Knowledge Base - Full Library

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.-). 

Fall is without a doubt my favorite time of year. The one downside is that the days get shorter leaving fewer hours of daylight. Fewer hours of daylight leads to prioritizing what I want to get accomplished on my off days. While deciding where to start is an easy choice when it comes to chores around the outside of my house versus driving through a state park to catch a glimpse of the fall foliage, deciding how to prioritize “at risk” issues for a hospital can be a challenge.  One good starting point is knowing what issues the Comprehensive Error Rate Testing (CERT) Program has found to be “at risk.” 

CERT Program Background

The objective of the CERT program is to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any payment that should not have been made or that was paid at an incorrect amount (including both overpayments and underpayments) to be an improper payment. It is important to note that the improper payment rate does not measure fraud. It estimates the payments that did not meet Medicare coverage, coding, and billing rules.”

The CERT Review contractor performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. A claim review entails checking for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and provisions in the CMS instructional manuals. A stratified random sample is chosen by claims types for review and using statistical weighting, the findings from the sample are projected to the total universe of Medicare FFS claims submitted during the report period.

Reconciliation of Improper Payments

The CERT program notifies the MACs of improper payments identified through the CERT process. The MACs then repay underpayments and recoup overpayments. MACs can recover the overpayments identified in the CERT sample but cannot recoup projections made to the claims universe.

Medicare Fee-For-Service 2016 Improper Payments Report

Annually, an Improper Payments Report is released as well an Appendices of tables breaking down the findings. The Medicare FFS 2016 Improper Payments report was posted on the CMS CERT Reports webpage in July of this year. This report includes claims submitted during the 12-month period from July 1, 2014 through June 30, 2015 and highlights the services and supplies that were the largest drivers of the 2016 improper payment rate.  

2016 Report by the Numbers:

• 89% - The estimated Medicare FFS Payment Accuracy Rate.
• $332.6 billion – the estimated amount paid correctly by Medicare for services and supplies provided to Medicare beneficiaries.
• 11% - The estimated Medicare FFS Improper Payment Rate
• $41.1 billion – the estimated amount paid incorrectly by Medicare.
• $22 million or 86% - the amount of actual overpayment dollars identified during the 2016 report period that the MACs had collected as of the time the 2016 report was published.

The report indicates that “the major contributor to the Medicare FFS improper payment rate decrease from 12.1 percent in 2015 to 11.0 percent in 2016, were implementation of CMS’ “Two Midnight” rule and corresponding educational efforts.” Also, as in prior years, “the most common cause of improper payments (accounting for 64.1 percent of total improper payments) was lack of documentation to support the services or supplies billed to Medicare. In other words, the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary.”

2016 Part A Driver of the Improper Payment Rate

The majority of hospital IPPS improper payments were due to the record not supporting a reasonable expectation that the admitting practitioner expected the patient to require a hospital stay that crossed two midnights. During the 2016 report period the CERT denied 733 claims for this reason totaling $7.4 million in actual overpayments. The projected overpayment to the universe of Medicare claims was $2.1 billion.

CMS goes on to note that errors are more likely to occur when the length of stay is shorter and where there is an elective surgical procedure. In fact, 18.6% of improper payments made to Part A IPPS Hospitals was for claims with a length of stay 0 or 1 days.

CMS Key Effort to Prevent and Reduce Improper Payments

One way that CMS and its contractors are working to reduce improper payments is by developing “medical review strategies using the improper payment data to ensure the areas of highest risk and exposure are targeted. MACs use improper payment data analysis to determine which claims to review on either a pre-payment or post-payment basis. Improper payment data analysis also guides the MAC’s corrective actions and educational efforts.

What Hospital Can do to Reduce Improper Payments

Examples of efforts hospitals can undertake to prevent and reduce improper payments include:

• Visit the CERT Provider Website that provides information about the CERT, how to submit records, sample request letters and much more.
• Become familiar with NCDs, LCDs and coverage articles that provide guidance on what is needed to support the medical necessity of the services you provide. The CERT Provider Website contains a link to a CMS CERT Presentation. Below is an example from the presentation reinforcing the need to be familiar with coverage determinations:

Medical Necessity Example

• “The CERT program received medical records from two different physicians documenting that a patient who underwent implantation of an AICD had severe dementia. The National Coverage Determination (NCD 20.4) specifies that the patient must not have irreversible brain damage from preexisting cerebral disease.
• The CERT contractor reviewers made an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies.”

• Visit the CERT A/B MAC Outreach & Education Task Force page on the CMS website which includes Education Resources, Web-based Training, Presentations and information about any upcoming events.
• Become familiar with and utilize your hospitals Program for Evaluating Payment Patterns Electronic Report (PEPPER).
• And last but not least be familiar with the improper payment issues identified in the Annual CERT Reports. 

