CCS Prep CTHIMA September 23, Speakers: Phyllis Hilt, MBA, RHIA Rachael D Andrea, MS, RHIA, CPHQ

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1 CCS Prep CTHIMA September 23, 2013 Speakers: Phyllis Hilt, MBA, RHIA Rachael D Andrea, MS, RHIA, CPHQ

2 CCS Prep Certified Coding Specialist (CCS ) The CCS credential denotes a high standard of competence in coding beyond the entry level certification. Medical coders must be very familiar with the ICD 9 CM coding system and the CPT (Current Procedural Terminology ) coding system's surgery section. Clinical coders must, in addition, be well versed in medical terminology, hospital practices, pharmacology and treatment options in order to translate the information within clinical case notes into medical codes. The CCS certification exam assesses mastery proficiency in coding rather than entry level skills.

3 Agenda 8:00-8:30 Registration 8:30-10:00 CCS Session #1 Introduction; Overview of test Domain #1: Health Information Documentation 10:00-10:15 Break 10:15-12:00 CCS Session #2 Domain #2: Diagnosis Coding, including Coding Clinic 12:00-12:45 Lunch 12:45-1:45 CCS Session #3 Domain #3: Procedure Coding 1:45-2:15 Break 2:15-3:00 CCS Session #4 Domain #4: Regulatory Guidelines and Reporting Requirements for Acute Care Service Domain #5: Regulatory Guidelines and Reporting Requirements for Outpatient Services Domain #6: Data Quality and Management 3:00-5:00 CCS Session #5 Domain #7: Information and Communication Technologies Domain #8: Privacy, Confidentiality, Legal and Ethical Issues Domain #9: Compliance

4 CCS Session #1 Introduction Overview of test Domain #1: Health Information Documentation Tasks Hands on

5 CCS Prep Introduction Please note that this workshop is designed to serve as a valuable supplement to your overall education plan for preparing for the CCS certification examination. This workshop will NOT teach you how to code. Attendees of this workshop should already have a good working knowledge of the basic coding rules of ICD-9 as how to apply them. Participation in this course does not guarantee a passing score on the examination. The exam WILL NOT BE ADMINISTERED DURING THIS WORKSHOP. We strongly encourage workshop participants to go to the AHIMA Certification website to learn more about the credential and the exam prior to attending this workshop. For this workshop, you will need to bring your ICD-9 CM and CPT 2013 coding books. The CCS exam is based on ICD-9-CM codes effective October 1, 2012, and CPT codes effective January 1, 2013 (exam will not be administered at workshop!)

6 CCS Prep Introduction Workshop Materials (Handout Information): At the workshop we will be providing handouts with study questions & scenarios/answers. We will NOT be providing handouts of the Powerpoint slides (the 3 slide per page handouts) at the workshop! Registered attendees will be sent a link to download the Powerpoints and will be able to print the 3 slides per page handout. If you wish, you may print these and bring them with you to the workshop.

7 Certified Coding Specialist (CCS) Examination Content Outline Number of Questions on Exam: 81 Multiple Choice (18 unscored/pretest) 8 Multiple Select (2 unscored/pretest 12 medical record cases Exam Time: 4 hours

8 CCS Prep Exam Overview Part 1 Pharmacology, anatomy & physiology, DRGs, legal issues & government regulations, pathophysiology. Coding conventions & guidelines; for example: which type of hernia repair can use mesh? You must read coding guidelines and practice coding exercises to gain experience prior to exam. 81 multiple choices. You don't have much time, so try to answer all questions on time. 8 multiple select. This means more than one answer to select. Part 2 12 inpatient and outpatient cases. You have around 15 minutes/case. Many have difficulty finishing this part on time. Some cases have pages. You need to read efficiently, focus and assign the codes correctly. If you don't understand the question, come back to do later if time permits. Do not spend too much time on single question. Part II can be complex and stressful. You need to remain calm and focused. Passing score is graded at 300/400 for entire exam.

9 Exam Overview Multiple Choice: One best answer item format requires the test taker to select the single best response from four (4) options. AHIMA certification exams currently utilize this format for all objective items. Multiple Select: More than one answer will be required by the test taker (example: select 2 correct answers out of 4 presented, 3 correct answers out of 5 or 4 correct answers out of 6). Candidates will be prompted within the question on how many answers are required.

10 Exam Overview Quantity Fill in the Blank (QFIB): Used for medical record cases. More than one answer will be required by the test taker. Candidates will receive the exact amount of boxes that they will need to provide diagnosis and procedure codes for.

