Posts Tagged ‘ICD-10-CM Coding’

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Good Coding: Helps Your Agency Keep Its Revenue Bad Coding: Can Mean You Lose Your Revenue

Friday, May 17th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions.   Per CMS and as per the Federal Register, “The  Coding Clinic by AHA is the US Official Clearinghouse for Coding.”

Agencies have hired coders, some are credentialed, some not.  All usually do not have audits of their coding compliance.  As a result, when asked, “Are you leaving dollars on the table?” most administrators pause.  Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves, but that is changing.  In the past, agencies have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not.  Most agencies rely on their coders. They put a portion of their financial welfare in the hands of unreviewed coders.  Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes. At the very least, contract for routine third party coding and billing audits.

If you were to use a third party coding firm, be certain they have external audits performed on their coding.  Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. Who has audited them? What are the firm’s names?  Yes, the audits are an increase cost, but ar $e you losing 200-$400 per episode of care delivered? Are you flagging your firm for a RAC, MAC, or Z-PIC audit?

You should take a close look at the coding completed in your agency. Look at the use of case-mix diagnoses and at comorbidities. Down coding can be as costly as upcoding, just in different regulatory ways, if it brings on an audit. Have your ADRs increased? Do you know the number of codes used routinely in your firm? Do you know the top 10 diagnoses assigned?  How many of the present 16,000 codes are your coders using? How much will preparing for ICD-10 cost you?  Is a plan in place now? How strong is your coder in anatomy, physiology, diagnostics, and pharmacology? How many of the 68,000 codes will they use?

Experts know that much training is required for ICD-10. If you do not properly prepare, how much more will it cost you? Perhaps it really is time to consider a third party coding specialty firm.

Consider a firm that has experienced, highly credentialed coding specialists. Ask if they employ a full time coding internal auditor. Ask if they have weekly training sessions paid for by the coding firm to keep their coding specialists current. Ask if they have a full time Compliance Officer, a compliance committee, and have current program policies and procedures. Ask if the firms’ employees are required to annually attend corporate compliance and HIPAA inservices. Ask if the coding specialists are reviewed quarterly. Ask about internal and external audits of the coding teams’ work. Ask about their % of documented accuracy as stated by an independent auditor.  If the coding agency is under 97% accuracy documented by independent external audit, look elsewhere. All of the above items are costly to the coding firm but a top coding firm should be investing in quality.

And lastly, identify the coding firm’s indepth ICD-10 curriculum for their coding specialists. Also, identify their overall plan for ICD-10 implementation including their plan for parallel coding of ICD-9 and ICD-10.  Do not continue to lose dollars. Make a move now.

For more information, call 714.524.2500

ICD-9-CM Official Guidelines for Coding and Reporting

Effective October 1, 2008 http://www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_full.pdf

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S.

Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are includedon the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself.

The following are the CMS ICD-9 Site:

  1. CMS ICD-9 Site

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/ICD9ProviderDiagnosticCodes/

  1. Attachment D

http://www.oasisanswers.com/downloads/HHQIAttachmentD.pdf

  1. Coding Clinic

https://www.cms.gov/Medicare/Coverage/CouncilonTechInnov/downloads/InnovatorsGuide5_10_10.pdf

Operational coding advice and guidelines for ICD-9-CM are published quarterly by the American Hospital Association (AHA) in Coding Clinic for ICD-9-CM (Coding Clinic). The Editorial Advisory Board (EAB) for Coding Clinic consists of representatives of AHA, the American Health Information Management Association (AHIMA), NCHS, CMS, the American Medical Association (AMA), the American College of Surgeons, and other hospital coders and physicians. Four of those parties (AHA, AHIMA, NCHS, and CMS) are identified as Cooperating Parties for Coding Clinic. The Cooperating Parties must agree on the coding guidance before it can be published in the Coding Clinic. Anyone may send issues to AHA for EAB discussion.

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Posted in ADRs, CMS, CMS Guidelines, coding, ICD-10-CM Coding, ICD9-CM Coding, MACs, MICs, RACs, Z-PICs | No Comments »

ICD-9-CM and ICD-10-CM: Some Differences and Similarities

Tuesday, April 30th, 2013

CMS is stating they expect 10% of all claims submitted to be denied with ICD-10 initially. Selecting and assigning accurate diagnoses in the proper sequence must be performed in compliance with Medicare rules and regulations, Coding Conventions and Coding Guidelines. That remains the same.