If you deal in the world of Medicare Parts A and B and you live in the state of Alabama, Georgia, or Tennessee, there was big news for you in early September.  On September 7, 2017, CMS awarded Palmetto GBA (Palmetto) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in the states of Alabama, Georgia, and Tennessee (A/B MAC Jurisdiction J).  Jurisdiction J is currently handled by Medicare Administrative Contractor (MAC) Cahaba GBA.

So if you are a provider in Jurisdiction J, what do you need to know about this change?

The A/B MAC Jurisdiction J Palmetto Contract…

• Will provide Medicare services to more than 400 hospitals, 52,000 physicians, and 2.5 million Medicare beneficiaries.
• Has a total estimated value of $274.6 million.
• Includes a base year and four option years, for a maximum duration of five years.
• Includes the following duties for Palmetto – processing and paying Medicare Part A and Part B provider claims, enrolling and auditing Medicare providers, educating providers on Medicare coverage requirements, and other duties.

Palmetto GBA …

• Is currently the A/B MAC for Jurisdiction M, which includes the states of North Carolina, South Carolina, Virginia, and West Virginia.
• Is also the MAC for Home Health and Hospice providers in Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas.
• Will be opening an office in Birmingham, AL; Palmetto will also perform the contract from offices in Columbia, Florence, and Camden, SC.
• Palmetto’s website - palmettogba.com

The Transition and Resources

• The implementation effective date for Part A in all 3 states is January 29, 2018
• The implementation effective date for Part B is February 26, 2018.
• CMS and Palmetto anticipate a smooth transition, with few, if any, service issues for Medicare beneficiaries and providers.
• Palmetto GBA’s goal is to communicate early, often and continually throughout the implementation to ensure all stakeholders, providers, medical and hospital associations and Members of Congress, are well-informed with consistent, open and clear information.
• Palmetto's Transition Website site includes general information, FAQs, and Outreach and Education
• Palmetto prefers questions concerning the transition be submitted via Twitter or Facebook (see Palmetto Transition FAQs)
• Face-to-Face JJ Implementation Workshops are planned for the end of October and the beginning of November. As soon as the dates and locations are determined, they will be advertised on the JJ website for registration.
• There are already educational videos on the Palmetto Transition Education and Outreach webpage about Palmetto GBA and some of their eServices features such as eUtilization, eAudits, eCBR (comparative billing reports), and Managing Your Medicare Information.

What Providers Need to Do

• Register for listserv email updates from Palmetto GBA. To register simply select listserv at the top of the Palmetto's Transition Website
• Visit this website for Medicare program information and updates. Palmetto GBA’s website is continually updated with the most current information.
• Read the MMP Wednesday@One newsletter for future information about Palmetto and the Jurisdiction J transition.

October 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.3

Quarterly update to the I/OCE which is the program Medicare uses to process claims for all outpatient institutional providers (OPPS and non-OPPS hospitals).  This update describes new or changed processing edits.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10230.pdf

October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Quarterly update to the hospital OPPS system. This update includes new/changed codes, directions on billing for Supervised Exercise Therapy (SET) for peripheral artery disease, and a revision to Medicare policy on Upper Eyelid Blepharoplasty and Blepharoptosis Repair.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10236.pdf

Screening for Hepatitis B Virus (HBV) Infection (Revision)

Revision includes clarifications for HBV for ESRD patients and pricing of HCPCS G0499.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9859.pdf

Internet Only Manual (IOM) Update to Pub. 100-04, Chapter 15 - Ambulance, to Restore Multiple Patients on One Trip Instructions

Restores missing instructions concerning “Multiple Patients on One Trip” to the Medicare Claims Processing Manual.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10245.pdf

Revision to Publication 100.06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment

Updates the Medicare Financial Management Manual section on Limitation on Recoupment Overpayments

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9815.pdf

Provider-Based Determination (Revision)

Revision related to acceptable checklist.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10095.pdf

Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4

Updates to Cardiac Rehab and Intensive Cardiac Rehab Programs to allow a one-time switch from the ICR program to the cardiac rehabilitation program. Policy clarifications regarding Smoking Cessation Services, and Colorectal Cancer Screening.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3848CP.pdf

National Coverage Determination (NCD) for Smoking and Tobacco-Use Cessation Counseling - RETIRED (210.4)

Effective September 30, 2015 Section 210.4 is deleted and the remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1) remains effective.

