Wound Care Coding Under Medicare in the Outpatient Setting

CCFN June 2014 Wound Care Coding Under Medicare in the Outpatient Setting Written from a facility perspective, this article provides clarity on the coding of wound care along with debridement. RAC UPDATEs Improper Payments for New Patient Evaluation and Management TALKING points Are Insulin Pen Devices Putting Your Patients at Risk? Don t get Scanned by CT Documentation ICD-10 Talk Cheating ICD-10: Reinventing the Diagnosis Code Cheat for ICD-10-CM FAQs Frequently Asked Questions for June 1

CCFN Title JUNE 2014 Editor s Note: One might surmise that some of us in healthcare are waiting as the old saying goes for the other shoe to drop. There is still no word from CMS about issuing an interim final rule (IFR) to reset the compliance date of October 2015 for ICD-10. Furthermore, the CMS enforcement delay of the two-midnight rule has been extended to March 31, 2015. But there s no need to wait for any shoe to drop. Current coding and compliance issues abound. CMS contractors and the OIG are focusing their attention elsewhere like evaluation and management (E/M) services, wound care coding and CT scan exams just three of the timely subjects we re reporting in the June edition of CCFN. Contents 4 10 12 14 FEATURE ARTICLE Wound Care Coding Under Medicare in the Outpatient Setting By Dawn M. Lui, RHIT RAC UPDATES Improper Payments for New Patient Evaluation and Management By Sandra V. McCurdy, MHA, CPC TALKING POINTS Are Insulin Pen Devices Putting Your Patients at Risk? By Sarah Cobb, BS, CPhT, RMC TALKING POINTS Don t get Scanned by CT Documentation By John Brazzel Wound care encounters are one of those areas that can be challenging for coders to code, reports Dawn M. Lui, in her feature article this month. In reviewing wound care documentation in the patient record, coders must decipher what services were actually provided to the patient during the encounter; which treatments could have been separately reported; and which ones were packaged. Lui writes that wound care services would seem easy to code, however, many coders have found these kinds of services to be complicated and confusing. Lui s article written from a facility perspective provides clarity on the coding of wound care along with debridement. Centers for Medicare & Medicaid Services (CMS) approved audits to review improper payments made for New Patient evaluation and management (E&M) services. Depending on previous provider encounters, patients are identified as either new or established when billing E&M services. According to the Food and Drug Administration (FDA), all insulin pens are approved only for single-patient use. This means that only one device should be used per patient. The complexity of computed tomography (CT) exams is highlighted by the fact that the Office of Inspector General s (OIG) 2014 Work Plan includes the agency s review of payments for high cost diagnostic radiology tests, reports John Brazzel. 17 ICD-10 Talk Cheating ICD-10: Reinventing the Diagnosis Code Cheat for ICD-10-CM By Darnacea Harris, MHA, RHIT, CCS A cheat sheet is a list of codes and corresponding diagnoses. The move to ICD-10 is an opportunity for facilities and physician offices to review cheat sheets or superbills.

SECTION Coding and Compliance Focus News Title Editor s Note June heralds the arrival of camping, hiking and plenty of physical activity as summer begins to bathe the nation. And with this outdoor activity comes the risk of accidents skinned knees and elbows, maybe worse. We re talking about wounds. And that s the subject of our feature article this month: wound care under Medicare s outpatient setting as reported by Dawn Lui. With recovery auditors essentially on pause for complex reviews until March 2015, auditors are looking elsewhere for coding errors like E/M services particularly new and established patient designations as Sandra V. McCurdy reports. John Brazzel offers a cautionary tale about the OIG s focus on CT scan exams, advising you how not to get scanned. Are insulin pen devices putting your patients at risk? Sarah Cobb reports that according to the Food and Drug Administration (FDA), all insulin pens are approved for single-patient use only. This means that only one device should be used per patient. But that might not be happening at some facilities. Finally, is there a way to cheat on ICD-10? Darnacea Harris reports how to create an ICD-10-CM cheat sheet. All this inside the June 2014 edition of Coding and Compliance Focus News. 3

Wound Care Coding under Medicare in the Outpatient Setting Wound care encounters are one of those areas that can be challenging for coders to code By Dawn M. Lui, RHIT In reviewing wound care documentation in the patient record, coders must decipher what services were actually provided to the patient during the encounter; which treatments could have been separately reported; and which ones were packaged. Wound care services would seem easy to code, however, many coders have found these kinds of services to be complicated and confusing. This article written from a facility perspective is intended to provide clarity on the coding of wound care along with debridement services. Defining Wounds In order to properly report wound care one must determine what type of wound for which the patient is seeking treatment. Medicare defines wound care as care of wounds that are refractory to healing or have complicated healing cycles either because of the nature of the wound itself or because of complicating metabolic and/or physiological factors. This definition excludes management of acute wounds, the care of wounds that normally heal by primary intention such as clean, incised traumatic wounds, surgical wounds that are closed primarily and other postoperative wound care not separately payable during the surgical global period. Wounds can be classified as either acute or chronic. Acute wounds are those that heal within weeks of their initial onset. Acute wounds, failing to heal, become chronic ones. Generally, wounds that do not heal within four weeks of their initial onset are classified as chronic. A wound can become chronic as a result of a lack of adequate blood supply and/or oxygen needed to aid in the process of the wound healing. Contributing to wounds not healing and becoming chronic are factors such as autoimmune, diabetic, or peripheral diseases; chemical or radiotherapeutic drugs; or even infections. Any of these factors could cause the wound tissue to break down and become necrotic or eschar. 4

