Take proactive approach to PACT compliance

April 2011 Vol. 14, No. 4 Take proactive approach to PACT compliance RACs continue to keep a close eye on the Post-Acute Care Transfer (PACT) policy that reduces the DRG payment to a per diem rate when patients are transferred to one of six postacute care settings. So what does this mean for coders? Experts say it underscores the importance of accurate discharge disposition code assignment, communication, and teamwork. Know how the PACT policy is triggered Hospitals trigger Medicare s PACT policy (42 CFR 412.4) when the following two conditions are met: The patient s discharge is assigned to one of the 273 transfer DRGs listed in Table 5 of the fiscal year 2011 IPPS final rule (at http://tiny.cc/55flq) The patient is discharged/transferred to a facility or setting denoted by one of the following six discharge disposition codes: IN THIS ISSUE p. 5 Craft effective physician queries Three coding and CDI experts offer suggestions for drafting attention-grabbing queries. p. 7 How adverse effects and poisonings differ Identify and address potential coding and sequencing compliance challenges. p. 9 Value-based purchasing program offers incentives Note highlights from CMS proposed rule giving hospitals incentives to provide higher-quality care. p. 11 Clinically Speaking Robert S. Gold, MD, addresses the importance of coding compliance in today s audit-intensive healthcare environment. Inside: Coding Q&A 03: Medicare skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care 05: Designated cancer center or children s hospital 06: Home under care of organized home health service organization in anticipation of covered skilled care 62: Inpatient rehabilitation facility including distinct part units of a hospital 63: Long-term care hospital 65: Psychiatric hospital or psychiatric distinct part unit of a hospital Provide coder education, resources Coder education about the PACT policy is essential, says Barbara Rodenbaugh, RHIT, CCS. Rodenbaugh is HIM revenue Did you know? integrity services manager at Catholic Healthcare The 273 transfer DRGs subject to the PACT policy are listed in Table 5 of the fiscal West (CHW) Corp. year 2011 IPPS final rule in Pasadena, CA. (at http://tiny.cc/55flq). Coders at CHW receive a PACT tip sheet (see p. 4) that is updated annually by CHW corporate coding compliance staff members to reflect new changes or updates, she says. Still, confusion about how to interpret physician documentation or lack thereof often exists, she says. For example, a physician may document discharge to SNF. However, the SNF could actually be the patient s place of residence, in which case coders should assign discharge disposition code 01 for home. The same patient may be discharged with an order for hospice care, in which case the correct disposition status code is 50 to reflect home hospice. Discharge plans sometimes change after a patient leaves the hospital. For example, a patient who is > continued on p. 2

Page 2 Briefings on Coding Compliance Strategies April 2011 PACT compliance < continued from p. 1 transferred from one hospital to another via private automobile with family members may decide to go home and spend the night before going to the recipient hospital. These cases are difficult to track, but once this information is known, hospitals should report discharge disposition code 01 to indicate the patient went home instead of 02 for an acute care transfer, says Rodenbaugh. Coders struggle with these cases because documentation is often insufficient, she explains. The coder doesn t know that the patient didn t follow through with the orders at the time of discharge. That s where hospitals need to monitor this retrospectively, she says. Home health is another potentially challenging disposition because the PACT policy is triggered only when home health services occur within three days Editorial Advisory Board Briefings on Coding Compliance Strategies Paul Belton, RHIA, MHA, MBA, JD, LLM Vice President Sharp HealthCare Corporate Compliance San Diego, CA Gloryanne Bryant, RHIA, CCS, CCDS Regional Managing Director of HIM NCAL Revenue Cycle Kaiser Foundation Health Plan, Inc. & Hospitals Oakland, CA Darren Carter, MD President/CEO Provistas New York, NY William E. Haik, MD, FCCP Director DRG Review, Inc. Fort Walton Beach, FL Group Publisher: Lauren McLeod Executive Editor: Ilene MacDonald, CPC Managing Editor: Geri Spanek Contributing Editor: Lisa Eramo, leramo@hotmail.com James S. Kennedy, MD, CCS Managing Director FTI Healthcare Atlanta, GA Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director, Coding and HIM HCPro, Inc. Danvers, MA Sandra L. Sillman, RHIT, PAHM DRG Coordinator Henry Ford Hospital and Health Network Detroit Jean Stone, RHIT, CCS Coding Manager - HIMS Lucile Packard Children s Hospital at Stanford Palo Alto, CA Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. Copyright 2011 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 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: customerservice@hcpro.com. Visit our website at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BCCS. 