CMS recently released its seventh maintenance update for National Coverage Determinations to incorporate ICD-10 and other coding updates, which may require providers to contact Medicare Administrative Contractors regarding previously submitted claims.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews scenarios for initial, subsequent, and sequela encounters, and helps coders better understand how to assign seventh characters for each type of encounter. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Kimberly Anderwood Hoy Baker, JD, writes about the many changes in the 2017 IPPS proposed rule, and explains how almost everyone could be affected by CMS’ proposals.
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to the categories of other cardiothoracic procedures without MCC, and injuries, poisonings and toxic effects of drugs.
The American Health Information Management Association has officially responded to proposed ICD-10-CM/PCS codes that were presented at the ICD-10 Coordination and Maintenance Committee meeting held in March by CMS.
Which services should clinical documentation improvement (CDI) specialists target in outpatient facilities? Anny Pang Yuen, RHIA, CCS, CCDS, CDIP , writes about how outpatient CDI differs from inpatient CDI and how it can be applied in hospitals or physician practices.
Sepsis isn’t the only clinical condition with an updated definition that could impact coding and documentation. A task force of the National Pressure Ulcer Advisory Panel recently changed terminology related to pressure ulcers that includes new terms that are not yet part of ICD-10-CM.
Modifier –GA isn’t the only modifier available to report how services may relate to Medicare coverage policies in hospitals. Learn more about how to properly report modifiers –GX, -GY, and -GZ.
CMS’ coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in a hospital to provide information about how a service relates to Medicare coverage policies.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, discusses strategies for reporting, and better understanding, pyeloplasty in ICD-10-PCS. Note: To access this free article, make sure you first register if you do not have a paid subscription.
CMS issued the fiscal year 2017 IPPS proposed rule on April 18, and has proposed changes to the Medicare Code Editor software program based on numerous provider requests.
With a widespread lack of awareness of national best practice guidelines for malnutrition, Joannie Crotts, RN, BSN, CPC , and Szilvia Kovacs, MS, RD, LDN , explain how identifying and diagnosing the condition is often still difficult, and how important changes can be made to improve a facility’s malnutrition program.
Q: We are currently using a hybrid medical record, so we have standard query forms with multiple-choice options that cannot be modified at this time. We wanted to include a statement so our query doesn’t seem leading. Is our approach to the multiple-choice query format appropriate?
Robert S. Gold, MD, writes about important changes made in hypertension since ICD-9-CM, and helps coders better understand the relatively complex diagnosis.
Clinical documentation and coding has a significant impact on value-based quality outcome performance. Such outcomes include risk-adjusted mortality, readmission, patient safety, complication rates, and cost efficiency measures.
ICD-10 has brought us I10 (essential [primary] hypertension). Some of us thought "That's a relief," while some of us thought "That's a travesty." I am one of the latter.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing ) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
Few in the healthcare industry would argue that the way the government currently pays for drugs is the most cost-effective, efficient, and equitable method possible.
Last year, as ICD-10 implementation approached, organizations throughout the U.S. reported varying levels of comfort with regard to readiness and understanding of the impact of ICD-10 on physician workflow. For some, it was business as usual. For other physicians, ICD-10 became one more check box on the list of reasons to leave practice.
CMS proposed an extensive five-year, two-phase plan to overhaul Part B drug payments for physicians and hospitals in March outside of the normal OPPS rulemaking cycle that could be implemented as early as this fall.
CMS released a list of the thousands of new ICD-10-CM and ICD-10-PCS codes set to be activated October 1, 2016, as part of the 2017 IPPS proposed rule.
Jugna Shah, MPH, looks at CMS’ new proposal to implement a new drug payment model for certain providers and how they can comment in order to the agency about its impact on their facilities.
CMS allows, and sometimes requires, providers to report certain modifiers in order to identify when a service has been provided by different types of therapists. Review the requirements for reporting modifiers –GN, -GO, -GP, and –KX.
Q: Our providers are reluctant to document a correlation between symptoms and a true diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or type II diabetes mellitus in pregnancy).
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about terminology coders will encounter in documentation for Pap tests and other cervical cancer screening report
Robert S. Gold, MD, writes about the significant changes in documentation needs for diseases of the brain and how this can affect patient data, as well as the treatment needs of the patients both during a hospital stay and afterward.
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP and Laurie Prescott, MSN, RN, CCDS, CDIP discuss how for the past few years, healthcare professionals have focused on ICD-10 preparation, and while prep work paid off and the transition has been largely successful, facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding.
Q: We have a teenager with systemic lupus erythematosus and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy. What should we choose as the principal diagnosis?
ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Learn more about root operations that involve the physician looking at a patient, Inspection and Map.
CMS issued the fiscal year 2017 IPPS proposed rule yesterday with updates to several quality initiatives and a reversal of the agency’s 0.2% payment reduction instituted along with the 2-midnight rule in the FY 2014 rule.
