HCPro.com - JustCoding News: Outpatient

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Wed, 30 May 2012 04:00:00 GMT

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Injections and Infusions case scenarios

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Wed, 30 May 2012 04:00:00 GMT

To receive AAPC and/or AHIMA credits, take the quiz after reading the following articles:

Get to the heart of cardiac catheterization coding
Note changes for skin substitutes, mental health codes
The guiding principles of Medicare Advantage: Keeping risk adjustment compliant
Healthcare News: CMS to cover transcatheter aortic valve replacement
Q&A: Reporting Not Otherwise Classified code for drugs

Get to the heart of cardiac catheterization coding

Wed, 30 May 2012 04:00:00 GMT

Cardiac catheterization is a common procedure performed to study cardiac function and anatomy and to determine if a patient is a candidate for intervention. The AMA revised the cardiac catheterization codes in 2011.

“Those codes are meant to represent not just a small part of the intervention, but the entire procedure—the specific intervention, accessing the vessel, the closure, the catheterization, the supervision, and interpretation [S&I],” says Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, MHP, president and CEO of ComplyCode in Binghamton, NY.

The new codes contain basically the same information as the old codes, but instead of having separate codes for components of the procedure, coders will now use one inclusive code, Harrington says.
The codes assigned to report cardiac catheterization procedures are separated into two types:

Cardiac catheterization for congenital anomalies
All other heart-related situations

Diagnostic cardiac catheterization for congenital conditions
If a patient has a congenital heart condition and undergoes a cardiac catheterization, coders would look to CPT® codes 93530–93533, says Terry Fletcher, CPC, CCC, CEMS, CCS?P, CCS, CMSCS, CMC, president/CEO of Terry Fletcher Consulting, Inc., in Laguna Beach, Calif.

Those codes reflect an increasing complexity of work performed by the physician. CPT code 93530 is simply a right heart catheterization for congenital cardiac abnormalities. But by the time coders get to 93533, the physician has performed not only a right heart catheterization, but a transseptal left heart catheterization though an existing septal opening. The physician sometimes also performs a retrograde left heart catheterization. All of that work is reflected in CPT code 93533.

If the physician uses contrast injections with the cardiac catheterization for congenital conditions, coders should report the appropriate add-on code from 93563–93568.

Cardiac catheterization procedures for non-congenital conditions
Cardiac catheterization procedures include measurements of oxygen saturation and cardiac output when performed. A right heart catheterization also includes the placement of a Swan-Ganz catheter.

Coders should not report 93503 (insertion and placement of flow-directed catheter (e.g., Swan- Ganz) for monitoring purposes) with any right heart catheterization procedure, Fletcher says. Coders should only report 93503 when the Swan-Ganz is placed for monitoring purposes only.

When a physician performs a diagnostic coronary angiography without a left heart catheterization —meaning the physician did not cross the aortic valve into the left ventricle—report CPT code 93454. If the physician performed injections for guidance only during the procedure, do not separately code the injection, Fletcher says.

When a physician performs a diagnostic coronary artery and bypass angiography without a left heart catheterization, report 93455. Again, do not code injections for guidance only.

A left heart catheterization includes vascular access, sedation and monitoring, inserton and positioning of the left heart catheter, measurement of pressures, removal of catheter(s), left ventriculography (when performed), coronary angiography, closure device angiography, closure device deployment, and report generation, Fletcher says.

If the provider also performs supravalvlar ascending aortography, be sure to report add-on code 93567, Fletcher adds.

Report code93459 f the physician performs a left heart catheterization (with or without a left ventriculography), coronary angiography, and bypass graft, angiography.

A right and left heart catheterization includes all left heart catheterization elements, including function of the mitral and aortic valves and left side aortic valve regurgitation, and may include angiography evaluation of coronary arteries and the left ventricle for disease such as stenosis or occlusion, mitral valve stenosis or regurgitation, ventricular hypertrophy, or aneurysm, Fletcher says.

The right heart catheterization evaluates the tricuspid and pulmonary valve function, measures pressures of the right atrium and ventricle, pulmonary artery, pulmonary valve stenosis, tricuspid valve stenosis, atrial and ventricular septal defects, she adds.

When a provider performs a right and left cardiac catheterization, coders should report 93453. This code includes vascular access, sedation and monitoring, insertion and positioning of the left heart catheter, measurement of pressures, catheter(s) removal, left ventriculography (when performed), closure device angiography, closure device deployment, and report generation.

