Updated ICD-10-CM guidelines, effective October 1, could cause confusion for some coders. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, looks at how changes to reporting linking conditions measure up to previous guidance.
Coders may not be aware of the impact place of service codes can have on coding and billing. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how the codes are used and what coders should know about their application.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, reviews additional changes to the ICD-10-CM guidelines for 2017, including coding and clinical criteria, new guidelines for Excludes1 notes, and updates for reporting pressure ulcers.
While the 2017 OPPS proposed rule includes a variety of tweaks and augmentations to existing regulations, its biggest impact is likely to come from its proposal to implement Section 603 provisions of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments (PBD) and move toward more site-neutral payment policies.
CMS released the 2017 OPPS proposed rule on July 5 without much fanfare. On July 14, the Federal Register version was posted, and upon initial review, it seems rather short at 186 pages.
CMS proposes aligning its conditional packaging logic with how it applies packaging to labs, while also proposing to delete the much-maligned modifier -L1 for separately payable laboratory tests in 2017.
CMS’ proposed changes to implement Section 603 of the Bipartisan Budget Act of 2015 would reshape payments for off-campus, provider-based departments (PBD) if finalized and represent the most significant changes in the calendar year (CY) 2017 OPPS proposed rule.
Jugna Shah, MPH, and Valerie Rinkle, MPA, recap CMS’ proposed changes to packaging logic in the 2017 OPPS proposed rule, as well as plans for new and deleted modifiers.
While coders can choose among many CPT codes, provider documentation may sometimes not differentiate between similar options. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about some tricky procedures to distinguish and how coders can ensure they’re reporting which procedures providers actually performed. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Debbie Mackaman, RHIA, CPCO, CCDS, reviews how CMS determines inpatient-only procedures and what changes the agency is considering in the 2017 OPPS proposed rule.
Modifier -58 describes a staged or related procedure or service by the same provider during the postoperative period. For outpatient hospitals, the postoperative period is defined as the same service date.
Jugna Shah, MPH, and Valerie Rinkle, MPA, review changes in the 2017 OPPS proposed rule for providers to comment on, including site-neutral payments and comprehensive APC updates.
Deciphering documentation is frequently the most difficult aspect of coding. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about what documented information coders can use to assign codes—and what to do when that information is lacking.
CMS' Transmittal 3523, issued May 13, is the quarterly July 1 OPPS update. In this transmittal, CMS briefly mentions billing physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to comprehensive APC (C-APC) services under revenue code 0940 (general therapeutic services) rather than the National Uniform Billing Committee--defined revenue codes for these services (i.e., 042x, 043x, and 044x, respectively).
CMS issued a final rule in June to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year and worked to ease administrative burden based on public comments.
Healthcare organizations have become mass gatherers of data. But without sophisticated analytics, integrated IT tools, and processes to mine that data, they may not be able to take advantage of it.
Modifier -58 describes a staged or related procedure or service by the same provider during the postoperative period. For outpatient hospitals, the postoperative period is defined as the same service date.
Providers must link the medical necessity of the treatment they give to the documented diagnoses or they may not get paid. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, looks at how to ensure medical necessity is proven for fertility services.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the types of treatment for infertility for both men and women, highlighting the associated diagnosis and procedure codes used to report them.
Comprehensive APCs (C-APC) have added another complication to coding and billing for outpatient services. Valerie A. Rinkle, MPA, writes about recent changes that could impact the reporting of physical and occupational therapy and speech-language pathology services provided in support of or adjunctive to a C-APC.
Congressional legislation is often written in a way that obfuscates or, at the very least, makes it difficult to discern the impact or intent of a bill.
Anatomical modifiers qualify a HCPCS/CPT® code by defining where on the body the service was provided. These modifiers are especially helpful to indicate services that would normally be considered bundled but were actually performed on different body sites.
