Q:

What is the correct discharge status code assignment for a state-designated vs. a non-state-designated ALF?

BACKGROUND
The Center for Medicare and Medicaid Services MLN Matters Number: SE0801 provides usage information on the correct patient discharge status codes for state-designated and non-state-designated ALFs, with an effective date of March 1, 2007. Since then, the National Uniform Billing Committee (NUBC) has made several revisions to the patient discharge status codes. The differences in the verbiage between CMS and the NUBC has caused a lot of confusion.

A:

Per the NUBC: The most recent (2014) Official UB-04 Data Specifications Manual is correct. “All of the “state designated” language was removed in December, 2008. The bottom line is that discharges to ALFs are always “04”.”

Per CMS:  “The NUBC is responsible for the maintenance and dissemination of guidance for the UB-04 code set.” The CMS has provided a subset of information for Medicare-participating providers. “For greater detail, providers should visit http://www.nubc.org/ in order to purchase a UB-04 manual.”

Please note: The NUBC has the final authority for the definition and instruction for all discharge disposition codes.

Source: MLN Matters Number: SE0801

Source: Direct email response from the NUBC on March 6, 2014

PNEUMONIA

Pneumonia is a common illness seen in the healthcare industry that affects millions of people each year in the United States. Bacteria are the most common cause of pneumonia in adults.

• Community Acquired Pneumonia (CAP) is acquired by people that have not recently been hospitalized or live in some type of healthcare facility such as a nursing home.
• Healthcare Associated Pneumonia (HCAP) is acquired by people while they’ve been in a healthcare facility such as a nursing home.
• Hospital Acquired Pneumonia (HAC) is acquired while a patient is hospitalized.

NOTE FROM AUTHOR
When a patient is admitted to the hospital with either HCAP or HAC, code Y95 for Nosocomial Condition should also be added – Refer to Coding Clinic 4th Qtr. 2013 page 118.

External sources may also be the source of Pneumonia.

• Aspiration Pneumonia – Caused by the inhalation of foreign material such as food, liquids, vomit or gastric secretions.
• Pneumonitis due to Inhalation of Food and Vomit – J69.0
• Code also any associated foreign body in the respiratory tract from category T17
• Pneumonitis due to Inhalation of Oil and Essences – J69.1
• Code first (T51-T65) to identify substance
• Pneumonitis due to Inhalation of Other Solids and Liquids – J69.8
• Code first (T51-T65) to identify substance
• Radiation Pneumonitis (J70.0) – Due to exposure of therapeutic doses of radiation.
• Use additional code (W88-W90, X39.0) to identify the external cause
• Ventilator Assisted Pneumonitis – J95.851

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.1

As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Code J95.851, should be assigned only when the provider has documented Ventilator Associated Pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12.0-J18.9 to identify the type of pneumonia.

Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.2

A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop ventilator associated pneumonia (VAP) J95.851. In this instance, the principal diagnosis would be the appropriate code from categories J12.0-J18.9 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.

RESPIRATORY FAILURE

In ICD-10-CM there will be combination codes to include Hypoxia and Hypercapnia

Acute Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.00
• With Hypoxia – J96.01
• With Hypercapnia – J96.02

Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.10
• With Hypoxia – J96.11
• With Hypercapnia – J96.12

Acute on Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.20
• With Hypoxia – J96.21
• With Hypercapnia – J96.22

Respiratory Failure, Unspecified

• Unspecified Whether with Hypoxia or Hypercapnia – J96.90
• With Hypoxia – J96.91
• With Hypercapnia – J96.92

Post-procedure Respiratory Failure

            Excludes 1 – Respiratory Failure in other conditions (J96)

• Acute Post-procedure Respiratory Failure – J95.821
• Acute and Chronic Post-procedure Respiratory Failure – J95.822

Respiratory Failure is always due to an underlying condition. Sequencing will be dependent on the circumstances of the admission. If two conditions are equally responsible and there are no chapter specific guidelines, the guideline for two or more diagnosis that equally meets the definition of principal diagnosis may be applied.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Official Guidelines for Coding and Reporting – Section I.C.10.b.3

BRONCHITIS

Manifestations of Acute Bronchitis can now be reflected in ICD-10-CM under category J20.

Acute Bronchitis due to:

• Mycoplasma Pneumoniae – J20.0
• Hemophilus Influenza – J20.1
• Streptococcus – J20.2
• Coxsackievirus – J20.3
• Parainfluenza Virus – J20.4
• Respiratory Syncytial Virus – J20.5
• Rhinovirus – J20.6
• Echovirus – J20.7
• Other Specified Organism – J20.8
• Unspecified – J20.9

EMPHYSEMA

Emphysema is a type of Chronic Obstructive Pulmonary Disease (COPD) involving damage to the air sacs (alveoli) in the lungs.

ICD-10 will now have codes to cover two different forms of Emphysema.

