Briefings on APCs. CMS changing MUEs April 2013 P11. Trendspotting

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1 Briefings on APCs P5 P8 P11 New molecular pathology coding still complex In the first in a series, we look at how to code for molecular pathology tests. Audits lock down processes, clarify coding Learn what to look for when conducting an internal audit to reduce compliance risk and takebacks by outside auditors. This month s coding Q&A Our experts answer questions about modifier -25, cardioversion performed during an ED code, denials for multiple port film line items, and procedure discontinued after administration of anesthesia. Volume 14 Issue No. 4 April 2013 CMS changing MUEs Trendspotting Healthcare fraud recoveries CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service (DOS) edits, effective April 1. An MUE represents the maximum units of service providers would typically report for a specific HCPCS or CPT code and is based on several factors, including anatomy, code description, the agency s own policies, and the overall nature of a service. The MUEs apply for the same provider, the same patient, and the same DOS. CMS is making this change to DOS edits because the OIG and the Government Accountability Office recently determined that facilities receive inappropriate payment because they report the same code as separate line items. What s odd about this is that CMS and its contractors have instructed providers to report legitimate units in excess of the MUE value on a separate claim line with the appropriate modifier, says Jugna Shah, MPH, president of Nimitt Consulting, Inc., in Washington, D.C. CMS announced the change in a letter to the American Hospital Association (AHA). However, the letter does not explicitly state what CMS will deny going forward. There are several scenarios for how CMS may process denials and report them back to providers. CMS may deny: Years Recovery in billions The government s healthcare fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in fiscal year 2012, according to the OIG. Source: hhs.gov/news/press/2013pres/02/ a.html

2 This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. editorial advisory board Senior Managing Editor Michelle Leppert, CPC Dave Fee, MBA Product Marketing Manager, Outpatient Products 3M Health Information Systems Murray, Utah Frank J. Freeze, LPN, CCS, CPC-H Principal The Wellington Group Valley View, Ohio Susan E. Garrison, CHCA, CHCAS, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR Executive Vice President of Healthcare Consulting Services Med Law Advisors, Inc. Atlanta, Ga. Kimberly Anderwood Hoy, JD, CPC Director of Medicare and Compliance HCPro, Inc. Danvers, Mass. Diane R. Jepsky, RN, MHA, LNC CEO & President Jepsky Healthcare Associates Sammamish, Wash. Lolita M. Jones, RHIA, CCS Lolita M. Jones Consulting Services Fort Washington, Md. Jugna Shah, MPH President Nimitt Consulting Washington, D.C. Questions? Comments? Ideas? Contact Senior Managing Editor Michelle Leppert at or , Ext Briefings on APCs (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $249/year. Copyright 2013 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be on this list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BAPCs. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Current Procedural Terminology (CPT) is copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of American Medical Association; no fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Quick Hits online New name for ICD-9 Coordination and Maintenance Committee CMS recently announced it will rename the ICD-9-CM Coordination and Maintenance Committee the ICD-10 Coordination and Maintenance Committee effective with the March 2014 committee meeting. This committee is responsible for the development and maintenance of both ICD-9-CM and ICD-10 codes. Starting in 2014, the committee will focus solely on the maintenance of ICD-10-CM and ICD-10-PCS codes. The committee last met March 5. Outpatient wound care coding webcast on demand Correct wound care billing and coding begins at the registration desk and flows through the entire facility clinical, coding, and billing. Incomplete documentation or an incorrect modifier can cost the facility a large amount of revenue. If you missed expert speaker Gloria Miller s presentation, you can still order a copy on demand and listen as she provides step-by-step strategies and tips to improve documentation, coding accuracy, and compliance. For more information or to order, call or visit the HCPro Healthcare Marketplace at Follow Us Follow and chat with us about all things healthcare compliance, management, and from the field If you haven t audited your charts and your coding, you won t know where gaps exist now and consequently won t have those deficiencies resolved before ICD-10 goes live. If you don t know what is happening now, how can you be prepared for later? Andrea Clark, RHIA, CCS, CPC-H stay connected BAPCS in Your Inbox Sign up for any of our 17 newsletters, covering a variety of healthcare compliance, management, and reimbursement topics, at Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to Briefings on APCs, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving Briefings on APCs, you are eligible for a free trial subscription. Contact customer service with your moving information at At the time of your call, please share with us the name of your replacement. 