When compared to data from past surveys, HCPro's 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, looks at the different types of bariatric surgical procedures and documentation details providers may include for them. She also reviews which CPT codes can be used to report these procedures
ICD-10-CM has brought codes to more specifically report obesity and related conditions. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, describes these codes and when to report them, while also taking a look at operative reports for bariatric surgeries.
In addition to laterality modifiers for right and left (-RT and –LT, respectively), coders can also report bilateral procedures with modifier -50. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, analyzes the guidelines for these modifiers and offers tips on how and when to report them.
The value modifier is having an increasing effect on physician payments and coding each patient’s severity is key to accuracy. Richard D. Pinson, MD, FACP, CCS, writes about how the value modifier impacts payment and conditions coders should be aware of that quality scores.
CMS recently announced changes to require providers to report modifier -JW (drug amount discarded/not administered to any patient) when appropriate. Jugna Shah, MPH, looks at when providers will need to use the modifier and how to remain compliant.
Anatomical CPT modifiers aren’t used just to distinguish laterality. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews how to report modifiers –LC, -LD, -LM, -RC, and –RI for percutaneous coronary interventions.
CMS' coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in order to provide information about how a service relates to Medicare coverage policies.
The April 2016 I/OCE update brought a host of code and status indicator changes, as well as corrections to CMS' large January update that instituted policies and codes from the 2016 OPPS final rule.
As healthcare providers increasingly accept financial risk associated with patient management due to the transition from fee-for-service to risk-/value-based reimbursement, the traditional model of healthcare reimbursement has been flipped upside down.
Coders can choose from a variety of anatomic modifiers to report procedures performed on specific toes. Review how to properly apply these modifiers and which codes they cannot be reported with.
Obesity is a condition that can complicate coding for other diagnoses in a patient’s record. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to report BMI and what must be documented in order to link it with other conditions.
CMS’ April I/OCE update includes numerous code and status indicator changes, as well as corrections to its January release. Kimberly Anderwood Hoy Baker, JD, CPC, looks at the changes providers should review to ensure claims including these codes are processed correctly.
Modifier –GA isn’t the only modifier available to report how services may relate to Medicare coverage policies in hospitals. Learn more about how to properly report modifiers –GX, -GY, and -GZ.
CMS’ coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in a hospital to provide information about how a service relates to Medicare coverage policies.
Which services should clinical documentation improvement (CDI) specialists target in outpatient facilities? Anny Pang Yuen, RHIA, CCS, CCDS, CDIP , writes about how outpatient CDI differs from inpatient CDI and how it can be applied in hospitals or physician practices.
Few in the healthcare industry would argue that the way the government currently pays for drugs is the most cost-effective, efficient, and equitable method possible.
Last year, as ICD-10 implementation approached, organizations throughout the U.S. reported varying levels of comfort with regard to readiness and understanding of the impact of ICD-10 on physician workflow. For some, it was business as usual. For other physicians, ICD-10 became one more check box on the list of reasons to leave practice.
CMS proposed an extensive five-year, two-phase plan to overhaul Part B drug payments for physicians and hospitals in March outside of the normal OPPS rulemaking cycle that could be implemented as early as this fall.
CMS allows, and sometimes requires, providers to report certain modifiers in order to identify when a service has been provided by different types of therapists. Review the requirements for reporting modifiers –GN, -GO, -GP, and –KX.
Jugna Shah, MPH, looks at CMS’ new proposal to implement a new drug payment model for certain providers and how they can comment in order to the agency about its impact on their facilities.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about terminology coders will encounter in documentation for Pap tests and other cervical cancer screening report
Pregnant patients with other health issues can lead to complicated coding scenarios. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the clinical documentation necessary to identify certain complications and how coders can report these diagnoses. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
CMS has proposed a new drug payment model that could impact providers nationwide. Jugna Shah, MPH, reviews the multiple stages of the rule and how providers can comment to CMS about the proposed changes.
