2013 PQRS Aligns with Other Quality Reporting Programs

By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS

The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.

Incentives: The Good, the Bad, and the Ugly

The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.

An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.

The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).

The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.

Subtle Changes to Traditional Reporting

The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).

The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.

Individual EP Reporting of Individual Measures

EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.

As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:

• Claims
• Registry
• Qualified direct electronic health record (EHR)
• Qualified EHR data submission vendor

Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.

Aligning Quality Initiatives

There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.

“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule

In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.

As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.

An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.

Individual EP Reporting of Measures Groups

EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).

There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:

• Diabetes Mellitus
• Chronic Kidney Disease
• Coronary Artery Bypass Graft (CABG)
• Preventive Care
• Rheumatoid Arthritis
• Perioperative Care
• Back Pain
• Coronary Artery Disease (CAD)
• Heart Failure
• Ischemic Vascular Disease (IVD)
• Hepatitis C
• HIV/AIDS
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Dementia
• Sleep Apnea
• Irritable Bowel Disease (IBD)
• Parkinson’s
• Hypertension
• Oncology
• Cardiovascular Prevention
• Cataracts

CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.

Group Practice Reporting

CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.

Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.

Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).

Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.

Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.

If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.

As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Physi​cianReview-ICN904144.pdf).

There’s Still Time to Act

Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).

Avoiding the PQRS Negative Adjustment

CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.

If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.

CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:

1. Satisfactorily report and earn the 2013 incentive of 0.5 percent.
2. Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
3. Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.

The Push for Better Care and Outcomes

CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”

Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.

April 1st, 2013

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Overcome ICD-10-CM Documentation Challenges

By Jacqueline J. Stack, BSHA, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC

November 1st, 2012

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NQF Pushes Forward with Value-based Purchasing Measures

Under contract with the U.S. Department of Health & Human Services (HHS), the National Quality Forum (NQF) recently added four efficiency measures that “could be combined with quality metrics as part of the Medicare value-based purchasing plan set to start in 2015,” American Medical News reports.

Two of the new measures evaluate relative resource use for patients with asthma and chronic obstructive pulmonary disease (COPD), and a third looks at total costs for treating pneumonia. The final measure focuses on total costs for hip and knee replacement.

These four measures join four others, endorsed in January, which include metrics to examine resource use for patients with diabetes and cardiovascular conditions, and total resource use and total cost of care for all patients.

The central concept of value-based purchasing in health care is that buyers should hold providers accountable for both the cost and quality of care. Value-based purchasing seeks to reduce inappropriate care and to identify the best-performing providers. Ideally, those providers and health care systems that provide the best care at the best cost would be rewarded with greater numbers of patients.

By measuring resources used, rather than raw costs only, the NQF “is aiming to give apples-to-apples comparisons of physician efficiency that are not distorted by geographic price variations,” American Medical News continues.

The American Medical Association (AMA), among other groups, supports value-based purchasing initiatives, but has expressed concern whether such a system could be implemented without penalizing doctors who treat the most difficult cases.

April 27th, 2012

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PQRS Solidifies PQRI for Years to Come

Big changes to PQRI in 2011 put pay for performance in the spotlight.

By Penny Osmon, BA, CPC, CPCI, CHC, PCS

Updates to the Physician Quality Reporting Initiative (PQRI) signal that the shift from pay for reporting to pay-for-performance has begun. The 2011 Physician Fee Schedule final rule, issued Nov. 2, 2010 by the Centers for Medicare & Medicaid Services (CMS), incorporates key provisions of the Patient Protection and Affordable Care Act (PPACA), and gives PQRI a new name—Physician Quality Reporting System (PQRS)—to reflect its permanence. Quality reporting no longer can be ignored; the time has come for practices to embrace the process.

For 2011, CMS has made the reporting process less cumbersome by reducing the threshold of claims reporting to 50 percent (down from 80 percent in 2010), offering a new group reporting option for entities of fewer than 200 eligible professionals (EPs), and adding a new measure group for asthma. The list of eligible professionals remains the same, and there still is no solution that allows participation of rural health clinics (RHCs), federally qualified health centers (FQHCs), or critical access hospitals (CAHs) to be reimbursed via method II (for additional information on CAH billing standards.

Participation Incentives

PPACA provisions not only extended the incentive payments for successful participation through 2014, but added payment adjustments for unsuccessful reporters beginning in 2015. A 1 percent incentive payment is available in 2011, and a 0.05 percent incentive payment is available for successful reporters from 2012 to 2014. A negative payment adjustment of 1.5 percent will apply for noncompliance in 2015, increasing to 2 percent in 2016.