The accuracy of this information contained in the clinical record is directly tied to payment and to justification for homecare services, so understanding how to select and assign accurate diagnoses is very important. This is the same but the specificity of the documentation becomes very very important. Increased specificity in data means more robust design of algorithms to predict outcomes and care by MACS, RACs, and Z-PICs.

ICD-10-CM presents an even greater challenge for documentation by the clinician. The word “documentation” is stated 72 times in the ICD-10-CM guidelines document.  Querying for additional information is noted 23 times in the same document. The instructions and conventions of the classification take precedence over guidelines which requires a keen understanding of the conventions.

ICD-10 requirements have raised the documentation expectations. Have your clinicians had an overview of ICD-10-CM? Here are just some observations.

  • Coding assignment will be based on the agency’s documentation of the relationship between the condition and the care that is planned.
  • Not all conditions that occur during or following surgery will be classified as complications
  • A cause and effect relationship must be present between the care provided and the condition clearly delineated within the documentation
  • Query for Clarification re documentation that supports codes assigned is expected
  • There will be specific documentation needed for specific codes and without the documentation, the codes may not be used
  • Code only those diagnoses that are relevant, unresolved, and impact the plan of care. Diagnoses that are resolved or have no impact on the plan of care should be excluded since they do not meet the criteria for a home health diagnosis
  • Code only those diagnoses that are supported by the medical record including diagnoses supported by the plan of care and the comprehensive assessment.
  • There are placeholders in ICD-10
  • There is laterality
  • There are sixth and seventh characters
  • ICD-10 requires expertise in anatomy, physiology, diagnostics, and pharmacology

Agency clinicians are expected to understand the patient’s clinical status and overall medical condition very well before approving/assigning diagnoses, so the comprehensive assessment must be ­completed in its entirety prior to the diagnoses decision. All coders should be properly educated on ICD-10-CM including how to use coding manuals properly. 50 + hours are being identified as necessary for each coding specialist to be properly prepared for ICD-10.

Your agency’s integrity and financial health could well depend on your preparation for ICD-10. Selecting and assigning accurate diagnoses must be performed in compliance with Medicare rules and regulations, in addition to ICD-10-CM coding guidelines.

You have choices; either prepare VERY VERY well for ICD-10 or consider third party experts for coding and remove that burden and concern.

Consider joining Susan Carmichael for a general overview of ICD-10CM Coding on May 7, 2013. Check the Select Data website for more details.

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Good Coding: Helps Your Agency Keep Its Revenue Bad Coding: Can Mean You Lose Your Revenue

Wednesday, February 20th, 2013

PPS has always meant that “close enough” isn’t good enough. A digit off can be costly. Coding to the highest level of specificity can be complex and confusing. CMS has published Coding Guidelines and the Coding Clinic remains the source document for any coding questions. Agencies have hired coders. Yet still, many agency administrators pause when asked, “Are you leaving dollars on the table?” Most acknowledge they believe their coding may be costing them at least $200-$400 per episode.  Why continue to lose dollars?

Agencies have usually decided to complete their coding themselves. They have hired coders, certified or otherwise. Some coders are routinely reviewed and audited, most are not. Lessen the worry regarding dollar loss and the quality of your agency coding by instilling specific processes.

Consider a third party audit. Quality third party coding firms should have quarterly internal audits and annual external audits completed in their firms. So should you. Yes, the audits are costly, but so is $200-$400 per episode of care delivered

You should take a close look at the coding completed in your agency. Look at the use of case-mix diagnoses and at comorbidities. Down coding can be as costly as upcoding, just in different regulatory ways, if it brings on an audit. Have your ADRs increased? Do you know the number of codes used routinely in your firm? Do you know the top 10 diagnoses assigned?  How many of the present 16,000 codes are your coders using? How much will preparing for ICD-10 cost you?  Is a plan in place now? How strong is your coder in anatomy, physiology, diagnostics, and pharmacology? How many of the 68,000 codes will they use?

Experts know that much training is required for ICD-10. If you do not properly prepare, how much more will it cost you? Perhaps it is time to consider a third party coding specialty firm.

