By Betty Hovey, BA, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC
On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released several important clarifications in their ICD-10 Industry Update email. There has been some confusion and frustration regarding the codes in Chapter 20, External Causes of Morbidity (V, W, X, and Y codes), which will replace the current ICD-9-CM E-Code section. The Official ICD-10-CM Guidelines (I.C.20) state that for any initial encounter from an illness or adverse effect, the codes found in this chapter should also be reported, along with the injury(ies) sustained. Many wondered if these codes in ICD-10-CM would be required by all payers, as not all payers currently require the E-codes to be assigned in ICD-9-CM. According to CMS, there will be no national stipulation for mandatory ICD-10-CM external cause code reporting. Unless a payer or state changes its current requirements, if you do not report external cause codes for ICD-9-CM, you will not report external cause codes in ICD-10-CM.
CMS also addressed usage of unspecified codes in ICD-10-CM. There are many more specific codes in ICD-10-CM when compared to ICD-9-CM (about 5 times as many), but unspecified codes are still part of the code set. CMS states that unspecified codes have acceptable, even necessary uses in ICD-10-CM. The coding guidelines state that each encounter should be coded to the highest level of specificity known. CMS further comments that it is inappropriate to either select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. When sufficient clinical information is not known or available to assign a more specific code, an unspecified code may be the most appropriate code to report.
These concepts had already been incorporated into AAPC’s industry-wide ICD-10 training; the clarifications are welcome.
May 23rd, 2013
In a proposed rule published in the Federal Register May 10, the Centers for Medicare & Medicaid Services (CMS) clarifies the rules governing physician orders of hospital inpatient admissions for payment under Medicare Part A. If finalized, hospital inpatient admissions spanning two midnights in the hospital would generally qualify as appropriate for payment under Medicare Part A. Anything less would be considered observation and paid under Part B, unless the physician could prove otherwise.
The purpose of this provision in the hospital Inpatient Prospective Payment System (IPPS) proposed rule for fiscal year 2014 is to resolve ongoing confusion as to when a patient should be admitted to inpatient status.
CMS states in the proposed rule, “The majority of improper payments under Medicare Part A for short-stay inpatient hospital claims have been due to inappropriate patient status (that is, the services furnished were reasonable and necessary, but should have been furnished on a hospital outpatient, rather than hospital inpatient, basis).”
Will the clarification be enough to resolve the longstanding dilemma for providers as to when it is appropriate to order an inpatient stay? Some are inclined to agree. Stacy Harper, JD, MHSA, CPC, of Lathrop & Gage LLP, is one of them.
“The current subjective guidelines for inpatient admission have resulted in numerous appeals and disputes regarding necessity of inpatient status. If the proposed two-midnight objective presumption is finalized, hospitals will have a new guide available to assist in these decisions,” Harper said.
But the American Hospital Association (AHA) has a difference of opinion. In a public statement released April 26, the AHA said it is more inclined to believe that the proposal will allow Medicare contractors to continue second-guessing physicians’ judgment.
“While we appreciate CMS’ efforts to provide clarity around when an inpatient admission is appropriate – such as for a patient on observation status – we are concerned that this could be applied in a way that undermines medical judgment,” Rick Pollack, AHA executive vice president, said in the statement.
According to CMS, however, review contractors won’t deny short-stay inpatient claims as long as they are documented correctly. “It is the documentation of the reasonable basis for the expectation of a stay crossing 2 midnights that would justify the medical necessity of the inpatient admission, regardless of the actual duration of the hospital stay and whether is ultimately crosses 2 midnights.”
To support an inpatient claim, in addition to the physician’s order and certification, the provider must document complex medical factors such as:
- Beneficiary medical history and comorbidity
- Severity of signs and symptoms
- Current medical needs
- Risk of an adverse event
In a related matter, CMS recently announced that it would allow hospitals to resubmit claims for payment under Part B after being initially denied by Part A (Read “CMS Addresses Part B Inpatient Billing Controversy,” AAPC Cutting Edge, June 2013, for details).
