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Is your hospital continuing to struggle to comply with Final Rule CMS-1599-F that went into effect on October 1, 2013? Are you still seeking any and all of the additional information that you can find to help comply with the new rules? If the answer is yes, you are not alone.

In the past couple of weeks CMS has been busy providing additional guidance. First, was the release of MLN Matters® Number: MM8586. This article provides guidance for the new use of Occurrence Span Code 72 to identify outpatient time associated with an inpatient hospital admission. Next, they posted updated guidance regarding the Hospital Inpatient Admission Order and Certification and an updated Reviewing Hospital Claims for Patient Status download to their Inpatient Hospital Review webpage. They also held yet another “Special Open Door Forum” (ODF) to discuss the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on February 4th.

As the question and answer portion of the ODF became more of a question being asked and CMS requesting that you submit that question to IPPSAdmissions@cms.hhs.gov, it became apparent that no big “aha” moments were going to be happening. It was at this point that all I could think about was the chorus to the Sonny and Cher 1967 hit song The Beat Goes On. For those old enough to remember this one sing along:

“The beat goes on, the beat goes on

Drums keep pounding

A rhythm to the brain

La de da de de, la de da de da.”

Now that this song is firmly stuck in your head, let’s take a look at the new and updated guidance from CMS.

Occurrence Span Code 72; Identification of Outpatient Time Associated with an Inpatient Hospital Admission and Inpatient Claim Payment:MLN Matters(R) Number: MM8586

Effective Date: December 1, 2013

Implementation Date: February 24, 2014

Why is this being implemented?

• “The redefinition of occurrence span code 72 allows providers to voluntarily identify those claims in which the 2-midnight benchmark was met because the beneficiary was treated as an outpatient in the hospital prior to the formal inpatient admission order. In other words, it permits providers and subsequently review contractors to identify the “contiguous outpatient hospital services (midnights) that preceded the inpatient admission,” as well as the total number of midnights after formal inpatient order and admission, on the face of the claim.”

Hospital Inpatient Admission Order and Certification (January 30, 2014)

CMS’s attempt to clarify the September 5th Guidance fell a little short. However, there were a few key pieces of information to point out to you.

• If you have a Medicare beneficiary waiting on a skilled nursing facility (SNF) bed, CMS indicates that “a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis.”
• Residents, non-physician practitioners and ED physicians who do not have admitting privileges can make the initial admission decision. “In countersigning the order, the ordering practitioner approves and accepts responsibility for the admission decision.” This counter-signature would “satisfy the order part of the physician certification, as long as the ordering practitioner also meets the requirements for a certifying physician.”
• “If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered an inpatient. The hospital stay may be billed to Part A as a hospital outpatient encounter.”

The entire update can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf

Highlights from the February 4, 2014 Special Open Door Forum

• CMS has extended the MAC Probe and Educate Period through September 30, 2014. CMS verified (at a caller’s request) that they have not cancelled or delayed the implementation of the new rule.
• In response to a question about whether or not there had to be a statement indicating the expected length of stay in the record, CMS indicated that there are no “magical words” that need to appear saying the physician certifies the stay. CMS would expect to find “regular good documentation” in the record, not a separate “I certify” statement.
• Another caller asked if the MD does not sign a verbal admit order until after the patient is discharged can we bill for anything? CMS responded that as far as the letter of the law you need the order to submit a Part A claim. If the order was not co-signed then you could submit a Part B Outpatient claim (a 13x type of bill).
• One hospital indicated that they were under the impression that they would receive a letter from their MAC after their records had been reviewed under the Probe & Educate program. CMS indicated that they had asked MACs to hold on letters until additional guidance was released regarding the Inpatient Admission Order and Certification. They went on to indicate that this information was released last week and the MACs should no longer be holding letters.

Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Last Updated: 01/31/14)

There were two specific clarifications made to this Guidance that I would like to point out to you. Prior to this update CMS had indicated that “it is not necessary for a beneficiary to meet an inpatient “level of care,” as may be defined by a commercial screening tool, in order for Part A payment to be appropriate.” In this updated version they further indicate that “In addition, meeting an inpatient “level of care,” as may be defined by a commercial screening tool, does not make Part A payment appropriate in the absence of an expected length of stay of 2 or more midnights.” Once again, CMS is making the point that good physician documentation supportive of a 2 or more midnight admission is the key to the decision to admit a patient as an inpatient.

