Coding Category

AAPC Testifies at NCVHS Hearing

HMicrophoneighlights from Rhonda Buckholtz’ testimony, CMS announcements, an open letter from AAPC to Secretary Burwell, and an invitation for an AAPC-CMS joint webinar.

On June 10, 2014, representatives across multiple industries participated in a National Committee on Vital and Health Statistics (NCVHS) hearing. Spokespeople from AAPC and the Centers for Medicare & Medicaid Services (CMS) offered statements regarding ICD-10. AAPC Vice President of ICD-10 Education and Training Rhonda Buckholtz, CPC, CPMA, CPC-I  conveyed the general feeling of AAPC’s 130,000+ members and suggested methods for facilitating the success of both individuals and organizations as they prepare for ICD-10 implementation. Representatives from CMS provided a status update on current initiatives and offered an outlook on upcoming plans.

AAPC Representation

As part of her testimony, Buckholtz shared the results of a recent AAPC member survey. One of the survey questions invited AAPC members to share their biggest concerns surrounding ICD-10 implementation. Buckholtz shared that a common sentiment among respondents included unclear communication from CMS, which is causing people to resist moving forward on ICD-10 implementation. She cited the testing cancellation­—originally scheduled for July—as an example.

“We understand why the testing would be delayed; [CMS] didn’t say we were delaying testing or the reasons why. They said testing is canceled until sometime in 2015. That stops the industry…” she said.

Later in her testimony, she stressed the importance of resolving ICD-10 code confusion:

“Right now, we know that there are many mistakes in the ICD-10 codes. We are holding onto them under the code set freeze. That is very detrimental to the industry.”

To combat the aforementioned issues and help industry professionals move forward, Buckholtz offered the following suggestions for improving the ICD-10 roll out:

“You need to broaden up the cooperating parties and allow more to participate, rather than just the two meetings per year. You need to have a larger panel. You need to have more representation on this, so that providers are represented on this, so that people have a good understanding of how providers’ offices work and how these codes will impact them, especially as payment models shift towards diagnostic coding…”

CMS Representation

Speaking further on the topic of testing, John Evangelist, director of Business Applications Management Evangelist at CMS, said:

“Prior to the passage of PAMA, Medicare fee-for-service had planned to conduct provider-initiated end-to-end testing to help the provider community prepare for ICD-10. This testing was postponed in order to give CMS time to update its software to reflect the new ICD-10 implementation date.”

CMS will announce more details about end-to-end testing, including the specific testing dates, as soon as possible.

Senior Health Insurance Specialist at CMS, Denescia Greene, indicated her desire for increased collaboration:

“I think that maybe now is a good time to bring all of those stakeholders to the table, including other partner and provider groups, as well. We have brought on rural health communities, small hospitals, critical access hospitals, safety net organizations, physician practice organizations, you name it.

I am really open to solutions on how do we get those small physician practices to the table. I will leave it there. I can let you know that CMS is committed to testing. You saw a postponement of the testing, but not a cancellation of testing… The messaging came across perhaps not in the most efficient way. There will be testing to ensure that this process goes through smoothly.”

Read the full transcript.

Open Letter to Health & Human Services Secretary

As a follow up to the suggestions made by Rhonda Buckholtz, AAPC CEO Jason VandenAkker sent a letter to U.S. Department of Health & Human Services Secretary Sylvia Burwell. In the letter, VandenAkker urges Burwell to open the Coordination and Maintenance Committee to additional groups, namely AAPC. Download a pdf copy.

If you would like to encourage the committee to include AAPC in future meetings, you can write to Secretary Burwell at

July 15th, 2014


CMS Proposes Eliminating Global Surgical Packages

Medicare’s 2015 Physician Fee Schedule Proposed Rule includes a plan to eliminate 10- and 90-day global periods for all CPT® procedure codes, beginning in 2017. If adopted, the plan would radically change how the Centers for Medicare & Medicaid Services (CMS) values procedures, as well as how it pays for post-procedure follow up.

