1. 2011 CODING & DOCUMENTATION UPDATE Healthcare Services Group October 2010

2. Overview of Topics Coding Changes Reminder 2011 Diagnosis Code Changes 2011 ICD-9-CM Procedure Code Changes 2011 CPT Code Changes RAC Audits – Physician & Hospital 2011 OIG Work Plan – Physician & Hospital 2

3. Coding Changes Reminder Remember to change the following to reflect the new diagnosis and procedure codes for 2011: –Superbill / Encounter Form –Practice Management Software Update ICD-9-CM and CPT Books 3

4. 2011 Diagnosis Code Changes Effective 10/1/10 New Diagnosis Codes Additional Digits Required Deleted Diagnosis Codes 4

5. 2011 Diagnosis Code Changes Neoplasms –Schwannomatosis - 237.73 One form of a genetic disorder called neurofibromatosis (NF) that has only been recently recognized –Neurofibromatosis, NEC - 237.79 Endocrine, Nutritional & Metabolic, Immunity –Deleted Disorders of Iron Metabolism – 275.0 –Additional 5 th Digit Required »Hereditary Hemochromatosis – 275.01 »Hemochromatos – RBC transfusions – 275.02 »Hemochromatosis NEC - 275.03 »Other Disorders of Iron Metabolism – 275.09 5

6. 2011 Diagnosis Code Changes Endocrine, Nutritional & Metabolic, Immunity –Deleted Fluid Overload 276.6 –Additional 5 th Digit Required »Transfusion associated circulatory overload – 276.61 »Other fluid overload – 276.69 –New Code Obesity hypoventilation syndrome – 278.03 6

7. 2011 Diagnosis Code Changes Blood and Blood-Forming Organs –Deleted Secondary Thrombocytopenia - 287.4 –Additional 5 th Digit Required »Post-transfusion purpura - 278.41 »Other secondary thrombocytopenia – 278.49 Mental Disorders –New Code Childhood onset fluency disorder – 315.35 7

8. 2011 Diagnosis Code Changes Circulatory System –New Codes Other disorders of arteries and arterioles - 447.7 Aortic Ectasia - 447.71 – 447.73 Respiratory System –Deleted Influenza due to identified avian influenza virus – 488.0 –Additional 5 th Digit Required »Influenza due to identified avian influenza virus with: »Pneumonia – 488.01 »Other Respiratory Manifestations – 488.02 »Other Manifestations – 488.09 8

9. 2011 Diagnosis Code Changes Respiratory System –Deleted Influenza due to identified novel H1N1 influenza virus – 488.1 –Additional 5 th Digit Required »Influenza due to identified novel H1N1 influenza virus with: »Other Respiratory Manifestations – 488.12 »Other Manifestations – 488.19 9

10. 2011 Diagnosis Code Changes Digestive System –New Code Fecal impaction – 560.32 Musculoskeletal System –New Code Spinal stenosis, lumbar region, with neurogenic claudication – 724.03 Congenital Anomalies –Deleted Other anomalies of uterus – 752.3 –Additional 5 th Digit Required: »752.31 – 752.47 10

11. 2011 Diagnosis Code Changes Symptoms, Signs and Ill-Defined Conditions –New Codes Post traumatic seizures – 780.33 Febrile non-hemolytic transfusion reaction – 780.66 Fluency disorder in conditions classified elsewhere – 784.52 Jaw pain – 784.92 Signs and Symptoms involving cognition –Attention or concentration deficit – 799.51 –Cognitive communication deficit – 799.52 –Visuospatial deficit – 799.53 –Psychomotor deficit – 799.54 –Frontal lobe and executive function deficit – 799.55 –Other signs and symptoms involving cognition – 799.59 11

12. 2011 Diagnosis Code Changes Symptoms, Signs and Ill-Defined Conditions –Deleted Codes Hemoptysis – 786.3 –Additional 5 th Digit Required: »Acute idiopathic pulmonary hemorrhage in infants – 786.31 »Other hemoptysis – 786.39 Incontinence of Feces – 787.6 –Additional 5 th Digit Required: »Incomplete defecation – 787.61 »Fecal smearing – 787.62 »Fecal urgency – 787.63 12

