Knowledge Base Category -

“I’m late! I’m late! For a very important date!”- The White Rabbit in the 1951 Disney Classic Alice in Wonderland

Much like the White Rabbit, CMS was a day late in the release of the Fiscal Year (FY) 2017 Inpatient Prospective Payment System (IPPS) Final Rule. Late or not, CMS noted in a related Fact Sheet that this rule finalizes policies that continue their commitment to increasingly shift Medicare payments from volume to value. This article focuses on final revisions made to the general acute care hospital Quality Programs.

HOSPITAL INPATIENT QUALITY REPORTING (IQR) PROGRAM

The Hospital IQR Program is a pay-for-reporting program established by the Medicare Prescription Drug, Improvement, and Modernization Act. General acute care hospitals successfully participating in this program and are also meaningful electronic health record (EHR) users will receive approximately 0.95 percent increase in their operating payment rates. The Final Rule finalized changes to this program for FY 2018 and FY 2019 payment determinations.

FY 2018 Program Year: Two Claims Based Measure Refinements

PN Payment: Hospital-Level, Risk-Standardized 30-Day Episode-of-Care Payment Measure for Pneumonia (NQF #2579)

This measure cohort will be expanded to include hospitalizations for patients with

• Principal discharge diagnosis of pneumonia, including not only viral or bacterial pneumonia, but also aspiration pneumonia; and
• Principal discharge diagnosis of sepsis (but not severe sepsis) with a secondary diagnosis of pneumonia (including viral or bacterial pneumonia and aspiration pneumonia) coded as present on admission (POA).

PSI 90: Patient Safety and Adverse Events Composite Measure (NQF #0531): The modified PSI 90 composite was adopted for the IQR Program. See table 3 for further detail.

FY 2019 Program Year: 15 Measures Removed & Four New Measures Added

CMS finalized the proposal to remove 15 measures for the FY 2019 payment determination and subsequent years (see Table 1).

Table 1: Measures Finalized for Removal for the FY 2019 Payment Determination and Subsequent Years

‍Four New Measures to be added to the Hospital IQR Program for the FY 2019 Payment Determination and Subsequent Years.

Table 2: New Measures Finalized for FY 2019 Payment Determination and Subsequent Years

CMS notes that the new “measures capture Medicare payment for services related to the episode procedure and take into account beneficiaries’ clinical complexity as well as geographic payment differences. We proposed these clinical episode-based measures to supplement the Hospital IQR Program’s Medicare Spending per Beneficiary (MSPB) Measure….the measures also support our mission to provide better healthcare for individuals, better health for populations, and lower costs for healthcare.”

In response to stakeholder concerns that these measures overlap with the Medicare Spending Per Beneficiary (MSPB) Measure, CMS notes “that unlike the overall MSPB measure, the clinical episode-based payment measures assess payment variation at the procedure level and only include services that are clinically related to the named episode procedure (for example, the spinal fusion measure includes inpatient admissions for “medical back problems” that occur following the initial spinal fusion procedure since the admission is likely a result of complications from the initial procedure).”

HOSPITAL VALUE BASED PURCHASING (VBP) PROGRAM

The Act instructs the Secretary to reduce the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this budget neutral program. CMS indicates in Table 16A of the Final Rule that the estimated amount available for value-based incentive payments to hospitals for FY 2017 is approximately $1.8 billion. Actual amounts will be displayed in Table 16B that is expected to be posted in October of this year.

FY 2019 Program Year: New Domain Name and Expansion of location for CAUTI and CLABSI

The Patient-and-Caregiver-Centered Experience of Care/Care Coordination Domain will become simply the Person and Community Engagement Domain.

The NHSN (National Health Safety Network) CAUTI (Catheter-Associated Urinary Tract Infection) and CLABSI (Central Line-Associated Blood Stream Infections) outcome measures will include select ward (non-ICU) locations. “This expansion of the CAUTI and CLABSI measures aligns with the Hospital IQR Program. It also aligns with the HAC Reduction Program, which adopted the expansion of the CAUTI and CLABSI measures beginning with its FY 2018 program year (80 FR 49576 through 49578).”

