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Hospitals claims are often denied by Medicare reviewers while the associated physicians’ claims receive payment. Hospitals and physicians strive for more complete and thorough documentation to prevent denials but physicians’ claims may never be evaluated based on the documentation even when there is a denial of the hospital claim. Based on a recent CMS manual update this may change and Medicare may be trying to kill two birds with one stone.

CMS has now opened the door for a direct effect on physician claims when hospital claims are denied. CMS had previously issued a transmittal for the denial of “related” claims, but that transmittal was rescinded. On August 8th, CMS released Transmittal 534, CR 8802 addressing claims that are related. This transmittal updates the Medicare Program Integrity manual to allow Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) the discretion to deny other “related” claims submitted before or after the claim in question. The transmittal is effective September 8, 2014.

A claim is considered “related” if documentation associated with that claim can be used to validate another claim. The MACs and ZPICs must obtain CMS approval prior to initiating requested “related” claim(s) review. Also, MACs must post the intent to conduct “related” claims review(s) to the website within one month of initiation. Recovery Auditors (RAs or RACs) shall utilize the review approval process outlined in their Statement of Work when performing reviews of “related” claims.

The transmittal only provides one approved example of claims that may be denied as “related”, but reserves the option for future approved “related” claim review situations. The example appears to address one of the most common denials for hospitals – the situation in which an inpatient admission is denied for Part A payment (inpatient setting not medically necessary). The example also offers two options on addressing the physician’s payment in this situation– 1) the physician’s Part B payment could be downgraded from inpatient evaluation and management (E&M) services to outpatient E&M services or 2) the physician services could be denied all together if the documentation does not support the medical necessity of the procedure performed.

The exact wording of the approved example is:

• “The MAC performs post-payment review/recoupment of the admitting physician's and /or surgeon's Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record and if the physician service was reasonable and necessary the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment will occur for the performing physician’s Part B service.”

 

It will be interesting to see how this plays out in reality, with the requirements for CMS approval, possible time delays resulting from the approval/notification process, and only one “related” scenario for now. But hospitals and physicians alike need to watch out for those stones.

The FY 2015 Inpatient Prospective Payment System (IPPS) Final Rule did little to nothing to alleviate the 2-Midnight Rule or Physician Certification requirements for hospitals. As we continue our review of the Final Rule, this week’s article focuses on public comments regarding creating a payment policy for short inpatient hospital stays, the continued request for suggested exceptions to the 2-Midnight rule, the Probe & Educate Program and Physician Certification changes in the IPPS Final Rule as well a proposed change in the FY 2015 Outpatient Prospective Payment System (OPPS) Proposed Rule.

Medicare Payment for Short Inpatient Hospital Stays

In the FY 2015 IPPS Proposed Rule CMS requested public comments on a payment methodology for short inpatient hospital stays. Specifically, CMS outlined specific questions/considerations that they considered to be critical for the payment methodology.

Defining Short or Low Cost Inpatient Hospital Stays

Question

How to define short inpatient hospital stays for determining an appropriate Medicare payment?

• Should a short inpatient hospital stay be one where the average mean length of stay (AMLOS) is short for the MS-DRG?
  Example: MS-DRG 313 (Chest Pain)
• In FY 2014 the AMLOS is 2.1 days with a national average payment of $3,217.87
• Should a short inpatient hospital stay be an atypically short or low cost case relative to other cases within the same MS-DRG
  Example: MS-DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ hours with MCC)
• In FY 2014 the AMLOS is 6.7 days with a national average payment of $9,949.52

Considerations

CMS believes that if a payment methodology was adopted that paid for atypically low-cost or short stay cases relative to the average case in the same MS-DRG (i.e. MS-DRG 871) this policy would be less likely to apply to MS-DRGs that are already low cost or a short stay (i.e., MS-DRG 313).

Determining Appropriate Payment for Short Inpatient Hospital Stays

Question

How is an appropriate payment determined once a short stay has been identified? “Some have suggested a per diem based payment amount, perhaps modelled on the existing transfer payment policy.”

Considerations

Again, a per diem based payment amount is more likely to impact payment for atypically short-stay or low-coast cases in an MS-DRG with a longer AMLOS. This would be less likely to impact MS-DRGs with a short AMLOS as the full IPPS payment would be made in 1 or 2 days.

Given that payment for the same case will be very different under the OPPS and IPPS dependent on whether or not the beneficiary has been formally admitted as an inpatient, pursuant to a physician order:

• When should an IPPS payment be limited to an OPPS payment amount?
• When would it be appropriate for the payment to be higher?
• If a higher payment is determined to be appropriate then how should the additional payment amount be determined?

Public Comments

Public comments received by the CMS made it apparent that for any short-stay policy there should be some general principles that the policy adheres and it should include some or all of the following:

• The policy “should provide more appropriate and adequate payment for medically necessary inpatient services that span less than 2 midnights."
• Payments should be higher than the OPPS rate but not exceed the full IPPS payment for a given MS-DRG.
• Admissions for procedures on the “inpatient only” list should be excluded from a short-stay policy.
• The policy should be budget neutral.
• “Hospitals should be eligible for all add-on payments they would otherwise receive (for example, DHS and IME), either in full or on a pro rate basis.”
• Short inpatient stays for beneficiaries should be considered inpatients and cost-sharing obligations should be calculated under Medicare Part A.
• The policy should not increase administrative burden for hospitals, physicians, or other medical providers.
• “CMS should provide clear and consistent guidance and allow adequate time for hospitals to implement the short-stay policy prior to its effective date.”
• Short stay policy considerations submitted included considering a per diem approach modeled after the existing transfer policy, creating MS-DRG weights for short-stay and nonshort-stay cases, or allowing the full MS-DRG payment for short stays in the interim while this issue is studied further.
• Other commenters indicated that to create a separate MS-DRG system for short stays undermines the MS-DRG system that “is predicated on the understanding that there will be a diversity of treatment patterns and individual patient circumstances for any given clinical condition, and that this diversity balances out – high-intensity cases are balanced by low-intensity cases.”
• MedPAC intends to explore alternative short-stay policies in their next work cycle.