2 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 The entire claim (as suggested in the letter, but this seems unlikely) All line items for a single code reported on the same DOS regardless of whether appropriate modifiers are used Just those units that exceed the MUE DOS limit Kathy Dorale, RHIA, CCS, CCS-P, vice president of HIM at Avera Health System in Sioux Falls, S.D., believes CMS will continue to deny line items with the same code and the same DOS, and facilities will continue to either submit an appeal or decide to accept the denial and take the write-off. Most MUE denials are for smaller payment amounts, meaning that even though a write-off isn t in their best interest, appealing these denials will simply be too costly for many facilities. Until further guidance is released or claims begin to be processed post April 1, we won t quite know for sure what will happen, says Shah. MUE values CMS has published some, but not all, MUEs. The agency generally does not publish codes with an MUE value of 4 or higher, but edits for some codes with lower MUE values may also not be published if CMS believes those codes are prone to fraud and abuse. Because facilities have been dealing with MUEs since 2007, they are familiar with many of the common unpublished MUEs. CMS will not publish any of the MUEs that will be edited by DOS, which will create new uncertainties for the provider community. As such, providers can only speculate about which codes the new logic affects, says John Settlemyer, MBA/MHA, assistant vice president of revenue cycle at Carolinas Healthcare System in Charlotte, N.C. My fear is that this change will impact the payment of multiple units of legitimate drug administration services, primarily injections, most egregiously. The additional MUE appeals will add additional backlog to the already-clogged appeal process and impact cash flow, he says. Before deciding whether to appeal, providers typically look at: The volume of the service (i.e., how often the facility provides the service) The expected reimbursement The expected cost in time and money to appeal MUE edits often apply to high-volume, lower-paid services, so the time and resources used to appeal an MUE denial frequently exceed the value of the payment being appealed, says Valerie Rinkle, MPA, vice president of revenue integrity informatics with Health Revenue Assurance Associates in Plantation, Fla. Often providers write these off, which may embolden CMS and other payers to increase the number of these types of edits, resulting in more and more of these types of denials, Rinkle says. If providers elect not to appeal, CMS data regarding number and volume of outpatient services delivered to beneficiaries will not accurately reflect actual services rendered to the patient, Rinkle says. This will impact future rate setting and profiles of service utilization, especially if used to define outpatient or episode-type payment bundles. Future payments will definitely be impacted since CMS won t have a complete and accurate clinical picture of the medically necessary units of service provided to different types of patients, Shah says. Furthermore, without providers filing appeals, it will be that much more difficult to get CMS to revise MUE DOS limits. New MUE categories CMS is dividing the new MUE DOS edits into two categories: Codes that will almost never be reported with more units of service than the MUE. For example, providers would almost never report CPT code (heart transplant, with or without recipient cardiectomy) with more than one unit of service. Codes that will rarely exceed the unit of service MUE. For example, typically providers would only ever report one unit of service for CPT code (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). In certain specific cases, a provider may need to perform a second hysterectomy for a patient with a double uterus. Based on CMS communication, it seems unlikely that providers will be able to bypass the new DOS MUEs using modifiers as they ve been able to do up until now, 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or April 2013 hcpro.com 3

4 but providers won t know for sure how claims are processed after April 1. Services like a hysterectomy are not the problem, Dorale says. The examples CMS provided in its letter announcing the change are obvious, but many of the unpublished MUEs are not. The unpublished MUEs often apply to services such as injections and infusions, which CMS does not address in the letter. Pitfalls to the new system One problem the unpublished MUEs will present is a lack of information throughout the entire provider community. Each provider will know only the MUEs that it triggers, just as it does today, Dorale says. But going forward, providers will have to compile a new list of the units of service allowed vs. those that are denied based on CMS change to the MUEs. We ve already had to go through this process once and it was and is cumbersome, and now we ll have to go through it again, she says. We compile this list not because we are trying to game the system, but because we have to know the right way to report our legitimate units on the claim. Even if an individual provider wins an appeal, this won t help everyone else facing similar denials. As everyone continues to appeal the same thing, time and resources are wasted, so it seems like there should be a process in place where CMS finds out what appeals it s getting regularly, and work quickly to make code-level unit changes, Dorale says. This problem has existed since the implementation of MUEs because CMS made clear that providers are not to share MUE limit information as they discover it, Shah adds. It seems like CMS is afraid that if providers share information they will engage in blatant fraud and abuse, when in