UPDATE

For updated information on this topic, please click here for the more recent article: Coding Guidelines for Respiratory Failure

Whether it’s ICD-9-CM or ICD-10-CM, the coding guidelines are actually the same for Respiratory Failure. The only difference is the code itself. It’s not only important for a coder to be familiar with these guidelines but also some of the basic clinical indicators as well.

DEFINITION

from Section II of the Official ICD-9-CM Guidelines for Coding and Reporting

“Principal Diagnosis”A condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care - defined by the Uniform Hospital Discharge Data Set (UHDDS).

 

NOTE FROM AUTHOR
Each admission is different. The Principal Diagnosis will not be the same in every situation. Selection of the Principal Diagnosis is dependent on the circumstances of the admission. Coders should ensure that the record contains documentation that indicates clinical credibility to support the presence of that condition. It is also important for coders to understand the clinical indicators of Acute and/or Chronic Respiratory Failure in order to establish a query when necessary.

 

Respiratory Failure

1. Life-threatening condition that may be caused by a respiratory condition as well as a non-respiratory condition.
2. Look for documented signs / symptoms of:
3. SOB (shortness of breath)
4. Delirium and/or anxiety
5. Syncope
6. Use of accessory muscles
7. Tachycardia
8. Tachypnea
9. Confusion
10. Sleepiness
11. Depressed consciousness
12. Cyanosis (bluish color to skin, lip and/or fingernails)
13. Acute Respiratory Failure is supported as principal diagnosis when at least 2 of the following critical values (ABG’s) are met.
14. pH < 7.35
15. PO2 < 55
16. PCO2 > 50
17. Keep in mind, this is a guideline and not solely to be the determining factor for   diagnosing Acute Respiratory Failure. A patient with a chronic lung disease such as COPD may have an abnormal ABG level that could actually be considered that particular patient’s baseline. What is normal for one patient could be abnormal for another. In a patient with a chronic lung condition, the physician would consider the degree of change from a patient’s baseline before diagnosing Acute Respiratory Failure.
18. Acute Respiratory Failure
19. Develops quickly
20. Usually admitted to ICU
21. Requires aggressive and/or emergency treatment via oxygen through nasal cannula, face mask, ventilation and/or tracheostomy
22. Absence of vent does not preclude diagnosis
23. Requires close monitoring and evaluation
24. Chronic Respiratory Failure
25. Develops slowly
26. Last longer
27. Home O2 is one indication of CRF

Four classifications types for ARF

• Hypoxic – most common
• Hypercapnia – often accompanied by hypoxemia
• Post-operative
• Shock – Septic, Cardiogenic or Hypovolemic

Acute Respiratory Failure as Principal Diagnosis

OFFICIAL CODING GUIDELINE

ICD-10-CM – Section I.C.10.b.1

(ICD-9-CM – Section I.C.8.c.1)

Acute or Acute on Chronic Respiratory Failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selectionis supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

 

OFFICIAL CODING GUIDELINE

ICD-10-CM – Section I.C.10.b.3

(ICD-9-CM – Section I.C.8.b.3)

When a patient is admitted with Respiratory Failure and another acute condition (e.g., Myocardial Infarction, Cerebrovascular Accident, Aspiration Pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission.   If both the Respiratory Failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II.C) may be applied in these situations.

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.

 

When coding Respiratory Failure (or any condition) and trying to determine whether it should be assigned as principal diagnosis or not, look for:

1. All signs and symptoms at the time of admission
2. Clinical indicators
3. Supporting physician documentation
4. Treatment plans

With any record, keep in mind that because a condition may be present on admission does not necessarily mean if qualifies for principal diagnosis. You have to ask yourself these questions:

• After study, is this the condition that was chiefly responsible for admission?
• How aggressive was the work-up and treatment?
• Is there another condition that equally meets the criteria for principal diagnosis?
• Are there any chapter specific guidelines to consider?
• Could this condition have been treated as an outpatient?

I wish I could say that assigning the appropriate principal diagnosis and coding in general was as easy as ABC, but it’s not. Some are a little easier than others but there seems to always be a little gray area to muddle through. Clear and precise documentation goes a long way in helping to determine the principal diagnosis.

