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Tip: CPT Chapter 11 codes take precedence in OB/GYN cases

Fri, 20 Nov 2009 19:20:00 GMT

When coding OB/GYN procedures, remember that ICD-9 codes 630–679 in Chapter 11 (Complications of Pregnancy, Childbirth, and the Puerperium) of the ICD-9 Manual take sequencing priority over other chapters.

Report codes from Chapter 11 in the ICD-9 Manual for conditions that appear in the maternal record only. Refer to code series 764–779 to assign codes for conditions that appear in the baby’s chart, if applicable. Remember that the baby does not have its own chart until its mother gives birth.

This tip was adapted from the article “Examine codes for complex OB/GYN procedures” in the December issue of Briefings on APCs.

Q/A: Billing telemetry daily monitoring

Fri, 20 Nov 2009 05:23:00 GMT

Q: Can our hospital code and bill telemetry daily monitoring in conjunction with a chest pain patient in observation?

A: No CPT code exists for cardiac telemetry daily monitoring, but revenue code 732 does. Consider revenue code 732 an ancillary revenue code, and use it in conjunction with these services when provided by a separate department with specially-trained staff.

Typically, separate department staff members do not perform cardiac telemetry monitoring. Instead, a facility installs telemetry monitors on a specific nursing floor, enabling staff members there to observe. Medical staff members usually admit patients to that particular nursing floor because telemetry is medically necessary and a physician orders it. This means that most patients on that floor receive telemetry.

The typical nursing cost center includes the cost of equipment and staff on this unit. This means that the telemetry is a routine cost, as confirmed by administrative decisions by the Medicare Provider Reimbursement Review Board (PRRB). Because it's a routine cost, you may not bill this service with an ancillary revenue code, such as 732.

Hospitals have has two choices when billing routine costs:

Include the charge in the room and board rate (or hourly observation rate) for that nursing unit.
Separately bill a charge with a recognized routine cost revenue code, such as 230. This allows hospitals to separately bill a line item charge on both inpatients and outpatients. However, note that this particular revenue code is not allowed on outpatient claims. Therefore, depending on the capabilities of an individual hospital’s billing system, it may be able to include charges in the observation hourly charge under revenue code 0762 if the units of service equal the documented hours of observation. Alternatively, establish an observation hourly rate for this area that includes the telemetry charge reported under revenue code 230 for inpatients plus the observation charges reported under revenue code 762.

Providers report first RAC denials in Florida, South Carolina

Tue, 17 Nov 2009 05:00:00 GMT

Healthcare providers in several states received their first RAC denials. Connolly Healthcare, the Region C RAC for Florida, South Carolina, and several other states, has been behind many of them.

One hospital in South Carolina reports having three claims denied. However, learning of those denials did not go smoothly. The hospital received a call in late October from Connolly regarding a denial letter the hospital never received. The RAC sent the original denial letter in early August, and although it was addressed to the hospital, it apparently had no specific contact person listed, and the hospital never received it. The hospital had provided Connolly with the name of the contact person for their facility months prior via the form Connolly provided on its Web site, according to a hospital employee.

“Connolly acknowledged that the absence of a contact person on the letter was their error and they are working to correct it,” she said.

In the meantime, the RAC faxed a copy of the denial letter to the hospital. The total take back was less than $200, but it has given the hospital a chance to test its RAC tracking system, which is reportedly working well thus far.

Another small contract rehab company that contracts with facilities across seven states, mainly in the southeast, also reported receiving RAC denials. Three of its facilities, all skilled nursing facilities averaging 120 beds, have now received demand letters, according to the Florida-based provider.

“A majority of what we are seeing is recoupment of service-based codes billed in error more than once per day, mainly speech therapy (ST) service-based codes,” according to a provider employee. “We have also received two that included recoupment for the ST codes of 92610 and 92526 billed on the same day, which we have disputed and reported this issue to the American Speech-Language-Hearing Association.”

The provider is appealing the denials where the RAC is seeking recoupment of the ST codes 92610 and 92526 billed on the same day.

“We have a dedicated denials and appeals department and we have been handling these very efficiently and effectively,” she said. The provider has had no problems so far with the appeals it has submitted.

The provider also noticed that the demand letters seem to be taking approximately two weeks to arrive, so timing is of the essence, particularly if the provider is going to respond with appeals.

The provider also notes that it has used the denials as a guide for its internal auditing. Staff members are now going back to look for trends or patterns related to those denials.

Note: More on deductibles and coinsurance

Tue, 17 Nov 2009 05:00:00 GMT

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010. For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services. Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.

Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins. That is, a patient once again has 90 covered inpatient days every time a new benefit period begins. Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted. Lifetime reserve days do not renew. Once used, they are gone forever.

