Knowledge Base Category -

Q:

Given the new Coding Guidelines for FY 2017 that went into effect October 1, 2017, do we automatically assume a causal relation between two diagnoses associated with the term “with”?

A:

Yes. You may interpret “with” to mean “due to” or “associated with” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. A relationship may be assumed even without a physician’s documentation linking the conditions together. In the Alphabetic Index, the term “with” is sequenced immediately following the main term instead of alphabetic order.

To name a few, this new rule will effect conditions such as hypertension, diabetes and congestive heart failure.

Examples:

1. Code I11.0 would be assigned for hypertension with heart failure along with an additional code to identify the type of heart failure (I50._)
2. Code E11.43 would be reported for type 2 diabetes with gastroparesis.
3. Codes I13.2, I50.22, E11.22 and N18.6 would be the codes to report for a patient with hypertension, chronic systolic heart failure, type 2 diabetes and ESRD.

This guideline was actually effective in March 2016 but the Official Coding Guidelines were not updated until October 2016. You can refer to Section I.A.15 of the Official Coding Guidelines for FY 2017 and Coding Clinic 1st Qtr. 2016 page 11, 2nd Qtr. 2016 page 36 and 4th Qtr. 2016 page 141.

Q:

Have there been any recent notifications where Medicare Administrative Contractors (MACs) are reviewing professional claims related to denied hospital claims?

A:

Yes. In July, Noridian JE posted notification of “initiation of CMS approved cross recovery of professional claims related to denied institutional facet injection services, CPT codes 64493 – 64495; 64635 – 64636.” As a reminder, CMS published Transmittal 534 in August 2014 stating MACs have the discretion of also reviewing “related” Part B claims for services denied by Part A. The MACs are required to post notification of such related reviews. Although this is not good news for physicians, it may help hospitals by improving communication and coordination between hospitals and physicians since both parties now have something at stake.

Dilemma:

A patient is admitted through the ER with pleuritic chest type pain, SOB, dyspnea, productive cough, and fever of 100.7. Patient has a previous history of CVA with continuing residual of dysphagia, MI and COPD. CXR shows RLL infiltrate and is treated with IV antibiotics. Patient is also noted to have a positive swallowing study. Discharge diagnosis was community acquired pneumonia (CAP), history of MI, history of COPD, CVA with Dysphagia, and Aspiration Pneumonia. What code would be reported for the patient’s pneumonia?

Solution:

Assign code J69.0 for the aspiration pneumonia only. Even though the physician documents both aspiration pneumonia and community acquired pneumonia, only one code would be reported. Given that CAP is not a type of pneumonia, there is not a code specifically for it like there is for a nosocomial type infection (Y95). When CAP is documented, this is just letting you know that the patient did not acquire the infection through some type of health care organization. 

Q:

Our hospital laboratory receives pathology specimens for testing from physician offices and ambulatory surgical centers. Since these are not hospital inpatients or outpatients, is it appropriate to use a type of bill (TOB) 14x like we do for clinical lab tests on non-patients?

A:

Per clarification in the August 30, 2016 Hospital Open Door Forum, using a TOB 14x for the technical component of pathology non-patient specimens is appropriate. Non-patients are those patients that are neither inpatients nor outpatients of a hospital, but that have a specimen that is submitted for analysis to a hospital; the patient is not physically present at the hospital.

Dilemma:

I have a claim where an anterior fusion was performed in the morning then the patient was brought back to the OR for a posterior fusion in the afternoon. The encoder groups these two procedures to DRG 455 Combined Anterior/Posterior Spinal Fusion without CC/MCC. Is this correct?

Solution:

DRG 455 is correct because it reflects that an Anterior and a Posterior fusion were performed during that admission. It is not an issue, from a coding standpoint, that the procedures were performed at two separate operative episodes.

Resources:

• TruCode Encoder

In late summer, the corn stalks grow tall and full across our nation. I love the rustle of a cornfield as the stalks move in the summer breeze. But have you ever been lost in a cornfield or a maze? There is this moment of panic when you think you may not be able to find your way out. The maze of Medicare requirements and reviews can also create feelings of panic. For example, a recent OIG review focused on sleep study services; at least nine Medicare Administrative Contractors (MACs) have local coverage determinations (LCDs) or Articles for sleep studies; and sleep study services have also been the focus of reviews by a Recovery Auditor (Region D HDI) and the Supplemental Medical Review Contractor (SMRC).

