The Coding Corner Archives

2021 Coding Corner

July 2021

  • Missed COPD coding capture during sick visit:
    • Example: Patient has a sick visit for flu-like symptoms and does have COPD that is being managed by the PCP and Pulmonary. The provider diagnosis capture is:
      • Muscle pain (M79.1), Fatigue (R53.83), Cough (R05), Shortness of breath (R06.02), Sneezing (R06.7), Loss of appetite (R63.0), Headache (R51), Nasal congestion (R09.81). The COPD (J44.9) could have been included to capture the chronic condition– this is a lung condition and the flu like symptoms such as cough, shortness of breath, and fatigue can be linked to the COPD.
  • Diabetes with Complications captured to the highest specificity:
    • Example: Patient has a 3 month follow-up visit and has the following chronic conditions: Diabetes II (E11.9), CKD 3 stage 3a (N18.31), Morbid Obesity (E66.01) with BMI >40 (Z68.41), hyperthyroidism (E03.9).
      • Accurate coding: Diabetes with CKD stage 3a: E11.22, N18.31, Diabetes with complications: E11.69, E66.01, Z68.41, E03.9.
  • Morbid Obesity and BMI accurate coding capture:
    • Example: Patient has Morbid Obesity (E66.01) and BMI is >40 (Z68.41). The provider captures the Morbid Obesity (E66.01) but does not capture the BMI (Z68.41).  This will not risk adjust as both the E66.01 and Z68.41 must be documented and coded together to accurately capture the risk adjustment coding. Both the E and Z code needs to be captured.
  • Missing High Risk conditions on an annual basis:
    • Example: Patient is having their annual visit with their PCP. The patient has been seeing Oncology for prostate cancer and is still on medication after radiation treatment. The PCP captured history of prostate cancer (Z85.46).
      • The patient is still on medication for prostate cancer so the cancer should be captured as prostate cancer (C61) not history of prostate cancer (Z85.46).
  • Missing chronic condition capture during annual visits – Annual Exam Encounter (Z00.00):
    • Example: Patient comes in for their Annual Exam and has the following chronic conditions: Asthma (J45.909), Diabetes II (E11.9), CKD 3 stage 3b (N18.32), Hypertension with Heart Failure (I11.0), Congestive Heart Failure (I50.82). The provider only codes the Annual Exam Encounter (Z00.00) and misses all chronic conditions. Accurate coding would include the following:
      • Z00.00, J45.909, E11.22, N18.32, I10, I50.32, I13.0 (Hypertensive Heart Disease with HF and CKD 3)
  • Missing HCCs Rx coding capture when provider is prescribing medication to manage condition:
    • Example: Patient has not been seen since October 2020 and PCP is prescribing medication for the following chronic conditions: Anxiety (Zoloft), Hypertension (Acebutolol), Hyperlipidemia (Lipitor). The provider is also managing the patient’s diabetes II – The patient visit was in February 2021 and the provider only codes the diabetes (E11.9). The patient might not come back for a visit in 2021 and the following codes that risk adjust with medication updates are missed Anxiety (F41.1), Hypertension (I10), and Hyperlipidemia (E78.5). To capture this patient accurately for 2021 the following coding should be captured:
      • E11.9, F41.1, I10, E78.5 and highest specificity if the hyperlipidemia was linked to the diabetes would be: Diabetes with complications E11.69, E78.5

NEPHO Education Plan 2021

Monthly Coding & Billing Webinars
Risk Adjustment Coding Capture Education
1×1 Provider Education Sessions – 44 Providers
New NEPHO Physician Coding On-Boarding Sessions – 23 Providers
2022 Coding Updates – ICD-10 CM & CPT
Telehealth Focused Education
Diabetes Coding with Complications

NEPHO Education Plan 2022 – Quarter 1

Smoking Cessation, TCM, CCM
NEPHO Coding & Billing Webinars
Depression & Anxiety HCC Capture Education
Provider 1×1 Sessions
New Physician Coding Onboarding
Welcome to 2022 Coding and Billing

Please reach out to Shawn Bromley if you are interested in reviewing more about Risk Adjustment Coding capture. Contact shawn.m.bromley@lahey.org or 978-236-1704.

June 2021

Medical Necessity Helps Support Evaluation and Management (E/M) Leveling

It has been 6 months since the new Evaluation and Management (E/M) updates became effective. Providers no longer have to include history and exam components in documentation to determine the E/M code level for the office/outpatient CPT codes 99202-99215. Instead they are now using updated guidance for determining the level of service based on either time or Medical Decision Making (MDM).

Though E/M guidelines have changed, medical necessity has not. The importance of supporting medical necessity by documentation is still an element of E/M coding guidelines. Although the history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing quality care. Documenting these components helps maintain continuity of care and assists other providers in management of patient care.

Medical necessity determines coverage and level of reimbursement from Medicare and the other payers:

Medicare

  • requires that the level of service provided must be supported by medical necessity.
  • defines medical necessity as health-care services or supplies needed to diagnose or treat an illness or injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
  • determines, on a case-by-case basis, if the method of treating a patient is reasonable and necessary.

Payers 

  • provide coverage for care, items and services that they consider to be medically necessary.
  • limit coverage, even if a service is reasonable and necessary, if the service is provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard of practice.
  • use National Correct Coding Initiative (NCCI) claim edits to ensure that payment is made for specific procedure codes when provided for a patient with a specific diagnosis code or predetermined range of ICD-10-CM codes. ICD-10-CM codes should support medical necessity for any services reported.

As we move forward with the implementation of the new E/M updates for outpatient services it is important to remember how medical necessity must be supported by documentation. This includes services based on time and on the MDM. To better support medical necessity for services reported, the following principles should be followed:

  • List the principal diagnosis, condition, problem, or other reason for the medical service or procedure
    • Example: Chief Complaint/Reason for Visits
  • Assign the diagnosis code to the highest level of specificity
    • Example: Diabetes with Complications should be coded to the highest specificity
  • For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis); a clerical error could permanently tag a patient with a condition that does not exist
    • Example: Patient seen in ED for racing heart– this is a new condition but ED provider added anxiety diagnosis to chart and prescribed Zoloft. Patient followed up with PCP and it was found the patient had a mini stroke. The anxiety is a suspect condition captured in the ED. Anxiety should not be captured on the problem list as a chronic treated condition. Anxiety is a suspect condition.
  • Distinguish between acute and chronic conditions, when appropriate
    • Example: Acute conditions are severe and sudden in onset. This could describe anything from a broken bone to an asthma attack. A chronic condition, by contrast is a long-developing syndrome, such as osteoporosis or asthma.
  • Identify how injuries occur
    • Example: Patient fell off bike and fractured hip

As we move forward into 2021 keeping medical necessity as a driving component when leveling E/M services ensures new guidelines are being followed and captured compliantly.

Please reach out to Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org if you have additional questions related to medical necessity and importance it has in supporting E/M leveling for outpatient services.

May 2021

Risk Adjustment HCC Coding Examples

HCC coding capture will help create the patient RAF score that will drive the future year allocation of resources to care for the patient. Making sure to capture a patients true health status is supported by ICD-10 CM coding capture. Highlighted are the top 10 HCC codes with coding examples to help support coding to the highest specificity.