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. of discharge and when they are related to the hospital stay, says Rodenbaugh. When home health services are unrelated to the hospital admission, billers must ensure inclusion of condition code (CC) 42 in the appropriate field on the UB04 form. This alerts the FI that the facility is entitled to the full DRG payment. Similarly, if home healthcare is related to the hospital stay but doesn t begin within three days post-discharge, billers should report CC 43 in the appropriate field on the UB04 form. This also alerts the FI that the facility is entitled to the full DRG reimbursement. Aside from learning the details of discharge disposition codes, simply identifying the type of facility to which patients are transferred can be challenging, says Nancy Cervi, RHIT. Cervi is a senior business systems analyst at QuadraMed, headquartered in Reston, VA. Consider creating a quick reference guide that maps local facilities to each of the categories specified by the six discharge disposition codes listed previously. A clerk can easily do this by calling each facility s administrative office and requesting its state licensing information, says Cervi. Be on the lookout for SNFs that are certified under Medicaid but not Medicare, says Cervi. When patients are transferred to these facilities, coders should report discharge disposition code 64 (discharged/transferred to a nursing facility certified under Medicaid but not Medicare), which does not trigger the PACT policy. Also watch for SNFs that include licensed skilled nursing beds as well as beds for custodial care or assisted living, and note this on the guide, Cervi advises. When patients are transferred to a SNF for the latter, coders should report 04 (discharged/ transferred to an intermediate care facility), which doesn t trigger the PACT. The Medicare Claims Processing Manual, Chapter 3, Section 40.2.4, as well as Special Edition (SE) MedLearn Matters article SE0801, are helpful resources and provide a detailed explanation of each discharge disposition code, Cervi says.

April 2011 Briefings on Coding Compliance Strategies Page 3 Conduct retrospective audits Hospitals can and should validate the original discharge disposition code assigned, says Rodenbaugh. Do this by taking the following steps: Generate a report capturing all transfer DRGs. Narrow these charts to those discharges assigned to one of six discharge disposition codes that trigger the PACT policy. Compare information in the Common Working File (CWF) with your claims and the disposition coders originally assigned. Revise and re-bill claims when necessary. RACs are already looking at the CWF, and they most likely are honing in on claims that include CWF edit 7272 (return to provider to change the disposition code), says Cervi. She anticipates that RACs will validate whether the discharge disposition code assigned at the transferring hospital matches up with a related claim from the appropriate post-discharge setting. The RACs will take the overpayments, but they sure won t be giving you clues as to your underpayments, says Cervi. Rodenbaugh somewhat disagrees based on her own experience with RACs. CHW has received more than $250,000 in additional reimbursement as a result of RAC activity, she says. The RAC discovered cases in which patients didn t follow through with an order for home healthcare services or didn t go to the receiving facility as ordered, she says. Hospitals shouldn t wait for a RAC review to reveal an underpayment because RACs probably aren t reviewing all 273 transfer DRGs, says Rodenbaugh. Instead, consider conducting an internal retrospective review, she suggests, adding that CHW s own such review has yielded far more profitable results than any RAC audit ever could have. The corporation began internal validation in July 2008 by examining more closely transfer DRGs for which the geometric length of stay (GMLOS) was at least 1.1 days shorter than the average GMLOS. Since then, CHW has generated $5.5 million in additional revenue from only 1,313 cases. Is it worth retrospectively going back? You bet it is! says Rodenbaugh. Advocate for better documentation Coding managers should advocate for thorough physician and case management documentation, says Rodenbaugh. I think it s critical for the case manager or discharge planner on the acute care side to document the level of care they expect the patient to receive by the postacute care provider, she says. Consider revamping the interfacility transfer form, a standardized form that travels with patients to receiving facilities. It should include spaces for skilled level of care or anticipated level of care at the time of patient transfer, she explains. Even after a patient is transferred, follow-up calls and documentation may be necessary. The receiving SNF must evaluate the patient to ensure that he or she meets the skilled level guidelines required by Medicare to bill for skilled services, says Rodenbaugh. Ideally, the discharge planners should document the name and telephone number of the receiving provider and the level of care anticipated at the time of discharge. However, coders also should take the initiative to follow up when possible, she says. For example, when coding a record, coders can call the receiving facility to inquire about the level of care being provided and determine whether the SNF will be billing Medicare. Cervi agrees. At the time of coding, coders should do a little bit more digging into the post-discharge documentation, or they should hand it off to someone who can perform an immediate audit to figure out where the patient went, she says. It may be helpful to flag cases that involve transfer DRGs so coders can review these cases more closely or at least ask a discharge planner to review them to verify the discharge disposition, she suggests. > continued on p. 5

Page 4 Briefings on Coding Compliance Strategies April 2011 PACT tip sheet Source: Barbara Rodenbaugh, RHIT, CCS, Corporate HIM Revenue Integrity Services, Catholic Healthcare West Corporation. Reprinted with permission.

