This is Respiratory Care Week and we at MMP would like to thank all of you who provide respiratory care for your hard work and dedication to improving the respiratory health of your patients. When my oldest son was eleven, he had severe pneumonia that required an extended hospitalization. I remember anxiously watching as the respiratory care team provided wonderful services that helped him to recover. Healthcare is most appreciated when truly needed and I am most appreciative of the care given by those respiratory therapists to my young son.

That son now has two beautiful children, the youngest a one-year old daughter. She now understands the word “no” but very much does not like to hear it. Like her, for all of us, it is sometimes hard to be told “no” constantly. Unfortunately, Medicare’s National Correct Coding Initiative (NCCI) often tells providers “no” about the reporting of certain code combinations. Respiratory services are no exception and in honor of Respiratory Care Week, I thought I would review some of the CCI edits for respiratory services. The complete CCI edits can be found at the Medicare NCCI webpage. The information below comes from the NCCI Policy Manual, Chapter 11. Please refer to this manual for more information.

• Alternate methods of reporting data obtained during a spirometry or other pulmonary function session should not be reported separately. For example, the flow volume loop is an alternative method of calculating a standard spirometric parameter. CPT code 94375 is included in standard spirometry (rest and exercise) studies.
• If multiple spirometric determinations are necessary to complete the service described by a CPT code, only one unit of service should be reported. For example, CPT code 94070 describes bronchospasm provocation with an administered agent and utilizes multiple spirometric determinations as in CPT code 94010. A single unit of service includes all the necessary spirometric determinations.
• Complex pulmonary stress testing (CPT code 94621) is a comprehensive stress test with a number of component tests separately defined in the CPT Manual. It is inappropriate to separately code venous access, ECG monitoring, spirometric parameters performed before, during and after exercise, oximetry, O2consumption, CO2production, rebreathing cardiac output calculations, etc., when performed as part of a complex pulmonary stress test.
• CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction. CPT code 94060 includes the administration of a bronchodilator. It is a misuse of CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) to report 94640 for the administration of the bronchodilator included in CPT code 94060. The bronchodilator medication may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) and CPT code 94664 (demonstration and/or evaluation of patient utilization of an aerosol generator...) generally should not be reported for the same patient encounter. The demonstration and/or evaluation described by CPT code 94664 is included in CPT code 94640 if it utilizes the same device (e.g., aerosol generator) that is used in the performance of CPT code 94640. If performed at separate patient encounters on the same date of service, the two services may be reported separately.
• CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction...) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes. CPT code 94640 should only be reported once during a single patient encounter regardless of the number of separate inhalation treatments that are administered. If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) should not be reported separately. It is a misuse of CPT code 94060 to report it in addition to CPT code 94640. The inhaled medication may be reported separately.

There has been a lot of discussion about the last bullet point, which was new for 2014, that states that inhalation treatment “should only be reported once during a single patient encounter”. The issue is the definition of the term “encounter”. According to a statement issued by a coding specialist for NCCI, “encounter” in this instance means “direct personal contact in the hospital between a patient and a physician (or other clinician)… If the professional completes the inhalation service(s) and terminates the patient encounter but returns later that day to initiate additional inhalation treatment(s) reportable as CPT code 94640, an additional UOS (unit of service) of CPT code 94640 may be reported for this subsequent patient encounter.” We encourage all providers to clarify the interpretation of the term “encounter” with your Medicare Administrative Contractor (MAC) and other payers.

These NCCI rules again demonstrate that healthcare involves more than just providing patient care. Coding and billing play a major part in all aspects of healthcare. So someone in your Respiratory Care department needs to be aware of and understand the coding and billing requirements for Medicare and other payers. Because when Medicare says “no”, they mean “no”.

Medical Management Plus enjoys acknowledging the various healthcare professionals with whom we work during their designated annual recognition times. October is National Physical Therapy month and we thank all of those who work diligently in the physical therapy occupation to improve the health of their patients. In association with this recognition, here are some questions and answers related to Medicare therapy services.

