Knowledge Base - Full Library

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.

In today’s busy world, calendars and notes help us keep track of all our appointments and to-do’s. But sometimes, I have too many calendars – a hand-written calendar on my refrigerator so I see it daily, an Outlook calendar at work and a calendar on my smart phone. I have to remember to synchronize my various calendars so I am not relying on an incomplete listing. This is a problem of information in too many places – similar to issues that sometimes occur with Medicare’s National Correct Coding Initiative (NCCI or CCI). Is the information in an edit table, the policy manual, or both?

If you are involved in healthcare coding, billing or compliance you best be aware of Medicare’s CCI edits. According to the NCCI webpage, “The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.” The NCCI information also applies to Medicaid claims and some other government and commercial insurances also follow some or all of these “correct coding” principles.

There are multiple parts to CMS’s National Correct Coding Initiative – three different types of edits and a policy manual.

Procedure-to-procedure (PTP) Edits

Originally labeled as “comprehensive/component” and “mutually exclusive” code pairs, these have been consolidated into the Column One/Column Two Correct Coding edit file. PTP edits prevent inappropriate payment of services that should not be reported together. There is a PTP file for practitioners and another for hospitals.

Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the column one code is eligible for payment but the column two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

Medically Unlikely Edits (MUEs)

CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only. The latter group of MUE values should not be released since CMS does not publish them. There are MUE files for practitioners, facilities, and DME.

A few years ago, CMS added MUE Adjudication Indicators (MAIs) to the MUE table to indicate whether an MUE was a line item edit (MAI of 1), an absolute date of service edit (MAI of 2), or an appealable date of service edit (MAI of 3).

Add-On Code Edits

Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment. See CR7501 for more information.

National Correct Coding Initiative Policy Manual for Medicare Services

The Policy Manual is a reference tool for correct coding and explains the rationale for NCCI edits. Chapter 1 addresses general coding principles, issues, and policies. Subsequent chapters correspond respectively to each CPT Manual section, Level 2 HCPCS codes and Category III CPT codes. These chapters further address the principles, issues, and policies dealing with specific groups of HCPCS/CPT codes.

Providers should carefully review the chapters of the manual that pertain to the code ranges they most often bill. These chapters include detailed information about correct coding and use of NCCI-associated modifiers for separately reportable services, and much more.

Source: MLN Product - How To Use the NCCI Tools

Providers must utilize all of the above tables and manual to ensure they are billing and coding correctly. Sometimes information is in a table or the manual but not in both. For example, there are no CCI edits between a thoracentesis (CPT codes 32554 / 32555) and a chest x-ray. But, in the Radiology chapter of the CCI policy, they include CPT codes 32554 and 32555 as examples of procedures where a chest x-ray should “not” be reported separately in the scenario described below as “usually performed”.

2016 CCI Policy Manual / chapter 9 / page 6: “When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.”

Providers may want to create an internal billing edit to identify claims with CPT codes 32554 / 32555 billed on the same date of service as a chest x-ray in order to comply with the CCI Policy Manual guidance.

So remember to check all your calendars to keep yourself on schedule and check all the NCCI resources to keep your billing and coding on point.

I regret the paper pages of newspapers and books are becoming obsolete in today’s digital age. There was some comfort in holding the pages, smelling the print, and hearing the sound of crinkling paper as you read. Newsprint was important – movies set in the 20’s and 30’s often show the newsboy running through the streets shouting, “Special edition! Special edition! Read all about it!” Now we receive most of our “printed” news on-line or on our smart phones. But thanks to Medicare there are still “special editions.” Most of CMS’s MLN Matters Articles are based on recent transmittals (change request) – these are named based on the change request number beginning with the alpha characters “MM.” CMS also publishes Special Edition (SE) articles, generally to clarify existing regulations.

Two recent SE articles address prolonged drug infusions using an external pump and coverage of substance abuse services.

Prolonged Drug Infusions Via External Pump

On April 25, 2016, CMS released MLN Matters Article SE1609 clarifying Medicare’s policy for prolonged drug and biological infusions started incident to a physician's service using an external pump. There are times when hospitals or physicians’ offices may start an infusion using an external pump in the hospital outpatient or office setting of a drug they purchased, then send the patient home for a portion of the infusion and have the patient return to the clinic/office at the end of the infusion.   In these situations, the drug or biological and the drug/biological administration are billable to the Medicare Administrative Contractor (MAC). Also, payment for the external pump is included in the drug administration payment. The external pump may not be billed separately as Durable Medical Equipment to the DME MAC.   The MAC may direct use of a CPT or HCPCS code for the drug administration service that also accounts for the cost of external pump. This may be an unlisted code if no specific CPT or HCPCS code exists.

