Getting it Right the First Time: Inpatient and Outpatient Coding Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Compliance 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. Compliance Concepts,Inc.
Coding Improper Payments Inpatient Outpatient Excisional debridements Lysis of adhesions Wrong Principal Diagnosis Coagulation Disorders DRGs/MS-DRGs with only one CC or MCC Discharge disposition Units of service Neulasta, Speech, Infusion, Blood Transfusions. Duplicate service-Colonoscopies New vs. Established E/M Compliance Concepts,Inc.
Inpatient Coding Improper Payments Compliance Concepts,Inc.
Excisional Debridements • RAC 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). Compliance Concepts,Inc.
Documentation Requirements/References-Debridements Documentation 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 8 4th Qtr 1988 Volume 5. Compliance Concepts,Inc.
Lysis of Adhesions • RAC 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. Compliance Concepts,Inc.
Documentation Requirements/References-Lysis of Adhesions Documentation 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.
Wrong Principal Diagnosis • RAC Findings • Principal 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. Compliance Concepts,Inc.
Documentation Requirements/References-Wrong Principal Diagnosis Documentation 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
Coagulation Disorders • RAC Findings • Coagulopathy 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. Compliance Concepts,Inc.
Documentation Requirements/References-Coagulation Disorders Documentation 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 3rd Qtr. 2004 Volume 21 Compliance Concepts,Inc.
DRGs/MS-DRGs with only one CC or MCC • RAC Findings • DRGs/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 Weight • MSDRG 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 ( Compliance Concepts,Inc.
Documentation Requirements/References-DRGs/MS-DRGs with only one CC or MCC Documentation 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. 3rd Qtr. 2008 Volume 25 Compliance Concepts,Inc.
Discharge Disposition Codes • RAC Findings • RAC 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** Compliance Concepts,Inc.
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. NUBC Medicare processing manual
Outpatient Coding Improper Payments Compliance Concepts,Inc.
Units of Service • RAC FINDINGS: Incorrect coding on the chargemaster • Injection, 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. Compliance Concepts,Inc.
Documentation Requirements/References-Units of Service Documentation 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) Compliance Concepts,Inc.
Duplicate Services • RAC Findings • Search 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. Compliance Concepts,Inc.
Documentation Requirements/References-Units of Service Documentation Requirements References: 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 Book AMA CPT Assistant AHA Coding clinic for HCPCS. July 2004 AMA CPT Assistant. **Note** -59 modifier may apply Compliance Concepts,Inc.
Evaluation and Management (E/M) • RAC Findings • Medicare’s global surgery payment rules even in cases involving E/M services. • E/M services that are not reasonable & necessary. • Duplicate E&M codes • New versus established E&M codes • Units of service (Lupron injections) Compliance Concepts,Inc.
Documentation Requirements/References-Units of Service Documentation Requirements References: 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 Book AMA CPT Assistant Consider Group practices –same tax ID # same specialty.
Coding Compliance Plan Compliance Concepts,Inc.
Become RAC Ready • Determine the coding focus for your healthcare facility by reviewing the same sources that the RAC uses: • OIG Audits/Reports/Annual Work Plan • CERT Audits/Reports • PEPPER Reports • National and local coverage determinations • Update your Coding compliance plan yearly! Compliance Concepts,Inc.
Educate staff EDUCATE,EDUCATE Compliance Concepts,Inc.
Physician Education • Attend 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. Compliance Concepts,Inc.
Hospital staff Education • Educate 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. Compliance Concepts,Inc.
Stay abreast & share with others • RAC 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 Managers • CEOs and CFOs also participated . **SCHA, RAC and CMS were on these calls** Compliance Concepts,Inc.
Appeal Your Coding Errors Compliance Concepts,Inc.
Appeal letters • Responsible 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. Compliance Concepts,Inc.
Hire outside assistance • Consider 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. Compliance Concepts,Inc.
REFERENCES Compliance Concepts,Inc.
Maintain Current Resources • ICD-9-CM Books Volumes 1-2 -3. • AHA Coding Clinic • ICD-9-CM Official Coding Guidelines • CPT Books • CPT Assistant Compliance Concepts,Inc.
References • http://www.cms.hhs.gov/RAC/ • http://www.ahacentraloffice.org/ • www.scha.org • http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.shtml Compliance Concepts,Inc.
Contact information • Donna D. Wilson, RHIA, CCSCompliance Concepts, Inc.Senior DirectorStonewood Commons II103 Bradford Road, Suite 320Wexford, PA 15090Office: (724) 940-0077Cell: (843) 345-4653Fax: (724) 940-0420EMail: firstname.lastname@example.org Compliance Concepts,Inc.