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Cardiology

Coding for the

Physician Office

2

Injections,

Infusions &

Hydration

3-4

IoT Attacks:

What are you

doing to protect &

prepare?

4

RMC News 6-7

Vol.7 Issue 3 3rd Quarter 2017

I N S I D E T H I S I S S U E :

Selection of Principal Diagnosis

By Marquita Rawlins RHIA, CCS

The selection of principal diagnosis can be a daunting task! 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." As coders we have been trained to pay close attention to those two words

“after study”. There have been numerous times when a patient has been hospitalized for one

condition; however, after study, a new condition has emerged. Thorough review of the entire

medical record is necessary for appropriate assignment of principal diagnosis. Coders should

review documentation such as: Discharge Summary, History and Physical, Progress Notes,

Consultation Report, Operative Report, and Physician Orders to name a few. When selecting

the principal diagnosis, it is important to keep your Official Coding Guidelines handy. They

provide guidance in different scenarios on assigning the most appropriate principal

diagnosis. For example, if a symptom code is documented as due to a related definitive

diagnosis, our Official Coding Guidelines tell us that the definitive diagnosis would be

sequenced as the principal diagnosis.

It’s imperative to also be mindful of our coding conventions. In determining principal

diagnosis, coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index

take precedence over these Official Coding Guidelines. Pay close attention to coding

conventions such as “code first” or “use additional code “notes in the etiology/manifestation

convention. This will determine sequencing! As found in our Official Coding Guidelines:

Certain conditions have both an underlying etiology and multiple body system

manifestations due to the underlying etiology. For such conditions, the ICD-10-CM

has a coding convention that requires the underlying condition be sequenced first, if

applicable, followed by the manifestation. Wherever such a combination exists, there

is a " use additional code"; note at the etiology code, and a "“code first” note at the mani-

festation code. ; These instructional notes indicate the proper sequencing order of the

codes, etiology followed by manifestation.

A new example of the differences between ICD-9-CM and ICD-10-CM of this convention

can be found at diagnosis code J44.0 (Chronic obstructive pulmonary disease with acute

lower respiratory infection). If a patient is admitted with lobar pneumonia and COPD,

instructional notes tell us the J44.0 will be assigned first and to use additional code to

identify infection. Additional details can be located in AHA Coding Clinic™, Third Quarter

2016, page 15. Reviewing those notes in the Tabular Index are extremely important as your

DRG can be affected if the etiology/manifestation convention is not followed.

Additionally, coders have to be aware of Chapter Specific Coding Guidelines when

assigning the principal diagnosis. Obstetric cases (Chapter 15 codes) have sequencing

priority over codes from other chapters. Continued...

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In conclusion, selection of the principal diagnosis can be challenging. However, if you follow your coding conventions and

Official Coding Guidelines they will assist in your selection of principal diagnosis. There are also many Coding Clinics that

have been published that can be a valuable asset. Happy coding.

Reference:

ICD-10 Official Coding Guidelines FY 2017

Marquita Rawlins, RHIA, CCS is RMC’s Senior Manager of Coding Review Services. Marquita joined RMC in 2015, bringing with her over

12 years of experience in the Health Information Management field. She is a graduate of the University of Alabama in Birmingham, with a Bachelor’s of Science in Health Information Management. Marquita’s past positions include Coding Specialist, Manager of Audit Services, DRG

RAC Auditor, and ICD-10 Auditor for acute care facilities nationwide. Marquita he has worked in both small and large bed hospitals prior to

coming to RMC, and in her time with RMC has performed services for facilities ranging from small critical access hospitals to large multi-hospital networks including trauma level 1 medical centers. Marquita is an AHIMA approved ICD-10-CM and ICD-10-PCS Train the Trainer,

and has been actively involved with RMC’s ICD-10 Training and education program. Marquita resides in Georgia and can be reached at

mrawlins@rmcinc.org

Did you know that CMS and many other insurance carriers have supervision requirements for diagnostic testing done in the

office? This important information often goes unnoticed by clinics but is important to understand in order to appropriately bill

and get paid for the tests you are performing. *Of note, this is not just for cardiology offices, so if you are part of an office with

providers of different specialties you will want to check this out too!

To determine whether the test you are performing has a supervision requirement you will need to check the Medicare Physician

Fee Schedule. The fee schedule assigns a numeric indicator to each CPT code so that providers can be sure to know what level

of supervision is required.

The main identifiers for cardiology procedures will be:

0 – Procedure is not subject to the supervision policy

1 – Procedure requires general supervision

2 – Procedure requires direct supervision

3 – Procedure requires personal supervision

General Supervision – Physician has overall control and direction of the procedure but is not required to be present during the

performance of the procedure.

Direct Supervision – Physician does not need to be in the room but must be present in the office and immediately available to

assist and direct throughout the performance of the procedure. (Stress test, nuclear testing, stress echo, etc.)

