Q: When would we use codes from ICD-10-CM category E13 (other specified diabetes mellitus)? If it's secondary diabetes but not due to an underlying condition or drug and is not chemically induced, what kind of diabetes could it be?
CMS expanded packaging and finalized Comprehensive APCs in the 2015 OPPS final rule. Jugna Shah, MPH, and Valerie Rinkle, MPA, analyze the changes and the potential impact on providers.
In a concerted effort to move healthcare payments to a system of "quality over quantity," CMS finalized policies that greatly expanded packaging for outpatient providers in the 2015 OPPS final rule. It also introduced complexity adjustments with comprehensive APCs (C-APCs).
As CMS pushes the OPPS from a fee-for-service program toward more of a true prospective payment system, financial impact analysis of changes, departmental budgeting, and forecasting has become more complicated each year.
Q: If the physician does not perform a formal myelography and just administers an injection before the patient goes straight for computed tomography (CT), which CPT ® code would we report in 2015? The 2015 combination codes are for use when the same radiologist or physician who performs the injection reads his or her own study.
Q: I have a question regarding CPT ® code 99184 (initiation of selective head or total body hypothermia in critically ill neonate, includes appropriate patient selection by review of clinical, imaging, and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling) in the 2015 CPT Manual . What if the neonate is in the hospital for several weeks? The total body hypothermia is performed, the baby improves, but remains in the hospital and then needs the procedure performed a second time. Can we report it a second time if several weeks have elapsed?
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for at least 20 days or the case is an outlier.
Q: We have a patient diagnosed with neuropathy due to poorly controlled insulin-dependent Type 1 diabetes mellitus. What should we report in ICD-10-CM?
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter? Do we need to code every comorbidity each time in order to meet hierarchical condition category (HCC) requirements?
Nearly 30% of Medicare patients are enrolled in Medicare Advantage (MA) programs, which come with specific coding and documentation challenges. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA, and Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, highlight key requirements for reporting diagnoses that map to Hierarchical Condition Category codes, the basis of MA plans.
Editor's note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Steven Espinosa , CCS , AHIMA-approved ICD-10-CM/PCS trainer, and Denise Williams, RN, CPC-H, outline the anatomy of the upper gastrointestinal system and how anatomical details, along with the provider's approach and intent, help determine the proper procedure code.
Q: Do any general guidelines exist for queries on outpatient services? We are beginning the process of developing such a query system for our hospital outpatient services and clinical documentation team.
When is a mammogram a screening procedure and when does it qualify as a diagnostic test? Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines the differences between the two and what to look for in the documentation.
Editor's note: Andrea Clark-Rubinowitz, RHIA, CCS, CPCH , has more than 30 years of experience working with healthcare professionals, information systems, hospital coding, and operational and compliance training. She founded and led Healthcare Revenue Assurance Associates from 2001 to 2014. Contact her at 954-465-0968 or aclark5678@gmail.com .
Q: A patient was in a hyperbaric oxygen chamber for eight minutes and the physician had to abort the treatment because the patient was feeling anxious. Which HCPCS/CPT ® code should the hospital bill: HCPCS code C1300 (hyperbaric oxygen under pressure, full body chamber, per 30 minute interval) or an E/M code? Which code should the supervising physician bill: CPT code 99183 (physician or other qualified healthcare professional attendance and supervision of hyperbaric oxygen therapy, per session) or an E/M code?
CMS has instructed MACs to reprocess claims and providers to reimburse beneficiaries due to a miscalculated copayment for stereotactic radiosurgery, according to the October update to the OPPS and Integrated Outpatient Code Editor (I/OCE).
Q: What if the provider states that diabetes is due to the adverse effects of a drug, but doesn't tell us which drug? How do we report that in ICD-10-CM?
Evaluation and management (E/M) services are one of the top areas of review by federal auditors. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about common errors found in audits and how providers can take steps to correct them.
The ICD-10-CM delay has at least one silver lining: the ability to spend more time on coding and documentation requirements before implementation. Providers may want to also think about aligning their ICD-10-CM efforts with outpatient clinical documentation improvement (CDI) during this time. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, examines the benefits and challenges of outpatient CDI programs.
Q: We're not sure what to report in this situation: A patient comes to the ED and goes into respiratory failure. The respiratory therapist comes in to put patient on a vent in the ED, then the patient is transferred to another facility. We can’t report CPT ® code 94002 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) because it is for inpatient/observation, per the definition. We wondered about using 94660 (continuous positive airway pressure ventilation [CPAP], initiation and management) for the CPAP. The lay description seems to be basically the same as 94002, except for “applies to ventilation assistance using adjustments in volume and pressure on the initial day…" Would 94660 be appropriate?
