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Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Getting it Right the First Time: Inpatient and Outpatient Coding 2/5/2009 Compliance.

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Presentation on theme: "Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Getting it Right the First Time: Inpatient and Outpatient Coding 2/5/2009 Compliance."— Presentation transcript:

1 Donna D. Wilson,RHIA,CCS Senior Director Compliance Concepts, Inc. Getting it Right the First Time: Inpatient and Outpatient Coding 2/5/2009 Compliance Concepts,Inc.

2 Objectives: List the improper payments due to coding. Outline documentation requirements in correct coding. Review official resources. Develop an effective coding compliance program. Educate physicians,coders and ancillary staff. Appeal with supporting documentation. 2/5/2009 Compliance Concepts,Inc.

3 Coding Improper Payments InpatientOutpatient Excisional debridements Lysis of adhesions Wrong Principal Diagnosis Coagulation Disorders DRGs/MS-DRGs with only one CC or MCC Discharge disposition Units of service Neulasta, Speech, Infusion, Blood Transfusions. Duplicate service- Colonoscopies New vs. Established E/M 2/5/2009 Compliance Concepts,Inc.

4 Inpatient Coding Improper Payments 2/5/2009 Compliance Concepts,Inc.

5 Excisional Debridements RAC Findings: Reporting of excisional debridement (86.22) without supporting documentation to meet the definition of excisional debridement. Per the CMS RAC Status Document 2007: In the medical record the physician documents debridement was performed and the coder assigned (excisional debridement). Debridement must meet documentation requirements as outlined in AHA Coding clinic 3 rd Qtr or coded to the non-operative ICD-9-CM code (non- excisional debridement). 2/5/2009 Compliance Concepts,Inc.

6 Documentation Requirements/References- Debridements Documentation Requirements Reference –AHA Coding clinic for ICD-9-CM: Size Depth Removal of devitalized tissue Instruments used. Definite cutting away of tissue- not the minor scissors removal of loose fragments. Query physician. 1 st Qtr 2008 Vol. 25 p th Qtr 2004 Vol. 21 p nd Qtr 2004 Vol nd Qtr 2000 Vol.17 p Rd Qtr 1991 Volume 8 4 th Qtr 1988 Volume 5. 2/5/2009 Compliance Concepts,Inc.

7 Lysis of Adhesions RAC Findings: According to AHA Coding clinic 4 th Qtr. 1990: Coders should not code adhesions and lysis thereof, based solely on mention of adhesions or lysis in an operative report. Determination as to whether the adhesions and the lysis are significant enough to code and report must be made by the surgeon. Minor adhesions may exist without being organized, causing any symptoms or additional difficulty of performing the procedure. Coding the lysis of adhesions is inappropriate on these cases-since this is an approach. 2/5/2009 Compliance Concepts,Inc.

8 Documentation Requirements/References- Lysis of Adhesions Documentation Requirements Reference-AHA Coding Clinic Dont code if used as an approach unless documented as extensive in the operative note. Documented as extensive by the surgeon, then code both the lysis of adhesions and the definitive surgery. 4 Qtr Pgs Qtr Pg Qtr Pgs /5/2009

9 Wrong Principal Diagnosis RAC Findings Principal Diagnosis on claim didnt match Principal Diagnosis on the medical record. (Example: Respiratory listed on claim but medical record supports Sepsis as Principal Diagnosis.) Clinical documentation must support principal diagnosis-example: Sepsis vs. Urosepsis (UTI). Overpayment request letter is issued by the RAC for the DRG difference. 2/5/2009 Compliance Concepts,Inc.

10 Documentation Requirements/References- Wrong Principal Diagnosis Documentation RequirementsReferences: The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. ICD-9-CM Official Coding Guidelines 4 th Qtr AHA Coding Clinic. PEPPER reports 2/5/2009

11 Coagulation Disorders RAC Findings Coagulopathy due to Coumadin: Cases with a Principal dx of (Hemorrhagic disorder due to intrinsic circulating anticoagulants) Examples of some of the Secondary diagnosis = 578.x( GI bleed), 784.7, (Epistaxis),599.7, (Hematuria), 786.3, (Hemoptysis.) Coumadin is not a Circulating anticoagulant. Coders may be incorrectly assigning to describe all patients on anticoagulants whether or not there is a resulting hemorrhagic disorder. 2/5/2009 Compliance Concepts,Inc.

