HCPro.com - Revenue Cycle - DO NOT USE Top Stories

Q/A: Coding for telescopic intraocular lens

Fri, 10 Feb 2012 05:00:00 GMT

Q: An ophthalmologist implanted a telescopic intraocular lens (C1840) that is supposed to be separately payable. Our FI/MAC didn’t pay us and said it processed the claim correctly. Do you have any information about this situation?

A: CMS established new HCPCS code C9732 (insertion of ocular telescope prosthesis including removal of crystalline lens) for calendar year 2012.

According to Transmittal 2386 (January update to OPPS), HCPCS code C1840 (lens, intraocular [telescopic]) is a pass-through category and is separately payable only when reported with new HCPCS code C9732. Review the claim to ensure that you reported both codes. If you did, discuss this with your FI/MAC because there may be a problem in its claims processing system.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: ICD-10-CM simplifies meaning of excludes notes

Fri, 10 Feb 2012 05:00:00 GMT

ICD-9-CM contains one type of excludes note with two possible meanings. Nothing in the ICD-9-CM manual tells coders which mean applies, so they must apply logic to determine the meaning.

An excludes note in ICD-9-CM could mean that coders should not use a particular code for a particular condition. Instead coders should look in a different category because they can’t code the two conditions together.

It can also mean that a condition is not included in a particular code. In these cases, coders should assign both codes, if applicable, when patients have both conditions simultaneously.

When coders are looking at the excludes notes, they can become confused. ICD-10-CM will resolve this confusion by instituting two different excludes notes—Excludes1 and Excludes2—to differentiate the meanings.

An Excludes1 note is a pure excludes note. An Excludes1 note indicates that a coder should never use the excluded code with the code above the Excludes1 note. The two conditions cannot occur together.

An Excludes2 note means a condition is not included in the code. An Excludes2 note indicates that the excluded condition is not part of the condition the code represents, but a patient may have both conditions simultaneously. When an Excludes2 note appears under a code, coders may report both the code and the excluded code together when appropriate.

This tip is adapted from “Start preparing for ICD-10-CM: Note differences between ICD-9-CM and ICD-10-CM” on JustCoding.com.

Start date announced for recovery audit prepayment review demo

Thu, 09 Feb 2012 05:00:00 GMT

On November 15, 2011, CMS unveiled three demonstration projects aimed at reducing improper payments in the Medicare program. More than a month later on December 21, CMS held a special open door forum detailing one of the programs: the recovery auditor prepayment review demonstration. As comments and concerns from providers made their way to CMS, news of a delay on two of three of the demos transpired shortly thereafter

Today, CMS announced that both the recovery auditor prepayment review and the prior authorization of power mobility devices (PMDs) demonstration projects are expected to move forward on or after June 1, 2012. The prior authorization of PMDs demonstration was significantly revised as a result of provider and supplier concerns, according to CMS.

For additional information on these demonstrations, click here:

http://go.cms.gov/cert-demos

MPPR to apply for certain diagnostic imaging procedures for Method II CAHs

Wed, 08 Feb 2012 05:00:00 GMT

On January 26, CMS issued a transmittal that implements the multiple procedure payment reduction (MPPR) for physician services for certain diagnostic imaging procedures in critical access hospitals (CAHs). Many facilities may not yet be aware of this implementation so CAHs billing under Method II need to take immediate notice, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

Section 1848(c)(2)(K) of the Social Security Act was added into the Affordable Care Act, thus specifying that the Secretary will identify potentially misvalued codes by examining codes that are frequently billed in conjunction with furnishing a single service. As a result of this examination, Medicare is making a change to the MPPR for physician services of certain diagnostic imaging procedures, according to MLN Matters article MM7684.

The release of transmittal R2395 applies the MPPR to physician services of certain diagnostic imaging procedures billed by CAHs that had elected the optional method (Method II) for outpatient billing. Payment made to the CAH for physician services billed on its outpatient claim form using revenue codes 96X, 97X, or 98X is based off of the Medicare Physician Fee Schedule (MPFS) supplemental file, according to the transmittal.

“Although this is good news for patients, since they will pay less out of pocket for the professional fees related to the imaging studies, this change could have a significant impact on CAHs that do a high volume of these services,” says Mackaman. “When looking at the list in attachment 1 (of the transmittal) it is quite lengthy and includes the highest-paying imaging services such as MRIs and CTs with and without contrast, as well as angiography.”