1. If a patient in a hospital setting (observation or inpatient) receives therapy services, do you have to follow the Part B (general considered outpatient) therapy guidelines?
2. outpatients receiving observatipon services
3. inpatients whose inpatient admission does not meet criteria so only Part B services are billed, and
4. inpatients who only have Medicare Part B coverage (patient does not have Medicare Part A or Part A benefits are exhausted).
   The 2014 IPPS Final Rule states “we (CMS) believe we also must apply the therapy caps and all other Part B coverage and payment rules to hospital inpatient therapy services paid under Part B. Accordingly, (therapy services) billed to Medicare Part B, … will be subject to the Part B therapy caps …, the therapy caps exceptions process, the manual medical review process, and all other requirements for payment and coverage of therapy services under Part B (for example, functional status reporting requirements).”
5. Is a discharge summary required for all Medicare patients receiving outpatient therapy services?Yes, the Medicare Benefits Policy Manual, Chapter 15, Section 220.3 states:
   “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment. … The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge. In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.”
6. If a patient discontinues outpatient therapy unexpectedly, must you report a discharge functional limitation HCPCS (G) code and modifier? What do you do if the same patient later returns to continue therapy?
   
   Per MLN Matters Special Article SE 1307: “Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly. When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
   
   When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
7. the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or
8. a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.
9. NOTE: A reporting episode will automatically be discharged when it has been 60 or more calendar days since the last recorded DOS.
10. Is it appropriate to use modifier 59 to by-pass CCI edits for therapy services that are performed during the same session but at separate times?
11. Yes, per the NCCI manual, “Some NCCI edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”
12. Where can I find the information on the time reporting requirements for rehabilitative therapy services?
13. That information can be found in the,Medicare Claims Processing Manual, chapter 5 ,section 20.2and also -Medicare Therapy Billing Scenarios
14. Are Medicare contractors and affiliates still performing medical review of therapy services?
15. Yes, the RACs continue to perform manual medical review of therapy services exceeding the annual threshold amount and the OIG recently published areview of outpatient therapy services. Although this review focused on an independent therapy provider (not hospital outpatient), the findings are relevant to therapy in either setting. Findings included:
    
16. Plan of Care (POC) goals that were not measurable or pertinent to the patient’s functional limitation,
17. Problems with the therapist’s signature on the POC and treatment notes
18. Lack of specific skilled interventions in the treatment notes
19. Lack of documentation of time
20. Lack of medical necessity for therapy services
21. Progress notes not performed every 10th treatment day
22. Physician certifications not signed and/or dated
23. Other Medicare contractors such as the Medicare Administrative Contractors (MACs) and CERT reviewers may also review therapy records.

As always, therapists have more to worry about than just how their patients are progressing.

In this week’s article, we are featuring Neoplasms focusing mainly on the differences between ICD-9-CM and ICD-10-CM Coding Guidelines. There are only a few changes in the wording of the guidelines but there are several additional guidelines in ICD-10-CM. Only the differences in the two classification systems are listed below.

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

GUIDELINES COMPARISON

‍Primary malignant neoplasms overlapping site boundaries

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere.

For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Malignant neoplasm of ectopic tissue

Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to pancreas, unspecified (C25.9).

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

EXAMPLE

If the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.

See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.

 ‍

GUIDELINES COMPARISON

‍Additional guidelines in ICD-10-CM

2.i) Malignancy in two or more noncontiguous sites

A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.

2.j) Disseminated malignant neoplasm, unspecified

Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.

2.k) Malignant neoplasm without specification of site

Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.

2.l) Sequencing of neoplasm codes

2.l.1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The metastatic sites.

2.l.2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.

2.l.3) Malignant neoplasm in a pregnant patient

When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.

2.l.4) Encounter for complication associated with a neoplasm

When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.

The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.

2.l.5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

2.l.6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, and followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

2.m. Current malignancy versus personal history of malignancy

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms inremission versus personal history

The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission.

There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues.