For right and left heart catheterization with coronary angiography, reference 93460, Fletcher says. For right and left heart catheterization with coronary and bypass graft angiography, refer to code 93461.

Physicians can also perform a left heart catheterization using a transapical puncture or a transseptal approach through an intact septum. Coders should report add-on code 93462 with codes 93452, 93453, 93458–93461 when physicians perform and document this approach, Fletcher says.

Cardiac catheterization and imaging
Cardiac catheterization codes 93451–93461 include all of the mapping angiography the physician performs in order to place the catheters, including any injections, imaging S&I, and report. These codes do not include contrast injections and imaging S&I, and report for imaging that is separately identifiable by a specific procedure code. Code 93451 does not include any contrast injections or imagining S&I.

Cardiac catheterization codes 93452–93461 include contrast injections, imaging S&I, and a report on the imaging that is typically performed. Left heart catheterization codes 93452–93453 and 93458–93461 include intraprocedural injections for left ventricular or left atrial angiography, and imaging S&I, when performed. For coronary catheter placement, codes 93454–93461 include intraprocedural injections for coronary angioplasty and imaging S&I.

If the provider performs right ventricular or right atrial angiography with a catheterization procedure, report add-on code 93566, Fletcher says.

When the provider performs supravalvlar ascending aortography with a right cardiac catheteriza¬tion, coders should also report add-on injection procedure CPT code 93567. Coders should report add-on injection CPT code 93578 when a provider performs pulmonary angiography with right heart catheterization. Coders can report these injections together when appropriate. Make sure the provider has documented all of the procedures performed to justify coding.

Codes 93566–93568 are not linked to any specific cardiac catheterization procedures, Fletcher says. Coders should assign them with both congenital and non-congenital cardiac catheterization procedures, when performed.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.

Note changes for skin substitutes, mental health codes

Wed, 30 May 2012 04:00:00 GMT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New pass-through drugs and biologics
CMS granted pass-through status for these four HCPCS codes:

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

CMS published specific instructions regarding code C9291:

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

Modifiers
CMS deactivated these two modifiers:

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

The complete April 2012 update to the I/OCE can be downloaded from the CMS website.

Editor’s note: This article was originally published in the June issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.

The guiding principles of Medicare Advantage: Keeping risk adjustment compliant

Wed, 30 May 2012 04:00:00 GMT

by Holly J. Cassano, CPC

The guiding principle is the definitive methodology used for all risk adjustment medical record reviews. Successful Medicare Advantage (MA) plans focus on early disease detection, coordination of care, and accurate reporting of members’ chronic conditions by primary care physicians, retrospective and prospective pursuits to drive and improve health outcomes.

MA plans accomplish this in several ways, including:

Annual Wellness Visit (AWV)—introduced in 2011
Annual Health Risk Assessment(HRA) for all members (mandatory for 2012)
Early detection and assessment of active chronic conditions
Continual coordination of care with ongoing assessments of any active chronic conditions
Observance of the guiding principles for risk adjustment (RA)

In order to properly understand the guiding principles for risk adjustment, we first must know what they are and how CMS intended MA Plans to follow them. In 2008, CMS published “The 2008 RAPs Participant Guide” for MA Plans to assist and offer guidance in the world of risk adjustment and to deter fraud and abuse in the healthcare system.

According to section 7.1.5 RADV of the 2008 RAPs Participant Guide:

The risk adjustment guiding principle states that all diagnoses submitted for payment (e.g. used for hierarchical condition categories [HCCs]) must be:

• Documented in a medical record that was based on a face-to-face health service encounter between a patient and a healthcare provider
• Coded in accordance with the ICD-9-CM Guidelines for Coding and Reporting
• Assigned based on dates of service within the data collection period
• From an acceptable RA provider type and RA physician specialty

A total of 10 Guiding Principles define CMS’ HCC Classification System:

Categories must be clinically relevant to ICD-9-CM codes within a category and relate to specific chronic medical conditions in order to prevent gaming and/or discretionary coding
Categories should predict medical expenditures and impacts on healthcare costs
Diseases within each category should allow accurate estimations of their impact on healthcare cost
Hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate
The diagnostic classifications should encourage specific coding in order to accurately reflect disease burden
The diagnostic classification should not reward coding proliferation
Providers should not be penalized for recording additional diagnoses, meaning no condition category should carry a negative payment weight, and a condition that is higher-ranked in a disease hierarchy should have at least as large a payment weight as lower-ranked conditions in the same hierarchy
The classification system should be internally consistent
The diagnostic classification should assign all ICD-9-CM codes
Discretionary diagnostic categories should be excluded from payment models

How does this relate to the OIG?