The other clarification is about the documentation that the MACs would expect to find to support the 2-midnight expectation. CMS indicates that “physicians need not include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

National Provider Call: 2-Midnight Benchmark: Discussion of the Hospital Inpatient Admission Order and Certification

CMS is already planning additional education through a National Provider Call on Thursday February 27, 2014 from 2:30 PM – 4:00 PM Eastern Time. The target audience for this call includes hospitals, physicians and non-physician practitioners, case managers, medical and specialty societies, and other healthcare professionals. Topics to be covered in this call are the order and certification guidance with case examples, transfers and a question and answer session.

Registration is open and those interested in participating can sign up at the CMS MLN Connects Upcoming Callsregistration website.

It appears that the truism that best applies with the new regulations and guidance is that “The only constant is change.” MMP continues to be on the lookout for updated guidance and education opportunities to pass along to you so, stay tuned.

One of the most significant changes to the Hospital Outpatient Prospective Payment System (OPPS) for 2014 was the packaging of clinical laboratory services. Prior to this year, clinical diagnostic laboratory tests were separately paid under OPPS at the Clinical Laboratory Fee Schedule (CLFS) payment rates. In 2014, most laboratory tests will be packaged under OPPS.

There are some limited exceptions where hospitals may receive separate payment for otherwise packaged lab services. Does your hospital understand these exceptions and do you know how to bill to receive payment in these circumstances?

The January OPPS Update MLN Matters Article and associated transmittal explain the details of when and how to appropriately receive separate payment for packaged laboratory services.

Packaged laboratory services are separately payable in three situations:

• When a specimen is submitted for analysis to a hospital and the patient is not physically present at the hospital. These are commonly referred to as non-patient services, outreach lab services or reference lab tests.
• When laboratory tests are the hospital outpatient services that a patient receives during an outpatient encounter. For example, patients that are referred from a physician’s office or clinic to a hospital outpatient laboratory for laboratory testing only and no other outpatient services.
• When laboratory tests are clinically unrelated to other outpatient services the patient receives during an outpatient encounter and the lab tests are ordered by a different practitioner than the one who ordered the other (non-lab) outpatient services.

For 2014, the packaged laboratory tests have a status indicator (SI) of “N” (packaged) – so how are hospitals to receive separate payment?

CMS is allowing hospitals to bill laboratory tests provided in any of the above listed exceptions on a 14X type of bill (TOB). Prior to this year, only non-patient services were required to be billed on a 14x TOB. Most outpatient laboratory services were generally billed on a 13x TOB. For 2014, in order to receive separate reimbursement for packaged laboratory services a hospital must submit the lab charges on a 14x claim. It is the hospital’s responsibility to determine which lab services meet the criteria for separate payment and therefore are appropriate for a 14x claim.

There are some exceptions to packaging of laboratory services:

• CMS did not package molecular pathology test codes since they are recently added laboratory codes. Since molecular pathology laboratory tests are not packaged under OPPS they should be billed on a 13x claim.
• Pathology, cytology and blood bank services are not packaged because they have a SI of “X” and are paid under OPPS, not under the CLFS.
• The status indicator for some other clinical lab tests remained “A” instead of being changed to the packaged status indicator “N” (for example new codes, screening services, and drug screening codes) so these will also still be separately paid under OPPS.

Hospitals should develop processes to ensure that lab tests that meet the criteria are submitted on a 14x claim while lab services that do not meet the criteria continue to be billed on a 13x TOB. These process changes may affect your outpatient laboratory, registration, and billing departments.

Every year, there are a number of Medicare provisions that expire on a particular date. For the requirements of these provisions to continue past the expiration date, Congress must take action through a new law. Such was the case for several rehabilitative therapy provisions set to expire at the end of 2013. The Pathway for SGR Reform Act of 2013, signed into law on December 26, 2013 extended the following provisions related to payments for Medicare outpatient therapy services through March 31, 2014.