Section II.B.4 of the proposed rule—properly titled “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015” and published in the Federal Register July 11—argues that the bundling of related services during 10- and 90-day global periods often result in inaccurate payments for several reasons, including:

  • … the payment rates for the global surgery packages are not updated regularly based on any reporting of the actual costs of patient care.
  • … payment for the PFS [physician fee schedule] global packages relies on valuing the combined services together. This means that there are no separate PFS values established for the procedures or the follow-up care, making it difficult to estimate the costs of the individual global code component services.
  • … the relationship between the work RVUs [relative value units] for the 10- and 90-day global codes (which includes the work RVU associated with the procedure itself) and the number of included post-operative visits in the existing values is not always clear.
  • … the 10- and 90-day global periods reflect a long-established but no longer exclusive model of post-operative care that assumes the same practitioner who furnishes the procedure typically furnishes the follow-up visits related to that procedure. In many cases, we believe that models of post-operative care are increasingly heterogeneous, particularly given the overall shift of patient care to larger practices or team-based environments.

The proposed rule goes on to lament “the fundamental difficulties in establishing appropriate relative values for these [global] packages, the potential inaccuracies in the current information used to price these services, the limitations on appropriate pricing in the future, the potential for these packages to create unwarranted payment differentials among specialties, the possibility that the current codes are incompatible with current medical practice, and the potential for these codes to present obstacles to the adoption of new payment models.”

The proposed rule further cites a 2012 Office of Inspector General (OIG) report that concluded the RVUs assigned to selected global surgical packages “are too high because they include a higher number of E/M services than typically are furnished within the global period for the reviewed procedures.”

Considering the above evidence, CMS does “not believe that maintaining the post-operative 10-and 90- day global periods is compatible with our continued interest in using more objective data in the valuation of PFS services and accurately valuing services relative to each other.” As a solution, the agency proposes transitioning all 10- and 90-day global codes to 0-day global codes.

Procedures with 10-day global periods would transition to 0-day global periods in 2017, while procedures with 90-day global periods would transition to 0-day global periods in 2018.

As such, all codes would be revalued to exclude services previously included within the global period. In other words: The current valuation for procedures with 10- or 90-day global periods would be adjusted downward, but providers would be allowed to report “medically reasonable and necessary visits … separately during the pre- and post-operative periods outside of the day of the surgical procedure.” In sum, CMS implicates that this would lower total overall payments.

CMS is currently seeking comments on this proposed change, as well as others outlined in the 2015 PFS proposed rule. All comments must be received by 5 p.m. September 2, 2014. See the proposed rule for commenting instructions.

July 11th, 2014

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ICD-10: Keeping on Track

By Doug Arrington, MSN, FNP, CPC, CPC-H, CPMA, CHC, CHRC

The other day I was in the clinic talking with the management staff. They were so relieved that there was another year before ICD-10 was going to be implemented. They all thought that they could put everything on hold for 10 or so months. As an AAPC Certified Coder and Nurse Practitioner this was a good opportunity to remind them of some of the things that still needed to be done to get ready for Oct. 2015. Here are some of the things that I discussed with the management team.

1. EMR templates – All of the history of present illness, physical exam, and medical decision making templates need to be updated to reflect the documentation requirements for ICD-10.

2. Principle diagnosis, and secondary diagnosis screens – Each clinical area has their own diagnosis screens. Each needs to be updated to reflect ICD-10. These have not been validated to make sure that they work for ICD-10. Two clinical teams use coding questions – for evaluation and management, procedure, and HCPCS codes. Create clinical scripts to make sure that these coding questions work correctly.

3. Dual Code each clinical provider – Each clinic needs to be working with their providers to make sure that they are documenting at the level required for ICD-10. I started back in February. Even as a certified coder, when I put on a white lab coat, I went back to the way I have been documenting charts since I graduated from my Master’s program some 25 years ago. I still take my ICD-10 cheat sheet in with me when I see patients. ICD-10 requires a whole new way of thinking for me. I cannot speak for other healthcare providers, but you can teach old dogs new things. It has taken much time and practice for me to get consistent in each clinic. For me, it was like going back to the very beginning and relearning required documentation for the key elements of HPI, PE, and MDM. I would suggest a schedule for each provider with increased frequency and another 6 months from October dual code all encounters. Healthcare providers, coders, billers, and other Revenue Cycle team members need to be comfortable with ICD-10.