Medicare Coverage of Substance Abuse Services

There is not a distinct benefit category for substance abuse services but Medicare will cover medically necessary services for substance abuse as explained in the April 28th MLN Matters Article SE1604. The almost epidemic national opioid abuse make these services extremely important for Medicare beneficiaries. Medicare covers:

• Inpatient Treatment
• Medically necessary inpatient services, associated professional services, and medications (bundled into the inpatient payment).
• Outpatient Treatment
• Professional services such as counseling by an enrolled licensed clinical social worker, psychologist, or psychiatrist.
• Incident-to services of auxiliary personnel in certain settings (such as an outpatient hospital)
• Medications used in an outpatient setting that are not usually self-administered may be covered under Part B if they meet all Part B requirements.
• Note that substance abuse treatment facilities are not recognized by Medicare as an independent provider type. There is no integrated payment for the bundle of services these providers provide (either directly, or incident to a physician’s service).
• Partial Hospitalization Programs (PHP)
• Available in hospital outpatient department or Medicare certified Community Mental Health Center (CMHCs)
• Includes psychotherapy, occupational therapy, some activity therapies, family counseling, patient education/training, diagnostic services, and covered Part B medications.
• Supplier Services
• Suppliers such as physicians (medical doctor or doctor of osteopathy), clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives may furnish substance abuse treatment services providing the services are reasonable and necessary and fall under their State scope of practice.
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
• Early intervention strategies for individuals with nondependent substance use prior to the need for more extensive or specialized treatment
• Easily used in primary care settings
• Consists of 1) Structured Assessment, 2) Brief Intervention, and 3) Referral to Treatment
• See Medicare's fact sheet, “Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services”
• Drugs Used to Treat Opioid Dependence
• Part D drugs medically necessary for the treatment of opioid dependence
• Medicare also covers laboratory drug testing services when necessary

Providers need to watch for Medicare MLN Matters Special Edition articles in order to stay informed about the latest changes to CMS Programs. Read all about it!

Q:

How should hospitals handle inpatient billing when both covered and non-covered procedures are performed during a hospital inpatient admission? For example, an inpatient had a prostatectomy due to prostate cancer but a vasectomy was also performed during the surgery. Per a Medicare National Coverage Determination, vasectomies are non-covered by Medicare.

A:

Medicare instructs hospitals to remove the procedure code and related charges for the non-covered procedure from the inpatient claim.

Per the Medicare Claims Processing Manual, Chapter 1, section 60.2.1:

“…when a non-covered procedure is provided during an inpatient stay where a covered procedure is also performed, the claims processing system is unable to decipher what procedure code(s) is/are non-covered, so as to not consider such procedure(s) for payment (more specifically, to ignore non-covered procedures when grouping to the MS-DRG). Therefore, effective for inpatient discharges April 1, 2010, hospitals must only seek payment for covered services by removing non-covered procedure codes and related charges from the payable Type of Bill (TOB) 11X.”

If the hospital needs to submit a claim for the non-covered service to receive a denial, that procedure code and related charges should be reported on a no-pay claim (Type of Bill 11x) with the same From and Through Date as the covered 11x claim.

Dilemma:

Our hospital received several denials in the past from outside auditors for incorrectly assigning, Hemorrhagic Disorder due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors (286.5-), when a patient was admitted with a hemorrhage due to an anticoagulant. What is the ICD-10-CM code to show hemorrhage due to an anticoagulant that was taken as prescribed?

 

Solution:

ICD-10-CM has a specific code for hemorrhage due to an anticoagulant which is, Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants, (D68.32). This code would be assigned in addition to a code for the site of the hemorrhage along with a code for the adverse effect of the anticoagulant.

Example:

K26.4  Duodenal Ulcer with Hemorrhage

D68.32  Hemorrhagic Disorder due to Extrinsic Circulating Anticoagulants

T45.515  Adverse Effect of Anticoagulants

Code 286.5- was incorrect because of the word Intrinsic in the code title. Intrinsic means, belonging naturally or situated within an organ. An anticoagulant such as Coumadin, as we know, is not naturally found in the blood system. Code 286.5- was to be used to identify rare blood disorders, such as Acquired Hemophilia and Hemorrhage Disorder due to Systemic Lupus Erythematosus and not for adverse effects of a medication.