fact providers want to share the information so they can avoid the trial-and-error work involved in ascertaining specific code limits for legitimate situations, says Shah. Given that CMS and other governmental agencies have so many mechanisms to ferret out fraud and abuse, it doesn t seem reasonable to make the already cumbersome MUE process even more complex and opaque. Another problem is CMS may have incorrect information in its system. Dorale points to Transmittal 2636 as an example. The transmittal deals with the NCCI edits and lists primary CPT codes for use with add-on codes. However, when reviewing the table of injections and infusions in the transmittal, Dorale found errors because of how CMS wrote the policy. With errors showing up in a transmittal that provides open information, the question arises of how many errors could be included in the unpublished MUEs. Those errors could hit edits and cause additional problems for providers. Overriding MUEs In some cases, the provider can legitimately perform a service in excess of the MUE limit. MUEs are not intended to be strict utilization guidelines, so a physician may prescribe more doses of a medication than the MUE allows, for example. Facilities can report the excess units on a separate line item with a modifier. Presumably, this will no longer be an option for certain services based on CMS letter to the AHA where it describes the change to date-of-service editing and MUE limits, Settlemyer says. Providers will be forced to expend valuable time and resources submitting appeals. Providers were reporting services the way Medicare contractors instructed them to and received payment for units in excess of the MUE limits when appropriate and medically necessary without going through an appeals process in many cases, Dorale says. Under the new program, it seems likely that providers will start seeing new denials from the DOS application of the new MUEs, resulting in increased denials likely to create a lot of confusion, Dorale says. Part of the problem is providers had no input into the MUE changes and whether the units of service are appropriate, Dorale says. In many cases, providers can comment on proposed changes either in the annual OPPS proposed rule or through the local coverage determination process. The best thing hospitals can do now is to estimate how many codes may be affected come April 1. They can do this by evaluating services where the same CPT was billed multiple times per DOS, says Rinkle. Different modifiers communicate why the facility billed the same CPT on a given DOS. With the edit no longer looking at units per line, but rather per date of 4 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 service, some of these modifiers will no longer enable a claim to process and be paid, she says. Because it appears the new MUEs will be applied by DOS and will also be unpublished, providers are not likely to be able to override legitimate excess units on the front end. They will be forced to appeal denials for DOS MUEs. There should be a better way to communicate legitimate, documented, and medically necessary services above an MUE that providers can communicate at the time they re processing the claim rather than going through the costly process of resubmitting and doing an appeal, Dorale says. That could cause a delay of days or months before the facility receives payment. Providers need to be aware of this change and brace for it, Settlemyer says. They can take certain steps now to prepare for the coming denials. Facilities should evaluate the number of MUE appeals they submit now so that they will have a basis for how this change impacts volume of appeals, Settlemyer says. Also if providers have any experiences with reporting comments and suggestions to NCCI and/or CMS, they should voice their concerns about this change. Tell CMS about the significant administrative burden associated with having to appeal MUE denials, Rinkle adds. CMS needs to develop a condition code where the provider can communicate to CMS that the medical record was reviewed and the number of units remains valid. The condition code would allow providers to essentially say they have reviewed the patient s record and the units are valid and medically necessary, so please pay the claim, Dorale adds. Providers need to be more vocal to CMS if these changes result in inappropriate claim denials, Rinkle says. The administrative burden is significant, and CMS is trying to reduce administrative burden to enable providers to focus resources on quality and value. Without consistent feedback from providers regarding these issues, CMS believes the changes they make are fairly insignificant and benign. Once providers start seeing these new denials, they will provide CMS with plenty of feedback, likely through Open Door Forum calls with the agency or on calls with contractors, Dorale says. I think we re going to hit so many edits that the billing staff is going to be overwhelmed, Dorale says. It s already a problem today and it s a guessing game. H New molecular pathology coding still complex Editor s note: Facilities need to address coding, payment, and coverage issues for molecular pathology. This article is the first in a series and discusses molecular pathology coding. At first glance, the new CPT codes for reporting molecular pathology services might seem simple. They certainly look easier than the old stacking codes that focused on methodology and processes, resulting in multiple codes and quantities being used to report a single test. In their place is a growing list of molecular pathology CPT codes that are