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Condition code 44 – The continuing saga

On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.

Read more here.

ICD-9-CM Coordination and Maintenance Committee meeting information available

If you haven’t already viewed the handouts from the ICD-9-CM Coordination and Maintenance Committee meeting held March 11–12, take a few moments to do so now. CMS posted various PowerPoint slides that address ICD-10 implementation, MS-DRG conversion, and ICD-10-PCS. Visit the CMS Web site to view the information.

APC panel spring meeting may hint at 2010 OPPS proposed rule

When the Advisory Panel on Ambulatory Payment Classification Groups panel (APC panel) holds its spring meeting, there are good reasons to pay attention. This year’s spring meeting took place in Baltimore, February 18-19.

“The important thing about [the spring APC] panel meeting is that the people who attend and the people who are presenting, get…an early preview of the types of things that Medicare is analyzing, “ says Jugna Shah, MPH, president of Nimitt Consulting, Inc. in Washington, DC. In turn, she says the subjects of CMS analysis offer a hint of what the agency may include in the proposed rule for 2010. The presenters and the audience also get a sense of what changes the APC panel itself is willing to recommend.

Of all the items on the APC panel agenda, Shah believes the most exciting is the likelihood that providers are finally going to see some relief on the contentious subject of separately payable drug APC reimbursement. The panel again recommends a set of clear changes that, if adopted by CMS, will finally stop and reverse the erosion we’ve seen for separately payable drug APC payments over the past several years, she says. For the first time, Shah says, the agency seems poised to embrace the recommendations made by the panel and echoed by the provider community as well as industry stakeholders.

Denise Williams, RN, CPC-H, director of revenue integrity services at Health Revenue Assurance Associates, Inc., Plantation, FL, agrees that movement on drug pricing, after two previous attempts by the presenting group of stakeholders, is the most exciting development to come out of the meeting. The change would be as good for CMS as it would be for providers, she says. “It helps them meet the statutory requirement for paying for pharmacy handling (also called overhead) separately from the payment for the acquisition cost of the drug.”

Among other activities, Williams notes a presentation that called CMS’ attention to the idea of expanding the present multiple imaging composites into more composites, based on the number of tests performed. Unfortunately, she says, the panel did not make any concrete recommendations to CMS on this, but did encourage the agency to study the proposal and its claims regarding multiple imaging composite APC payment rates and payment policy.

A detailed description of the APC panel is available on the CMS Web site. You can also download a zip file with the APC panel’s spring 2009 agenda and recommendations from this site.

[ via APCs Weekly Monitor ]

CIOs don't feel prepared for ICD-10

A new trade group survey has found that health care CIOs are a bit worried about the coming switch from ICD-9 to ICD-10 code sets. The survey, which was conducted by the College of Healthcare Information Management Executives, included responses from about 72 hospital CIOs.

CIO respondents brought up a number of concerns about how vendors were responding to ICD-10. About 55 percent told CHIME that vendor readiness (and cooperation) was likely to be one of the biggest hurdles in achieving compliance.

Sixty percent of CIOs said that their HIT vendors haven't updated them on proposed new regulations and timelines for ICD-10/5010 implementations. Worse, about 72 percent of CIOs said they don't know if ICD-10 upgrades will be included in annual software grades. What's more, CIOs said they don't know if the ICD-10 upgrades will cost them money or not, and whether those charges will be covered by "federal and state" clauses in contracts, as they usually are with government-related upgrades.

To learn more about this study, read this Healthcare IT News article.

[ via FierceHealthIT ]

CMS posts Q&A about coding for hospital ED visits

The Centers for Medicare & Medicaid Services has posted answers to frequently asked questions about coding emergency department visits under the hospital outpatient prospective payment system. Topics include Type A and B ED visits and critical care services.

Error detected in MPFS for 2007

Everyone makes mistakes. The Centers for Medicare and Medicaid Services (CMS) has made its share to be sure. Its most recent blunder comes from inappropriately assigning zero physician work values to several radiology CPT codes in the 2007 Medicare Physician Fee Schedule Final Rule.