At the end of the day, CMS thanked the commenters and they “look forward to continuing to actively work with stakeholders to address the complex question of how to further improve payment policy for short inpatient hospital stays.”

Suggested Exceptions to the 2-Midnight Benchmark

The CMS has identified that unforeseen circumstances such as a beneficiary’s death, transfer to another hospital, unexpected clinical improvement, election of hospice care, or leaving the hospital against medical advice (AMA) are all situations that could result in a hospital stay shorter than the two midnight expectation by the physician. In these instances, when a medical record contains an inpatient order, the physician’s clinical expectation and orders are clearly documented and support an expected medically necessary two midnight stay, “the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A.”

The CMS has also indicated that there can be exceptions to the 2-midnight benchmark and it would still be appropriate for the beneficiary to be an inpatient. Specifically, in the 2014 IPPS Final Rule the exception was provided of procedures on the OPPS inpatient only list always being appropriate as an inpatient regardless of length of stay as long as the procedure is medically necessary and performed pursuant to a physician order and formal admission.

To date, one additional exception has been added in sub-regulatory guidance. “CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, if the physician expects that the beneficiary will only require 1 midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate.”

The CMS continues to be open to suggestions regarding potential additional exceptions to the 2-midnight benchmark. Suggestions can be sent to CMS via written correspondence or email at SuggestedExceptions@cms.hhs.gov.

Medicare Administrative Contractor (MAC) Probe and Educate Program

While there were no changes made to the 2-midnight rule that was finalized in the FY 2014 IPPS Final Rule, CMS does indicate in the 2015 IPPS Final Rule that “during the summer and fall of 2014, CMS plans to evaluate the results of the “probe & educate” process (a process by which MACs are reviewing a prepayment, provider-specific probe sample of inpatient Part A claims for appropriateness of inpatient admission under the revised 2-midnight benchmark and providing provider-specific education, as necessary, to correct improper payments) and issue additional subregulatory guidance to our claim review contractors, if necessary, to ensure consistency in application of the 2-midnight policy.”

Revision of the Requirements for Physician Certification for Critical Access Hospital Inpatient Services

For Critical Access Hospitals (CAHs) to receive payment under Medicare Part A for inpatient services a physician must certify “that the individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the critical access hospital.”

The 2014 IPPS Final Rule revised the physician certification timing requirement for CAHs from being required no later than 1 day before the date on which the claim for payment for the inpatient CAH service is submitted to require that “the certification must be completed, signed, and documented in the medical record prior to discharge (78 FR 50970).”

The 2015 IPPS Final Rule reversed the 2014 ruling and finalized that “a CAH is required to complete all physician certification requirements no later than 1 day before the date on which the claim for the inpatient service is submitted.”

FY 2015 OPPS Proposed Changes to the Physician Certification

Within the July 3rd, 2014 release of the FY 2015 OPPS Proposed Rule came two proposals that have the potential to ease some of the burden created by the FY 2014 IPPS Final Rule for Inpatient hospitals.

Inpatient Order Proposed Change

“While we continue to believe that the inpatient admission order is necessary for all inpatient admissions, we are proposing to require such orders as a condition of payment based upon our general rulemaking authority under section 1871 of the Act rather than as an element of the physician certification under section 1814(a)(3) of the Act.”

Physician Certification Proposed Change

“We are proposing to change our interpretation of section 1814(a)(3) of the Act to require a physician certification only for long-stay cases and outlier cases.”

“We are proposing to revise paragraph (a) of § 424.13 to specify that ‘Medicare Part A pays for inpatient hospital services (other than inpatient psychiatric facility services) for cases that are 20 inpatient days or more, or are outlier cases under subpart F of Part 412 of this chapter, only if a physician certifies or recertifies the following:

1. The reasons for either –
2. Continued hospitalization of the patient for medical treatment or medically required diagnostic study; or
3. Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F or part 412 of this chapter).
4. The estimated time the patient will need to remain in the hospital.
5. The plans for posthospital care, if appropriate.’

If both proposals are finalized, hospitals need to be mindful of the following:

• The Inpatient Order remains a Condition of Participation (CoP) and a requirement for payment for Medicare Part A Services.
• Thorough physician documentation in the medical record (i.e. History & Physical, MD Progress Notes and Physician Orders) continues to be required to support the medical necessity for hospital care expected to span at least two midnights.
• The Inpatient Admission Order must still be signed prior to the beneficiary’s discharge. Without the inpatient order hospitals should not submit a Medicare Part A claim. In a response to a comment in the 2014 IPPS Final Rule, CMS indicated that “because the physician order is a requirement as a condition of payment, if the order is not documented in the medical record, the hospital should not submit a claim for Part A payment.”
• For Medicare beneficiaries that reach a 20 day length of stay it will be important to make sure that the Physician Progress notes on that day support the need for a continued medically necessary hospitalization and the plan of care for the beneficiary.

For more information:

• Details regarding short inpatient hospital stays, 2-midnight benchmark exceptions, and the probe and educate program can be found on pages  50146 – 50148 of the Final Rule at http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf.
• Details regarding the Physician Certification for CAHs can be found on pages 1278-1286 of the pre-published Final Rule.
• The proposed revision to the Physician Certification can be found in the Federal Register / Vol. 79, No. 134 / Monday, July 14, 2014 / Proposed Rules
• The Final Rule has a scheduled publication date of 08/22/2014 and will be available online at: http://ofr.gov/(S(pcl2zalo5cz115uiw2as4qqr))/inspection.aspx.

As we continue our review of the FY 2015 Inpatient Prospective Payment System (IPPS) Final Rule, this week’s article focuses on MS-DRG changes and the resulting changes to the Post-Acute Transfer DRGs.

MS-DRG Classification Changes in the Final Rule

Endovascular Cardiac Valve Replacement

Request

There was a request to create a new MS-DRG specific for various types of cardiac valve replacements performed by an endovascular or transcatheter technique.