13. 2011 Diagnosis Code Changes Injury and Poisoning –Deleted Poisoning by other specified central nervous system stimulants – 970.8 –Additional 5 th Digit Required: »Poisoning by cocaine – 970.81 »Poisoning by other central nervous system stimulants – 970.89 ABO incompatibility reaction – 999.6 –Additional 5 th Digit Required: »ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed – 999.61 »Acute – 999.62 Delayed – 999.63 »Other ABO incompatibility reaction - 999.69 13

14. 2011 Diagnosis Code Changes Injury and Poisoning –Deleted Rh incompatibility reaction – 999.7 –Additional 5 th Digit Required: »Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed – 999.71 »Acute – 999.72 Delayed – 999.73 »Other Rh incompatibility reaction – 999.74 –Non-ABO Incompatibility »Non-ABO incompatibility reaction, unspecified – 999.75 »Not specified as acute or delayed – 999.76 »Acute – 999.77 Delayed – 999.78 »Other non-ABO incompatibility reaction – 999.79 14

15. 2011 Diagnosis Code Changes Injury and Poisoning –New Codes Transfusion reaction, unspecified – 999.8 Hemolytic transfusion reaction, incompatibility unspecified – 999.83 Acute hemolytic transfusion reaction, incompatibility unspecified - 999.84 Delayed hemolytic transfusion reaction, incompatibility unspecified – 999.85 External Causes of Injury and Poisoning –New Codes Volunteer Activity – E000.2 15

16. 2011 Diagnosis Code Changes Factors Influencing Health Status (V Codes) –New Codes – Personal History of: –Combat & operational stress reaction – V11.4 –Vaginal dysplasia – V13.23 –Vulvar dysplasia – V13.24 –Other (corrected) congential malformations of: »Genitourinary system – V13.62 »Nervous system – V13.63 »Eye, ear, face and neck – V13.64 »Heart and circulatory system – V13.65 »Respiratory system – V13.66 »Digestive system – V13.67 »Integument, limbs and musculoskeletal – V13.68 16

17. 2011 Diagnosis Code Changes Factors Influencing Health Status (V Codes) –New Codes – Personal History of: –Retained foreign body fully removed – V15.53 Do not resuscitate status – V49.86 Physical restraints status – V49.87 Homicidal ideation – V62.85 Acquired absence of pancreas – V88.1 –Total – V88.11 Partial – V88.12 17

18. 2011 Diagnosis Code Changes Factors Influencing Health Status (V Codes) –New Codes – Retained: –Foreign body – V90 »Radioactive fragment – V90.0 »Depleted uranium fragments – V90.01 »Other radioactive fragments – V90.09 –Metal fragments – V91 »Metal fragments, unspecified – V90.10 »Magnetic metal fragments – V90.11 »Non-magnetic metal fragments – V90.12 –Plastic fragments – V90.2 –Organic fragments – V90.3 –Animal quills or spines – V90.31 18

19. 2011 Diagnosis Code Changes Factors Influencing Health Status (V Codes) –New Codes – Retained: –Tooth – V90.32 –Wood fragments – V90.33 –Other organic fragments – V90.39 –Other specified foreign body – V90.8 –Glass fragments – V90.81 –Stone or crystalline fragments – V90.83 –Other specified foreign body, NEC – V90.89 –Foreign body, unspecified material – V90.9 Multiple Gestation Placenta Status –Codes V91.0 – V91.99 19

20. 2011 Diagnosis Code Changes Factors Influencing Health Status (V Codes) –Deleted Encounter for insertion of intrauterine contraceptive device (IUD) – V25.1 –Insertion of IUD – V25.11 –Removal of IUD – V25.12 –Removal and re-insertion of IUD – V25.13 Body Mass Index (BMI) 40 and over, adult – V85.4 –BMI 40.0 – 44.9, adult – V85.41 –BMI 45.0 – 49.9, adult – V85.42 –BMI 50.0 – 59.9, adult – V85.43 –BMI 60.0 – 69.9, adult – V85.44 –BMI 70 and over, adult – V85.45 20

