2nd Quarter 2013 Vol.2 Issue 2 COMPLIANCE CONNECTIONS Formerly The HIM Reporter ; Compliance Connections ; and As The Practice Codes. I N S I D E T H I S I S S U E : Cover Story Continued Facility Critical Care Coding To Code or Not to Code? Physician Use of Scribes: The Living Recorder Business Associates Really? RAC Updates with RMC Audio Conference Information 800.538.5007 www.rmcinc.org RMC s Newsletter Archives: CLICK HERE 2 2-3 4-5 5-6 7 8 ICD-10, Education, and Clinical Documentation By Marcia Vaqar MPH, RHIA, CCS, CCS-P, CCDS With the ICD-10 transition fast approaching, the importance of a successful Clinical Documentation Program is more crucial than ever. In the past, CDI programs were built to help documentation focus on short-term goals of reducing retrospective queries and trying to eliminate denials only for those selected DRGs and specific types of cases payers (i.e. Medicare, Medicaid) were auditing. Over the years, with MS-DRGs, and now with the impending ICD-10 implementation, CDI programs are in the spotlight more than ever. It s important to set up all the key players of documentation for success. The question of the hour is. What should CDI programs do to prepare for the ICD-10 transition? As we will see when we begin to delve into ICD-10, physicians will soon need to document in ways they have not in the past. It is important to let the physicians know the importance and benefits of ICD -10 to their practices and personal revenue. Having the right diagnosis coding to prove medical necessity under ICD-10 will be a hot issue for physicians. If their denials spike and reimbursements are stalled- this will be a major problem for their practice. With the expansion of RACs into the physician practice, this is a concerning possibility. It is important for us to emphasize to our physicians, the consequences that could potentially occur. If all the new concepts of ICD-10 are not captured in documentation, three things will happen: the claim will be coded at a lower DRG than it should be and reimbursed at a lesser amount; the coder will need to query the physicians which is fine but it will slow down the process significantly; and/or the claim can be submitted and billed but it will be denied in the end. A successful CDI program is a great way to educate clinical staff and physicians so that these consequences can be avoided. A visionary CDI program takes a wider view of areas surrounding documentation improvement by education, building the framework for strong documentation practices, quality initiatives, healthcare initiatives, and pay for performance. By incorporating these into the CDI program this will make for better long-term outcomes and will also allow to help implement ICD-10 into the CDI program in the facility. There are several ways to set up your CDI program to thrive thru the ICD-10 transition. Remember that your education must be solid and specific to the respective services. It s also important to keep interest and intrigue in your program members-this can be done by customizing your program to best fit your department. Here are some things to keep in mind when preparing your program: 1. Focused Education. All presentations and communications when presenting to specific service/departments should focus on ICD-10 areas that are important and informative to their respective services. Educate them on the diagnosis and procedure codes that are real and practical to them. For example, Cardiology will have a different implementation education program with their specific needs that is different than their counterparts Orthopedic Surgeons or OB/GYNs, etc. Continued on following page...
