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ARE YOU READY FOR ICD-10?
By Judy Terry, RHIA
The deadline for implementation of ICD-10 is getting closer and will actually be a reality in less than three years. Many of us have been complacently waiting for this to become official and now that it is looming around the corner, providers are scrambling to put together a plan for training and implementation.
Prior to the ICD-10 deadline is a revision to the HIPAA electronic claims form (5010) which is required to be imple-mented by January 1, 2012. There is a lot of work to do to be ready for both of these enormous changes.
A survey conducted by Noblis in February 2010 reported that more than 50% of executives consider their organizations to NOT be adequately knowledgeable about ICD-10 and HIPAA 5010 requirements. The majority are planning on using external help to prepare for this major undertaking. Training of coding staff was named as the number one priority fol-lowed closely by challenges in implementing new technology solutions. Conversion to ICD-10 is especially complex be-cause of the thousands of codes. ICD-9 contains around 18,000 codes and ICD-10 contains more than 141,000 codes.
Some hospital systems are contracting with vendors to conduct ICD-10 readiness assessments along with coordinating a multi-disciplinary approach to implementation but many are barely starting the process.
So how can we be ready? The American Health Information Management Association (AHIMA), the American Acad-emy of Professional Coders (AAPC) as well as other companies are offering ICD-10 training modules. AHIMA is using a phased approach similar to the method that has been used by other countries. This year, the first phase is designed as an introduction to the structure and features of the new coding system. This will be followed by a more in-depth understand-ing of the fundamentals in 2011 and 2012. Becoming proficient with ICD-10 is the focus of training in late 2012 and 2013.
Many long time coders have indicated that they may retire before the implementation of ICD-10 which could leave a huge need for trained, experienced coders in the industry. This could be viewed as job security for those who want to stay in the field, but this shortage along with decreased productivity due to training could really hit providers hard. When ICD-10 was implemented in some hospitals overseas, the decrease in productivity was felt for six to twelve months. While productivity is expected to go down during the initial learning period, it should return to near normal after coders are trained and more familiar with the system. It will depend heavily on the amount and quality of the training the coders are given.
Setting timelines for readiness and implementation will be important for all organizations. These should include an im-pact analysis, budget estimates, staffing needs, contacting vendors and setting up training programs. Finally, outcomes measurements should be developed to ensure a successful implementation. For coders, this means pursuing appropriate training and taking this change seriously. Increasing your knowledge and improving your mind can be exciting if ap-proached with a positive attitude. Becoming an expert in the field of ICD-10 can make each of us more valuable to our organization and bring us a sense of personal achievement at the same time.
If you have any questions, concerns, or would like further information on this topic, please contact judyt@rmcinc.org.
For more information, please visit www.ahima.org or www.aapc.com
ICD-9-CM Diagnosis Codes for 2010
A brief refresher of some diagnosis codes that were updated October 1, 2009. Some of the highlights are as follows:
Merkel Cell Carcinoma (209.31-36 and 209.75) can now be specifically coded to identify this type of skin cancer. The codes available are spe-cific to the location of the malignancy on the body.
Retina and Choroid Neoplasms are now assigned to 239.81 which is a neoplasm of unspecified nature of the retina and choroid.
Gout can now be specified as acute or chronic and without or without tophus.
Antineoplastic Chemotherapy-Induced anemia (285.3) is now available for anemia caused by chemotherapy and no E-code is required.
Venous Thrombosis and Embolism and Pulmonary Emboli can also now be specified as acute or chronic.
Avian and Novel Influenza Virus are categorized under 488. The H1N1 influenza virus is now coded to 488.1.
Fluency Problems such as dysphonia or hoarseness of speech are now coded to 784.42. There are also new codes for hypernasality and hypo-nasality as well as a new code for dysarthria as a result of a stroke (438.13).
Colic now has a specific code of 789.7.
Inconclusive Mammogram-Nonspecific Finding can now be coded to 793.82. This will be useful for a routine mammogram that describes ―dense breasts.‖
Failed Sedation is coded to 995.24 to describe instances when conscious sedation fails to provide adequate pain relief or amnesia to patients undergoing a procedure.