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=308&ncdver=2&TimeFrame=7&DocType=All&bc=AgAAYAAAAAAAAA%3d%3d&

2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

SNF consolidated billing defines which services are “included” in the SNF payment and which services are “excluded” (can be directly billed to Medicare by other providers). This updates the HCPCS codes edits for 2018.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10262.pdf

Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

Implements policy changes for the Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10273.pdf

ICD-10-CM FY 2018 Guidelines

These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Associated (AHA), the American Health Information Management Association (AHIMA), CMS, and the National Center for Health Statistics (NCHS). These guidelines are to be used as a companion document to the official version of the ICD_10-CM as published on the NCHS website.

https://www.cdc.gov/nchs/icd/icd10cm.htm

Office of Inspector General Report: Medicare Inappropriately Paid Acute-Care Hospitals for Outpatient Services they Provided to Beneficiaries who were Inpatients of Other Facilities

The OIG identified outpatient claims from acute-care hospitals that overlapped with the identified inpatient claims from other types of facilities - LTCHs, IRFs, IPFs, and CAHs. The OIG found inappropriate payments of $51.6 million to acute-care hospitals for outpatient services that overlapped inpatient admissions elsewhere.

https://oig.hhs.gov/oas/reports/region9/91602026.pdf

Office of Inspector General Reports Highlight Hospital Billing Issues

Discusses coding concerns for Right Heart Catheterizations (RHCs) with heart biopsies that used modifier -59 and claims for 96 or more continuous hours of mechanical ventilation.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17017.pdf

Annual Clotting Factor Furnishing Fee Update 2018

The clotting factor furnishing fee for 2018 is $0.215 per unit.  For dates of service from January 1, 2018, through December 31, 2018, the clotting factor furnishing fee of $0.215 per unit is added to the payment limit for the clotting factor.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10254.pdf

October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) (Revision)

Revised to add or clarify information on Transuretheral Waterjet Prostate Ablation Procedure (CPT code 0421T) and the OPPS status indicator for Q5102.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10236.pdf

Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations

Reminder of the fundamental guidance governing billing where liability insurance (including self-insurance) is involved.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17018.pdf

Accepting Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA)

This article explains what a Medicare Set-Aside Arrangement (MSA) is and explains why it is appropriate to accept payment from a patient that has a funded MSA.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17019.pdf

Targeted Probe and Educate

CMS is expanding the existing Targeted Probe and Educate (TPE) Pilot to include all MACs in order to reduce appeals, decrease provider burden, and improve the medical review/education process.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf

Revisions to the State Operations Manual (SOM) Appendix A– Survey Protocol, Regulations and Interpretive Guidelines for Hospitals

Adds a current regulation with interpretive guidelines not previously included in Appendix A as well as revising interpretive guidelines defining whether a hospital is primarily engaged in providing inpatient services under section 1861(e)(1) of the Social Security Act.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R170SOMA.pdf

Contract Award for A/B MAC Jurisdiction J (posted 9/8/2017)

CMS awarded the Medicare Administrative Contract to Palmetto GBA (Palmetto) for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims in Jurisdiction J (AL, GA, and TN)

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

CMS Reveals New Medicare Card Design

The first look at the newly designed Medicare card. The new Medicare card contains a unique, randomly-assigned number that replaces the current Social Security-based number.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-09-14.html

Local Medicare Administrative Contractor (MAC) coverage updates during the last month included a new Article from Noridian Jurisdiction E and a combining of existing Parts A and B articles for Noridian JF concerning the topic of Lymphedema Decongestive Treatment.  Noridian is the only MAC with a separate Article or Local Coverage Determination (LCD) that specifically addresses this topic.  However, almost all the other MACs do address lymphedema treatment as part of their Physical/Occupational Therapy policies. Lymphedema treatment is important to restore normal shape, reduce the likelihood of complications, and to restore function (such as self-care and other activities of daily living [ADLs]).

There are similarities and differences between the coverage policies from the various MACs, so be sure to refer to the policy for your jurisdiction to understand the requirements that apply to your hospital.  In general, complex or comprehensive decongestive therapy (CDT) consists of skin care, manual lymphatic drainage (MLD), compression wrapping, and therapeutic exercises.  Other key points related to the treatment are listed below.

• There must be a physician-documented diagnosis of primary or secondary lymphedema. Treatment is not for tissue edema from other causes (e.g. congestive heart failure).
• The patient should have documented signs and symptoms and functional limitations due to the lymphedema.
• The ultimate goal of treatment is to reduce and maintain reduction of lymphedema by establishing a management program that can be carried out by the patient, patient’s family, or patient’s caregiver. This means a major component of treatment is education of the patient and/or caregiver. 
• Skilled therapy should not be continued once the patient/caregiver has been sufficiently trained.
• It is necessary for the patient or their caregiver to have the ability to understand and comply with continuation of the treatment regimen after skilled therapy is complete.
• Treatment should be provided by a skilled professional (physician, non-physician practitioner, or therapist) who has received specialized training in this form of treatment.  
• Almost all the coverage policies place limits on the amount and duration of treatment. Common limits are 3-5 treatments weekly for up to 12-18 visits but vary by MAC.
• Most MACs support the use of CPT code 97140 (manual therapy) for manual lymphatic drainage and CPT 97110 (therapeutic exercise) for the exercise portion of CDT. Some MACs state they do not accept the compression application codes (29581-29584) for compression wrapping for lymphedema.
• Documentation requirements, when addressed, require supportive documentation of patient history and etiology, prior treatments, ability of patient and/or caregiver to continue home treatment, functional limitations and pain levels, limb measurements and any other skin conditions in that area.