Unfortunately, this creates another cause for concern, according to the American Medical Association (AMA). “For patients, reclassification as ‘observation’ rather than admitted can result in unanticipated costs and co-payments,” the AMA stated in an Aug. 31 letter to CMS. For example, Medicare covers skilled nursing facility (SNF) care when a patient spends at least three days as an inpatient, but not as an outpatient under observation status. If a patient were to spend three days as an inpatient and then be transferred to an SNF, that individual would be charged the full shot for the SNF stay in the event the inpatient claim is denied and subsequently paid under Part B.
More Changes on the Horizon
Also in the IPPS proposed rule, CMS would:
- Implement statutory provisions contained in the Affordable Care Act of 2010;
- Update rate-of-increase limits for hospitals excluded from the IPPS and paid on a reasonable cost basis;
- Update IPPS payment policies and annual payment rates;
- Make changes relating to direct and indirect graduate medical education payments; and
- Update policies relating to the hospital value-based purchasing program and the hospital readmissions reduction program, as well as revise the conditions of participation.
The IPPS proposed rule is open for comment until June 25. For complete details, download the proposed rule from the Federal Register website (www.federalregister.gov). The final rule is expected Aug. 1, with most of the provisions going into effect Oct. 1.
May 21st, 2013
By Evan M. Gwilliam, DC, CPC, CCPC, NCICS, CCCPC
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
Code the Primary Diagnoses in ICD-10-CM
Medicare administrative contractors (MACs) release local coverage determinations (LCDs) for chiropractic services. Most require the first diagnosis code to be selected from category 739 Nonallopathic lesions, not elsewhere classified. The ICD-9-CM definition of this code has long been a source of frustration to chiropractic coders because the documented phrase used by chiropractic physicians is usually “vertebral subluxation.” The fine print in ICD-9-CM explains that category 739 can include “segmental or somatic dysfunction.” But throughout ICD-9-CM, the term “subluxation” is used to describe a “partial dislocation,” which is not how the term is defined by many chiropractors. Medicare, by contrast, defines subluxation reasonably well on behalf of the chiropractic profession. Per the Medicare Learning Network Chiropractic Services booklet, page 7:
“A motion segment, in which alignment, movement integrity and/or physiological function of the spine are altered although contact between joint surfaces remains intact. For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically.”
Put more simply, subluxation is a condition of minor, sometimes painful, misalignment that is treatable by manipulation.
ICD-9-CM has never provided a code that differentiates between the chiropractic subluxation and the allopathic subluxation. Chiropractors have been compelled to try to fit a square peg into a round hole for many years. With its expanded detail, ICD-10-CM looks like a chiropractic coder’s dream. At first glance, ICD-10-CM offers a wide range of new possibilities.
If the general equivalence mappings (GEMs) are used as a starting point for this investigation, the commonly used ICD-9-CM code 739.1 Nonallopathic lesions; cervical region may be replaced with M99.01 Biomechanical lesions, segmental and somatic dysfunction of cervical region. This differs little from ICD-9-CM, and still does not use the word “subluxation.” Nearby code M99.11, however, is defined as “Subluxation complex (vertebral) of the cervical region.” This sounds just like the verbiage most chiropractors use, but the GEMs point this code back to 839.00 Closed dislocation, cervical vertebra, unspecified, not 739.1, in ICD-9-CM. Medicare does not allow 839.00.
Another possible replacement for the 739 codes can be found in chapter 19 (Injuries) of ICD-10-CM there are several appealing codes in the S13.11 Subluxation and dislocation of C0/C1 cervical vertebrae category. They are defined as “subluxation of cervical vertebrae.” The new codes provide information about the specific spinal level, whether it’s a subluxation or dislocation, and whether the encounter is the initial or a follow-up visit.
These codes not only use the word “subluxation,” they include detail that chiropractic physicians have never been able to report using ICD-9-CM. Unfortunately, GEMs point these codes back to the 839 category in ICD-9-CM, rather than to the 739 category. This implies that these new codes may be intended for use by allopathic physicians for dislocations, rather than for the chiropractic subluxation. No one has let chiropractic coders know if they should use M99.01, M99.11, S13.11xx, or something else.