As you take on a record to code, forget about the one you just finished. Each record and the circumstances surrounding the admission will be different.   Always be aware of the coding guidelines and follow through the steps listed above. You’ll find that assigning the principal diagnosis will be a little easier.

 

Medicare has recently added yet another review contractor to audit your claims – the Supplemental Medicare Review Contractor (SMRC). So why does CMS need so many contractors to fight improper payments and ensure compliance? And what are the differences between the different contractors? I am not sure the answers are really clear, but here is some information from a recent transmittal about the various contractors and their functions.

CMS Transmittal 508 updates the Medicare Program Integrity Manual to include information about the Supplemental Medicare Review Contractor. According to the manual update, SMRCs, along with CERT contractors, Medicare Administrative Contractors (MACs), and Recovery Auditors (RAs) are contracted by CMS to fight improper payments and promote provider compliance in the Medicare fee-for-service program.

CERT Contractors

The CERT program establishes error rates and estimates of improper payments (implemented as part of the Improper Payments Elimination and Recovery Improvement Act).

Medicare Administrative Contractors (MACs)

MACs prevent improper payments through initiatives to help providers comply with Medicare’s coverage, coding and billing rules. This is accomplished through provider education; pre-and post-payment claim review; and local coverage determinations (LCDs), articles, and coding instructions. The MACs use error rates and vulnerabilities identified through the CERT and RA programs to target their efforts.

Recovery Auditors

Because of the large volume of claims that Medicare processes and the difficultly with catching all improper payments, the RAs provide additional review to detect and correct improper payments to help protect the Medicare Trust Funds.

Supplemental MR Contractor (SMRC)

The SMRCs are a centralized medical review (MR) resource that can perform large volume MR nationally. They perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The focus of SMRC reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports. Their primary duties include:

• Serving as a readily available source of medical information to provide guidance in questionable situations, including questionable claim review situations
• Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines
• Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse
• Providing clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse

Are the differences between the contractors clear as mud? Yes, I thought so. But even so, you need to know who the Medicare contractors for your region are. You can find that information by using the Review Contractor Directory.

 

This week the focus is on Chapter 12 – Diseases of Skin and Subcutaneous Tissue.   Like many chapters in ICD-10-CM, Chapter 12 has also been restructured.   Diseases that are related in one way or another have been grouped together. In ICD-10-CM, Chapter 12 has 9 subchapters:

• L00 – L08  Infections of the skin and subcutaneous tissue
• L10 – L14  Bullous disorders
• L20 – L30  Dermatitis and eczema
• L40 – L45  Papulosquamous disorders
• L49 – L54  Urticaria and erythema
• L55 – L59  Radiation-related disorders of the skin and subcutaneous tissue
• L60 – L75  Disorders of skin appendages
• L76  Intraoperative and post-procedural complications of skin and subcutaneous tissue
• L80 – L99  Other disorders of the skin and subcutaneous tissue

There is greater specificity for many of the codes at the fourth, fifth and sixth character. Examples for Decubitus (Pressure) Ulcers would be:

• Specified site (elbow, hip, sacral, ankle, back, buttock, heel, other site, unspecified site and contiguous site of back, buttock and hip)
• Laterality (right, left)
• Severity (stage)
• Classified Stage 1 through Stage 4
• Unspecified Stage
• Unstageable

Under ICD-9-CM 2 codes were required for Decubitus (Pressure) Ulcers. One code in ICD-10-CM provides:

• Ulcer site
• Laterality
• Stage
• Additional code should be assigned and sequenced first for any associated Gangrene.

CODING GUIDELINE

I.C.12.1

Pressure Ulcer Stages: Codes from category L89, Pressure Ulcer, are combination codes that identify the site of the Pressure Ulcer as well as the stage of the Ulcer. ICD-10-CM classifies Pressure Ulcer Stages based on severity, which is designated by Stages 1-4, Unspecified Stage, and Unstageable. Assign as many codes from category L89 as needed to identify all the Pressure Ulcers the patient has, if applicable.

Different stages for Pressure Ulcers:

• Stage 1 – Wounds that only involve the upper epidermis. Pre-ulcer skin changes limited to persistent focal edema
• Stage 2 – A wound progressing toward the dermis. An abrasion, blister and partial skin loss involving epidermis and/or dermis.
• Stage 3 – A wound involving the subcutaneous tissue. Full skin loss involving damage or necrosis of subcutaneous tissue
• Stage 4 – A wound that goes down into the deeper tissue. Necrosis of soft tissue through to underlying muscle, tendon, or bone.