Personal Supervision – Physician must be present in the room for the performance of the procedure. (TEE, Cardiac Cath, etc.)

New for 2017 – Moderate Sedation is now separately reportable!!

CPT guidelines changed for 2017 and moderate sedation is no longer included in CPT procedures. It is important to know the

difference between moderate sedation and deep sedation or monitored anesthesia. Moderate sedation is considered to be a drug

induced depression of consciousness in which a patient can still respond to verbal commands.

Moderate sedation codes are broken down into three categories:

Preservice Work – Assessment of pt (see CPT manual for full listing of assessment requirements), completion of

pre-sedation form, informed consent, and initiation of IV access.

Intraservice Work - * This is where timing begins! Begins when sedating agent is administered and ends when

procedure is complete, patient is stable for recovery status and the provider ends personal face-to-face time.

Postservice Work – Continued assessment of the patient, readiness for discharge, and communication with

patient and family regarding sedation services.

Your CPT book has all of the required pieces of each category broken down for you in detail at the beginning of the moderate

sedation (9915_) section. Please be sure to review each section in detail to understand what is required. Preservice and post

service components are included when determining time reporting for intraservice work, so they are not separately reportable but

are required for accurate and complete billing.

“Selection of Principal Diagnosis” continued...

Page 2 C O M P L I A N C E C O N N E C T I O N S

Cardiology Coding for the Physician Office

Moderate Sedation and other important tips for 2017! By Monique Vanderhoof RHIT, CPC, CCA, CRC

Continued...

Providers should report 99151 – 99153 when performing the procedure AND sedation.

99151 – Moderate sedation services performed by the provider performing the diagnostic service that sedation supports,

requiring the presence of and independent trained observer to assist in the monitoring of the patient’s level of conscious-

ness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age.

99152 – initial 15 minutes of intraservice time, patient 5 years or older

+ 99153 – each additional 15 minutes intraservice time (list separately in addition to code for primary service)

Many carriers are bundling 99153 when performed in the facility setting. Please check with your carriers for specific policy/

coding requirements.

For more on cardiology coding visit our website www.rmcinc.org

The coding of injections, infusions and hydration services can be challenging. What is the initial service, was there any sequen-

tial infusions and when was that injection given? In order to be successful you will need good documentation, knowledge of a

few key definitions and a possibly a good sense of humor!

Orders & Documentation

To start, there must be an order from your provider that is dated, timed and signed. It should include the name of the drug, the

dose and the route and rate of administration.

Nursing documentation must state the route of administration and the start/stop time. The start and stop time…my favorite

documentation when coding infusion services! Also very important is the site of administration. In some cases, documentation

of separate sites may support coding of two initial services. For instance, when protocol or the patient’s condition requires two

separate IV sites.

Where is the service being provided?

When coding for a provider, selection of the initial code is based upon the key or primary reason for the encounter. Physicians

may bill for services provided in their office but cannot bill for services provided in the facility setting.

In the facility setting, select the initial service based on the coding hierarchy. Chemotherapy services are primary to therapeutic,

prophylactic and diagnostic services, which are primary to hydration services.

Chemotherapy

Infusions

Injections

Hydration

What kind of service are we talking about?

When reviewing the medication administration record, or the MAR, note each medication given and the time administered.

Which service is initial; what medication is first in the hierarchy, or in the case of provider billing which service was key? Were

there any sequential medications provided? Sequential meaning after another service was provided. If a concurrent medication

was given, performed at the same time as another administration, adding code +96368 might be appropriate. Remember, +96368

can only be billed once per encounter, no matter the number of concurrent services provided. Were injections also given? Were

they intramuscular or an intravenous push perhaps? Was hydration given separate from all the other services provided? Did the

provider indicate a reason for the additional hydration? Remember hydration products used as carriers for other medications are

considered incidental and therefore are not coded separately.

A few friendly reminders!

Initial therapeutic infusions are > 15 min up to one hour. Initial hydration administration is 31 min to one hour.

Injections, Infusions and Hydration By Sarah Reed, RHIT, CCS

Page 3 C O M P L I A N C E C O N N E C T I O N S

Continued...

Monique Vanderhoof, RHIT, CPC, CCA, CRC is Director of Coding Services at RMC. Monique started in healthcare in 1993, working in various roles in the clinic setting. Monique’s aptitude for coding and management was noted and Monique quickly ascended to a position as

office manager of a cardiology clinic which she held for 14 years. In 2011 Monique joined RMC as the Manager of the HCC/Risk Adjustment

Division where Monique’s sharp coding skills and management ability was recognized. In 2016 Monique was promoted to Director of Coding Services. In this new role she is directly responsible for all coding services at a large psychiatric hospital. Additionally, Monique retained the

HCC/Risk Adjustment Division, performing audits, coder and provider education. Monique has done an outstanding job at RMC, focusing on

quality services, and excellent customer service. Monique can be reached at moniquev@rmcinc.org.