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12 Exam Scoring Multiple Choice and Multiple Select questions are worth 1 point. Fill in the Blank items are worth 1 point per correctly assigned code. For example: Multiple Choice Correct answer = 1 point, Incorrect answer = 0 points Multiple Select Correct answers = 1 point (you have to select all right answers to get the entire question correct), Incorrect answers = 0 points Fill in the Blank Correct codes = 1 point (each code that you enter will be worth 1 point), Incorrect codes = 0 points If the medical record cases requires the candidate to code eight (8) correct codes and the candidate only correctly answers six (6) codes, the candidate will have a point total of 6 for that medical record case

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17 Procedures for Coding Medical Record Cases Instructions and official guidelines for coding medical records are included in the following resources: ICD 9 CM, CPT, UHDDS, Coding Clinic for ICD 9 CM and CPT Assistant. However, hospitals and other organizations may develop their own procedures in the absence of approved guidelines. To ensure consistent coding, the following procedures have been developed for use in the CCS examination. The procedures do not supersede or replace official coding advice and guidelines included in the resources identified above. These procedures are to be used only in completing the CCS examination. They will be provided to test takers as part of the examination packet. Not adhering to these procedures may result in the miscoding of an exercise, which may result in the deduction of points when the item is scored.

18 Inpatient Cases 1. Apply UHDDS definitions, ICD 9 CM instructional notations and conventions, and current approved national ICD 9 CM coding guidelines to assign correct ICD 9 CM diagnostic and procedural codes to hospital inpatient medical records. 2. Sequence the ICD 9 CM codes, listing the principal diagnosis first. 3. Code other diagnoses that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. These represent additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. A. Code diagnoses that require active intervention during hospitalization. For example: Admission for small bowel ileus and subsequent aspiration pneumonia that is treated with antibiotics and respiratory therapy. Code the ileus and aspiration pneumonia.

19 Inpatient Coding (cont.) E. Do not code status post previous surgeries or histories of conditions that have no bearing on the management of the patient. For example: Admission for pneumonia; status post hernia repair six months prior to admission. Code only the pneumonia. Previous surgeries involving transplants, internal devices, and prosthetics should be coded. F. Do not code localized conditions that have no bearing on the management of the patient. For example: Admission for hernia repair; the patient has a nevus on his leg that is not treated or evaluated. Code only the hernia and its repair. G. Do not code abnormal findings (laboratory, x ray, pathologic, and other diagnostic results) unless there is documentary evidence from the physician of their clinical significance. For example: Admission for elective joint replacement for degenerative joint disease. The laboratory report shows a serum sodium of 133; no further documentation addresses this laboratory result. Code only the degenerative joint disease and the replacement surgery. For example: Admission for elective joint replacement for degenerative joint disease. The laboratory report shows a low potassium level, and the physician documents hypokalemia. Intravenous potassium was administered by the physician for hypokalemia. Code the degenerative joint disease, the replacement surgery, and hypokalemia.

20 Inpatient Coding (cont.) B. Code diagnoses that require active management of chronic disease during hospitalization, which is defined as a patient who is continued on chronic management at time of hospitalization. For example: Admission for acute exacerbation of COPD. The patient has depression that extends the stay and for which psychiatric consultation is obtained. Code the COPD and depression. For example: Admission for acute exacerbation of COPD. Physician lists "history of depression" on face sheet, and the patient is given Desyrel. Code the COPD and depression. C. Code diagnoses of chronic systemic or generalized conditions that are not under active management when a physician documents them in the record and that may have a bearing on the management of the patient. For example: Admission for breast mass; diagnosis is carcinoma. Patient is blind and requires increased care. Code the breast carcinoma and blindness. D. Code status post previous surgeries or conditions likely to recur that may have a bearing on the management of the patient. For example: Admission for pneumonia; status post cardiac bypass surgery. Code the pneumonia and status post cardiac bypass surgery (V code).

21 Inpatient Coding (cont.) H. Do not code symptoms and signs that are characteristic of a diagnosis. For example: A patient has dyspnea due to COPD. Code only the COPD. I. Do not code condition(s) in the Social History section that has no bearing on the management of the patient. 4. Do not assign E codes, except those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered and/or poisoning (E850 E949). 5. Do not assign Morphology codes (M codes). 6. Code all procedures that fall within the code range through 86.99, but do not code (Foley catheter).

