospital claims to search for this information as well.

When Part A hospital claims are denied, TrailBlazer has also denied the Part B physician claim, Lenahan says. "Now it affects physicians' bottom line, and they're very interested in this," she says. "If we're getting a payment denial, they're getting one right behind it."

Centura Health has made a concerted effort to include details from physician documentation in documentation submitted with hospital claims, says Lenahan. For example, although hospital documentation must satisfy Joint Commission requirements and inpatient admission criteria, staff members also ensure that it includes elements of physician documentation specified by TrailBlazer (e.g., a physician's description of the failure of outpatient therapy). The health system is in the process of designating someone (e.g., intake clerk, scheduling clerk, or medical records staff member) to ensure this information is included.

"There may be lots of documentation in the physician record that would help us substantiate these procedures," Lenahan says. "We're establishing a checklist at the beginning of the process to ensure that we have everything we need because we're pretty sure this will be challenged on the back end. That's something we've never done before."

Good news going forward

CMS recognizes that direct communication between MACs and providers is an essential part of solving compliance problems going forward. The Medicare Program Integrity Manual requires that MACs include "an offer to provide individualized education in the notification letter along with contact information for provider outreach and education."

Resources

Consider these resources:

Medicare Program Integrity Manual, Chapter 3-Verifying Potential Errors and Taking Corrective Actions: http://tinyurl.com/7ux7qmu
TrailBlazer joint replacement documentation: http://tinyurl.com/7xnl4jg
TrailBlazer documentation tips: http://tinyurl.com/7m2po55

Seven savvy tips for coding sepsis and SIRS

Fri, 01 Jun 2012 04:00:00 GMT

Seven savvy tips for coding sepsis and SIRS

Many physicians say that SIRS criteria are insufficient and confusing at best, and don't indicate whether a patient is truly sick, says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.

Some patients-particularly those who are critically ill-may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria (e.g., heart rate > 90 and respiratory rate > 20)-which technically constitutes a diagnosis-but not have SIRS.

"Abnormalities in vital signs and abnormalities in laboratory studies can be due to things that are totally unrelated to a patient's infectious process in the body or can be present totally unrelated to an inflammatory process in the body," says Gold. "If there is no inflammatory process, docs should not call it SIRS because you must have an inflammatory process to get a systemic inflammatory response."

For example, tachycardia with atrial fibrillation and rapid ventricular rate doesn't justify a SIRS diagnosis, says Gold. If a patient has leukocytosis with injection of steroids, this also doesn't imply SIRS. Similarly, tachypnea with tachycardia caused by running does not meet SIRS criteria, he says.

To confuse matters, some patients-particularly those who are immunocompromised-may have sepsis without meeting any criteria, says Gold. "You have to look at the possibility that a patient can be septic and indeed be in septic shock and not have the SIRS criteria met at all," he says. "It's a clinical judgment of the physician in looking at the patient to be able to determine if the patient has a risky infectious process or a risky noninfectious process."

Bridge coder-physician communication gap

So where does all of this information leave coders? Often, between a rock and hard place, says Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist at HCPro, Inc., in Danvers, Mass. Physicians don't diagnose-or document-consistently, which often leads to inaccurate data capture, she says. Many coders are uneasy coding records in which physicians mention sepsis or SIRS only once or twice without documenting any clear clinical evidence or treatment. They hesitate to code the condition because they know the claim may be denied, she says.

Coders should take time to more thoroughly review and learn from these records rather than be overwhelmed by them, says Avery.

"Coders have never had to be as clinical as we're challenged to be now," she says. "Coders have the ability to gain some of the pathophysiology knowledge to read the record and be able to abstract what's important."

As with all documentation challenges, it's always best to emphasize to physicians the importance of capturing patient severity. This includes the following elements related to sepsis and SIRS:

The inflammatory condition, whether infectious or noninfectious
The causal organism
Whether a noninfectious process is contributing to a patient's illness and the specific process

When in doubt, coders should query even though it may seem as if they are questioning physicians' clinical judgment, says Avery.

"I don't think it's really that we're questioning their judgment per se, I think it's more that we're questioning the accuracy of the record," she says. "If the condition is not clearly documented, then we shouldn't be picking it up."

Effective strategies for coding sepsis

Coders should review documentation more thoroughly, query when necessary, and consider the following seven coding tips:

1. Note differences between streptococcal sepsis and streptococcal septicemia. When physicians document streptococcal septicemia, coders should report code 038.0 (streptococcal septicemia) only. They should not report code 995.9x (SIRS) as an additional code. Coders also should query physicians to determine whether a patient actually has sepsis instead, in accordance with official coding guidelines.

Nonetheless, query with caution, says Avery. "I think we over-query in this area for a condition that's really not there," she says. "I think a lot of physicians over time have become desensitized to it."

Coders should review clinical evidence in the record before querying physicians, she says. They should also be careful when referencing SIRS criteria to avoid backing physicians into a corner to provide diagnoses that may technically satisfy diagnostic criteria without actually being present, she says.

Conversely, if physicians document streptococcal sepsis, coders should report codes 038.0 and 995.91 (SIRS due to infectious process without acute organ dysfunction).

2. Look for linkage between organ dysfunction/failure and severe sepsis. Severe sepsis (995.92) occurs when sepsis is accompanied by signs of failure of at least one organ. Documentation of all organ dysfunctions and failures-including any related treatments (e.g., tracheostomy)-is important with respect to supporting the overall diagnosis, says Avery.

However, an acute organ dysfunction must be associated with the sepsis to assign the severe sepsis code, she says.

"Just because a physician identifies a patient has acute respiratory failure or acute renal failure [doesn't mean] that you can jump to a conclusion that it's sepsis," Avery says. Coders should query physicians when documentation is unclear regarding whether acute organ dysfunction is related to sepsis or another medical condition, she says.

3. Know how to apply sequencing guidelines. "It's really clear if a patient comes in with some type of localized infection and then develops sepsis while they're in the hospital," says Avery.

However, sequencing isn't as clear when patients appear to be admitted for sepsis, organ failure, localized infection, or something else, she says. Consider the following suggestions:

Sepsis or severe sepsis is POA and meets the definition of a principal diagnosis-Assign a code for the systemic infection (e.g., 038.xx or 112.5 [disseminated or systemic candidiasis]) first, followed by 995.91 or 995.92.
The reason for admission is sepsis, severe sepsis, or SIRS and a localized infection (e.g., pneumonia or cellulitis)-Assign a code for the systemic infection (e.g., 038.xx or 112.5) first, followed by 995.91 or 995.92, and then a code for the localized infection. Refer to
A patient is admitted with a localized infection (e.g., pneumonia), but sepsis or SIRS doesn't develop until after admission-Assign a code for the localized infection as the principal diagnosis. Also assign a code for the systemic infection (e.g., 038.xx or 112.5) and code 995.91 or 995.92 as secondary diagnoses.
Sepsis or severe sepsis is not POA but develops during the encounter-Assign a code for the systemic infection and code 995.9x both as secondary diagnoses. Remember that when signs or symptoms of sepsis are POA but physicians don't document the condition until after admission, the record may justify a query to determine whether sepsis was POA. Official coding guidelines instruct coders to assign "Y" for conditions diagnosed during an admission that were clearly present but not diagnosed until after admission occurred.

4. Wait for the discharge summary. If a physician documents a diagnosis as probable, suspected, likely, questionable, possible, or still to be ruled out at the time of discharge, coders can report the condition as if it existed or was established. Physicians might document possible sepsis or probable sepsis in the record. If the condition is also documented in the discharge summary, coders can report it as if it existed, says Avery. If it's not included in the discharge summary, clinical evidence in the record might justify a query and possibly confirm the diagnosis, she says.

5. Note unique aspects of coding newborn sepsis. When a physician documents newborn sepsis, coders should report code 771.81 (septicemia [sepsis] of newborn) with a secondary code from category 041.x (bacterial infection in conditions classified elsewhere and of unspecified site) to identify the organism. Coders shouldn't report a code from category 038, nor should they assign code 995.91, says Avery. Conversely, if a newborn has any associated acute organ dysfunction, report 995.92.

Remember that the 770 code series is reserved for conditions that follow the birth process and are directly related to it. These conditions must occur within the first 28 days of life. For example, coders should report 038.x when a baby develops sepsis from bacterial superinfection of a viral pneumonia caused by his 2-year-old sibling.

6. Encourage physicians to stop documenting urosepsis. This vague term currently maps to code 599.0 (UTI, site not specified) in ICD-9-CM. However, in ICD-10-CM, urosepsis is not a codeable term. The Alphabetic Index instructs coders to "code to the condition," and it doesn't provide a default code. Start encouraging physicians to document greater specificity now, says Avery.

7. Don't make assumptions when coding post-procedural sepsis. "You cannot make an assumption that just because the patient has some type of post-procedure infection that develops into sepsis that the two [i.e., the procedure and sepsis] are related," says Avery. "Physicians must clearly document the cause-and-effect relationship."

If a localized infection is post-procedural and related to an operation, assign a code for the complication (e.g., 998.59, other postoperative infection, or 674.3, other complications of obstetrical surgical wounds) first, followed by the appropriate sepsis codes (i.e., 995.91 or 995.92). Report additional codes for any acute organ dysfunction or failure in cases of severe sepsis. Refer to Coding Clinic, Fourth Quarter 2011, pp. 151-153 for more information.

Editor's note: This information was originally presented during HCPro's audio conference "Sepsis Coding: Learn Documentation Improvement Techniques to Ensure Accurate Coding." For details, visit http://tinyurl.com/73h6eah.

Address medical necessity, coding challenges

Fri, 01 Jun 2012 04:00:00 GMT

Address medical necessity, coding challenges

Medical necessity denials traditionally focus on high-dollar DRGs, such as those for hip and knee replacements; others may also soon become targets.

Inpatient wound care frequently lacks sufficient documentation and could be one such service, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent HIM consultant in Madison, Wis.

"[Auditors] haven't gotten there yet, but I suspect they will," says Krauss. "Documentation lacks the clinical substance necessary to support medical necessity, and it doesn't capture a physician's clinical judgment and medical decision-making for performing the procedure. Doctors have been conditioned to document excisional debridement, but if you look at what they need for their own payment, they need to do a lot more than that."

Outpatient wound care documentation is often more detailed and thorough than its inpatient counterpart because physicians providing these services often specialize in this area and are "more attuned to the business side," Krauss says. Outpatient wound care center documentation often includes dictated notes, pictures, documentation of failed conservative treatment, wound etiology notes, and information about patient compliance and the stability and interaction of active comorbidities. Hospitals often can't obtain this specificity, he says.

Local coverage determinations that focus on outpatient wound care documentation, such as that published by TrailBlazer Health Enterprises®, can be helpful on the inpatient side, he says. (Visit www.trailblazerhealth.com/Tools/LCDs.aspx?id=2897.)

"If we [used this information] on the inpatient side, everything would be golden," says Krauss. Some hospitals use TrailBlazer's information to develop inpatient wound care documentation templates for their physicians, he says. One copy is for the hospital; the other is the physician's for billing purposes.

Excisional or non-excisional?

Medicare Quarterly Compliance Newsletter, February 2011, Vol. 1, Issue 2, reminds coders to distinguish between excisional and non-excisional debridement.

The newsletter describes excisional debridement as the surgical removal or cutting away of devitalized tissue, necrosis, or slough. It notes that coders incorrectly report excisional debridement when physicians perform autolytic, enzymatic, or mechanical (whirlpool) debridement. Instead, they should report non-excisional debridement of wound, infection, or burn (86.28). Recovery Auditors have performed validation for these MS-DRGs:

463-465 (Wound debridement and skin graft except hand, for musculo-connective tissue disorders with MCC/CC, with CC, and without CC/MCC respectively)
573-575 (Skin graft and/or debridement for skin ulcer or cellulitis with MCC, with CC, and without CC/MCC respectively)
901-903 (Wound debridements for injuries with MCC, with CC, and without CC/MCC respectively)

Unfortunately, the terms excisional and non-excisional are specific to ICD-9-CM and may not be how physicians identify procedures, says Nelly Leon-Chisen, RHIA, director of coding and classification at the AHA in Chicago. Physicians must understand how ICD-9-CM terminology differs from their own clinical terminology, and also the risk of inaccurate coding, she says.

Coders, meanwhile, must realize that documentation of excisional debridement won't necessarily survive payer scrutiny, says Krauss. "Just because the magic word is in the chart doesn't mean that you're going to get paid," he says. "It's not just about getting the buzzword-it's about getting the support for the buzzword."

Documentation of indications for a procedure (i.e., why debridement was necessary) is often lacking, says Krauss. When combined with a brief progress note indicating excisional debridement without complications, it can appear that services may not have been medically necessary. Payers seek documentation of clinical progression, advancement of wounds, and failure of previous conservative therapy as a primary basis for establishing medical necessity of debridements, he says.

Debridement of multiple layers

Medicare Quarterly Provider Compliance Newsletter, October 2011, Vol. 2, Issue 1, reminds coders to assign a code only for the deepest layer of debridement when coding multiple-layer debridements of the same site.

The newsletter scenario involves a debridement including skin, subcutaneous tissue, and muscle. Assign 83.45 (debridement of muscle, NOS)-not 86.22 (excisional debridement of wound, infection, or burn).

Debridement depth documentation challenges may continue, says Leon-Chisen. For example, "debridement down to the bone" could be interpreted as debridement stopped short of taking bone tissue or including the bone. Review documentation to determine the deepest layer debrided; seek clarification if necessary, she says.

The multiple-layer rule (i.e., code only the deepest layer debrided) applies solely to same-site debridement, says Krauss. Report debridement of separate sites independently and according to the deepest depth of the debridement performed at the specific site, he says.

