Knowledge Base Category -

Q:

Can code J45.909 for Unspecified Asthma, uncomplicated be reported in addition to COPD?

A:

No.  According to Coding Clinic 1st Qtr. 2017 page 25 there should be documentation specifying the type of asthma.  There is an instructional note listed under category J44, Other COPD, which states “code also type of asthma, if applicable (J45-).  “Unspecified” is not considered a type of asthma.

Example: However, if a patient is shown to have moderate persistent asthma, uncomplicated, then it would be appropriate to assign code J45.10 with COPD (J44.-). 

Q:

Our hospital is receiving Medicare denials for claims when the patient has outpatient dialysis (HCPCS code G0257) and a balloon angioplasty of the dialysis catheter (CPT 36905) during the same outpatient encounter.  We know CPT 36905 has a status indicator (SI) of J1 and payment for all adjunctive services will be bundled into the payment for that code.  We do not understand why we are not being paid at all for this claim

A:

The most likely reason your claim is denying is because there is a procedure-to-procedure (PTP) National Correct Coding (NCCI) edit for the code combination G0257 and 36905. The outpatient dialysis code (G0257) is the column one code and the PTA (36905) is the column two code.  A modifier appended to the column two code (36905) is allowed to by-pass this edit. 

Even though there is no separate payment for the outpatient dialysis due to the “J1” packaging, Medicare still applies NCCI edits to all codes submitted on the claim.  If there is a PTP CCI edit for a code combination on the claim that is not modified to by-pass the edit, that line item will deny.  In this case, all of your payment is associated with the denied line item and there is $0 payment for the entire claim.

We have also seen denials for services that pay separately under the J1 packaging, such as brachytherapy sources which have an SI of “U”.  The brachytherapy source denied because a modifier was not added to the HCPCS code to by-pass a CCI edit. In one example the brachytherapy source (HCPCS C2616) was billed with radiopharmaceutical localization of a tumor (CPT 78800).  There is a PTP edit for this code combination with C2616 being the column two code.  As such it requires a modifier to by-pass the edit and allow separate payment when reported with a J1 comprehensive APC.

Most hospitals’ billing systems have Medicare pre-claim submission edits that alert the billers when an NCCI PTP code combination without a modifier to by-pass the edit is reported. The billers should have clear guidance, procedures, and assistance in determining when the addition of a modifier is appropriate.  This is especially important for high-dollar claims where the facility stands to lose a substantial amount of reimbursement if denied. 

Dilemma:

Why can’t the Root Operation, ‘Destruction’ be used when cauterization is performed in the nose to stop bleeding instead of ‘Control’? For instance, a patient was admitted for surgery due to multiple failed attempts to stop epistaxis.  The surgeon saw no active bleeding; but did see some suspicious sites so he cauterized the right turbinate and the nasal septum. 

Also, using ‘Destruction’ grouped the case to an ENT DRG (see table) which appears to be an appropriate clinical representation of the admission.  However, using ‘Control’ grouped the case to Extensive OR Procedure Unrelated to Principal Diagnosis. 

FY 2017 ICD-10-PCS Coding Guideline:

• Control
  Stopping, or attempting to stop, postprocedural or other acute bleeding. If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Solution:

The Root Operation, ‘Control’ was broadened to include these types of cases, so regardless of the method, the coding reflects the main objective of these types of procedures, which is to control bleeding.

The above procedure grouping is a DRG shift that has been reported to CMS and should be corrected in the next October 1st update. 

Resource:  Rhonda Butler, Clinical Research Manager for 3M Health Information Systems

FY 2017 ICD-10-PCS Coding Guidelines

Back in June when the Office of Inspector General (OIG) changed the process and publication of their Work Plan, they used the word “dynamic” to describe their work planning process.  The Merriam-Webster dictionary defines dynamic as “marked by usually continuous and productive activity or change.”  So far, the OIG is remaining true to this definition by posting numerous new issues each month.  For July, the OIG posted 14 new issues all focused on the CMS agency.  The OIG is responsible for oversight for all agencies of Health and Human Services (HHS), but a review of active issues shows that most of their efforts are related to CMS.