There are also many new V Codes and E Codes which are described in the September issues of the AHIMA Journal or online at: http://journal.ahima.org
RMCs Coding Tip: How to Code H1N1 vaccine and its administration
How to Code H1N1 vaccine and its administration:
CPT 90663 – Influenza virus vaccine (pandemic H1N1 formulation)
CPT 90470 – H1N1 immunization, both intramuscular and intranasal, including counseling
ICD-9-CM diagnosis code – V04.81
To be paid for H1N1 vaccine administration, providers should bill 90663 in conjunction with 90470, the AMA said. The 90663 code should be billed at zero dollars, because the vaccine itself is being provided by the federal government at no charge. Providers will be paid for vaccine administration.
MEDICARE PART B: Report HCPCS G9141, Influenza A (H1N1) immunization administration (includes the physician)
Recovery Audit Contractor (RAC) Issues – 2010
By Judy Terry RHIA,CCS RMC, Inc. Director of Review Services
RAC audits are the hot topic in hospitals this year as most areas of the country have already begun to receive requests for charts. Health Data Insights (HDI) is one of four RACs contracted by the Centers for Medicare and Medicaid Services (CMS) to provide audits in the RAC Permanent Program. HDI covers three territories and 17 states including Washington, Oregon and California. Early in January, 2010, HDI posted an extensive list of issues that have been approved for complex reviews. The dates of service being reviewed can go back to October 1, 2007 and the issues include overpayment as well as under-payment. At this time medical necessity is not part of the review process but could be added in the future. A total of 530 DRGs have been chosen for review which encompass 70% of all DRGs.
It is recommended that hospitals concentrate on their own internal review processes to ensure that high risk areas are being coded appropriately. Charts with only one CC or MCC should be reviewed by a second coder prior to billing to be certain that the documentation supports the coding. The query process needs to be air tight to avoid leading the physician to document information that is not supported by clinical indicators. Procedures that drive the DRG should also be care-fully coded to ensure appropriate DRG assignment.
The following DRGs are only a small portion of those selected by HDI but are some of the highest risk areas:
Blood and Immunological Disorders
DRGs 808-816
Coagulation disorders are a common source of confusion for coders. Patients who are on anticoagulants often have abnormal bleeding times but not necessarily an actual problem with coagulation. Coumadin will often cause pro-longed bleeding times, but that is the expected effect of the medication. For further information, see Coding Clinics, 3rd Qtr. 1990, 4th Qtr. 1993, and 3rd Qtr. 2004.
Gastrointestinal Procedures
DRGs 326-358, 405-415, 417-425
Procedure coding for bowel surgeries is important since this code will usually drive the DRG assignment. The operative report should describe the approach (laparoscopic or open) as well as any repair or resection of the bowel. A code for suturing a bowel laceration will change the DRG assignment and must be supported by documentation. If the documentation is vague or doesn’t fully describe the procedure, the physician should be queried.
Respiratory
DRGs 163-168, 175-207
The approach to chest procedures such as those done for lung biopsies is very important in the selection of the correct code. Documentation should specifically support the open or closed approach and the site of any biopsies. Transbronchial biopsies and endoscopic biopsies of the bronchus are categorized into two separate DRGs. Ventilator sup-port of 96+ hours will also change the DRG so it is important to correctly calculate the number of hours that the patient is on the ventilator.
Septicemia
DRGs 870-872
The appropriate documentation of sepsis, septicemia, bacteremia, and urosepsis is still an area of concern for coders and will be scrutinized by the RACs. If urosepsis is documented, but there are clinical indicators for sepsis, the physician can be queried for clarification. However, urosepsis is categorized as a Urinary Tract Infection by ICD-9 and should not be assumed to be sepsis. It is important that the documentation of sepsis be specific and clear. If it is present on admission, it can usually be the principal diagnosis but the guidelines for selecting principal diagnosis must be followed. If the patient is on a ventilator, the DRG will be affected so specific documentation by respiratory therapy is very important. See Coding Clinic 4th Qtr. 1991 regarding ventilator hours.
Skin Graft & Connective Tissue Procedures
DRGs 463-465, 477-502, 515-517, 573-581, 622-624, 901-905
The appropriate documentation of wound debridement can drastically affect the DRG payment. Physicians must document that the debridement was excisional in order to apply this code. The terminology of ―sharp‖ debridement is no longer accepted and physicians should always be queried if the documentation is incomplete or unclear. See 2009 ICD-9 Official Coding Guidelines and Coding Clinic, 1st. Qtr. 2008 for further information.
