The Signs and Symptoms category in I-9 has received a major overhaul in I-10. Not only have there been organizational changes; several new conditions have also been included in the chapter.  Let’s take a closer look at the differences...

• (Chapter 16) is now (Chapter 18)
• In addition to symptom guidelines, guidelines for several other conditions are listed in Chapter 18, i.e., Repeated falls, coma scale, functional quadriplegia, SIRS due to non-infectious process, and death nos
• Some of the symptoms previously found in a specific chapter, have been moved into the symptom chapter.
• Example 1: Hematuria, previously listed in the (Genitourinary System) is now listed in the (Symptoms) chapter
• Example 2: Sinus Bradycardia, previously listed in the (Diseases of the Circulatory System) is now listed in the (Symptoms) chapter
• Symptoms are sequenced by body system within the chapter (called blocks)

Chapter 18 is organized in the following blocks:

‍

The following is the beginning of the Symptom Chapter (block) for circulatory and respiratory systems in the tabular section:

R00 | Abnormalities of heart beat

R00.0 | Tachycardia, unspecified

NOTE

Reviewer’s Note: Sinus Bradycardia is now listed in the symptom chapter instead of in (Diseases of the Circulatory System) chapter as it was in I-9.

Rapid heart beat

Sinoauricular tachycardia NOS

Sinus (sinusal) tachycardia NOS

R00.1 | Bradycardia, unspecified

Sinoatrial bradycardia

Sinus bradycardia

Slow heart beat

Vagal bradycardia

R00.2 | Palpitations

Awareness of heart beat

R00.8 | Other abnormalities of heart beat

R00.9 | Unspecified abnormalities of heart beat

Official ICD-9-CM Guidelines for Coding and Reporting

Reviewer’s observation: I-9 previously provided only general guidelines for coding signs and symptoms under Section II. Selection of Principal Diagnosis. We now have chapter-specific guidelines for coding signs and symptoms in I-10.

I-9

Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799)

Reserved for future guideline expansion

I-10

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded. Signs and symptoms that point to a specific diagnosis have been assigned to a category in other chapters of the classification.

1. Use of symptom codes
2. Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
   
   
3. Use of a symptom code with a definitive diagnosis code
4. EXAMPLE
5. Respiratory arrest (R09.2) should not be coded in addition to Respiratory Failure (J96-).
6. Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
   
   
7. Combination codes that include symptoms
8. ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
   
   
9. Repeated falls
10. Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.
11. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.
    
    
12. Coma scale
13. The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
14. These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
15. At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
    
    
16. Functional quadriplegia
17. Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.
    
    
18. SIRS due to non-infectious process
19. NOTE
20. This guideline has been moved from Chapter 17: Injury and Poisoning (I-9).
21. The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11. If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.
    
    
22. Death NOS
23. Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival. It does not represent the discharge disposition of death.

Remember:

• Symptom codes are not coded and reported when a confirmed diagnosis has been established by the provider.
• Chapter 18 contains many, but not all codes for symptoms.

As you can see, there have been several changes to the symptom chapter for I-10. In my personal opinion, organizing the symptoms in “blocks” under each specific body system, makes the information much easier to locate specific symptoms at-a-glance.

Resources:

ICD-9-CM Coding book by Ingenix ICD-10-CM Coding Book by Ingenix AHIMA ICD-10-CM Training Manual

 

Our next topic for the I-10 corner is the mental health chapter, Mental, Behavioral, and Neurodevelopmental Disorders. Chapter 5 is another example of the massive expansion of codes in ICD-10. I have highlighted some changes and included tips that I think are important to know for coding these conditions.

See below how the codes in this chapter are no longer grouped by psychotic, non-psychotic disorders, or mental retardation.

CODE COMPARISON

‍NOTE FROM ICD-10-CM CODER TRAINING MANUAL 2014

Many title changes for categories and subcategories were made in Chapter 5. Such as:Bipolar 1 Disorder, Single Manic Episode (296.0x) = Manic Episode (F30.xx)

Many changes were made due to outdated terminology. Examples can be seen in the accompanying table.

 

 

DID YOU KNOW?