Debridement with another procedure

Don't code minor debridement to clean a bone or debridement that is part of a larger procedure separately, says Leon-Chisen. For example, debridement is integral to arthroscopic shoulder repair, she says.

Coders often err when reporting incision and drainage (I&D) performed with debridement, says Krauss. Don't separately report debridement performed to ensure the effectiveness of I&D, but separately report debridement performed after I&D to address presence of significant necrotic tissue around an area that was incised and drained, he says. Documentation must clearly describe the necrotic tissue and procedure performed. Coding Clinic, Second Quarter 2005, pp. 3-4, notes that debridement performed with another procedure is often, but not always, included in the procedure code. Refer to Coding Clinic, Third Quarter 2008, p. 8; Second Quarter 2006, pp. 23-24; and Second Quarter 1990, p. 27.

The challenges of new technology

New technology can be challenging; coders might not know whether it can be classified as excisional, says Leon-Chisen. For example, when physicians use the Qoustic Wound Therapy System®, report 86.28, in accordance with Coding Clinic, Second Quarter 2010, pp. 11-12. When they use ultrasonic-assisted curette and VersaJet™, report 86.28, in accordance with Coding Clinic, Third Quarter 2009, p. 13.

Wound care and the POA indicator

Coders are often too cautious when assigning a POA indicator for pressure ulcers, especially when not documented until several days after inpatient admission, says Krauss. If signs or symptoms are POA, coders can and should report an ulcer as POA. A query may be necessary without documentation of signs or symptoms.

Educate ED clinicians about the importance of documenting chronic conditions (e.g., chronic heel wounds) in addition to acute conditions that prompt patients to seek treatment, says Krauss. This facilitates accurate POA assignment and reduces queries, he explains.

Prepare for ICD-10

ICD-10 distinguishes between excisional and non-excisional debridement. The ICD-10-PCS root operations excision and extraction denote excisional debridement and non-excisional debridement, respectively.

This doesn't mean that physicians must use the term extraction, but if documentation shows that the tissue was pulled or stripped away, rather than cut, the debridement is an extraction, says Leon-Chisen.

ICD-10 will require coders to capture laterality and more specific anatomic wound locations, says Krauss.

Will acute respiratory failure be CC instead of MCC?

Fri, 01 Jun 2012 04:00:00 GMT

Will acute respiratory failure be CC instead of MCC?

by Robert S. Gold, MD

Acute kidney injury or acute renal failure has up to a 78% mortality rate, yet it has been demoted from MCC to CC status.

Why? Coders have overreported code 584.9 based on medical record documentation that patients have the condition when they don't. I fear the same fate for the same reasons for code 518.8x (acute respiratory failure).

In some cases, it's obvious that patients are in acute respiratory failure. In others, it may be less obvious and open to interpretation. In still others, patients are clearly not in acute respiratory failure.

A patient receiving oxygen or a mechanical ventilator isn't necessarily in acute respiratory failure. Even physician documentation of acute respiratory failure doesn't always validate acute respiratory failure. Someone must take a stand and repair the inaccurate data before acute respiratory failure is demoted to CC status and viewed as clinically insignificant.

Two well-known clinical models of respiratory failure currently exist:

Type I, hypoxemic respiratory failure
Type II, hypercapnic respiratory failure

Both types can exist in either the acute or chronic states. A patient can have one type exclusively or manifest elements of both types. Coders, however, have two choices: code 518.81 for acute respiratory failure and code 518.83 for chronic respiratory failure. These codes don't reflect Type I or Type II, and there is no classification of either hypoxemic or hypercapnic types.

Hypoxemic respiratory failure

Type I (hypoxemic) respiratory failure, the most common form, occurs when a patient's arterial partial pressure of oxygen (PaO2) is lower than 60 while breathing room air and when there is a normal or low arterial partial pressure of carbon dioxide (PaCO2). Type II (hypercapnic) occurs when a patient's PaCO2 is higher than 50. These indicators alone do not account for acuity.

Hypoxemic respiratory failure may be seen in patients with cardiogenic or noncardiogenic pulmonary edema, pneumonia, pulmonary embolism, or pulmonary fibrosis. It can also occur with lung toxicity due to certain antiarrhythmic drugs and pulmonary hemorrhage.

Hypercapnic respiratory failure

Type II (hypercapnic) respiratory failure often occurs in patients with severe chronic airway disorders (e.g., chronic asthma, COPD, neuromuscular diseases, cystic fibrosis). Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air. Patients with hypercapnic respiratory failure often have an elevated carbon dioxide level in arterial blood gases (55-110 or higher instead of 35-45).

Acute and chronic types

The distinction between acute and chronic hypoxemic respiratory failure is not readily made on the basis of arterial blood gases. A patient with chronic hypoxemic respiratory failure may have a high hematocrit that shows polycythemia (i.e., increased red blood cell production to permit the transport of additional oxygen molecules to the body from the lungs), but this doesn't always occur.

A physician who knows a patient may determine that the patient's PaO2 is 10%-15% lower than normal for this individual. If a patient's oxygen saturation on pulse oximeter cannot be maintained over 90% on 6 liters flow of oxygen, physicians often interpret this as hypoxemic respiratory failure. If these levels are different from that which was recorded an hour earlier, the patient is in acute hypoxemic respiratory failure. If the levels remain the same hour after hour, day after day, it's chronic.

Acute hypercapnic respiratory failure develops over minutes to hours. The arterial pH, which is normally in the range of 7.35-7.45, is less than 7.3. Physicians may refer to this low pH and high PaCO2 as "respiratory acidosis." In chronic hypercapnic respiratory failure, the kidneys compensate for the acidity by increasing bicarbonate concentration. Therefore, the pH is usually only slightly decreased compared to the normal range.

Patients with acute respiratory failure often exhibit signs of anxiety-as if they fear imminent death. This often is seen in those with pulmonary embolisms. They may demonstrate an increased rate of breathing (more than 20-24 breaths per minute) and inability to speak more than a few words without stopping for another breath. They may exhibit use of accessory muscles of respiration as the neck and intercostal muscles retract, showing the increased muscular work to try to get the lungs moving. Eventually, patients experience cyanosis and loss of consciousness. A physician doesn't need a blood gas determination to know the patient is tiring and requires intubation or other respiratory support.

So where do things go wrong if it's all so clear?

Intubate for airway protection

Patients found unconscious after a stroke may be paralyzed, intubated, and placed on ventilators in case they vomit while unconscious and can't respond to protect their airways. Patients who can't respond will aspirate and possibly go into acute respiratory failure. However, if and until this happens, they are not in acute respiratory failure. Patients unconscious due to alcohol or drug use, but breathing, are not in acute respiratory failure. They may be paralyzed, intubated, and placed on a ventilator for airway protection, but they're not in acute respiratory failure. Similarly, patients who have an allergic reaction with laryngeal edema may be intubated before the airway closes (if it's going to close) for airway protection. They're not in acute respiratory failure.

Recovery from anesthesia

Surgical patients are typically sent to the postanesthesia care unit (PACU) to recover from anesthesia. An anesthesiologist and PACU nurses monitor them until they are released to home, the medical-surgical unit, or the ICU. Often, these patients are totally reversed and extubated before leaving the OR. However, if an operative procedure lasts long or starts late, and the PACU is closed, the anesthesiologist may complete reversal of the patient the same night in the ICU. Nurses there monitor the patient and the anesthesiologist usually notices that the patient has blown off all anesthetic gases and is "bucking" on the tube, indicating it should be removed. The anesthesiologist observes that the lungs are moving just fine, and the patient is extubated. Documentation problems can occur if the anesthesiologist must assist elsewhere and asks an intensivist or hospitalist covering the ICU to oversee the patient. Having been less involved or not involved in the patient's care, they may incorrectly document acute respiratory failure even if all other circumstances, including extubation, remain the same.

Purposeful maintenance on a ventilator

Physicians sometimes maintain patients under anesthesia and on a ventilator overnight so that they can return to the OR the next day to complete the case. Surgeons who perform liver transplants may delay closure to be certain the transplanted liver is working correctly and to prevent abdominal compartment syndrome. Similarly, patients explored for ischemic disease of the bowel found with occlusion of the arteries to the intestine or those with internal hernias may be packed with their bellies open so that they can return to the OR in a few hours or the next day. Physicians then determine whether the bowel will live or whether it must be resected. Patients maintained on ventilators for these purposes are not in acute respiratory failure.

Warn your chief medical officer, vice president of medical affairs, or medical staff president if physicians incorrectly document acute respiratory failure.

Editor's note: Dr. Gold is CEO of DCBA, Inc., an Atlanta firm that provides physician-to-physician CDI programs. Contact him at 770-216-9691 or rgold@DCBAInc.com.

Quality of care emerges as FY 2013 theme

Fri, 01 Jun 2012 04:00:00 GMT

IPPS proposed rule

Quality of care emerges as FY 2013 theme

Inpatient hospitals will see CMS payment rates increase 2.3% in FY 2013 if the agency finalizes the change in the IPPS proposed rule released in April. CMS expects that in FY 2013, the documentation and coding adjustment will net an aggregate 0.2% increase. Other quality-of-care initiatives could reduce payments.

Hospital readmissions reduction program

Beginning in FY 2013, CMS will reduce payments for some hospitals with excess readmissions for heart attack, heart failure, and pneumonia. The rule includes methodology for establishing an excess readmission ratio and payment adjustment factors. "Patient noncompliance will be the chief uncontrollable issue. Docs should identify that event and the coders should assign the appropriate ICD code," says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.

HACs

CMS proposes adding surgical site infection following cardiac implantable electronic device and iatrogenic pneumothorax with venous catheterization to the HAC list. It also wants to add codes 999.32 and 999.33 to the vascular catheter-associated infection HAC category. Coders must be careful when assigning iatrogenic pneumothorax, says Gold. Incidental findings of an apical cap on a chest film after insertion of a central line may or may not have clinical significance. Untreated, it also wouldn't meet UHDDS criteria for a valid secondary diagnosis, he says.

Other coding changes

As expected, there are no major ICD-9-CM code changes for FY 2013 to facilitate ICD-10 preparations, but there are some notable changes. When coders report principal diagnosis code 487.0 (influenza with pneumonia) with one of several pneumonia codes as a secondary diagnosis, cases will map to MS-DRGs 177-179. They previously mapped to MS-DRGs 193-195.

MS-DRGs 177-179 are higher-weighted than 193-195 and more accurately reimburse hospitals for resources used to treat patients, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla. Coders must capture secondary diagnoses of more specified pneumonia, which may require evaluating sputum cultures and querying for the cause, he says.

CMS proposes adding 263.0 (malnutrition of moderate degree), 263.1 (malnutrition of mild degree), and 440.4 (chronic total occlusion of artery of the extremities) to the CC list. The addition will rectify a likely oversight, says Haik. Previously, unspecified malnutrition, but not the more specific types, was added to the list. CMS also proposes demoting code 584.8 from MCC to CC status.

Quality initiatives

Beginning in FY 2013, CMS will adjust hospital payments annually under the Value-Based Purchasing program based on how well hospitals perform or improve performance on a set of quality measures. The FY 2012 final rule included the initial 13 measures. The FY 2013 proposed rule includes four new measures for FY 2015-statin prescribed at discharge, a patient safety indicator composite measure, a measure related to central line-associated bloodstream infections, and a measure pertaining to Medicare spending per beneficiary.

The proposed rule would increase payment rates 2.3% for facilities that successfully participate in the voluntary Inpatient Quality Reporting program. Those that do not successfully participate would see a 2% point reduction or 0.3% payment rate update. Approximately 95% of hospitals may not receive the full increase in any fiscal year, according to CMS.

Editor's note: Read the proposed rule at http://tinyurl.com/cs94q5z. CMS will accept comments until June 25. The agency will publish a final rule by August 1.

Briefings on Coding Compliance Strategies, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Continue preparations despite proposed delay

CMS has proposed delaying ICD-10 implementation until October 1, 2014, but coders shouldn't delay their preparations for the new code system, experts say.

The proposed one-year delay will increase costs because organizations must stretch their implementation preparation another year and try to maintain momentum, says Endicott.

Editor's note: Access the proposed rule, published in the April 17 Federal Register, at http://tinyurl.com/cl6brmn.

MAC prepayment reviews hit hospitals hard

MACs have already begun prepayment reviews at hospitals nationwide, and Medicare Recovery Auditors aren't far behind.

Other hospitals are experiencing similar headaches.

Neither rhyme nor reason seems apparent

One puzzling aspect of Centura Health's MAC prepayment reviews is the inconsistency with respect to the type or volume of DRGs reviewed at each of the system's 13 hospitals, says Lenahan.

Is there an accurate physician status order?
Does the physician demonstrate his or her complex medical judgment by documenting the patient's current symptomatology, past medical history, CC conditions, and ancillary studies with interpretation?

"All of this reinforces the fact that case management must work with HIM more than ever before," he says.

Understand the process

So how do MAC prepayment reviews actually work?

Identify operational challenges

Denied (MAC conducted a prepayment review and denied the claim)
Paid (MAC conducted a prepayment review and agreed to pay the claim)
Pending (MAC prepayment review is pending)
Withdrawn (MAC is in the process of reviewing the claim, payment is pending, but the review is taking longer than anticipated)

TrailBlazer notifies Centura Health of its payment decision via a reason code as well (e.g., no payment is forthcoming), says Lenahan.

Encourage physician involvement

Good news going forward

Resources

Consider these resources:

Medicare Program Integrity Manual, Chapter 3-Verifying Potential Errors and Taking Corrective Actions: http://tinyurl.com/7ux7qmu
TrailBlazer joint replacement documentation: http://tinyurl.com/7xnl4jg
TrailBlazer documentation tips: http://tinyurl.com/7m2po55

Seven savvy tips for coding sepsis and SIRS

Bridge coder-physician communication gap

Coders should take time to more thoroughly review and learn from these records rather than be overwhelmed by them, says Avery.

