Some people may not get their gift from Santa this Christmas. When I was a child, I was always told that Santa Claus would not come until I went to sleep. If the number of people having sleep study testing is any indication, a lot of people in the US are having trouble sleeping. An OIG audit reported that from 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39 percent.

Because of this dramatic increase in the volume of sleep studies, several Medicare review contractors have sleep studies and polysomnography as one of their review topics. Two such contractors are the Comprehensive Error Rate Testing (CERT) reviewers and the Supplemental Medical Review Contractors (SMRC). (see the SMRC Polysomnography Project )

Medicare covers diagnostic testing of sleep disorders when the patient has symptoms or complaints of narcolepsy, sleep apnea, impotence or parasomnia. Polysomnography for chronic insomnia is not covered. (See Medicare Benefit Policy Manual, Chapter 15 section 70) There is also a National Coverage Determination (NCD 240.4.1) and several Local Coverage Determinations (LCDs) concerning the coverage requirements for sleep studies.

All reasonable and necessary diagnostic tests for the conditions listed above are covered when the following criteria are met:

• The clinic is either affiliated with a hospital or is under the direction and control of physicians. Diagnostic testing routinely performed in disorder clinics may be covered even in the absence of direct supervision by a physician;
• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s order; and
• The need for diagnostic testing is confirmed by medical evidence, e.g. physician examination and laboratory tests.

Based on the findings from CERT reviews, discussed in the October 2014 Medicare Quarterly Compliance Newsletter, 97% of improper payments are due to insufficient documentation. So what do providers need to do to ensure they receive payment for their polysomnography services? Make sure the documentation in the medical record for sleep studies includes:

• A valid physician’s order for the diagnostic study or documentation to support the intent to order study (if there is no order, evidence of the intent to order PSG documented in the medical record can be accepted)
• A physician’s signature on the procedure note; and
• Clinical documentation to support the reason/need for the diagnostic study (e.g. documentation to support the fact that the beneficiary had symptoms and signs of sleep apnea).

You have to be good (and asleep) to get your presents from Santa, but you have to have complete and appropriate documentation to get your present (payment) from Medicare for sleep testing.

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

Having undergone back surgery at the age of twenty-seven, I would tell you that yes I needed that back surgery. Whether or not my chart demonstrated that need or not, who knows. That was then and this is now and in the current Medical Review Contractor environment, if the documentation in a medical record does not support the medical necessity of the procedure, claims submitted by hospitals and in some instances the surgeon can and are being denied.

There are countless types of back surgeries but for this article the focus is on documentation required to support the medical necessity of lumbar spinal fusions that code to DRGs 459 (Spinal Fusion Except Cervical with Major Co-morbidity or Complication) and DRG 460 (Spinal Fusion Except Cervical without Major Co-Morbidity or Complication).

Who is Looking?

The CMS Inpatient Hospital Reviews webpage indicates that despite the current Medicare Administrative Contractor (MAC) Probe & Educate Program, “MACs, Recovery Auditors and the Supplemental Medical Review Contractors will continue other types of inpatient hospital reviews” including “reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary.”

MACs

Jurisdiction-N (J-N): First Coast Services Options, Inc.

First Coast is the MAC for Florida and in the absence of a National Coverage Determination (NCD) they were the first and to date the only MAC to have a Local Coverage Determination (LCD) for Spinal Fusions. LCD L32074: Lumber Spinal Fusion for Instability and Degenerative Disc Conditions had an original effective date for services performed on or after October 16, 2011.

Key LCD Guidance

• It is “when conservative therapy (non-surgical medical management) is unsuccessful after at least 3 to 12 months, depending on the diagnosis, lumbar spinal fusion may be considered for certain conditions.”
• “The hospital records are the primary source of information for the audit of hospital/procedure services. Therefore, any historical data supporting the medical necessity of the fusion (for example, duration and outcome of physiotherapy, injection therapy, anatomic factors influencing the decision for surgery, etc.) must be included in the inpatient medical record as noted in the history and physical examination, operative note and/or copies of office notes. For example, fusion of iatrogenic instability (i.e., surgical resection of facet as essential portion of the required decompression rendering an unstable segment) should be documented in a pre-operative note and/or an operative note.”
• “To meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) can be denied.”
• Physician documentation must support the need for surgery and “must include the following:
• Office notes/hospital record, including history and physical by the attending/treating physician
• Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management) when applicable. Failure of non-surgical medical management can be historical and does not have to be under the direction of the operating surgeon.
• Interpretation and reports for X-rays, MRI’s, CT’s, etc.,
• Medical clearance reports (as applicable)
• Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted (if applicable)
• Complete operative report outlining operative approach used and all the components of the spine surgery

Medical record documentation must be made available to Medicare upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.”

