1. health and fitness
2. disease

Advance Coding & Billing
Necessary Tools for Optimal Reimbursement
In the past five years healthcare providers has experienced a tremendous change in maximize reimbursement. Today’s healthcare it is expected that the providers have a clear understanding of payers guidelines, coding requirements, and billing requirements. In the past it has been bill the claim and wait for payment or denial. Now that is no longer the case , providers face the scrutiny of not understanding and/or utilizing coding , or billing standards that have been set forth.
What are the provider’s challenges for reimbursement? Centers for Medicare and Medicaid has set forth standards that forces the provider review the entire picture for facility and practice standards which include, but not limited to keep abreast of constant changes, understanding of the required standard not only for Medicare, but for Medicaid as well. Since the implementation of Recovery Audit Contractors the federal government continues to identify fraud, waste and abuse that providers are unintentionally committing. And how does that affect the provider? Often this begins merely by not having enough staff to achieve daily task accurately or appropriately. Lack of continue education to keep the provider and staff abreast on the rapid healthcare changes. Not capturing denials in ample time or allowing timely filing to occur. In which providers fall into the trap of overbilling equating to Recovery Audit Contractors as overpayment that can lead into fraudulent billing.
ICD‐9 CM provides codes to classify diseases and hospital procedures. It utilizes a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. There may be up to five characters long. Hospital procedures utilize a 4 digit system to index operations. The lists of codes for ICD‐9CM are published by the World Health Organization. This classification of coding is used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Volume 3 (procedures) is used in assigning codes associated with inpatient procedures. ICD-9-CM CODING
GUIDELINES
There are three volumes of codes, the first two of which are diagnoses and the third procedural codes. The codes are updated annually with the effective date of the codes being October 1 of each year. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD‐9‐CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are included on the official government version of the ICD‐9‐CM, and also appear in “Coding Clinic for ICD‐9‐CM” published by the AHA. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD‐9‐CM itself. These guidelines are based on the coding and sequencing instructions in Volumes I, II and III of ICD‐9‐CM, but provide additional instruction. Adherence to these guidelines when assigning ICD‐9‐CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1‐2) have been adopted under HIPAA for all healthcare settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. ICD-9-CM Steps to Correct
Coding
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official. 4. To determine the appropriateness of the code selection, read all instructional material:
* “includes”, and “excludes” notes
* “see”, “see also”, and “see category” cross reference
* “use additional code”, and “code first underlying disease” instructions
* “code also” and “omit code” notes
* Forth and fifth digit requirements
1. Look up the main term in the Alphabetic Index and scan the subterm entries as appropriate. Follow any cross reference such as “see” and “see also” . Do not code from the Alphabetic Index without verifying the accuracy of the code in the Tabular List.
2. Locate the code in the numerically arranged Tabular List.
3. Observe the punctuation, footnotes, cross refernce , color –coded prompts and other conventions described in the “Convention”.
5. Consult definitions, relevant illustrations 6. Consult the official ICD‐9‐CM guidelines for coding and reporting , and refer to AHA Coding Clinic for coding guidelines governing the use of specific codes.
7. Confirm and transcribe the correct code Documentation Tips for
2011
ABO/non‐ABO incompatibility Indicate whether with hemolytic transfusion reaction; and, if so, whether acute or delayed BMI Document precise body mass index; codes are more precise for BMI of 40 or greater Cognitive deficits Document precise manifestation; e.g., attention or concentration deficit, cognitive communication deficit, visuospatial deficit, psychomotor deficit, f
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Ectasia, aortic Specify site; e.g., thoracic aorta, abdominal aorta, thoracoabdominal aorta Fluid overload Indicate if related to transfusion or otherwise Hemochromatosis Document whether due to hereditary, repeated red blood cell transfusion, other Hemolytic transfusion reaction Indicate whether acute or delayed, type of incompatibility (ABO, non‐ABO, Rh) Intrauterine device Must specify whether encounter occurred for insertion, removal, or removal and insertion. Multiple gestations Note the precise number of placenta and amniotic sacs present during fetal development Personal history of congenital anomoly Documentation should specify whether condition has been corrected Personal history of hypospadias Purpura Indicate whether post‐transfusion or otherwise Retained foreign bodies Document the material of which the foreign body is composed, whether it is magnetic, and whether the foreign body remains or was removed (history of) Rh incompatibility Indicate whether with hemolytic transfusion reaction; and, if so, whether acute or delayed New Acronyms/Abbreviations for 2011 Codes
Spinal stenosis (lumbar) Indicate with or without neurogenic claudication Uterus, anomalies Document precise manifestation; e.g., agenesis, hypoplasia, unicornuate, bicornate, septate, arcuate, other
DHTR—Delayed hemolytic transfusion reaction FNHTR—Febrile nonhemolytic transfusion reaction HPA—Human platelet antigen HTR—Hemolytic transfusion reaction NF—Neurofibromatosis OHS—Obesity hypoventilation syndrome ABO—A, B, and O are the three major blood types. ABO incompatibility is a reaction of the immune system that occurs if two different and not compatible blood types are mixed together. AHTR—Acute hemolytic transfusion reaction AIPHI—Acute idiopathic pulmonary hemorrhage in infants BMI—Body mass index PTP—Post transfusion purpura Rh—Refers strictly to the most immunogenic D antigen of the Rh blood group system: may be Rh positive (does have the D antigen) or Rh negative (does not have the D antigen). Rh incompatibility is a condition that develops when a pregnant woman has Rh‐negative blood and the baby in her womb has Rh‐
positive blood. Rh incompatibility can cause symptoms ranging from mild to serious. At its mildest Rh incompatibility causes destruction
ICD‐9‐CM Changes / Updates 2011
TACO—Transfusion‐associated circulatory overload TRALI—Transfusion associated lung injury Introduction
Rationale: Neurofibromatosis (NF) describes a set of distinct genetic disorders that cause tumors to grow along various types of nerves. NF also can affect the development of non‐nervous tissues such as bones and skin. Neurofibromatosis is recog‐
nized in ICD‐9‐CM by subcategory 237.7. There is fifth digit specification for type 1 (von Recklinghausen’s disease) and type 2 (acoustic neurofibromatosis). Schwannomatosis recently has been recognized as a distinct (although rare) form of NF in which patients have multiple Schwannomas on cranial, spinal, and peripheral nerves; how‐
ever, they do not develop vestibular tumors and do not go deaf as in the type 2 NF. Rationale: Hemochromotosis is only one form of an iron metabolic disorder. Hemochromatosis may result in organ damage, including heart, renal, and liver dysfunction.New codes establish why the iron isn’t metabolizing, or the results of the faulty metabolism. Fifth digit specificity in this category now recognizes that some hemochromatosis disorders are hereditary, while others are due to iatrogenic effects of other treatments Transfusion‐associated
Neoplasms: Neoplasm of uncertain behavior of endocrine glands and nervous system 237.73 Schwannomatosis 237.78 Other neurofibromatosis Endocrine, Nutritional and Metabolic, Immunity: Disorders of mineral metabolism • 275.0 Disorders of iron metabolism • 275.01 Hereditary hemochromatosis
• 275.02 Hemochromotosis due to repeated red blood cell transfusion • 275.03 Other hemochromatosis
