When Medicare reviewers audit your records, your documentation should “tell a good story.” For example, for rehabilitative therapy does your record tell what was wrong, when it happened, how it affected the patient’s life, why skilled services are needed, which services are needed and for how long and often, that a physician was involved in the patient’s care, and finally what was the patient’s outcome? I also review therapy records and complete, accurate documentation tells a compelling story of a patient’s therapy episode.

The first CERT Task Force scenario is a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. In addition to actual pre- and post-payment reviews, Medicare Administrative Contractors (MACs) provide feedback and education to providers through publication of their review findings, direct provider education, and now through collaboration with each other and the CERT review program. Certain A/B MACs are working together through the CERT A/B MAC Outreach and Education Task Force to educate providers on costly claim denials and billing errors to Medicare with an ultimate goal of reducing the national payment error rate.  

This focus on therapy services is timely as April is National Occupational Therapy month. In addition to sharing some of the key points from this guide, MMP would like to acknowledge the valuable contribution of Occupational Therapists to healthcare. The older I get, the more I value the ability to perform the physical functions necessary to lead an active lifestyle and to accomplish simple activities of daily living. When age, illness, or injury impairs function, occupational therapists are there to help patients restore and maintain their abilities.

In addition to their technical skills, all rehabilitative therapists must document their services in a manner consistent with Medicare’s documentation requirements. According to the CERT Task Force guide, “The leading cause of payment errors for therapy services is ‘insufficient’ documentation in the medical records.” Therapy documentation is often missing the required elements as outlined in applicable local coverage determinations and the Medicare manuals.

Here are some of the key documentation elements from the guide, LCDs, and the Medicare manuals.

• Plan of Care must include:
• The patient’s diagnoses (helpful to include functional limitations)
• Measurable long term goals for the entire episode of care
• Type of therapy (PT, OT, or SLP) (helpful to describe specific treatments, such as therapeutic activities, neuromuscular reeducation, etc.)
• The amount, duration and frequency of services
• Legible, dated signature and professional identity of the person establishing the plan and the practitioner certifying the plan
• Treatment notes must include:
• Date of treatment
• Specific intervention(s) provided and billed
• Total timed code treatment minutes and total treatment time in minutes
• Signature and professional identification of the qualified professional who furnished the services
• Functional Reporting
• Nonpayable G-codes and severity modifiers reported on claim must be documented in the therapy record
• Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

I encourage therapists to review the CERT Task Force guide, as well as the Medicare manuals and LCDs for therapy services for a complete discussion of the documentation requirements. I realize a lot of documentation is required, but good therapy documentation paints a complete and accurate picture of the patient’s conditions, the need for therapy, the treatments provided, and the patient’s ultimate outcome. For my nerdy, healthcare brain, it is like reading a good novel!

On April 1st, President Obama signed into law the Protecting Access to Medicare Act of 2014. Per a White House Press Secretary release this new law “averts cuts to Medicare physician payments that will go into effect on April 1, 2014, under the current-law “sustainable growth rate” system, to extend other health-related provisions set to expire, and to make other changes to current-law health provisions.” In addition to averting cuts to physician payments, this law includes additional “Medicare Extenders” and “Other Health Provisions.” But before looking at some of the more significant topics within the law, it is interesting to note how quickly this bill was presented, voted on and became law.

• March 26, 2014: Representative Joe Pitts (R-PA), Chairman, Energy and Commerce Subcommittee on Health introduced H.R. 4302 the Protecting Access to Medicare Act of 2014.
• March 27, 2014: The House voted by a voice vote and approved the bill. This vote was under special rules that provided for no amendments, limited debate and only needed a two-thirds majority votes.
• March 31, 2014: The United States Senate passed the bill with a vote of 64 YEAs, 35 NAYs and 1 Not Voting.

April 1, 2014: The Act was signed into law by President Obama signed the Protecting Access to Medicare Act of 2014 into Law.