As with all documentation challenges, it's always best to emphasize to physicians the importance of capturing patient severity. This includes the following elements related to sepsis and SIRS:

The inflammatory condition, whether infectious or noninfectious
The causal organism
Whether a noninfectious process is contributing to a patient's illness and the specific process

When in doubt, coders should query even though it may seem as if they are questioning physicians' clinical judgment, says Avery.

Effective strategies for coding sepsis

Coders should review documentation more thoroughly, query when necessary, and consider the following seven coding tips:

Conversely, if physicians document streptococcal sepsis, coders should report codes 038.0 and 995.91 (SIRS due to infectious process without acute organ dysfunction).

However, an acute organ dysfunction must be associated with the sepsis to assign the severe sepsis code, she says.

3. Know how to apply sequencing guidelines. "It's really clear if a patient comes in with some type of localized infection and then develops sepsis while they're in the hospital," says Avery.

However, sequencing isn't as clear when patients appear to be admitted for sepsis, organ failure, localized infection, or something else, she says. Consider the following suggestions:

Sepsis or severe sepsis is POA and meets the definition of a principal diagnosis-Assign a code for the systemic infection (e.g., 038.xx or 112.5 [disseminated or systemic candidiasis]) first, followed by 995.91 or 995.92.
The reason for admission is sepsis, severe sepsis, or SIRS and a localized infection (e.g., pneumonia or cellulitis)-Assign a code for the systemic infection (e.g., 038.xx or 112.5) first, followed by 995.91 or 995.92, and then a code for the localized infection. Refer to
A patient is admitted with a localized infection (e.g., pneumonia), but sepsis or SIRS doesn't develop until after admission-Assign a code for the localized infection as the principal diagnosis. Also assign a code for the systemic infection (e.g., 038.xx or 112.5) and code 995.91 or 995.92 as secondary diagnoses.
Sepsis or severe sepsis is not POA but develops during the encounter-Assign a code for the systemic infection and code 995.9x both as secondary diagnoses. Remember that when signs or symptoms of sepsis are POA but physicians don't document the condition until after admission, the record may justify a query to determine whether sepsis was POA. Official coding guidelines instruct coders to assign "Y" for conditions diagnosed during an admission that were clearly present but not diagnosed until after admission occurred.

Address medical necessity, coding challenges

Medical necessity denials traditionally focus on high-dollar DRGs, such as those for hip and knee replacements; others may also soon become targets.

Excisional or non-excisional?

Medicare Quarterly Compliance Newsletter, February 2011, Vol. 1, Issue 2, reminds coders to distinguish between excisional and non-excisional debridement.

463-465 (Wound debridement and skin graft except hand, for musculo-connective tissue disorders with MCC/CC, with CC, and without CC/MCC respectively)
573-575 (Skin graft and/or debridement for skin ulcer or cellulitis with MCC, with CC, and without CC/MCC respectively)
901-903 (Wound debridements for injuries with MCC, with CC, and without CC/MCC respectively)

Debridement of multiple layers

Debridement with another procedure

Delayed implementation and its effect on coders

Tue, 01 May 2012 04:00:00 GMT

Delayed implementation and its effect on coders

The wait is over-CMS has announced a proposed rule that would postpone ICD-10 implementation from October 1, 2013, to October 1, 2014, if finalized.

Be prepared for just about anything, experts advised when CMS said in February that it would initiate a process to postpone the implementation date. The agency provided no specific information about a timeline for the delay until it announced the proposed rule April 9.

The initial announcement of a delay was made despite a final rule to adopt the new code set by October 1, 2013, issued more than three years earlier. Some wondered after the February announcement why CMS would delay ICD-10 at this stage of the implementation. In an April 9 press release announcing the proposed rule and new implementation date, CMS said:

What does the delay mean for coders who have spent the past several years psychologically preparing for a countdown to October 1, 2013?

For coders, in particular, a delay in ICD-10's implementation has definitely caused angst, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, Calif. "I think this is a disappointment among coding professionals, and this can extend the anxiety of the change in general terms," she says.

What are advantages, disadvantages of a delay?

Rather than seeing the delay as a setback, coders should view it as valuable time to continue to improve processes and enhance readiness, says Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates in Plantation, Fla. A delay will give coders more time to drill down into data, identify areas for documentation improvement, and implement CDI efforts, she says.

Bryant agrees. "More time in and of itself is an advantage," she says. "This may spread cost out a little farther, which might help some. For those who are currently behind in planning and implementation, a delay will be an advantage."

The delay could also serve as a foundation for more meaningful dialogue among coders and physicians, says James S. Kennedy, MD, CCS, managing director of FTI Consulting in Atlanta. "I hope that coders welcome this as an opportunity to engage their physicians, hear what their fears are, and negotiate win-win solutions," he says.

Ideally, physicians should direct the development of ICD-10 with coders, hospitals, payers, and the Centers for Disease Control and Prevention, says Kennedy. "I believe that adding a physician group, such as the College of American Pathologists, the AMA, or the American College of Physicians, as a fifth Cooperating Party would be a strong move that unites all parties invested in the clinical language we are to use in our day-to-day patient care activities," he says.

However, some disadvantages also accompany delayed implementation of ICD-10.

"There has been a lot of work already done in the healthcare industry in preparation for ICD-10," says Bryant. "This work equates to monies spent already. The education and training timeline may need to be moved. Those that have already had some ICD-10 training may need refresher training now to retain the knowledge going forward."

Another concern is the current ICD-9 code freeze, which would continue to be prolonged until ICD-10, says Kennedy. "This freezing of ICD-9 does not allow for improvements in the disease specificity that we need to measure outcomes," he says.

Some wonder whether a delay could simply cause more procrastination. Sue Bowman, MJ, RHIA, CCS, director of coding policy and compliance at AHIMA in Chicago, fears that providers and others advocating the delay will continue to procrastinate and postpone ICD-10 preparation activities as close to the deadline as possible, defeating the purpose of a delay.

"People argue that it gives providers more time to prepare, which may be true, but the problem with the 2009-2013 time frame is that nobody started in 2009," she says. "It's not really clear whether the delay is going to really help people achieve compliance or just delay people's worrying about compliance."

Is waiting for ICD-11 a viable option?

The World Health Organization has said that ICD-11 will be released by 2015.

However, the United States then must clinically modify the code set and develop a procedural code set, says Bowman. She anticipates that seven or eight years will be necessary to do so. This means providers could realistically start using it in 2022 or 2023 at best, she says, adding that the United States can't wait that long to replace the outdated and failing ICD-9-CM system.

"Waiting that long just does not make sense due to the many benefits the ICD-10 coding system can bring to healthcare," says Bryant. "We really need ICD-10 and the benefits of improved clinical data. For those providers that have an integrated delivery system, this might be more challenging and have some logistics issues."

What should providers do now?

Experts agree that halting ICD-10 preparations is not the answer.

"All hospitals should continue with their education plans," says Clark. "Once we get a firmer foundation of what the date will be, you can always readjust the timeline. Hospitals can't sit in fear and become immobile."

Bryant says hospitals should determine the following:

Which key milestones and steps may require revision because of the delay
The effect on previously secured funding
Whether a delay will extend implementation costs beyond current budget estimates, and by how much

Other plans for 2012 should include documentation assessment and preliminary coder training, says Bryant, with a focus on the following foundational core competency areas:

Medical terminology
Anatomy and physiology
Disease process and pharmacology
ICD-10 coding guidelines

In-depth ICD-10 coder training should begin approximately six months before the go-live date. Kennedy is aware of several hospitals that had planned to start using the new coding system January 1, 2013, prior to announcement of the delay. These hospitals will begin in-depth coder training as early as this summer, he says.

A delayed compliance deadline could be problematic with respect to scheduling training and perhaps incurring additional training costs, says Bowman. "Now, it raises the question of when will it be? This is an area where I think we will see additional cost. The people who have been trained to become trainers will have to maintain their skills and stay up to date," she says. "Coders will need to be in some type of holding pattern with their knowledge. If you're not using it every day, it's hard to keep it up."

The delay will affect anyone who modified curricula to accommodate the 2013 date, says Bowman. "It's not an easy process to change an entire academic curriculum, particularly because you've got some students in the system already," she says.

Hospitals should be reviewing queries to ensure that they are up to date and incorporate information necessary for ICD-10, says Kennedy. They should determine whether their EHRs are compatible with the specificity of ICD-10. If not, vendors should provide a clear timeline for activating this capability regardless of the compliance deadline, he says.

The timeline shouldn't affect when or whether hospitals educate physicians about documentation necessary to support ICD-10, says Clark. "[Y]ou don't teach doctors how to code," she says. "You teach them how to build better documentation in order to assign an ICD-10 or ICD-9 code. You can continue that process of documentation improvement without uttering the words ICD-10."

"I think that one thing this has taught everybody and shown is that this is a big transition that was perhaps underestimated by some in the beginning," says Bowman. "So keep it at, and that will ensure that you're ready."

Tara Blum, RHIA, CCS, manager of clinical coding at Northwestern Memorial Hospital in Chicago, says her facility will move forward with implementation plans despite the delay. The prioritized to-do list includes:

Finalizing ICD-10 coding salary structure
Continuing to actively recruit new graduates and reducing reliance on contract coders
Implementing computer-assisted coding to help offset productivity losses
Assessing coder skills before training
Developing and implementing tailored ICD-10 educational plans for each coder
Dual coding in ICD-9 and ICD-10 until going live with ICD-10

Editor's note: CMS announced the proposed rule and new ICD-10 compliance date at presstime. Access information about the proposed rule at www.cms.gov/apps/media/fact_sheets.asp. Select "April 9 HHS Proposed One-Year Delay of ICD-10 Compliance Date." The fact sheet includes links to the press release and the proposed rule.

Comments on the proposed rule are due within 30 days of publication in the Federal Register, scheduled for April 17. Comment on the proposed rule at www.regulations.gov.

ICD-10 implementation delay sparks questions, elicits mixed reactions

CMS' announcement in February that it would delay ICD-10 implementation set off an avalanche of mixed reactions from coders, providers, and other stakeholders.

The agency's April 9 announcement of a proposed rule that would postpone implementation from October 1, 2013, to October 1, 2014, will likely do the same.

"What do you mean a delay? We've already had a delay! We've sort of been in this delay approach for 10 years now," said Sue Bowman, MJ, RHIA, CCS, director of coding policy and compliance at AHIMA in Chicago, in describing her reaction to the February announcement.

The announcement of the ICD-10 delay was surprising, considering the time the healthcare industry has had to prepare, Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, said after hearing the initial news in February.

"I do understand that some providers-especially small physician practices-may not be as ready as others," said Bryant, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, Calif. "However, I go back to the final rule, which provided nearly five years to plan."

The decade-long delay has caused challenges with other types of data-driven initiatives that rely heavily on ICD-10, such as value-based purchasing, hospital-acquired conditions, payment reform, and meaningful use, said Bowman.

"How much longer can we expect ICD-9 to go limping along? It just continues a trend of deteriorating data. The data is actually going to get worse the more we try to use ICD-9 with all of the other initiatives," said Bowman.

Providers have had more than enough time to prepare, Bowman said. "If everybody had started in 2008 or 2009, we'd be looking pretty good right now," she said.

Not everyone completely opposed the delay, however. "I have mixed thoughts and feelings as I watch physicians, particularly the AMA and [Medical Group Management Association (MGMA)], oppose an improvement in the currently flawed ICD-9-CM diagnosis reporting system," James S. Kennedy, MD, CCS, managing director of FTI Consulting in Atlanta, said after the February announcement.

"While I certainly relate to physicians' frustration about the cost of all of the initiatives they are asked to participate in, ICD-10 provides a platform for the physicians to improve patient care by creating the potential for a more robust vocabulary and data set that can be abstracted, analyzed, and applied," he said.

The AMA and MGMA's reasons to resist ICD-10 aren't necessarily valid, said Kennedy. "What is so different about ICD-10 that troubles them?" he said. "The diseases we've treated haven't changed. The need for specificity has always been there, even in ICD-9." Rather than attack the nosology and length of the codes, physicians should lobby the Cooperating Parties to more proactively align ICD-10's language with credible physician literature, he said.

A revised timeline at this point challenges CMS' credibility, said Kennedy. "How many times has CMS and the other Cooperating Parties said that there would be no grace period to the October 1, 2013, deadline for ICD-10's implementation? This was after CMS granted a two-year extension at the request of the AMA in 2009," he said.

This delay could signal a litany of other delays as well, said Kennedy. "Given that CMS has already bowed to political pressure for this once, after having said that there would be no grace periods, who is to say that they won't bow to political pressure again?" he said.

From a logistical perspective, Bowman said after the initial announcement that she would be surprised if the delay was less than a year. Implementing a new code set that drives the DRG, home health, and numerous other payment systems in the middle of a government fiscal year would be challenging, she said.

Bowman said it was likely that CMS would delay ICD-10 by a minimum of one year so that the change coincides with the regular coding updates in October. However, even a yearlong delay would be problematic for hospitals because it would create additional rework and training that could increase the cost of implementation exponentially, Bowman said. AHIMA and other organizations have advocated retaining the original compliance date.

Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates in Plantation, Fla., disagreed. CMS is more likely to delay implementation by three to six months rather than a year or more, she said after the February announcement.

"I think what CMS will be satisfying is the comment period for the provider community to send in their comments," said Clark. "It might help as a sounding board, but because this train is already in motion-and we are so far behind the rest of the world-I think they're going to take those comments and listen to them. I don't think there will be a lengthy delay."