22 Inpatient Coding (cont.) 7. Do not code procedures that fall within the code range through But code procedures in the following ranges: Cholangiograms and Retrogrades, urinary systems Arteriography and angiography Radiation therapy Psychiatric therapy Alcohol/drug detoxification and rehabilitation Insertion of endotracheal tube Other lavage of bronchus and trachea Mechanical ventilation ESWL Chemotherapy

23 Ambulatory Cases 1. Apply ICD 9 CM instructional notations and conventions and current approved Diagnostic Coding and Reporting Guidelines for Outpatient Services (Section IV of the official ICD 9 CM Guidelines for Coding and Reporting),to select diagnoses, conditions, problems, or other reasons for care that require ICD 9 CM coding in an ambulatory care encounter/visit either in a hospital clinic, outpatient surgical area, emergency room, physician's office, or other ambulatory care setting. 2. Sequence the ICD 9 CM code so that the first diagnosis shown in the medical record is the one chiefly responsible for the outpatient services provided during the encounter/visit. 3. Code the secondary diagnoses as follows: A. Chronic diseases that are treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

24 Ambulatory Cases (cont.) B. Code all documented conditions that coexist at the time of the encounter/visit that require or affect patient care, treatment, or management. C. Conditions previously treated and no longer existing should not be coded. 4. Do not assign E codes, except those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered and/or poisoning (E850 E949). 5. Do not assign Morphology codes (M codes). 6. Do not assign ICD 9 CM procedure codes. 7. Assign CPT codes for all surgical procedures that fall in the surgery section.

25 Ambulatory Cases (cont.) 8. Assign CPT codes from the following ONLY IF indicated on the case cover sheet: a) Anesthesia section b) Medicine section c) Evaluation and management services section d) Radiology section e) Laboratory and pathology section 9. Assign CPT/HCPCS modifiers for hospital based facilities, if applicable (regardless of payer). 10. Do not assign HCPCS Level II (alphanumeric) codes.

26 Domain 1 Health Information Documentation(10%) Tasks: Interpret health record documentation Determine when additional clinical documentation is needed. Consult with physicians/health care providers to obtain further documentation. Consult reference materials. Identify patient encounter type. Identify and post charges for health care services.

27 CCS Prep Exercises for Domain 1 Hands on exercises Page 20

28 CCS Session #2 Domain II Diagnosis Coding Tasks Overview Coding Clinic Topics Stroke Adverse effect Additional topics Hands on CCS Prep Text Page 22 Health Records TBD

29 Domain II Diagnosis Coding (64%*) Tasks* (% combined w Domain III Procedure coding) Select diagnoses according to current coding/reporting requirements for inpatients. Select diagnoses according to current coding/reporting requirements for outpatients. Interpret conventions, formats, notations, tables and definitions for the encounter. Sequence diagnosis codes according to UHDDS. Apply official ICD 9 CM coding guidelines.

30 Coding Clinic Topics Stroke (Coding Clinic, First Quarter, 2010) Hemiplegia as an additional diagnosis Change in guidance: because hemiplegia is not inherent in an acute cerebrovascular accident, coders should report the hemiplegia. This is true even if the condition has resolved with or without treatment at the time of hospital discharge.

31 Coding Clinic Topics Symptom versus diagnosis Seizure in ICD 9 CM is a symptom code; a seizure disorder is a diagnosis. Providers required to differentiate whether these symptoms are current or related to the current stroke; or whether they re a late effect of a previous stroke. Unresponsive: query for the level of unresponsiveness (e.g., stupor versus coma) because it can affect the risk adjustment in MS DRGs and APR DRGs.

32 Coding Clinic Topics Cerebral edema due to stroke Is it appropriate to code vasogenic edema when the physician documents it for a patient admitted and diagnosed with intracerebral hemorrhage? It is appropriate to assign code 431 (intracerebral hemorrhage) as the principal diagnosis and code (cerebral edema) as an additional diagnosis. Documented clinical circumstances (e.g., ICU, intubation).

33 Coding Clinic Topics Hemorrhagic conversion of stroke A physician admitted a 77 year old with expressive aphasia and documented that it was due to an acute cerebral infarction. The physician ordered and documented IV tissue plasminogen activator (tpa) within 4.5 hours of onset of symptoms, as approved by the Food and Drug Administration. After the tpa, there was evidence of an asymptomatic hemorrhagic conversion of the stroke caused by the tpa, despite the fact that the physician administered the tpa as directed (i.e., it was not an accidental overdose).

34 Coding Clinic Topics Coding Clinic stated the following codes are appropriate to report for this scenario: (cerebral artery occlusion, unspecified, with cerebral infarction) as the principal diagnosis (iatrogenic cerebrovascular infarction or hemorrhage) 431 (intracerebral hemorrhage) for the cerebral hemorrhagic conversion due to the thrombolytic therapy (aphasia) E (drugs, medicinal, and biological substances causing adverse effects in therapeutic use, fibrinolysisaffecting drugs) as additional diagnosis

35 Coding Clinic Topics Patient sustained a left frontal cerebral infarction with hemorrhagic conversion. The provider documented that the patient presented with expressive aphasia due to an acute cerebral infarct and later developed hemorrhagic conversion of the infarct. When queried, the provider stated that this hemorrhagic conversion was spontaneous.