Secondary Diagnoses: Use Category I, II, and III
According to the LCD for Arizona, whose MAC is Noridian, the secondary diagnosis selected by chiropractic physicians must come from a list of about 60 choices (see LCD for Chiropractic Services (L24288), the Centers for Medicare & Medicaid Services (CMS) Noridian Administrative Services, Feb. 27, 2012).
These ICD-9-CM codes are separated into three categories: Category I generally requires short-term treatment (approximately 6-12 visits); Category II generally requires moderate term treatment (approximately 12-18 visits); and Category III may require long-term treatment (approximately 18-24 visits). To demonstrate, one cervical diagnosis has been selected from each category to investigate. Chiropractic is primarily concerned with disorders of the musculoskeletal and nervous systems; therefore, the old and new codes come from those respective chapters in ICD-9-CM and ICD-10-CM.
There are 16 ICD-9-CM codes listed in this first category. One of the most commonly used is 723.1 Cervicalgia, or neck pain, which is not a very specific code. This is probably why it is considered “short term” in the LCD. GEMs, which only give approximations, suggest M54.2 Cervicalgia as the ICD-10-CM equivalent. This new code has the same definition, and seems like a straightforward one-to-one map.
There are a few details to consider, however. In ICD-9-CM, this code excludes conditions due to intervertebral disc disorders. Those are coded using the 722 Intervertebral disc disorders series, which are Category III codes. In other words, if the GEMs hold true and this specific diagnosis applies, a Category III code should be used instead because Medicare recognizes this type of neck pain may require longer-term treatment.
There is another lesson here. Code M54.2 in ICD-10-CM has an “Excludes1” note regarding cervicalgia due to intervertebral disc disorders (in M50.xx). “Excludes1” is a new convention in ICD-10-CM that tells us these two codes may not be used together, ever. If it were an “Excludes2,” the two conditions can co-exist, but both must be coded to adequately report the situation.
These codes may require a moderate term of treatment. A commonly used code from this list of 36 codes is 847.0 Sprain of neck. The GEMs point to two ICD-10-CM codes in this instance: S13.4xxA Sprain of ligaments of the cervical spine, initial encounter and S13.8xxA Sprain of joints and ligaments of other parts of the neck, initial encounter. The difference is the first code lists three specific ligaments, as well as whiplash injury. The other code covers anything else in the neck. ICD-10-CM provides payers with a little more detail because there is now more than one code to describe this condition. Medicare may likely replace the ICD-9-CM code with both of these ICD-10-CM codes; however, they may only choose to cover the first code. That is just part of the mystery.
There are a couple of ICD-10-CM coding convention lessons here, as well. The new codes contain seven characters, but the fifth and sixth are “x” because they are placeholders. They don’t add meaning to the code; they simply make sure the seventh character stays in the seventh position, where it’s supposed to be.
The seventh character here could be “A” for initial encounter, “D” for subsequent encounter, or “S” for sequela. As such, there are actually six possible codes. This ability to report on the status of the encounter is new in ICD-10-CM, and may be found on several codes that chiropractic physicians may use. The code will end with the letter “A” on the first visit and “D” for follow-up. You would use “S” only if the condition has technically resolved, but the patient is still experiencing problems a long time later.
Medicare may not approve of sequela codes because they fit better with its definition of “maintenance care.”
There are only a dozen codes to choose from in this section, and they are the most serious. Patients with these conditions may require long-term treatment, per many Medicare LCDs. A commonly used ICD-9-CM code from this section is 722.4 Degeneration of a cervical intervertebral disc, which also includes the “cervicothoracic” region.