“Cardiology” continued...

Multiple medications administered in one intravenous push are coded as one push. IVP administration codes were created

to capture the work of administering the drug, not based on the number of drugs given per push. One push = one CPT

Injections and infusions that are a normal part of a surgical procedure are not separately billable. Services provided that are

unrelated may be billable with supportive documentation.

For some additional helpful information review your CPT coding manual. CPT Assistant and Coding Clinic for HCPCS are also

a great resources when coding questions arise. Happy coding!

Sarah Reed, RHIT, CCS is RMC’s Senior Outpatient Auditor. Sarah joined RMC in 2013, and has nearly 10 years of experience in the Health

Information Management Field. She has a love for all Outpatient Coding, ER, Outpatient, Profee and specializes in SDS. Prior to joining RMC, Sarah’s past positions include Surgery Coding Specialist, Senior Coding Compliance Auditor and Revenue Integrity Failed Claims Specialist. She

has worked in a variety of acute care hospitals, ranging from a 25-bed critical access hospitals to large multi hospital networks including trauma

level 1 teaching hospitals. Sarah is a multi-talented coder, auditor, educator and trainer. Sarah has been actively involved with RMC’s ICD-10

Training and education program. Sarah resides in Oregon and can be reached at sreed@rmcinc.org

Product and gadget creators get in a tight spot when IoT (the Internet of Things) security takes a back seat. It sounds harmless:

“Let’s get to market then release security updates.” Getting market share vs taking care of security seems like a matter of course.

Until someone uses that security gap to shut down a power plant.

“Security by design is more of a concept than a reality.” - Chris Apgar, CISSP

So take a step back and prepare. Because even if you can’t prevent IoT attacks – and you can’t stop them all – you can be pre-

pared. Not being so is indefensible. A few critical steps:

1. Have your go-to vendor(s) contact info at-hand in case of an attack. The information should be part of your security incident

response plan.

2. Test – before the attack – security incident response, disaster recovery and business continuity plans. Make corrections and

test again.

3. Train your security incident response team on what to do when an attack happens. Repeat the training regularly.

4. Make it difficult for hackers: encrypt. On mobile devices, portable media, in the EHR.

5. A quick, effective response to an IoT attack can mitigate damage. But it takes preparation, aka sound risk management;

training, sharing information with critical staff, taking security incident response seriously. As I stated in a recent article

about IoT attacks, “A risk management program is neither a one-time event nor static. Risks are constantly changing as new

attack methods are being developed.”

One more point: Spread the training love. Training is too often overlooked. Talk about the clicks that bring down an organization

in moments, like phishing. And try for something beyond the same old PowerPoint, perhaps use scenario-based training, look at

all the ways everyday actions can halt business in its tracks.

Otherwise people tune out.

If you’re not sure where to start, the guidance from the Department of Homeland Security (DHS) and the National Institute of

Standards and Technology (NIST) recommendations are very helpful when trying to figure out all the risks that can come with

IoT device implementation.

Page 4 C O M P L I A N C E C O N N E C T I O N S

Chris Apgar, founder of Apgar & Associates is a Certified Information systems Security Professional (CISSP). He is one of

the country’s foremost experts and spokespersons on healthcare privacy, security, regulatory arriafs, state and federal

compliance and secure and efficient electronic health information exchange. Chris has more than 19 years of experience in

regulatory compliance and is a leader of regional and national privacy, security and health information exchange forums. As

a member of Workgroup for Electronic Data Interchange, and serving on the Board of Directors since 2006, Chris is an

honest, reliable, trustworthy expert in the field of privacy and security.

Email capgar@apgarandassoc.com for more details.

IoT Attacks: What are you doing to protect & prepare?

By Chris Apgar, CISSP

“Injections & Infusions” continued...

Page 5 C O M P L I A N C E C O N N E C T I O N S

Yep. You read that right. Totally free.

Visit our website: www.rmcinc.org to submit your questions today!

Our new website features a “Coding Questions” button. Submit your question, and one of our

RMC coding experts will reply.

*Also - don’t forget to follow RMC on Facebook, LinkedIn and Twitter. We post coding tips, reminders and updates weekly!

Page 6 C O M P L I A N C E C O N N E C T I O N S

Camille Walker: cwalker@rmcinc.org or Kristin Gibson: kristin@rmcinc.org

RMC is currently looking for experienced, credentialed, hard-working coding experts to join our team.

Positions are all remote, and all RMC staff are issued a company laptop.

Qualified candidates:

Must have a minimum of 5 solid years of coding experience

Must be AHIMA/AAPC credentialed

Must pass RMC's coding test

Must be reliable, friendly and flexible

Full-time AND part-time positions available! Some positions qualify for sign-on bonus!

If you want to join our team and LOVE your job, please send your resume to employment@rmcinc.org