Knowledge Base Category -

Q:

Any time a patient is documented with (acute/chronic) congestive heart failure and diastolic or systolic dysfunction, can this be coded as diastolic or systolic heart failure?

A:

No.  In ICD-10-CM, there is no longer an index for diastolic/systolic dysfunction. The provider must now link the heart failure (acute and/or chronic) with the diastolic or systolic dysfunction. 

Refer to Coding Clinic, First Quarter 2017: Page 46

• When provider has linked acute/chronic (congestive) heart failure with either diastolic or systolic dysfunction, it should be coded as “acute/chronic” diastolic and/or systolic heart failure.
• I50.20 – Unspecified systolic (congestive) heart failure
• I50.21 – Acute systolic (congestive) heart failure
• I50.22 – Chronic systolic (congestive) heart failure
• I50.23 – Acute on chronic systolic (congestive) heart failure
• I50.30 – Unspecified diastolic (congestive) heart failure
• I50.31 – Acute diastolic (congestive) heart failure
• I50.32 – Chronic diastolic (congestive) heart failure
• I50.33 – Acute on chronic diastolic (congestive) heart failure
• I50.40 – Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
• I50.41 – Acute combined systolic (congestive) and diastolic (congestive) heart failure
• I50.42 – Chronic combined systolic (congestive) and diastolic (congestive) heart failure
• I50.43 – Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
• If there is not supporting documentation linking the two conditions by the provider; assign code I50.9, Heart failure, unspecified.
• In ICD-10-CM, Congestive heart failure is included in the codes for diastolic and systolic heart failure. When documentation lists congestive heart failure along with either diastolic or systolic heart failure, assign a code for the type of heart failure only (diastolic/systolic).

Example:    

• Congestive heart failure with acute on chronic diastolic heart failure
• Assign code I50.33 only. Code I50.9 would not be reported in addition.

Q:

Is the “with” guideline used when there is documentation of Diabetes and Arthritis?

A:

No, the “with” guideline does not apply to “not elsewhere classified” (NEC) conditions. Arthritis, a form of Arthropathy, can be due to many other conditions besides Diabetes. Therefore, coders should not assume a cause and effect relationship between Diabetes and a “NEC” condition. The physician would have to document Arthritis as a diabetic complication in order for E11.618 to be assigned.

Diabetes, diabetic (mellitus) (sugar)

with

arthropathy NEC E11.618

References:

Coding Clinic: Second Quarter 2018, page 6

Fourth Quarter 2017, page 100-101

Q:

Are there any proposed rule changes from the 2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule that may affect hospitals?

A:

Yes, there are several proposed revisions that could affect hospitals, although some of these will not be effective until 2020.  Here is a review of some of the issues:

Non-excepted Off-Campus Provider Based Departments

These are off-campus PBDs that did not begin billing Medicare until after November 2, 2015.  The Bipartisan Budget Act of 2015 required services in these PBDs be paid under a payment system other than the Outpatient Prospective Payment System (OPPS) in order to make payments more equitable with payments for similar services provided in a physician office setting. Medicare pays for these services under the Medicare Physician Fee Schedule at a percentage of the OPPS payment rates. For 2019, Medicare proposes to continue to pay 40% of the OPPS rate for these services. Hospitals will continue to bill these services on an institutional claim form using the PN modifier to identity non-excepted services. Packaging and other OPPS claims processing logic also apply to these services.

Clinical Laboratory Fee Schedule (CLFS)

The Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. Under the CLFS final rule, applicable laboratories must report to CMS for laboratory tests the private payor rates, the volume and the specific

HCPCS code associated with the test. Beginning in 2018, Medicare CLFS rates are based on this information specifically, equal to the weighted median of the private payor rates for each test.

The 2019 MPFS Proposed Rule seeks comments on a couple of suggestions that could affect whether a hospital outreach laboratory would meet the definition of an applicable reporting lab or not. One suggestion is using Form CMS-1450 bill type 14x to determine the majority of Medicare revenues and low expenditure thresholds in deciding if a lab must report data. The other suggestion is to use the CLIA certificate rather than the NPI to identify a laboratory that would be considered an applicable laboratory.