Page 2 ICD-10 Education and CDI Continued. 2, Keep it Brief and Simple. It is also important to use verbiage between ICD-9 and ICD-10. Plan accordingly when doing education and do in small/short timeframes. Remember physicians want HIM to tell them what to say. Consider having short fact briefings, maybe use graphs and pocket size documentation tip sheets as useful clinician tools. 3. One-on-one is a great option. The Peer approach is a successful way to engage physicians. If you are able to engage multiple physician champions for peer-to-peer education that is even better. PAs and other respected clinicians may serve in these roles too. Having the support of your medical staff leadership will be an even stronger partner for ICD-10 education and the CDI team. 4. Make it fun. Make learning fun and interactive by using mobile applications devices and texting and keeping the audience engaged. Many of the ICD-10 funny codes might be used to both demonstrate the new specificity that is necessary but also will be entertaining to your audience. 5. There is always room for a little healthy competition. Inspire and motivate by setting up ICD-10 challenges for clinician. HIM departments have done this in the past to get physicians to complete dictation, deficiencies, and other delinquencies. By posting results, offering award prizes in the physicians lounge, will allow a bit of competition and this helps the learning process to go a long way. The key to success really is to custom-tailor your approach to what each service/department will need in their day-to-day work. Each implementation will need to meet the specific needs for the specific group of physicians and their practices. It will take a little bit more time and planning, but in the end the physicians will thank you for the specialized education they receive, and everyone within the CDI, HIM, and Coding departments will be able to succeed all the more better. Marcia Vaqar, MPH, RHIA, CCS, CCS-P, CCDS, Director of Coding Services, has spent over twenty years in the HIM field. Her past experience includes but is not limited to Inpatient/Outpatient coder, Severity of Illness Data Collection and Verification, Coding Management, Project Management, Coordinator of HIM Operations, and CDI Coder Team Manager before joining our team. Marcia has developed an in-house student coding program, was team member of Revenue Cycle Committee, Tumor Register Committee, Electronic Health Record Committee. She is an AHIMA approved ICD-10 Trainer. Facility Critical Care Coding To Code or Not to Code? By Jane Barta, RHIA Facility Critical Care coding is not easy. In the last few years there have been rule changes on the part of both the AMA s Current Procedural Terminology (CPT) editorial panel and the Center for Medicare and Medicaid Services (CMS) regarding what procedures are and are not included in the billing of this service. Critical Care involves the highest level of service and use of resources by a facility. The reimbursement that can be realized by correct coding of Critical Care is an important source of revenue that should be captured. Facilities should have internal policies and procedures in place regarding Critical Care. These should address minimum standards for documentation, methods of calculation of time, and guidelines on CPT coding procedure selection. Education should be provided to nursing and coding staff on these issues. Three basic issues in the coding of Critical Care include: when CPT 99291 (Critical Care) may be coded; should facilities bill both 99291 and 99292; ancillary service coding and Critical Care. A lot of facilities do not code Critical Care unless the attending physician has documented the time that was spent. This is an easy way for facilities to help ensure they are coding appropriately, but there may be missed revenue opportunities with this policy. Critical care is defined by OPPS rules as the time spent by a physician and/or hospital staff engaged in active face-to-face care of a critically ill or injured patient. Note that this involves physician and/or hospital staff, so this would indicate that facilities may bill Critical Care even if the physician documentation does not support the time spent in Critical Care or support that Critical Care is provided. Facilities should review their policies on this issue. A facility may decide that if nursing documentation supports Critical Care and the nursing time spent that they willcode the service, even if the physician documentation is lacking. Other facilities may decide that they will code Critical Care for the facility only when the physician documentation supports Critical Care services, but they may not require that the physician document the time. Continued on following page...
Page 3 Facility Critical Care Coding Continued. The physician will not be able to bill for his own Critical Care services without time documentation, but if nursing documentation shows the time spent, the facility can bill. Lastly, some facilities may make the policy that they will only bill Critical Care if the physician documentation both supports Critical Care and the time spent. In all of these scenarios, facilities should not bill Critical Care if nursing documentation does not support the service. The question of whether or not a facility can bill both 99291 and 99292 is an interesting one. Some sources state that 99291 is not a time-based code for facilities, as time is not a factor in a facility E&M visit code. Therefore, facilities can only bill 99291 per ED encounter. However, CMS does not consider 99291 a status indicator V or visit codes, but have defined it as a status indicator S code. In addition, the CPT description of 99291 includes time (31-74 minutes) in the description. Therefore, if 99291 is status indicator S, significant procedure, not discounted when multiple procedures performed, the description in the manual should be followed and be billed for the first 31-74 minutes. CPT 99292 for the additional time involved