Consider a firm that has experienced, highly credentialed coding specialists. Ask if they employ a full time coding auditor. Ask if they have weekly training sessions paid for by the coding firm to keep their coding specialists current. Ask if they have a full time Compliance Officer, a compliance committee, and have current program policies and procedures. Ask if the firms’ employees are required to annually attend corporate compliance and HIPAA inservices. Ask if the coding specialists are reviewed quarterly. Ask about internal and external audits of the coding teams’ work. Ask about their % of documented accuracy.  If the coding agency is under 97% accuracy documented by independent external audit, look elsewhere. All of the above items are costly to the coding firm but a top coding firm should be investing in quality.

And lastly, identify the coding firm’s indepth ICD-10 curriculum for their coding specialists. Also, identify their overall plan for ICD-10 implementation including their plan for parallel coding of ICD-9 and ICD-10.  Do not continue to lose dollars. Make a move now.

Susan Carmichael
MS, RN, CHCQM, COS-C
Executive Vice President
Chief Compliance Officer
Select Data
714.524.2500
949.584.6296

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Proper Coding, Homebound Status, and Awareness of Common Edits: Paid But Will You Retain Your Revenue? An Update.

Tuesday, January 22nd, 2013

No matter which MAC or RAC reviews your agency, high risk probes are on the rise. The intermediaries are mandated by CMS to monitor areas of greater risk. The RACs are paid by contingency on aberrant findings and their algorithms are making findings easier. When MACs or RACs find trends of concern they will launch probes. Some of these high risk areas include revenue in relation to diagnoses in relation to visits, certain stand alone diagnoses or diagnoses in combination with certain numbers of episodes or number of visits.

In late 2012, RAC auditors began sending out chart requests expansively. They were and continue to target specific issues such as medical necessity, seeking to have those specific issues approved by CMS. Once approved, other RACs can investigate those same issues in their areas. One issue all RACs are looking at involves specific numbers of therapy in specific episodes with specific diagnoses.

NAHC’s Mary St Pierre, VP, Regulatory Compliance, identified in the fall of 2012, that Comprehensive Error Rate testing (CERT) contractor inquiries are also on the rise. The CERTs are the QA component of MAC billing. In addition, they also oversee Z-PIC claim payments and the denials issued. They are looking at Face to Face documentation of medical necessity and homebound status documentation.

The OIG remains focused on both home health and hospice citing “Six Measures of Questionable Billing” especially in home health.

The OIG has announced that, in 2009 and again in 2010, Medicare-Medicaid paid over $54 billion in improper payments. There have been 2500 persons/entities indicted from Federal health care programs. There have been 625 criminal actions with over 400 civil actions including actions involving the False Claims Act. There have been another 2400 investigations that yielded expected results. The GAO has reported that improper payments due to fraud and abuse are escalating.

Dollars and processes have been approved to target areas of high risk. Monitoring that the principal diagnosis code accurately portrays the patient’s focus of care is a MAC missive. Probe edits are one such process expected by CMS from the MACs to achieve that goal. Monitoring for homebound status is yet another area of review.

The Edits

Specificity requirements to support codes have always been expected but are being actively scrutinized now. Expect specificity and complexity to rise even higher with ICD-10.

Coding Specialists must also keep clients or their agency aware of edits and trend areas with insufficient documentation to substantiate proposed diagnosis.

A second recertification of Lymphoma will trigger a long used edit.

Recertifications with a primary diagnosis of Diabetes and a secondary diagnosis of CHF will be monitored if the edit continues after a MAC quarterly review. Because the FIs have found merit, this edit has continued for years.

Other Edits include:

Recertifications with a primary diagnosis of Alzheimer’s disease, Schizophrenia disorders, or Long Term use of anticoagulants with no therapy ordered.

Claim Denial Potential

The above diagnoses run a great risk for denial because of probe edits and recertifications. Those records are reviewed also for homebound status. There must be “clear documentation that it is with considerable and taxing effort for the beneficiary to leave home, otherwise the episode or specific visits could be denied for lack of homebound status. (74% of ADRs reviewed for lack of homebound status were denied).”

Common documentation deficiency areas include lack of progress in:

* Repetitive clinical notes frequently seen stating the same things over and over with no patient progress identified; how is it that the clinician is unable to teach a new med successfully within a visit or two?