  • Diabetes without Complication (HCC 19)
    • Example: Patient is seen in office for diabetes management. Diabetes is stable and patient working on nutrition improvement, exercise, stopped smoking and will continue seeing PCP every 3 months to support diabetes management.
      • Code Diabetes Type II – E11.9
  • Breast, Prostate, and Other Cancers and Tumors (HCC 12)
    • Example: Patient is seeing PCP after prostate cancer treatment. The patient is stable, still seeing oncologist and on treatment with Flutamide. The prostate cancer is still being treated.
      • Code Prostate Cancer – C61
  • Diabetes with Chronic Complications (HCC 18)
    • Example: Patient is coming in for 3 month check and has Diabetes Type II, Hypertension, CKD 3 stage 3a, and Morbid Obesity with BMI >40.
      • Code Diabetes with CKD stage 3a – E11.22, N18.31, Diabetes with Complications E11.69, I10, E66.01, Z68.41, Hypertension with CKD E13.0
  • Seizure Disorders and Convulsions (HCC 79)
    • Example: Patient was diagnosed 2 years ago with seizure disorder. The patient is still taking ethosuximide to manage condition but the provider did not document the condition last year. Patient is having Annual Wellness Visit (AWV) and the provider documented the seizure disorder is stable.
      • Code Seizure Disorder – J40.909
  • Specified Heart Arrhythmias (HCC 96)
    • Example: Codes for Atrial Fibrillation (AF) types, these four unique codes describe the types of AF:
      • Persistent AF (I48.11) describes AF that does not terminate within seven days, or that requires repeat pharmacological or electrical cardioversion.
      • Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot or will not be performed, or is not indicated.
        • Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent or permanent AF.
        • Chronic persistent AF has no widely accepted clinical definition or meaning. Code I48.19, Other persistent atrial fibrillation, should be assigned.
          • Documentation should include: In coding, “history of” indicates a condition is no longer active. Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.
  • Congestive Heart Failure (HCC 85)
    • Example: A patient is seen for chronic diastolic heart failure and essential hypertension, the provider documents that both conditions are stable.
      •  Code I11.0 (hypertensive heart disease with heart failure), I50.32 (chronic diastolic heart failure), I10 (hypertension).
  • Other Significant Endocrine and Metabolic Disorders (HCC 23)
    • Example: Patient is seen by provider for management of Diabetes II, the patient has hyperlipidemia, hypertension, CKD stage 3a, the patient is morbidly obese BMI >40.
      • Code Diabetes with CKD 3 E11.22, N18.31, Diabetes with complications E11.69, E78.5, I10, E66.01, Z68.41
  • Chronic Obstructive Pulmonary Disease (HCC 111)
    • Example: Patient is seen for 3 month follow-up visit for COPD with asthma and history of tobacco dependence. You don’t need a code for asthma since the type of asthma isn’t documented; you do need a code for history of tobacco dependence.
      • Code J44.9, COPD, unspecified, Z87.891, personal history of nicotine dependence
  • Major Depressive, Bipolar, and Paranoid Disorders (HCC 59)
    • Example: The patient is a 35-year-old woman seeking weight loss surgery. She has struggled trying to lose weight; she states she has always been an overeater. Her spouse passed away October 2019 due to unexpected complications in the hospital. She was diagnosed with depression. Since then, she has been able to cope and feeling much better. She is calm and denies suicidal ideations. She denies tobacco use at this time but does have a history of smoking.
      • Code F32.5 Major depressive disorder, single episode, in full remission, E66.01 Morbid (severe) obesity due to excess calories, Z68.42 Body mass index (BMI), 45.0-49.9, adult, Z87.891 Personal history of nicotine dependence.
  • Morbid Obesity (HCC 22)
    • Example: The diagnosis of Morbid Obesity with a BMI of 40 or greater. If no BMI is documented, the diagnosis of Morbid Obesity will be accepted as documented by the provider. The documentation of a BMI of 40 or greater is not accepted on face value to indicate a diagnosis of Morbid Obesity. The provider must document the clinical condition – Morbid Obesity.
      • Code Morbid Obesity with BMI>40 to have coding risk adjust – Morbid Obesity E66.01, BMI>40 Z68.41.

Please contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-238-6702 if you would like more detail regarding the importance of risk adjustment coding capture for outpatient services.

April 2021

Medicare recently announced a second quarter update to the HCPCS Level II code set used for reporting products, supplies, and services. 23 codes are added to these categories and additionally, six codes are revised and 12 are discontinued, effective April 1, 2021. The 2021 Official HCPCS Level II Codes are an essential key to quality measures, durable medical goods, injectable drugs, outpatient surgery, and other areas related to coding and billing.

The Quarter 2 HCPCS Level II Code Updates Include the following:

New Codes:

  • A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie
  • C9074 Injection, lumasiran, 0.5 mg
  • C9777 Esophageal mucosal integrity testing by electrical impedance, transoral (list separately in addition to code for primary procedure)
  • G2020 Services for high intensity clinical services associated with the initial engagement and outreach of beneficiaries assigned to the sip component of the pcf model (do not bill with chronic care management codes). CMS recommends that the G2020 service must be provided and billed at least one day before any other services subject to the flat visit fee may be reimbursed accordingly.
  • G2172 All-inclusive payment for services related to highly coordinated and integrated opioid use disorder (oud) treatment services furnished for the demonstration project
  • J1427 Injection, viltolarsen, 10 mg
  • J1554 Injection, immune globulin (asceniv), 500 mg
  • J7402 Mometasone furoate sinus implant, (sinuva), 10 micrograms
  • J9037 Injection, belantamab mafodontin-blmf, 0.5 mg
  • J9349 Injection, tafasitamab-cxix, 2 mg
  • K1013 Enema tube, any type, replacement only, each
  • K1014 Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
  • K1015 Foot, adductus positioning device, adjustable
  • K1016 Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve
  • K1017 Monthly supplies for use of device coded at k1016
  • K1018 External upper limb tremor stimulator of the peripheral nerves of the wrist
  • K1019 Monthly supplies for use of device coded at k1018
  • K1020 Non-invasive vagus nerve stimulator
  • M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
  • Q0245 Injection, bamlanivimab and etesevimab, 2100 mg
  • Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
  • S1091 Stent, non-coronary, temporary, with delivery system (propel)

Revised Codes:

  • C9761 Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with litotripsy, and ureteral catheterization for steerable vacuum aspiration of the kidney, collecting system, ureter, bladder, and urethra if applicable
  • G9868 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, less than 10 minutes
  • G9869 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, 10-20 minutes
  • G9870 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, more than 20 minutes
  • J7321 Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose

Deleted HCPCS Level II Codes

  • C9068 Copper cu-64, dotatate, diagnostic, 1 millicurie
  • C9069 Injection, belantamab mafodontin-blmf, 0.5 mg
  • C9070 Injection, tafasitamab-cxix, 2 mg
  • C9071 Injection, viltolarsen, 10 mg
  • C9072 Injection, immune globulin (asceniv), 500 mg
  • C9073 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
  • C9122 Mometasone furoate sinus implant, 10 micrograms (sinuva)
  • J7333 Hyaluronan or derivative, visco-3, for intra-articular injection, per dose
  • J7401 Mometasone furoate sinus implant, 10 micrograms
  • K1010 Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
  • K1011 Activation device for intraurethral drainage device with valve, replacement only, each
  • K1012 Charger and base station for intraurethral activation device, replacement only

Please review the new, revised, and deleted codes to ensure your chargemaster is updated with current billing and coding to ensure accuracy in reimbursement. Reach out to Shawn Bromley at Shawn.M.Bromley@Lahey.org or 978-236-1704 if you have questions related to coding and billing.

March 2021

Modifiers Utilized To Ensure Accurate Reimbursement

Modifiers 24, 25, and 57 are often misunderstood. Each modifier has specific circumstances for use. Proper application of these modifiers will help ensure proper reimbursement.

Modifier 24

  • Unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period

Modifier 25

  • Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

Modifier 57

  • Decision for surgery

These specific modifiers are appended to evaluation and management (E/M) codes only. Use them in accordance to global surgery guidelines, set forth by the Centers for Medicare & Medicaid Services (CMS) in the National Correct Coding Initiative (NCCI) edits.

Global Period

When an E/M service is billed in the global period of a procedure without a modifier, the E/M service is denied as incidental to the procedure. Medicare advises there is an E/M component of every procedure in the CPT. CMS also designated every procedure with a 0-, 10-, or 90-day global period. Necessary components of every procedure include:

  • The decision to perform a procedure
  • Ensuring the patient is healthy enough to receive the procedure
  • Informing the patient about the procedure

E/M services within these global periods that meet these criteria are not separately payable and should not be reported; however, when providers render E/M services within these global periods that do not meet the above criteria, append the appropriate modifier to ensure separate reimbursement.

Modifier 24

Modifier 24 is used if the E/M service is within the 10- or 90-day global period but is unrelated to the procedure. It is not used for an E/M service on the same day as a procedure. For example: A patient has a fractured wrist. The patient comes into the office during the 90-day global period of the fractured wrist to discuss knee pain. The knee pain is completely unrelated to the wrist fracture treatment, so the provider should get separate reimbursement for the E/M service rendered that day. To communicate this to the payer, append modifier 24 to the appropriate E/M code.

Unexpected complications of a procedure can also result in an E/M service that goes above the routine care included in the global period of a procedure. If a new history, exam, and medical decision-making (MDM) are rendered, you may bill an E/M service with modifier 24 appended, even if those services are provided to the same body part that is already in a global period.