12 Documentation Requirements/References- Coagulation Disorders Documentation Requirements Reference-AHA Coding Clinic Code is used only when such an adverse condition has occurred If only an abnormal lab finding was documented then code should be assigned. Query the physician. 3 rd Qtr Volume 7 3 rd Qtr 1992 Volume 9 4 th Qtr Volume 10 3 rd Qtr Volume 21 2/5/2009 Compliance Concepts,Inc.

13 DRGs/MS-DRGs with only one CC or MCC RAC Findings DRGs/MS-DRGs grouping with a CC (complication or comorbidity) or MCC (major complication or comorbidity) containing only one secondary diagnosis. Example of MS-DRG Grouping: MS-DRG Weight MSDRG 329 Major Small & Large bowel with MCC MSDRG 330 Major Small & Large bowel with CC MSDRG 331 Major Small & Large bowel w/o cc/MCC ( 2/5/2009 Compliance Concepts,Inc.

14 Documentation Requirements/References- DRGs/MS-DRGs with only one CC or MCC Documentation Requirements Reference-AHA Coding Clinic Coders should not code findings from path. reports on inpatient records w/out confirmation of the diagnosis from the attending physician. Query the physician regarding the clinical significance of radiological findings. 1 st Qtr pgs nd Qtr pgs rd Qtr Volume 25 2/5/2009 Compliance Concepts,Inc.

15 Discharge Disposition Codes RAC Findings RAC identified incorrect discharge disposition code assignments such as: First claim indicated pt went home. Second claim indicated pt. transferred to another inpatient acute care hospital. Two hospitals should split a single DRG payment instead of both receiving a full DRG payment. ** Automated review under demonstration will become a complex review under the Permanent RAC** 2/5/2009 Compliance Concepts,Inc.

16 Documentation Requirements/References- Discharge Disposition Code Assignments: Documentation Requirements References: Implement effective quality control programs to ensure accurate code assignments. Work closely with Case Mgmt. Follow-up with receiving facility. Retain history chart of discharge disposition code changes over the years. Click on Compliance & Finance/Third party payors/Patient discharge status code history. NUBC Medicare processing manual 2/5/2009

17 Outpatient Coding Improper Payments 2/5/2009 Compliance Concepts,Inc.

18 Units of Service RAC FINDINGS: Incorrect coding on the chargemaster Injection, pegfilgrastim 6mg (J2505) – Neulasta: Provider billed one service per 1 mg; however the definition of this code is one service per 6 mg vial. Speech/hearing therapy (92507)- Provider billed one service for each 15 minutes; however the definition of this code is one service per session. Blood transfusion service (36430) - Provider billed one service per pint of blood;however,definition of this code is one service per transfusion session. 2/5/2009 Compliance Concepts,Inc.

19 Documentation Requirements/References- Units of Service Documentation Requirements References: Review chargemaster descriptions frequently. Educate departments. Document services rendered by session. Denote correct units administered. Transmittal 949 ansmittals/downloads/R949 CP.pdf (Neulasta). ansmittals/downloads/R949 CP.pdf CMS Claims Processing Manual 100-4, Chapter 5, Section anuals/downloads/clm104c0 5.pdf (Speech) anuals/downloads/clm104c0 5.pdf 2/5/2009 Compliance Concepts,Inc.

20 Duplicate Services RAC Findings Search for claims for two or more identical surgical procedures for the same beneficiary on the same day at the same hospital. Example: Two colonoscopies billed on the same day due to incorrect coding of CPT codes. Be more careful when submitting claims for colonoscopies (45355, 45378, 45380, 45383, 45384, 45385) to ensure you do not bill for more than one per day per pt. 2/5/2009 Compliance Concepts,Inc.