Click over to the MedicareMentor Blog to read more.

HIPAA Q&A: Returned mail with patient records

Mon, 16 Nov 2009 18:59:00 GMT

Q. Returned mail for a patient account is sent to a business associate (BA), who looks for another address or guarantor. Sometimes, the people at the new address the BA gives us call to say they don’t have children or a medical bill with us. Is this a HIPAA privacy breach?

A. You should take appropriate steps to ensure that a new address is correct before sending PHI to that address. The BA should try to contact the patient or guarantor by telephone, using telephone numbers you have on file, to determine the correct mailing address.

Editor’s note: Mary D. Brandt, MBA, RHIA, CHE, CHPS, answered this question. This is not legal advice. Consult your attorney regarding legal matters.

TIP: Avoid vague education on communication devices, Web sites

Mon, 16 Nov 2009 18:47:00 GMT

Covered entities and business associates can protect themselves against the dangers of unsecured social networking Web sites and communication practices by taking a hard stance against them, experts advise.

You can protect your organization by investing in communication devices such as BlackBerry® smartphones and banning sites such as Facebook and Twitter from hospital computers, says Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR.

Education is essential, and it must be specific—it’s no good if it’s vague, he says.

Use these four models together to educate employees and protect your facility:

New employee training (i.e., orientation)
Annual refresher training
Security reminders (e.g., weekly helpful e-mails, information in the hospital newsletter, messages that flash on staff member computer monitors)
Communication policy: During annual staff member performance reviews, require staff members to acknowledge in writing that they have read and understood the policy

Teach clinical staff members to adopt the habit of texting messages that express urgency without including PHI. For example, write “Call me” or “I have an important message and I’m going to leave you a voicemail.” Then, if you lose information, you’re not losing anything that’s personally identifiable.

Editor’s note: This is an excerpt from an article in the November edition of the HCPro, Inc. newsletter, Briefings on HIPAA.

HIPAA Update hot posts

Mon, 16 Nov 2009 18:43:00 GMT

Check out the posts on our HIPAA blog that have generated the most conversation over the past month:

New HIPAA whitepaper!

Mon, 16 Nov 2009 18:42:00 GMT

Download a free copy of our new white HIPAA whitepaper, “HHS breach notification interim final rule: Form your incident response team, set policies and procedures to comply with new federal HIPAA Regulations. November 2009.”

November is Diabetes Awareness Month

Mon, 16 Nov 2009 15:10:00 GMT

By Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS

As children polish off the last bit of leftover Halloween candy, it comes to mind that sugar is not always every American’s friend. November is American Diabetes Month. There are approximately 18 million Americans who live with this disease. Diabetes is the body’s inability to produce or properly use insulin which is vital in converting sugar and starches into energy.

This disease has recently affected my mother and I have been so proud of her dedication to manage the condition with such a positive attitude. I have heard about her escapades of searching for the right glucose monitoring machine, finding the test strips, and effectively getting the blood sample into the monitoring machine – but that was only the beginning of her journey. She visited the dietician and was essentially told “no white stuff,” which included some of her favorite foods like potatoes and pasta.

There are a variety of underlying causes which lead to the development of diabetes. The causes can range from hereditary conditions, adverse effects of medications, pregnancy even preventable causes such as obesity.

There are a few major types of diabetes mellitus:

Type 1 – a condition where the body lacks the ability to produce insulin. Commonly referred to as “juvenile” diabetes because it is generally diagnosed in the adolescent years.
Type 2 – a condition where the body is unable to properly use insulin. Type 2 diabetes is the most common type and affects approximately 70% of those with diabetes.
Gestational – the condition develops during the anetpartum period and generally resolves postpartum. Only about 5-10% will be diagnosed as Type 2 diabetes.
Secondary – a condition due to an underlying cause such as a genetic condition, or other disease affecting the pancreas.

The common symptoms of diabetes are the “polys”: Polyuria (excessive urination), polyphagia (excessive hunger), polydipsia (excessive thirst). Other related symptoms can include unexplained weight loss, fatigue and blurry vision. Many patients are relatively asymptomatic therefore it is estimated that approximately 6 million people either have the disease or are suffering from the early signs of development of the disease known as “pre-diabetes”.

Routine testing for diabetes should be integral to a patient’s health care maintenance especially if there is a family history of the disease. Screenings can be performed via simple lab tests like Fasting Plasma Glucose Test or the Oral Glucose Tolerance Test.

Preventative measures, include things we should be doing routinely anyway; healthy diet, exercise, smoking cessation and reduction in alcohol consumption. Remember we only get one body, so we need to take care of it!