• 275.09 Other disorders of iron metabolism Endocrine, Nutritional and Metabolic, Immunity: Disorders of fluid, electrolyte, and acid‐base balance • 276.6 Fluid overload • 276.61 Transfusion associated circulatory overload • 276.69 Other fluid overload
Rationale: Transfusion‐Associated Circulatory Overload (TACO) is a circulatory overload following transfusion of blood or blood components, which may be due either to: 1. the high rates and large volumes of infusion that cannot be effectively processed by the recipient, or 2. underlying cardiac or pulmonary pathology. Endocrine, Nutritional and Metabolic, Immunity: Overweight, Pbesity and Other phyperalimentation • 278.03 Obesity hypoventilation syndrome Rationale: In obesity hypoventilation syndrome (OHS)also called Pickwickian syndromebreathing problems during sleep cause chronic hypoventilation that manifests with decreased oxygen levels and elevated carbon dioxide The breathing problems may be related both to obesity and to neurological issues. This new fifth digit code was added to explain better the cause of hypoventilation (in this case, excess body fat). Blood and Blood‐Forming Organs: Purpura and other hemorrhagic conditions • 287.4 Secondary thrombocytopenia • 287.41 Post transfusion purpura
• 287.49 Other secondary thrombocytopenia Rationale: Post transfusion purpura (PTP) is characterized by sudden severe thrombocytopenia (low blood platelet count), usually arising five to 12 days following transfusion of blood components (e.g., whole blood, RBCs, plasma, or platelets). This reaction is associated with presence of antibodies directed against the Human Platelet Antigen (HPA) system. Previously, there was no specific ICD‐9‐CM diagnosis code for PTP Four‐digit code 287 4 has been
Circulatory System: Other disorders of arteries and arterioles • 447.70 Aortic ectasia, unspecified site • 447.71 Thoracic aortic ectasia • 447.72 Abdominal aortic ectasia • 447.73 Thoracoabdominal aortic ectasia Rationale: “Ectasia” is defined as a swelling of a hollow tube of the body. Applied specifically in this case, ectasia is weakening of the wall of the aorta with some dilation. It is not an aneu‐
rysm, but may lead to aneurysm over time, as well as to dissection of the aorta or other complications. Previously, this would have been reported using code 441.9 Aortic aneurysm, unspecified. Digestive System—Other Diseases and Intestines and Peritoneum: Intestinal obstruction without mention of hernia • 560.32 Fecal impaction Rationale: Problems with the rectum and anal sphincter (for instance, rectoceles) may result in fecal incontinence. The incontinence may present as problematic symptoms such as fecal smear‐
ing, fecal urgency, and incomplete defecation. Genitourinary System: Other specified disorders of female genital organs • 629.81 Recurrent pregnancy loss habitual aborter without current pregnancy Rationale: The wording in the preceding codes was changed from “habitual aborter” to “recurrent pregnancy loss.” The term “habitual aborter” holds negative connotations for a woman, and can increase the anxiety that comes with the Complications of Pregnancy, Childbirth & Puerperium: Other complications of pregnancy, not elsewhere classified • 646.30 Recurrent pregnancy loss, pregnancy complication, habitual aborter unspecified as to episode of care or not applicable • 646.31 Recurrent pregnancy loss, delivered, pregnancy complication, habitual aborter
with or without mention of antepartum
condition Rationale: The wording in the preceding codes was changed from “habitual aborter” to “recurrent pregnancy loss.” The term “habitual aborter” holds negative connotations for a woman, and can increase the anxiety that comes with the medical reality of not being able to carry a fetus to term. Musculoskeletal System and Connective Tissue: Other and unspecified disorders of back 724.02 Spinal stenosis, lumbar region, without neurogenic claudication 724.03 Spinal stenosis, lumbar region, with neurogenic claudication Rationale: Lumbar spinal stenosis is spinal canal narrowing. Neurogenic claudication is a commonly used term for a syndrome associ‐
ated with significant lumbar spinal stenosis leading to compression of the cauda equina (lumbar nerves). Neurogenic claudication symptoms can be similar to vascular claudica‐
tion symptoms but are due to multiple lumbar nerve root compression rather than vascular insufficiency
Symptoms, Signs, and Ill‐Defined Conditions: General symptoms 780.33 Post traumatic seizures Rationale: Post traumatic seizures are acute, symptomatic seizures following a head injury. A unique code for this type of seizure is essential because these patients need to be followed for treatment as well as prognostic and epidemiologic considerations. Symptoms, Signs, and Ill‐Defined Conditions: Symptoms involving digestive system • 787.6 Incontinent of feces 787.60 Full incontinence of feces 787.61 Incomplete defecation 787.62 Fecal smearing 787.63 Fecal urgency Rationale: Problems with the rectum and anal sphincter (for instance, rectoceles) may result in fecal incontinence. The incontinence may present as problematic symptoms such as fecal smear‐
ing, fecal urgency, and incomplete defecation. Incomplete defecation is distinct from constipation and fecal impaction. The deletion of four‐digit code 787.6, and the five‐digit codes added to this category further l i
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Symptoms, Signs, and Ill‐Defined Conditions: Other ill‐defined and unknown causes of morbidity and mortality 799.50 Unspecified signs and symptoms involving cognition 799.51 Attention or concentration deficit 799.52 Cognitive communication deficit 799.53 Visuospatial deficit 799.54 Psychomotor deficit 799.55 Frontal lobe and executive function deficit 799.59 Other signs and symptoms involving cognition Rationale: Documentation very often showed exactly the signs and symptoms of the cognitive deficits, but the coding could not reflect it as accurately. This new subcategory allows for Injury and Poisoning: Poisoning by central nervous system stimulants • 970.8 Poisoning by other specified central nervous system stimulants 970.81 Poisoning by cocaine 970.89 Poisoning by other central nervous system stimulants •
E Codes: External cause status‐Activity E000.2 Volunteer activity Rationale: A new code for volunteer activity was requested by the Bureau of Labor Statistics. With the many disasters and crises facing the world, there have been many volunteers who rush to do the work, and they sometimes suffer with injuries and threats to their health. Previously, this external cause would have ICD-9-CM Coding Notes
E Codes: External cause status‐Activities involving roller coasters and other types of external motion V017.0 Roller coaster riding Rationale: External cause status codes are used along with external cause codes to indicate the status of the patient at the time the event occurred. 1. Content
This chapter contains the following broad groups: 140...195: Malignant neoplasm's, stated or presumed to be primary, of specified sties, except of lymphatic and hematopoietic tissue
196...198: Malignant neoplasm's, stated or presumed to be secondary, of specified sties
199: Malignant neoplasm's, without specification of site
200...208: Malignant neoplasm, stated or presumed to be primary, of lymphatic and hematopoietic tissue
209: Neuroendocrine tumors
210...229: Benign neoplasm's
230..234: Carcinoma in situ
235...238: Neoplasm's of uncertain behavior [see Note, above category 235]
239: Neoplasm of unspecified nature
Categories for "late effects" of infectious and parasitic diseases are to be found at 137...139.
Includes: diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin
Excludes: acute respiratory infections (460...466), carrier or suspected carrier of infectious organism (V02.0...V02.9), certain localized infections, influenza (487.0...487.8, 488.0...488.1)
2. Functional activity
All neoplasm's are classified in this chapter, whether or not functionally active. An additional code from Chapter 3 may be used to identify such functional activity associated with any neoplasm, e.g.:
catecholamine‐producing malignant pheochromocytoma of adrenal: code 194.0, additional code 255.6
basophil adenoma of pituitary with Cushing's syndrome: code 227.3, additional code 255.0
3. Morphology [History]
For those wishing to identify the histological type of neoplasm's, a comprehensive coded nomenclature, which comprises the morphology rubrics of the ICD‐Oncology, is given in Appendix A.