Secondary lymphedema may be the result of surgical removal of lymph nodes (such as in association with surgery for breast cancer or other cancers), fibrosis secondary to radiation, and traumatic injury to the lymphatic system. Decongestive therapy for lymphedema is a valuable treatment for those patients who need it.  Providers should be familiar with and follow the guidance of their area Medicare contractors for this beneficial service.

The first weekend in September marked the return of college football for another season.  Football is a rough sport that requires a lot of padding to prevent and lessen injuries, so football pads are a good thing.  If you have ever done home projects that require working on your knees, you quickly realize the value of knee pads.  And for long-winded speakers, you hope your chair has a comfortable pad.  All of these are good “pads,” but some pads are not so welcome.  The extra padding of weight gain and aging is not so good – for example those extra “pads” around your eyes.  Peripheral artery disease, abbreviated PAD, is another pad that is bad.  The October 2017 update of the Outpatient Prospective Payment System addresses ways Medicare handles these examples of bad “pads.”

Supervised Exercise Therapy (SET) for Peripheral Artery Disease (PAD)

Under a new National Coverage Determination (NCD) effective May 25, 2017, Medicare will pay for supervised exercise therapy (SET) for beneficiaries with intermittent claudication for the treatment of symptomatic peripheral artery disease. The October OPPS update provides details of the requirements and CPT coding for this service.

The Medicare requirements for coverage of SET for PAD are:

• A therapeutic-exercise training program consisting of 30-60 minute sessions,
• Generally up to 36 sessions over 12 weeks,
• Referral from the physician responsible for PAD treatment,
• Contractor discretion for an additional 36 sessions over an extended period of time with a second referral,
• Performed in a hospital setting or physician’s office,
• Delivered by personnel trained in exercise therapy for PAD and who ensure benefits outweigh harms,
• Direct supervision by a physician or non-physician practitioner trained in both basic and advanced life support techniques,
• Patient has no absolute contraindications to exercise as determined by their primary physician, and
• A face-to-face visit with the physician responsible for PAD treatment to obtain:
• The referral for supervised exercise therapy, and
• Information regarding cardiovascular disease and PAD risk factor reduction, such as education, counseling, behavioral interventions, and outcome assessments.

Peripheral artery disease (PAD) rehabilitation is reported with CPT code 93668 for each session.  This service is paid under OPPS with a status indicator of “S” (separate APC payment, not discounted when multiple).

Upper Eyelid Blepharoplasty and Blepharoptosis Repair

CMS is revising their policy on blepharoplasty and blepharoptosis when performed together.  Before addressing the revision, let’s review the differences in these procedures and the prior policy.  Blepharoplasty is removing “pads” (excess fat or skin) around the eye. This is often a cosmetic procedure to improve appearance and cosmetic procedures are not covered by Medicare.  Medicare may cover blepharoplasty if there is medical need, such as an injury or the excess skin interferes with vision.  Ptosis repair tightens muscles around the eye to raise the height of a drooping eyelid.  Medicare’s prior policy, as clarified in the July 2016 OPPS Update, was that any removal of upper eyelid tissue (blepharoplasty) performed in conjunction with a ptosis repair of the same eye was considered a part of the blepharoptosis repair and could not be billed separately to Medicare or to the patient.

Effective October 1, 2017, CMS is revising this policy to allow either cosmetic or medically necessary blepharoplasty to be performed in conjunction with a medically necessary upper eyelid blepharoptosis surgery.  This means both procedures can be billed when performed together on the same eye – medically necessary procedures to Medicare and procedures performed for cosmetic reasons to the patient.  Patients should be made aware of their financial obligations for cosmetic procedures per Advance Beneficiary Notice (ABN) instructions.  If both the ptosis repair and the blepharoplasty are medically necessary and billed to Medicare, the payment for the blepharoplasty is bundled into the comprehensive APC payment for the blepharoptosis. In other words, when Medicare covers both procedures, there is no separate payment for the blepharoplasty.

The article also includes a list of practices related to blepharoplasty and blepharoptosis that are not appropriate for separate payment under Medicare, such as procedures performed on different dates.  Please refer to the October 2017 OPPS Update for the full list.  You can also find additional information on the original policy clarification in a prior article on this subject.

When billing Medicare for exercise therapy for PAD or blepharoplasty procedures, you need to grab your pad of paper and your favorite padded ink pen, sit in your most comfortable padded chair, and make notes on Medicare’s rules about “pads.”

It was Miss Peacock in the Dining Room with the Candlestick is just one of the many possibilities in solving the murder mystery in the game of Clue. Learning to put the pieces together to solve the mystery as a child has served me well when it comes to the world of Clinical Documentation Improvement where each chart is a new mystery and I am the detective. When reviewing a chart you may find clinical indicators without a diagnosis that provides you with the needed “clues” to query the physician. You may also find a diagnosis lacking the supporting “clues” (clinical indicators) that again require querying the physician.  And, if all goes well, at the end of the hospitalization the mystery is solved and there is clear documentation supporting a principal diagnosis, secondary diagnoses, the resources utilized and the medical necessity of the admission.  