If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

2.o. Aftercare following surgery for neoplasm

See Section I.C.21. Factors influencing health status and contact with health services, Aftercare

2.p. Follow-up care for completed treatment of a malignancy

See Section I.C.21. Factors influencing health status and contact with health services, Follow-up

2.q. Prophylactic organ removal for prevention of malignancy

See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal

NOTE FROM AUTHOR

Notice the dashes (-) in the neoplasm table below:

Note: Codes listed with a dash (-), following the code, have a required additional character for laterality. The tabular must be reviewed for the complete code.

Example: Adrenal cortex (C74.0-) requires a fifth digit to determine right, left, or unspecified adrenal cortex for code completion.

If you haven’t done so already, MMP strongly encourages you to review all of the ICD-10-CM Coding Guidelines for each chapter. Often, we tend to use our memory when utilizing the guidelines and a refresher just might be helpful. You may be amazed at the guidelines that you remember and those you may have forgotten.

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.

Resources:

AHIMA ICD-10-CM Training Manual

ICD-10-CM Coding Book by Ingenix

The Fourth Time’s the Charm

CMS is having a hard time getting their transmittal concerning the denial of related claims correct. Perhaps the fourth time is the charm and hopefully between the writing of this article and its subsequent publication in our weekly newsletter, CMS will not rescind and republish this change request yet again. Originally back in February, CMS published Transmittal 505 but in a little over a month, it was rescinded due to the need to “clarify CMS policy.” Then on August 8th, Transmittal 534 was released – please refer to our article Medicare Allows Denials of Related Claims. This one lasted less than a month, and four days before the effective date it was replaced with Transmittal 540. I immediately recognized a discrepancy in Transmittal 540 between the policy section and the Manual Instructions. Evidently CMS also saw the error and hence the latest revision to these instructions in Transmittal 541.

So what has changed from version 1 to 2 to 3 to 4?

Version One (Transmittal 505) gave the MAC, RAC and ZPIC the discretion to deny a part B claim related to a denied part A claim which was not considered reasonable and necessary. It included an example of a diagnostic test deemed not reasonable and necessary, allowing the denial of the professional component for that test.

In Transmittal 534, the second version, the diagnostic test example was removed and the RACs must utilize the review approval process as outlined in their scope of work when performing reviews of “related” claims. This transmittal also required CMS approval before MACs and ZPICs can initiate “related” reviews and MACs must publish notice of such reviews on their website. The example given in this transmittal included denial of physician claims if a procedure was determined to not be medically necessary and downgrading the physician’s E&M service from inpatient to outpatient if the inpatient stay was determined to not meet criteria (that is, the services could have been provided on an outpatient basis).

Version Three, Transmittal 540, replaced 534 “to adhere to CMS Inpatient recoding policy standards” and the part of the above noted example related to down-coding physician E&M services from inpatient to outpatient was removed. The only example now listed is:

“When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. 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 may occur for the performing physician’s Part B service.”

Transmittal 540 corrected the above example in the Manual Instructions, but kept the “old” example in the policy section – likely an oversight. Transmittal 541, the fourth and hopefully final version, makes the example consistent in both sections.

So for now it appears the denial of related claims is limited to inpatient surgical claims where the surgical procedure itself is determined to not be medically necessary based on the documentation in the hospital record. This should be an impetus for both hospitals and physicians to make sure documentation in the hospital’s record supports the medical necessity of the procedure. This may require including documentation from the physician’s office records in the hospital medical record to provide sufficient history of the condition and previous treatments to justify the procedure. Though this step toward coordination of reviews between hospital and physician records has gotten smaller and smaller, at least it is a starting point. Maybe in the future CMS will expand its scope.

Q:
An article in a recent Wednesday@One talked about the medically unlikely edits (MUEs) and the newly published MUE Adjudication Indicators (MAIs). In the past, CMS did not publish all MUE values – some were maintained as confidential. Does the implementation of the MAIs mean that all MUE values are now published? 