4. Malignant neoplasm's overlapping site boundaries Categories 140...195 are for classification of primary malignant neoplasm's, according to their point of origin. A malignant neoplasm that overlaps two or more subcategories within a three‐digit rubric and whose point of origin cannot be determined should be classified to the subcategory .8 "Other." For example, "carcinoma involving tip and ventral surface of tongue" should be assigned to 141.8. On the other hand, "carcinoma of tip of tongue, extending to involve the ventral surface" should be coded to 141.2 as the point of origin, the tip, is known. Three subcategories (149.8, 159.8, 165.8) have been provided for malignant neoplasm's that overlap the
boundaries of three‐digit rubrics within certain systems. Overlapping malignant neoplasm's that cannot be classified as indicated above should be assigned to the appropriate subdivision of category 195 (Malignant neoplasm of other and ill‐defined sites). ICD‐9‐CM Coding Tips
Coders cannot make assumptions
When a patient presents with a history of recent large volume blood loss and resultant “anemia,” the coder cannot code the type of anemia as due to blood loss without physician documentation supporting the cause/ effect relationship of these two events.
Diagnosis codes cannot be assigned for
abnormal laboratory values
For example, arterial blood gas levels of 7.23/56/178 cannot be coded without accompanying physician documentation of the associated diagnosis. A patient who presents with shock will not have this condition coded when it is described in terms of abnormal vital signs and laboratory values alone; the term “shock” must be noted in the record before it b
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Diagnoses listed as Pathology and Radiology reports cannot be coded in the inpatient setting unless the attending physician documents such diagnoses in the record
If the attending physician does not validate diagnoses
from these sources in the content of the inpatient
record, the coder must request validation of such
Diagnoses stated by house staff members can be coded if there is no contradicting documentation by the attending physician.
Be certain to closely evaluate house staff notes and clarify any conflicting or incorrect documentation by them.
Be careful, precise and consistent in using
seemingly similar words that for coding
purposes are not interchangeable.
For example, “sepsis,” “septicemia,” and “bacteremia” each have significant implications in code/DRG assignment. Descriptors such as “insufficiency” and “failure” have different codes. Please be consistent and precise in your documentation regarding such conditions
The term “urosepsis” is to be coded as a urinary tract infection only, unless it is also stated as “sepsis due to UTI” or other similar diagnostic statement within the record.
If you use the term “urosepsis” alone, you will likely
be queried to clarify whether or not the patient had
sepsis in addition to his/her urinary tract infection.
Codes can be assigned for “presumed,” “possible” or “probable” conditions
• Complete, accurate documentation and code assignment have far‐reaching benefits in the health care environment.
In the event, for instance, that a septic‐
appearing
has negative blood cultures but all other clinical
indicators point to being septic, “presumed sepsis”
would be an appropriate diagnostic statement,
and the diagnosis code for sepsis would be
• Accurate codes support your level of billing, assist
in accurate reimbursement, and provide meaningful
data in outcomes assessment and other quality indicators
Hypertension Coding
• Specificity in code assignment provides the full picture of treatment rendered to the patient and can impact the reimbursement for all care providers.
Hypertension is defined as a persistently elevated arterial blood pressure with a systolic pressure reading at rest that averages 140 millimeters of mercury or more, a diastolic pressure at rest that averages 90 millimeters of mercury or more, or both. Only the systolic or the diastolic pressure reading needs to be high for the physician to diagnose hypertension. Typically, hypertension does not cause any symptoms, but does increase the patient’s risk of certain diseases such as stroke, aneurysm, heart failure, myocardial infarction, and kidney damage.
Challenges of Coding Hypertension
A code for benign or malignant hypertension should not be assigned unless the physician documents the specific type in the body of the medical record. Documentation of hypertensive crisis or uncontrolled hypertension is not indicative of malignant hypertension. Without further clarification, assign code 401.9 for a diagnosis of hypertensive crisis or uncontrolled hypertension. Example: Just because a patient has congestive heart failure or an enlarged heart along with hypertension, it doesn’t give you freedom to code 402 (hypertensive heart disease) or 404 (hypertensive heart and chronic kidney disease). The official coding guidelines require you to assume a relationship between hypertension and chronic kidney disease when the two conditions occur together. But you’re headed for trouble if you take that rule too far. • When not to assume relationships between CKD and HTN and when you must. • How to sequence multiple manifestations of hypertension and heart disease. • When to use mandatory additional codes. • How to uncover clues in the documentation. • How to use the hypertension chart. Example 1: If your physician documents a patient with benign hypertensive renal disease with renal failure, you would report 403.11 (Hypertensive chronic kidney disease; benign; with chronic kidney disease stage V or end stage renal disease). You need only this one code to describe the patient's entire condition.
Example 2: If your physician treats a patient with benign hypertensive disease with heart failure, you would report 402.11 (Hypertensive heart disease; benign; with heart failure). This code indicates the patient's entire hypertensive status.
Underlying Conditions Essential Hypertension
Note: You also would need to report an additional code to specify the type of heart failure, such as 428.0 (Congestive heart failure, unspecified).
Red flag: If your physician documents the patient has heart disease due to hypertension, he should also indicate whether the disease is with or without heart failure. "This [distinction] will help the coder select the best code in the 402 or 404 categories. And if the patient does have heart failure remember to
√ High blood pressure √ Hyperpiesia
√ Hyperpiesis
√ Hypertension (arterial)
√ Hypertensive vascular: degenera on disease
Underlying Condition Secondary Hypertension
√ Renal Artery
√ Renal Artery Stenosis
√ Pyelonephri s
√ Glomeulonephri s
√ Polycys c kidney disease, Cushing disease, Coarctation of the Aorta, and Acute intermittent porphyria Coding ICD-9-CM Statements
Statements of “probable” , “rule out”, “questionable “ can only be coded for inpatient as an definitive diagnosis. Such statements can not be utilized for outpatient coding.
Case One
Patient was admitted for an evaluation of her adrenal malfunction. She had a 4yr history of hypertension with evidence of primary aldosteronism. A CT san of the abdomen also suggested a left adrenal mass. She was discharged and was to return for a left adrenalectomy the following week.
D/C diagnosis: Probable adrenal mass, hypertension and hypokalemia due to primary aldosteronism
255.8, 255.10, 276.8,401.9
Case Two
Group B which grew from the urine culture and was treated with oral anitbiotics.
D/C diagnosis: New onset type 2 diabetes mellitus, out of control, urinary tract infection with beta Streptococcus
The patient fell at home and was unable to get up. Neighbors found him several hours later, and he does not remember any circumstances surrounding the event. Blood sugars were mentioned, and diagnosis of diabetes mellitus was given. It became rapidly evident to the attending physician that, even with dietary restriction, the patient would need insulin therapy to lower it. Insulin therapy was started. The only other positive finding was beta ‐Streptococcus
Rationale
The interrelated diagnosis , adrenal mass or aldosteronism, can be designated as principal diagnosis because the patient was admitted for evaluation of adrenal malfunction.
250.02, 599.0, 041.02, E888.9, E849.0
Rationale:
The condition after study , that necessitated admission was newly diabetes out of control. Type 2 diabetic patients often require insulin to bring blood sugar down to an acceptable level, but this does not mean that the diabetes has become insulin dependent. Code V58.67, long term use of insulin is not appropriate because insulin was just started.