More and more emphasis is being put towards outpatient Clinical Documentation. For many this is an entirely new and different mystery to be solved. One key to solving this mystery is having a basic understanding of Hierarchical Condition Categories (HCCs). This article is meant to be a starting point to unraveling the mystery of HCCs. 

Background

• Medicare Advantage (Part C) plans are paid a monthly capitation rate to provide health care services to enrolled beneficiaries.
• Historically, payments to Medicare Advantage (Part C) plans were linked to Fee-for-Service expenditures. “Research showed that the managed care program was increasing total Medicare Program expenditures, because its enrollees were healthier than FFS enrollees.”¹
• The Benefits Improvement Protection Act (BIPA 2000) required the implementation of a risk adjustment model using not only diagnoses from inpatient hospital stays, but also from ambulatory setting beginning in 2004.
• The CMS-HCC model was implemented in 2004 as a risk-adjustment model. Per CMS this allows them “to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk and risk scores are used to adjust payments for each beneficiary’s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.”²
• CMS-HCC data is calculated once a year based on information reported on claims.
• To continue to be factored into an enrollees risk adjustment, all chronic conditions, including past surgeries, must be documented annually during a face-to-face encounter.

CMS-HCC Model Basics

• An HCC is a category of disease type (e.g., congestive heart failure) with multiple individual ICD-10 diagnoses that map to that HCC category.
• Similar to severity weighted MS-DRGs in the acute hospital inpatient setting, each HCC is assigned a Risk-Adjustment Factor (RAF) This score is a total of all relative factors related to one patient for a total year. Specifically, demographic (age and whether the patient is community-based or living in a skilled nursing facility (SNF) and disease complexity factors. There is an Interaction Factor for certain conditions indicating the presence of several conditions at the same time.
• Diagnoses from inpatient, outpatient and professional practice encounters are used to calculate the RAF score.
• There are currently 79 HCC Categories (e.g., Infection, Diabetes with Acute Complications, Diabetes with Chronic Complications, Cerebrovascular Disease).

CMS-HCC Model: Guiding Principles

The CMS-HCC model uses demographic information (age, sex, Medicaid dual eligibility, disability status) and a profile of major medical conditions in the base year to predict Medicare expenditures in the next year. The following 10 principles guided the creation of the CMS-HCC diagnostic classification system:

• Principle 1: Diagnostic categories should be clinically meaningful,
• Principle 2: Diagnostic categories should predict medical expenditures.
• Principle 3: Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures.
• Principle 4: In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate.
• Principle 5: The diagnostic classification should encourage specific coding. “Vague diagnostic codes should be grouped with less severe and lower-paying diagnostic categories to provide incentives for more specific diagnostic coding.”²
• Principle 6: The diagnostic classification should not reward coding proliferation. “Neither the number of times that a particular code appears, nor the presence of additional, closely related codes that indicate the same condition should increase predicted costs.”²
• Principle 7: Providers should not be penalized for recording additional diagnoses.
• Principle 8: The classification system should be internally consistent.
• Principle 9: The diagnostic classification should assign all ICD-10-CM codes as each code potentially contains relevant clinical information.
• Principle 10: Discretionary diagnostic categories should be excluded from payment models.

CMS-HCC Model: Disease Hierarchy

Similar to the surgical hierarchy in the inpatient setting. The CMS-HCC model follows a disease hierarchy. The hierarchy addresses “situations when multiple levels of severity for a disease, with varying levels of associated costs, have been reported for a beneficiary. The hierarchies prioritize the inclusion in a risk score of multiple HCCs where diagnoses are clinically related and ranked by costs. In the case of a disease hierarchy, Part C payment is based only on the most severe and costly manifestation of the disease. Hierarchies are published in the Rate Announcement for the years when CMS recalibrated the CMS-HCC model.”²

CMS-HCC Model: Risk Adjustment Data Submission Requirements

The following bullets can be found in Chapter 7 of the Medicare Managed Care Manual and detail some of what plan sponsors must do when submitting data.

• “Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting.

• Implement procedures to ensure that diagnoses are from acceptable data sources. The only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities, and physicians. Plan sponsors are responsible for determining provider type based on the source of the data.

• Submit the required data elements from acceptable data sources according to the coding guidelines.

• Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at least once during the risk adjustment data-reporting period. Submitters must filter diagnosis data to eliminate the submission of duplicate diagnosis clusters.

• For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit diagnosis codes under the same rules as for a beneficiary with both Parts A and B. The plan should also submit diagnosis codes for Part A services provided under a non-Medicare contract.

If upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any diagnosis codes that have been submitted do not meet risk adjustment submission requirements, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible.”²

HCCs beyond Medicare

The CMS-HCC Model is just one example of HCCs being used. Examples of different ways HCCs are being used includes the following:

• The CMS-RxHCC Model is used separately to address Medicare Part D (Medicare prescription drug coverage),
• The Department of Health and Human Services maintains the HHS-HCC Model to address commercial payer populations;
• Accountable Care Organizations (ACOs) participating with the Medicare Shared Savings Program (MSSP); and
• The Medicare Hospital-Value-Based Purchasing Program measure Medicare Spending per Beneficiary.

Risk-Adjustment Payment Models are an integral part of CMS’s move away from paying for volume and towards payment for quality. To accurately reflect risk, there should be no mystery as to what the physician meant in the documentation. Documentation needs to reflect all medical conditions being managed, evaluated, assessed and treated and be detailed enough so the conditions can be coded to the highest specificity.

Resources:

1. Pope G, Kautter J, Ellis R, Ash A, Ayanian J, Iezzoni L, Igber M, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing 2004; 25:119-141. Accessed August 31, 2017 at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04Summerpg119.pdf
2. Medicare Managed Care Manual, Chapter 7 – Risk Adjustment Accessed August 31, 2017 at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c07.pdf

There are times in life when your first attempt at something is just not good enough.  Throughout life, you may often be told to try again to get it right:

• As a teenager, you cleaned your room. Your mother took one look and said, “Not good enough – do it again.”
• You turned in a school term paper and the teacher promptly returns it with lots of red writing that points out errors, offers suggestions and says “try again.”
• Your boss tells you the proposal you submitted is not exactly what she wanted and requests you make modifications and try again.

Such constructive criticism may make you mad, embarrassed, or simply thankful for a second chance.  However you feel, you must get to work and try again.  It happens to everyone.

Case in point, it happened in February of this year to CMS, specifically to the Secretary of Health and Human Services.  The Court told the Secretary to try again in regards to the Educational Campaign for the Jimmo settlement. 

First a review of the Jimmo Settlement – in 2011, a class action suit was filed against the Secretary of HHS, Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors (MACs) were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits).  In other words, MACs were denying claims for skilled care because there was no expectation the patient could improve. The argument was that Medicare should cover these services because the beneficiary did require a covered level of skilled care in order to prevent or slow further deterioration in his or her clinical condition. The Court agreed.  Medicare also agreed such services should be covered, but claimed that had always been their policy.  They denied ever having an “Improvement Standard” rule-of-thumb.  They further stated Medicare policy had long recognized skilled care may be required in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function.

To promote better understanding and application of their existing policies concerning maintenance care, Medicare agreed to clarify that “when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.”  To accomplish this, CMS agreed to:

• Revise the relevant program manuals used by Medicare contractors to reinforce the intent of the policy. Specifically, coverage of therapy “...does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”
• Provide an educational campaign for contractors, adjudicators, and providers and suppliers. Education efforts would include written materials, such as Program Transmittals, MLN Matters articles, updated 1-800 MEDICARE script, and national conference calls to communicate the policy clarifications and answer questions.
• Establish accountability measures such as random reviews to determine trends and identify problems, and review of individual claims determinations that may not have been made in accordance with the principles set forth in the settlement agreement.

Medicare stressed that this was not an expansion of coverage, but clarification of existing policies. They also used the Jimmo settlement revisions to introduce additional guidance on documentation requirements.

“Care must be taken to assure that documentation justifies the necessity of the skilled services provided. Justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that:

• In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
• In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers.”

CMS revised the manuals.  The revisions can be seen as red text in the attachments to Transmittal 179 (CR8458) updating chapters of the Medicare Benefit Policy manual regarding Inpatient Rehab facilities, Home Health services, Skilled Nursing Facilities, and Outpatient Rehabilitative Therapy services (physical therapy, occupational therapy and speech language pathology services).

They also provided some education, but alas, it was not good enough.  In a second suit brought in 2016 (Jimmo v. Burwell), the Court found that CMS (the Secretary) “failed to fulfill the letter and spirit of the Settlement Agreement with respect to at least one essential component of the Educational Campaign.…(S)ome of the information provided by the Secretary in the Educational Campaign was inaccurate, nonresponsive, and failed to reflect the maintenance coverage standard.”

In a February 2017 ruling, the Court mandated implementation of a Corrective Action Plan developed by the Secretary (which goes beyond the requirements of the Settlement agreement) with two required additions.  Here are some of the actions CMS is required to take by September 4, 2017:

• CMS will create a webpage on its website dedicated to the Jimmo The webpage will include:
• A message at the top of the webpage summarizing the clarifications to Medicare policy made pursuant to the settlement,
• A statement from CMS disavowing the application of the so-called "Improvement Standard" as improper under Medicare policy for the SNF, HH, and OPT benefits, while making clear that CMS has consistently denied the existence of such an "Improvement Standard."
• Access to public documents related to the settlement,
• Directions for providers and suppliers to the appropriate MAC for questions regarding individual claims,
• A set of Frequently Asked Questions (FAQs) regarding the policy clarification resulting from the Jimmo settlement,
• Messages notifying providers, adjudicators, contractors, and other stakeholder of the webpage and including the disavowal statement, and
• Letters to the MACs and Medicare Advantage Organizations (MAOs) directing them to conduct, within a specified timeframe, additional training on the Jimmo manual clarifications with training materials provided by CMS.