DRG Shift

The CMS ICD-10 website contains information on the ICD-10 MS-DRG Conversion Project. An article from CMS, “Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments”, lists the top 10 MS-DRGs that shift to another DRG when re-coded with ICD-10. DRG 885, Psychoses is on that list. Currently, ICD-9 cases that have 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis will group to DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9 (also includes Depression NOS) which groups the case to DRG 881, Depressive Neuroses, a lower-weighted DRG. Interestingly, many hospitals in Alabama have DRG 885 listed in their top 10 diagnoses each year. It would be a good idea to see how this change will impact your facility.

A large classification change was made to the drug and alcohol abuse/dependence codes.

• There are codes to denote alcohol and drug “use”.
• No longer identify “Continuous” and “Episodic” in I-10
• Can code Blood Alcohol Levels as an additional code, if applicable:
  Y90.0, Evidence of alcohol involvement determined by blood alcohol level

Chapter 5 Guidelines

• Physician documentation of a history of drug or alcohol dependence is coded as “in remission”.
• For psychoactive substance use, abuse and dependence:

TIP

 

The codes in Chapter 5 parallel the codes in DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders-4 Text Revision) in most cases….from the ICD-10-CM Coder Training Manual, 2014 Instructor’s Edition. Psychiatrists tend to document these conditions as they are listed in the codebooks, which can make mental health coding a little easier. In addition, I hope all of the information provided to you in the I-10 Corner has helped make your job a little easier.

Have you ever seen the guy spinning numerous plates at once at the top of poles? This used to be a regular segment on the Ed Sullivan Show many years ago. Sometimes keeping up with all the different payer regulations is like spinning plates. For example, there are numerous ways to report bilateral procedures, but Medicare only wants it one way. Reporting it wrong will end up in a denial for certain procedures. Coders’ heads are spinning like those plates.

Medicare has published MLN Matters Article SE1422 to address improper Medicare billing of bilateral surgical procedures and date of service Medically Unlikely Edits (MUEs). As a reminder, per Medicare’s MUE webpage an MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single patient on a single day of service.  Medicare FAQ 2277 explains that line-item MUEs are adjudicated separately against the MUE value for the procedure code on thatline. The appropriate use of CPT modifiers (such as -76, -77, -59, or anatomic modifiers) to report the same code on separate lines of a claim will enable a provider to report medically reasonable and necessary units of service in excess of an MUE value. 

Medicare, with back-up from the Office of Inspector General, is convinced that providers are inappropriately by-passing line item MUEs by reporting multiple line items. To address this concern, CMS is converting most MUEs into per day edits. That means that all lines of a CPT code will be denied if the units for that CPT code exceed the MUE limit for the day of service. In this case, reporting CPT codes on separate lines, with or without modifiers, will not by-pass the edits.

CMS is also adding MUE Adjudicator Indicators (MAIs) to indicate the type of MUE and its basis.

• An MAI of 3 indicates an MUE based on clinical information such as billing patterns or prescribing information. Exceptions to the MUE limits can occur but would be rare, so Medicare considers items exceeding MUE limits when the MAI is 3 to be a billing error. Providers can appeal denials for MUEs with an MAI of 3 if they have verified that the units are correct, the service is medically necessary, and they have correctly interpreted all coding instructions.
• An MAI of 2 indicates an MUE based on regulation or subregulatory instruction (“policy”), including the instruction that is inherent in the code descriptor or its applicable anatomy. MUE denials where the MAI is 2 will not be overturned on appeal.
• If a provider receives an MUE denial and determines that the units originally billed were incorrect due to a clerical error, they can request a reopening instead of having to go through the appeals process. They can then submit a corrected claim with the correct number of units.

There is now a revised July 1, 2014 update on the MUE webpage that identifies the published MUE edits with an MAI value of 1 (line edit), 2 (date of service edit: policy) or 3 (date of service edit: clinical).

These per day MUEs will create a problem with bilateral codes for surgical procedures if they are not billed according to Medicare instructions. Medicare instructs in the Medicare Claims Processing Manual and the National Correct Coding Initiative Manual that bilateral surgical procedures (if bilateral is not included in the code description) should be reported using a single unit of service and the -50 modifier. If these procedures are incorrectly reported on two lines with RT and LT modifiers or on one line with units of 2, they may exceed the MUE if the per day MUE limit is one. A date of service MUE of one is fairly common for bilateral surgical procedures. The article only discusses bilateral surgical procedures; it does not address the correct reporting of bilateral radiology procedures.

