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.-). 

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

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:

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. 

Q:

What is the appropriate diagnosis code for Pleural Effusion when there is documentation of Pleural Effusion with CHF and the Pleural Effusion requires a Thoracentesis?

A:

Assign J91.8, Pleural Effusion in Other Conditions Classified Elsewhere, when the Pleural Effusion with CHF requires treatment, such as a Thoracentesis or diagnostic testing. Typically, Pleural Effusion with CHF would not be reported because it is minimal and does not require specific treatment. Previously, in ICD-9-CM, we used 511.9, Unspecified Pleural Effusion. Resource: Coding Clinic, Second Quarter 2015, page 15

Q:

Can debridement be reported separately in addition to shoulder arthroscopy procedures?

A:

The answer is it depends. Although the shoulder has three “areas” or “regions”: the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space, CMS generally considers the shoulder to be a single anatomic structure. Arthroscopic treatment of a shoulder injury in adjoining areas of the same (ipsilateral) shoulder constitutes treatment of a single anatomic site. National Correct Coding Initiative (NCCI) procedure-to-procedure edits should not be bypassed with the addition of a modifier for arthroscopic shoulder procedures unless performed on the opposite (contralateral) shoulder.Limited debridement (e.g. CPT code 29822) and usually extensive debridement (e.g. CPT code 29823) are included in shoulder arthroscopy procedures even if the limited debridement is performed in a different area of the same shoulder than the other procedure. According to the American Association of Orthopaedic Surgeons Coding, Coverage and Reimbursement Committee, “Code 29822 covers limited debridement of soft or hard tissue and should be used for limited labral debridement, cuff debridement or the removal of degenerative cartilage and osteophytes. Code 29823 should be used only for extensive debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis and supraspinatus.” (see April 2006 AAOS Bulletin)

However, CMS does make three exceptions related to separate reporting of extensive debridement in Section E, Chapter 4 of the NCCI policy manual. If extensive debridement (CPT 29823) is performed in a different area of the same shoulder with one of the following arthroscopic shoulder procedures, it may be reported separately:

• CPT 29824 – Arthroscopic claviculectomy including distal articular surface
• CPT 29827 – Arthroscopic rotator cuff repair
• CPT 29828 – Biceps tenodesis

Remember, the separate reporting of extensive debridement only applies to the three CPT codes listed above. Extensive debridement is included in other shoulder arthroscopy procedures, for example CPT codes 29806, 29807, and 29821. Section I. of Chapter 4 of the NCCI policy manual states, “With limited exceptions open or arthroscopic procedures performed on a joint include debridement (open or arthroscopic) if performed. A debridement code may be reported with a joint procedure code only if the debridement is performed on a different joint or at a site unrelated to the joint. See Section E (Arthroscopy) for discussion of exceptions.”

Reference: National Correct Coding Initiative (NCCI) Policy Manual, 2017, Chapter 4. 

Q:

Do the same guidelines in ICD-10-CM apply to chronic pain and chronic pain syndrome as they did in ICD-9? In ICD-9 coders were instructed not to code chronic pain (338.29) if a definitive diagnosis was documented but chronic pain syndrome (338.4) could be reported with a definitive diagnosis.

A:

No, the guidelines in ICD-10 are different than that in ICD-9.

Section I.C.6.a.1 of the (ICD-9) Official Coding Guidelines state “A code from subcategories 338.1 and 338.2 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

As you can see the code 338.4 was not included in with that particular guideline so it was therefore assumed that it could be assigned with a documented definitive diagnosis.

The codes in ICD-10 are chronic pain G89.29 and chronic pain syndrome (G89.4).

Section I.C.6.b.1 of the (ICD-10-CM) Official Coding Guidelines state “A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

Given that both conditions begin with the category G89, the guideline would include both diagnoses and chronic pain syndrome should not be reported when there is a known definitive diagnosis documented.

Q:

What is required if a hospital wants to outsource its Medicare appeals?

A:

The hospital will need to follow the instructions in Section 270, Chapter 29, Medicare Claims Processing Manual.
Some key points from these instructions include:

• A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is released only to the individual so named.
• A written appointment of the representative must be submitted: the hospital can use Form CMS-1696 or a written instrument which must contain:
• A statement appointing the representative to act on behalf of the hospital, and authorizing the adjudicator to release identifiable health   information to the appointed representative;
• A written explanation of the purpose and scope of the representation;
• Dated, handwritten ink signatures of both the hospital signee and the individual accepting the appointment (both must sign the request within 30 days of each other);
• The name, phone number and address of both the hospital and the representative;
• The representative’s professional status and relationship to the appointing party; and
• The hospital’s NPI number.
• Appointed representatives are responsible for submitting a valid appointment instrument to the contractor with each new appeal request.
• A photocopy of the original may be submitted as long as the original is available upon request.
• Resubmission of the instrument at subsequent levels of appeal for the item(s)/service(s)/claims(s) at issue is encouraged though not required.
• The hospital may appoint a representative to assist with filing an appeal at any time during the course of an appeal.

“If an individual is attempting to act as a representative of a party that is not the beneficiary (such as a hospital) and fails to include an appointment instrument with the appeal request, the individual lacks the authority to act on behalf of the party, and is not entitled to obtain or receive any information related to the appeal. The MAC shall notify the   individual that no redetermination will be performed until a valid request is received from the party or a valid appointment instrument is resubmitted with the redetermination request.”