Spotlight on Extensions and Health Provisions in the Law:

Section 101: Physician Payment Update: This section provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through December 31, 2013. Further, it provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.

Section 103: Extension of Therapy Cap Exception Process: This section extends the exceptions process for outpatient therapy caps through March 31, 2015. When a provider requests an exception to the cap for medically necessary services they must submit the KX modifier on their claim. This law extends the application of the caps, exceptions process, and threshold for therapy services provided in a hospital outpatient department (ODP).

Therapy caps for 2014:

 

• Occupational Therapy (OT) cap is $1,920
• Physical Therapy (PT) and Speech-Language Pathology Services (SLP) combined is $1,920

 

Additional information regarding therapy caps can be found on the CMS Therapy Cap webpage as well as Chapter 5, Section 10.3 in the Medicare Claims Processing Manual.

Section 106: Extension of the Medicare-Dependent Hospital (MDH) Program: This program provides enhanced payment to small rural hospitals where Medicare beneficiaries makes up a significant percentage of inpatient days or discharges. This provision extends the program through March 31, 2015.

More information about MDH Hospitals can be found in the Acute Care Hospital Inpatient Prospective Payment System Fact Sheet. Specific criteria to be designated a MDH Hospital includes:

 

• It is rural (located in a rural area);
• It has 100 or fewer beds during the cost reporting period;
• It is not also classified as a Sole Community Hospital (SCH); and
• At least 60 percent of its inpatient days or discharges were attributable to Medicare Beneficiaries entitled to Part A during the hospital’s cost reporting period.

 

Section 111: Extension of Two-Midnight Rule:

For hospital staff closely involved in trying to implement the Two-Midnight Rule, I felt it was important to provide you with the exact language in the bill.

“(a) CONTINUATION OF CERTAIN MEDICAL REVIEW ACTIVITIES.— The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘‘Selecting Hospital

Claims for Patient Status Reviews: Admissions On or After October 1, 2013’’, posted on the Internet website of the Centers for Medicare & Medicaid Services, through the first 6 months of fiscal year

2015 for such additional hospital claims as the Secretary determines appropriate. (b) LIMITATION.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).”

What does this mean for hospitals?

 

• The Medicare Administrative Contractor (MAC) Probe and Educate program has now been extended for a fourth time through March 31, 2015.
• Recovery Audit Contractors “shall not conduct patient status reviews on a post-payment review basis” for inpatient claims with dates of service October 1, 2013 through March 31, 2015. It is important to remember that on February 18th CMS announced that current RAC activity is winding down during the new contract procurement round.
• Hospitals should take advantage of this additional time to continue to educate staff and fine tune your processes.

Section 212: Delay in Transition for ICD-9 to ICD-10 Code Sets

“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.”

This is a significant delay for everyone that has been proactively planning and providing education for an October 1, 2014 transition to the ICD-10 Code Sets. MMP plans to continue to provide I-10 Corner articles and encourages all to not look at this as a setback but as an opportunity to provide more training to your staff and test the readiness of your computer systems.

Section 221: Medicaid DSH

This law delays reductions in payments to Disproportionate Share Hospitals (DSH) by a year and then makes additional reductions through 2024.

There are still quite a few extensions and provisions not discussed in this article. MMP encourages those interested to review the Protecting Access to Medicare Act of 2014 in its entirety.

For this edition of the I-10 Corner, we have included some helpful hints that will make coding procedures in the Endocrine System a little easier.   To gain familiarity, practice looking up procedures in the ICD-10-PCS coding book that are performed at your facility on a routine basis.