gene and analyte specific. The AMA began the move away from stacking codes as part of the 2012 CPT Manual by introducing 101 Tier 1 and nine Tier 2 molecular pathology codes; for 2013, the AMA has added still more codes. Tier 1 (CPT codes ) includes codes that represent gene-specific and genomic procedures. These codes represent more commonly performed tests. Tier 2 ( ) includes codes that describe molecular pathology procedures not listed in Tier 1. These codes are categorized according to the level of technical resources and interpretive professional work required. Since Medicare did not recognize these molecular pathology codesin 2012, many hospitals may just be starting to work with them by loading them in their chargemaster, says Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C. One thing that will definitely help everyone gain a 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or April 2013 hcpro.com 5

6 better understanding of the codes and their nuances is a thorough review of the molecular pathology introductory text and 22 frequently asked questions that appear in the CPT Manual, says Shah. The questions and answers include clinical examples and begin on p. xx of the 2013 CPT Manual introduction. The AMA uses specific, straightforward language in the examples and makes clear that code selection will be critically dependent on a careful and literal review of each code descriptor as there are many subtle nuances associated with reporting the new codes as well as using the unlisted code, Shah says. Noting the nuances Part of the challenge with the new molecular pathology codes lies in the use of the abbreviates ie (that is) and eg (for example), says Michelle L. Ruben, project manager of revenue and rate setting strategy at M.D. Anderson Cancer Center in Houston. In general, the CPT Manual is very specific in how it uses ie and eg, and this holds true for the molecular pathology codes as well. According to the 2013 CPT Manual (p. xxi): When a code descriptor in the CPT codebook has a parenthetical note that begins with ie, this means that the term that follows clarifies the intent of the word or phrase preceding the parenthetical statement. If the content of the parenthetical is not met, then the code should not be used. For example, the description of CPT code is FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis, internal tandem duplication (ITD) variants (ie, exons 14, 15), which has a specific parenthetical note of ie exons 14, 15. If the lab does not test both exons 14 and 15, then it would not be appropriate to report code 81245; instead the unlisted code, 81479, would need to be reported, Shah says. Similarly, CPT code specifies ITD variants, but many labs may test this along with an additional variant, Ruben says. There appears to be strong agreement [within the industry] that in such a case, the unlisted code would need to be reported along with CPT code The 2013 CPT Manual also states: When a code descriptor in the CPT codebook has a parenthetical note that beings with eg, it means that the following language represents an example or examples of the intent of the word or phrase preceding the parenthetical statement. If a code description states eg (for example) and lists some variants, then that code can be used to report other variants that are similar even though they are not listed as part of the code descriptor, Ruben says. One of the frequently asked questions deals specifically with the use of ie and eg. Consider the CPT code 81235: EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q). If the laboratory performed the test for some but not all of the listed variants, plus one or more additional common variants, CPT code can be reported, Ruben says. In fact, even if the lab tests for multiple variants for the EGFR gene, only one unit of CPT code would be reported since the code description specifies variants (more than one). On the other hand, if only a single variant was tested, this code would not be appropriate to report because, again, it specifies variants (more than one), and if only one is tested, then the unlisted code would need to be reported, says Shah. Other codes do not include eg for variants, such as CPT code (BRAF [v-raf murine sarcoma viral oncogene homolog B1] [eg, colon cancer], gene analysis, V600E variant). Unlike other molecular pathology codes that allow for other variants through the use of eg, CPT code does not state common variants (eg, A, B, and C). Therefore, if the lab performs a test on a variant other than the V600E variant, CPT code would not be appropriate to use and an unlisted code would have to be reported, Ruben says. If a physician orders BRAF testing for the V600E variant and an additional variant is also tested, then it would be appropriate to report two codes: CPT code for variant V600E and the unlisted molecular pathology CPT code for the second variant. Coders are literal people, which is great because 6 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 they read code descriptors word for word and ask questions when they are not sure whether a code fits the service provided, but this may not be a common practice in the lab or among others involved in charging for molecular pathology services, says Shah. As such, coding staff may need to work closely with charging staff and lab personnel. Coders will need to review the description of a code and compare it to the genes/variants tested. If they don t match perfectly, then coders will need to check if the code description includes an ie or an eg and determine whether the code can be reported, whether an unlisted