The 2015 OPPS proposed rule includes new Comprehensive APCs, increased packaging, and many other changes. Kimberly Anderwood Hoy Baker, JD, and Jugna Shah, MPH , review the proposed rule and policies that may be finalized by CMS.
CMS refined and updated its Comprehensive APC policy in the 2015 OPPS proposed rule released July 3, adding a new complexity adjustment factor. CMS also proposes significantly expanding the packaging of ancillary services. Additionally, the proposed rule includes a significant change to requirements related to inpatient physician certification.
When CMS releases rules, the length can be intimidating. But even at a relatively slim 700 pages, the 2015 OPPS proposed rule isn't able to include details on each of the changes CMS is planning. This is probably a good thing?otherwise the rules could be thousands of pages long. Updates like codes being moved around or status indicators changing often aren't described in full in the narrative text, necessitating a deeper look at the addenda CMS releases as Excel® files on its website.
Modifier -25 (significant, separately identifiable E/M service by the same physician on the day of a procedure) is used to distinguish visits from procedures on the same day. It is not used to distinguish observation from a visit service on the same day.
Q: We're wondering about how to use CPT ® code 73225 (magnetic resonance angiography [MRA], upper extremity, with or without contrast material) in our hospital. When providing an MRA of an upper extremity with and without contrast material, should we bill this service twice (since CPT indicates with or without contrast material) or only once?
Q: My physicians perform procedures in the office such as angioplasties, catheter insertions, venograms, and repairs of grafts and fistulas. What is the proper way to code the medications they administered during the procedures?
Hospitals will still use CPT ® codes to report procedures after ICD-10 is implemented, but some will also code with ICD-10-PCS. Andrea Clark, RHIA, CCS, CPC-H , reviews the advantages and challenges outpatient facilities may face when using ICD-10-PCS.
"Sometimes the questions are complicated and the answers are simple." ?Dr. Seuss This quote seemed an appropriate way to begin a discussion about outpatient encounters and ICD-10-PCS. You see, outpatient procedures will still be coded using CPT ® /HCPCS?the HIPAA-approved code set for reporting hospital outpatient procedures?regardless of when ICD-10 is implemented.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver new modifier -L1. Hospitals will use the new modifier to submit outpatient laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) in certain circumstances to claim separate payment.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver a new modifier. Debbie Mackaman, RHIA, CHCO, Jugna Shah, MPH , and Denise Williams, RN, CPC-H , explain how to use the modifier, as well as the impact of APC changes.
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The physician states the patient needed “aggressive” pain control for treatment, because what was given in the beginning provided only minimal relief. Could I code using CPT ® code 99285 (ED visit for evaluation and management of a patient, including a comprehensive history, comprehensive exam, and high complexity medical decision making)?
Q: We are coding for pain management procedures and have been doing dual coding in ICD-9-CM and CPT ®. With a medial branch block ablation at two levels for L3-L4 and L4-L5 for a bilateral injection, we are coding: ICD-9-CM procedure code 04.2 (destruction of cranial and peripheral nerves) CPT codes 64635 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single facet joint) and 64636 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, each additional facet joint [List separately in addition to code for primary procedure]), each with modifier -50 (bilateral procedure) appended. What would be your recommendation for the ICD-10-PCS code? Currently we are coding 015B3ZZ (destruction, lumbar nerve, percutaneous) twice. We are not sure if we should be picking this code up twice or only once.
Documentation and billing for observation stays has come under increased scrutiny from the OIG, though many hospitals have struggled with changing regulations and frequently updated guidance.
Q: I work for general surgeons. Here is a common scenario: The surgeon is called in to see patient in the ED for trauma or consult. The patient is admitted, but our physician is not the admitting physician. I would tend to bill the ED code set, but do I have to use the subsequent hospital care codes instead?
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
On July 1, CMS will implement a variety of changes to current supervision requirements as recommended by the Hospital Outpatient Payment Panel. Debbie Mackaman, RHIA, CHCO , reviews the panel's recommendations, and which CMS plans to accept or reject.
Hospital outpatient therapeutic services, such as ED or clinic visits, that are paid under the OPPS or to critical access hospitals (CAH) on a cost basis must be furnished "incident to" a physician's service to be covered.