Appropriate Use of Modifier 24

A 4-year-old patient is seen in the physician’s office with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed five days ago (CPT code 12031). The patient presents to the physician’s office today complaining of bilateral ear pain. The patient’s mother states he was up all night crying. The physician performs an expanded problem-focused history and examination. The final diagnosis is bilateral otitis media. The provider prescribes amoxicillin and instructs the mother to bring the patient back in seven days to recheck his ears.

Inappropriate Use of Modifier 24

A 4-year-old patient was seen in the physician’s office five days ago with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed (CPT code 12031). The same patient now presents with redness, swelling, and drainage to the sutured area. The final diagnosis was infected laceration.

Modifier 25

Modifier 25 is used if the E/M service is rendered the same day as a procedure with a 0- or 10-day global period. The debate over appropriate use of modifier 25 has been ongoing for years. The Office of Inspector General (OIG) routinely finds this modifier misused. The decision to perform a procedure cannot be the sole justification for coding a separate E/M with modifier 25. Similarly, being a new patient is not justification alone for billing a separate E/M. If an E/M service is unrelated to the procedure, or if the E/M service goes above and beyond the decision-making required for the procedure, the provider should get separate reimbursement for that work, and modifier 25 should be appended to the E/M code.

Appropriate Use of Modifier 25

A 4-year-old established patient presents to his family practice physician’s office with a 2.5-cm laceration to the right anterior side of the wrist. The laceration is closed by the physician with 2-0 Vicryl. During the visit, the patient’s mother asks the physician about her child’s asthma. The physician decides to adjust the patient’s asthmatic medication and performs an expanded problem-focused physical.

The coding assigned would be:

  • 12001 Simple Repair, Superficial Wounds, Scalp/Neck/Axillae/Genitalia/Trunk/Extremities; 2.5 cm.
  • 99213-25 Office Outpatient Visit, established patient, expanded problem focused history; expanded problem focused physical; medical decision making of low complexity.

Modifier 57

Modifier 57 is applied to E/Ms that result in major procedures. Surgical procedures are not the only procedures where modifier 57 should be applied. The CPT manual states modifier 57 can be used on any E/M during which the physician decides a “major” procedure/surgery is necessary.

Appropriate Use of Modifier 57

A patient presents to the emergency department (ED) with abdominal pain and fever. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy. The appropriate coding for payment of the preceding E/M is 99243-57; 44950.

Click here to be directed to a Training Forum for Mass Health Claims.

Please contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you have questions regarding coding and billing.

February 2021

NEPHO Coding Audit Results Quarter 4 2020

The NEPHO Coding Team completed an audit at the end of January 2021. The scope of the audit focused on the Risk Adjustment Coding capture during Quarter 4 2020. NEPHO will be working to help educate providers on Risk Adjustment coding capture to ensure patient health status is accurately presented to the payers. This recent audit showed that many high risk patient conditions are not being captured to their highest specificity. Patients that are being managed with a higher level of risk need resources to support potential relapse, medications, treatment planning to better support their chronic condition management such as: diabetes, COPD, and Vascular Disease. The areas of missed coding opportunities from the Northeast PHO patients and providers include the following:

Missed COPD coding capture during sick visit:

  • Example: Patient has a sick visit for flu like symptoms and does have COPD that is being managed by the PCP and Pulmonary. The provider diagnosis capture is:

Muscle pain (M79.1), Fatigue (R53.83), Cough (R05), Shortness of breath (R06.02), Sneezing (R06.7), Loss of appetite (R63.0), Headache (R51), Nasal congestion (R09.81). The provider does not capture the chronic condition COPD (J44.9) – this is a lung condition and the flu like symptoms such as cough, shortness of breath, and fatigue can be linked to the COPD.

CKD Stage 3 coding updates effective 10/1/2020

  • Example: Patient has CKD Stage 3 and the current coding is CKD 3 (N18.3). This code was broken down to 3 sub-stages effective 10/1/2020.
    • N18.30 (CKD, stage 3 unspecified)
    • N18.31 (CKD, stage 3a)
    • N18.32 (CKD, stage 3b)

Diabetes with Complications captured to the highest specificity:

  • Example: Patient has a 3 month follow-up visit and has the following chronic conditions: Diabetes II (E11.9), CKD 3 stage 3a (N18.31), Morbid Obesity (E66.01) with BMI >40 (Z68.41), hyperthyroidism (E03.9).
    • Accurate coding: Diabetes with CKD stage 3a: E11.22, N18.31, Diabetes with complications: E11.69, E66.01, E03.9.

Morbid Obesity and BMI accurate coding capture:

  • Example: Patient has Morbid Obesity (E66.01) and BMI is >40 (Z68.41). The provider captures the Morbid Obesity (E66.01) but does not capture the BMI (Z68.41) this will not risk adjust as both the E66.01 and Z68.41 must be documented and coded together to accurately capture the risk adjustment coding. Both the E and Z code needs to be captured.

Capturing chronic conditions during Telehealth visits:

  • Example: Patient is having 3 month check in call with provider. Could not have face-to-face visit due to flu like symptoms. Patient is being managed by provider for depression (F33.8), Anxiety (F41.1), Hypertension (I10), and Rheumatoid Arthritis (RA) (M06.9).
  • The provider has a check in call with the patient via Video/Audio and captures/documents Depression & Anxiety only. Accurate coding and documentation should have included:
    • Depression
    • Anxiety
    • Hypertension
    • RA

Updating Problem List to help support accurate coding capture:

  • Example: Patient has diabetes II (E11.9) and morbid obesity with BMI >40 (E66.01, Z68.41). The patient has been focused on weight loss and diet changes. Their blood sugar level has been normal and their BMI is below <32.
    • The provider should update the problem list as Diabetes – Resolved and BMI should be updated to <32 (Z68.32).

Missing High Risk conditions on an annual basis:

  • Example: Patient is having their annual visit with their PCP. The patient has been seeing Oncology for prostate cancer and is still on medication after radiation treatment. The PCP captured the prostate cancer (C61) as history of prostate cancer (Z85.46).
    • The patient is still on medication for prostate cancer so the cancer should be captured as prostate cancer (C61) not history of prostate cancer (Z85.46).

Missing chronic condition capture during annual visits – Annual Exam Encounter (Z00.00):

  • Example: Patient comes in for their Annual Exam and has the following chronic conditions: Asthma (J45.909), Diabetes II (E11.9), CKD 3 stage 3b (N18.32), Hypertension with Heart Failure (I11.0), Congestive Heart Failure (I50.82). The provider only codes the Annual Exam Encounter (Z00.00) and misses all chronic conditions. Accurate coding would include the following:
    • Z00.00, J45.909, E11.22, N18.32, I10, I50.32, I13.0 (Hypertensive Heart Disease with HF and CKD 3)

Missing HCCs Rx coding capture when provider is prescribing medication to manage condition:

  • Example: Patient has not been seen since October 2020 and PCP is prescribing medication for the following chronic conditions: Anxiety (Zoloft), Hypertension (Acebutolol), Hyperlipidemia (Lipitor). The provider is also managing the patient’s diabetes II – The patient visit was in February 2021 and the provider only codes the diabetes (E11.9). The patient might not come back for a visit in 2021 and the following codes that risk adjust with medication updates are missed Anxiety (F41.1), Hypertension (I10), and Hyperlipidemia (E78.5). To capture this patient accurately for 2021 the following coding should be captured:
    • E11.9, F41.1, I10, E78.5 and highest specificity if the hyperlipidemia was linked to the diabetes would be: Diabetes with complications E11.69, E78.5

High Level Results: Area of Coding Capture Opportunity – Quarter 4

  • COPD was missed during sick visits.
  • CKD Stage 3 was missed in early October – this condition was updated on October 1, 2020 to include 3 sub stages (ICD-10 Updates). November and December showed better capture.
  • Diabetes with complications is missing specificity and missing accuracy when capturing complications.
  • Missing complete Morbid Obesity coding – must capture E and Z code for Morbid Obesity to Risk Adjust.
  • Weight on Telehealth visits and Chronic Conditions are not being captured during Video/Audio Telehealth visits.
  • Missing updates to the problem list – this is across the NEPHO organization – maintain an accurate problem list is necessary to keep diagnosis coding accurate – updating resolved conditions, in remission updates and condition progression updates must be maintained.
  • Missing high risk conditions annually are being missed such as: Multiple Sclerosis (MS) G35, Cancer – prostate cancer C61 when patient is still on medication.
  • Physical Exams (Annual) Coding Z00.00, the provider is not updating chronic conditions during these visits and are only coding Z00.00 (Annual Exam Encounter).
  • HCCs that risk adjust when provider is prescribing medication are being missed – example: Hypertension I10, Hyperlipidemia E78.5, and Asthma J45.909.