A:

No, even with the implementation of MAIs, not all MUEs and their corresponding MAIs are published. This is explained best in Transmittal 1421. Below is the excerpt from Transmittal 1421. Transmittals are technical directions to the Medicare Administrative Contractors (MACs) so the organization referenced in the quote refers to the MACs.

“For HCPCS codes with confidential MUEs (i.e., Publication Indicator = 0), the MAI levels may not be published or shared with anyone outside of your organization. All other MAIs for non-confidential MUEs can be published or shared.”

What Is and What Is Not?

Since CMS guidance on the two-midnight benchmark and presumption was put forth in the 2014 IPPS Final Rule, CMS and their contractors have worked at educating providers on what appropriately constitutes a two-midnight expectation and how that needs to be documented in the medical record. The Medicare Administrative Contractors (MACs) are in the midst of the Probe and Educate program where they review short stay inpatient claims, make their determination regarding the appropriateness of inpatient status and then educate providers on their specific cases. So a lot is being said about “what is” an appropriate inpatient admission, but “what is not” an appropriate inpatient admission beyond the consideration of two midnights?

With the implementation of the two-midnight benchmark, CMS intended to reduce inappropriate payments for medically unnecessary short-stay inpatient admissions and to reduce extended observation stays. CMS has made it clear that if a patient receiving observation services is approaching a second midnight and will still be receiving medically necessary services requiring a hospital setting, then it is appropriate for the physician to order an inpatient admission. In our review of 835 claims data, Medical Management Plus is seeing some hospitals that continue to have a large percentage of their observation stays that go beyond the second midnight. These cases could potentially have been converted to an inpatient admission prior to the second midnight. We encourage all hospitals, but especially those hospitals with a high incidence of obs stays beyond a second night, to have systems in place that allow case managers to carefully evaluate observation stays approaching a second midnight to determine if they should be appropriately converted to an inpatient status. This would result in the hospital receiving an MS-DRG payment instead of an outpatient payment.

But don’t assume that just because the patient is there past a second midnight that an inpatient admission is always correct. With this in mind, is it ever appropriate to have an outpatient stay or outpatient with observation stay that goes beyond a second midnight? The answer is yes because not all patients staying for a second night are still receiving medically necessary therapeutic or diagnostic services that require a hospital setting. Medical Management Plus recently reviewed several outpatient records with a length of stay exceeding 24 hours and two midnights to determine if we thought an inpatient admission would have been appropriate.

We admit that although CMS has indicated they believe their current guidance is much easier to understand and implement, there is still a lot of subjective judgment in determining patient status. But here are some of the circumstances that we observed in our review that we believe do not warrant an inpatient admission:

• Patients who complete diagnostic testing prior to the second midnight but remain in the hospital a second night waiting on the attending physician to evaluate test results
• The patient’s treatment is not completed until late at night and the patient remains overnight due to the late hour to be discharged the next morning
• Needed tests or treatments are delayed because it is the weekend
• Lack of communication, timely orders, physician availability or other causes of delays in obtaining needed consultations
• Unable to discharge patient while making post-acute care discharge arrangements
• Outpatient testing that could have been safely provided on an outpatient basis after the patient was discharged, but is provided while the patient is in the hospital for patient convenience

There were also some records where the reason for the second midnight stay was not clearly documented. For example, if the patient is staying for tests that could be provided on an outpatient basis, is he/she staying because of physician concerns about the patient‘s risk? Is that last hemodialysis treatment in the hospital due to the patient’s medical condition or for the patient’s convenience? As always, clear and complete physician documentation is critical to knowing the correct patient status.

Part I can be found by clicking here.

Coding of Burns and Corrosions

There is now a distinction made in ICD-10-CM between burns and corrosions. Coding guidelines are the same for both burns and corrosions. The difference between the two would be:

• Burns – Thermal burns from a heat source.