Jurisdiction-11 (J-11) Palmetto GBA

Palmetto, the MAC for North Carolina, South Carolina, Virginia and West Virginia posted the YouTube Presentation Clinical Updates: DRG 459, 406earlier this year on August 11th. The most common reason cited by Palmetto for denials was a lack of information in the medical record about the conservative care provided prior to the surgical intervention.

Palmetto goes on to list documentation examples of conservative treatment that when clearly documented may help support payment for spinal fusion-related hospital care. Physical therapy, joint injections, neurologic deficits and upper and lower extremity strength are just a few of the examples provided.

Cahaba GBA, the MAC for Alabama, Georgia and Tennessee, has on more than one occasion indicated that simply documenting “failed outpatient therapy” for a total joint replacement is not sufficient to support the surgery. Similarly, Palmetto notes in this presentation that “failed outpatient therapy, admit for spinal fusion” is not sufficient evidence of Medical Necessity for a spinal fusion.

Supplemental Medicare Review Contractor (SMRC)

Transmittal 508 had an Effective and Implementation date of April 8, 2014 and added the Supplemental Medicare Review Contractor (SMRC) to the already long list of “Review Contractors” (MACs, CERT, RAC, PSCs, and ZPICs) performing medical review activities.

Strategic Health Solutions, LLC was awarded the SMRC Contract and they have been busy this year fulfilling one of their primary tasks of “conducting medical review based on the analysis of national claims data versus data that is limited to a specific jurisdiction as performed by Medicare Administrative Contractors (MACs).”

One such Project was a review of Medicare Part A Inpatient Services for Spinal Fusions. As part of the Project Background they noted that “analysis of Medicare claims data for calendar years 2012 and 2013 indicated a significant increase in billing and payment in Inpatient Hospitals Stays of Diagnosis-Related Group (DRG) Codes 459 (Spinal Fusion, except cervical spine, with major complications or comorbidities) and 460 (Spinal Fusion, except cervical spine, without major complications or comorbidities).”

The purpose of this project was to determine if claims had been appropriately adjudicated according to Medicare regulations and guidelines. At the end of the project 986 claims had been reviewed. Of those claims 589 were denied due to no response from the hospital and 374 claims were denied after review with a resultant overall Error Rate of 49%.

Project findings also included Specific Denial Reasons and Ways to Prevent Denials.

Denial Reasons

• Providers not responding to Additional Documentation Request (ADR) within the 45 day time frame
• Lack of documentation supporting the medical necessity of the procedure.
• Lack of documentation showing that conservative treatment was done prior to the surgical intervention.

Ways to Prevent Denials

• “Responding timely to SMRC ADR letters,
• Submit all documentation related to the services billed which support the medical necessity of services billed.”

Moving forward, hospitals need to be aware of NCD and LCD requirements to ensure records support the medical necessity of a procedure, be mindful of all of the Review Contractors that could be requesting records and submit requested information within the allowed time frame.

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout “by encouraging smokers to use the date to make a plan to quit, or to plan in advance and quit smoking that day.” We at MMP would also like to use this date to encourage our readers to make a plan and be prepared for the documentation changes for smoking in ICD-10.

In record reviews I have seen doctors note a patient has never smoked, is a smoker, is a reformed smoker, patient has cut back to 2-3 cigarettes a day. While all of this is interesting, currently in ICD-9 physicians simply need to document when a patient smokes or uses tobacco.

However, in ICD-10, physicians will need to provide more detailed documentation. Physicians will need to document the following additional information for the coder to most accurately report a patient’s tobacco use:

• The physician should document the type of tobacco a person uses (e.g. cigarettes, chewing tobacco, pipe, and/or gum).

• To further specify the type of tobacco dependence that a patient has, the physician will need to document the frequency of use.
• The patient uses nicotine, or
• The patient abuses nicotine, or
• The patient has a nicotine dependence or
• The patient is in remission from nicotine.

• Also, when it is applicable, the physician should document the type of second hand smoke experienced by the patient (e.g. from parent, at work, perinatal, etc.).