CMS Data Analysis

The ICD-9-CM procedure codes (35.05, 35.06, 35.07, 35.08 and 35.09) are currently assigned to MS-DRGs 216, 217, 218, 219, 220 and 221. FY 2013 MedPar data revealed the following number of cases:

CMS established five criteria in the FY 2008 IPPS final rule (72 CFR 47169) to determine if subgroups of base MS-DRG cases should be created. In 2008 the criteria was based on average charges that was later converted to average costs. Criteria warranting a creation of a CC or MCC subgroup within a base MS-DRG must meet all of the following:

1. A reduction in variance of costs of at least 3 percent.
2. At least 5 percent of the patients in the MS-DRG fall within the CC or MCC subgroup.
3. At least 500 cases are in the CC or MCC subgroup.
4. There is at least a 20-percent difference in average costs between subgroups.
5. There is a $2000 difference in average costs between subgroups.

Data analysis supported the creation of a new base MS-DRG subdivided into two severity levels. CMS’s advisors noted that patients undergoing endovascular cardiac valve replacements are significantly different than the population undergoing an open chest cardiac valve replacement. They also noted that grouping these procedures separately “provides greater clinical cohesion for this subset of high risk patients.”

FY 2013 MedPar data for the two proposed MS-DRGs as provided in the final rule:

Final Rule

Two new MS-DRGs were created for endovascular cardiac valve replacements.

• MS-DRG 266 (Endovascular Cardiac Valve Replacement with MCC); and
• MS-DRG 267 (Endovascular Cardiac Valve Replacement without MCC).

Shoulder Replacement Procedures

Request

A request was made to change the MS-DRG assignment for the following two shoulder replacement procedure codes:

 

• 81.88 (Reverse total shoulder replacement); and
• 81.97 (Revision of joint replacement of upper extremity).

 

 

For procedure code 81.88 the request was made to reassign this procedure from MS-DRGs 483 and 484 (Major Joint/Limb Reattachment Procedure of Upper Extremities with CC/MCC and without CC/MCC respectively) to MS-DRG 483 only.

For procedure code 81.97 the request was made to reassign this procedure code from MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC, with CC, and without CC/MCC, respectively), to MS-DRG 483.

Based on the five criteria to determine if subclasses should be created for a base MS-DRG the claims data no longer supported the two severity level MS-DRGs 483 and 484. In the proposed rule CMS “proposed to collapse MS-DRGs 483 and 484 into a single MS-DRG by deleting MS-DRG 484 and revising the title of MS-DRG 483 to read “Major Joint/Limb Reattachment Procedure of Upper Extremities”.”

Final Rule

• Procedure code 81.97 will continue to be assigned to MS-DRGs 515, 516 and 517.
• MS-DRGs 483 and 484 have been collapsed into MS-DRG 483 (Major Joint/Limb Reattachment Procedure of Upper Extremities).

Back and Neck Procedures

Request

A request was made to reassign cases with a complication or comorbidity (CC) in MS-DRG 490 (Back & Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator) to MS-DRG 491 (Back & Neck Procedures Except Spinal Fusion without CC/MCC or Disc Device/Neurostimulator). The suggestion was made to create a new MS-DRG subdivided based solely on the “with MCC or Disc Device/Neurostimulator” and the “without MCC” (and no device) criteria.

CMS Data Analysis

FY 2013 MedPar data was evaluated using a three-way severity level split with the three subgroups in the following table:

Final Rule

CMS adopted the proposed new MS-DRG grouping of:

• MS-DRG 518 (Back & Neck Procedures Except Spinal Fusion with MCC or Disc Device/Neurostimulator);
• MS-DRG 519 (Back & Neck Procedure Except Spinal Fusion with CC); and
• MS-DRG 520 (Back & Neck Procedure Except Spinal Fusion without CC/MCC).

MDC 15: Newborns & Other Neonates with Conditions Originating in the Perinatal Period

Request

A request was made to evaluate the MS-DRG assignment of seven ICD-9-CM diagnosis codes in MS-DRG 794 (Neonate with Other Significant Problems). The requestor noted that the codes in question had no bearing on the neonate and do not represent a neonate with a significant problem. It was recommended that MS-DRG logic change so that the codes would not lead to assignment of MS-DRG 794.

The recommendation was to add these seven codes to the “only secondary diagnosis” list under MS-DRG 795 (Normal newborn) so the case would be assigned to MS-DRG 795 (Normal newborn).

Final Ruling

The proposal was adopted as final to reassign the following seven diagnoses to the “only secondary diagnosis list” under MS-DRG 795 (Normal newborn) so that the case would be assigned to MS-DRG 795 (Normal newborn):

• V17.0 (Family history of psychiatric condition),
• V172 (Family history of other neurological diseases),
• V17.49 (Family history of other endocrine and metabolic diseases),
• V18.0 (Family history of diabetes mellitus),
• V18.19 (Family history of other endocrine and metabolic diseases),
• V18.8 (Family history of infectious and parasitic diseases); and
• V50.3 (Ear piercing).

MS-DRG Surgical Hierarchy Changes

Background

The MS-DRG Surgical Hierarchy is “an ordering of surgical classes from most resource-intensive to least resource-intensive.” “Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the MS-DRG associated with the most resource-intensive surgical class.”

Hierarchy Changes in the Final Rule

MDC 5: Diseases and Disorders of the Circulatory System

• New MS-DRG 266 (Endovascular Cardiac Valve Replacement with MCC) and new MS-DRG 267 (Endovascular Cardiac Valve Replacement without MCC) will be sequenced above MS-DRG 222 (Cardiac Defibrillator Implant with Cardiac Catheterization with AMI/HF/Shock with MCC).

 

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

• MS-DRGs 490 and 491 (Back & Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator and without CC/MCC or Disc Device/Neurostimulator respectively) are being removed from the hierarchy.
• New MS-DRG 518 (Back & Neck Procedure Except Spinal Fusion with MCC or Disc Device/Neurostimulator), new MS-DRG 519 (Back & Neck Procedure Except Spinal Fusion with CC), and new MS-DRG 520 (Back & Neck procedure Except Spinal Fusion without CC/MCC) are being sequenced above MS-DRG 492 (Lower Extremity and Humerus Procedure Except Hip, Foot, Femur with MCC).

