Coding & Alan L. Plummer, MD Editor

Transcription

1 Coding & Billing Quarterly march 2014 EDITOR ALAN L. PLUMMER, MD ATS RUC Advisor ADVISORY BOARD MEMBERS: KATINA NICOLACAKIS, MD Chair, ATS Clinical Practice Committee ATS Alternate RUC Advisor STEPHEN P. HOFFMANN, MD ATS CPT Advisor MICHAEL NELSON, MD ATS Alternate CPT Advisor STEVE G. PETERS, MD In This Issue will require a higher level of documentation, page 2 Q&A Transesophageal Echocardiography, page 3 CMS Delays Implementation of the Two Midnight Rule, page 4 How to for the Provision of Positive Pressure Therapy, page 5 Letter from the Editor What a different a day (or two) can make. When I first drafted this article in mid-march it looked favorable that Congress would pass legislation that permanently repealed SGR. Even as late as March 25th, a permanent repeal of SGR seemed a real possibility. Two days later, in one fell swoop, SGR repeal is dead (for the short-term); ICD-10 has been delayed for another year; the two midnight rule has been further delayed and a 1-year SGR freeze has been passed by Congress. I imagine the reaction in the physician community to the sum total of this news will be decidedly mixed. Real disappointment over the inability of Congress to fix the flawed SGR formula is probably tempered (slightly) with a small sigh of relief that at least the 24% cut is delayed, again, for the 17th time (but who is counting!). Early adopters of ICD-10 are probably very angry (it would be inappropriate to use a stronger, more accurate word in a newsletter) that the time, cost and training they have invested to prepare for ICD-10 has been wasted, while those still in the midst of the ICD-10 transition are probably overjoyed with the delay. My own small personal travesty with ICD-10 delay is that this edition of the ATS Coding and was largely dedicated to ICD-10 transition, providing crosswalks from ICD-9 to ICD-10 for common pulmonary and critical care diagnosis. Subsequent issues of this newsletter were going to be dedicated to additional pulmonary diagnoses and sleep crosswalks. We will run that article anyway, hoping that the information will be useful as the planning for should be continued until October 1, 2015 when it likely will become law. This issue also answers questions on positive pressure billing, transesophageal echocardiography billing, and provides information on the delay in implementation of the two midnight rule. As I wrap up this article I must say I am angry. Angry that Congress can t fix SGR. Angry on behalf of my colleagues who invested time, energy and significant money into the ICD-10 transition, but feel relief for the physician community which would have been burdened with the increased documentation, time and problems using the new codes. Angry that Congress seems to think looming payment cuts and variable implementation deadlines is an acceptable way run a massive health program like Medicare. The physician community and our Medicare patients deserve better from Congress. Sincerely, Alan L. Plummer, MD Editor 1

2 WILL REQUIRE A HIGHER LEVEL OF DOCUMENTATION. Since January s CBQ, the Centers for Medicare and Medicaid Services (CMS) has confirmed the October 1st compliance deadline will not be delayed. CMS aims to expand data capture with. With better data, CMS hopes to improve quality measurements, achieve better analysis of disease patterns, and identify fraud and abuse more easily. Also, is designed with better capability for expansion. In order to improve data capture, will emphasize specificity. CMS may not pay if the code is not specific. This will require excellent documentation. A component of excellent documentation is being fastidious when describing the disease or disorder. As a rule there are several documentation themes that need to be addressed and we will discuss these below. We also will give specific examples of common Pulmonary and Critical Care Diagnoses with the new ICD-10 CM s. Blue Cross of Michigan has said, Physicians may be ICD-10 compliant, but if they abuse the other or unspecified codes, payment will not occur if a more specific alternative exists. Anatomy is the primary axis of classification for ICD-10 CM. Documentation of specific anatomy including laterality when appropriate is essential. All documentation including E & M and procedure notes will need to include this specificity. Disease acuity must also be specified as acute or chronic in order to identify the severity of illness. If this is not specified, for acute bronchitis for example, it will default to chronic bronchitis. Next, supporting laboratory values must be documented, such as abnormal sputum and blood cultures including specific pathogens when possible. Documentation also needs to include the associated or underlying conditions as well as common manifestations associated with the disease or condition. Additionally, ICD-10 CM allows for documentation and measurement of the effect of outside influences such as tobacco and other toxins and their impact on disease. Therefore, tobacco exposures must always be documented along with the primary disease process. Some specific examples are shown here: Respiratory Failure The acuity of respiratory failure (acute, chronic, or acute on chronic) will need to be specified. One will need to differentiate respiratory failure from ARDS and post-procedural respiratory failure. Also, the presence of hypoxia and/or hypercapnia- will need to be documented. Any related tobacco use and exposure will need to be specified. Below is a table with some ICD-10- CM codes to illustrate the code structure. Sepsis The cause of sepsis will need to be documented. Erase urosepsis from your vocabulary. It did not exist in ICD-9 and will not exist in ICD-10. If circulatory failure is due to sepsis, state septic shock. One will need to state if sepsis started before or after admission. You will need to describe evidence of organ dysfunction when diagnosing severe sepsis. J96.0 Acute respiratory failure (4th character required)(check 5th) J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.1 Chronic respiratory failure (4th character required) (check 5th) J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.11 Chronic respiratory failure with hypoxia J96.12 Chronic respiratory failure with hypercapnia J96.2 Acute and Chronic respiratory failure (4th character required) (check 5th) J96.20 Acute and Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.21 Acute and Chronic respiratory failure with hypoxia J96.22 Acute and Chronic respiratory failure with hypercapnia J96.9 Respiratory failure, unspecified (4th character required) (check 5th) J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia continued on page 3 2