Through our 835 claims analysis (HIQUP reports), MMP has identified denials of services that appear to be the result of inappropriate reporting of bilateral surgical procedures with RT and LT instead of the -50 modifier. For example, such CPT codes as 30140, 49505, 64483, and 67904 submitted with RT/LT modifiers are being denied with Claim Adjustment Reason Code (CARC) 151 (information submitted does not support this many services).

Hospitals need to watch for these types of denials and educate coders and billers or adjust chargemasters to assure bilateral surgical procedures are being reported correctly. Hospitals will also need to be aware of the per day MUEs and their respective MAIs for other services that may be affected. Something else to watch for and another acronym to remember.

 

 

As a young laboratory manager, I was unwittingly thrust into an environment that required some knowledge of medical billing. One of my now best friends, then hospital billing manager, could almost bring me to tears with intimidating terms such as “UB”, “revenue code” and “type of bill.”   We now laugh about the time I told her, “I don’t know what a revenue code is and I don’t ever want to know!” Just goes to show you – never say never.

There have been a lot of hospital issues lately involving type of bill (TOB). There were instructions, then changed instructions, on the use of bill types 13x and 14x for laboratory services under the new OPPS packaging rules. The new Part B inpatient claim rules focus on type of bill 12x. So I thought this would be a good time to review some basic information on medical claim type of bill, even if you think you don’t want to know.

Type of bill consists of four digits, the first digit being zero. This leading zero is ignored by Medicare for processing and is usually dropped when discussing bill types. The type of bill goes in FL 4 on the UB-04. The second digit identifies the type of facility and the third classifies the type of care being billed. For example, claims with a second digit of “1” are hospital claims, such as 011x or 013x.

The fourth digit of the TOB indicates the sequence of the bill for a specific episode of care as defined below:

• “0” indicates a non-payment/zero claim. For example, if a facility determines an inpatient admission is not medically necessary after discharge, they would first submit a no-pay/provider liable inpatient claim, a 110 TOB. After denial, they would then submit a Part B inpatient claim (TOB 121) to receive payment for the Part B services furnished.
• “1” is for an admit-through-discharge claim.
• “2” is the first interim claim in a series of claim when the patient is expected to remain in a facility for an extended period of time or is receiving outpatient recurring services, such as physical therapy.
• “3” is a continuing claim in a series of claims.
• “4” indicates the last claim in a series.
• “5” is used as the last digit for late charges only claims.
• “7” is a replacement claim to be used when a previously finalized claim needs to be rebilled entirely such as corrected or adjustment claims.
• “8” is used to cancel a claim.

There are some additional fourth characters for special providers such as hospice and home health.

As usual with Medicare, nothing is as straight forward as it seems. Be sure to read the Medicare manual and other resources to ensure you are using the type of bill codes correctly. For example, Medicare Claims Processing Manual, Chapter 1, section 50.2 discusses Frequency of Billing for Providers.

In this week’s article, we’re discussing a few of the changes for ICD-10-CM in the Nervous System (Chapter 6): Alzheimer’s Dementia, Epilepsy, Hemiparesis/Hemiplegia (Dominant vs. Non-Dominant), Migraine, Phantom Limb Pain and Sleep Apnea

Alzheimer’s Dementia

I-9: Alzheimer’s Dementia

• with behavioral disturbance (aggressive) (combative) (violent) (331.0 / 294.11)
• without behavioral disturbance (331.0 / 294.10)

NOTICE:

The category for Alzheimer’s disease (G30) has been expanded to reflect onset (early vs. late)

I-10: Alzheimer’s Dementia

• behavioral disturbance (G30.9 / F02.81)
• early onset (G30.0 / F02.81)
• late onset (G30.1 / F02.80)
• specified NEC (G30.8 / F02.80)

 

Epilepsy

Terms for Epilepsy have been updated to classify the disorder, e.g,

• Localization-related Idiopathic Epilepsy
• Generalized Idiopathic Epilepsy
• Special Epileptic Syndromes

Example:

I-9: Epilepsy, epileptic (idiopathic) (345.9)

Epilepsy, localization related (focal) (partial) and (epileptic syndromes)

• With
• Complex partial seizures (345.4)
• Simple partial seizures (345.5)

NOTICE:

Within each category, more specificity can be described to identify: Seizures of Localized Onset, Complex Partial Seizures, Intractable and Status Epilepticus.