in Critical Care by the facility is status indicator N, item or service packaged into APC rates, and no reimbursement is attached to the code. Facilities should be billing 99292 as CMS captures status indicator N procedures and uses the historical data for further adjustment and modification of payments under the OPPS system. Consultation with your Fiscal Intermediary is recommended to ensure that FI regulations and guidance are followed. Another very common concern with billing Critical Care is what services are included in CPT 99291. For many years, CMS instructed facilities to follow the guidelines in the CPT manual and multiple procedures such as ventilation management or cardiac output measurement were included in the definition of Critical Care and were not billed separately. As of January 1, 2011, the AMA CPT editorial panel revised the guidance and stated hospitals are to report all of the ancillary services and their associated charges separately when they are provided in conjunction with Critical Care. This guidance did not apply to physicians, only facilities. (See CPT Manual Critical Care instructions.) CMS, however, stated that their APC payment rate for Critical Care for CY 2011 (calendar year 2011) was based on historical data from 2009, when the ancillary services were bundled into the Critical Care code. If facilities were to bill the ancillary procedures separately along with the Critical Care code, facilities would get a higher reimbursement than was intended. Therefore, CMS developed edits that when hospitals bill the ancillary services separately, the charges are bundled into the APC rate for the CPT code 99291. This process is still in place. E&M/Critical Care Ancillary Procedure Status Indicators APCs Reimbursed 99284-25 94660 V and S 615 and 78 99291 94660 S and N 617 If you bill CPT 99284, E&M visit in the ED, along with CPT 94660, CPAP, there is an APC payment for both the visit and the CPAP ( APC 615 & 78). If you bill CPT 99291, Critical Care along with CPT 94660, CPAP, there is only one APC payment (617). The status indicator for the CPAP is S when it is billed with an ED visit code but changes to N when billed with a Critical Care CPT. Hospitals should continue to bill Critical Care and also bill the ancillary services performed. References: Coding Clinic for HCPCS, 4 th Qtr, 2010 Coding Clinic for HCPCS, 1 st Qtr, 2011 CMS Manual Facility Coding for Critical Care under CMS OPPS Rules, Candace E Shaeffer, RN, MBA, RHIA, CCO, Illinois HIMA Newsletter Jane Barta, RHIA has worked in hospitals both small (5 bed) and large (350+ beds) in Colorado, Montana and Idaho before joining RMC 2000. Her past experience covers Quality Assurance, Utilization Review and departmental management in addition to Coding Quality. With RMC, Jane concentrates on the areas of Ambulatory Surgery, Emergency and Urgent Care coding. During the last 10 years, she has worked with over 38 hospitals in addition to multiple physician offices and insurance companies.
Page 4 The Joint Commission describes the position of the scribe to be an unlicensed person hired to enter information into the electronic medical record or chart at the direction of a physician or other healthcare practitioner. The scribe is to document verbatim, not to provide documentation as an independent observer. In many cases the person who is acting as the scribe may have his or her own medical expertise, possibly as a nurse practitioner, medical assistant or even a peer physician. In these cases, the scribe should not interpret the office visit based on his or her own medical understanding and experience, but simply document exactly what the provider dictates word-for-word. On the occasion the scribe is a clinical assistant, it may be in the practice s best interest to limit that person to only one role during the encounter. DOCUMENTING THE USE OF A SCRIBE The provider rendering the service must validate the scribed notes. This is a critical part of the service that is often improperly documented. Improper documentation of validation is a prime reason scribed claims are denied. Third party payers have specific guidelines for how the use of a scribe is documented. GENERAL RULES FOR PROPER DOCUMENTATION OF SCRIBE USE Many clinics utilize an electronic health record (EHR) which may include a feature that can differentiate between the provider and the person who enters the information. Regardless of whether the note is handwritten or whether it is electronically documented with automatic features indicating authorship, the scribe should sign the documentation and indicate that s/he was scribing for the provider. The rendering provider shall then also sign and affirm with an attestation statement that the text does describe the work performed and that the note accurately reflects work and decisions made by the provider. WHAT TO INCLUDE IN A SCRIBE NOTE? -The name of the provider rendering the service -The date and time the service was provided -The name of the patient for whom the service was provided -Authentication, including date and time "Written by, (credential), acting as scribe for, MD/NPP." Signature Date Time WHAT TO INCLUDE IN THE PROVIDER ATTESTATION? -Affirmation of the provider s presence during the time the encounter was recorded -Verification that the provider reviewed the information -Verification of the accuracy of the information -Any additional information needed -Authentication, including date and time "The scribed notes accurately reflect the service I personally performed and the decisions made by me." Signature, MD/NPP Date Time ENVIRONMENT IN THE EXAM ROOM Physician Use of Scribes: The Living Recorder By: Brianne Eckenrodt, CPC-A It can be challenging to the provider to communicate to the scribe using technical terminology to be recorded in the medical record without disengaging the patient. It is important that provider does not speak to the scribe as a layperson in an effort to create a welcoming patient Continued on following page...
