4th quarter 2018 vol.8 issue 4 - rmc · jennifer is an ahima approved icd-10-cm and icd-10-pcs...
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Adult Critical Care Overview –Part 2
continued 2
PCS Coding in 2019 3-4
The Importance of Policies: Are your
Polices Up-To-Date? 4
MA vs. ACA: What’s the Difference?
5
RMC News 6-7
Vol.8 Issue 4 4th Quarter 2018
I N S I D E T H I S I S S U E :
Can you believe we’ve made it? One might inquire what have we made it through. The overwhelming question most coders have asked—did we survive the transition from ICD-9 to ICD-10? Yes, we survived! Here we are ready to begin the new calendar year of 2019, and although most of the wrinkles have been ironed out, there are still struggles with some aspects of PCS. The basics are still proving to be challenging, including approaches, body parts, and devices.
Let’s start with taking a closer look at the some of the basics. After reading through an entire Procedure Note and in preparation of coding the procedure, the first thing you should do is determine what the intent of the procedure is. This is the most important point to consider. After the intent has been determined, the coder should follow that step with determining what approach is being used, what body part(s) are involved, and whether a device was used and if so, did it remain after the procedure was completed. Knowing the intent or objective of the procedure will always give the best starting point, and knowing what the reason or rationale is behind the performance of a surgery is essential. Is the procedure considered therapeutic? Is the procedure being done to determine a diagnosis or is that information already available? Is the procedure being done to eradicate a disease process? Are there multiple objectives?
One of the most important basics that coding professionals still struggle with is “Approach”. What are the options available to us, what are some clues, and what should be included in the documentation? First there is the Open approach. Some things to consider in determining if an approach is Open would be documentation of cutting through multiple layers, the site of the disease/disorder being visible to the surgeon, and a description of how organs look without mention of a scope or scan to visualize those organs. If these are all present, then the approach is more than likely an Open approach.
For Percutaneous approach, things get a little trickier. It’s not always easy to tell what is and isn’t considered a minor incision. The determination of whether an approach is Open or Percutaneous cannot be made on the size of an incision alone. The surgeon may document cutting through layers of skin, mucous membranes, and other body layers, but the distinction to remember with a Percutaneous approach is that the operative site is not being exposed by cutting through these layers. Instrumentation and cutting through layers may be used to reach the operative site, but there is no actual exposure of the operative site itself. This is a minor difference, but very critical to appropriate and accurate PCS code assignment.
Regarding Percutaneous Endoscopic approach, the concept is similar to the Percutaneous approach in that the operative site is not exposed, however a scope is used in this procedure. Examples of procedures using Percutaneous Endoscopic approaches include hysteroscopy, endoscopy and laparosco-py. If you are unsure if a procedure was doing using a scope, look for key words such as “insertion of trocars” or “insufflation of CO2”
Lastly, there is the External approach. It seems like the External approach should be a fairly obvious, straight-forward approach to recognize, but unfortunately that is not always the case. The definition per the 2019 ICD-10-PCS Official Code set is: Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach External. External approach may be used during procedures performed on the ear, nose and throat, as well as from the mouth and throat chapters in the PCS book. A question to ask yourself when trying to determine if an approach is External is “can the provider view and reach the procedure site without cutting through skin and mucous membrane?” If the answer is yes, then the correct approach is External.