I understand the OIG’s responsibility “to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS.” But having worked in hospitals for years, I also understand the challenges of complying with all of the Medicare rules. If it were easy we might not need the OIG, but it is definitely not an easy task. 

Since MMP’s focus is hospital Medicare issues, I will only describe the new OIG Work Plan items related to hospitals and Medicare.  For a list of all the new issues, see the OIG’s Recently Added updates.

Nationwide Medicare Electronic Health Record Incentive Payments to Hospitals

Hospital can receive incentive payments for adopting electronic health record (EHR) technology. The OIG is concerned about potential incentive overpayments. Their concerns are based on the following:

• The Government Accountability Office (GAO) identified improper incentive payments as the primary risk to the Medicare EHR incentive program.
• An OIG report found CMS faces obstacles in oversight of the EHR program.
• OIG reviews showed that State agencies have and will continue to overpay hospitals millions of dollars due to inaccuracies in the hospitals’ calculations.

The OIG will be reviewing hospitals’ incentive payment calculations to ensure appropriate payment amounts and prevent future overpayments.  This is a hospital finance issue which is not my area of expertise, but I bet it is not that easy.  Calculations never are.

Review of Medicare Payments for Nonphysician Outpatient Services Provided Under the Inpatient Prospective Payment System

Medicare pays hospitals a prospective payment amount for inpatient services – we know this as the DRG payment.  The DRG payment is payment for all the hospital’s operating costs associated with the inpatient admission. This also includes diagnostic and related therapeutic outpatient services provided the day of admission or within the 3 days prior to admission under Medicare’s 3-day payment window rule.  Identifying those outpatient services that should be bundled with the inpatient claim and then billing correctly in compliance with the 3-day payment window is not an easy task either. Prior OIG reviews have found overpayments where hospitals billed inappropriately and Medicare contractors paid for outpatient services provided during or before the inpatient admission. The OIG will review to determine if outpatient payments during an inpatient admission and under the payment window rule were correct.

Medicare Payments for Unallowable Overlapping Home Health Claims and Part B Claims

Home Health (HH) agencies are also paid a Medicare prospective payment which covers all of their costs for providing services to the patient.  This includes services furnished by the home health agency and certain items or services provided under arrangement. The home health consolidated billing requirements mandate that certain items, supplies, and services are part of the home health payment and should not be billed separately to Medicare Part B from other entities. The OIG will be looking to see if Part B payments were allowable and followed the consolidated billing requirements.  From my experience, the major area of concern related to HH consolidated billing for hospitals is rehabilitative therapy services.  Medicare patients may present to a hospital’s therapy department for services even though they are receiving HH services. Hospitals should check Medicare eligibility systems and question the patient carefully to determine if they are currently under a home health plan of care.

Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims

Once a Medicare beneficiary elects hospice care, all services related to the terminal illness are handled by the hospice.  Hospitals must seek payment for services provided to a hospice patient and related to the terminal illness from the hospice agency and not from Medicare. The OIG is reviewing to make sure any separate Part B payments were appropriate. Hospitals are often caught unaware when a hospice patient shows up in their emergency department. The hospital must determine if the patient has elected hospice and if so, is the medical condition for which they are seeking treatment related to the terminal illness.  If the answer to both is yes, the hospital must coordinate with the hospice agency to determine appropriate treatment and billing.  Not an easy task, especially in an emergency department setting. The same applies to non-emergency hospital services – reference laboratory testing is one example, but your clue here should be that the specimens are brought in by a hospice nurse.  In MMP’s experience, edits in the Medicare claims processing system catch most of these overlaps with hospice agencies and deny the hospital’s payment. It is then up to the hospital to spend extra time and effort to determine the circumstances and obtain payment from the hospice agency.  Not an easy task on the back end either.