Take a look at what your physicians are currently documenting about tobacco use and begin to educate your physicians on what needs to be documented for the accurate reporting of tobacco use.

The 2014 IPPS Final Rule placed a significant burden on hospitals by requiring that a Physician Certification be completed on ALL Medicare inpatient admissions. In their effort to achieve “policy goals with the minimum administrative requirement necessary,” CMS finalized the 2015 OPPS proposed changes to the physician certification process that only requires physician certification for long-stay and outlier cases.

Implications for Hospitals:

• The physician certification change does not change the fact that there must be a signed inpatient order prior to a beneficiary being discharged as a hospital Condition of Participation (CoP) & a requirement for payment for Medicare Part A Services.
• Physician documentation in the medical record (e.g., History & Physical, MD Progress Notes and Physician Orders) still must support the medical necessity for hospital care that is expected to span at least two midnights.

• For Medicare beneficiaries that reach a 20 day length of stay it will be important to make sure that the “physician certifies or recertifies the following:

1. (1)The reasons for either –
2. (i)Continued hospitalization of the patient for medical treatment or medically required diagnostic study; or
3. (ii)Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F or part 412 of this chapter).
4. (2)The estimated time the patient will need to remain in the hospital.
5. (3)The plans for posthospital care, if appropriate.’

• The physician certification continues to be a requirement until January 1, 2015 and must include the following:
• Authentication of the Practitioner order prior to the beneficiary being discharged,
• The reason for inpatient services,
• The estimated time that the patient will require as an inpatient; and
• The plans for hospital care.

Final Rule Comments and Responses

• Comment: CMS indicates that several commenters “continued to disagree that CMS has the statutory authority to require signed admission orders for all inpatient cases.”
  
  Commenters further “argued that the continued requirement for admission orders is essentially the same as the certification requirement and stated that section 1814(a)(2) of the Act is explicit in requiring physician certification only for services “furnished over a period of time” and not for all services.”
  
  Response: Not surprising, CMS disagrees noting that, “While the inpatient admission order was a required component of the physician certification under our previous policy, the order and the physician certification do not serve identical policy goals under our proposal, which we are now finalizing. For all cases, a properly authorized and documented admission order is necessary because the admission order is integral to a clear regulatory definition of when and how a beneficiary becomes an inpatient.”

• Comment: There were also several commenters that requested that the timing of a signed admission order be by the time of billing as is permitted for Critical Access Hospitals (CAHs).
  
  Response: Again, not surprising, CMS disagrees and indicates that “we believe that, in most cases, matters relating to the determination of patient status should be resolved before discharge, due to the consequences that flow from such a determination. For example, whether services are billed under Medicare Part A or Part B can have a significant impact on a beneficiary’s financial liability. Therefore, we do not believe it is appropriate to change our existing policy which requires that inpatient orders be signed prior to discharge by a practitioner familiar with the case and authorized by the hospital to admit inpatients.”

• Comment: Several commenters also requested additional guidance around the required content and format of the physician certification statement.
  
  Response: CMS reiterates in the Final Rule that “the physician certification requirements at § 424.13 generally may be satisfied by elements routinely found in a patient’s medical record, such as progress notes. CMS does not require that a physician certification comply with a specific standard or format--only that it ensures that the conditions at § 424.13(a) were met. If the medical record adequately describes the reasons for continued hospitalization, the estimated time the patient is expected to require inpatient care, and discharge planning (where appropriate), and the medical record is signed by a physician involved with and responsible for the patient’s care, this would satisfy certification requirements.”

Final Rule

“We are finalizing the policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases”

“We are also are finalizing our proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

For those interested, the Revision of the Requirements for Physician Certification of Hospital Inpatient Services Other Than Psychiatric Inpatient Services can be found on pages 901-912 of the Display Copy of the Final Rule.

Link to the Display Copy of the Final Rule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1613-FC.html?DLPage=1&DLSort=2&DLSortDir=descending

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

Coding Kwashiorkor has been and continues to be a hot topic for contractors (e.g., Recovery Auditors and the Office of Inspector General (OIG)). In fact, auditing claims including a diagnosis of Kwashiorkor to determine if the record adequately supports the diagnosis was a new scope of work in the FY 2014 OIG Work Plan and is a continued scope of work in the FY 2015 OIG Work Plan. In the Work Plan the OIG indicates that “a diagnosis of Kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare.”

What is Kwashiorkor?