Pregnant patients with other health issues can lead to complicated coding scenarios. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the clinical documentation necessary to identify certain complications and how coders can report these diagnoses. 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: Can CPT® code 76700 (ultrasound, abdominal, real time with image documentation; complete) be coded with 76770 (ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited) on the same date of service during the same session?
E/M services resulted in a projected $4.5 billion in improper Medicare payments in 2014, according to the April 2016 Medicare Quarterly Compliance Newsletter, accounting for 9.3% of the overall Medicare fee-for-service improper payment rate.
CMS has proposed a new drug payment model that could impact providers nationwide. Jugna Shah, MPH, reviews the multiple stages of the rule and how providers can comment to CMS about the proposed changes.
Richard D. Pinson, MD, FACP, CCS , describes the Third International Consensus Definitions for sepsis and septic shock as published on February 23 in the Journal of the American Medical Association , and what the impact will be for both clinicians and coders.
An infographic newly released by CMS guides healthcare providers toward better assessing, addressing, and maintaining progress since ICD-10 implementation. Identifying key performance indicators and creating baselines for KPI analysis are important steps in tracking progress, says CMS.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward, but some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015 and requesting charts for inpatient-only surgeries.
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explains how under the Comprehensive Care for Joint Replacement, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement episodes, and how this now requires a CDI evolution.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)¹ as published on February 23 in the Journal of the American Medical Association represents a radical departure from the prior sepsis definitions in 1991² (identified as Sepsis-1) and 2001³ (identified as Sepsis-2) and subsequent Surviving Sepsis Campaign (SSC) guidelines through 2015.
Under the CJR, which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement (LEJR) episodes. Episodes begin with admission to an acute care hospital for an LEJR procedure that is paid under the IPPS through MS-DRGs 469 or 470 (Major joint replacement or reattachment of lower extremity with or without MCC, respectively) and end 90 days after the date of discharge from the hospital.
There have been some significant changes in documentation needs for diseases of the brain since October 2015. These can affect accurate patient data as well as providing information for the treatment needs of the patients both during a hospital stay and afterwards. They will enable patient information to be available to all providers and ensure that you get paid appropriately for the complexity of the patients under your care.
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing ) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
Providers need to keep more in mind than just diagnosis and procedure coding when performing sterilizations for men and women. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews the requirements for sterilizations and the part coders can play in avoiding denials.
ICD-10 implementation represented an unprecedented challenge for the U.S. healthcare system. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, writes about the impact of the change by looking at survey results that compare ICD-10 productivity benchmarks to ICD-9-CM.
The Centers for Disease Control and Prevention released new guidance last week with updated clinical recommendations for patients exposed to the Zika virus and also announced a registry for pregnant women infected with the virus.
Q: What is the proper ICD-10-CM coding for bilateral hip pain? Should we report M25.551 (pain in right hip) and M25.552 (pain in left hip) or M25.559 (pain in unspecified hip)?
Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
Barbara A. Anderson, RN, MSM, says that in 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. Anderson explains how CDI programs can be a valuable bridge between clinical care and coding at hospitals, and gives examples on how to improve upon a facility’s program.
Q: Can you clarify the expectations related to documenting the discussion between a physician and a clinical documentation improvement specialist when a query is done verbally? The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.
On March 9 and 10, CMS held the ICD-10 Coordination and Maintenance Committee meeting to discuss approving changes, additions, and other modifications to the ICD-10 code set.
The AHA's Coding Clinic for ICD-10-CM/PCS , Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement-diagnoses with a long history of coding and clinical documentation confusion, explains Sharme Brodie, RN, CCDS.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation.
Cyndi Pickney, DO, FACP explains that as ICD-10 implementation approached last year, organizations reported varying levels of readiness and understanding of the impact on physician workflow, and now, there are unforeseen consequences.
A recent Association of Clinical Documentation Improvement Specialists poll says that 53% of respondents are not experiencing any real problems with ICD-10-CM/PCS, but coding experts have identified a few tricky diagnoses for coders to be aware of.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient
Q: Our physicians sign off on diagnoses that the nursing staff prepares on admission of a new patient, can you suggest a process to capture all relevant diagnoses?
According to the American Hospital Association’s 2015 fourth quarter RACTrac survey, the most commonly cited reason for a Recovery Auditor’s complex claim denial is due to an inpatient coding error.
The Zika virus has become a major concern over the last couple months and new information about treatment and symptoms seems to emerge daily. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the latest information regarding the Zika virus and how coders can report it.
Q: When a foreign body is removed from the eye, does it matter what instrumentation is used to remove it? We recently had two cases in which the ED physician stated that the foreign body was easily removed with a cotton swab. She is questioning whether we should charge (facility and professional) for this type of removal or whether it should just be considered when determining the E/M level.