1. Fire
2. Hot appliance
3. Electricity
4. Radiation
5. Sunburns are not included

• Corrosion – A burn secondary to chemicals (as it makes contact with external or internal tissue) such as:

1. Acids
2. Bases
3. Oxidizers
4. Solvents
5. Alkylants
6. Mustard gas

Current burns are classified in ICD-10-CM by:

• Body site
• Depth – Burns located at the same site but of different degrees is coded to the highest degree documented by provider
• First degree – erythema
• Second degree – blistering
• Third degree – full thickness injury
• Extent – Total Body Surface (TBS) for Third Degree Burns

1. Burns – Category T31
2. Corrosions – Category T32

• T31 and T32 are based on the classic “rule of nines” in estimating TBS

1. Head and neck – 9%
2. Each arm – 9%
3. Each leg – 18%
4. Anterior trunk – 18%
5. Posterior trunk – 18%
6. Genitalia – 1%

• Percentage assignment may be changed by providers to accommodate patients with larger heads, buttocks, thighs or abdomen
• Categories T30.0 and T30.4 for Burn or Corrosion of unspecified body region, unspecified degree are not to be assigned on inpatient accounts
• External cause / Agent
• Laterality
• Left
• Right
• Unspecified
• Encounter – Seventh character designates episode of care
• Initial encounter – A
• Subsequent encounter – D
• Sequela – S (encounters for late effects of burns or corrosions such as scars or joint contractures)

NOTE FROM ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING

Section I.C.19.d.3

Non-healing burns are coded as acute burns.

Necrosis of burned skin should be coded as a non-healed burn.

Sequencing Burns / Corrosions

• Sequence code reflecting the highest degree first when more than one burn/corrosion is documented
• When both internal and external burns/corrosions have been documented, the circumstances of admission govern the selection of the principal diagnosis
• When the admission is for burn injuries and other related conditions such as respiratory failure and/or smoke inhalation, the circumstances of admission govern the selection of principal diagnosis

Adverse Effects, Poisoning, Under-dosing and Toxic Effects

Codes within the category T36 – T65 range are combination codes. This would include the substance related to the poisoning, adverse or toxic effect, under-dosing and the external source. There will be no need to assign an additional external cause code in ICD-10-CM.

Adverse Effect

An appropriate code should be assigned for Adverse Effect when the drug was correctly prescribed and administered. An additional code should be assigned to show the manifestation of the Adverse Effect. Examples would be:

• Tachycardia
• Delirium
• GI Bleeding
• Renal Failure
• Respiratory Failure
• Nausea and vomiting

Poisoning

A Poisoning would constitute a reaction to the improper use of a medication via:

• Intentional overdose
• Error made in drug prescription
• Interaction of drugs and alcohol
• Nonprescription drug taken with correctly prescribed and administered drug

Poisoning codes have an associated intent shown in the 5th or 6th character.

• Accidental
• Intentional self-harm
• Assault
• Undetermined

An additional code should be assigned for all manifestations associated with poisonings.

A code for abuse or dependence should also be assigned if the provider documents a diagnosis of abuse or dependence of a drug/substance.

Coders should assign as many codes necessary to fully describe all drugs/substances and manifestations described for a particular admission.

Under-dosing

Under-dosing is a new concept under ICD-10-CM and is defined as taking less of a drug than is recommended or prescribed by a provider or the manufacturer.

• A code for under-dosing should never be assigned as a principal diagnosis.
• Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) code is to be used with an under-dosing code to indicate intent, if known.

Q:

Where can I find the new QIO contact information that we should put on the Important Message from Medicare (IM) letter?

 

A:

As of August 1st, the QIO Program began its 11th Scope of Work (SOW). The newly created Beneficiary and Family Centered Care – Quality Improvement Organizations (BFCC-QIOs) are responsible for managing discharge appeals.

There are two BFCC-QIOs for the nation. CMS awarded the two BFCC-QIOs contracts to Livanta, LLC located in Annapolis Junction, Maryland and KePRO located in Seven Hills Ohio. The 50 states, DC, Puerto Rico and the Virgin Islands have been divided into Five (5) Areas.