36 Coding Clinic Topics For this circumstance, code: (cerebral artery occlusion, unspecified, with cerebral infarction) and code 431 (intracerebral hemorrhage) Cause and effect relationship

37 Coding Clinic Topics Coding Clinic (Q3 2011) was asked what the correct coding for a diagnostic statement of depression and anxiety. Coding Clinic advised that the correct coding was 311 and , not 300.4, because the physician had not established a linkage between the two conditions. Coding Clinic (Q3 2011) was asked about the clinical significance of obesity or morbid obesity, when the physician does not perform any further assessment, monitoring or care for the condition. Coding Clinic indicated that these patients are at increased risk of certain medical conditions, and that they should be coded when documented by the physician.

38 Coding Clinic Topics The question of a diagnostic statement of "pneumonia with hemoptysis" was raised. Coding Clinic (Q3 2011) pointed out that hemoptysis is a Chapter 16 code, and as such should not be coded if it was integral to a disease process. In Q4 2011, Coding Clinic was asked how a diagnosis of chemotherapy induced pancytopenia was coded. The questioner was advised to code , Antineoplastic chemotherapy induced pancytopenia. Further, the questioner was told that it was unnecessary to code E933.1, Antineoplastic and immunosuppressive drugs, since it was inherent in the title of However, providers could choose to capture this information if they wished.

39 CCS Session #3 Domain III Procedure Coding Tasks Overview Hands on CCS Prep Text Page 26 Health Records TBD

40 Domain III Procedure Coding (64%*) Tasks* (% combined w Domain II Diagnosis Coding) Select procedures according to current coding/reporting requirements for inpatients. Select procedures according to current coding/reporting requirements for outpatients. Interpret conventions, formats, notations, tables and definitions that require coding. Sequence procedure codes according to UHDDS. Apply official ICD 9 CM coding guidelines. Apply the official CPT/HCPCS Level II coding guidelines.

41 CCS Session #4 Domain IV Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (5%) Domain V Regulatory Guidelines and Reporting Requirements for Outpatient Services (6%) Domain VI Data Quality and Management (4%) Tasks Overview Hands on CCS Prep Text Page 31

42 Domain IV Acute Care Regulatory Guidelines and Reporting Requirements (5%) Tasks: Select principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and procedures according to UHDDS and Coding Clinic. Evaluate impact of codes on DRG assignment. Verify DRG assignment based on IPPS. Assign appropriate discharge disposition.

43 Domain V Outpatient Services Regulatory Guidelines and Reporting Requirements (6%) Tasks: Select reason for encounter, pertinent secondary conditions, primary procedure and other procedures according to UHDDS, CPT Assistant, Coding Clinic for ICD 9 CM and HCPCS. Apply OPPS reporting requirements: Modifiers CPT/HCPCS Level II Medical necessity. Evaluation and Management code assignment (facility reporting)

44 Domain VI Data Quality and Management (4%) Tasks: Assess quality of coded data. Educate providers regarding reimbursement methodologies, documentation and regulations. Analyze documentation for quality and completeness. Review accuracy of abstracted data elements for integrity and claims processing. Review/resolve coding edits: CCI, MCE, OCE.

45 CCS Session #5 Domain VII Information and Communication Technologies (3%) Domain VIII Privacy, Confidentiality, Legal and Ethical Issues (4%) Domain IX Compliance (4%) Tasks Overview Hands on CCS Prep Text Page 38

46 Tasks: Domain VII Information and Communication Technologies (3%) Use computer to ensure data collection, storage, analysis and reporting of information. Use common software applications in execution of work processes. Use specialized software in completion of HIM processes.

47 Domain VIII Privacy, Confidentiality, Legal and Tasks: Ethical Issues (4%) Apply policies and procedures for access and disclosure of PHI. Apply AHIMA Code of Ethics/Standards of Ethical Coding. Recognize/report privacy issues/problems. Protect data integrity and validity using software/hardware technology.

48 Domain IX Compliance (4%) Tasks: Participate in institutional coding policies to ensure compliance with official coding rules/guidelines. Evaluate accuracy/completeness of patient record as defined by organizational policy/external regs/standards. Monitor compliance with organizational wide health record documentation/coding guidelines. Recognize/report compliance concerns/findings.

49 Questions? CCS Exam with ICD 10 CM/PCS starting April 1, Expect modifications to ICD 9 CM format.