FY 2021 Program Year: Two New Condition-Specific Payment Measures and Expansion of a 30-Day Mortality Measure Cohort

Two New Measures

Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI) (NQF #2431), and

Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure (HF) (NQF #2436).

Expansion of 30-Day-PN Mortality Cohort

Also for the FY 2021 Program Year, CMS finalized expansion of the cohort used for the 30-Day-PN Mortality measure to include patients with a principal discharge diagnosis of pneumonia, patients with a principal diagnosis of aspiration pneumonia and patients with a principal diagnosis of sepsis with a secondary diagnosis of pneumonia coded as present on admission (POA).

FY 2022 Program Year: CMS finalized the addition of Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following CABG Surgery (NQF #2554) (MORT-30-CABG) measure.

HOSPITAL ACQUIRED CONDITIONS (HAC) REDUCTION PROGRAM

This program creates an incentive for reducing the incidence of HACs by adjusting payments to hospitals in the worst performing quartile for HACs. CMS finalized the following five changes to the existing HAC Reduction Program policies:

• Clarified data requirements for Domain 1 (PSI-90),
• Established National Health Safety Network (NHSN) Centers for Disease Control and Prevention (CDC) Healthcare Associated Infection (HAI) data submission requirements for newly opened hospitals,
• Established performance periods for the FY 2018 and 2019 HAC Reduction Program,
• Adopted the refined Patient Safety Indicator (PSI) 90: Patient Safety for Selected Indicators Composite Measure (NQF #0531) beginning with the FY 2018 payment determination.
• Changed the Program scoring methodology from the current decile-based scoring to a continuous scoring methodology.

FY 2018 Program Year: Finalized Refinements to PSI 90

• First, the name of the PSI 90 measure will change to “Patient Safety and Adverse Events Composite: (NQF #0531).
• Second, the modified PSI 90 measure will include three new indicators (PSI-09, PSI-10 and PSI-11),
• Third, two Indicators will be re-specified in the modified PSI 90.
• PSI-12 Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate no longer includes ECMO procedures in the denominator or isolated deep vein thrombosis (DVT) of the calf veins in the numerator.
• PSI 15 Accidental Puncture and Laceration Rate is now limited to discharges with an abdominal/pelvic operation, rather than including all medical and surgical discharges.
• Fourth, PSI-07 Central venous catheter-related blood stream infections rate will be removed in the modified PSI 90.
• Fifth, weighting of component indicators will be based not only on volume of each patient safety and adverse events, but also the harms associated with the events.

PSI 90: To Expand from 8 to 10 Indicators for FY 2018 Program

Table 3: PSI 90: Patient Safety and Adverse Events Composite (NQF #0531) for FY 2018

‍HOSPITAL READMISSIONS REDUCTION PROGRAM (HRRP)

This program requires a reduction to a hospital’s based operating DRG payment to account for excess readmissions associated with the applicable conditions. For FY 2017 and subsequent years, a hospital’s potential reduction will be based on a risk-adjusted readmission rate during a three-year period for the following six conditions:

• Acute Myocardial Infarction (AMI),
• Heart Failure (HF),
• Pneumonia (PN),
• Chronic Obstructive Pulmonary Disease (COPD),
• Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA), and
• New Condition for FY 2017 (pursuant to prior rulemaking): All-Cause, Unplanned Readmission Following Coronary Artery Bypass Graft (CABG) Surgery (inclusion of this condition was finalized in the FY 2015 IPPS/LTCH Final Rule).

CMS is updating the public reporting policy so that excess readmission rates will be posted to the Hospital Compare website as soon as feasible following the hospitals’ preview period.

More Than Half a Billion Dollars in Readmission Penalties for FY 2017

Set to begin October 1, 2016, Jordan Rau of Kaiser Health News (KHN)reports that readmission penalties are set to reach a new high of more than half a billion dollars in payments being withheld in the coming fiscal year. To see if and how much your hospital will be penalized you can get the data in KHN’s Article Medicare's Readmission Penalties Hit New High.