Discharge disposition codes will also be validated by the RACs since they can affect the DRG assignment. For a full expla-nation of RAC issues that have been selected by HDI, please go to: www.healthdatainsights.com. For information provided by CMS, please go to: http://www.cms.hhs.gov/RAC/
If you have any questions, concerns, or would like further information on this topic, please contact judyt@rmcinc.org.
NOW HIRING!!! Pro Fee CMS Auditor
RMC is an Oregon-based coding review and coding support services company, founded to assist healthcare facilities in obtaining correct reimbursement and minimizing lost revenue through complete and accurate coding, documentation improvement, and education. RMC has been providing comprehensive onsite and remote coding and auditing services to our hospital clients since 1994, and to our physician practice clients since 2002.
RMC is currently recruiting for an experienced professional fee coding compliance auditor who has a strong background in CMS coding, billing and reimbursement guidelines. The position is responsible for analyzing mental health medical records to determine the accuracy of coding, billing and supporting clinical documentation.
Responsibilities:
Under general supervision of the Director of Physician Coding & Compliance
- Audit physician E/M, diagnosis and procedure coding/billing.
- Conduct documentation compliance reviews and audit report writing.
- Identify and communicate trends in coding compliance.
- Work with physicians and other staff to provide education and training pursuant to audit results.
- Perform backlog coding of professional services.
Our ideal candidate will have:
- Minimum 5 years experience as an E/M coder required, prior auditing experience desirable in either a provider or payer environment.
- RHIT, CCS-P, or CPC credential required.
- Expert ICD-9, CPT, HCPCS coding knowledge required, mental/behavioral health experience highly preferred.
- Perform all coding and review services in accordance with official coding guidelines set forth by AHIMA, AHA’s Coding Clinic, AMA’s CPT Assistant, CMS regulations, and other applicable federal and/or state guidelines, and client-specific policies.
- Working knowledge of applicable coding rules and regulatory requirements (e.g. NCDs, LCDs).
- Ability to work independently.
- Proficiency in Microsoft Word & Excel.
This is an ONSITE position in Salem, Oregon. Full-time. Employee or independent contractor status.
Contact: Connie Eckenrodt EMAIL: connie@rmcinc.org or PHONE: 503.658.7274
Ancillary Audio Conference – July 15th
LAST IN THE CODING SERIES! Ancillary Coding with our President, Dana Brown, RHIA, CHC Earn CEUs! Contact Kristin@rmcinc.org for registrationRMC Audio Conference Series 1 (2)
Compliance Auditing in a Group Practice
An effective auditing program is one of the most important compliance activities a group practice can accomplish, and proper documentation is the key. It can protect a practice from fraud allegations and lawsuits. According to the Office of Inspector General (OIG) model compliance plan for small group practices, compliance audits should determine whether:
Services are documented adequately to support the level of service billed
Bills are coded accurately to reflect the services provided
Services are medically necessary and reasonable
The OIG recommends practices annually audit a minimum of 5-10 medical records per physician. More in-depth audits must be performed if the baseline audit reveals problem areas. Physicians who are new to a practice should have their cod-ing/billing audited for at least one full month to ensure coding and documentation standards are upheld.
RMC offers customized and cost-effective services to supplement your group’s compliance activities. Call RMC at 800-538-5007 to inquire about coding and documentation compliance audits for your group TODAY!
Change in CMS Reimbursement Policy Regarding Consultation Services
By Connie Eckenrodt, RHIT, CHCA, CHC Director, Physician Coding & Compliance
No doubt you have heard about the change in CMS reimbursement policy regarding consultation services. Effective January 1, 2010, CMS will consider the consult codes (99241–99255) invalid for payment. Although CPT® Professional Edition 2010 still maintains the codes, CMS will take the payments for consultation codes 99241–99255 and redistribute them to office visits (99201–99215), hospital care (99221–99233), and nursing home (99304–99310) codes.
For outpatient consultation services providers will report an office visit code (99201–99215, Office or other outpatient service), based upon the complexity of the visit and whether the patient is a new or established patient to that provider.