Partial Code Freeze

The Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-9) was signed into law on April 1, 2014. PAMA specified that the Secretary may not adopt ICD-10 prior to October 1, 2015. On August 1st CMS issued a rule finalizing October 1, 2015 as the new ICD-10 Compliance Date. Changes in the final rule to the schedule for the partial code freeze include:

• On October 1, 2012, October 1, 2013 and October 1, 2014, there will be only limited code updates to both the ICD-9-CM and ICD-10 codes sets to capture new technologies and diseases as required by section 1886(d)(5)(K) of the Act.
• On October 1, 2015, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 1886(d)(5)(K) of the Act. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.
• On October 1, 2016 (1 year after implementation of ICD-10), regular updates to ICD-10 will begin.

MS-DRGs Subject to the Post-acute Care Transfer Policy (§412.4)

Background

§412.4(a) defines a discharge under the IPPS as when “a patient is formally released from an acute care hospital or dies in the hospital.”

§414.4(f) “provides that when a patient is transferred and his or her length of stay is less than the geometric mean length of stay for the MS-DRG to which the case is assigned, the transferring hospital is generally paid based on a graduated per diem rate for each day of stay, not to exceed the full MS-DRG payment that would have been made if the patient had been discharged without being transferred.”

MLN® Acute Care Hospital Inpatient Prospective Payment System Fact Sheet (ICN 006815 April 2013) indicates that under the Transfer Policy DRG payments are reduced when:

• The beneficiary’s LOS is at least 1 day less than the geometric mean LOS for the MS-DRG;
• The beneficiary is transferred to another IPPS acute care hospital or, for certain MS-DRGs, discharged to a post-acute setting;
• The beneficiary is transferred to a hospital that does not participate in Medicare (effective October 1, 2010); and
• The beneficiary is transferred to a CAH (effective October 1, 2010).

Post-acute care settings subject to the transfer policy include:

• Long-term care hospitals;
• Rehabilitation facilities;
• Psychiatric facilities;,
• Skilled nursing facilities (SNFs);
• Home Health Care (HHC) when the beneficiary receives clinically related care within 3 days after a hospital stay;
• Rehabilitation distinct part (DP) units located in an acute care hospital or CAH;
• Psychiatric DP units located in an acute care hospital or CAH;
• Cancer hospitals; and
• Children’s hospitals.

 

How CMS calculates the Per Diem Rate for the transferring hospital:

• Full MS-DRG payment ÷ geometric mean length of stay (GMLOS) = Per Diem Rate

CMS’s policy for Post-acute Care Transfer MS-DRGs payment calculation:

• The transferring hospital will receive 2x the Per Diem Rate on the first day of the hospitalization.
• The hospital will receive the Per Diem Rate for subsequent days up to the full MS-DRG payment (§412.4(f)(1)
• Note: Transfer cases are also eligible for outlier payments

CMS’s policy for Post-Acute Special Payment MS-DRGs:

• Hospital will receive 50% of the full MS-DRG payment + the single day Per Diem Rate on the first day of the hospitalization.
• The hospital will receive 50% the Per Diem Rate for subsequent days up to the full MS-DRG payment (§412.4(f)(6)).

In the FY 2015 final rule the MS-DRG changes were evaluated against the post-acute care transfer policy criteria as well as the special payment methodology criteria. The following table is a breakdown of the new MS-DRGs and whether or not they qualify as a Transfer MS-DRG and if yes did it also qualify for a Special Payment MS-DRG:

For more information:

• Additional details regarding MS-DRG changes can be found in the pre-published https://www.federalregister.gov/articles/2014/08/22/2014-18545/hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the-long-term-care">Final Rule (pages 93 - 592).
• The Final Rule has a scheduled publication date of 08/22/2014 and will be available online at: http://ofr.gov/(S(pcl2zalo5cz115uiw2as4qqr))/inspection.aspx.

• MLN Matters® Number: SE0459 Clarification of Medicare’s Transfer Policy Under the Inpatient Prospective Payment System (IPPS) at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0459.pdf

One of the greatest features pertaining to ICD-10-CM/PCS that we as coders can look forward to is greater specificity. For the most part, the coding guidelines for ICD-10-CM regarding poisonings and injuries will remain the same as they are now in ICD-9-CM. A seventh character extension which identifies the encounter is one of the new features in ICD-10-CM. Refer to Section I.C.19.a of ICD-10-CM Official Guidelines for Coding and Reporting.

1. A - Initial encounter:     Used while patient is receiving active treatment for the condition. Examples of active treatment:
2. surgical treatment
3. emergency department encounter
4. evaluation and treatment by a new physician
5. D - Subsequent encounter:     Used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care:
6. cast change or removal
7. removal of external or internal fixation device
8. medication adjustment
9. S – Sequela:     Used for complications or conditions that arises as a direct result of a condition or injury. Example of sequel care:
10. painful scar formation secondary to 3rd degree burn right lower leg
11. complete quadriplegia secondary to traumatic C2 displaced vertebral fracture - G82.51 & S12.100S

FROM THE AUTHOR

Please note the last paragraph of Section I.C.19. a of ICD-10-CM Official Guidelines for Coding and Reporting regarding application of “S” as the seventh character.

When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequel and the code for the sequel itself.     The “S” is added only to the injury code, not the sequel code. The 7th character “S” identifies the injury responsible for the sequel.   The specific type of sequel is sequenced first, followed by the injury code.

Injuries – Section I.C.19.b of the ICD-10-CM Official Guidelines for Coding and Reporting

• A separate code should be assigned for each individual injury unless a combination code is provided.
• Code T07 for Unspecified multiple injuries should not be assigned in the inpatient setting unless supporting documentation for a more specific code is not available. Always query the MD in an attempt to gain information to support a more specific diagnosis code.
• Do not assign traumatic injury codes (S00-T14.9) for normal healing surgical wounds or to identify complications of surgical wounds.
• Sequence first the more serious injury as determined by the MD/provider and receiving main focus of treatment.
• Do not assign a code for superficial injuries (abrasions or contusions) when a more severe injury is associated with the same site.
• When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord and/or injury to blood vessels. When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

Traumatic Fractures – Section I.C.19.c of the ICD-10-CM Official Guidelines for Coding and Reporting