These examples highlight the areas that are being missed on an annual basis. Complete diagnosis risk capture must be updated annually to ensure the patient’s Risk Adjustment Factor (RAF) score is calculated accurately to have the funds available to support patient care management.

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you would like more information regarding risk adjustment coding capture for your practice or providers.

January 2021

Risk Adjustment Coding Overview

Hierarchical Condition Categories (HCC) are used to reimburse Medicare Advantage and Commercial plans based on the health status of their members. It pays for the predicted cost of patients by calculating payments based on demographic information and patient health status. A patient’s risk score is captured accurately by coding to their disease and conditions to the highest specificity. HCCs are diseases and conditions that are organized into body systems or similar disease processes. The top HCC categories include:

  • Major depressive and bipolar disorders
  • Asthma and pulmonary disease
  • Diabetes
  • Specified heart arrhythmias
  • Congestive Heart Failure
  • Breast and prostate cancer
  • Rheumatoid arthritis
  • Colorectal, breast, kidney cancer.

Risk Adjustment Coding a Joint Effort

Risk adjustment coding requires health plan management, provider group management, providers, practices, and coding professionals to work together to capture the health status of their patient membership. Each team member is critical for success of an organizations risk adjustment program. Health plan management and provider group management must provide leadership that supports the risk adjustment coding department to execute initiatives to improve health record documentation and risk adjustment coding. Providers must ensure their documentation complies with HCC reporting requirements and demonstrates that conditions are evaluated, monitored, assessed, and/or treated during face-to-face encounters (In-person and Telehealth). Risk adjustment coding professionals must follow best practice guidelines to ensure accurate coding and reporting of HCCs on an annual basis. By working together, the health plan and provider organizations can ensure compliance and meeting financial goals that better support HCC performance measures.

NEPHO has some very specific coding and documentation practices in place to help support provider HCC performance. The following examples provide guidance to practices that are working to improve risk adjustment coding capture:

Document and code all chronic conditions discussed and documented during a patient encounter: Chronic and/or permanent diagnoses should be documented as often as they are assessed or treated.

  • In-Person & Telehealth Example: Patient with diabetes II and CKD 3 stage 3a: Code E11.22, N18.31 – provider is also helping to manage recurrent depression and prescribing Zoloft every 3 months – Code: F33.8 (recurrent depression) – provider is helping to manage hypertension 2nd to diabetes – Code: I15.2

Clarify whether a diagnosis is current or “history of”: Anything that is listed as “repaired” or “resolved” should not be coded as current. Providers should be made aware of Z codes that are appropriate for these scenarios.

  • Example: Neoplasms that are current code to ICD-10 codes in Chapter 2: Neoplasms. Code: C61 (prostate cancer)
  • Example: Neoplasms that are no longer present should be coded to Chapter 18: History of Neoplasms. Code: Z85.46 (personal history of prostate cancer)

Update the patient’s problem list regularly: Make sure all problems listed as active are appropriate and haven’t been brought forward (copied and pasted) in error.

  • Example: Morbid Obesity with BMI > 40 Code: E66.01 BMI>40 Z68.41 – Patient lost 100 lbs updated Coding: E66.3 BMI >32 Z68.32

Providers should document conditions they monitor and treat: Diagnosis codes are not limited to what brought the patient to the office today. Any condition the provider monitors, evaluates, assesses, or treats should be included in the documentation.

  • Example: Patient has visit for fever and the provider also manages the patients hypertension – Code R50.8 (fever), I10 (hypertension)

Avoid using generic or unspecified codes: Code to the highest level of specificity. Use of generic or unspecified codes does not fully support medical necessity and the management of care for the patient. Payers need to have an accurate picture of the patient’s health status.

Example:  Congestive heart failure should be coded by type and acuity. The term congestive heart failure is considered nonspecific, outdated, and inadequate to fully describe the condition. Documentation should be present in the record of systolic and/or diastolic failure or dysfunction and acuity. Code: I50.31 (Acute diastolic congestive heart failure)

It is important to link manifestations and complications. Providers need to make the link between a manifestation and complication. Some terms that can be used to link conditions are “because of,” “related to,” “due to,” or “associated with.”

  • Example: Peripheral Vascular Disease “due to” diabetes – Code: E11.51
  • Example: Diabetes “associated with” Peripheral Vascular Disease – Code: E11.40

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you would like to learn more about the impact of risk adjustment coding capture and/or would like additional education with a provider or at the practice level.

2020 Coding Corner

Coding Corner - December 2020

Telehealth Coding and Billing Moving Into 2021

We are moving past 2020 and starting a new year on January 1, 2021. There were many areas of challenges that 2020 brought forth for practices and providers. The year had constant movement with payer updates, state and federal rules and regulation changes, and growth with Telehealth services. NEPHO worked to provide practices and providers with the latest updates to ensure coding and billing accuracy.

Patients across the nation were encouraged to stay home and as a result practices were looking for alternative methods of providing patient care. Telehealth was still in early phases of development in Massachusetts when the pandemic hit in March of 2020. Practices had to adopt a Telehealth program quickly to ensure patient care continued during the pandemic. NEPHO will continue to support practices with Telehealth services as we move forward into 2021. Telehealth focus in 2021 will include the following areas:

  • Care management for chronic conditions: Remote monitoring devices will be emerging for patients with conditions such as diabetes, hypertension, and high cholesterol.
  • Provide coaching and support: Helping patients manage chronic health conditions such as weight management and nutrition counseling.
  • Screen patients for COVID 19 symptoms: Screening without having a patient come into the office will help minimize disease spread and provide referral as appropriate.
  • Offer physical and occupational therapy: This approach will help support better access to care for optimal health results.
  • Case management access: Support case management efforts for patients who have difficulty accessing care (patients that live in rural areas, older adults, and patients with limited mobility).
  • Inpatient stay follow-up: Providers can follow-up in a timely manner with patients after a hospitalization.
  • Support advance care planning and counseling: Providers can help to deliver advance care planning and counseling to patients, caregivers, and family members when a life-threatening event or medical crisis occurs.
  • Non-emergent care to long-term care patients: Supporting non-emergent care to residents in long-term care facilities as needed.

Telehealth will have coding and billing updates effective January 1, 2021. These updates will support the new Evaluation and Management (E/M) changes for outpatient/clinic services. Practices and providers need to be aware of these updates to ensure documentation requirements are being met. Updates include the following:

  • American Medical Association released the new set of E/M coding guidelines that will be effective on January 1, 2021
  • CPT 99201 level of care will be deleted
  • There are new time ranges assigned to each level of service for new and established office patients
  • History (HPI) and Exam will no longer affect the level of care being billed
  • Code selection will be driven by the “time spent” or the Medical Decision Making (MDM)
  • There is a new prolong service code payable for each 15 minute increment of prolong service for level 5 visits (high complexity)

There will be NEPHO monthly coding and billing webinars that will provide the most up to date information related to Telehealth coding and billing. Please reach out to Shawn Bromley if you have questions regarding Telehealth services and/or Telehealth coding and billing. shawn.m.bromley@lahey.org or 978-236-1704.