CMS might suggest a phased-in approach, allowing one delay for physicians and another for hospitals, said Clark, noting that this option might pose more challenges, particularly on the outpatient hospital side.

A phased-in approach is not a solution, said Bowman. "I think there would be a lot of push-back," she said. "To have some providers on one coding system and some providers on another coding system would be a horrendous nightmare. Also, the government has no intention, nor do they have the resources, to maintain two code sets." This type of division would affect initiatives such as interoperable EMRs and accountable care organizations, said Bowman.

Editor's note: CMS announced the proposed rule postponing ICD-10 implementation until October 1, 2014, at presstime. Briefings on Coding Compliance Strategies will publish information about reaction to announcement of the proposed rule and new implementation date next month.

Are your ICD-10 implementation fears justified?

Tue, 01 May 2012 04:00:00 GMT

Are your ICD-10 implementation fears justified?

by Robert S. Gold, MD

The healthcare industry has been aware of the impending transition to ICD-10 for years and has developed significant angst as a result.

Hospitals and healthcare groups have spent significant dollars on ICD-10 readiness. However, CMS announced in February that it would rethink the implementation timeline.

This comes in the wake of AMA pleas that there are too many initiatives for independent physician practitioners to juggle in a short period of time. The AMA has said that ICD-10 would create a massive financial burden for physicians on the front end and create billing confusion and payment reduction on the back end.

The system will change regardless of whether the industry converts to ICD-10 or whether it transitions directly to ICD-11 or SNOMED. This means that the healthcare industry will continue to wait, worry, and spend more money before all is said and done.

But does ICD-10 really merit all the worry-particularly for coders?

The diseases won't change

Coders must realize that the names and causes of diseases won't change in ICD-10.

As long as diseases have the same etiologies and the same effects on other organ systems, the terminology won't change. Only the codes that represent the terminology will change. If physicians document the diseases as well as their causes and effects, coders can report them with ICD-10.

Some coders may worry about the additional specificity required by ICD-10, decreased productivity, increased accounts receivable, and staffing shortages. However, if your medical staff members are ready for ICD-9, they're ready for ICD-10. If the information available in the medical record is present today, it will be present when ICD-10 becomes effective.

Congestive heart failure (CHF)

Consider CHF. If physicians know how to identify heart failure as acute or chronic or as an exacerbation of a chronic state, coders can report the condition accurately. This won't change with ICD-10. If physicians can identify a patient's left ventricular functional abnormalities as systolic, diastolic, or both, coders can report the condition accurately. This won't change with ICD-10.

The term congestive currently requires coders to assign a second code in some cases. However, this won't be necessary with ICD-10 because left ventricular dysfunction codes include a nonessential modifier built into the specific heart failure code. The fourth and fifth digits in ICD-10 will be exactly the same as they are in ICD-9. What's different is that the rheumatic heart failure code no longer excludes the specificity of left ventricular dysfunction.

The industry will have the added benefit of being able to report both the rheumatic failure code and the left ventricular dysfunction code. If medical staff members know this now, there's nothing new for them to learn when ICD-10 is implemented. Even though coders will no longer see a 428.xx code, encoders that have been updated correctly for ICD-10 will direct them to the correct code for patients with chronic diastolic heart failure due to aortic stenosis.

Stroke

Next, consider stroke. Physicians who currently document whether a stroke is occlusive from a left atrial clot in a patient with atrial fibrillation won't need to change their documentation habits. Other documentation won't likely require change either. For example, if an event occurred in the patient's middle cerebral artery circulation, a neurologist likely already documented it. If a patient's embolic middle cerebral artery stroke is on the left side of the brain, the MRI likely shows this. If the resulting hemiparesis is on a patient's nondominant side, the physical or occupational therapist likely already documented this.

Hypertension

Next, consider hypertension. Coders using ICD-9 can accurately report the cause of hypertension that is not essential hypertension if a physician documents it.

The terms malignant and accelerated are deleted from ICD-10, and there is only one code set for hypertension. If a patient has hypertensive kidney disease, hypertensive heart disease, or hypertension caused by another condition, coders already look for that documentation.

Physicians already document whether pheochromocytoma (a tumor of the adrenal gland) is the cause of a patient's hypertension. Thus, the ICD-10 code will appear different at first until coders become accustomed to seeing these new classifications. However, ICD-10 classifications are based on the same thought processes coders use with ICD-9.

Diabetes

Like ICD-9, ICD-10 divides diabetes into causative factors (i.e., type 1, type 2, secondary to other conditions, and gestational diabetes). Similarly, the codes reflect that diabetes affects the same body systems and requires the same documentation. For example, with nephropathy, physicians must document the stage of chronic kidney disease and the pathologic cause, when applicable. With neuropathy, physicians must document which nerve or nerves are affected. With retinopathy, physicians must specify proliferative or nonproliferative and mild, moderate, or severe.

ICD-10 includes additional body systems that can be affected, each of which has its own code sets. Examples include arthropathy (for Charcot foot), dermopathy (for diabetic skin ulcers), and dental disorders related to diabetes. However, coders will use the same thought processes that they did for ICD-9. The only exception is that ICD-10 doesn't specify uncontrolled diabetes. Instead, this condition appears in the hyperglycemia code set.

Laterality

Although many coders are concerned about laterality, this information is almost always documented somewhere in the chart. Alternatively, coders can locate specificity in an x-ray report if the physician provides a diagnosis. As with other codable information, coders will likely be able to retrieve information about laterality from sources other than attending physicians.

Skin ulcers

All coders are concerned about obtaining the cause and stage of skin ulcers. However, if physicians are diagnosing the hole, this information is likely already provided, whether it's an arterial ulcer, pressure ulcer, or diabetic foot ulcer.

Physicians don't need to learn staging. Instead, they only need to tell coders what tissue is involved at the deepest level (i.e., skin, skin and subcutaneous tissue, tissue involving muscle, or tissue involving bone). If physicians actually look at the hole and document what they think caused it and what tissue is involved, coders will be able to report it.

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770-216-9691 or rgold@DCBAInc.com.

Review guidelines for coding pregnancy, its complications

Tue, 01 May 2012 04:00:00 GMT

Review guidelines for coding pregnancy, its complications

Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually-reviewing coding guidelines is helpful.

Principal diagnosis

Coders must remember that pregnancy is a disease process separate from other disease processes that patients may experience, says Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC. Even when patients present for other conditions (e.g., hypertension management), pregnancy is the principal diagnosis, says Webb, a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer.

A pregnancy diagnosis is always first, she says. This may seem counterintuitive to coders trained to report the principal diagnosis as the condition after study that is chiefly responsible for admission, she says.

Webb recently coded a case in which a pregnant patient was admitted for treatment of a broken leg. The principal diagnosis was pregnancy because it affected decisions regarding treatment of the leg (e.g., administration of certain drugs or sedation), she says.

Sequencing an actual delivery is somewhat different. The ICD-9-CM Official Guidelines for Coding and Reporting, §I.C.11.b.4 (p. 45/107) states: "When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery."

This guideline further explains that for cesarean deliveries, coders should select the principal diagnosis based on the condition established after study that was responsible for admission. This means that if a patient is admitted with a condition that results in a cesarean delivery, the condition that prompts the delivery should be reported as the principal diagnosis. If the admission is unrelated to the condition that results in a cesarean delivery, the condition that relates to the admission should be reported as the principal diagnosis.

Current guidelines indicate that 648.21 is the principal diagnosis for a woman with a pregnancy complicated by anemia who undergoes a cesarean delivery due to fetal distress not present at admission, says Susan Proctor, RHIT, CCS, CPC, a coding consultant in Willits, Calif., and an AHIMA-certified ICD-10-CM/PCS trainer.

Other complications

Coders must also capture all other conditions that affect management of a pregnancy, says Proctor.

The ICD-9-CM Official Guidelines for Coding and Reporting, §I.C.11.a.1 (p. 44/107) states: "It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy."

Report all documented conditions unless physicians indicate otherwise, says Proctor. "All conditions are complications unless stated otherwise by the provider, and the Chapter 11 codes are sequenced first," she says.

Signs and symptoms

Signs and symptoms may also pose coding challenges. This is because physicians often document signs and symptoms that may indicate a more definitive condition, says Webb. Dehydration and excessive vomiting-commonly experienced and documented during pregnancy-could indicate metabolic syndrome. Elevated blood pressure, severe headaches, and edema could indicate preeclampsia. Query when documentation is vague; it may point to a more definitive diagnosis, she says.

Failure to progress

Physicians continue to document nonspecific terminology despite more specific codes and diagnoses available in ICD-9-CM, says Proctor. Failure to progress (i.e., inability to deliver without a cesarean) is one example, she says. Coding Clinic, July-August 1985, p. 11, instructs coders to report code 661.21 (uterine inertia, delivered) when physicians document failure to progress.

Decreased fetal movement

Decreased fetal movement (655.7x)-a condition in which a mother cannot feel the fetus move-can be an early sign of a problematic pregnancy. Physicians often document this term before administration and interpretation of a fetal non-stress test that indicates normal development, says Webb.

The following documentation is necessary to help determine whether decreased fetal movement is present:

Was the fetus stressed during the fetal non-stress test?
How many heartbeats per minute, including accelerations and decelerations, did the fetus have during the test? Is this normal?
How many contractions occurred during the test?
What was the patient's blood pressure during the test?
Was the patient hydrated or dehydrated during the test?

Query when documentation is unclear, says Webb.

Fetal conditions and management of mothers

Coders should assign codes from the following categories only when the fetal condition is responsible for modifying management of a mother:

655 (known or suspected fetal abnormality affecting management of the mother)
656 (other known or suspected fetal and placental problems affecting management of the mother)

For example, report fetal conditions that require termination of a pregnancy, diagnostic studies, additional observation, or special care. The mere existence of a fetal condition does not justify assigning a code for that condition, in accordance with the guidelines.

Complicating matters is that one physician could be treating the mother and another could be monitoring the fetus, says Webb. Interconnected EMRs help ensure documentation is updated and available. This isn't always possible, making it difficult for coders to determine how and whether certain fetal conditions affect the mother, she explains.

Normal deliveries

Normal deliveries (code 650) are so rare that Proctor asks colleagues to review cases to ensure she didn't forget to code something that was documented. Coders should remember that in addition to procedures listed under the description for code 650, normal deliveries include induction of labor by artificial rupture of membranes without any indication. Refer to Coding Clinic, Third Quarter 2000, p. 5, for more information.

Abortions

The term abortion has a legal connotation, but several more specific terms are also associated with this diagnosis, says Webb. These include the following:

Spontaneous abortion, including miscarriage (634.x)
Legally induced abortion (635.x)
Illegally induced abortion (636.x)
Unspecified abortion, including retained products of conception following abortion, not classified elsewhere (637.x)
Failed attempted abortion (638.x)

Intrapartum care

Coders often forget to report codes for complications that occur during labor and delivery (codes 660-669), says Webb. For example, when a delivery trauma, such as an episiotomy (73.6), occurs, coders often forget to report a code for cervical laceration (655.3x).

ICD-10

ICD-10 pregnancy, childbirth, and puerperium codes are more detailed than their ICD-9-CM counterparts and often refer to the fetus as a product of conception, says Proctor. Furthermore, ICD-10-PCS fetal and obstetrical MRI codes will require coders to capture the specific fetal body part examined and whether contrast was used, says Webb.

Take time to learn what motivates your coding staff

Tue, 01 May 2012 04:00:00 GMT

Take time to learn what motivates your coding staff

Coders tend to be highly motivated by nature, but they're constantly put to the test during times of increased demands, expectations, and change.

Experts agree that today's coders face a variety of stressors. A few examples include:

Learning ICD-10
Meeting stringent productivity standards
Withstanding third-party auditor scrutiny
Surviving staffing shortages
Satisfying demands for coding accuracy
Keeping up with ever-changing coding guidelines

"The present environment of increased scrutiny and demand requires organizations to look hard for what motivates employees," says Laura Legg, RHIT, CCS, a revenue control coding consultant at Providence Health & Services in Renton, Wash.

Diane Grapp, CCS, coding coordinator at Wheaton Franciscan Healthcare, a six-hospital system in southeastern Wisconsin, agrees. "When more is expected out of a coder, more motivation is needed to help the coder achieve their potential," she says.

Coder retention

Motivated employees tend to work harder, and motivation is important with respect to coder retention, says Legg. "Coders are pretty hard to find. If you have a good coder, you want to keep them motivated and happy and keep them learning so that they stay with you," she says.

Retention is particularly important as hospitals begin to budget for ICD-10 training. Some hospitals are concerned that considerable attrition between now and the ICD-10 compliance deadline will mean that providing extensive ICD-10 training to current staff may be a futile effort, says Legg. This attrition may be due to coders who retire, an inability to retain qualified coders, or both, she says.

Motivating coders is important with respect to retention and maintaining ICD-10 momentum, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS. Hospitals and coders must continue to move forward with training and preparations despite CMS' announcement of an implementation delay, says Bryant, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, Calif.

Money and promotions are obvious incentives, but experts say other factors also contribute to motivation.

ICD-10-CM/PCS

ICD-10-CM/PCS-along with its inherent learning and leadership opportunities-motivates some coders, says Legg. Consider involving coders in ICD-10 initiatives, such as a newsletter devoted to ICD-10 topics, monthly conference calls, or meetings that offer coders an opportunity to ask questions and share information, she says.

Conversely, some coders may be completely overwhelmed by ICD-10, says Bryant. "That much change de-motivates some," she says. "You have to find the balance. Change can take a certain group of employees and pull them down in terms of being motivated." Working one-on-one with these individuals will help ensure a smooth transition in which motivation remains constant, she says.

Continuing education

Coding managers need to know which areas pose challenges and provide educational opportunities to address these needs. "Education and knowledge equal power," says Grapp. "When a coder is empowered with information necessary to perform his or her job, the coder will succeed."

