Coding & Alan L. Plummer, MD Editor

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1 Coding & Billing Quarterly july 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 FDA Proposes to Regulate All Tobacco Products, page 1 CMS updates two-midnight guidance to reflect extension of enforcement delay, page 2 ICD-10-CM: The Obstructive Lung Diseases, page 3 Medicare Severity & All Patient Refined DRG s: The Keys to Your Profile, page 4 ATS Talks to CMS on CT Scans for Lung Cancer, page 5 Letter from the Editor The July issue of the ATS Coding and will take a small departure and cover ground not directly related to medical coding, billing and regulatory compliance. In this issue we will briefly cover FDA s proposed rule to regulate all tobacco products. Because of the severe impact tobacco has on the patients pulmonary and critical care physicians treat, I thought it would be appropriate to review what s in the FDA s proposed rule, what s not in the rule (but should be!) and what happens next. We will be returning to more familiar ground with the other articles in the July issue. There is a brief update on CMS s two midnight policy. Also we will provide information on how coding for obstructive lung diseases will change under ICD-10 and information on how physician profiling under Medicare Severity DRGs and All Patient Refined DRGs will likely impact physician reimbursement. We will also provide a quick update on where things are in CMS s decision making process on Medicare coverage of CT screening for lung cancer. We will also answer members questions on coding and billing. If you have a question about coding, billing or regulatory compliance in the pulmonary, critical or sleep medicine, please feel free to send it to CodingQuestions@thoracic.org. Our experts will respond to your questions. Sincerely, Alan L. Plummer, MD Editor FDA PROPOSES TO REGULATE ALL TOBACCO PRODUCTS In 2009, Congress passed and the President signed the Family Smoking Prevention and Tobacco Control Act. The legislation immediately established FDA s authority to regulate all cigarettes and directed the FDA to take action on cigarettes including requiring graphic warning labels, advertising restrictions, disclosure of ingredients and a ban on candy flavored cigarettes. The legislation also gave FDA authority to regulate other types of tobacco products, but did not set a timeline for this. After 5 years of waiting, the Food and Drug Administration has finally issued proposed rules to extend their regulatory authority over all tobacco products, including cigars and e-cigarettes. The proposed rule is notable both for the regulatory actions the FDA is proposing, and for the actions the FDA is not taking. continued on page 2 1

2 continued from page 1 FDA s proposals The proposed rule would establish important basic regulatory authority over all tobacco products including: Prohibition of the sales of tobacco products to anyone under the age of 18 Prohibition of vending machine sales (except in places where only adults have access) Registration by all manufactures with FDA, including a list of all tobacco products they sell Disclosure of ingredients by manufacturers to FDA Elimination of free sampling of all tobacco products Safe and reliable manufacturing practices Premarket review for any new tobacco product Premarket review of any product wishing to make a modified risk or harm claim Collecting user fees for all newly regulated tobacco products The ATS supports the above regulatory actions as important next steps to provide effective regulatory oversight over all tobacco products. Where FDA Does Not Propose Action The proposed rule is also notable for what it does not address. The rule would not ban TV or radio advertising for newly deemed products. Based on legislation passed in the 1970s, cigarettes are banned from TV and radio advertising. E-cigarettes are not covered under the ban and some e-cigarette companies have advertised on TV. The proposed rule also does not ban cigars and e-cigarette companies from sponsoring concerts, sports events or other cultural events. Cigarette companies are prohibited from such event sponsorship. The proposed rule would also allow cigars and e-cigarette manufacturers to brand non-tobacco related products (T-shirts, hats etc). In the past, the cigarette industry has used branding of non-tobacco related products to successfully advertise their product to youth. While the FDA certainly discussed the issue in the proposed rule, it did not propose to ban candy flavored cigars or e-cigarettes. FDA is seeking comments on what action, if any, they should take on candy flavored tobacco products. FDA also did not propose to require child proof packaging for