PQRS incentive payments are based on total allowed, reimbursed charges for services covered under the Medicare Part B Physician Fee Schedule (PFS) during the reporting period. Although the money may provide incentive to participate, don’t forget the future alignment of PQRS with quality improvement programs. This is illustrated in the final rule:

“As the program matures and we phase out the incentives for satisfactory reporting and phase in payment adjustments for failing to satisfactorily report, we envision continuing further refinements aligning PQRS with a more robust role in quality improvement.”

An additional 0.05 percent incentive payment is available from 2011 through 2014 for EPs who provide data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year, submitted through an MOC program, the physician must participate in and successfully complete an MOC program. Board certification status may require more frequent reporting. For physicians to wade through the confusion, CMS must issue further clarification and guidance on the interaction between CMS contractors and the medical boards. This optional incentive may prove too confusing and require duplicate work triggering physicians to ask: “Is it worth the effort?”

Quality Reporting Methods

The four reporting methods from which to choose in 2011 are: (1) claims; (2) CMS qualified registry; (3) CMS qualified electronic health record (EHR); and (4) group reporting, which is divided into sub groups a) GPRO I (>200 EPs) and b) GPRO II (2199–EPs).

In addition to the four reporting methods, EPs can choose to report on either individual quality measures or measure groups. If an EP chooses to report individual quality measures and submit by claims, three measures must be reported on at least 50 percent of all eligible Medicare patients.

If submitting through a registry, there is a threshold of 80 percent of all eligible Medicare patients. If less than two individual quality measures apply to a particular EP, one or two measures may be reported through claims reporting; however, the EP is subject to a measure applicability validation process to verify that additional measures did not apply.

The reporting periods for both registry and claims continue to provide flexibility, with both a six month and 12 month option—with the exception of the 30 patient measure group reporting method, which is a 12 month reporting period for claims and registry. EHR reporting is available only as a 12 month option and requires submission of 20 predetermined quality measures. Quality data recorded through this method will be submitted to CMS in early 2012. A list of certified EHR products for 2011 is online at: www.cms.gov.

To participate in either GPRO option, organizations must make a decision and self-nominate between Jan. 3 and Jan. 31, 2011. The GPRO I option requires the entire group to participate on 26 predetermined measures focused on preventive and chronic conditions. Groups selecting this method will receive a pre-populated collection tool from CMS. Reporting GPRO II is based on group size and requires reporting a combination of individual and group measures. CMS plans to accept approximately 500 groups for GPRO II participation in 2011.

Claims Based vs. Registry Based Reporting

Claims and registry based reporting continue to be the primary methods of choice. In the 2010 PFS final rule, CMS hinted at potential elimination of the claims reporting option. In the 2011 rule, this position is clarified:

“CMS believes it would be premature to eliminate the claims based reporting mechanism for 2011 and by doing so would create a barrier to participation. When there is an adequate number and variety of registries available, a transition may occur.”

CMS recently announced, through an open door forum, the success rate of claims reporting in 2008 and 2009 was 50 percent, while the success rate for registry reporting was 90 percent. Although the statistics might initially guide EPs directly to the registry option, most registries have costs associated with them. Another important aspect is workflow within the clinic. The claims process is built on collection of real time data, while a registry allows EPs to collect the data along the way and report on it later.

Reporting a measure group on 30 Medicare Part B fee-for-service (FFS) patients using the claims method must be initiated by reporting a measure group specific intent G code to indicate the selected reporting method. Claims reporting of measure groups also allow EPs to submit one measure group specific composite G code when all applicable measures within the measure group are completed successfully on a patient. When deciding which option best meets the needs of an EP, there are many components to consider.

Tip: To learn more about PQRS related G codes, go to www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage, select the link labeled “Additional 2011 Physician Quality Reporting System Measure Documents,” and open the 2011 Physician Quality Reporting System (Physician Quality Reporting) Measures Groups Specifications Manual (2011_PhysQualRptg_MeasuresGroups_SpecificationsManual_121510.pdf) file.

The practical first step is to determine which of the 194 measures for 2011 best apply to the EP’s clinic, noting the 44 measures that can be submitted only through a registry. If there are less than two measures that apply, EPs must report via claims.