The discharge diagnosis for a patient who was admitted for dyspnea were as follows: pneumonia, Klebsiella pneumonia, COPD with emphysema, multifocal atrial tachycardia, mild dementia.
ICD‐10‐CM
482.0, 492.8, 427.89, 294.8, Rationale: Correctly identify the diagnoses stated
The compliance date for implementation of the International Classification of Diseases, 10th Edition, Procedure Coding System/Clinical Modification (ICD‐10‐ PCS/CM) is October 1, 2013 for all covered entities. ICD‐10‐CM, including the ICD‐10‐
CM Official Guidelines for Coding and Reporting, will replace the International Classification of Diseases, 9th Edition, Clinical Modification (ICD‐9‐ CM) diagnosis code set in all health care settings for diagnosis reporting with dates of service, or dates of discharge for inpatients, that occur on or after October 1, 2013. This publication discusses the benefits of ICD‐10‐CM, similarities and differences between the two coding systems, and new features and additional changes that can be found in ICD‐10‐CM.
Benefits of ICD‐10‐CM
ICD‐10‐CM incorporates much greater clinical detail and specificity than ICD‐9‐ CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for:
➤ Measuring the quality, safety, and efficacy of care;
➤ Reducing the need for attachments to explain the patient’s condition;
➤ Designing payment systems and processing claims for reimbursement;
➤ Conducting research, epidemiological studies, and clinical trials;
➤ Setting health policy;
➤ Operational and strategic planning;
➤ Designing health care delivery systems;
➤ Monitoring resource utilization;
➤ Improving clinical, financial, and administrative performance;
➤ Preventing and detecting health care fraud and abuse; and
➤ Tracking public health and risks.
Non‐specific codes still exist for use when the medical record documentation does not support a more specific code.
Similarities and Difference between Two Coding Systems
ICD‐9‐CM Diagnosis Codes
ICD‐10‐CM uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD‐9‐CM (e.g., ICD‐10‐CM has the same hierarchical structure as ICD‐9‐CM). The 7th character in ICD‐10‐CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (e.g., in the Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect). Primarily, changes in ICD‐10‐CM are in its organization and structure, code composition, and level of detail.
➤ 3–5 digits;
➤ First digit is alpha (E or V) or numeric (alpha characters are not case sensitive);
➤ Digits 2–5 are numeric; and
➤ Decimal is used after third character.
Examples:
496 – Chronic airway obstruction, not elsewhere classified (NEC);
511.9 – Unspecified pleural effusion; and
V02.61 – Hepatitis B carrier.
ICD‐10‐CM Diagnosis Codes
New Features found in ICD‐10‐CM
➤ 3–7 digits;
➤ Digit 1 is alpha; Digit 2 is numeric;
➤ Digits 3–7 are alpha or numeric (alpha characters are not case sensitive); and
➤ Decimal is used after third character.
Examples:
A78 – Q fever;
A69.21 – Meningitis due to Lyme disease; and
S52.131A – Displaced fracture of neck of right radius, initial encounter for closed fracture.
1) Laterality (left, right, bilateral)
Examples:
C50.511 – Malignant neoplasm of lower‐outer quadrant of right female breast;
H16.013 – Central corneal ulcer, bilateral; and
L89.012 – Pressure ulcer of right elbow, stage II. The following new features can be found in ICD‐10‐CM:
2) Combination codes for certain conditions and common associated symptoms and manifestations
Examples:
K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding;
E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema; and
I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina pectoris.
3) Combination codes for poisonings and their associated external cause
Example:
T42.3x2S – Poisoning by barbiturates, intentional self‐harm, sequela.
4) Obstetric codes identify trimester instead of episode of care
Example:
O26.02 – Excessive weight gain in pregnancy, second trimester.
5) Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character.
Examples:
T46.1x5A – Adverse effect of calcium‐channel blockers, initial encounter; and
T15.02xD – Foreign body in cornea, left eye, subsequent encounter.
6) Two types of Excludes notes
Example:
L27.2 – Dermatitis due to ingested food.
Excludes 2: Dermatitis due to food in contact with skin due to food in contact with skin (L23.6, L24.6, L25.4).
7) Inclusion of clinical concepts that do not exist in ICD‐9‐CM (e.g., underdosing, blood type, blood alcohol level)
Examples:
T45.526D – Underdosing of antithrombotic drugs, subsequent encounter;
Z67.40 – Type O blood, Rh positive; and
Y90.6 – Blood alcohol level of 120–199 mg/100 ml.
8) A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications)
Examples:
E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy;
F10.182 – Alcohol abuse with alcohol‐induced sleep disorder; and
T82.02xA – Displacement of heart valve prosthesis, initial encounter.
9) Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders
Examples:
D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen; and
D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen.
Category restructuring and code reorganization have occurred in a number of ICD‐10‐CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD‐9‐CM;
➤ Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge;
➤ New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks); and
➤ The codes corresponding to ICD‐9‐CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD‐9‐CM.
➤ Excludes 1 – Indicates that the code excluded should never be used with the code where the note is located (do not report both codes).
Example:
Q03 – Congenital hydrocephalus
Excludes 1: Acquired hydrocephalus (G91.‐)
➤ Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions).
CPT 2011 CHANGES
Evaluation and Management – 3 New Codes
Integumentary System – 3 New & 2 Deleted codes
Digestive System – 18 New & 4 Deleted
Urinary System – 1 New Code
Musculoskeletal System – 5 New Codes
Respiratory System – 4 New Codes
Female Genitourinary System – 1 New Code
Cardiovascular System – 20 New & 23 Deleted
Nervous System – 8 New & 2 Deleted codes
Excision Lesion Coding Tips
Eye and Ocular Adnexa – 4 New Codes
Radiology – 5 New Codes
Medicine – 39 New & 41 Deleted codes • Lesion excision, the defect may require simple, intermediate, or complex closure and in unusual circumstances, tissue transfer procedures. Bandaging , strip closure, or simple closure is considered to be a component of the excision and should not be reported separately. Intermediate , complex, or other forms of more complicated repair must be fully documented in the medical record or they should not be reported.
Measurement, report, location ensures coding accuracy
• Patience is a virtue, particularly when it comes to coding lesion removal. • Waiting for the pathology report to come back is critical for choosing the correct benign or malignant excision set. Use these steps to prevent mislabeling a patient and assigning a lesser paying code.
• Key factor in determining if the claim is coded correctly is when a biopsy is performed as part of a lesion removal, the biopsy is a component of the overall procedure and is not reported separately.
Step 1: Encourage Your Physician to Measure First
You should select the appropriate lesion excision size code based on the physician's report. "If the physician doesn't measure the lesion before he cuts it out, he's cutting his reimbursement in half.
Once the specimen is put in the jar, the specimen shrinks down to half its original size. If the doctor doesn't put the original size in the note, the coder has to code based on the smaller excision size listed in the pathology report. "That will cost the practice a lot of money.”
CPT's excision sizes, including margins, are based on the physician's measurements. "Train providers to measure an excision, and document it with a statement, such as 'I'm going to excise this X cm length by X width lesion. I took 4 cm margins.’