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing ) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
Providers need to keep more in mind than just diagnosis and procedure coding when performing sterilizations for men and women. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews the requirements for sterilizations and the part coders can play in avoiding denials.
Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
ICD-10 implementation represented an unprecedented challenge for the U.S. healthcare system. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, writes about the impact of the change by looking at survey results that compare ICD-10 productivity benchmarks to ICD-9-CM.
Drug administration services follow a hierarchy for reporting, but coding can become complex when providers administer multiple drugs. Review these tips to help tackle tough injection and infusion scenarios.
The Zika virus has become a major concern over the last couple months and new information about treatment and symptoms seems to emerge daily. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the latest information regarding the Zika virus and how coders can report it.
Reporting modifier –PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments) only recently became mandatory, but new rules and regulations could change the requirements in certain settings. Kimberly Anderwood Hoy Baker, JD, CPC, reviews recent legislation that could have an impact on modifier –PO and looks ahead to when CMS intends to offer more guidance.
The 2016 CPT® code update may have been relatively small compared to previous years, but the urinary and genital system sections did receive numerous changes to align them with other sections of the code book.
Remember, the hierarchy applies to all IV injection and infusion services. Chemotherapy services are primary and should be selected as initial when provided in conjunction with therapeutic, prophylactic, or diagnostic services.
This month's column is all about data--the importance of providers reporting accurate and complete data, as well as CMS having complete, accurate, and consistent data to compute future payment rates.
Specialty groups are often able to move faster on creating guidelines for new procedures and codes than other ruling bodies. But sometimes this guidance can create conflicts between physician and facility coders. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to avoid these scenarios and come to the best resolution for providers, payers, and patients.
CPT codes for drug administration follow a hierarchy that is unique to those procedures. Review the hierarchy in order to understand how to apply codes for any type of scenario.
Accurate coding and billing data is important for both providers and CMS. Jugna Shah, MPH, writes about challenges providers have faced with providing that data to CMS and what the agency can do to ease provider burden.
The AMA introduced new CPT codes for 2016 to report intracranial therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC, reviews the changes and provides examples on how to use them in a variety of procedures.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CEMC, CCS-P, explain when to report the new codes introduced in the 2016 CPT Manual for genitourinary procedures.
Post-traumatic stress disorder isn’t only reported for military personnel. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about when PTSD may be reported and which diagnosis and procedures codes should be included.
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016.
Per CPT, modifier -52 is used when a service or procedure is partially reduced or eliminated at the provider's discretion. Such a situation is identified by using the service's usual HCPCS/CPT code and adding modifier -52, signifying that the service is reduced.
Hospital coders can choose multiple modifiers to apply to a procedure code if the service was discontinued. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, provides an overview of these codes and in which instances to use them.
The government recently approved changes for physician payment systems. Is your clinical documentation improvement (CDI) team ready to tackle these challenges? More importantly, are your physicians ready?
CMS audits for meaningful use could mean collecting information across the coding and HIM departments. David Holtzman, JD, CIPP, and Darice Grzybowski, MA, RHIA, FAHIMA, review what auditors could request and how to prepare your facility.
Jennifer Avery, CCS, COC, CPC, CPC-I, writes about how the increased specificity in ICD-10-CM changes pregnancy coding and how to use gestational weeks in physician documentation to report trimesters.
Modifier -52 is used to report procedures that are partially reduced or eliminated at the provider’s discretion. Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, looks at how the modifier should be applied in hospitals and tips for compliance.
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CEMC, CCS-P, review updates to the digestive system and E/M codes.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review new comprehensive APCs (C-APC) CMS added in the 2016 OPPS final rule as well as the negative payment update due to a CMS overestimation in 2014.
Before the new year begins, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, recommends taking a look at post-implementation risks CMS and third-party payers have identified. She also offers solutions on auditing and reviewing these risks. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Providers will only have to report one data collection modifier related to a C-APC in 2016. Jugna Shah, MPH, and Valerie A. Rinkle MPA, examine the requirements behind the modifier and how APCs will also be restructured next year.