She continues, “A 25% reduction on the lower paying multiple service(s) does not seem like much until you consider how often a hospital provides multiple imaging services during the same session, both for high quality care and for the convenience of the patients. Hospitals should analyze their volume reports, imaging services combinations and payments for those services to anticipate the financial setback to their facilities.”

When the reduction is applied, the remittance advice will show a claim adjustment reason code of 59 (Processed based on the multiple or concurrent procedure rules) and a Group Code of CO (contractual obligation). In addition, deductible and coinsurance are based on the reduced amount, but the 115% add-on after deductible and coinsurance still applies, according to CMS.

The application of the MPPR for diagnostic imaging will apply to the professional fee when multiple services are furnished by the same physician to the same patient in the same session on the same day. Full payment is made for the service that yields the highest payment under the MPFS, and for subsequent services, payment is made at 75%.

Even though the implementation date for the FIs/MACs to begin paying the reduced amount is not until July 2, 2012, the effective date for providers is January 1, 2012. Once the Medicare contractors update their systems to align with this change, hospitals will begin to see the reductions in payments, says Mackaman.

In addition, she added: “It is unclear from the transmittal if contractors will mass adjust claims with dates of service from January 1 forward, so until the claims processing systems are updated hospitals should monitor related transmittals for more information.

“It is not uncommon for CMS to direct contractors to ‘reprocess claims brought to their attention’ and thereby leaving the CAH responsible for resubmitting claims for the proper reimbursement, which would include copayment refunds to their patients as well.”

The current list of codes subject to the MPPR on diagnostic imaging can be found in attachment one of transmittal R2395CP.

Q/A: New device pass-through categories

Fri, 03 Feb 2012 05:00:00 GMT

Q: Will CMS ever approve any new device pass-through categories?

A: CMS established one new device pass-through category for CY 2012, HCPCS code C1886 (catheter, extravascular tissue ablation, any modality [insertable]).

Under OPPS payment methodology, a pass-through payment for a device includes an offset of the APC payment. When a pass-through code is reported and reimbursed, CMS deducts amount for the procedure the APC payment because payment for devices without pass-through has been included in the calculation of the APC payment.

Finance and billing departments should monitor these payment amounts to ensure appropriate application of this methodology.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Note physician supervision changes

Fri, 03 Feb 2012 05:00:00 GMT

CMS finalized two significant changes to the physician supervision requirements as part of the 2012 OPPS Final Rule.

First, CMS agreed to delay enforcement of physician supervision rules for critical access hospitals (CAH) as well as small and rural hospitals with 100 or fewer beds.

Second, CMS will use the Federal Advisory Panel on Ambulatory Payment Classification Groups (APC Panel) to review supervision levels for outpatient services. These reviews could begin as soon as the winter 2012 APC Panel meeting.

CMS' decision to apply the supervision requirements in 76 Federal Register 74580 §410.27 to all OPPS therapeutic services and all CAH services is particularly interesting. Services to which the requirements will apply include physical, occupational, and speech therapy.

The tip is adapted from “CMS finalizes numerous provider-friendly OPPS changes for CY 2012” in the January issue of Briefings on APCs.

Q/A: Reporting negative pressure therapy

Fri, 27 Jan 2012 05:00:00 GMT

Q: The new guidelines for the integumentary system section state that CPT^® codes 15002–15005 are noted to be reportable for surgical preparation of the site, including for negative pressure wound therapy. Please explain how to use these codes when reporting negative pressure wound therapy? This may affect how we report certain wound care services that we provide.

A: The 2012 CPT^® Manual includes a new subheading, “Skin Replacement Surgery” that includes definitions for surgical preparation codes 15002–15005.

The AMA expanded the instructions in 2011 to include negative pressure wound therapy and further defined the instructions for 2012. The 15002–15005 code range denotes the initial preparation of a wound site to create a clean and viable surface for skin graft placement or for negative pressure wound therapy.

CPT codes 15002–15005 may be reported in addition to the codes for skin grafting and negative wound therapy when the intent is for the wound to heal by primary intention. Do not report these codes if a wound is left to heal by secondary intention.

Negative pressure wound therapy, also known as a wound vac, plays an important role in treating wounds. The wound vacuum applies subatmospheric pressure, either continuously or intermittently, to the surface of a wound to promote healing.