April 2011 Briefings on Coding Compliance Strategies Page 5 PACT compliance < continued from p. 3 The bottom line is that all stakeholders patients, financial services, HIM, compliance, discharge planning, utilization review need to collaborate and communicate, advises Cervi. Organizations should consider forming a discharge disposition team similar to a RAC or ICD-10 team, she adds. Consider software solutions Hospitals may also want to consider a software solution that prompts coders to verify the six discharge disposition codes that trigger the PACT policy, says Cervi. For example, if a patient is transferred to home health, the software can prompt coders to verify whether home health services occurred within three days post-discharge. n Nine tips to help improve physician queries Physician queries are a predictable part of any coder s job. Coders may pose hundreds even thousands of queries throughout their careers. One thing remains constant; there s always room for improvement. How can coders write more effective queries and essentially get more bang for their buck? Briefings on Coding Compliance Strategies asked several experts, and this is what they said: Tip 1: Keep it short and sweet. I think what grabs a physician s attention is a query that s clear, factbased, and direct, says Gail B. Marini, RN, MM, CCS, LNC, manager of clinical documentation at South Shore Hospital in Weymouth, MA. I think when it gets wordy, or it looks as though there s a paragraph to read, the query is often ignored. Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children s Hospital at Stanford in Palo Alto, CA, agrees. A compliant query can be created without filling up a full page with unnecessary verbiage, and we ve had better success with shorter not longer queries, Stone says. Tip 2: Keep it compliant. Queries should comply with AHIMA s practice brief Managing an Effective Query Process, says Stone. The brief is available at http://tiny.cc/2a9hv. Tip 3: Make it obvious. Queries should be easy to identify (e.g., use colored paper rather than white paper) and should clearly reference a tab in the record that points to the exact progress note and date for which the query is relevant, says Marini. Tip 4: Include official coding references. For problematic diagnoses (e.g., urosepsis), include Coding Clinic references that briefly explain how physician documentation affects the final coding, says Marini. Giving a reference shows a reason why this information is needed, and it validates why you posted the query, she explains. Providing physicians with follow-up articles about the effect of documentation on coding can also be helpful, says Stone. I ve written articles for our medical staff publications regarding the benefits of comprehensive, accurate coding which results in optimum severity-ofillness and risk-of-mortality levels through the APR-DRG classification system, she says. Tip 5: Send follow-up e-mail. My staff members e-mail physicians anytime they enter a query on the chart. This seems to work reasonably well, says Stone. A typical statement might be: This note is to alert you that there is a query in your Cerner box pertaining to your patient, Mr. Smith. Please respond to the query form itself in the same manner you would amend dictation. Please let me know if you have any questions or concerns. Coder name and contact information Tip 6: Introduce yourself to physicians. Coders should have an opportunity during departmental > continued on p. 6

Page 6 Briefings on Coding Compliance Strategies April 2011 Physician queries < continued from p. 5 meetings to introduce themselves and explain that they will be asking for documentation clarification, says Donna D. Wilson, RHIA, CCS, CCDS. Wilson is senior director of Compliance Concepts, Inc., in Wexford, PA. Coders should only attend meetings specific to their department, she says. For example, two coders are assigned to the surgical unit. Only those two coders and the coding manager should attend the surgery department meeting. Coders should remember that they may need to reintroduce themselves to physicians even after the initial introductions at departmental meetings, says Wilson. Keep in mind that physicians are super busy and have a lot on their minds, she says. She suggests approaching physicians by saying: Hello, Dr. Smith. My name is Jane Brown. I am a coder here at Anywhere Hospital, and I have one quick question for you regarding your patient, Mr. Jones. If you get a negative response, don t take it personally, Wilson says. Tip 7: Work closely with CDI staff. CDI specialists can alert coders regarding when certain physicians are typically on the floors. They also may be able to help coders author a more clinically based query, says Marini. Tip 8: Make friends not enemies. Start daily conversations with physicians even if you don t have a query, says Wilson. A simple Good morning! goes a long way. Coders also should take time to become acquainted with charge and staff nurses. They are a wealth of knowledge, says Wilson. The nurses will know the time of day the physicians round on the nursing units and when to approach the physicians. Peak rounding hours (7 9 a.m., lunchtime, or 5 7 p.m.) are opportune times, she says. Also, if the coding department is located near the cafeteria or lounge, coders can approach physicians at lunchtime. However, waiting until physicians have eaten and are leaving to ask your question is preferable to interrupting them en route to the cafeteria or lounge, says Wilson. Tip 9: Mind your manners. Queries should always include a thank you. This small gesture helps maintain relationships with physicians, advises Marini. n Questions? Comments? Ideas? Contact Contributing Editor Lisa Eramo Telephone 401/780-6789 E-mail leramo@hotmail.com BCCS Subscriber Services Coupon Start my subscription to BCCS immediately. Options No. of issues Cost Shipping Total Electronic 12 issues $249 (CCSE) N/A Print & Electronic 12 issues of each $249 (CCSPE) $24.00 Order online at www.hcmarketplace.com. Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at 888/209-6554. *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax E-mail address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of BCCS.) Mail to: HCPro, P.O. Box 3049, Peabody, MA 01961-3049 Tel: 800/650-6787 Fax: 800/639-8511 E-mail: customerservice@hcpro.com Web: www.hcmarketplace.com