The first “additional requirement” of the Court agreement is a prescribed “Corrective Statement” adopted by the Court to be included on the Jimmo webpage, in the FAQs, and in the written materials and oral statements the Secretary has agreed to disseminate as part of her corrective action plan.  The second is that CMS shall hold a national call in which the Corrective Statement is orally disseminated.  To alleviate any confusion about the purpose of the call, the call notice must state, “This call will include corrective action mandated by the court overseeing the Jimmo settlement, clarifying the rejection of an improvement standard and explaining the maintenance coverage standard now included in the Medicare Beneficiary Policy Manual."

In plain language, what does this mean for therapy providers? 

1. It means they can provide therapy services to Medicare patients who do not have the potential to improve, but need skilled care to prevent further decline in function.
2. The term “skilled” is key; these services could not safely and effectively be provided by non-skilled personnel.
3. Documentation must support the need for skilled care and that the therapy is expected to prevent or slow further deterioration in the patient’s condition.
4. As with all therapy, the patient should benefit from the therapy as expected in established goals. If the goals are to slow further decline, documentation should support that the therapy is accomplishing that goal.
5. Therapy caps and the therapy threshold still apply to these services. Medically necessary services beyond the cap and threshold can still be provided, but may be reviewed by Medicare to ensure it was indeed medically necessary.

So bottom line for therapists – be reasonable with therapy duration and document thoroughly.

For inpatient hospital providers, this “maintenance therapy” standard could affect the need for care in post-acute care settings such as IRF, SNF, or HH care.

The new Jimmo Settlement webpage  was made live a couple of weeks ago and a notice was published in the August 24, 2017 MLN Connects publication both including the required “Corrective Statement.”  CMS appears to be off to a good start on their re-try.  Glad it wasn’t my term paper.

For over a year now, MMP has included updates to CMS transmittals and other CMS news related to acute-care hospitals as a standing article in our Wednesday@One newsletter. Do your eyes sometimes glaze over as you scan titles, numbers, dates, links, etc. or do you hear the adult-speak from the Peanuts cartoons (warnk, warnk, warnk)?  I know I do, so beginning this month, we are presenting this information in a different format. We will present a single straight-forward short description of the topic of the transmittal or other update.  Then if you want to know more, we provide the link to the MLN Article or other applicable document. We hope you find this new format easier to read and a better direction on what you need to know. We welcome your feed-back on our new format.

Updated Part B Drug Pricing Files

Quarterly updates to the ASP Medicare Part B Drug Pricing files.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10187.pdf

New Waived Tests

New waived laboratory tests approved by the FDA for performance in a waived laboratory.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10198.pdf

NPI for CWF Provider Queries

Beginning January 2018, the CWF Provider Queries will only accept NPIs as Valid Provider Numbers.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10098.pdf

Correction to Transfer Payment for MS-DRG 385

CMS is correcting the FISS IPPS Pricer for correct calculation of transfer payments for DRB 385.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10145.pdf

2018 ICD-10-CM POA Exempt Codes Available

The 2018 ICD-10-CM Present on Admission (POA) Exempt Codes are posted on the 2018 ICD-10-CM and GEMs webpage.

Updated Editing of Always Therapy Services

Revised editing of “always therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10176.pdf

NCD 20.8.4 for Leadless Pacemakers

Effective January 1, 2018, Medicare will cover leadless pacemakers when provided in a CMS-approved study.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10117.pdf

Provider-Based Determination

Beginning November 6, 2017, MACs are required to use a uniform electronic Provider-Based (PB) checklist to perform uniform reviews of provider-based applications.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10095.pdf

HCPCS Codes Used for SNF CB Enforcement

Quarterly (October 1, 2017) update to the list of HCPCS codes that are subject to the Consolidated Billing provision of the SNF Prospective Payment System.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10163.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2018

Updates to the Medicare Claims Processing Manual based on the IPF PPS final rule for FY 2018 (October 1, 2017 – September 30, 2018)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10214.pdf

Quarterly Influenza Virus Vaccine Code Update – January 2018

Quarterly update to flu vaccine codes. Effective January 2018, there is one new influenza virus vaccine code: 90756

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10196.pdf

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

Periodic updates of claim processing edits based on ICD-10 coding for NCDs.  Watch these carefully as they may affect which ICD-10 codes support medical necessity for the involved services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10184.pdf

ICD-10 GEMS for 2018 Available

The 2018 General Equivalence Mappings (GEMs) are available:

• Diagnosis: 2018 ICD-10-CM and GEMs webpage
• Procedures: 2018 ICD-10-PCS and GEMs webpage

This is the last year that the GEMs will be produced. The 2018 ICD-10-CM Guidelines and Conversion Table will be posted once the Centers for Disease Control and Prevention finalizes them.