• Once again, specificity is the name of the game. ICD-10-CM fracture codes can now indicate the fracture type:
• Greenstick
• Transverse
• Oblique
• Spiral
• Comminuted
• Segmental
• Documentation should specify:
• Displaced
• Non-displaced
• Open
• Closed
• Laterality
• Specific anatomical site
• Routine vs delayed healing
• Non-union
• Mal-union
• Type of encounter
• A fracture not indicated as displaced or non-displaced should be coded as displaced.
• A fracture not indicated as open or closed should be coded to closed.
• Multiple fractures are sequenced in accordance with the severity of the fracture.
• Fracture extensions are expanded to include:
• A – Initial encounter for closed fracture
• B – Initial encounter for open fracture
• D – Subsequent encounter for fracture with routine healing
• G – Subsequent encounter for fracture with delayed healing
• K – Subsequent encounter for fracture with non-union
• P – Subsequent encounter for fracture with Mal-union
• S – Sequela
• Fractures in a patient with known Osteoporosis should be assigned a code from category M80 (non-traumatic fracture), even if the patient had a minor fall or trauma. Refer to Section I.C.13 of the ICD-10-CM Official Guidelines for Coding and Reporting.

Open Fracture Classification System

The Gustilo open fracture classification system is utilized in the 7th character extender lists for some fractures. This indicates the energy of the fracture, soft tissue damage and the degree of contamination. The Gustilo classification system is divided into 3 major categories.

Facilities will need to educate their providers on using the scale below to ensure supporting documentation for proper code assignment. This will also help lessen the number of queries sent to the provider.

Grade I

• Low energy, wound less than 1 cm with minimal soft tissue damage
• Wound bed is clean
• Bone injury is simple with minimal comminution
• With intramedullary nailing, average time to union is 21–28 weeks

Grade II

• Wound is > than 1cm with moderate soft tissue damage
• High energy wound > than 1cm with extensive soft tissue damage
• Wound bed is moderately contaminated
• fracture contains moderate comminution
• With intramedullary nailing, average time to union is 26-28 weeks

Grade III

The following fracture types automatically results in classification as type III.

• Segmental fracture with displacement
• Fracture with diaphyseal segmental loss
• Fracture with associated vascular injury requiring repair
• Farmyard injuries or highly contaminated wounds
• High velocity gunshot wound
• Fracture caused by crushing force from fast moving vehicle

Grade IIIA

• Wound less than 10cm with crushed tissue and contamination
• Adequate soft tissue coverage of bone is usually possible
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIB

• Wound greater than 10cm with crushed tissue and contamination
• Inadequate soft tissue coverage and requires regional or free flap
• With intramedullary nailing, average time to union is 30-35 weeks

Grade IIIC

• Associated major arterial injury with fracture which requires repair for limb salvage
• In some cases it will be necessary to consider BKA following tibial fracture

Seventh character extensions to designate the specific type of open fracture – based on the Gustilo open fracture classification.

• B – Initial encounter for open fracture type I or II (open fracture NOS )
• C – Initial encounter for open fracture type IIIA, IIIB, or IIIC
• E – Subsequent encounter for open fracture type I or II with routine healing
• F – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
• H – Subsequent encounter for open fracture type I or II with delayed healing
• J – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
• M – Subsequent encounter for open fracture type I or II with non-union
• N – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with non-union
• Q – Subsequent encounter for open fracture type I or II with mal-union
• R – Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with mal-union

The Gustilo classification is not used for all bones or all fracture types (such as Greenstick fracture or Torus fracture). Coders will need to be sure to look at each 7th character extender box for correct assignment.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

We all learned our ABCs in kindergarten, but now we have to know Medicare’s version of the alphabet. For example this article looks at LCDs by the MACs and a new CMS NCD for coverage of CHF for CR for certain NYHA classes. And don’t forget to add the KX modifier when needed.

Cahaba, Palmetto, and First Coast - Medicare Administrative Contractors (MACs) for Jurisdictions 10, 11 and N respectively - did not have any new, retired or draft Local Coverage Determinations (LCDs) last month, but Novitas, the MAC for Jurisdictions H and L, retired a number of policies and replaced most of them with new policies. It appears Novitas is working toward having one policy on a topic for both of their jurisdictions and for both Part A and B. This will ensure consistency in coverage criteria for all providers handled by Novitas. See the table at the conclusion of this article for the list of this month’s new and retired policies.

On the national front, CMS manualized the National Coverage Determination (NCD) for coverage of congestive heart failure (CHF) for cardiac rehabilitation (CR) (see MLN Matters Article MM8758). The transmittals, to be implemented August 18, 2014, allow Medicare coverage, effective for dates of service on and after February 18, 2014, of cardiac rehabilitation services for patients with stable, chronic heart failure.

Stable, chronic heart failure is defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks. Stable patients are defined as patients who have not had recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures.

In addition to CHF, Medicare covers cardiac rehab for the following conditions:

• Acute myocardial infarction within the preceding 12 months
• Coronary artery bypass surgery
• Current stable angina pectoris
• Heart valve repair or replacement
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting or
• Heart or heart-lung transplant

This is a good time to remind CR providers about the maximum number of sessions for CR and appropriate billing. MMP, as part of our 835 reviews for the HIQUP reports, consistently sees some cardiac rehab services denied with claim adjustment reason code (CARC) 151 (Payment adjusted because the payer deems the information submitted does not support this many services). This appears to be denials for cardiac rehab services exceeding the allowed maximum sessions.

Cardiac rehabilitation program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. For medically necessary CR sessions beyond 36, the provider should append a KX modifier on the claim lines as an attestation that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary. The Medicare contractor will accept the KX modifier and allow payment. Medicare will not cover CR sessions beyond 72 sessions, with or without the inclusion of a modifier.

The CARC for these maximum benefit denials may be changing as the Claims Processing Manual update included the following instructions:

The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a KX modifier is not included on the claim line:

Claim Adjustment Reason Code (CARC) 119 – Benefit maximum for this period or occurrences has been reached

Regardless of the denial reason code, providers need to carefully monitor their CR patients’ number of sessions and use the KX modifier when appropriate to assure proper payment. This will be even more important now that the volume of cardiac rehab will likely increase due to the inclusion of CHF as a covered indication.

