New Documents Posted to the HCCUniversity.com

We have posted a number of new documents to the Full Encounter Data/ICD 10 page of HCCUniversity.com.  Scroll down to CMS Encounter Work-Groups and you'll see the documents listed below.

All of the documents are related to the January 2012 implementation of full encounter data, and the CMS workgroups that are ongoing.  Most of the questions are unanswered as of this time, but we hope as new documents become available, CMS will make more decisions.

Capitated and Staff Model Plans Summary Notes

Chart Review Work Group

Encounter Data Newsletter - Quarter 1

Encounter Data Newsletter –Quarter 2

Encounter Data Work Group Summary Notes for Editing and Reporting: Key Findings and Recommendations

Third Party Submitters Work Group

2012 Combined Advance Notice and Call Letter Posted to the CMS Website

The 2012 Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter has been posted to the CMS website at: 2012 Advance Notice and Call Letter.  


Although we have not had time to analyze the notice in detail, CMS is proposing not to implement the new model that was proposed for Part C for 2012 in order to minimize changes during 2012.

Based on the proposal released on Friday, there will be no changes to the CMS-HCC Model for 2012.  CMS will not implement previously proposed changes (e.g. addition of dementia and morbid obesity) until 2013 at the earliest, unless they change what is in the Advance Notice.  We will know with certainty on April 4, 2011 when the Announcement is published, but at this time, it is extremely unlikely that the model will change in 2012.

We will have more information for you at a later date.

Common ICD-9-CM Coding Errors

Usually, it’s a misunderstanding the rules of ICD-9 –but no matter the reason, many codes are found to be unsupported in a Risk Adjustment Data Validation or other audit.  The most common reasons for this seem to be that the ICD-9 doesn’t “talk” the way doctors do, or the person choosing the code doesn’t know that there’s a special rule related to it.  In an audit situation, the cause isn’t relevant—an error is an error.  The best way to avoid these errors is to make physicians aware of these common problems, and help them understand the ICD-9 rules.  Remember that those rules include Coding Clinic, which is officially tasked with clarifying coding rules for ICD-9.  So, what are the most common errors we see?

“Wound care” coding – Every time I drive by a wound care clinic, or see wound care written in a chart, I cringe.   I know that there’s a coding error ahead.  When you search the alphabetic index of the ICD-9 for the term wound, you won’t find any decubitus or vascular ulcers. You’ll see operative wounds (incisions) or lacerations (cuts).  I *know* what the provider means – he/she is treating an ulcer.  But if the doctor doesn’t call it an ulcer, choosing an ulcer code is wrong.  Physicians need to be instructed in the proper documentation for ulcers—location and type of ulcer must be described for vascular ulcers. For decubitus ulcers, the location, type (decubitus/pressure) and stage of ulcer must be documented.  For decubitus ulcers, two codes must be selected—one for the location and one for the stage.

Coronary Artery Disease (CAD) coding—Almost always, when I see a diagnostic statement of “CAD”, the code 414.00 (coronary artery disease, of unspecified type of vessel, native or graft) is attached.  Isn’t that correct? It sounds correct. No one mentioned whether it was a native or graft vessel, so it has to be correct! Except that it’s not. If there is no record of prior coronary artery bypass grafting, the correct code is 414.01 (coronary artery disease, of native coronary artery), because there’s a Coding Clinic that says so.  In Q2 1995, the following Coding Clinic ruling was issued:

Is it appropriate to assign code 414.01, Coronary atherosclerosis, of native coronary artery, if the medical record documentation does not indicate that the patient has a history of prior coronary artery bypass surgery?

Answer:
"Assign code 414.01, Coronary atherosclerosis, of native coronary artery, if medical record documentation shows no history of prior coronary artery bypass. If the documentation is unclear concerning prior bypass surgery, query the physician."

Aortic Atherosclerosis coding – Documentation that indicates “aortic atherosclerosis” or “atherosclerosis of the aorta” without further clarification cannot be coded according to Coding Clinic, Q4, 1988.  If the physician can be queried (i.e., the note is new, and can be amended within approximately 72 hours of the visit) then the physician can clarify whether it is the aorta (vessel) or the aortic valve.  If it is the vessel, then the correct coding is 440.0.  Atherosclerosis of the aortic valve is coded 424.1.  Going forward, the physician should be sure to clarify whether it is valve or vessel.  For example, noting that there is atherosclerosis of the abdominal aorta makes it clear that it is the vessel.

