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An old problem with DRG assignments

 has ICD-10 repercussions

by CARL NATALEDEC 27, 2016 - 12:01 AM

  

The Office of Inspector General (OIG) is applying greater scrutiny to a couple DRG assignments.

One focuses on mechanical ventilation. An OIG audit found a 95 percent error rate in Medicare billing from 2009 to 2011. That isn't an ICD-10 problem. The problem has existed long before ICD-10 implementation. But if there is greater scrutiny of medical ventilation diagnoses, healthcare providers need to make sure they nail the right assignments of ICD-10 codes and DRGs.

It underscores the need for healthcare providers to continue training. Their medical coders need to know more than just new codes. They need to understand the rule and guidelines. The correct application is as tricky and important as it every was.

Why Black Friday was a Big Day for ICD10 Coding!

     www.ICD10Monitor.com 

by CARL NATALENOV 28, 2016 - 06:00 AM

  

After processing the Thanksgiving Day calamities, it would be nice to get a break. Except Black Friday isn't known as a day of recuperation.

The good news is that most of the possible diagnoses will come from one section of the ICD-10-CM code set. The bad news is this:

• R46.1 - Bizarre personal appearance (just saying)
• W03.xx - Other fall on same level due to collision with another person (Please, watch where you're going)
• W10.0XXA - Fall on/from escalator, initial encounter (What happens on the escalator doesn't always stay on the escalator)
• W21.01 - Lack of adequate sleep (After a day of giving thanks, who got enough rest to get the best Black Friday deals?)
• W50.3XXA, Y92.512 and Y99.0 - Clerk accidentally bit by another human while at work (It's a jungle out there.)
• W51.XXXA - Accidental striking against or bumped into by another person, initial encounter (Which can cause the W03.xx.)
• W52.XXXA - Crushed, pushed or stepped on by crowd or human stampede, initial encounter (That mad rush when doors open at midnight.)
• Y04.0xxA - Assault by unarmed brawl or fight (Deep discounted appliances bring out the worst in us.)

After all of that, it seems like the safest strategy is to avoid the crowds and do the shopping online. But there's always G56.00 (carpal tunnel syndrome).

AHA pens letter to Trump calling for support of hospital policies

Written by Emily Rappleye   | November 30, 2016

The letter called on Mr. Trump not to make any abrupt changes or to repeal the ACA without a replacement plan, and it outlined the following five areas of healthcare policy for Mr. Trump to consider."To help advance health in America, we ask that your administration — in collaboration with Congress and the courts, and in partnership with healthcare providers — help modernize the public policy environment to enhance providers' ability to improve care and make it more affordable for patients," wrote Richard Pollack, president and CEO of AHA.

1. The AHA called for some regulatory trimming and pruning. They specifically called for the elimination of Stage 3 meaningful use for hospitals, implementation of a penalty for high rates of incorrect denials under the Recovery Auditor Contractor program, protection of clinical integration arrangements under the Anti-Kickback Statute, standardization of the Federal Trade Commission's merger review process and elimination of several post-acute care regulations.

2. The organization called for the President-elect's support on several financial policies. These include addressing drug prices, protecting the 340B Drug Pricing Program, challenging mergers among payers and considering Medicare reforms, such as raising the eligibility age.

3. It asked the Trump administration to consider redesigning many quality reporting requirements. The AHA wrote that requirements are excessive, redundant and not always meaningful. Notably, it called for suspension of the hospital star ratings on the Hospital Compare website.

4. The AHA urged Mr. Trump to ensure access to care in his healthcare policies. Particularly, the hospital association pointed to continued funding for CHIP, expanded mental health services, elimination of site-neutral payment cuts and establishment of a permanent Veterans Choice Program, which allows veterans to access care outside of the VA health system.

5. The association also called for the preservation of value-based care models adopted under the ACA. The AHA asked that several models be updated, including several ACO requirements and the advanced alternative payment models under the Medicare Access and CHIP Reauthorization Act.

"We look forward to working with you and your administration on public policy solutions to achieve our vision of a society of healthy communities where all individuals reach their highest potential for health," Mr. Pollack concluded.

