ICD-10 Monitor’s Talk Ten Tuesday interviews this week included AAPC’s Vice President of ICD-10 Education and Training Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, who discussed physician involvement in ICD-10 training.
“A lot of providers… know that they need to make the transition but they’re overwhelmed with where to start,” Ms. Buckholtz said. “We’ve just opened up our ICD-10 Implementation Tracker tool to the public… to help get these providers ready and give them a sense of where they can actually start on the implementation process.”
Maria Bounos, RN, CPC-H, was also interviewed in the podcast and noted the same concern, saying that a lack of physician cooperation was the primary obstacle to ICD-10 preparation.
“It could lead to one or two years of losses financially for an organization, post-implementation, if they’re not ready,” Ms. Bounos explained.
Listen to the archived podcast.
April 3rd, 2013
In small to midsized practices, failing to educate staff about correct coding may contribute to the practice’s downfall. Medical coding errors can be a huge source of lost revenue. A recent article in Physicians Practice reviews common billing and coding mistakes and offers suggestions on avoiding them. Several AAPC members were interviewed and quoted in the article as experts in the field, including Lynn Anderanin, CPC, CPC-I, COSC; Nancy Enos, CPC, CPMA, CPC-I, CEMC; Raemarie Jimenez, CPC, CPMA, CPPM, CPC-I, CANPC, CRHC; Debra Seyfried, CPC; and Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I.
The solutions offered include:
- Internal auditing
- Dedicating staff to following up on denials
- Verifying patients’ personal and insurance information
- Reviewing how to correctly use modifiers
- Teaching physicians what documentation is needed
- Learning the most recent code changes
Read the full article.
By William C. Fiala, MA, CPC, CCS-P, and Nicholas J. Jouriles, MD, FACEP
Research and reporting going back nearly two decades suggests that hospital inpatients are increasingly sicker, and their care more complicated. Intuitively, this greater inpatient acuity should result in higher emergency department (ED) evaluation and management (E/M) service levels for those patients admitted through the ED. This article examines whether that circumstance exists and, if so, how clinicians and coders can use this information to improve coding and compliance.
Inpatient Acuity Is on the Rise
Studies agree that inpatient acuity has been increasing, whether measured against clinical or coding criteria.
In 1986, three years after the introduction of Medicare’s Inpatient Prospective Payment System (IPPS), Bruce Steinwald and Laura A. Dummit reviewed changes in hospital case mix. The results, published in Health Affairs (“Hospital Case-mix Change: Sicker Patients or DRG Creep?” May 1989, 8:p. 35-47), noted that some of the increase in case-mix acuity was a result of better documentation. The review also distinguished changes resulting from “increases attributable to patient need” or “‘real’ case-mix change.”
In part, the so-called “real” case-mix change was the result of less acute cases moving into the outpatient setting, thus leaving higher case weight (higher acuity) cases in the inpatient setting. Cataract cases provide one example (Health Affairs, May 1989, 8:p. 35-47):
“The shift of less complex cases to outpatient settings is particularly noticeable with the treatment of certain illnesses of the eye in DRG 39 (lens procedures). DRG 39 had a weight of approximately 0.57 in 1986, significantly below the average case weight of approximately 1.21. As these patients were moved to the outpatient settings for ambulatory surgery, the overall average DRG weight for inpatients increased. Medical advances have also led to increased acuity among inpatients. The increase in inpatient acuity has been reflected in the DRG coding.”
In a 1996 survey of registered nurses published in the American Journal of Nursing (AJN) (vol. 96, no. 11, p. 25-39), three-fourths of nurses indicated that the acuity of patients assigned to them had risen. Another study published in 2003 (Medical Care, “Licensed Nurse Staffing and Adverse Outcomes in Hospitals,” 41(1):142-152) similarly indicated that acuity increased 21 percent in Pennsylvania hospitals during 1991-1997, as measured by MedQual severity scores.
Many Inpatients Come from the ED
Many inpatients with increasing acuity come through the ED. An analysis of 2003 data by the Agency for Healthcare Research and Quality (AHQR) supports this, concluding, “65 percent of patients admitted on a weekend were initially seen in hospital emergency departments, compared with 44 percent of weekday-admitted patients” (AHRQ News and Numbers, “Patients Admitted to Hospitals on a Weekend Wait for Major Procedures,” March 4, 2010).
MDM as the E/M Service Level Pointer
For outpatient visits by established patients, as well as subsequent hospital care and other visits with established patients, the selection of the E/M code requires two of three key components—history, exam, and medical decision making (MDM)—under American Medical Association’s (AMA) CPT® guidelines. Many coders interpret the discussion on medical necessity in section 1862(a)(1)(A) of the Social Security Act to mean that MDM must be one of the two key components.
For example, consider an article that appeared recently in the American Academy of Family Physicians (AAFP) Family Practice Management Journal titled “Thinking on Paper: Guidelines for Documenting Medical Decision Making.” Authors Robert Edsall and Kent Moore quote Dr. Pat Price, medical director for Medicare Part B in Kansas and Nebraska, as writing, “It should be the complexity of the medical decision making process and the medical problem which is the most heavily weighted factor in determining the E/M service level.”