Hemiparesis vs. Weakness -  We often see documentation that states “history of CVA with R. sided weakness”, and the physician has selected 438.20 –late effect of CVA, hemiparesis/hemiplegia of unspecified side.  While paresis does mean weakness, the issue is a little more complicated.  The term hemiparesis means more than weakness, it means weakness affecting an entire side of the body. And, in this case, it’s not just about the definition—but coding rules.   In Q1 2005, Coding Clinic was asked the following question:

Please provide clarification on the correct code assignment for a residual deficit of muscle weakness secondary to late effect of cerebrovascular accident. We have a difference of opinion on whether this should be coded to code 438.2x, Late effects of cerebrovascular disease, hemiplegia/ hemiparesis. What is the appropriate code assignment for residual weakness that is a late of effect of CVA?
Answer:
Assign code 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident.
Therefore, when the physician documents weakness secondary to an old CVA, you cannot code 438.20.  Physicians must be educated regarding this rule, so that they can adjust their documentation going forward.

Finally, there’s a whole group of diagnoses that are coded when the physician really means that the patient had them in the recent past.  We see this most often when a patient is seen for the first time in the office after a hospitalization for:

                        CVA

      Sepsis

      Acute MI (except in 1^st 8 weeks)

Acute Coronary Syndrome

Non-ST Elevation MI (NSTEMI)

Unstable Angina

Acute Respiratory Failure

Once the patient has been discharged from the hospital, these conditions should no longer be coded. In some cases, it’s appropriate to code the “history of” code, or the underlying condition.  But coding these conditions in the office setting is only appropriate if the patient presents in the office and is (generally) transported by ambulance to the hospital.

There are other common errors that we see, but these are among the most common.  Understanding coding rules can help you avoid these pitfalls.

Do you have questions about coding rules?  Leave us a comment or email your question to coding@scanhealthplan.com.

New CMS Full Encounter Data Document Posted to HCCUniversity.com

There is a new document related to the CMS Full Encounter Data workgroups that are ongoing. It has been posted on SCAN Health Plan : Full Encounter Data/ICD-10 .  The document is titled Encounter Data Workgroup Summary Notes for Editing and Reporting: Key Findings and Recommendations.




On January 12, 2011, there was a workgroup meeting regarding editing and reporting of full encounter data (i.e., 5010 transactions) required as of January 2012.  Note that all of these documents contain as many unanswered questions as answered ones.  We will provide updates as they become available.

New Full Encounter Data CMS Q&A Document Posted

Beginning in January 2012, we will be required to submit full encounter data for all services, using the ANSI 837v 5010 format, to CMS.  These data will be used for Risk Adjustment, quality initiatives as well as measuring healthcare utilization in MA plan members. Because of this, it is more important than ever that health plans and their providers work together to ensure that encounter data is complete and accurate. Basically, health plan data must follow the criteria of your fee-for-service Medicare claim submissions.

SCAN is committed to keeping our providers informed of all developments related to this CMS initiative.  We've created a special section on HCCUniversity.com dedicated to the 5010 transition, as well as the related implementation of ICD-10-CM in 2013.

We have just posted a new document released by CMS in that section:

CMS Full Encounter Data Q&As

More joint CMS/Health Plan meetings are planned related to this initiative.  We will continue to post information on HCC University, and share what we know in our monthly EHUG calls.

There are many unknowns at this point, and health plans continue to work with CMS to clarify requirements and raise concerns about the implementation.  However, CMS remains committed to moving forward on this requirement effective January 2012.

Other Medicare Changes under the Affordable Care Act (ACA)

In addition to the Annual Wellness Visit (AWV) with Personalized Prevention Plan Services (PPPS), the ACA makes several additional changes in Fee-for-Service (FFS) Medicare.  These changes were published in the Nov. 29, 2010 Federal Register: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011. 