April 2011 Briefings on Coding Compliance Strategies Page 7 Correctly code adverse effects, poisonings Did the patient have an adverse effect from a specific drug, or was it a poisoning? The answer to this question often lies buried within physician documentation, and coders should take the time to review all information in the record to ensure compliance and accurate code assignment. Know the definitions The first step is to determine what actually happened to the patient. The diagnosis will either be an adverse effect or a poisoning not both, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS. McCall is director of coding and HIM at HCPro, Inc., in Danvers, MA. ICD-9-CM provides the following guidance: Adverse effect An unintended negative reaction that occurs when a drug or medicinal or biological substance (or combination of such substances) is correctly prescribed and properly administered. Examples include tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure. Poisoning A reaction to the improper use of a medication. A poisoning can occur due to an error in drug prescription, an overdose of a drug intentionally taken, a nonprescribed drug taken with a correctly prescribed and properly administered drug, or the interaction of a drug(s) and alcohol. Understand the context Understanding the context in which an adverse effect or poisoning may occur is equally as important as knowing the definitions. Patients experience adverse effects for two primary reasons: Differences among patients (e.g., age, gender, disease, and genetic factors) Drug-related factors (e.g., type of drug, route of administration, duration of therapy, dosage, and bioavailability) For example, patients can react to substances used during medical procedures, such as radiographic dye properly administered during a radiological procedure, says McCall. When this occurs, assigning a poisoning code is inappropriate. Instead, assign an E code to identify the substance administered for therapeutic use. William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, says adverse effects also can occur due to: A cumulative effect of a drug (e.g., nausea and vomiting due to an accumulation of a theophyilline when mixed with an antibiotic) An allergic reaction (e.g., a rash due to sulfa medication used to treat bacterial and fungal infections) A synergistic reaction between drugs (e.g., thrush caused by mixing an antibiotic and inhaled steroid) A paradoxical reaction (e.g., bronchoconstrictions that occur as a result of albuterol, which normally dilates the lungs) One area of confusion is illicit drugs, says McCall. For example, a physician may document heroin in a patient s record. However, this might not mean that the patient overdosed on the drug resulting in a poisoning, she says. Documentation in the patient s history may indicate the patient is simply a heroin abuser or heroin dependent. Technically, you can abuse or be dependent on an illicit drug without overdosing on it, says McCall. When this is the case, and it s documented as merely abuse or dependence, report a code from the 304 305 series (to denote drug abuse, dependence, and frequency of use) rather than a poisoning code. Terms such as reaction and hypersensitivity generally denote adverse reactions, and terms such as poisoning, overdose, wrong substance given, wrong substance taken, or intoxication can, at times, denote a poisoning, she explains. Toxicity is a term that can be misleading, says Haik. For example, a patient receiving digoxin for congestive > continued on p. 8

Page 8 Briefings on Coding Compliance Strategies April 2011 Correctly code < continued from p. 7 heart failure presents with nausea and vomiting. The patient s kidney function has deteriorated over the past few years, causing the drug to accumulate in the patient s body. The physician documents digoxin toxicity. Without evaluating the chart further, a coder might think of toxicity and poisoning as synonymous terms, says Haik. In reality, it s an adverse effect because the patient did take the drug appropriately. Poisonings can occur regardless of whether the patient could have known of the harmful interaction between drugs, says Haik. For example, a patient receiving Coumadin presents with a gastrointestinal (GI) bleed after taking aspirin for a headache. This is a poisoning; the patient mixed prescription and nonprescription drugs, and it wasn t under the direction of a physician, he says. But consider this scenario. A patient receiving Coumadin presents to the ED and receives aspirin from a physician who is unaware that the patient takes a blood thinner. A subsequent GI bleed is considered an adverse effect. ICD-9 treats this as an adverse effect because both drugs