code is needed, or whether multiple codes are required to report the complete service, say Shah and Ruben. Based on the CPT instructions and examples provided in the CPT Manual, hospitals may find themselves having to report the unlisted code more often than not, Ruben notes. Evolving codes One question that arises is why some molecular pathology codes clearly list variants as examples, not an exclusive list, while other codes don t. The answer may lie in the rapid scientific advances that are being made for some gene mutations and associated tests. This may explain why the code for FLT3 was created to cover only the ITD variants, for example, even though there are other variants of interest such as the D835 variant. Some genes already have multiple molecular pathology codes, which means coders must know exactly what is being tested. For example, for KRAS gene testing (v-ki-ras2 Kirsten rat sarcoma viral oncogene), Tier 1 CPT code covers variants in codons 12 and 13, while Tier 2 CPT code covers variants in exon 3 (codon 61). In addition, labs test for other variants in the KRAS gene, which require coders to report unlisted code 81479, Ruben says. Simplifying molecular pathology coding Some of the guidelines surrounding molecular pathology codes will be second nature to coders because they are similar to how other services are reported. For example, coders use CPT code to report Mapping new and old molecular pathology codes Unfortunately for coders, they will not be able to create crosswalks from the old molecular pathology stacking codes to the new Tier 1 and Tier 2 codes, although they can map the services from the old stacking system to the new codes. A map is not the same as a direct crosswalk, says Michelle L. Ruben, project manager of revenue and rate setting strategy at M.D. Anderson Cancer Center in Houston. The primary thing you can use the map for is to compare reimbursement and charges on a test-by-test basis. The map allows Ruben and her colleagues at M.D. Anderson to look at the stacked codes they used to report for molecular pathology tests and how much reimbursement they received. They can then map that information to the new code to see how the reimbursement matches up. The old stacking codes resulted in considerable overlap between tests. One code could be reported for 20 different tests because with stacking, coders reported a different code for each step of the procedure required to perform the test. You can t take your old data and map it to new codes without additional information, Ruben says. When coders think of mapping and crosswalking, they often think of a 1:1 match, says Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C. For example, coders used to report CPT code for the initial hour of IV hydration. Now they report That s an easy crosswalk because the AMA replaced one single code with another single code. Coders may also think of crosswalks between ICD-9 and ICD-10, where one ICD-9 code maps to one or more ICD- 10 codes. Coders use those crosswalks to figure out what to code in the future, Shah says. Unfortunately, you can t use that exercise to figure out what to code in molecular pathology.the crosswalking or mapping doesn t help with coding at all. It helps with internally determining what you might charge for the service today with the one new code compared to what you used to charge with multiple stacking codes HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or April 2013 hcpro.com 7

8 a revision of total shoulder arthroplasty of the humeral and glenoid component. If the physician only performs a revision of one component, coders report The same holds true with molecular pathology coding. If the lab does not perform all of the components specified by an ie, coders can t use the code. Coders also know that if the code specifies variants, plural, and the lab only tests for one variant, they cannot report the code, Shah says. When you read the FAQs, it becomes clear how complicated things can get with reporting the new molecular pathology codes, Shah says. Hospitals should understand the differences between the Tier 1 and Tier 2 molecular pathology codes, which CPT describes clearly in the manual. CPT clearly states that for Tier 2 codes, if the code does not include the specific gene and region, coders cannot report the Tier 2 code they must report the unlisted code. A coder might believe a test is comparable to testing genes A, B, and C, and as a result he or she is sure it should be a Level 4 Tier 2 code. If the lab is testing gene D, the coder cannot report the Level 4 code unless the CPT Panel has specifically included the gene to its Level 4 Tier 2 list and published it in the CPT Manual. This is likely to be an area of confusion in the use of the Tier 2 codes, Ruben says. Some coders will simply self-assign a test to one of the Tier 2 levels. This adds a whole other level of confusion, she says. Some people are going to self-assign either because they don t know any better or they think it is so obvious they are just going to use it anyway. If a test is not listed in Tier 1 or Tier 2, instead of trying to force a best match, Ruben says, the unlisted code should be used, according to CPT. H Audits help lock down processes, clarify coding Being audited is rarely fun. After all, you re probably going to lose money, face a fine, or both. More and more entities are auditing healthcare claims Recovery Auditors, Medicare Integrity Contractors, MACs, FIs, commercial payers, and on and on. How can you make sure your facility is ready to face an audit and emerge as unscathed as possible? Consider performing