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Compliance Question of the Week

Cardiology

For the Week of November 14, 2016

If the doctor places a drug-eluting stent (DES) in the left anterior descending (LAD) artery and also does an angioplasty only of a diagonal artery, would the appropriate coding for a Medicare patient be C9600 and 92920 or C9600 and 92921?

If a DES is placed in the LAD, and separate angioplasty of a diagonal is performed, you would report the codes listed below. The angioplasty is in an additional branch of the LAD.

C9600

Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch

92921

Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure)

Horrifying Compliance Excuses!

Hi Joyce,

In my twenty years of professional work in the healthcare compliance field, I’ve heard some horrifying compliance excuses. For example, “Let’s just correct the problem moving forward, we don’t really need to go back and return money.” I was shocked the first time I heard that little doozy.

“Correcting from now on,” is a terrible attitude to have when it comes to overpayment. Is saving a little cash now worth owing millions later? Unfortunately, excuses like this are par for the course. As a compliance professional, I hear dozens of them, all the time. It’s a nightmare.

In the spirit of Halloween, download our free eBrief, "10 Compliance Horror Stories," for compliance excuses that will make you want to scream.
 

Download the Holiday eBrief >>

Trick or treat, 

CJ

CJ Wolf, MD, CHC, CPC, CCEP, CIA Senior Compliance Executive healthicity.com  |  email

How hospitals code superbug

Has big impact on bottom line

Written by Brooke Murphy | October 04, 2016

The nuances of coding bacterial infections related to antibiotic-resistant superbugs can have a significant impact on hospital revenue streams, according to ICD10monitor.

A study published in the American Journal of Infection Control found hospital costs rose dramatically in cases where patients contracted different superbugs. Patients that contracted renal impairment increased treatment costs by an average of $8,942. 

Patients that contracted an immunocompromised status or concomitant antibiotic exposure increased treatment costs by $8,692 and $8,545, respectively.

Given the high cost of these cases and associated risk factors for contamination, ensuring correct identification, coding and nationwide tracking of superbug infections is critical, said ICD10monitor.

It is imperative hospital and physician coders stay up-to-date with changes to bacterial coding practices. 

Effective Oct. 1, codes for c. diff and MRSA changed to designate their status as hospital acquired infections. There are also ICD-10 codes for 22 different types of medication, including codes for resistance to medication, a condition that makes patient cases more difficult and costly to treat.

For more information on ICD-10 guidance updates from CMS, click here.

What Happens on October 1st this year?!?!

END OF MEDICARE ICD10 "GRACE PERIOD".

https://youtu.be/Lp9a-SGZVm4

Do NOT use unspecific ICD10 codes!

Your diagnosis codes will start affecting payment January 1st!

Going forward, CMS & the third-party payers are "matching" your CPT codes with ICD10 codes
to build payment policies for the future.

The codes you submit now will affect current reimbursement & FUTURE reimbursement.

Check out this video -- very interesting!

RN-Coder Compliance Question of the Week

Respiratory

For the Week of September 19, 2016

Can you provide some examples of chest manipulations and the documentation required to report the applicable codes?
Chest manipulations are described in CPT with examples such as cupping, percussing and vibration to facilitate lung function by mobilization of sputum. These services must be documented as reasonable and necessary to be covered, and there must be evidence of the following:

• Consistent with the nature and severity of the individual’s symptoms and diagnosis
• Reasonable in terms of modality, amount, frequency and duration of treatment
• Generally accepted by the professional community as being safe and effective treatment for the purpose used.

RN-Auditor COMPLIANCE Question of the Week

For the Week of September 12, 2016

I have heard that the Medicare “ICD-10 flexibilities” will expire on October 1, 2016. What does this mean exactly?

According to the Centers for Medicare & Medicaid Services (CMS), ICD-10 flexibilities were solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud. 

As you say, these ICD-10 medical review flexibilities will end on October 1, 2016, and providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines. 

Note, however, that providers should already be coding to the highest level of specificity as this is not a new requirement.

RN-CDS Compliance Question of the Week

For the Week of September 5, 2016

What is the difference between “history of” and “follow-up” in physician documentation?

Using “history of” and “follow-up” as if they are the same is a common documentation mistake.