Coding Corner - November 2020

NEPHO 2020 Coding and Billing Highlights

NEPHO practices during 2020 were focused on managing COVID 19 and building a Telehealth program to better support patient access to care during the pandemic. NEPHO focused efforts in supporting practices during this unique time frame. Areas of focus included the following:

  • Telehealth Program Build
  • Practice Coding Support
    • Coding and Billing Webinars
    • Practice Coding Audits
    • Provider Education
  • COVID 19 Updates
  • Payer Updates
  • Practice Workflow Development

The rapid expansion of Telehealth services due to the pandemic came with a number of coding and reimbursement challenges for practices and providers. NEPHO practices and providers responded effectively to the pandemic and kept patient care as a priority. Many practices were delivering Telehealth services by April 2020. There were many challenges due to COVID 19 that impacted NEPHO practices at a business level. These challenges included the following:

  • Inconsistent payer rules
  • Implementing a HIPAA compliant Telehealth program
  • Reduction in practice resources due to decrease in practice revenue
  • Patient access to care during the state emergency directive
  • Limited knowledge of new coding and billing requirements due to COVID 19
  • Video/Audio vs. Audio only Telehealth services

NEPHO helped to support practices and providers overcome these challenges and focused on obtaining the most up to date information to better manage coding and billing. As 2020 progressed so did the development of a “new normal” for practices and providers. Patients have started to come back to the office but the implementation of Telehealth services has now brought an additional patient access source that is here to stay. As COVID-19 continues, payers at a state and national level are loosening restrictions around Telehealth and licensing requirements to make it easier for providers to deliver care. As we move towards 2021 NEPHO will keep Telehealth as an area of focused support to providers and practices. Having a solid understanding of the guidelines related to Telehealth services will be necessary to maximize reimbursement opportunity. The Telehealth service restrictions that payers lifted due to the pandemic have started to be put back in place and the Office of Inspector General (OIG) have listed Telehealth services on the 2021 work plan. There are best practices that can be put in place to better manage Telehealth services and stay compliant during this changing time frame.

HIPAA guidelines on Telehealth is contained within the HIPAA Security Rule and stipulates:

  • Only authorized users should have access to ePHI.
  • A system of secure communication should be implemented to protect the integrity of ePHI.
  • A system of monitoring communications containing ePHI should be implemented to prevent accidental or malicious breaches.

Why You Should Not Use SMS, Skype or Email for Telemedicine:

When ePHI created by a medical professional or a healthcare organization (covered entity) is stored by a third party, the covered entity is required to have a Business Associate Agreement (BAA) with the party storing the data. This BAA must include methods used by the third party to ensure the protection of the data and provisions for regular auditing of the data’s security.

Telehealth services are billed as a face-to-face visit E/M service when supported by audio/video technology. There are additional services that can be billed when audio/video is not available. The following services have been updated to help support patient access to healthcare:

Online Digital E&M Services

  • 99421 – Online digital E/M service, for an established patient for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422 – 11-20 minutes
  • 99423 – 21 or more minutes
  • (99421-99423 replaces 99444)

These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Report these services once during a 7-day period, for the cumulative time.

Non-Face-to-Face Services Audio Only

  • 99441 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
  • 99442 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.
  • 99443 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

Please reach out to Shawn Bromley if you would like to review your current Telehealth program or to discuss implementation of a HIPAA compliant Telehealth program moving into 2021. Contact shawn.m.bromley@lahey.org or 978-236-1704.

Coding Corner - October 2020

Diagnosis Capture and Documentation Complete the Patient Visit

Patient Risk Adjustment Factor (RAF) is reset annually on January 1, 2021. Accurate diagnosis coding and documentation contribute to a complete picture of patient health status. Complete documentation supports the patient medical status and diagnosis captured. The following support best practice to follow for complete visit documentation:

Elements of good clinical documentation

When documenting, it is useful to keep in mind the potential audience – clinical staff, other providers, payers and administration. This will help achieve clarity and allow you to focus on the details that are most relevant to include.

  • The basics of documentation:
    • Date, time and signature.
      • Timing of events and review is crucial in putting together the information regarding a patient’s health.
    • Include your name and title, add the names and titles of others present at the encounter.
    • Document immediately or as soon as possible after care is provided.
    • Prompt documentation reduces the risk of forgetting key details, and ensures all other team members are aware of any changes to a patient’s condition or management of care.
    • If you are returning to the patient’s notes later, document clearly in the heading that it was documented in retrospect with current date and time.
    • Document legibly.
    • Be thorough, accurate and objective.
    • Only use approved abbreviations
      • It is better to use to no abbreviations at all to avoid confusion.
      • If an addendum is made, communicate the change in documentation to other team members and clinical staff. Sign off any addenda with the time, date and full details.
    • Documentation mistakes
      • If a mistake is made, correct it with a single strikethrough, clearly sign and date the correction.
  • Documentation Examples:
    • Documenting a face-to-face visit based off time:
      In the office, a physician selects the level of service based on face-to-face time, when more than 50 percent of that time is spent discussing with the patient and family the diagnosis, prognosis, risk and benefits, instructions for management, and education. You can count only face-to-face time.
      An example of documenting based off time: “I spent 30 minutes with the patient and 50% of time was spent counseling and reviewing plan of care.”
    • Documenting a Telehealth visit:
      The technology used to conduct the visit via video/audio, the location of the provider conducting the visit, the patient name and location, include others on the video visit such as parent, spouse or care manager, verbal patient consent to have the visit conducted via telehealth video/audio (HIPAA compliant platform). The rest of the documentation will follow a face-to-face encounter requirements.
    • Documenting a telephone visit:
      It is important to document phone conversations with other medical teams and relatives of patients or clinical staff involved in the care of your patient.  After the phone conversation, write a note clearly stating who was involved in the conversation including their role. Document the clear question that was posed, and summarize the main information and points that were gained from the conversation. It’s important to note the pager number/telephone number of the person who was contacted to facilitate further contact if they need to be contacted again.
    • Important Areas of Documentation:
      • Principal diagnosis – the condition which after investigation was found to be the cause for the admission.
      • Co-morbidities – any conditions present on admission and treated. These conditions resulted in a change to the patient’s treatment, care or length of stay.
      • Complications – conditions which arose during the admission and affected the patient’s treatment and length of stay.
      • Procedures – surgical, non-operative, diagnostic, therapeutic procedures which required anesthesia, sedation or injected contrast.

Please contact Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org if you would like more information related to diagnosis capture and/or documentation requirements.

Coding Corner - September 2020

ICD-10 CM and CPT code updates due to COVID 19

Recent updated CPT codes approved by the American Medical Association (AMA) recently announced the addition of two more CPT codes in relation to COVID 19 and the Public Health Emergency (PHE):

  • 87426: Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semi quantitative, multiple-step method
  • 86408: COVID-19 Antibody
  • 86409: COVID-19 Antibody
  • 86413: COVID-19 Antibody
  • 99072: Miscellaneous Medicine Services
  • 0223U: Proprietary Laboratory Analyses (PLA) Codes
  • 0224U: Proprietary Laboratory Analyses (PLA) Codes
  • 0225U: Proprietary Laboratory Analyses (PLA) Codes
  • 0226U: Proprietary Laboratory Analyses (PLA) Codes

Updated ICD-10 CM codes approved due to the COVID 19 pandemic:

  • Confirmed case (symptomatic, asymptomatic, or presumptive positive) (U07.1)
  • Contact with COVID-19 (suspected exposure) (Z20.828)
  • Possible exposure, ruled out (Z03.818)
  • Asymptomatic (none or unsure of exposure), ruled out (Z11.59)

Risk Adjustment Coding Reminder:

ICD-10- CM Diagnosis Codes Reset January 1, 2021

The words “risk adjustment” often are paired with the acronym “HCC,” which stands for hierarchical condition categories. HCCs are diagnostic categories assigned based on diagnosis codes on encounter claims or by Medicare Advantage health plans. These categories filter patients into “buckets” that are clinically similar and are expected to have similar cost patterns to predict future healthcare costs.

  • Each patient is assigned a risk adjustment factor (RAF) score that is determined by multiple variables, including demographics and chronic diseases. The types of diseases that map to a CMS HCC are high-cost medical conditions and current conditions that impact the encounter in terms of requiring monitoring, evaluation, assessment, or treatment.
  • Diagnoses that are excluded from HCC mapping are those that do not predict future cost, such as appendicitis, and those that have a high degree of discretion or variability in diagnosis, diagnostic coding, or treatment, such as symptoms. Diagnosis codes from lab, radiology, and home health claims are not used because they are not reliable and may indicate rule-out diagnoses.
  • An important point to remember is that each condition must be mapped at least once in a calendar year. Each January, the facility starts with a “clean slate.” Each chronic non-resolving diagnosis that maps must be reported at least once during the calendar year, on a claim including a face-to-face visit with an acceptable type of provider and in an acceptable setting.

NEPHO will continue to help educate providers through the rest of 2020 to help continue efforts to impact the patient’s health status accurately and offer guidance on new updates coming in 2021.