On August 1st the Centers for Medicare and Medicaid Services (CMS) released the FY 2015 Inpatient Prospective Payment System (IPPS) Final Rule. Over the next few weeks we will share with you key portions of the Rule.

As with the FY 2015 IPPS Proposed Rule, the Final Rule’s main focus is on Quality. Specifically, the following three Affordable Care Act (ACA) mandated Programs:

• Hospital Readmission Reduction Program,
• Hospital Value Based Purchasing (VBP) Program; and
• Hospital-Acquired Condition (HAC) Reduction Program.

All three Programs are designed to improve quality of care to the patient during and after a hospitalization. At the national level several of the measures within these Programs are closely aligned with the Institute for Health (IHI) Triple Aim. “In 2008 Don Berwick, Tom Nolan, and John Whittington first described the Triple Aim of simultaneously improving population health, improving the patient experience of care, and reducing per capita cost. The Institute for Healthcare Improvement (IHI) developed the Triple Aim as a statement of purpose for fundamentally new health systems that contribute to the overall health of populations while reducing costs. The idea struck a nerve. It has since become the organizing framework for the US National Quality Strategy, for strategies of public and private health organizations around the world, and for many of the over 100 sites from around the world that have been involved in IHI’s Triple Aim prototyping initiative.”1

The Triple Aim of improving population health, improving the patient experience of care, and reducing per capita cost is not only the right thing for our patients it is a key framework to guide hospitals as our health care system moves forward towards pay for performance. Beyond the patient, it is also critical for hospitals to be aware of the potential payment reduction impact that these three Programs combined can have for hospitals with low quality performance.

‍Readmission Reduction Program:

Background

This Program began on October 1, 2012. In the first two years of the program hospitals with excessive 30 day readmission rates for Acute Myocardial Infarction (AMI), Heart Failure (HF) and Pneumonia (PN) were penalized a percentage of their base operating DRG payment amount for ALL Medicare discharges.

What’s New?

• Eligible hospital discharges occurring between July 1, 2010 and June 30, 2013 were used to calculate the FY 2015 Excess Readmission Rates (ERRs).
• The maximum hospital payment adjustment is increasing to 3%, as required by the ACA.
• Two new readmission measures are being added to the program.
• 30-day Risk Standardized Readmission for Chronic Obstructive Pulmonary Disease (COPD), and
• 30-day Risk Standardized Readmission following elective, primary total hip and/or total knee replacement (THA/TKA).
  To ensure that hip fracture patients are excluded from this measure, CMS finalized a refinement to the measure cohort to exclude patients with hip fracture coded as either the principal or secondary diagnosis during the index admission.
• The FY 2015 Hospital Readmission Reduction Program results are to be publically posted on Hospital Compare in December at http://www.medicare.gov/hospitalcompare/readmission-reduction-program.html.
• The rule finalized Readmissions for Coronary Artery Bypass Graft (CABG) Surgical Procedure as an new measure in FY 2017.
• Though not new it is important to note that discharge diagnoses for each applicable condition are based on specific ICD-9-CM codes for that condition. These codes can be found on the QualityNet Web site at: http://www.QualityNet.org > Hospital-Inpatient > Claims-Based Measures > Readmission Measures > Measure Methodology.

Hospital Value-Based Purchasing Program:

Background

The Hospital VBP Program also began October 1, 2012. A CMS Fact Sheet indicates that this program works by rewarding hospitals “based on the quality of care provided to Medicare patients, how closely best clinical practices are followed, and how well hospitals enhance patients’ experiences of care during hospital stays. Hospitals are no longer paid solely based on the quantity of services they provide.”

As this program matures the weighting of measures is shifting away from clinical process of care measures towards the patient experience, patient outcomes and efficiency as evidenced in the following table:

‍What’s New?

• The percent reduction for redistribution is increasing to 1.5% of the base operating DRG payment amount for all participating hospitals.
• The total estimated amount available for value-based incentive payments in FY 2015 is approximately $1.4 billion.
• As finalized in the FY 2013 Final Rule, the Efficiency Domain is being added in FY 2015. The current measure in this domain is the Medicare Spending Per Beneficiary (MSPB) measure. This measure “assesses Medicare Part A and Part B payment for services provided to a Medicare beneficiary during a spending-per-beneficiary episode that spans from 3 days prior to an inpatient hospital admission through 30 days after discharge.”
  The QualityNet MSPB web page indicates that “by measuring cost of care through this measure, CMS hopes to increase the transparency of care for consumers and recognize hospitals that are involved in the provision of high-quality care at lower cost to Medicare.”
• Six measures are to be removed from the program in FY 2017 due to them being “Topped-Out.” Topped out measures meet the two criteria of having a statistically indistinguishable performance at the 75th to 90th percentile and having a truncated coefficient variation of ≤ 0.10. The Topped-Out measures include:

 

‍

• Three new measures were finalized for FY 2017.
• Two new Outcome Measures for the Safety Domain
• Hospital-onset Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteremia
• Clostridium difficile infection
• One new Clinical Process of Care Measure
• Elective Delivery Prior to 39 Weeks Gestation
• Two new measures were finalized for FY 2019.
• Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA)
• This measure will assess “complications occurring after THA and TKA surgery from the date of the index admission to 90 days post date of the index admission.”
• The outcome is one or more of the following complications:
• AMI, PN, or sepsis/septicemia within 7 days of admission;
• Surgical site bleeding, pulmonary embolism or death within 30 days of admission; or
• Mechanical complications, periprosthetic joint infection or wound infection within 90 days of admission.
• PSI-90 Composite Measure which includes PSI-3 – Pressure Ulcer Rate, PSI-6- Iatrogenic Pneumothorax Rate, PSI-7-Central Venous Catheter-Related Blood Stream Infections Rate and PSI-8-Post-op Hip Fracture Rate.

Hospital-Acquired Condition (HAC) Reduction Program:

Background

The Deficit Reduction Act of 2005 (DRA) required that the Secretary identify at least two HACs by October 1, 2007. HACs are high cost and/or high volume conditions that have been designated as a complication (CC or MCC) for coding purposes, have evidence-based guidelines to prevent the condition and if it was the only secondary diagnosis driving the MS-DRG assignment to a higher paying MS-DRG it would be discounted and the hospital would receive payment as if the HAC never occurred. HACs began to impact payment for hospitals for discharges occurring on or after October 1, 2008.