Application of therapy caps and therapy threshold to therapy services furnished in a hospital outpatient department -

Therapy caps are a financial limitation on the amount Medicare allows for outpatient therapy services for a single Medicare patient in a given calendar year. The therapy cap amount for each patient starts over each January 1st. For 2014, the therapy cap is $1,920 for physical therapy (PT) and speech language pathology (SLP) services combined; and a separate $1,920 for occupational therapy (OT) services.

Exceptions process for outpatient therapy caps -

When providers of therapy services furnish medically necessary therapy services beyond the therapy cap, they may request an exception by appending the KX modifier to the appropriate therapy services on the claim. Additional information about the exception process for therapy services may be found in the http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf">Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

Manual medical review of outpatient therapy services exceeding the threshold amount -

Medicare mandates that a Medicare contractor perform a manual medical review of therapy services exceeding a $3,700 threshold for PT and SLP services combined and a $3,700 threshold for OT services. Currently this review function is being handled by Medicare Recovery Auditor contractors.

Critical Access Hospitals will also want to study MLN Matters Article MM8426 concerning the application of therapy caps, the exceptions process, and manual medical review to outpatient therapy services provided in the CAH setting.

So we are all set for … well, three months. If this year follows the pattern of previous years, another law will likely extend these provisions through the remainder of 2014. But, we will just have to wait and see.

For the I-10 Corner this week, we’re discussing a few of the procedural coding guidelines for Cardiac Bypass Procedures, including a few examples.

Remember: The letters I and O and not used in PCS since they are easily confused with numbers one (1) and zero (0).

ICD-10-PCS Coding Guidelines

Coronary Bypass Procedures

B3.6b. Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.

Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the ‘aorta’ as the body part bypassed from.

B3.6c. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

Coronary Excision for Graft

B3.9. If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Coronary bypass with excision of saphenous vein graft; excision of saphenous vein is coded separately.

Coding Example: CABG of LAD using left internal mammary artery, open; off pump (02100Z9). Root Operation: Bypass, Coronary Artery, One Site, (0210), Open (0), No Device (z), Internal Mammary, Left (9).

                Note: The Internal Mammary Artery = No Device. It is not considered graft material.

Coding Example: Open coronary artery bypass graft of three coronary arteries using left autologous greater saphenous vein (021209w). Root Operation: Bypass, Coronary Artery, Three Sites (0212), Open, (0), Autologous Venous Tissue (9), Aorta (w).

Note: For Coronary Bypass, the Body Part identifies the number of coronary artery sites bypassed to-- which is the Aorta.

Coronary Body Parts

B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number or arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site, with Intraluminal Device, and Dilation of Coronary Artery, One Site, with no device.

Coding Example: PTCA of two coronary arteries: RCA with stent (intraluminal device) (02703DZ) and LAD without stent (02703ZZ). Root Operation: Dilation, Artery, Coronary, One Site (0270)—one with an intraluminal device and one without.

Note: Coronary arteries are counted as single body parts. It doesn’t matter how many arteries were treated. The main distinguishing factor is the number of sites treated.

MMP hopes this article was beneficial in helping you become more familiar with cardiac bypass procedures in ICD-10-PCS.         

The Centers for Medicare and Medicaid Services (CMS) hosted a National Provider Call regarding the 2-Midnight Rule that went into effect on October 1, 2013 with the Fiscal Year (FY) 2014 IPPS Final Rule. For those of you that were unable to attend here is a run-down of 5 key takeaways from the session.

1. CMS is already planning future training sessions for Physician Orders/Certification and Transfers.
2. CMS has acknowledged that there could be times when an inpatient stay would still be appropriate even though an “unforeseen circumstance” occurs and the patient ultimately does not require a 2-Midnight or greater hospitalization. Specific examples from CMS have included patient death, transfer, leaving against medical advice (AMA) or the patient rapidly improving. New to this list is a patient that is admitted, documentation clearly supports a 2-Midnight expectation and the patient / family elect Hospice care and the patient is discharged home to hospice. Key to all of these “unforeseen circumstances” is that documentation in the record clearly supports the physician expectation of a 2-Midnight stay.
3. Effective December 1, 2013, the NUBC redefined Occurrence Span Code 72 to allow “Contiguous outpatient hospital services that preceded the inpatient admission” to be reported on inpatient claims. At this time this is a voluntary code but CMS encourages hospital to use this code.
4. Prior to opening the call up to questions and answers, CMS provided answers to two common questions that they had received prior to this call.
5. Q: How does level of care factor into the 2-Midnight Rule?
6. A: Under the 2014 IPPS Final Rule, the decision to admit is based on medical necessity of hospital care whether it is observation or inpatient care. If the answer is yes then the next question to ask is do you think this patient will be in the hospital for at least 2-Midnights?
7. Q: Can any elective surgeries be ok in Inpatient setting?
8. A: If there is an “unexpected circumstance” requiring 2-Midnights (i.e. a complication) then the stay would be appropriate as an Inpatient admission.
9. During the open Q&A session a question was asked regarding patients staying beyond 2-Midnights and whether or not a hospital would still be able to use InterQual® criteria. CMS responded by indicating that they believe hospitals will not use InterQual® or Milliman. They did go on to indicate that these screening tools could be used to help determine whether a patient should remain in the hospital or is safe for discharge.

