HCPro.com - Briefings on Coding Compliance Strategies

E codes: Rounding out the patient's story

Sat, 01 Jun 2013 04:00:00 GMT

E codes: Rounding out the patient's story

Auto manufacturers rely on them to make decisions about improving passenger restraints in vehicles. Industrial engineers may reference them when advocating for improved design of staircases to prevent falls. Drug companies use them to bolster support for child-resistant packaging.

What's the magic information to which we're referring?

E codes. These information-laden and sometimes underappreciated ICD-9-CM codes capture environmental events, circumstances, and conditions that cause an injury, poisoning, or other adverse effect. In essence, they tell us the "where," "why," and "how" of the patient's injury.

E codes are incredibly important in a variety of settings, says Pamela L. Owens, PhD, senior research scientist, Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md. This information can be used to evaluate the effectiveness of policies and programs, determine the need for new interventions, and perform injury surveillance. AHRQ is one of many organizations that rely on E codes and other data gathered through the Healthcare Cost and Utilization Project (HCUP), the largest all-payer collection of hospital inpatient care statistical information in the United States. AHRQ uses the data to analyze utilization, costs, lengths of stay, and more.

Despite the fact that most E codes aren't used in public reporting, says Owens, assignment of E codes for injuries is fairly high nationwide. According to a 2009 update/addendum to an HCUP E code report, approximately 92% of inpatient injury discharges included an injury E code. This is up from approximately 86% in 2001, the year in which the report was originally published. However, there is variation among states from as low as 65% in Ohio to as high as 99% in Connecticut. This report did not examine variation in E coding among hospitals within the states.

Only a few E codes are required. The ICD-9-CM Official Guidelines for Coding and Reporting require coders to report a code from the E930-E949 series to identify the causative substance for an adverse effect of a drug, medicinal, or biological substance that is correctly prescribed and properly administered. As of October 1, 2009, CMS also requires all providers to submit E codes for three surgical "never events," when appropriate, despite not receiving payment for these procedures. These codes include E876.5 (wrong operation/procedure on correct patient), E876.6 (operation/procedure on patient not scheduled for surgery), and E876.7 (correct operation/procedure on wrong side/body part).

Some states, payers, public health departments, and other agencies may require E codes; however, even this isn't consistent, which only continues to muddy the waters, says Owens.

Why hospitals should report E codes

E codes and their implications should be on every hospital's radar, says Kathy Vermoch, MPH, project manager, quality operations at the University HealthSystem Consortium (UHC) in Chicago. UHC is an alliance of 119 academic medical centers, 291 affiliated hospitals, and 80 faculty practice groups nationwide that shares clinical, operational, financial, satisfaction, and safety data to benchmark performance and improve care.

Vermoch says many hospitals aren't aware of the role that E codes play in triggering certain patient safety indicators (PSI), for example. One indicator, PSI 15 (accidental puncture or laceration rate), is triggered when coders report one of the following ICD-9-CM codes in any secondary diagnosis field to denote an accidental cut, puncture, perforation, or laceration during a procedure:

E870.0 (accidental cut/hemorrhage in surgery)
E870.1 (accidental cut/hemorrhage in infusion or transfusion)
E870.2 (accidental cut/hemorrhage in kidney dialysis or other perfusion)
E870.3 (accidental cut/hemorrhage in injection or vaccination)
E870.4 (accidental cut/hemorrhage with endoscopic exam)
E870.5 (accidental cut/hemorrhage with catheterization)
E870.6 (accidental cut/hemorrhage with heart catheterization)
E870.7 (accidental cut/hemorrhage with enema)
E870.8 (accidental cut/hemorrhage in other specified medical care)
E870.9 (accidental cut/hemorrhage in unspecified medical care)
998.2 (accidental operative laceration)

Six other PSI indicators also use E codes to identify discharges associated with that indicator, says Owens. These include PSIs 5, 8, 16, 21, 25, and 26, she adds.

All PSIs are essentially based on a fraction, Owens explains. The denominator of this fraction generally indicates the number of surgical and medical discharges for patients 18 years and older. For PSI 15, the numerator indicates the number of these surgical and medical discharges that involved an accidental puncture or laceration. "If you have a low number in the numerator, it means you have a low rate of accidental punctures or lacerations," she adds.

However, because PSIs largely depend on E codes, hospitals that perform more robust E code reporting could inadvertently appear as though they have a higher PSI rate than those that don't report these codes, says Leslie Prellwitz, MBA, CCS, CCS-P, senior director, performance improvement analytics at UHC. "It doesn't necessarily mean that their care is any worse, it just means that they're more diligent about finding and coding these items with E codes," she says. Likewise, those reporting fewer-or no-E codes could inadvertently appear as though they're providing better patient care, she adds.

Consistency is particularly important as PSIs begin to affect reimbursement through the Value-Based Purchasing (VBP) Program. As of October 1, 2014 (FY 2015), PSI 15 is one of several indicators that comprise a PSI composite score outcomes measure. "In the simplest explanation, [a composite score] is an aggregation of various indicators with various weights assigned to them," says Owens.

Other outcomes measures that drive the VBP score include central line-associated bloodstream infections, acute myocardial infarction 30-day mortality rate, heart failure 30-day mortality rate, and pneumonia 30-day mortality rate. Together, these outcomes measures will encompass 30% of a hospital's VBP score, as proposed.

Improving PSI documentation

UHC is particularly interested in the validity of data related to PSIs. The consortium is in the process of developing consensus statements for documentation of PSIs to ensure accurate and consistent coding. Although the project doesn't focus on E codes, Vermoch says coding consistency is one indirect benefit of improving documentation. UHC's goal is to encourage providers to "consistently use terms that will make it easier and clearer for coders so that when coders code, they will be coding more consistently, and the reporting of PSIs will be more comparative and accurate," she says.

PSI 15 is UHC's first target. According to a UHC study that examined PSI 15 data reported by 207 hospitals over a 12-month period, 7.7% of 9,471 cases that included PSI 15 were based solely on E code assignment. Some of the E codes were paired with 998.2; however, approximately 8% were paired with another diagnosis (i.e., hemorrhage). This can skew the data, says Vermoch, because a patient may have only had a hemorrhage-not a cut, puncture, or tear. However, because the E code definitions include both descriptors (i.e., hemorrhage as well as accidental cut), there may be false positives and slightly elevated rates of PSI 15 particularly in states that require E code reporting, she says. UHC is in the process of continuing to monitor the effect of E codes on PSIs.

ICD-10-CM

ICD-10-CM marks a significant improvement in terms of being able to capture additional information about an injury or complication, says Suzanne Rogers, RHIA, CCS, CCDS, senior specialist, HIM at UHC. In ICD-10-CM, codes for external causes of morbidity (V01-Y99) appear in Chapter 20 and capture the following:

How the injury of condition happened (cause)
Intent (unintentional or accidental versus intentional)
Place where the event occurred
Activity at the time of the event
Patient status (i.e., civilian or military)

Complications of medical or surgical care appear in disease-specific chapters. Adverse effects of drugs and biologicals as well as injuries appear in Chapter 19 (S00-T88). Certain T codes are combination codes that include the nature of the complication (diagnosis) as well as the type of drug or biological that caused the event. Chapter-specific complication of care codes also include the complication (diagnosis) as well as the type of procedure that caused the complication (external cause). For example, ICD-10-CM code I97.820 denotes a postoperative stroke due to a cardiac procedure.

Combination codes will be helpful because the diagnosis code with which a particular E code should be paired isn't always clear in ICD-9-CM, says Prellwitz. "With ICD-10-CM, the same concept is still there, but it's all rolled up into one code so there's no guesswork." She says combination codes will be much easier to tabulate and research to improve patient safety.

Ensuring compliance

At a minimum, hospitals should have an internal coding policy that includes E codes. Some hospitals require a second review for E codes that affect PSIs, says Rogers. "I would encourage hospitals to code and report E codes whenever the circumstances of the encounter lend themselves to identifying an external cause associated with illness or injury," she adds. "E codes provide additional information that, if applied consistently, would benefit the systematic and consistent reporting of data, whether for research, billing, public reporting, registries, health forecasting, and other data applications and reporting."

E codes will continue to have a variety of implications, says Prellwitz. "Coders need to focus on making sure they have an accurate representation of the patient. There's a myriad of metrics and measures …many of which will use the administrative data sets such as E codes in their calculations. I think the underlying goal is to make sure that the patient is accurately represented in the data," she says.

Stopping diabetes in its tracks: How ICD-10-CM can help

Sat, 01 Jun 2013 04:00:00 GMT

Stopping diabetes in its tracks: How ICD-10-CM can help

More than 8% of the population in the United States (i.e., 25.8 million children and adults) has some form of diabetes, according to the American Diabetes Association. In 2007, diabetes was listed as the underlying cause on 71,382 death certificates. It was a contributing factor on an additional 160,022 death certificates.

If these numbers aren't staggering enough, take a moment to consider the costs for treatment. In 2012, the total cost of diagnosed diabetes, including direct medical costs and reduced productivity, was $245 billion.

Experts say the only way to combat the disease and its rising costs is to collect and track more specific data that can better pinpoint the causes of diabetes and indirectly assist with interventions. The good news is that as of October 1, 2014, ICD-10-CM makes this task a lot easier.

Diabetes: Clinically speaking

Diabetes is a condition in which a patient's blood sugar is either abnormally high (hyperglycemia) or abnormally low (hypoglycemia), explains Pamela Rand, RD, LDN, dietitian and certified diabetes outpatient educator in Peace Dale, R.I. Unregulated blood sugars occur when an individual either doesn't produce any insulin to distribute circulating blood glucose, a byproduct of food, into the body's cells for energy (Type 1 diabetes), or when an individual produces insulin, but the insulin is resistant to circulating blood glucose to cells for energy (Type 2 diabetes).

However, diabetes can also occur due to drugs or chemicals, an underlying condition, or some other cause (e.g., removal of the pancreas, genetic defects in insulin action, or genetic defects of beta-cell function).

In addition, gestational diabetes occurs when women who are pregnant and who don't have a previous history of diabetes develop a high blood glucose level. This high glucose level may resolve after the baby is delivered.

Diabetes: ICD-9-CM vs. ICD-10-CM

In ICD-9-CM, codes for diabetes distinguish between secondary diabetes (249.xx) and Type 1 or Type 2 (250.xx), and secondary diabetes.

The fourth digit for both code categories indicates the presence of a complication. Coders must report an additional code to denote the specific complication. For example, when a patient has secondary diabetes with diabetic cataract, coders must report 249.5x (secondary diabetes with ophthalmic manifestations) and 366.41 (diabetic cataract).

The fifth digit in code category 249.xx indicates whether the secondary diabetes is

Not stated as uncontrolled
Uncontrolled
Unspecified

The fifth digit in code category 250.xx indicates Type 1 versus Type 2 and whether the diabetes is not stated as uncontrolled, uncontrolled, or unspecified.

Coders may be surprised by the expansion and reorganization of codes for diabetes in ICD-10-CM, says Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, senior director of HIM innovation at Nuance Communications in Atlanta. Not only are the codes far more detailed than their ICD-9-CM counterparts, but they also comprise nearly six pages of the ICD-10-CM Manual. Thankfully, there are plenty of instructional notes along the way, she says. Once published, Coding Clinic for ICD-10-CM will also likely provide guidance and examples on which coders can base compliant decisions, she adds.

In ICD-10-CM, codes for diabetes appear in category E08-E13. These codes distinguish between the following types of diabetes:

Diabetes due to an underlying condition (E08)
Drug- or chemical-induced diabetes (E09)
Type 1 diabetes (E10)
Type 2 diabetes or diabetes not otherwise specified (E11)
Other specified diabetes (E13)

Note that coders should assign code O24.4- for gestational diabetes and P70.2 for neonatal diabetes.

What will be most striking for coders is the fact that none of the ICD-10-CM codes for diabetes specify whether the condition is uncontrolled-a detail for which coders have become quite accustomed to querying, says Cassidy. Instead, codes focus on and are indexed by type, cause, and complications/manifestations.

Also notable is the fact that Type 1 and 2 diabetes each have their own categories, says Laura Legg, RHIT, CCS, HIM and coding consultant in Renton, Wash. Drug- or chemical-induced diabetes as well as diabetes due to an underlying condition are also separate from secondary diabetes. In ICD-9-CM, secondary diabetes is a "catch-all" category that includes both, she adds.

Researchers will benefit from this enhanced data capture of each specific type of diabetes that can be easily identified by category, says Cassidy.

With greater delineation comes the need for more specific documentation. For example, coders must code first one of the following specific underlying conditions when they report a code from category E08:

Congenital rubella
Cushing's syndrome
Cystic fibrosis
Malignant neoplasm
Malnutrition
Pancreatitis and other diseases of the pancreas

"It's really important to know the underlying condition," says Rand. "The diabetes could be due to acromegaly or pancreatitis, and if those conditions aren't treated, then the diabetes won't go away."

As a dietitian, Rand says she is particularly interested in malnutrition's relationship with diabetes. "Malnutrition is a serious stress on the body. When you don't eat enough, there is a mechanism that triggers your liver to produce sugar. However, it produces too much or too little and nothing in between," she says.

The underlying condition isn't the only piece of information that coders will need. When reporting E09, coders must code first the specific drug or chemical that causes the diabetes. To do so, they'll choose a code from category T36-T65. For example, a physician documents an initial encounter with a patient who has drug-induced diabetes without complications due to an adverse effect of Pravastatin. Coders should report T46.6x5 followed by E09.9. This is despite the fact that sequencing the codes in this way may seem counterintuitive, and it may also affect the MS-DRG, says Cassidy.

Being able to track the drugs and chemicals that can cause diabetes is extremely valuable, says Rand. It may help researchers determine whether antihypertensive drugs as well as corticosteroids can cause diabetes when taken in high doses, she adds.

"Statins are the most widely prescribed drugs to lower cholesterol, but those drugs also have a side effect that some researchers are noticing can cause high blood sugar," says Rand.

Incretin mimetics-drugs used to treat Type 2 diabetes-are also under scrutiny, says Rand. "There's a lot of research that these drugs that are used to treat diabetes can actually damage the pancreas where the insulin is produced," she adds.

Coders must also report code Z79.4 to denote long-term insulin use, when appropriate. Type 1 diabetes doesn't require this code. In ICD-9-CM, coders reported V58.67 for this purpose. "The code is different, but the concept is the same," says Legg.

Another noticeable change in ICD-10-CM is that codes for diabetes are combination codes, meaning they identify both the etiology and any manifestations/complications. For example, only one ICD-10-CM code (E08.351) is necessary to describe diabetes due to an underlying condition with proliferative diabetic retinopathy with macular edema.

This information is invaluable, says Rand. The longer a patient's glucose levels are uncontrolled, the more likely he or she is to develop a complication, she adds. These codes will allow researchers to compare A1C levels with specific types of diabetes and any ensuing complications. Rand says she would eventually love to see a combination code that can help track depression as a complication of diabetes. "Depression is equally as related to diabetes as a foot ulcer," she says.

As with ICD-9-CM, the link between the diabetes and its manifestation/complication must be clear. "Oftentimes, the physician will document the diabetes and the underlying condition, but not tie them together," says Legg. Coders must continue to query when documentation is vague, she adds.

Start prepping physicians now

It's never too early to start asking for more specific documentation or incorporating additional elements into EHR templates, says Cassidy.

ICD-10-CM will require the following details for diabetes:

Specific type of diabetes
Specific type of underlying condition (if applicable)
Specific type of drug or chemical (if the diabetes is drug- or chemical-induced) as well as how that drug or chemical was taken (e.g., adverse effect vs. poisoning)
Complications and/or manifestations of the diabetes (including the specific site of an ulcer or stage of chronic kidney disease)

"If physicians don't provide enough of this specific documentation, coders will have a really big challenge," says Cassidy.

Documentation of medical necessity drives successful RA appeals

Sat, 01 Jun 2013 04:00:00 GMT

Documentation of medical necessity drives successful RA appeals

Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.

"There has been a great deal of overload and overburden on the system in general," says Marilyn S. Palmer, DO, vice president of audit, compliance, and education at Executive Health Resources in Newton Square, Pa. "This is part of the reason why CMS is addressing this Part A to B rebilling." (See p. 10 for an overview of the Administrative Ruling and proposed rule related to Part B rebilling.)

Qualified Independent Contractors (QIC)-the entities responsible for processing level two appeals-have 60 days to make a determination. If they're unable to do this, they must provide hospitals with a process to escalate the denial directly to the Administrative Law Judge (ALJ)-the third level of appeals.

Palmer says the ALJ is increasingly remanding cases back to the QIC, which only increases the burden placed on it. Executive Health Resources, which assists hospitals in the appeals process, receives approximately 2,500 escalation notices per week, she adds.

Medical necessity is a top target

What are some of the most common RA denials to date?

"Cardiovascular procedures have been looked at since the RA demonstration project began, and they continue to be looked at going forward mainly because of the dollar amounts of these procedures," says Palmer. "Screening doesn't normally cover these cases very well, and physician review is often needed."

Three out of four RAs list medical necessity of cardiovascular procedures as their top issue, according to CMS data published in May 2012. Medical necessity of minor surgery or other treatment billed as an inpatient stay is the top issue for the fourth RA.

This data doesn't surprise Jonathan G. Wiik, MSHA, MBA, chief revenue officer at Boulder (Colo.) Community Hospital. Forty-three percent of the hospital's RA audits pertain to cardiovascular cases. Gastrointestinal and musculoskeletal cases rank second and third at 24% and 21% respectively. The remaining 12% fall under the "other" category.