Reminder: If documentation indicates the margin is applicable to both sides of the lesion, double that measurement. For instance, taking a 4 cm margin on each side of the lesion equals a total of 8 reportable cm in addition to the diameter of the lesion itself. Step 2: Wait for Path Report
You should always choose the malignant or benign excision code based on the results of the pathology report even if the physician did not know at the excision time that the lesion was malignant. The pathology report offers the definitive diagnosis that serves as the basis for the CPT excision code selection.
Step 3: Check Anatomical Grouping
• After receiving the pathology report, review the documentation for excision size and location. • Then it's all about location from the anatomical site to make sure the practice is getting all revenue. • Choose the correct code by adding the greatest clinical diameter of the apparent lesion and the margins. Each anatomical group contains lesion excision sizes ranging from small to large lesions. Example: Documentation reads, "I'm going to excise this back 1.0 cm length by 2.0 cm width lesion. I took 0.2 cm margins." The pathology report comes back benign, and you mark 11403 (Excision, benign lesion including margins, except skin tag [unless listed else‐where], trunk, arms or legs; excised diameter 2.1 to 3.0 cm) for the 2.4 cm codeable size ([2.0 lesion diameter] + [0.2 x 2 margins]). If, however, the physician had failed to document the size and the pathology report measured a 1.0 cm lesion plus 0.1 margins, you could code only 11402 (... excised diameter 1.1 to 2.0 cm), resulting in a loss of $21 (Code 11403 has 4.50 transitional non‐facility total relative value units [RVUs] compared to 11402, which the 2009 Medicare Physician Fee Schedule assigns 3.91 RVUs). Forgetting to give the physician credit for the margins would reduce the code to 11401 (... excised diameter 0.6 to 1.0 cm). This would cost the practice approximately $36 (Code 11401 contains 3.50 RVUs, as compared to 11403's 4.50 RVUs). Repairs
• Choice of codes for wound repair (code range 12001‐13160) depends on the anatomic site. Length of the wound in centimeters, and the type of repair. There are three types of wound repairs simple, intermediate, and complicated.
Simple Repair Tips 12001 ‐ 12021
• Using a simple repair code when a more complex procedure was performed.
• Not reporting decontamination or debridement when it constitutes a separately identifiable service. See codes from ranges 11010‐ 11012, and 11040‐ 11044 for more information.
Wound Care
Intermediate Repair Tips 12031 – 12057
□ Intermediate repairs includes the report of wounds that require layered closure of one or more of the deep layers of subcutaneous tissue and superficial fascia, in addition to skin closure. Single layered closure of heavily contaminated wounds that require extensive cleaning and removal of foreign matter also constitute intermediate repair.
Debridement
• Debridement codes 11040 – 11044 are used to report debridement of skin, subcutaneous tissue, and muscle a (soft tissue) or bone. Two of the codes in this series 11043 – 11044 go beyond the integumentary system and into the musculoskeletal system normally listed in the 20000 series. • Debridement is reportable with repair codes when contamination requires prolonged cleansing, when appreciable amount of devitalized or contaminated tissue are removed, or when debridement is performed separately without immediate primary closure of the wound.
Issues with Debridement
• Do not use these codes to report debridement of open fractures or dislocations. Debridements of open fractures are reported by codes 11010 – 11012.
• Do not use these codes to report minor debridement or irrigation of the wound. Significant debridement of contaminated or devitalized tissue must be performed in order to assign a code from the series of codes.
Coding Points
• Procedure meets the criteria for debridement of open fracture. CPT code 11012.
• Treatment of the fracture was not performed. It will be reported when the patient is brought back to the operating room at another surgical session.
• Second open wound containing contaminant and extending into the muscle was derided and dressed. CPT code 11043.
Active Wound Care Management
Non‐physician personnel perform the procedure 97597‐ 97606 described in Active Wound Care Management codes. The codes are not used with or replace the surgical debridement represented by codes 11040 – 11044; a physician performs the procedures the procedures reported with codes 11040‐
11044.
These wound management codes are based on nonselective or negative pressure procedures. Nonselective debridement is that in which healthy tissue is removed along with necrotic tissue. The tissue is gradually loosened with water. Loosened tissue may be cut away with sharp instruments. Nonselective debridement is usually done over the course of several office visits.
Negative Pressure Wound Therapy 97605 – 97606 may include vacuuming then drainage and tissue from the wound area, application of topical medications or ointments, assessment of the wound, and directions dependent on the square centimeters treated.
Physical Therapy
Billing and Coding for Physical Therapy services may be tricky and might affect your reimbursement. These services are only covered if medically necessary. Coverage based on the diagnosis and the patient’s condition should also be determined. The patient’s diagnosis may be different of that from the referring physician. The plan of care and the duration of the care must also be carefully determined.
Physical Medicine and Rehabilitation subsection 97001 – 97799 can be used by a physician or therapist. The subsection includes codes dealing with different modalities of treatments (traction, whirlpool, and electrical stimulation) as well as various types of training. Codes are reported on the basis of time or treatment area, as stated in the description of the code. Codes are divided by supervision or constant attendance. Unit coding is necessary if the time spent administering the treatment exceeds the time listed in the code.
8 Services Not included in Medicare Global Package
Test and measurement codes are listed by the type of testing and the time the testing and the time the testing takes. The type of test would be items such as orthoses, prostheses, and musculoskeletal or functional capacity. Time must be noted in the documentation that is placed in the patient’s medical record. The codes in Physical Medicine and Rehabilitation are used for physical medicine and therapy as well as for other rehabilitation, for example, community / work reintegration (97537).
The following things are not included in Medicare's global package:
1. The visit that determines the need for surgical intervention. Tip: This is the decision for surgery, and if the visit occurs on the day before or day of surgery, append modifier 57 (Decision for surgery) to the E/M code to indicate a major secondary surgical procedure and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for a minor secondary procedure.
2. Unrelated visits for the treatment of a different problem. You'll need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to show that the service is unrelated to the surgery.
3. Treatment of an underlying condition that is not part of normal recovery. Example: Treatment of carcinoma of the prostate found on pathologic examination following a TURP of the prostate for suspected benign prostatic hypertrophy.
4. Diagnostic testing. Example: Laboratory tests such as a urinalysis as well as radiological studies such as renal or bladder sonograms are not included in the global package for either Medicare or private insurances. You may report these studies without a modifier, and they are payable even when the physician performs them in the global period.
5. Other surgeries, including:
• prospectively planned staged procedures (append modifier 58 to the second surgical code);
• more extensive procedures (append modifier 58 to the second code);
• complications with a return to the operating room (append modifier 78 to the second code);
• or other distinct unrelated surgeries (append modifier 79 to the second surgical code).
6. Surgical trays, when noted.
7. Immunosuppressive therapy.
8. Critical care services in the global period unrelated to the surgery. Example: If a patient requires critical care for a serious myocardial infarction (heart attack) following an uncomplicated laparoscopic procedure such as a laparoscopic nephrectomy. Append modifier 24 to the critical care codes, 99291 and 99292, to ensure payment within the global period of i l
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CPT EXERCISES
CASE STUDY ONE
Post Operative Seroma of the back
Procedure: Incision and drainage of postoperative seroma of the back
Anes: 5cc 1% lidocaine with epinephrine
65 yr old woman S/P excision of melanoma of the back one week ago returns today for follow‐up. Post‐Op seroma noted at the previous excision site.
Area on the back prepped and draped in the usual sterile fashion. 5CC 1% lidocaine with epinephrine injected in the area of the seroma. The seroma was punctured with a 16 gauge needle and 30cc of fluid aspirated. A pressure dressing was applied to the wound. The patient tolerated the procedure well. Return to clinic in two days.