were prescribed by physicians, neither of whom was aware of the other physician s orders. Both drugs were written properly for the case, says Haik. Correctly sequencing a poisoning is important with respect to compliance and it has RAC implications, says Haik. Consider the following scenario. A patient takes Ambien (a sleep medication) and then drinks beer. The patient develops respiratory failure due to the combination of the sedating drugs, is rushed to the hospital, and is put on a mechanical ventilator. Report the Ambien poisoning as the principal diagnosis and the respiratory failure as an additional diagnosis, says Haik. Coding Clinic, January 2005, explains why. When a patient is admitted with respiratory failure and a nonrespiratory condition, sequence the conditions based on the circumstances of the encounter unless ICD-9-CM guidelines provide a more specific sequencing directive. In this case, the ICD-9-CM guidelines provide more specific sequencing directives regarding poisonings, says McCall. The guidelines state: When a reaction results from the interaction of a drug(s) and alcohol, this would be classified as poisoning When coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, wrong route of administration), the poisoning code is sequenced first, followed by a code for the manifestation. Know coding, sequencing guidelines For adverse effects, first code the reaction to the drug, followed by an appropriate code from the E930 E949 series to identify the causative substance. These E codes are also located in the therapeutic use column of the Table of Drugs and Chemicals. For poisonings, first report a code from the 960 979 series listed in the poisoning column of the Table of Drugs and Chemicals to identify the poisoning, followed by the code(s) for the manifestation(s) of the poisoning. Also assign an E code to describe the circumstances of the poisoning (i.e., accidental, intentional, or undetermined). If the physician also documents a diagnosis of drug abuse or dependence on the substance, report an additional code for the abuse or dependence. To some, it may seem as though the focus may be directed toward the treatment of the respiratory failure than the poisoning. Unfortunately, based on the Coding Clinic and the coding guidelines, the poisoning code must be sequenced first, says McCall. Incorrectly sequencing respiratory failure as the principal diagnosis could result in a sizable overpayment that an auditor could target, she says. Consider the differences in payment for a hospital with a wage index of 1: DRG 207 (respiratory system diagnosis with ventilator support 96+ hours): $29,385 DRG 208 (respiratory system diagnosis with ventilator support <96 hours): $12,771 DRG 917 (poisoning and toxic effects of drugs with an MCC): $8,391

April 2011 Briefings on Coding Compliance Strategies Page 9 Haik frequently consults with hospitals that incorrectly sequence the respiratory failure as the principal diagnosis in these types of cases. This is noncompliant and puts hospitals at risk for a RAC audit, says Haik. RACs are targeting a principal diagnosis of respiratory failure with a secondary diagnosis of a poisoning because this typically raises a red flag in terms of noncompliance with coding guidelines, he says. Prepare for ICD-10 The good news is that ICD-10-CM may make life a bit easier for coders, says McCall. For example, coders will still need to distinguish between adverse effects and poisonings, but they will need to look in only one place to find a code for either the T36 T65 code series. Coders will sequence a code from this series first, regardless of whether it s an adverse effect or poisoning. Coders also will see a change in the Table of Drugs and Chemicals. In ICD-10-CM, the table will include an explicit column for adverse effects rather than therapeutic use. Under ICD-9-CM, coders had to infer that the therapeutic use column denoted adverse effects, so now it will be more clearly stated, says McCall. One new concept in ICD-10-CM is specific code assignment for underdosing, which refers to taking less of a medication than prescribed by a provider or a manufacturer s instruction. The Table of Drugs and Chemicals includes a separate column for underdosing, and the ICD- 10-CM guidelines state that coders should never assign these codes as the principal or first-listed diagnosis. When reporting an underdosing, coders should also report a code for noncompliance (category Z91.12 Z91.13) to indicate intent or a code for complication of care (Y63.61, Y63.8 Y63.9), when known. For example, an elderly patient with dementia forgets to take prescribed blood pressure medication, causing an unintended increase in blood pressure. Report T46 (for the underdosing) sequenced first, followed by Z91.130 (patient s unintentional underdosing of medication regimen due to age-related debility) and a code to denote dementia. Under ICD-9-CM, coders likely would have reported V15.81 (noncompliance with medical treatment) for this scenario, says McCall. n CMS proposes value-based purchasing incentives Healthcare quality continues to take center stage, and now it could play an important role in reimbursement as well. That is, if CMS finalizes a proposed rule published in the Federal Register January 13 that would incorporate incentive payments into the IPPS effective for discharges on and after October 1, 2012. The proposed hospital value-based purchasing (VBP) program provides financial incentives to hospitals based on their achievement or improvement related to a set of specific quality measures. We really view value-based purchasing as an important driver of revamping how we pay for healthcare services, and [it moves us] toward rewarding better value, innovation, and outcomes, said Jean Moody- Williams, director of the quality improvement group in the office of clinical standards and quality at CMS. Moody- Williams and several other CMS representatives explained the proposed rule during a February 10 Special Open Door Forum (ODF). VBP scoring As part of VBP, hospitals will receive the following two scores, the higher of which will drive the incentive payment: Improvement score Awarded by comparing a hospital s scores during the performance period to its > continued on p. 10