As an equivalent to this code, GEMs lead us to M50.30 Other cervical disc degeneration, unspecified cervical region. This is another example of how GEMs point the coder in the right direction, but do not take him or her all the way to the end of the journey. M50.30 is an “unspecified” code. One reason that ICD-10-CM exists is to keep providers from using unspecified codes. M50.31 Other cervical disc degeneration, occipito-atlanto-axial region specifies the occipito-atlanto-axial region; M50.32 Other cervical disc degeneration, mid-cervical region specifies the mid-cervical region; and M50.33 Other cervical disc degeneration, cervicothoracic region specifies the cervicothoracic region.
It would be great if GEMs simply provided the code that will be approved when ICD-10-CM is finally implemented, but in this example, the result is an unspecified code. It’s likely Medicare will not cover M50.30. It’s reasonable to guess the other three specified codes (M50.31, M50.32, and M50.33) will appear as part of an updated LCD when ICD-10-CM arrives, and providers will have to indicate that level of detail in their documentation, which was not necessary previously.
Stay Tuned as ICD-10-CM Approaches
Because 95 percent of the ICD-10-CM codes do not map one-to-one, the new list will look very different. Selection of the correct codes will depend on the payer, not GEMs. Payers will have to rewrite their guidelines around the new codes. For now, coders and providers must simply do their best to get familiar with the new system and make calculated guesses.
Chirocode. 2011. Complete & Easy ICD-10 Coding For Chiropractic, First Edition
Noridian, Medicare LCD for Arizona, L24288, Chiropractic
Medicare Learning Network, October 2011. Chiropractic Services (ICN 906143)
Evan M. Gwilliam, DC, CPC, NCICS, CCPC, CCCPC, is the director of education and consulting for the ChiroCode Institute. He teaches seminars around the country on behalf of Cross Country Education and Target Coding, serves on the editorial board of ICD10Monitor.com, and he will be speaking on ICD-10 at the American Chiropractic Association’s National Legislative Conference this year. You can see Dr. Gwilliam at the “Anatomy Expo” and hear him speak at the AAPC National Conference in April on “Coding Secrets in Physical Medicine.” Dr. Gwilliam can be reached at DrG@ChiroCode.com.
April 1st, 2013
By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO
To ensure high quality patient care and proper reimbursement, and to help protect you from audits, evaluation and management (E/M) documentation must meet or exceed complex requirements for every encounter. When it comes to determining medical necessity—the overarching criterion for payment—for E/M services, one area of provider documentation that is typically deficient is the history of present illness (HPI).
Documentation of the history element of an E/M service tells a story about an illness, and how it has affected a patient. The story must have a beginning, some development, and an ending to adequately describe the E/M of the patient’s presenting problem(s). To help you meet documentation requirements, specifically relating to the history component, let’s take a closer look at the requirements, as laid out by the Centers for Medicare & Medicaid Services (CMS):
- Every encounter must have a chief complaint. It can be separate from the HPI and review of systems (ROS), or it can be part of the HPI or ROS; but it must make the reason for the visit obvious.
- The chief complaint is the patient’s presenting problem. “Follow-up” is not a chief complaint.
- If the patient doesn’t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service.
- Every encounter must have a minimum of one HPI or the status of at least one chronic illness. The provider must describe the problem (how bad it is, how long it has been going on, etc.)
- Visits that will be billed at a high level E/M (level IV or V, for most categories) must have at least four HPI documented, or the status of three or more chronic illnesses. The problem has to be serious enough to justify a higher level of service, and the medical record must reflect this.
- HPI may be documented by the performing provider ONLY. Copying the nurse’s notes does not count.
- ROS is the patient’s positive and negative responses about his or her experiences with symptoms. ROS is the patient’s observations, not those of the provider.
- ROS and past, family, social history (PFSH) may be recorded by someone other than the provider (e.g., ancillary staff, the patient), as long as the provider references the information in his or her own notes.
There are a lot of nuances to understanding the different elements of HPI. Some, such as location and severity, are pretty straightforward. Others, such as timing and context, can be more difficult to spot. To help you understand this better, be sure to read the May 2013 issue of Cutting Edge, where we will cover this topic in depth.
March 20th, 2013