Therapy Services

CMS is proposing to discontinue functional limitation reporting beginning January 1, 2019. If finalized, they will also delete the HCPCS codes that were created for this reporting.

The Bipartisan Budget Act of 2018 (BBA of 2018) requires reduced payment for therapy services provided in whole or in part by a therapy assistant beginning in 2022. This includes payment to providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs) but, not to critical access hospitals (CAHs). CMS will create a new modifier that must be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. These two therapy modifiers would

be added to the existing three therapy modifiers – GP, GO, and GN − that are currently used to identify all therapy services delivered under a PT, OT or SLP plan of care, respectively. Modifiers GP and GO will be redefined to be reported when physical or occupational services are provided by a therapist.

Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Effective January 1, 2020, professionals must consult appropriate use criteria (AUC) before ordering applicable advanced diagnostic imaging services and furnishing professionals must report AUC consultation information on the Medicare claim. The first year (2020) is for education and operations testing and claims will not be denied for failure to include proper AUC consultation information.

Information in the proposed rule clarifies that hospital outpatient departments are required to report AUC information on claims. Specifically, the proposed MPFS rule clarifies that AUC consultation information must be reported on all claims for an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system. Applicable settings include a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and proposed this year, an independent diagnostic testing facility (IDTF). The AUC information to be reported on a claim includes which qualified clinical decision support mechanism (CDSM) was consulted; whether the service met, did not meet, or was not applicable for the AUC and the NPI of ordering physician. CMS also proposed to use established coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims.

Although emergency departments are listed specifically in the applicable settings, the exceptions for AUC consulting and reporting are 1) a service ordered for an individual with an emergency medical condition, 2) a service ordered for an inpatient, and 3) a service ordered by an ordering professional with a significant hardship.

To find out more about the above issues, you can find the 2019 MPFS Proposed Rule here. 

Q:

Services for Medicare patients referred to our hospital for outpatient treatments or testing are being denied by Medicare due to “clinical documentation not provided.”  Examples of the types of services being denied are therapeutic outpatient infusions and diagnostic tests such as CT scans. The only information the hospital has is the physician’s order and the nursing documentation or diagnostic report. How are we supposed to provide the clinical documentation to support the medical necessity of the service to the Medicare auditor?

A:

Information addressing this can be found in the Medicare Program Integrity Manual, Chapter 3. The bottom line is the billing provider is ultimately responsible for submitting all supporting documentation for services for which they billed, even if they have to obtain such information from another provider. 

Medicare auditors include the:

• Medicare Administrative Contractors - MACs,
• Recovery Auditors - RACs,
• Comprehensive Error Rate Testing reviewers - CERT and
• Zone or Unified Program Integrity Contractors - ZPICs/UPICs.

These auditors generally request documentation to support the services billed to Medicare from the billing provider. The CERT, and at their discretion, other Medicare auditors, may also request information from the referring provider when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentation necessary to support the service billed and supported by the Local and National Coverage Determinations.

However, because the provider selected for review or appealing a denial is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the requested documentation.  This means hospitals may have to obtain information supporting the medical necessity of services from the referring provider, such as physician office notes, and forward that documentation to the Medicare auditor. Failure to get this documentation to the Medicare auditor can result in payment denial for the billed service.

Q:

Would you please clarify guidelines for when it is appropriate to code excisional vs non-excisional debridement?

A:

One thing to keep in mind, is the difference between an excisional debridement and a non-excisional debridement. 

An excisional debridement:

• Is a surgical procedure that involves an excisional method of removal, or cutting away tissue, necrosis and/or slough
• Groups to a surgical MS-DRG
• Results in a higher relative weight
• Translates into higher reimbursement
• Is classified to root operation “Excision”

A non-excisional debridement:

• Non-operative procedure involving brushing, scrubbing, irrigating or washing of devitalized tissue, necrosis, slough, and/or foreign material.
• May be classified to root operation “Extraction” (pulling or stripping out or off all or portion of a body part by use of force)
• Use “Extraction” of the specific body part instead of “Irrigation” when coding for debridement of areas other than skin
• May be classified to root operation “Irrigation” when procedure is performed by irrigating the devitalized tissue
• Does not group to a surgical MS-DRG

As stated in 3rd Qtr. Coding Clinic 2015: pages 3-5, "the provider is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the provider when the correlation between the documentation and the defined PCS term is clear.  It is the coder's responsibility to determine what the documentation equates to in the PCS definitions."   