Hopefully this has helped clarify approaches in PCS coding. If you have any questions, feel free to contact us at [email protected]
Jennifer Jones, CCS is one of RMC’s Manager of Coding Services and also a CDI Specialist. Jennifer has been with RMC since 2009. Jennifer has over 27 years of experience in the HIM field and has held such positions as Manager of Coding Services, Inpatient & Outpatient Coding Specialist, Medical Transcriptionist, Medical Assistant, Medical Biller, and Medical Receptionist. Jennifer also has experience Clinical Documentation Improvement starting in 2010. Jennifer has worked in 25-bed Critical Access Hospitals, midsize hospitals, and large trauma level 1 medical centers. Jennifer is currently working on obtaining her RHIT, completion toward the end of 2017. Jennifer 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. Jennifer resides in Oregon and can be reached at [email protected]
PCS Coding in 2019 By Jennifer Jones, CCS
In this second installment of critical care services, we will discuss services that are included and excluded in critical care services. “The AMA CPT 2018 book includes instructions for services that are included in critical care services and therefore cannot be reported separately and include:
Interpretation of cardiac output (93561, 93562)
Chest X-rays (71010, 71020)
Blood draw for specimen (36415)
Blood gases, and information date stored in computers – i.e.. ECGs, BP, hematologic data (99090)
Gastric Intubation (43752, 43753)
Pulse Oximetry (94760, 94761, 94762)
Temporary transcutaneous pacing (92953)
Ventilator management (94002-94004, 94660, 94662)
Vascular access procedures (36000,36410,36415,36591,36600)”
There are, however, services that are not included in critical care and can be separately reported. For example, if the patient was stable at the
morning visit the provider should bill a subsequent hospital visit (99231-99233). If later in the afternoon, the patient’s health deteriorates and
critical care is warranted and documented, both an E/M and critical care codes would be reported. Modifier 25 would be appended to the
critical care code(s). Providers should link the proper diagnosis code(s) to the E/M and critical care visit, in order to further support the medical
necessity of reporting both a subsequent E/M service and the critical care codes for the same day. An ER visit (99281-99285) cannot be
reported in addition to critical care code(s).
**NOTE: Insurance carriers may request to see documentation to support billing the EM and critical care on the same calendar date by same
physician/group.
Procedures that are not bundled into the critical care services may be billed separately. When critical care services and procedures are
performed on the same day, it is crucial the provider documents the total critical care time and also that total critical care time excludes the
time of the procedure(s). The provider needs to subtract out the procedure time if it is done in the middle of performing critical care. Example:
Provider is providing critical care services and the patient continues to deteriorate, intubation was necessary. The critical care time stops when
the intubation procedure begins and critical care starts again, if medically necessary, once the procedure is complete. Example of proper
statement: I spent a total of 43 minute performing critical care excluding the procedure time. Although not an all-inclusive list, some common
procedures performed for critically ill patients includes: endotracheal intubation, CPR, Swan Ganz, CVP, IABP. Modifier 25 would be
appended to the critical care codes(s) 99291-99292.
Preoperative critical care may be paid in addition to the global surgical fee if the patient is critically ill and requires the full attention of the
provider and critical care is unrelated to the specific injury or surgical procedure performed. Modifier 25 would be added to the 99291 and/or
99292. Postoperative critical care may be paid in addition to the global fee if the provider’s documentation supports that critical care was
unrelated to specific surgery performed. Modifier 24 would be added to 99291 and/or 99292.
Note: The pre, intra and/or post procedure work is excluded from the time spent providing critical care
Stay tuned for the next installment of Critical Care Coding.
References:
AMA’s Current Procedural Terminology 2018
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Adult Critical Care Overview - Part 2 of 4 Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGS
Chris Breithoff, CPC, CPCO, CDEO, CRC
Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC is a Manager of Physician Coding Services at RMC. Susan has been working in the medical field since 1996, within physician offices. In addition being a Certified Professional Coder, she also holds specialty certifications in Evaluation and Management, General Surgery and OB/GYN. She is also a certified AAPC instructor. She has experience in professional fee coding, provider auditing (retrospective and prospective) and coder/provider education. Her experience ranges from small to large multispecialty groups and large teaching hospitals. Susan also has experience coding Ophthalmology (to include Optho-plastics), Infusions for Chemotherapy, General Surgery (to include bariatric surgery), and Dialysis. Susan can be reached at [email protected].
