10/8/2015
1
Billing & Coding
“What Compliance Officers Need to or Should know?”
Coding and Compliance
� Why should Compliance Officers be coders?
� Coding is critical driver for hospitals and clinics
� Except for physician arrangements, probably one of
the most critical areas for fraud, waste, and abuse
� Critical part of auditing & monitoring
10/8/2015
2
Top Billing and Payment
Issues� Two-midnight rule
� Bundled payments
� ICD-10 implementation
� IPPS, OPPS, MPFS Updates
IPPS
� “Inpatient Prospective Payment System”
� ICD-10: Still happening
� 2-Midnight rule
� Disproportionate Share Hospital (DSH) payment
� New DRGs for Medicare Severity Diagnosis Groups
� Quality of care initiatives
� Changes in hospital readmission requirements
10/8/2015
3
OPPS
� “Outpatient Prospective Payment System”
� Changes in E & M services
� Payment rate changes for drug and
radiopharmaceutical reimbursement
� Payments for outpatient services and ambulatory
medical centers
� Changes in codes—specifically “bypass codes”
MPFS
� “Medicare Physician Fee Schedule”
� RVUs, pricing amounts, payment policy indicators
� Stronger link to quality and PQRS (Physician Quality
Reporting System)
� Physician compare benchmark
� EHR incentive program revision
10/8/2015
4
OIG Work Plan
� Good source for “hot topics in all areas
� Coding and Billing are certainly key areas of concern
and focus
“Incident-To” payments
� “Incident to” payments—huge issue for mid-level providers
� Risk Assessment
� Documentation needed
� License verification and scope of practice
� Supervision: Direct, Personal, General/Indirect
� Which payers will pay what for what?
� Medicare rules
� Hawaii’s rules
10/8/2015
5
Place of Service (POS)
� Key for documentation
� Allowable depending on rules and coding policies
� Different payments depending on POS
� Higher in non-hospital settings
� Outpatient department POS pay less
National Correct Coding
Initiative (NCCI)� Reviews included in OIG Work Plan
� Goal is to promote correct coding. Automatic
computer edits and consistent policies
� Federal law required States to incorporate
methodologies compatible with NCCI for Medicaid
claims 10/1/10
� Could be deferred until 9/1/11
� After 9/1/11 only conflict with state laws allow
deactivation
10/8/2015
6
Outpatient Drugs and
Administration� Overbilling of units
� Correct documentation of units
� Particular interest in chemotherapy drugs
ICD-10
�IT’s FINALLY
HERE!!!
10/8/2015
7
ICD-10
� Increase from approximately 9000 codes to over 68,000 codes
� Specificity: Trimesters and weeks of gestation
� More Combination codes
� Episode of care (7th character)
� X placeholders
� Laterality must be documented
� Use of unspecified codes limited and more documentation required
10/8/2015
8
The Wonderful World of
ICD-10� V97.33XD: Sucked into jet engine, subsequent
encounter
� W51.XXXA: Accidental striking against or bumped
into by another person, sequela
� V00.01XD: Pedestrian on foot injured in collision with
roller-skater, subsequent encounter
� Y93.D: Activities involved arts and handcrafts
� Z99.89: Dependence on enabling machines and
devices, not elsewhere classified
And they keep coming…
� Y92.146: Swimming-pool of prison as the place of occurrence of the external cause
� Also a code for “day spa of the prison”
� Z99.89: Dependence on enabling machines and devices, not elsewhere classified
� S10.87XA: Other superficial bite of other specified part of neck, initial encounter
� W55.41.XA: Bitten by pig, initial encounter
� W61.62.XD: Struck by duck, subsequent encounter
10/8/2015
9
And just when you
thought it was safe….� Z63.1: Problems in relationship with in-laws
� W22.2XD: Walked into a lamppost, subsequent encounter
� Y93.D: V91.07XD: Burn due to water-skis on fire, subsequent encounter
� W55.29XA: Other contact with cow, subsequent encounter
� W22.02XD: V95.43XS: Spacecraft collision injuring occupant, sequela
� W61.12XA: Struck by macaw, initial encounter
� R46.1: Bizarre Personal appearance
www.healthcaredive.com
Coding Complexity
� Both ICD-9 and ICD-10 coexist for quite a while
� Hospitals must keep both systems going until all
payments made
� Keep documentation for ICD-9 around for reviews,
audits, challenges
10/8/2015
10
ICD-10: Proposed
Transitions� HR 2652: Provides 2-year grace period for physicians
to transition to ICD-10
� HR 2126: Prohibits implementing, administering, or enforcing regulations to replace ICD-9 with ICD-10
� HR 2247: Requires comprehensive end-to-end testing to assess whether ICD-10 claims process is fully functional
� HR 3018: Requires that claims submitted with iCD-9 codes continue to be paid during the transition—a safe harbor
EMR: Coding
Challenges� Charge Slips: automatically generated with the
presumed codes as physicians document the patient
visit.
� Systems have tools with built-in calculators for visits
and procedures and automated selection of diagnosis
codes.
� Can result in upcoding
� Physician ends up being a coder by default
10/8/2015
11
EMR: Templates!!!
� EHR templates are designed with a particular launch point, such as a chief complaint, chronic diseases, or preventive exams.
� Within the templates are pre-defined generic statements that are associated with a particular treatment plan.
� Other systems may include pick lists, evaluation and management (E/M) tools, even pop-up messages that remind physicians of appropriate actions they “should” take to achieve a higher level.
EMR: Auto-generated
Claims� Auto-generated claims sent to payers, bypassing the
coder.
� Physicians and software designers don’t understand
the technical side of coding that goes beyond
choosing codes.
� Commercial payer rules, local coverage
determinations, etc. all factor into proper claim
submission and are not integrated into EHR’s
10/8/2015
12
2-Midnight Rule
� Controversial from its inception
� New proposed rules and clarification
� Greater deference to physician decision-making in
determining appropriateness for inpatient admission
� New Medicare part A rule that allows case-by-case
basis:
� Documentation!!
� Determination (DOCUMENTED) that visit will require formal admission
2-Midnight Rule
� Proposed Rule:
� Severity of the signs and symptoms
� Predictability of something adverse happening to patient
� Need for diagnostic services that are appropriately outpatient
� Elimination of routine RAC audits
10/8/2015
13
Coding Compliance
� Policies, policies, policies
� Despite ICD-10 specificity and despite EMR making
coding more “automatic” there will still be decisions
that need to be made
� Hospitals must have consistent rules in place to
support consistent coding processes
Coding Compliance
� Coding reviews
� Physician education
� Coder education and individual reviews
� Outside monitoring
� RAC reviews and feedback
10/8/2015
14
In conclusion….
� Coding remains a huge compliance risk
� Compliance Officers must pay increased attention to
coding during this time of major transition
� As coding becomes more automated, pressure will be
on to ensure the documentation supports the medical
necessity
� Compliance and Coding---BOTH begin with “CO”
Partners with coders, HIM, is vital