The entire slide presentation from this call can be downloaded at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-01-14-Midnight-Presentation.pdf

CMS’s Medicare Learning Network (MLN) offers a number of articles, booklets, podcasts and other educational materials to educate providers concerning Medicare requirements. MMP encourages providers to utilize these resources but also to be aware of the topics addressed. MLN educates concerning issues that Medicare contractors or other government entities have found to be at-risk areas for non-compliance. So the benefit of the MLN products is two-fold: identification of issues that you may need to consider for internal review and guidance on achieving compliance.

For example, MLN recently released an article (SE1401) on overpayments identified by Recovery Auditors when the wrong admission source is reported for a patient transferred from an acute care stay to a distinct-part psychiatric unit in the same facility. Inpatient psych facilities receive additional payment for the first day of admission if the facility has a qualifying emergency department. This payment is not appropriate if the patient is transferred from acute care to psych within the same facility. In order to prevent inappropriate overpayment, the Point of Origin for Admission or Visit Code "D" (formerly the Source of Admission Code) must be used when a patient is discharged from an acute-care stay in a hospital and transferred to the same hospital’s inpatient psychiatric Distinct Part Unit (DPU). This issue has also been identified on several OIG Hospital Compliance Audits.

This quarter’s Provider Compliance Newsletter did not address any inpatient hospital issues (perhaps due to the change in Medicare admission guidelines and the mandated delay in contractor reviews of medical necessity of admissions). Two articles did address outpatient hospital issues related to dose versus units billed for the drugs zolendronic acid (Zometa) and Adenosine. Correct billing of drug units is a long-standing compliance challenge for hospitals. Drugs units billed are based on the dosage administered and the HCPCS code description of the drug. For example, as noted in the Compliance newsletter, adenosine HCPCS code J0152 was defined as 30 mg. So an injection of 30 mg of Adenosine was properly billed as 1 unit of J0152.

Adding to the challenge of billing drug units correctly are changes in codes and/or descriptions. For 2014, Adenosine is now billed with HCPCS code J0151 which is per 1 mg – in 2014 a 30 mg injection of Adenosine will be billed as 30 units of J0151. And although the units describing Zometa have not changed, there have been 3 different codes within the past year (J3487 prior to July 1, 2013; Q2051 from July 1 through December 31, 2013; and J3489 effective January 1, 2014). In order to submit Medicare claims with compliant drug charges, hospitals must:

• have someone diligently watch for Medicare updates to drug codes and descriptions,
• verify their charge description master drug codes and “multiplier” units are correct and updated as needed, and
• ensure correct “translation” from the pharmacy module to the billing module.

One other MLN product that might be of interest to hospitals is the Discharge Planning booklet. Experienced case managers, discharge planners, and social workers are likely familiar with the information in the booklet, but it offers a good overview and links to the relevant Medicare manuals. It would be an excellent resource for new staff members dealing with discharge planning.

Providers should take advantage of the educational products provided by CMS and their area MACs. The information is good and the topics are important. And in the case of errors related to these topics, a hospital wouldn’t have much luck arguing they didn’t know the rules.

Regular readers of our weekly newsletter are likely aware that we publish a monthly article on updates to Medicare national and local coverage policies – NCDs and LCDs.  So it should be no surprise that I found the OIG report on LCDs very interesting and enlightening.  The OIG found that LCDs have significant influence on Medicare’s coverage of items and services.  They also found that due to inconsistency between the LCDs from various contractor regions, Medicare patients’ access to items and services can depend on geography as much as their clinical indications.