I-10: Epilepsy, epileptic, epilepsia (attack) (cerebral) (convulsion) (fit) (seizure) (G40.909)

Epilepsy, localization-related (focal) (partial)

• Idiopathic (G40.009)
• With seizures of localized onset (G40.009)
• Intractable (G40.019)
• With status epilepticus (G40.011)
• Without status epilepticus (G40.019)
• Not intractable (G40.009)
• With status epilepticus (G40.001)
• Without status epilepticus (G40.009)

NOTE

Category G40, Epilepsy and Recurrent Seizures

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Hemiplegia and Hemiparesis  (Dominant vs. Non-Dominant Side)

This category is to be used only when the listed conditions are reported without further specification, or are stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these conditions resulting from any cause.                                      

I-9:

The following fifth-digits are for use with codes 342.0-342.9:

• 0 affecting unspecified side
• 1 affecting dominant side
• 2 affecting non-dominant side

I-10:

Per ICD-10-CM Official Coding Guidelines: Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or non-dominant side is affected.

Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows:

• For ambidextrous patients, the default should be dominant
• If the left side is affected, the default is non-dominant
• If the right side is affected, the default is dominant

Example: G81.9 Hemiplegia, unspecified

• G81.90:  Hemiplegia, unspecified affecting unspecified side
• G81.91:  Hemiplegia, unspecified affecting right dominant side
• G81.92:  Hemiplegia, unspecified affecting left dominant side
• G81.93:  Hemiplegia, unspecified affecting right non-dominant side
• G81.94:  Hemiplegia, unspecified affecting left non-dominant side

            Excludes1: Hemiplegia and hemiparesis due to sequela of cerebrovascular disease

Migraine

I-9: Migraine, Unspecified (Idiopathic) (346.9x)

I-10: Migraine, Unspecified (Idiopathic) (G43.909)

NOTE

Category G43, Migraine

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

 

Phantom Limb

The sensation that an amputated or missing limb is still attached to the body and is moving along with other body parts. An estimated 60% to 80% of people that have had an amputation, experience phantom sensations in the amputated limb with the majority being painful.  

I-9: Phantom limb (syndrome) (353.6)

NOTICE:

I-10 has given us the ability to identify whether pain is present or not after an amputation.

I-10: Phantom limb syndrome (G54.7)

• with pain (G54.6)
• without pain (G54.7)

 

Sleep Apnea

Sleep Apnea has its own subcategory with fifth character specificity identifying the type

Example:      

I-9: Sleep Apnea, Unspecified (780.57)

• with
• Hypersomnia, unspecified (780.53)
• Hyposomnia, unspecified (780.51)
• Insomnia, unspecified (780.51)
• Sleep disturbance (780.57)
• Central, in conditions classified elsewhere (327.27)
• Obstructive (adult) (pediatric) (327.23)
• Organic (327.20)
• other (327.29)
• Primary central (327.21)

I-10: Sleep Apnea, Unspecified (G47.30)

• Central (primary) (G47.31)
• in conditions classified elsewhere (G47.37)
• Obstructive (adult) (pediatric) (G47.33)
• Primary central (G47.31)
• Specified NEC (G47.39)

As you can see, there are several new terms and descriptions in the Nervous System Chapter for I-10-CM, providing more specificity and better clarity of certain conditions. If we can take just a little extra time assigning diagnosis codes for I-10, we will reflect the true severity of illness (SOI) for each and every patient.

Resources:

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Wikipedia

The term “argue back” is listed as an idiom in an on-line dictionary, similar to the phrases “answer back”, “talk back” or “back talk”. Parents often reprimand their children for “talking back”. However in the grown-up world, making a persuasive argument to support your opinion is not only acceptable, but often necessary to achieve fair and just outcomes. But then again, sometimes life just isn’t fair.