  • The following coding education will be a focus as move into 2020 Quarter 4:
  • Evaluation and Management Updates 2021
  • ICD-10 CM Updates
  • Risk Adjustment Best Practice
  • How to Better Capture Chronic Conditions
  • NEPHO will be working with providers directly to address education opportunities and to ensure accurate coding and reporting of HCCs is continued through the year. Working together can help ensure compliance and optimal financial results under HCC risk adjustment contract models.

Through pre-visit and post-visit review of our NEPHO providers Diabetes with complications and COPD seem to be an area that are missed the most during follow-up visits. Capturing these chronic conditions help support a better patient budget while better supporting a patient’s health status. The following are examples of coding opportunity for some of the most commonly reported chronic conditions. The examples include documentation requirements supporting the condition(s) and ICD-10-CM code(s) as well as tips to accurately document the condition:

  • Diabetes with Hyperglycemia & Diabetes is not controlled. Patient unable to keep blood sugar (BS) low enough. The provider will adjust insulin and see patient for follow up in two weeks. The provider asked the patient to keep log of daily BS during this time frame:
    • ICD-10-CM Codes • E11.65– Type 2 Diabetes Mellitus with Hyperglycemia. • Z79.4– Long-term (current) use of insulin.
    • Documentation/ Coding Tips • E11(Type 2 Diabetes Mellitus) must document type I or II
    • Hyperglycemia – not controlled/uncontrolled diabetes Z79.4 – code to indicate patient uses insulin
  • Assessment/Plan Acute exacerbation of COPD with acute bronchitis due to patient smoking. Provider Advises patient on smoking cessation, increases prednisone, prescribed antibiotic and increased nebulizer treatments to every two to four hours. Follow up in five days or sooner if symptoms worsen.
    • Documentation/ Coding Tips Four codes are required for the scenarios above:
      • J440.0– COPD with acute lower respiratory infection
      • J20.9– Acute bronchitis, unspecified
      • J44.1– COPD with (acute) exacerbation
      • F17.218 – Nicotine dependence, cigarettes, with other nicotine-induced disorder

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org or call 978-236-1704 if you would like to learn more about the new codes updates and/or Risk Adjustment Coding capture.

Coding Corner - August 2020

Get Ready for ICD-10 Clinical Modification (CM) Updates 

The new 2021 ICD-10 CM codes have been released and updates are set to be significantly larger than 2020.
Updates will be effective on October 1, 2020.

Summary of updates by chapter are:

  • Chapter 1: Certain Infectious & Parasitic Disease
    • Has a new section for reporting Coronavirus infections.
  • Chapter 3: Diseases of Blood & Blood-forming organs
    • Has 18 new, detailed codes available for sickle cell anemia.
  • Chapter 4: Endocrine, Nutritional & Metabolic Disease
    • Includes new coding instructions to follow for diabetic patients treated with insulin, oral hypoglycemics and injectable non-insulin drugs
  • Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders
    • Contains 21 new codes that describe withdrawal from substances including alcohol, cocaine, and opioids.
  • Chapter 6: Diseases of the Nervous System
    • Has added “pseudotumor” as a clarifying term to G93.2 (Benign intracranial hypertension).
  • Chapter 9: Diseases of the Circulatory System
    • Contains many revisions to the “includes” and “excludes” notes for existing codes.
    • A new hypertension guideline provides instruction that when a patient has hypertensive chronic kidney disease and acute renal failure, code both conditions and sequence the codes based on the reason for the encounter.
  • Chapter 10: Diseases of the Respiratory System
    • Now has code also instructions for cases of acute laryngitis and tracheitis (J04) and acute obstructive laryngitis (croup) and epiglottitis (J05).
    • This chapter also has a new section specifically for vaping-related disorders.
  • Chapter 13: Musculoskeletal System
    • Several updates this year including 12 new codes to capture other pathological fractures (M80.8AX- and M80.0AX-).
    • Updates include an expanded list of codes for rheumatoid arthritis, as well as primary and secondary arthritis, and arthritis caused by trauma.
    • New codes in the M24 category for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture and ankyloses.
  • Chapter 14: Disease of Genitourinary
    • Has two new sub-stages to Stage 3 chronic kidney disease (CKD).
    • New codes are: N18.30 (Chronic kidney disease, stage 3 unspecified), N18.31 (Chronic kidney disease, stage 3a) and N18.32 (Chronic kidney disease, stage 3b).
  • Chapter 15: Pregnancy, Childbirth, and the Puerperium
    • Contain new language that warns coders they should not report O85 for sepsis that follows an obstetrical procedure.
      • A note points them to the Sepsis due to a postprocedural infection of Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99), U07.1
    • There is a new section that provides instruction on reporting COVID-19 infections in pregnancy, childbirth, and the puerperium
  • Chapter 16: Certain Conditions Originating in the Perinatal Period
    • Has a new section for reporting COVID-19 Infections in newborns.
  • Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
    • Has several changes. Code R51 (Headache) will be split into two codes: R51.0 (Headache with orthostatic component, not elsewhere classified) or R51.9 (Headache, unspecified).
  • Chapter 19: Injury, poisoning & certain other consequences
    • Has 128 additions that include new codes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics.
  • Chapter 21: Factors influencing health status and contact with health services
    • Include new observation language.
    • The new language creates a second exception to the rule that observation codes are primary.
    • Guidelines state, “An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis.”
  • NEW Chapter 22: Codes for Special Purposes
    • (U00-U85) includes just two codes: U07.0 Vaping- related disorder and U07.1 COVID-19, these codes took effect in the earlier this year.

2021 ICD-10 CM Code Changes

NEPHO will be providing Coding and Billing provider and practice education webinars that are focused on the new ICD-10 CM changes effective October 1, 2020. Webinars will provide a detailed review of the official ICD-10 CM coding guidelines, highlight areas of significant change, and address areas that have been impacted due to COVID 19. Please contact Shawn Bromley at 978-236-1704 and/or shawn.m.bromley@lahey.org if you are interested in learning more about the specific changes coming and how they will impact your specific practice.

Coding Corner - July 2020

Get Your Practice Prepared for the 2021 Evaluation and Management (E/M) Updates

The 2021 E/M updates will provide significant potential to give physicians more time to spend with their patients by reducing the documentation burden. The focused changes include:

  • Eliminating history and physical exam elements for code selection
  • Allowing physicians to choose whether their documentation is based on MDM or total time spent
  • Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition

NEPHO is working to help support practices implement the 2021 E/M updates. Centers for Medicare and Medicaid Services (CMS) has confirmed the new direction, which would mark the first significant revision to the E/M code set from Medicare in more than 20 years. Because E/M services are at the heart of practice revenue, these changes will have an impact to current E/M payment policies and documentation guidelines. Practices need to understand updates to be fully prepared by the effective date of January 1, 2021.

NEPHO’s Education Plan for E/M 2021 Updates:

  • Monthly Webinars Focused on the Following Areas:
    • E/M Updated Guidelines Overview
    • Medical Decision Making (MDM) Table Updates
    • Complexity of Problems Addressed Review
    • 2021 MDM Terms and Definitions
    • Prolonged Services Update
    • Staying Compliant

Practices are encouraged to start planning now for the operational, infrastructural, and administrative workflow adjustments that will result from this E/M overhaul.  NEPHO has put together the following checklist to help practices make a plan for implementation of E/M updates:

  • Identify a Project Lead
  • Schedule Practice Team Preparation Time
  • Update Practice Procedures
  • Consider Coding Support
  • Have an Awareness of Medical Malpractice Liability
  • Guard Against Fraud and Abuse Law Infractions
  • Update your Practice Compliance Plan
  • Meet with your Electronic Health Record (EHR) Vendor
  • Assess the Potential Financial Impact
  • Understand Employer and Payer Guidelines

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you would like to set up time to discuss next steps in making a practice plan to prepare for the new E/M changes coming 2021.

Coding Corner - June 2020

Risk Adjustment Coding Capture Guidance for Telehealth Services

CMS allows Medicare Advantage organizations and other organizations that submit diagnoses for risk adjusted payment to include diagnosis captured during a Telehealth visit when those visits meet all criteria for risk adjustment eligibility (Same as Face-to-Face visit). Diagnoses resulting from telehealth services can meet the risk adjustment Face-to-Face requirement when the services are provided using and audio/video interactive real-time communication. The inclusion of diagnoses for risk adjusted payment when using Telehealth will allow for a more accurate calculation of patient risk adjustment scores.