Wound Care Coding under Medicare in the Outpatient Setting continued General routine wound care involves assessment and management of the wound, cleansing of the wound, simple debridement of the wound, and removal and reapplication of the wound dressings. Wounds can be further classified as open or closed. Closed wounds are those in which the skin is not broken or open and the skin is intact. A closed wound may have underlying trauma such as contusion, hematoma, or the tissue may become necrotic or eschar. As for open wounds, the skin and underlying tissue is exposed. Examples of open wounds are skin/tissue ulcers, second and third degree burns, healing by secondary intention, infected wounds caused by trauma/surgery. Again the tissue can become necrotic or eschar. A wound that is not healing may require active wound care treatment and/or procedures in order to promote healing. One of the therapeutic processes utilized in wound care treatment is the removal of the devitalized and/or necrotic or eschar tissue. The types of wounds generally needing wound care treatment are chronic, pressure, arterial, diabetic or venous status ulcers; second and/or third degree burn wounds; trauma or surgery induced infected open wounds; wounds with necrotic or eschar tissue; and wounds healing by secondary intention. Wound Care Wound care involves evaluating, management, and treatment of non-healing wounds. The type of wound care provided to the patient will be dependent on the type and number of wounds being treated and the condition/status of the wound(s). General routine wound care involves assessment and management of the wound, cleansing of the wound, simple debridement of the wound, and removal and reapplication of the wound dressings. Please note that simple debridement is not the same as excisional debridement. Evaluation Evaluating the wound(s) is an essential and integral part of wound treatment. The provider assesses the wound status and, depending on the type of wound and current condition or state of the wound(s), the evaluation may require a more comprehensive evaluation (i.e., medical, vascular, orthopedic, functional, metabolic, nutritional, etc.) and implementation or revision of a plan of care. The evaluation also involves identifying any potential causes for the delay of wound healing. Generally, wound care involves evaluation, management, and treatment of the wound(s). Thus, it would be inappropriate to report an evaluation and management (E&M) CPT in addition to a wound care service (i.e., debridement, application of an Unna boot, etc.). If, however, during the wound care encounter the provider evaluates the patient for a significant separately identifiable service from the wound care services and documents this in the patient s medical record, then it may be appropriate to report an E/M in addition to a wound care service code and append significant, separately identifiable E/M service modifier 25 to the E/M CPT code. To be considered a significant separately identifiable service, the reason for the E/M would need to be a condition/issue not related to the scheduled visit and would require further medical treatment. During the evaluation and management of the wound, the provider may see indicators necessitating further or additional treatment(s) and/or procedure(s) to optimize the healing process changes that will result in the implementation or modification of the treatment plan of care. The additional treatments may include surgical debridement, negative pressure wound therapy (NPWT), skin grafting, or the application of an Unna boot(s). Although not an exhaustive list of treatments, these are merely examples of various wound care procedures that may be provided. These additional services may be reported as long as they are not bundled or integral to the wound care service provided. Documentation In order for wound care services to be covered, the services provided must be ordered by the physician or by qualified personnel. The services must be reasonable and necessary, and meet coverage requirements. It is essential that documentation in the medical record supports each of the coverage requirements. 5

Wound Care Coding under Medicare in the Outpatient Setting continued There is an old saying in the coding world: if it s not documented, then it didn t happen! Without the documentation, there is no objective evidence to provide support for medical necessity regarding the treatment provided. Medical record documentation also supports the evidence to validate the necessity of the therapist s skills and justifies the need to continue a therapist s services in order to improve the patient s care and therapy outcome. From a billing perspective, all codes utilized to report the wound care services and/or procedures provided must also be supported by medical record documentation. Essentially, the documentation must meet the criteria of the code being billed. Reviewing the medical record to examine the specific details documented about the wound will assist in coding of the wound care services. For example, locate details on the onset and duration of the wound(s) to determine if the wound is a chronic or acute one. Next, review notes on the documentation of the wound(s) size looking for measurement of the wound depth, length and width. Review the chart notes for documentation indicating the presence of edema, and/ or infection, and/or a disease causing underlying problems/complication(s) for the wound healing process. View documentation of the wound site and the surrounding tissue and also see if there is any undermining (presence of a cavity under the periwound) or tunneling (a tract or sinus that extends into the underlying tissues from the wound bed). These points will assist in coding of the wound care services. Debridement Services Medicare defines debridement as the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. Wound care debridement services under Medicare are reported with CPT codes 97597-97598 for selective debridement, or 97602 for non-selective debridement, or 11042-11047 for surgical removal of devitalized tissue. In order to select the appropriate debridement CPT code, it is pertinent to know the differences between these three groups and the types of debridement identified within the code details. Selective debridement is performed more at the surface level and may be performed with or without anesthesia by sharp dissection (i.e., done with scissors, scalpel, forceps, etc.) or by using a water jet. Medicare defines selective debridement as the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. When using the selective debridement codes, only report the types of debridement identified within the code description. In order to report the following selective debridement codes, Medicare requires the presence of devitalized tissue (necrotic cellular material). Repeated debridements are usually selective debridements. 97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, There is an old saying in the coding world: if it s not documented, then it didn t happen! Without the documentation, there is no objective evidence to provide support for medical necessity regarding the treatment provided. biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq. cm or less + 97598 Each additional 20 sq. cm, or part thereof (List separately in addition to code for primary procedure) Non-selective debridement is the gradual removal of devitalized tissue that may involve mechanical debridement, chemical debridement (enzymatic debridement), autolytic debridement/abrasion, blunt debridement (scraping), or maggot therapy. This is not an exhaustive list of techniques utilized for nonselective debridement. 97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 6