• Panlobular Emphysema (J43.1) - alveolar destruction occurs in all alveoli within the lobule simultaneously.
• Centrilobular Emphysema (J43.2) - destruction that begins at the center of the lobule.

When reporting categories for COPD (J44), Asthma (J45), Chronic Bronchitis (J42) and Emphysema (J43), an additional code should be assigned to show any specific external factors such as:

• Exposure to environmental tobacco smoke (Z77.22)
• Exposure to tobacco smoke in the perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17-)
• Tobacco use (Z72.0)

SINUSITIS

In ICD-10, there will also be individual codes for Acute Sinusitis, Acute Recurrent Sinusitis and Chronic Sinusitis for each individual sinus cavity.

• Acute Sinusitis – defined as symptoms of less than 4 weeks’ duration.
• Maxillary – J01.00
• Frontal – J01.10
• Ethmoidal – J01.20
• Sphenoidal – J01.30
• Pansinusitis – J01.40
• Other Acute Sinusitis – J01.80
• Acute Sinusitis, Unspecified – J01.90
• Acute Recurrent Sinusitis – defined as three or more episodes per year, with each episode lasting less than 2 weeks.
• Maxillary – J01.01
• Frontal – J01.11
• Ethmoidal – J01.21
• Sphenoidal – J01.31
• Pansinusitis – J01.41
• Other Acute Recurrent Sinusitis – J01.81
• Acute Recurrent Sinusitis, Unspecified – J01.91
• Chronic Sinusitis – defined as symptoms lasting longer than 8 weeks.
• Maxillary – J32.0
• Frontal – J32.1
• Ethmoidal – J32.2
• Sphenoidal – J32.3
• Pansinusitis – J32.4
• Other Chronic Sinusitis – J32.8
• Other Chronic Sinusitis, Unspecified – J32.9

Pansinusitis is when each sinus cavity on one or both sides of the face is affected. When multiple sinus cavities are affected but not Pansinusitis, a code from Other Acute, Acute Recurrent or Chronic (J01.80, J01.81 or J32.8) should be assigned.

Note:   When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should then be classified to the lower anatomic site. One example would be Tracheobronchitis to Bronchitis – J40.

INFLUENZA

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.C

Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.

If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category

J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.

Subcategory J10.8 - Influenza due to Other Identified Influenza Virus with Other Manifestation has been expanded to reflect the manifestations of the Influenza.

Influenza Due to Other Identified Influenza Virus with -

• Encephalopathy – J10.81
• Myocarditis – J10.82
• Otitis Media – J10.83
• Other Manifestation – J10.89

To derive at the most appropriate code for any condition, be sure to always read the additional instructions and Excludes Notes in your coding book and/or encoder.

This week, March 9-15, 2014, is Pulmonary Rehabilitation Week. MMP would like to thank all of the healthcare professionals who enhance the quality of life of individuals with lung disease through a Pulmonary Rehab program. We are glad that Medicare finally recognized Pulmonary Rehab as a distinct payable comprehensive program. But along with the benefit of Medicare coverage comes the challenges of meeting all of Medicare’s requirements for coverage. And for Pulmonary Rehab, like a lot of other services, that is no easy task.

The Medicare rules for Pulmonary Rehab can be found in the Medicare manuals, specifically the Benefit Policy Manual, Chapter 15, section 231 and the Claims Processing Manual, Chapter 32, section 140.4. Also, some local Medicare Administrative Contractors (MACs) have coverage policies or articles that further define coverage, such as specific diagnosis codes. Pulmonary Rehab professionals need to be fully aware of Medicare’s requirements and ensure that their program is in compliance.

A recent medical review of Pulmonary Rehab programs by Palmetto GBA, the Part A MAC for Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) found charge denial rates of 76-93%. All PR providers could learn from the results of these reviews so I would like to share some of the major findings.

Claims were denied for the following reasons related to the requirements for:

Diagnosis

• The documentation submitted does not represent a patient with moderate to severe chronic obstructive pulmonary disease (COPD) as defined by the Gold Classification II, III, and IV per 42 CFR 410.47.
• The documentation of post-bronchodilator pulmonary function studies does not meet the requirement of FEV1 less than 80% of predicted and FEV1/FVC of less than 70%.

Physician Referral

• There is no physician’s order/referral for admission to pulmonary rehabilitation services present.

Required Program Components

• Does not contain the required components for pulmonary rehabilitation program as defined in 42 CFR 410.47
• There is no psychosocial assessment of the individual's mental and emotional functioning as it relates to their rehabilitation or respiratory condition.
• There is no outcomes assessment as a written evaluation of patient progress related to the rehabilitation.
• Does not contain mandatory individualized treatment plans as a written, established, reviewed, and signed by a physician every 30 days as defined in 42 CFR 410.47.
• There is no physician's prescribed exercise program present in the documentation.
• There is no documentation of the patient's education or training as it relates to care and treatment.