Dx: 998.13
Procedure : 10160
Evaluation& Management
Modifiers
24‐ Unrelated evaluation and management services by the same physician during a post‐operative period.
Physician may need to indicate that an evaluation and management service was performed during a post‐operative period for a reason(s) unrelated to the original procedure. Modifier 24 is appropriate when a physician provides a surgical service related to one problem and, during the post‐operative period or follow‐up for the surgery, provides and E/M service unrelated to the problem requiring the surgery. The diagnosis code selection is critical when indicating the reason for the additional E/M service.
Example
A patient had a cholecystectomy and returned to the general surgeon for his 2 week follow‐up visit. The patient at the follow‐up complains of a sore throat and throbbing headache. Examination showed a streptococcal throat infection, which was unrelated to the post‐operative follow‐up, and the physician prescribed medication for the infection in addition to the routine postoperative evaluation. 99212‐24
25‐ Significant separately identifiable evaluation and management service by the same physician on the same day of procedure or other service.
Physician may need to indicate that on the day of a procedure or service indentified by a CPT code was performed; the patient’s condition required significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and post‐
operative care associated with the procedure that was performed. E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. A different diagnosis is not required for reporting of the E/M services on the same date. Modifier 25 is not used to report an E/M service that resulted in a decision to perform surgery. Modifier 25 should be used with E/M codes only.
57‐ Decision Surgery
Evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier 57 to the appropriate level of E/M service. Modifier 57 should be appended to an E/M code only when that E/M service represents the initial decision to perform a major surgical procedure. Modifier 57 allows separate payment for the visit at which the decision to perform the surgery was made, if adequate documentation is available demonstrating the decision for surgery was made during specific visit.
Example:
A patient with coronary artery disease who was well known to the cardiologist was seen for the patient’s annual visit. The patient had not seen the cardiologist for the past year. After performing a comprehensive history and detailed examination, the cardiologist determined that the patient would benefit from a valve replacement and schedule surgery for the following day. The patient was counseled for 15 minutes regarding treatment options, risk and projected outcomes. The procedure planned was valvuloplasty, mitral valve, with cardiopulmonary bypass (33425). 99214‐57
Example
An established patient presented with a 2.0cm laceration of the right index finger. While in the physician’s office, the patient asked the physician to evaluate swelling of the left leg and ankle. An expanded problem focus history and physical exam with low medical decision making were performed for this problem: 99213‐25 12001 Modifier 57 should not be used with E/M visit furnished during the global period of minor procedure (0‐10 global days) unless the purpose of the visit is a decision for major surgery. No separate documentation is required for the use of this modifier when the claim form is submitted. 51‐ Multiple Procedures
When multiple procedures, other than E/M services. Physical Medicine and Rehabilitation services or provision of supplies are performed at the same session by the same provider, the primary procedure or service may be reported as listed.
52 – Reduced Services
Under certain circumstances a service or procedure is partially reduced or eliminated at the physician discretion. Under these circumstance the service provided can be identified by its usual procedure number and the addition of modifier 52. For hospital outpatient reporting of a previously schedule procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior or after the administration of anes. Review modifier 73 or 74.
Correct Coding Initiative-CCI
Edits
The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. The coding policies are based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice. CPT codes representing services denied based on NCCI edits may not be billed to Medicare beneficiaries. Since these denials are based on incorrect coding rather than medical necessity, the provider cannot utilize an “Advanced Beneficiary Notice” (ABN) form to seek payment from a Medicare beneficiary. Furthermore, since the denials are based on incorrect coding rather than a legislated Medicare benefit exclusion, the provider cannot seek payment from the beneficiary with or without a “Notice of Exclusions from Medicare Benefits” (NEMB) form. 59‐ Distinct Procedural Services
Under certain circumstances it may be necessary to indicate that a procedure or service was distinct or independent from other non E/M services performed on the same day. Modifier 59 is used to identify procedure /services , other than E/M services that are not normally reported together, but are appropriate under the circumstances.
CCI Modifiers
Correct coding modifier indicator for both comprehensive /component table and the mutually exclusive table. This indicator determines whether a CCM causes the code pair to bypass the edit. This indicator will be a “0”, “1” or a 9”. The definition of each is:
0= CCM is not allowed and will not bypass the edits.
1= CCM is allowed and will bypass edits
9 = Use of modifiers is not specified. Indicator is used for all code pairs that have a deletion date that is the same as the effective date.
A physician should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A physician should not report CPT code 49000 (Exploratory laparotomy,...) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150). What are “incident‐to” services
"Incident to" is a Medicare billing provision that allows services provided by a non‐physician practitioner (NPP) in an office setting to be reimbursed at 100 percent of the physician fee schedule by billing with the physician's NPI. According to the Medicare Benefit Policy Manual "incident to", is defined, in part, as "services furnished as an integral although incidental part of a physician's personal professional service."
To bill Medicare "incident to" for services provided by an NPP the following criteria must be met:
• The service performed must be one that is typically performed in a physician's office.
• The service performed should be within the scope of practice of the NPP and in accordance with state law.
• The physician must personally treat the patient on the patient's first visit to the practice or treat any established patient who comes to the office with a new medical condition. NPPs may provide follow‐up care.
• The physician must be in the suite of offices (on‐site) when the NPP is rendering the service.
It is important to remember that the physician must continue to see the patient at a frequency that reflects ongoing management of the patient's care as defined by state law.
Medicare Physician Supervision Requirements
For diagnostic services is an outpatient setting, only
“ a doctor of medicine or osteopathy legally authorized to practice” medicine in his or her state as defined by ?1861®of the Social Security Act, may act as a supervisory physician.
CMS recognizes three primary levels of physician supervision. In the context Outpatient diagnostic services, theses are d fi d
General Supervision‐ the procedure is furnished under the physician’s overall direction and control. The physician must order the diagnostic test and is responsible for training staff performing the test, as well as maintaining the testing equipment.
Direct Supervision‐ the meaning of “ direct supervision” varies according to the precise location at which the services provided:
* In the physician office, physician must be present in office or immediately available.
* Hospital outpatient diagnostic services provided under agreement in non‐hospital locations. Supervising physician must be present in the office suite and immediately available to furnish assistance and direction through out the procedure performance
* Services furnished directly or under arrangement in the hospital or an on campus provider based department. The supervising physician must be present on the same campus and immediately available to furnish assistance and direction throughout the procedures performance.
3. Personal Supervision – physician must be in attendance in the room during the procedure performance, regardless of the location.
Treating Physician A “treating physician” is a physician, as defined in §1861(r) of the Social Security Act (the Act), who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem. Treating Practitioner A “treating practitioner” is a nurse practitioner, clinical nurse specialist, or physician assistant, as defined in §1861(s)(2)(K) of the Act, who furnishes, pursuant to State law, a consultation or treats a beneficiary for a specific medical problem, and who uses the result of a diagnostic test in the management of the beneficiary‟s specific medical problem. Order An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative then perform test Y) An order may
Claim Checklist
A written document signed by the treating physician/practitioner, which is hand‐
delivered, mailed, or faxed to the testing facility; NOTE: Signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; Proofing claims prior to submittal can prevent denials, maximize reimbursement and confirm accuracy. It is imperative that the biller understands the requirements to submit an accurate claim. Questions a biller should ask:
1. Do you have the right patient ?
2. Have you changed for the correct tests, procedures/ services that were given or received ?
3. Are the hospital days, and services billed accurate?
Medical Records
4. Are the times correct?
5. Have you over‐coded?
6. Are the quantities and items correct?
7. Are there overcharges or unbundle? Documentation in the medical record not only identifies the service(s) or procedure(s) carried during an encounter, visit or date of service, but documentation should support and meet or exceed the medical necessity. In the past 3yrs it has been identified by CMS that documentation is not meeting the medical necessity, but documentation key elements are missing or incomplete. Key elements being missed or oversight has caused alarm with CMS that indicates fraud among many providers. Appropriate documentation that not only coincides and /or meets medical necessity in accordance to the services/ procedures that are billed CMS, but not limited to other payers.
