Knowledge Base Category -

Q:

In our Cancer Center, we are giving the drug Rasburicase (Elitek) by infusion. Should we charge this as a chemotherapy infusion or as a therapeutic infusion?

A:

Rasburicase is classified as an antihyperuricemic drug, so you should report the infusion as a therapeutic infusion – not as a chemotherapy infusion.

Q:

Our claims for FDG PET scans are being denied when reported with a personal history diagnosis code, Z85.XXX. Why is this happening?

A:

CMS Transmittal 2200 (CR 10859) added the following note concerning PET scans for oncologic conditions (NCD 220.6.17) when reported with a personal history diagnosis:

“Note: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D or R diagnosis codes.”

The transmittal referenced above includes a link to the NCD spreadsheet updates for the PET Scan diagnosis codes. You can find the updated list of covered diagnosis codes for PET scans and all other NCD ICD-10 code updates at the Medicare coverage ICD-10 webpage.

Q:

In ICD-9, there were several Coding Clinics that instructed us to sequence Acute Renal Failure as the principal diagnosis when a patient is admitted with Acute Renal Failure due to Dehydration. Has this advice changed in ICD-10?

A:

Yes, this advice has changed per Coding Clinic, First Quarter 2019, page 12.  Effective with discharges March 20, 2019, either Dehydration or Acute Kidney Injury could be sequenced as the principal diagnosis based on the reason for admission. Querying the physician is advised when the reason for admission is unclear. Coding Clinic has specified, “There is no rule that acute kidney injury should always be sequenced first.”

The MACs have begun selecting Acute Renal Failure DRGs for review.  Please review your cases with this Coding Clinic in mind.

Reference:

Coding Clinic, First Quarter 2019, page 12. 

Q:

We are being told that it is Alabama Medicaid Policy that we can obtain a physician order for inpatient admission after discharge on a Medicaid patient that has emergency room charges, observation charges and surgery charges. Is this true?

A:

Chapter 19 of the Alabama Medicaid Provider Billing Manual is specific for hospitals and includes the following regarding patient status orders:

Medicaid will utilize Alabama Medicaid and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes.

• It is the hospital’s responsibility to utilize its own physician advisor.
• The attending physician and/or resident may change an order up to 30 days after discharge, as long as the patient met criteria for inpatient or observation charges.”

Both the Alabama Medicaid and Pediatric Inpatient Care Criteria and a link to Chapter 19 can be accessed on the Alabama Medicaid Hospital Services webpage at http://www.medicaid.alabama.gov/content/4.0_Programs/4.4_Medical_Facilities/4.4.1_Hospital_Services.aspx

Q:

A Colonoscopy was performed to identify the source of GI bleeding in a patient.  The physician diagnosed arteriovenous malformation (AVM) of the large intestine.  However, this condition is assigned to a congenital code, Arteriovenous Malformation of Digestive System Vessel (Q27.33), which is not specifically documented in the record.  In prior ICD-9-CM Coding Clinics, we did not use the congenital codes and were instructed to code AVM to Angiodysplasia.  Is this still the case in ICD-10-CM?

A:

Yes, assign a code for Angiodysplasia of Colon with Hemorrhage (55.21) for the bleeding AVM of the large intestine.  These codes are not assigned to a congenital code as they are believed to be degenerative in nature.

Vascular Ectasias, also known as Angiodysplasias and Arteriovenous Malformations are dilated vessels that develop in the cecum and ascending colon.  They occur in people >60 years of age and are the most common cause of lower GI bleeding.  They appear as bright red, can be flat or raised and covered by thin tissue.

References:

Coding Clinic:

                3rd Quarter 2018, page 21

                4th Quarter 1990, page 4

                3rd Quarter 1996, page 9-10

Vascular GI Lesions – Gastrointestinal Disorders Merck Manual 

Q:

Our hospital has had Implantable Cardiac Defibrillator (ICD) claims denied by our Medicare Administrative Contractor (MAC) for what appears to be a missing Q0 modifier. The Q0 modifier was required for ICDs implanted for primary prevention to attest the patient was in a clinical trial or the data was reported to a qualifying data registry. We thought this requirement went away with the update to the ICD National Coverage Determination (NCD) which was effective for dates of service on and after February 15, 2018. Why are our claims being denied and is there anything we can do about it?

