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Question:
A patient is discharged from our facility (disposition code 01) and is to go to a doctor’s appointment the same day. The patient is then admitted to another hospital after seeing the doctor. What disposition code is appropriate, 01 or 02?

Answer:
Based on the information the hospital had at discharge, the patient was discharged to home (01).  If your facility was unaware of the planned admission at the second facility, it is likely that you will have to modify/adjust your previously submitted claim to indicate a disposition code 02, which reflects where the patient was later admitted on the same date.

Resource: MLN Matters Number: SE0801 / NUBC FAQs

 

Through review of hospital 835 remittances and communication with our clients, MMP, Inc. has become aware of an increasing number of Medicare denials for units exceeding a Medically Unlikely Edit (MUE) limit. MUEs were implemented in 2007 by CMS to reduce paid claim error rates. Per the CMS MUE webpage “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” The MUE list is available on the above webpage; it is updated quarterly but CMS considers some MUEs confidential and does not publish these. Remember that MUE and CCI edits apply to both Medicare and Medicaid claims.

We are seeing a large number of MUE denials for drugs. We have also heard from providers concerning recent denials for additional infusion services, such as for CPT codes 96366 (IV infusion, each additional hour) and 96361 (Hydration, each additional hour). Since these MUEs are unpublished, the MUE limits for these CPT/HCPCS codes are not known.

MMP, Inc. encourages our clients to determine if they are having issues with MUE denials. Line items exceeding an MUE limit will deny with a Claim Adjustment Reason Code (CARC) of B5 (Coverage/program guidelines were not met or were exceeded.) Note that CARC B5 is also used for denials involving Correct Coding Initiative (CCI) edits and for inpatient-only procedures billed on an outpatient claim.  Also look for Remittance Advice Remark Code N362 (The number of Days or Units of Service exceeds our acceptable maximum) to identify MUE denials.

If you are having MUE denials, determine if you are indeed trying to bill the appropriate number of units. The MUE limits for drugs are likely based on the manufacturer’s package insert for recommended dosage amount. To address drug MUE denials, providers should:

• ensure that conversion factors in the CDM are correct for the drug HCPCS description,
• verify that charges are being entered correctly,
• determine if there is a medically necessary reason to exceed the recommended dosage, and
• contact your Medicare contractor if you believe an MUE is unreasonable.

Once you verify that the units you are billing are correct and you determine the MUE value (either the MUE limit is published or you are able to determine it by a trial and error process), you can by-pass the MUE by using an appropriate CPT modifier to report the same code on separate lines of a claim. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, no single line should be reported with units that exceed the MUE limit. For example, if an MUE value is 6 and you provided 18 medically necessary units, you should report three lines each with units of 6 and the appropriate CPT modifier on the additional lines. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service), will accomplish this purpose. Providers/suppliers should use Modifier 59 only if no other modifier describes the service.

If you receive denials for MUEs, you may appeal the denial. Documentation in the medical record should clearly support the number of units and the medical necessity for the quantity of services. If a drug dosage exceeds the package insert amount, you will want to provide medical literature to support the dosage amount as part of your appeal.

One last point to consider – a number of the drugs that are being denied for exceeding the MUE value are not separately reimbursed by Medicare but are instead “packaged” drugs. Providers likely will not want to put in time and effort to appeal these denials, but MMP, Inc. encourages providers to ensure that for future claims the units billed are accurate and submitted correctly to by-pass the MUE limits when appropriate. This will prevent the submission of any “false” claim information.

For more information on MUEs, see the link on the CMS MUE webpage to MUE FAQs. And although CMS Transmittal 9490 addresses a technical correction it also contains good information on the MUE process.

Consumers are increasingly using the internet to direct where they seek health care services. Therefore, it is more important than ever for healthcare providers to be aware of what data is available to the public. 

This past Friday, August 5th, CMS issued a press release announcing a “new tool” and “enhanced initiatives” that will help “empower consumers to make informed choices about their health care, and to help improve the quality of care in America’s hospitals, nursing homes, physician offices, and other health care settings.” The new tool and enhanced initiatives include:

• A Quality Care Finder providing consumers a single online site to all of Medicare’s Compare tools. Below is a “snap shot” of this site that can be accessed at www.Medicare.gov/QualityCareFinder;

• The Hospital Compare site has been updated and now includes:

1.  
2.  
3. New Outpatient outcomes for surgical infections and treatment for patients with suspected hear attacks;
4. Updated data for the Patient Experience, 30 Day Mortality Measures and 30 Day Readmission rates for inpatients admitted with heart attack, heart failure and pneumonia; and

Enhancements to the Quality Improvement Organization (QIO) program.