CMS staff expect to fix the error with an updated Excel version online within the next few weeks, according to a release from the American College of Radiology. CMS does not plan to reprint the amended version, however.

The mistake affects the following codes:

70555-Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing

76998-Ultrasonic guidance, intraoperative

77013-Computerized tomography guidance for, and monitoring of, parenchymal tissue ablation

77022-Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

93624-Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia

96020-Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report

[ via Compliance Monitor ]

UB-04s: How will ICD-9-CM expansion affect outpatient coding?

Q: We have heard about possible expansion of ICD-9-CM diagnosis codes for the new UB-04 claim form. Do you have any insight as to how this will affect outpatient coding and OPPS?

A: CMS institutional providers may use the UB-04 beginning March 1, 2007, however, they will have a transitional period between March 1, 2007 and May 22, 2007 where they can use the UB-04 or the UB-92. Starting May 23, 2007, all institutional paper claims must use the UB-04. The UB-92 will no longer be accepted after this date. See CMS Transmittal 1018 , issued July 28, 2006, for more details.

The National Uniform Billing Committee made significant upgrades to the UB-04 form locator (FL) fields. The following ICD-9-CM diagnosis requirements are effective for outpatient reporting as listed below. Remember that although you must report ICD-9-CM procedure codes through your technology or encoder, per CMS, ICD-9-CM procedure codes are not part of the outpatient HIPAA data set, and the agency will not accept these codes.

FL 69: Admitting diagnosis: required. For inpatient hospital claims subject to QIO review, the admitting diagnosis is required. Admitting diagnosis is the condition requiring hospitalization that the physician identifies at the time of the patient’s admission. This definition is not the same for SNF admissions.

FL 70A-70C: Patient’s reason for visit: situational. The patient’s reason for visit is required for all un-scheduled outpatient visits for outpatient bills. The hospital will have three ICD-9-CM diagnosis(es) to report, if applicable. This is a great addition and will certainly assist in the effort for supporting medical necessity of tests ordered in the ED.

FL 67: Principal diagnosis code: required. The hospital enters the ICD-9 code for the principal diagnosis. The code must be the full ICD-9 diagnosis code, including all five digits where applicable.

FL 67A-67Q: Other diagnosis codes outpatient: required. The hospital enters the full ICD-9 codes in FLs 67A–67Q for up eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. Note: Medicare will ignore data submitted in 67I-67Q. This area has been upgraded to capture 17 secondary diagnoses, however CMS will only identify the first eight. It is important that you capture the ICD-9-CM diagnosis which supports medical necessity within these eight secondary diagnoses.

FL 72: External cause of injury (ECI): codes not used. Any data entered here will be ignored. This area will hold one E code.

Review this information with your outpatient coding professionals to ensure capture of accurate ICD-9-CM diagnoses, which will strengthen your severity of illness and improve your case-mix now and in the future. Work with your facility and vendors to make sure they know the timeline and are prepared for implementation.

[ via APCs Weekly Monitor ]

CMS proposes to pay for six packaged services separately

In the 2007 outpatient prospective payment system (OPPS) proposed rule, the Centers for Medicare and Medicaid Services (CMS) creates a new payment category called “special package” codes for six CPT codes that are currently packaged (i.e., not paid separately). CMS proposes to provide separate APC payment for these services when reported on a date of service with no other separately payable OPPS service. These CPT codes and their corresponding APC and payment include

• 36540, Collect blood, venous access device. APC 0624, $32.96.
• 36600, Arterial puncture; withdrawal of blood for diagnosis. APC 0035, $12.45.
• 38792, Sentinel node identification. APC 0389, $86.92.
• 75893, Venous sampling through catheter, with or without angiography, radiological supervision and interpretation. APC 0668, $393.35.
• 94762, Noninvasive ear or pulse oximetry for oxygen saturation by continuous overnight monitoring. APC 0443, $61.39.
• 96523, Irrigation of implanted venous access device. APC 0624, $32.96.