Chris Breithoff, CPC, CPCO, CDEO, CRC is the Director of Physician Coding Services at RMC. She has worked in the medical arena since 1985 with an emphasis on coding & compliance for 18 years. Chris has a diverse background which includes managing large private practices, additionally, managing a physician coding department for a large teaching hospital. In these roles, Chris’ was responsible for the day to day coding, education of coders and providers, as well as overall compliance of the revenue cycle. Chris’ areas of expertise include Evaluation and Management coding, Critical Care, Emergency, Gastroenterology, Pulmonary, Cardiology and Sleep Medicine. Chris joined RMC in 2012 as an Auditor. In 2015 Chris took the helm of the Physician Coding Services and has done an outstanding job assuring exceptional services to our client and focusing on RMC staff engagement. Chris can be reached at [email protected].
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Quality, up-to-date, understandable policies can make or break an audit or outside review. Policies are the first look into your organization’s
practices and pulse check of your compliance status. Not only will a reviewer ask to see existing policies but upon an onsite audit, employees
may be questioned about how they comply with those policies. Recently, the Office of Civil Rights Director, Roger Severino confirmed that
the OCR intends to use the audit protocol for investigations and enforcement activities (https://rmcinc.org/privacy-security-forum-update-ocr
-activity-audit-protocols-ransomware-the-hipaa-security-rule/). Within the OCR Updated HIPAA Audit Protocol, many of the items state
that the OCR will “obtain and review policies and procedures…evaluate whether the policies and procedures are consistent with the
established performance criterion.” Are you prepared for an OCR investigator to review your policies and procedures?
Whether your organization is completing a self-review or preparing for an audit, reviewing your organizational policies and procedures is an
important activity. The Health Care Compliance Association and Office of Inspector General produced the “Measuring Compliance Program
Effectiveness: A Resource Guide” in March 2017 (https://oig.hhs.gov/compliance/compliance-resource-portal/files/HCCA-OIG-Resource-
Guide.pdf). This guide suggests ideas on how to measure an organization’s effectiveness of its compliance efforts. In relation to policies,
there are several focus areas that may help an organization identify needed improvements. When reviewing your policies, consider the
following questions:
1. Access
Can employees readily access policies?
Are policies written at a level staff can understand?
When a policy is updated, is it distributed and how?
2. Accountability
Is there a clear process to define the ownership and accountability of policies?
Is management taking responsibility for implementing and following policies?
3. Review/Approval Process:
How are policies maintained?
What is the review process for policies and timeline?
Is there a written process for reviewing and approving policies?
4. Quality
Are policies as good as industry practice?
Question to staff: Do policies assist you in doing your job effectively?
Are policies written in plain language, appropriate grade reading level and written in applicable languages for the organization?
5. Assessment
Can staff actually articulate policies and procedures?
Are policies effective based on actual procedures? Do they match?
6. Enforcement
When a policy is violated, is enforcement/disciplinary action consistent?
Policy review activities can take time and resources not always available or viewed as a priority yet its importance is key to a successful
external review. Taking the time now to review and update your policies will say your time and money in the long run.
The Importance of Policies: Are Your Policies Up-to-Date? By Aurae Beidler, MHA, RHIA, CHC, CHPS
Aurae Beidler, MHA, RHIA, CHC, CHPS has worked in the health care industry since 2002, for health systems and outpatient clinics including behavioral and dental health, with an emphasis in compliance operations and program implementation, training, auditing and privacy and security of health records. Aurae has experience with coding and billing issues, risk assessments, regulatory interpretations, internal investigations, responding to external audits and investigations, writing appeals for denied claims, policy and procedure creation, provider education and training, risk management and provider malpractice insurance and determining clinical billing risk by performing audits and investigations. She has overseen and assisted with the implementation of a privacy and security program for outpatient clinics and developed an institutional compliance program. She has also published several articles in Compliance Today and the Journal of AHIMA, and serves on AHIMA’s Privacy and Security Practice Council. Aurae earned a Master’s degree in Healthcare Administration (MHA) from Pacif-
ic University in 2010, a graduate certificate in biomedical informatics from Oregon Health and Sciences University and a B.A. in Journalism from University of Oregon in 2002. Aurae is currently credentialed as a CHC, certified in healthcare compliance, RHIA, registered health information administrator and CHPS, Certified in Healthcare Privacy and Security.