* Notes from different disciplines that reflect a lack of plan coordination

* Visit notes that do not substantiate orders and goals on Plan of Care/485.

* Clinical interventions without orders.

* If a chronic diagnosis is the primary reason for ongoing care, the skilled nurse should be VERY VERY clear as to why (s)he is still making visits.

* If visit notes do not EACH stand alone and justify care, the clinical visits are at risk.

The casemix co-morbidities; such as CHF, CAD, COPD, DM, Parkinson’s disease should be included in the diagnoses list. If they are standing alone, the nurse should carefully justify the skilled need because of the chronic disease.

* In justifying observation and assessment, note if:

* There is significant change in meds, treatments, or conditions

* There is teaching, reteaching, and training needed

* The condition or disease symptomology has exacerbated or changed in another way

* Teaching on new medications must include instruction or intervention on the related diagnosis.

The clinician providing injections such as insulin require specific documentation to support the need; specifically, why the patient cannot self inject the med such as tremors, impaired cognitive function, and no willing and capable caregiver.

Though we have heard this over and over, one of the most common home health reasons for denial is that the documentation does not support medical necessity.

Therapy is STILL under scrutiny

Functional ability improvement is expected or why is therapy present?

Therapy may be covered if the patient or caregiver received teaching that is reasonable and necessary.

In 2008, claims chosen with 10-11 therapy visits and discharge in episode two had a 74% rate of denial essentially due to poor or insufficient documentation displaying no or low progress and/or incongruence between care and OASIS assessment. The 2012-13 expectations are rigorous and denials are imminent if documentation is insufficient or inadequately substative.

The therapy treatment plan must:

* Relate to the exact diagnosis that has required therapy intervention.

* Identify visit frequency and duration.

* Identify the present and prior functional level.

* State specifically the procedures, treatments, and/or exercises to be performed.

* Clearly list the reasonable and measureable goals to be achieved.

* Care must be specific, safe, and effective supported by the diagnoses according to accepted practice.

* Specify the rehab potential.

* Specify the discharge plan.

Additional Ways to Decrease Risk

Adequate documentation begins with the correct diagnosis and being alert for edits. Besides agency PI projects, consider professional coding teams to decrease risk. Third party coding and auditing can provide the buffer needed to diminish risk and increase compliance. It is hard for one or two or a few in-house coders to not only keep up with the average 350 coding changes each year but to also locate the ever changing edits of each FI. The edits are usually disclosed AFTER the MAC probe results. Third party coding firms, like Select Data, monitor the FI sites, newsletters, and alerts to dig for present edits.

Agencies need to be aware the edits will increase over the next year as CMS, the RACs, the MACs, and the Z-PICs ready for ICD-10 and the move from the present 17,000 codes to over 68,000 codes or a 400% increase in codes. Will there be a 400% increase in edits also? Will there be a 400% increase in claim denials? Let us hope not.

Protecting justly due reimbursement starts with proper data gathering, coding to the highest level of specificity with sufficient documentation, and coding specialists looking out for the specific documentation needed. Do you have the coding specialists that you need in place to assist you in protecting your justifiably deserved reimbursement?

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ICD – 10 CM: Completing the Gap Analysis and Transition Plan (Part 2 of a Coding Series)

Thursday, August 30th, 2012

ICD-10 CM is going to impact the entire home health industry and every department of your agency. Now that we know that the implementation date will be October 1, 2014, agencies need to establish a solid plan now. You need every day of the 24 months to educate, plan, educate, implement, reevaluate, test and retest, and educate.  Training for coding specialists is important, but training for those who will use the data will be equally important.

Creating a roadmap for ICD-10 integration within an organization may appear daunting. Let’s break down the process. CMS suggests presenting an overview of ICD-10 to the entire organization. This allows individuals to process the changes in ICD-10 and align those changes to processes they presently complete. This assists the organization to understand the depth and impact of ICD-10.

Completing the Gap Analysis

Define the agency’s present state. Review the list of processes for each department from intake of a potential patient to filing of the final claim of the patient and the resulting data analytics. Identify how the coding touches each area of work flow.