Page 10 Briefings on Coding Compliance Strategies April 2011 Purchasing incentives < continued from p. 9 scores from the baseline period. For fiscal year 2013, the performance period is July 1, 2011, to March 31, 2012. Achievement score Awarded by comparing an individual hospital s scores during the performance period with all hospitals scores from the baseline period. Measure improvement scores mean that all hospitals have an opportunity to benefit from hospital VBP not just the best-performing hospitals, Jim Poyer, director of the division of quality improvement for acute care, said during the call. Any hospital can benefit by showing improvement from its baseline performance. CMS proposes that a hospital would earn 0 10 points for achievement, depending on where its performance falls within an achievement range. A hospital would earn 0 9 points for improvement, depending on how much performance is improved in comparison with its own baseline. VBP domains Overall improvement and achievement points will be awarded based on hospital performance in two domains: Clinical process of care Patient experience of care These include 17 clinical process of care measures and eight patient experience of care dimensions. The clinical process of care measures must be posted on the Hospital Compare website for at least one year before the VBP reporting period. CMS will evaluate a hospital s clinical process of care when it has at least 10 cases for at least four applicable measures during the performance period. Clinical process of care measures include: Acute myocardial infarction (AMI)-2: aspirin prescribed at discharge AMI-7a: fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a: primary percutaneous coronary intervention received within 90 minutes of hospital arrival Heart failure (HF)-1: Discharge instructions HF-2: Evaluation of left ventricular systolic (LVS) function HF-3: Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for LVS dysfunction Pneumonia (PN)-2: Pneumococcal vaccination PN-3b: Blood cultures performed in the ED prior to initial antibiotic received in the hospital PN-6: Initial antibiotic selection for communityacquired pneumonia in immunocompetent patient PN-7: Influenza vaccination Surgical Care Improvement Project (SCIP)-Inf-1: Prophylactic antibiotic received within one hour prior to surgical incision SCIP-Inf-2: Prophylactic antibiotic selection for surgical patients SCIP-Inf-3: Prophylactic antibiotics discontinued within 24 hours after surgery end time SCIP-Inf-4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose SCIP-Card-2: Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period SCIP-VTE-1: Surgery patients with recommended v enous thromboembolism prophylaxis ordered SCIP-VTE-2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery The eight patient experience of care dimensions derive from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. CMS will evaluate a hospital s patient experience of care when at least 100 HCAHPS surveys are completed for that hospital during the performance period. Patient experience of care dimensions include the following: Nurse communication Doctor communication

April 2011 Briefings on Coding Compliance Strategies Page 11 Hospital staff responsiveness Pain management Medicine communication Hospital cleanliness and quietness Discharge information Overall hospital rating CMS also proposes adopting three mortality outcome measures, eight hospital-acquired condition (HAC) measures, and nine Agency for Healthcare Research and Quality measures for fiscal year (FY) 2014. Incentive payments As proposed, a hospital s Total Performance Score (TPS) will be based primarily on clinical process of care measures (70%). The remainder (30%) will be based on patient experience of care measures. After calculating each hospital s TPS, CMS will use a linear exchange function to calculate a value-based incentive payment. The incentive payments will be funded through a reduction in base operating DRG payments for all hospital discharges. This will begin with a 1% reduction to base operating DRG payments in FY 2013 and increase to a 2% reduction by FY 2017. Caller comments Joanna Kim, senior associate director of policy at the American Hospital Association, was among several callers who commented on the rule. Kim urged CMS to reconsider its inclusion of HACs in the proposed list for FY 2014 because hospitals will be penalized heavily for HACs in 2015 under another law. Kim also said the 10-case minimum requirement for evaluation of clinical process of care measures is inconsistent with the Hospital Compare website s 25-case requirement. Exclusions, eligibility, and more information VBP does not apply to hospital units excluded from the IPPS (e.g., psychiatric, rehabilitation, long-term acute care, children s, and cancer hospitals). Obtain information about