Based on the findings from the recent Sleep Study Review, the OIG estimated overpayments of over $1 Million for the audit period for this particular independent sleep study provider. The LCD for the provider’s jurisdiction required that prior to sleep testing, the patient must have a face-to-face clinical evaluation by the treating physician that must include, among other requirements:

• the patient's sleep history and symptoms,
• a physical examination that documents body mass index, neck circumference, and
• a focused cardiopulmonary and upper airway evaluation.

Out of 130 lines of services, 50 had no documentation for the face-to-face clinical evaluation, attending physician's orders, technician's report, or interpretation report and 80 failed to include one or more of the following requirements of the face-to-face clinical evaluation: patient's sleep history and symptoms, Epworth sleepiness scale, body mass index, or neck circumference.

A previous OIG report on sleep studies from 2013 found that Medicare paid nearly $17 million for polysomnography services that did not meet one or more of three Medicare requirements – inappropriate diagnosis codes, duplicate studies for the same date of service, or invalid NPI numbers. According to the report, “Payments for services with inappropriate diagnosis codes composed a majority of these payments. Eighty-five percent of claims with inappropriate diagnosis codes came from hospital outpatient departments.”

The SMRC review from 2014 found that sixty-three percent (63%) of denials were because providers did not provide a History and Physical or other documentation to support medical necessity for polysomnography testing.

Providers need to be familiar with their MAC’s requirements for sleep testing. Hospital-based and independent sleep clinics should verify they are following the Medicare requirements and including appropriate documentation in their records. This is the best way to avoid the panic and ensure a good night’s sleep for you and your patients.

A summary of some Medicare medical review updates from last month are listed below.

Medicare Administrative Contractor (MAC) Review Updates

MAC J15 CGS

• Cataract Removal (HCPCS 66984, 66983, 66982)
• Error rate of 61.5% - 68.5%
• Review to continue

MAC JF Noridian

• Facet Joint Injections, CPT 64493
• Error rate 37% - 54%%
• Review to continue

MAC JE Noridian

• Brotezomib (Velcade), HCPCS J9041
• Error rate 10.7%
• Review to continue

MAC JM Palmetto

• Infliximab, HCPCS J1745
• Error rate 44% - 54%
• Review to continue
• HCPCS G0424, Outpatient Pulmonary Rehabilitation
• Error rate 26.3% – 55.3%
• Discontinued
• HCPCS Code J2505, Pegfilgrastim, 6 mg
• Error rate – 15.2% - 41.2%
• Discontinue in VA and WV, continue in NC and SC
• HCPCS Code J9035, Bevacizumab, 10 mg
• Error rate – 26.3% - 37.6%
• Discontinue in SC; continue in NC and VA/WV

Are you tired of hearing about and reading about provider-based departments? If so, sorry, but some governmental agencies (for example, the Office of Inspector General (OIG), the Medicare Payment Advisory Commission (MedPAC), and even Congress) just won’t let it go. This issue is evidently “stuck in their craw” and so the discussion continues, and continues, and continues… This article looks at information from the June 2016 OIG report concerning provider-based facilities.

What Is a Provider-Based Department?

Provider-based status is a Medicare payment designation established by the Social Security Act that allows facilities with a provider-based designation to bill Medicare as a hospital outpatient department and thereby receive higher payments. Provider-based facilities may be on campus (within 250 yards of the main buildings of the main provider) or off campus (more than 250 yards but less than or equal to 35 miles from the main buildings of the main provider). Hospitals and their provider-based departments (PBDs) have to meet specific requirements described in 42 CFR § 413.65 and CMS Transmittal A-03-030. The requirements include practice licensure, integration of clinical services and financial operations, and compliance with nondiscrimination and health and safety rules. In addition, off-campus PBDs must meet requirements for administration, supervision, and location.

Major Concerns – Cost and Increasing Numbers

According to the OIG report, “Medicare often pays over 50 percent more for services performed in provider-based facilities than for the same services performed in a non-hospital based facility (i.e., a freestanding facility). Beneficiaries generally are responsible for higher copayments for most services in provider-based facilities than in freestanding facilities.” In provider-based departments, Medicare makes a payment to the PBD based on Outpatient Prospective Payment System (OPPS) payment rates and a separate payment to physicians for their professional services.