Frequency and Limits

• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 36 and no more than two sessions per day as defined in 42 CFR 410.47.
• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 72 sessions, with KX modifier and no more than two sessions per day as defined in 42 CFR 410.47.

Physician Oversight

• The documentation submitted does not indicate the supervising physician was available and accessible for medical consultations and emergencies at all times, when services were provided under the program as defined in 42 CFR 410.47.

As you can see, there are a lot of requirements which equals a lot of reasons for Medicare to deny your Pulmonary Rehab claim. Make sure you are following all of Medicare’s requirements so that you can continue to provide this valuable service and actually get paid for your work.

This month the focus is on national news instead of the local news. But this national news is not from one of the major television networks, such as NBC, CBS, ABC, or even FOX. It comes to you from the studios of CMS. In February, CMS manualized four National Coverage Determinations (NCDs) ranging from PETs and pacemakers to oral anti-emetics. These NCDs have different effective dates, but all are set for implementation on July 7, 2014.

Pacemaker NCD

The Pacemaker NCD removes the differential coverage requirements for single versus dual chamber pacemakers. Under the revised policy, both single chamber and dual chamber implanted permanent cardiac pacemakers are covered for the same indication - treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion). The effective date of the policy is August 13, 2013. See MLN Matters Article MM8525 for more information including non-covered indications, affected CPT codes, specific diagnosis codes required for coverage, and billing instructions. Of particular note is the requirement to include a KX modifier on the claim line(s) as an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia.

PET Aβ for Alzheimer’s Disease

Effective with dates of service on and after September 27, 2013 CMS will cover beta amyloid PET scans (PET Aβ) through coverage with evidence development (CED) during a clinical trial to:

1. develop better treatments or prevention strategies for Alzheimer’s Disease (AD), or, as a strategy to identify subpopulations at risk for developing AD, or
2. resolve clinically difficult differential diagnoses (e.g., frontotemporal dementia

Claims for PET Aβ imaging, through CED during a clinical trial, must contain the following:

• Condition code 30, (for institutional claims only);
• Modifier Q0 and/or modifier Q1 as appropriate;
• ICD-9 dx code V70.7 / ICD-10 dx code Z00.6 (on either the primary/secondary position);
• A PET HCPCS code 78811 or 78814;
• A covered diagnosis code; and
• Aβ HCPCS code A9586 or A9599.

Coverage of PET Aβ is limited to one scan in a patient’s lifetime. See MLN Matters Article MM8526 for more information and a list of the covered diagnosis codes.

FDG PET for Solid Tumors

The second NCD addressing PET scans, effective June 11, 2013, revises the coverage of FDG PET scans for solid tumors to remove the requirement for coverage with evidence development (CED). Providers will no longer have to report data to the National Oncologic PET Registry (NOPR) for FDG PET or FDG PET/CT. Also these claims will no longer require the elements indicating CED: modifier Q0, condition code 30 or diagnosis V70.7. See MMP July Article "Changes to PET Coverage"for a coverage table by cancer type.

Modifiers PI and PS, indicating initial or subsequent treatment strategy are still required.  The NCD allows coverage of three subsequent treatment strategy PET scans after an initial treatment strategy PET. Coverage of any additional FDG PET scans (that is, beyond three) used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis will be determined by the local MACs. Cahaba GBA has indicated that they do not currently have a policy capping the allowed number of FDG PET scans beyond three. They stated that providers should rely on the medical judgment of the clinicians and ensure that documentation clearly supports the need for any additional scans. Providers not within Cahaba’s jurisdiction should check with their local MAC for guidance.

Billing instructions in MLN Matters Article MM8468 explain that:

• a KX modifier is required for subsequent treatment strategy FDG PET scans exceeding three (claims for fourth or more oncologic FDG PET for same diagnosis)
• claims with subsequent treatment strategy (-PS) oncologic FDG PET scans without an initial treatment strategy (-PI) claim present in claims history will be denied (Exception: prostate cancer does not require initial since it is non-covered).
• Alemtuzumab (J9010);

Aprepitant for Chemotherapy Induced Emesis

The final NCD manualized in February concerns aprepitant for chemotherapy induced emesis. Since 2005, Medicare has covered the use of the oral three-drug regimen of aprepitant, a 5HT3 antagonist, and dexamethasone for patients who are receiving certain highly emetogenic chemotherapeutic agents when the antiemetic therapy fully replaces an IV antiemetic. Effective for services on or after May 29, 2013, the following anticancer chemotherapeutic agents have been added to the list of anticancer chemotherapeutic agents for which the use of the oral antiemetic 3-drug combination of oral aprepitant, an oral 5HT3 antagonist, and oral dexamethasone is deemed reasonable and necessary:

• Azacitidine (J9025);
• Bendamustine (J9033);
• Carboplatin (J9045);
• Clofarabine (J9027);
• Cytarabine (J9098, J9100, J9110);
• Daunorubicin (J9150, J9151);
• Idarubicin (J9211);
• Ifosfamide (J9208);
• Irinotecan (J9206); and
• Oxaliplatin (J9263)

MLN Matters Article MM8418 contains all the details including a complete list of all chemotherapeutic agents.