In today’s healthcare environment health information is collected in various formats: paper based electronic resident records, and computerized physician and residents databases. Documentation standards apply to paper or electronic medical record. In the past years the documentation standards have fallen by the wayside or even disregard in some cases. As CMS structures RACS, MICs and other entities to identify if documentation supports the billed charge(s) it is imperative that documentation standards clearly understood by all authors of the medical record.
Documentation provides a view and health history of a patient. It provides, a record of the patient’s health status including observations, measurements, prognosis and a legal document describing the services/procedures provided to the patient at any given point of the physician patient relationship of care. The medical record provides evidence of the quality of patient care by:
PHYSICIAN SIGNATURES
• Describing services provided to the patient.
• Providing evidence that the care was necessary.
• Documenting the patient response to care and changes made to the plan of care.
• Identifying the standards by which was delivered.
• Documentation adherence to the payer standards.
• Method clinical communication and plan of care among healthcare providers serving the patient.
• Documentation provides support for maximized reimbursement of services rendered or provided to the patient.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used must be a hand written or an electronic signature. Stamp signatures are not acceptable.
Those contractors who review Medicare claims include MACs, Affiliated Contractors (ACs), the CERT contractors, Recovery Audit Contractors (RACs), Program Safeguard Contractors (PSCs), and Zone Program Integrity Contractors (ZPICs). These contractors are tasked with measuring, detecting, and correcting improper payments as well as identifying potential fraud in the Fee for Service (FFS) Medicare Program. The AC, MAC and CERT reviewers shall apply the following signature requirements: If there are reasons for denial unrelated to signature requirements, the reviewer need not proceed to signature authentication. If the criteria in the relevant Medicare policy cannot be met but for a key piece of medical documentation which contains a missing or illegible signature, the reviewer shall proceed to the signature assessment. Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead may make use of the signature authentication process. ELECTRONIC MEDICAL RECORDS
1. A fully Integrated EMR Software System as opposed to interfaced systems
Replacing an existing Practice Management application in favor of an integrated EMR Software and Medical Billing software . If a physician has been using a medical billing and practice management application for several years. It is important for the EMR software system to be integrated with the Medical Billing or Practice Management software application. Integration means that they share the same database and there is not a need for different data elements being pushed out from one system to another on the basis of defined business rules using an interface based on an API (Application Programming Interface). Interfaced applications work but occasionally cause for both systems to become out of sync due to buggy interfaces. • 2) Integration of EMR Software with ePrescription to receive bonus payments
In 2009 and 2010 providers who use a qualified Electronic Prescribing system can earn a Bonus Payment equal to 2% of their total allowed charges through Medicare part B. By using a Certified Electronic Medical Record (EMR) which has in‐built e‐prescribing capability, medical practices can experience dramatic efficiency gains and enhanced patient safety. The provider may or can choose a stand‐alone ePrescription application but it will mean creating yet another avoidable interface or reduced efficiency because of extra data entry operation. It is best to go in for an EMR System with inbuilt ePrescribing capabilities
3) Electronic Medical Record Software that supports PQRI Automation
CMS continues to expand the scope of PQRI (Physician Quality Reporting Initiative) with increased bonus payments. Physicians who satisfactorily follow PQRI guidelines and report quality‐measures data for services furnished January 1, through December 31, 2009, will earn a single consolidated incentive payment of 2.0% of the estimated total allowed charges for services covered under Medicare Part B in mid‐2010. These requirements are complex, and different measures will apply to each practice. The EMR Software that you select should have a built‐in ability that automates the additional documentation while you are examining your patients without any additional work, or creating special reports, or cost. Additionally your EMR Software should make it easy for you to modify and add customized metrics for your i
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• 4) Electronic Medical Software with adaptive learning
Adaptive learning refers to the ability of the EMR Software to remember how each physician documents and allows previous data entry to suggest steps in treatment and documentation going forward. In essence, the EMR Software keeps track of how all users document within the system and "remembers" lists and assessments such as frequently used lists, previous patient generated lists, and prompts physicians based on previously documented diagnosis/ assessments by the physician...the system adapts to each provider's practice patterns, configuring itself automatically. The more you use the EMR Software, the more it learns and the more accurate, faster, and well documented your patient encounters become, saving you time and money.
• 5) Secure Portability and access to your electronic medical records even without an internet connection
Typically, physicians should have access to patient data anytime, anywhere either by using their own laptop or tablet pc, or an off‐site desk top by accessing a server over a secure internet connection. However, there may be many instances when the physician is making trips to hospitals, satellite clinics, at a conference, or traveling where internet access may not be available or you lose internet connectivity at your Clinic, or your server goes down. Thus, your EMR Software application must be able to save selected data including, charts for that day's or the next few week's appointments and your most active or recent patient records, on the provider's tablet pc or laptop. This critical function allows you and your medical staff to continue working and seeing patients, charting, writing Rx's, review patient records, and then, once you return to your main Clinic, or your internet access is restored, your portable device should easily or automatically synchronize right back up with your server. Essentially, you never skip a beat. As an added note, it is imperative that you have the appropriate security measures in place in order to safeguard access to all of your portable devices. 6). Integrated patient portal ‐ Keeping more in‐touch with your patients
Your EMR Software needs to provide your practice with an integrated patient portal that allows patients to connect with your practice in ways that will improve their loyalty and compliance, and have access to key personal health information. Patient portals (or secure patient access to information you authorize) have been traditionally thought of as just allowing patients to provide access to their medical records to other consulting physicians but now, you need an EMR Software that supports a patient portal that also allows for appointment scheduling, re‐fill requests, exchanging secure messages with physicians and other clinical staff, patient education and other health information, and much more. Your patient portal should also be able to be extended and integrated with a website that is customized to your specific needs and helps you to d l b
7) Electronic Medical Record Software that does not box you into rigid templates
Many Electronic Medical Record Software solutions provide pre‐
defined templates that can only be changed by the vendor or IT personnel. However, a growing number of EMR solutions are now template free which is because they are driven by 'Chief Complaint(s)' . Since the system is "CC‐driven", it allows the doctor to "chart at the speed of thought" without being tethered to a template or form that may not fit the particular patient that is being charted. This is proven to offer significant speed in charting over template based systems, especially at point‐of‐care since the physician can navigate to any screen or function at anytime without having to leave a template. • Look for Electronic Medical Record Software that offers the best of both worlds : it is template free but can also use templates, known as COMMON PROBLEM PALETTES. This allows physicians to use predefined templates or forms to document very common and repetitive procedure and visits.