The AMA has not taken an explicit stand on this issue. The November 2008 CPT® Assistant indicates that the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are not the AMA’s, but goes on to say:
“…any element of history and examination must be relevant to the care of the patient, not simply serve as documentation to support code selection. Each E/M service states, “evaluation and management of a patient which requires the key components…” [emphasis in original]
This implies history or exam elements should be recorded only to the extent that MDM requires them, which may be another way of saying MDM is always a required key component.
ED E/M codes require three of three key components to assign a service level. Based on the aforementioned information, when you determine the level of service, MDM should be the pointer.
MDM’s Influence on Level of Service
Because acuity among inpatients is increasing, and significant number of inpatients are coming through the ED, you can reasonably expect that ED patients who are admitted should have higher levels of E/M codes assigned, and that the validity of the coding can be tested by looking at MDM. Said differently, the assigned ED E/M code should be at a higher level (99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity or 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)—and if it’s not, MDM should be checked to see if the original code was assigned as a result of error or documentation deficiency.
Put the Numbers to the Test
ED encounters at a 511-bed, 26-bassinet, adult, tertiary-care, not-for-profit, teaching hospital with 56,507 ED visits at its main facility ED were selected from three days in November 2009. Review of the coders’ posting logs identified patients who were admitted.
The facility admitted 16,381 cases from the ED in 2009; the three days’ ED admissions represent approximately 0.8 percent of all 2009 admissions from this department. Coding for those encounters was reviewed using 1995 guidelines supplemented by the Iowa Medical Society form (version 010198). This form has been used by the Ohio State Medical Association (OSMA) for its chart auditing training classes. Certified Professional Coders (CPCs®) completed the initial coding; a certified coder also completed the review.
On the first day examined, 40 patients were admitted. Of those, 37 were initially coded with either 99285 or 99291; 93 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Review coding confirmed the initial coding. Of the three remaining encounters, one was not coded due to a lack of documentation at the time of the review. The remaining two were originally coded 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity, reflecting moderate complexity MDM.
On the second day, 50 patients were admitted. Of those, 31 were assigned either 99285 or 99291; 62 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the 19 remaining encounters, two were not coded at this facility because they were transferred from freestanding EDs to be admitted through the main ED. One was not coded due to a lack of documentation at the time of the review. Among the remaining 16 encounters, 12 had circumstances that pointed to high complexity MDM (see Chart A), but level of service coding was limited due to incomplete review of systems (ROS).
Exam documentation limited the level of service in another encounter, where the circumstances of the encounter pointed towards a higher level of service (see Chart A). Three of the four remaining encounters did not rise above moderate complexity MDM. The last encounter was review coded at 99285, one level higher than initially coded. The original coding for all other encounters was review coded consistent with the initial coding. Adjusting for documentation deficiencies and review coding, 88 percent of admitted patients on day two were (or should have been) coded with either 99285 or 99291 when MDM was used as the pointer to level of service.
On day three, 34 patients were admitted. Of those, 28 were coded with either 99285 or 99291; 82 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the six remaining encounters, two were not coded at this facility because they were transferred in from freestanding EDs, as they could not be admitted through the main ED. On review of the remaining four, one was found to be appropriately coded 99284. Three had circumstances pointing to high complexity MDM (see Chart A), but level of service coding was limited due to an incomplete ROS. Adjusting for documentation deficiencies and review coding, 91 percent of day three’s admitted patients were, or should have been, coded with either 99285 or 99291 when MDM was used as the pointer to level of service.
Use the Correlation to Resolve Documentation Deficiencies
With a 90.3 percent overall rate, the modest sample of encounters reviewed clearly suggests that when MDM points to the level of ED E/M service among patients subsequently admitted to the hospital, that level will be higher. This conclusion is intuitively reasonable, since the studies reporting shows the acuity of admitted patients—measured by both coding and clinical measures—has been increasing.
ED compliance staff may want to examine level of service distributions of treated and released patients separately from those of admitted patients. Although this sample suggests higher levels of ED E/M codes are appropriate for these patients, it does NOT mean all admitted patients should be coded with the higher levels of service. It means clinical staff should be aware of this suggestion and document appropriately, consistent with their facility’s compliance guidelines. Coding staff should also know this, and help clinical staff to resolve documentation deficiencies.
William C. Fiala, MA, CPC, CCS-P, is an instructor for the University of Akron’s Allied Health Department. Beyond the university setting, his company, Fiala Analytical Services, Inc., assists clients with audits and compliance issues.
Nicholas J. Jouriles, MD, FACEP, is an academic emergency physician and is professor and chair of emergency medicine at Northeast Ohio Medical University. Dr. Jouriles is also a past president of ACEP.
Editor’s note: An expanded version of this article, complete with footnoted references, is available by contacting John Verhovshek, MA, CPC, at firstname.lastname@example.org.
April 1st, 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.