·         The Hospital Compare  site has been updated and now includes:

o   New Outpatient outcomes for surgical infections and treatment for patients with suspected hear attacks;

o   Updated data for the Patient Experience, 30 Day Mortality Measures and 30 Day Readmission rates for inpatients admitted with heart attack, heart failure and pneumonia; and

Enhancements to the Quality Improvement Organization (QIO) program.

CMS recently released MLN Matters Article SE1117 that describes significant changes in the reporting of the Admission Date and Statement Covers Period (from/through dates) on the UB-04.

Effective October 1, 2011, providers should use the following definitions for these form locators (FLs):

• Admission Date (FL12) – the date the patient was admitted as an inpatient to the facility. (This is the date the patient is formally admitted, i.e. the day an order is written to admit the patient as an inpatient).
• Statement Covers Period (“From” and “Through” dates in FL 6) – span of service dates included on the claim. The “From” Date is the earliest date of service on the bill.

Medicare Fiscal Intermediary Shared System (FISS) edits will be changed to accommodate these new definitions so that:

• These two data elements are not required to match, and
• The number of days in the Statement Covers Period will not be compared to any other data element (e.g. total accommodation days reported in the revenue code section).

Providers should review this information carefully and make sure practices and systems are changed as needed to meet these new definitions October 1, 2011. For complete information, please refer to the MLN Matters article.

CMS recently released a special MLN Matters® Article for inpatient hospitals, in regards to Recovery Auditors having reviewed a significant number of records for DRG Validation that had an incorrect principal diagnosis. This article focuses on assisting hospitals in identifying key steps to take to avoid unnecessary denials of claims.

CMS has noted that Recovery Auditors review the entire medical record when performing DRG Validation while some hospitals possibly choose to code the record before all documentation is completed. There is a risk when hospitals choose to do this “since they are responsible for reporting codes that accurately reflect the patient’s conditions and procedures. Therefore hospitals may increase their chance of errors by choosing to code the case prior to receiving the complete medical record. Recovery Auditors will not take this into consideration.”

Hospitals are reminded that when there is conflicting or contradictory information in the medical record the attending physician should be queried to clarify the principal and secondary diagnoses. Further, “Coding Clinic, First Quarter 2004 states, if there is conflicting physician documentation, and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician’s version. However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict. So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it.”

The entire article can be viewed at: http://www.cms.gov/MLNMattersArticles/downloads/SE1121.pdf.

CMS continues to provide information to help providers understand and avoid common billing errors and other improper activities identified through claim review programs, such as the Recovery Audit Contractor (RAC) program.

CMS recently released the April 2011 Medicare Quarterly Provider Compliance Newsletter. This edition contains the following information relevant to hospitals:

• Improper Coding of MS-DRG 813 Coagulation Disorders (Inpatient Hospital): Hospitals should ensure that their billing staffs are up to date on the guidelines for coding diagnoses for patients with coagulation disorders, adverse effects of anticoagulants in therapeutic use and coagulation profile.
• HIV – Wrong Diagnosis Code or Wrong Principal Diagnosis Code Billed (Inpatient Hospital): The “ICD-9 CM Official Guidelines for Coding and Reporting” states that, if a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(a), page 13.) Once a patient has developed an HIV-related illness, the patient should always be assigned the code 042 on every subsequent admission/ encounter. However, this does not mean that 042 must be the principal diagnosis. If the condition responsible for the admission is AIDS related (on the MDC 25 list or tied to AIDS by the physician in documentation), 042 is the appropriate principal diagnosis. If the admission was prompted by an unrelated illness, the principal diagnosis is that illness, and 042 is a secondary diagnosis. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(b), page 14.)
• Extensive OR Procedure Unrelated to Principal Diagnosis MS-DRGs 981, 982, and 983 (previously DRG 468) (Inpatient Hospital): RAC auditors found many errors in the assignment for MS-DRG 981, MS-DRG 982, and MS-DRG 983 that resulted in overpayments to hospitals.
• Oxaliplatin – Dose vs. Billed Units (Outpatient Hospital): Due to the vast difference for certain time periods in the amounts used (5.0 mg or 0.5mg) to calculate the number of service units being billed, Recovery Auditors found that many hospitals incorrectly calculated the number of service units billed, resulting in overpayment.
  Oxaliplatin HCPCS codes and units are:
• Before July 1, 2003 – J3490 – 0.5 mg
• July 1, 2003 to December 31, 2005 – C9205 – 5 mg
• On and after January 1, 2006 – J9263 – 0.5 mg
• Untimed Codes – Excessive Units (Outpatient Hospital): No matter how long the evaluation or service, providers can bill only one unit of untimed codes for a patient per date of service with some exceptions. Certain services are limited to certain numbers of units per day for physical therapy, occupational therapy and speech-language pathology, separately to control inappropriate billing. Specifically, the HCPCS codes involved are: 90901, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92609, 92610, 92611, 92612, 92614, 92616, 95833, 95834, 96110, 97001, 97002, 97003, 97004, 97010, 97022, 97026, 97597 and 97598.