Reporting modifier –PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments) only recently became mandatory, but new rules and regulations could change the requirements in certain settings. Kimberly Anderwood Hoy Baker, JD, CPC, reviews recent legislation that could have an impact on modifier –PO and looks ahead to when CMS intends to offer more guidance.
Implementation of electronic health record (EHR) systems can reduce queries and create more standardized documentation for providers, but now, according to a study published by the Journal of Patient Safety , EHRs are also linked to fewer in-hospital patient complications.
Drug administration services follow a hierarchy for reporting, but coding can become complex when providers administer multiple drugs. Review these tips to help tackle tough injection and infusion scenarios.
Remember, the hierarchy applies to all IV injection and infusion services. Chemotherapy services are primary and should be selected as initial when provided in conjunction with therapeutic, prophylactic, or diagnostic services.
Since the dinosaurs roamed the earth (OK, since 1983), coding professionals have been tasked with ensuring that bills for Medicare patients included the proper elements of the diagnosis-related group (DRG) system so that the hospital got as much money as possible from Medicare.
The 2016 CPT® code update may have been relatively small compared to previous years, but the urinary and genital system sections did receive numerous changes to align them with other sections of the code book.
The AHA's Coding Clinic for ICD-10-CM/PCS, Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement‑diagnoses with a long history of coding and clinical documentation confusion.
The root operation identifies the intent of the procedure. It is identified in the third character of the ICD-10-PCS code. ICD-10-PCS guideline A.11 states that the coder is responsible for selecting the root operation that most closely matches the intent of the procedure.
This month's column is all about data--the importance of providers reporting accurate and complete data, as well as CMS having complete, accurate, and consistent data to compute future payment rates.
For years, coding professionals have been tasked with ensuring that bills for Medicare patients include the proper elements of the diagnosis-related group (DRG) in order to try to accurately show a patient’s severity, but, as Robert S. Gold, MD , writes, there is much more to coding than DRG maximization.
Allen Frady, RN, BSN, CCS, CCDS , and Gwen S. Regenwether, BSN, RN , combat coders’ and clinical documentation improvement (CDI) specialists’ querying bad habits, and show how to support productivity and revenue flow for the facility.
The mosquito-borne illness known as Zika virus still has unanswered questions surrounding the illness its self, but thanks to the Centers for Disease Control and Prevention, an official ICD-10-CM diagnosis code has been assigned to the virus.
Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction instead of diastolic or systolic. They say the heart failure is not diastolic or systolic. What is the best way to approach this issue?
CMS administers the Medicare program and it is currently the single largest payer for healthcare in the United States. Medicare Part A, B, C, and D, all encompass a wide variety of services, all of which providers need to understand to determine which services are covered for patients.
CPT codes for drug administration follow a hierarchy that is unique to those procedures. Review the hierarchy in order to understand how to apply codes for any type of scenario.
Q: If a physician orders a consultation for a patient who is experiencing a headache due to hypertension, which ICD-10-CM codes would be assigned? Would hypertension be coded since headache is a common sign and symptom of hypertension, or would both the headache and hypertension be coded?
CMS recently announced a delay in the anticipated system release of outpatient and inpatient quality reporting data due to the relocation of the Health Care Quality Information System Data Center responsible for the Hospital Quality Reporting programs.
Accurate coding and billing data is important for both providers and CMS. Jugna Shah, MPH, writes about challenges providers have faced with providing that data to CMS and what the agency can do to ease provider burden.
Specialty groups are often able to move faster on creating guidelines for new procedures and codes than other ruling bodies. But sometimes this guidance can create conflicts between physician and facility coders. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to avoid these scenarios and come to the best resolution for providers, payers, and patients.
Q: Our facility is developing clinical definitions regarding types of atrial fibrillation (afib) given the specificity changes in ICD-10. Could you provide suggestions for these definitions? Do you think it is appropriate to query for persistent atrial fibrillation for the period of more than seven days and chronic afib sustained for more than 12 months Are you aware of any strategies other institutions are using when querying regarding afib?
Beginning April 1, approximately 800 hospitals will be required to participate in CMS’ new joint replacement payment model. Shannon Newell, RHIA, CCS, outlines the requirements and what providers need to do in order to prepare.
Root operations are the fundamental building block of ICD-10-PCS codes, but providers may not use the same terminology coders are familiar with. Review these root operations that involve taking out all or some of a body part.
CMS is reporting that the Quality Improvement and Evaluation System (QIES) will be down for five days in March due to extended systems maintenance. The QIES will be unavailable starting at 8 p.m. Eastern on March 16, and returning March 21 at 11:59 p.m., according to CMS.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, reviews anatomic details related to hernias and how to use operative report details to report the appropriate procedure codes for hernia surgeries.