Knowing the Root Operations is the key to making all of this work!                                              

FROM THE ICD-10-PCS REFERENCE MANUAL

Examples of Root Operations

Excision—Root operation B

Definition: Cutting out or off, without replacement, a portion of a body part

Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies

Examples: Partial thyroidectomy, ovarian biopsy

Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to

• Scalpel
• Wire
• Scissors
• Bone saw
• Electrocautery tip

Resection—Root operation T

Definition: Cutting out or off, without replacement, all of a body part

Explanation: N/A

Examples: Total nephrectomy, total lobectomy of lung

Resection is similar to Excision, except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

Release—Root operation N

Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out

Examples: Adhesiolysis of right ovary

The objective of procedures represented in the root operation Release is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Reposition—Root operation S

Definition: Moving to its normal location or other suitable location all or a portion of a body part

Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Examples: Reposition of undescended testicle

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

Laterality is necessary in code assignment for the following organs:

• Thyroid
• Ovaries
• Testicles
• Adrenals

EXAMPLE

‍

Don’t Forget: 0 vs O:

FROM THE ICD-10-PCS REFERENCE MANUAL

Values

One of 34 possible values can be assigned to each character in a code: the numbers 0 through 9 and the [whole] alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

 

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014
B4. Body Part

B4.3 Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.

 

Since the release of the 2014 IPPS Final Rule (CMS-1599-F), the Centers for Medicare and Medicaid Services (CMS) have provided additional guidance to several elements of the rule. On March 21st they released MLN Matters® Number: MM8666 proving guidance on how to implement the Part B Inpatient Payment Policies in the CMS-1599-F. This article is based on Change Request (CR) 8666 that updates the Medicare Benefit Policy Manual Chapter 6 – Hospital Services Covered under Part B. Now, let’s walk through highlights from the article.

When would a Hospital consider rebilling Part A to Part B?

When a hospital “self-audits” a Medicare beneficiary’s hospitalization after they have been discharged and determines that the inpatient admission was not reasonable and necessary and instead should have been a hospital outpatient stay, then they should consider rebilling.

A hospital can also consider rebilling when a Medicare Contractor has performed a complex review of an inpatient claim and denied the claim.

What Services are allowable by Medicare when the claim is rebilled?

“Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient…except for those services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatient and not inpatients.”

What are limitations of being able to rebill?

• The beneficiary must be enrolled in Part B,
• The allowed timeframe for submitting claims (within one calendar year from the date of service) hasn’t expired; and
• Waiver of liability payment is not made.

What is the process for submitting a claim?

• If you have already submitted a claim to Medicare for Part A payment, this claim must be cancelled before submitting the Part B services claim.
• Even if you have not yet submitted a claim “Medicare requires the hospital to submit a “no pay” Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services.”

At this point you would submit an inpatient claim for payment under Part B (a 12x type of bill).

How are Part B Payments made?

“Payment is made according to the Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients.”

What Type of Hospitals can submit Part B inpatient claims?

All hospitals that bill Part A services are eligible to bill the Part B inpatient services, including:

 

• Short Term Acute Care Hospitals paid under IPPS,
• Hospitals paid under OPPS,
• Long Term Care Hospitals (LTCHs),
• Inpatient Psychiatric Facilities (IPFs) and IPF hospital units,
• Inpatient Rehabilitation Facilities (IRFs) and IRF hospital units,
• Critical Access Hospitals (CAHs),
• Children’s Hospitals,
• Cancer Hospitals; and
• Maryland Waiver Hospitals.

 

What the Medicare Beneficiary Liability is and the Hospitals Responsibility for Payment?

 

• A Medicare Beneficiary is liable for their usual Part B financial liability.
• “If the beneficiary’s liability under Part A for the initial claim submitted for inpatient services is greater than the beneficiary’s liability under Part B for the inpatient services they received, the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts.”
• However “if the beneficiary’s liability under Part A is less than the beneficiary’s liability under Part B for the services they received, the beneficiary may face greater cost sharing.”

The MLN Article goes on to discuss what services a Hospital can and cannot bill for. The CMS makes a point to remind hospitals that “the services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions. Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization review determination must be filed no later than the close of the period ending 12 months or one calendar year after the date of service.”