8) Document and Image Management
Your EMR Software should go beyond simply scanning and attaching documents and make sure it provides a complete records management system built into the application. Your EMR Software must be able to either copy documents into the EMR database or link to files without copying. This can be particularly helpful with PACS images and other very large files. Your EMR Software must also enable attaching documents and images to a patient chart at the click of a button and then, make sorting and searching for any kind of document, image or even video as simple as using your email or cell phone.
• 9) Integrated with voice recognition and handwriting recognition
Integration of speech recognition technology in the EMR Software is not an option anymore. When we talk about speech recognition, we implicitly talk about compatibility with Dragon NaturallySpeaking software. With advancement in technology, it is possible for a physician to achieve 98%+ accuracy rate which is at par with the accuracy that is achieved by a human medical transcriptionist. Speech recognition is traditionally utilized to capture the historical portion of the medical health record since pre‐designed templates can not anticipate the full spectrum of facts presented by the patient. • Your EMR Software must also allow the physicians to follow their own preferences for documentation method ‐ handwriting recognition, point and click with stylus, typing or a combination. As you become more comfortable with using your stylus, you will find that it is much easier for you to write on your tablet PC (just as you would scribble on a writing pad) and the handwriting recognition capabilities of the EMR Software converts natural handwriting into ready for use digital information.
• 10) Meets all regulatory and compliance requirements
Your EMR Software must satisfy all mandatory Federal and State regulatory and compliance reporting, general reporting requirements, and appropriate coding documentation. The other upside of requiring that these features be built‐into your Electronic Medical Records Software, is that this is extremely important to qualifying each provider in your practice to receive all the incentives available for EMR from Federal and State agencies. Additionally, many malpractice insurance carriers offer Physicians a substantial discount for having an Electronic Medical Record software with these functionalities.
HIPPA Security
The security series of papers will provide guidance from the Centers for Medicare & Medicare Services (CMS) on the rule titled “Security Standards for the Protection of Electronic Protected Health Information” found at 45 CRF§ Part 160 and Part 164, Subparts A and C, commonly known as the Security Rule. The Security Rule as adopted to implement provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Technical safeguards are becoming increasingly more important due to technology advancements in the health care industry. As technology improves, new security challenges emerge. Healthcare organizations are faced with the challenge of protecting electronic protected health information (EPHI), such as electronic health records, from various internal and external risks. To reduce risks to EPHI, covered entities must implement technical safeguards. Place of Service
Implementation of the Technical Safeguards standards represent good business practices for technology and associated technical policies and procedures within a covered entity. It is important, and therefore required by the Security Rule, for a covered entity to comply with the Technical Safeguard standards and certain implementation specifications; a covered entity may use any security measures that allow it to reasonably and appropriately do so.
Place of Service Codes are two‐digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.
• 11 (Office) — Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Fair market value for the office must be paid for this office in order to qualify for an office and POS 11.
• 22 (Outpatient hospital) — A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Observation uses POS 22 even if the patient is in an inpatient bed (but in observation status).
• 31 (Skilled nursing facility) — A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
• 32 (Nursing facility) — A facility that primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health‐related care services above the level of custodial care to other than mentally retarded individuals.
• 33 (Custodial care facility) — A facility that provides room, board and other personal assistance services, generally on a long‐term basis, and does not include a medical component.
This code set is required for use in the implementation guide adopted as the national standard for electronic transmission of professional health care claims under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA directed the Secretary of HHS to adopt national standards for electronic transactions.
These standard transactions require all health plans and providers to use standard code sets to populate data elements in each transaction. The Transaction and Code Set Rule adopted the ASC X12N‐837 Health Care Claim: Professional, volumes 1 and 2, version 4010, as the standard for electronic submission of professional claims. This standard names the POS code set currently maintained by CMS as the code set to be used for describing sites of service in such claims. POS information is often needed to determine the acceptability of direct billing of Medicare, Medicaid and private insurance services provided by a given provider.
Scenario 1: Patient is an IP at the hospital. They wheeled the patient down to the physicians office so the physician could see the patient (physician did not want to leave his office and since the hospital is right down the hall they brought the patient to him). The physician did x‐rays in his office (he owns the equipment and does the interpretation) and he dictated the progress note in the hospital chart. This is basically a subsequent IP visit except they brought the patient to the physician, instead of the physician going to the patient.
Scenario 2: Patient is an IP at the hospital. They wheeled the patient down to the OP clinic and the physician saw the patient and dictated a progress note in the hospital chart.
Does the location of the visit matter in these situations or would they just bill the 9923x with a POS 21 even though the actual visit took place at a POS 11 and POS 22? What about the x‐rays?
A patient called about a month ago, complaining that his bill was too high. His insurance pays 80% of his hospital bills. The bill he reviewed with me indicated that he would owe our practice a total of over $3000.00; all on one date of service. We balance billed him after response from his insurance carrier showing this was the patient's liability due to plan requirements not being met. Initially, when I saw this, I told him that this was his balance according to his plan; and that he needed to contact them for assistance. I had assumed it was a deductible, so I filed that call away as "completed" and went on with my daily work as usual. Three weeks later, the patient called again to dispute the bill. This time, I took a broader look at his charges. Upon review, I discovered that our office had in fact entered his charges incorrectly.
What Did We Do Wrong?
Upon reviewing his charge history, I found out that the patient had been Inpatient at Charlton‐Methodist Medical Center from 3/19 to 3/24/09. He had been evaluated during this timeframe by one of our cardiologists. He was then transferred to Methodist Medical Center on 3/23/09 for a pacemaker implant performed by another one of our physicians, as an Outpatient procedure. He was then sent back to Charlton for recovery and discharged on the following day (3/24).
• For his charges on 3/23 at Methodist hospital, we billed this claim as an Inpatient procedure. This patient was only at Methodist Medical Center for one day and less than 24 hours. This qualified him as Outpatient. • The patient was being held liable according to his health plan; as the inpatient reporting requirements had not been met.
• When I discovered we had made a mistake, I immediately corrected the claim and sent it back to the insurance company with a request to rework it. With this discovery, we are able to collect timely on a claim that may have been otherwise overlooked
What Did We Learn?
I learned that we must take a closer look at the charges that are being entered; paying special attention to the place of service, along with many other details. The hospital face sheet is the best resource for information regarding a patient's hospital stay.
• I also learned that as a collector, you must not forget to look at the whole picture. Always check what is going on before and after the visit to get a thorough review.
• Diligence matters. So let's all move forward in it to prevent costly mistakes!
Writing Appeals
Appeal Letter Writing
The first paragraph should introduce yourself and explain why you are writing the letter. Although it may be difficult, be sure to keep your tone and emotions in check so that you can show that you can present an objective viewpoint. Keep the first paragraph as concise and clear as possible so that the reader can immediately understand its urgency. The last part should summarize everything you have stated above. Repeat the necessary points that need to be elucidated. Also include the contact details and where you can be reached. Close out the letter by thanking the reader for their time. The next paragraph(s) should narrate the account of what happened, and why your appeal should be granted. Include all the necessary facts in order to legitimize your case. You can start by referring to your handbook or guidelines as member of that particular group or institution. Also, provide specific times and date when particular events occurred. To make your letter more reader‐friendly, use bullet‐points every time you need to enumerate. After doing this, refer to testimonials from people related to your work, transcript of records, and medical certificate, if necessary. Be certain to cover all the bases necessary to PATSY DUNSON
DUNSONPATSY@YAHOO.COM
PATSY@MEDICALASSESSMENTSOLUTIONS.CO
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