Resources

CMS Fact Sheet Announcing release of 2017 IPPS Final Rule: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-02.html

2017 IPPS Final Rule (Display copy): https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page-Items/FY2017-IPPS-Final-Rule-Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

Dilemma:
How do you code COPD with Acute Exacerbation of Asthmatic Bronchitis?

Solution:

Two codes are necessary to capture the full diagnosis, one code for the Acute Exacerbation of COPD (J44.1) plus a second code to identify the type of Asthma (J45.901).
Per ICD-10-CM, coders are instructed as follows:

Bronchitis (diffuse) (fibrinous) (hypostatic) (infective) (membranous) (J40)

Asthmatic (J45.9)

Chronic (J44.9)

with

Acute lower respiratory infection (J44.0)

Exacerbation (acute) (J44.1)

OR

Asthma, asthmatic (bronchial) (catarrh) (spasmodic) (J45.909)

with

Chronic Obstructive Bronchitis (J44.9)

with

Acute Lower Respiratory Infection (J44.0)

Exacerbation (acute) (J44.1)

Chronic Obstructive Pulmonary Disease (J44.9)

with

Acute Lower Respiratory Infection (J44.0)

Exacerbation (acute) (J44.1)

Under category (J44) (Other Chronic Obstructive Pulmonary Disease) there is a Code also note instructing coders to code the type of Asthma, if applicable (J45.-). In this case, Unspecified Asthma with Acute Exacerbation (J45.901) is added.

Two things to remember:

1. Since an Acute Exacerbation is a worsening of a Chronic Condition, we automatically know that the Asthmatic Bronchitis is a Chronic condition.
2. The diagnosis of Acute Asthmatic Bronchitis is not the same as Acute Bronchitis.

If an MD documents Acute Bronchitis and then further specifies it as Acute Asthmatic Bronchitis, a code for Acute Bronchitis (J44.0) is not coded in addition. In this case, the patient does not have Acute Bronchitis, only Acute Asthmatic Bronchitis.

If the documentation is unclear as to whether a patient has Acute Bronchitis and an Acute Exacerbation of Asthmatic Bronchitis or just an Acute Exacerbation of Asthmatic Bronchitis, query the physician for clarification. Work with your physicians to help them understand the different descriptions and options in ICD-10-CM.

Information Source(s):

• ICD-10-CM Official Coding Guidelines
• ICD-10-CM and ICD-10-PCS Coding Handbook, Chapter 19 – Diseases of the Respiratory System, written by Nelly Leon-Chisen, RHIA, American Hospital Association
• TruCode encoder 
• ICD-10-CM Expert for Hospitals, by Optum

National Medicare (CMS) and their local Administrative Contractors (MACs) are responsible for a variety of different tasks – processing and paying claims, educating providers, ensuring payments are appropriate, and verifying that providers are following the Medicare regulations. It’s a big job but, lucky for them, they have help, especially in the area of oversight. There are the Recovery Auditors, the Quality Improvement Organizations (QIOs), Supplemental Medical Review Contractors (SMRCs), Comprehensive Error Rate Testing (CERT) auditors, and the Office of Inspector General (OIG). A recent OIG audit concerning mechanical ventilation found billing errors so the OIG offered a number of recommendations to CMS on how to make things better.

The OIG conducted a review to determine whether Medicare payments to hospitals for inpatient claims with certain MS-DRGs that required 96 or more consecutive hours of mechanical ventilation complied with Medicare requirements. MS-DRG 207 (respiratory system diagnosis) and MS-DRG 870 (septicemia or severe sepsis) both require that the patient has received 96 hours or more continuous mechanical ventilation, indicated on the claim with procedure code 96.72. These MS-DRGs pay a higher reimbursement rate than the corresponding MS-DRG assignments for a patient who did not receive 96 hours or more of ventilation.

Due to findings from previous OIG audits and the known risk of overpayments associated with mechanical ventilation, CMS has already taken actions to reduce the number of payment errors. They have claims processing edits based on the inpatient admission length of stay and also have provided education concerning the requirements for coding mechanical ventilation of 96 hours or more. One such education offering is the October 2011 Medicare Quarterly Compliance Newsletter.