Information Source(s):

• Coding Clinic, First Quarter 2016, page 14
• Coding Clinic, Third Quarter 1992, page 15

Senseless massacres and suicides of prominent people in recent years have drawn attention to mental health issues in America. Some in our elderly population face a diagnosis of Alzheimer’s or other forms of dementia as they age. Our youth and all ages are at risk of life-altering drug and alcohol addictions. According to a Washington Post article from 2012, although the United States spends over $113 billion on mental health treatment, that is still not enough to serve all those who need it. Costs, limited access, and attitudes about mental health remain big barriers to treatment. One positive cited by the article is that recent federal legislation requires more expansive insurance coverage for mental health services.

Medicare covers a continuum of mental health services from inpatient hospital services, to partial hospitalization, to outpatient services. The coverage requirements of psychiatric Partial Hospitalization Program services are described in the Medicare Benefits Policy Manual, Chapter 6, section 70.3.

What a PHP Is

“Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.”

What a PHP Is Not

A PHP is not a program that is:

• Comprised primarily of diversionary activity, social, or recreational therapy
• A psychosocial program which provides only a structured environment, socialization, and/or vocational rehabilitation
• Only for monitoring the management of medication for patients whose psychiatric condition is otherwise stable

Patients eligible for a PHP program are patients trying to avoid a new or continued hospitalization for psychiatric services – hence, the need for the acute, intense, structured combination of services provided by a PHP. Patients participating in a PHP program must:

• Be under the care of a physician who certifies the need for PHP
• Have a plan of care that requires at least 20 hours a week of therapeutic services
• Have a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning (generally acute in nature)
• Have an adequate support system to sustain/maintain themselves outside the PHP and must not be an imminent danger to themselves or others
• Be willing and able to participate with active treatment of their mental disorder and tolerate the intensity of a PHP

Medicare recently released a MLN Matters Special Education (SE) Article SE1607 describing edits being implemented to enforce the requirement for a minimum of 20 hours per week of therapeutic services for patients in a Partial Hospitalization Program (PHP). There are three edits that will become effective July 2016:

• IOCE Edit 95 (FISS Reason Code W7095) - Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service
• IOCE Edit 96 (FISS Reason Code W7096) - Partial hospitalization interim claim from and through dates must span more than 4 days
• IOCE Edit 97 (FISS Reason Code W7097) - Partial hospitalization services are required to be billed weekly

Initially all three edits will cause the claim to “return to provider” (RTP) for correction, but beginning with the October 2016 IOCE updates, edit 95 (insufficient hours) will cause the claim to deny.

In addition to the amount of treatment, documentation requirements for a PHP admission include an initial physician certification that identifies the patient’s diagnosis, psychiatric need, and that the patient would require inpatient treatment if not for the PHP. Recertifications, required at day 18 and at least every 30 days after that, describe the patient’s response to treatment, reason for continued need for PHP and goals to facilitate discharge. Patients in a PHP must be under a treatment plan that:

• Is prescribed and signed by a physician,
• Identifies treatment goals that directly address the presenting symptoms and are the basis for evaluation of patient response,
• Describes a coordination of services including a multidisciplinary team approach to patient care, and
• Is individualized and structured to meet the particular needs of the patient.

Documentation must also include progress notes showing the services were provided, the nature of the treatment service, the patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.

Hopefully expanded mental health coverage, growing awareness of mental health issues, and programs such as the partial hospitalization programs will make a positive impact on this country’s mental health. It is an issue that could affect any of us, directly or indirectly. It is a cry for help.

A medical claim is a form of communication with a healthcare payer that request payment and describes the services provided to a patient, plus other pertinent information. Medicare and other payers have detailed specifications about the types of information that must be included on a claim. Modifiers are often used on claims to explain the special circumstances of a particular item or service. In honor of National Occupational Therapy (OT) month, we examine some modifiers that are often required for rehabilitative services.

The American Occupational Therapy Association website states that occupational therapists and assistants are part of a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities. In addition to clinical responsibilities, including complete and thorough documentation of their medical services, OTs and other rehabilitative therapists such as physical therapists (PT) and speech language pathologists (SLP) are required to understand some aspects of Medicare therapy billing. For example, therapists need to understand the proper use of some billing modifiers.

Therapy Discipline Modifiers

Services for Medicare patients provided by rehabilitative therapists must be appended with a modifier that describes the therapy discipline. Modifiers are used to identify therapy services whether or not financial limitations (therapy caps) are in effect. When limitations are in effect, Medicare tracks the financial limitation based on the presence of therapy modifiers. The therapy modifiers are:

• GN – Services delivered under an outpatient speech-language pathology plan of care;
• GO - Services delivered under an outpatient occupational therapy plan of care; or,
• GP - Services delivered under an outpatient physical therapy plan of care.