CMS has provided a 2014 QIO Program Transition Fact Sheet for Providers and Suppliers. In this fact sheet CMS instructs Providers that a list of current BFCC-QIOs as well as the Quality Innovation Network (QIN) QIOs can be found at http://www.qioprogram.org under Locate Your QIO.

We have all experienced times when our first attempt at something did not work out the way we planned. Then, if we didn’t just give up, we had to tweak our solution or try something different to accomplish our goal. Evidently Medicare is having a similar experience with their attempts to reduce Medicare paid claims error rates through the National Correct Coding Initiative and the Medically Unlikely Edits. CMS has recently made some modifications to both with the hope of better controlling improper coding and billing.

NCCI Edits and Modifier 59

The National Correct Coding Initiative (NCCI) contains Procedure to Procedure edits to prevent unbundling of services and inappropriate payments. The edits are based on the principle that the second code defines a subset of the work of the first code. However for some code combinations, there are times when reporting the two codes together on a claim is appropriate and there are HCPCS modifiers that allow some CCI edits to be by-passed.

One of the most commonly used modifiers is modifier 59 which is used to indicate that a service is “separate and distinct” from another service with which it is sometimes bundled. Directions in the NCCI manual instruct to use modifier 59 (if no other modifier fits) to report different encounters, different anatomic sites, and distinct services. For providers it is sometimes difficult to know exactly when the 59 modifier is appropriate and CMS reports that this modifier is indeed associated with considerable abuse and high levels of manual audit activity.

Modifier 59 is used infrequently and usually correctly for different encounters and used more frequently, but less correctly for separate anatomic site. And interestingly, CMS says the most common reason for using modifier 59 is also the most frequently incorrect usage – that is when it is used to define a distinct service. All of this incorrect usage voids the very purpose of the CCI edits.

In Transmittal 1422 (see MLN Matters Article MM8863), CMS is proposing four new HCPCS modifiers to define specific subsets of the -59 modifier. These modifiers are not required to be used at this time, and CMS will accept either a -59 modifier or one of the new modifiers for now, although they are encouraging providers to “rapidly” implement use of the new modifiers. CMS and/or the local Medicare Administrative Contractors (MACs) may require the usage of the new modifiers in the future especially for certain codes at high risk for incorrect billing.

The new modifiers (known as –X {ESPU} modifiers) are:

• XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
• XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
• XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
• XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

Transmittal 1422 explains a little better than the corresponding MLN Matters article that modifier 59 will still be accepted in many instances. However current, existing guidance concerning modifier 59 continues to apply - “the -59 modifier should not be used when a more descriptive modifier is available” which now includes the new more descriptive –X {ESPU} modifiers.

Medically Unlikely Edits

In a separate Transmittal (see MLN Matters Article MM8853) CMS reviews modification to the Medically Unlikely Edit (MUE) Program. This is basically the same information as previously presented in MLN Matters Special Edition article SE1422 but more details are provided (see the MMP article Medicare MUEs and Correct Bilateral Billing from July).

Like the NCCI edits, the MUE program (which began in January 2007) was implemented to reduce the Medicare paid claims error rate. The MUE is a limit on the number of units that Medicare will adjudicate. Initially, the MUE values were only adjudicated against the units reported on each line item of a claim. In April, 2013, CMS modified the MUE program so that some MUE values would be date of service edits. This means that if the units reported for one day of a HCPCS code (with a date of service MUE) exceed the MUE limit, no payment would be made for that code unless the denial was overturned on a provider-initiated appeal.

At the same time as the date of service edits, CMS introduced an “MUE adjudication indicator” (MAI) to the MUE edit table. The MAI field was not made public knowledge or published until the July 2014 MUE update. These indicators describe the type of MUE and how it is adjudicated.