Bryant agrees. "In professional coding and HIM, learning is inherent to the profession. To be able to support that and provide education and training is a motivator," she says.

Unfortunately, hospitals provide varying degrees of educational opportunities for coders, says Legg. Hospitals that don't value continuing education tend to struggle most with coder motivation. "It's very defeating to feel as though you're not appreciated enough to be worthwhile for investment," she says. "Coders are expected to know what they need to know, which isn't going to happen unless they have those learning opportunities. 'You need to know all of this, but we aren't going to pay for it' is not a good message."

Allowing coders to conduct regular coding audits is one way to enhance more traditional avenues for learning (e.g., audio conferences, online courses, coding publication subscriptions), says Grapp. "I tell coders that auditing is a great educational tool to help enhance coding skills," she says. "The audits can sharpen professional skills and help coders move forward."

Recognition and communication

Coding managers should communicate regularly with coders, not just when a problem exists, says Legg. Low motivation can occur when coding managers or HIM directors interact with coders only to discuss errors during audit result meetings. "Coders need audit results because obviously it's a learning opportunity, but it shouldn't be the only time they're communicated with," she says.

Motivation is higher when coders are recognized for their work, says Legg. A simple "thank you" from management each morning can go a long way to motivate staff, she says.

When coders express concerns or ask questions, managers should take their comments seriously, says Bryant. For example, don't ignore a coder's concern about a query form or certain EHR functionality. "Your staff will be motivated if they can see that you're working on resolving the problem," she says. Something as simple as a coding tip sheet can motivate coders because it shows managers are trying to simplify coders' work, she says.

Allow coders to vent their frustrations, says Bryant. "The work can be frustrating and challenging, and we don't have all the answers," she says.

Managers should consider hosting roundtables to discuss coding questions. The staff might agree on how to interpret a particular guideline or coding convention or decide that additional AHA clarification is necessary. Coding managers should support coders' decisions to pursue additional clarification.

"Follow-through is really important to show your staff that you care about their work. This will motivate them because they can see that you're dedicated, too," says Bryant.

Allowing coders time to meet is helpful with respect to compliance; it also can provide psychological motivation, she says. Coders sometimes think they're the only one with a question. A roundtable discussion is motivating because it's inclusive and makes people feel like they're part of a team, she says.

Goals

Goal-setting can be a powerful incentive, particularly when coders can provide input that lends specificity, says Legg. "This establishes a sense of ownership for meeting those goals," she explains. For example, some coders may strive to undergo cross-training or training for a non-coding-related task, she says.

Grapp agrees. "A goal will challenge our talents and give us guidelines to achieve. It brings a sense of accomplishment to the coder to reach certain goals," she says.

Coders don't typically provide input regarding productivity goals, but reminding them that certain charts will take longer than others to code is important, says Grapp. This helps coders understand that ultimately, productivity is based on an average number of charts per hour.

Remote coding

Remote coding can improve motivation and productivity because coders know that trust exists between them and management, says Grapp.

Legg agrees. "I think coders really enjoy the flexibility of working at home," she says. "It provides some freedoms not offered in the office setting, and it implies a sense of trust."

Ask coders what they want

Coding managers shouldn't assume that a successful incentive for one individual will be universally effective, says Legg. "I think the best strategy is to ask coders. Asking them is a sure way to know," she says.

Grapp agrees. "Learn who your coders are as individual people. Learn their personalities and how each one responds to different styles of motivation," she says.

Surveys can gauge what motivates staff, says Bryant. Also consider scheduling monthly departmental meetings or office hours for individual discussions, she says.

Individual and team incentives

Use of individual and team incentives is ideal, experts say. Respective examples are an award for helping a colleague code a difficult case and a relaxed Friday dress code for all coders if the team meets a certain goal, says Legg.

Briefings on Coding Compliance Strategies, May 2012

Tue, 01 May 2012 04:00:00 GMT

Delayed implementation and its effect on coders

The wait is over-CMS has announced a proposed rule that would postpone ICD-10 implementation from October 1, 2013, to October 1, 2014, if finalized.

What does the delay mean for coders who have spent the past several years psychologically preparing for a countdown to October 1, 2013?

What are advantages, disadvantages of a delay?

However, some disadvantages also accompany delayed implementation of ICD-10.

Is waiting for ICD-11 a viable option?

The World Health Organization has said that ICD-11 will be released by 2015.

What should providers do now?

Experts agree that halting ICD-10 preparations is not the answer.

Bryant says hospitals should determine the following:

Which key milestones and steps may require revision because of the delay
The effect on previously secured funding
Whether a delay will extend implementation costs beyond current budget estimates, and by how much

Other plans for 2012 should include documentation assessment and preliminary coder training, says Bryant, with a focus on the following foundational core competency areas:

Medical terminology
Anatomy and physiology
Disease process and pharmacology
ICD-10 coding guidelines

Finalizing ICD-10 coding salary structure
Continuing to actively recruit new graduates and reducing reliance on contract coders
Implementing computer-assisted coding to help offset productivity losses
Assessing coder skills before training
Developing and implementing tailored ICD-10 educational plans for each coder
Dual coding in ICD-9 and ICD-10 until going live with ICD-10

Comments on the proposed rule are due within 30 days of publication in the Federal Register, scheduled for April 17. Comment on the proposed rule at www.regulations.gov.

ICD-10 implementation delay sparks questions, elicits mixed reactions

CMS' announcement in February that it would delay ICD-10 implementation set off an avalanche of mixed reactions from coders, providers, and other stakeholders.

The agency's April 9 announcement of a proposed rule that would postpone implementation from October 1, 2013, to October 1, 2014, will likely do the same.

Providers have had more than enough time to prepare, Bowman said. "If everybody had started in 2008 or 2009, we'd be looking pretty good right now," she said.

Are your ICD-10 implementation fears justified?

by Robert S. Gold, MD

The healthcare industry has been aware of the impending transition to ICD-10 for years and has developed significant angst as a result.

Hospitals and healthcare groups have spent significant dollars on ICD-10 readiness. However, CMS announced in February that it would rethink the implementation timeline.

But does ICD-10 really merit all the worry-particularly for coders?

The diseases won't change

Coders must realize that the names and causes of diseases won't change in ICD-10.

Congestive heart failure (CHF)

Stroke

Hypertension

Next, consider hypertension. Coders using ICD-9 can accurately report the cause of hypertension that is not essential hypertension if a physician documents it.

Diabetes

Laterality

Skin ulcers

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770-216-9691 or rgold@DCBAInc.com.

Review guidelines for coding pregnancy, its complications

Principal diagnosis

Other complications

Coders must also capture all other conditions that affect management of a pregnancy, says Proctor.

Signs and symptoms

Failure to progress

Decreased fetal movement

The following documentation is necessary to help determine whether decreased fetal movement is present:

Was the fetus stressed during the fetal non-stress test?
How many heartbeats per minute, including accelerations and decelerations, did the fetus have during the test? Is this normal?
How many contractions occurred during the test?
What was the patient's blood pressure during the test?
Was the patient hydrated or dehydrated during the test?

Query when documentation is unclear, says Webb.

Fetal conditions and management of mothers

Coders should assign codes from the following categories only when the fetal condition is responsible for modifying management of a mother:

655 (known or suspected fetal abnormality affecting management of the mother)
656 (other known or suspected fetal and placental problems affecting management of the mother)

For example, report fetal conditions that require termination of a pregnancy, diagnostic studies, additional observation, or special

Coders need to understand their role in the process

Sun, 01 Apr 2012 04:00:00 GMT

Coders need to understand their role in the process

Coding isn't just about reading documentation and selecting codes based on certain words. It's about processing information and assessing whether the codes reported accurately depict the clinical picture and medical necessity for an admission.

Coders are well versed in assigning a principal diagnosis, but less so in the concept of medical necessity, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS. They tend to simply code what's in the record rather than determine which conditions actually justify the services performed, says Krauss, an independent HIM consultant in Madison, WI. So why does this matter?

Miscommunication mishaps

Omitting codes that capture medical necessity, some of which may be payer-specific, can result in denials, says Krauss. But reporting codes simply to satisfy medical necessity-when physician documentation doesn't justify doing so-can also be problematic, he says.

This is perplexing for inpatient coders. Although certain conditions may help justify the medical necessity of an admission, coders can't report them unless physicians clearly document treatment (e.g., medications or diagnostic tests), says Heather Greene, MBA, RHIA.

"Just because the doctor documented the patient as having a certain diagnosis, if it was not treated during the stay ... the code cannot be picked up," says Greene, a coding and documentation consultant at Kraft Healthcare Consulting, LLC, in Lexington, KY.

Some physicians may even list problems or conditions that they ultimately never treat or address, says Greene. For example, coders may find a singular reference to a urinary tract infection among hundreds of pages of documentation. Then they must determine which medications or tests, if any, were provided.

"Sometimes you see the opposite. There may be a urinalysis with positive results and Bactrim® ordered without a diagnosis listed anywhere," she says.

Krauss provides another example: A patient is admitted to the hospital with leg pain and a leg wound that is not healing. A physician suspects osteomyelitis and performs an MRI scan that doesn't reveal any signs of the condition. However, the physician doesn't rule the diagnosis in or out, and a coder reports acute osteomyelitis as the principal diagnosis with a Stage III ulcer as secondary.

"The problem is that the patient was in the hospital and didn't ever receive any antibiotics," he says. "If it's truly osteomyelitis, they're going to likely receive a six-week course of antibiotics."

Mistakes happen

Sometimes physicians make mistakes, and coders are in a position to catch those mistakes, says Jessica Whitley, MD, MBA, an independent physician reviewer for Ohio KePRO in Seven Hills, OH. In this role, Whitley validates DRGs and medical necessity. Her other work as a hospitalist at a large academic tertiary center and a small community hospital gives her a unique perspective of medical necessity.

As an independent peer reviewer, Whitley may not validate the presence of documented conditions in the absence of any documented signs, symptoms, or confirming tests to substantiate a diagnosis. The only exception occurs when physicians clearly and reasonably state their reasons for suspecting the diagnosis despite a lack of clear evidence.

"Doctors think that once they document a diagnosis, that outside reviewers may not look for signs, symptoms, and diagnostic tests to support that diagnosis," says Whitley. Physicians also may think that if testing clearly supports a diagnosis, a patient's signs and symptoms become irrelevant. However, signs and symptoms-and the diagnosis-are often what demonstrates severity of illness and justifies or warrants admission, she says.

Sepsis is an example Whitley often encounters. Physicians may document sepsis when a patient has an elevated white blood count and bacteremia on a blood culture, but vital signs and symptoms the patient describes show no evidence of SIRS (e.g., elevated temperature, tachycardia, tachypnea, altered mental status). If coders note obvious tests or signs and symptoms that fail to support a documented diagnosis, they should consider the possibility that the diagnosis is not present and query physicians for more information, she says.

Whitley provides an example of a nursing home patient who presents to the hospital. Nursing home documentation indicates a history of end-stage renal disease (ESRD). ED and attending physicians document a history of ESRD even though hospital laboratory work reveals a creatinine of 0.9 and a BUN of 20. These results are normal and not consistent with a diagnosis of ESRD, says Whitley.

This inconsistency between the laboratory results and diagnosis should raise a red flag, she says. The documentation is indicative of chart lore-information in previous documentation that physicians repeat without evaluating its validity. Seek clarification if something clearly contradicts a documented diagnosis, Whitley says.

Identify sequencing challenges

Sequencing is a challenge, particularly when two conditions meet the definition of principal diagnosis but only one justifies medical necessity for admission, says Krauss.

Many coders don't consider the major role sequencing plays in determining whether Recovery Auditors target cases for medical necessity review, he says. For example, a patient presents with acute exacerbation of chronic obstructive pulmonary disorder and acute pneumonia. Both conditions are POA, are treated equally, and equally qualify as the reason for admission. Coders can select either as principal diagnosis and generally choose the one that yields a higher-weighted DRG, Krauss says. However, if a physician doesn't show the instability of both conditions in clinical documentation, auditors opt for the lower-paying one, and sometimes they're right, he says.

When evaluating cases in which two or more conditions equally meet the definition of principal diagnosis, consider which actually prompted admission. Would the patient have been admitted for one without the other?

"[Recovery Auditors] don't just pick these cases out of a hat. They have screens," says Krauss. "If we sequence something incorrectly and don't have the appropriate documentation, then we're contributing to unnecessary denials. Our goal is not to get the maximum money-it's to get the optimum reimbursement based on medical necessity and supporting clinical documentation of the same."

Inpatient vs. observation status

Although coders don't play a significant role in determining patient status, they may be able to identify documentation that could alert case managers to scenarios requiring clarification, says Whitley.

"To doctors, inpatient versus observation status may seem irrelevant," she says. "Doctors may think that just because a patient's signs and symptoms or diagnosis may warrant some time in a hospital, then an inpatient stay is warranted, too. Doctors equate in the hospital' with inpatient."

Medical necessity is a sensitive topic, says Whitley. Ensuring physicians understand that patient status (i.e., inpatient, outpatient, observation) in no way interferes with the plan of care is important, she says.

Remind physicians that documentation can help demonstrate the medical necessity of inpatient admissions, says Whitley. Documentation should include illness severity and acuity, along with signs and symptoms, she says. Encourage physicians to answer these questions:

How long has the patient had the problem?
Is it a chronic problem that can be worked up on an outpatient basis?
Is it an acute-onset problem with a severity that requires a hospital stay?

Clarify questions of medical necessity

"I think coders have a great opportunity to educate physicians regarding the essential elements of documentation," says Whitley. Many physicians don't understand the details that reviewers scrutinize when assessing cases for medical necessity, she says.