CPT code 97605 (negative pressure wound therapy) and CPT code 15002 (preparation of the wound bed) do not trigger a National Correct Coding Initiative (NCCI) Edit triggers. No NCCI instructions prevent reporting the codes together.

The keys to appropriate reporting are to ensure:

Medical necessity is met relative to NCDs or LCDs
Documentation is complete, includes the correct dimensions of the wound, and supports the need for wound preparation
Wound is meant to heal by primary intention

Providers should review the “Skin Replacement Surgery” codes in the 2012 CPT® Manual carefully and ensure that documentation clearly supports the service before assigning any codes in the 15002–15278 range.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Set rates that reflect intent of new codes

Fri, 27 Jan 2012 05:00:00 GMT

CMS expects hospital charges to reflect the relative resources that are required to provide a particular service. Therefore, someone at each hospital must understand new and replaced code changes, determine the intent of the new codes, and work with the appropriate individuals to develop an accurate charge.

Inputting a code in the chargemaster and calling it a day isn’t enough because new codes often represent new combinations even if they don't always represent new services.
If a new code is similar to an existing service, determine how similar (or dissimilar) it is with respect to time, resources, billing units, dosage, and other factors, and then move forward to develop the charge.

Increasingly more new codes represent a combination of existing codes and services. For example, in 2011, the AMA introduced three new combination codes for CT of the abdomen and pelvis. The codes were new, but they did not represent new services; instead they combined two existing services into single codes.

In this example, if the individual who updates the chargemaster simply replaces the old single-service code with a new combination code without reviewing and changing the dollar charge associated with the new code the hospital will continue to bill as if it rendered only a single service, even though the new code represents two services.

The tip is adapted from “Reevaluate charge setting in light of 2012 OPPS final rule” in the January issue of Briefings on APCs.

CMS posts Q4 improper payment figures, top issues by region

Thu, 26 Jan 2012 05:00:00 GMT

Each quarter CMS issues a recovery audit program update that details the total amount of overpayments and underpayments indentified in that quarter. In addition, CMS posts the top recovery auditor issue for each region.

The most recent update, which provides information on the time period July 1, 2011 to September 30, 2011, identifies $277.1 million in overpayments and $76.6 million in underpayments, for a total of $353.7 million in improper payments. These numbers are up from the previous quarter, for which CMS reported $233.4 million in overpayments and $55.9 million in underpayments for a total correction amount of $289.3 million.

For each quarter CMS has issued these reports, the total correction amount numbers have raised dramatically:

October 2009 – September 2010: $92.3 million
October 2010 - December 2010: $94.3 million
January 2011 - March 2011: $208.9 million
March 2011- June 2011: $289.3 million
July 2011 – September 2011: $353.7 million

Perhaps most telling of all the figures, however, is the quarterly difference in the correction amount of the total national program since its inception. The Q3 update lists the total correction amount of the national program at $684.8 million, while the latest report has the amount at $939.4 million. This jump is indicative of the individual recovery auditors ramping up their efforts to identify improper payments nationwide—specifically targeting medical necessity issues, as indicated by the Q4 report:

Region A: Renal and urinary tract disorders (Medical necessity)
Region B: Surgical cardiovascular procedures (Medical necessity)
Region C: Acute inpatient admission neurological disorders (Medical necessity)
Region D: Minor surgery and other treatments billed as inpatient (Medical necessity)

For Region A and D, the top identified issues didn’t change from the Q3 report, but the fact that Region B and C now both identify a medical necessity issue as their top issue truly signifies that the recovery auditors have increased their efforts and focus on issues that may have not been medically necessary for the setting in which they were billed.

To view the Q4 report, click here: http://www.cms.gov/Recovery-Audit-Program/Downloads/FY2011QtrlyReport.pdf

To view the Q3 report, click here: http://www.cms.gov/Recovery-Audit-Program/Downloads/NatProg.pdf

To stay on top of the latest RAC-approved issues in your state, visit the Revenue Cycle Institute website.

Confusing the rebuttal process with the discussion period

Wed, 25 Jan 2012 05:00:00 GMT

The following question and answer is an exchange between a reader and the Revenue Cycle Institute team:

Question: I’m new to handling RAC audits, so I was reading up on the rebuttal process, also known as the “discussion period,” which must be filed within 15 calendar days of the date on the demand letter. I called my RAC (Connolly Healthcare) and was told that the rebuttal letter along with the “stop recoupment” letter should go to my local Medicare administrative contractor (MAC).

