Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Getting it Right the First Time:...

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Donna D. Wilson,RHIA,CCSSenior Director

Compliance Concepts, Inc.

Getting it Right the First Time: Inpatient and Outpatient Coding

2/5/2009Compliance Concepts,Inc.

Objectives:

List the improper payments due to coding.Outline documentation requirements in correct

coding. Review official resources.Develop an effective coding compliance program.Educate physicians ,coders and ancillary staff.Appeal with supporting documentation.

Coding Improper Payments

Inpatient OutpatientExcisional

debridementsLysis of adhesionsWrong Principal

DiagnosisCoagulation

DisordersDRGs/MS-DRGs with

only one CC or MCCDischarge disposition

Units of serviceNeulasta, Speech,

Infusion, Blood Transfusions.

Duplicate service-Colonoscopies

New vs. Established E/M

Inpatient Coding Improper Payments

Excisional DebridementsRAC Findings:Reporting of excisional debridement

(86.22) without supporting documentation to meet the definition of excisional debridement.

Per the CMS RAC Status Document 2007: “In the medical record the physician documents debridement was performed and the coder assigned 86.22 (excisional debridement). “

Debridement must meet documentation requirements as outlined in AHA Coding clinic 3rd Qtr. 1991 or coded to the non-operative ICD-9-CM code 86.28 (non-excisional debridement).

Documentation Requirements/References-DebridementsDocumentation Requirements

Reference –AHA Coding clinic for ICD-9-CM:

Size Depth Removal of

devitalized tissue Instruments used. Definite cutting away

of tissue- not the minor scissors removal of loose fragments.

Query physician.

1st Qtr 2008 Vol. 25 p. 3.

4th Qtr 2004 Vol. 21 p. 137.

2nd Qtr 2004 Vol. 21.2nd Qtr 2000 Vol.17 p.

9.3Rd Qtr 1991 Volume

84th Qtr 1988 Volume

5. 2/5/2009Compliance Concepts,Inc.

Lysis of AdhesionsRAC Findings:According to AHA Coding clinic 4th Qtr. 1990:”

Coders should not code adhesions and lysis thereof, based solely on mention of adhesions or lysis in an operative report. Determination as to whether the adhesions and the lysis are significant enough to code and report must be made by the surgeon.”

Minor adhesions may exist without being organized, causing any symptoms or additional difficulty of performing the procedure. Coding the lysis of adhesions is inappropriate on these cases-since this is an approach.

Documentation Requirements/References-Lysis of AdhesionsDocumentation Requirements Reference-AHA Coding Clinic

Don’t code if used as an approach unless documented as “extensive” in the operative note.

Documented as extensive by the surgeon, then code both the lysis of adhesions and the definitive surgery.

4 Qtr. 1996 Pgs. 65-67.

3 Qtr. 1994 Pg. 8.

4 Qtr. 1990 Pgs. 18-19.

2/5/2009

Wrong Principal DiagnosisRAC FindingsPrincipal Diagnosis on claim didn’t match

Principal Diagnosis on the medical record. (Example: Respiratory listed on claim but

medical record supports Sepsis as Principal Diagnosis.)

Clinical documentation must support principal diagnosis-example: Sepsis vs. Urosepsis (UTI).

Overpayment request letter is issued by the RAC for the DRG difference.

Documentation Requirements/References-Wrong Principal DiagnosisDocumentation Requirements References:The principal

diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

ICD-9-CM Official Coding Guidelines

4th Qtr. 2008 AHA Coding Clinic.

PEPPER reports

2/5/2009

Coagulation DisordersRAC FindingsCoagulopathy due to Coumadin: Cases with a

Principal dx of 286.5 (Hemorrhagic disorder due to intrinsic circulating anticoagulants)

Examples of some of the Secondary diagnosis = 578.x( GI bleed), 784.7, (Epistaxis),599.7, (Hematuria), 786.3, (Hemoptysis.)

Coumadin is not a Circulating anticoagulant.Coders may be incorrectly assigning 286.5 to

describe all patients on anticoagulants whether or not there is a resulting hemorrhagic disorder.

Documentation Requirements/References-Coagulation DisordersDocumentation Requirements Reference-AHA Coding Clinic

Code 286.5 is used only when such an adverse condition has occurred

If only an abnormal lab finding was documented then 790.92 code should be assigned.

Query the physician.

3rd Qtr. 1990 Volume 7

3rd Qtr 1992 Volume 9

4th Qtr. 1993 Volume 10

DRGs/MS-DRGs with only one CC or MCC

RAC FindingsDRGs/MS-DRGs grouping with a CC (complication or

comorbidity) or MCC (major complication or comorbidity) containing only one secondary diagnosis.

Example of MS-DRG Grouping: MS-DRG

WeightMSDRG 329 Major Small & Large bowel with MCC 4.5059

MSDRG 330 Major Small & Large bowel with CC 2.8935

MSDRG 331 Major Small & Large bowel w/o cc/MCC 1.8415

(2/5/2009Compliance Concepts,Inc.

Documentation Requirements/References-DRGs/MS-DRGs with only one CC or MCCDocumentation Requirements Reference-AHA Coding Clinic

Coders should not code findings from path. reports on inpatient records w/out confirmation of the diagnosis from the attending physician.

Query the physician regarding the clinical significance of radiological findings.

1st Qtr. 2004 pgs. 20-21.

2nd Qtr. 2002 pgs. 17-18.