Another concern is the increasing numbers of PBDs. Over the past seven years, there has been a 33% increase in hospital outpatient services including those provided in PBDs. One reason for the increased number of PBDs is that more and more hospitals are purchasing freestanding facilities and converting them to provider-based facilities.

Findings from Previous OIG Audits

In earlier reviews, the OIG found that CMS was not aware of the number of provider-based facilities or the increased cost associated with PBDs without a corresponding benefit. CMS has claimed that PBDs improve quality of care by offering increased beneficiary access and integration of care. CMS also has maintained that increased payments are appropriate to accommodate higher costs resulting from financial and clinical integration. But per the OIG, CMS has yet to provide any evidence provider-based facilities produce specific benefits to justify the higher costs compared to freestanding facilities.

Hospitals may voluntarily attest to provider-based status with supporting documentation required to be submitted to the Medicare Administrative Contractors for off-campus PBDs. The OIG found inconsistent reviews by the Medicare Regional Offices confirming the attestations. The OIG has also found that some physicians are receiving overpayments for services provided in PBDs if they report the incorrect place-of-service (POS) code.

Bottom line is the OIG recommended the complete elimination of provider-based status.

CMS Fixes

CMS did not concur with the OIG recommendation for eliminating provider-based status but did take some actions based on the OIG’s findings. Specifically, CMS

• Produced a set of standards (i.e., 42 CFR § 413.65) for provider-based facilities and entities designed to guard against abuse of the payment system,
• Developed a management information system that contains the results of provider-based reviews and enables CMS to monitor review status, and
• Developed detailed guidance on the proper use of place- of-service codes.

Due to continuing concerns from the OIG, the MedPAC committee, and Congress, CMS created new physician place-of-service codes to distinguish between services performed in on- or off-campus provider-based facilities. Effective January 1, 2016, physicians use place-of-service code 22 for services in on-campus provider-based facilities and place-of-service code 19 for services in off-campus provider-based facilities. Also, voluntary beginning January 2015 but mandatory effective January 1, 2016, CMS requires that hospital claims contain a specific two-digit modifier (modifier PO) for OPPS services furnished in an off-campus PBD.

Another significant development concerning provider-based status is the Bipartisan Budget Act of 2015 (BBA) which mandates that, effective January 1, 2017, only off-campus outpatient departments billing the OPPS for services before November 2, 2015, (grandfathered provider-based facilities) may continue to receive payment under OPPS. New off-campus provider-based facilities will be paid under payment systems equitable with independent and physician office payments. (Be on the lookout in next week’s Wednesday@One for details of how CMS proposes to handle this in the 2017 OPPS Proposed Rule.)

Remaining Problems

Although CMS has taken steps to improve its monitoring of provider-based billing, the OIG details a long list of remaining vulnerabilities related to PBDs, some of which include:

• Grandfathered facilities under the BBA will continue to generally receive higher payments (i.e., payments from both the OPPS and MPFS) for services than if the same services were provided in a freestanding facility (i.e., receiving payment only from the MPFS).
• Some hospital PBDs may be receiving overpayments because they do not meet all the PBD requirements. Due to the voluntary attestation process, CMS is unable to determine whether all provider-based facilities meet requirements to bill at the higher provider-based rate. CMS also reports challenges with the provider-based attestation review process because of difficulties obtaining supporting documentation.
• Some physicians may be receiving overpayments due to reporting of incorrect place-of-service codes. CMS has no means to ensure physicians use the correct POS codes because they do not match the facility component of a claim to the associated professional component of a claim.
• CMS cannot segregate billing by provider-based facilities, which is critical to ensuring appropriate payments and implementation of the BBA of 2015.

OIG Recommendations

The OIG continues to recommend that CMS eliminate provider-based status or equalize payment for the same services provided in different settings. If CMS does not accept these recommendations, the OIG recommends CMS:

• Implement systems and methods to monitor on- and off-campus billing by provider-based facilities to help implement the Bipartisan Budget Act of 2015 and better monitor billing by individual facilities.
• Require hospitals to submit attestations and supporting documentation for all of their provider-based facilities, both on and off campus with a deadline after which Medicare would deny claims for services in provider-based facilities that do not have an attestation on file with CMS.
• Determine how to address the issue of grandfathered facilities that do not meet regulatory requirements after January 1, 2017, and determine whether they may continue billing as provider-based facilities if they later come into compliance.
• Ensure that its regional offices and MACs apply provider-based requirements appropriately when reviewing documentation during their attestations reviews.
• Recover overpayments and take action to ensure hospitals and facilities improperly billing as provider-based do not receive higher provider-based payment in the future until non-compliance is corrected.