For inpatient consultation services providers will report an initial hospital care visit code (99221-99223, Initial hospital care). Contrary to previous definition of these codes, any physician or qualified non-physician practitioner (NPP) who performs an initial evaluation may bill an initial hospital care visit code where appropriate. However, the at-tending physician will append modifier “-AI” to the E/M code billed to differentiate his/her service overseeing the patient’s care as the “Principal Physician of Record.”
For hospital outpatient observation services for patients who are not subsequently admitted to the hospital as inpatients, providers should report CPT codes 99217-99220. Any physician/NPP providing an additional evaluation should bill the appropriate new or established patient office or other outpatient visit code when providing services to the patient.
If an emergency department physician requests that another physician/NPP evaluate a given patient, the other provider should also bill an emergency department visit code (CPT 99281-99288.)
In all cases, providers should bill the code(s) that most appropriately describes the complexity and level of service provided.
Specific documentation requirements that previously applied to the use of consultation codes will no longer be upheld. However, physicians making a referral and physicians accepting a referral should continue to adhere to appropriate documentation standards (document the request and reason for the evaluation) as an integral part of conventional medical practice. The results of the evaluation should be communicated to the requesting physician to promote proper coordination of patient care.
Providers should pay close attention to which commercial payers will continue to allow consultation codes. RMC recommends that practices implement a tracking system to collect information regarding commercial payers’ policies for reporting and reimbursing consultations in 2010. Practices should watch for denials and reimbursements related to consultations in the first half of 2010, and resolve any issues in a timely manner to lessen long-term financial impact.
Q & A with RMC’s Angela Harrington
Q. Is physician supervision required in clinic at the time EKG, B12, Depo, Testosterone, Gold Injections, Pregnancy tests, Zostavax, Gardasil services are rendered?
A. Yes. All services performed by auxiliary staff incident-to the physician must meet the direct supervision requirements, with the exception of ancillary diagnostic tests and pneumonia, influenza or hepatitis vaccines. See CMS Publication 100-2, Chapter 15 §60 to review the incident-to requirements.
Q. When a physician is externally contracted by a facility to perform the interpretation of a sleep study, is it appropriate for the physician to report the sleep study code with modifier 26?
A. Yes. The CPT instructions for sleep studies state “The sleep services (95805-95811) include recording, interpretation and report. For interpretation only, use modifier 26.” The facility will record the same CPT code with modifier TC.
Q. If a physical therapy practice performs services to a patient for two separate body areas involving two separate diagnoses, with individual plans of care for each diagnosis, should we bill on the same claim for all services or should we bill on separate claims for each area/diagnosis treated?
A. All supervised and constant attendance modalities (CPT 97010-97039) as well as most therapeutic procedures (CPT codes 97110-97140) include “1 or more areas” or “1 or more regions” in their code descriptor. For modalities, which are not time based (CPT 97010-97028), these are limited to one unit per day, regardless of the number of areas treated even when for different reasons or by two different therapists of the same specialty (both physi-cal therapists for example) in the same practice. For timed modalities (CPT 97032-97039) and therapeutic procedures including the “1 or more areas” or “1 or more regions” in their descriptors (CPT 97110-97140), the maximum total units billed for all timed modalities cannot exceed the total time spent by the therapist(s) in a given day, regardless of the number of separate areas/regions treated for separate diagnoses.
For example, if therapeutic exercises (CPT 97110) are performed for 8 minutes for the knee and 8 minutes for the shoulder and massage (CPT 97124) is performed for 10 minutes on the knee and 10 minutes on the shoulder, you would have a total time of 36 minutes for the day and would therefore be limited to 2 total units for all timed therapy procedures that day. You would bill only 1 unit of each 97110 and 97124 for a total of 2 units. You could not bill 2 units of 97110 (1 for each 8 minutes applied to separate areas) and 2 units of 97124 (1 for each 10 minutes applied to separate areas) on the same claim, nor could you bill 1 unit of each 97110 and 97124 separately on separate claims with a different diagnosis for the two areas treated because this represents overbilling of actual therapist time as a total of 60 minutes from the same practice for the same patient.
Please refer to the CMS Claims Processing Manual, Pub 100-4, Chap 5, §20, (http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf) for addi-tional information.
*If you have a question you would like answered in our next newsletter, please e-mail it to Angela@rmcinc.org.