A:

You are correct that the updated NCD removed this requirement. Here are two statements from MLN Matters Article MM10865 which addressed the updated ICD NCD:

“Effective February 15, 2018, coverage policy is no longer contingent on participation in a trial/study/registry. Therefore, claims with a Date of Service (DOS) on an after February 15, 2018, no longer require any trial-related coding.”

The reason you have had claim denials for this requirement after it was no longer effective is due to the implementation date of the NCD. Once a new or revised NCD is announced, it takes Medicare contractors a while to implement the business requirements, including revising any claims processing system edits they have in place. That is why the transmittals announcing the changes include both an effective date and an implementation date. For a more thorough discussion of decision memos and NCD effective and implementation dates, see our prior Wednesday@One article, Effective Dates of New ICD NCD Rules.

A provider’s options when new NCD rules are released are to:

• Continue to follow the guidelines of the old NCD for claim submission until the implementation date,
• Follow the new NCD guidelines, but hold your claims until the implementation date for submission, or
• Submit your claims following the new NCD guidelines, but realize they may be denied under the old NCD requirements and you will have to appeal these claims to obtain proper payment.

Since your claims have been denied, you will have to appeal the denial or you may be able to resubmit the claim. Palmetto GBA, the MAC for jurisdictions J and M, recently released the following instructions.

Clinical Trial Implantable Defibrillator Claims

Issue Identified: 3/22/2019

Current Status

Claims reporting Implantable Cardiac Defibrillators (ICDs) related to National Coverage Determination (NCD) 20.4, with dates of service on or after February 15, 2018, previously rejected due to absence of clinical trial/study/registry codes may be submitted after March 26, 2019. Please refer to Palmetto GBA Medical Policy Article A56343   regarding applicable billing/coding changes.

Situation
CMS revised Change Request (CR): 10865   (PDF, 113 KB),

"National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)". The implementation date for Medicare Administrative Contractor (MAC) local edits is to March 26, 2019. Effective February 15, 2018, NCD 20.4 is no longer contingent on participation in a clinical trial/study/registry. Therefore, claims with dates of service on an after February 15, 2018, no longer require any trial-related coding.”

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BAHQ6T4283?opendocument

If you are in another MAC Jurisdiction and have received denials for lack of reporting the Q0 modifier on ICD claims with dates of service on and after February 15, 2018, check with your MAC to see if you can resubmit those claims after March 26, 2019 (the implementation date).  If you have to go the appeal route and send in your medical records, be sure the ICD procedure meets all the requirements of this complex NCD and that your medical record contains the appropriate supporting documentation. Hopefully, this is something for which you already have processes in place and will not be an issue. The ICD procedure has a significant Medicare payment, so whatever you do, be persistent with your MAC in obtaining your proper payment. 

Q:

I am new to Case Management and am searching for resources to help me understand more about Medicare and Medicare Policies for hospitals.

A:

Hospital Conditions of Participation (CoP)

As a new Case Manager, I would first direct you to the Conditions of Participation (CoP) for Utilization Review and Discharge Planning that can be found in the electronic Code of Federal Register: (eCFR) Title 42 Public Health

• Part 482 (482.1 – 482.104) Conditions of Participation for Hospitals
• §482.30 CoP: Utilization Review
• §482.43 CoP: Discharge Planning

To help you better understand CMS’ expectations you can view their Survey Protocol in the CMS State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals.

CMS.gov website

There are several useful webpages available on the www.CMS.gov website. I would start with the Medicare Learning Network® (MLN) Home page.  

Medicare Learning Network® (MLN) Homepage

The Medicare Learning Network® provides free educational materials for health care professionals on CMS programs, policies, and initiatives. From the Homepage you can link to:

• Publications &Multimedia,
• Events & Training, and
• News & Updates.

