Just when you thought you had your RAC processes in place, more changes appear on the horizon. CMS wasn't shy about making changes to the Medicare RAC program in 2011. For example, the second half of the year saw demand letters shift to become the responsibility of Medicare Administrative Contractors (MAC)—a change that went into effect January 3, 2012. Joseph Zebrowitz, MD, and Debbie Mackaman, RHIA, CHCO, comment on this change as well as other updates, including the RAC Statement of Work, the Medicaid RAC final rule, and the new pre-bill demonstration program.
Coders who are preparing for the upcoming transition to ICD-10-CM should note some significant changes to the coding guidelines for glaucoma coding as part of the 2012 updates to the ICD-10-CM Official Guidelines for Coding and Reporting .
The goals of coding should always be ensuring data accuracy and capturing a patient's true clinical picture. Knowing the intent of an ICD-9-CM code is crucial. However, coding guidelines and official coding guidance sometimes conflict with these goals, putting coders between a rock and a hard place. Robert S. Gold, MD, examines cardiomyopathy, a disease that affects the heart muscle, as an example of a diagnosis that is frequently misreported due to inaccurate guidance.
CMS added four new J codes for reporting drugs and biologicals that previously did not have specific codes available as part of the 2012 Outpatient Prospective Payment System updates ( Transmittal 2376 ).
Although the New Year marked the deadline for Version 5010 compliance, CMS recently reminded providers that it will not exercise enforcement until April 1, 2012. Despite the 90-day discretionary period, CMS urged providers that they should complete the transition to Version 5010 as soon as possible. This extension will not have any effect on the implementation date for ICD-10-CM/PCS, which remains set for October 1, 2013.
Q: I have been told by our billers that infusion codes reported in the ED along with an E/M code that has modifier -25 (significant, separately identifiable evaluation and management service on the same day of the procedure or other service) require another modifier. I thought that -25 is the only modifier that should be submitted, unless the provider started a second infusion at a second site on the body. This is the first time I’ve been told the infusion coder need a modifier if the E/M has modifier -25 appended. All of my educational articles tell me that the two can be reported together. Have I missed an update somewhere along the way?
Q: In my facility, we are supposed to send an email to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
Q: I have a question regarding facility coding for evaluation and management (E/M) levels, not for an ED physician, but for facility-level nursing in the ED. If a specialist is called to evaluate or consult on a patient, the nursing intervention is what the facility-level criteria is based on. For example, a patient has difficulty walking, a nurse assists the patient to get an x-ray, takes vitals, does an initial assessment, then provides discharge instructions of moderate complexity. I would code this scenario as a level 3.