MA plans need to follow the guiding principles for several reasons, including observance of CMS compliance. In addition, the OIG has put MA plans on its radar for the 2012 Work Plan, published in October 2011.

As part of the 2012 Work Plan, the OIG plans to:

Review diagnoses submitted to CMS for compliance with federal rules
Review the extent to which MA organizations identified and addressed potential fraud and abuse incidents
Ensure documentation supports diagnoses submitted to CMS
Review claims for HCC upcoding

The OIG is targeting MA plans and providers who collude and submit claims that are considered to be upcoded. Upcoding under MA is when a plan encourages providers and facilities to submit false claims in a variety of ways that may include some of the following practices:

Induces physicians to submit diagnoses that are fictitious or indicate a more severe disease process than the member actually has
Encourages physicians to falsify medical records in order to support higher levels of complexity than what actually is present
Arbitrarily submits claims inclusive of the above and without the physicians knowledge to gain higher HCC reimbursement

Why take such a risk for risk adjustment?

As sad a realization as this may be, a physician or group may participate in the first two practices on the list in exchange for one or several types of inducements from the plan. This practice can infuse significant dollars back to the physician or group in an environment when physician reimbursement has been declining and costs to treat patients continue to rise.

Inducements can be in the form of one or several of the following:

Higher capitation rates per member per month
Higher fee-for-service payments
Periodic “bonus” payments that have no relation to medical loss ratio/ healthcare effectiveness data and information set bonuses

The following is an actual case example of MA fraud.

This case involves an alleged fraud against the federal Medicare program, in violation of the federal False Claims Act (FCA). The Department of Justice (DOJ) alleged that Walter Janke, MD and Lalita Janke (and Medical Resources, LLC (MR), violated the FCA by making, or causing to be made, false statements and claims that resulted in millions of dollars of Medicare overpayments in excess of $12 million.

The Jankes falsely represented or caused MR and America's Health Choice Medical Plan (AHC) to falsely represent that AHC beneficiaries suffered from serious illnesses that were not supported by the patients' own medical records, according to the DOJ. AHC, now defunct, was a MA health plan, of which the Jankes were sole shareholders. MR, a network of clinics that provided primary health care to AHC beneficiaries, was its corporate affiliate.

The government alleged that the defendants:

Submitted false or fraudulent claims to cause overpayments to an MA Plan (the Jankes were the sole owners of the MA Plan)
Improperly assigned ICD-9-CM codes that were not documented by medical records or supported by the actual medical conditions of beneficiaries
Knowingly failed to review claims for erroneous data before submitting them to CMS
Failed to delete incorrect diagnoses from CMS’s database after they learned of the inaccuracies

The DOJ and the Jankes settled the case for $22.6 million in November 2010.

This practice is commonly known as “gaming the system” and not only goes against the guiding principles for risk adjustment, but also directly violates the FCA and anti-kickback laws. When a plan chooses this course of deception, it not only is fraudulent, but it depletes precious resources from an already exhausted fund pool for present and future generations of Medicare and Medicaid enrollees.

Editor’s note: Holly J. Cassano, CPC, is a clinical documentation improvement specialist for Preferred Care Partners for The Villages, in Lady Lakes, FL. E-mail her at hjcpmg@yahoo.com.

Healthcare News: CMS to cover transcatheter aortic valve replacement

Wed, 30 May 2012 04:00:00 GMT

Providers will soon be reimbursed by Medicare for a new, less-invasive aortic valve replacement procedure. Medicare Acting Administrator Marilyn Tavenner announced CMS’ decision to pay for transcatheter aortic valve replacement (TAVR) under specific conditions.

TAVR is used to treat patients whose aortic heart valves are damaged, causing the valve to narrow. Until recently, physicians performed an invasive procedure to replace the aortic valve. With TAVR, physicians are able to replace a patient’s aortic valve through a small opening in the leg.

Because TAVR technology is still new, CMS is using “coverage with evidence development,” which requires certain provider, facility, and data collection criteria to be met. For more on the specific criteria, review CMS’ decision memo.