Wound Care Coding under Medicare in the Outpatient Setting continued A surgical debridement is a more extensive debridement of the underlying/soft tissue and/or bone, and it is the original (initial) debridement service. Generally, once the initial debridement is performed, there usually is not any necrotic muscle/bone remaining to be debrided during a repeated (subsequent) debridement. The stage or type of wound does not warrant the use of reporting a surgical debridement code. Instead rely on the documentation in the chart to validate the code selection. For example, on the initial surgical debridement of a Stage IV ulcer, muscle was debrided; however, on the subsequent debridement no muscle was debrided. For the initial visit you should code to surgical debridement, then for the subsequent visit, code selective debridement. 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq. cm or less + 11045 Each additional 20 sq. cm, or part thereof (List separately in addition to code for primary procedure) Use extreme caution when reporting the excisional debridement. Chart notes must clearly describe the tissue as being cut away with sharp tools such as scissors, scalpel, forceps, etc. 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq. cm or less + 11046 Each additional 20 sq. cm, or part thereof (List separately in addition to code for primary procedure) 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq. cm or less + 11047 Each additional 20 sq. cm, or part thereof (List separately in addition to code for primary procedure) Debridement Cautions There are a few debridement cautions to which to adhere when coding wound care debridement services. First, Medicare does not consider maintenance of the wound to be a debridement service. Second, a selective or a non-selective debridement code is not to be reported with a surgical debridement code for the same wound. Third, non-selective debridement is mutually exclusive to the selective debridement codes; thus, it would be inappropriate to report a non-selective debridement code (97602) with a selective debridement code (97597-97598). Finally, use extreme caution when reporting the excisional debridement. Chart notes must clearly describe the tissue as being cut away with sharp tools such as scissors, scalpel, forceps, etc. Make sure that the tissue is being cut away and removed, and not merely being removed by having loose fragment tissues scraped away. Per the AHA 4th Qtr 1988 Coding Clinic, an excisional debridement is the surgical removal or cutting away of devitalized tissue, necrosis, or slough. The article continues on, stating that non-excisional debridement is the non-operative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, or slough. Then in AHA 2nd Qtr 2004 Coding Clinic, it states that in excisional debridement a scalpel is used to remove devitalized tissue involves cutting outside or beyond the wound margin. Debridement Code Selection When reporting debridement CPT codes for wound care, code assignment reflects the level of tissue debrided or removed (i.e., subcutaneous tissue, muscle and/or fascia and/or bone) and the total surface area of a single wound or, if multiple wounds, sum of the surface area of those wounds that are at the same depth. Do not combine sums from different depths. Review procedure documentation in the chart to obtain and calculate the depth and diameter of the total area debrided (post debridement). Calculate the wound based on what was documented as being debrided. The size of the debridement should be based on the surface area debrided, not necessarily the size of the wound itself. Assigning the correct debridement code is dependent on the type of debridement being performed as well as the wound size; therefore, documentation in the medical record should include frequent wound measurements. The documentation should also include a description of the appearance of the wound, 7

Wound Care Coding under Medicare in the Outpatient Setting continued especially the size as well as the depth, stage, bed characteristics, etc. Additionally, the type of tissue or material removed should be documented. There should also be documentation of the improvement of the measurable changes, for example indicating a decrease in: drainage, inflammation, necrotic tissue or slough, pain, swelling, or the wound dimensions. The Centers for Medicare & Medicaid Services (CMS) have assigned both CPT codes 97602 and 97597 with a Medically Unlikely Edit (MUE) of 1 unit. CMS defines an MUE as the maximum unit of service edits for HCPCS/ CPT codes for services rendered by a single provider/ supplier to a single beneficiary on the same date of service. Therefore, codes 97602 and 97597 may only be reported once per encounter. Compression Dressings For venous wound care, compression dressings are used in the treatment of edema, ulcers or sores, and they control the swelling and promote circulation. There are various types of compression dressings; however, verify in the chart notes which type was ordered by the provider and applied during the wound care encounter, and what body area it was applied to. The following are the CPT codes to report compression dressing: 29580 Strapping; Unna boot 29581 Application of multi-layer compression system; leg (below knee), including ankle and foot 29582 Thigh and leg, including ankle and foot, when performed 29583 Upper arm and forearm 29584 Upper arm, forearm, hand, and fingers In January 2012, changes were made to the codes for application of multi-layer compression, revising CPT 29581, and creating three new codes (29582-29584) to report body areas other than the leg. This change became effective for use for services provided on or after Jan. 1, 2012. The Unna boot is another type of compression dressing, but is more of a moisture-keeping type. It is typically made of cotton and may include, but is not limited to, cream, ointment, paste, hydrogel, hydrocolloid, or a combination of products. For example, zinc oxide paste and calamine lotion may be applied on this cotton before applying it to the patient s leg. Use of calamine lotion may help reduce itching, pain and skin irritation, while the zinc oxide helps promote healing within the wound. Reporting Compression Dressings If the compression dressing (i.e., Unna boot, multi-layer) is applied during the same encounter as the debridement, only report the debridement since the dressing is integral to debridement and not separately reimbursed under Medicare. If the compression dressing is applied and the wound was not debrided, then the application of the compression dressing is eligible for reimbursement under Medicare; therefore, report the appropriate CPT code for the application of the compression dressing. All compression dressing applications may be performed by a nurse or non-physician provider when incident to physician services and performed within the scope of their licensure. When reporting the application of the Unna boot (29580) or multi-layer compression (29581-29584) in a hospital s outpatient facility center, only one unit may be reported per date of service. CMS has assigned each of these codes a MUE of 1 unit; therefore, if it is applicable to report, only report the compression dressing once per encounter. However, for the bilateral application of Unna boot or multi-layer compression, report a unit of 1 and append modifier 50 (Bilateral procedure). As a special note, some FI/MACs require modifier LT (Left side) or RT (Right side) to be applied for the unilateral application of the Unna boot or multi-layer compression dressings. However, you will want to follow-up with your FI/MAC to learn of their specific billing requirements. All compression dressing applications may be performed by a nurse or non-physician provider when incident to physician services and performed within the scope of their licensure. Negative Pressure Wound Therapy (NPWT) Essentially, the NPWT consists of sponge placed over the wound and a drain tube inserted into the sponge, then the drain tube is connected to a vacuum pump and the drained particles (exudates, wound fluids, and bacteria) are collected into a canister. This process creates a negative pressure over the wound to cleanse and evacuate from the wound bacteria, wound fluids and exudates and promote wound healing and closure. Benefits of NPWT for the wound(s) include increased blood flow (circulation), reducing edema, decreasing 8