Coding Guidelines for healed or healing Pressure Ulcer

• Section I.C.12.a.4 – Pressure Ulcer documented as healed – no code would be assigned.
• Section I.C.12.a.5 – Pressure Ulcer documented as healing – assign appropriate Pressure Ulcer Stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing Ulcer, assign the appropriate code for Unspecified Stage.Codes for Non-pressure Ulcers of the lower extremity also include site, laterality and severity (depth of the Ulcer). Examples of depth description for Chronic Ulcer of Right Ankle:
• Limited to breakdown of skin – L97.311
• With fat layer exposed – L97.312
• With necrosis of muscle – L97.313
• With necrosis of bone – L97.314
With unspecified severity – L97.319

Code first any associated underlying condition:

• Atherosclerosis
• Gangrene
• Diabetic Ulcers
• Varicose Ulcer
• Chronic Venous Hypertension
• Post-phlebitic Syndrome
• Post-thrombotic Syndrome

CODING GUIDELINE

I.B.14

Documentation for BMI and Pressure Ulcer Stages: For the body mass index (BMI) and Pressure Ulcer Stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e. physician or other qualified practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietician often documents the BMI and nurses often document the Pressure Ulcer Stages). However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

In ICD-10-CM, terms “Dermatitis” and “Eczema” are used synonymously and interchangeably.

CODING NOTE

An instructional note appears in the Tabular, under codes L27.0 and L27.1, stating to use an additional code for Adverse Effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).

 

CODING GUIDELINE

I.C.19.e

Adverse Effects, Poisoning, Under-dosing and Toxic Effects: Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent.

No additional external cause code is required for poisonings, toxic effects, adverse effects and under-dosing codes.

 

CODING GUIDELINE

I.C.19.e.5.a

Adverse Effect: When coding an Adverse Effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the Adverse Effect of the drug (T36-T50). The code for the drug should have a fifth or sixth character of 5.

Radiation-related disorders of the skin and subcutaneous tissue now have their own subchapter. Previously in ICD-9-CM, Sunburns were listed in the Injury and Poisoning Chapter.

DEBRIDEMENT

Anyone that has coded for any length of time knows the difference between Excisional and Non-excisional Debridement. This procedure has been under scrutiny by Medicare’s Recovery Auditors (RA previously known as RAC) due to the vast difference in DRG payment.   One of the biggest problems is getting required documentation necessary to code Excisional Debridement. I hate to say, but ICD-10-PCS is not going to make it any easier.

Unlike ICD-9-CM, ICD-10-PCS codes according to root operations. Depending on the method used, a Debridement procedure could actually fit into two different root operations.

• Excision – Cutting out or off, without replacement, a portion of a body part.
• Excisional Debridement would fit this category
• Extraction – Pulling or stripping out or off all or a portion of a body part by the use of force.
• Non-excisional Debridement would fit this category

It is not enough for a physician to state they did an Excisional or Non-excisional Debridement. In order to code this procedure correctly there are documentation requirements that must be met.

• Condition requiring Debridement
• Location of wound
• Depth of Debridement – code to the deepest layer
• Method of Debridement (sloughing off tissue, cutting away etc.)
• Specific tissue removed (skin, bone, muscle etc.) – cutting back to pink tissue or removal of necrotic tissue does not help with coding the procedure. It does not describe the type of tissue removed.
• Instruments used (scissors, scalpel etc.)

Sometimes coders tend to think that the type of instrument alone is indicative as to the type of Debridement that was performed. This is not always true. A scalpel and/or scissors can be used to cut or scrap the wound. The physician should accurately describe in detail each bullet listed above in his/her procedure note.

Please note, there is no default code for Debridement.   There must be precise documentation within the record and/or procedure note.   Physicians should always be queried anytime documentation provided is not clear.  

Happy National Laboratory Week to all the laboratorians who work behind the scenes to assist in the diagnosis and treatment of patients. Laboratory science has come a long way since I entered the profession many years ago with a lot more instrumentation and ever evolving tests offerings, such as genetic molecular pathology testing. Thanks to all the dedicated laboratory professionals who play a valuable role in maintaining and improving our nation’s health.