e-cigarette cartridges. With the reported rise in poison control calls concerning nicotine poisoning from e-cigarette products, the ATS finds FDA s silence in this area troubling. FDA is also seeking public comments on whether premium cigars should be exempt from regulation. While the FDA has proposed a more extensive definition, the exemption would apply to large hand-rolled cigars that do not have a characterizing flavor other than tobacco. The ATS Response The American Thoracic Society has been waiting for the FDA proposed rule for over five years. While we are pleased that the rule is finally out and the process can move forward, we are disappointed that FDA has not proposed more aggressive regulations of all tobacco products. The ATS will support the initial steps the FDA has proposed, while urging the FDA to take further actions. The ATS is particularly concerned that the FDA is considering exempting premium cigars from any regulation, allowing TV and radio ads for certain tobacco products, and taking no action on candy-flavored cigars and e-cigarettes. These are significant flaws and the ATS intends to make a strong case during the public comment period for why FDA should take more aggressive action in these areas. ATS Member Response The public comment period of FDA s proposed rule closes July 9th. To date, over 10,000 individuals have commented on the proposed rule, with the majority urging FDA to exempt premium cigars or take minimal steps on e-cigarette regulations. ATS members are encouraged to submit comments in support of strong regulations on tobacco control. ATS members can submit comments to FDA at: gov/#!documentdetail;d=fda-2014-n CMS updates two-midnight guidance to reflect extension of enforcement delay The Centers for Medicare & Medicaid Services updated its twomidnight guidance to reflect changes required by the Protecting Access to Medicare Act of Specifically, CMS indicates that medical review activities under the Medicare Administrative Contractor Probe & Educate process will be extended through March 31, In addition, CMS said it will prohibit recovery auditors from conducting inpatient hospital patient status reviews on claims with dates of admission between Oct. 1, 2013 and March 31, While CMS has delayed enforcement of these rules, CMS has not rescinded the guidance and interpretations. CMS published on June 13, 2014 a YouTube video of the January 14, 2014 National Provider Call which outlines the current CMS guidance regarding the two-midnight rule. That video can be viewed at 2

3 ICD-10-CM: THE OBSTRUCTIVE LUNG DISEASES ICD-10-CM was scheduled to be the classification system used by US physicians beginning October 1, However, to avoid a disastrous drop in 2014 Medicare payments to physicians from SGR, Congress not only delayed a fix to the SGR in March, but also delayed the initiation of ICD-10-CM to October 1, This was confirmed by CMS on May 1, This article will continue a series of articles in the CBQ until October 2015 discussing ICD-10-CM coding for pulmonary diseases. This article will discuss coding for many of the obstructive lung diseases except for asthma, which was discussed in the March issue of CBQ. Table 1: Coding for Obstructive Lung Diseases ICD-9-CM: Simple chronic bronchitis Mucopurulent chronic bronchitis Obstructive chronic bronchitis without exacerbation Obstructive chronic bronchitis with exacerbation Obstructive chronic bronchitis with acute bronchitis 496 Chronic airway obstruction, not elsewhere classified Emphysematous bleb Other emphysema (includes centrilobular, panlobular, unilateral) ICD-10-CM: J41.0 Simple chronic bronchitis J41.1 Mucopurulent chronic bronchitis J41.8 Mixed simple and mucopurulent chronic bronchitis J44 Other chronic obstructive pulmonary disease (includes emphysema) J44.0 Chronic obstructive bronchitis with acute bronchitis J44.1 Chronic obstructive bronchitis with acute exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J43 Emphysema J43.0 Unilateral pulmonary emphysema (McLeod s syndrome) J43.1 Panlobular emphysema J43.2 Centrilobular emphysema J43.8 Other emphysema J43.9 Emphysema, unspecified The ICD-9-CM and ICD-10-CM codes for many of the obstructive diseases are listed in Table 1. There will be a direct cross-walk from ICD-9-CM to ICD-10-CM for the non-obstructive bronchitis codes. A new code, J41.8, mixed simple and purulent chronic bronchitis has been added. The obstructive bronchitis codes have been renamed chronic obstructive pulmonary disease (COPD). Currently, stable obstructive bronchitis (which includes emphysema) is With an exacerbation or acute bronchitis, the fifth digit becomes 1 or 2, respectively. The comparable codes for ICD-10-CM would be J44 for the stable