Providers often document “global developmental delay” in pediatric charts. The phrase is used to describe when a child takes longer to reach certain development milestones than other children the same age, such as walking or talking. Children with conditions such as Down syndrome or cerebral palsy may also have a global developmental delay.
A benefit of the switch to ICD-10-CM is the ability to be as specific as possible about a patient’s condition, but the downside of this is that it can make coding fractures time-consuming and confusing. Knowledge of bone anatomy and how fracture codes work is therefore an invaluable asset in fracture coding.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, discusses the use of unspecified codes after the ICD-10-CM grace period and advises providers on how to decrease the use of those codes.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
Audited hospitals generally applied modifier -59 (distinct procedural service) incorrectly when billing for outpatient right heart catheterizations and heart biopsies provided during the same encounter, leading to overpayments totaling approximately $7.6 million, according to a March report from the Office of Inspector General.
Q: The CPT Assistant advice on how to apply modifier -59 to CPT code 29874 (knee arthroscopy with removal of loose/foreign body) seems to conflict with NCCI edits. Do the NCCI edits override the advice in CPT Assistant ?
Queries are definitely not what they used to be. When I first started as a CDI specialist, back when dinosaurs roamed the earth, the query process was a muddy exercise in creative writing. CDI specialists wrote all kinds of crazy things in order to get physicians to answer a query. Then in 2001 came the first AHIMA practice brief, “Developing a Physician Query Process,” which gave order and standards to the query process.
Erica E. Remer, MD, FACEP, CCDS , comments on a recent Coding Clinic that has garnered a lot of questions on inpatient obstetrics coding and gives advice on how she thinks this new guidance is flawed. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy?
Written comments on upcoming ICD-10-CM/PCS code changes presented during the ICD-10 Coordination and Maintenance Committee meeting in March are due Friday, April 7.
Clinical documentation improvement (CDI) specialists bridge the gap between physicians and coders. This article takes a look at the benefits of CDI and coding collaboration, and how CDI specialists can address coding hot topics at their own facilities.
Peggy S. Blue, MPH, CPC, CCS-P, CEMC , writes about hemophilia and how this condition is important for inpatient coders to understand since incorrect reporting can affect MS-DRG assignment.
Long before ICD-10 became a focus, working as a clinical documentation improvement manager with physicians to improve their progress and/or operative notes was a challenge—doctors either got it or they didn’t. But as the transition from paper charts to an electronic medical record began, providers started to understand how to better document their visits, since they had to choose from drop-down menus and multiple options to complete their notes.
The 2017 calendar year marks the beginning of a new approach to physician payment through the Quality Payment Program (QPP), an initiative created by the Medicare Access and CHIP Reauthorization Act to revise the physician payment system previously updated through the Sustainable Growth Rate.
Medicare recently published revisions to its appeals process, focusing on the Administrative Law Judge (ALJ) level of appeal. These revisions were published in the Federal Register in the form of final regulations on January 17, 2017, and became effective March 20.
Our experts answer questions about hitting MUEs on injections and infusions, setting multiple prices for the same CPT codes, payment rates for cancer centers, and more.
In the first part of a two-part series on the Merit-based Incentive Payment System (MIPS), discover the basics of the MIPS program, understand who is eligible for 2017 participation, and navigate the scoring system for the first year of reporting.
Q: We have trouble billing multiple units of injections and infusions – mostly CPT add-on codes 96375 and 96376–that are done during observation stays and exceed the medically unlikely edits number. What is the correct way to bill these and get paid?
CMS released a new educational initiative , Connected Care , on March 15 to help raise awareness of the benefits of chronic care management services, as Medicare has recently added and started paying for these services.
Glands located throughout the body are responsible producing hormones and releasing chemicals into the bloodstream as part of the endocrine system. These glands help maintain many important purposes of the body, including metabolism, growth, and reproductive functions. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
In the second part of this two-part series on the Merit-based Incentive Payment System (MIPS), dive deeper into the four performance categories, their requirements, and their scoring parameters for the first year of MIPS reporting. This article also gives readers tips on what clinicians need to do to prepare for and participate in MIPS in 2017.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each definition. This article takes a look at the root operations Drainage, Extirpation, and Fragmentation. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
On March 8, CMS released eight frequently asked questions (FAQ) related to the Medicare Outpatient Observation Notice (MOON). The FAQs reinforce that psychiatric hospitals must comply with the Notice of Observation Treatment and Implication for Care Eligibility Act and MOON.