The OIG report studied Part B LCDs but Part A LCDs that apply to hospital services have similar characteristics.  Some basic facts concerning Local Coverage Determinations:

1)    they apply only in States within the contractor’s jurisdiction;

2)    they must follow all Medicare statutes, rulings, regulations and national coverage, payment and coding policies; and

3)    they may limit coverage of an item or service to a specific diagnosis or condition, or they may prohibit coverage of an item or service completely.

The OIG is not the only government entity that has weighed in on LCDs.  In 2001, the Medicare Payment Advisory Commission (MedPAC) recommended the elimination of LCDs and in 2003, the Government Accounting Office (GAO) reported LCDs resulted in inequitable variations in coverage.  The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) affected LCDs in two ways.  First, it replaced Fiscal Intermediaries (FIs) and Carriers with Medicare Administrative Contractors (MACs).  Medicare Contractor Reform is continuing to refine Medicare jurisdictions as it decreases the number of MACs.  Secondly, the MMA called for a plan to evaluate new LCDs for possible national application and to increase consistency among LCDs.

The OIG report looked at LCDs in October 2011 and still found problems with inconsistencies.  The OIG found that the presence of LCDs was unrelated to the cost and utilization of items and services, LCDs limited coverage for items and services differently across States, and they defined similar clinical topics inconsistently.  Due to these types of inconsistencies, coverage for a given service may be restricted in one State where an LCD is in place and completely unrestricted in another State where no LCD is in place.  Forty percent of procedures with no coverage allowed in one or more States had allowed charges in other States where LCDs did not prohibit coverage. This means Medicare patients in some States did not have access to items and services that had significant use among Medicare patients in other States.  The report also noted that the State-by-State differences in coverage created by LCDs are contrary to the growing practice of evidence-based medicine that eschews local variation.

Also the volume of affected services varied greatly between States.  LCDs affected coverage for over 50 percent of items and services in some States (California, North Carolina, South Carolina, and Virginia) and as few as 5 percent of items and services in other States (Alabama, Georgia, and Tennessee). Over a fifth of the LCDs in effect during the OIG review restricted coverage for items and services in only 3 States—Florida, Puerto Rico, and the Virgin Islands. Remember these findings were for Part B policies, but likely similar for Part A coverage also.

The OIG recommended that CMS:

Ø  Establish a plan to evaluate new LCDs for national coverage consistent with MMA requirements

Ø  Continue efforts to increase consistency among existing LCDs

Ø  Consider requiring MACs to jointly develop a single set of coverage policies

Although CMS agreed with all of the OIG’s recommendation, they believe their current workgroups and other initiatives are addressing these recommendations.  The OIG maintains that pursuing a single set of coverage policies would simplify and strengthen Medicare coverage policy while lessening the administrative burden of LCDs.  So are changes in the LCD process likely – that remains to be seen.  Until then, we trudge along…

Most of the LCD updates for this month are related to the CPT/HCPCS coding changes for 2014.  One change of note is the removal of two drugs (Cimzia and Simponi) from Cahaba GBA’s Self-Administered Drug (SAD) list.

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

What do Probe Reviews, the start time for when the 2 midnight benchmark begin, Physician Documentation, automatic denials and Occurrence Span Code 72 have in common? All of these issues were addressed in the CMS Frequently Asked Questions (FAQs) December 23, 2013 update. Let’s break it down be each updated FAQ.

Q1.1: “Will CMS direct the Medicare review contractors to apply the 2-midnight presumption-that is, contractors should not select Medicare Part A inpatient claims for review if the inpatient stay spanned 2 midnights from the time of formal admission?”

• Yes, when a patient has been in your hospital for two midnights AFTER the inpatient order was written review contractors are to presume that the Medicare Part A inpatient admission was reasonable and necessary.
• New to this answer is that for inpatient admissions from October 1, 2013 through March 31, 2014 “CMS will not permit Recovery Auditors to conduct patient status reviews on inpatient claims with dates of admission between October 1, 2013 and March 31, 2014. These reviews will be disallowed permanently; that is, the Recovery Auditors will never be allowed to conduct patient status reviews for claims with dates of admission during that time period.”
• Caution: These same admissions CAN be reviewed for other issues (i.e. medical necessity of a surgical procedure or coding validation).

