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
In 1996, CMS implemented the National Correct Coding Initiative or NCCI, sometimes referred to as CCI. The claim system edits were developed to “promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.” CMS realized that even if they created edits that bundled or disallowed procedures performed on the same date of service, there would be rare instances that would support using a modifier to override an edit. Thus, certain CPT modifiers were given that designation – modifier 59 among them.
On August 15, 2014, CMS released Transmittal 1422, CR8863 “Specific Modifiers for Distinct Procedural Services” effective January 1, 2015. The Transmittal explains that modifier 59, which is the most highly utilized of the CPT modifiers that CMS allows to override for NCCI edits, has been overused. It is associated with considerable abuse of high-level, costly manual audits, reviews, appeals and even cases of fraud and abuse. Continue reading
Last month, I blogged about the History of Present Illness (HPI) portion of an E&M note. The HPI section details the specifics of why the patient is seeing their physician. Prior to that, I wrote about the two sets of E&M guidelines, specifically the different exams within those guidelines to guide physicians and/or coders to select a level of care provided during that visit. This month, I’d like to dig into the point at which these two sets of guidelines converge: chronic conditions.
The 1995 E&M documentation guidelines stipulate that to support the higher levels of care, a provider must document four or more elements of the HPI. The 1997 E&M documentation guidelines added a chronic conditions option. These guidelines state that a provider could document the status of three or more chronic conditions rather than four or more elements of the HPI. Continue reading
Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading
I wish I could claim this quote as my own! I attended the AHIMA CDI Summit in Washington, D.C. this week and our keynote speaker was Laura Zubulake. My two takeaways from her presentation were the quote above and the affirmation that we should always do the right thing…not the easy thing.
One of the more interesting presentations of the week was from a cardiologist who provided insights into the CDI and HIM query process from his perspective. He had an excellent grasp of what was needed for accurate coding–until that one moment. I am sure many of us have been there: listening to a presentation, engaged and learning until we hear something that makes us cringe. He described the following scenario: Continue reading
As healthcare professionals, we have a lot of acronyms to keep straight, don’t we? Feels like alphabet soup in my head some days. I’m reminded of a scene in the movie, Good Morning Vietnam, where Robin Williams’ character has an entire conversation using acronyms, making fun of the military jargon. We could do the same in healthcare, especially in E&M coding.
Today, let’s think a bit about HPI, not to be confused with PHI. If you have a translator in your head the way I do, these two don’t even sound the same, but for those outside the realm of coding, these acronyms can get confusing. PHI is Protected Health Information. HPI, or History of Present Illness, is the portion of the E&M (Evaluation and Management) visit during which the patient describes why they are seeing the physician. Continue reading
July 4th has come and gone, but we can still look for fireworks in next year’s OPPS proposed rule, which is now available on the CMS website.
CMS plans to continue expanding the packaging they began in 2014 by implementing comprehensive APCs and packaging of ancillary services.
A recent blog by François de Brantes, executive director of HCI3, titled “Letting the Facts Get in the Way of So-called Truths,” is highly critical of the DRG based Medicare inpatient prospective payment system (PPS). He urges readers to discover the facts about DRGs, a system he describes as endorsed by “agents of the status quo” that produces “meaningless comparisons” of patient data, with hospitals “being hurt more than helped by false truths.” As a member of the research team that developed Diagnosis Related Groups in the late 1970s, I want to respond to his assertions. Mr. de Brantes’ blog is rife with errors and distortions of fact; any valid points are lost in a barrage of misinformation. Continue reading
I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.
In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web). Continue reading
Evaluation and Management (E&M) coding has a lot of ins and outs. It’s the most commonly billed service, so as 3M’s first blogger in the realm of Professional coding, I think E&M coding is the best place to start this blog series. The first thing a coder or provider needs to decide is which set of guidelines to use. On the facility side of things, there aren’t any CMS guidelines to follow, but on the professional side, we have two sets: the 1995 guidelines and the 1997 guidelines. Why do we have two sets? Well, that’s a good question. Way back in the dark ages, when I was a production coder, we had one set, the 1995 guidelines. They had their problems, primarily for the specialists. The exam of the 1995 guidelines was body part and/or organ system based. This meant that a specialist had to do a head to toe exam of a patient to qualify for the higher levels of care. For many providers, this wasn’t an issue, but for some it was. A head to toe exam isn’t really necessary for a complex ophthalmology patient. But, we all knew the body parts (arms, legs, head, neck, etc) and organ systems. We also knew how to total them up to select the level of exam documented. In short, that’s the good and bad of the 1995 exam. Continue reading