As of this month, the Office of Inspector General (OIG) is approaching 100 reports on Medicare compliance reviews of hospitals. There are similarities between the reports: the issues are often the same, and the reviews are based on computer matching, data mining and data analysis techniques to identify at-risk claims. There are differences between the reports: some hospitals have a much greater overpayment than others and some refund amounts are extrapolated from the overpayment amounts while others are not. We at MMP have not been able to determine a pattern for which audits result in extrapolation versus those that do not.

Last week, the OIG published the report on Compliance Review of University of Cincinnati Medical Center that is particularly interesting. So what makes this report stand out among all the many compliance reviews?

• The refund amount of $9,818,296 was extrapolated from an overpayment amount of $603,267 (to date refund amounts have been extrapolated on only 10 of 99 compliance reviews).
• The refund amount of almost $10 million is the largest of all the compliance reviews. In fact, only three other reviews topped $2M refund and no other refund amounts prior to this one (even other extrapolated reviews) exceeded $5M.
• The University of Cincinnati Medical Center (UCMC) vehemently argued their case at great length against some of the OIG’s decisions from the audit. They make some interesting points in their arguments as noted below.

UCMC believes the OIG claim selection method contains a judgmental bias toward inclusion of claims likely to have overpayments and exclusion of claims likely to have underpayments. The biased findings are further magnified by the use of extrapolation.

UCMC disagreed with 50 of 57 claims the OIG determined were “incorrectly billed as inpatient.” Some of the reasons for disagreement were:

• Some were for inpatient-only procedures
• Reviewers based review decision on information that was not available to the admitting physician at the time of admission
• The hospital was not allowed to have discussion with the reviewers regarding their decisions or request re-review of the cases
• Extrapolation is not appropriate because decisions are judgmental and case-specific, and the potential effect of Part B rebilling is not considered in the extrapolation amount

It is interesting to note that on the seven cases UCMC concurred with, they cite lack of documentation to support the clinical decision of the physician to admit the patient, physician receptiveness to the involvement of RN Case Managers, and interpretation of third party vendor services as weaknesses in existing internal controls.

UCMC was cited for failing to pursue credits for replaced devices. According to UCMC’s response, the Medicare Claim Processing Manual (CMS Pub. 100-04, Sec. 100.8, Replaced Devices Offered Without Cost or With Credit) does not require hospitals to pursue manufacturers for credits on replaced devices. Medicare policy only requires that hospitals report credits actually received where the credit is more than 50% of the cost of the replacement device. UCMC argues that the prudent buyer principle is applicable to defining allowable costs for Medicare cost reports but does not apply to Medicare claims-based audits.

On June 2, 2014, the American Hospital Association (AHA) submitted a letter to the U.S. Department of Health and Human Services also objecting to the OIG hospital compliance audits. The AHA arguments are similar to those made by UCMC and include:

• OIG audits redundant to RAC reviews thereby being unduly burdensome to hospitals
• The OIG misconstrued and misapplied numerous Medicare regulations and policies
• The OIG used flawed sampling and extrapolation methods to estimate overpayments and refunds
• The OIG audits do not take into consideration Part B payments that may have been appropriate for the hospital to receive by their own admission
• They are in violation of reopening time frames and MAC statutory limits on extrapolation

For complete details, read the AHA's letter.

The “arguing back” of both UCMC and the AHA is well thought out, supported by references, and clearly explained, but whether either will prevail concerning their arguments and/or planned appeals remains to be seen.

All Medicare discharges from acute Inpatient Prospective Payment System (IPPS) hospitals are not created equal. Specifically, hospitals must determine whether the patient was “discharged” or “transferred” from the hospital.

In May, the Office of Inspector General (OIG) released the report, Medicare Inappropriately Paid Hospitals’ Inpatient Claims Subject to the Postacute Care Transfer Policy.