Complications and manifestations of diabetes should be a common concern for those with the disease. Diabetes mellitus is known to affect other organ systems such as the kidneys, eye, heart and vascular system.

Coding for diabetes depends on the type of diabetes and the absence or presence of complications and manifestations.

Type 1 – 250.x1 or 250.x3
Type 2 – 250.x0 or 250.x2
Gestational – 648.8x
Secondary – 249.xx

V58.67 can also be assigned for patient with long term (current) use of insulin.

There are many Americans who suffer from this often silent disease that is commonly overlooked or ignored. Please be aware of the warning signs and don’t hesitate to discuss your symptoms with your physician. The most common type of diabetes (Type 2) can be prevented with proper care.

I am sure many reading this have a loved one or even an acquaintance who suffers from a form of diabetes mellitus. Please join me in continuing to support people like my mother in dealing with this disease. We need to focus on taking care of ourselves and making the right decisions concerning diet and exercise so that we can hopefully avoid being in her shoes in 25 years. In fact, my best buddy (my dog, Damian) is looking at me now wanting to go on yet another walk… where are my tennis shoes??? Let’s go!

Q/A: Documenting lesion size

Fri, 13 Nov 2009 05:18:00 GMT

Q: A surgeon excises a lesion on a patient’s back, but fails to document its size or the margins in the operative report. The pathology report lists the total size of the excised specimen, including the lesion size. May we use the pathology report as documentation for the lesion size and the margins excised?

A: CPT Manual introductory notes for this section state “The measurement of lesion plus margin is made prior to excision.” This requires physicians to provide the size before removing a lesion.

Using the pathology report as documentation for coding purposes may result in reporting of an incorrect size. CPT Assistant, August 2000, p. 5, states that pathology reports usually provide specimen size rather than size of the lesion or the excised specimen. Specimens shrink when added to formalin or other preservative. Therefore, measurements in pathology reports are not accurate and don’t provide accurate information for proper CPT procedure code assignment.

Query physicians when they remove a lesion but fail to document its size. Specifically, request the size of the lesion and margins. Physicians need this information to submit accurate bills for their professional services.

Tip: Don't overlook small-dollar savings

Fri, 13 Nov 2009 05:16:00 GMT

When considering ways to reduce revenue loss at your facility, don’t look just for big-dollar savings. Small-dollar savings can add up to a significant amount.

Also, be sure to inform coworkers of changes—large and small—that you implemented. If you don’t tell them about the potential additional revenue, they won’t know.

This tip was adapted from the article “Eliminate missed charges, errors to reduce lost revenue” in the December issue of Briefings on APCs.

HealthDataInsights posts several new RAC DME claim issues

Thu, 12 Nov 2009 05:00:00 GMT

HealthDataInsights (HDI) has added multiple new RAC issues to their CMS-approved list in late October and early November. The new issues are approved for RAC audits in Region D for DME claims.

According to the HDI Web site, the new issues and their descriptions are as follows:

PEN supplies more than one time a day. The description or the billing guidelines state parenteral/enteral nutrition codes are allowed once a day.
Infusion pump denied/Accessories and drug codes should be denied. When the infusion pump is denied, then the infusion accessories and infusion drug codes are also denied.

To stay on top of the latest RAC-approved issues in your state, visit the “Tools” section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.

Could RAC mass adjustment changes mean increase in automatic audits?

Thu, 12 Nov 2009 05:00:00 GMT

Providers who believe their RAC denials will be limited to 200 every 45 days (corresponding with the medical record request limits) may be in for a surprise. Those limits apply only to complex audits, but no such limits exist for the number of automatic reviews RACs can perform.

“RACs can do as many [automated reviews] as they want. I think it is in people’s heads that they can look at only 200 at any one time, but that’s really not true,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

In fact, recent changes to the RAC process for handling mass quantities of recoupments from automatic reviews may even make it easier for RACs to increase their auditing capabilities—meaning the potential for even more denials for providers.

In the past few weeks CMS released three transmittals (R561OTN, R571OTN and R573OTN) detailing several technical changes to “enhance” the RAC mass adjustment process. Essentially, the changes improve the process for the RACs by automating what used to be much more labor-intensive process of initiating mass adjustments of similar claim and/or service types.

“CMS is going to allow RACs to now upload entire files to the intermediary to make mass adjustments, and this is going to make automated denials much quicker for RACs,”

Hoy says. “And whenever you go from manual to automated, you’re going to have a huge increase in efficiency. The changes mean a hospital could get literally thousands of claims denied in one day.”

CMS first came out with a RAC-oriented mass adjustment process in 2007, but the changes should make it easier for the RACs. “Basically they can just run reports now,” Hoy explains.