Discharge Disposition CodesRAC FindingsRAC identified incorrect discharge disposition

code assignments such as: First claim indicated pt went home. Second claim indicated pt. transferred to

another inpatient acute care hospital. Two hospitals should split a single DRG payment

instead of both receiving a full DRG payment.** Automated review under demonstration will

become a complex review under the Permanent RAC**

Documentation Requirements/References-Discharge Disposition Code Assignments:Documentation Requirements References:

Implement effective quality control programs to ensure accurate code assignments.

Work closely with Case Mgmt.

Follow-up with receiving facility.

Retain history chart of discharge disposition code changes over the years.

www.scha.org Click on Compliance & Finance/Third party payors/Patient discharge status code history.

NUBCMedicare processing

manual

2/5/2009

Outpatient Coding Improper Payments

Units of ServiceRAC FINDINGS: Incorrect coding on the

chargemasterInjection, pegfilgrastim 6mg (J2505) – Neulasta:

Provider billed one service per 1 mg; however the definition of this code is one service per 6 mg vial.

Speech/hearing therapy (92507)- Provider billed one service for each 15 minutes; however the definition of this code is one service per session.

Blood transfusion service (36430) - Provider billed one service per pint of blood;however,definition of this code is one service per transfusion session.

Documentation Requirements/References-Units of ServiceDocumentation Requirements References:

Review chargemaster descriptions frequently.

Educate departments.

Document services rendered by session.

Denote correct units administered.

Transmittal 949 http://www.cms.hhs.gov/transmittals/downloads/R949CP.pdf (Neulasta).

CMS Claims Processing Manual 100-4, Chapter 5, Section 20.2 http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf (Speech)

Duplicate ServicesRAC FindingsSearch for claims for two or more identical

surgical procedures for the same beneficiary on the same day at the same hospital.

Example: Two colonoscopies billed on the same

day due to incorrect coding of CPT codes. Be more careful when submitting claims for

colonoscopies (45355, 45378, 45380, 45383, 45384, 45385) to ensure you do not bill for more than one per day per pt.

Codes 45380 (Colonoscopy w/ bx), 45384 (Colonoscopy w/ polypectomy hot bx forceps or bipolar cautery), and 45385 (Colonoscopy w/ polypectomy w/ snare) are different techniques & can only be used once for a single colonoscopy.

Current CPT BookAMA CPT AssistantAHA Coding clinic for

HCPCS.July 2004 AMA CPT

Assistant.**Note** -59

modifier may apply

Evaluation and Management (E/M)RAC Findings1)Medicare’s global surgery payment

rules even in cases involving E/M services.

2)E/M services that are not reasonable & necessary.

3)Duplicate E&M codes4)New versus established E&M codes5)Units of service (Lupron injections)

Medicare requires that if a physician (or practice) has not seen a patient in three or more years, he/she can file the claim as a new patient.

If it has been less than three (3) years, the physician must charge for an established patient.

Current CPT BookAMA CPT AssistantConsider Group

practices –same tax ID # same specialty.

2/5/2009

Coding Compliance Plan

Become RAC ReadyDetermine the coding focus for your

healthcare facility by reviewing the same sources that the RAC uses:OIG Audits/Reports/Annual Work PlanCERT Audits/ReportsPEPPER ReportsNational and local coverage determinations

Update your Coding compliance plan yearly!

EDUCATE,EDUCATE

Educate staff

Physician EducationAttend each department to educate physicians.Each physician was provided with a listing of

his/her records reviewed by the RAC and the outcome of the reviews.

Visit physician practices to explain RAC and pt. status-give them contact names and numbers.

Utilize hospital intranet to post most common inpatient only procedures/pt. type keys and order sets for ease of use in physician practices.

Hospital staff EducationEducate coders and clinical

documentation specialists on RAC targets and process.

Communicate with Case Management to improve discharge disposition code assignment.

Attend service line director, managers and nursing leadership meetings.

Provide RAC updates to senior leadership, internal audit and board.

Stay abreast & share with othersRAC team participated in monthly

conference calls in the state of South Carolina demo:

SCHA sponsored call for:Business Office Managers / Compliance Officers

Utilization Review/Reimbursement Managers Coding/DRG ManagersCEOs and CFOs also participated .

**SCHA, RAC and CMS were on these calls**

Appeal Your Coding Errors

Appeal lettersResponsible department writes the appeal

letter.Advice from physician advisor and outside

consulting agency was sought on some cases.

Cover letter and entire medical record was mailed with each appeal.

Copies of Interqual and AHA Coding Clinic accompanied the appeals.

Flagged the medical record to provide easier review for the auditor.

Hire outside assistanceConsider hiring

external auditors to assist in the appeal process.

Assist at all levels of appeal.

Allows you to appeal with an unbiased party at your side.

2/5/2009 Compliance Concepts,Inc.

REFERENCES

Maintain Current ResourcesICD-9-CM Books Volumes 1-2 -3.AHA Coding ClinicICD-9-CM Official Coding GuidelinesCPT BooksCPT Assistant

References

http://www.cms.hhs.gov/RAC/http://www.ahacentraloffice.org/www.scha.orghttp://www.ama-assn.org/ama/

pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.shtml

Contact informationDonna D. Wilson, RHIA, CCS

Compliance Concepts, Inc.Senior DirectorStonewood Commons II103 Bradford Road, Suite 320Wexford, PA 15090Office: (724) 940-0077Cell: (843) 345-4653Fax: (724) 940-0420EMail: dwilson@ccius.comwww.complianceconcepts.com

Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Getting it Right the First Time:...

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