MMP strongly recommend that hospital read the entire article as well as (CR) 8666 and share this information with all staff members that would be involved in this process.

Q:

What discharge disposition do I use if one of our patients is transferred to a swing bed in another hospital since the description for discharge disposition (61) is entitled, “Discharged/Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed?”

A:

Discharge disposition (61) may also be used for patients who are transferred to a Medicare-approved swing bed located in another facility. CMS notes that there has been confusion with this discharge disposition and refers us to MedLearn Matters, article SE0408, March 10, 2004 for further review. Please note the two additional references below, Medicare State Operations Manual and the Uniform Billing Editor by Optum also states a patient may be transferred to a Medicare-approved swing bed in another facility.

Medicare State Operations Manual

§482.66 Special Requirements for Hospital Providers of Long-Term Care Services (“Swing-Beds”)

The change in status from acute care to swing-bed status can occur within one facility or the patient can be transferred to another facility for swing-bed admission.

Uniform Billing Editor by Optum

For Medicare, this code is used to report patients who have been discharged/ transferred to a SNF level of care within the hospital’s approved swing-bed arrangement, or to another Medicare-approved swing bed in another location.

This edition addresses some of the changes found in the Endocrine System. Please refer to your ICD-10-CM code book to gain familiarity with the codes as this chapter has significantly expanded. Then try to notice what documentation is missing from the records you are reviewing so that you can advise your physicians on what is needed for I-10. Once again, brushing up on your Anatomy and Physiology will also be crucial for this chapter.

The Endocrine System consists of glands of the body that secrete hormones into the blood stream. The word Hormone means to set in motion. Hormones start the process of change in:

• Cells of specific body tissues
• A single organ
• A group of organs
• All cells of the body

Did you know? There are other organs in the body that produce hormones but, that is not their main function, such as the heart and stomach.

What Changed in the Endocrine Chapter?

• The diseases of the endocrine, nutritional, and metabolic diseases moved from Chapter 3 in I-9 to Chapter 4 in I-10
• Certain disorders of the immune system have been moved out of the endocrine chapter and into Chapter 3 in I-10, "Diseases of the Blood, Blood Forming Organs, and Certain Disorders".
• Gout was moved out of the Endocrine chapter and placed in Chapter 13, "Diseases of the Musculoskeletal System and Connective Tissue".
• The type and cause of Cushing's Syndrome is now needed to assign the correct code.
• More information is required to assign the correct code.
• For example: Congenital Hypothyroidism- The code has been expanded and we now must know if there is documentation of a goiter in order to assign the appropriate code.
• Diabetes Mellitus
• Many code titles were revised

Notice below how the two code sets differ. Chapter 4 has more than doubled in size!

DEFINITON

It will be Easy to remember that the Endocrine chapter codes begin with the letter E!

Diabetes Mellitus
One of the major changes we see in I-10 is in the Endocrine System for Diabetes Mellitus. First of all, Diabetes has its own subchapter heading. And, in I-9, Diabetes was classified to one category, 250. Now there are 5 categories for Diabetes in I-10 and they are listed below:

• E08, Diabetes Mellitus due to underlying condition
• E09, Drug or chemical induces Diabetes Mellitus
• E10, Type 1 Diabetes Mellitus
• E11, Type 2 Diabetes Mellitus
• E13, Other specified Diabetes Mellitus

Please note: "Use additional code to identify any insulin use (Z79.4)" is to be used with all diabetic cases except for Type 1. This additional insulin code is not assigned for Type 1 diabetic cases because insulin is required to maintain life.

The diabetic codes were expanded to reveal manifestations and complications of the disease via 4th or 5th characters instead of using an additional code to identify the manifestation.