In the current review, the OIG identified overpayments of $1.5 million for the specific claims reviewed. The OIG estimates overpayments of over $19.5 million for MS-DRGs 207 and 870 for the two-year audit period. Based on this finding, they determined current controls were inadequate to prevent incorrect billing and recommended additional actions by CMS to reduce payment errors. Specifically the current billing edit is based on total length of stay – the OIG recommends the edit be modified to look at the date mechanical ventilation begins and the discharge date to ensure there is sufficient time for 96 or more hours of mechanical ventilations. CMS concurred with the recommendation and replied, “Effective October 1, 2016, CMS will implement an edit to ensure correct coding of mechanical ventilation greater than 96 consecutive hours by using the mechanical ventilation procedure service date as the start date to calculate consecutive days.” CMS published official guidance for this in Transmittal 3504 from April 2016. To fulfill other recommendations from the audit Medicare will also be recouping the identified overpayments, expanding their own reviews, and providing additional education.

Hospitals need to be sure their coders understand the correct assignment of the procedure code for mechanical ventilation. Coders also need to be aware of the change in procedure code description from ICD-9 to ICD-10. The I-10 description for 5A1955Z is Respiratory ventilation, greater than 96 consecutive hours, which differs from the I-9 procedure code 96.72 description of 96 consecutive hours or more. The “greater than” description equates to a patient being on continuous mechanical ventilation for at least five (5) days, one day longer than the minimum 4 days of “96 hours or more.” This means Medicare’s new edit for October 2016 will look for less than 5 days from the date of initiation of mechanical ventilation until discharge.

Hospitals may want to consider some internal education and/or audits of claims assigned this procedure code. In other words, hospitals may want to “oversight” themselves, before oversight by Medicare or the overseers of Medicare oversight.

Growing up in the south, I remember being told that summer is mosquito season. What I found in writing this article is that it’s more about the temperature levels. Specifically, when temperatures reach a consistent 50°F mosquito eggs begin hatching and mosquito season begins. So, in more temperate parts of the nation, mosquitoes can be present year-round. Here in my home state of Alabama the mosquito season typically begins in early March.

I also learned that there are over 3,000 different species of mosquitoes throughout the world; currently 176 of these species has been recognized in the United States. Today, we are focusing on just one group of mosquito, Aedes mosquitoes that can transmit the Zika virus.

About the Virus

The Zika Virus was first discovered in 1947 in the Zika Forest of Uganda. The first human cases of the virus were detected in 1952 and since outbreaks have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. The disease is transmitted by Aedes mosquitoes who also transmit three other vector-borne diseases (dengue, chikungunya and yellow fever).

The Centers for Disease Control (CDC) indicates that most infected people are asymptomatic. When a person is symptomatic, common symptoms of the virus normally lasts for 2-7 days and can include:

• Acute onset of fever,
• Maculopapular rash,
• Headache,
• Muscle and joint pain, and
• Conjunctivitis.

The World Health Organization (WHO) notes two serious complications reported by Brazil:

• July 2015: Brazil reported an association between the virus and Guillain-Barre syndrome.
• October 2015: Brazil reported an association between the virus infection and microcephaly.

On February 1, 2016 the WHO declared the Zika virus a Public Health Emergency of International Concern (PHEIC) and since then has been posting weekly Zika Situation Reports. The last report posted at the time of this article was June 23, 2016. Key notes of concern from the June 23rd Summary includes:

• As of June 22, 2016, 61 countries and territories report continuing mosquito-borne transmissions of which:
• 47 countries are experiencing a first outbreak of the virus since 2015 with ongoing transmissions by mosquitoes.
• Ten countries have reported evidence of person-to-person transmission of the virus noted to probably be via a sexual route.
• As of June 22, 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with the virus or suggestive of congenital infection have been reported by twelve countries or territories.
• As of June 9th, the CDC has reported three live born infants with birth defects and three pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection.
• 13 Countries and territories worldwide have reported an increase incidence of Guillain-Barre syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.