internal audits to find problems before the official auditors arrive. Reasons to audit If the thought of the government recouping your payments (often with interest) isn t enough to convince you of the necessity of internal audits, consider other ways your facility could be losing legitimate revenue. If the physician isn t accurately and completely documenting the services he or she provides, coders can t report them. For example, a physician sees a new patient and takes a comprehensive history, conducts a complete review of systems, and performs complex medical decision-making. However, the physician only documents that he or she reviewed all systems. That is not enough documentation to credit the physician with a complete review of systems, so instead of being able to code a high-level E/M visit, the coder must downgrade the service to a Level I E/M. That s legitimate revenue lost because of incomplete documentation. The transition to ICD-10 is another reason to conduct internal audits. ICD-10 requires considerably more specificity than ICD-9. If you haven t audited your charts and your coding, you won t know where gaps exist now and consequently won t have those deficiencies resolved before ICD-10 goes live, says Andrea Clark, RHIA, CCS, CPC-H, CEO, chairman, and founder of Health Revenue Assurance Associates, Inc., in Plantation, Fla. If you don t know what is happening now, how can you be prepared for later? Examine more than just the coding When conducting an internal audit, look at more than just whether the codes are correct, Clark says. A revenue cycle assessment is very different from a coding assessment. Coding is a huge portion of revenue cycle, but audits 8 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 should be all encompassing to include all departments/charges, Clark says. That includes physician orders and modifiers, especially those appended in departments other than HIM. It also includes transfer documentation and units of service. If the coder reports the correct code but with too many units, the facility faces potential compliance risks and possible accusations of upcoding. However, if the coder fails to report all of the units, the facility loses legitimate revenue because it isn t paid for the unreported units. That can add up to a significant amount of money, especially for drugs. CPT/HCPCS code descriptions do not always match up to the dosage the physician provides. For example, HCPCS code J0120 specifies an injection of tetracycline up to 250 mg. If the physician actually administers 500 mg of tetracycline, coders must report two units. Also be sure to review your chargemaster to determine whether any modifiers are hard-coded, meaning the modifier is automatically appended every time a staff member reports a certain CPT code. Some modifiers can be hard-coded, but others should never be appended automatically, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., in Danvers, Mass. For example, modifiers -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and -59 (distinct procedural service) should never be hard-coded, says Mackaman. Coders need to review the documentation thoroughly before deciding whether to append one of these modifiers. Take down the wall between departments now, Clark says, because you ll have to do it once the United States moves to ICD-10. Dissect the documentation During the audit, take a close look at the actual documentation coders are currently using to code, Clark says. The auditor, whether internal or an outside contractor, will need all of the documentation coders are using. Where are the physician orders located? Are they paper orders? Are they scanned into the system? Can auditors get to the orders? Can the coders? You have to reconcile the documentation so that the audit is successful, Clark says. If you don t have the documentation, the audit will not be successful. When performing an audit, think like the federal government, Clark suggests. If a Recovery Auditor reviewed the documentation, would it support the coding? Be sure you understand what type of medical record each department is using. Some departments may be completely electronic or completely paper-based, while others may use a hybrid record. In any case, coders and auditors must be able to find all of the documentation. If documentation is missing, determine why. Did the physician fail to include the information? Did someone misfile a paper record or forget to scan it in? Did an electronic entry not save to the correct place? Each of those scenarios requires a different corrective action after the audit. If you don t know why the problem occurred, you can t correct it moving forward. Recognize the importance of a diagnosis Clark refers to the ICD-9 diagnosis codes as the soul of the claim. The diagnosis codes provide the medical necessity for the procedure codes. No one really knows where coders are getting the diagnosis codes from, Clark says. Coders may be assigning diagnosis codes from physician documentation, a nurse s triage notes, or even the reason for an ED visit. It s important to know your coders and know where they are getting their information, Clark says. As you prepare for the transition to ICD-10, you need to make sure everyone is getting the information from the same place and uses the information the same way. Ensure that you have specific policies that all coders across all departments follow, including: Same-day surgery ED Ancillary procedures with orders Other outpatient departments Also look at coding of secondary diagnoses. Make sure coders are picking up chronic conditions that influence the care of the patient. The auditor also needs to make sure coders are reporting diagnoses consistently, not just because they memorized one code that supplies medical necessity, Clark says. Ask if you have policies and procedures for finding 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or April 2013 hcpro.com 9