21. 2011 ICD-9-CM Volume 3 Procedure Code Changes ICD-9-CM Volume 3 Procedure Code Changes –22 New Codes & 1 Deleted Code Insertion of drug-eluting stent(s) of superficial femoral artery – 00.60 Cranial implantation or replacement of neurostimulator pulse generator – 01.20 Removal of cranial neurostimulator pulse generator – 01.29 Non-coronary intra-operative fluorescence vascular angiography (IFVA) – 17.71 Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle – 32.27 Percutaneous mitral valve repair with implant – 35.97 Excision or destruction of other lesion or tissue of heart, thoracoscopic approach – 37.37 21

22. 2011 ICD-9-CM Volume 3 Procedure Code Changes ICD-9-CM Volume 3 Procedure Code Changes –22 New Codes & 1 Deleted Code Central venous catheter placement with guidance – 38.97 Implantation or replacement of carotid sinus stimulation device –Total system – 39.81 –Lead(s) only – 39.82 –Pulse generator only – 39.83 Revision of carotid sinus stimulation –Lead(s) only – 39.84 –Pulse generator – 39.85 22

23. 2011 ICD-9-CM Volume 3 Procedure Code Changes ICD-9-CM Volume 3 Procedure Code Changes –22 New Codes & 1 Deleted Code Removal of carotid sinus stimulation –Total system – 39.86 –Lead(s) only – 39.87 –Pulse generator – 39.88 Other operations on carotid body, carotid sinus and other vascular bodies – 39.89 (Deleted 39.8) Reverse total shoulder replacement – 81.88 Insertion of sternal fixation device with rigid plates – 84.94 Fat graft to breast – 85.55 Fat graft of skin & subcutaneous tissue – 86.97 Extraction of fat for graft or banking – 86.90 23

24. 2011 CPT Code Changes Effective 1/1/11 New Codes Deleted Codes 24

25. 2011 CPT Code Changes Evaluation and Management – 3 New Codes –Code added and resequenced Subsequent Observation Care, Low Severity - 99224 Subsequent Observation Care, Mod. Severity - 99225 Subsequent Observation Care, High Severity - 99226 Integumentary System – 3 New & 2 Deleted –Code added and resequenced – (Add-on Codes) Debridement, each additional 20 sq cm –Subcutaneous Tissue - 11045 –Muscle/Fascia - 11046 –Bone – 11047 –Deleted Debridement; skin; partial & full thickness – 11040 & 11041 25

26. 2011 CPT Code Changes Musculoskeletal System – 5 New Codes –Neck & Spine Fusion, Additional – 22551 –Add’l Neck & Spine Fusion (Add-On Code) - 22552 –Code added and resequenced Hip Arthroscopy with –Femoroplasty – 22914 –Labral Repair – 22915 –Acetabuloplasty - 22916 Respiratory System – 4 New Codes –Nasal Sinus Endoscopy with Dilation of: Maxillary Sinus – 31295 Frontal Sinus – 31296 Sphenoid Sinus – 31297 –Bronchoscopy with Balloon Occlusion - 31634 26

27. 2011 CPT Code Changes Cardiovascular System – 20 New & 23 Deleted –New Codes Application of Pulmonary Artery Bands - 33620 Transthoracic Insertion of Catheter or Stent - 33621 Reconstruction Complex Cardiac Anomaly - 33622 Revascularization with Stent –Iliac, Femoral/Popliteal Artery, Tibial/Peroneal Artery »37220 - 37235 Intraoperative Identification of Sentinel Lymph Nodes - 38900 –Deleted Codes Transluminal balloon angioplasty - 35454 – 35474 Transluminal peripheral atherectomy – 35480 - 35495 Repair, diaphragmatic hernia – 39520 - 39531 27