state, J44.0 for COPD with acute bronchitis and J44.1 for an exacerbation of COPD. Another change will be that there is no code for chronic obstructive asthma or asthmatic bronchitis, 493.2x. Instead you will need to use J44.9, COPD, unspecified. In the patient with COPD and asthma, you will need an additional asthma code describing the severity of asthma (J45.2-J45.5) for proper coding. Including one of the asthma codes under COPD will only serve to blur the distinction between the two diseases, which does not occur with ICD-9-CM. Additionally, you will need to code for tobacco use, Z72.0, for a history of tobacco use; Z87.89 for those who have stopped smoking; or F17.2x for those who cannot quit smoking. For proper coding with ICD-10-CM, you will need two codes for chronic bronchitis with or without emphysema. For patients with airflow limitation without an obvious etiology, you would use J44.9 in ICD-10-CM instead of 496 (using this ICD-9 code excludes chronic bronchitis with or without emphysema). For emphysema without chronic bronchitis or airflow limitation, there are six emphysema codes in ICD-10-CM instead of the two emphysema codes in ICD-9-CM (Table 1). If you have chest CT evidence for panlobular or centrilobular emphysema you would code J43.1 for the former and J43.2 for the latter instead of If the patient has paraseptal emphysema, you should use J43.8, other emphysema. If the patient has centrilobular and paraseptal emphysema, use J43.1 and J43.8. If the patient is a current or former smoker, a tobacco use code listed above (Z72.0, Z87.89 or F17.2x) should also be used. Thus, to use ICD-10-CM coding for emphysema, you most likely will need two codes. However, if the patient has unilateral emphysema, you would need only one code, J43.0, provided the patient had no history of tobacco use. Thus the documentation for chronic bronchitis and emphysema will be more complicated after October 1, The coding for bronchiectasis in ICD-10-CM has been expanded by two codes (Table 2). In ICD-9-CM, there are continued on page 4 3

4 continued from page 3 Table 2: Coding for Bronchiectasis ICD-9-CM: Bronchiectasis without acute exacerbation Bronchiectasis with acute exacerbation Congenital bronchiectasis Bronchiectasis secondary to tuberculosis ICD-10-CM: J47 Bronchiectasis J47.0 Bronchiectasis with acute bronchitis J47.1 Bronchiectasis with acute exacerbation J47.9 Bronchiectasis, uncomplicated Q33.4 Congenital bronchiectasis A15.0 Bronchiectasis secondary to tuberculosis only two codes, for stable bronchiectasis and for bronchiectasis with an acute exacerbation or infection. In ICD-10-CM two new codes, J47.0, bronchiectasis with acute bronchitis and J47.9, bronchiectasis, uncomplicated, have been added. Using ICD-10-CM, stable bronchiectasis will be coded as J47 whereas bronchiectasis with an acute infection will be coded J47.0 and bronchiectasis with an exacerbation will be coded J47.1. There will be a 1:1 cross-walk for congenital bronchiectasis, to Q33.4, and bronchiectasis due to tuberculosis, to A15.0. Again, if the patient is or has been a smoker, the tobacco use codes should also be used (see above). Coding of the obstructive lung diseases with ICD-10-CM will require expanded documentation particularly with the tobacco use codes and if the patient has emphysema without airflow limitation. In general the documentation requirements for pulmonary physicians will increase when ICD-10-CM is instituted. MEDICARE SEVERITY & ALL PATIENT REFINED DRG S: THE KEYS TO YOUR PROFILE David C. Law, MD, FCCP Medical Director, Respiratory Care Saddleback Memorial Medical Center Board Chair, Physician Society MemorialCare Health System We all know the importance of documenting the appropriate CPT code. It drives how we are reimbursed. What many physicians are unaware of, however, is the importance of two other metrics: the Medicare Severity DRG (MS-DRG) and the All Patient Refined DRG- (APR-DRG). We have always thought that these codes apply only to the hospital, but it has become clear that these DRGs have a direct impact on our profiles which are becoming more and more transparent. In the future, they also may define how we will be paid, if we will be paid, and how much we may have to pay back. This has become clear given the bundled payment models that have been proposed. MS-DRG: It is assigned to every patient based on the principal reason for admission. That DRG is then reassigned according to the documentation of all the secondary diagnoses present. These are categorized as CCs (co-morbid / complications) or MCCs (Major co- morbid / complications). This DRG system classifies patients into clinically cohesive groups that demonstrate similar consumption of hospital resources and length-of- stay patterns. There are generally three levels to most DRGs that are determined by the documentation of the co-morbid/complications.