10 and reporting diagnosis codes, Clark recommends. Those policies should be more than just a repetition of the outpatient coding guidelines. Make sure all of your coders, including contract coders, know your policies and apply them consistently. Your audit can help determine which coders are following policies and procedures and which are not. Report the correct procedure codes Once you resolve any confusion around the diagnosis codes, start looking at the CPT/HCPCS procedure codes. One problem area with code assignment is that one person may be coding a procedure, while a different person charges for it, Clark says. Coding and charging are not the same things. Auditors often find confusion between who is coding and who is charging. Different people may interpret rules and guidelines differently, which can lead to incorrect coding, charging, or reimbursement. Everyone involved in coding and charging needs to understand the entire process so that the data remains solid, Clark says. Depending on the setup at your facility, you may need to educate staff in areas other than HIM. In some facilities, for example, the physical therapy staff code their procedures. Radiology staff may code the radiologic supervision and interpretation portion of a procedure while a coder codes the surgical part. In some cases, those codes don t match up correctly. In other cases, the radiology staff may separately report supervision and interpretation that is bundled into the procedure code. If staff members in other departments are submitting codes, are HIM coders verifying and validating those codes? An audit can help you determine whether coders are validating the codes every time and also help you decide if they should be, Clark says. If you find that a large number of codes submitted by other departments are incorrect, consider requiring HIM coders to always review the record and validate the codes. On the other hand, if your audit finds that a certain department always or almost always submits the correct codes, you may decide to have HIM coders randomly validate those codes. Operations need to be solidified so you understand who is doing what, Clark says. Remember, if you expect coders to look at the complete record, you need to educate them on what that means. They need to know what their exact responsibilities are. An audit can help you clarify where you stand so you can plan for where you want to go. H Decide who performs the audit In-house staff or external contractors can perform audits for you. Both options offer pros and cons. In-house staff members know their way around the facility s systems and may know the people involved. That can help the auditors find records and get answers from the appropriate personnel. However, it can also result in the auditors making assumptions based on common practice at the facility, says Peggy Stilley, CPC, CPMA, CPC-I, COBGC, ACS-OB, director of auditing services at AAPC Physician Services in Salt Lake City. In-house auditors need to be objective and only give a physician credit for a service or procedure when the physician completely documents the work performed. Auditing a chart from a physician you don t know can often be easier than reviewing a chart from a physician you work with every day, Stilley says. Try to correct for these biases. Coders should never assume; if it is not in the documentation, don t consider it. Outside auditors, meanwhile, come in with little to no preconceived ideas about how your facility codes and bills patients or which physicians are strong (or weak) at documenting. They may be more critical about assumptions coders make based on past interactions with a particular physician. When you re looking at a chart as an outsider looking in, you can be very objective, Stilley says. If the documentation does not answer the who, what, where, when, and how questions, it is not thorough enough to properly code the encounter. On the downside, outside auditor fees can be expensive and you may spend a significant amount of time showing them where to find information and people. 10 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 Appending modifier -25 Q A patient comes in to an outpatient clinic. The provider performs an E/M. The patient needs an influenza injection. On the professional side, we would bill the E/M visit. On the facility side, we re going to bill the E/M with a modifier -25 for the flu injection and administration of the injectable. Would that be correct? A An injection charge is like any other procedure charge, so you d want to take a look and see if you had additional work. Did the physician perform the E/M for conditions that were unrelated to the injection? Let s say the patient came in about his or her diabetes. The nurse did a workup, took a look at the patient s blood sugars, and gathered that information up for the physician to review, or entered some history. While the patient was there, the nurse or physician also administered a flu vaccination. You certainly would append modifier -25 for that visit. But CMS has said on the facility side that simply because the patient interacts with the facility does not mean the facility is entitled to report an E/M code. Make sure that you have some additional work above and beyond your flu vaccination or your flu