28. 2011 CPT Code Changes Digestive System – 18 New & 4 Deleted –New Laparoscopy, Esophageal Lengthening (Add-On) - 43283 Esophagogastric Fundoplasty - 43327 – 43328 Hiatal Hernia Repair - 43332 – 43338 Gastric Intubation & Aspiration, Necessitating Physician Skill - 43753 Gastric/Duodenal Intubation & Aspiration- 43754 - 43754 Laparoscopy Placement of Interstitial Device - 49327 Placement of Interstitial Device (Add-On) - 49412 Insertion of Tunneled Intraperitoneal Catheter – 49418 –Deleted Esophagogastric fundoplasty – 43324 & 43326 Biopsy of Stomach - 43600 28

29. 2011 CPT Code Changes Urinary System – 1 New Code – Transurethral Radiofrequency Treatment for Stress Incontinence - 53860 Female Genitourinary System – 1 New Code –Insertion of Vaginal Brachytherapy Device - 57156 Nervous System – 8 New & 2 Deleted –Stereotactic Computer Assisted Cranial Procedures – 61781 -61783 –Posterior Tibial Neurostimulator - 64566 –Cranial Nerve Neurostimulator Electrodes - 64568 – 64570 –Chemodenervation of Parotid & Submandibular Glands - 64611 29

30. 2011 CPT Code Changes Eye and Ocular Adnexa – 4 New Codes –Placement of Amniotic Membrane on Ocular Surface – 65778 – 65779 –Transluminal Dilation of Eye Canal - 66174 - 66175 Radiology – 5 New Codes –CT Angioplasty Abdomen/Pelvis Without Contrast – 74176 With Contrast – 74177 Without Contrast 1+ Body Regions – 74178 –Ultrasound Extremity Non-Vascular Complete - 76881 Limited – 76882 Pathology & Laboratory–15 New & 13 Deleted 30

31. 2011 CPT Code Changes Medicine – 40 New & 41 Deleted –New Codes Immunization Administration thru 18 years –First Vaccine/Toxoid – 90460 –Each Additional – 90461 H1N1 Immunization Administration, including counseling - 90470 Meningococcal Vaccine, 2-15 months - 90644 Influenza Virus Vaccine –Intranasal – 90664 –Intramuscular, Preservative Free – 90666 –Intramuscular, Split Virus, Adjuvanted – 90667 –Intramuscular, Split Virus – 90668 31

32. 2011 CPT Code Changes Medicine – 40 New & 41 Deleted –New Codes Therapeutic repetitive transcranial magnetic stimulation treatment; planning – 90867 –Delivery and management, per session - 90868 Esophageal Motility (Add-On Code) – 91013 Sleep Study 95800 - 95801 –Deleted Codes Immunization Administration – 90465 – 90468 Esophageal/Gastric Intubation/Motility – 91000-91105 Telephonic Transmission of Post-Symptom EKG strips –93012 & 93014 Holter Monitors –93230 - 93233 –93235 - 93237 32

33. 2011 CPT Code Changes Medicine – 40 New & 41 Deleted –New & Deleted Heart Catheterization Codes New –93451 - 93464 –93563 - 93568 Deleted –93501 –93508 - 93511 –93514 –93524 –93526 - 93529 –93539 - 93545 –93555 - 93556 33

34. 2011 CPT Code Changes Category II Codes (F Codes) – 31 New Codes –Major Depressive Disorder –Parkinson’s Disease –Epilepsy –Body Mass Index –Cervical Cancer Screening –BloodTyping –ClinicalTumor Staging –Anesthesia –Tobacco Use & Cessation Counseling 34