Coders should consider medical necessity when querying in cases for which two or more conditions meet the definition of principal diagnosis, says Krauss. The Social Security Act, 42 USC §139y(a)(1)(A), states:

Including this provision in queries pertaining to medical necessity might be helpful, Krauss says.

The tendency of CDI programs to focus on diagnostic specificity and not medical necessity is perplexing because of the number of medical necessity denials, says Whitley-she adds that physician resistance could be a reason. "Medical necessity questions seem like they are more challenging to the doctor. It seems more contentious, she says, noting that clarifying a diagnosis is not as controversial as asking whether a patient truly meets criteria for inpatient admission.

"Emphasize to physicians that clarifications regarding medical necessity have nothing to do with challenging a physician's clinical judgment," says Whitley. "They have more to do with helping physicians determine the best and most cost-effective place to provide that care."

Planning can maximize benefits of internal coding audits

Sun, 01 Apr 2012 04:00:00 GMT

Planning can maximize benefits of internal coding audits

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

Define the purpose and scope of audits

"You need to go into the audit with a clear understanding of the reason and purpose of the audit," says Joe Rivet, CCS-P, CPC, CEMC, CPMA, CICA, CHRC, CHPC, CHC. Rivet is the corporate compliance and privacy officer at Wayne State University Physician Group in Detroit.

Consistency is key, says Julie Daube, BS, RHIT, CCS, CCS-P, coding quality review and education manager at Care Communications, Inc., in Chicago. Too often, hospitals are inconsistent with respect to the volume of records audited per coder, she says.

"You want to be able to compare apples to apples in order to trend quality and provide educational opportunities," says Daube. "If you find that the coder has shown improvement in an area that was originally focused on, then instead of changing the quantity, you need to change the focus to continue to identify areas of risk."

Volume should be consistently based on the average number of discharges at the facility. Approximately 20-30 records per coder per quarter is typical, says Daube.

Senior leadership buy-in is essential

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

Without this buy-in, coding auditors and compliance professionals may fight an uphill battle, says Rivet. "You could have all the appropriate head-nodding and lip service but when a live issue comes up and they start to crumble or fall back on what was clearly defined and agreed to, then you need to evaluate yourself as a professional individual within that group," he says.

Obtaining buy-in also involves helping senior leadership establish realistic expectations for audits, says Daube. A coding audit won't necessarily reveal a clear reason why the case-mix index has decreased significantly, for example. "Sometimes hospitals will perform this audit thinking they're going to find an issue with the coding, then we do an audit, and everything is fine. There are other factors that can impact the case mix, such as a drop in the medical or surgical volumes," she says. Hospitals also might conduct coding audits incorrectly, assuming that they will discover a plethora of CDI opportunities, and this might not be the case either because of the patient population or the severity of illness, says Daube.

Don't let dollars drive an audit

Too many audits are based purely on financial performance, says Rivet. Hospitals should not perform coding audits solely to increase revenue in a particular area-this could raise a red flag for auditors and might not even yield anticipated results. CFOs often incorrectly assume that incorrect coding causes decreased revenue, but the decrease could be due to other factors, including a lower volume of cases, he says.

"Your auditing and monitoring should really be risk-based-not driven by financial performance or a check-off box method" says Rivet.

Also, don't strive to perform a certain number of audits annually to reach a quota, he says. "That really doesn't do any good because the selection and process is just to meet a number rather than focusing on key risks that you have as an organization," he says.

Timing is an important consideration

The frequency of coding audits-whether annual, quarterly, monthly, or some other frequency-should be based on associated risk, says Rivet.

Conducting random audits at random intervals is not helpful. "You're not helping to reduce overall risk. You leave yourself pretty vulnerable by not looking at and evaluating the true risks," he says.

Risks don't always remain the same

Auditing the same areas each year is not beneficial to hospitals, says Rivet. "Risks are a moving target," he says. "They may not carry over year to year, quarter to quarter, or month to month. Many of them will but it's important to keep monitoring both internal and external activity."

External sources should include the following:

Recovery Auditor activity in your region. Network with other colleagues in your geographic area, says Rivet. If a nearby hospital has experienced a particular Recovery Auditor review, other local hospitals should be assessing that issue immediately, he says.
MAC or FI notifications. Even if a notification doesn't pertain to your specific region, evaluating your own comfort level with that area of risk is helpful, says Rivet. Ask when the most recent audit of this issue occurred, who performed it, and what the results were.
The Medicare Quarterly Provider Compliance Newsletter.

Some facilities already know the internal issues on which they'd like to focus their audits, says Daube. Most of her clients also incorporate Recovery Audit targets when deciding what to audit. "This is pretty much every DRG now anyway," she says. Many clients also base audits on their Program for Evaluating Payment Patterns Electronic Reports.

Remember that just because a Recovery Auditor may investigate a particular issue at a hospital doesn't imply that an internal audit is necessary, says Rivet. The hospital might have identified the errors and implemented a corrective action plan after the date of service being audited during the look-back period, he says.

Hospitals have increasingly requested internal coding audits to prepare for ICD-10, says Daube. She has also noticed industrywide trends toward combining a coding audit with a more formal documentation assessment. Care Communication's clients often request granular assessments that highlight the need for individual physician education related to specific codes, she says.

For example, a coding audit may reveal that coding is correct based on documentation. However, a more thorough documentation assessment could reveal a physician documentation challenge or missed query opportunities (e.g., no documentation of the type of sepsis despite the existence of blood work that identifies it).

"We gather this information anyway when we're looking in the record, but it's just good for the client when we can report coding deficiencies along with any documentation deficiencies so if there are any parallels, they can kill two birds with one stone and address it all at once," says Daube.

Formally report the documentation assessment and follow up on education opportunities, says Daube. This helps prepare for ICD-10 because the ability to identify physicians who don't document laterality of certain procedures might be helpful, for example.

Ensure thorough post-audit follow-up

If hospitals don't intend to follow through with audit results and take corrective action when necessary, the audit will be essentially useless and even potentially damaging to the organization, says Rivet.

When concluding an audit, consider noting the scope, objective, number of records audited, detailed findings, the applicable rule to which coding or documentation findings apply, and the action plan based on that rule.

Senior leaders need to know general audit findings, how they might affect the hospital, and whether the findings can potentially become more serious over time, says Rivet. Conversely, physicians should see actual medical records to which audit reports apply. Coders and CDI specialists should receive more detailed findings, he says.

CDI specialists may be best suited to provide audit feedback to physicians because they have already established a rapport, says Daube.

Identify potential Medicaid RAC target areas

Sun, 01 Apr 2012 04:00:00 GMT

Identify potential Medicaid RAC target areas

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

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

Addressing documentation, coding, and billing problems on the front end is the best way to prepare for Medicaid RACs, says William L. Malm, ND, RN, CMAS.

"Are you putting that effort in on the front end to make sure that the claim is as clean as possible before it goes out?" says Malm, a healthcare consultant at Craneware in Atlanta. "Clearly, the front end [route] is going to be most cost-efficient."

Physicians need to understand and appreciate the role they play, says Elizabeth Lamkin, MHA, CEO and partner at PACE Healthcare Consulting, LLC, in Hilton Head, SC. "A third party has to be able to look at [physician] notes and independently validate the inpatient stay," she says. Documentation of the history and physical should include an explicit explanation of the patient's severity of illness, says Lamkin. Physician orders should reflect the intensity of the services provided. Problem notes must also justify the ongoing intensity of a service that supports a continued stay, she says.

Physician advisors can help coders and CDI specialists better partner with medical staff, says Lamkin. "This role is the bridge between physicians and the facility," she says. Physicians, coders, and other staff must understand payer rules, state-specific coding and sequencing requirements, and the appropriate clinical documentation needed to justify services.

"The government has repeatedly said that it will template Medicaid after Medicare with state-specific nuances and flexibility," says Malm.

Third-party auditors cannot duplicate efforts by auditing the same claim for the same issue, says James Berger, MD, senior director of the Medicaid appeals team at Executive Health Resources. However, hospitals may see certain themes emerge, many of which may be applicable to Medicaid RACs, notes Berger.

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

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

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

Syncope. "Many of these cases, in retrospect, turn out to be vasovagal in etiology rather than having a more serious cardiac cause," says Berger.
Transient ischemic attack (TIA). "TIA by its nature is a self-limited condition, but it may be a precursor to stroke and therefore be of more concern," says Berger.
Pain (i.e., abdominal pain and back pain). "A frequent question that arises is whether outpatient treatment was attempted prior to admission," says Berger. Documentation should reflect the nature and extent of that treatment, he says.
Short-stay surgery. Laparoscopic procedures (e.g., appendectomies and cholecystectomies) aren't elective. However, RACs may deny them if no complications are associated with the surgery and treatment is rendered in fewer than 24 hours, says Berger. RACs also may target coronary artery stent procedures if there are no complications, the procedure is elective, and the patient is in the hospital for fewer than 24 hours. "Unfortunately, many contractors are not considering the patient's comorbid conditions contributing to an increased risk associated with the procedure," he says. "They're not considering what coronary artery vessels are being stented and how many stents are being placed at one given time." Also, genitourinary procedures, such as nephrolithotripsy, may be targeted.

However, coders shouldn't consider these potential targets as being set in stone, emphasizes Malm. The opposite may be true. "There has been no activity from which we can make determinate actions at this point," he says.

Lamkin agrees that it's too soon to predict what Medicaid RACs will target. "Providers should learn from Medicare but stay close to their states' RAC websites for guidance on audit issues such as medical necessity," she says.

The good news is that ICD-10 may help alleviate Recovery Auditor recoupments-eventually, says Lamkin. The specificity in ICD-10-CM, particularly ICD-10-PCS, will result in less ambiguous and more detailed codes, leading to fewer erroneous, rejected, and exaggerated claims, according to the RAND Corporation. RAND estimates that although these kinds of claims will likely rise initially after ICD-10 implementation, hospitals may see positive cumulative benefits after a period of five years. (Visit www.rand.org/pubs/technical_reports/2004/RAND_TR132.pdf for more information.)

Editor's note: The content in this article was originally presented during HCPro's audio conference "New Medicaid RAC Program: Overpayment Target Areas and Tips to Prevent Large Take Backs." For more information, visit www.hcmarketplace.com/prod-10038.

Compare Medicare, Medicaid when developing audit processes

States will have flexibility when they structure their individual Medicaid Recovery Audit Contractor (RAC) programs, says William L. Malm, ND, RN, CMAS, a healthcare consultant at Craneware, Inc., in Atlanta.

However, they should retain some of the components and functions of the Medicare Recovery Audit Program, says Malm. This will come as welcome news for some facilities because they will be able to use some processes already in place for Medicare to formulate their Medicaid processes.

However, despite some similarities between the two programs, important differences exist that necessitate policies unique to Medicaid. Malm cites the appeal rights processes as an example-these processes will be state-specific and likely not the same as Medicare.

"Now you have to think in terms of having internal auditors or RAC auditors who have governmental experience," he says.

One auditor should be responsible for Medicare claims while the other should be responsible for Medicaid claims, Malm says, acknowledging that this will likely be a hardship for hospitals.

Malm emphasizes that organizations must transition from their current defensive nature to a more offensive stance during audits. He advises organizations to train and hire certified coders with the same attention to quality as those who work for the Medicaid RAC Program. By requiring their coders to have the same credentials as CMS coders, organizations will ensure their quality matches CMS' expectations, says Malm.

Organizations should take the lessons learned from the Medicare Recovery Audit Program process and apply them offensively when developing processes for Medicaid, advises Elizabeth Lamkin, MHA, CEO of PACE Healthcare Consulting, LLC, in Hilton Head, SC. "It is important when you're going through this initial period with the Medicaid RACs to keep track of the sorts of issues you are having," she says.

As a result of her Medicare Recovery Audit Program experience, Lamkin recommends that hospitals and facilities discuss any concerns and issues they encounter with Medicaid audits and present them as a unified group to CMS. The agency tends to respond to trends, rather than individual experiences, so joining forces, especially through a hospital association or other professional association, will ensure the collective message gets across, allowing CMS to make the appropriate changes.

Editor's note: The content in this article, adapted from the HCPro newsletter Strategies for Health Care Compliance, was originally presented during HCPro's audio conference "New Medicaid RAC Program: Overpayment Target Areas and Tips to Prevent Large Take Backs."

Consider the big picture before querying physicians

Sun, 01 Apr 2012 04:00:00 GMT

Consider the big picture before querying physicians

by Robert S. Gold, MD

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

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

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

Malnutrition

Consider this scenario: A coder questioned whether a patient's height, weight, and BMI constituted malnutrition, and if so, what the level of severity was (i.e., mild, moderate, or severe). The patient was a thin young girl with a BMI of 14.6. She did not receive any treatment (e.g., dietary consultation or special diet) related to her nutritional status. She was hospitalized for something completely unrelated to her BMI. She likely cared a great deal about how she looked, and she probably reveled in the fact that she was a size 2. There was no clinical indication of concern regarding the patient's body habitus. She also did not have any weight loss, and she did not have any disease process impacting her nutritional status. She did not receive any dietary and nursing attention. Therefore, her nutritional status is not a codeable secondary diagnosis according to Uniform Hospital Discharge Data Set criteria.

Acute renal failure

Another case involved a 78-year-old patient who was admitted from a nursing home with probable pneumonia, low-grade fever, and slightly elevated white blood cell count. A physician later validated the pneumonia. A coder, who noticed an elevated creatinine level of 3.1 mg%, communicated with the physician to inquire whether the patient had acute renal failure. However, the coder failed to realize that the patient's creatinine after fluid hydration was still 3.0. If the coder had reviewed the patient's historical data, the coder would have realized that the patient's creatinine had actually been between 3.0 and 3.3 for the past year. Is there any chance that this patient could have had acute renal failure? No way!