According to the National Institutes of Health, “Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet. Kwashiorkor is most common in areas where there is:

• Famine
• Limited food supply
• Low levels of education (when people do not understand how to eat a proper diet)
• Dates of service of records reviewed ranged from 2010 – 2013 with most records being prior to 2013.

This disease is more common in very poor countries. It often occurs during a drought or other natural disaster, or during political unrest.”

“Kwashiorkor is very rare in children in the United States. There are only isolated cases. However, one government estimate suggests that as many as 50% of elderly people in nursing homes in the United States do not get enough protein in their diet.

When Kwashiorkor does occur in the United States, it is usually a sign of child abuse and severe neglect.”

Kwashiorkor and the OIG Work Plan

In fulfillment of the Work Plan, the OIG has completed several hospital audits that found that hospitals had incorrectly billed Medicare inpatient claims with Kwashiorkor.

In the audit reports, the OIG indicates that Kwashiorkor generally affects children and the Medicare program is primarily provided to people age 65 or older. Yet, “for calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis for Kwashiorkor. Therefore, we are conducting a series of reviews of hospitals with claims that include this diagnosis code.”

Key Takeaways from 2014 OIG Reports:

• Consistent in the findings for all of the hospitals was that almost all claims reviewed did not comply with Medicare requirements for billing Kwashiorkor in that they used code 260 but should have used codes for other forms of malnutrition. In several instances removing code 260 did not result in a DRG change. When it did result in a DRG change it resulted in overpayments being made to the hospital.
• The combined overpayment by Medicare was $2,074,341. This is staggering when you consider that this amount is overpayment for one single secondary diagnosis code at only twelve hospitals.
• The reasons for coding errors sited by the hospitals included:
• Lack of clarity in the coding guidelines,
• Issues with the medical coding software program used to code the diagnosis; and
• Incorrect guidance from a third party consultant.

What Guidance is Available to Hospitals?

To answer the “lack of clarity in coding guidelines” for coding Kwashiorkor here are two resources that hospitals can look to for malnutrition coding guidance.

Coding Clinic

Volume 3, Issue 1 , page 3 of the October 2012 Medicare Quarterly Compliance Newsletter, provides an example of a Recovery Auditor findings where Kwashiorkor had been coded as a secondary major comorbidity incorrectly and refers the reader to Coding Clinic, Third Quarter 2009.

Specifically, Coding Clinic, Third Quarter 2009, p. 6 advises hospitals to only code 263.0 for moderate protein malnutrition as this category also includes protein-calorie malnutrition. Coding Clinic further advises that unless the physician specifically documents Kwashiorkor Code 260 should not be used.

Consensus Statement

The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) published a Consensus Statement in the May 2012 Journal of the Academy of Nutrition and Dietetics.

This article acknowledges that “the diagnosis of malnutrition in a patient is an undeniably complicating condition that in many cases significantly increased resource utilization in the acute care setting beyond that experienced by the patient in nutritional health.”

While hospitals have historically looked to serum albumin and prealbumin levels as an indicator of malnutrition, the Academy’s Evidence Analysis Library (EAL) analysis found that “acute-phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.”

This article also notes that “CMS has also questioned the use of acute-phase serum proteins as primary diagnostic criteria for malnutrition since studies increasingly suggest limited correlation of these proteins with nutritional status.”

The Academy and Aspen state that two of the following six characteristics should be identified in a patient when diagnosing malnutrition:

• Weight loss;
• Loss of muscle mass;
• Loss of subcutaneous fat;
• Localized or generalized fluid accumulation that sometimes mask weight loss; and
• Diminished functional status as measure by hand grip strength
• Insufficient energy intake;

It is advised that these characteristics be assessed at the time of the hospital admission and “at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.”

The article goes on to site a study by Fry and colleagues that “showed that preexisting “malnutrition and/or weight loss” was a positive predictive variable for all eight major surgery-associated “never events” (inexcusable outcomes in a health care setting.”

Assessment, diagnosis and treatment of malnutrition are critical for the wellbeing of our patients. Equally important is identifying the characteristics that need to be assessed in formulating the correct type of malnutrition (e.g. moderate or severe) diagnosis. This article contains a table with detailed clinical criteria to assist in determining the severity levels of malnutrition and I strongly encourage you to read this article.

Medical Management Plus enjoys acknowledging the various healthcare professionals with whom we work during their designated annual recognition times. October is National Physical Therapy month and we thank all of those who work diligently in the physical therapy occupation to improve the health of their patients. In association with this recognition, here are some questions and answers related to Medicare therapy services.