Here are a few examples detailing how to better support documentation and risk adjustment coding for chronic conditions during a Face-to-Face visit and Telehealth visit:

  • Document plan of care for chronic conditions, condition status
    • Example: A Fib I48.91 – heart rate within normal limits, converting back to normal sinus rhythm, apixaban is helping to regulate heart rate
  • Chronic conditions need to be captured/recaptured annually
    • Example: Depression (F33.8) or depression in remission (F33.4), Opioid dependence (F11.20) or opioid dependence in remission (F11.21)
      • Depression: when depression has stabilized coding depression in remission would be appropriate
  • Chronic conditions should be discussed and documented during a new patient visit
    • Example: New patient visit with the following chronic conditions: Hypertension I10, CKD state 3 N18.3, Recurrent depressive disorder F33.8, Opioid dependence in remission F11.21
  • Document confirmed chronic conditions to their highest specificity
    • Example: Diabetes with CKD stage 3: E11.22, N18.3 (1st code diabetes with chronic kidney disease then code chronic kidney disease)

The following grid highlights the Top 10 Risk Adjustment Condition Categories that are being captured during a Face-to-Face visit versus a Telehealth visit. This provides an overview of the chronic condition focus during each patient visit type:
When providers capture chronic conditions accurately they support quality patient care and risk adjustment coding. The use of Telehealth for management of chronic conditions and risk adjustment coding capture can benefit both the patient and providers in the following ways:

  • Treatment Plan Management: The treatment of chronic conditions sometimes involves changes to the patient’s lifestyle. Weight management, smoking cessation, conditions specific dietary changes, and other behavioral changes all support patient healthy living. Using telehealth to conduct visits helps to stay on top of the treatment plan management and will increase the changes for a positive impact on the patient health outcome.
  • Medication Management: Patients with chronic conditions often need more than one medication. Telehealth medication management takes the burden of multiple visits off the patient, making it easier for them to balance their need for treatment.
  • Triage: There are times chronically ill patients react by seeing providers very frequently, while other patients ignore new symptoms until they become serious. The option to have a Telehealth visit to determine if a symptom is normal or needs more attention. This triage can help support the provider in making an appropriate clinical decision. This will help address issues in a timely manner.

While the risk adjustment eligibility for telehealth visits is close to that of in person visits, there are some key limitations to the video visit:

  • Most in-person diagnostic tests, such as PAD testing or spirometry, are not being performed
  • Blood pressure, BMI, and other portions of the physical exam are infrequently documented
  • Some tests can be mailed to members, such as a FIT kit, but delivery returns drive the completion to document

Capturing a patient’s true health status is an ongoing effort for the providers. Diagnosis capture helps support the patient’s health status and ensures their risk score is accurate for their health care delivery.  Risk adjustment coding capture needs to continue to be a focused effort by providers during a Face-to-Face visit or a Telehealth Video visit to complete the patient’s true health story.

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org and/or 978-236-1704 if you would like to review risk adjustment coding capture in more detail.

References:

https://www.sheppardhealthlaw.com/2020/04/articles/centers-for-medicare-and-medicaid-services-cms/cms-issues-guidance-on-risk-adjustment-and-telehealth-services/

Coding Corner - May 2020

Overview of Evaluation and Management (E/M) Changes Coming in 2021

E/M changes are coming in 2021. The changes focus on documentation-related updates for office/outpatient E/M visits (CPT codes 99201 through 99215). The following changes will be effective January 1, 2021:

  • Deletion of level outpatient visit CPT code 99201: Code 99201 Office or other outpatient visit for the evaluation and management of a new patient, will be deleted due to low utilization.
  • History and exam will not be a necessary element of office/outpatient E&M code selection: History and exam elements will no longer be factored into office/outpatient E&M code selection, though they will be necessary to report the office/outpatient E&M service. Instead, the codes will be selected either by total time or by level of medical decision-making.
  • “Time” definition has changed: The definition of time associated with 99202-99215 has been changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Starting 2021, physicians will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each office/outpatient E&M code will reflect the total time spent on the day of the visit.
  • Revisions to the MDM elements associated with codes 99202-99215: There will be changes to the language of the MDM elements:
    • “Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
    • “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
    • “Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management”
  • Additional E/M documentation changes: Guidelines for hospital observation, hospital inpatient, consultations, Emergency Department, nursing facility, domiciliary, rest home, custodial care, and home E&M services will not change.
  • Guideline Update for Office or Other Outpatient codes 99202-99215:
    • Adding new guidelines that are applicable only to Office or Other Outpatient codes 99202-99215; adding a Summary of Guideline Differences table of the differences between the different sets of guidelines.
    • Adding a MDM table applicable to codes 99202-99215.
    • Adding guidelines for reporting time when more than one individual performs distinct parts of an E/M service.
  • Changes to Prolonged Services: Proposed updates include:
    • Revising codes 99354 and 99355 to exclude reporting of Office and other Outpatient Services codes.
    • Revising code 99356 to include observation.
    • Adding a new code to report prolonged office or other outpatient E/M services.
  • These updates will have implications for documenting E/M services and assigning codes. Payers, including Medicare, have their own set of guidelines for claim submission.  Physicians need to be knowledgeable about payer guidelines and policies to ensure accurate CPT coding and error-free claim submission.
  • Implement Changes Effectively:
    • Designate a practice/project lead
    • Allow for preparation time
    • Educate team on coding and documentation changes
    • Connect with your EHR vendor
    • Update practice policies and workflow documents
    • Understand Medicare and commercial payer requirements
    • Review the potential practice financial impact related to changes
    • Have an understanding of RVU updates and fee schedule changes
    • Review documentation changes with your medical malpractice liability insurer
    • Stay compliant with federal and state regulations

Please contact Shawn Bromley at 978-236-1704 and/or shawn.m.bromley@lahey.org if you would like to discuss a plan to get your practice ready for the E/M changes coming January 1, 2021.

Coding Corner - March 2020

In an effort to keep all NEPHO providers up to date with COVID-19 news we are providing detail to the new ICD-10 CM codes that have been released by the CDC. These new codes will support tracking of the virus and support medical management of virus containment. Important links are provided to keep all providers current with COVID-19 updates. In addition I have attached a detailed summary of current Telehealth coding and billing information to help support reimbursement for Telehealth services.

Please reach out to me directly with questions regarding these new coding and billing updates – all providers need to check in with their system vendors and billing/coding vendors to ensure updates have been made to systems and billing and coding is current.

Thank you,
Shawn M. Bromley@Lahey.org
978-236-1704

Announcement:

The CDC released the official diagnosis coding guidance for encounters and deaths related to the 2019 novel coronavirus (COVID-19), effective February 20, 2020.

COVID-19 infections cause a range of illness severity, from no symptoms to severe illness and potentially death. Coronavirus symptoms include fever, cough, and shortness of breath and may appear between two and 14 days after exposure.

This guidance is intended to be used in conjunction with current ICD-10-CM classifications and will be updated to reflect new clinical information as it becomes available. The codes provided are intended to give information on the coding of encounters related to COVID-19; other codes for conditions unrelated to coronavirus might be required to fully code scenarios in accordance with ICD-10-CM Official Guidelines for Coding and Reporting.