Boulder Community Hospital, a 265-bed acute care facility, began experiencing RA audits in 2010. The audits focused largely on DRG code validations. However, throughout 2011 and 2012, Wiik says the audits have shifted in focus exclusively to medical necessity.

"We've got several million dollars held up in appeal right now," says Wiik. "That [amount] is only going to get larger."

Part B rebilling provides another option

Wiik says hospitals essentially have two choices in light of CMS' recent Administrative Ruling and anticipated final rule on Part B rebilling:

Defend the admission criterion and utilization review (UR) process in an appeal and wait for the reimbursement to which you're entitled
Ignore the UR criterion and process and accept reimbursement at a lower rate now by rebilling the denied Part A claim to Part B

"We have taken the position at our hospital to appeal [cases] that have appropriate documentation and that are compliant," says Wiik. "The incremental financial reimbursement that we're getting is substantial. We need to continue to appeal and justify what we've done."

Hospitals must look at each case individually to determine the financial impact of rebilling to Part B, says Palmer. "If you're thinking about withdrawing cases that are in the process of appeal, you want to think carefully about the implications of your decision," she says. Not only could the financial reimbursement be significantly less, but it will also require hospitals to refund the Part A deductible to patients and rebill them for Part B. Communication with patients about this change in status and what it means for them is-and will continue to be-a challenge, she adds.

Concurrent reviews, strong RA process are key

"The best practice is to get it right from the start," says Palmer. "The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation."

Wiik says that Boulder Community Hospital has managed to overturn all of its denials at various stages of appeal-and most frequently at levels one and two. He attributes this success to staff members who are dedicated to the audit and appeals process. Wiik says 2.5 FTEs examine patient status seven days a week. The hospital's UR committee works in conjunction with Executive Health Resources to substantiate and defend/appeal inpatient determinations.

The hospital also has a clearly defined procedure for managing the appeals process. First, the patient financial services (PFS) department receives a denial/request notification. Next, a member of the PFS department sends the denial/request to a coder for review. The coder then sends the denial/request to the appropriate department for review. The hospital tracks each of these transfers using its homegrown tracker as well as Executive Health Resources' appeals portal.

Education and diligence play a large role in ensuring compliance going forward, says Wiik. For example, the hospital's chief medical officer leads education sessions for various specialties that are geared toward documentation compliance. The hospital also tracks metrics and audits of inpatient vs. observation determinations and then reports feedback to senior leadership. In addition, it publishes a medical staff newsletter. A Program for Evaluating Payment Patterns Electronic Report committee also reviews data quarterly to look for DRG outliers that could eventually become RA targets.

Physician education is crucial

Educating physicians about how to properly document medical necessity is an incredibly crucial part of ensuring success with RA audits and appeals, says Palmer. Documentation should include the following:

Medical history (H&P)
Current medical needs
Severity of signs and symptoms
Facilities available for adequate care
Predictability of adverse outcomes

Predictability of adverse outcomes is the most challenging for physicians. "Physicians actually do this very well, but we do it in our heads," says Palmer. These questions can help get physicians thinking about articulating their thought processes:

What's your impression of the patient?
What are your concerns for this patient?
Based on these concerns, what's the potential for a poor outcome?

Discourage physicians from reporting a sign or symptom rather than a diagnosis. "This is a really hard habit to break," says Palmer. Many physicians say that they simply don't know what to document, she adds.

Encourage physicians to document what they think is the cause of a patient's chest pain, for example. Ask them to document their top few suspected diagnoses and concerns for those diagnoses, says Palmer. "If you expect the auditor to dig through and put two and two together and build a story themselves, you're kind of asking a lot of them," she adds.

Editor's note

This article is based on content originally presented during HCPro's audio conference "Medical Necessity 2013: Reduce Risk and Overturn Denials." For more information, visit http://tinyurl.com/c8grjk9.

CMS releases FY 2014 IPPS proposed rule

Sat, 01 Jun 2013 04:00:00 GMT

CMS releases FY 2014 IPPS proposed rule

Consider the following: A beneficiary is admitted to a hospital pursuant to a physician order and receives medically necessary care spanning at least two midnights. CMS will consider this appropriate for payment under Medicare Part A, according to the FY 2014 IPPS proposed rule released April 26. Actuaries estimate that this proposal for what constitutes appropriate inpatient care would increase IPPS expenditures by $220 million due to an expected net increase in inpatient encounters. CMS proposes a 2% reduction to offset projected spending increases.

The concept of appropriate Part A payments centers around whether a physician expects the patient to require a stay that crosses at least two midnights and admits him or her based on that expectation. Medicare contractors will continue to focus on inpatient admissions with lengths of stay crossing only one midnight or less, according to CMS. Physician documentation of a patient's medical history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event will be paramount. CMS states the following:

Other notable changes in the proposed rule include:

Two new readmission measures (hip/knee arthroplasty and chronic obstructive pulmonary disease) that would be used to calculate readmission penalties beginning in FY 2015.
New measures for the FY 2016 Value-Based Purchasing Program, including one new clinical process measure (influenza immunization) and two new healthcare-associated infection measures (catheter-associated urinary tract infection and surgical site infection).
Payment reduction for hospitals that rank among the lowest-performing 25% with regard to HACs. These hospitals will be paid 99% of what they would have been paid under the IPPS.

CMS is accepting comments on the proposed rule until 5 p.m. EST on June 25. Visit www.ofr.gov/OFRUpload/OFRData/2013-10234_PI.pdf to view the rule.

Consider Part B inpatient billing option for Part A denials

On March 13, CMS announced in an Administrator's Ruling (at www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMS1455R.pdf) that it would allow full Part B payment for inpatient stays that a contractor denies because it deems them to be not reasonable and necessary.

To be eligible for such payment, hospitals must submit a Part B inpatient claim for reasonable and necessary services that would have been payable had the beneficiary originally been treated as an outpatient rather than an inpatient.

CMS has issued instructions stating contractors must address the automation of claims processing by July 1, 2013. Until this process is implemented, providers should use temporary instructions (www.cms.gov/Center/Provider-Type/Hospital/Other-Content-Types/Quick-Reference-CMS-1455-R.pdf) for rebilling Part B inpatient and outpatient claims. On March 22, CMS published Transmittal R1203OTN (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1203OTN.pdf) with instructions for contractors and providers about how the process will work after July 1, 2013.

During an April 2 Open Door Forum (ODF) call, David Danek of CMS said the ruling applies to the following Part A claims that a contractor denies as not reasonable and necessary:

Recent denials (i.e., denials that occurred prior to March 13 but for which the time frame to file an appeal had not yet expired as of March 13). Hospitals may submit Part B claims without filing an appeal first. However, they can't pursue an appeal and submit a Part B claim simultaneously, Danek said during the ODF call.
Denials for which there is a pending appeal (i.e., denials that occurred prior to March 13 but for which an appeal is pending). If a hospital has a pending appeal, it must withdraw that appeal from the entity processing it and receive a dismissal order from that entity before it can rebill a Part B inpatient claim. For example, if the appeal is pending with the Administrative Law Judge (ALJ), the request for withdrawal must be filed with the ALJ. If it's pending at the Qualified Independent Contractor (QIC) level, it must be filed with the QIC. There are special instructions if a hospital has a pending appeal at the ALJ level or if the appeal has been remanded to the QIC from the ALJ. In that case, a hospital must submit a request to withdraw that appeal (at www.hhs.gov/omha/Data/cms-ruling.pdf) prior to billing the Part B inpatient claim.
Prospective claim denials (i.e., denials that occur after March 13). Hospitals may submit Part B claims without filing an appeal first. As with recent denials, hospitals can't submit an appeal and a Part B claim simultaneously.

The ruling doesn't apply to the following:

Part A hospital inpatient claim denials for which the time frame to appeal expired prior to the effective date of the ruling (March 13, 2013)
Instances in which CMS currently provides for limited Part B inpatient billing when a beneficiary has no Part A coverage for an inpatient hospital stay (e.g., when a beneficiary has exhausted Part A benefit days)
Claim denials that result from a hospital self-audit

If hospitals choose to rebill a Part B claim, they must do it within 180 days of receipt of the last adjudication (i.e., within 180 days of receipt of the unfavorable appeal decision, order of dismissal, or actual claim denial). The date of receipt is presumed to be five days after the date of the notice, Danek said during the ODF call.

Transmittal R1203OTN provides additional instruction for contractors and providers about how the Part B inpatient billing process will work. The transmittal states that the ruling only applies to denials while the ruling is in effect. CMS sought comments until 5 p.m. May 17 on a proposed rule (at www.gpo.gov/fdsys/pkg/FR-2013-03-18/pdf/2013-06163.pdf) that, once finalized, would apply a permanent policy for Part B inpatient billing.

However, as proposed, the rule would limit some policies of the interim ruling, including the exception from timely filing. Imposing the timely filing deadlines would mean that hospitals would have 12 months from the date of service to file the Part B inpatient and outpatient claims. The proposed rule does expand the Part B inpatient billing policy to include provider self-audit denials. The interim ruling does not include these types of audits.

Don your thinking cap before querying for acute cor pulmonale

Sat, 01 Jun 2013 04:00:00 GMT

Don your thinking cap before querying for acute cor pulmonale

by Robert S. Gold, MD

Someone recently asked me about the appropriateness of querying for acute cor pulmonale-a rare form of acute right heart failure that carries significant mortality risk.

Acute cor pulmonale is defined as a right ventricular end-diastolic area/left ventricular end-diastolic area ratio in the long axis greater than 0.6 associated with septal dyskinesia in the short axis-that is, acute dilation of the right ventricle due to sudden massive increase in pulmonary vascular resistance.

Where confusion sets in

Chronic cor pulmonale occurs when the right side of the heart fails due to long-term hypertension in the pulmonary arteries and right ventricle of the heart. Chronic cor pulmonale can reflect hypertrophy of the right ventricle in response to valvular disease of the right side (pulmonary and tricuspid valves). It also reflects chronic lung disease that causes a secondary increase in pulmonary vascular resistance or primary pulmonary artery hypertension.

Ischemic heart disease can cause problems with right and left ventricular function. Alcoholism, chemotherapeutic drug toxicity, amyloidosis, and systemic conditions can cause right and left (biventricular) heart failure. Systemic hypertension primarily causes left heart failure. Pulmonary hypertension primarily causes right heart failure. Left heart valve disease primarily causes left heart failure. Right heart valve disease primarily causes right heart failure. One caveat is that mitral regurgitation is a major cause of secondary pulmonary hypertension, and thus, right heart failure.

When a patient is admitted to the hospital with congestive heart failure (CHF) that a physician later determines is systolic or diastolic left ventricular dysfunction, coders query for acute on chronic left heart failure. When a patient presents with acute right heart failure, why not query for acute cor pulmonale? Coders can't query for cor pulmonale in these instances because cor pulmonale and right heart failure aren't synonyms.

Cardiomyopathies

Cardiomyopathies are usually chronic diseases that can lead to ventricular dysfunction regardless of the side of the heart in question. Some dysfunction may primarily affect one side of the heart circulation and have secondary effects on the other side. Once a cardiomyopathy leads to significant dysfunction, the patient begins to experience symptoms of heart failure. The patient will usually continue to have chronic heart failure until he or she receives a new heart.

The left ventricle is bigger than the right ventricle and has a greater capacity to create higher heads of pressure. When a left and right ventricle is dilated, this means that they dilate chronically. When the left ventricle hypertrophies, it's called left ventricular hypertrophy. However, when the right ventricle hypertrophies considerably, it's called chronic cor pulmonale.

How can coders tell the difference between chronic cor pulmonale and acute cor pulmonale?

Chronic cor pulmonale occurs when there is hypertrophy of the right ventricle caused by chronic disease downstream of the right ventricle. It's manifested by increased back pressure effects into the peripheral venous circulation.

A patient with chronic cor pulmonale demonstrates dilation of peripheral veins. This increase in pressure in the venous system can lead to a secondary hypercoagulable state with increased incidence of deep venous thrombosis and pulmonary embolism. The increased pressure in the venous side causes increased pressure in the hepatic veins. The liver cannot decompress with the resultant hepatic congestion and leakage of liver enzymes occurs into the circulation.

When this occurs, it's inappropriately referred to as transaminitis. The correct diagnosis is cardiac cirrhosis.

The increased right atrial pressure leads to edema in the legs as well as edema in the patient's back (if he or she is frequently recumbent). It can also lead to abdominal ascites.

These are all chronic manifestations treated by reducing strain on the right heart. This is done controlling the cause, if possible, and by controlling the symptoms.

When a patient has acute cor pulmonale, he or she also has acute dilation of the right heart. The patient may have had a totally normal heart prior to the event. He or she may also have had right ventricular hypertrophy of chronic cor pulmonale or chronic dilation related to a systemic disease as baseline. However, acute cor pulmonale is mainly observed as a complication of massive pulmonary embolism or acute respiratory distress syndrome (ARDS)-two significantly acute conditions.

Some consultants cite an article published in Medscape (at http://emedicine.medscape.com/article/154062-overview#aw2aab6b2) as a basis to justify querying for the presence of acute cor pulmonale as well as acute on chronic cor pulmonale. In reality, much of the article is devoted to chronic cor pulmonale and is misleading at best in terms of the acute form of the condition. The references to acute cor pulmonale are totally misleading.

How many inpatients with exacerbation of chronic obstructive pulmonary disease (COPD) aren't treated with bronchodilators and antibiotics? None. How many patients with chronic, infiltrative, or fibrotic lung disease aren't treated with steroids or immunosuppressive agents? None.

How many patients are evaluated by right heart catheterization or transesophageal echocardiogram to try to demonstrate dilation of the right ventricle? None. How many of these patients receive mandatory cardiac support with inotropes to improve right ventricular function? None.

How many patients are placed on a ventilator for support during the acute and life-threatening phase of their disease? None.

Physicians don't diagnose a patient with acute cor pulmonale unless these elements are present, and the physician has proof.

Acute cor pulmonale has a 23%-70% mortality rate. Standard admissions for acute exacerbation of COPD have lower than 5% mortality. Can someone with COPD who has chronic cor pulmonale also get acute cor pulmonale?

Sure, but this is going to occur with massive pulmonary embolism or ARDS-not simply from routine acute exacerbation of COPD.

ICD-10-CM

Consider the following upcoming ICD-10-CM codes for acute cor pulmonale:

I26.01: Septic pulmonary embolism with acute cor pulmonale
I26.02: Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09: Other pulmonary embolism with acute cor pulmonale
I26.9: Pulmonary embolism without acute cor pulmonale
I26.90: Septic pulmonary embolism without acute cor pulmonale
I26.92: Saddle embolus of pulmonary artery without acute cor pulmonale
I26.99: Other pulmonary embolism without acute cor pulmonale

ICD-10-CM recognizes the seriousness of acute cor pulmonale in massive pulmonary embolism. No similar codes for ARDS with or without acute cor pulmonale have been developed. Coders must remember that only 25% of patients with a massive pulmonary embolism also get acute cor pulmonale. Thus, don't query for acute cor pulmonale unless there is clear clinical evidence to do 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 rgold@DCBAInc.com.

Briefings on Coding Compliance Strategies, June 2013

Sat, 01 Jun 2013 04:00:00 GMT

E codes: Rounding out the patient's story

What's the magic information to which we're referring?

Some states, payers, public health departments, and other agencies may require E codes; however, even this isn't consistent, which only continues to muddy the waters, says Owens.

Why hospitals should report E codes

E870.0 (accidental cut/hemorrhage in surgery)
E870.1 (accidental cut/hemorrhage in infusion or transfusion)
E870.2 (accidental cut/hemorrhage in kidney dialysis or other perfusion)
E870.3 (accidental cut/hemorrhage in injection or vaccination)
E870.4 (accidental cut/hemorrhage with endoscopic exam)
E870.5 (accidental cut/hemorrhage with catheterization)
E870.6 (accidental cut/hemorrhage with heart catheterization)
E870.7 (accidental cut/hemorrhage with enema)
E870.8 (accidental cut/hemorrhage in other specified medical care)
E870.9 (accidental cut/hemorrhage in unspecified medical care)
998.2 (accidental operative laceration)

Six other PSI indicators also use E codes to identify discharges associated with that indicator, says Owens. These include PSIs 5, 8, 16, 21, 25, and 26, she adds.

Improving PSI documentation

ICD-10-CM

How the injury of condition happened (cause)
Intent (unintentional or accidental versus intentional)
Place where the event occurred
Activity at the time of the event
Patient status (i.e., civilian or military)

Ensuring compliance

Stopping diabetes in its tracks: How ICD-10-CM can help

Diabetes: Clinically speaking

Diabetes: ICD-9-CM vs. ICD-10-CM

In ICD-9-CM, codes for diabetes distinguish between secondary diabetes (249.xx) and Type 1 or Type 2 (250.xx), and secondary diabetes.

The fifth digit in code category 249.xx indicates whether the secondary diabetes is

Not stated as uncontrolled
Uncontrolled
Unspecified

The fifth digit in code category 250.xx indicates Type 1 versus Type 2 and whether the diabetes is not stated as uncontrolled, uncontrolled, or unspecified.

In ICD-10-CM, codes for diabetes appear in category E08-E13. These codes distinguish between the following types of diabetes:

Diabetes due to an underlying condition (E08)
Drug- or chemical-induced diabetes (E09)
Type 1 diabetes (E10)
Type 2 diabetes or diabetes not otherwise specified (E11)
Other specified diabetes (E13)

Note that coders should assign code O24.4- for gestational diabetes and P70.2 for neonatal diabetes.

Researchers will benefit from this enhanced data capture of each specific type of diabetes that can be easily identified by category, says Cassidy.