* Each level is assigned a geometric mean length of stay (GMLOS) and a relative weight (RW) which is the surrogate for resource consumption. For example: DRG GMLOS RW COPD without CC/MCC COPD (i.e. COPD with with CC acute renal failure) COPD (i.e. COPD with with MCC acute resp. failure) Here s how it works, the more specific the secondary diagnoses are documented (using Medicare desired language), the more time (i.e. GMLOS) you are given to care for the patient and the higher the RW (relative weight). This is intended to reflect the relative resource consumption associated with each DRG. continued on page 5 4

5 continued from page 4 Each hospital is assigned a base rate that is then multiplied by the RW to obtain a payment for that stay. Let s say a hospitals base rate is $10,000. If you document only COPD without a CC/MCC the hospital receives $10,000 x.7120 = $7,120 for that patient. On the other hand, if you documented acute respiratory failure the hospital receives $10,000 x = $11,708. The importance to you is the following: 1. You want to help the hospital keep the doors open. It s where you work! 2. Lower reimbursement may mean fewer nurses to take care of your patients. 3. You would like to have that new Arctic Sun unit for the ICU, a second DaVinci, etc. 4. If you are participating in one of the bundled payment models you want to ensure that the bundle is optimized so that your portion will be appropriate. But there s more! Although the MS-DRGs describe the complexity of disease and resource consumption, they say nothing about the risk of mortality and severity of the illness. Enter APR-DRGs: All Patient Refined Diagnostic Groups. This is a system devised by 3M which categorizes patients into 4 levels for both risk of mortality and severity of illness. Level 1 = Minor Level 2 = Moderate Level 3 = Major Level 4 = Extreme Again, these are based on your documentation of comorbidities. The more specific the documentation is, the higher the severity or risk of mortality. The documentation includes the patient s age, nutrition status, procedures, sex, discharge disposition as well as all secondary diagnoses. We are in a period of transparency with our metrics going out to CMS, Physician Compare, Healthgrades, Leapfrog, all third party payers, etc. These include 30 day readmissions, LOS, mortality, and complications. These metrics depend on expected outcomes as the denominators and our data as the numerator. If we fail to capture the comorbidities, our own data will not truly reflect the severity of the patients for which we care. The Clinical Documentation Specialists at your facility may be your most valuable consultants. Make it a point to get to know them *Primarily, these should be co-morbidities. ATS TALKS TO CMS ON CT SCANS FOR LUNG CANCER In June, the ATS joined sister organizations on a meeting with CMS staff to discuss Medicare coverage for low dose CT scans for lung cancer screening. The goal of the meeting was to express the ATS s support for Medicare coverage of low dose CT lung cancer screening in well-defined at risk populations under Medicare. CT lung cancer screening has recently gained significant attention as two federally convened advisory boards came to different conclusions about CT lung cancer scans. In December 2013, the US Preventative Services Taskforce (USPSTF) a panel of non-federal independent experts convened by Agency for Healthcare Quality and Research to provide recommendations on preventative services gave low dose CT scans for lung cancer screening in high risk populations a B grade. Under the Affordable Care Act, any preventive service that gets an A or B grade from the USPSTF must be covered by private health insurance companies at no cost to consumers. Medicare is not required to follow USPSTF recommendations and has a separate coverage review process. In April of 2014, the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) recommended against low dose CT scans for lung cancer screening in high risk populations for the Medicare program. While CMS is not bound by MEDCACs recommendation, it is common for for CMS to follow MEDCACs advice. However, in this case, following MEDCAC s advice will create an awkward coverage situation for CT scans, with high risk patients receiving it free under private insurance plans, but losing coverage for the service when they quality for Medicare. The ATS will continue to work with CMS, through meetings and through the public comment process, to encourage Medicare coverage of CT lung cancer screening in a welldefined at risk population. 5