Modifiers GN, GO, and GP refer only to services provided under plans of care for rehabilitative therapy services. They should never be used with codes that are not on the list of applicable therapy services. For institutional claims, the modifiers must correlate with the respective revenue code (PT – modifier GP with revenue code 42x; OT – modifier GO with revenue code 43x; and SLP – modifier GN with revenue code 44x).

Modifier 59

Modifier 59 is appended to a CPT/HCPCS procedure code to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

For PT, OT and SLP services, providers should not report more than one physical medicine and rehabilitation therapy service for the same fifteen minute time period with the exception of “supervised modality” codes. Some National Correct Coding Initiative (NCCI) procedure-to-procedure edits pair a “timed” therapy CPT code with another “timed” CPT code or a non-timed CPT code as services that would not normally be reported together. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter. When modifier 59 is used, documentation in the therapy record must support that the services were performed at separate and distinct time periods.

Modifier KX

Medicare sets financial limitations on the amount of therapy services a beneficiary may receive in a calendar year. For 2016 the therapy cap amounts are $1,960 for physical therapy (PT) and speech-language pathology (SLP) services combined and $1,960 for occupational therapy (OT) services. Medicare allows an exception when the patient’s condition requires continued skilled therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Documentation in the therapy record must justify a medically necessary need for additional therapy beyond the therapy cap.

When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider must add a KX modifier to the therapy HCPCS code subject to the cap limits. By appending the KX modifier, the provider is attesting that the services billed:

• Are reasonable and necessary services that require the skills of a therapist; and
• Are justified by appropriate documentation in the medical record,; and
• Qualify for an exception using the automatic process exception.

When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be reported.

Be sure that services are medically necessary and that documentation is sufficiently detailed to support the use of the modifier. Medicare is aware of the potential for misuse of the KX modifier. Note that:

• Routine use of the KX modifier for all patients with certain conditions will likely show up on data analysis as aberrant and invite inquiry.
• Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive.
• If the use of the KX modifier is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim.

For more information on the use of the KX modifier, see the Medicare Claims Processing Manual, Chapter 5 , Section 10.3.

Functional Limitation Modifiers

In 2013, Medicare began requiring the reporting of rehabilitative therapy functional limitation information on claims. Claims for outpatient therapy services are required to include non-payable G-codes and modifiers, which describe a beneficiary’s functional limitation and severity level, at specified intervals during the therapy episode of care. The severity modifier reflects the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge.

Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals. For more information on functional limitation codes and modifiers, see the Medicare Benefit Policy Manual, Chapter 15, Section 220.4.

When communicating with Medicare and other payers, providers must know the specifics of the service and claim requirements. Proper use of modifiers to provide additional information about the services rendered is necessary for clear communication.

If you have ever audited electronic healthcare medical records, you have likely seen patients that are the same one day as another – exactly the same – no, I mean EXACTLY the same - the exact same wording of the patient’s condition, patient statements, treatment plan and/or other documentation elements. This is the result of “copy and paste” within an electronic medical record.

There are benefits and risks associated with the use of “copy and paste” within EHRs as described by the Partnership for Health IT Patient Safety. Benefits include time savings and a more efficient way to capture complex information which may result in improved tracking of multiple problems and improved continuity of care. It can also reduce transcription errors and omissions of important information. However, the outdated, inaccurate, irrelevant, and misleading information that can result from “copy and paste” erodes confidence in the record, may have medico-legal implications, and can result in more queries and work to determine if the information is correct. Charts and notes can become overwhelmingly long and effective communication is compromised because important findings and problems are intertwined with normal patient information, making it difficult to decipher what is important or current.

In response to safety concerns, the Partnership for Health IT Patient Safety developed a Toolkit for the Safe Use of Copy and Paste. Although the focus of the toolkit is patient safety, other concerns associated with “copy and paste” include billing and compliance issues and potential malpractice implications.

The recommendations provided in the toolkit and listed below are not intended to impair usability of EHR systems or impede workflow. Their goal is to allow providers the opportunity to evaluate the best ways to see the information that is being reused and to take steps toward the safe use of “copy and paste.”

Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

• Allows verification of accuracy and facilitates review for edits
• Potential Actions: Create policies and procedures; block certain areas of documentation from copying; have a different appearance for copied material (italics, different color, etc.)