Medicare to Cover Diagnostic Testing for Zika Virus

CMS has released MLN Matters Article SE1615 titled Medicare Coverage of Diagnostic Testing for Zika Virus. Specific Provider Action Needed includes:

• Informing the public that Medicare covers testing under Medicare Part B “as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury,”
• As currently there are no HCPCS codes for testing of the Zika virus, laboratories furnishing the Zika tests should contact their Medicare Administrative Contractors (MACs) for guidance on appropriate billing codes to use on the claims; and
• Labs should provide “resources and cost information as may be requested by the MACs in order for the MACs to establish appropriate payment amounts for the tests.”

ICD-10-CM Coding for Zika

The Zika Virus was discussed during the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee Meeting. ICD-10-CM currently classifies the virus to code A92.8, Other specific mosquito-borne virus.

In December 2015 the WHO noted the need for a separate code for the Zika Virus to allow for tracking of cases. The WHO proposed a new code for the Zika virus (A92.5). To be consistent with the planned WHO ICD-10 update, effective October 1, 2016 ICD-10-CM will include the addition of the following:

Chapter 1 – Certain Infectious and Parasitic Diseases (A00-B99)

A92 – Other Mosquito-borne viral fevers

New Code: A92.5 – Zika virus disease
Zika virus fever
Zika virus infection
Zika, NOS

Prevention

The American Mosquito Control Association (AMCA) is an association “dedicated to providing leadership, information and education leading to the enhancement of public health and quality of life through the suppression of mosquitoes.” In fact, this past week of June 26 – July 2nd was National Mosquito Control Awareness Week 2016. In a Press Release template, the AMCA® reminds the public to practice the THREE D's of Mosquito Prevention and Protection:

• Drain: Empty out water containers at least once per week
• Dress: Wear long sleeves, long pants, and light-colored, loose-fitting clothing, and
• Defend: Properly apply an approved repellant such as DEET, picaridin, IR3535 or oil of lemon-eucalyptus.

Dilemma:

A patient is diagnosed with Atherosclerosis of the Left Superficial Femoral Artery with Total Occlusion and a Non-healing Ulcer of the Left Lower Extremity. The patient also has a history of Polyneuropathy and Type 2 Diabetes Mellitus. What are the diagnosis codes for this scenario?

Solution:

The diagnoses for this patient include Atherosclerosis of Native Arteries of Left Leg with Ulceration of Other Part of Lower Left Leg (I70.248), Chronic Total Occlusion of Artery of the Extremities (I70.92) (cc), Type 2 Diabetes with Other Skin Ulcer (E11.622), Non-pressure Chronic Ulcer of Other Part of Left Lower Leg with Unspecified Severity (L97.829) (cc) and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (E11.42). The principal diagnosis depends on the circumstances of the admission.

Please note: ICD-10 assumes a cause-and-effect relationship between the Diabetes, the Leg Ulcer and the Polyneuropathy. This is a change from ICD-9-CM.

Information Source(s):

• Coding Clinic, First Quarter, 2016, pages 11 and 12
  Effective with discharges March 18, 2016
• ICD-10-CM Alphabetic Index
• ICD-10 Coding Handbook

In today’s busy world, calendars and notes help us keep track of all our appointments and to-do’s. But sometimes, I have too many calendars – a hand-written calendar on my refrigerator so I see it daily, an Outlook calendar at work and a calendar on my smart phone. I have to remember to synchronize my various calendars so I am not relying on an incomplete listing. This is a problem of information in too many places – similar to issues that sometimes occur with Medicare’s National Correct Coding Initiative (NCCI or CCI). Is the information in an edit table, the policy manual, or both?

If you are involved in healthcare coding, billing or compliance you best be aware of Medicare’s CCI edits. According to the NCCI webpage, “The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.” The NCCI information also applies to Medicaid claims and some other government and commercial insurances also follow some or all of these “correct coding” principles.

There are multiple parts to CMS’s National Correct Coding Initiative – three different types of edits and a policy manual.