When the physician’s intent of the procedure is to debride the wound, in most cases, he or she is not likely to use the PCS terms “Extraction, Irrigation or even Excisional”, as emphasized in the guideline above”   Documentation in the body of the procedure note should be descriptive enough for the coder to determine which procedure code to assign.

It should also be noted that this same Coding Clinic also emphasizes that a code is assigned for excisional debridement when the provider documents “excisional debridement” “AND / OR” the documentation meets the definition of the Excision root operation.  

Even when the physician states an excisional debridement was carried out; elements must also be documented in the body of the procedure note to support an excisional debridement.  You may find it easier to memorize “TINA D” in order to help with assignment of the more appropriate code for the procedure performed.

T - Technique used by the provider (cutting, scrubbing, trimming)

I - Instruments used (scissors, scalpel, pulse lavage, or curette)

N - Nature of the tissue removed (slough, necrosis, devitalized tissue, or non-viable tissue)

A - Appearance and size of the wound (fresh bleeding tissue or viable tissue)

D - Depth of the debridement (down to and including)

Additional things to remember:

1. Use of sharp instrument is not always indicative of excisional debridement.
2. Only one code, for the deepest layer documented is assigned when there are multiple layers involved of the same site
3. Both excisional and non-excisional debridement can be performed by:

• Physician
• Physician assistant
• Nurses
• Therapists

4. The location in which the procedure is performed is no indication of the type of debridement carried out.

Remember:  We cannot assume anything.  Documentation in the record needs to clearly support and reflect the procedure that was performed.   If not, then a query should be sent for clarification.

Q:

Have there been any recent updates to the hospital Post-acute Care Transfer (PACT) Policy?

A:

Yes. Transmittal 2055 added discharges to hospice care as a post-acute care setting that would invoke the payment adjustments of the Post-acute Care Transfer policy beginning FY 2019.

The transmittal summarizes the facts of Medicare’s transfer policies in the Background section:

“When a patient is transferred to another hospital and his or her length of stay is less than the geometric mean length of stay for the Medicare Severity Diagnosis-Related Group (MS–DRG), the transferring hospital would be paid based on a graduated per diem rate for each day of stay, not to exceed the full MS–DRG payment.  For discharges to certain post-acute care settings, this per diem-based payment adjustment is limited to discharges to certain MS-DRGs. Currently, the regulation limits post-acute care transfers to those where the patient is transferred to a distinct part hospital unit, a skilled nursing facility, or discharged with a written plan for home health services commencing within 3 days of discharge.”

The policy revision is based on the requirements of Section 53109 of the Bipartisan Budget Act of 2018. Beginning in FY 2019 (October 1, 2018), discharges to hospice care will also qualify as a post-acute care transfer and be subject to payment adjustments.

The post-acute care setting and discharge statuses to which the policy applies are:

• Inpatient rehab facilities and units (discharge status code 63)
• Long term care hospitals (code 62)
• Psychiatric hospitals and units (code 65)
• Children’s and Cancer hospitals (code 05)
• Skilled nursing facilities (code 03)
• Home with a home health plan of care that begins within 3 days (code 06)
• Hospice care (code 50 or 51) – NEW for claims with through date on or after October 1, 2018

Here are some other facts about the post-acute care transfer policy from a prior Wednesday@One article.

• PACT policy only applies to certain MS-DRGs. The list of MS-DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
• PACT policy only applies when the patient is transferred to certain post-acute care settings – see list above
• Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code if needed.
• Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
• There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
• Transfer cases are eligible for outlier payments.

Q:

What is the “Approach” for a needle aspiration of Bone Marrow from a lumbar vertebra when performed during an open lumbar spinal fusion?