Wound Care Coding under Medicare in the Outpatient Setting continued bacterial growth, and increasing growth of healthy tissue covering the wound. NPWT is typically utilized on non-healing wounds that have not responded to wound care or have responded poorly. NPWT is often termed as wound vac in the chart notes and is reported with the following CPT codes: 97605 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters + 97606 total wound(s) surface area greater than 50 square centimeters G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters + G0457 total wounds(s) surface area greater than 50 square centimeters CPT codes 97605/97606 are reported when negative wound pressure therapy services are provided relating to the DME benefit. As for HCPCS codes G0456/G0457, they were created to provide a payment mechanism for negative pressure wound therapy which is unrelated to the durable medical equipment (DME) benefit, for example, the SNaP Wound Care System. The NPWT CPT codes (97605-97606, G0456-G0457) should be reported only once for the total wound surface, regardless of the number of wounds. CMS has codes 97605, 97606, G0456, and G0457 assigned with a MUE of 1 unit. When NPWT is performed with a debridement, according to the NCCI facility edits, NPWT (97605-97606, G0456-G0457) is mutually exclusive to the selective (97597-97598) and non-selective debridement (97602) therapy services when performed on the same date of service during the same patient encounter. Mutually exclusive procedures cannot be reported together because they cannot be reasonably performed at the same anatomical site or same patient encounter. The NCCI facility edits do not allow for a modifier to be reported with NPWT (97605-97606, G0456-G0457) with non-selective debridement (97602); however, a modifier is allowed with NPWT (97605-97606, G0456-G0457) with selective debridement (97597-97598) when appropriate. Based on this guidance, it is not appropriate to report NPWT and selective or nonselective debridement when performed on the same anatomical site. A modifier assignment (i.e., distinct procedural service modifier 59) would only be appropriate if the NPWT and debridement were performed at different anatomical sites and supported by facility documentation. Conclusion When billing wound care services it is imperative to review the patient s medical record and decipher what services were actually provided to the patient during the encounter. Do not report services that are integral to another service. Append a modifier when applicable. Review wound care policies published by your FI/MAC as well as guidance published by CMS to ensure medical necessity and documentation requirements are met and ensure you are reporting the service following the latest wound care guidelines. References FI/MAC local coverage determinations (LCDs) WPS MAC J5 Medicare Part A policy L28572 titled Wound Care Noridian MAC JF Medicare Part A policy A50355 titled Wound Care and Dressing Changes Cahaba MAC J10 Medicare Part A policy L30004 titled Surgery: Debridement Services CMS Medicare Manual 100-03 National Coverage Determinations Manual, Chapter 1, Section 270 AHA coding publications CPT Assistant June 2005, Vol. 15 Issue 6 ICD-9-CM Coding Clinic: 4th Qtr 1988, Vol. 5, No. 4; 1st Qtr 2008, Vol. 25 No. 1; and 2nd Qtr 2004, Vol. 21 No. 2 Author Bio Dawn M. Lui, RHIT has been a coding and CDM analyst with MedAssets since 2004. She is currently responsible for researching and responding to complex facility coding inquiries as well as database maintenance and management. Dawn has more than 25 years of experience in health information management (HIM), including expertise in long term facility coding; inpatient and outpatient facility coding with a specific emphasis on Outpatient Prospective Payment System (OPPS) and Inpatient Prospective Payment System (IPPS). 9

RAC UPDATES Improper payments for New Patient Evaluation and Management (E&M) services By Sandra V. McCurdy, MHA, CPC With the Centers for Medicare & Medicaid Services (CMS ) not having its Recovery Auditors (RAs) conduct post-payment patient status reviews for claims with admission dates between Oct. 1, 2013 through Oct. 1, 2014,now is a perfect opportunity to review past RA audits to ensure proper billing of claims. So let s review! CMS approved audits under the RA program to review improper payments made for New Patient evaluation and management (E&M) services. Depending on previous encounters with the provider of service, patients are identified as either new or established when billing E&M services. Since new patient services were billed two or more times within three years by the same physician or physician group, RAs discovered that these payments were inappropriately paid. New and established patient status is detailed in Chapter 12, Section 30.6.7 of the Medicare Claims Processing Manual. A new patient status is described as a patient who has not received any professional services (e.g. E&M service), or other face-to-face service (e.g. surgery) from the physician or physician group practice (same physician specialty) within the previous three years. An established patient is described as a patient who has received professional services (e.g. E&M service), from the physician or physician group practice (same physician specialty) within the previous three years. For example, a patient will remain as a new patient for the initial visit if a component of a previous procedure is billed within three years (e.g. lab interpretation is billed with no E&M or face-to-face service). New patient status will also remain for interpretation of diagnostic test (e.g. X-ray or EKG when no E&M service or other face-to face service is provided). Basically, new patient services are only covered without office based face- to- face encounters within a three-year period. Recovery Audit contractor Health Data Insight received CMS approval number D000482009 on Nov. 6, 2009 to audit New Patient CPT claims. This audit examined claims paid on or after Oct. 1, 2007 and covered AB MACs carriers and all states in RA region D. RA contractor Connolly Healthcare, received CMS approval number C002972010 on Dec. 23, 2010 to review new patient claims. This review examined claims submitted by states in RA region C that were paid on or after Oct. 1, 2007. As a result of these audits, the common working file (CWF) will now check edits for New Patient CPT codes 99201-99205, 99324-99328 99341-99345, 99381-99387, 92002, and 92004. These edits will also verify that New Patient CPT codes are not paid prior to payment with an Established Patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012 and 92014). Conclusion These audits revealed improper payments for new patient services that should have been paid as established patient services. As a result, CMS has implemented changes in the CWF system requiring contractors to confirm that two New Patient E&M services are not being paid within three years. CMS contractors will recoup the payment if a new patient service is paid more than one time in a three-year period by the same physician. Thus, if the overpayment is discovered before the payment of the second claim, the second claim will be rejected. 10