Recommendation B: Ensure that the provenance of copy and paste material is readily available.

• Helps verify that the information is appropriate and accurate and increases the potential to defend the record and achieve billing compliance
• Potential Actions: Identify original source of information and track changes and authors

Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.

• Helps providers understand their liability and the potential patient safety and compliance risks of copy and paste
• Potential Actions: Provide regular training and feedback; identify methods to verify current and correct information

Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.

• Ensures the integrity of the clinical record, the quality and safety of care rendered, and compliance with state and federal regulations
• Potential Actions: Create auditing policy; perform regular audits and report findings and provide feedback

I personally think this toolkit offers excellent recommendations for the safe use of a “copy and paste” function. As explained in the Toolkit, some of the recommendations will take time to implement, particularly those that require technology changes by developers and workflow changes for providers. However, there are some steps that hospitals could implement now to improve the use “copy and paste.” A realization of the associated risks of “copy and paste” is one first step.

Dilemma:

A patient was recently admitted to an acute care hospital diagnosed with an infection from a vascular access device.  The patient was then discharged from the acute care hospital and admitted to a long-term acute care hospital (LTACH) to continue antibiotics for the infection.  What 7th character would be assigned for the principal diagnosis to the LTACH, initial encounter (A) or subsequent encounter (D)?

Solution:
The principal diagnosis for the LTACH admission is (T82.7XXA) for Infection/Inflammatory Reaction due to Other Cardiac/Vascular Device, Initial Encounter.  The patient is still receiving active treatment for the infection of the vascular device so the 7th character is an A.  Examples of active treatment are:  surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. 
Information Source(s):

• ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 19,  Application of 7th Characters
• 1Q, Coding Clinic, 2015, under the heading, Applying the 7th Character for Continued Treatment in Other Care Settings

When I was first introduced to the concept of Case Mix Index (CMI) in the late 90’s, documentation in the medical record was handwritten. And I can remember understanding that CMI depends on the physician’s pen.

Flash forward to 2016 and the electronic health record. It is now fair to say that it all begins with the click of a button. I am not sure if it is due to the fact that I wrote my college term papers on a Brother Typewriter or from auditing electronic records remotely, the “click of the button,” has not improved the telling of the patient’s story which is at the heart of what needs to happen.

In fact, it seems to me that it is harder than ever to find proof that your “patients are sicker.” Understanding CMI is a good way to answer the question of “how do I know my patients are sicker.” However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:

In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.  

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.  

Assigning a DRG:

Principal Diagnosis:

The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):

These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication.  When the DRG system transitioned to MS-DRGs the comorbidities and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities (CC) are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting.
• For example: A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications (CC) are those conditions that occur during the inpatient hospitalization.
  For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions. 
• Major Comorbidities and Complications (MCCs): DRGs with MCCs reflect the highest level of severity. For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.
  

As many times as we have heard it said it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record.   Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.  

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated that “we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG.

Case Mix Index (CMI) is defined by CMS as representing “the average diagnosis-related group (DRG) relative weight for the hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.”

GPA Example:

(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA

30 ÷ 10 = 3.0 GPA

Case Mix Index Example A:

Formula for Case Mix Index: Sum of Relative Weights ÷ Total Number of DRGs Coded = CMIExample A CMI: 3.7688 ÷ 4 = 0.9422 Case Mix IndexExample B: The Potential Impact Physician Queries can have on DRG Assignment

Example B CMI: 4.5823 ÷ 4 = 1.1456 Case Mix Index

“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.” (Source: Optum 360 2016 DRG Expert)

Challenges for Hospitals:

Understanding what can make your hospitals CMI fluctuate?

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.
• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.  
• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

In 2013, the American Health Information Management Association (AHIMA) published the practice brief Guidelines for Achieving a Compliant Query Practice. The AHIMA brief states that “A query is a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

ICD-10-CM/PCS and CMI

We are now six months post ICD-10-CM/PCS implementation. Has this transition impacted CMI? To answer this question I analyzed paid claims data from our sister company RealTime Medicare Data (RTMD). The following tables compare CMI data from October through December of 2014 compared to 2015.

Figure 1: Alabama CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 2: South Carolina CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 3: Texas CMI Compare Pre and Post ICD-10-CM/PCS Implementation

So far, it appears that the transition has not had a negative impact on CMI but it is still early and MMP, Inc. will continue to keep an eye on the trends and report key findings to our readers. In the meantime, remember that a successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.