MA vs. ACA...What’s the Difference? By Dott Campo, RHIT
The most common models within the Risk Adjustment world are those for the Medicare Advantage (MA) and Affordable Care Act (ACA) health plans. The Medicare Advantage model, created by CMS, has been around the longest of the two models. The Department of Health and Human Services created the Affordable Care Act model, based on the successful MA model, and making changes to fit the ACA patient (enrollee) population.
There are many similarities between the MA and ACA models, but there are some differences. The first difference is the population. For Medicare Advantage, the population includes those over 65 and those eligible for Medicare. Within the ACA model, the population includes everyone else, all ages. Because of the how the different models are split, based on age/Medicare eligibility, there is a very large population difference between the two models.
Medicare Advantage
6.8 million people on MA plan
Nationally 31% of all Medicare beneficiaries are on an MA Plan
40% of California Medicare beneficiaries are enrolled in a Medicare Advantage Plan
44% of Oregon Medicare beneficiaries are enrolled in a Medicare Advantage Plan Affordable Care Act
179 million people w/insurance under ACA
Nationally 59% of people w/insurance under ACA
54% of Californians w/insurance under ACA
53% of Oregonians w/insurance under ACA
The two models are very similar. The focus is on keeping patients healthy, and paying healthplans more depending on disease burden. “Disease Burden” represents how healthy (or sick) an enrollee is, and healthplans get more (or less) depending upon this factor. In theory, the goal is to keep patients healthy but yet allocate more funds to pay to treat the most ill patients. These payments are based on the patients’ disease and/or illness (which is based on the diagnoses codes reported in a given period). Certain diagnosis codes (not all) map to a Hierarchal Condition Category or “HCC”.
Between MA and ACA, there are HCCs that are common to both models. However, the differences in the numbers and types of patients within these two models, leads to differences in the codes/diagnosis used for HCCs. There are some HCCs found on one model that may not be found within the other. Below are some examples:
HCCs not found in the ACA model
Obesity/BMI
Acute Kidney Injury
Alcohol/Substance Abuse HCCs not found in the MA model
Pediatric conditions
Postpartum care
Low birth weight status
The above HCC examples, and all other HCCs are bundled together into disease groups (i.e. Diabetes, Chronic Kidney Disease, Malignant Neoplasms, etc). Where an HCC lands within these disease groups determines the level of payment. Again because of the population differences between the models, there are differences in the number of HCCs within each respective model. The Medicare Advantage has 79 Hierarchal Condition Categories, and the Affordable Care Act has 127 Hierarchal Condition Categories.
As you can see, although the Risk Adjustment models are in theory quite similar, there are quite a few differences between the MA and ACA programs. Regardless of the differences, the core goal remains the same. Keeping patients healthy.
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Dott Campo, RHIT is an expert in Risk Adjustment Coding and currently holds a leadership position in the Risk Adjustment Division at Reimbursement Management Consultants, Inc. In this role, Ms. Campo performs Risk Adjustment/HCC coding, auditing and education of coders and providers. Ms. Campo expertise in the review of patient profiles, records, and Annual Wellness Visits to assure RMC clients compliance with reported HCC’s, RAF scores, and appropriate reimbursement. Prior to coming to RMC in 2017, Ms. Campo held various HIM positions. Most recently, she held a position at a large regional healthcare network in which she was Quality Data Coordinator, responsible for review and abstraction of data in conjunction with CMS and TJC core measures, reporting results and education of stakeholders. Ms. Campo is actively involved in the Oregon AHIMA CSA holding various positions. She is currently enrolled at Western Governors University, pursuing her B.S. in Healthcare Informatics
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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: [email protected] or Kristin Gibson: [email protected]
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 [email protected]