1. If a patient in a hospital setting (observation or inpatient) receives therapy services, do you have to follow the Part B (general considered outpatient) therapy guidelines?
2. outpatients receiving observatipon services
3. inpatients whose inpatient admission does not meet criteria so only Part B services are billed, and
4. inpatients who only have Medicare Part B coverage (patient does not have Medicare Part A or Part A benefits are exhausted).
   The 2014 IPPS Final Rule states “we (CMS) believe we also must apply the therapy caps and all other Part B coverage and payment rules to hospital inpatient therapy services paid under Part B. Accordingly, (therapy services) billed to Medicare Part B, … will be subject to the Part B therapy caps …, the therapy caps exceptions process, the manual medical review process, and all other requirements for payment and coverage of therapy services under Part B (for example, functional status reporting requirements).”
5. Is a discharge summary required for all Medicare patients receiving outpatient therapy services?Yes, the Medicare Benefits Policy Manual, Chapter 15, Section 220.3 states:
   “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment. … The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge. In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.”
6. If a patient discontinues outpatient therapy unexpectedly, must you report a discharge functional limitation HCPCS (G) code and modifier? What do you do if the same patient later returns to continue therapy?
   
   Per MLN Matters Special Article SE 1307: “Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly. When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
   
   When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
7. the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or
8. a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.
9. NOTE: A reporting episode will automatically be discharged when it has been 60 or more calendar days since the last recorded DOS.
10. Is it appropriate to use modifier 59 to by-pass CCI edits for therapy services that are performed during the same session but at separate times?
11. Yes, per the NCCI manual, “Some NCCI edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”
12. Where can I find the information on the time reporting requirements for rehabilitative therapy services?
13. That information can be found in the,Medicare Claims Processing Manual, chapter 5 ,section 20.2and also -Medicare Therapy Billing Scenarios
14. Are Medicare contractors and affiliates still performing medical review of therapy services?
15. Yes, the RACs continue to perform manual medical review of therapy services exceeding the annual threshold amount and the OIG recently published areview of outpatient therapy services. Although this review focused on an independent therapy provider (not hospital outpatient), the findings are relevant to therapy in either setting. Findings included:
    
16. Plan of Care (POC) goals that were not measurable or pertinent to the patient’s functional limitation,
17. Problems with the therapist’s signature on the POC and treatment notes
18. Lack of specific skilled interventions in the treatment notes
19. Lack of documentation of time
20. Lack of medical necessity for therapy services
21. Progress notes not performed every 10th treatment day
22. Physician certifications not signed and/or dated
23. Other Medicare contractors such as the Medicare Administrative Contractors (MACs) and CERT reviewers may also review therapy records.

As always, therapists have more to worry about than just how their patients are progressing.

In this week’s article, we are featuring Neoplasms focusing mainly on the differences between ICD-9-CM and ICD-10-CM Coding Guidelines. There are only a few changes in the wording of the guidelines but there are several additional guidelines in ICD-10-CM. Only the differences in the two classification systems are listed below.

Unless otherwise indicated, these guidelines apply to all health care settings.‍

GUIDELINES COMPARISON

‍Primary malignant neoplasms overlapping site boundaries

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere.

For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Malignant neoplasm of ectopic tissue

Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to pancreas, unspecified (C25.9).

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

EXAMPLE

If the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.

See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.

 ‍

GUIDELINES COMPARISON

‍Additional guidelines in ICD-10-CM

2.i) Malignancy in two or more noncontiguous sites

A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.

2.j) Disseminated malignant neoplasm, unspecified

Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.

2.k) Malignant neoplasm without specification of site

Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.

2.l) Sequencing of neoplasm codes

2.l.1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The metastatic sites.

2.l.2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

2.l.3) Malignant neoplasm in a pregnant patient

When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.

2.l.4) Encounter for complication associated with a neoplasm

When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.

The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.

2.l.5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

2.l.6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, and followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

2.m. Current malignancy versus personal history of malignancy

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms inremission versus personal history

The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission.

There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues.

If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.o. Aftercare following surgery for neoplasm

See Section I.C.21. Factors influencing health status and contact with health services, Aftercare

2.p. Follow-up care for completed treatment of a malignancy

See Section I.C.21. Factors influencing health status and contact with health services, Follow-up

2.q. Prophylactic organ removal for prevention of malignancy

See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal

NOTE FROM AUTHOR

Notice the dashes (-) in the neoplasm table below:

Note: Codes listed with a dash (-), following the code, have a required additional character for laterality. The tabular must be reviewed for the complete code.