Trey La Charité, MD, discusses the importance of monitoring your facility’s case-mix index, and how evaluating each component of a case-mix index allows you to narrow your focus and to hone in on all of the factors that might be affecting them.
James S. Kennedy, MD, CCS, CDIP , reviews recent coding audits at that Northside Medical Center of Youngstown, Ohio, and Vidant Medical Center of Greenville, North Carolina, and gives readers tips on how to better prepare their facilities through these examples.
Q: One of my coworkers thought we needed the phrase “unable to clinically determine” as an option on every multiple-choice query we send. My take on it is that if we have “other” with an option for free text, that would cover us for compliance. Further, I thought it was inappropriate to include this option in some cases, as it may offer an option that is preventing me from obtaining the detail and specificity I need.
Q: I am the coding manager for our inpatient coding department. I am wondering if I should create an audit plan to monitor new coders or difficult diagnosis. If so, is there anything specific I should consider when trying to implement a plan?
The incidence of stroke and transient ischemic attack is increasing as the baby-boomer population ages. James S. Kennedy, MD, CCS, CDIP , writes that understanding and embracing clinical and coding fundamentals for these conditions is essential in the joint effort to promote providers’ complete documentation and the coder’s assignment of clinically valid codes.
A study conducted by Journal of American Medical Association (JAMA) based on data obtained from the 2013 Nationwide Readmissions Database, revealed that sepsis accounts for a higher rate of unplanned readmissions than the other studied medical conditions.
Laura Legg, RHIT, CCS, CDIP , explains how external coding audits are an important part of shining a light into all coding operations and turning risk into security and peace of mind. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
The human eye may be small, but it’s one of the most complex organ systems in the body. Review the anatomy of the eye and how to code for conditions affecting the system, including new details for 2017.
The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.
Red letter days in coding compliance occurred in December 2016 and January 2017 with the Office of Inspector General’s (OIG) release of two audit reports. These reports asserted that Northside Medical Center of Youngstown, Ohio, and Vidant Medical Center of Greenville, North Carolina, improperly submitted ICD-9-CM codes for marasmus and severe malnutrition.
In today’s ever-changing healthcare landscape, emphasis is shifting away from fee-for-service to pay-for-performance, from volume-based care to value-based reimbursement, and from case-mix index to outcome measures.
Coders prepared for 2017 with numerous changes to the Official Coding Guidelines for the ICD-10-CM and the addition of many new codes. Quietly waiting in the wings was the updated CPT® Manual for 2017 with its changes waiting to be discovered.
As OPPS packaging has increased, providers may be less likely to appeal claims for certain denied charges based on medically unlikely edits, since it would not increase payments. However, providers should consider appeals when services are medically necessary and appropriate, as CMS bases future payment rates on accepted claims.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
The intersection of CMS’ packaged payment policy and the increasing volume of Medically Unlikely Edits (MUE) can be likened to a car crash waiting to happen. Hospitals are having valid, medically necessary claim lines denied – including charges and units below MUE limits. Providers can help stop the crash by ensuring their claims, CPT coding, medical necessity, and the units are all correct.
The ICD-10 Coordination and Maintenance Committee will meet March 7-8 to discuss new conditions, procedures, and expanded details that could appear in a future update of the code set.
Q: Facilities often have two charges for services performed in an operating room (OR) suite. For example, a facility performs a colonoscopy and an esophagogastroduodenoscopy, which took a total of 20 minutes in the procedure room. The facility charged two set-up fees plus an additional five minutes of OR time. Would this be considered a duplicate charge?
Amber Sterling, RN, BSN, CCDS , and Jana Armstrong, RHIA, CPC , discuss revenue integrity and how it focuses on three operational pillars: clinical coding, clinical documentation improvement, and physician education.