A:

The operative “Approach” for needle aspiration of Bone Marrow would be assigned to “Open”.  This would not be considered a “Percutaneous” approach because the aspiration did not cut through the skin.  The code assigned would be 07DS0ZZ, Extraction of Vertebral Bone Marrow, Open Approach

In addition, needle aspiration of bone marrow from the iliac crest is commonly performed during spinal fusions and would be assigned to 07DR0ZZ, Extraction of Iliac Bone Marrow, Open Approach.  This would be reported once even if performed bilaterally.  

Resources:

Coding Clinic, Third Quarter 2016, page 41

Coding Tip: Biopsy Coding in PCS When Fluid is Aspirated; Kim Carrier, Health Information Associates

Q:

We understand that effective January 1, 2018, hospital outpatient facilities are required to use the “FY” modifier with the applicable HCPCS code(s) to describe an imaging service that is an X-ray taken using computed radiography technology. Do we need to report the “FY” modifier if an imaging study includes computed radiography x-rays and digital radiography images?

A:

No.  CMS clarified in the April 2018 OPPS Update Transmittal that the “FY” modifier is not required when the imaging service is comprised of multiple images that include both X-rays taken using computed radiography technology and images taken using digital radiography.

Modifier “FY” (X-ray taken using computed radiography technology/cassette-based imaging) is to be used with the applicable HCPCS code(s) to describe an imaging service that is an X-ray taken using computed radiography technology.  The application of the modifier results in a payment reduction of 7% for calendar years 2018-2022, and 10% in 2023 and after. The payment adjustment applies to an imaging service that is an X-ray taken using computed radiography technology where the X-ray taken using computed radiography technology is not combined with digital radiography in the same imaging service.

The payment reduction is a result of provisions of the Consolidated Appropriations Act, 2016 designed to incentivize the transition from traditional X-ray imaging to digital radiography.

Q:

What codes would be assigned for an endarterectomy of the left common carotid artery, left internal carotid artery and the left external carotid artery?

A:

First let’s review the new Body Parts General Guideline for FY2018:

B4.1c:  If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry.

Based on this guideline, procedure codes for endarterectomy of the left internal carotid artery and the left external carotid artery would be assigned because these two arteries are branches of the common carotid artery and the furthest from the point of entry.

Extirpation of Matter from Left Internal Carotid Artery, Open Approach (03CL0ZZ)

Extirpation of Matter from Left External Carotid Artery, Open Approach (03CN0ZZ)

References:

Body Part, General Guidelines, 2018 ICD-10-PCS

Highlights of ICD-10-CM & PCS, Changes for FY 2018 and Other Hot Topics, AAHIM Coding Symposium, Joy King Ewing, RHIA, CCS

Q:

On February 15, 2018, CMS issued a final Decision Memo that included revised criteria for Medicare coverage of Implantable Cardioverter Defibrillators. When should our hospital start following the new criteria such as the requirement for the shared decision-making visit and the end of the requirement for registry data collection and submission?

A:

There are differences in the expected compliance with a coverage decision memorandum and a National Coverage Determination (NCD).  CMS addresses this in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

“CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. … The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

Providers need to bear in mind however, that the final NCD backdates the effective date of the changes to the date of the decision memo. The issue lies with the implementation date which is communicated in a CMS Transmittal once the NCD changes are finalized. Medicare Administrative Contractors (MACs) will not start enforcing the new rules until the implementation date, but then they will enforce rules for dates of service on and after the date of the decision memo. This means once the final update to the NCD is made and manualized, the effective date will revert to the date of the decision memo but following the new rules will be based on an implementation date.  Claims submitted on and after the implementation date, will follow the new guidelines for dates of service on and after February 15, 2018 (decision memo date).

Best practice is for providers to implement new requirements, such as the shared decision-making visit, as quickly as possible. Until an implementation date is communicated, providers should not stop complying with the requirements of the current NCD if they are continuing to submit claims for the service.  For this NCD, continue to report to a registry and submit applicable claims with the Q0 modifier indicating registry submission and abide by the current waiting periods until the revised NCD is released.  Another option for providers is to follow the new criteria in the Decision Memo and hold claims until after the implementation date of the revised NCD.

For more information about the Decision Memo, see the prior Wednesday@One ICD Decision Memo article.