Page 5 Physician s Use of Scribes Continued. experience. The provider must speak to the scribe using the language that would validate medical necessity and medical decision making as if the provider were writing the note himself and also make an additional effort to translate the information into a conversation with the patient. It is the responsibility of the provider to translate and clarify the visit. It is not permissible to allow the scribe (regardless of medical education) to translate the visit from layperson language to technical medical documentation or vice versa. Use of scribes is an ever-growing area of support and need to many practitioners in the exam room. It is important to keep in mind that scribes are living recorders. As with transcribed documentation, providers must be mindful to provide the proper validation and authentication of scribed notes to ensure the accuracy of the recorded information for continuity of care and appropriate reimbursement. References: AHIMA e-him Work Group on Maintaining the Legal EHR. "Update: Maintaining a Legally Sound Health Record Paper and Electronic." Journal of AHIMA 76, no.10 (November-December 2005): 64A-L. CAHABA Government Benefit Administrators, LLC. Guidelines for the Use of Scribes in Medical Record Documentation Reminder. Retrieved May 30, 2013, from http://www.cahabagba.com/news/guidelines-for-the-use-of-scribes-in-medical-record-documentation-2/ AHIMA. "Using Medical Scribes in a Physician Practice." Journal of AHIMA 83, no.11 (November 2012): 64-69 [expanded online version]. WPS Health Insurance Medicare Legacy Part B. Guidelines for the Use of Scribes in Medical Record Documentation. Retrieved May 30, 2013, from: http:// www.wpsmedicare.com/part_b/departments/medical_review/2009_1221_scribes.shtml Brianne has been with RMC since 2010. Her current position is as Coordinator of Business Development for Physician Services., and also works as the Professional Fee Auditor Coordinator. Business Associates Really? By Chris Apgar, CISSP The omnibus rule is here along with new HIPAA/HITECH myths. It seems that all vendors operating in the healthcare space are being tagged business associate. There has been little thought given to the requirements of HIPAA, HITECH and definitions around who is and who is not a business associate. As an example, HIPAA specifically excludes life insurance vendors and workers compensation vendors from the category of covered entity. They are definitely also not business associates. Entities are not HIPAA covered entities or business associates just because they use, disclose, maintain and/or transmit personally identifiable health information. If that were the case, property and casualty insurance carriers would be covered entities, all employers with an HR department would be covered entities and so forth. HIPAA specifically defined who was and, in a number of cases, who was not a covered entity or a business associate. The definition was further clarified via the omnibus rule. Vendors aren t legally HIPAA business associates unless in some way up stream or downstream those vendors are connected to a covered entity. Financial institutions offering 401ks and other forms of tax exempt retirement savings are definitely not business associates. Neither are security services that patrol parking lots outside a health plan. If they don t go in, if they re only around at night and they will never see that PHI, they re not business associates. Web hosting vendors are not business associates just because they host web sites. These vendors would be if they stored ephi on behalf of a covered entity or business associate. Cleaning companies and janitorial services vendors are definitely not business associates. This goes all the way back to OCR guidance published in 2003. OCR may change its mind but OCR has not published new guidance as of yet. Exposure to incidental disclosure doesn t always a business associate make. Also, HIPAA prohibits most marketing without individual authorization. If a hospital foundation institution purchases a publicly available list of individuals based on what s in the phone book and available from sites like US Search and then sends out general marketing information to individuals, that doesn t make that vendor that supplied the list a business associate even if that vendor sends out a general marketing blast for the foundation. Continued on following page...