The letter we received from Connolly states that we are to notify the “claim processing contractor” and they will review and advise of their decision within 15 days. I’m confusing about who should be receiving the rebuttal letter. When I spoke with Palmetto (our MAC) they were under the impression that I submitted an appeal letter and that they have 60 days to respond. Can you please clarify?

Peeling away the confusion: Split billing guidance

Wed, 25 Jan 2012 05:00:00 GMT

The concept of split billing in both the inpatient and outpatient setting is a hot topic amongst providers as of late, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

The guidance for billing in these two settings can both be found within the Medicare Claims Processing Manual, first of which comes in chapter 1, section 70.8.1.

Outpatient split billing

There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims, according to CMS. Splitting claims is necessary for the following reasons: Proper recording of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes.

According to the manual, expenses incurred in different calendar years cannot be processed as a single claim, so a separate claim is required for the expenses incurred in each calendar year. In addition, Palmetto GBA, a Medicare administrative contractor (MAC), elaborates by stating: “All outpatient claims, SNF claims and non-PPS inpatient claims (e.g. critical access hospitals), which can be billed on an interim basis, should be split at the provider’s fiscal year end and at the calendar year end. It should not be split at Medicare’s fiscal year end unless it corresponds with the provider’s fiscal year.”

Inpatient split billing

For inpatient split billing requirements for the inpatient setting, Trailblazer Health Enterprises, LLC, another MAC, offers a sound summary: Non-PPS providers and providers who are reimbursement through periodic interim payments (PIPs) split-bill their claims at the fiscal year end (FYE), and the days are allocated to the provider year in which they occurred. When services span a non-PPS provider’s FYE for inpatient bills, a provider must submit two claims, the first of which reflects the admission date to the FYE using TOB 112 and status code 30 (still patient). The second claim reflects the first day of the new FY to the discharge date using TOB 115 and the appropriate discharge status code.

Guidance on split billing for inpatient and outpatient services is important to providers since it can prevent delays in payment because they will have to rebill their claims if their outpatient, rural health clinic and swing bed claims cross over calendar years, says Mackaman.

“If providers keep in mind that every calendar year, the patient’s deductibles and coinsurance amounts change for both Part A and Part B services, they can put the split billing process on their radar as part of their annual procedures.”

She continued, “CAHs also need to remember this at the end of their fiscal years for these services as well as their inpatient claims.”

For more information on when to split Part A bills, click here:

http://www.trailblazerhealth.com/Publications/Job%20Aid/WhentoSplitPartABills.pdf

For information on split billing for IPPS hospitals that are paid under the DRG, see section 20.7.2 of the Medicare Claims Processing Manual:

http://www.cms.gov/manuals/downloads/clm104c03.pdf

Q/A: Reporting molecular pathology codes

Fri, 20 Jan 2012 05:00:00 GMT

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

A: Providers use molecular pathology tests to detect the presence of specific genes. Currently, coders report these tests with multiple CPT^® codes to describe the specific testing being performed. Reporting in this manner is sometimes referred to as “stacked” codes.

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

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

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

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

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

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

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairperson, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

Tip: Corrrectly code image-guided lumbar decompression

Fri, 20 Jan 2012 05:00:00 GMT

Percutaneous image-guided, minimally invasive lumbar decompression witha specially designed toolkit (mild^tm) has been proposed as an ultra-minimally invasive treatment for central lumbar spinal stenosis.

During this procedure, physicians fill the epidural space with contrast medium under fluoroscopic guidance. Using a 6-gauge cannula clamped in place with aback plate, physicians employ single-use tools (e.g., portal cannula, surgical guide, bone rongeur, tissue sculpter, and trocar) to resect thickened ligamentum flavum and small pieces of lamina. Tissue and bone sculpting occurs entirely under fluoroscopic guidance, with additional contrast media added throughout the procedure to aid visualization of the decompression. The process is repeated on the opposite side for bilateral decompression of the central canal.

Report CPT^® category III code 0275T (percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements) that became effective July 1, 2011, to denote this procedure. This code maps to APC 0280 with a national payment of $3,535.92. Note, however, that automatic CMS coverage is not implied simply because a CPT code with payment exists under OPPS.