Now the local news – Cahaba did not have any coverage updates this month, while Novitas (both JH and JL) continues to be prolific with new and revised policies and Palmetto has some updates. See the links below for the local coverage updates for your region.

Novitas JH Coverage Updates

February 27, 2014

The following JH MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L32723)

The following JH MAC LCD has been revised:

Pain Management (L32702)

February 6, 2014

The following JH MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L32619)

Frequency of Dialysis (L32755)

Infrared Photocoagulation (IRC) of Hemorrhoids (L34350)

Intraoperative Neurophysiological Testing (L32605)

Outpatient Sleep Studies (L32711)

Qualitative Drug Testing (L34352)

Surgery: Blepharoplasty (L32715)

Vascular Access for Hemodialysis (L32708)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L32687) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L32735)

The following JH MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JL MAC LCDs. The following LCDS will also become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L32690)

Glaucoma Treatment with Aqueous Drainage Device (L32733)

Lacrimal Punctum Plugs (L32607)

Wireless Capsule Endoscopy (L32686)

Novitas JL Coverage Updates

February 27, 2014

The following JL MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L29547)

February 6, 2014

The following JL MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L34344)

Frequency of Dialysis (L34388)

Glaucoma Treatment with Aqueous Drainage Device (L34355)

Intraoperative Neurophysiological Testing (L27499)

Lacrimal Punctum Plugs (L34358)

Outpatient Sleep Studies (L27530)

Surgery: Blepharoplasty (L34396)

Vascular Access for Hemodialysis (L32465)

Wireless Capsule Endoscopy (L34342)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L27547) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L33658)

The following JL MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JH MAC LCDs.  The following LCDS will also become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L34495)

Qualitative Drug Testing (L32050)

Palmetto J11 Coverage Updates

Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Q:

Is it appropriate for a testing laboratory to provide a copy of lab results directly to the patient or their representative?
 

A:

Yes. On February 6, 2014, CMS released a final rule that allows laboratories, upon the patient’s request (or upon the request of the patient’s personal representative), to provide access to completed lab tests results directly to the patient or their personal representative under the Clinical Laboratory Improvement Act (CLIA) and HIPAA privacy regulations. Laboratories that are HIPAA covered entities (i.e. conduct covered health care transactions electronically) are required to provide patients with access to their lab results upon request under this new rule. This final rule is effective April 7, 2014 and HIPAA covered entity laboratories have until October 6, 2014 to comply with the new rule. Prior to this new regulation, CLIA regulations limited the release of laboratory tests results to persons authorized under state law to order and/or receive test results, the person responsible for using the test results in the treatment context, and the laboratory that initially requested the test.

Hospital-based laboratories have a big advantage over independent laboratories in the implementation of this rule. Most hospital laboratories will likely handle the new requirement by directing patients to the Hospital HIM Release of Information (ROI) department. These hospital ROI departments are already knowledgeable concerning the HIPAA regulations and have processes in place to address the requirements of HIPAA, such as positive identification of the person requesting a copy of the medical record, pricing for copies, documentation of the release, etc.

For complete information, please see the CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports; Final Rule.

Over the next several months a lot of information will be posted concerning the do’s and don’ts of ICD-10-CM. At times it may be overwhelming. You will find the transition to be easier and less stressful the earlier you start training.

This week the focus will be on the Respiratory System. Many familiar conditions are identified in this chapter such as Asthma, COPD and Pneumonia.

The Respiratory System is made up of organs and tissues that enable us to breathe.

Airways

• Mouth
• Nose and Nasal Cavities
• Pharynx
• Larynx
• Trachea
• Bronchial Tubes or Bronchi, and their tubes

Lungs

• Right Lung – 3 lobes
• Upper
• Middle
• Lower
• Left Lung – 2 lobes
• Upper
• Lower

Lower Linked Vessels – Provide pulmonary circulation

Muscles

• Diaphragm
• Intercostal
• Abdominal
• Muscles in the Neck and Collarbone area – (accessory muscles)

Here is a list of common signs and symptoms seen in the Respiratory System that may be indicative of a more severe condition. Keep in mind, you always want to be as specific as possible when coding for appropriate reimbursement and data quality.