Inpatient Prospective Payment System (IPPS) Final Rule

The IPPS final rule was published in the Federal Register on Monday, August 14, 2017. The rule finalizes 2018 payment and policy updates for Medicare hospital admissions.

https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf

ICD-10-CM Official Guidelines for Coding and Reporting

National Center for Health Statistics (NCHS) published new coding and reporting guidelines for using ICD-10 for fiscal year 2018.

https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

Credentials of Reviewers

This transmittal instructs Medicare reviewers (MACs, CERT, RACs, and ZPICs) to ensure complex reviews for coverage determinations are performed by Registered Nurses (RNs), therapists or physicians.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R737PI.pdf

Medicare Parts A & B Appeals Process Booklet

A new MLN booklet (June 2017) describes the appeals process, including the latest changes to the appeals process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2017-2018 Season

Provides the Medicare Part B payment allowances for influenza vaccines for August 1, 2017-July 31, 2018.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10224.pdf

Claim Status Category and Claim Status Codes Update

Updates, as needed, the Claim Status and Claim Status Category Codes for electronically submitted health care claims status requests and responses to explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10132.pdf

Enforcement of the Partial Hospitalization Program (PHP) 20 Hours per Week Billing Requirement - Rescinded

MLN Matters Article SE1307 was rescinded on August 18, 2017.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1607.pdf

Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program – Revision

Revision on August 23, 2017 about system changes to identify the QMB status and exemption from Medicare cost sharing, ways to promote compliance with QMB billing rules, and reminder on Medicare bad debt.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf

Proposed Rule- Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P)

Proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model.

https://www.federalregister.gov/documents/2017/08/17/2017-17446/medicare-program-cancellation-of-advancing-care-coordination-through-episode-payment-and-cardiac

Provider Error Rate Formula

Instructs Medicare Administrative Contractors (MACs) to include claims denied due to no response to additional documentation requests (ADRs) when calculating the provider error rate.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R738PI.pdf

It’s hard to believe that school is back in session and fall is just around the corner. Here in the Deep South, fans celebrate the return of high school football on Friday night and SEC football on Saturday. Whether you are on a team or a supportive spectator, to truly enjoy the game, you need to have an understanding of the game rules.

This is also the time of year when the IPPS Final Rule and ICD-10-CM Official Guidelines for Coding and Reporting are released for the coming Fiscal Year (FY). For Professional Coders and CDI Specialists, to accurately reflect the severity of illness and resource consumption for your patient population, you need to have an understanding of the changes. This week we focus on highlights from the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting. 

NARRATIVE Changes

Narrative changes within the Guidelines appear in bold text.

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

In the 2017 Guidelines update, guidance was changed to include that “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. New in 2018 this guidance goes on to include the following: “or when another guidelines exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).  For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”

“Code also” note

“A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer-Stages, Coma Scale, and NIH Stroke Scale

Prior to ICD-10 there was no way to capture the National Institutes of Health Stroke Scale (NIHSS). Coding the NIHSS was first included in this section of the Guidelines in 2017 and instructed that coders may code this “based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient… codes should only be reported as secondary diagnoses.”

In the FY 2018 IPPS Final Rule, CMS finalized the proposal to refine the Stroke 30-Day Mortality Rate Measure for the FY 2023 payment determination by including the National Institutes of Health (NIH) Stroke Scale.

Key Takeaway’s for Hospitals

CMS “proposed this measure now to inform hospitals that they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”

• You will need to work with your Physicians to ensure that they are measuring and recording stroke severity.
• Coders will need to include the appropriate ICD-10 code from the Physician’s documented NIH Stroke Scale score.
• CMS clarified in the FY 2018 IPPS Final Rule that “The intent of the risk adjustment for stroke severity is to account for patients’ clinical status at the time they are admitted to the hospital. Therefore, the refined Stroke 30-Day Morality Rate measure would utilize only the initial NIH Stroke Scale score, which is administered upon admission.”
• Advice on the subcategory to report the NIH Stroke Scale scores can be found in Coding Clinic 2016, 4th Quarter, page 61.

In addition to narrative changes, it is essential for the Professional Coder and/or CDI Specialist to pay close attention to when there is guidance to query the provider. The following table details when a query is advised.  

This article provides an overview, be aware that there are several additions to the Chapter-Specific Coding Guidelines (i.e., patient admission/encounter for the insertion of implantation of radioactive elements, diabetes mellitus, blindness, pulmonary hypertension, acute myocardial infarction (AMI) and non-pressure chronic ulcers). Reading the Guidelines is a must for Coding and CDI Professionals as you prepare for the rule changes to the “game” with the start of the 2018 IPPS Fiscal Year on October 1.