From a Medicare reimbursement standpoint, it has been a tough year for hospital outpatient clinical laboratory services. The 2014 OPPS Final Rule finalized a proposal to package payment for clinical laboratory tests performed during the same encounter with other outpatient services. This means there is no additional separate payment for lab tests performed on Medicare patients in the following areas:

• Patients treated in the Emergency department
• Patients in Outpatient hospital clinics, such as a Wound Care clinic or Cancer clinic
• Patients receiving Observation services
• Patients during an outpatient surgery
• Patients having lab tests performed during the same encounter as any other outpatient services such as imaging studies

Medicare still pays separately for clinical laboratory tests in the following exceptions if the claims are billed correctly:

1. 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.
2. When laboratory tests are the only hospital outpatient services that a patient receives during an outpatient encounter. For example, patients that are referred from a physician’s office/clinic to a hospital outpatient laboratory for laboratory testing only and no other outpatient services.
3. 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.

And as if this were not confusing enough already, the rules for billing laboratory claims to receive separate payment are about to change again. Effective January 1, 2014, CMS instructed hospitals to bill laboratory claims in the above listed situations on a 14x type of bill. However, because of concerns from hospitals and the National Uniform Billing Committee (NUBC) that all of these situations do not conform to the NUBC definition of a 14x bill as a “non-patient” claim, CMS is modifying the billing instructions effective July 1, 2014 as explained in MLN Matters Article SE1412.

Effective for claims billed on or after July 1, 2014, CMS will create a new modifier (yet to be determined) to be used on the 013X TOB (instead of the 014X TOB) when non-referred lab tests are eligible for separate payment under the Clinical Laboratory Fee Schedule (CLFS) for exceptions (2) and (3) listed above. For claims with dates of service on or after January 1, 2014 that are billed to Medicare on or after July 1, 2014 the following billing instructions apply:

‍Hospitals should continue to bill all exceptions for separate payment for laboratory tests on a 14x TOB until July 1, 2014. It continues to be the hospital’s responsibility to determine when laboratory tests qualify to receive separate payment. Starting with claims received July 1, 2014, and after, when a hospital appends the new modifier to a laboratory service, the provider is attesting that exception (2) or (3) listed above is met. The requirement for all OPPS services to be submitted on a single 13x claim (other than recurring services) continues to apply. In addition, laboratory tests for molecular pathology tests described by CPT codes in the ranges of 81200 through 81383, 81400 through 81408, and 81479 are not packaged in the OPPS and do not require the new modifier.

MMP will provide more information, specifically the new modifier and any accompanying instructions, as it becomes available. Please refer to the MLN Matters Article reference above for more information, including some billing scenarios.

I am often thankful that I do not have to deal with the verbose writings of the legal profession. But sometimes medical terminology, medical coding descriptions and Medicare regulations can offer similar challenges. Take for example the CPT code 92941- with words like “percutaneous transluminal” and “atherectomy” in the description, you wouldn’t think the confusion would be about the term “acute myocardial infarction” but evidently it is.

CODE DESCRIPTION

CPT code 92941

Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel.

 

Luckily, the AMA has clarified what constitutes an acute MI for the use of this CPT code. According to the ZHealth Online Newsletter for March 21, 2014, the AMA states that all of the following criteria must be met in order to support the assignment of CPT code 92941:

• EKG changes consistent with an AMI, such as:
• ST elevation not attributable to a bundle branch block or pericarditis
• New or undetermined left bundle branch block
• New or evolving Q waves
• Persistent horizontal ST depressions in the anterior leads consistent with posterior ST elevation
• Ongoing ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, or asystole consistent with an AMI
• Ongoing symptoms suggestive of an AMI despite nonspecific EKG changes.
• Emergent coronary angiography and intervention. This is an essential component – it is not appropriate for the intervention to be scheduled, even from the day before. It must be performed immediately.
• The intervention is performed on a target lesion that is totally or sub-totally occluded (no or markedly reduced flow through the lesion).

It is not appropriate to report CPT code 92941 for non-cardiac chest pain, unstable angina, a non-ST elevation MI (unless it requires emergent intervention for a totally or sub-totally occluded lesion), or non-emergent interventions after a completed or recent MI.

Coders need to be sure the required components are present before assigning CPT 92941 for a coronary intervention. Like lawyers, coders must read the fine print.