• An MAI of “1” is a claim line edit. The MUE may be by-passed when appropriate by reporting units exceeding the MUE on separate lines with an acceptable modifier.
• An MUE with an indicator of “2” is an absolute date of service edit. Units of service exceeding the MUE value are considered “impossible” because they are contrary to statute, regulation or subregulatory guidance, including correct coding policies. Denials for services with an MAI of “2” will not be overturned on appeal.
• MUEs for HCPCS codes with an MAI of “3” are date of service edits based on clinical guidelines. These edits will cause an automatic denial if the units for a date of service exceed the limit, but the denial may be overturned on appeal if there is adequate documentation of medical necessity of correctly reported units.

Additional information in this MLN article reminds providers that a denial of services due to an MUE is a coding denial and not a medical necessity denial. Therefore an Advance Beneficiary Notice (ABN) will not shift liability to the beneficiary. There is also a reminder that bilateral services should be reported on one line with a modifier 50 and units of 1 to avoid an MUE denial. Corresponding Transmittal 1421 explains that in determining date of service edits, Medicare will consider all units of the date of service HCPCS on “all claim lines on the current claim and paid claim lines of prior finalized claims”, although only lines on the current claim will be denied. Is this a proactive step to prevent providers from reporting units on separate claims?

As Medicare modifies their regulations, hospitals have to modify their processes to comply and adjust to the new requirements. The two transmittals discussed here will require hospitals to utilize new modifiers and be aware of the different types of MUEs and their impact on billing and appeals. It is always something!

Over the past several weeks, our series of FY 2015 IPPS Final Rule articles have included Quality Program updates (Hospital Value Based Purchasing Program, Readmission Reduction Program and HAC Reduction Program), MS-DRG updates and the discussion of a potential Short Stay Hospital Payment System for Hospitals.

Common to all three articles is the payment impact to hospitals whether it is a quality program payment incentives or penalties, new MS-DRGs impacted by the Post-Acute Transfer Rule or what payment to hospitals for Short Inpatient Stays may look like in the future.

This week our focus takes a one-eighty as we discuss hospital charges by reviewing the Final Rule discussion of the Requirement for Transparency of Hospital Charges Under the Affordable Care Act. CMS used the Final Rule to serve as an opportunity to reiterate the requirement for hospitals to share what they charge for items and services provided to their patients. Even though the text for this topic takes up less than one page of the 597 page Final Rule, it is important that hospitals are aware of and quickly put a plan in place to comply with this requirement.

What is in the Final Rule?

The discussion in the Final Rule is broken into an overview of hospital charges and the Transparency of Hospital Charges Requirement. Key information from both sections is as follows:

Overview

• Hospital charges are determined by the individual hospital for items and services provided to patients.
• What Hospitals charge and what hospitals are paid from Medicare for items and services provided are two very different amounts.
• “Hospital reported charges are used in determining Medicare’s national payment rates (for example, billed charges are adjusted to cost to determine how much to pay for one type of case relative to another.)”
• Per CMS, hospital charges “remain an important component of our healthcare system. For example hospital charges are often billed, in full, to uninsured patients who cannot benefit from discounts negotiated by insurance companies.”
• The wide variation in charges by hospital makes it challenging for patients to compare the cost of similar services.
• In 2013, CMS released inpatient and outpatient data providing hospital charges that “in general were significantly higher than the amount paid by Medicare under the IPPS or the OPPS.”
• CMS believes that this “charge data comparisons is introducing both transparency and accountability to hospital pricing, and we are continuing to pursue opportunities to report on hospital charging practices.”

Transparency Requirement Under the Affordable Care Act

Section 2718(e) of the Public Health Service Act requires that “[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including diagnosis-related-groups established under section 1886(d)(4) of the Social Security Act.”

In the FY 2015 IPPS Proposed Rule CMS reminded hospitals of their obligation to comply with this section of the Act. With the Final Rule they reiterated the following specific guideline for hospitals:

• “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or their policies for allowing the public to view a list of these charges in response to an inquiry.”

CMS went on to indicate that “hospitals are in the best position to determine the exact manner and method by which to make the list public in accordance with the guidelines.”