The tip is adapted from “This month’s coding Q&A” in the January issue of Briefings on APCs.

Conference Update: 2012 CDI Professional of the Year nominations, poster session submission period open; additional discount hotel rooms acquired

Thu, 19 Jan 2012 13:46:00 GMT

Professional of the Year nominations
It’s time to submit your nominations for the 2012 CDI Professional of the Year award. Each year the ACDIS annual conference committee selects one CDI Professional of the Year Award winner and two winners of Recognition of CDI Professional Achievement to be recognized at the annual conference. The fifth annual ACDIS Conference will be held May 10-11 in San Diego.

The winner of the Professional of the Year award receives free admission to the ACDIS annual conference. All three winners are recognized before their peers at the conference’s networking and awards luncheon.

Nominees should be ACDIS members who have a passion for the CDI profession and adhere to the ACDIS Code of Ethics. Consider nominating those who may have made a difference to your hospital’s CDI program or someone who positively influenced your CDI team. We also encourage you to nominate individuals who have made an impact on the broader CDI profession, outside of their own programs.

Click here to download the 2012 award nomination form. It is in ‘word’ format; you can type into the form and return it as instructed in the form. The deadline for nominations is February 3. For additional information, e-mail ACDIS Director Brian Murphy at bmurphy@cdiassociation.com.

Poster Session submissions sought

The 2012 ACDIS Conference will again include a poster session as part of its conference offerings. It’s an informal way for hospitals to share their CDI-related successes with each other, network, and exchange ideas and information.

If you would like to present your poster at this year’s conference, please download our poster application form, complete it, and e-mail it to ACDIS Director Brian Murphy at bmurphy@cdiassociation.com. Accepted poster presenters will receive a 50% discount off the price of conference admission.

Any and all ideas are welcome. View a complete listing of last year’s poster presenters on the ACDIS blog or download the 2011 ACDIS Conference Special Section. All final decisions on posters will be made by the 2012 ACDIS Conference Committee. The deadline to submit your poster is Friday, February 24.

Additional conference hotel rooms secured

ACDIS has secured an additional 300 hotel rooms at the Manchester Grand Hyatt, 1 Market Place, San Diego, for Friday, May 11.

The discounted room rate is $199 per night, a rate honored through April 16. However, ACDIS strongly recommends early registration as the first Friday evening room block already sold out.

For registration and additional hotel information, visit http://www.hcmarketplace.com/ev-9584/5th-Annual-ACDIS-Conference-San-Diego-CA.html.

CMS revises HIPAA 5010, COBA MLN Matters article

Wed, 18 Jan 2012 21:36:00 GMT

CMS revised this week guidance it issued in December to help providers understand why they were seeing greater instances of Medicare correspondence letters that said error N22226 serves as the basis for why their patients’ claims could not be crossed over.

CMS made the revision to the December 5 Special Edition MLN Matters Article (SE1137) entitled “Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Process.”

CMS announces RHC and FQHC payment rate increases for 2012

Wed, 11 Jan 2012 05:00:00 GMT

In early November, CMS issued a transmittal that provides the payment rate increases for rural health clinics (RHCs) and federally qualified health centers (FQHCs), which are effective January 1, 2012. These changes specifically update chapter 9, section 20 of the Medicare Claims Processing Manual.

The RHC upper payment limit per visit increased from $78.07 to $79.48 effective January 1, 2012 through the calendar year. This increase reflects a 1.8% increase over the 2011 limit in according with the rate of increase in the Medicare Economic Index as authorized by §1833(f) of the Social Security Act, according to the CMS transmittal.

For urban FQHCs, the upper payment limit per visit also increased by 1.8%; from $126.22 to $128.49. The maximum Medicare payment limit per visit for rural FQHCs went from $109.24 to $111.21. Both of these increases are effective for calendar year 2012, according to CMS.

Though the effective date on the transmittal is January 1, 2012, a January 3, 2012 implementation date is necessary in order to update RHC and FQHC payment rates in accordance with §1833(f) of the Social Security Act. Contractors—to avoid administrative burdens—shall not retroactively adjust individual RHC/FQHC bills paid at previous upper payment limits. However, the contractor has the ability to make adjustments to the interim payment rate or a lump sum adjustment to total payments already made to take into account any excess or deficiency in payments to date, according to CMS.