Q: If a patient is admitted to the hospital with diabetic ketoacidosis (DKA) and cholelithiasis, and is treated for both, would you code the cholelithiasis as the principal diagnosis because the patient had his or her gallbladder removed?
CMS pushed the February 15 submission deadlines for select inpatient clinical and healthcare-associated infection measure data, citing system glitches and inaccessibility to QualityNet reports.
Erica E. Remer, MD, FACEP, CCDS , explains what clinical validation denials are, how they are determined, and how a coder can help to limit these rebuffs.
Radiation oncology services billed to CMS had a 9.6% improper payment rate in 2015, leading to Medicare improperly paying $137 million for these services, according to a study reported in the January 2016 Medicare Quarterly Compliance Newsletter .
Q: We have claims that are hitting an edit between a procedure HCPCS code and the new codes for moderate sedation (99151–99153). Since moderate sedation is no longer inherent in any procedure beginning January 1, why are these scenarios hitting an edit?
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about the transition of the CPT code for reporting ablation of uterine fibroid tumors from a Category III to Category I code and the impact that could have on coding and billing.
Inpatient coding departments are likely familiar with integrating clinical documentation improvement (CDI) specialists into their processes. Crystal Stalter, CPC, CCS-P, CDIP, looks at how CDI techniques can benefit outpatient settings and what services and codes facilities should target.
The codes in ICD-10-CM Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, cover diagnoses for conditions throughout the body. Due to the wide scope of conditions in the chapter, it had extensive updates for 2017. Review some of the most significant changes and the details required to accurately report the codes.
Clinical documentation improvement managers discuss their management duties and program priorities and how they strive for the best possible results at their facility.
Crystal R. Stalter, CPC, CCS-P, CDIP, writes about how fully specified documentation is the key to quality care, compliance, and eventual reimbursement, and how documentation software can help to streamline these processes.
In January, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine released the 2016 Surviving Sepsis guidelines, adopting the new consensus definitions for sepsis and septic shock (Sepsis-3) established last year.
James S. Kennedy, MD, CCS, CDIP, discusses bundled payments and the importance of applying proper ICD-10-CM/PCS-pertinent documentation and coding principles to remain compliant.
Q: My hospital’s coding team keeps having trouble distinguishing between J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and J44.1 (chronic obstructive pulmonary disease with [acute] exacerbation. Is there any guidance out there that can help clarify their differences? We would appreciate any help.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
The focus for clinical documentation improvement (CDI) specialists has historically been on the inpatient hospital stay. Review of the chart for conditions that are not fully documented and/or evidence of conditions not documented at all has been standard practice.
In promoting ICD-10-CM coding integrity and compliance, cerebrovascular disease represents one of the greatest challenges for providers and coders alike. It seems that clinicians, ICD-10-CM, and risk-adjusters (those who create the DRG system), do not sing the same tune.
The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present-on-admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder.
Optimal ICD-10 accuracy cannot be achieved by simply looking up a code in an encoder or book. Knowing the rationale for what you are coding, why you are applying one code versus another, and having the knowledge base to correctly apply the 2017 Official Guidelines for Coding and Reporting are the ingredients necessary for accurate clinical coding.
Q: We just heard about a new add-on HCPCS code for 2017, C1842 (retinal prosthesis, includes all internal and external components; add-on to C1841) for the Argus Retinal Prosthesis, but are not sure how to report it along with C1841 (retinal prosthesis, includes all internal and external components). It has nearly the same description as C1841, so this is confusing.
A Comprehensive Error Rate Testing study showed insufficient documentation caused most improper payments for facet joint injections, according to the January 2016 Medicare Quarterly Compliance Newsletter .
Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews when coders should report modifiers -76 and -77 and notes methods for auditing a facility’s accuracy when using these modifiers.
Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes retrospectively that a patient was not really afflicted by a condition that was documented in the medical record and coded by the coder.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Coders have likely noticed that the 2017 CPT Manual features big changes for reporting moderate sedation. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes about how to define moderate sedation and includes tips on reporting the new codes appropriately.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal (GI) tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Laura Legg, RHIT, CCS, CDIP, writes about the new round of Recovery Auditor (RA) contracts, and how even the most experienced RA response team will need to understand the new challenges providers face with CMS’ 2017 changes. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Hospital-acquired conditions (HAC) declined by 21% between 2010 and 2015, saving an estimated 125,000 lives and $28 billion in health care costs, according to preliminary results published by the Agency for Healthcare Research and Quality .
Q: I have a question about coding a medically induced coma. For example, how would I report a patient on a Precedex drip for alcohol withdrawal, supported with mechanical ventilation, and intensive nursing care?
The advent of the electronic record changed (EHR) how clinical documentation improvement specialists work with providers and coders. As more healthcare organizations take on the arduous process of implementing an EHR, new challenges and considerations arise.
James S. Kennedy, MD, CCS, CDIP, reviews important coding recommendations mentioned in various Medicare Quarterly Provider Compliance Newsletters, covering the MS-DRG postacute discharge policy, readmissions to the same hospital on the day of discharge, and postoperative respiratory failure.
One of my favorite sayings when teaching clinical documentation integrity, as well as coding, is that a good lawyer knows the law, but a better lawyer knows the law, the judge, and the jury. In learning the judge and the jury, one of my favorite references is the Medicare Quarterly Provider Compliance Newsletter , an official CMS publication written in plain language that serves as a summary of how Medicare and its contractors interpret the Medicare rules, regulations, and policy statements.
Coding managers cannot always monitor every guideline update or coding-related issue targeted by the Office of Inspector General. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, reviews what a coding manager can do during a coding audit and how to implement a plan.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the challenges faced in OB hospitalist practices and which procedures and services to focus on for coding, billing, and documentation.
Q: We have an off-campus, provider-based department that is “non-excepted,” so we have to report modifier –PN (nonexcepted service provided at an off-campus outpatient, provider-based department of a hospital). Is that just for the services that would be paid under the OPPS if the department were “excepted”?
Review the bones of the pelvic girdle, along with the differences in the bones between genders, and ICD-10-CM coding conventions to properly code fractures of the pelvis.
Insufficient documentation caused most improper payments for retinal photocoagulation payments reviewed in a Comprehensive Error Rate Testing study, according to the January 2016 Medicare Quarterly Compliance Newsletter.
All coders know that working with providers is not always a positive experience. It can be tough providing them education or getting responses from queries. Conversely, providers are busy and typically do not like anything to do with coding. When they hear coding they often take that to mean more work on their part.
A clinical documentation improvement (CDI) team can rapidly lead to quality improvements, according to a recent survey conducted by Black Book Market Research.
Shannon Newell, RHIA, CCS, explains that pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program, as well as the Hospital Readmission Reduction Program, and conveys what CDI teams can do to help.
James S. Kennedy, MD, CCS, CDIP, says that since the clinical intent and language of physicians does not translate into the administrative language of ICD-10-CM, understanding and embracing both their clinical foundations is essential to accurately measure outcomes and ensure coding compliance.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , writes about how one of the many coder obligations is to report noncompliant activities and provides information on how to do this anonymously. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Q: I manage an inpatient coding department, and I am considering having them cross-trained. Are all coders usually cross-trained? And where would be the best place to train my staff?
Many coders may know that the human body contains 206 bones, but they may not realize that more than 10% of them are in the cranium. In addition to reviewing skull anatomy, examine common ICD-10-CM codes for skull conditions.
Late in 2016, CMS finalized three bundled payment models focusing on cardiac care and another for orthopedic care, while also updating aspects of the Comprehensive Care for Joint Replacement (CJR) Model introduced in April 2016.
Q: I notice the parenthetical remarks underneath the new 2017 CPT spinal epidural injection codes (62321, 62323, and 62327) indicate that fluoroscopy, CT, and ultrasound codes are not to be reported with the code. However, the code descriptors only include fluoroscopy and CT, without any mention of ultrasound (76942). Is ultrasound included in the description for 62321?