When Medicare reviewers audit your records, your documentation should “tell a good story.” For example, for rehabilitative therapy does your record tell what was wrong, when it happened, how it affected the patient’s life, why skilled services are needed, which services are needed and for how long and often, that a physician was involved in the patient’s care, and finally what was the patient’s outcome? I also review therapy records and complete, accurate documentation tells a compelling story of a patient’s therapy episode.

The first CERT Task Force scenario is a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. In addition to actual pre- and post-payment reviews, Medicare Administrative Contractors (MACs) provide feedback and education to providers through publication of their review findings, direct provider education, and now through collaboration with each other and the CERT review program. Certain A/B MACs are working together through the CERT A/B MAC Outreach and Education Task Force to educate providers on costly claim denials and billing errors to Medicare with an ultimate goal of reducing the national payment error rate.  

This focus on therapy services is timely as April is National Occupational Therapy month. In addition to sharing some of the key points from this guide, MMP would like to acknowledge the valuable contribution of Occupational Therapists to healthcare. The older I get, the more I value the ability to perform the physical functions necessary to lead an active lifestyle and to accomplish simple activities of daily living. When age, illness, or injury impairs function, occupational therapists are there to help patients restore and maintain their abilities.

In addition to their technical skills, all rehabilitative therapists must document their services in a manner consistent with Medicare’s documentation requirements. According to the CERT Task Force guide, “The leading cause of payment errors for therapy services is ‘insufficient’ documentation in the medical records.” Therapy documentation is often missing the required elements as outlined in applicable local coverage determinations and the Medicare manuals.

Here are some of the key documentation elements from the guide, LCDs, and the Medicare manuals.

• Plan of Care must include:
• The patient’s diagnoses (helpful to include functional limitations)
• Measurable long term goals for the entire episode of care
• Type of therapy (PT, OT, or SLP) (helpful to describe specific treatments, such as therapeutic activities, neuromuscular reeducation, etc.)
• The amount, duration and frequency of services
• Legible, dated signature and professional identity of the person establishing the plan and the practitioner certifying the plan
• Treatment notes must include:
• Date of treatment
• Specific intervention(s) provided and billed
• Total timed code treatment minutes and total treatment time in minutes
• Signature and professional identification of the qualified professional who furnished the services
• Functional Reporting
• Nonpayable G-codes and severity modifiers reported on claim must be documented in the therapy record
• Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

I encourage therapists to review the CERT Task Force guide, as well as the Medicare manuals and LCDs for therapy services for a complete discussion of the documentation requirements. I realize a lot of documentation is required, but good therapy documentation paints a complete and accurate picture of the patient’s conditions, the need for therapy, the treatments provided, and the patient’s ultimate outcome. For my nerdy, healthcare brain, it is like reading a good novel!

On April 1st, President Obama signed into law the Protecting Access to Medicare Act of 2014. Per a White House Press Secretary release this new law “averts cuts to Medicare physician payments that will go into effect on April 1, 2014, under the current-law “sustainable growth rate” system, to extend other health-related provisions set to expire, and to make other changes to current-law health provisions.” In addition to averting cuts to physician payments, this law includes additional “Medicare Extenders” and “Other Health Provisions.” But before looking at some of the more significant topics within the law, it is interesting to note how quickly this bill was presented, voted on and became law.

• March 26, 2014: Representative Joe Pitts (R-PA), Chairman, Energy and Commerce Subcommittee on Health introduced H.R. 4302 the Protecting Access to Medicare Act of 2014.
• March 27, 2014: The House voted by a voice vote and approved the bill. This vote was under special rules that provided for no amendments, limited debate and only needed a two-thirds majority votes.
• March 31, 2014: The United States Senate passed the bill with a vote of 64 YEAs, 35 NAYs and 1 Not Voting.

April 1, 2014: The Act was signed into law by President Obama signed the Protecting Access to Medicare Act of 2014 into Law.

Spotlight on Extensions and Health Provisions in the Law:

Section 101: Physician Payment Update: This section provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through December 31, 2013. Further, it provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.

Section 103: Extension of Therapy Cap Exception Process: This section extends the exceptions process for outpatient therapy caps through March 31, 2015. When a provider requests an exception to the cap for medically necessary services they must submit the KX modifier on their claim. This law extends the application of the caps, exceptions process, and threshold for therapy services provided in a hospital outpatient department (ODP).