• Cough
• Dyspnea
• Asphyxia
• Shortness of breath
• Epistaxis
• Hemoptysis
• Rales
• Hypoxemia
• Intercostal pain
• Tachypnea
• Hyperventilation
• Respiratory arrest

Categories J00 – J99

• J00 – J06 Acute Upper Respiratory Infections
• J09 – J18 Influenza and Pneumonia
• J20 – J22 Other Acute Lower Respiratory Infections
• J30 – J39 Other Diseases of Upper Respiratory Tract
• J40 – J47 Chronic Lower Respiratory Diseases
• J60 – J70 Lung Diseases due to External Agents
• J80 – J84 Other Respiratory Diseases Principally Affecting the Interstitium
• J85 – J86 Supportive and Necrotic Conditions of the Lower Respiratory Tract
• J90 – J94 Other Diseases of the Pleura
• J95 Intraoperative and Postprocedural Complications and Disorders of Respiratory System, Not Elsewhere Classified
• J96 – J99 Other Diseases of the Respiratory System

Classification changes in ICD-10 will provide greater specificity.

While the overall organization of ICD-10 is similar to ICD-9, diseases have been rearranged. Certain diseases/disorders have been removed from other chapters and placed in Chapter 10.

• Streptococcal Pharyngitis (J02.0) now classified in Chapter 10, no longer will be classified with the Infectious and Parasitic Disease Chapter.
• Ventilator Associated Pneumonia (J95.851) was previously found in the “Injury and Poisoning” Chapter in ICD-9-CM.
• Intraoperative and post-procedure complications pertaining to the Respiratory System have been grouped together in Chapter 10 – J95.

Some codes in Chapter 10 have been expanded to include notes indicating that an additional code should be assigned or an associated condition should be sequenced first. Example:

• Use additional code to identify the infectious agent
• Use additional code to identify the virus
• Code first any associated lung abscess
• Code first the underlying disease
• Use additional code to identify other conditions such as tobacco use or exposure

As with any chapter in ICD-10, coders must be familiar with the Official Coding Rules and Guidelines. Refer to http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

COPD and ASTHMA

Many of the instructions in ICD-9-CM pertaining to COPD have been eliminated in ICD-10-CM. Here are the two hair splitting requirements in ICD-9 that have been eliminated in ICD-10:

• Physicians will no longer have to distinguish Asthma as Intrinsic or Extrinsic.
• Will no longer need separate codes for “Chronic Obstructive Asthma”, as opposed to “Chronic Obstructive Bronchitis” or plain ole “COPD”.
• In ICD-10-CM, Asthma is just Asthma and COPD is just COPD.

If a patient is documented with both COPD and Asthma, two codes will be required to show each condition.

EXAMPLE
Patient presented to ER with gradual increase in shortness of breath which was unresponsive to home nebulizer treatments. In the ER, patient received more respiratory treatments; however, the patient was admitted after he failed to improve. Theophylline level was 5.9 upon admission. Chest x-ray showed no evidence of active infiltrates. The patient was bolused with IV Steroids and started on frequent respiratory therapy treatments. IV Aminophylline boluses and drip were used to increase his theophylline level to therapeutic range. The patient gradually cleared and by the next day was much better. IV Aminophylline was changed to PO. The Ventolin treatments were decreased to q 4 hr. and his Steroids were rapidly tapered back to 10 mg of Prednisone.

Discharge Diagnosis: Moderate persistent Asthma with Status Asthmaticus – J45.42
Acute Exacerbation of COPD – J44.1

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.a

The Codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Terminology terms have been updated and added to reflect current the clinical classification of Asthma – J45. Asthma must be documented as mild, moderate or severe. Mild Asthma must be documented as intermittent or persistent.

DEFINITON

‍

• Mild intermittent Asthma
• Uncomplicated – J45.20
• With (Acute) Exacerbation – J45.21
• With Status Asthmaticus – J45.22
• Mild persistent Asthma
• Uncomplicated – J45.30
• With (Acute) Exacerbation – J45.31
• With Status Asthmaticus – J45.32
• Moderate persistent Asthma
• Uncomplicated – J45.40
• With (Acute) Exacerbation – J45.41
• With Status Asthmaticus – J45.42
• Severe persistent Asthma
• Uncomplicated – J45.50
• With (Acute) Exacerbation – J45.51
• With Status Asthmaticus – J45.52

Intrinsic (non-allergic) and Extrinsic (allergic) Asthma will both be classified to J45.909 – Unspecified Asthma, Uncomplicated.

MMP highly recommends an early start with ICD-10-CM/PCS training. There is no doubt the transition will be challenging. Any type of procrastination is sure to bring on stress with increased complexity and costs. Early planning and preparation will be the key to a smooth and successful transition. For timely updates and informative articles, Continue to follow MMP through their weekly newsletter Wednesday@One Part 2 of Chapter 10 – Diseases of the Respiratory System will post March 12, 2014.

Illustration: Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].

Were you anxiously awaiting its release? Did you lie awake at night thinking about what old and new features might be included? When it was released, did you drop everything and rush to check it out? No, we are not talking about the latest version of some Smart Phone, a movie sequel, or a new video game. We are talking about the 2014 OIG Work Plan which was finally released at the end of January.