eligible hospitals, proposed VBP scoring, and more by accessing the proposed rule at www.gpo.gov/fdsys/pkg/fr-2011-01-13/pdf/2011-454.pdf. Access discussion materials for the Special ODF at www.cms.gov/hospitalqualityinits. n Coding is a tough job, but someone has to do it by Robert S. Gold, MD Coders have a huge responsibility. They must ensure accurate coding and compliance. Otherwise, hospitals, offices, and clinics don t receive money. Coders control assignment of hospital-acquired conditions, the present-onadmission indicator, complications, and more. They possess much power. However, hospitals gradually are adopting automated coding. In some clinics and offices, physicians assign codes a totally inadequate practice. Hospitals can automate CPT coding somewhat with a charge description master, assuming it is set up properly. However, ICD diagnosis and procedure coding cannot be automated with electronic software currently available. Current software solutions permit and encourage assignment of a code or even several codes with essentially no value that is, not otherwise specified codes. The solutions also don t provide adequate help to physicians. With the advent of severity-adjusted payments for physician services, physicians who use this software are destined for the poorhouse. Coders provide value because they presumably assign codes properly and compliantly, helping to ensure proper > continued on p. 12

Page 12 Briefings on Coding Compliance Strategies April 2011 Coding is a tough job < continued from p. 11 reimbursement and compliant billing. This also protects facilities and medical staffs from organizations seeking to retrieve inappropriate payments due to erroneous billing. Coders must know the rules, the physicians, and the diseases. Coders are under pressure to code and group records to maximize reimbursement. The stakes are high, but coders are human; they make mistakes. Official coding guidelines and sources sometimes prompt mistakes. I ve previously written that most bacterial infections (e.g., every case of pyelonephritis, acute diverticulitis, and bacterial pneumonia) is manifested by two, three, or four of the criteria for SIRS. However, the ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic tell coders to assign ICD-9-CM code 038.9 (unspecified septicemia) as the principal diagnosis when physicians document SIRS in the face of an infectious process or when SIRS is due to an infectious process. Coders must report SIRS as the systemic condition and the pyelonephritis, diverticulitis, or pneumonia as a secondary diagnosis. This logic is why hospitals received a documentation and coding adjustment of -2.9% in overall Medicare payments this year and next year. Coding Clinic, Third Quarter 2010, tells coders that they can report a condition when a physician documents it, regardless of the clinical circumstances. For example, a patient with end-stage renal disease who has been on dialysis for more than three months cannot possibly have clinically significant acute renal failure. However, this Coding Clinic reference instructs coders to report both conditions. This is one reason why acute renal failure is a CC rather than an MCC. Are coders supposed to oversee physician documentation? Are they supposed to diagnose? The answer to both questions is no. So what can coders do? Coders can and should put on their thinking caps. For example, an intensivist documents acute respiratory failure for a patient being electively maintained on ventilator overnight so nurses working during the morning shift can monitor reversal from anesthesia. Did the patient have acute respiratory failure? Absolutely not. Thinking clearly about this scenario would prevent assignment of a code for acute respiratory failure when the patient didn t have the condition. The result would be better data and more accurate reimbursement. What should coders do when an ED physician identifies acute renal failure from a creatinine of 1.6 on admission for a patient with a hip fracture whose creatinine remains at 1.6 throughout the entire hospital stay? Determine whether documentation indicating that the patient s creatinine has been 1.6 or thereabouts for the past two years exists. Does physician documentation indicate that something was done to work up or treat the acute renal failure? If the answer is no, the patient doesn t have acute renal failure and it shouldn t be coded. The phrase clearly documented has numerous implications. For example, when an apparent patient injury is not clearly documented as a complication, discuss the circumstance with the physician before assigning a complication code. Coders shouldn t assume that documentation of postoperative implies postoperative complication, and that they should assign an ICD-9-CM code from the 995 999 series. Physicians use the term postoperative as an adverb, demonstrating that an event occurred after an operative procedure. Coders use it as an adjective, implying a causative rather than a temporal relationship. How can we ensure compliance if we don t use the term similarly? CFOs must recognize that coders have much responsibility and provide needed support, perhaps by hiring a CDI specialist who can learn clinical standards and communicate with medical staff or by appointing a physician liaison to advise physicians. Ultimately, coders deserve a raise for doing a great job. n Editor s note: Dr. Gold is CEO of DCBA, Inc., an Atlanta consulting firm that provides physician-to-physician CDI programs. Contact him at 770/216-9691 or at rgold@dcbainc.com.