Q&A: Reporting Not Otherwise Classified code for drugs

Wed, 30 May 2012 04:00:00 GMT

QUESTION: When would you use the table labeled as not otherwise classified (NOC) drugs at the end of the HCPCS Level II Table of Drugs and Biologicals? Many other drugs are not assigned a HCPCS code and are not in this table.

ANSWER: You would report an NOC drug when the documentation states that a healthcare professional administered one of these drugs to a patient.

When a provider documents administering a pharmaceutical that is not immediately identifiable in the HCPCS Level II Table of Drugs and Biologicals, you need to check a Physician’s Desk Reference. This book includes ALL legal drugs (prescription and over-the-counter). Look for the drug’s brand name, generic name, and classification. You should be able to find the drug that was administered on the table using one of these alternate terms.

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

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

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC-A, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.

Product of the week: ICD-9-CM vs. ICD-10-CM Coding live audio conference

Wed, 30 May 2012 04:00:00 GMT

The upcoming change from the ICD-9-CM to ICD-10-CM coding systems has many coders overwhelmed. But ICD-10-CM is not as bad as it might seem.

Join HCPro at 1 p.m. Eastern June 15 for ICD-9-CM vs. ICD-10-CM Coding: Preparation and Tools for Managers, Coders, and Physicians. During this live 90-minute audio conference. Our expert speakers will use real-life examples to demonstrate the comparative and contrasting data coders will need for ICD-10-CM. In many cases coders will discover that for diagnosis coding there are similarities between the two systems. Speakers will also provide tools that will help physicians, managers, and coders handle the transition to ICD-10-CM.

For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.

Trivia winner

Wed, 30 May 2012 04:00:00 GMT

Congratulations to this week’s winner, Karen Y. Mitchell, CPC, a pediatric coder with UT Physicians Pediatrics and OBGGYN Billing Department. Karen correctly answered this question:

What is the correct ICD-10-CM code for lattice degeneration of the retina of the left eye?
a. H35.412
b. H35.422
c. H35.432
d. H35.442

Answer: A

Here’s a little bit about Karen:

What are your current job responsibilities?
I am a coder of pediatric specialties: gastroenterology, nephrology, cardiology, and genetics.

Why did you decide to pursue a career in health information management?
I decided to pursue a career in HIM because it is a rewarding career. It has endless possibilities.Coding has so many opportunities.

What do you like most about your job?
What I like about my job is learning new things, which is an excellent challenge for me.

What is your favorite area of coding?
My favorite area of coding is cardiology.

What is your least favorite area of coding?
I don’t really have a least favorite area.

What are some of your hobbies?
My favorite hobby is bowling.

Do you have a personal motto that you live by?
I read this motto and it stayed in my mind, “The only way of finding the limits of the possible is by going beyond them into the impossible.”

Coder chat

Wed, 30 May 2012 04:00:00 GMT

How do you code from an outpatient doppler study of extremity: a diagnosis of "mild occlusive artery of lower extremity" or mild occlusion of lower extremity artery?

Do you assume this is embolus/thrombus and code to 444.22 as the index leads? There was no follow-up related to an embolus or thrombus. We later asked the radiologist and he said there was no documentation of thrombus. Do we need to have him document "without embolus/thrombus" in order to code the 440.20?

Click here to share your thoughts.

Mini-poll

Wed, 30 May 2012 04:00:00 GMT

Are you planning a summer vacation?

Yes
No
I haven’t decided

Vote here

Last week’s mini-poll

How would you rate the communication between the coders and physicians at your practice or facility?

Excellent: 9%
Very good: 12%
Getting better, but we still have work to do: 40%
Not very good: 27%
Practically nonexistent: 13%

Thank you to the 78 readers who participated in last week’s mini-poll!

Free quiz

Wed, 30 May 2012 04:00:00 GMT

Test your knowledge with this week’s free quiz, which features questions nuclear medicine CPT^® codes. (View)

Blogs

Wed, 30 May 2012 04:00:00 GMT

Access the latest blog posts on ICD–10 Trainer, a free, online forum for all matters related to ICD–10:

Access the latest blog posts on Coding Educator, a free, online forum with helpful information on clinical topics and both CPT^® and ICD-9-CM coding:

New on JustCoding Platinum!