I want to point out a few of the issues, especially billing and payment issues that are most relevant to the types of issues with which we at MMP normally deal. For other issues addressed in the OIG Work Plan that might be of interest to hospitals, see the list at the end of this article.

First, let’s look at some of the issues that are not new to this year’s work plan.

• Compliance reviews of acute care hospitals to determine compliance with selected inpatient and outpatient billing requirements. These types of reviews have been ongoing for several years and address a number of different billing issues, including but not limited to medical necessity of inpatient admissions, inpatient DRG coding, outpatient CPT/HCPCS codes, discharge status, device credits, and units of service.
• One of the most notable aspects of these reviews is that in four of the 87 compliance reviews to date, the OIG has extrapolated the overpayment amount causing an overpayment of hundreds of thousands of dollars to become millions of dollars.
• Inpatient claims for mechanical ventilation to determine if the hospitals’ DRG assignments and payments are appropriate. For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Past OIG reviews have revealed overpayments when one of these DRGs was assigned, but the patient did not receive 96 or more hours of mechanical ventilation.
• Outpatient dental claims have also been previously identified at risk for overpayments. Generally dental services are excluded from Medicare coverage with only a few exceptions. Examples of covered dental services would be if teeth have to be removed in order to perform another covered procedure, such as excision of a tumor or to prepare for radiation treatments.

New OIG activities for 2014 include:

• Determining the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary payments. The new admission criteria of a two-midnight expectation are substantially different than the previous admission criteria. Previous OIG reviews found overpayments, inconsistencies, and inappropriate billing under the old rules. It will be interesting to see if the new rules result in improved consistency or not.
• Review of Medicare outpatient payments to hospitals for clinic visits billed at the new patient rate. Prior to this year clinic visits were billed with Evaluation and Management (E&M) codes including both new and established patient codes. The higher paying “new patient” codes were only to be used if the patient had been registered as an inpatient or outpatient at the hospital within the past three years. With the changes to clinic visit reporting for 2014, hospitals no longer have to differentiate new vs. established patients or different levels of service intensity for clinic visits.
• Review of cardiac catheterizations and heart biopsies. Right heart catheterizations performed during the same operative session are included in the heart biopsy procedure and should not be billed separately unless a separate medical necessity for the right heart catheterization can be established eg: evaluate for rejection; failed previous heart procedure; compromised pulmonary status, etc.
• The OIG will review Medicare payments made to hospitals for claims that include a diagnosis of Kwashiorkor to determine whether the diagnosis is adequately supported by documentation in the medical record. Kwashiorkor is a severe form of protein malnutrition that is usually not found in the United States. Coding malnutrition as Kwashiorkor results in a larger payment from Medicare that is not appropriate if the patient really does not have this type of malnutrition.
• Although this is listed as a new issue, the OIG has already released three audit reports addressing this topic from January and February 2014. The reports note that Medicare paid hospitals $711 million for claims that include a diagnosis of Kwashiorkor. The audits have found no claims where the diagnosis of Kwashiorkor was appropriate. Removing the Kwashiorkor diagnosis has changed the DRG in about 18% of the claims reviewed, resulting in total overpayments for the three reviews exceeding $310,000.

Other Topics in the Work Plan include:

Hospitals; Policies and Practices:

Reconciliation of outlier payments
Medicare costs associated with defective medical devices (new)
Analysis of salaries included in hospital cost reports (new)
Impact of provider-based status on Medicare billing
Comparison of provider-based and free-standing clinics (new)
Critical Access Hospitals - Payment policy for swing-bed services
Critical Access Hospitals - Beneficiary costs for outpatient services
Long Term Care Hospitals - Billing patterns associated with interrupted stays

Hospitals: Billing and Payments:

Duplicate graduate medical education payments
Bone marrow or stem cell transplants (new)
Indirect medical education payments (new)

Hospitals: Quality of Care and Safety:

Participation in projects with quality improvement organizations
Emergency preparedness and response - Hurricane Sandy (new)
Oversight of pharmaceutical compounding (new)
Oversight of hospital privileging (new)
Adverse events in inpatient rehabilitation facilities

Nursing Homes:

Questionable billing patterns for Part B services during nursing home stays

Other Providers: Billing and Payments

Diagnostic radiology – medical necessity of high-cost tests
Electrodiagnostic testing – questionable billing
Laboratory tests – billing characteristics and questionable billing
Partial hospitalization programs
High utilization of sleep-testing procedures

Q:

When we perform a self-audit after a patient has been discharged and the documentation does not support a 2-Midnight expectation do we have to notify the beneficiary of the change from a Part A claim to a Part B claim?

A:

This question was addressed on pages 50913 – 50914 of the 2014 IPPS Final Rule.

Commenters asked that CMS clarify whether or not they were “proposing a self-audit process that would have to conform to the utilization review rules under the CoPs, notably physician concurrence, beneficiary notification, and other aspects related to continuation of an inpatient stay.”