3 continued from page 2 Obesity The cause of the obesity will need to be documented: excess calories, drug induced obesity, etc. Avoid compliance queries by only listing morbid obesity for BMI s greater than 40. You should indicate the body mass index, especially if it is greater than 40. If alveolar hypoventilation is present, document it. Asthma E66.0 Obesity due to excess calories E66.01 Morbid (severe) obesity due to excess calories E66.09 Other Obesity due to excess calories E66.1 Drug-induced obesity (Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5) E66.2 Morbid (severe) obesity due to excess calories with alveolar hypoventilation E66.3 Overweight E66.8 Other obesity E66.9 Obesity, unspecified Using ICD-9, the various forms of asthma (chronic obstructive, cough variant, exercise induced bronchospasm, extrinsic, intrinsic, unspecified) and the complications (acute exacerbation, status asthmaticus, unspecified) were sufficient. mandates describing the severity (mild intermittent, mild persistent, moderate persistent, and severe persistent) in addition to the form and the complications. In, extrinsic allergic replaces extrinsic and intrinsic nonallergic replaces intrinsic. Also, idiosyncratic is added as a form of asthma. J45.2 Mild intermittent asthma J4520 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma, with (acute) exacerbation J45.22 Mild intermittent asthma, with status asthmaticus J45.3 Mild persistent asthma J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma, with (acute) exacerbation J45.32 Mild persistent asthma, with status asthmaticus J45.4 Moderate persistent asthma J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma, with (acute) exacerbation J45.42 Moderate persistent asthma, with status asthmaticus J45.5 Severe persistent asthma J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma, with (acute) exacerbation J45.52 Severe persistent asthma, with status asthmaticus J45.90 Unspecified asthma J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Unspecified asthma uncomplicated J45.99 Other asthma J Exercise induced bronchospasm J Cough variant asthma J Other asthma continued on page 4 Q&A Transesophageal Echocardiography Q. Can a physician bill CPT Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis, with one of the critical care codes, when performed by the same physician on the same date of service? A. This issue has come into question in light of the development of transesophageal monitoring probes that can remain in the critically ill patient for many days. The answer is yes for the date of insertion but continued billing on subsequent days would not be appropriate. This is similar to the rule for CPT code Insertion and placement of flow directed catheter (e.g. Swan-Ganz) for monitoring purposes. As there is a Medicare National Correct Coding Initiative (NCCI) edit in place effective July 1, 2014, when billing one of the critical care codes , append the modifier 25 to inform Medicare an insertion was performed when billing on the same date of service by the same physician. 3

4 continued from page 3 Glasgow Coma Scale (GCS) The GCS is not reported in ICD-9. It is reportable in ICD-10- CM. Along with describing the components of the score, the setting where the score was obtained should also be described (in the field, upon ER arrival, upon admission, 24 hours or more after admission). Pulmonary Embolism R40.24 Glasgow coma scale, total score R Glasgow coma scale score R Glasgow coma scale score 9-12 R Glasgow coma scale score 3-8 R Other coma, without documented Glasgow coma scale score or with partial score reported In ICD-9-CM, only the type (iatrogenic, saddle, other) was described. In, you will need to describe whether or not cor is present. In, post- operative or post-procedural PE is reported as a vascular complication. I26.0 Pulmonary embolism with acute cor I26.01 Septic pulmonary embolism with acute cor I26.02 Saddle embolus of pulmonary artery with acute cor I26.09 Other pulmonary embolism with acute cor I26.9 Pulmonary embolism without acute cor I26.90 Septic pulmonary embolism without acute cor I26.92 Saddle embolus of pulmonary artery without acute cor I26.99 Other pulmonary embolism without acute cor These are only a few of the many increases in documentation which will be necessary when the use of is mandated, October 1, More information will be forthcoming in the June and September issues of CBQ. CMS DELAYS IMPLEMENTATION OF THE TWO MIDNIGHT RULE In January, the Centers for Medicare and Medicaid Services (CMS) posted notice that it will delay until October 2014 implementation of the hospital two midnight rule. The two midnight rule refers to policy that CMS issued in 2013 stating that any hospital stay of less than two midnights must be treated and billed as an outpatient hospital visit. The two midnight rule has been strongly opposed by the hospital and physician community and if implemented as proposed would undermine physician clinical judgment and expose Medicare beneficiaries to significantly greater financial liability. The policy has generated so much concern that legislation has been introduced in Congress (H.R. 2698/S.2082 the Two Midnight Stay Rule Delay Act) to delay implementation of the rule. Additionally, the rule would require CMS to seek public input and provide regulatory compliance guidance before implementing the two midnight hospital stay rule. While the two midnight stay rule is still the official policy of CMS, the delay will give providers and CMS more time to address concerns with the policy, its impact on patient care, and provide regulatory guidance and educational materials to assist hospitals in complying with this policy. For more information on CMS two midnight stay rule, please visit the CMS website at: Statistics-Data-and-Systems/Monitoring-Programs/ Medicare-FFS-Compliance-Programs/Medical-Review/ InpatientHospitalReviews.html 4