Wed, 16 May 2012 04:00:00 GMT

A new webcast in our Webcast library:

Top Diagnoses Needing Additional Documentation in ICD-10

Also on JustCoding Platinum:

Did you see this in our Coding Sample Policies and Forms?

The Coder's Guide to ICD-10: Circulatory System

Be sure to check out these other great Platinum benefits:

Continuing education credits

Wed, 16 May 2012 04:00:00 GMT

To receive AAPC and/or AHIMA credits, take the quiz after reading the following articles:

Crossing the divide: Closing the language gap between coders and physicians
ICD-10 anatomy refresher: Digestive system
Fracture coding in ICD-10-CM requires greater specificity
Healthcare News: AHIMA files comment letter on proposed ICD-10 delay
Q&A: Denials for different level of detail between surgeon, anesthesiologist in ICD-10-CM

Crossing the divide: Closing the language gap between coders and physicians

Wed, 16 May 2012 04:00:00 GMT

Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder.

This language barrier looms even larger as ICD-10 implementation draws closer. As specificity increases, so does the need for more detailed documentation.

Improving documentation should not be about coders versus clinicians. “At the end of the day, good documentation is really about good patient care,” says Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of ICD-10 education and training for the AAPC in Salt Lake City, Utah.

A patient’s record is used for more than just coding, Buckholtz says. It is also used for:

Quality measures
Decision support
Risk prediction
Policy development

So coders, clinicians, and payers need to be able to look at the record and know exactly what is happening with the patient, Buckholtz says.

ICD-10 also has the potential to change the way coders and physicians interact, she says. The level of specificity will present challenges for both clinicians and coders, so teamwork is essential.

It’s critically important to have better communication,” adds Joseph Nichols, MD, a board-certified orthopedic surgeon and medical director for healthcare informatics with ViPS, based in Baltimore.

Change coming with ICD-10
ICD-10-CM introduces new concepts and requires greater specificity, while ICD-10-PCS procedure coding represents a completely new system. The changes and new concepts in ICD-10 include:

More specific anatomical locations
Laterality
Classifications
Functional impairments
Sequelae
Complications
Etiology
Environmental impacts

“Specific anatomic locations make a big difference in clinical care,” says Nichols. A three-inch difference in the location of a fracture can change the patient’s risk and mortality. If physicians don’t document the location with enough specificity, the coders won’t be able to assign the most detailed, accurate code. As a result, the documentation and coding don’t represent a true picture of the patient’s condition.

The increased specificity in ICD-10-CM will also show up when physicians treat a Salter-Harris fracture of the bone plate. Salter-Harris fractures are classified by location and severity. For example, a level I Salter-Harris fracture indicates a break through the bone at the growth plate, separating the bone end from the bone shaft and completely disrupting the growth plate. A level IV Salter-Harris fracture breaks through the bone shaft, the growth plate, and the end of the bone.

The level of Salter-Harris fracture makes a big difference in how the physician treats the patient and what outcome the physician expects, Nichols says. In ICD-10-CM, coders will be able to report exactly what level of Salter-Harris fracture a patient suffered and which bone is involved, provided the clinician documents the information.

For example, a patient may suffer a Salter-Harris fracture of the arm. In ICD-10-CM, coders need to know:

Laterality—which side of the body
Specific bone—humerous, radius, or ulna
Location of break—upper or lower end
Level of Salter-Harris fracture—I through IV

So if a patient suffered Salter Harris Level III physeal fracture of lower end of the humerus of the right arm and is seen for an initial visit, coders would report S49.131A. However, they can only do that if the clinician documents all of the necessary information.

In ICD-10-CM, physicians will also need to alter the way they document some conditions, such as diabetes. In ICD-9-CM, coders need to know if the diabetes is controlled or uncontrolled. That distinction disappears in ICD-10-CM.

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

Type of diabetes
Body system affected
Complications affecting that body system

These combination codes make coding diabetes mellitus less confusing and decrease the number of codes necessary to describe diabetic complications, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, Mass. Coders may report as many combination codes as needed to fully describe all complications. Coders should sequence the codes based on the reason for a particular encounter.

If provider documentation includes words such as uncontrolled, out of control, or poorly controlled, coders should report the type of diabetes with hyperglycemia.

Problems from a coder’s perspective
Coders and clinician see the language barrier and its associated problems from different perspectives. Coders are sometimes reluctant to interact with physicians, Buckholtz says. “They don’t feel qualified to tell the physician what he or she should be documenting.”