Congenital rubella
Cushing's syndrome
Cystic fibrosis
Malignant neoplasm
Malnutrition
Pancreatitis and other diseases of the pancreas

"Statins are the most widely prescribed drugs to lower cholesterol, but those drugs also have a side effect that some researchers are noticing can cause high blood sugar," says Rand.

Start prepping physicians now

It's never too early to start asking for more specific documentation or incorporating additional elements into EHR templates, says Cassidy.

ICD-10-CM will require the following details for diabetes:

Specific type of diabetes
Specific type of underlying condition (if applicable)
Specific type of drug or chemical (if the diabetes is drug- or chemical-induced) as well as how that drug or chemical was taken (e.g., adverse effect vs. poisoning)
Complications and/or manifestations of the diabetes (including the specific site of an ulcer or stage of chronic kidney disease)

"If physicians don't provide enough of this specific documentation, coders will have a really big challenge," says Cassidy.

Documentation of medical necessity drives successful RA appeals

Medical necessity is a top target

What are some of the most common RA denials to date?

"We've got several million dollars held up in appeal right now," says Wiik. "That [amount] is only going to get larger."

Part B rebilling provides another option

Wiik says hospitals essentially have two choices in light of CMS' recent Administrative Ruling and anticipated final rule on Part B rebilling:

Defend the admission criterion and utilization review (UR) process in an appeal and wait for the reimbursement to which you're entitled
Ignore the UR criterion and process and accept reimbursement at a lower rate now by rebilling the denied Part A claim to Part B

Concurrent reviews, strong RA process are key

"The best practice is to get it right from the start," says Palmer. "The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation."

Physician education is crucial

Medical history (H&P)
Current medical needs
Severity of signs and symptoms
Facilities available for adequate care
Predictability of adverse outcomes

What's your impression of the patient?
What are your concerns for this patient?
Based on these concerns, what's the potential for a poor outcome?

Editor's note

CMS releases FY 2014 IPPS proposed rule

Physician engagement is key to coding accuracy

Wed, 01 May 2013 04:00:00 GMT

William E. Haik, MD, FCCP, CDIP, a practicing pulmonologist and director of DRG Review, Inc., in Fort Walton Beach, Fla., says he first became interested in coded data in 1986 after a local newspaper published his hospital’s costs, length of stay, and mortality rates for simple pneumonia. At the time, he was the only pulmonologist in the local area. The patients he treated were often those with multiple comorbidities as well as gram-negative bacterial pneumonia who had been transferred from two smaller facilities in the county.

“It looked like my patients were dying twice as often and costing twice as much as the other hospitals in the county,” he recalls.

After talking with coders at his facility, he realized that ICD-9-CM didn’t include a code for gram-negative pneumonia. Thus, the codes assigned couldn’t possibly depict the severity of his patients, nor did they help explain the outcomes. He approached CMS about these inconsistencies between clinical terminology and coding and says he has been interested in coded data ever since.

Physician profiling

All physicians should care about how coded data can potentially affect them, particularly as the industry becomes more transparent to consumers, says Timothy Brundage, MD, physician champion at Brundage Medical Group, LLC, in St. Petersburg, Fla., and ACDIS advisory board member. “I think that as [CMS] continues to gather data, it will continue to publish more data,” he says. “All of this will be attempts to empower the consumer.”

Brundage, who frequently lectures physicians about the importance of documentation and coded data, says physicians are generally interested in peer-to-peer education once they move past initial resistance. He teaches residents informally on the fly during rounds as well as during more formal lunchtime CME sessions in the hospital. “I find them to be hungry for knowledge,” he says. “They pepper me with questions.”

Explaining how coded data relates to profiling can be extremely helpful when engaging physicians, says Haik. Physician performance is determined by length of stay, cost, and death rate for a particular patient severity level. That level is driven by the ICD-9-CM codes that coders assign. “The healthcare industry believes that high cost for a low severity of illness equals poor quality of care,” says Haik.

Consumers are starting to understand this data and make decisions based upon it, says Brundage. “You can pull up Healthgrades.com on your smartphone as you’re walking into the doctor’s office.” Inadequate documentation drives inadequate coding, and physicians are ultimately the ones who appear subpar when compared with their peers, he adds.

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, director of HIM Practice Excellence at AHIMA in Chicago, agrees. “A lot of consumers know about [Healthgrades] and are using it to select a provider to perform their surgery,” she says.

Payment today and in the future

Many physicians incorrectly assume that coded data doesn’t—and won’t—affect their own reimbursement. One way to engage them is to focus on how codes can drive the complexity of their medical decision-making, thereby affecting their payment, says Haik. Reporting simple bronchitis, for example, may justify a level 1 E/M code. Reporting acute infected bronchitis superimposed on chronic obstructive pulmonary disease may justify a level 2 code. If this same patient also has acute respiratory failure or some other type of catastrophic illness, physicians may be able to report a critical care code.

Haik says that payers in Florida actually use edits to ensure the presence of a catastrophic illness when physicians report a critical care code. If such an illness is absent, the payer automatically downgrades the payment.

Physicians will be directly affected as accountable care organizations and bundled payments become more common, says Haik. “Once physicians realize that they’re getting paid based on the DRG, HIM won’t be chasing them,” he says. “It will put the hospital and physician on the same side of the equation.”

Quality of care, research

It’s helpful to link coded data with quality of care, says Cathy Testerman, CCS, EMT, coding compliance manager at WellSpan Health in York, Pa. Most physicians don’t understand how the diagnoses they use to support their E/M levels can affect hospital quality ratings.

At WellSpan, coders and CDI specialists educated physicians about the significance of documenting acute respiratory failure—an MCC—for patients who had undergone coronary artery bypass grafting and valve replacement surgeries and who were being weaned off the ventilator.

“This affected our PSI #11 [postoperative respiratory failure] quality rating,” says Testerman. “By educating intensivists regarding the outcomes of their documentation, we were able to come up with common clinical indicators for when acute respiratory failure is appropriate.”

Donna Walker-Thomas, MBA, RHIA, CPC, CMA, director of coding at Miriam Hospital in Providence, R.I., says physicians at the hospital are especially interested in research, and she uses this to her advantage when engaging them. In particular, she talks with physicians in her office about ICD-10 while they wait for her to run reports. For example, she recently explained to a couple of residents that if a condition isn’t documented, it won’t get coded. This surprised them because it directly affected their research project. It also gave them a greater appreciation for coded data and its link to documentation.

Unlike formal educational sessions that often reprimand physicians for inadequate documentation, she says a more informal approach makes physicians more curious about the topic. “They’ll actually say, ‘Give me that page in the code book,’ or ‘Where can I get a book to learn more?’ ” she says.

Dos and don’ts

Consider the following tips to get physicians more interested in coded data:

Do:

Explain how accurate coding captures patient severity and can potentially justify a longer length of stay. Severe sepsis, for example, justifies significant nursing care, tests, and an overall higher utilization of resources, says Brundage. (See the sepsis order set on p. 4 that physicians can use to improve capture of this diagnosis.)
Start communicating with physicians about ICD-10-CM. “Dispel the myths,” says Endicott. “There aren’t a whole lot of differences between ICD-9-CM and ICD-10-CM.”
Tag team with a physician or CDI specialist, if possible. When choosing a physician, consider someone who is approachable, who wants to better understand coded data, who documents well, and who is diligent about answering queries, says Endicott.
Remind physicians that documentation and coded data improve patient care. “The financial health of the hospital and the medical health of the patient are directly intertwined. They’re inseparable,” says Haik. “You can’t expect the hospital to provide the latest drugs and expensive technology or even adequate nursing ratios unless you can show how sick the patient is.”
Consider engaging attending physicians. “Medical school is such a daunting task that I’m not sure there is enough time for physicians to be taught [how to document properly],” says Brundage. “What we really should be doing is teaching attending physicians who can teach documentation to medical students.”

Don’t

Schedule a three-hour meeting with physicians to discuss coding. “What we recommend is to get on their medical staff meeting and take five to 15 minutes of their time to show them how documentation is key to getting the correct codes,” says Endicott.
Minimize what physicians already know. Keep it simple, but not overly simple, says Endicott. Use actual examples that demonstrate how their documentation affects the capture of patient severity through ICD-9-CM codes, she adds.

Don't let underpayments fly under the radar

Wed, 01 May 2013 04:00:00 GMT

Nearly 75% of participating hospitals nationwide with RA activity reported receiving at least one underpayment determination, according to the AHA RACTrac survey, fourth quarter 2012, released in March. Sixty-nine percent of hospitals with underpayment determinations cited incorrect MS-DRG as a reason for the underpayment.

Incorrect principal diagnosis code assignment—as well as the inadvertent omission of CCs and MCCs—can potentially yield lower-paying and inaccurate DRGs, says Donna Didier, MEd, RHIA, CCS, director of coding compliance for TrustHCS in Springfield, Mo. It’s important to monitor data and ensure accurate coding that reflects patient severity, she adds.

“In our experience, we have found that if a chart is coded incorrectly, more often than not, the chart is undercoded,” says Patricia L. Belluomini, RHIA, director of CBIZ KA Consulting Services, LLC, in East Windsor, N.J. Missing CCs or MCCs is usually the culprit, she adds.

Even though RAs are tasked with finding underpayments, Belluomini says hospitals shouldn’t sit back and assume that auditors will catch all instances for which hospitals are underpaid. “Hospitals are interested in where they’ve left money on the table,” she says. “They want it billed correctly just like Medicare does, but the motivation is different.”

Second-level, pre-billing, or post-billing reviews are all helpful, says Belluomini. Some hospitals target all DRGs that don’t include a CC or MCC and ensure that a coder performs a review before the claim is billed. However, Belluomini admits this may pose an operational challenge.

“Hospitals should be doing this, but the reality is that HIM departments everywhere are understaffed. It’s hard to convince CFOs to give HIM the staff members to do this work,” she says.

Internal reviews can also be tricky. “If one coder is reviewing another coder’s work, they may be less likely to point out mistakes. It’s easier and more effective if an auditor comes in because they’re an outside entity,” says Belluomini.

Top underpayment issues

In its FY 2011 Report to Congress (available at http://tinyurl.com/br4oygk), CMS lists top issues by RA for underpayments, including the number of claims, total dollar amount, and mean claim amount. Top issues span a variety of MS-DRGs.

For example, hospitals may receive underpayments for cholecystectomy (MS-DRGs 411–419) when coders omit MCCs, such as acute pancreatitis (577.0), or CCs, such as cholangitis (576.1), says Belluomini.

The difference in relative weight can be significant. For example, DRG 419 (laparoscopic cholecystectomy without common duct exploration without CC or MCC) has a relative weight of 1.2050. DRG 417 (laparoscopic cholecystectomy without common duct exploration with MCC) has a relative weight of 2.5189.

Major large and small bowel procedures (MS-DRGs 329–331) are also challenging. DRG 330 (major large and small bowel procedures with CC) has a relative weight of 2.5731. DRG 329 (major large and small bowel procedures with MCC) has a relative weight of 5.2599.

“That can be a $20,000 difference,” says Belluomini. Peritonitis (567.x) is an MCC that coders may inadvertently omit and that can lead to such an underpayment, she adds.

Hospitals may also receive underpayments for severe sepsis (MS-DRGs 870–872) when coders omit MCCs, such as pneumonia (486) or acute respiratory failure (518.81), says Belluomini.

Incorrectly sequencing sepsis can also cause an underpayment. If a coder incorrectly codes a localized infection, such as a UTI or pneumonia, as the principal diagnosis, this could result in a lower-weighted DRG, says Didier. Coders should always be on the lookout for signs and symptoms of sepsis POA and query when it’s unclear whether sepsis is the principal diagnosis, she adds.

MS-DRGs 870–872 also take into consideration whether the patient receives mechanical ventilation.

For example, DRG 870 (septicemia or severe sepsis with mechanical ventilation 96+ hours) has a relative weight of 5.8399. This is significant when compared with DRGs 871 and 872 (without mechanical ventilation), which have relative weights of 1.8803 and 1.0988 respectively.

If coders undercount the hours of ventilation, this could result in an underpayment for these DRGs as well as others, such as DRGs 003, 004, 207, 927, and 933, says Didier.

Distinguishing between TIA and cerebral infarction is also important, says Didier. If a patient has a TIA only, the MS-DRG is 069, which has a relative weight of 0.7449. However, she says, if an imaging study identifies the presence of an infarction—but the physician doesn’t document a clear diagnosis—coders should query to determine whether the patient actually has a cerebral infarction, which would map to MS-DRGs 064 (infarction with MCC) with a relative weight of 1.8424, 065 (infarction with CC) with a relative weight of 1.1345), or 066 (infarction without CC/MCC) with a relative weight of .8135.

Hospitals may be underpaid for intracranial hemorrhage or cerebral infarction (MS-DRGs 064–066) when coders omit cerebral edema (348.5) and cerebral compression (348.4), both of which are MCCs, says Didier. “A lot of times, the physician will just say midline shift, and he or she will talk about how big it is and how it needed to be drained,” she says. “They may only see it on a CT or MRI report. That’s an indication that they should query and ask the physician to clarify if the cerebral edema noted on the CT or MRI was a clinically significant diagnosis rather than just a finding noted in the report.”

Although MS-DRGs 216–221 (cardiac valve procedures) didn’t make the report’s top list of underpayments, Didier says she frequently sees underpayments in this area. Rupture of chordae tendineae (429.5) and rupture of papillary muscle (429.6) are MCCs that coders frequently miss when patients have severe mitral valve prolapse that requires replacement or repair of the cords or papillary muscle, she says.

Keep current on changes to the three-day �payment rule

Wed, 01 May 2013 04:00:00 GMT

The three-day payment window has been wrought with compliance challenges since its inception. In January, CMS updated the policy to provide additional clarification.

The information is published in the Medicare Claims Processing Manual (Pub. 100-4), Chapter 3, section 40.3, “Outpatient Services Treated as Inpatient Services” (available at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf ). Following is a brief summary of the changes.

Single, continuous outpatient encounters

The three-day rule applies only to the three days prior to the inpatient admission. In its recent update, CMS clarifies that services provided more than three days before the admission should be billed separately as outpatient Part B services even when those services are part of a single encounter that extends into the three-day window.

The line item date of service is crucial in identifying services that should be rolled into the inpatient admission, says Debbie Mackaman, RHIA, CHCO, an instructor for HCPro’s Medicare Boot Camp®–Hospital Version and the Medicare Boot Camp®–Critical Access Hospital Version.

Observation may be particularly challenging because it often spans a period of time. “If observation was ordered, then the coder will need to look at the start time based on the physician order and split the observation hours for billing purposes,” Mackaman explains.

Observation hours that occur outside the payment window must be billed on a separate outpatient claim, says Mackaman. Observation hours that occur inside the payment window must be separated out and included on the inpatient claim when related to the admission. Observation hours are usually billed on one line with revenue code 762 using the date the observation services began. Overpayments can occur when at least eight hours of observation are billed using the date the observation services began. Doing so could trigger an E/M composite payment based on the ER or clinic level when coders bill the observation hours outside of the payment window.

Certain diagnostic tests that span a period of time can also be tricky. A 24-hour urine test is one example. “The billing caveat with this test is that you use the date the collection ended for the date of service rather than the date the collection began,” says Mackaman. “You wouldn’t be able to reasonably split costs of this lab test out if the first half of the test occurred outside of the payment window and the remainder of the test occurred inside the payment window because the HCPCS code is billed with a unit of one.”

Subsequent hours of infusion is another area to review carefully. “Again, the costs could not be reasonably expected to be split out if a particular infusion hour went past midnight,” says Mackaman. “The additional hours of infusion beyond midnight should have a different date of service and then may be billed inside of the payment window and included on the inpatient claim when clinically related.”

Self-administered drugs

In its recent update, CMS clarifies that inpatient claims should not include self-administered drugs and other services provided in the three-day window that aren’t payable under Part B. This includes self-administered drugs provided while the patient is in the ED, observation, or even outpatient surgery prior to a later inpatient admission.

The date of service is important, says Mackaman. “If self-administered drugs are provided in the outpatient setting on the day of or three days prior to the admission, these should be reviewed to determine if the outpatient revenue code 637 [self-administrable drugs not requiring detailed coding] is appropriate. If it is, these should not be billed as covered inpatient charges. This includes the related administration code (i.e., subcutaneous injection),” she says.

However, self-administered drugs may be difficult to detect. Coders cannot rely on the drug name and/or dosage. “The same drug given as an inpatient may be covered and billed with revenue code 250 [pharmacy], but when it’s used in the ER, it’s billed under revenue code 637 and is non-covered,” says Mackaman.

The HCPCS code (with modifier -GY [item or service statutorily excluded or does not meet the definition of any Medicare benefit]) may also not be visible on the inpatient claim. That’s because some information systems automatically convert revenue code 637 to a 250 or 259 without a HCPCS code. “Coders need to understand how their information system works and the process behind combining outpatient charges into inpatient claims,” says Mackaman.

Diagnostic cardiology procedures

CMS also clarifies certain CPT codes billed with revenue codes 481 (cardiac catheter lab) and 489 (other cardiology) that should be treated as diagnostic services for the purpose of application of the three-day window. The specific codes considered diagnostic when provided in these revenue centers are 93451–93464, 93503, 93505, 93530–93533, 93561–93568, 93571–93572, G0275, and G0278.

“This isn’t a change in policy, but rather an update to the current CPT codes associated with those revenue codes to which the payment window applies,” says Mackaman.