RAC UPDATES Improper payments for New Patient Evaluation and Management (E&M) services continued References Medicare Claims Processing Manual, Chapter 12, Physicians/ Non-physician Practitioners, Section 30.6.7 CMS Outreach and Education Medicare Learning Network-MLN, Evaluation and Management Services Guide, December 2010, ICN: 006764 CMS Outreach and Education Medicare Learning Network-MLN, MLN Matters Articles downloads, MM8165 CMS Transmittal R124OTN, May 07, 2013, Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a new patient visit billed by the same physician or physician group within the past three years. CMS Outreach and Education Medicare Learning Network-MLN, MLN Matters Articles downloads, MM4032 Medicare B news, Noridian Medicare B Jurisdiction F, June 2013, Issue No. 286 RAC: Health Data Insights.com Connolly Health care.com Author Bio Sandra V. McCurdy is a charge and revenue integrity analyst with MedAssets. She holds a MHA degree from Mercer University and a BS degree from Troy University. Her experience includes more than 20 years in the durable medical equipment (DME) industry. 11

TALKING POINTS Are Insulin Pen Devices Putting Your Patients at Risk? By Sarah Cobb, BS, CPhT, RMC Diabetes insulin delivery devices continue to advance with modern technology. The first insulin pen was introduced in the mid-1980 s to ease patient use and promote self-administration accuracy. These devices are pen-shaped injectors that contain a disposable needle and a reservoir or cartridge for insulin. According to the Food and Drug Administration (FDA), all insulin pens are approved only for single-patient use. This means that only one device should be used per patient. Although these devices are intended for singlepatient use, there have been incidents of improper multiple-patient use that have occurred in the outpatient setting. The Centers for Medicare & Medicaid Services (CMS), in May 2012, issued a memo, Use of Insulin Pens in Health Care Facilities, reminding facilities of the risks of using insulin pens on multiple patients. The memo indicates the improper use of insulin pens is occurring in hospitals. Consequently, patients are being put at risk for contracting life-threatening illnesses by using insulin pens that are intended for a single patient. The sharing of insulin pens has been compared to sharing needles or syringes. While a new needle is used for each injection, the reservoir or cartridge of insulin may become contaminated with regurgitated blood after an injection. A study published in the May edition of Medical Care concluded that between the years of 2001 through 2011, at least 130,000 patients were potentially exposed to bloodborne pathogens due to multiple patients using the same insulin pen. Most of these incidents occurred in the outpatient setting. One specific incident occurred during which time a clinic employee inappropriately used an insulin pen during patient visits for nearly five years, between 2006 through 2011. This also resulted in patients possibly being exposed to several bloodborne diseases. The clinic subsequently notified over 2,300 patients of their possible exposure. Insulin pens, of course, are not the only concern, as there have been numerous incidents of single-use syringes being used on multiple patients. According to the Centers for Disease Control and Prevention (CDC), nearly 100 oncology patients became infected with hepatitis C in the early 2000 s as a result of a single-use syringe being shared among patients. You may have also heard the infamous incident when a Tulsa, Okla. dental surgeon exposed nearly 7,000 patients to HIV and hepatitis B and hepatitis C by reusing syringes. Overall, the CDC reports since 2001, more than 150,000 patients have been potential exposed to hepatitis and HIV due to improper injection practices. In response to the improper use of insulin devices and other injections, the CDC and the Safe Injection Practices Coalition (SIPC), have launched a campaign to raise awareness and improve healthcare provider education. The One & Only Campaign aims to eradicate outbreaks resulting from unsafe injection practices. With healthcare providers practicing the CDC s One Needle, One Syringe, and Only One Time guidance for each and every injection, the risk should be reduced of patients contracting hepatitis and other serious infections through medical injections. Additionally, the CDC has made the following recommendations to assist healthcare providers in meeting campaign goals to eliminate the risk of infection for their patients: Insulin pens containing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person s name or other identifying information to ensure that the correct pen is used only on the correct individual. Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices. If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up including blood borne pathogen testing. 12

TALKING POINTS Are Insulin Pen Devices Putting Your Patients at Risk? continued In an attempt to avoid wasting medication from a single-use device or package, some misinformed healthcare providers with all good intentions may be reusing devices in an effort to save the facility money. As a reminder, however, Medicare does provide reimbursement for medication that is wasted from single-dose packages. Under the hospital outpatient prospective payment system (OPPS), it is possible for a facility to be reimbursed for the amount of drug or biological that is discarded. Local contractors may require the use of modifier JW to identify an unused drug or biological from single use packages that are appropriately discarded. This modifier will provide reimbursement for the unused drug or biological. If the discarded drug or biological is from a single use vial or package, CMS will provide payment for the amount of the substance administered and the discarded amount up to the amount of the drug or biological as indicated on the vial or package label. The Claims Processing Manual, Chapter 17 Section 40, addresses reporting discarded drugs and biologicals. This guidance states: The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. When a physician, hospital or other provider or supplier must discard the remainder of a single use vial or other single use package after administering a dose/ quantity of the drug or biological to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label. According to this guidance, CMS has left the requirements for reporting modifier JW (Drug amount discarded/not administered to any patient) up to the discretion of local Medicare Administrative Contractors (MACs). Additionally, the guidance for reporting wasted drug and biologicals may vary among MACs. It is important to check the local coverage determination (LCD) policies for definitive guidance related to reporting discarded drugs. In March of 2010, the MedAssets Coding & Compliance Focus News (CCFN) published a detailed article on Modifier JW. For your reference, here is a summary of the circumstances when modifier JW may or may not be appropriate to report drug wastage. Circumstances when modifier JW may be appropriate: Drugs packaged in single use vials Biologicals, such as bioengineered skin substitutes, in single use packaging The units billed correspond with the smallest dose available for purchase from the manufacturer and provide the appropriate dose for the patient The amount provided and wasted/discarded is documented in the patient record Circumstances when modifier JW is not appropriate: Multi-use vials are not subject to payment for discarded amounts of drug or biological. Discarded products cannot be reported with modifier JW when the drug or biological has not been administered to a patient. Drugs and biologicals are billed in multiples of the dosage specified in the HCPCS code long descriptor. Modifier JW would not be reported if the long description of a HCPCS code representing the drug or biological already includes the amount provided and the amount discarded. Drug wastage and modifier JW should not be reported on Medicare Part B claims for drugs provided under the Competitive Acquisition Program (CAP). Conclusion Facilities can reduce financial losses and prevent the improper use of insulin pens and the inadvertent risk of bloodborne pathogen transmission to patients by adhering to the safe practices guidance provided by the CDC and through staff education on the risk of using insulin pen devices on multiple patients. References CMS Use of Insulin Pens in Health Care Facilities, Survey & Certification General Information CMS Claims Processing Manual, Chapter 17 Section 40: FDA News & Events Insulin Pens and Insulin Cartridges Must Not Be Shared CDC Injection Safety Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person CDC SIPC One & Only Campaign Safe Injection Practices AUTHOR Bio Sarah Cobb is a Registered Medical Coder and Nationally Certified Pharmacy Technician. As a healthcare professional, Sarah has more than 13 years of pharmacy experience. She has been with MedAssets for more than eight years. Currently, Sarah is a coding and CDM analyst for MedAssets pharmacy services. In this position, Sarah is responsible for maintaining the pharmacy content for MedAssets products. Sarah also provides Medicare guidance for billing and coding pharmacy services. She is a graduate of Georgia State University. 13