35. 2011 CPT Code Changes Category III Codes (T Codes) –52 New Codes & 13 Deleted Codes –Cryopreservation Ovary Tissue / Oocyte – 0058T & 0059T –Audiometry and Speech Audiometry – 0208T – 0212T –Injection Paravertebral Facet Joint – 0213T – 0218T –Placement Posterior Intrafacet Implants – 0219T – 0222T –Transluminal Peripheral Atherectomy – 0234T – 0239T –Esophageal Motility – 0240T – 0242T –Measurement of Wheeze Rate for Bronchodilator 0243T & 0244T –Open Treatment of Rib Fractures – 0245T – 0248T –Ligation Hemorrhoid with Ultrasound – 0249T 35

36. 2011 CPT Code Changes Category III Codes (T Codes) – 52 New Codes – 52 New Codes & 13 Deleted Codes –Bronchial Valve Procedures – 0250T – 0252T –Endovascular Repair – 0254T – 0256T –Aortic Heart Valve Replacement with and without Cardiac Bypass – 0258T & 0259T –Hypothermia, Neonate, 28 days or less – 0260T & 0261T 36

37. RAC Audits – Region A Outpatient Hospital - Physician Untimed Codes –Certain untimed codes are billed for more than one unit i.e. Physical Therapy Newborn/Pediatric Codes –Patients that exceed the age limit defined by CPT code Global Surgery –Pre- and Post-Operative visits New Patient Visits –Guidelines for a new patient New to practice Has not been seen in practice for 3 years 37

38. RAC Audits – Region A Outpatient Hospital - Physician Technical Component of Radiology Neulasta –Drug that reduces risk of infection in cancer patients Commonly reported with a chemotherapy drug administration code rather than a therapeutic administration code which creates an overpayment Global Billing of Radiology or Diagnostic Tests in Facility Setting Add-On Codes –Add-on code reimbursed when primary procedure either was not billed or not paid NCCI Edits 38

39. RAC Audits – Region A Outpatient Hospital - Physician Duplicate Claims IV Hydration –When billed for more than one unit per date of service Once in a Lifetime –i.e. Removal of organs; genetic testing; dialysis training etc. Bronchoscopy Services –When billed for more than one unit per date of service Global vs. TC/PC Split Reimbursements –Reimbursement for global and then additional reimbursement for TC or PC 39

40. RAC Audits – Region A Inpatient Hospital MS-DRG Validation – –Currently Medical Necessity Excluded Tracheostomy Coronary Bypass, Cardiac & Cardiac Valve Procedures Extensive & Non-Extensive OR Procedures Joint Disorders Major Chest Procedures Major Large & Small Bowel Procedures Hip & Femur Procedures Intracranial Hemorrhage or Cerebral Infarction Pulmonary Edema & Respiratory Failure Ventilator Support of 96+ Hours Craniotomy & Endovascular Intracranial Procedures Excisional Debridement 40

41. RAC Audits – Region A Inpatient Hospital MS-DRG Validation – Currently Medical Necessity Excluded Severe Sepsis Complications of Cholecystectomy Seizures Lysis of Adhesions Pathological Fractures Cardiac Defibrillator –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 41

42. RAC Audits – Region A Inpatient Hospital DRG Coding and Medical Necessity Validation –Diseases of Blood, Blood Forming Organs & Immunological Disorders Currently for MS-DRG 811 – Red Blood Cell Disorders with MCC –Endocrine, Nutritional & Metabolic Disorders Currently for MS-DRG 640 –Nutritional & Miscellaneous Metabolic Disorders with MCC –Nervous System Disorders Currently for MS-DRG’s 056 & 057 –Degenerative Nervous System Disorders with MCC –Degenerative Nervous System Disorders w/o MCC 42

43. RAC Audits – Region A Inpatient Hospital DRG Coding and Medical Necessity Validation –Musculoskeletal Disorders Currently for MS-DRG’s 551 & 552 –Medical Back Problems with MCC –Medical Back Problems w/o MCC –Gastrointestinal Disorders Currently for MS-DRG’s 391 & 393 –Esophagitis, Gastroenterology & Miscellaneous Digestive Disorders with MCC –Other Digestive System Diagnoses with MCC –Kidney and Urinary Tract Disorders Currently for MS-DRG’s 683 & 684 –Renal Failure with CC –Renal Failure w/o MCC 43