Example: Adrenal cortex (C74.0-) requires a fifth digit to determine right, left, or unspecified adrenal cortex for code completion.

If you haven’t done so already, MMP strongly encourages you to review all of the ICD-10-CM Coding Guidelines for each chapter. Often, we tend to use our memory when utilizing the guidelines and a refresher just might be helpful. You may be amazed at the guidelines that you remember and those you may have forgotten.

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

Resources:

AHIMA ICD-10-CM Training Manual

ICD-10-CM Coding Book by Ingenix

Q:Should physician queries be part of the legal medical record? 

 

A:

At MMP we have seen facilities maintain queries as part of the legal medical record and other facilities maintain the query forms within the CDI Department. Ultimately, this is a hospital specific decision.

Below are excerpts from two complimentary AHIMA Practice Briefs where they have provided guidance regarding query retention.

Query Retention

Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database.

Before this decision is made a discussion with the facility compliance and legal staff may be beneficial. Regardless, the query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query a permanent part of the health record to demonstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It also can demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documentation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

Article Citation: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010); expanded web version.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

Develop Query Retention Policies

Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated. As noted in AHIMA’s toolkit, “Amendments in the Electronic Health Record,” “the addendum should be timely, bear the current date, time, and reason for the additional information being added to the health record, and be electronically signed.”

Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.

An important consideration in query retention is the ability to collect data for trend analysis, which provides the opportunity for process improvement and identification of educational needs.

Article Citation: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018

Our next topic for the I-10 corner is the mental health chapter, Mental, Behavioral, and Neurodevelopmental Disorders. Chapter 5 is another example of the massive expansion of codes in ICD-10. I have highlighted some changes and included tips that I think are important to know for coding these conditions.

See below how the codes in this chapter are no longer grouped by psychotic, non-psychotic disorders, or mental retardation.

CODE COMPARISON

‍NOTE FROM ICD-10-CM CODER TRAINING MANUAL 2014

Many title changes for categories and subcategories were made in Chapter 5. Such as:Bipolar 1 Disorder, Single Manic Episode (296.0x) = Manic Episode (F30.xx)

Many changes were made due to outdated terminology. Examples can be seen in the accompanying table.

 

 

DID YOU KNOW?

DRG Shift

The CMS ICD-10 website contains information on the ICD-10 MS-DRG Conversion Project. An article from CMS, “Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments”, lists the top 10 MS-DRGs that shift to another DRG when re-coded with ICD-10. DRG 885, Psychoses is on that list. Currently, ICD-9 cases that have 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis will group to DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9 (also includes Depression NOS) which groups the case to DRG 881, Depressive Neuroses, a lower-weighted DRG. Interestingly, many hospitals in Alabama have DRG 885 listed in their top 10 diagnoses each year. It would be a good idea to see how this change will impact your facility.

A large classification change was made to the drug and alcohol abuse/dependence codes.

• There are codes to denote alcohol and drug “use”.
• No longer identify “Continuous” and “Episodic” in I-10
• Can code Blood Alcohol Levels as an additional code, if applicable:
  Y90.0, Evidence of alcohol involvement determined by blood alcohol level

Chapter 5 Guidelines

• Physician documentation of a history of drug or alcohol dependence is coded as “in remission”.
• For psychoactive substance use, abuse and dependence:

TIP

 

The codes in Chapter 5 parallel the codes in DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders-4 Text Revision) in most cases….from the ICD-10-CM Coder Training Manual, 2014 Instructor’s Edition. Psychiatrists tend to document these conditions as they are listed in the codebooks, which can make mental health coding a little easier. In addition, I hope all of the information provided to you in the I-10 Corner has helped make your job a little easier.