injection administration code. Reporting cardioversion performed during an ED code We ve just completed our yearly audit and Q the ED portion was pretty good. We agreed with one item: The auditor said that we should not report CPT code (cardioversion, elective, electrical conversion of arrhythmia; external) for the defibrillation that is done in our ED during a code. When the patient is shocked to restart his or her heart, we charge for the cardioversion because that is what the clinicians are doing converting the patient s rhythm. Could you help us defend this? A A cardioversion involves converting the patient s heart rhythm, but the shock is timed so that it s delivered at the appropriate time to reset the rhythm. Although defibrillation is also an electrical shock, it does not have to be timed to the rhythm because many times the patient does not have a sustained heart rhythm in cases where defibrillation is required. Defibrillation is performed in response to a heart that is not functioning as a heart should quivering instead of beating. It is included in the code for CPR and is not separately reportable. The NCCI manual, Chapter 11, provides the following instruction: There is no CPT code to report emergency cardiac defibrillation. It is included in cardiopulmonary resuscitation (CPT code 92950). If emergency cardiac defibrillation without cardiopulmonary resuscitation is performed in the emergency department or critical/intensive care unit, the cardiac defibrillation service is not separately reportable. Physicians should not report CPT code (cardioversion, elective...; external) for emergency cardiac defibrillation. CPT code describes a planned elective procedure. If a planned elective external cardioversion is performed by a physician reporting critical care time (CPT codes 99291, 99292), the time to perform the elective external cardioversion should not be included in the critical care time. In this scenario, the auditor is correct. Educate staff, especially in the ED, so everyone knows how to appropriately report the service. Denials for multiple port film line items We received a line item denial for our port films. Q The documentation in the record supported the films we billed, but the line item was not reimbursed. We have run out of theories as to why. Do you have any thoughts about why this happened? 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or April 2013 hcpro.com 11

12 A Multiple port films may be ordered and performed, but regardless, you may only report one unit. The definition for CPT code states Therapeutic radiology port film(s). Since the specific wording in the definition is film(s), this includes one or several films performed. According to Chapter 9 of CMS NCCI manual, updated January 1, 2013, the MUE value for this code is 1 since it includes all port films. If providers frequently perform more than one port film, review the cost/charge reported for this code and reflected in the line item. Typically, this is a chargemaster-driven code, so facilities may be able to indicate the number of port films performed in the chargemaster description. That would allow the facility to adjust the cost/charge accordingly, depending on its charge methodology. Reporting a procedure discontinued after administration of anesthesia A patient went to the operating room under anesthesia for cataract extraction and repair of retinal Q detachment of the same eye. The surgeon successfully removed the cataract. The surgeon then accessed the back of the eye to begin to repair the detachment. After reviewing the condition of this eye area, the surgeon determined that the eye was in such bad shape it could not be saved, so the detachment was not repaired and surgery was ended. The patient was under anesthesia and the retinal detachment repair procedure was begun (although barely) but then cancelled. Should we report this procedure since the facility incurred expenses for the surgical attempt at repair? A If you are reporting CPT codes, report the procedure code for the repair of the retinal detachment with modifier -53 (discontinued procedure) if the procedure was performed on an inpatient basis, or modifier -74 (discontinued outpatient procedure after administration of anesthesia) if the procedure was performed in a hospital outpatient or ambulatory surgical center. Regardless of which procedure code set you are using, you want to make certain that you are also reporting one of these diagnosis codes on this patient s claim: V64.1, surgical or other procedure not carried out because of contraindication V64.2, surgical or other procedure not carried out because of patient s decision V64.3, procedure not carried out for other reasons In the situation you describe in your question, it seems either V64.1 or V64.3 would be accurate. I strongly recommend appending a report to explain the circumstances under which one procedure was completed while the second was discontinued and include the reasons why. H Contributors We would like to thank the following contributors for answering the questions that appear on pp : Andrea Clark, RHIA, CCS, CPC-H Chairman, CEO, and Founder Health Revenue Assurance Associates Plantation, Fla. Kimberly Anderwood Hoy, JD, CPC Director of Medicare and Compliance HCPro, Inc. Danvers, Mass. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, AHIMA-Approved ICD-10 Trainer Safian Communications Services Orlando, Fla. Denise Williams, RN, CPC-H Director of Revenue Integrity Services Health Revenue Assurance Associates, Inc. Plantation, Fla. 12 hcpro.com April HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or