And if the back-end work involved in processing mass quantities of automatic denials decreases for the RACs, does it mean an increase in their ability to further audit healthcare providers?

We may have to wait until April 5, 2010, when the changes take effect, to find out.

Note: Signature for Laboratory Tests, Clarification in the MPFS Final Rule

Tue, 10 Nov 2009 05:00:00 GMT

This week, I would like to review a “clarification” regarding physician signatures on orders for clinical diagnostic testing that came out in the Final Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for 2010. Although this publication is hospital-directed and we do not normally report on physician fee schedule issues, this “clarification” could affect hospital policies on obtaining signatures for the laboratory services they provide.

Click over to the MedicareMentor Blog to read more.

Guidance on HIPAA implications of H1N1

Mon, 09 Nov 2009 19:16:00 GMT

Following the recent declaration for H1N1 flu as a national health emergency, the government posted a number of documents that have HIPAA implications, says Frank Ruelas, director of compliance and risk management at Maryvale Hospital and principal, HIPAA Boot Camp, in Casa Grande, AZ.

Ruelas points to this document on the CDC Web site that summarizes other related documents online.

“Many of these documents help clear up questions on whether the subsequent 1135 waivers suspend HIPAA, the time frame related to these waivers, and those provisions of the HIPAA privacy rule where the Secretary of HHS may waive sanctions and penalties,” Ruelas says.

Red Flags Rule enforcement delayed to June 1

Mon, 09 Nov 2009 19:13:00 GMT

The Federal Trade Commission is delaying enforcement of its identity theft Red Flags Rule for a fourth time, pushing back the November 1 deadline to June 1, 2010.

The latest delay comes at the request from Congress, which is considering exempting entities with fewer than 20 employees from the identity theft rule.

The House of Representatives passed the bill late last month. The Senate is now considering the bill.

The previous delay announcement—from August 1 enforcement to November 1—came in July. The House Appropriations Committee requested the additional three months to educate small businesses about Red Flags Rule compliance. The delay also allowed financial institutions and creditors more time to implement written identity theft prevention programs, according to the FTC.

Red Flags requires creditors and financial institutions to have in place identify theft prevention, detection, and response systems. The rule is mandated by the Fair and Accurate Credit Transactions Act of 2003.

Red Flags was initially supposed to go into effect November 1, 2008, but was pushed back to May 1, 2009, then to August 1, 2009, then to November 1, 2009, and now to June 1, 2010.

New HIPAA whitepaper!

Mon, 09 Nov 2009 19:10:00 GMT

Q/A: May we bill an E/M code for a wound care first visit

Fri, 06 Nov 2009 05:41:00 GMT

Q. Several of our facilities that include hospital-based outpatient wound care clinics have requested guidance in the following scenario.

A patient arrives at the clinic with a physician order for wound debridement. This is the patient’s first visit, and the patient meets the CPT new patient definition. The nurse performs the debridement and documents a history and physical.

Because this is a first visit, may we bill for an E/M level and the debridement? Should we bill only for the debridement in subsequent visits?

A. Medicare “incident to” guidelines for hospitals state that nurses must carry out orders from treating physicians and not add to or take away from any order. Just because the patient presents for an initial visit, you may not automatically report an E/M service.

In this case, the answer depends on how the physician ordered the first wound care visit. If the physician order is for wound debridement only, the hospital should bill for wound debridement. Bill the services described with one of the wound management codes—97597, 97598, or 97602. Each of these CPT codes’ descriptors includes the term “wound assessment” so wound evaluation is included when reporting the documented procedure.

After assessing the patient’s presenting condition, the wound care nurse might think that additional services are necessary or that a new issue has arisen since the patient saw the physician. In either situation, the wound care nurse should contact the ordering physician to determine whether further or different medically necessary services are indicated. You may bill an E/M service in addition to the wound care service only if it represents a medically necessary, significant, separately identifiable service ordered by the treating physician and provided by the hospital.

Tip: Determine the number of specimens to code surgical pathology correctly

Fri, 06 Nov 2009 05:39:00 GMT

If you perform a level IV surgical pathology (88305) on more than one specimen from the same patient, the unit of service for this code is the number of specimens requiring individual exam and pathologic diagnosis. Use modifier -59 to indicate tests provided for different specimens.

If you test a single specimen, report only the code that describes the highest level of specificity within a group of related codes if the tests are performed on a specimen with the same end result. For example, within the code range of 88104–88112, report only one code. If you perform multiple tests on multiple specimens, use modifier -59.

This tip was adapted from the article “Q&A: Determining the proper use of modifier -59” in the November issue of Briefings on APCs.