TALKING POINTS Don t get Scanned by CT Documentation By John Brazzel Computed tomography (CT) imaging, also referred to as a computed axial tomography (CAT) scan, and involves the use of rotating x-ray equipment, combined with digital computer technology, to produce cross-sectional images of the body. CT image data can also be reconstructed to allow viewing of body sections in a different plane or in 3D images. The complexity of CT exams is highlighted by the fact that the Department of Health and Human Services Office of Inspector General (OIG) has focused attention on this important subject. The OIG 2014 Work Plan includes the agency s review of payments for high cost diagnostic radiology tests. Claims for CT scans are reviewed for evidence of abuse, which might include the absence of reasonable indications for the scans, an excessive number of scans, or unnecessarily expensive types of scans considering the facts in the particular cases. Hospitals that receive improper payments for CT exams must determine the root cause of the improper payments. The prime suspect is inadequate documentation. In a 2008 OIG study, the agency reported that 19 percent of CT scans were not in compliance with Medicare billing requirements due to insufficient documentation. Compliance with documentation requirements for CT scans continues to be a problem for many hospitals. As reported in the May 2014 Comprehensive Error Rate Testing (CERT) newsletter, Medicare Administrative Contractors (MACs) made improper payments of approximately 16 percent of CT scan claims that were submitted for payment from July 2011 through June 2012. Today, evidence continues to support that insufficient documentation is the primary reason for improper payments. Insufficient Documentation Insufficient documentation means missing documentation. Insufficient documentation may include the following: No record of the billed service No order or no evidence of intent to order billed service No signature on order and/or no signature log or attestation No physician signature on the image report No diagnostic test results available No documentation to support medical necessity for the service Medicare policy is that CT scans must be medically appropriate considering the patient s symptoms and preliminary diagnosis. Hospitals must also be aware of any Local Coverage Determinations (LCDs) published by their MAC to ensure compliance with all billing requirements including medical necessity are met when submitting CT claims. If a billed claim for a CT scan is questioned, Medicare may require supporting documentation be made available to them upon request. High-quality patient care requires adequate documentation. The American College of Radiology (ACR) guidance for documentation requires that there be a permanent finalized record of CT exams including their interpretations. All images should be recorded in a suitable format that can be archived. Retention of CT examination records should be consistent both with clinical need and with relevant legal and local health care facility requirements. An official interpretation (final report) of the CT findings should be included in If a billed claim for a CT scan is questioned, Medicare may require supporting documentation be made available to them upon request. the patient s medical record. When a service or procedure is not documented in the medical record, it is considered nonexistent and non-billable. How is this 14

TALKING POINTS Don t get Scanned by CT Documentation continued possible you ask? The answer: clerical error the simple selection of the wrong patient account can also cause insufficient documentation. As an example: a hospital radiology department has multiple patients with the name James Smith. The wrong James Smith s account is selected, and a CT scan is being billed to a patient who will have no record of ever having a CT exam performed. In the absence of an order, a CT exam should not be performed or billed. Hospital Conditions of Participation, section 482, indicates that radiology services can only be provided if ordered by medical practitioners or other providers with clinical privileges granted by governing authorities. Those conditions also require that providers maintain records for radiology services including signed final reports. Hospitals must maintain reports, printouts, and films, scans, or other images for at least five years (or as required by state/local laws if greater than five years). The ACR legal office reports that it responds to a number of questions, seeking to clarify regulations for ordering tests. They indicate that, except for selfreferred patients who seek a screening mammogram, federal and state laws prohibit radiologists and their practices from performing and interpreting tests unless they have a valid order from a physician or other authorized practitioner. An order may include a written communication signed by the treating physician or practitioner in the form a telephone call, or an email / fax from his or her office to the testing facility. Private payers may follow different guidelines from Medicare regarding the ordering of diagnostic tests. Many commercial payers require prior authorizations for all imaging studies including CT scans. If a prior authorization is required, a patient may be asked to present a written order from a treating physician or practitioner for the payer to approve the exam. In the absence of an order, a CT exam should not be performed or billed. Possible Outcome Due to Insufficient Documentation Medicare contractors analyze provider compliance with coding and coverage guidelines. Whether intentional or not, repeated noncompliance often times indicating potential fraud and abuse may result in severe administrative action including referral to the Program Safeguard Contractors (PSCs) or the Zone Program Integrity Contractors (ZPICs) for investigation. Most errors, however, do not represent fraud and are not acts committed intentionally. For example, some errors will be the result of a provider misunderstanding or the failure to pay adequate attention to Medicare policies. Fraudulent errors represent calculated plans to knowingly acquire unwarranted payment. Medicare contractors evaluate the circumstances surrounding the errors and proceed with an appropriate correction plan which may include recoupment and civil penalties in addition to potential removal from Medicare participation. If radiology documentation is not properly maintained, hospital payment for these services may be considered an overpayment and the facility s MAC is authorized to recoup payments for these services. The law requires the Centers for Medicare & Medicaid Services (CMS) to recover all overpayments identified. Recoupment means that the overpayment will be recovered from current payments due or from future claims submitted. Unless the action is appealed, unpaid recoupment may be referred to the Department of Treasury for offset or collection as it is considered a debt owed to the US government. Conclusion With respect to Medicare claim submission, it is important that hospitals have written policies and procedures, emphasizing that claims should be submitted only when appropriate documentation is available and maintained to support those claims. The 2005 Federal Register reported that the single biggest risk area for hospitals was the preparation and submission of claims or other requests for payment from federal healthcare programs. The Federal Register also emphasized that all claims and supporting documentation must be complete, accurate and must reflect reasonable and necessary services as ordered by an appropriately licensed medical professional who is a participating provider in the payer program. If a hospital knowingly submits a fraudulent claim, it may be liable under the False Claims Act or other statutes and be subject to civil monetary penalties (CMPs) or exclusion from Medicare programs. 15