44. RAC Audits – Region A Inpatient Hospital DRG Coding and Medical Necessity Validation –Respiratory Currently for MS-DRG’s 190, 191 & 192 –COPD with MCC –COPD with CC –COPD w/o CC and MCC –Cardiovascular Procedures Currently for MS-DRG 249 –Percutaneous Cardiovascular Procedure with Non-Drug Eluting Stent w/o MCC 44

45. RAC Audits – Region A Inpatient Hospital IPPS Hospital to Hospital Transfers –Per diem rate should be paid for transferring hospital –Full MS-DRG payment to final discharge hospital –Validating that both hospitals don’t receive full MS-DRG payments 45

46. 2011 OIG Work Plan Physician Evaluation and Management (E/M) Coding and Electronic Health Record (EHR) Bonuses –Review E/M utilization to identify trends in the level of services Certain providers billing lower or higher-level codes –Review documentation for E/M Services To determine if identical or very similar documentation was used for different E/M codes –OIG believes the reliance on EHR systems’ automated documentation features may be causing improper payments based on identical documentation 46

47. 2011 OIG Work Plan Physician EHR Bonuses and Attestation –OIG will check that those receiving bonuses have met meaningful use standards Error-Prone Providers –Providers with high claims denial rates over the last four years Will be singled out for medical claims review Will receive overpayment demand letters Coding of E/M Services –Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide 47

48. 2011 OIG Work Plan Physician Place of Service Errors –Physician’s Office vs. Ambulatory Surgical Center (ASC) / Hospital Outpatient Departments E/M Services Billed During Global Surgery Periods Part B Imaging Services –Review whether the utilization rates reflect industry standards Excessive Payments for Diagnostic Tests –Determine if testing was medically necessary Trends in Laboratory Utilization –Will review types of lab tests ordered and number of lab tests ordered 48

49. 2011 OIG Work Plan Hospital Medicare Excessive Payments –Hospitals required to report units of service as the number of times that a service or procedure was performed Review outpatient claims in which payments exceeded charges and selected HCPCS codes for billings that appear aberrant Medicare Disproportionate Share (DSH) Payments –Determine if payments were in accordance with Medicare methodology Medicare Outlier Payments –Verify that outlier payments are based on the most recent cost- to-charge ratio from the cost report to properly determine outlier payments 49

50. 2011 OIG Work Plan Hospital Reliability of Hospital-Reported Quality Measure Data –Review hospitals’ controls for ensuring the accuracy of data related to quality of care Hospital Readmissions –Readmitted to hospital less than 31 days after being discharged –Determine trends in the number of hospital readmission cases –Determine if the hospital services met professional standards of care Payments for Diagnostic Radiology Services in Hospital Emergency Departments 50

51. 2011 OIG Work Plan Hospital Hospital Admissions with Conditions Coded Present-on- Admission (POA) –Determine which types of facilities and specific providers are most frequently transferring patients with certain diagnoses that were coded POA Responses to Adverse Events in Hospitals –Determine whether hospitals have taken corrective actions and are in compliance with Medicare standards –Will identify and analyze potential overlaps, conflicts and gaps in responses Hospital Reporting for Adverse Events –Review type of information hospitals’ internal incident- reporting systems capture 51

52. Contact Information –Contact Information Michael McLafferty CPA, MBA, FACMPE, CHFP EisnerAmper, LLP Partner, Healthcare Services Group Michael.McLafferty@eisneramper.com Michael.McLafferty@eisneramper.com Steven Bisciello, MBA EisnerAmper, LLP Supervising Consultant, Healthcare Services Group Steven.Bisciello@eisneramper.com Steven.Bisciello@eisneramper.com Maureen Doherty, CPC, CPC-H EisnerAmper, LLP Supervising Consultant, Healthcare Services Group Maureen.Doherty@eisneramper.com Maureen.Doherty@eisneramper.com 52

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