4. Revenue Cycle – Look at each stage of the Revenue Cycle. How does ICD-10 impact each step? Has every internal point been validated? Has every external vendor been validated?

5. Dual Testing with External Vendors – Create some test files that can be sent to the external vendors to make sure that you communication links work and that the information comes through correctly. Then set up a date before Oct. 2015 when you will submit two files – one ICD-9 and another ICD-10. Compare each patient side by side to make sure the information matches.

6. Backup plan – What is the plan if the EMR is down? How is the clinic going to function? Consider each step from patient check-in to check out. What is the down time protocol? Even more importantly, what is the practice going to do in the case of a power outage? Patients need to be seen. Have a disaster plan for fire, flood, tornado, or any other type of natural disaster. It is time to take that plan out and update to reflect what the practice is going to do.

After talking to them for about five minutes, they all agreed that there were many things that each clinic site needed to do. They decided to pull in the clinic managers and reexamine the ICD-10 implementation plan. There are still many things on ICD-10 implementation plans that healthcare providers, clinics, and health systems need to do. Each action on your ICD-10 implementation plan needs to be checked, tested, verified (see #5 above), and then tested on a regular basis. Use the extra 12 months to perfect your implementation plan.

July 9th, 2014

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Never Assume a Diagnosis

Question: If the provider documentation states that a patient is taking a certain medication, may we report the diagnosis that the medication is meant to treat?

Answer: Never infer a diagnosis from medications prescribed, test results, or any other data, no matter how informed or educated your opinion. If the provider doesn’t explicitly document the diagnosis, you cannot report it. There are many reasons for this, a few of which include:

  • Medications may be prescribed “off label” or for a variety of conditions;
  • Tests results may be ambiguous
  • You do not want to mistakenly label a patient with a diagnosis that he or she does not have
  • The diagnosis (whether correctly assumed, or not), may not be relevant to the current service
  • You do not want to submit claims unsupported by documentation.

“Not documented = not done” is often called the Golden Rule of coding, but behind it lies a more fundamental directive: Never assume anything. Instead, if documentation is unclear or incomplete, query the provider for more information.

July 1st, 2014

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Use Queries to Prompt Complete Documentation

Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI) program. A query is a communication and education tool that prompts physicians to provide detail about under-reported conditions found in the medical record.

Queries may address several documentation areas, such as:

  • To specify the severity of a condition
  • To clarify the underlying cause of a presented symptom
  • To substantiate present-on-admission issue
  • To identify a potentially preventable complication

As an example, if pneumonia is the primary diagnosis, but the type of pneumonia is not noted, the query may ask the provider to further describe the etiology of the condition, and may even provide options such as “viral,” “bacterial,” “community acquired,” “hospital acquired,” etc.

Warning: Be careful not to design “leading” queries, which may prompt providers to select an unsupported diagnosis, and could lead to upcoding. For example, you may ask a provider to give additional detail about a diagnosis, such as in the pneumonia example cited, but should not attempt to steer the provider’s answer by asking, “Was the pneumonia due to virus?”

The documentation resulting from a query can improve the capture of co-morbidity/complication (CC) and major co-morbidity/complications (MCCs), which optimizes facility reimbursement. By contrast, nonspecific documentation leads to nonspecific coding, and the severity of illness, mortality rate, and intensity of service are not captured. Patient care, data integrity, compliance, and reimbursement suffer.

The physician may answer a query verbally, or in writing in the history or physical, a progress note, or the query form. Providers may complete the queries either concurrently (at the time of the provider/patient encounter) or retrospectively.

Developing clinical indicators to determine when the clinical picture suggests a particular diagnosis ensures that queries will be clear, concise, and timely. These clinical guidelines are written in the query template for each condition, and are updated appropriately.

Several organizations offer example templates, or facilities may create their own guidelines based on medical literature. To learn more, type “CDI queries” into your favorite search engine, and browse the results.

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