CMS’s response was that “we did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self audit determination that does not conform to the requirements for utilization review under the CoPs. We do not agree with the commenters that beneficiaries need not be notified of a hospital’s determination that the inpatient admission was not reasonable and necessary. Part B billing pursuant to such a determination may result in an increase in financial liability for some beneficiaries which hospitals may not be able to ‘‘waive’’ or forego attempting to collect (we refer readers to sections XI.B.5 and B.6. of the preamble of this final rule). We believe that the CoP rules for beneficiary notification and physician involvement in hospital utilization review decisions are important for maintaining beneficiary rights, consistent with 42 CFR 482.13.”

§482.30 Condition of participation: Utilization Review

This CoP instructs that if after review the Utilization Review Committee determines that a stay was not medically necessary, written notification must be provided to the hospital, patient and MD responsible for the patient’s care, within 2 days of the decision being made.

With the major changes to Medicare’s inpatient admission requirements, trying to keep up with all the nuances of the rules and education efforts is like trying to juggle bowling balls. The Probe and Educate Review Process is replacing most previous Medicare Administrative Contractor (MAC) reviews, so this article addresses some questions concerning this process. If you have other questions, please refer to the resources listed at the end of this article or send me an email.

What is the purpose of the Probe and Educate Review Process?

The Probe and Educate Review Process is a focused prepayment medical review strategy for MACs designed to ensure provider understanding of the new two-midnight benchmark for determining the necessity of an inpatient admission (42 CFR 412.3) and to provide responsive provider-specific education, as necessary, to correct improper payments.

How long will the Probe and Educate Review Process last?

At the end of January, CMS decided to extend the Probe and Educate Review Process through September 30, 2014.

Will the MAC actually deny inpatient claims for not meeting the new inpatient criteria (2 midnight benchmark) during the Probe and Educate program?

Yes, claims that do not meet the two-midnight benchmark for an appropriate inpatient admission will be denied. Because the probe reviews will be conducted on a prepayment basis, hospitals can rebill for medically reasonable and necessary Part B inpatient services provided during denied Part A inpatient hospital stays provided the denial is on the basis that the inpatient admission was not reasonable and necessary. Hospitals may rebill for Part B inpatient services in accordance with Medicare Part B payment rules and regulations.

Will other Medicare review contractors be allowed to audit records for the medical necessity of inpatient admission?

No, Recovery Auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014.  

What types of inpatient claims will be selected for review by the MACs under the Probe and Educate Review Process?

MACs will select Medicare Part A inpatient claims spanning 0 to 1 midnight after formal inpatient admission.

Will claims containing inpatient-only procedures with stays less than 2 midnights be included in the Probe and Educate reviews?

No. However, CMS indicated on the last Special Open Door Forum concerning the new 2-midnight rule, that the contractors are not able to easily identify inpatient only procedure admissions up front. These claims may be initially selected for review, but will be released for payment when the MAC determines it was an inpatient–only procedure.

How many claims can a hospital expect to be selected for review?

MACs will initially select 10-25 records per hospital (25 for large hospitals, although “large” has not been defined). If a hospital has more than 1 error in a 10 record sample or more than 2 errors in a 25 record sample, after a three month education period, a repeat Probe & Educate sample of 10-25 records will be selected. Continuing problems of major concerns (7/10 or 14/25 errors) after a second three month education period could result in a third sample of 100-250 records for that hospital.

How will I be notified of the request for records for the Probe and Educate Review Process?

Providers will receive additional development requests (ADR) through the normal process. Providers that have claims selected for prepayment review may receive an ADR letter through the mail or will receive an ADR notice via the Fiscal Intermediary Standard System (FISS). Providers should monitor the Fiscal Intermediary Standard System (FISS) for claim status instead of seeking hard copy request for ADRs.

The MACs have published announcements on the Probe and Educate program; some include specific information on the ADR edits; for example Cahaba GBA 2-midnight ADR information, Novitas Probe and Educate information, and Palmetto Probe Reviews.

What elements will the MAC be looking for in the inpatient record for the Probe and Educate Review Process?

MACs will assess the hospital’s compliance with three things:

1. the admission order requirements,
2. the certification requirements, and
3. the 2-midnight benchmark

Will I be notified of the results of the reviews and if so, how?

Yes. MACs will send detailed results letters to providers for both denials and reviews with no findings.

Can the MAC and other Medicare Review Contractors audit inpatient claims for issues other than the medical necessity of the inpatient admission?

Yes. Medicare review contractors may review claims to ensure the services provided during the inpatient stay were reasonable and necessary in the treatment of the beneficiary, to ensure accurate coding and documentation, and may conduct other reviews as dictated by CMS and/or another authoritative governmental agency.

CMS will also monitor provider billing trends for variances indicative of abuse, gaming, or systematic delays in the submission of claims, for the purpose of avoiding the MAC prepayment probe audits during this initial probe and educate period.  Any evidence of systematic gaming, abuse or delays in the provision of care in an attempt to receive the 2-midnight presumption could warrant medical review.