Therapy caps for 2014:

 

• Occupational Therapy (OT) cap is $1,920
• Physical Therapy (PT) and Speech-Language Pathology Services (SLP) combined is $1,920

 

Additional information regarding therapy caps can be found on the CMS Therapy Cap webpage as well as Chapter 5, Section 10.3 in the Medicare Claims Processing Manual.

Section 106: Extension of the Medicare-Dependent Hospital (MDH) Program: This program provides enhanced payment to small rural hospitals where Medicare beneficiaries makes up a significant percentage of inpatient days or discharges. This provision extends the program through March 31, 2015.

More information about MDH Hospitals can be found in the Acute Care Hospital Inpatient Prospective Payment System Fact Sheet. Specific criteria to be designated a MDH Hospital includes:

 

• It is rural (located in a rural area);
• It has 100 or fewer beds during the cost reporting period;
• It is not also classified as a Sole Community Hospital (SCH); and
• At least 60 percent of its inpatient days or discharges were attributable to Medicare Beneficiaries entitled to Part A during the hospital’s cost reporting period.

 

Section 111: Extension of Two-Midnight Rule:

For hospital staff closely involved in trying to implement the Two-Midnight Rule, I felt it was important to provide you with the exact language in the bill.

“(a) CONTINUATION OF CERTAIN MEDICAL REVIEW ACTIVITIES.— The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘‘Selecting Hospital

Claims for Patient Status Reviews: Admissions On or After October 1, 2013’’, posted on the Internet website of the Centers for Medicare & Medicaid Services, through the first 6 months of fiscal year

2015 for such additional hospital claims as the Secretary determines appropriate. (b) LIMITATION.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).”

What does this mean for hospitals?

 

• The Medicare Administrative Contractor (MAC) Probe and Educate program has now been extended for a fourth time through March 31, 2015.
• Recovery Audit Contractors “shall not conduct patient status reviews on a post-payment review basis” for inpatient claims with dates of service October 1, 2013 through March 31, 2015. It is important to remember that on February 18th CMS announced that current RAC activity is winding down during the new contract procurement round.
• Hospitals should take advantage of this additional time to continue to educate staff and fine tune your processes.

Section 212: Delay in Transition for ICD-9 to ICD-10 Code Sets

“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.”

This is a significant delay for everyone that has been proactively planning and providing education for an October 1, 2014 transition to the ICD-10 Code Sets. MMP plans to continue to provide I-10 Corner articles and encourages all to not look at this as a setback but as an opportunity to provide more training to your staff and test the readiness of your computer systems.

Section 221: Medicaid DSH

This law delays reductions in payments to Disproportionate Share Hospitals (DSH) by a year and then makes additional reductions through 2024.

There are still quite a few extensions and provisions not discussed in this article. MMP encourages those interested to review the Protecting Access to Medicare Act of 2014 in its entirety.

For this edition of the I-10 Corner, we have included some helpful hints that will make coding procedures in the Endocrine System a little easier.   To gain familiarity, practice looking up procedures in the ICD-10-PCS coding book that are performed at your facility on a routine basis.

Knowing the Root Operations is the key to making all of this work!                                              

FROM THE ICD-10-PCS REFERENCE MANUAL

Examples of Root Operations

Excision—Root operation B

Definition: Cutting out or off, without replacement, a portion of a body part

Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies

Examples: Partial thyroidectomy, ovarian biopsy

Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to

• Scalpel
• Wire
• Scissors
• Bone saw
• Electrocautery tip

Resection—Root operation T

Definition: Cutting out or off, without replacement, all of a body part

Explanation: N/A

Examples: Total nephrectomy, total lobectomy of lung

Resection is similar to Excision, except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

Release—Root operation N

Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out

Examples: Adhesiolysis of right ovary

The objective of procedures represented in the root operation Release is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Reposition—Root operation S

Definition: Moving to its normal location or other suitable location all or a portion of a body part

Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Examples: Reposition of undescended testicle

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

Laterality is necessary in code assignment for the following organs:

• Thyroid
• Ovaries
• Testicles
• Adrenals

EXAMPLE

‍

Don’t Forget: 0 vs O:

FROM THE ICD-10-PCS REFERENCE MANUAL

Values

One of 34 possible values can be assigned to each character in a code: the numbers 0 through 9 and the [whole] alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

 

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014
B4. Body Part

B4.3 Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.