The Newsletter also includes information on Inpatient Rehabilitation Facility (IRF) over- and under-payments related to incorrect discharge status codes and OIG findings related to physician billing of Transforaminal Epidural Injection Services. Although this article concerns physician billing, hospitals may find some of the information helpful in their coding and billing of transforaminal injections.

CMS has also added a quick tips feature to the MLN Provider Compliance webpage. A new “fast fact” will be added monthly to this webpage, so be sure to check it often. This month’s fast fact is:

Issue: Physician Orders

Solution: A physician's order is not valid without a legible signature. The physician must authenticate the order. If the order is not signed or authenticated, the physician's intent must be clearly established in the medical records.

The CMS RAC webpage was recently updated with the addition of a downloadable 2011 FFS Newsletter (RAC). This newsletter contains RAC overpayment and underpayment amounts as of March 2011. Providers should note the increase in activity for the last quarter versus the two previous quarters of the National RAC program. Through March 2011, the corrections of the permanent RAC program totals $365.8M. The newsletter also includes the top issues per Recovery Auditor.

Clients of Medical Management Plus can also find the above referenced documents in the Resource section of our website.

MMP, Inc. Presents “Pain Points”

 Case Mix Index (CMI): It all begins with the Physician’s Pen

When talking to hospital staff and Physicians about high resource consumption, high readmission rates and high mortality rates, one explanation you almost always hear is “my patients are sicker.”

But how do you know if your patients are sicker? Understanding your facility’s Case Mix Index (CMI) is a good way to answer this question. However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:
In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.  

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.

Assigning a DRG:

Principal Diagnosis:
The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):
These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication.  When the DRG system transitioned to MS-DRGs the comorbidites and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting. For example:
• A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin.
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications are those conditions that occur during the inpatient hospitalization.
  For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.  
• Major Comorbidities and complications (MCCs): DRGs with MCCs reflect the highest level of severity.
  For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.

As many times as we have heard it said, it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record.  Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.  

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated that “we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG. For CMS fiscal year 2011 (October 1, 2010 through September 30, 2011) relative weights range from as high as DRG 001: Heart Transplant or Implant of Heart Assist System with MCC at 26.3441 to as low as DRG 795: Normal Newborn at 0.2284. Medical DRGs (e.g. chest pain, pneumonia, congestive heart failure) will have a lower relative weight than surgical DRGs.

Case Mix Index (CMI):  The Ingenix 2011 DRG Expert defines CMI as “the sum of all DRG relative weights, divided by the number of Medicare cases. A low CMI may denote DRG assignments that do not adequately reflect the resources used to treat Medicare patients.”

An easier way to explain CMI is to compare it to a student’s Grade Point Average (GPA). A higher GPA is reflective of a student’s academic success. Likewise, a higher CMI for a hospital is reflective of a successful DRG program.

GPA Example:
(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA
21 ÷ 10 = 2.10 GPA

Case Mix Index Example A:

Formula for Case Mix Index:
Sum of Relative Weights ÷ Total Number of DRGs Coded = Case Mix Index

Example A Case Mix Index: 3.7543 ÷ 4 = 0.9386 Case Mix Index

Example B: The Potential Impact Physician Queries can have on DRG Assignment:

Example B Case Mix Index: 4.9944 ÷ 4 = 1.2036 Case Mix Index

“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.”

(Source: Ingenix 2011 DRG Expert)

Challenges for Hospitals:

Understanding what can make your hospital's CMI fluctuate:

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:  

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.
• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.  
• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

The American Health Information Management Association (AHIMA) published a practice brief “Managing an Effective Query Process” in October 2008. The AHIMA brief states that “Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” or if “additional information is needed for correct assignment of the POA indicator.”

Further, AHIMA suggests querying when documentation in the patient’s record fails to meet one of the following five criteria:

• Legibility
• Completeness (e.g. abnormal test results without notation of clinical significance)
• Clarity (e.g. diagnosis without statement of cause or suspected cause)
• Consistency (e.g. conflicting documentation)
• Precision (e.g. greater specificity)

The entire brief can be found at AHIMA's Managing an Effective Query Process.