Coders are also often removed from the day-to-day operations, which makes it harder for them to interact with physicians.

In addition, coders may also think they are consistently asking for the same information over and over. They may also be afraid to take a stand because they fear retribution from an unhappy provider.

Problems from a physician’s perspective
Clinicians don’t always understand what coders do. They may view coders as a necessary part of the business, but not as partners in taking care of patients, says Nichols.

Clinicians often view coding as an administrative task, Nichols says. It doesn’t help them take care of patients. They know it influences payment, but may assume someone else is taking care of coding.
Clinicians are often bothered by repeated queries from coders and don’t know why the coder keeps asking them for certain information, Nichols says. “They wonder why others want to know about their interactions with patients. They view patient interaction as private.”

Physicians can also become frustrated because what is obvious to them isn’t obvious to everyone else, Nichols adds.

Physicians are also struggling with the financial impact of various healthcare initiatives, such as ICD-10 and HIPAA version 5010, combined with decreased reimbursement.

Physicians also need to remember that it’s not all about them, Nichols adds. A lot of people are involved in healthcare. “[Physicians] are a part of it, but we aren’t the center of the universe,” he says. That should be the patient. “We want the best information possible about the patient.”

Solution: Define a common goal
Closing the distance between coders and clinicians is about changing the mindset, Nichols says. “It’s not about coding. It’s about patient care.”

Coders and clinicians already share values, Nichols says, but don’t communicate well.

Coders know they need to assign the code with the highest level of specificity, Buckholtz says. The number of additional codes in ICD-10 isn’t overwhelming, she says. “Coders need to work with clinicians to be able to get the best quality data.”

The goal for both clinicians and coders is to “represent as accurately as possible the patient’s clinical condition,” Buckholtz says.

Physicians understand the importance of good documentation, but just don’t document well, Nichols says. Physicians are going to take a productivity hit after the switch to ICD-10, just like coders, he adds. “They have to go back and document better, which is what they should have been doing all along.”

One way coders can help physicians improve documentation for ICD-10-CM is to provide physicians with a list of information coders need in order to assign codes for a certain condition, Nichols says.

Coders and physicians also need to create an open dialogue, Nichols says. Talk to the other group and say, here’s what our problems are, here’s what we think your problems are, then work to find middle ground.

Clinicians can educate coders about the medical conditions, while coders can educate clinicians about coding.

“Nobody can be an expert overnight,” Buckholtz says. “We need to exercise a little bit of patience.”

Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.

ICD-10 anatomy refresher: Digestive system

Wed, 16 May 2012 04:00:00 GMT

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

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

Mouth
Pharynx
Esophagus
Stomach
Small intestine
Large intestine
Rectum
Anus

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

Salivary glands
Liver
Gallbladder
Pancreas

In ICD-10-CM, codes for diseases of the digestive system fall under category K00-K95and are broken down into the following blocks:

K00-K14, diseases of oral cavity and salivary glands
K20-K31, diseases of esophagus, stomach, and duodenum
K35-K38, diseases of appendix
K40-K46, hernia
K50-K52, noninfective enteritis and colitis
K55-K64, other diseases of intestines
K65-K68, diseases of peritoneum and retroperitoneum
K70-K77, diseases of liver
K80-K87, disorders of gallbladder, biliary tract, and pancreas
K90-K95, other diseases of the digestive system

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

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

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

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

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

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

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

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

One common condition coders see is gingivitis. ICD-10-CM includes codes for acute and chronic gingivitis. The codes further specify whether the gingivitis is plaque induced or non- plaque induced.

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

Nasopharynx
Oropharynx
Hypopharynx, also called the laryngopharynx

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

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

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

If a patient does indeed suffer from GERD, coders have two choices in ICD-10-CM:

K21.0, gastro-esophageal reflux disease with esophagitis
K21.9, gastro-esophageal reflux disease without esophagitis

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

The lining of the stomach, a mucous membrane, contains gastric glands that secrete gastric juices. Similar to the function of saliva in the processing of food in the mouth, the gastric juices support the extraction of nutrients from the contents that entered from the esophagus.

Mucous cells coat the internal wall of the stomach to prevent the gastric juices from digesting the stomach itself. When this coating is flawed, a person might develop a gastric (peptic) ulcer, where the acids in the stomach actually eat a hole in the lining and wall of the stomach.