This was not a new type of review for the OIG. In prior similar reviews, the OIG found issues and made the following recommendations to the Centers for Medicare and Medicaid Services (CMS):

• Recommend that CMS provide hospitals education regarding the transfer policy
• Require Medicare Administrative Contractors (MACs) to put edits in place to “prevent and detect postacute care transfers that are miscoded as discharges.”

In spite of prior OIG reviews and recommendations, the OIG once again found in more recent reviews that hospitals not complying with the policy received approximately $12.2 million in overpayments from Medicare contractors. In the May report, the OIG once again conducted a review with the objective of determining if appropriate payments were being made to hospitals by Medicare for claims subject to the postacute care transfer policy. Before examining the report findings, I believe it is important to first have a basic understanding of Medicare’s Postacute Transfer Policy.

Postacute Care Transfer (PACT) Policy Background

• This policy was established by CMS effective October 1, 1998.
• The purpose of this policy is to prevent Medicare from having to pay twice for the same care: once to the hospital as a MS-DRG payment and second to a postacute facility or level of care.
• This policy distinguishes between beneficiary “discharges” and “transfers” from IPPS hospitals.
• A discharge status code is required by CMS for all inpatient claims. This two-digit code determines whether Medicare pays for a “discharge” or a “transfer.”
• Full Medicare Severity Diagnosis-Related Group (MS-DRG) payments are made for inpatient “discharges” to home or certain types of health care institutions.
• A per diem rate is paid for each day of the stay for “transfers.” This amount is not to exceed the full MS-DRG payment made for discharges to home.
• A “transfer” MS-DRG rate is paid for Medicare inpatients who have a qualifying DRG and one of the following discharge status codes assigned:

(Source: MLN Matters Number: SE0801at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf)

How CMS determines what DRGs will be Transfer DRG:

• The DRG has a least 2,050 total postacute care transfer cases;
• At least 5.5 percent of the cases in the DRG are discharged to postacute care prior to the geometric mean length of stay (LOS)for the DRG;
• The DRG must have a geometric mean LOS greater than 3 days; and
• If the DRG is a paired set based on the presence/absence of a comorbidity or complication, both paired DRGs are included if either one meets the first three criteria.

Again, the May OIG Report was conducted to determine if inpatient claims subject to the postacute care transfer policy were being appropriately paid by Medicare. The OIG reviewed Medicare beneficiary transfers to postacute care with dates of service from January 2009 through September 2012. Specific claims were identified through data analysis. Specific OIG findings and recommendations are as follows:

OIG Findings by the Numbers:

• 6,635: The number of inappropriately paid claims by Medicare for claims subject to the postacute care transfer policy.
• 91%: The percentage of inappropriately paid claims where the inpatient hospitalization was followed by claims for home health services.
• $19,471,432: The amount Medicare overpaid to hospitals due to Common Working File (CWF) edits related to home health care, SNFs, and non-IPPS hospital not working properly.
• $31.7 million: The approximate amount of money that Medicare could have saved over 4 years if it had had controls to ensure that the Common Working File (CWF) edits were working properly.

OIG Recommendations to CMS:

• “Direct the Medicare contractors to recover the $19,471,432 in identified overpayments in accordance with CMS’s policies and procedures;
• direct the Medicare contractors to identify any transfer claims on which the patient discharge status was coded incorrectly and recover any overpayments after our audit period;
• correct the CWF edits and ensure that they are working properly; and
• educate hospitals on the importance of reporting the correct patient discharge status codes on transfer claims, especially when home health services have been ordered.”

What the Hospital Needs to know:

“The Federal Register emphasizes that the hospital is responsible for coding the bill on the basis of its discharge plan for the patient. If the hospital subsequently determines that postacute care was provided, it is responsible for either coding the original bill as a transfer or submitting an adjusted claim.”

63 Fed. Reg. 40954, 40980 (July 31, 1998). See also MLN Matters Number: SE0408.

There were no changes made to the Post-Acute payment policy for the current 2014 CMS Fiscal Year that goes from October 1, 2013 through September 30, 2014. A complete list of applicable DRGs can be found in Table 5 of the IPPS Final Rule.

Specific detail regarding the PACT policy can be found in the Code of Federal Regulations (CFR) Title 42: Public Health §412.4 Discharges and transfers.