“History of” is often used to indicate the current clinical indication. However, in ICD-10-CM, “history of” means that the patient has a past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence.

“Follow-up” goes along with “history of” because follow-up codes indicate continued surveillance following a completed treatment of a condition, not follow-up during treatment.

http://www.healthleadersmedia.com/nurse-leaders/5-reasons-nurses-want-leave-your-hospital

5 Reasons Nurses Want to Leave Your Hospital

Rebecca Hendren, August 9, 2011

      

Your nurses have one eye on the door if you do any of the following.

Although economic woes abound, nurses are planning their exit strategies and will make a move when things improve. A recent survey from healthcare recruiters AMN Healthcare found that one-quarter of the 1,002 registered nurses surveyed say they will look for a new place to work as the economy recovers.

Are your nurses engaged, committed employees? Or are they biding their time until they can go somewhere better? To predict whether you face an exodus, take a look at the following five reasons why your nurses want out.

1. Mandatory overtime

Nurses work 12-hour shifts that always end up longer than 12 hours due to paperwork and proper handoffs. At the end, they are physically, mentally, and emotionally exhausted. Forcing them to stay longer is as bad for morale as it is for patient safety.

Some overtime is acceptable. People get sick, take vacations, or have unexpected car trouble and holes in the shift must be filled to ensure safe staffing. Nurses are used to picking up the slack, taking overtime, and pitching in. In fact, overtime is an expected and appreciated part of being a nurse. Many use it to help make ends meet. Mandatory overtime, however, is a different matter. Routinely understaffed units that rely on mandatory overtime as the only way to provide safe patient care destroy motivation and morale.

Take a look at the last couple of years' news stories about RN picket lines. Most include complaints about mandatory overtime.

ICD10CM Updates for 2017

Effective October 1, 2016:

Deleted 2017 ICD-10-CM Codes

The following 311 ICD-10-CM codes will be deleted in the 2017 ICD-10-CM code set, effective October 1, 2016.

• Page 1/2: ICD-10-CM D49.5 to T85.83XA
• Page 2/2: ICD-10-CM T85.83XD to Z98.89

New 2017 ICD-10-CM Codes

The following 1,974 ICD-10-CM codes will be added to the 2017 ICD-10-CM code set, effective October 1, 2016.

• Page 1/8: ICD-10-CM A92.5 to E13.3419
• Page 2/8: ICD-10-CM E13.3491 to I69.910
• Page 3/8: ICD-10-CM I69.911 to M97.21XA
• Page 4/8: ICD-10-CM M97.21XD to R82.79
• Page 5/8: ICD-10-CM R93.41 to S02.80XD
• Page 6/8: ICD-10-CM S02.80XG to S99.131A
• Page 7/8: ICD-10-CM S99.131B to T83.512D
• Page 8/8: ICD-10-CM T83.512S to Z98.891

Revised 2017 ICD-10-CM Codes

The following 425 ICD-10-CM codes have desciption changes in the 2017 ICD-10-CM code set, effective October 1, 2016.

• Page 1/2: ICD-10-CM C7A.094 to S49.039D
• Page 2/2: ICD-10-CM S49.039G to T85.690S

ICD-10 Denials Increase for Practices

ICD-10 – a diagnostic coding system developed by the World Health Organization, is in its early implementation stages, and it has already caused the health care organizations to cope with a number of challenges arising due to poor education and preparation regarding ICD-10. Poor education regarding this new coding system has led to a number of consequences, including compliance issues, claim rejections, coding backlogs, delays, and denials.

In this article, we will be discussing how implementation of ICD-10 has led to increased number of denials and what an organization can do to limit the impact of this new coding system on its denial rates.

ICD-10 Denial Rate Forecast

The health IT industry, has published white papers predicting that the implementation of ICD-10 will lead to a 100 to 200 percent increase in claim rejection and/or denial rates.

Explaining that during the post-implementation phase of ICD-10, healthcare organizations may experience significant impact on the length of time and amount of rework required for claim rejects and their productivity. Practices may suffer a negative impact of ICD-10 on their cash flow and revenue due to lost productivity and increasing number of coding errors.