To code for an ulcer in ICD-10-CM, coders need to know what type of ulcer it is:

Gastric
Duodenal
Peptic (site unspecified)
Gastrojejunal

Physicians will also need to document whether the ulcer is acute or chronic, and with or without hemorrhage, perforation, or both.

For a patient with an acute duodenal ulcer with both hemorrhage and perforation, coders would report K26.2.

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

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

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

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

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

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

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

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

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

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

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

Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, Wis. Email her at ssafian@embarqmail.com.

Fracture coding in ICD-10-CM requires greater specificity

Wed, 16 May 2012 04:00:00 GMT

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

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

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

For open fractures, coders must also know what type of associated trauma the patient suffered. This information helps coders choose the appropriate character based on the Gustilo-Anderson classification system.

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

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

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

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

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

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

Site of fracture
Coders must know the site of the fracture. This includes not only which bone is broken, but also the specific location of the fracture on that bone, Gold says. For example, a patient fractures his femur.

Coders should look for documentation of which part of the femur he fractured. A physician may perform different procedures depending on the site of the fracture.

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

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

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

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

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

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

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

ICD-10-CM pathologic fractures
If a fracture is caused by disease, not trauma, it is classified as a pathologic fracture. Not all pathologic fractures are due to cancer. Unfortunately, most physicians don't call a fracture pathologic unless it is caused by a malignancy, Gold says.

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

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

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

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

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

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

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

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

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

Seventh character for closed fractures
The meaning of the seventh character for ICD-10-CM codes varies according to chapter and category.

Fracture codes are an example of a category of codes for which the seventh character includes additional information about the type of encounter.

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

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

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

Surgical treatment
ED encounter
Evaluation and treatment by a new physician

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

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

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

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

Editor’s note: This article was originally published in the May issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.

Healthcare News: AHIMA files comment letter on proposed ICD-10 delay

Wed, 16 May 2012 04:00:00 GMT

The American Health Information Management Association (AHIMA) continues to advocate for no delay in the implementation date for ICD-10-CM and ICD-10-PCS.

Delaying ICD-10 implementation “ignores both the efforts of the healthcare industry and the ability to use the much-improved data code sets to support the crucial data needed to move the nation toward an electronic health record (EHR) and exchange infrastructure that will improve the quality of care through more detailed data, Dan Rode, MBA, CHPS, FHFMA, vice president of advocacy and policy for AHIMA said in the letter to HHS Secretary Kathleen Sebelius.

Moving the compliance date to October 1, 2014 could also disrupt the Meaningful Use Stage 2 and 3 EHR implementation, Rode said.

If HHS does finalize a delay, Rode urged HHS to limit it to a one-year delay to limit financial and information losses. In addition, HHS and CMS must provide a clear indication that it will not further delay ICD-10-CM or ICD-10-PCS compliance, Rode added.

Not everyone agrees with AHIMA’s position. Robert Tennant, senior policy advisor with Medical Group Management Association told HealthLeaders Media that a one-year delay would be helpful, but would not solve the underlying flaws in the current process.

To comment on the proposed rule, visit www.regulations.gov. HHS published the proposed rule in the Federal Register April 17 and comments are due within 30 days of publication.

Q&A: Denials for different level of detail between surgeon, anesthesiologist in ICD-10-CM

Wed, 16 May 2012 04:00:00 GMT

QUESTION: We are a small anesthesia group and we are concerned about the specificity for ICD-10-CM. If we submit a claim with an unspecified code and the surgeon submits a claim with more specificity, will we still get paid?

ANSWER: This question has come up in discussions with major government payers but there is no definitive answer.

ICD-10-CM includes options for right, left, and unspecified for many conditions and injuries, including fractures. An anesthesiologist may document a fractured finger without specifying which hand or which specific finger. However, the physician needs to include that information for coders to accurately report the ICD-10-CM code.

Payer systems probably are not sophisticated enough to compare documentation from the anesthesiologist to documentation from the surgeon, especially since different practices or organizations submit two claims.

However, some payers do exclude unspecified codes routinely now as part of their payer policies. At this point, we don’t know for sure how payers will handle unspecified codes in ICD-10-CM. Payers may provide a grace period and reimburse for unspecified claims for a certain period of time after the switch to ICD-10-CM. On the other hand, payers may decide not to pay for any unspecified codes.

Editor’s Note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, MA, answered this question during the “JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS.”

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

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC-A, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.