What’s New?

The HAC Reduction Program is set to begin on October 1, 2014. This program is a penalty program that will reduce payments to hospitals with excessive HACs by 1% for ALL Medicare discharges.

In the FY 2014 Final Rule CMS indicated that “the HAC Reduction Program aligns with our national strategy to improve health care quality by promoting the prevention of HACs, such as “never events” and HAIs. Our goal for the HAC Reduction Program is to heighten the awareness of HACs and reduce the number of incidences that occur.” They went on to state that “we believe that our efforts in using payment adjustments and our measurement authority will encourage hospitals to eliminate the incidence of HACs that could be reasonably prevented by applying evidenced based guidelines.”

In an August 5th MLN Connects™ Provider eNews CMS indicated that “this new program builds on the progress in this area achieved through the existing HAC program, which is currently saving approximately $30 million annually.”

The measures in this program are separated into two domains and scoring for each measure will begin at the minimum value for each measure. Scoring of the measures will result in a Total HAC Score. The finalized domains, domain weight and measures are as follows:

‍

At the end of the day it really is all about the patient.

For more information:

• Additional details about all three of these programs can be found in the pre-published https://www.federalregister.gov/articles/2014/08/22/2014-18545/hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the-long-term-care">Final Rule (pages 722-820, 822-976 and 976 – 1,049).
• The Final Rule has a scheduled publication date of 08/22/2014 and will be available online at: http://ofr.gov/(S(pcl2zalo5cz115uiw2as4qqr))/inspection.aspx.

Reference

1Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org)

The Office of Inspector General (OIG) regularly posts reports of their audit findings. A number of these reports relate to hospital payment errors, although the reports often address the same issues from hospital to hospital. However, I always read through the findings to see if there are any new twists to the issues and to remind myself of these OIG target areas – in other words to see what’s in it for me.

Recently the OIG released three reports of hospital audits – two related to drug payment errors and one general compliance review. Here are a couple of issues from these reports worth noting.

Non-covered Use of Reteplase

The drug reteplase (HCPCS code J2993 – injection, reteplase, 18.1 mg) is approved by the Food and Drug Administration (FDA) to treat cardiac conditions using a single-use dose. The OIG identified a billing error that occurred when a provider billed Medicare for one full single-use dose of reteplase when they had actually split a single dose into multiple doses and used them as a thromblytic agent to clean dialysis patient catheters. This is a non-covered use of reteplase and resulted in an overpayment to the facility. (OIG Report Drug Overpayments Jurisdiction 13)

Bundled IMRT Planning Services

In the OIG Medicare Compliance Review of Good Samaritan Hospital, the OIG identified that the hospital had billed separately for services performed as part of Intensity Modulated Radiation Therapy (IMRT) planning resulting in an overpayment. These services are included in the payment for IMRT planning even when provided on a different date of service.

Hospitals are to report CPT code 77301 for IMRT planning. The Medicare Claims Processing Manual, Chapter 4, section 200.3.2 states that “Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301.” Therefore these codes should not be billed in addition to IMRT planning (CPT 77301), regardless if provided on the same or different dates of service, unless they are not provided as part of developing the IMRT treatment plan.

A quick review of OIG reports relating to hospital findings is a great way to become familiar with the OIG target areas and to evaluate issues against your hospital’s practices. Better to be proactive than regretfully reactive.

          

Q:

How do you determine the level of physician supervision required for hospital outpatient therapeutic and diagnostic services?

 

A:

The answer is sort of like putting together a jigsaw puzzle. There is a piece here and a piece there. Terms defined in one place, then defined further in another place, codes in the physician RVU file, and a new type of service supervision designation altogether. Let’s see if we can put the pieces in place.

Definitions

Definitions of the levels of supervision can be found in the Code of Federal Regulations at 42 CFR 410.32 (b).

• General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
• Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. CMS has further defined direct supervision for services provided in a hospital in the Medicare Benefit Policy manual, chapter 6, sections 20.4 and 20.5 as noted below.
• Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

This section of the CFR also discusses some exceptions to diagnostic supervision requirements such as mammography services, audiology tests, laboratory tests, and a few other exceptions.

In the Medicare Benefit Policy manual, CMS clarifies the definition of “direct supervision” as it relates to hospital services performed during or after CY 2011 – “whether directly or under arrangement in the hospital or in an on-campus or off-campus outpatient department of the hospital as defined at 42 CFR 413.65, “direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. As discussed below, the physician is not required to be present in the room where the procedure is being performed or within any other physical boundary as long as he or she is immediately available…. Immediate availability requires the immediate physical presence of the supervisory physician. CMS has not specifically defined the word “immediate” in terms of time or distance; however, an example of a lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt. Also, for services furnished on-campus, the supervisory physician may not be so physically distant on-campus from the location where hospital outpatient services are being furnished that he or she could not intervene right away. The hospital or supervisory physician must judge the supervisory physician’s relative location to ensure that he or she is immediately available… The supervisory physician must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure… The supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure or provide additional orders.”

Hospital Outpatient Diagnostic Services

The supervision requirements for hospital outpatient diagnostic services can be found in the Medicare Benefit Policy manual, chapter 6, section 20.4. Section 20.4.4 explains that supervision levels for individual diagnostic tests are listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found on the Medicare Physician RVU File webpage. After selecting the year and quarter (quarters identified by A (January), B (April), C (July), etc.), download the zip files, select the PPRRUV14 spreadsheet and locate the “Physician Supervision of Diagnostic Procedures” column (column Z in this year’s spreadsheets). Hospitals are interested in the designation for the technical component (TC) of diagnostic services. The supervision levels are listed by codes, the definitions of which can be found in the Medicare Benefit Policy manual, chapter 15, section 80. The main designations are:

• 1 - Procedure must be performed under the general supervision of a physician.
• 2 - Procedure must be performed under the direct supervision of a physician.
• 3 - Procedure must be performed under the personal supervision of a physician.
• 9 - Concept does not apply.