21 Documentation Requirements/References- Units of Service Documentation Requirements References: Codes (Colonoscopy w/ bx), (Colonoscopy w/ polypectomy hot bx forceps or bipolar cautery), and (Colonoscopy w/ polypectomy w/ snare) are different techniques & can only be used once for a single colonoscopy Current CPT Book AMA CPT Assistant AHA Coding clinic for HCPCS. July 2004 AMA CPT Assistant. **Note** -59 modifier may apply 2/5/2009 Compliance Concepts,Inc.

22 Evaluation and Management (E/M) RAC Findings 1) Medicares global surgery payment rules even in cases involving E/M services. 2) E/M services that are not reasonable & necessary. 3) Duplicate E&M codes 4) New versus established E&M codes 5) Units of service (Lupron injections) 2/5/2009 Compliance Concepts,Inc.

23 Documentation Requirements/References- Units of Service Documentation Requirements References: Medicare requires that if a physician (or practice) has not seen a patient in three or more years, he/she can file the claim as a new patient. If it has been less than three (3) years, the physician must charge for an established patient. Current CPT Book AMA CPT Assistant Consider Group practices – same tax ID # same specialty. 2/5/2009

24 Coding Compliance Plan 2/5/2009 Compliance Concepts,Inc.

25 Become RAC Ready Determine the coding focus for your healthcare facility by reviewing the same sources that the RAC uses: OIG Audits/Reports/Annual Work Plan CERT Audits/Reports PEPPER Reports National and local coverage determinations Update your Coding compliance plan yearly! 2/5/2009 Compliance Concepts,Inc.

26 EDUCATE,EDUCATE Educate staff 2/5/2009 Compliance Concepts,Inc.

27 Physician Education Attend each department to educate physicians. Each physician was provided with a listing of his/her records reviewed by the RAC and the outcome of the reviews. Visit physician practices to explain RAC and pt. status- give them contact names and numbers. Utilize hospital intranet to post most common inpatient only procedures/pt. type keys and order sets for ease of use in physician practices. 2/5/2009 Compliance Concepts,Inc.

28 Hospital staff Education Educate coders and clinical documentation specialists on RAC targets and process. Communicate with Case Management to improve discharge disposition code assignment. Attend service line director, managers and nursing leadership meetings. Provide RAC updates to senior leadership, internal audit and board. 2/5/2009 Compliance Concepts,Inc.

29 Stay abreast & share with others RAC team participated in monthly conference calls in the state of South Carolina demo: SCHA sponsored call for: Business Office Managers / Compliance Officers Utilization Review/Reimbursement Managers Coding/DRG Managers CEOs and CFOs also participated. **SCHA, RAC and CMS were on these calls** 2/5/2009 Compliance Concepts,Inc.

30 Appeal Your Coding Errors 2/5/2009 Compliance Concepts,Inc.

31 Appeal letters Responsible department writes the appeal letter. Advice from physician advisor and outside consulting agency was sought on some cases. Cover letter and entire medical record was mailed with each appeal. Copies of Interqual and AHA Coding Clinic accompanied the appeals. Flagged the medical record to provide easier review for the auditor. 2/5/2009 Compliance Concepts,Inc.

32 Hire outside assistance Consider hiring external auditors to assist in the appeal process. Assist at all levels of appeal. Allows you to appeal with an unbiased party at your side. 2/5/2009Compliance Concepts,Inc.

33 REFERENCES 2/5/2009 Compliance Concepts,Inc.

34 Maintain Current Resources ICD-9-CM Books Volumes AHA Coding Clinic ICD-9-CM Official Coding Guidelines CPT Books CPT Assistant 2/5/2009 Compliance Concepts,Inc.

35 References resources/solutions-managing-your- practice/coding-billing-insurance/cpt.shtml resources/solutions-managing-your- practice/coding-billing-insurance/cpt.shtml 2/5/2009 Compliance Concepts,Inc.

36 Contact information Donna D. Wilson, RHIA, CCS Compliance Concepts, Inc. Senior Director Stonewood Commons II 103 Bradford Road, Suite 320 Wexford, PA Office: (724) Cell: (843) Fax: (724) /5/2009 Compliance Concepts,Inc.

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