5 HOW TO CODE FOR THE PROVISION OF POSITIVE PRESSURE THERAPY When managing positive airway pressure (PAP) therapy, confusion can arise whether it is appropriate to report code 94660, Continuous positive airway pressure ventilation (CPAP), initiation and management. Noninvasive, continuous positive airway pressure (CPAP) therapy or bi-level positive airway pressure (BPAP) is commonly prescribed for the treatment of obstructive sleep apnea. Less frequently, these forms of positive airway pressure therapy may also be used to treat other forms of sleep disordered breathing. In addition, other forms of positive airway pressure therapy are available, such as auto-titrating positive airway pressure and adaptive servo ventilation for patients diagnosed with complex sleep apnea. All such positive airway pressure therapies may be delivered through a variety of mask interfaces including: nasal only circuit, a nasal mask circuit, an oro-nasal mask or full face mask, which are all tightly fitted to reduce air leaks describes the initiation or the subsequent management of all these forms of PAP therapy. Although it was initially used to describe the institution of positive airway pressure therapy in the ICU, in recent years, a rise in reporting of code has paralleled the increased diagnosis of sleep disordered breathing, the variation in forms of NIPPV, and the proliferation of device types. PAP therapy is distinct from airway pressure therapy delivered through an endotracheal tube in mechanically ventilated patients. Positive airway pressure can be delivered through endotracheal tube or non-invasively with the use of a mask interface. For management of mechanically ventilated patients, use codes or an appropriate evaluation and management service, such as a hospital or critical care code includes reviewing medical history, performing a physical examination, and reviewing diagnostic test results, all focused on the management of airway positive pressure therapy and the underlying disorder. Discussions with the patient may include various device options and masks available, prior experiences with airway positive pressure devices, desensitization therapy to manage side effects such as claustrophobia or facial lesions, ordering durable medical equipment (DME), and addressing any related health care needs. A chart note to document the service is included in code Positive Pressure Therapy Frequently Asked Questions Can I report code for an inpatient? Or a nursing home patient? Yes, since code has no site of service restrictions. Can I report both an evaluation and management code ( ) and code on the same day? No, since code is bundled into every evaluation and management code ( ), including critical and intensive care codes ( , ). Can I report an evaluation and management code ( ) instead of code 94660? Yes. Certainly if addressing other issues or diagnoses besides sleep apnea in the same patient encounter, an evaluation and management service may be a more appropriate code to select. However, even if only instructing a patient on CPAP initiation, an evaluation and management code (at the proper code level, based upon the Documentation Guidelines) can be appropriate to select. Also, remember an evaluation and management code may be selected in this circumstance based on time spent counseling the patient and coordinating their care for sleep disordered breathing. Can an advanced practice provider report code 94660? As long as such services remain within their state regulated scope of practice, an advanced practice provider may report code Can my clinical practice staff (such as a registered nurse or respiratory therapist) provide this service under my supervision? Assuming such services remain within their state regulated scope of practice, clinical practice staff may report code under the incident to regulations in the physician office setting. However, in the facility setting, clinical practice staff cannot provide this service under your supervision since the split/ shared regulations do not apply to procedures such as code 94660, and only apply to advanced practice providers. References Manaker, S., and Pohlig, C.A. Editors. Coding for Chest Medicine 2013: Pulmonary, Critical Care, Sleep, American College of Chest Physicians, Northbrook, McCarthy C, O Rourke NC, Madison, JM. Integrating advanced practice providers into medical critical care teams. Chest 2013;143(3): Lewarski JS, Gay PC. Current issues in home mechanical ventilation. Chest 2007;132(2):