Knowledge Base Category -

Q:I am confused about how to charge and bill for inhalation treatments, CPT code 94640. I heard the Correct Coding Initiative (CCI) information changed, but I notice the MUE limit is still 2. Could you please explain what the rule is and how hospitals should handle this? 

A:
You are correct that the CCI information changed for 2017. In the 2017 CCI Policy Manual, the wording for how often CPT code 94640 can be reported changed from “once during a single patient encounter” to “once during an episode of care” regardless of the number of separate inhalation treatments that are administered. The manual further clarifies exactly what is meant by an episode of care.“An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.

If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT code 94640.

If inhalation drugs are administered in a continuous treatment or a series of “back-to-back” treatments exceeding one hour, CPT codes 94644 (continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour) and 94645 (...; each additional hour) should be reported instead of CPT code 94640.”

Based on this information, the MUE limit of 2 would be appropriate to accommodate those patients that return to the facility for a second episode of care.

Now let’s address “charging” versus “billing:”

This is a “billing” rule for Medicare, and it is specific to outpatient “billing”. The hospital may “charge” for one treatment for each face-to-face encounter with the patient, but when the bill drops for outpatient Medicare, the hospital would have to apply a “billing” rule of reporting a quantity of 1 for each episode of care.

If a hospital does not charge for each treatment, their gross revenue will be affected; it is important to report charges for all services to Medicare so total cost is accurately reflected regardless of the number of units reported in accordance with Medicare requirements. Other payers may not have quantity limits for 94640 in which case billing more than one would be appropriate. Your hospital should check with each payer to determine their requirements.

Also remember, that under Medicare outpatient payment (OPPS), CPT code 94640 is conditionally packaged with a Status Indicator of “Q1.” These means Medicare does not provide separate payment if the code is on a claim with other outpatient services with status indicators of S (significant procedures), T (mostly surgical procedures), or V (visit codes including ED visits). 

Q:

If a patient is admitted and documented with a condition in which laterality can be distinguished such as bilateral osteoarthritis of the knees, and only one side is being treated, would you report a diagnosis code only for the side receiving treatment?

A:

No.
You would assign the “bilateral” code.

• When a patient has a bilateral condition and the condition still exists on both sides, then a bilateral code is reported.
• Once one side has been treated and that condition no longer exists on that particular side then the appropriate “unilateral” code would be assigned.
• If treatment does not completely resolve the condition for the first side treated, then the “bilateral” code would continue to be reported.

Example #1: Patient is documented with bilateral osteoarthritis of the knees (stage IV of the right and stage III of the left) and is admitted for total knee replacement of the right knee.

ICD-10-CM code assignment would be:

M17.0 for Bilateral Primary OA of Knee

Example #2: H&P states patient with history of bilateral senile nuclear sclerosis cataract. Patient had great success with cataract surgery for the left eye 3 months prior and is now admitted for surgery on the right eye.

ICD-10-CM code assignment would be:

H25.11 for Age-related Nuclear Cataract, Right Eye

Example #3: Documentation shows patient with history of bilateral osteoarthritis of the hip. Total hip arthroplasty was performed on the left side 9 months prior successfully eliminating all pain and symptoms on that side. Patient is admitted now with continued pain on the right side which has been interfering with her daily activities.

ICD-10-CM codes assigned would be:

M16.11 for Unilateral Primary OA, Right Hip and
Z96.642 for Presence of Left Artificial Hip Joint

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

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.

Q:

Since payment for observation services has changed from a composite payment to a comprehensive APC payment (see MMP article Observation Payment for 2016), have the requirements for reporting observation hours changed?

A:

No. The reporting of observation services remains the same as described in the Medicare Claims Processing Manual, Chapter 4, section 290.2.2. Some of the key information from this manual is:

• Observation services are only covered when provided by the order of a physician or other individual authorized to admit patients or to order outpatient services.
• Observation services are generally reported with revenue code 762.
• Other ancillary services performed while the patient is receiving observation care are separately reported.
• Observation time is reported per hour, rounded up to the nearest hour.
• Observation time begins at the clock time documented when observation care is initiated in accordance with a physician’s order.
• Observation time ends when all medically necessary services related to observation care are completed.
• Although 8 or more hours of observation care are required for an observation payment, all hours of observation should be reported.
• Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure. This means providers may have to “carve out” procedure time from the total stay to calculate observation hours.
• Standing orders for observation services following outpatient surgery are not appropriate.
• When observation services span more than one day, all observation hours are reported as a single line item for the date observation care began.

Dilemma:

What Place of Occurrence code is assigned for an injury that occurred in the backyard of the patient’s home?

Solution:

Use Y92.096, Garden or Yard of Other Non-Institutional Residence as the Place of Occurrence of the External Cause. There are more options now for home as the Place of Occurrence in I-10, such as, House, Single Family. However as a reminder, these specific sites must be documented in order for that code to be assigned. Do not assume the home to be a single-family house.

Resource: AHA ICD-10 Coding Handbook, TruCode Encoder