If EPs identify three or more applicable measures, the next step is to determine whether to use individual or measure group reporting. The 2011 measure groups are:

• Diabetes Mellitus
• Chronic Kidney Disease (CKD)
• Preventive Care
• Rheumatoid Arthritis
• Coronary Artery Bypass Graft (CABG)
• Rheumatoid Arthritis
• Perioperative Care
• Back Pain
• Hepatitis C
• Heart Failure
• Coronary Artery Disease (CAD)
• Ischemic Vascular Disease (IVD)
• HIV/AIDS
• Community Acquired Pneumonia
• Asthma

Note that measure group specifications may vary from the individual measure specifications that comprise the group. The specifications for both are online at
www.cms.gov.

After determining quality measures for reporting, the EP can identify which method (claims or registry) is most appropriate. Two important changes to registry reporting in 2011 are:

• If an EP chooses to report a measure group on 30 patients through a registry, all 30 patients must be Medicare Part B FFS patients. In 2010, only two Medicare Part B FFS patients were required.
• A zero-measure performance rate will not be accepted for registry submission. If reporting on a measure group, this means all individual measures within the measure group must be reported at least once for the 30 Medicare patients. When submitting individual measures through a registry, all three measures must be reported as performed at least once.

A list of CMS approved registries for 2011 will be available in spring 2011 at www.cms.gov/pqri. If an EP chooses the registry option, clinical data collection begins in January 2011, and the data will be entered into the registry tool at a later date. If you select this reporting method, consider how you will capture and track the data for submission at a later date. This could include a spreadsheet, printed summary report, or another alternative that meets the needs of organizations.

When deciding between claims and registry, consider other initiatives or projects occurring in the clinic. Important considerations include: current workload, potential workflow changes, and potential return on investment recognized by staff time gained; less room for errors on claims, and; the ability to submit quality data at your convenience.

Pay for Performance Is Coming

Ultimately, the focus of clinical quality measure data collection will shift to performance improvement. PPACA requires CMS to develop a plan by 2012 outlining how to integrate the PQRS measures with the EHR meaningful use incentive program. The 2011 PFS proposed rule specifically sought comments on how best to align the two incentive programs, and stated:

“In an effort to align PQRI with the EHR incentive program, we propose to include many American Recover and Reinvestment Act (ARRA) core clinical quality measures in the PQRI program to demonstrate meaningful use of EHR and quality of care furnished to individuals. We propose the selection of these measures to meet the requirements of planning the integration of PQRI and EHR reporting.”

Clearly, we are slowly migrating to a pay-for-performance reimbursement system where clinical data will help drive quality improvement in health care.

PQRS Reporting Requirements at a Glance

Penny Osmon, BA, CPC, CPCI, CHC, PCS, is the director of educational strategies for the Wisconsin Medical Society. She has over 15 years of experience in Medicare compliance, coding, and practice management. She presents educational programs on revenue cycle, risk management, and health information management for physician practices throughout Wisconsin and the Midwest region with an emphasis on reducing waste, mitigating risk, and improving quality. She serves on the Wisconsin Medical Group Management Association Third Party Payer and Medicare and Medicaid Workgroups.

February 1st, 2011

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COPD: Frequently Used, Frequently Misreported

By Jill M. Young, CPC, CEDC, CIMC

Chronic obstructive pulmonary disease (COPD) is a progressive disease that causes coughing, wheezing, shortness of breath, chest tightness, and other symptoms. The leading cause of COPD is smoking; most people who smoke, or have smoked, have some form of COPD. In 2007, an estimated 12.1 million Americans had the disease, which is not only a major cause of disability but also the fourth leading cause of death in America.

Coders will encounter COPD frequently in medical documentation, but often without the specificity required to code the condition appropriately. A little physician education will go a long way to solve this problem.

Be Cautious of Shortcuts

As coders, we become so familiar with certain anagrams that we memorize the corresponding diagnosis code—HTN for hypertension (401.9 Essential hypertension; Unspecified), DM for diabetes mellitus (250.00 Diabetes mellitus without mention of complication; type II or unspecified type, not state as uncontrolled), and OA for osteoarthritis (715.98 Osteoarthritis, unspecified whether generalized or localized; Other specified sites), to name just a few. Although you may know what ICD-9-CM codes to assign in such cases, you do a disservice to providers if you allow them to document with such nonspecific code assignments. Ensure accurate representation of the patient’s illness by looking at the specificity available to diseases such as COPD.

“COPD” may be written in the record, but that does not give essential details about the patient’s condition, and this leads to coding quandaries. Was the patient ill at this encounter with another respiratory process? Was this illness and its severity included in the record documentation? This information is necessary if you are to select codes that accurately identify the patient’s condition.