TALKING POINTS Don t get Scanned by CT Documentation continued Hospitals should utilize Medicare resources such as the RAC, CERT, and OIG reports to assess risk areas within their facility to ensure they are compliant with all applicable billing policies for claim submission. CT scans are a very complex set of diagnostic radiology exams. Their inherent complexity comes with the increased challenge to capture and provide the necessary documentation for appropriate billing of these services. Hospitals must continue to be aware of the regulatory guidelines associated with CT exams in order to avoid being scanned by CMS and the OIG. References Program Integrity Manual, chapter 3, section 1, Introduction Author Bio John Brazzel is a member of the MedAssets coding and compliance team. He currently assists in maintaining proprietary database information in compliance with regulatory and manufacturer guidelines. John has nearly 20 years of healthcare experience including hospital clinical, hospital revenue cycle, and healthcare consulting. Other areas of involvement and expertise include Chargemaster, CPT and HCPC, Outpatient Prospective Payment System (OPPS) coding, decision support assistance, denials management, patient billing and compliance issues, durable medical equipment (DME) charge capture and billing compliance, as well as revenue cycle management. Federal Register /Vol. 70, No. 19 /Monday, January 31, 2005 /Notices - Supplemental Compliance Program Guidance for Hospitals, pages 4859-4860 Medicare Condition of Participation for Hospitals, section 482.24 Condition of participation: Medical record services and 482.26 Condition of participation: Radiologic services CMS Medicare Learning Network, The Medicare Overpayment Collection Process Fact Sheet, July 2011 Medicare Program Integrity Manual, chapter 1 section 1.3.6 Quality of Care Issues and Potential Fraud Issues and section 1.3.9 Provider Self Audits Highlights from OIG Report on CT, MR and X-ray Performed in ER, ACR Radiology Coding Source for March-April 2011 CMS Medicare Learning Network Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors, Volume 4, Issue 3 April 2014 16

ICD TALK Cheating ICD-10: Reinventing the Diagnosis Code Cheat Sheet for ICD-10-CM By Darnacea Harris, MHA, RHIT, CCS If you re coding, you undoubtedly have committed certain common ICD-9-CM diagnosis codes to memory. Sometimes, these codes are documented on a cheat sheet. A cheat sheet is a list of codes and corresponding diagnoses. The move to ICD-10 is an opportunity for facilities and physician offices to review cheat sheets or superbills. ICD-10 has improved coding in most clinical specialties. Here are a few pointers to use when refining the cheat sheet: Review and understand which codes are most prevalent in your specialty. Keep in mind that what you ve always used may not suit your current practices. Take advantage of the specificity available in ICD-10. Some common codes may have new subdivisions that will help better direct coding. For example, coding for diabetes now separates type 1 and type 2 into different categories; body system, and combination codes. Subdivisions of the diabetes codes like controlled or uncontrolled in ICD-9-CM, are replaced with inadequately controlled, out of control, or poorly controlled with hyperglycemia. Some ICD-9-CM codes are combined into one ICD-10-CM code. This means that some codes on your cheat sheet will need to be deleted. The ICD-10-CM code for Essential (primary) Hypertension (ICD-10-CM code I10) combines three codes from ICD-10; 401.0, 401.1, and 401.9. Brush up on your terminology. Newer, more specific codes apply different terminology. When adding these codes to your cheat sheet, make sure you understand the terminology behind them. In ICD-10, the terms intrinsic and extrinsic have been removed as asthma qualifications. The index in ICD-10-CM directs coders to use allergic asthma (J45.901) or non-allergic asthma (J45.909) Companies that publish coding materials offer complete cheat sheets based on clinical specialty, but you may want to tailor your sheet to the facility s needs. Involve your clinical staff so that changes may be in line with new documentation initiatives. You may also want to coordinate changes with your software vendors to ensure your most frequently used codes are programmed into the software. Cheat sheets offer quick and easy referencing for ICD-10 codes. As your facility transitions to ICD-10 coding, adding a cheat sheets by clinical specialty, and for ICD-9 to ICD-10 diagnosis codes may be the ticket for more accurate and consistent coding. AUTHOER BIO Darnacea Harris MHA, RHIT, CCS, is an AHIMA approved ICD-10-CM/PCS Trainer with more than 20 years experience in the coding, compliance and reimbursement industry. Darnacea has previously held such positions CCA rules manager, assistant director HIM, HIM manager, coding manager, and consultant. She has also held teaching positions at several colleges and universities where she taught coding, billing, HIM, and supporting courses. The move to ICD-10 is an opportunity for facilities and physician offices to review cheat sheets or superbills. 17