So, how do you know if your patients are sicker?

Internally, hospitals can:

• Work with their Decision Support staff to develop CMI reports by facility and by individual physicians.  
• Perform root-cause-analysis when you see fluctuations in the CMI rate.
• Use CMI reports to compare Physicians in like specialties to each other.

External Resource for hospitals:

MMP, Inc’s sister company RealTime Medical Data (RTMD) affords hospitals the unique ability to finally compare their CMI rates to other hospitals within their defined market as well as statewide. RTMD uses real Medicare paid claims data and reports are based on the total market – all residents, all physicians, and all hospitals within Alabama, Mississippi, Tennessee, Georgia, Florida, Louisiana and Arkansas.

RTMD reports that can help a hospital and physician’s answer this question include:

• CMI Detail Reports
• Provider CMI Details by DRG with Statewide CMI: This report represents CMI for the Provider with DRG details and includes Statewide CMI for all providers.
• Provider CMI Details by Physician: This report represents CMI for the Provider with Physician Details.

A successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.

Effective April 1, 2011, for services furnished on and after January 1, 2011, providers should report HCPCS code G0010 for administration of Hepatitis B vaccine in an outpatient facility setting instead of CPT codes 90471 and 90472. This will ensure that cost-sharing waivers for Preventive Services are correctly applied to the vaccine administrations.

Here is the complete CMS announcement:

"Please note that a correction has been issued by CMS to the Preventive Services Table (via Change Request #7012), with specific regard to CPT codes 90471 and 90472.  Beginning Friday, April 1, for services that were or are furnished on or after Saturday, January 1, 2011, when providers are furnishing Hepatitis B Vaccines in outpatient  facility settings they must report HCPCS code G0010 (Administration of Hepatitis B vaccine) rather than CPT code 90471 or 90472.  This is in order to ensure that cost-sharing waivers are correctly applied to vaccine administration.  As of Friday, April 1, CR 7012 will no longer recognize CPT codes 90471 and 90472 for applying cost-sharing waivers on claims submitted for preventive services."

Link to Transmittal 864 (CR 7012)

Question:
What is the correct way to bill for myocardial perfusion studies that are performed over multiple days, for example the resting portion of the study is done one day and the stress portion is performed the next day?

Answer:
Even if performed on two separate dates of service, MMP, Inc. recommends billing only CPT code 78452 or CPT code 78454 (with a quantity of 1) representing myocardial perfusion imaging “multiple studies”, at rest and/or stress and/or redistribution and/or rest injection.

Do not use the single study CPT codes 78451 or 78453 (even with a reduced service modifier) to charge separately for each day. This would be considered unbundling.

References to support this recommendation include:

• Society of Nuclear Medicine and MedLearn, Nuclear Medicine & PET Coder, 2010, page 87; and
• Dr. Z, Diagnostic & Interventional Cardiovascular Coding Reference, 2011, page 484, coding instruction #5.

It has been brought to the attention of MMP, Inc. by one of our clients that Alabama Medicaid is still applying a unit restriction of one (1) for CPT code 97598. The descriptions of CPT codes 97597 and 97598 changed in 2011 – prior to 2011, CPT 97597 was for selective debridement of total wound(s) less than or equal to 20 sq cm and CPT 97598 was for selective debridement of total wound(s) greater than 20 sq cm. In 2011, CPT 97597 is for the first 20 sq cm debrided and CPT 97598 is an add-on code for each additional 20 sq cm, or part thereof, debrided.

MMP, Inc. also notes that the Medicare January 2011 published MUE list also has a quantity of 1 for CPT code 97598 and hospital CCI edits effective for the first quarter of 2011 do not allow the billing of 97597 and 97598 together, even with a modifier. Physician CCI edits have deleted this edit effective December 31, 2010, but since hospital CCI edits are a quarter behind physician edits, this edit change will not be effective for hospitals until April 2011. We have not heard of any problems with Medicare processing of multiple units of CPT 97598 or the billing of CPT 97597 and 97598 for the same date of service, but would appreciate notification if anyone encounters such issues.

Per correspondence to our client facility, Alabama Medicaid recommended holding claims with CPT code 97598 until they are able to address the quantity issue. Due to the above noted Medicaid quantity issue and the Medicare MUE and CCI edits, MMP, Inc. recommends hospital providers, upon administrative approval, consider the option of holding Medicaid and Medicare claims with CPT code 97598 until April 1, 2011.

We will provide further updates on this issue as we become aware of new information.