Requirements to be a PBD and Documents to Prove It

Hospitals need to understand the requirements for provider-based status, ensure that any on-campus or off-campus facilities for which the hospital is billing as provider-based meets the requirements, and be prepared to furnish appropriate documentation to CMS to support the PBD designation. The OIG report contained valuable information on the requirements and supporting documentation that is summarized below. Hospitals should read the OIG report for complete details of everything discussed in this article.

Requirement: A provider-based facility and the main provider must be operated under the same license, unless State laws prohibit this or require separate licenses.
Supporting Documentation: Copy of the State license or documentation that the State in which the facility is located requires a separate license

Requirement: Integrated clinical services including same clinical privileges, same monitoring and oversight, reporting relationship between PBD medical director and hospital chief medical officer, oversight by hospital medical staff committees, a unified medical records retrieval system, and integrated and fully accessible services.
Supporting Documentation: Information about whether professional staff of the PBD has clinical privileges at the main provider, a copy of the record retrieval policy of the main provider and provider-based facility, and examples of inpatient and outpatient service integration

Requirement: Fully integrated financial operations including costs reporting and financial status.
Supporting Documentation: Appropriate section of a main provider’s cost report or trial balance that show the provider-based facility’s revenues and expenses

Requirement: Provider-based facility is held out to the public and other payers as part of the main provider.
Supporting Documentation: Letterhead with a shared name, websites, and other examples to show that the facility is part of the main provider

Requirement: Compliance with applicable rules related to hospital anti-dumping, nondiscrimination, health and safety, Medicare agreement and Medicare payment.
Supporting Documentation: Copies of anti-dumping and nondiscrimination policies

Requirement (Off-Campus PBD): The hospital main provider must own 100-percent of the provider-based facility, have final responsibility and approval for administrative and personnel decisions, have the same governing body, and operate under the same organizational documents.
Supporting Documentation: Bylaws for the main provider and provider-based facility

Requirement (Off-Campus PBD): Hospital and PBD must have the same frequency, intensity, and level of accountability reporting relationship that exists between the main provider and one of its existing facilities plus additional requirements concerning direct supervision, monitoring, and oversight of the provider-based facility and the integration of administrative functions (e.g., billing services, payroll).
Supporting Documentation: An organizational chart that reflects reporting relationships and a list of the integrated administrative functions

Requirement (Off-Campus PBD): A provider-based facility must be located within a 35-mile radius of the main provider’s campus (with some exceptions).
Supporting Documentation: Maps indicating the location of each facility

Requirement (Off-Campus PBD): When providing treatment to a Medicare beneficiary that is not required by anti-dumping rules, off-campus PBDs must give beneficiaries written notice of potential hospital and physician co-insurance liabilities including an estimate of the amount of the additional liability before delivering the service.
Supporting Documentation: A copy of the form given to patients and a copy of policies regarding distribution of the form

It seems obvious that the discussions and changes regarding provider-based status are not over. So stay tuned for further news and be prepared for what may come.

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

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

Q:

Recent National Correct Coding Initiative (NCCI) procedure-to-procedure edits effective April 1, 2016 list the CPT codes for urinalysis (81000, 81001, 81002, 81003 and 81005) as column two codes with the new HCPCS codes for drug testing (G0477-G0483) column one codes. What is the reason for these edits and when is it appropriate to by-pass these edits with a modifier?

A:

All of the new drug testing HCPCS codes for 2016 (G0477-G0483) include “sample validation when performed” in the code description. Sample validation is testing to confirm the specimen has not been tampered with. Various urinalysis tests, such as specific gravity which is part of a routine urinalysis and urine creatinine for example, are common tests that are used for sample validation. Although CMS does not give a reason for all CCI edits, it is likely this is the reason for these edits.

Providers will need to check the physician’s order to see if the urinalysis was done for sample validation or for medically necessary reasons related to the patient’s condition. If there was a medical need for the urinalysis, it is appropriate to add a 59 modifier (separate and distinct service) to by-pass the CCI edits. The modifier is to be appended to the column two code, in this case, the urinalysis codes. If the testing is for sample validation (also known as specimen integrity) then you should not bill the 8100x code separately.