“We acknowledge that there is a cost to the hospital associated with registering and treating a patient, regardless of whether the specific service provided requires minimal or significant hospital resources,” CMS says in the proposed rule. Each of the above codes has a special status indicator Q, but the outpatient code editor (OCE) and PRICER software will determine how they are paid. If one of these codes is the only OPPS service on the claim, it will be paid the above APC. When two such services are provided as the only services on a claim, CMS will reimburse the higher paid APC. If you report one of these services on the same claim as another separately payable OPPS service, it will remain packaged.

“This is great news as providers and the APC Advisory Panel have been trying to get CMS to recognize that separate payment should be provided for certain packaged services that can and are legitimately the only service rendered to a patient on a given date of service,” says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC.

“It would be nice if CMS recognized pulse oximetry and other services, but we got the vast majority of services that need this special recognition,” adds Valerie Rinkle, MPA, revenue cycle director for Asante Health System in Medford, OR. Rinkle and other providers have written to CMS and presented to the APC Advisory Panel about this concern for three years.

No low-level E/M
Previously, providers had no way to report these services, Rinkle says. Many chose to do so with a low-level E/M code, due to CMS’ advice in Transmittal A02-129, “2003 Update of the hospital OPPS.” The advice concerns nonselective wound care debridement (97602) and states:

It is common for 97602 to be performed at the time of another physical therapy service, in which case payment for 97602 is packaged into payment for the other physical therapy service. If a service coded under 97602 is performed at the time of a clinic or emergency visit, the E/M service must be documented in accordance with the hospital’s documentation guidelines for clinic and emergency visits. If the only service provided to a beneficiary is 97602, the hospital may bill outpatient visit code 99211. Payment for 97602 will be packaged into the payment for 99211.

Unfortunately, CMS has now backed off this statement of reporting a low-level E/M in place of a packaged service. On p. 93 of the 2007 OPPS proposed rule, CMS states:

While we have been told that some hospitals may bill for a low-level visit if a packaged service only is provided so that they receive some payment for the encounter, we note that providers should bill a low-level visit code in such circumstances only if the hospital provides a significant, separately identifiable low-level visit in association with the packaged service.

“That is a significant departure from past CMS policy,” says Rinkle.

Note: This article was adapted from the newsletter Briefings on APCs

[ via HIM Connection ]

Reference guide helps providers bill Medicare for common vaccines

The Centers for Medicare & Medicaid Services has published a quick reference guide to help Medicare fee-for-service providers file claims for flu, pneumococcal and hepatitis B vaccines and their administration. Print copies of the guide, Quick Reference Information: Medicare Immunization Billing, will be available this fall.

Append modifier -59 to ED injection with appropriate documentation

QUESTION: A patient presents to the ED with a finger laceration (883.0). The physician repairs the wound (12001) and gives the patient an intramuscular injection (90772) of Ancef ®. The NCCI edits indicate that the injection (90772) is a component of the comprehensive procedure (12001). Is it appropriate to append modifier -59 to 90772?

ANSWER: On January 1, 2006, CMS released updated information indicating that providers could append modifier -59 to injections/infusions provided in the ED. From January through March 2006, NCCI edits were disabled for injections and infusions in the ED. Then, from April through June 2006, CMS resurrected the NCCI edits for injections and infusions with multiple combinations requiring the use of modifier -59.

But based on hospital feedback, Medicare decided to release a limited pair of NCCI edits for injections and infusions beginning with Version 12.1 of the outpatient code editor effective July 1, 2006. For more information, read Medlearn Matters article SE0635 at the CMS Web site.

Even with the elimination of the most common drug administration code pairs, hospitals continue to see a combination of codes that evoke NCCI edits involving injection(s) or infusion(s) with procedures and services provided on the same date of service. The example above is a common set of code pairs that require providers to append modifier -59 to 90772 in order to receive APC payment. Again, documentation must be present for the use of modifier -59.

Continue to monitor your internal claims scrubber technology, encoder logic, and personnel to ensure a complete understanding of the updates and requirements for drug administration code pairs and the current NCCI edits in order to achieve APC revenue integrity.

[ via APCs Weekly Monitor ]