Certain diagnostic tests performed personally by non-physician practitioners (NPPs) do not require physician supervision but NPPs may not supervise diagnostic tests when performed by other hospital staff.

Hospital Outpatient Therapeutic Services

Section 20.5.2 of chapter 6 of the Benefit Policy Manual describes the supervision requirements for therapeutic services - all therapeutic services provided to hospital outpatients generally require direct supervision by an appropriate physician or NPP although CMS may assign a different level of supervision to some therapeutic services. In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services. However, pulmonary and cardiac rehab services require that a physician provide the direct supervision.

CMS may designate certain services to general or personal supervision or beginning in 2011, as non-surgical extended duration therapeutic services. Extended duration services require direct supervision during the initiation of the service followed by general supervision for the remainder of the service at the discretion of the supervising practitioner. The service can transition to general supervision after the beginning portion of the service when the supervising practitioner decides the patient is stable enough for general supervision. The point of transition to general supervision must be documented in the patient’s progress notes or medical record. A list of “Hospital Outpatient Therapeutic Services Designated as General or NSEDTS” is available in the downloads section on the Hospital OPPS webpage.

 

Coders probably sometimes feel as if they are searching for the proverbial needle in the haystack. They must evaluate an entire medical record to pick out the key condition responsible for a patient’s admission and other conditions that affect the patient’s treatment. Not easy considering the issues with incomplete, illegible, and conflicting documentation that may be present. And then there are the numerous coding rules of which coders must be aware and stay current. Our hats off to coders everywhere.

Last week, we reviewed the CERT findings from the July 2014 Medicare Compliance Quarterly Newsletter which focused on documentation deficiencies. This week we will look at some coding errors identified by the Recovery Auditors (RACs) detailed in the July Compliance Newsletter. These are brief summaries of the examples given in the newsletter. I encourage everyone to carefully review the examples in the newsletter for complete understanding.

Heart Failure and Shock (MS-DRGs 291, 292 and 293)

The RACs identified errors for these DRGs in both the sequencing of the principal diagnosis and in improper coding of the secondary diagnosis.

• The patient presented with decompensated congestive heart failure (CHF) and a pleural effusion with pulmonary edema. The physician did not state the cause of the pleural effusion so this should be coded as pleural effusion not otherwise specified (NOS) (511.9), instead of pleural effusion not elsewhere classified (NEC) (511.8). Coding Clinic has noted that pulmonary effusions are often seen with CHF with and without pulmonary edema and may be reported as an additional diagnosis. In this case the change in the secondary diagnosis changes the DRG assignment from 291 to 292, resulting in an overpayment.
• In the second example provided, a patient is diagnosed with CHF and an acute myocardial infarction. The reason for admission as determined after study was the acute MI (410.71), not the heart failure (428.20) also changing the DRG assignment to a lower weighted DRG.

NOTE

Medical Management Plus Inpatient Coders offer the following comments concerning pleural effusions with CHF: Coders assume a relationship between pleural effusions and CHF unless stated otherwise. Pleural effusion is considered to be integral to the CHF disease process and will normally clear with treatment for the CHF. It would not typically be assigned its own diagnosis code. Pleural effusions may only be reported as an additional diagnosis if the condition is specifically evaluated or treated, but reporting is not required. Evaluation may involve special x-rays such as decubitus views or diagnostic thoracentesis and it may be necessary to address the effusion by therapeutic thoracentesis or chest tube drainage.

Effective 2009, ICD-9 code 511.8 required a 5th digit and was removed from the MCC list. Both 511.8x and 511.9 are now CCs.

Postoperative or Posttraumatic Infections with Operating Room (OR) Procedure with Complications and Comorbidities (CC) (MS-DRG 857)

Both examples given for this DRG involve improper diagnosis code assignment in cases where the infection and complications were associated with implanted devices and not with the surgical procedure itself. In these examples, code 998.59 (postoperative infections) should not have been assigned as the principal diagnosis code because it excludes infections due to implanted devices.

• The first involved a total knee prosthesis which should have been coded with a principal diagnosis code of 996.66, Infection and inflammatory reaction due to internal prosthetic device implant and graft. The secondary diagnosis code of 998.12, hemorrhage or hematoma complicating a procedure, was replaced with ICD-9 diagnosis code 997.77 other complication due to internal joint prosthesis. This resulted in a DRG change from 857 to 487.
• The second patient was treated surgically for a pocket infection of a pacemaker. A correct principal code assignment of 996.61, Infection and inflammatory reaction due to cardiac device, implant, and graft changed the MS-DRG from DRG 857 to DRG 261.

Amputations (MS-DRGs 239, 240, 241, 474, 475, and 476)

The final inpatient coding errors involved secondary diagnoses coded with amputation DRGs. The code assignments were not supported by the physician documentation for acute heart failure or acute renal failure. Removing or correcting these diagnosis codes removed the MCC resulting in lower weighted DRGs.

Coders have a difficult task of reviewing an entire medical record and selecting the appropriate principal and secondary diagnoses. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” but careful consideration must be used in making this determination, such as what was the actual reason for the admission and the focus of treatment. Also, secondary diagnoses must be clearly supported by the physician’s documentation in the medical record and correctly selected based on coding guidelines. Errors in code sequencing and selection can easily lead to an overpayment.

Q:Should physician queries be part of the legal medical record? 

 

A:

At MMP we have seen facilities maintain queries as part of the legal medical record and other facilities maintain the query forms within the CDI Department. Ultimately, this is a hospital specific decision.

Below are excerpts from two complimentary AHIMA Practice Briefs where they have provided guidance regarding query retention.

Query Retention

Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database.

Before this decision is made a discussion with the facility compliance and legal staff may be beneficial. Regardless, the query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query a permanent part of the health record to demonstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It also can demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documentation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

Article Citation: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010); expanded web version.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

Develop Query Retention Policies

Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated. As noted in AHIMA’s toolkit, “Amendments in the Electronic Health Record,” “the addendum should be timely, bear the current date, time, and reason for the additional information being added to the health record, and be electronically signed.”

Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.

An important consideration in query retention is the ability to collect data for trend analysis, which provides the opportunity for process improvement and identification of educational needs.

Article Citation: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018