Don't ask a question unless you already know the answer. Physicians must look at historical data to put a particular creatinine level into a larger context and determine whether it represents acute renal failure. Coders should do the same before posing this question. The question is totally inappropriate when coders don't first look at the historical data.

SIRS

Last, but certainly not least, we have the topic of SIRS. Consider this scenario: A 60-year-old male patient was admitted to the hospital from the nursing home after a syncopal episode. The patient was living at the nursing home due to disabilities resulting from the Korean War. An evaluation in the ED revealed atrial fibrillation with rapid ventricular response. He was treated with Cardizem® and underwent studies to rule out other sources of syncope. The studies included a workup for sepsis, stroke, and acute myocardial infarction. A resident noted that his white blood cell count was 15,200 with normal differential. Tests revealed nothing other than white cells in the urine and bacteria with positive nitrite. The patient received a dose of ciprofloxacin IV and was sent for monitoring on ciprofloxacin orally.

Our well-intentioned resident identified the tachycardia and the elevated white count (leukocytosis) along with the abnormal findings on urinalysis. After having received CDI training at a former hospital, he documented, "The patient has two of the four criteria of SIRS (tachycardia and leukocytosis) and a urinary tract infection (UTI). Therefore, he has sepsis."

Every physician and midlevel provider who treated the patient thereafter copied and pasted these sentences from note to note for three days. The tachycardia was due to the patient's arrhythmia, which he'd had intermittently for years. A rheumatologist identified his leukocytosis as due to a steroid injection he had undergone a few days ago for osteoarthritis. The patient's UTI was both asymptomatic and treated with oral antibiotics. Did this patient have sepsis? Did the patient even have SIRS? Not a chance.

Acute blood loss anemia

Conversely, there may be instances in which coders should query physicians when laboratory values or other numbers just don't seem to match the diagnosis. I recently encountered a case involving a 22-year-old female patient with type I diabetes who had undergone debridement of necrotic areas on the foot as well as resection (amputation) of a toe due to osteomyelitis. The patient's hemoglobin was 8.6 before surgery. She received one liter of Ringer's lactate during the operation. Her hemoglobin after surgery was 8.2. The patient lost 22 cc of blood during the procedure, and she did not have any additional blood loss on her dressings. A midlevel provider documented acute blood loss anemia as a secondary diagnosis. Is this accurate? Not a chance.

There was no acute blood loss, and the patient's hemoglobin level hadn't changed at all with the exception of being slightly diluted due to the IV fluids. Instead, the patient had anemia due to a chronic infection (i.e., diabetic osteomyelitis). The midlevel provider had likely been trained inappropriately to document acute blood loss anemia, which I consider a bogus diagnosis. This provider, in an attempt to be helpful, provided inaccurate documentation. This needs one-on-one education.

Conclusion

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

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770/216-9691 or by e-mail at rgold@DCBAInc.com.

Know how to translate physician �documentation

Sun, 01 Apr 2012 04:00:00 GMT

Know how to translate physician documentation

It's no wonder experts say ICD-10-PCS may be more challenging for coders coding procedures than for physicians trying to document information.

Not only will the number of procedure codes jump from approximately 4,000 to more than 72,000 when ICD-10-PCS becomes effective, but assigning a code will also be more complicated. ICD-10-PCS codes consist of a seven-digit alphanumeric formula, and each character within the code has as many as 34 possible values.

"I think how we look at clinical documentation for procedure coding and diagnosis coding will be different. A lot of the details that we think will be required to make the transition to the code in ICD-10[-PCS] are readily available in the physician operative and procedures notes, as well as other parts of the medical record," says Karen Farrell, director of healthcare solutions marketing at Nuance Healthcare in Burlington, MA. "I think the real impact is going to be on the coders."

Consider this example: In ICD-9-CM, coders report code 39.50 to denote an angioplasty. In ICD-10-PCS, however, there are 170 angioplasty codes that specify the body part, approach, and device. Some examples include the following:

047K04Z: Dilation of the right femoral artery with drug-eluting intraluminal device, open approach
047K0DZ: Dilation of right femoral artery with intraluminal device, open approach
047K0ZZ: Dilation of right femoral artery, open approach

Focus on certain characters

The seven characters in an ICD-10-PCS code include the following:

Type of procedure or section (e.g., obstetric, medical, or surgical)
Body system (e.g., central nervous system or endocrine system)
Root operation (e.g., revision, repair, or excision)
Body part (e.g., liver, kidney, or skin)
Approach (e.g., open or percutaneous)
Device (e.g., implants or grafts)
Qualifier

The second and fourth characters will require extensive knowledge of anatomy and physiology, says Laura Legg, RHIT, CCS, a revenue control coding consultant at Providence Health & Services in Renton, WA.

Farrell agrees that anatomy and physiology will play a large role and that physicians won't necessarily change the manner in which they document this information.

"It's going to be up to the coder on the back end to identify what has been entered in that document and then make the translation," she says.

For example, when a physician documents performing a repair of an inguinal hernia, coders shouldn't expect the physician to specify that this is a repair of a lower extremity. This information is intuitive to physicians, says Farrell. "They know that, and it's not relevant to them to explain that any further," she says.

The third character, root operation, may be the most difficult for coders to assign, says Legg.

"There are currently 31 root operations, and some of the terminology used to describe the root operation is not the terminology frequently used in ICD-9-CM Volume 3," she says. "Coders should not expect physicians to specifically document the root operation."

The ICD-10-PCS coding guidelines echo this. The guidelines state:

The guidelines provide the example of a physician documenting a partial resection. Coders can correlate this documentation to the root operation excision without having to query the physician for clarification.

Likewise, physicians probably won't document the term "extirpation" (i.e., taking/cutting out solid matter), but coders should know the procedures that fall within this category, says Legg.

A new way of thinking for coders

Coders should consider the following questions when assigning a root operation:

What did the physician do?
How does the physician's documentation translate to an ICD-10-PCS root operation?

Note that complex procedures involving multiple body systems may require multiple ICD-10-PCS codes, says Farrell. For example, in ICD-9-CM, coders report code 52.7 to denote the Whipple procedure. In ICD-10-PCS, no singular code captures this procedure. Instead, coders must report multiple codes, each of which specifies a particular body part and root operation. Physicians likely will continue to reference the Whipple procedure in their documentation, so coders should be prepared to approach physicians to gather the information necessary to assign the appropriate codes.

Coders generally should become accustomed to the idea that they must be able to cross-reference physician documentation, says Mary Mills, RHIT, CCS, president and CEO/consultant at Documentation Solutions, LLC, in Detroit.

"All these years, we're told not to interpret anything. But we're not reading into it and turning it into a diagnosis. We're taking one word and cross-referencing the word with the ICD-10 word," says Mills.

For example, an open reduction internal fixation is synonymous with repositioning. "Coders need to know how to alter the terminology to the [coding] terminology. My fear is that the nurses and coders are going to be running to the doctors and querying them for all of these things that aren't necessary," she says.

Strategies to help coders prepare now

As with any monumental change, taking action is better than panicking at the thought of how much ICD-10-PCS and ICD-9-CM will differ.

First, review the ICD-10-PCS coding guidelines. Unlike ICD-9-CM, ICD-10-PCS includes 14 pages of coding guidelines pertaining to inpatient procedure codes. The guidelines are available at www.ahacentraloffice.com/ahacentraloffice/files/PDF2011/PCS2011guidelines.pdf.

"The ICD-10-PCS guidelines give a real good definition of each root operation," says Legg. "I think coders are going to need to learn these definitions really well and then apply them."

Next, assess documentation. How does your current documentation translate to ICD-10-PCS codes? Review top DRGs and high-volume procedures, says Legg.

"Discovering [upon implementation] that your surgeons don't document the specific information needed to assign procedure codes for coronary bypass will be difficult to recover from," she says.

Third, start educating physicians now. "At this point, I doubt if physicians are aware of the specificity needed [in ICD-10-PCS] unless they have had some ICD-10 education," says Legg. Coders should review query forms and seek opportunities to add ICD-10 documentation tips so that physicians will become accustomed to providing this information, she says.

Fourth, consider a software solution to assist with documentation and coding. Computer-assisted coding software may help coders tremendously, says Farrell. Likewise, computer-assisted physician documentation (CAPD) can prompt physicians using voice recognition to clarify diagnoses and procedures. Over time-and as the technology prompts physicians while they dictate-they will become accustomed to providing this information. CAPD is more frequently used on the diagnosis side, although it can be used to encourage documentation for the few procedures that affect MS-DRG assignment, says Farrell.

When using CAPD technology, avoid overwhelming physicians, says Carina Edwards, vice president of solutions marketing at Nuance Healthcare. Limiting the number of queries per record is helpful. Integrating the technology directly into physicians' work flow with either front-end or back-end voice recognition software is essential. Although CAPD can significantly reduce the volume of routine queries related to ICD-10, coders and CDI specialists must continue to communicate with physicians regarding more complex cases.

"There's always going to be complex cases and complex queries and the need to look through multiple documents and make those correlations," says Edwards.

Editor's note: U.S. Department of Health and Human Services (HHS) Secretary Kathleen G. Sebelius recently announced that HHS will initiate a process to postpone the date by which certain healthcare entities must comply with ICD-10-CM/PCS. The compliance date was October 1, 2013; HHS will announce a new compliance date moving forward.

ICD-10: Test your knowledge

How well do you know ICD-10-PCS? Not sure? Find out by taking the following quiz. Answers are on p. 12.

1.How should you code extracorporeal shockwave lithotripsy, bilateral ureters?

2.How should you report dilation and curettage of the endometrium, vaginal approach (no scope), for menorrhagia?

3.How should you report a lumpectomy of the left breast?

4.How should you report a right open iliofemoral bypass using an autologous vein?

5.How should you report a banding of the right pulmonary artery using extraluminal device via thoracotomy?

6.How should you code an open neurorrhaphy of the abdominal aortic plexus?

Editor's note: These questions originally appeared in The Coder's Guide to ICD-10, published by HCPro. For more information about this book or to purchase a copy, visit www.hcmarketplace.com/prod-9661.

ICD-10: Test your knowledge answers

1.Report 0TF7XZZ, 0TF6XZZ. Look up Fragmentation, Ureter. There is no body part value for bilateral based on the root operation fragmentation. Therefore, the procedure must be reported twice to identify the distinct body part values.

2.Report 0UDB7ZZ. Look up Curettage; it directs coders to either "see Excision" or "see Extraction." Curettage is to pull/strip away the lining of the uterus or the uterine components.

3.Report 0HBU0ZZ. Look up Lumpectomy; it directs coders to "see Excision." Because the question does not include documentation that this was a diagnostic procedure, the seventh character value is Z.

4.Report 041C09H. Look up Bypass, Common Iliac. Bypass procedures are reported with the fourth character identifying the body part bypassed from (common iliac) and the seventh character identifying the body part bypassed to (femoral). The sixth character identifies the type of graft used for the bypass. Note that if an autograft is obtained from a different body part to complete the objective of the procedure, a separate procedure is coded. This question does not contain sufficient information to determine whether a second procedure code is necessary.

5.Report 02VQ0CZ. Look up Banding; it directs coders to "see Restriction.?

6.Report 01QM0ZZ. Look up Neurorrhaphy in the Alphabetic Index. It directs coders to "see Repair." Based on the body part key at Appendix C, the abdominal aortic plexus is reported with the body part value for abdominal sympathetic nerve.

Briefings on Coding Compliance Strategies, April 2012

Sun, 01 Apr 2012 04:00:00 GMT

Coders need to understand their role in the process

Miscommunication mishaps

"Sometimes you see the opposite. There may be a urinalysis with positive results and Bactrim® ordered without a diagnosis listed anywhere," she says.

Mistakes happen

Identify sequencing challenges

Sequencing is a challenge, particularly when two conditions meet the definition of principal diagnosis but only one justifies medical necessity for admission, says Krauss.

Inpatient vs. observation status

How long has the patient had the problem?
Is it a chronic problem that can be worked up on an outpatient basis?
Is it an acute-onset problem with a severity that requires a hospital stay?

Clarify questions of medical necessity

Including this provision in queries pertaining to medical necessity might be helpful, Krauss says.

Planning can maximize benefits of internal coding audits

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

Define the purpose and scope of audits

Volume should be consistently based on the average number of discharges at the facility. Approximately 20-30 records per coder per quarter is typical, says Daube.

Senior leadership buy-in is essential

Don't let dollars drive an audit

"Your auditing and monitoring should really be risk-based-not driven by financial performance or a check-off box method" says Rivet.

Timing is an important consideration

The frequency of coding audits-whether annual, quarterly, monthly, or some other frequency-should be based on associated risk, says Rivet.

Risks don't always remain the same

External sources should include the following:

Recovery Auditor activity in your region. Network with other colleagues in your geographic area, says Rivet. If a nearby hospital has experienced a particular Recovery Auditor review, other local hospitals should be assessing that issue immediately, he says.
MAC or FI notifications. Even if a notification doesn't pertain to your specific region, evaluating your own comfort level with that area of risk is helpful, says Rivet. Ask when the most recent audit of this issue occurred, who performed it, and what the results were.
The Medicare Quarterly Provider Compliance Newsletter.

Ensure thorough post-audit follow-up

CDI specialists may be best suited to provide audit feedback to physicians because they have already established a rapport, says Daube.

Identify potential Medicaid RAC target areas

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

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

Addressing documentation, coding, and billing problems on the front end is the best way to prepare for Medicaid RACs, says William L. Malm, ND, RN, CMAS.

"The government has repeatedly said that it will template Medicaid after Medicare with state-specific nuances and flexibility," says Malm.