CMS is introducing multiple new modifiers that providers may need to report beginning January 1, 2016. Jugna Shah, MPH, reviews the modifiers and the conditions for reporting them.
Nearly half a million patients receive dialysis services each year. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, writes about the ICD-10-CM and CPT® codes providers will need to know in order to report these services accurately.
In addition to updating procedures for 2-midnight rule reviews, the 2016 OPPS final rule includes new guidance on coding and billing issues, including reporting certain CT scan services. Jugna Shah, MPH, examines the changes and what providers need to do before 2016.
Providers need to be careful when reporting multiple services with status indicator J1 on the same claim, as NCCI logic could result in no payment for any of the reported comprehensive APC (C-APC) services. Typically, when multiple J1 procedures or services appear on the same claim, the procedure with the highest rank according to CMS is assigned to the C-APC. Certain code combinations of J1 services will also lead to a complexity adjustment to a higher-paying C-APC.
Provider-based clinics and departments are increasingly common, but the rules for provider-based billing can often be confusing, especially given recent changes to modifiers and place of service codes.
CMS and Medicare Administrative Contractors are aware of certain issues regarding National Coverage Determinations and Local Coverage Determinations related to ICD-10 and working to resolve them as soon as possible, according to CMS.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review newpolicies and regulations from CMS in the 2016 OPPS final rule, including a new comprehensive APC for observation.
CMS introduced several new HCPCS codes and added comprehensive APCs (C-APC), including one for observation, in the 2016 OPPS final rule, released October 30.
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blood transfusion (we do not bill for the blood) can we bill HCPCS code A4750 (blood tubing, arterial or venous, for hemodialysis, each) for the tubing used in the procedure and also A4913 (miscellaneous dialysis supplies, not otherwise specified) for miscellaneous supplies pertaining to administering the blood?
CMS finalized its proposals regarding the 2-midnight rule in the 2016 OPPS final rule, including moving responsibility for enforcement and education of the rule from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
Providers know the drill for addressing and operationalizing CMS' annual IPPS and OPPS updates, along with the usual ICD-9-CM and CPT® coding changes. The industry has become used to CMS' timetable for releasing inpatient and outpatient proposed and final rules and knows that it has to be ready to go live with coding, billing, and operational changes October 1 and January 1, respectively.
Q: I have a question about coding infusion/injections in the ED prior to a decision for surgery. A patient comes into the ED with right lower abdominal pain. The physician starts an IV for hydration, gives pain medication injections, then does blood work and an MRI to rule out appendicitis. The blood work comes back with an elevated white blood count, so the patient is started on an infusion of antibiotics. Then the MRI results come in with a diagnosis of appendicitis. So a surgeon is called in to consult and take the patient to surgery. Can we bill the infusions/injections prior to the decision for surgery? I realize that once the decision is made, then the infusion/injections are off limits and are all included in the surgical procedure. But up until that time, can the ED charge the infusions/injections? They are treating the patient’s symptoms and can’t assume the patient will have surgery until the decision is made by the surgeon.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided documentation and coding examples for reporting breast care procedures and ICD-10-CM diagnoses.
Q: Our business office wants us to start using modifier -PO (services, procedures, and/or surgeries furnished at off-campus, provider-based outpatient departments) for services that are provided in some of our outpatient departments, but not all. We want to hard code this to our charge description master but are not sure why some services will get this modifier and some won't.
Charlotte L. Kohler, RN, CPA, CVA, CRCE-I, CPC, ACS, CHBC, discusses how modifiers -59 and -91 differ and what coders need to know to use them when reporting laboratory services.
Because CMS has not created any national ED E/M guidelines, providers must create their own criteria for each visit level. CMS has developed a list of 11 criteria that it uses when auditing facility E/M criteria.