Just as you think you have mastered the challenge of complying with a Medicare rule, the rule changes and you have to start over. So it goes like this – know about the rules, understand the rules, implement processes to comply with the rules and then make sure the rules don’t change on you. Such was the case with the instructions for billing for certain laboratory tests.

It is almost July and just in time, CMS has issued the modifier to be appended to laboratory services when separate payment under OPPS is appropriate. Modifier L1 will be used starting July 1, 2014 to indicate that laboratory services provided to hospital outpatients meet one of the exceptions of “unrelated” or “lab test only” lab services.

As a reminder, the 2014 OPPS final rule packaged almost all clinical laboratory services as ancillary services with a revised Status Indicator (SI) of “N”. There are exceptions when lab tests are the only service provided or if the lab services are “unrelated” to other outpatient services. The original instructions from CMS for obtaining separate payment for the excepted lab services, was to submit a 14x type of bill (TOB). After concerns from the National Uniform Billing Committee (NUBC) and providers, CMS agreed to change the requirements effective July 1, 2014.

CMS Transmittal 2971 (CR 8776) (MLN Matters Article MM8776) issued May 23, 2014 manualized changes related to the new billing requirements for separately reimbursable laboratory services.

• Non-Patient (Referred) Laboratory Specimen - A non-patient is neither an inpatient nor an outpatient of a hospital. The patient is not physically present at the hospital but has a specimen submitted for analysis, for example, from a physician’s office or a non-hospital clinic. These non-patient laboratory services are to be billed on a TOB 14X. They are paid under the clinical laboratory fee schedule (CLFS) at the lesser of the actual charge or the fee schedule amount. Part B deductible and coinsurance do not apply.
• Outpatient lab tests only - If the only services the hospital provides to an outpatient are outpatient laboratory tests, the lab services are separately reimbursable and may be submitted on a TOB 13x with modifier L1 beginning July 1, 2014. The L1 modifier must be added to each lab line item on the claim. Such patients do not receive any other hospital outpatient services on the same day of service.
• Unrelated outpatient lab tests- If the hospital provides an outpatient laboratory test on the same date of service as other hospital outpatient services that is clinically unrelated to the other hospital outpatient services, then this lab service is also separately reimbursable and may be submitted on a TOB 13x with modifier L1 beginning July 1, 2014. Again, each lab line item that meets the exception requirements for separate Medicare reimbursement must be appended with the L1 modifier. Clinically unrelated means the laboratory test is
• ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, and
• for a different diagnosis.
• Payment for separately reimbursable outpatient laboratory tests is the lesser of the actual charge or the fee schedule amount for lab tests paid under the CLFS with no Part B deductible or co-pay.

The transmittal also addressed the payment of laboratory services related to Part B Inpatient claims (12x claims when there is no Part A payment). The new Part A to B rebilling rules from the 2014 IPPS Final Rule allow the submission of all Part B services on a 12x TOB when there is no Part A payment because the inpatient admission was not medically necessary. For these claims, the laboratory services will be packaged according to the OPPS rules since associated Part B services are payable under the expanded Part B billing.

When there is no Part A payment because the patient is not eligible for Part A or has exhausted Part A benefits, only limited Part B services may be billed on a 12x TOB. For these types of claims, the laboratory services will be reimbursed separately if the associated Part B services are not billable / payable under the limited Part B billing.

Just as hospitals had likely gotten their systems and processes in place to handle the 14x type of bill, the rules changed. Now hospitals need to start again on new systems and processes for use of the new modifier L1 to allow separate payment for laboratory services. Job security for someone?

Have you ever questioned whether a patient actually has a UTI or not, based on the clinical signs and symptoms documented in the medical record, even if “UTI” is documented by the physician? In this week’s article, we'll be discussing UTIs in more specified detail to help with this very issue, as well as CKD.

UTI

Lab Results

We all should be aware that urine cultures growing greater than 100,000 colony forming units (CRU/mL) usually indicates that an infection is present.

Sometimes an infection, if symptoms are present, may be indicated with lower numbers (1,000 to 100,000 CFU/mL).

If a patient has a urine sample collected with a catheter, which minimizes contamination, results of 1,000 to 100,000 CFU/mL may be considered significant.