 

Since the release of the 2014 IPPS Final Rule (CMS-1599-F), the Centers for Medicare and Medicaid Services (CMS) have provided additional guidance to several elements of the rule. On March 21st they released MLN Matters® Number: MM8666 proving guidance on how to implement the Part B Inpatient Payment Policies in the CMS-1599-F. This article is based on Change Request (CR) 8666 that updates the Medicare Benefit Policy Manual Chapter 6 – Hospital Services Covered under Part B. Now, let’s walk through highlights from the article.

When would a Hospital consider rebilling Part A to Part B?

When a hospital “self-audits” a Medicare beneficiary’s hospitalization after they have been discharged and determines that the inpatient admission was not reasonable and necessary and instead should have been a hospital outpatient stay, then they should consider rebilling.

A hospital can also consider rebilling when a Medicare Contractor has performed a complex review of an inpatient claim and denied the claim.

What Services are allowable by Medicare when the claim is rebilled?

“Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient…except for those services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatient and not inpatients.”

What are limitations of being able to rebill?

• The beneficiary must be enrolled in Part B,
• The allowed timeframe for submitting claims (within one calendar year from the date of service) hasn’t expired; and
• Waiver of liability payment is not made.

What is the process for submitting a claim?

• If you have already submitted a claim to Medicare for Part A payment, this claim must be cancelled before submitting the Part B services claim.
• Even if you have not yet submitted a claim “Medicare requires the hospital to submit a “no pay” Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services.”

At this point you would submit an inpatient claim for payment under Part B (a 12x type of bill).

How are Part B Payments made?

“Payment is made according to the Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients.”

What Type of Hospitals can submit Part B inpatient claims?

All hospitals that bill Part A services are eligible to bill the Part B inpatient services, including:

 

• Short Term Acute Care Hospitals paid under IPPS,
• Hospitals paid under OPPS,
• Long Term Care Hospitals (LTCHs),
• Inpatient Psychiatric Facilities (IPFs) and IPF hospital units,
• Inpatient Rehabilitation Facilities (IRFs) and IRF hospital units,
• Critical Access Hospitals (CAHs),
• Children’s Hospitals,
• Cancer Hospitals; and
• Maryland Waiver Hospitals.

 

What the Medicare Beneficiary Liability is and the Hospitals Responsibility for Payment?

 

• A Medicare Beneficiary is liable for their usual Part B financial liability.
• “If the beneficiary’s liability under Part A for the initial claim submitted for inpatient services is greater than the beneficiary’s liability under Part B for the inpatient services they received, the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts.”
• However “if the beneficiary’s liability under Part A is less than the beneficiary’s liability under Part B for the services they received, the beneficiary may face greater cost sharing.”

The MLN Article goes on to discuss what services a Hospital can and cannot bill for. The CMS makes a point to remind hospitals that “the services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions. Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization review determination must be filed no later than the close of the period ending 12 months or one calendar year after the date of service.”

MMP strongly recommend that hospital read the entire article as well as (CR) 8666 and share this information with all staff members that would be involved in this process.

Q:

What discharge disposition do I use if one of our patients is transferred to a swing bed in another hospital since the description for discharge disposition (61) is entitled, “Discharged/Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed?”

A:

Discharge disposition (61) may also be used for patients who are transferred to a Medicare-approved swing bed located in another facility. CMS notes that there has been confusion with this discharge disposition and refers us to MedLearn Matters, article SE0408, March 10, 2004 for further review. Please note the two additional references below, Medicare State Operations Manual and the Uniform Billing Editor by Optum also states a patient may be transferred to a Medicare-approved swing bed in another facility.

Medicare State Operations Manual

§482.66 Special Requirements for Hospital Providers of Long-Term Care Services (“Swing-Beds”)

The change in status from acute care to swing-bed status can occur within one facility or the patient can be transferred to another facility for swing-bed admission.

Uniform Billing Editor by Optum

For Medicare, this code is used to report patients who have been discharged/ transferred to a SNF level of care within the hospital’s approved swing-bed arrangement, or to another Medicare-approved swing bed in another location.