CMS’s Expectations

• Make data consumer friendly “to help patients understand what their potential financial liability might be for services they obtain at the hospital, and to enable patients to compare charges for similar services across hospitals.”
• CMS expects hospitals to update their data at a minimum annually or as needed to reflect their current charges.
• CMS will continue to post data on the CMS Web site in a consumer friendly way. Data currently posted includes:
• May and June 2013 hospital charge data release,
• April 2014 physician data releases; and
• Data on geographic variation in payments and payments per beneficiary.

Consider yourself reminded, now what?

While you as the hospital are in the best position to determine how you are going to comply with these guidelines, the question that comes to mind is what information is already available to the public? It is amazing how much data is available and yet how far we still have to go to provide data in a consumer friendly format, let alone helping the public understand that charges and costs are two very different things.

What Data is Available?

As just mentioned, there is quite a bit of information available on the internet for consumers. However, after spending quite some time looking for and at the data, I am not convinced that consumers know what is available or could understand what it means.

State Level

The National Conference of State Legislature Web Site has a Web page dedicated to Resources for transparency and disclosure of health costs and provider payments: state actions. For those interested I encourage you to visit this site to see what if any legislation has been enacted in your state.

Ultimately, what I found was that the issue of price transparency is not a new one, several states have no legislation in place and several state health price information websites are maintained by State Hospital Associations.

Examples provided on this site include:

• “California’s Common Surgeries and Price Comparisonis a website allowing healthcare consumers to view and compare the price of 28 common elective inpatient procedures at hospitals across California.
• Florida has established a Website that enables consumers to obtain data on hospitals' charges and readmission rates (http://www.floridahealthfinder.gov/CompareCare/SelectChoice.aspx).
• Maryland’s Health Care Commission provides consumers with an online hospital pricing guidethat lists, for each acute care hospital in Maryland, the number of cases, the average charge per case, and the average charge per day for the 15 most common diagnoses.
• Oregon’s website "Oregon Pricepoint," is sponsored and maintained by the Oregon Association of Hospitals and Health Systems and allows health care consumers to receive basic, facility-specific information about services and charges.
• New Jersey launched to help consumers make informed choices regarding price and quality of hospital services in New Jersey.”

A couple of other states examples that I found include:

• Iowa’s Hospital Association Web site includes their Iowa Hospital Charges Compare that “allows health care consumers to access basic information about services and charges at Iowa hospitals.”
• Virginia’sPricePoint System through the Virginia Hospital & Healthcare Association that is described as “a user friendly resource created to provide basic demographic, quality and charge information on Virginia hospitals and to promote consumer/hospital interaction. Virginia’s hospitals are committed to providing hospital charge and quality data to help consumers make informed decision about their health care.”

National Level

The CMS releases Medicare Provider Utilization Payment Data

On May 8, 2013 the Department of Health and Human Services (HHS) released new hospital charge data. The data posted was comprised of charges for services for the 100 most common Medicare inpatient stays. In a related Fact Sheet, CMS indicated that “this data enables comparisons between the amounts charged by individual hospitals within local markets, and nationwide, for services that may be provided during similar inpatient stays.”

American Hospital Association (AHA) and Price Transparency

A search for “hospital price transparency” on the AHA website resulted in about 841 items. There were two recent items of interest to share with you in this article.

• A March 21, 2014 Issue Paper: Hospital Price Transparency that provides a background, current initiatives and the AHA Principles for Price Transparency.
• The August 15, 2014 release of the resource “Achieving Price Transparency for Consumers: Toolkit for Hospitals.” According to the AHA, “this resource will spark conversation and action by allowing hospitals to assess their current efforts and learn from others through case examples and sample price transparency tools.”

If you are unsure where to start I encourage you to look to the examples of hospitals efforts in the AHA Toolkit. Whatever you choose, remember that you are in the best position to determine how your facility will comply with the price transparency requirement in the Affordable Care Act.

Resource:

FY 2015 IPPS Final Rule pages 50145 – 50146 at:

http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18545.pdf

Link to Medicare Provider Utilization and Payment Data CMS webpage:

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html

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.