Q2.1: “Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

• All time that a Medicare beneficiary is receiving outpatient services at the hospital will be considered in whether or not the 2-midnight benchmark was met.
• Note: “The Medicare review contractor will count only medically necessary services responsive to a beneficiary’s clinical presentation as performed by medical personnel.”
• Services to be included: observation services, treatments in the Emergency Department, and procedures provided in the operating room or other treatment area
• Services not to be included: treatment received in an outlying Emergency Department or in an ambulance en-route to your hospital.

Q4.1: “What documentation will Medicare review contractors expect physicians to provide to support that an expectation of a hospital stay spanning 2 or more midnights was reasonable?”

• Physician complex medical decision making: The expectation of a 2-midnight stay “must be supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”
• Documentation: Medicare review contractors will expect the Physician’s decision making factors to be documented in the physician assessment and plan of care. “CMS does not anticipate that physicians will include a separate attestation of the expected length of stay, but rather that this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

Q4.9: “Under the new guidance, will all inpatient stays of less than 2 midnights after formal inpatient admission be automatically denied?”

• Medicare does anticipate that most stays less than 2 midnights would be as an outpatient. However, “because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, we expect to see services payable under Part A in a number of instances for inpatient stays less than 2 total midnights after formal inpatient admission.”
• CMS has provided specific exceptions to the 2-midnight benchmark when inpatient would still be appropriate:
• Beneficiary death,
• Beneficiary transfer to another acute inpatient facility,
• Beneficiary leaving against medical advice (AMA),
• Beneficiary was admitted for a medically necessary service on the Inpatient-Only List,
• Mechanical ventilation initiated during the present visit (Note: is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment),
• Or a Beneficiary unexpectedly improves and was discharged in less than 2 midnights.
• New to this answer: “Lastly, there may be rare and unusual cases where the physician did not expect a stay lasting 2 or more midnights but nonetheless believes inpatient admission was appropriate and documents such circumstance. The MACs are being instructed to deny these claims and to submit these records to CMS Central Office for further review. If CMS believes that such a stay warrants an inpatient admission, CMS will provide additional subregulatory instruction and the Part A contractors will review any claims that are subsequently submitted for payment in accordance with the most updated list of rare and unusual situations in which an inpatient admission of less than 2 midnights may be appropriate.”

Q5.2: “Is there a way for providers to identify any time the beneficiary spent as an outpatient prior to admission on the inpatient claim so that Medicare review contractors can readily identify that the 2-midnight benchmark was met without conducting complex review of claim.”

• “Effective December 1, 2013, Occurrence Span Code 72 was refined to allow hospitals to capture ‘contiguous outpatient hospital services that preceded the inpatient admission’ on inpatient claims.”
• For now, “Occurrence Span Code 72 is a voluntary code, but may be evaluated by CMS for medical review purposes.”

The entire FAQ download can be found at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews_12232013_508Clean.pdf With the MAC Probe and Educate program just getting underway, you can expect there to be several additional updates to the FAQs.

For the I-10 Corner this week, we’re focusing on diagnostic coding guidelines, plus a few examples,for Chapter 9: Diseases of the Circulatory System (I00-I99)

Quick Tips:

• The types of hypertension (benign, malignant, accelerated, etc.) are all listed as modifiers in I-10. The Hypertension table has been deleted.
• Combination codes include Coronary Artery Disease (CAD) plus all types of Angina. These combination codes include native arteries as well as CAD of bypass graft(s).
• The time frame for Acute Myocardial Infarction (AMI) codes have changed from eight (8) weeks or less to four (4) weeks or less (within 28 days).
• Myocardial Infarction (MI) codes specify ST Elevation (STEMI) Myocardial Infarction, along with the site of the MI, or Non-ST (NSTEMI) Myocardial Infarction, in each descriptive heading.
• Atrial Fibrillation and Atrial Flutter can now be identified as paroxysmal, persistent, typical, atypical, and unspecified.
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.

ICD-10-CM Coding Guidelines

9 .a. 1) Hypertension with heart disease

Heart conditions classified to I50.-I51.9, are assigned to a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

The same heart conditions (I50.-, I51.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter.