Other changes

CMS also reiterates the applicability of the three-day window to outpatient services rendered in a critical access hospital, physician practice, rural health clinic, or federally qualified health center owned or operated by a hospital to which the patient is later admitted. The agency also reiterates clarifications on the definition of wholly operated and discusses “sponsorship” by a nonprofit hospital, stating that it’s treated the same as “ownership” for purposes of the rule.

In addition, CMS incorporates updates related to the following:

Converting CPT codes. CPT codes must be converted to ICD-9-CM procedure codes when moving services onto the inpatient claim. Hospitals must only include outpatient diagnostic and admission-related nondiagnostic services that span the period of the payment window. All nondiagnostic services performed on the day of admission are included on the inpatient claim regardless of whether they are related to the admission.
POA indicator for bundled services. If the outpatient services are bundled with the inpatient claim, hospitals must code any conditions the patient has at the time of the order to admit as an inpatient as POA regardless of whether the patient had the condition at the time of being registered as a hospital outpatient.
Applicable Common Working File (CWF) edits. The CWF will reject outpatient claims for nondiagnostic services when condition code 51 is not included on the outpatient claim and the line item date of service falls on the day of admission or any of the three days immediately prior to the admission to an IPPS hospital (or on the day of admission or one day prior to admission for hospitals excluded from IPPS).
Proper use of condition code 51 (attestation of unrelated outpatient nondiagnostic services). Billers should report condition code 51 on the separately billed outpatient nondiagnostic services claim to indicate that specific nondiagnostic services are unrelated to the hospital claim (i.e., the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary’s admission).

Ensure compliance

Communication between inpatient and outpatient coders and billing staff is a crucial part of maintaining compliance with the three-day window, says Mackaman. Inpatient coders may not be aware of outpatient services that fall under the three-day window if they aren’t coding the outpatient claim. If outpatient coders don’t notify billers to move the outpatient services to the inpatient claim prior to billing, compliance challenges may arise.

“If the process is fragmented and is only caught on the back end by a billing edit based on a date of service, there may be problems with compliant billing based on this new clarification,” she adds.

Comply with new ACDIS/AHIMA query practice brief

Wed, 01 May 2013 04:00:00 GMT

In February, AHIMA published an update to its 2010 query practice brief. The updated brief, Guidelines for Achieving a Compliant Query Practice, is the result of a joint effort between AHIMA and the Association for Clinical Documentation Improvement Specialists (ACDIS).

Nearly 50 individuals—including physicians, coders, and nurses/CDI specialists—provided input into the 12-page practice brief. The most notable change is an expansion of when coders can use a yes/no format query. Other information pertains to when and how to query, how to define the term “leading,” and more. It also includes an appendix of query example templates.

Understand the changes

So what’s new about the latest version of the query practice brief? First, it clarifies to whom the brief applies. ACDIS and AHIMA are clear that the guidance is relevant to all CDI professionals as well as those who manage the CDI process regardless of their credentials, the setting in which they work, or whether they are members of AHIMA.

Second, it reiterates the importance of consistency and continuity in the record by stating the following:

Because the patient record should provide a sequence of events, best practice is to capture the content of a verbal and/or written query, as well as any practitioner response to the query. This practice allows reviewers to account for the presence of documentation that might otherwise appear out of context.

“It always seems odd if a diagnosis is suddenly introduced without having any context around it,” says Cheryl Ericson, RN, MS, CCDS, CDIP, CDI education director at HCPro, Inc. in Danvers, Mass. “It’s often helpful for the query to be memorialized somewhere in the record to show why that information is being added.” This includes memorialization of verbal queries. Hospitals should retain verbal and written queries in the same manner, she adds.

Verbal queries should include clinical indicators that support the query. These queries should also be documented at the time of discussion or immediately after, according to the practice brief.

Consider this example of a compliant verbal query: “Spoke with Dr. X regarding documentation of heart failure based on the risk factors of an ejection fraction of less than 40%, signs and symptoms of difficulty breathing, and treatment with Lasix.”

A provider’s response to the written query will dictate organizational retention guidelines, says Ericson. “Whenever the physician writes directly onto the query form, the best practice is to keep that form part of the health record because it supports why that documentation is being added,” she says. “If the physician is not documenting directly onto the query form, then oftentimes the form can be kept as part of the administrative or business record.”

The compliance and legal departments as well as the medical executive committee should be involved in the creation of query retention policy or guidelines, she adds.

Third, the practice brief instructs coders and CDI specialists that they must query when there is a lack of clinical indicators to support a documented condition—that is, when the physician provides a diagnosis without underlying clinical validation. The clinical indicator doesn’t necessarily need to be one that’s listed in a Coding Clinic reference. The brief states:

Although AHA’s Coding Clinic for ICD-9-CM often references clinical indicators associated with particular diagnoses, it is not an authoritative source for establishing clinical indicators of a given diagnosis. … Clinical indicators should be derived from the specific medical record under review and the patient’s unique episode of care.

When using templates, coders and CDI specialists should refine the comprehensive list of clinical indicators to reflect the patient’s record. “There needs to be unique identifiers to link that particular query to that particular patient or episode of care,” says Ericson.

Queries regarding a lack of clinical validity can be challenging because coders and CDI specialists may feel that they are questioning a physician’s clinical judgment, says Ericson. The practice brief recommends that coders and CDI specialists follow an internal escalation policy in which they refer the matter to a CDI or coding manager, physician advisor, or chief medical officer. “It takes the [coder or CDI specialist] out of the line of fire and allows them to maintain their relationship with the provider,” says Ericson.

“We need to have a firm clinical rationale for the query to justify it not being leading in nature,” says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla. Sometimes, there may only be one clinical indicator to support a query, he says. For example, a reduced ejection fraction may be the only clinical indicator to clarify the specific type of heart failure.

The practice brief also clarifies that it’s not considered leading to include a new diagnosis as a choice within the multiple-choice format, permitted the diagnosis is supported by clinical indicators. In some cases, multiple-choice queries may list new information as the only option along with “other” and “clinically undetermined,” says Haik. The caveat is that the new information cannot be in the question, nor can it be in the title of the query, he adds.

Fourth, the practice brief provides clarification regarding query formats. Perhaps the most significant change in the entire brief is that coders and CDI specialists can now use yes/no queries in the following circumstances:

To substantiate or further specify a diagnosis that’s already present in the record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician
To establish a cause-and-effect relationship between documented conditions, such as manifestation/etiology, complications, and conditions/diagnostic findings
To resolve conflicting documentation from multiple practitioners

Coders and CDI specialists cannot use yes/no queries when only the clinical indicator(s) is present, and the condition has yet to be documented, says Haik. Another important addition is that AHIMA discourages use of the term “possible” in a query. The practice brief states, “Unlike other qualifiers . . . possible is a very broad term, and therefore its use in a query is discouraged.”

Editor’s note

The content in this article was originally presented during HCPro’s audio conference “Physician Queries: Comply With New ACDIS/AHIMA Guidance.” For more information, visit http://tinyurl.com/aft9o5b. To view the updated practice brief, visit http://tinyurl.com/agjsjoj.

Why coders should be aware of advice for coding ESRD, excisional debridement, and more

Wed, 01 May 2013 04:00:00 GMT

by Robert S. Gold, MD

Editor’s note: This is the second article in a two-part series.

Coders should question the validity of coding advice and work collaboratively with physicians to develop sound coding guidelines. Last month, I addressed coding advice related to percutaneous endoscopic gastrojejunostomy and cardiorenal syndrome. This month, I’ll address coding advice related to several other conditions.

End-stage renal disease (ESRD)

A patient with ESRD can’t develop acute kidney injury (AKI) despite Coding Clinic advice that indicates otherwise. Patients with chronic kidney disease (CKD) can develop acute renal failure (AKI) as the citation properly suggests. In this case, coders should assign codes for both the AKI and CKD.

ESRD is defined as end-stage CKD that requires chronic dialysis. The National Kidney Foundation and the Kidney Disease Outcomes Quality Initiative classify patients with ESRD as those who receive chronic dialysis for more than three months and who don’t improve to a lower stage at which dialysis is no longer required. This prevents physicians from incorrectly labeling patients with AKI who require acute dialysis therapy while their renal function is recovering as having ESRD.

A patient with a glomerular filtration rate of 15 who began chronic dialysis a year ago can develop severe sepsis and have a decline in function to anuria for more than 24 hours. Is this AKI? Sure. But is it codable? How do physicians treat a patient with ESRD who has a decline in renal function? They dialyze him or her. Does this treatment differ from what the patient underwent prior to the event? No. The patient is already on dialysis. Does it truly meet Uniform Hospital Discharge Data Set criteria as a valid secondary diagnosis? Do you observe it anymore? If the patient had no urine output (kidney sweat) prior to admission, can the patient get worse?

It’s widely known that patients with ESRD are admitted to the hospital with elevated creatinine levels, receive dialysis, and return home. Under normal circumstances, this treatment might be considered codable as admission for dialysis (V56.0). The diagnosis shouldn’t be considered acute renal failure on ESRD.

Regardless of how coders sequence codes 584.9 and 585.6, the DRG assignment is 684. However, assigning V56.0 as the principal diagnosis results in DRG 685, which has a 20% higher relative weight. Reporting code 584.9 as a reason for inpatient status seems to justify an inpatient admission. However, if the patient only has an elevated creatinine because he or she was noncompliant with dialysis or diet, it doesn’t deserve 584.9 or inpatient status unless there is something else that adds significant risk.

Excisional debridement

Many hospitals have followed guidance published in Coding Clinic, First Quarter 2008, p. 3 related to excisional debridement. Unfortunately, they’ve also probably experienced RA denials because of this. This Coding Clinic advice states that when a physician documents that he or she performed excisional debridement, coders should assign code 86.22. There’s no caveat that coders should determine whether the procedure documented in the operative note actually meets the definition of excisional debridement. It doesn’t state that coders should look at the instrumentation used or whether the physician removed fascia, muscle, or bone. As a result, coders are stuck with incomplete coding advice to follow. Coders should review all aspects of excisional debridement before coding.

Hypostatic pneumonia

Hypostatic pneumonia, which was originally called apoplexy of the lung, is a condition found during an autopsy on individuals who had been severely malnourished and who had been lying in one position for weeks to months, likely with tuberculosis, cancer, or another terminal disease, before they died. Their lung tissue becomes congested with blood, and any local inflammation is due to the solidified blood in the bronchi and alveoli—not due to an infectious source as in pneumonia. This was the original clinical description of the condition and intent of code 514.

Coding Clinic, Third Quarter 1988, p. 5 originally instructed coders to report code 514 when a physician documents noncardiac chronic pulmonary edema. Coding Clinic, Second Quarter 1998, pp. 6–7 states coders should assign 514 when the physician documents hypostatic pneumonia. This led coders to suggest that if a patient develops pneumonia after having atelectasis, the physician should call it hypostatic pneumonia. However, patients with what may be called hypostatic pneumonia are usually treated with antibiotics, and it’s obviously thought to be a bacterial pneumonia. A CMS representative paraphrased this Coding Clinic citation, implying that coders should consider that the patient may have bacterial pneumonia and seek clarification regarding whether this is the reason for the treatment. If this is the case, they should report code 482.9.

Coders are advised to report code 514 when documentation indicates pulmonary edema not specified as acute. If the physician documents that the patient has pulmonary edema, then it’s likely that he or she means that the patient has acute congestive heart failure. He or she may also mean that the patient has pulmonary edema in ESRD due to volume overload or pulmonary edema related to some acute insult or trauma. The patient is likely in the hospital for a totally identifiable reason. The cause of the pulmonary edema is important to capture.

Foreign body accidentally left behind

Coding Clinic, First Quarter 2009, p. 18 states that coders should assign 998.4 (foreign body accidentally left in place) when a patient has a sponge removed from the body in the process of a sponge count after surgery. I originally suggested to Coding Clinic that code 998.4 is inappropriate because the patient left the operating room without the foreign body. However, Coding Clinic consultants stated this advice is based on the National Quality Forum’s definition of “end of surgery.” I was subsequently able to work with the National Quality Forum, the Agency for Healthcare Quality and Research, the American College of Surgeons, and others to correct this definition. Even though the definition has been revised, Coding Clinic has not changed its advice. Don’t report 998.4 when a sponge is removed during the sponge count.

More conditions to ponder

Be sure to check out the December 2012 issue of Briefings on Coding Compliance Strategies in which my column addresses coding advice related to anemia of pregnancy, delivered, with complication; SIRS and sepsis; and conditions during the perinatal period.

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.

Briefings on Coding Compliance Strategies, May 2013

Wed, 01 May 2013 04:00:00 GMT

Don't let underpayments fly under the radar

“Hospitals should be doing this, but the reality is that HIM departments everywhere are understaffed. It’s hard to convince CFOs to give HIM the staff members to do this work,” she says.

Top underpayment issues

“That can be a $20,000 difference,” says Belluomini. Peritonitis (567.x) is an MCC that coders may inadvertently omit and that can lead to such an underpayment, she adds.

Hospitals may also receive underpayments for severe sepsis (MS-DRGs 870–872) when coders omit MCCs, such as pneumonia (486) or acute respiratory failure (518.81), says Belluomini.

MS-DRGs 870–872 also take into consideration whether the patient receives mechanical ventilation.

If coders undercount the hours of ventilation, this could result in an underpayment for these DRGs as well as others, such as DRGs 003, 004, 207, 927, and 933, says Didier.

Physician engagement is key to coding accuracy

“It looked like my patients were dying twice as often and costing twice as much as the other hospitals in the county,” he recalls.

Physician profiling

Payment today and in the future

Quality of care, research

Dos and don’ts

Consider the following tips to get physicians more interested in coded data:

Do:

Explain how accurate coding captures patient severity and can potentially justify a longer length of stay. Severe sepsis, for example, justifies significant nursing care, tests, and an overall higher utilization of resources, says Brundage. (See the sepsis order set on p. 4 that physicians can use to improve capture of this diagnosis.)
Start communicating with physicians about ICD-10-CM. “Dispel the myths,” says Endicott. “There aren’t a whole lot of differences between ICD-9-CM and ICD-10-CM.”
Tag team with a physician or CDI specialist, if possible. When choosing a physician, consider someone who is approachable, who wants to better understand coded data, who documents well, and who is diligent about answering queries, says Endicott.
Remind physicians that documentation and coded data improve patient care. “The financial health of the hospital and the medical health of the patient are directly intertwined. They’re inseparable,” says Haik. “You can’t expect the hospital to provide the latest drugs and expensive technology or even adequate nursing ratios unless you can show how sick the patient is.”
Consider engaging attending physicians. “Medical school is such a daunting task that I’m not sure there is enough time for physicians to be taught [how to document properly],” says Brundage. “What we really should be doing is teaching attending physicians who can teach documentation to medical students.”

Don’t

Schedule a three-hour meeting with physicians to discuss coding. “What we recommend is to get on their medical staff meeting and take five to 15 minutes of their time to show them how documentation is key to getting the correct codes,” says Endicott.
Minimize what physicians already know. Keep it simple, but not overly simple, says Endicott. Use actual examples that demonstrate how their documentation affects the capture of patient severity through ICD-9-CM codes, she adds.

Keep current on changes to the three-day payment rule

The three-day payment window has been wrought with compliance challenges since its inception. In January, CMS updated the policy to provide additional clarification.

Single, continuous outpatient encounters

Self-administered drugs

Diagnostic cardiology procedures

“This isn’t a change in policy, but rather an update to the current CPT codes associated with those revenue codes to which the payment window applies,” says Mackaman.

Other changes

In addition, CMS incorporates updates related to the following:

Converting CPT codes. CPT codes must be converted to ICD-9-CM procedure codes when moving services onto the inpatient claim. Hospitals must only include outpatient diagnostic and admission-related nondiagnostic services that span the period of the payment window. All nondiagnostic services performed on the day of admission are included on the inpatient claim regardless of whether they are related to the admission.
POA indicator for bundled services. If the outpatient services are bundled with the inpatient claim, hospitals must code any conditions the patient has at the time of the order to admit as an inpatient as POA regardless of whether the patient had the condition at the time of being registered as a hospital outpatient.
Applicable Common Working File (CWF) edits. The CWF will reject outpatient claims for nondiagnostic services when condition code 51 is not included on the outpatient claim and the line item date of service falls on the day of admission or any of the three days immediately prior to the admission to an IPPS hospital (or on the day of admission or one day prior to admission for hospitals excluded from IPPS).
Proper use of condition code 51 (attestation of unrelated outpatient nondiagnostic services). Billers should report condition code 51 on the separately billed outpatient nondiagnostic services claim to indicate that specific nondiagnostic services are unrelated to the hospital claim (i.e., the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary’s admission).

Ensure compliance

Comply with new ACDIS/AHIMA query practice brief

Understand the changes

Second, it reiterates the importance of consistency and continuity in the record by stating the following:

Verbal queries should include clinical indicators that support the query. These queries should also be documented at the time of discussion or immediately after, according to the practice brief.

The compliance and legal departments as well as the medical executive committee should be involved in the creation of query retention policy or guidelines, she adds.

To substantiate or further specify a diagnosis that’s already present in the record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician
To establish a cause-and-effect relationship between documented conditions, such as manifestation/etiology, complications, and conditions/diagnostic findings
To resolve conflicting documentation from multiple practitioners

Editor’s note

The content in this article was originally presented during HCPro’s audio conference “Physician Queries: Comply With New ACDIS/AHIMA Guidance.” For more information, visit http://tinyur

Use caution when reporting unrelated DRGs

Mon, 01 Apr 2013 04:00:00 GMT

Use caution when reporting unrelated DRGs

DRGs for procedures unrelated to the principal diagnosis shouldn't occur frequently. If they do, coding managers should take a closer look at coding compliance efforts to ensure accuracy and avoid costly audits.