FROM THE MANUAL

Here is an example of how the diabetic codes have been expanded to include more information as compared to I-10:

‍NOTE FROM AUTHOR
Trying to code controlled and uncontrolled diabetes is no longer a coding issue! Even better, we can capture inadequately controlled, out of control, and poorly controlled diabetes and code it to Diabetes Mellitus, by type with hyperglycemia.

 

DEFINITON

‍Hemoglobin A1c: 7 is not a lucky number when it comes to Diabetes!

A1C is a blood test that will determine an average blood sugar reading over a period of 3 months and will reveal how well diabetes is being controlled. An A1c level of <7% is the goal for all diabetics. The higher the A1c level, the higher the risk of developing diabetic complications. The table shows an A1c with the corresponding estimated average glucose reading (eAG).

FYI - Secondary Diabetes Mellitus
This type of diabetes is caused by another disease or condition. The code title has changed in I-10 for Secondary Diabetes:

I-9 Secondary diabetes mellitus, 249.0
vs.
I-10 Diabetes due to underlying condition, E08

NOTE FROM AUTHOR
Pay attention to the code instructions under E08 when coding Secondary Diabetes:
Code first the underlying condition, such as:

• Congenital Rubella (P35.0)
• Cushing's Syndrome (E24.-)
• Cystic Fibrosis (E84.-)
• Malignant Neoplasm (C00-C96)
• Malnutrition (E40-E46)
• Pancreatitis and other diseases of the pancreas (K85.-, K86.-)

Use additional code to identify any insulin use (Z79.4)

 

Coding Guidelines for Diabetes Mellitus

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014

Coding Guideline I.C.4.a., Diabetes Mellitus
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting the body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08-E13 as needed to identify all of the associated conditions that the patient has.

Coding Guideline I.C.4.a.5 (a), Underdose of insulin due to insulin pump failure
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code T38.3x6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned.

Coding Guideline I.C.4.a.6., Secondary Diabetes Mellitus
Codes under categories E08, Diabetes mellitus due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, poisoning).

Coding Guideline I.C.4.a.6.b., Assigning and Sequencing Secondary Diabetes Codes and Its Causes
The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09.

There are expanded instructions in Chapter 4 for coding late effects now called "Sequelae" in I-10.

EXAMPLE FROM ICD-10-CM CODER TRAINING MANUAL
Excludes 1 notes have been added to some categories between E50-E63 to indicate that the sequelae of the nutritional deficiency are assigned a code from category E64.

 

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

 

Have you noticed that when Medicare changes the rules, you are always working to come up with new processes to deal with the changes? Such was the case with the numerous revisions finalized for OPPS for 2014. Hopefully since it is now the middle of March, most hospitals have the new processes in place. But we thought it would be a good reminder to review the new requirements and some suggested process revisions for Skin Substitutes.

The 2014 OPPS Final Rule contained a lot of changes, one of which was the packaging of skin substitute products for 2014. Medicare now considers these products to be in the category of “drugs and biologicals that function as supplies or devices when used in a surgical procedure” so in 2014 Medicare will not make a separate payment for the product itself. The payment for the product is “packaged” into the payment for the application procedure.

The good news is that due to comments from the proposed rule, Medicare created two levels of payment for the application of skin substitutes based on whether the skin product was high or low cost. The addition of new HCPCS codes to accommodate the differential application codes requires hospitals to have processes to ensure the correct application code is billed with the correct type of skin product. The payment rates for application of a high-cost substitute are more than double the low-cost substitute application for most codes so the process is definitely important.

High-cost skin substitutes will continue to be billed with the current CPT skin substitute application codes, 15271-15278. The application of low-cost skin substitutes are to be reported with new HCPCS codes C5271-C5278. Note that the HCPCS codes are the same as the CPT codes with the beginning numeral “1” replaced with a “C” (for example CPT 15271 equates to HCPCS C5271).