COPD 496 Is a Non-Specific Code

Code 496 Chronic airway obstruction not elsewhere classified is one of the few valid three-digit codes in the ICD-9-CM manual. The code includes a subcategory listing of “chronic obstructive pulmonary disease (COPD) NOS,” and is both a not otherwise specified (NOS) and not elsewhere classified (NEC) diagnosis. In other words, 496 is a legitimate diagnosis, but it lacks specificity. Providers like to write the short anagram “COPD” when there may be (and perhaps should be) a more specific code for a patient encounter.

Fold COPD into 491-493, When Present

You should not report 496 with chronic bronchitis (491.xx), emphysema (492.x), or asthma (493.xx), according to ICD-9-CM instructions. Just as shortness of breath normally should be integrated in the coding for pneumonia, COPD should be incorporated into categories 491-493 for the other lung diseases listed.

For example, when COPD is documented with other specified conditions, such as an acute exacerbation (491.21 Obstructive chronic bronchitis) or asthma (493.2x), per coding guidelines, code 496 is not used. In such a case, COPD should not be documented separately because it is redundant to the more-inclusive diagnosis. Nor should you report 496 with 491.0 Simple chronic bronchitis, 492.8 Other emphysemia, or asthma of any kind (493.xx).

A tip in ICD-9-CM 2011 reminds, “COPD is a nonspecific term that encompasses many different respiratory conditions. Review medical record and query physician for more specific documentation of emphysema, bronchitis, asthma, etc.”

One useful tool is the Venn diagram, as shown in Figure A. Similar to what appears in the ICD-9-CM manual, this diagram shows the interrelationship between chronic bronchitis (491.xx), asthma (493.xx), and emphysema (492). The overlapping areas are indicative of diagnoses with shared qualities of two or all three of the major disease processes. As you can see, COPD has attributes of both chronic bronchitis and emphysema; how much of each changes with every patient, and potentially with each encounter.

Tip: As a note of caution, not all physicians agree with the classifications this diagram offers, so you may want to have a discussion with your provider to avoid any confusion.

The Venn diagram helps us to understand that these are three different and distinct diagnoses, but there are  related disease processes that must be considered. Your code book may have definitions listed in several of the subsections that are very helpful in differentiating codes with common characteristics. Coding tips from the 2011 ICD-9-CM book specifically state, “Due to the overlapping nature of conditions that make up COPD, it is essential that the coder review all instructional notes carefully.”

For example, documentation of a patient visit may end with the physician listing COPD and chronic bronchitis. This should be coded to 491.0; the chronic bronchitis is the more specific code to the COPD, according to ICD-9-CM guidelines. The same guidelines are applied if the documentation was COPD and asthma. In this example, it is particularly difficult to omit the 496 COPD code because an unspecified code for the asthma is indicated with an unspecified subclassification, which codes to 493.90 Asthma, unspecified; unspecified.

ICD-10 Raises the Stakes

COPD documentation and specificity will become even more important with ICD-10-CM. COPD is classified with acute lower respiratory infections (also identifying the infection), and with exacerbation. You also are instructed, where applicable, to use additional codes to identify exposure to tobacco. This exposure is identified in codes representative of environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and tobacco use.

Help Providers, Help You

How can coders educate providers to document all the necessary information to code COPD accurately? I recommend you take your code book to providers (or, copy and send them the relevant pages) to show them firsthand the ICD-9-CM guidelines. If a physician sees, for example, there are separate codes for a patient with or without COPD and acute bronchitis, chronic bronchitis, or acute and chronic bronchitis together, they will better understand why you are asking for more specificity. Remind the provider that you cannot code what is not documented. Any dialog between coders and providers is invaluable to producing detailed documentation that leads to code selection with the best-possible specificity.

The next time you see COPD (or 496) listed as a diagnosis, think of the prevalence of patients with this disease process, and remember that this code lacks specificity. Don’t forget there are 24 distinct ICD-9-CM code listings for which COPD should not be listed separately as a diagnosis, according to guidelines. Look to the documentation and your provider for the data needed to represent the patient encounter accurately, with the greatest specificity that the ICD-9-CM system offers.

Jill M. Young, CPC, CEDC, CIMC, has more than 30 years of medical experience working in all areas of the medical practice including clinical, billing, and rounding with physicians. She is the principal of Young Medical Consulting, LLC, and is the current chair of the AAPC Chapter Association (AAPCCA).

January 1st, 2011

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