Unrelated DRGs, as they're more succinctly known, include the following:

981-983 (extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

984-986 (prostatic operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

987-989 (non-extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

"Avoid these DRGs when possible, but you have to realize that there are certain circumstances when they're right, and you don't try to avoid them when they're right," says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director at HCPro, Inc., in Danvers, Mass., agrees. "It's not that you're never going to have these cases, it's just that you should always be diligent in verifying that it's an accurate DRG assignment," she says.

Gold recently performed an analysis of 2012 MedPAR data and found that approximately 2.27% of all national surgical DRGs reported are those for which the principal diagnosis is unrelated to the operating room procedure.

"If your hospital is reporting considerably more than 2.27%, then you're probably going to be a Recovery Auditor target," says Gold. He says he's aware of one hospital at which 80% of its surgical DRGs were unrelated DRGs. "They were at risk for tens of millions of dollars in fines over the last seven years," he adds.

How they're triggered

Unrelated DRGs essentially occur when a patient presents to the hospital with one diagnosis and needs surgery for a different diagnosis. Sounds simple, right?

Not quite. Keep in mind that unrelated DRGs are technically only triggered when the surgical procedure and principal diagnosis aren't classified in the same major diagnostic category or body system within the DRG classification system, says Ericson.

For example, a patient is admitted to the hospital due to a stroke. While in the hospital, he or she falls and requires hip surgery. The stroke (principal diagnosis) is unrelated to the hip surgery (principal procedure) because the two are classified in completely different body systems (i.e., nervous system vs. musculoskeletal system), explains Ericson. This is an example of an unrelated DRG that is triggered appropriately, she adds.

"The irony with this example, though, is that you have to look at the concept of HACs. You can't get reimbursed for the MCC associated with the hip fracture since the fracture wasn't POA … but you can still bill a surgical DRG, and it would go to DRG 983," says Ericson. "It's sort of a loophole. You get less money, but you're not really being punished to the fullest extent because you can still receive a surgical DRG, which is typically reimbursed at a higher rate compared to a medical DRG."

Coders can't rely on assumptions when determining whether a diagnosis and procedure are related. For example, a patient is admitted due to pneumonia. While in the hospital, he or she must undergo excisional debridement for an ulcer. Coders may assume that reporting the pneumonia with debridement would result in an unrelated DRG; however, this isn't the case.

"Because excisional debridement is in every body system within the DRG classification system, you won't go to an unrelated DRG even though it seems bizarre that excisional debridement would be related to a respiratory system condition," says Ericson.

Unrelated DRGs tend to occur more frequently in tertiary care centers or regional academic medical centers. "Sometimes, these centers have all of this technology available, and they can perform all of these exhaustive workups and may find other issues while the patient is in the hospital," says Ericson. These "other issues" can lead to operative procedures that may be unrelated to the principal diagnosis. However, any hospital can struggle with unrelated DRGs, which is why it's important to monitor data and take steps to improve compliance when appropriate, she adds.

Why they're a target

Normally, DRGs capture the resources associated with treatment for a particular nonsurgical disease. However, unrelated DRGs must account for unanticipated resources that require a patient to undergo an operative procedure for a condition that isn't related to the reason for admission, Gold explains. Therefore, these unrelated DRGs carry a much higher weight than their counterparts that include an operative procedure for the intended diagnosis. This higher weight makes them a target for the OIG as well as other auditors, he adds.

Correct assignment of the principal diagnosis is paramount. For example, a patient is admitted to the hospital due to pneumonia. While in the hospital, lab results reveal that the patient has a low red blood cell count. The red blood cells are pale and small, and the patient also has blood in his stool. After recovering from the pneumonia, the patient undergoes a colonoscopy that reveals colon cancer. The patient then undergoes a colon resection. In this case, even though the patient underwent a colon resection, the principal diagnosis is pneumonia-not colon cancer, says Gold.

"When there are two diagnoses that lead to treatment, you need to look at the circumstances of admission. It was the pneumonia that led to the admission. Nobody knew that the patient was anemic," he adds.

Some consulting companies incorrectly advise coders to do the opposite, says Gold. "There are a lot of companies that teach people to cheat," he says. "They say that if a patient comes to the hospital with two coprincipal diagnoses, one of which leads the patient to the operating room, coders should choose the other one as the principal diagnosis."

Coders should also pay close attention to assigning the principal procedure. Coding Clinic, Fourth Quarter 2012, p. 80, states that when a physician performs more than one procedure, coders should choose the procedure most closely related to the principal diagnosis as the principal procedure. For example, a patient presents to the hospital with severe headaches and is taken to the operating room for a biopsy that reveals the patient has brain cancer. Postoperatively, the patient has a significant rectal bleed from hemorrhoids and is taken to the operating room for ligation of bleeding hemorrhoids.

"You can't choose the brain cancer and ligation of the hemorrhoids because they're not related to each other. You choose the brain cancer and the brain biopsy. If you choose any other combination, you'll get an unrelated DRG," says Gold. Although there is no definitive guidance stating the reverse to be true (i.e., coders should choose the condition that most closely relates to the principal procedure as the principal diagnosis), logic indicates that this is likely the case, he says.

Beware of incidental findings when determining the principal diagnosis, says Gold. For example, a patient is admitted to the hospital for an open gallbladder surgery to remove gallstones. While in the hospital, she undergoes a urinalysis that is positive for a UTI. Coders may inappropriately select the incidental UTI finding as the principal diagnosis when, in fact, the patient has actually been admitted to the hospital for gallstones. Selecting the UTI will incorrectly result in an unrelated DRG, he adds.

A robust CDI program can help providers understand the importance of documenting the condition that prompted the admission, says Ericson. "A goal of CDI is to educate providers to document in such a way that all those who review the medical record will come to the same conclusion while retaining the intent of the provider," she adds.

Three-day rule

The three-day rule, which requires hospitals to include relevant outpatient services on the inpatient claim when they occur within 72 hours of admission or on the same day of admission, can certainly throw a monkey wrench into a hospital's compliance efforts, says Ericson. She says one of the most frequent reasons why hospitals incorrectly trigger unrelated DRGs is because their billing software automatically merges all outpatient charges into the inpatient claim when those charges occur within 72 hours of an inpatient admission.

To avoid this, coders should manually review claims to ensure that only the following information is included in the patient claim:

All outpatient services provided on the date of admission

Any outpatient diagnostic services provided within three days of admission that are related to the admission

Any nondiagnostic services that are clinically related to the admission

Questions to ask

Coders should ask the following two important questions when reviewing unrelated DRGs:

Did the patient have any outpatient procedures within three days that were bundled into the inpatient claim? If so, are they appropriate and related to the inpatient admission?

Does the diagnosis sequencing affect the DRG assignment? If the principal and major secondary diagnoses were reversed, would the case still trigger an unrelated DRG? Pay close attention to coequal conditions to ensure that they are truly coequal, Ericson says. This scenario should be rare, and coders should look at the circumstances of admission before selecting the principal diagnosis. "Unless there is an etiology/manifestation pair or something in the tabular list that specifies sequencing, you have to think about why the patient is being admitted," she adds. Two conditions that appear to be equal may not actually be equal if one of them required a surgical intervention.

Clarification

In the March issue, we stated that coders should assign code 768.5 or 768.6 as the principal diagnosis for a preterm infant born via cesarean section with severe birth asphyxia. Note that code 768.x identifies the infant's diagnosis status upon delivery. The actual principal diagnosis is code V30.01, which denotes the birth episode.

Get to know the ICD-10-PCS root operations

Mon, 01 Apr 2013 04:00:00 GMT

Get to know the ICD-10-PCS root operations

Editor's note: This is the second article in a two-part series about ICD-10-PCS root operations.

Experts say it's definitely not too early to start learning ICD-10-PCS. Kristi Stanton, RHIT, CCS, CPC, senior consultant at The Haugen Consulting Group in Denver, and Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, president of Safian Communications Services, Inc., in Orlando, provide insight into several root operations below to help coders get started:

Fragmentation: This denotes breaking solid matter in a body part into pieces. Lithotripsy fits this definition because it's most often performed to break up calculi in the kidney or other places in the body, says Safian.

Note that fragmentation doesn't include the removal of any solid matter. If a physician performs lithotripsy and a basket extraction to remove the stone fragments, coders can report the basket extraction separately as an extirpation, says Stanton.

Fusion: This includes procedures designed to join together portions of an articular body part, rendering it immobile. It involves taking "two anatomical sites that were created to fit together to enable motion and fuse them so that motion is denied," explains Safian. Examples include spinal and joint fusions as well as arthrodesis.

Keep in mind that for spinal fusion procedures, the fusion is typically only one part of the procedure, says Stanton. The physician may also decompress nerves and remove pieces of bone, which require separate codes.

When a physician uses a device (e.g., an internal fixation device) with the fusion, coders must ensure that the sixth character in the PCS code reflects this information. Note that the PCS guidelines include very detailed instructions regarding fusion procedures of the spine.

Insertion: This denotes putting in a nonbiological device that monitors, assists, performs, or prevents a physiological function but doesn't physically take the place of a body part. Examples include insertion of a pacemaker or vascular access device. It doesn't include administration of blood products because those aren't devices and they can't be later removed from the body, says Stanton.

Don't be tempted to report insertion just because documentation states insertion of Foley catheter. "Physicians won't document 'drainage of the bladder with a Foley catheter,' " says Stanton. "That's something the coder will need to interpret. You really have to go back and say, 'What is the purpose of the procedure?' "

Inspection: This includes procedures designed to visually and/or manually explore a body part. Examples include diagnostic laparoscopy, exploratory laparotomy, and diagnostic arthroscopy. Note that surgeons may perform some inspections with another procedure. The PCS guidelines state that coders should separately report the inspection procedure when a surgeon performs it on the same body part and during the same episode but using a different approach than the other procedure. For example, a physician performs an inspection of the bladder through a scope followed by an open procedure to remove the gallbladder. Coders should report an inspection with a percutaneous endoscopic approach (for the laparoscopy) and a resection using an open approach (for the gallbladder removal), says Stanton.

Map: This denotes tracking electrical impulses and/or locating functional areas in the body. It includes cortical mapping of the brain and cardiac mapping to target heart arrhythmias and the functioning of the heart's conduction system. Note that for EKGs, coders should report the root operation measurement and monitoring, says Safian.

Occlusion: This denotes completely closing a natural or artificially created orifice or the lumen of a tubular body part. Examples include tubal ligation (blocking the fallopian tubes) or uterine artery embolization, during which a physician inserts embolization coils into the branches of the uterine artery to block them so the blood vessels stop feeding uterine fibroids, explains Stanton.

Note that the term occlusion may be used to diagnose a patient (e.g., occluded veins), but it won't be the root operation for the procedure performed to address the problem, says Safian. "It's very likely that a patient with occluded veins would have an angioplasty," she says.

Reattachment: This includes procedures designed to put back in or on all or a portion of a separated body part to its normal location or another suitable location. Examples include reattachment of hand or finger. Don't confuse this root operation with reposition, says Stanton. Reattachment involves putting a separated body part back, whereas reposition involves simply moving it.

Release: This includes procedures meant to free a body part. Examples include carpal tunnel release and lysis of adhesions. When a physician performs lysis of adhesions, coders need to know what body part is being released, says Stanton. "A lot of times, the physician will say that he or she lysed adhesions in the abdominal cavity, and we don't know if he or she lysed the intestines, the ureter, the uterus, or an ovary," she adds.

Don't confuse release with division, says Stanton. "Release is cutting around a body part to free it. Division is cutting into a body part to make it bigger or to divide it," she says. An example of division is Achilles tendon lengthening to prevent contractions.

Also don't confuse release with resection. Resection involves actually removing a body part, says Safian.

Removal: This denotes taking out or off a device from a body part. Examples include pacemaker removal or drainage tube removal.

Don't confuse removal with replacement, says Stanton. For example, a physician takes out a pacemaker generator to put in a new battery and then reinserts it into the patient. "Today, we call this a replacement," she says. "However, in PCS, replacement means replacing a body part with a biological or synthetic material-not replacing a device with another device. So in order to code a pacemaker change, you need to code a removal and then an insertion of a new device." The root operation change is used for switching out the same exact device without making a puncture or incision (e.g., changing a gastrostomy tube).

Repair: This denotes restoring a body part to its normal anatomic structure and function. Examples include suture of laceration or herniorrhaphy. "When you see this term in physicians' notes, you can't take it at face value," says Safian. "Technically, any therapeutic procedure is there to fix or repair. Make sure that this is the most specific root operation to explain what the physician did."

Replacement: This denotes putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part. Examples include total hip replacement and free skin graft.

Reposition: This includes procedures designed to move all or a portion of a body part to its normal location from either an abnormal location or a normal location where it isn't functioning properly. A physician may or may not cut the body part out or off to move it. Examples include fracture reduction and reposition of undescended testicle. Another example is parathyroid implantation. "A lot of times when a physician performs a thyroidectomy, the parathyroid glands are stuck to the thyroid glands," says Stanton. "If the physician removes the thyroid glands, the patient will die of severe calcium deficiency. So they'll take out the thyroid, test the tissue to make sure it's still functioning, and then reimplant it, usually in the sternocleidomastoid muscle, and it will continue to function and produce calcium."

Resection: This includes procedures designed to cut out or off all of a body part without replacing it. Resection can be compared with excision, which involves removing (and not replacing) a portion of a body part, says Safian.

Note that physicians may document resection when it's actually an excision in terms of coding a root operation, says Stanton. For example, a physician may document wedge resection of the lung; however, this procedure involves removing only a portion of the lung tissue-not the entire lung or lobe of the lung.

Also note that PCS defines body parts. "If it has a body part value, then it's considered a body part," says Stanton. For example, when a physician removes the right lobe of the lung, this is a resection, not an excision, because PCS considers each lung lobe as a separate body part.

Restriction: This denotes partially closing a natural or artificially created orifice or the lumen of a tubular body part. Note this differs from occlusion (total closing), says Safian.

Examples include esophagogastric fundoplication and cervical cerclage. This root operation also includes aneurysm repairs when a surgeon slows-but doesn't cease-blood flow, says Stanton.

Revision: This denotes correcting a malfunctioning or displaced device. Examples include adjusting a pacemaker lead or hip prosthesis as well as fixing a valve on a ventricular peritoneal shunt. This root operation pertains only to devices-not anatomical sites, says Safian.

Supplement: This denotes putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part. Examples include hernia repair with mesh. Note that when the hernia repair is performed without mesh, you should report the root operation repair, says Stanton.

Transfer: This denotes moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part. Examples include skin pedicle flap transfer and tendon transfer. Don't confuse this root operation with reattachment, says Stanton. Transfer involves not only moving a body part but also taking over the function of a body part. Reattachment simply involves putting a separated body part back in or on its normal location or another suitable location. "The entire root operation definition must apply to the procedure," she says. "If any part of it isn't true, then you can't use that root operation."

Transplantation: This denotes putting in or on all or a portion of a body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part. Examples include kidney transplant and heart transplant. "The only transplant that doesn't belong here is bone marrow because that's actually infused," says Stanton. "It would code as an infusion, which is not one of the root operations in the medical and surgical section. It's in the administration section."

Condition code 44: How coders and billers can help ensure compliance

Mon, 01 Apr 2013 04:00:00 GMT

Condition code 44: How coders and billers can help ensure compliance

Although coders and billers don't play a role in determining whether condition code 44 is appropriate, they most certainly ensure correct billing of the code.

Coders report condition code 44 only on outpatient claims when a physician who orders inpatient services later determines upon internal review that those services don't meet inpatient criteria. Reporting condition code 44 allows hospitals to receive payment for the medically necessary Part B services that were ordered and provided to the patient. These services can potentially include the following:

Surgical procedures

Implants/devices

Injections and infusion therapy

Rehabilitation therapy

ED services

Surgical dressings

Note that this list excludes observation services. "Observation care was not ordered from the very beginning, so consequently, even though a nursing equivalent of the service was provided, we're not entitled to be reimbursed for that observation care," says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla.

Condition code 44 and short stays

The creation of condition code 44 prompted Quality Improvement Organizations to review one-day stays to ensure that documentation supports the medical necessity of the admission, says John Zelem, MD, FACS, executive medical director of client relations and education at Executive Health Resources in Newtown Square, Pa. "PEPPER became a data tool that was utilized for all acute care hospitals to determine their areas of risk," he says.

Eventually, Recovery Auditors (RA) began to focus on medical necessity for one-day stays. Today, MACs also perform prepayment reviews/denials on short stays. This intense regulatory environment has propelled many hospitals to take a closer look at medical necessity as well as condition code 44 compliance, adds Zelem.

Some cases are clearly appropriate for the inpatient setting (e.g., acute myocardial infarction, acute intracranial bleed, and valve transplant). Other cases are clearly appropriate for the outpatient setting (e.g., chemotherapy, inner ear infection, and dilation and curettage). Cases that aren't so clear include those that require individual assessment due to unclear medical necessity (e.g., chest pain, anemia, and dehydration).

"This gray area is growing every single year for different reasons," says Zelem. "What's the determining factor [for ensuring valid admissions]? Medical necessity."

Medical necessity-something that only a physician can determine using complex medical judgment-should be clearly documented in the record. This includes the patient's level of risk, severity of signs and symptoms, medical predictability of an adverse outcome, and the need for diagnostic studies.

Such documentation is particularly important for short stays, says Zelem. "Patients may come in and get well very quickly, but they still present with high risk," he says. "Part of the reason why they get better quickly is because of the sophistication of the care we're able to deliver to them."