Symptoms of a UTI

• Painful urination
• Frequent urination
• Urine that is cloudy, bloody, or has an odor
• Pain and pressure in the pubic bone area (women) and rectal pressure (men)
• Feeling of a full bladder but only have drops of urine on urination
• Tiredness
• Weakness
• Fever if the UTI has spread to the kidneys or blood
• Fever is not common with a UTI of the lower urinary tract (urethra or bladder)

NOTE FROM 2Q Coding Clinic, page 20

The provider must clearly document the causal relationship between the UTI and catheter. A coder cannot automatically assign a Catheter-Associated Urinary Tract Infection (CAUTI) when the patient has an indwelling catheter and then develops a UTI.

However, preventing and tracking CAUTIs is very important so if a patient has an indwelling catheter and a UTI, the coder should query the provider as to the cause of the UTI. This information should be documented in the record, as well.

UTI’s in the Elderly

TIP

Look for catheter use in the elderly.

Symptoms can appear non-specific and a diagnosis may be more difficult to determine in the elderly population and/or for those patients in healthcare settings requiring long-term catheter use.

UTI Due to a Catheter--See Complication, catheter, urethral, indwelling, infection and inflammation in the alphabetic index.

• ICD-9--(996.64)
• ICD-10—(T83.51X_) (seven characters)
• initial encounter
• subsequent encounter
• sequela

Contaminant

Remember, if a UTI is documented and the urine sample grows >100,000 colonies, but is labeled as contaminated, no UTI code is reported.

Something You May Not Know

• Females get UTIs more frequently than males.
• For patients that have frequent UTIs, their bacteria may become resistant to antibiotics over time.
• Patients may be more prone to recurring UTIs if the following are present:
• Kidney disease
• Diseases that affect the kidneys, i.e. Diabetes, Hypertension, etc.
• Compromised immune systems

Chronic Kidney Disease

Chapter 14: Disease of Genitourinary System (I-10)-Coding Guidelines

(Unless otherwise indicated, these guidelines apply to all health care settings)

1. Stages of chronic kidney disease (CKD)
   
   The ICD-10-CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).
   
   If both a stage of CKD and ESRD are documented, assign code N18.6 only.
   
   
2. Chronic kidney disease and kidney transplant status
   
   Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
   
   
3. Chronic kidney disease with other conditions
   
   Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

See I.C.9. Hypertensive chronic kidney disease

See I.C.19. Chronic kidney disease and kidney transplant complications

NOTE FROM 3Q Coding Clinic, page 3

Complications of a transplanted organ are assigned when the transplanted organ is being rejected by the recipient or there are other complications or diseases of the transplanted organ. Ex: A patient develops Acute Renal Failure after a transplant. If the post-transplant condition affects the function of the transplanted organ, two codes are required. One for the Complication of the Transplanted Organ (996.81) (T86.12), which is sequenced as the principal diagnosis, and a second code describing the Acute Renal Failure (584.9) (N17.9).

Pre-existing conditions or medical conditions that develop after a transplant are coded as Complications of the Transplanted Organ only when they affect the function of that organ.

Status code V42.0 should only be used if there is no complication of the organ replaced. A V42.x status code is never used in conjunction with a (996.8x) code if there is no complication of the same transplanted organ.

Sometimes there are no easy solutions when it comes to coding. After all record documentation has been thoroughly reviewed and analyzed there may be only one solution left. When in doubt, query the physician. The worst that can happen is the physician says ‘no’, right?

Resources:

American Association for Clinical Chemistry

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Medicine.Net

Q:
We have been told to use modifier 76 on CPT code 93005 when more than 1 EKG is performed on the same date of service, and not to use modifier 59. We are seeing claims where the EKG is hitting our internal billing edit for a CCI conflict. These are scenarios where it would be appropriate to separately report the EKG. Will modifier 76 by-pass a CCI edit? 

A:

No. Chapter 1 of the CCI policy manual states modifier 76 will not bypass a CCI edit.

In your scenario, you would have to use modifier 59 to bypass the CCI edit; this would indicate the EKG was performed as a separate and distinct service from the other procedure(s) hitting the internal CCI edit.