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

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

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

Syncope. "Many of these cases, in retrospect, turn out to be vasovagal in etiology rather than having a more serious cardiac cause," says Berger.
Transient ischemic attack (TIA). "TIA by its nature is a self-limited condition, but it may be a precursor to stroke and therefore be of more concern," says Berger.
Pain (i.e., abdominal pain and back pain). "A frequent question that arises is whether outpatient treatment was attempted prior to admission," says Berger. Documentation should reflect the nature and extent of that treatment, he says.
Short-stay surgery. Laparoscopic procedures (e.g., appendectomies and cholecystectomies) aren't elective. However, RACs may deny them if no complications are associated with the surgery and treatment is rendered in fewer than 24 hours, says Berger. RACs also may target coronary artery stent procedures if there are no complications, the procedure is elective, and the patient is in the hospital for fewer than 24 hours. "Unfortunately, many contractors are not considering the patient's comorbid conditions contributing to an increased risk associated with the procedure," he says. "They're not considering what coronary artery vessels are being stented and how many stents are being placed at one given time." Also, genitourinary procedures, such as nephrolithotripsy, may be targeted.

Compare Medicare, Medicaid when developing audit processes

"Now you have to think in terms of having internal auditors or RAC auditors who have governmental experience," he says.

One auditor should be responsible for Medicare claims while the other should be responsible for Medicaid claims, Malm says, acknowledging that this will likely be a hardship for hospitals.

Consider the big picture before querying physicians

by Robert S. Gold, MD

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

Malnutrition

Acute renal failure

Clinical evidence offers clues

Thu, 01 Mar 2012 04:00:00 GMT

To query or not to query?

Clinical evidence offers clues

Clinical evidence in the medical record must always support queries, and the record is usually a gold mine of information that can indicate whether a query is justified, says William E. Haik, MD, FCCP.

Knowing when and how to query for all conditions is crucial, and this couldn't be truer for CCs and MCCs, conditions that affect payment and help capture a patient's true clinical picture and complexity, says Haik, director of DRG Review, Inc., in Fort Walton Beach, FL.

Angina

Angina, not otherwise specified (code 413.9) was downgraded from CC to non-CC status in 2008 when MS-DRGs became effective. However, the following specified forms of angina are considered CCs:

Unstable, preinfarction, crescendo, progressive, accelerated, initial, and acute coronary syndrome-code 411.1
Angina decubitus or nocturnal angina-code 413.0

Any of these terms may be pertinent to a particular patient's clinical scenario, and striving for specificity when possible is important, says Haik. Physicians may be more likely to respond to queries written in a multiple-choice format using some of the previously listed terms, he says. The choices should include all reasonable options along with "other" and "undetermined."

Coders and CDI specialists must remember that physicians often document acute coronary syndrome (ACS) instead of myocardial infarction or angina because ACS is a more inclusive term. "It includes the total physiology and pathophysiology of a patient who presents with acute coronary ischemia," says Haik. However, ICD-9-CM indicates that ACS maps to code 411.1 (unstable angina). Therefore, querying for clarification is reasonable when a patient is documented as having ACS and an elevated troponin level to determine whether the patient actually has unstable angina or a myocardial infarction (410.x1), he says.

Asthma

It's not uncommon for patients with pneumonia to also present with wheezing and underlying asthma, says Haik. Physicians may document pneumonia and asthma together, but they may not state whether the patient has an acute exacerbation of asthma or status asthmaticus. Unspecified asthma is neither a CC nor an MCC. However, asthma with status asthmaticus and asthma with acute exacerbation are both CCs.

Coders and CDI specialists should review the documentation for use of Solu-Medrol® or some other type of cortisone medication. These medications are used to treat the inflammatory effects of pneumonia (e.g., bronchial inflammation and bronchospasm) and not purely the pneumonia itself, says Haik. If the record includes documentation of these medications, query to determine the specific type and acuity of asthma.

Cardiomyopathy

Cardiomyopathy (code 425.x) is a CC that's sometimes overlooked even when clinical evidence in the record justifies a query, says Haik. More specifically, when patients have left ventricular dysfunction with an ejection fracture of less than 40%, coders and CDI specialists should query for cardiomyopathy. Querying when documentation indicates that patients have both cardiomyopathy and congestive heart failure (CHF), not otherwise specified, is also important. If a physician further specifies the CHF, the cardiomyopathy will be considered a CC. Otherwise, it's excluded as a CC when the two conditions are documented and reported together, says Haik.

Hemiplegia, acute and as a late effect of CVA

Patients who present to the hospital with a recent or previous cerebrovascular accident (CVA) often have one-sided weakness, says Haik. When physicians document this description without specifically documenting hemiplegia, this may be an opportunity to query, he says.

Malnutrition

Although it may seem counterintuitive, unspecified malnutrition is a CC, and moderate or mild malnutrition are neither CCs nor MCCs, says Haik. Coders and CDI specialists must recognize that it may be appropriate to query a physician in certain clinical settings when a patient has hypoalbuminemia to determine whether the condition can be further specified as malnutrition, he says. For example, consider querying for clarification when a patient experiences weight loss due to inadequate intake or has cancer or malabsorption.

Haik says the following might be biomarkers for malnutrition:

Ideal body weight
Pre-albumin level
Albumin level

Pathological fracture

All pathological fractures are CCs, but not all traumatic fractures are CCs, says Haik. Coders and CDI specialists should reiterate to physicians that in ICD-9-CM, a pathological fracture (code 733.1x) refers to a spontaneous fracture that occurs due to a minimal amount of trauma, he says.

Terms synonymous with pathological include osteoporotic, insufficiency, nontraumatic, and spontaneous. Using these terms when querying physicians may be helpful because the terms may resonate with the physicians, says Haik.

Pneumothorax

Pneumothorax and air leak (code 512.xx) are CCs that may be overlooked even when documentation justifies reporting them, says Haik. Code 512.0 (spontaneous tension pneumothorax) is the only MCC in this category.

Capturing code 512.xx when the condition is clinically significant is important. For example, querying for the condition when a patient requires a chest tube for more than a few days or requires intervention, such as thoracoscopic mechanical and/or chemical pleurodesis, may be appropriate, says Haik.

Unspecified schizophrenia

Unspecified schizophrenia (code 295.9x) is a CC only when it's documented and coded as subchronic, chronic, subchronic with acute exacerbation, or chronic with acute exacerbation.

Coders and CDI specialists should query physicians to clarify the acuity of the schizophrenia, particularly when a patient is taking multiple psychotropic drugs and is clinically stable because this might at least represent chronic schizophrenia, says Haik.

Urinary tract infection

Urinary tract infection (UTI), unspecified (code 599.0) is a CC that can be overlooked if coders and CDI specialists don't query for clarification when physicians document "pyuria on antibiotics," says Haik. Pyuria is not a condition that physicians typically treat, whereas a UTI is definitely treatable, he says.

Decubitus ulcer

Most coders and CDI specialists know that although they can code the stage of an ulcer based on nursing documentation, physician documentation of the type and site of an ulcer is a prerequisite for coding.

However, if a nurse documents the narrative description of the ulcer but doesn't include the actual stage (e.g., the nurse documents "full thickness skin loss that involves the damage or necrosis of subcutaneous tissue" without specifying stage III), coders can report code 707.23, says Haik. This is because the previously quoted description is an inclusion term under the code itself.

This is important to keep in mind because coders may use this documentation to justify code assignment, says Haik. Note that stages III and IV are both MCCs. Stages I, II, unspecified, and unstageable are neither CCs nor MCCs.

Editor's note: Dr. Haik originally presented this information during the HCPro audio conference "FY 2012 CC/MCC List: A Clinical Review of Documentation Requirements for MS-DRGs." For more information, visit http://tinyurl.com/77h7xsz.

Prospective process helps identify PACT underpayments

Thu, 01 Mar 2012 04:00:00 GMT

Prospective process helps identify PACT underpayments

What comes to mind first when you consider the postacute care transfer (PACT) policy?

For some, Recovery Auditor overpayments may be an immediate association. That's not surprising because Recovery Auditors have been busy auditing hospital-to-hospital transfers for quite some time. They've used automated reviews mostly to confirm that patients discharged home (status code 01) actually go to some other type of postacute care setting instead.

This means the transferring hospital likely should have received a reduced payment. However, hospitals don't need this type of audit to realize that transfers also can result in underpayments that can add up over time.

On average, 1% of all Medicare inpatient discharges include a discharge status code error that ultimately results in an underpayment, says David Jupp, founder and CEO of MCare Solutions, Inc., in Houston.

This percentage may seem insignificant, but the average reimbursement lost per case is approximately $2,500, says Jupp. If a hospital has 3,000-4,000 Medicare inpatient discharges annually, this means that 30-40 of them (i.e., 1% of the total) are likely underpaid due to status code errors with lost revenue of $75,000-$100,000, he explains.

Approximately 10%-15% of claims affected by the PACT policy are potential underpayments, says Kathy Ruggieri, director of revenue cycle services at Besler Consulting in Princeton, NJ. This percentage varies among hospitals and may increase as they take more initiative to look for underpayments internally, she says.

Hospitals should proactively monitor underpayments because of the potential financial ramifications and because doing so encourages better patient care, says Jupp.

"I would suggest that hospitals not hang their hats on the assumption that a [Recovery Auditor] is going to be doing an underpayment review for them," says Jupp. Underpayments typically are incidental findings that occur when auditors target the more lucrative overpayments, he says.

Know why underpayments occur

Most discharge status code errors that result in underpayments occur when patients are transferred to skilled nursing facilities (SNF) (status code 03) or home health (HH) (status code 06), says Jupp.

How do errors occur? Sometimes coders report either 03 or 06 when another discharge status code is more appropriate. Other times these codes are assigned correctly, but patients simply don't follow through with discharge plans.

The former often occurs because of lack of coder education about the nuances associated with discharge status code assignment and vague provider documentation on which the codes are based. The latter occurs when patients pursue alternatives to that which is documented in discharge orders. Deviation from a plan is difficult to track because patients have left a facility.

HH claims, in particular, are a gold mine for underpayments, says Jupp. With HH, hospitals must ensure that they:

Review the Common Working File (CWF) to determine whether the HH agency submitted any HH bills after the patient is discharged from the transferring hospital
Determine whether the HH services are provided to the patient within three days of discharge

If both criteria are met, the transferring facility is entitled to the full DRG payment-not a reduced payment based on the PACT policy, says Jupp.

Errors pertaining to SNF transfers can occur when coders don't distinguish between skilled care (status code 03) and intermediate care (status code 04), says Ruggieri. Code 04 is not subject to the PACT policy, but code 03 is.

Hospitals that successfully implement a compliant discharge status code assignment process coordinate care and communication with SNFs to which they frequently transfer patients, says Jupp. Hospitals should contact SNFs in advance when physicians anticipate skilled care. SNFs can send representatives to acute care facilities to review patient records and make initial determinations regarding whether patients will likely meet skilled criteria.

Hospitals that own certain HH agencies may be able to better coordinate communication with those agencies to determine whether patients actually receive HH within three days of discharge, says Ruggieri.

Coders also need to know when a SNF is certified by Medicare rather than Medicaid. When patients are transferred to a SNF certified under Medicaid and not Medicare, coders should report status code 64, which is not subject to the PACT policy. As always, documentation must support code assignment, says Ruggieri.

Unlike with HH, hospitals can't rely solely on the CWF to determine underpayments for SNF transfers, says Ruggieri. Instead, a manual review of the record and telephone call to the SNF are necessary. This is particularly true when patients don't meet the three-day qualifying stay requirement for Medicare to pay for SNF care. If the requirement is not met, the SNF still must submit a no-pay bill, but this doesn't always happen, she says. The result is that the CWF makes it appear as though the patient never received SNF care.

"They can't assume that just because there isn't activity in the Common Working File that the patient wasn't in a Medicare-certified bed receiving skilled care," says Ruggieri.

A January 11 e-mail exchange with CMS staff revealed that the agency has ordered the Region C Recovery Auditor (Connolly, Inc.) to stop auditing hospital-to-hospital transfers entirely. Other regions continue to review the issue, however.

Concurrent monitoring, retrospective reviews

Ensuring a concurrent review process of claims to identify and correct discharge status code errors is paramount, says Jupp. This requires solid communication and collaboration between coders and case managers, he says.

Providing ongoing general education to both will improve compliance overall regardless of whether a particular DRG is subject to the PACT policy, says Ruggieri. For example, consider hosting an annual education session for coders and case managers to discuss Medlearn Matters article SE0801, which explains in detail each discharge status code, she says. Also, patient accounting departments that have responsibility with respect to the PACT underpayment initiative must collaborate with coders and case managers as well.

Ideally, hospitals would implement a concurrent review process and conduct retrospective audits to identify any underpayments, says Jupp. Retrospective audits should be conducted approximately six months after claim submission. "That gives any postacute care facility ample time to get their claim in and get it processed," he says.

Auditing after claim submission is often time- and resource-intensive, which is why many hospitals outsource this task to a vendor, says Jupp. "The lack of a claim is not de facto proof that the patient did not receive the level of care indicated in the discharge order," he says. "It still requires contacting the postacute care facility."

"The validation of the level of care of the patient is what needs to occur," says Ruggieri, noting that not all hospitals or vendors do this.

Note CCs, MCCs on auditors' radar

Ensure your documentation and coding are up to par for two conditions that Recovery Auditors have frequently targeted, says William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL:

Atelectasis (code 518.0). Coders and CDI specialists can't assume that just because the condition is listed as an isolated x-ray finding that a physician clinically addressed it and that it's valid to report it. Refer to Coding Clinic, Second Quarter 1990, p. 15, for more information.
Hyponatremia (code 276.1). Don't separately report this condition when it's integral to syndrome of inappropriate antidiuretic hormone secretion.