Study: HIPAA breaches on the rise

Mon, 09 Jan 2012 05:00:00 GMT

Patient information data breaches climbed 32% in 2011, according to the Ponemon Institute’s “2011 Benchmark Study on Patient Privacy and Data Security” report, released in December 2011.

Breaches cost the healthcare industry about $6.5 billion each year, according to report from the Traverse City, MI,-based institute, which conducts independent research on privacy, data protection, and information security policy.

Sloppy mistakes by staff members and unsecured mobile devices cause many of the breaches, according to the study.

The 72 hospitals and healthcare providers that participated in the study averaged four data breaches each over the last two years, putting patient’s PHI at high risk, the study concludes.

Tip: Understand the three-day rule

Fri, 06 Jan 2012 05:00:00 GMT

The three-day rule bundles certain outpatient preadmission services into the inpatient MS-DRG payment. This means they are billed as part of the inpatient claim, and payment is made as part of the applicable DRG for the case.

These three factors can help coders determine whether an outpatient service is subject to the three-day rule:

The relationship of the inpatient and outpatient providers—Outpatient services furnished by a hospital or an entity wholly owned or operated by the hospital are potentially subject to the three-day rule.
The nature of the service—CMS considers all nondiagnostic services occurring three calendar days prior to admission related. Coders may only separately bill for services when they are clinically unrelated to the admission and documentation supports this determination. Diagnostic services are defined by revenue codes and sometimes a HCPCS code. CMS considers surgical services, clinic and ED services, and observation nondiagnostic services, and it treats them differently than diagnostic services for purposes of the rule.
The date the outpatient service is rendered—The three-day rule applies to the day of admission and the three calendar days prior to admission. The rule is based on calendar days, not hours, even though the rule is sometimes referred to as the 72-hour rule.

The tip is adapted from “Report condition code 51 for nondiagnostic services unrelated to inpatient stay” in the December issue of Briefings on APCs.

CMS makes several key changes to MS-DRGs for FY 2012

Wed, 04 Jan 2012 05:00:00 GMT

Coders should already be familiar with the 285 new, revised, and deleted ICD-9-CM codes that CMS finalized for fiscal year (FY) 2012. However, it’s critical that providers also examine how these changes directly affect MS-DRG assignment.

CMS uses MS-DRGs not only to determine reimbursement, but also to track the quality of care, taking into account all the assigned diagnoses—not just principal diagnoses, said Robert Gold, MD, CEO of DCBA, Inc., a consulting firm in Atlanta. As a result, hospitals should look at all significant diagnoses and procedures occurring at their facility because CMS is always examining the possibility of changing the reimbursement system in the future.

It is important to track all diagnoses so that you can get credit as each of these goes into the development of the cost report, said Gold. “If you do not have a diagnosis that justifies the cost for a service billed, you will lose in the long-run,” said Gold, who spoke during HCPro’s December 9 audio conference “FY 2012 IPPS MS-DRG Update: Analyze and Understand the Impact.”

To better understand the potential impact of the code revisions, take a closer look at some specific MS-DRG changes. “There are some neat things that have been coming out,” Gold said.

Two new cardiac-specific comorbidities
Gold noted a division in the classification of hypertrophic cardiomyopathy. The separation occurred because previously, code 425.4 for hypertrophic cardiomyopathy without obstruction also existed. So with the exception of the “obstruction” designation, ICD-9-CM codes 425.1 and 425.4 refer to the same disease, said Gold. As a result, CMS agreed that it should not have two code sets and instead classifies these codes as hypertrophic obstructive cardiomyopathy (425.11) and other hypertrophic cardiomyopathy (425.18), and they have been added to the MS-DRG CC list for FY 2012.

“Be aware that this is not the same thing as left ventricular hypertrophy due to a condition because that is a secondary cardiomyopathy,” said Gold. For example, “when there is a left ventricular hypertrophy due to hypertension that gets coded to 402.xx series or 404.xx if it’s associated with renal disease,” he said. Gold warns that coders should use code 425.8 (cardiomyopathy in other diseases classified elsewhere) and not 425.4 (other primary cardiomyopathies), which is dependent on the word “primary”, where there are a lot of Coding Clinic references that send you to the wrong area.