Page 6 Business Associates Really? Continued. All subcontractors of business associates are not business associates. As an example, if a subcontractor prints the business associate or covered entity s newsletter and has no access to PHI, that subcontractor is not a business associate. To be a business associate a subcontractor needs to use, disclose, maintain and/or transmit PHI on the behalf of a covered entity or an upstream business associate. If they don t,they re not. You need to evaluate what a subcontractor or vendor does for you. Not all attorneys are business associates but some attorneys are. Not all cloud vendors are business associates but some are. No workers compensation vendors are business associates because they offer workers compensation insurance. No life insurance vendor is a business associate just because they sell life insurance and payroll vendors are definitely not business associates just because they only cut and track payroll checks. It may look like PHI but that doesn t make it PHI (unless it s electronic and you re in Texas). Chris Apgar, founder of Apgar & Associates is a Certified Information systems Security Professional (CISSP). He is one of the country s foremost experts and spokespersons on healthcare privacy, security, regulatory arriafs, state and federal compliance and secure and efficient electronic health information exchange. Chris has more than 19 years of experience in regulatory compliance and is a leader of regional and national privacy, security and health information exchange forums. As a member of Workgroup for Electronic Data Interchange, and serving on the Board of Directors since 2006, Chris is an honest, reliable, trustworthy expert in the field of privacy and security. Email capgar@ apgarandassoc.com for more details. Relax. RMC has your training needs covered. 10X Training is comprehensive, methodical, and thoughtfully prepared ICD-10-CM/PCS training with the learner in mind. 10X Training encompasses all of the necessary education AND training to ensure a smooth transition to ICD-10. 10X Training is 3-fold, utilizing audio conference presentations, real charts for coding, and LIVE interactive webinars. Contact us today 800.538.5007 for more info or click here
Page 7 RAC UPDATES WITH RMC RAC issues 1 st Quarter 2013 The new issues for hospital inpatient are: January 2013- Pre-payment review claims March 2013- Pre-payment review of MS-DRG 069. Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary s medical record. Reviewers will validate for MSDRG 069, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. Pre-Payment Review of MS-DRG 377-379 Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MSDRG 377, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs. The new issues for hospital outpatient are: Medical Necessity of Vagus Nerve Stimulation Vagus Nerve Stimulation (VNS) is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for resistant depression. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. Postpayment Review Manual Medical Review of Outpatient Therapy Claims above the $3,700 Threshold In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, reviews will be conducted on outpatient therapy claims in Outpatient Rehabilitation Facility settings reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services. REIMBURSEMENT MANAGEMENT CONSULTANTS, INC. Partnering with our clients to ensure appropriate reimbursement and effective compliance Offering Comprehensive Compliance Review & Coding Services. Nationwide.
Page 8 RMC S AUDIO CONFERENCE SERIES 2013 January 17th ICD-10: Intro to CM Laura Legg, RHIT, CCS and AHIMA approved ICD-10 trainer February 21st Neoplasm Coding Jennifer Jones, CCS March 21st Chart to Bill Audits Sarah Goodman, CPC-H April 18th Newborn Complications Stacy Hardin, CCS May 16th ICD-10: Intro to PCS Laura Legg, RHIT, CCS, and AHIMA approved ICD-10 Trainer July 18th 2013 CPT Code Changes for Psychiatric Services Connie Eckenrodt RHIT, CHC, CHCA August 15th ER Coding Jane Barta, RHIA September 19th Clinical Documentation Improvement Marcia Vaqar MPH RHIA, CCS, CCS-P October 17th Combination/Complication Coding for ICD-9 Monique Vanderhoof, CPC November 21st Coding for Hospitalists Sharla Mesecher, CPC, MCS-P, CPMA, CEMC June 20th CPT Coding Challenges Jane Barta, RHIA December 19th TBA REGISTER HERE