The companies recommended that organizations should measure their denial rates and types of rejects or denials during the transition phase in order to plan and act accordingly.

• Of 4.6million claims submitted every day, only 2 percent were rejected because of invalid or incomplete data.
• About 0.09 percent claims were rejected due to invalid ICD-10 codes.
• About 0.11 percent claims were rejected due to invalid ICD-9 codes.

3 Most Common ICD-10 Denials

The implementation of ICD-10 can prove to be a bumpy ride for your practice if you haven’t done enough preparation. In order to gain maximum benefit from this transition and to minimize denial rates, it is important that you act proactively.

To help you do so, we are listing 3 most common ICD-10 denials and ways to avoid them.

1. “Diagnosis Code: Invalid; Diagnosis code must be most specific.”

The new ICD-10 coding system provides specific codes for specific condition. In order to avoid denials due to unspecific codes, select the most specific code for each condition and claim.

2. “Diagnosis Code: Invalid; Must be a valid ICD-10-CM diagnosis code.”

Denials that specify the above reason can be caused by a number of issues. In order to avoid these denials, choose the most specific and valid ICD-10 code that rightly represents the patient’s documented condition.

3. “Diagnosis Code: Invalid; Claim cannot contain a mixture of ICD-9 and ICD-10 codes.”

In order to avoid claim denials due to this reason, make sure that the outpatient claim contains either ICD-10 or ICD-9 codes.

The best way to handle ICD-10 rejections and denials is to stay proactive. Educate your staff on how documentation and procedures may affect denial and rejection rates. Learn from the denials and establish best practices on how to prepare proper medical claims.

Why clinical documentation is the missing link

to value-based reimbursement

Written by Emily Rappleye (Twitter | Google+)  | August 10, 2016

in

The key to successfully making the jump from the old era of healthcare — one where fee-for-service is king — to the new era of healthcare — one where transparency, consumerism and value dominate — may actually be as simple as improving clinical documentation, according to Anthony Oliva, DO, vice president and CMO of Nuance Healthcare.

"For those who thought, 'Maybe we can just hold out and [value-based care] will all go away,' it's never going to go away; it's only going to get worse," Dr. Oliva said at the Becker's 2nd annual CIO/HIT + Revenue Cycle Conference in Chicago.

Healthcare is a classic example of a model explained in Ian Morrison's book The Second Curve, according to Dr. Oliva. This two-curve model posits that any market undergoing transformation has two curves: the old and the new. Companies must ride the first curve and learn how and when to jump to the second, Mr. Morrison explains in the book.

In healthcare, the first curve was designed around the provider, according to Dr. Oliva. This is because the provider had control over the entire healthcare economy and was able to dictate supply and demand. On the first curve is a carefully controlled entry of physicians into the market, according to Dr. Oliva. On this curve, physicians are able to exert absolute control over demand, too. The attitude was, "Cut my fees by 5 percent and I'll just see 5 percent more people," Dr. Oliva said.

Now this fee-for-service world is being challenged by cost controls, informed consumers and transparency, and it is flipping the power dynamic to a second curve. The trouble is that physicians need to understand how to make the leap to the second curve — value-based care — and remain financially stable.

One of the big changes in the second curve is newly found transparency, according to Dr. Oliva. Patients can go online and not only find information about diseases and medical treatments, but also find information about the quality of care their hospitals or even their individual physicians provide.

"In the past, quality was really determined for the most part by the relationship you had with your physician," Dr. Oliva said. "We never knew whether a physician was good or bad. How would you know that a physician is practicing in a standard of care that's acceptable for his or her specialty? We did a lot of assuming."

Now not only are quality outcomes tied to reimbursement by CMS, but the transparency of information magnifies this change because patients can go online and compare physician performance. These physician transparency tools — Dr. Oliva named ProPublica's Surgeon Scorecard as an example — use Medicare billing information to compare physician performance.

"We see that the connection is vital between what the physician writes in the record to what's billed to insurance companies and Medicare," he said. This means a physician won't be properly reimbursed — or accurately scored on public scoring systems — if he or she is not properly documenting the severity of his or her patients.