Maximum Period For Submission Of Medicare Claims Reduced To Not More Than 12 Months– The Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service.  This change, which applies to services furnished after Jan. 1, 2010, reflects a reduction to the prior maximum timely filing deadline of 15 to 27 months.  The Affordable Care Act also mandated that providers and suppliers file claims for services furnished prior to Jan. 1, 2010 no later than December 31, 2010.  The final rule revises the timely filing regulations to reflect these new requirements.  It also establishes three new exceptions to the timely filing requirements for retroactive entitlement situations, dual-eligible beneficiary situations, and retroactive disenrollment from Medicare Advantage plans or PACE provider organizations.  NOTE: CMS has notified MA plans that they will be held to the same timely filing requirements for MA plan encounter data submitted to CMS for risk adjustment purposes.


Incentive Payments To Primary Care Practitioners For Primary Care Services:   The ACA provides incentive payments equal to 10 percent of a primary care practitioner's allowed charges for primary care services under Part B.  Under this policy,  primary care practitioners are:  (1) specialists whose primary  specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants. In order to qualify, at least 60% of the provider's FFS Medicare allowed charges  for a prior period must be primary care services.  The law defines primary care services as limited to new and established patient office or other outpatient visits (CPT codes 99201 through 99215); nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); and patient home visits (CPT codes 99341 through 99350).  

Physician Assistants Now Permitted To Order Post-Hospital Extended Care Services:  The Affordable Care Act newly authorizes physician assistants to perform the level of care certification that is one of the requirements for coverage under Medicare’s skilled nursing facility (SNF) benefit. 

Payment For Bone Density Tests:  The Affordable Care Act increases the payment for two dual-energy x-ray absorptiometry (DXA) CPT codes for measuring bone density for 2011. 

Payment Increase for Certified Nurse-Midwife Services:  The ACA increases the Medicare payment for certified nurse-midwife services from 65 percent of the physician fee schedule amount for the same service furnished by a physician to 100 percent of the physician fee schedule amount for the same service furnished by a physician.

Multiple Procedure Payment Reduction Policy for Therapy Services:  Although not part of the Affordable Care Act, to more appropriately recognize the efficiencies when combinations of therapy services are furnished together, CMS has adopted a  multiple procedure payment reduction policy for therapy services that will reduce by 25 percent the payment for the practice expense component of the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service.  This policy will apply to all outpatient therapy services paid under Part B, including those furnished in office and facility settings.  This policy is similar to the multiple surgery reduction that has long been a part of Medicare payment rules.

Do you find these posts on FFS Medicare helpful? What other coding related topics would you find helpful?  Leave us a comment and let us know.

The Myth of Coding the "Rule Out" Diagnosis

We get a lot of questions in our "Ask A Coder" inbox, coding@scanhealthplan.com.   There is no doubt that far and away, the most frequent question we get is some variation of "can I code all "rule-out" diagnoses for an inpatient"?

I've been coding a lot of years (about 25).  As a disclaimer, I have never been employed by a hospital as a coder --BUT--in my role at SCAN and other health plans, I've coded hundreds (maybe thousands) of inpatient charts. I can honestly tell you, the number of times I've coded a rule-out diagnosis can be counted on the fingers of both of my hands.  I'm sure that hospital coders have done so many more times than I have, but I'd bet they would tell you that this is not a common occurrence. 

Why isn't it?  Let's take a look at the Official Coding Guidelines themselves.  I've highlighted particularly important passages of the guideline.

H. Uncertain Diagnosis If the diagnosis documented at the time of discharge   is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.    This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.  

First, note that the condition is still probable, uncertain--i.e., not yet ruled out, then if the documentation indicates  at the time of discharge it is still a possible condition, then it is possible it can be coded.Second, you must have the entire hospital chart--why? Because you can't know if the treatment during the hospitalization was directed at that condition without it.

As to the related question of whether or not this can be used for the physician's record...the answer is NO.   Coding Clinic and the Official Guidelines indicate that physicians use the Outpatient coding guidelines, no matter what the place of service.

I hope this clarifies when coding a "rule-out" condition is acceptable.

What coding questions do you have?  Send them to us at coding@scanhealthplan.com.  We'll do our best to answer within 72 hours. We de-identify questions of general interest and post them on HCCUniversity.com under Ask A Coder.