Procedure-to-procedure (PTP) Edits

Originally labeled as “comprehensive/component” and “mutually exclusive” code pairs, these have been consolidated into the Column One/Column Two Correct Coding edit file. PTP edits prevent inappropriate payment of services that should not be reported together. There is a PTP file for practitioners and another for hospitals.

Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the column one code is eligible for payment but the column two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

Medically Unlikely Edits (MUEs)

CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. 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. All HCPCS/CPT codes do not have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only. The latter group of MUE values should not be released since CMS does not publish them. There are MUE files for practitioners, facilities, and DME.

A few years ago, CMS added MUE Adjudication Indicators (MAIs) to the MUE table to indicate whether an MUE was a line item edit (MAI of 1), an absolute date of service edit (MAI of 2), or an appealable date of service edit (MAI of 3).

Add-On Code Edits

Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment. See CR7501 for more information.

National Correct Coding Initiative Policy Manual for Medicare Services

The Policy Manual is a reference tool for correct coding and explains the rationale for NCCI edits. Chapter 1 addresses general coding principles, issues, and policies. Subsequent chapters correspond respectively to each CPT Manual section, Level 2 HCPCS codes and Category III CPT codes. These chapters further address the principles, issues, and policies dealing with specific groups of HCPCS/CPT codes.

Providers should carefully review the chapters of the manual that pertain to the code ranges they most often bill. These chapters include detailed information about correct coding and use of NCCI-associated modifiers for separately reportable services, and much more.

Source: MLN Product - How To Use the NCCI Tools

Providers must utilize all of the above tables and manual to ensure they are billing and coding correctly. Sometimes information is in a table or the manual but not in both. For example, there are no CCI edits between a thoracentesis (CPT codes 32554 / 32555) and a chest x-ray. But, in the Radiology chapter of the CCI policy, they include CPT codes 32554 and 32555 as examples of procedures where a chest x-ray should “not” be reported separately in the scenario described below as “usually performed”.

2016 CCI Policy Manual / chapter 9 / page 6: “When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.”

Providers may want to create an internal billing edit to identify claims with CPT codes 32554 / 32555 billed on the same date of service as a chest x-ray in order to comply with the CCI Policy Manual guidance.

So remember to check all your calendars to keep yourself on schedule and check all the NCCI resources to keep your billing and coding on point.

Dilemma:

Our hospital received several denials in the past from outside auditors for incorrectly assigning, Hemorrhagic Disorder due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors (286.5-), when a patient was admitted with a hemorrhage due to an anticoagulant. What is the ICD-10-CM code to show hemorrhage due to an anticoagulant that was taken as prescribed?

Solution:

ICD-10-CM has a specific code for hemorrhage due to an anticoagulant which is, Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants, (D68.32). This code would be assigned in addition to a code for the site of the hemorrhage along with a code for the adverse effect of the anticoagulant.

Example:

K26.4  Duodenal Ulcer with Hemorrhage

D68.32  Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants

T45.515  Adverse Effect of Anticoagulants

Code 286.5- was incorrect because of the word Intrinsic in the code title. Intrinsic means, belonging naturally or situated within an organ. An anticoagulant such as Coumadin, as we know, is not naturally found in the blood system. Code 286.5- was to be used to identify rare blood disorders, such as Acquired Hemophilia and Hemorrhage Disorder due to Systemic Lupus Erythematosus and not for adverse effects of a medication.

Information Source(s):

• Coding Clinic, First Quarter 2016, page 14
• Coding Clinic, Third Quarter 1992, page 15

Dilemma:

An elderly female presented to the hospital with shortness of breath and chest pain. The patient was admitted and Acute Coronary Syndrome was ruled out.   The patient was also noted to have a Hematocrit of 26.4, Acute Renal Failure, Diabetes Mellitus, Hypothyroidism, and Diverticulosis with recent hemorrhage. The attending physician documented Anemia of Chronic Disease to be the reason for admission and the principal diagnosis. Can Anemia of Chronic Disease (D63.8) be sequenced as a principal diagnosis in this case?

Solution:

No, Anemia of Chronic Disease has been designated as a manifestation; therefore, D63.8 cannot be sequenced as a principal diagnosis. Coding instructions state to code the underlying disease first. Therefore, if the documentation of the cause of the anemia is not clear, then querying the physician is recommended.