This makes clinical documentation improvement essential to landing the jump from the first curve to the second curve in healthcare. Dr. Oliva advised attendees not to take their clinical documentation improvement programs for granted. "If you look at it as a severity capture program first, the revenue will take care of itself," he said.

DEVELOPING: CMS Releases 2017 ICD-10-PCS Codes

Written by Laurie M. Johnson, MS, RHIA, CPC-H, FAHIMA | Friday, 03 June 2016 00:00

The Centers for Medicare and Medicaid Services (CMS) released the 2017 ICD-10-PCS codes as well as other supporting documentation on Thursday.

Before you get excited, the 2017 ICD-10-CM codes have not been released yet. The additional supporting documentation includes the 2017 ICD-10-PCS Official Coding and Reporting Guidelines, the addenda for the ICD-10-PCS Index and Tables, a text listing of the 2017 procedure codes with the file layout description, the order file which includes the long and short descriptions of the 2017 procedure codes, and a conversion table for the 2016 to 2017 codes.

The update also states that the following documents will not be updated beyond 2016: The ICD-10-PCS Reference Manual, the document describing the development of the ICD-10 Procedure Coding System (ICD-10-PCS), and the ICD-10 Procedure Coding System Power Point slides.

The long-awaited 2017 ICD-10-PCS codes are 75,789 in number. The new codes are found in the Medical and Surgical, Administration, Measurement and Monitoring, Extracorporeal Therapies, and New Technology sections. The highest number of changes is in the Medical and Surgical section, which now totals 65,676 codes. The Administration section has 39 changes, which increases the number of codes to 1,427. Extracorporeal Therapies section adds four new codes to increase the total to 46. The New Technology section has added 27 new codes which give us a glimpse into the procedures, devices, and substances that will be approved for New Technology add-on payments to MS-DRG v34.

The biggest changes include the revision of the definitions of root operations Control and Crea
tion, new root operation “Perfusion,” which was added to the Extracorporeal Therapies section, and changing the body part terminology in the Heart and Great Vessels Body System. The coronary arteries will now be identified by the number of arteries treated and not sites. This change is supported in the 2017 ICD-10-PCS Coding and Reporting Guidelines. The new definition of Control is stopping, or attempting to stop, post-procedural or other acute bleeding. This revision now includes “other acute bleeding,” which may be based on the clinical documentation. The new definition of Creation is putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part which has changed the focus of this root operation from only sex-change operations to operations in other body systems. The new root operation of Perfusion is defined as extracorporeal treatment by diffusion of therapeutic fluid.

The 2017 ICD-10-PCS Official Coding and Reporting Guidelines were developed based on the internal review of the 2016 version and public input. The areas that have been revised include B2.1a, B3.2, B3.4a, B3.6b, B3.6c, B3.7, B3.9, B4.2, and B4.4. Guideline B2.1a revision provides an alternative when clinical documentation is not present and the coder may use the general anatomic region as an unspecified code. The expectation is that this option will be used rarely. B3.2 (Multiple procedures) has been altered in the examples of this guideline. B3.4a adjusted the spacing for the provided examples. B3.6b and B3.6c adjusted the guideline to match the changes from coronary sites to coronary arteries in the Tables. B3.7 added “other acute bleeding” to reflect the change in the definition of root operation Control. B3.9 addresses the excision of an autograft. This guideline change provides more information to other body part value. This change includes “different procedure site” rather than other body part value. This revision will assist the coders to determine if a separate code should be reported. B4.2 adds information regarding cardiovascular structures that could have branches and how to assign a code when the specific artery or vein is not available in the correct table, but a general body part is available. The provided example of this guideline is the occlusion of the bronchial artery being coded to the body part value Upper Artery in the body system Upper Arteries, and not to the body part value Thoracic Aorta, Descending in the body system Heart and Great Vessels. Guideline B4.4 addresses coronary arteries as a body part value. As discussed earlier, coronary arteries as body parts are a big change for the 2017 version. The change involves a switch from the number of sites treated to the number of coronary arteries treated.

The first update to the ICD-10-PCS codes is finally here! The link to the new files for ICD-10-PCS is provided below. The industry continues to look for the 2017 ICD-10-CM codes and most importantly, MS-DRG v34.
Resources: https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html