Because this is a new year, my mind turns to the things I’d like to change. Rather than making the tried and true, or tried and failed “New Year’s resolutions,” I like to set goals for myself. Since 2014 was difficult in terms of my health, one of my goals is to return to my previous fitness. But, I also like to think about my professional life and the goals I’d like to set within that realm. What sort of fitness can I improve on in my professional life?
The world of professional coding is changing fast. I don’t mean ICD-10. The new code set has been imminent since I started coding many, many years ago. I’m talking more about ACOs, HCCs, PBCs, and the ever present EMRs. Continue reading
Last week, CMS published updated I/OCE specifications and software. The changes revolved around calculations of the complexity adjustment for the comprehensive APCs (C-APCs).
Bypassing the code pair ranking
The specific language change in the specifications is in Appendix L where there is a note added: “In some instances, code pair combinations specified for complexity-adjustment may have a secondary procedure with a higher rank than the primary procedure. In these cases, the rank is ignored and the complexity-adjusted APC remains assigned to the primary procedure of the code pair.” Continue reading
A 72 –year old male was admitted to the hospital with a chief complaint of a fever with a temperature of 101° F and feeling ill with worsening chills, cough, nasal congestion and body aches that began two days prior to admission. A chest x-ray revealed bilateral infiltrates in both lower lobes of the lungs. A viral culture was positive for AH3N2 influenza. The patient received antiviral medication and supportive care. The patient recovered enough to be discharged three days later with a diagnosis of pneumonia due to AH3N2 influenza.
Assign ICD-10 diagnosis codes for the inpatient hospitalization. Continue reading
A 49-year old female arrived in the trauma ED via helicopter in cardiac arrest after sustaining a stab wound to her upper torso. The patient was attacked by an unknown assailant with a knife (found at the scene) as she was walking to her car in a parking lot. The patient was unable to be resuscitated and expired. The Emergency Department physician documented the following diagnoses:
1. Penetrating laceration of anterior left thorax with near complete laceration of thoracic aorta
Assign diagnosis codes for this Emergency Department encounter. Continue reading
One of the most controversial complications is an accidental laceration. It is a potentially preventable complication (PPC), a complication in all surgical cohorts for Healthgrades and is a patient safety indicator (PSI 15). Additionally, PSI 15 is included in the PSI 90 composite score and is the highest weighted component (29.83%). Hence, the importance of “getting it right” cannot be underestimated.
So when should an accidental laceration be documented, coded or clarified? Continue reading
How many of us have worked for providers who, regardless of showing them the descriptor in the CPT book, insist upon charging critical care time for a patient in the ICU? For coders, the directions are clear: Regardless of the location of the patient, if the provider treated a critically ill or critically injured patient for 30 or more minutes, it is appropriate to report that service with a critical care code. So, when we see those magic words within the provider’s note, we submit the appropriate code(s). But, some coders don’t see the record. Some are just given a charge slip with the patient’s identifying information, procedure and diagnosis information. What is the right thing to do in this case? Because the critical care reimbursement is much higher than other E&M codes, some clinics review documentation for all critical care codes before submitting. Each group must decide how to handle the coding of these services. Continue reading
A 70-year old man presented at an Ambulatory Surgery Center for an upper GI endoscopy to be evaluated for the cause of his recent complaints of some dysphagia. The patient received Midazolam 6mg IV and Fentanyl 100 mcg IV and Benzocaine spray was applied to the back of his throat. After obtaining informed consent, the endoscope was passed under direct vision. It was introduced through the mouth and advanced to the second part of the duodenum. A small hiatal hernia was present. A mild Schatzki ring was found at the gastroesophageal junction at 35 cm. A TTS dilator was passed through the scope. Dilation with at 15-16.5-18 mm x 240 cm CRE balloon (to a maximum balloon size of 18 mm) dilator was performed with mild treatment effect. The esophageal body mucosa appeared mildly corrugated. Biopsies were taken from the upper and lower esophagus. At that point, the patient went into cardiac arrest. We quickly removed the endoscope and began resuscitative efforts. The patient was emergently transferred to the local hospital. Postprocedure diagnoses: Schatzki ring, hiatal hernia, cardiac arrest. Continue reading
On September 10, 2014, OIG announced it settled with a physician group practice in Illinois for overuse of modifiers. The practice exceeded the number of units allowed for certain services as regulated by CMS. According to the OIG, the physician practice used a code to bypass computer edits that otherwise would have rejected their claims. The group entered into a $590,763.45 settlement to resolve allegations of submitting false or fraudulent claims to Medicare. In addition, OIG contends the group upcoded services and submitted claims for high complexity tests when it performed less expensive, low or moderate complexity tests.
In September, I posted a blog regarding the modifications CMS plans to make to modifier 59 by creating four new, more specific modifiers that can be used to bypass an NCCI edit. CMS is requiring providers to be more specific with regard to what they believe a separate service really is. What is not new is that using the new modifiers will require documentation that adequately supports their use. A few thoughts on the new modifiers: Continue reading
A year ago my family changed to a high deductible health plan and started using a health savings account. Because we expect to pay higher upfront out-of-pocket expenses, we pay careful attention to the network requirements and out-of-pocket thresholds. Our local providers, though, seem to manage patients with high-deductible plans as if they were no different from traditional PPO plans.
There are several things I wish my providers would do differently, and not just to make it easier for me to manage my family’s health care. My providers inadvertently increased administrative time, delayed payment, and resulted in denials and write-offs. They would do better if they adapted their processes in light of the different plan requirements. Here are four suggestions for avoiding the mistakes my doctors made with my high-deductible plan: Continue reading
In keeping with the theme of previous blog posts–the professional realm of E&M coding–I’d like to discuss medical necessity as it relates to the final level of care. CMS has stated that medical necessity is the over-arching criterion for payment of E&M services, which, in pure CMS fashion, gives us a goal, but not guidelines as to how to get there. We have no medical necessity policies for the differing E&M codes.
I think we all understand the intent of that statement, which I interpret as “don’t game the system”. But how do I, as a coder, teach a provider how to do that? And, how does the provider document a record to reflect the medical necessity clearly? So, let’s put a pin in that and talk about the calculation of the E&M codes, then circle back. Continue reading