Hospitals will have to consider if skin substitute application codes are built into the Charge Description Master (CDM) and selected when a charge is entered by the department or if the applications are coded by Medical Records coders. If these codes are built into the CDM, you will now have to have two sets of application charges, one for high-cost substitutes and one for low cost substitutes. Instead of eight items, you now have sixteen CDM entries.

Then the person selecting the charge in the department or the coder selecting the code will have to know whether a high-cost or low-cost skin substitute was applied. See the table (link) at the bottom of this article for a list of high and low-cost skin substitutes. This table includes the changed assignment of two skin products from the April OPPS update. For department charge entry, the superbill or charge sheet will need to be revised to reflect the new application codes. Coders will have to be careful in their selection of codes; automated coding systems may have edits to assist in assigning the proper codes.

Finally, Medicare has installed edits on their billing systems to identify mismatches between the skin substitute product and the application code. Claims hitting these edits will RTP (return to the provider) for correction. Billers will have to be made aware of what the RTP issue is and how to correct it. It is likely they will have to communicate with the department or coders to determine the proper correction.

As I stated above, it is always a process when dealing with Medicare. Guess that means job security for those of us who track and handle compliance with Medicare regulations.

Skin Substitute Product Assignment to High Cost/Low Cost Status for CY 2014

Q:

What is the correct discharge status code assignment for a state-designated vs. a non-state-designated ALF?

BACKGROUND
The Center for Medicare and Medicaid Services MLN Matters Number: SE0801 provides usage information on the correct patient discharge status codes for state-designated and non-state-designated ALFs, with an effective date of March 1, 2007. Since then, the National Uniform Billing Committee (NUBC) has made several revisions to the patient discharge status codes. The differences in the verbiage between CMS and the NUBC has caused a lot of confusion.

A:

Per the NUBC: The most recent (2014) Official UB-04 Data Specifications Manual is correct. “All of the “state designated” language was removed in December, 2008. The bottom line is that discharges to ALFs are always “04”.”

Per CMS:  “The NUBC is responsible for the maintenance and dissemination of guidance for the UB-04 code set.” The CMS has provided a subset of information for Medicare-participating providers. “For greater detail, providers should visit http://www.nubc.org/ in order to purchase a UB-04 manual.”

Please note: The NUBC has the final authority for the definition and instruction for all discharge disposition codes.

Source: MLN Matters Number: SE0801

Source: Direct email response from the NUBC on March 6, 2014

PNEUMONIA

Pneumonia is a common illness seen in the healthcare industry that affects millions of people each year in the United States. Bacteria are the most common cause of pneumonia in adults.

• Community Acquired Pneumonia (CAP) is acquired by people that have not recently been hospitalized or live in some type of healthcare facility such as a nursing home.
• Healthcare Associated Pneumonia (HCAP) is acquired by people while they’ve been in a healthcare facility such as a nursing home.
• Hospital Acquired Pneumonia (HAC) is acquired while a patient is hospitalized.

NOTE FROM AUTHOR
When a patient is admitted to the hospital with either HCAP or HAC, code Y95 for Nosocomial Condition should also be added – Refer to Coding Clinic 4th Qtr. 2013 page 118.

External sources may also be the source of Pneumonia.

• Aspiration Pneumonia – Caused by the inhalation of foreign material such as food, liquids, vomit or gastric secretions.
• Pneumonitis due to Inhalation of Food and Vomit – J69.0
• Code also any associated foreign body in the respiratory tract from category T17
• Pneumonitis due to Inhalation of Oil and Essences – J69.1
• Code first (T51-T65) to identify substance
• Pneumonitis due to Inhalation of Other Solids and Liquids – J69.8
• Code first (T51-T65) to identify substance
• Radiation Pneumonitis (J70.0) – Due to exposure of therapeutic doses of radiation.
• Use additional code (W88-W90, X39.0) to identify the external cause
• Ventilator Assisted Pneumonitis – J95.851

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.1

As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Code J95.851, should be assigned only when the provider has documented Ventilator Associated Pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12.0-J18.9 to identify the type of pneumonia.

Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

 

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.2

A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop ventilator associated pneumonia (VAP) J95.851. In this instance, the principal diagnosis would be the appropriate code from categories J12.0-J18.9 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.

RESPIRATORY FAILURE

In ICD-10-CM there will be combination codes to include Hypoxia and Hypercapnia

Acute Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.00
• With Hypoxia – J96.01
• With Hypercapnia – J96.02

Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.10
• With Hypoxia – J96.11
• With Hypercapnia – J96.12

Acute on Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.20
• With Hypoxia – J96.21
• With Hypercapnia – J96.22

Respiratory Failure, Unspecified

• Unspecified Whether with Hypoxia or Hypercapnia – J96.90
• With Hypoxia – J96.91
• With Hypercapnia – J96.92

Post-procedure Respiratory Failure

            Excludes 1 – Respiratory Failure in other conditions (J96)

• Acute Post-procedure Respiratory Failure – J95.821
• Acute and Chronic Post-procedure Respiratory Failure – J95.822

Respiratory Failure is always due to an underlying condition. Sequencing will be dependent on the circumstances of the admission. If two conditions are equally responsible and there are no chapter specific guidelines, the guideline for two or more diagnosis that equally meets the definition of principal diagnosis may be applied.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Official Guidelines for Coding and Reporting – Section I.C.10.b.3

BRONCHITIS

Manifestations of Acute Bronchitis can now be reflected in ICD-10-CM under category J20.

Acute Bronchitis due to:

• Mycoplasma Pneumoniae – J20.0
• Hemophilus Influenza – J20.1
• Streptococcus – J20.2
• Coxsackievirus – J20.3
• Parainfluenza Virus – J20.4
• Respiratory Syncytial Virus – J20.5
• Rhinovirus – J20.6
• Echovirus – J20.7
• Other Specified Organism – J20.8
• Unspecified – J20.9

EMPHYSEMA

Emphysema is a type of Chronic Obstructive Pulmonary Disease (COPD) involving damage to the air sacs (alveoli) in the lungs.

ICD-10 will now have codes to cover two different forms of Emphysema.

• Panlobular Emphysema (J43.1) - alveolar destruction occurs in all alveoli within the lobule simultaneously.
• Centrilobular Emphysema (J43.2) - destruction that begins at the center of the lobule.

When reporting categories for COPD (J44), Asthma (J45), Chronic Bronchitis (J42) and Emphysema (J43), an additional code should be assigned to show any specific external factors such as:

• Exposure to environmental tobacco smoke (Z77.22)
• Exposure to tobacco smoke in the perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17-)
• Tobacco use (Z72.0)

SINUSITIS

In ICD-10, there will also be individual codes for Acute Sinusitis, Acute Recurrent Sinusitis and Chronic Sinusitis for each individual sinus cavity.

• Acute Sinusitis – defined as symptoms of less than 4 weeks’ duration.
• Maxillary – J01.00
• Frontal – J01.10
• Ethmoidal – J01.20
• Sphenoidal – J01.30
• Pansinusitis – J01.40
• Other Acute Sinusitis – J01.80
• Acute Sinusitis, Unspecified – J01.90
• Acute Recurrent Sinusitis – defined as three or more episodes per year, with each episode lasting less than 2 weeks.
• Maxillary – J01.01
• Frontal – J01.11
• Ethmoidal – J01.21
• Sphenoidal – J01.31
• Pansinusitis – J01.41
• Other Acute Recurrent Sinusitis – J01.81
• Acute Recurrent Sinusitis, Unspecified – J01.91
• Chronic Sinusitis – defined as symptoms lasting longer than 8 weeks.
• Maxillary – J32.0
• Frontal – J32.1
• Ethmoidal – J32.2
• Sphenoidal – J32.3
• Pansinusitis – J32.4
• Other Chronic Sinusitis – J32.8
• Other Chronic Sinusitis, Unspecified – J32.9

Pansinusitis is when each sinus cavity on one or both sides of the face is affected. When multiple sinus cavities are affected but not Pansinusitis, a code from Other Acute, Acute Recurrent or Chronic (J01.80, J01.81 or J32.8) should be assigned.