Even inpatient-only procedures aren't exempt from RA and other denials, says Zelem. These denials can occur for one of the following reasons:

The RA didn't realize the procedure was on the inpatient-only list

The hospital thought the procedure was on the inpatient-only list, and it wasn't

The documentation doesn't support an inpatient level of care

"You can't just rest on the laurels of the inpatient-only list as a sole indication for billing the case as an inpatient," says Zelem. "[Physicians] must talk about the procedure, the complications of the procedure, and the comorbidities of the patient."

What coders and billers need to know

To report condition code 44, hospitals must ensure that the following criteria are met:

The inpatient admission meets admission criteria

The physician responsible for the care of the patient agrees with the decision to change the patient's status to outpatient

The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still an inpatient in the hospital and has been notified of the change

The hospital has not submitted a claim to Medicare for the inpatient admission

An attending physician concurs with the utilization review (UR) committee's decision

The physician's concurrence is documented in the patient's medical record

The decision to change a patient's status from inpatient to outpatient is one that only a UR committee physician can make in conjunction with the physician who is responsible for the care of the patient, says Hale. The physician must concur with the committee and document his or her decision in the patient's medical record for coders to be able to report condition code 44.

If these criteria are not met, condition code 44 cannot be reported. Instead, the hospital must submit a no-pay bill followed by a 12x bill type only for certain covered Part B services that were furnished to the patient, says Hale. For example, this can occur when the attending/admitting physician refuses to change the patient's status from inpatient to outpatient even though a UR physician has determined that the admission is unnecessary.

When all criteria are met, coders and billers should treat the entire episode of care as though the inpatient admission never occurred. Instead, they should bill it as an outpatient episode of care, says Hale. They should report condition code 44 on the outpatient claim (13x or 85x bill type) in one of form locators 24-30 with qualifier BG.

Be careful when reporting observation services for cases that involve condition code 44. The cost for nursing services provided prior to the decision to switch the inpatient order to outpatient can be captured by billing those hours using revenue code 762. Hospitals are not permitted to report G0378 on the line item with this revenue code.

However, if a physician determines that a patient continues to require observation services after his or her status is switched from inpatient to outpatient, the physician can write an order for observation at that time.

"We can start counting observation hours after the physician's order is written, and we continue to count all the way through the completion of the observation service," says Hale. In this case, coders and billers report revenue code 762 and G0378 on the same line item along with the total number of observation hours provided.

"The G0378 code generates the composite APC payment when all requirements are met," says Hale.

Open the lines of communication

The best way to ensure condition code 44 compliance is to open the lines of communication with case managers. These individuals provide crucial information that coders and billers need to report condition code 44 appropriately, says Hale.

"One of the problems that I often see is that perhaps case management, UR committee, and physicians' advisor gets their parts right, but they forget to notify the hospital coding and billing offices," she says. "Consequently, the claim goes out as an inpatient claim as it was initially ordered. So we have to make sure that when we're auditing this process, we're working through the entire revenue cycle."

The content in this article was originally presented during HCPro's audio conference "Condition Code 44: Best Practices for a Compliant Process." For more information, visit http://tinyurl.com/bgrkxgy.

For more information about condition code 44, view Transmittal 299, available for download at http://tinyurl.com/akmcsla.

Plan for the worst, hope for the best

Mon, 01 Apr 2013 04:00:00 GMT

Plan for the worst, hope for the best

When Lori Belanger, RN, BSN, RHIT, inpatient coder and CDI specialist at Northern Maine Medical Center in Fort Kent, Maine, began to practice coding charts using ICD-10-CM/PCS, she was a bit surprised by how much her productivity decreased.

Today, using ICD-9-CM codes, she can code three to five inpatient records per hour. When using ICD-10 codes, that number dropped to one record per hour. She says many of the diagnoses that she captured using ICD-10 mapped to nonspecific codes.

Belanger, who handles all of the inpatient coding (and queries) and serves as the sole CDI specialist for the 50-bed facility, says she fears this decrease in productivity will make it nearly impossible for her to perform both functions in 2014 and beyond.

"I know I'm never going to be able to keep up by myself," she says. "One of the biggest reasons is going to be the documentation."

Before creating a formal CDI process, Belanger queried physicians approximately 30 times per month. She has since lowered that number to approximately six per month, although she says the volume of queries will likely increase until physicians begin to document to the degree of specificity that ICD-10 requires.

Run the numbers, start making plans

Experts agree that coder productivity will decline once ICD-10 goes into effect. But by how much?

"Our Canadian counterparts experienced a 50% decrease in production when they went live with ICD-10," says Cheryl Robbins, RHIT, CCS, director of remote coding operations at Precyse Solutions in Alpharetta, Ga. "Over a period of three years after that, they only recovered approximately 20% of that." This means that coding productivity in Canada is only 70% of what it used to be pre-ICD-10, she adds.

Comparing ourselves with Canada is helpful because of the similarities in terms of coder skill sets and the level of complexity of the data collected, says Robbins. "The Canadians are not coding for payment as we are here in the States, but they are still coding to the same level of data collection," she says.

Some coders' productivity may decline and never come close to rebounding, notes Robbins. "Even if someone has been trained, some people may just not grasp the nomenclature," she says. Coding managers must anticipate these situations and determine how they can be prevented with additional training, she adds.

"I think it's always prudent to plan for the worst and be pleased and relieved to find that the thorough planning avoided the worst from happening," says Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer at First Class Solutions, Inc., in Maryland Heights, Mo.

Getting a gauge on productivity in ICD-10 requires coding managers to have a solid understanding of coders' current productivity levels in ICD-9-CM, says Dunn. This includes knowing how many records per hour a coder codes on average for each record type.

If coding managers don't already capture this information, they should plan to do so by October 1, 2013, says Dunn. "Productivity should be measured and captured at least quarterly and preferably monthly," she says. "I'd also suggest capturing the case-mix index on the same interval. This will provide the baseline data for management to assess the impact of ICD-10."

Once a baseline has been established, dual coding can help coding managers get a sense of how ICD-10 may affect productivity. Ideally, contract coders would perform ICD-9-CM coding four to six weeks prior to October 1, 2014, so full-time coders can concentrate on dual coding in ICD-10, says Dunn. "This way, management will be able to assess whether there has been any progress on the learning curve," she says.

Keep CFOs well aware of any anticipated productivity declines, says Robbins. "CFOs may be expecting a production hit for a small amount of time, and then they'll expect people to be right back to where we are with ICD-9," she adds. "That's not going to happen. It will take months or even a year to get back to 70%. There needs to be a lot of frank discussions."

Strategies for success

Experts agree planning ahead can help offset productivity losses. Consider the following ways to mitigate these losses and prepare for a smoother transition to ICD-10:

Make CDI a priority. "Without a CDI program in place, there's absolutely no way that coders are going to be able to keep up," says Belanger. Not only does Belanger publish a monthly CDI newsletter for staff members, but she also attends daily interdisciplinary team meetings. "If there is something missing, that's the time to mention it to the doctor," she says. Physicians attend these meetings, but so do nurses, nutritionists, occupational therapists, physical therapists, pharmacy technicians, social services, and respiratory therapists. As she provides education regarding documentation requirements, all team members overhear this information.

Consider cross-training. Cross-training inpatient and outpatient coders can help offset losses. At Northern Maine Medical Center, all coders, including outpatient coders, will be cross-trained in ICD-10 diagnosis and procedure coding.

Consider contract labor, including overseas coding firms. "I know that there is a still a significant amount of angst in terms of using overseas firms to code, but there will likely be a shortage of coders when we go live on October 1, 2014, and this may be a viable option," says Robbins. "Our overseas coding counterparts have already had experience with coding ICD-10 in other countries, and they are very skilled. Many of them are CCS-credentialed from AHIMA."

It's never too early to reach out to contract companies, says Robbins. She says Precyse began to receive requests last year for coverage beginning in October 2014.

Don't let the ICD-10 delay hinder your preparations. "I would like to see folks become more aggressive and start addressing their productivity now instead of waiting until January 1 of next year and then coming to us or another company in absolute panic because they realize they're not going to have enough coders," says Robbins.

Forge ahead with coder training. Facilities must be aggressive with training even despite the ICD-10 delay to 2014, says Robbins. "Those of us who have gone through the AHIMA ICD-10 training would all likely concur that there's no such thing as too much education when it comes to ICD-10."

Take a closer look at the tasks coders perform. "We find that a lot of facilities require lead coders to work edits and other information that comes back from the business office," says Robbins. "This is a drain on productivity, and it takes them away from actively coding."

A coding assistant or coding liaison can often handle these tasks so coders can focus on production. Although many coding managers and HIM directors may feel pressured to downsize the HIM department after the implementation of an EHR, adding an assistant or liaison position is well worth it in the long run, says Robbins. "Hospitals need to be focusing on the coder and what can be done to keep the DNFB down," she says. "You can easily justify these [clerical] positions when you quantify the downstream impact of a $40,000 a year, highly-skilled technician versus several million dollars a day holding in your discharge not final billed."

Also look closely at the level of abstracting that coders perform to avoid duplication. "Make sure that what the coder is capturing in the abstract process isn't already being captured somewhere else so that the coder can stay focused on those pieces of information that are absolutely critical to drop that bill," says Robbins.

Identify whether environmental issues may be a factor. A challenging work environment may have even more of a detrimental effect on coders in 2014, says Dunn. For example, are coders constantly interrupted? Does the environment include a lot of auditory or other distractions? Do all coders have an equal mix of difficult and more straightforward cases? Is Internet connectivity slow or unreliable? Take steps now to address these questions and to ensure a quiet and equitable environment for all coders, adds Dunn.

Consider computer-assisted coding (CAC). Although many hospitals currently use CAC for certain high-volume outpatient services (e.g., radiology and lab reports), inpatient coders may find it helpful as well, says Robbins. "There's still not a lot of comfort using CAC in the inpatient realm, but it's coming, and it's coming quickly," she says.

However, CAC will only be as helpful as the existing documentation, says Dunn. "If the documentation isn't there, the CAC won't be able to help," she adds.

ICD-9-CM codes for PEGJ and cardiorenal syndrome require physician input

Mon, 01 Apr 2013 04:00:00 GMT

ICD-9-CM codes for PEGJ and cardiorenal syndrome require physician input

by Robert S. Gold, MD

Editor's note : This is the first in a two-part series.

Once upon a time, hospitals were paid on a variety of bases, none of which directly related to ICD-9-CM code assignment. These included per diem payments as well as payments based on portions of charges, allowable fees, or a percentage of fees. When the federal government created the IPPS in 1983, Medicare payment methodology shifted from a fee-for-service model to a fixed fee model driven by ICD-9-CM codes.

Cooperating Parties

The four Cooperating Parties (CMS, the National Center for Health Statistics [NCHS], AHA, and AHIMA) began to coordinate and maintain the code sets in the United States. The NCHS oversaw diagnosis ICD code assignment and classification, and CMS assumed responsibility for the procedure codes. AHIMA (which was known as the American Medical Record Association until 1991) took on the task of educating coding professionals about the assignment of ICD codes. The AHA created Coding Clinic to provide clarification on hospital inpatient and outpatient coding. CMS (formerly known as the Health Care Financial Administration) oversaw DRGs.

All four of these organizations began to meet periodically to develop and approve the ICD Official Guidelines for Coding and Reporting that coders use to supplement the definitions and terms provided in the ICD index. Although each of the four parties included physician advisors, the advisors' advice was generally based on their own individual experiences-not sound research and evidence regarding the coding hierarchy.

At the inception of the DRG system, medical record librarians were responsible for assigning ICD codes based on what was often very inadequate physician documentation. Physicians had very little interest in these codes and what they meant in terms of hospital reimbursement. As coding rules and advice were created and then became engraved in stone over time, nobody questioned the validity of the advice, much of which was determined by nonclinical professionals. I commend coding professionals for the work they've done; however, I'm here to say that it's time to question the validity of coding advice.

Percutaneous endoscopic gastrojejunostomy

In 2005, I evaluated a series of records at a large hospital regarding the validity of what was then DRG 468 (major surgery for other than the admitting diagnosis). Many of these DRGs involved a principal diagnosis of stroke, late effects of stroke, failure to thrive, or malnutrition. The operating room procedure was percutaneous endoscopic gastrojejunostomy (PEGJ).

As a general surgeon, I wasn't completely familiar with this procedure. I did know that it involved patients who had previously undergone the insertion of a percutaneous endoscopic gastrostomy (PEG) tube through the abdominal wall. An endoscopist then placed the tube and its balloon within the stomach. At a later date, an endoscopist inserted another tube through the existing PEG and repositioned the tube end into the jejunum in patients who were at high risk of recurrent regurgitation and aspiration.

I checked my coding resources and saw that the code for a PEGJ (44.39) was in the same group as other gastroenterostomies, all of which were major operating room procedures. To my surprise, Coding Clinic advised coders to report code 44.39 for this procedure as well. Coding Clinic, First Quarter 2001, pp. 16 and 17 both describe the conversion of a gastrostomy feeding tube to a jejunostomy feeding tube. Both references instruct coders to report 44.39. However, I knew that a PEGJ was not a gastroenterostomy at all; it was merely a repositioning of a feeding tube. Insertion of any feeding tube was, and still is, a non-operating room procedure.

I contacted Coding Clinic and expressed my observation that a PEGJ tube was merely a type of feeding tube and that repositioning such a tube wasn't a major operating room procedure. Coding Clinic convened its advisory board, which ultimately decided to retain its guidance regarding 44.39. Paying for a major operating room procedure placed a significant unnecessary burden on the Medicare system.

It wasn't until four years later-when I discovered a true percutaneous endoscopic anastomosis of stomach and jejunum had been investigated in Europe-that I approached CMS with information that physicians hadn't ever performed gastrojejunostomy using laparoscopic-assisted endoscopy on human beings in the United States. In response, a new code (46.32) for PEGJ was created. Coding Clinic, Third Quarter 2010, p. 13 modifies the AHA's original advice to state that coders should report 46.32 for conversion of a PEG to a feeding jejunostomy. Sadly, I suspect some coders continue to report 44.39 when the physician documents performance of a PEGJ.

Cardiorenal syndrome

Code 404.90 denotes cardiorenal syndrome. This code states that the condition is without heart failure and with chronic kidney disease (CKD) stage I through IV or unspecified. As such, one may presume that cardiorenal syndrome is always due to hypertension. However, this isn't true. The heart disease associated with cardiorenal syndrome can be also be due to ischemic heart disease, alcoholic heart disease, amyloid heart disease, or any origin of heart disease. The renal disease of cardiorenal syndrome can be due to diabetes, obstruction, rhabdomyolysis, lupus nephritis, or any origin of renal disease.

Both heart disease and renal disease can occur due to hypertension; however, it's incorrect to assume that this is always the case. Coding rules state that renal disease (CKD) is automatically linked to hypertension without other specification. These rules also state that heart failure is never automatically linked to hypertension. Thus, how can cardiorenal syndrome automatically denote that the heart disease is hypertensive?

Cardiorenal syndrome is classified by type. Acute decompensation of heart failure may have an adverse effect on renal function. Acute decompensation of renal failure may also have an adverse effect on heart function. Worsening chronic heart failure can worsen renal function, and worsening CKD can worsen heart failure. The current ICD-9-CM classification completely ignores these facts.

Cardiorenal syndrome should identify any chronic heart disease and its cause as well as any CKD and its cause. The syndrome should also identify any acute decompensation of chronic heart disease and/or CKD as well as their cause(s). Code 404 shouldn't be associated with cardiorenal syndrome unless the physician documents the involvement of hypertension for both entities.

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.

Briefings on Coding Compliance Strategies, April 2013

Mon, 01 Apr 2013 04:00:00 GMT

Use caution when reporting unrelated DRGs

DRGs for procedures unrelated to the principal diagnosis shouldn't occur frequently. If they do, coding managers should take a closer look at coding compliance efforts to ensure accuracy and avoid costly audits.

Unrelated DRGs, as they're more succinctly known, include the following:

981-983 (extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

984-986 (prostatic operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

987-989 (non-extensive operating room procedure unrelated to principal diagnosis with MCC, with CC, and without CC/MCC, respectively)

"Avoid these DRGs when possible, but you have to realize that there are certain circumstances when they're right, and you don't try to avoid them when they're right," says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director at HCPro, Inc., in Danvers, Mass., agrees. "It's not that you're never going to have these cases, it's just that you should always be diligent in verifying that it's an accurate DRG assignment," she says.

Gold recently performed an analysis of 2012 MedPAR data and found that approximately 2.27% of all national surgical DRGs reported are those for which the principal diagnosis is unrelated to the operating room procedure.

"If your hospital is reporting considerably more than 2.27%, then you're probably going to be a Recovery Auditor target," says Gold. He says he's aware of one hospital at which 80% of its surgical DRGs were unrelated DRGs. "They were at risk for tens of millions of dollars in fines over the last seven years," he adds.

How they're triggered

Unrelated DRGs essentially occur when a patient presents to the hospital with one diagnosis and needs surgery for a different diagnosis. Sounds simple, right?

Not quite. Keep in mind that unrelated DRGs are technically only triggered when the surgical procedure and principal diagnosis aren't classified in the same major diagnostic category or body system within the DRG classification system, says Ericson.

For example, a patient is admitted to the hospital due to a stroke. While in the hospital, he or she falls and requires hip surgery. The stroke (principal diagnosis) is unrelated to the hip surgery (principal procedure) because the two are classified in completely different body systems (i.e., nervous system vs. musculoskeletal system), explains Ericson. This is an example of an unrelated DRG that is triggered appropriately, she adds.