MLN Publications & Multimedia

One example available are MLN Articles. These articles explain national Medicare policy in an easy-to-understand format with a focus on coverage, billing, and payment rules for specified provider types. Just posted to this webpage is an index of MLN Matters® Article from 2017-2019 in pdf format. One interesting section allows you to search articles specific to individual HCPCS codes.

MLN Events & Training

In this section you will find MLN Web-Based Training page provides you free 24/7 access to web-based training (WBT) courses.

MLN News & Updates

This section provides you access to the MLN Connects weekly e-newsletter for health care professionals. CMS notes this newsletter is your single source for:

• CMS program and policy details,
• Updates and announcements,
• Press Released,
• Upcoming Educational Event Registration and Reminders,
• Claims, Pricer, and Code Information, and
• Updates on New and Revised MLN Publications.

Medicare Quarterly Provider Compliance Newsletter Archive

Another great resource is the Medicare Quarterly Provider Compliance Newsletter that provides education regarding how to address common billing errors and other claims review findings. You can search newsletters by common keywords, phrases, and claim review findings.

CMS National Training Program (NTP)

One additional resource to consider is the NTP website. This site provides materials and educational opportunities to help you better understand and educate others about Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace.

Q:

In the Public Comment section of the February 18, 2018 ICD Final Decision Memo (CAG-00157R4), CMS responded to a comment with the following statement:

“CMS believes in the importance of an evidenced based tool but they are not specifying the type of tool that is required. They do provide an example of an evidence based decision aid for patients with heart failure who are at risk for sudden cardiac death and are considering an ICD. This tool was funded by the National Institutes on Aging and the Patient-Centered Outcomes Research Institute and can be found at https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf. CMS notes that this tool is based on published clinical research and interviews with patients and includes discussion of the option for future ICD deactivation.”

I noticed that there is a copyright notice on the last page of this tool. Are providers allowed to use this tool “as is” for their Shared Decision Making Encounter with individual patients?

A:

This tool can be found on the Colorado Program for Patient Centered Decisions website. Included on this website are “Terms of Use.” MMP reached out to the contact listed on this page and asked your question. Dan D. Matlock, MD, MPH, Associate Professor of Medicine indicated that “our tools are publicly available for clinic/patient use.”

As a reminder, the Implementation Date for providing a Shared Decision Making Encounter as well as all other changes to the NCD is March 26, 2019. You can read more about all of the changes being implemented in MLN Matters MM10865

Q:

I am reviewing a case where the principal diagnosis will be Acute Exacerbation of Diastolic CHF with Hypertension (I11.0).  There was documentation of an elevated BUN and Creatinine with “probable stage 2 renal insufficiency.” The renal insufficiency was not specified as “chronic”.  Based on this documentation, would it be appropriate to change the principal diagnosis to Hypertensive Heart and Chronic Kidney Disease (CKD) with Heart Failure and CKD, Stages 1-4 (I13.0)?

A:

Query the physician to clarify the renal insufficiency, because the documentation did not specify the renal insufficiency to be “chronic.” In addition, there is no entry in the code book/encoder for stage 2 renal insufficiency that will give the code for Stage 2 CKD. Assigning a code that is not specifically documented in the record may be viewed as up-coding.

Resources:

Coding Clinic, 2nd Quarter 2000, pages 17-18

FY 2019 Inpatient Coding Guidelines 

Q:

The documentation in the record specified “intentional Wellbutrin overdose, but not done in a suicidal fashion”.  Should the intent be coded as “intentional self-harm?

A:

Assign the code for Poisoning, By Other Antidepressants, Accidental (Unintentional), Initial Encounter (T43.291A).  Per the guidelines specific for Chapter 19, when the intent of the overdose is not documented then we are to assign the code for accidental intent.  

References:

Coding Clinic, 2nd Quarter 2016, page 8

FY 2019 - ICD-10 Official Guidelines for Adverse Effects, Poisoning, Underdosing and Toxic Effects