Resource: ICD-10-CM Codebook, TruCode

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

After struggling with application of Medicare’s incomplete listing of drug testing codes for 2015, I was so hopeful that Medicare would accept the drug testing CPT codes for 2016. For 2015, the American Medical Association (AMA) majorly revised the CPT drug testing codes, reorganizing the drug testing codes as presumptive, definitive, or therapeutic.

• Presumptive testing is for the possible use or non-use of a drug. Presumptive methods of testing are mainly immunoassays, enzymatic methods, and thin-layer chromatography (TLC). The CPT codes for presumptive testing, 80300-80304, are defined based on testing method and whether the drugs being tested are in Drug Class List A or Drug Class List B (also defined in the CPT manual).
• Definitive testing uses more complex testing methods, such as gas or liquid chromatography (GC/LC) with mass spectrometry (MS) and identifies individual drugs.
• Therapeutic drug assays are performed to monitor clinical response to a known, prescribed medication.

A helpful tool in the CPT code manual is the “Definitive Drug Classes Listing” that describes some of the particular drugs and metabolites included in each drug class for definitive testing. The most significant statement in the CPT instructions relative to definitive testing is, “Each category of a drug class, including metabolite(s) if performed (except stereoisomers), is reported once per date of service.” I admit some of the technical speak in the CPT instructions is even over my head (what is a stereoisomer??) but bottom line, this sentence means that CPT codes 80320 – 80377 are to be reported once a day per drug class. MMP even confirmed this with the American Hospital Association Coding Clinic. So if you test for oxycodone and oxymorphone, you only report CPT code 80365 with one unit.

Back to my wishful thinking - you don’t always get what you want. For 2016, Medicare is not accepting the CPT codes for drug testing. CMS has deleted all of the drug testing HCPCS codes from last year (G0431, G0434, and G6030 – G6058) and created new HCPCS codes for 2016. The bad news is that there is still not a one-to-one correlation between CPT and HCPCS codes for drug testing; the good news is that this year’s HCPCS codes appear a little easier to use and understand.

There are three new presumptive testing HCPCS codes based on testing methods. Only one of the three presumptive G codes may be billed per day.

• G0477 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• G0478 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.
• G0479 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service.

The most likely correlation for presumptive testing is that HCPCS codes G0477 and G0478 correlate with CPT codes 80300; HCPCS code G0479 correlates with CPT codes 80301, 80302, 80303, and 80304.

The new definitive HCPCS codes correlate with all of the CPT codes 80320 through 80377, depending on the number of definitive drug classes tested. The instructions in the 2016 Clinical Lab Fee Schedule Final Determinations state:

• Only one of the four definitive G codes may be billed per day.
• The unit used to determine the appropriate definitive G code to bill is “drug class.”
• Each drug class may only be used once per day in determining the appropriate definitive G code to bill.
• Drug classes are consistent with their usage in the AMA CPT Manual. The AMA CPT Manual may be consulted for examples of individual drugs within each class.

This means you can count the number of definitive CPT drug test codes to determine which of the HCPCS codes to bill. The new Medicare definitive codes are defined as: “Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day,…”

• G0480 - 1-7 drug class(es), including metabolite(s) if performed.
• G0481 - 8-14 drug class(es), including metabolite(s) if performed.
• G0482 - 15-21 drug class(es), including metabolite(s) if performed.
• G0483 - 22 or more drug class(es), including metabolite(s) if performed.

Even though Medicare has their own codes for definitive drug testing, as you can see, they rely heavily on CPT definitions. Very important verbiage for both CPT codes 80320-80377 and HCPCS codes G0480-G0483 is that these codes are not to be used for drug testing by immunoassay and enzymatic methods. One last thing to note – all the HCPCS drug testing codes include testing for specimen validation, such as pH, creatinine, etc. Testing to ensure the integrity of the specimen should not be billed separately.

For 2016, we may not have gotten what we wanted when it comes to drug testing codes, but we have to live with what we got. So get busy and update your charge description master.