"The irony with this example, though, is that you have to look at the concept of HACs. You can't get reimbursed for the MCC associated with the hip fracture since the fracture wasn't POA … but you can still bill a surgical DRG, and it would go to DRG 983," says Ericson. "It's sort of a loophole. You get less money, but you're not really being punished to the fullest extent because you can still receive a surgical DRG, which is typically reimbursed at a higher rate compared to a medical DRG."

Coders can't rely on assumptions when determining whether a diagnosis and procedure are related. For example, a patient is admitted due to pneumonia. While in the hospital, he or she must undergo excisional debridement for an ulcer. Coders may assume that reporting the pneumonia with debridement would result in an unrelated DRG; however, this isn't the case.

"Because excisional debridement is in every body system within the DRG classification system, you won't go to an unrelated DRG even though it seems bizarre that excisional debridement would be related to a respiratory system condition," says Ericson.

Unrelated DRGs tend to occur more frequently in tertiary care centers or regional academic medical centers. "Sometimes, these centers have all of this technology available, and they can perform all of these exhaustive workups and may find other issues while the patient is in the hospital," says Ericson. These "other issues" can lead to operative procedures that may be unrelated to the principal diagnosis. However, any hospital can struggle with unrelated DRGs, which is why it's important to monitor data and take steps to improve compliance when appropriate, she adds.

Why they're a target

Normally, DRGs capture the resources associated with treatment for a particular nonsurgical disease. However, unrelated DRGs must account for unanticipated resources that require a patient to undergo an operative procedure for a condition that isn't related to the reason for admission, Gold explains. Therefore, these unrelated DRGs carry a much higher weight than their counterparts that include an operative procedure for the intended diagnosis. This higher weight makes them a target for the OIG as well as other auditors, he adds.

Correct assignment of the principal diagnosis is paramount. For example, a patient is admitted to the hospital due to pneumonia. While in the hospital, lab results reveal that the patient has a low red blood cell count. The red blood cells are pale and small, and the patient also has blood in his stool. After recovering from the pneumonia, the patient undergoes a colonoscopy that reveals colon cancer. The patient then undergoes a colon resection. In this case, even though the patient underwent a colon resection, the principal diagnosis is pneumonia-not colon cancer, says Gold.

"When there are two diagnoses that lead to treatment, you need to look at the circumstances of admission. It was the pneumonia that led to the admission. Nobody knew that the patient was anemic," he adds.

Some consulting companies incorrectly advise coders to do the opposite, says Gold. "There are a lot of companies that teach people to cheat," he says. "They say that if a patient comes to the hospital with two coprincipal diagnoses, one of which leads the patient to the operating room, coders should choose the other one as the principal diagnosis."

Coders should also pay close attention to assigning the principal procedure. Coding Clinic, Fourth Quarter 2012, p. 80, states that when a physician performs more than one procedure, coders should choose the procedure most closely related to the principal diagnosis as the principal procedure. For example, a patient presents to the hospital with severe headaches and is taken to the operating room for a biopsy that reveals the patient has brain cancer. Postoperatively, the patient has a significant rectal bleed from hemorrhoids and is taken to the operating room for ligation of bleeding hemorrhoids.

"You can't choose the brain cancer and ligation of the hemorrhoids because they're not related to each other. You choose the brain cancer and the brain biopsy. If you choose any other combination, you'll get an unrelated DRG," says Gold. Although there is no definitive guidance stating the reverse to be true (i.e., coders should choose the condition that most closely relates to the principal procedure as the principal diagnosis), logic indicates that this is likely the case, he says.

Beware of incidental findings when determining the principal diagnosis, says Gold. For example, a patient is admitted to the hospital for an open gallbladder surgery to remove gallstones. While in the hospital, she undergoes a urinalysis that is positive for a UTI. Coders may inappropriately select the incidental UTI finding as the principal diagnosis when, in fact, the patient has actually been admitted to the hospital for gallstones. Selecting the UTI will incorrectly result in an unrelated DRG, he adds.

A robust CDI program can help providers understand the importance of documenting the condition that prompted the admission, says Ericson. "A goal of CDI is to educate providers to document in such a way that all those who review the medical record will come to the same conclusion while retaining the intent of the provider," she adds.

Three-day rule

The three-day rule, which requires hospitals to include relevant outpatient services on the inpatient claim when they occur within 72 hours of admission or on the same day of admission, can certainly throw a monkey wrench into a hospital's compliance efforts, says Ericson. She says one of the most frequent reasons why hospitals incorrectly trigger unrelated DRGs is because their billing software automatically merges all outpatient charges into the inpatient claim when those charges occur within 72 hours of an inpatient admission.

To avoid this, coders should manually review claims to ensure that only the following information is included in the patient claim:

All outpatient services provided on the date of admission

Any outpatient diagnostic services provided within three days of admission that are related to the admission

Any nondiagnostic services that are clinically related to the admission

Questions to ask

Coders should ask the following two important questions when reviewing unrelated DRGs:

Did the patient have any outpatient procedures within three days that were bundled into the inpatient claim? If so, are they appropriate and related to the inpatient admission?

Does the diagnosis sequencing affect the DRG assignment? If the principal and major secondary diagnoses were reversed, would the case still trigger an unrelated DRG? Pay close attention to coequal conditions to ensure that they are truly coequal, Ericson says. This scenario should be rare, and coders should look at the circumstances of admission before selecting the principal diagnosis. "Unless there is an etiology/manifestation pair or something in the tabular list that specifies sequencing, you have to think about why the patient is being admitted," she adds. Two conditions that appear to be equal may not actually be equal if one of them required a surgical intervention.

Clarification

In the March issue, we stated that coders should assign code 768.5 or 768.6 as the principal diagnosis for a preterm infant born via cesarean section with severe birth asphyxia. Note that code 768.x identifies the infant's diagnosis status upon delivery. The actual principal diagnosis is code V30.01, which denotes the birth episode.

Get to know the ICD-10-PCS root operations

Editor's note: This is the second article in a two-part series about ICD-10-PCS root operations.

Experts say it's definitely not too early to start learning ICD-10-PCS. Kristi Stanton, RHIT, CCS, CPC, senior consultant at The Haugen Consulting Group in Denver, and Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, president of Safian Communications Services, Inc., in Orlando, provide insight into several root operations below to help coders get started:

Fragmentation: This denotes breaking solid matter in a body part into pieces. Lithotripsy fits this definition because it's most often performed to break up calculi in the kidney or other places in the body, says Safian.

Note that fragmentation doesn't include the removal of any solid matter. If a physician performs lithotripsy and a basket extraction to remove the stone fragments, coders can report the basket extraction separately as an extirpation, says Stanton.

Fusion: This includes procedures designed to join together portions of an articular body part, rendering it immobile. It involves taking "two anatomical sites that were created to fit together to enable motion and fuse them so that motion is denied," explains Safian. Examples include spinal and joint fusions as well as arthrodesis.

Keep in mind that for spinal fusion procedures, the fusion is typically only one part of the procedure, says Stanton. The physician may also decompress nerves and remove pieces of bone, which require separate codes.

When a physician uses a device (e.g., an internal fixation device) with the fusion, coders must ensure that the sixth character in the PCS code reflects this information. Note that the PCS guidelines include very detailed instructions regarding fusion procedures of the spine.

Insertion: This denotes putting in a nonbiological device that monitors, assists, performs, or prevents a physiological function but doesn't physically take the place of a body part. Examples include insertion of a pacemaker or vascular access device. It doesn't include administration of blood products because those aren't devices and they can't be later removed from the body, says Stanton.

Don't be tempted to report insertion just because documentation states insertion of Foley catheter. "Physicians won't document 'drainage of the bladder with a Foley catheter,' " says Stanton. "That's something the coder will need to interpret. You really have to go back and say, 'What is the purpose of the procedure?' "

Inspection: This includes procedures designed to visually and/or manually explore a body part. Examples include diagnostic laparoscopy, exploratory laparotomy, and diagnostic arthroscopy. Note that surgeons may perform some inspections with another procedure. The PCS guidelines state that coders should separately report the inspection procedure when a surgeon performs it on the same body part and during the same episode but using a different approach than the other procedure. For example, a physician performs an inspection of the bladder through a scope followed by an open procedure to remove the gallbladder. Coders should report an inspection with a percutaneous endoscopic approach (for the laparoscopy) and a resection using an open approach (for the gallbladder removal), says Stanton.

Map: This denotes tracking electrical impulses and/or locating functional areas in the body. It includes cortical mapping of the brain and cardiac mapping to target heart arrhythmias and the functioning of the heart's conduction system. Note that for EKGs, coders should report the root operation measurement and monitoring, says Safian.

Occlusion: This denotes completely closing a natural or artificially created orifice or the lumen of a tubular body part. Examples include tubal ligation (blocking the fallopian tubes) or uterine artery embolization, during which a physician inserts embolization coils into the branches of the uterine artery to block them so the blood vessels stop feeding uterine fibroids, explains Stanton.

Note that the term occlusion may be used to diagnose a patient (e.g., occluded veins), but it won't be the root operation for the procedure performed to address the problem, says Safian. "It's very likely that a patient with occluded veins would have an angioplasty," she says.

Reattachment: This includes procedures designed to put back in or on all or a portion of a separated body part to its normal location or another suitable location. Examples include reattachment of hand or finger. Don't confuse this root operation with reposition, says Stanton. Reattachment involves putting a separated body part back, whereas reposition involves simply moving it.

Release: This includes procedures meant to free a body part. Examples include carpal tunnel release and lysis of adhesions. When a physician performs lysis of adhesions, coders need to know what body part is being released, says Stanton. "A lot of times, the physician will say that he or she lysed adhesions in the abdominal cavity, and we don't know if he or she lysed the intestines, the ureter, the uterus, or an ovary," she adds.

Don't confuse release with division, says Stanton. "Release is cutting around a body part to free it. Division is cutting into a body part to make it bigger or to divide it," she says. An example of division is Achilles tendon lengthening to prevent contractions.

Also don't confuse release with resection. Resection involves actually removing a body part, says Safian.

Removal: This denotes taking out or off a device from a body part. Examples include pacemaker removal or drainage tube removal.

Don't confuse removal with replacement, says Stanton. For example, a physician takes out a pacemaker generator to put in a new battery and then reinserts it into the patient. "Today, we call this a replacement," she says. "However, in PCS, replacement means replacing a body part with a biological or synthetic material-not replacing a device with another device. So in order to code a pacemaker change, you need to code a removal and then an insertion of a new device." The root operation change is used for switching out the same exact device without making a puncture or incision (e.g., changing a gastrostomy tube).

Repair: This denotes restoring a body part to its normal anatomic structure and function. Examples include suture of laceration or herniorrhaphy. "When you see this term in physicians' notes, you can't take it at face value," says Safian. "Technically, any therapeutic procedure is there to fix or repair. Make sure that this is the most specific root operation to explain what the physician did."

Replacement: This denotes putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part. Examples include total hip replacement and free skin graft.

Reposition: This includes procedures designed to move all or a portion of a body part to its normal location from either an abnormal location or a normal location where it isn't functioning properly. A physician may or may not cut the body part out or off to move it. Examples include fracture reduction and reposition of undescended testicle. Another example is parathyroid implantation. "A lot of times when a physician performs a thyroidectomy, the parathyroid glands are stuck to the thyroid glands," says Stanton. "If the physician removes the thyroid glands, the patient will die of severe calcium deficiency. So they'll take out the thyroid, test the tissue to make sure it's still functioning, and then reimplant it, usually in the sternocleidomastoid muscle, and it will continue to function and produce calcium."

Resection: This includes procedures designed to cut out or off all of a body part without replacing it. Resection can be compared with excision, which involves removing (and not replacing) a portion of a body part, says Safian.

Note that physicians may document resection when it's actually an excision in terms of coding a root operation, says Stanton. For example, a physician may document wedge resection of the lung; however, this procedure involves removing only a portion of the lung tissue-not the entire lung or lobe of the lung.

Also note that PCS defines body parts. "If it has a body part value, then it's considered a body part," says Stanton. For example, when a physician removes the right lobe of the lung, this is a resection, not an excision, because PCS considers each lung lobe as a separate body part.

Restriction: This denotes partially closing a natural or artificially created orifice or the lumen of a tubular body part. Note this differs from occlusion (total closing), says Safian.

Examples include esophagogastric fundoplication and cervical cerclage. This root operation also includes aneurysm repairs when a surgeon slows-but doesn't cease-blood flow, says Stanton.

Revision: This denotes correcting a malfunctioning or displaced device. Examples include adjusting a pacemaker lead or hip prosthesis as well as fixing a valve on a ventricular peritoneal shunt. This root operation pertains only to devices-not anatomical sites, says Safian.

Supplement: This denotes putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part. Examples include hernia repair with mesh. Note that when the hernia repair is performed without mesh, you should report the root operation repair, says Stanton.

Transfer: This denotes moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part. Examples include skin pedicle flap transfer and tendon transfer. Don't confuse this root operation with reattachment, says Stanton. Transfer involves not only moving a body part but also taking over the function of a body part. Reattachment simply involves putting a separated body part back in or on its normal location or another suitable location. "The entire root operation definition must apply to the procedure," she says. "If any part of it isn't true, then you can't use that root operation."

Transplantation: This denotes putting in or on all or a portion of a body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part. Examples include kidney transplant and heart transplant. "The only transplant that doesn't belong here is bone marrow because that's actually infused," says Stanton. "It would code as an infusion, which is not one of the root operations in the medical and surgical section. It's in the administration section."

Condition code 44: How coders and billers can help ensure compliance

Although coders and billers don't play a role in determining whether condition code 44 is appropriate, they most certainly ensure correct billing of the code.

Coders report condition code 44 only on outpatient claims when a physician who orders inpatient services later determines upon internal review that those services don't meet inpatient criteria. Reporting condition code 44 allows hospitals to receive payment for the medically necessary Part B services that were ordered and provided to the patient. These services can potentially include the following:

Surgical procedures

Implants/devices

Injections and infusion therapy

Rehabilitation therapy

ED services

Surgical dressings

Note that this list excludes observation services. "Observation care was not ordered from the very beginning, so consequently, even though a nursing equivalent of the service was provided, we're not entitled to be reimbursed for that observation care," says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla.

Condition code 44 and short stays

The creation of condition code 44 prompted Quality Improvement Organizations to review one-day stays to ensure that documentation supports the medical necessity of the admission, says John Zelem, MD, FACS, executive medical director of client relations and education at Executive Health Resources in Newtown Square, Pa. "PEPPER became a data tool that was utilized for all acute care hospitals to determine their areas of risk," he says.

Eventually, Recovery Auditors (RA) began to focus on medical necessity for one-day stays. Today, MACs also perform prepayment reviews/denials on short stays. This intense regulatory environment has propelled many hospitals to take a closer look at medical necessity as well as condition code 44 compliance, adds Zelem.

Some cases are clearly appropriate for the inpatient setting (e.g., acute myocardial infarction, acute intracranial bleed, and valve transplant). Other cases are clearly appropriate for the outpatient setting (e.g., chemotherapy, inner ear infection, and dilation and curettage). Cases that aren't so clear include those that require individual assessment due to unclear medical necessity (e.g., chest pain, anemia, and dehydration).

"This gray area is growing every single year for different reasons," says Zelem. "What's the determining factor [for ensuring valid admissions]? Medical necessity."

Medical necessity-something that only a physician can determine using complex medical judgment-should be clearly documented in the record. This includes the patient's level of risk, severity of signs and symptoms, medical predictability of an adverse outcome, and the need for diagnostic studies.

Such documentation is particularly important for short stays, says Zelem. "Patients may come in and get well very quickly, but they still present with high risk," he says. "Part of the reason why they get better quickly is because of the sophistication of the care we're able to deliver to them."

Even inpatient-only procedures aren't exempt from RA and other denials, says Zelem. These denials can occur for one of the following reasons:

The RA didn't realize the procedure was on the inpatient-only list

The hospital thought the procedure was on the inpatient-only list, and it wasn't

The documentation doesn't support an inpatient level of care

"You can't just rest on the laurels of the inpatient-only list as a sole indication for billing the case as an inpatient," says Zelem. "[Physicians] must talk about the procedure, the complications of the procedure, and the comorbidities of the patient."

What coders and billers need to know

To report condition code 44, hospitals must ensure that the following criteria are met:

The inpatient admission meets admission criteria

The physician responsible for the care of the patient agrees with the decision to change the patient's status to outpatient

The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still an inpatient in the hospital and has been notified of the change

The hospital has not submitted a claim to Medicare for the inpatient admission

An attending physician concurs with the utilization review (UR) committee's decision

The physician's concurrence is documented in the patient's medical record

The decision to change a patient's status from inpatient to outpatient is one that only a UR committee physician can make in conjunction with the physician who is responsible for the care of the patient, says Hale. The physician must concur with the committee and document his or her decision in the patient's medical record for coders to be able to report condition code 44.

If these criteria are not met, condition code 44 cannot be reported. Instead, the hospital must submit a no-pay bill followed by a 12x bill type only for certain covered Part B services that were furnished to the patient, says Hale. For example, this can occur when the attending/admitting physician refuses to change the patient's status from inpatient to outpatient even though a UR physician has determined that the admission is unnecessary.

When all criteria are met, coders and billers should treat the entire episode of care as though the inpatient admission never occurred. Instead, they should bill it as an outpatient episode of care, says Hale. They should report condition code 44 on the outpatient claim (13x or 85x bill type) in one of form locators 24-30 with qualifier BG.