Identify the agency’s strong competencies and the additional training to maintain those competencies. Look at performance levels and consider the impact of ICD-10 on performance. Considering the increased specificity of ICD-10 coding, what will be the impact on clinical and operational processes? What new clinical tools will be needed? What form changes will be required? How will internal and external reports be impacted?

List, then communicate with vendors, payor sources, and clearinghouses. Where are they in their processes? What are their plans? Will they be ready?

Identify the timeline for the Gap analysis.

Organize an ICD-9/ICD-10 Transition Team

The goal of the team is to establish an overall organizational plan after the Transition Team either completes or receives from another committee, a Gap analysis; operational and technical impact analysis. The new Transitional Team should review that overall analysis, using those specific organization findings to provide the base of their project/transition plan.

The Transition Team should have representatives of each department: intake, clinical, IT, HIM, billing, QA, internal auditing, and administration so that they can adequately develop an expansive implementation strategy.

Choose a project leader of the transition team. This leader must organize the development of a budget, a timeline and action/project plan that will include a training plan for the organization. It must demonstrate how findings and planning will be communicated. The project/transition plan needs to be tied to endpoints that are reasonable and measureable. Compliance plays a huge role. The plan must be compliance oriented; attending to statute, convention, guideline and regulation.

Report from each Department Representative and Plan Creation

The representative from each department; IT/technology, Clinical, Coding, Revenue Cycle/billing/finance, QA/QI/Audit, Data Analytics, and Education/Training  must lead the indepth department evaluation as well as the department project plan.

What will be the impact to each department?

Coding specificity?

Impact on data capture at intake? At time of assessment? On data analytics and reports?

Impact on the plan of care (485)? Consistency of diagnosis/supportive documentation/careplan

What about the schedule and the depth of schedule notes?

Utilization and quality process and improvement

Need for increased clinical cues

Time/ amount to capture data at all time/patient points

Field sizes, alphanumeric composition, and decimal use

Code value alteration with Table structure alteration

Edit and logic changes

Overlapping time point of ICD-9 and ICD-10

Impact on the EMR

Impact on interfaces

Impact on HR and personnel needs

Education and training needed for each department

Budget creation for the project

Who will monitor the vendors and payors?

Do not trust the statement that the vendor will be ready. Your agency cash flow could be dependent upon their planning, testing, and implementation.

Ask to see the vendor plan and monitor progress to general goal completion. When will the upgrades or new software be available?

Evaluate health plan readiness. Evaluate the impact of ICD-10 on usual and customary reimbursement fee schedules as well as episodic reimbursement.

Training and Education

You want to prevent agency claim rejections as well as delays in processes. You want personnel comfortable with new processes. You want to be compliant.

Each department will have different training needs. Obviously, the biller does not need the same level of coding expertise as a credentialed coder, but they require an understanding of the impact of the new coding on their particular processes.

The leader of this department will need to work closely with each department head as to specific training needs as well as the best methods of training. Additional assessments needed include: Can the agency provide all, some, or none of the training needed? What training method will work best for the learners? Will classrooms and teleconferences work best? Should they be augmented by web-based learning? Are inservices and seminars by experts another route to pursue?

Consider length of time for education and training. Some departments will require more training over a longer period of time.

Coders will need an indepth review of Anatomy, Physiology, Pathophysiology, Diagnostics, and Pharmacology. Each of these areas should be relational to disease states so that a comprehensive understanding of the new code application exists.

Whether you code inhouse or you contract with outside experts, be certain that parallel coding will occur for several weeks before the new codes are applied to the claims. October 1, 2014 should mean all training and education has been completed, processes have been reviewed and tested. Be certain that data analytics and infomatics are meeting the new specificity requirements.

Clinicians will need a solid understanding of the specificity of the documentation now required. They will need orientation to the more indepth assessment tools. Clinical cues as to diagnosis documentation requirements will be needed.  

Hopefully, vendors will be able to assist clinicians so technology can be leveraged to make up for the detailed documentation needed.

October 1, 2014 will be the ICD-10 implementation date. You have only 2 years to complete the Gap analysis, establish the Transition Team, create the transition plans, lead and evaluate training/education needs of all departments, create new tools needed, modify and test processes as well as review data created and have all processes in place to submit compliant claims. You need to start NOW! You only have two years and the clock is ticking.

 

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