9. a. 2) Hypertensive chronic kidney disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition, classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease.

The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease.

If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

9. a. 3) Hypertensive heart and chronic kidney disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease.

See Section I.C.14 Chronic kidney disease

The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13. If a patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for hypertension, heart disease and chronic kidney disease, or codes from I11 or I12.

Example: CKD, stage 3, with CHF due to Hypertension is coded to I113.0 (Hypertensive heart and chronic kidney disease with CHF, Stage 3 CKD), I50.9 (Heart failure, unspecified), and N18.3 (CKD, Stage 3).

9. a. 4) Hypertensive cerebrovascular disease

For hypertensive cerebrovascular disease, first assign the appropriate code from categories I60-I69, followed by the appropriate hypertension code.

9. a. 5) Hypertensive retinopathy

Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension. The sequencing is based on the reason for the encounter.

9. a. 6) Hypertension, secondary

Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I14 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter.

9. a. 7) Hypertension, transient

Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. Assign code O13.-, Gestational [pregnancy-induced] hypertension without significant proteinuria, or O14.-, Pre-eclampsia, for transient hypertension of pregnancy.

9. a. 8) Hypertension, controlled

This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. a. 9) Hypertension, uncontrolled

Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories I10-I15, Hypertensive diseases.

9. b. Atherosclerotic coronary artery disease and angina

I-10 has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.

When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.

Example: A patient is diagnosed with CAD and Angina with no previous history of a CABG. The correct code is I25.19 (ASHD of Native Coronary Artery with other forms of Angina Pectoris).

If a patient with coronary artery disease is admitted due to an AMI, the AMI should be sequenced before the coronary artery disease.

See Section I.C.9. Acute myocardial infarction (AMI)

9. c. Intraoperative and post-procedural cerebrovascular accident

Medical record documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or post-procedural cerebrovascular accident.

Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.

9. d. 1(Category I69, sequelae of cerebrovascular disease

Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequel (neurologic deficits), they themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

9. d. 2) Codes from category I69 with codes from I60-I67

Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.

9. d. 3) Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)

Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

See Section I.C.21.4 History (of) for use of personal history codes

9. e. 1) Acute myocardial infarction (AMI) --ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI)

The ICD-10-CM codes for AMI identify the site, such as anterolateral wall or true posterior wall. Subcategories I21.0-I21.2 and code I21.3 are used for STEMI. Code I21.4, NSTEMI myocardial infarction, is used for NSTEMI and nontransmural MIs.

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

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported. For encounters after the 4 week time frame and the patient is still receiving care related to the MI, the appropriate aftercare code should be assigned, rather than a code from category I21. For old or healed MIs not requiring further care, code I25.2, Old myocardial infarction, may be assigned.

9. e. 2) Acute myocardial Infarction, unspecified

Code I21.3, STEMI of unspecified site, is the default for the unspecified term acute myocardial infarction. If only STEMI or transmural MI without the site is documented, query the provider as to the site, or assign code I21.3.

9. e. 3) AMI documented as nontransmural or subendocardial but site provided

If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.

See Section I.C.21.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.

9. e. 4) Subsequent acute myocardial infarction

A code from category I22, Subsequent STEMI and NSTEMI, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.

Example: A patient is being treated for an Acute Non-ST Anterior Wall MI which she suffered 5 days ago. The patient also has Atrial Fibrillation. The correct diagnoses are: I21.4 (Non-ST Elevation (NSTEMI) Myocardial Infarction) and I48.91 (Unspecified Atrial Fib).

The next I-10 corner will be featured around a PCS discussion for Chapter 9: Diseases of the Circulatory System (I00-I99)

Question:

Were there any changes to the Post-Acute Transfer and Special Payment Policy in the 2014 IPPS Final Rule?

Answer:

MLN Matters® Number: MM8421 (Effective Date: October 1, 2013) indicates that no changes were made to the Post-acute and Special Post-acute payment policy or applicable DRGs for FY 2014.

This article goes on to “note that the new Patient Status codes (81-95) that refer to ‘Planned Readmissions’ have been mapped to their non-planned readmission counterparts and are included in the transfer policy.

The entire MLN Matters® article can be found at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8421.pdf