Be careful when reporting observation services for cases that involve condition code 44. The cost for nursing serv

Look for clinical clues when querying for CCs and MCCs

Fri, 01 Mar 2013 04:00:00 GMT

Look for clinical clues when querying for CCs and MCCs

Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.

CC conditions

Following are some-but not all-of the CCs for which coders and CDI specialists should keep their eyes peeled:

Angina: Unstable angina (411.1) is a CC for which coders and CDI specialists query often, says Haik. "The problem with this is that [unstable angina] usually implies a patient who is preinfarctional. Sometimes that's not what the physician means," he says.

For example, a patient may present with atrial fibrillation, a rapid ventricular response, and angina-but no infarction. Instead of asking whether a patient has unstable angina, Haik says coders and CDI specialists should use less severe forms of the condition, such as progressive, accelerated, or initial angina. "These terms are all indexed in the code book under the same code-411.1-so it would be a CC," he says.

Take note of acute coronary syndrome (ASC). ASC codes to unstable angina, which may not be what the physician means, particularly when the patient has an increased troponin level, says Haik. If a patient has ASC with an increased troponin level, this meets the definition of acute myocardial infarction, he adds.

Asthma: All types of asthma with acute exacerbation or status asthmaticus (493.xx) are considered CCs. Be on the lookout for exacerbation of asthma in patients with pneumonia, says Haik. "We don't treat pneumonia with prednisone or Solu-Medrol. These are medications that reduce inflammation and aren't antibiotics. If you see us using steroids in a patient with pneumonia who is also wheezing and has a history of asthma, you need to ask if they have an exacerbation of asthma," he adds.

Bacteremia: A positive blood culture indexes to bacteremia (790.7), says Haik. "Therefore, if it's clinically significant-and it usually is-then you would code that without having to query the attending physician," he adds.

Body mass index (BMI): Coders may report BMI (V85.x) based solely on documentation of clinicians who are not the patient's provider (e.g., nurses and dietitians). However, a physician must document associated conditions, such as obesity. "BMI with obesity can be reported as a chronic systemic condition even without active intervention," says Haik. See Coding Clinic, Third Quarter 2011, p. 94 for more information. BMI isn't excluded as a CC when listed with a principal diagnosis of obesity hypoventilation syndrome. It is excluded as a CC when listed with a principal diagnosis of morbid obesity.

Cardiomyopathy: Coders and CDI specialists should query regarding cardiomyopathy (425.x) when a physician documents left ventricular dysfunction, especially if the patient is taking cardiac medication and has an ejection fraction of less than 40%. Cardiomyopathy is excluded as a CC when listed with a principal diagnosis of congestive heart failure, not otherwise specified. "If you can specify the type of heart failure as systolic or diastolic, then it would act as a CC," says Haik.

Drop in hematocrit: Coders may report a drop in hematocrit (790.01) if a physician addresses it through treatment or routine follow-up, and it decreases by at least 10% and usually less than 30%. "One caveat is that if the physician documents anemia, then you cannot report a drop in hematocrit as an additional diagnosis, as it's excluded with anemia," says Haik.

Drug-induced delirium: "I see physicians all the time documenting 'confusion after surgery' or 'sundowners' typically when the patient has been given pain medications with opiates or sedating medications like sleeping medications," says Haik. In these instances, coders and CDI specialists should query for clarity regarding drug-induced delirium (292.81).

Hemiplegia: Hemiplegia (438.2x) is a CC regardless of whether it's acute or a late effect of a cerebrovascular accident. "The problem is that physicians will often say 'left-sided weakness,' " says Haik. Coders and CDI specialists should clarify whether the left-sided weakness refers to hemiplegia.

Obesity hypoventilation syndrome: Coders and CDI specialists should suspect obesity hypoventilation syndrome (Pickwickian syndrome) (278.03) in patients with chronically elevated pCO2 (carbon dioxide partial pressure) regardless of whether they're using continuous positive airway pressure, says Haik. If a pCO2 is not documented in the health record, then coders and CDI specialists can locate the CO2 (sometimes referred to as the HC03) in the basic metabolic profile. The HC03 may also be elevated, Haik explains. Obesity hypoventilation syndrome is not excluded as a CC when listed with a principal diagnosis of morbid obesity.

Chronic respiratory failure: Query the physician when he or she documents "O2 dependent," as this may mean the patient has chronic respiratory failure (518.83), says Haik.

Schizophrenia: Patients with schizophrenia (295.xx) may be on a variety of medications. If the physician doesn't specify the type of schizophrenia, coders or CDI specialists should query for this information. "Even if the patient is stable and controlled, it would be reasonable to query whether the patient has chronic schizophrenia, which is a CC," says Haik.

Thrush: Coders or CDI specialists should query for thrush (112.0) when the physician documents "sore mouth" and the patient is taking Mycostatin®. "Mycostatin treats one thing and one thing only-thrush," says Haik.

UTI: Coders or CDI specialists should query for UTI (599.0) when the physician documents "pyuria on antibiotics," says Haik.

MCC conditions

Following are some-but, again, not all-MCCs of which coders and CDI specialists should be aware:

Cerebral edema: Haik says coders and CDI specialists frequently omit cerebral edema (348.5). "If it's only on the CT scan, you can't report it. But if it's on the CT scan, and you see the physician treating it with Decadron®, then this is obviously a place where you want to query the attending physician regarding its clinical significance for reporting purposes," he says. See Coding Clinic, Third Quarter 2009, p. 8, and First Quarter 2010, p. 8 for more information.

Decubitus ulcer: Stages III (full-thickness skin loss, 707.23) and IV (skin ulcer with necrosis of soft tissue to bone, 707.24) are MCCs. A wound care nurse can document the stage of the ulcer, but a physician must document the ulcer's site and type.

"If the wound care nurse does not document the [specific] stage, but rather describes the stage-and that description is similar to the inclusion term in the tabular part of the code book-then you can report that stage," says Haik.

Remember that if the decubitus ulcer isn't POA, then it won't act as an MCC. "One caveat is that you would code to the highest level of evolution of a decubitus ulcer if it's present on admission, and you would assign Y rather than N," says Haik. Thus, when a Stage I ulcer POA evolves to Stage III, coders should report a stage III ulcer POA. See Coding Clinic, First Quarter 2009, p. 19.

End-stage renal disease: Coders and CDI specialists should query for end-stage renal disease (585.6) when the physician documents Stage V chronic kidney disease and the patient is receiving chronic dialysis, says Haik. Code 585.5 has an excludes note stating coders should report 585.6 for chronic kidney disease, Stage V requiring chronic dialysis.

Mallory-Weiss syndrome: Coders and CDI specialists should query for Mallory-Weiss syndrome (530.7) when the physician documents an esophageal tear after forceful vomiting. The patient usually presents with an upper gastrointestinal bleed and hematemesis, says Haik. The ICD-9-CM Manual doesn't include an index entry for esophageal tear, which is why coders must query for the syndrome instead.

Reporting secondary conditions

Coders must ensure that all secondary/other diagnoses (i.e., all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay) meet reporting criteria regardless of whether they are CCs or MCCs. Secondary/other diagnoses must affect patient care in terms of involving any of the following:

Clinical evaluation (e.g., coders can report atelectasis when a pulmonary consultation is performed)

Therapeutic treatment (e.g., coders can report a UTI when a patient receives Septra® orally)

Diagnostic procedures (e.g., coders can report hyponatremia when a patient undergoes a serum cortisol level lab test to determine its etiology)

Extended length of hospital stay (e.g., coders can report a gastrointestinal bleed that extends the patient's stay)

Increased nursing care and/or monitoring (e.g., coders can report nonsustained ventricular tachycardia monitored on telemetry)

Implications for future healthcare needs (e.g., hydrocele in a newborn)

Coding Clinic, Second Quarter 1990, pp. 12-16 is the original article on this subject, and it provides more examples and information about when to report secondary diagnoses.

Coders should note that the last bullet directly above applies to newborn coding only, says Haik.

Coders should also note that there are certain chronic systemic conditions (e.g., COPD, diabetes, Parkinson's disease, or a BMI indicating morbid obesity) that they should always report regardless of whether the physician documents any active intervention; this is because these conditions always increase the need for nursing care and monitoring. See Coding Clinic, Third Quarter 2007, p. 13, and Third Quarter 2011, pp. 4-5 for more information.

Likewise, there are times when coders definitely shouldn't report secondary diagnoses. "A patient may have just an isolated lab results or radiological abnormality without it being evaluated. Then it would not be reported," says Haik. "Additionally, if a condition is integral to, meaning it's routinely seen with another condition, then it would not be reported." For example, a patient has acute respiratory insufficiency and acute exacerbation of COPD. Coders shouldn't report the acute respiratory insufficiency because it's integral to the COPD exacerbation.

In general, any and all queries should adhere to AHIMA guidelines, says Haik.

Editor's note

Haik originally presented this material during HCPro's audio conference "FY 2013 CC/MCC List: Clinical Indicators and Query Opportunities." For more information, visit http://tinyurl.com/d8h22jm.

Coded data drives so much more than �reimbursement

Fri, 01 Mar 2013 04:00:00 GMT

Coded data drives so much more than reimbursement

Researcher Bill Rudman, PhD, RHIA, says he didn't fully understand the implications of codes that coders assign until he was sitting around a table with several criminal justice officials who said that coded data helps reduce violent crimes and recidivism.

"I've found that people in the community have an incredible appreciation for coded data and what coders do," says Rudman, vice president of education visioning at AHIMA in Chicago and the executive director of the AHIMA Foundation.

Mental health data is particularly important for those working in criminal justice, says Rudman. "If [previously convicted felons] aren't taking medications, they're more likely to commit violent acts," he says. "Without codes, we're unable to provide data to health professionals and others in the community."

HIPAA allows covered entities to disclose protected health information without an individual's authorization for a variety of reasons, one of which is to prevent or lessen a serious and imminent threat to a person or the public.

Research is another reason. Rudman says he frequently uses aggregate coded data to track and trend disease outbreaks. For example, coded data once helped him and other researchers track the spread of the flu in Mississippi. "For some reason, the flu always started in certain areas of the state," he says, adding that outbreaks would continue to occur in areas along major highways and travel routes. "We were able to call various communities and tell them to start pushing flu shots because they would be the next community to get [the outbreak]. Then they could mobilize their resources."

Coded data and research

Coded data is incredibly important to researchers nationwide, says Roxanne Andrews, PhD, senior researcher at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md. "The work that coders perform provides the building blocks for what we, as researchers, can do," she says. "We rely on coders to collect the data in an accurate and complete way."

AHRQ uses coded data collected by state organizations to produce databases that governmental agencies (such as the Centers for Disease Control and Prevention and the National Institutes of Health), hospital associations, and others use for research purposes. "There are thousands of researchers who use our databases alone," says Andrews.

The agency cross-tabulates the coded data with de-identified demographic information (e.g., age, gender, race, ethnicity, and ZIP code) to produce meaningful results. "We can look at the geographic characteristics of where the patient lives and associate that with some of the outcomes," Andrews explains. "If there are vast differences in hospitalization rates, it helps us understand that there are probably some prevention activities in the outpatient setting that could be used to prevent hospitalizations."

Researchers most commonly query AHRQ's databases for more information about specific diagnoses and procedures (e.g., the average length of stay for a hip replacement). "With our query system, this can be easily answered," she says. "The only reason it can be answered is because of the work that coders are doing."

AHRQ published a report in 2005 titled The Value of Hospital Discharge Databases (available at https://www.hcup-us.ahrq.gov/reports/final_report.pdf) in which the agency describes several other important uses for coded data. The uses have only continued to grow since that time, says Andrews. Some examples cited in the report include the following:

Public safety and injury surveillance and prevention (e.g., the Crash Outcomes Data Evaluation System, which combines inpatient discharge data with motor vehicle accident data and information from other sources to examine myriad issues related to motor vehicle safety)

Public health, disease surveillance, and disease registries (e.g., tracking the effects of environmental conditions, such as air quality, on health)

Public health planning and community assessments (e.g., to identify services that are lacking in a community, plan for better future allocation of resources, and assess the potential impact of hospital conversions, mergers, and closures)

The agency also uses coded data to produce Inpatient Quality Indicators (www.qualityindicators.ahrq.gov) that hospitals can use to assess and improve the quality of care. The indicators are based on rates of mortality, utilization, and volume for certain diagnoses and procedures.

Coded data also contributes to the Healthcare Cost and Utilization Project Statistical Briefs (https://www.hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp). The briefs provide simple, descriptive statistics on a variety of specific, focused topics (e.g., readmission for heart attack, post-surgical readmissions among patients living in the poorest communities, and transitions between nursing homes and hospitals in the elderly population).

Andrews says she personally works with coded data to contribute information to the National Healthcare Quality Report and National Healthcare Disparities Report, both of which measure trends in the effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care.

"One of the issues that [researchers] face is that we really need complete coding-not just the principal diagnosis and maybe one or two secondary diagnoses," she says. "What we've found is that in some hospitals, there's a tendency to only use a few data fields." Andrews says this affects researchers' ability to extrapolate more meaningful data, and it's something that coders and hospitals nationwide can-and should-work to improve. In particular, E codes are important in terms of tracking injuries and care. "These are public health issues in which states are quite interested," she adds.

Clinical research is paramount in terms of developing and understanding diseases and outcomes, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, HIM consultant in Fremont, Calif. "This is an important piece that sometimes gets forgotten. As costs increase, we need to look at ways to treat that are more cost-effective but that also ultimately have better outcomes and even cures," she says.

Hospitals-particularly academic institutions-may also use coded data to perform research internally, says Bryant. Other hospitals may be receiving a grant that relies on coded data and research. Researchers use coded data (i.e., individual codes or DRGs) to identify cases that should be included in a particular study, she adds.

Spreading the word

Susan Beever, RHIT, CCS, supervisor of clinical coding at Sarah Bush Lincoln Health System in Mattoon, Ill., says she has spent the majority of her career in HIM trying to educate others about the importance of coded data. "Coding is about much more than payment, even though payment seems to have become the focal point," she says.

Beever's approach to educating others is one that she refers to as "walk and talk," meaning she takes any and all opportunities to discuss the importance of coded data during informal conversations with coders, physicians, and others.

Research is an area on which she focuses. "How can we have an overall view of pandemics, chronic diseases, congenital malformations, etc., without a base of searchable data? That's what codes provide," she says. "If you pull up an LCD from CMS and actually read the whole thing, you will see that the decision to pay or not pay for testing/treatment is based on research. Research cites the efficacy of the particular test to track, identify, or treat a disease."

The World Health Organization frequently uses coded data to shape health research, set norms and standards, articulate evidence-based policy options, monitor and assess health trends, and more, says Beever. "You cannot do all of this without coded data that can be mined," she adds.

Once physicians start to understand the ways in which coded data is used, they become more open to improving that data, says Beever. "I think HIM and coding have been viewed as a necessary evil in times past," she says. "I believe that if everyone has an understanding that code assignment is much more than something needed to get the bill out, there will be a cooperative effort to get it right."

Bryant agrees, adding that coding supervisors and HIM directors need to emphasize the value of coders' work. "Although coders need to be knowledgeable of the reimbursement structure…we also want to emphasize the value in terms of patient care, quality, severity of illness [SOI], and risk of mortality [ROM]," she says.

In California, Medicaid is moving toward an APR-DRG system that directly incorporates SOI and ROM derived from coded data. "Systems like this enhance the value of coded data," says Bryant. "I think more states are really going to be looking at what can be improved to reflect how sick the patient is. They may look at APR-DRGs or similar systems. I do think this will be an ongoing trend."

Coded data and quality of care

Another trend is the use of coded data to enhance regulatory initiatives aimed toward improving the quality of care, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, Wis.

For example, 30-day readmissions is a hot topic in many hospitals nationwide. "We need to be sure that the data reflects acuity-not only CCs and MCCs," Krauss says. "Some payers use risk-adjusted data. If coders don't list all of the diagnoses that may impact the risk of readmission and risk of mortality and morbidity, does this do justice for the hospital? No, it doesn't. It doesn't do justice for the doctor managing the case either."

Value-based purchasing is another buzz phrase. "CMS is using the data to transform quality into financial incentives," says Bryant. Stage 2 meaningful use requirements also require more reporting of quality measures that are tied with coded data, she adds. In addition, information derived from coded data is increasingly becoming more transparent through statistics published on sites such as Healthgrades and Hospital Compare. "With ICD-10, there should be greater transparency into the coded data and what it means and stands for," she adds.

Bryant says some hospitals are using coded data to monitor performance internally before the state or federal government publishes that information publicly. For example, hospitals can identify secondary comorbid conditions (e.g., COPD, diabetes, or history of smoking) for patients who present with cerebral hemorrhage POA to identify risk of mortality and explain cost and expenditure of care.

Bryant suspects that CMS will use coded data more frequently going forward to assist with public reporting on quality measures, pay-for-performance initiatives, and more. "Coded data is used all the time to identify, track, and trend fraud and abuse. I think this is going to be increasing," she says.

Looking ahead

As the importance of coded data continues to evolve, coders must understand the role they play, says Krauss. HIM directors and coding supervisors must remind coders of the ways in which the codes they assign are used for purposes other than reimbursement. "We can't hold coders accountable for understanding the implications of coded data if the people above them aren't held accountable themselves," he adds.

"Coders are going to be playing such an important role in the future of healthcare," says Rudman. He says he hopes coders will gradually move into CDI where they can focus on data quality. "CDI provides job opportunities for coders, and I think it also provides opportunities to make sure that the data has more integrity," he adds.

Andrews agrees. "Individual coders are doing extremely valuable work not only for their individual hospitals but also for their communities, their state, and the nation," she says.