April 2011 Coding Q&A A monthly service of Briefings on Coding Compliance Strategies We want your coding and compliance questions! The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions. To submit your questions, contact Briefings on Coding Compliance Strategies Contributing Editor Lisa Eramo at leramo@hotmail.com. Editor s note: Answers to the following questions are based on limited information submitted to Briefings on Coding Compliance Strategies. Review all documentation specific to your scenario before determining appropriate code assignment. May I report Lewy body dementia (LBD) for a patient who has Parkinson s disease with dementia? LBD is the second most common type of progressive dementia after Alzheimer s disease. The condition causes a progressive decline in mental abilities. Signs and symptoms of LBD include visual hallucinations, movement disorders, delusions, cognitive problems, sleep difficulties, and fluctuating attention. Dementia with Lewy bodies overlaps clinically with Alzheimer s disease and Parkinson s disease and is more closely associated with the latter. The alphabetic coding conventions of ICD-9-CM instruct coders to report two codes: ICD-9-CM code 331.82 (dementia with Lewy bodies) for patients who have Parkinson s disease with dementia; and Either code 294.10 (dementia in conditions classified elsewhere without behavioral disturbances) or 294.11 (dementia in conditions classified elsewhere with behavioral disturbance), depending on whether behavioral disturbances are present Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant, answered the previous question. The following procedures are performed in the radiology department: 51.01 (percutaneous cholecystostomy for drainage) 51.02 (trocar cholecystostomy) Code 51.01 has no effect on the DRG. However, code 51.02 generates a surgical DRG. How do these procedures differ clinically? You are correct. A percutaneous cholecystostomy often is performed in the interventional laboratory. However, a true trocar cholecystostomy is a procedure performed in the operating room under laparoscopic guidance. A surgeon may perform this procedure when a patient has a severely distended gallbladder and is too ill to withstand a formal open cholecystectomy. The surgeon inserts a trocar into the gallbladder to permit drainage of a blocked biliary system, thus preventing ascending cholangitis and fatal infection by removing bile, pus, and stones. However, this procedure requires visual guidance with a laparascope. Surgeons also may perform it during an open exploration. Please define ventilator dependent. Does it refer to long-term dependence, or can it also refer to short-term situations (e.g., failed weaning parameters, brain injuries/strokes, or trauma)? The intent of code V46.11 (dependence on respirator, status) for ventilator dependent is to denote a patient whose life has been and will be spent with ventilator support. This patient is not on a ventilator for only a day or two, or during a hospital stay, unless a physician determines > continued on p. 2 A supplement to Briefings on Coding Compliance Strategies

the ventilator is necessary for the foreseeable future or until something changes after several weeks or months. Use of the ventilator dependent code is not intended for physicians covering patients postoperatively in an ICU during recovery from anesthesia. Similarly, don t use this code for patients with aspiration pneumonitis who will need the ventilator for three to four days or a week and then resume a normal existence. A patient in a coma after a head injury who is transferred to a long-term acute care facility for months or the rest of his or her life is ventilator dependent. This code was created for polio patients placed on iron lungs; they were ventilator dependent. Use code V46.11 only for patients who have been or will be ventilator-dependent for the long term. Otherwise, use code 518.81 (acute respiratory failure) or 518.5 (pulmonary insufficiency following trauma and surgery) for acute respiratory failure or acute respiratory distress syndrome, if that is the diagnosis. Use the 96.7x procedure codes to report ventilator use. Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, answered the previous two questions. A patient presents to the ED with a urinary tract infection (UTI). A physician documents the UTI, orders a culture, and prescribes an antibiotic. When a coder receives the record, the culture results are available. However, the physician does not include an addendum with these results. Is coding the cause of the UTI appropriate, or is physician documentation necessary before doing so? Based on this information, the physician documented a UTI during the visit. Therefore, the physician has diagnosed a UTI in a definitive manner, and a coder may report it. A physician must interpret a diagnostic test before a coder may report it, according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section IV (Diagnostic Coding and Reporting Guidelines for Outpatient Services), subsection L (Patients Receiving Diagnostic Services Only). Without this interpretation or a retrospective query to obtain the information the culture results may not be coded. Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children s Hospital at Stanford in Palo Alto, CA, answered the previous question. Clarification The February Briefings on Coding Compliance Strategies advises coders to report ICD-9-CM code 300.4 when a physician documents that a patient has depression and anxiety even absent an explicit link between the two. A reader informed us that Coding Clinic provided her hospital with information contradicting this advice. Coding Clinic confirmed this; Cherrsse Ruffin, RHIT, AHA coding consultant, explained via e-mail: The coding advice provided by the American Hospital Association, which was forwarded to you from a coder at an individual hospital, is valid. The advice instructs the coder to assign code 311 (depressive disorder, not elsewhere classified) for depression and code 300.00 (anxiety state, unspecified) for anxiety. Code 300.4 (dysthymic disorder) is only assigned if provider documentation links the anxiety with the depression. The coder should not assume that this is one disease process. When there is no association between the conditions in the medical record, assign two separate codes. This issue was recently clarified by the Editorial Advisory Board (EAB) for Coding Clinic. A clarification regarding anxiety and depression will be published in a future issue of Coding Clinic. Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber s institution is forbidden without prior written permission from HCPro, Inc. Copyright 2011 HCPro, Inc., Danvers, MA. Telephone: 781/639-1872; fax: 781/639-2982. CPT codes, de scriptions, and material only are Copyright 2011 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. BCCS, P.O. Box 3049, Peabody, MA 01961-3049 Telephone 781/639-1872 Fax 781/639-2982