One last issue somewhat related to hospitals:

Review of Medicare Payments for Telehealth Services

One of the Medicare requirements for telehealth payment is that the services be between a beneficiary located at a rural originating site and a practitioner located at a distant site.  An eligible originating site must be the practitioner’s office or a specified medical facility, such as a hospital.  The OIG will be looking for telehealth payments where there was not a corresponding claim from the originating site to ensure the payments were correct.  More information on billing telehealth services can be found in the Medicare Telehealth Fact Sheet.

Not much about health care and hospital services is easy, but the OIG work plan gives us some areas on which to focus our scrutiny when it comes to billing Medicare.

Q:

What information will a Review Contractor accept when reviewing a record for medical necessity of the services provided?

A:

The answer can be found in Chapter 3 of the Medicare Program Integrity Manual. Specifically, Section 3.3.2.1 – Documents on Which to Base a Determination indicates that “The MACs, CERT, Recovery Auditors, and ZPICs shall review any information necessary to make a prepayment and/or postpayment claim determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted with the claim and any other documentation subsequently requested from the provider or other entity when necessary. Reviewers also have the discretion to consider billing history or other information obtained from the Common Working File (in limited circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among others.

For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.”

This guidance applies to Medicare Administrative Contractors (MACs), the Comprehensive Error Rate Testing (CERT), Recovery Auditors, and Zone Program Integrity Contractors (ZPICs).

Q:

If a patient is diagnosed with encephalopathy secondary to gram negative pneumonia, which ICD-10-CM codes would be appropriate to report? J15.6 & G93.49 or J15.6 & G94?

A:

Per AHA Coding Advisor (question submitted by MMP) the “EAB (Editorial Advisory Board) recommends assigning codes G93.40, Encephalopathy, unspecified and a code for Gram-negative pneumonia” (J15.6).According to the AHA Coding Advisor, “the EAB of Coding Clinic recently resolved the issue of coding encephalopathy in diseases classified elsewhere”.

“Code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94 for certain etiologies”.

Look for information, in regards to encephalopathy and/or code G94, to be published in the upcoming Coding Clinic 2nd Qtr. 2017.

Another thing you want to keep in mind; encephalopathy is generally a manifestation from a source such as pneumonia, sepsis, UTI etc. Quite often this could reflect a metabolic type encephalopathy that temporarily may affect a patient’s electrolytes, vitamin or other chemical type balance that would adversely alter or affect brain function.   In order to give greater specificity, be sure to query the provider if there is lack of supporting documentation. 

How do you go from laboratory technologist to compliance professional? You see it often because the detail oriented mind of laboratorians fits well into the myriad details of compliance requirements. For me, I happened to be the manager of a hospital outpatient laboratory at the time the Office of Inspector General (OIG) released the Compliance Program Guidance for Clinical Laboratories. In short order, it fell upon my shoulders to “do something” about this Compliance Guidance. The OIG guidance was in part a response to recent concerns about laboratory billing practices. A prominent national laboratory had at the time been under scrutiny for adding one more laboratory test to a large, frequently ordered lab profile that consisted of a significant number of different lab tests. According to the government, this caused physicians to unknowingly (or at least without careful consideration of medical need) order “medically unnecessary” lab tests.

I often refer to this as “the original compliance sin” and the issue of medical necessity is still a major concern for compliance, and not only for laboratory tests. Medical necessity now involves various types of medical services – from ambulances, to cardiology procedures, to high-cost drugs, to joint replacements, to many other services and even back to laboratory tests. Two recent enforcement actions posted on the OIG’s website are related to medically unnecessary laboratory pathology services.

The first case involves Poplar Healthcare located in Memphis, Tennessee, which paid nearly $900,000 to resolve False Claims Act allegations. According to the Department of Justice (DOJ) Press Release, “The government alleges that Poplar, directly and through a subsidiary known as GI Pathology, promoted and billed the government for diagnostic tests that the government contends were not medically necessary.” Poplar conducted an extensive, multi-year promotional campaign promoting the use of a special pathology stain they claimed could definitively diagnose “mast cell enterocolitis.” The government contended Poplar’s claims about the stain were not supported by scientific evidence and were not consistent with FDA approval requirements.