Division of autologous bone marrow transplant MS-DRG classifications
Previously, autologous bone marrow transplants were classified under MS-DRG 015. However, CMS determined this classification did not take into account the severity of complications or comorbidities that may exist with certain patients. “It was identified that even though autologous bone marrow transplant carries a much lower risk than a bone marrow transplant from somebody other than self or identical twin [allogenic], there is still a considerable difference in the sickness of these patients going into the transplant than necessarily complications derived from the transplant,” said Gold.

Subsequently, CMS has deleted DRG 015 and separated autologous bone marrow transplants into two classifications: MS-DRG 016 (autologous bone marrow transplant with CC/MCC) and MS-DRG 017 (autologous bone marrow transplant without CC/MCC).

Reclassification for excisional debridement
Gold further pointed to changes made in the way in which CMS now classifies skin debridement as skin debridement differs when associated with a skin graft. CMS has reassigned cases from their current single MS-DRG to three new MS-DRGs so that they still qualify as operating room procedures, but also adjust for a lower payment to account for the lower cost of debridement alone.

The new MS-DRGs, which are based on procedure code 86.22, are:

MS-DRG 570 (skin debridement with MCC)
MS-DRG 571 (skin debridement with CC)
MS-DRG 572 (skin debridement without CC/MCC)

Because of the additional cost and risk associated with performing skin grafts, coders must identify cases in which physicians performed skin grafts in conjunction with debridement from cases in which physicians perform debridement alone, said Gold. CMS revised these MS-DRGs based on codes currently assigned to MS-DRG 573–578 whether excisional debridement is documented or not, so long as skin grafting is performed:

MS-DRG 573 (skin graft for skin ulcer or cellulitis with MCC)
MS-DRG 574 (skin graft for skin ulcer or cellulitis with CC)
MS-DRG 575 (skin graft for skin ulcer or cellulitis without CC/MCC)
MS-DRG 576 (skin graft except for skin ulcer or cellulitis with MCC)
MS-DRG 577 (skin graft except for skin ulcer or cellulitis with CC)
MS-DRG 578 (skin graft except for skin ulcer for cellulitis without CC/MCC)

Changes to thoracic aneurysm repair
“Two code sets were developed for thoracic aneurysm repair because it’s important to be able to identify an open repair of a thoracic aneurysm from a stent for a thoracic aneurysm,” said Gold. Though CMS had previously grouped them together, a stent for a thoracic aneurysm is an outpatient procedure, whereas open repair of a thoracic aneurysm is a major inpatient procedure, said Gold.

Previously, CMS listed these codes under MS-DRG 237 (major cardiovascular procedures with MCC or thoracic aortic aneurysm repair) and MS-DRG 238 (major cardiovascular procedures without MCC). For FY 2012, CMS moved them to the higher paying MS-DRG 219 (cardiac valve and other major cardiothoracic procedure without cardiac catheterization with MCC) and MS-DRG 221(cardiac valve and other major cardiothoracic procedure without cardiac catheterization and without MCC).

Guidance for assigning sleeve gastrectomy procedure for morbid obesity
CMS provided new direction for sleeve gastrectomy used to treat morbid obesity. Laparoscopic vertical [sleeve] gastrectomy (ICD-9-CM procedure code 43.82) and the existing procedure code 43.89 (open and other partial gastrectomy) are assigned to the following MS-DRGs

619 (operating room procedures for obesity with MCC)
620 (operating room procedures for obesity with CC)
621 (operating room procedures for obesity without CC/MCC)

“There’s a lot of attention being paid to the overuse of bariatric surgery for patients who do not necessarily require it,” said Gold. Additionally, certain bariatric surgeries (e.g., band procedures) carry lower death and complication rates than other technologies, said Gold. As a result, CMS separated those procedures that carry a higher risk from the band procedures to account for the additional potential complications, Gold said.

Coders need to check for proper documentation in the operative report to ensure proper coding, Gold emphasized. “You need really good documentation to be able to identify that there is a partitioning of the stomach creating a long, tubular channel from the esophagus to the duodenum, which is the laparoscopic vertical sleeve gastrectomy, as opposed to doing a division of the stomach and suturing that to the jejunum,” he said.

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at dbentley@hcpro.com. To learn more about post-operative aspiration pneumonia and the dangers of respiratory insufficiency after trauma or surgery, purchase a copy of HCPro’s audio conference “FY 2012 IPPS MS-DRG Update: Analyze and Understand the Impact.”