FAQs In this section, MedAssets has reviewed and analyzed the questions that are received via our compliance help desk. We offer some of the most frequently asked questions and the MedAssets response for your convenience. Frequently Asked Questions for June Q: I rarely review the Inpatient Prospective Payment System (IPPS) proposed rules because we primarily work with Outpatient Prospective Payment System (OPPS). However, this year I thought I d see how the Centers for Medicare & Medicaid Services (CMS) are changing the inpatient rule. I noticed there is something in the IPPS about the Affordable Care Act (ACA) and how hospitals are now supposed to publish their rates online. Can you elaborate on that? It appears to affect both inpatient and outpatient charges. Your question falls under the category of Hospital Price Transparency. The ACA contains a provision that is consistent with the MedAssets effort to improve the transparency of hospital charges one that requires each hospital to establish and make public a list of its standard charges for items and services. MedAssets reminds hospitals of their obligation to comply with the statutory requirements. MedAssets guidelines for implementing the provision are that hospitals either make public a list of their standard charges or their policies for allowing the public to view a list of those charges in response to an inquiry. MedAssets encourages hospitals to undertake efforts to engage in consumer-friendly communication of their charges to help patients understand what their potential financial liability might be for services they receive while enabling them to compare charges for similar services at other hospitals. Our guidelines for implementing section 2718(e) of the Public Health Service Act are that hospitals either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or their policies for allowing the public to view a list of those charges in response to an inquiry. A: Per the 2015 IPPS proposed rule, CMS has been comparing hospitals inpatient and outpatient charges for specific services/procedures verses Medicare reimbursements for the same services/ procedures. CMS findings indicate that hospital inpatient and outpatient charges are significantly higher than Medicare s reimbursement was under IPPS and/or OPPS. Per CMS Medicare Provider Utilization and Payment Data site, These data include information for the 100 most common inpatient services, 30 common outpatient services, and all physician and other supplier procedures and services performed on 11 or more Medicare beneficiaries. Providers determine what they will charge for items, services, and procedures provided to patients and these charges are the amount the provider will bill for an item, service, or procedure. The CMS website page for Medicare Provider Utilization and Payment Data provides additional guidance for inpatient and outpatient requirements. To learn more how this applies to the outpatient setting, read the following: In 2013, CMS published this data for public review affording healthcare consumers the opportunity to compare charges across the country and within their own communities. The new transparency requirements forces hospitals to be accountable for their charges, while providing health care consumer access to charges for specific services and procedures. The ACA transparency provision requires each hospital to make public a list of the hospital s standard charges for items and services provided by the hospital, including diagnosis-related services. The hospital s list of standard charges should be updated at least annually, or more often when appropriate. It is up to each hospital to establish transparency of their charges and the method by which to make their charges available to the public. However, CMS expects hospitals either to make public a list of their standard charges (i.e., the hospital s chargemaster, or another form of hospital choice), or make public the hospital s policies for allowing the public to view a list of their 18

Frequently Asked Questions for June charges in response to an inquiry. CMS encourage hospitals to use a transparency method that is consumer friendly that will help health care consumers understand what their potential financial liability would be at their hospital, and the method should be in a form that allows health care consumers to compare charges for similar services across hospitals. The aforementioned overview was published in the 2015 IPPS proposed rule. CMS or Medicare Administrative Contractors (MACs) may publish additional guidance and clarification if the requirements for transparency of hospital inpatient and outpatient charges is finalized in the 2015 IPPS final rule. Q: We are debating how to bill for the 1 gm vial of Methotrexate. There are two options (below). Can you please assist? J9250 per 5 mg J9260 per 50 mg A2: The codes in question are: J9250 [Methotrexate sodium, 5 mg] J9260 [Methotrexate sodium, 50 mg] The MedAssets Best Practice recommendations are to report J9250 for line items that are equal to or less than 5mg, and report J9260 for line items that are 50mg and greater. However, based on guidance from Transmittal R1760CP, either code may be appropriate. The transmittal states that regardless of the units identified in the drug descriptor, hospitals may choose which code to report. Pub 100-04 Transmittal R1760CP - July 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) states under the Recognition of Multiple HCPCS Codes For Drugs states: indicator B indicating that another code existed for OPPS purposes. For example, if drug X has 2 HCPCS codes, one for a 1 ml dose and a second for a 5 ml dose, the OPPS would assign a payable status indicator to the 1 ml dose and status indicator B to the 5 ml dose. Hospitals then were required to bill the appropriate number of units for the 1 ml dose in order to receive payment under the OPPS. However, beginning January 1, 2008, the OPPS has recognized each HCPCS code for a Part B drug, regardless of the units identified in the drug descriptor. Hospitals may choose to report multiple HCPCS codes for a single drug, or to continue billing the HCPCS code with the lowest dosage descriptor available. Prior to January 1, 2008, the OPPS generally recognized only the lowest available administrative dose of a drug if multiple HCPCS codes existed for the drug; for the remainder of the doses, the OPPS assigned a status 19

WORD SEEK Wound Care Coding Under Medicare CHEMICAL CLASSIFIED COMPLICATED CONFUSING DEBRIDEMENT DECIPHER DEVITALIZED EDEMA ESSENTIAL EVALUATION INFECTION PACKAGED PRESSURE SURGICAL TISSUE TREATMENT WATERJET WOUND (answers on following page) H F M I R D I C C I E E K B Z U Y P L E G O L Z N T E L T H D L T Y T Y R A Z R F C T I Z F W I B R E Y Y D T C C V T U W P U I D S E K F T M M F Y A I H G R S M S K H K E L C C I A X Q R G R N P E S P X B N P P G C T J S N T R A I J D A E E S S E N T I A L I C S U L S R E N T R P U Q S W T M C K H O S A U N B Q S M P N U X O W R Q O E C L N F L R F S P E X D H U Y U D W M B F A N U I C E E U N K L N I U H M I P N M O P D R I F T V T N D A B D K C K L S C R E H P I C E D U O X T F Y A R Y I I P M W A T E R J E T I V L I L J P G C D E Z I L A T I V E D T V O B B D R U A N T Y P A Y D H N U U A C Z A N U J T T V N I N O U O Z V E D U G G R V A S J E W X J S O V J A V T T L O D D V Y N O D F F T F S M T I C E Z A X Y G C P W S G W A L T O U N K T D Q V C Z B H Z W U U P Z S Q Q K E G X G Q E 20