Where can I obtain additional information about the Probe and Educate Review Process?

• Inpatient Hospital Reviews webpage
• See the following downloads at the bottom of this page:
• Questions and Answers Relating to Patient Status Reviews
• Selecting Hospital Claims for Patient Status Reviews
• Reviewing Hospital Claims for Patient Status
• MLN Matters Article SE1403
• Also check your local MAC’s website

For the I-10 Corner this week, we are discussing a few of the specific coding differences for cardiac diagnoses and conditions in ICD-9-CM and ICD-10-CM.

Angina Pectoris with Atherosclerotic Heart Disease (ASHD):

I-9

Angina, Unspecified (413.9)

ASHD, Unspecified (414.00)

I-10

Angina with ASHD, Unspecified—see Arteriosclerosis, Coronary (artery), Unspecified (I20.9)

NOTE FROM AUTHOR
Attention: Two codes in I-9 vs. one code in I-10

Atrial Fibrillation:

I-9

Atrial Fibrillation (established) (paroxysmal) (427.31)

I-10

Atrial Fibrillation or Auricular (established) (I48.91)

Chronic (I48.2)

Paroxysmal (I48.0)

Permanent (I48.2)

Persistent (I48.1)

Atrial Flutter:

I-9

Atrial Flutter or Auricular (427.32)

I-10

Atrial Flutter or Auricular (I48.92)

Atypical (I48.4)

Type I (I48.3)

Type II(48.4)

Typical (I48.3)

NOTE FROM AUTHOR
Attention: There are specific descriptions for Atrial Fibrillation and Atrial Flutter in I-10. In addition, there are no specific codes for Postoperative Fibrillation or Postoperative Flutter in the alpha index.

Heart Failure:

I-9

Congestive Heart Failure (compensated) (decompensated) (428.0)

Diastolic (428.30)

Acute (428.31)

Acute on Chronic (428.33)

Chronic (428.32)

Systolic (428.20)

Acute (428.21)

Acute on Chronic (428.23)

Chronic (428.22)

I-10

Congestive Heart Failure (compensated) (decompensated) (I50.9)

Diastolic (congestive) (I50.30)

Acute (congestive) (I50.31)

            and (on) chronic (congestive) (I50.33)

Chronic (congestive) (I50.32)

            and (on) acute (congestive) (I50.33)

Combined with Systolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Systolic (congestive) (I50.20)

Acute (congestive) (I50.21)

            and (on) chronic (congestive) (I50.23)

Chronic (congestive) (I50.22)

            and (on) acute (congestive) (I50.23)

Combined with Diastolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Myocardial Infarction (MI):

I-9

Infarct, Myocardial (acute or with a stated duration of 8 weeks or less) (with Hypertension) (410.9x)

NOTE FROM MANUAL
Note—Use the following fifth-digit subclassification with category 410:

0 - episode unspecified

1 - initial episode

2 - subsequent episode without recurrence

I-10

Infarct, Myocardial (acute) (with stated duration of 4 weeks or less) (I21.3)

NOTE FROM AUTHOR
Attention:

• For the episode of care in I-10, MIs are identified as either Acute (I21.xx) or Subsequent (I22.xx).
• The timeframe (stated duration of the MI) has decreased in I-10 to 4 weeks from 8 weeks in I-9.

Most MIs are considered to be ST-Elevation (STEMI) unless stated as Non-ST Elevation (NSTEMI) or Subendocardial.

STEMI

Anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) (I21.09)

Inferior (I21.09) (diaphragmatic) (inferolateral) (inferoposterior) (wall) NEC (I21.19)

Inferoposterior Transmural (Q wave) (I21.11)

Lateral (I21.29) (apical-lateral) (basal-lateral) (high) (I21.29)

Posterior (I21.29) (posterobasal) (posterolateral) (posteroseptal) (true) I21.29)

Septal (I21.29)

Specified NEC (I21.29)

NSTEMI

Subendocardial (I21.4)

Non-Q wave NOS (I21.4)

Nontransmural NOS (I21.4)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

NOTE FROM AUTHOR
For Acute MIs, we can now identify the specific coronary artery impacted. For example, per the alpha index:

Infarct, Myocardial, Involving

Coronary artery of anterior wall NEC (I21.09)

Coronary artery of inferior wall NEC (I21.19)

Diagonal coronary artery (I21.02)

Left anterior descending coronary artery (I21.02)

Left circumflex coronary artery (I21.21)

Left main coronary artery (I21.01)

Oblique marginal coronary artery (I21.21)

Right coronary artery (I21.11)

Please refer to the our article, ICD-10-CM Diseases of the Circulatory System, describing specific coding guidelines for cardiac diagnoses and conditions.

I hope this article has been beneficial in helping you become more familiar with cardiac diagnoses and conditions in ICD-10-CM.