Note:   When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should then be classified to the lower anatomic site. One example would be Tracheobronchitis to Bronchitis – J40.

INFLUENZA

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.C

Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.

If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category

J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.

Subcategory J10.8 - Influenza due to Other Identified Influenza Virus with Other Manifestation has been expanded to reflect the manifestations of the Influenza.

Influenza Due to Other Identified Influenza Virus with -

• Encephalopathy – J10.81
• Myocarditis – J10.82
• Otitis Media – J10.83
• Other Manifestation – J10.89

To derive at the most appropriate code for any condition, be sure to always read the additional instructions and Excludes Notes in your coding book and/or encoder.

This week, March 9-15, 2014, is Pulmonary Rehabilitation Week. MMP would like to thank all of the healthcare professionals who enhance the quality of life of individuals with lung disease through a Pulmonary Rehab program. We are glad that Medicare finally recognized Pulmonary Rehab as a distinct payable comprehensive program. But along with the benefit of Medicare coverage comes the challenges of meeting all of Medicare’s requirements for coverage. And for Pulmonary Rehab, like a lot of other services, that is no easy task.

The Medicare rules for Pulmonary Rehab can be found in the Medicare manuals, specifically the Benefit Policy Manual, Chapter 15, section 231 and the Claims Processing Manual, Chapter 32, section 140.4. Also, some local Medicare Administrative Contractors (MACs) have coverage policies or articles that further define coverage, such as specific diagnosis codes. Pulmonary Rehab professionals need to be fully aware of Medicare’s requirements and ensure that their program is in compliance.

A recent medical review of Pulmonary Rehab programs by Palmetto GBA, the Part A MAC for Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) found charge denial rates of 76-93%. All PR providers could learn from the results of these reviews so I would like to share some of the major findings.

Claims were denied for the following reasons related to the requirements for:

Diagnosis

• The documentation submitted does not represent a patient with moderate to severe chronic obstructive pulmonary disease (COPD) as defined by the Gold Classification II, III, and IV per 42 CFR 410.47.
• The documentation of post-bronchodilator pulmonary function studies does not meet the requirement of FEV1 less than 80% of predicted and FEV1/FVC of less than 70%.

Physician Referral

• There is no physician’s order/referral for admission to pulmonary rehabilitation services present.

Required Program Components

• Does not contain the required components for pulmonary rehabilitation program as defined in 42 CFR 410.47
• There is no psychosocial assessment of the individual's mental and emotional functioning as it relates to their rehabilitation or respiratory condition.
• There is no outcomes assessment as a written evaluation of patient progress related to the rehabilitation.
• Does not contain mandatory individualized treatment plans as a written, established, reviewed, and signed by a physician every 30 days as defined in 42 CFR 410.47.
• There is no physician's prescribed exercise program present in the documentation.
• There is no documentation of the patient's education or training as it relates to care and treatment.

Frequency and Limits

• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 36 and no more than two sessions per day as defined in 42 CFR 410.47.
• The documentation submitted does not meet the requirements for pulmonary rehabilitation services up to 72 sessions, with KX modifier and no more than two sessions per day as defined in 42 CFR 410.47.

Physician Oversight

• The documentation submitted does not indicate the supervising physician was available and accessible for medical consultations and emergencies at all times, when services were provided under the program as defined in 42 CFR 410.47.

As you can see, there are a lot of requirements which equals a lot of reasons for Medicare to deny your Pulmonary Rehab claim. Make sure you are following all of Medicare’s requirements so that you can continue to provide this valuable service and actually get paid for your work.