In this week’s article, we’re discussing a few of the changes for ICD-10-CM in the Nervous System (Chapter 6): Alzheimer’s Dementia, Epilepsy, Hemiparesis/Hemiplegia (Dominant vs. Non-Dominant), Migraine, Phantom Limb Pain and Sleep Apnea

Alzheimer’s Dementia

I-9: Alzheimer’s Dementia

• with behavioral disturbance (aggressive) (combative) (violent) (331.0 / 294.11)
• without behavioral disturbance (331.0 / 294.10)

NOTICE:

The category for Alzheimer’s disease (G30) has been expanded to reflect onset (early vs. late)

I-10: Alzheimer’s Dementia

• behavioral disturbance (G30.9 / F02.81)
• early onset (G30.0 / F02.81)
• late onset (G30.1 / F02.80)
• specified NEC (G30.8 / F02.80)

 

Epilepsy

Terms for Epilepsy have been updated to classify the disorder, e.g,

• Localization-related Idiopathic Epilepsy
• Generalized Idiopathic Epilepsy
• Special Epileptic Syndromes

Example:

I-9: Epilepsy, epileptic (idiopathic) (345.9)

Epilepsy, localization related (focal) (partial) and (epileptic syndromes)

• With
• Complex partial seizures (345.4)
• Simple partial seizures (345.5)

NOTICE:

Within each category, more specificity can be described to identify: Seizures of Localized Onset, Complex Partial Seizures, Intractable and Status Epilepticus.

I-10: Epilepsy, epileptic, epilepsia (attack) (cerebral) (convulsion) (fit) (seizure) (G40.909)

Epilepsy, localization-related (focal) (partial)

• Idiopathic (G40.009)
• With seizures of localized onset (G40.009)
• Intractable (G40.019)
• With status epilepticus (G40.011)
• Without status epilepticus (G40.019)
• Not intractable (G40.009)
• With status epilepticus (G40.001)
• Without status epilepticus (G40.009)

NOTE

Category G40, Epilepsy and Recurrent Seizures

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Hemiplegia and Hemiparesis  (Dominant vs. Non-Dominant Side)

This category is to be used only when the listed conditions are reported without further specification, or are stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these conditions resulting from any cause.                                      

I-9:

The following fifth-digits are for use with codes 342.0-342.9:

• 0 affecting unspecified side
• 1 affecting dominant side
• 2 affecting non-dominant side

I-10:

Per ICD-10-CM Official Coding Guidelines: Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or non-dominant side is affected.

Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows:

• For ambidextrous patients, the default should be dominant
• If the left side is affected, the default is non-dominant
• If the right side is affected, the default is dominant

Example: G81.9 Hemiplegia, unspecified

• G81.90:  Hemiplegia, unspecified affecting unspecified side
• G81.91:  Hemiplegia, unspecified affecting right dominant side
• G81.92:  Hemiplegia, unspecified affecting left dominant side
• G81.93:  Hemiplegia, unspecified affecting right non-dominant side
• G81.94:  Hemiplegia, unspecified affecting left non-dominant side

            Excludes1: Hemiplegia and hemiparesis due to sequela of cerebrovascular disease

Migraine

I-9: Migraine, Unspecified (Idiopathic) (346.9x)

I-10: Migraine, Unspecified (Idiopathic) (G43.909)

NOTE

Category G43, Migraine

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

 

Phantom Limb

The sensation that an amputated or missing limb is still attached to the body and is moving along with other body parts. An estimated 60% to 80% of people that have had an amputation, experience phantom sensations in the amputated limb with the majority being painful.  

I-9: Phantom limb (syndrome) (353.6)

NOTICE:

I-10 has given us the ability to identify whether pain is present or not after an amputation.

I-10: Phantom limb syndrome (G54.7)

• with pain (G54.6)
• without pain (G54.7)

 

Sleep Apnea

Sleep Apnea has its own subcategory with fifth character specificity identifying the type

Example:      

I-9: Sleep Apnea, Unspecified (780.57)

• with
• Hypersomnia, unspecified (780.53)
• Hyposomnia, unspecified (780.51)
• Insomnia, unspecified (780.51)
• Sleep disturbance (780.57)
• Central, in conditions classified elsewhere (327.27)
• Obstructive (adult) (pediatric) (327.23)
• Organic (327.20)
• other (327.29)
• Primary central (327.21)

I-10: Sleep Apnea, Unspecified (G47.30)

• Central (primary) (G47.31)
• in conditions classified elsewhere (G47.37)
• Obstructive (adult) (pediatric) (G47.33)
• Primary central (G47.31)
• Specified NEC (G47.39)

As you can see, there are several new terms and descriptions in the Nervous System Chapter for I-10-CM, providing more specificity and better clarity of certain conditions. If we can take just a little extra time assigning diagnosis codes for I-10, we will reflect the true severity of illness (SOI) for each and every patient.

Resources:

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Wikipedia