A similar case against Piedmont Pathology in Hickory, N.C also involves the medically unnecessary use of pathology stains. In this case, the pathology laboratory was performing and billing for special stains on certain gastric biopsies. The special stains were performed before a pathologist reviewed routinely stained specimens to determine if there was a medical need for the additional special stains. Piedmont Pathology has agreed to pay the United States $601,000 to settle allegations that it violated the False Claims Act by submitting false claims to Medicare and Medicaid for medically unnecessary procedures. The DOJ press release provides further details.

Another similarity between these two cases is that both were “whistleblower” cases where a private citizen can bring suit on behalf of the government for false claims under provisions of the False Claim Act. The government can decide to take over the case and the whistleblower shares in any monetary recovery. In these cases, the relator’s share was $205,841 and approximately $120,200, respectively.

There are important take-aways for all providers from these settlements:

• The government is serious about the medical necessity of services (for all types of healthcare services);
• No service is too big or too small for government attention;
• Be careful what a vendor tries to sell you;
• Verify the medical need for the services you provide; and
• Watch out for the whistleblowers!

Q:

Several of our physicians sometimes have scribes do their documentation for them.  Do both the scribe and the physician have to sign this documentation?

A:

No; only the physician’s signature is required.  CMS recently released Transmittal 2017 updating the Medicare Program Integrity Manual to provide instructions to providers regarding signature requirements when scribe services are used by a physician/non-physician practitioner (NPP).

According to the Transmittal, “Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.” 

Q:

Sometimes patients are provided with orthoses they will carry home with them (such as a back brace) while they are an inpatient in the hospital. How do we determine if the hospital absorbs the cost of the orthosis or if the DME company can bill the patient’s Medicare?

A:

Medicare provides good information about this in the Fact Sheet Provider Compliance Tips for Spinal Orthoses. For orthoses provided to patients before or during an inpatient stay, the key is whether the patient will be using the orthosis for medically necessary treatment or rehabilitation during the inpatient stay. Payments for orthoses are included in payments to hospitals if the patient uses the orthosis during the admission. In these situations, the supplier should not submit claims to the DME MAC. The applicable situations are stated as follows in the Fact Sheet:

• The supplier provides the orthosis to the beneficiary prior to an inpatient admission or Part A covered SNF stay and the medical necessity begins during the stay (for example, after spinal surgery)
• The supplier provides the orthosis to the beneficiary during an inpatient stay prior to discharge and the beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.

However, if the orthosis is given to the patient for home use within two days prior to discharge and is not used during the hospitalization, then the DME may bill the patient’s Medicare. Per the Fact Sheet, “Payments for spinal orthoses are eligible for coverage by DME MACs if the orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay and the supplier provides the orthosis to the beneficiary within two days prior to discharge home, and the orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.” 

Back in September, 2016, an article was published concerning coding acute renal failure with ESRD. (Click here to see that article.) In answering the question I stated that a question had been submitted to the AHA Coding Advisor regarding patients diagnosed with both acute renal failure and ESRD. I finally received an answer on 4/12/17 and have added an update to the question.

Q:

Can acute renal failure be coded (ARF) with end stage renal disease (ESRD). Our PA has advised us not to code ARF with ESRD. He stated that once a patient has developed ESRD their kidneys are basically dead and no longer have the capability to function or produce any urine output so therefore would not be able to go into acute failure.

A:

This makes total sense but as coders we have to follow the Official Coding Guidelines and instructions given in the AHA Coding Clinic. MMP has re-submitted this question to the AHA Coding Clinic Advisor for further clarification. For the time being, until we receive a response back from them, you should follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both ARF and ESRD are both documented by the provider, code each condition separately.

Update – April 12, 2017
Confirmation was received from the AHA Coding Clinic Advisor. Continue to follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both acute renal failure and ESRD are clearly documented in the record, both conditions are to be coded.