For confirmed cases of pneumonia due to COVID-19, use codes:

  •  J12.89, Other viral pneumonia, and
  •  B97.29, Other coronavirus as the cause of diseases classified elsewhere

For confirmed cases of acute bronchitis due to COVID-19, use codes:

  •  J20.8, Acute bronchitis due to other specified organisms, and
  •  B97.29, Other coronavirus as the cause of diseases classified elsewhere

For bronchitis not otherwise specified (NOS) due to COVID-19, use codes:

  • J40, Bronchitis, not specified as acute or chronic, along with code
  • B97.29, other coronavirus as the cause of diseases classified elsewhere

For lower respiratory infections, NOS, or an acute respiratory infection, NOS,
with associated documented COVID-19, assign codes:

  • J22, Unspecified acute lower respiratory infection, with code
  • B97.29, Other coronavirus as the cause of diseases classified elsewhere

For respiratory infections, NOS, with associated documented COVID-19, use codes:

  • J98.8, Other specified respiratory disorders, with
  • B97.29, Other coronavirus as the cause of diseases classified elsewhere

For confirmed acute respiratory distress syndrome (ARDS) due to COVID-19, assign codes:

  • J80, Acute respiratory distress syndrome, and
  • B97.29, Other coronavirus as the cause of diseases classified elsewhere

To code a concern about COVID-19 exposure that was ruled out after evaluation, use code:

  • Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out

To code actual COVID-19 exposure with a confirmed coronavirus case, assign code:

  • Z20.828, Contact with and (suspected) exposure to other viral communicable diseases

For patients presenting with symptoms where a definitive coronavirus diagnosis is not established,
assign the appropriate codes for each presenting symptom, such as:

  • R05, Cough
  • R06.02, Shortness of breath
  • R50.9, Fever, unspecified

Diagnosis code B34.2, Coronavirus infection, unspecified, would not generally be appropriate for COVID-19 because confirmed cases have universally been respiratory in nature, so the site would not be unspecified.
According to the new guidelines, do not assign code B97.29 if the provider documents “suspected,” “possible,” or “probable” COVID-19. Instead, assign codes explaining the reason for the encounter (such as fever, or Z20.828).

https://journal.ahima.org/new-icd-10-cm-code-for-covid-19-becomes-effective-october-1/

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf

Coding Corner - February 2020

New 2020 CPT Updates And Changes Coming In 2021

Understanding the new 2020 Evaluation and Management (E/M) changes will help to optimize reimbursement within your practice. Changes are effective January 1, 2020.  CPT developed three new CPT codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform.

Online digital E/M Service

99421 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422            11—20 minutes
99423            21 or more minutes

These codes are for use when E/M services are performed, type that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

  • Report these services once during a 7-day period, for the cumulative time.
    “The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician  or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.”

  •  Other requirements: 
    • The interaction must be documented in the permanent record.
    • If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
    • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
    • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
    • This is for established patients, per CPT®.
    • This may not be billed by surgeons during the global period.
    • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.
  • Additionally:
    • These services may only be reported once in a 7-day period.
    • Clinical staff time may not be included.
    • Don’t double count time with any other separately reported services, such as care management, INR monitoring, remote monitoring. (CPT book has a list of codes)

Blood pressure self-measurement: patient education, training, and analysis:

  • Two new CPT codes in 2020. The first is for patient education and calibration of a home blood pressure device
  • The second is for reviewing data collected by the patient at home, with a report and communication back to the patient
  • These join existing CPT codes for remote monitoring, but these are based on the patient’s self-measurement and reporting

99473: Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration

99474: separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

Remote Physiologic Monitoring (RPM) has a new 20 minute code and allows remote care managers to bill an additional 20 minutes

99458, which pays for an additional 20 minutes of clinical care management time relating to vitals monitoring. This 99458 code is in addition to the existing CPT 99457 code for the first 20 minutes.


E/M Changes coming in 2021:

The changes are only impacting E&M codes 99201 through 99215. In particular, code 99201 is being eliminated entirely. Providers now will be allowed to select the level of service based on time or medical decision-making (MDM) only history and exams will still be documented, but they will not be considered in the selection of the level of service. There are several things you need to look at as you put together your preparation plan for the next year.

  • Understand the guidelines and what E&M codes will impact current workflow.
  • Updates will need to be made to electronic medical record (EMR) templates to support correct documentation.
  • Have an understanding of the financial impact to your practice by implementing these changes.
  • Practices will need to work directly with outside vendors to ensure a clear understanding of coding updates within the system they use.
  • Begin to think about a communication plan and establish a timetable for successful implementation.

NEPHO will be working to help prepare providers on new requirements.

Please reach out directly to Shawn Bromley at Shawn.M.Bromley@Lahey.org or 978-236-1704 if you have questions regarding the new 2020 E/M updates or would like to start reviewing changes that will need to take place at a practice level for the 2021 E/M coding changes.

Coding Corner - January 2020

Transitional Care Management Coding and Billing Update

Transitional care management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making. TCM services involve a transition of care from one of the following hospital settings:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility
  • Inpatient rehabilitation facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a community mental health center

The transition necessitates management services, and there is an ascertained level of risk due to the nature of the patient’s condition. The responsibility for patient care rests with the healthcare professional overseeing transitional care services and the medical facility must be able to demonstrate that the patient’s psychosocial or medical issues necessitate intervention.

There are 2 CPT codes that may be used to report TCM:

99495: The patient requires “moderate medical decision complexity” within 14 calendar days of discharge

99496: The patient requires “high medical decision complexity” within 7 calendar days of discharge

In addition, all TCM services must meet required criteria in order to be deemed successful and thus qualify for reimbursement. Criteria includes:

  1. Interaction within two days of discharge, with exceptions set for those situations wherein the assigned case manager or medical professional is unable to reach the patient
  2. Non face-to-face services, typically things like review of tests and procedures, provision of educational materials, and assistance with appointment scheduling and community resources assignment.
  3. A face-to-face visit that must occur within either 14 days (moderate complexity cases) or 7 days (high complexity cases). Click here for the MLN Fact Sheet.

Reimbursement is greater than routine E/M visits and helps to reduce readmission cost:

Please contact Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org for more information regarding TCM coding and billing requirements.

Online digital evaluation and management (E/M) services

In the 2020 CPT book, CMS is deleting code 99444, which was defined as an online E/M service by a physician or other qualified health care professional. CPT is adding three new time-based codes for online evaluation and treatment, for use by clinicians who have E/M in their scope of practice:

  • 99421  For an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
  • 99422  11—20 minutes
  • 99423  21 or more minutes

Report these services once during a 7-day period, for the cumulative time according to CPT. These codes are for use when E/M services are performed, type that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Other requirements:

  • The interaction must be documented in the permanent record.
  • If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
  • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
  • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
  • This is for established patients, per CPT®.
  • This may not be billed by surgeons during the global period.
  • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.

 

2019 Coding Corner

Coding Corner - December 2019 Edition

Diagnosis Capture and Documentation Complete the Patient Health Story

Patient Risk Adjustment Factor (RAF) is reset annually. Accurate diagnosis coding contribute to a complete picture of patient health status. As more payers move towards risk adjusted payment models the need to code accurately is necessary for total medical expense control.

Elements of good clinical documentation

When documenting, it is useful to keep in mind the potential audience – clinical staff, other providers, payers and administration. This will help achieve clarity and allow you to focus on the details that are most relevant to include.

The basics of documentation:

  • Date, time and signature.
    • Timing of events and review is crucial in putting together the information regarding a patient’s health.
    • Include your name and title, add the names and titles of others present at the encounter.
    • Document immediately or as soon as possible after care is provided.
  • Prompt documentation reduces the risk of forgetting key details, and ensures all other team members are aware of any changes to a patient’s condition or management of care.
  • If you are returning to the patient’s notes later, document clearly in the heading that it was documented in retrospect with current date and time.
  • Document legibly.
  • Be thorough, accurate and objective.
  • Only use approved abbreviations.
    • It is better to use no abbreviations at all to avoid confusion.
    • If an addendum is made, communicate the change in documentation to other team members and clinical staff. Sign off any addenda with the time, date and full details.
  • Documentation mistakes
    • If a mistake is made, correct it with a single strikethrough, clearly sign and date the correction.
  • The SOAP Documentation method (Subjective, Objective, Assessment, Plan):
    • Subjective
      • This section describes the patient’s current condition in a narrative form. Include the patient’s chief complaints, including onset, chronology, quality, and severity. It is important to document what the patient tells you about how they are feeling, in their own words. Use quotations if appropriate, using quotation marks.
    • Objective
      • Here, you should document objective, repeatable and measurable facts about the patient’s status.
      • You may include objective observations about how the patient appears from the end of the bed. For example, “Patient appears pale and in discomfort”.
      • In this section, also include observations and vital signs.
      • Findings from physical examination, For example, “Widespread expiratory wheeze on auscultation of the chest”.
      • If relevant, also include laboratory results, fluid balance (urine, IV fluids, NG feeds, drain outputs) and other measurements (age/weight).
    • Assessment
      • Summarize the primary medical diagnosis in this section. If the diagnosis has already been made, comment on whether the patient is clinically improving or deteriorating. For example,“Impression: Resolving community acquired pneumonia”.
      • A complete list of all diagnoses and issues should ideally be completed in this section every 1-2 days, or whenever a new issue arises. This is extremely useful, especially for after-hours staff that may need to rapidly assess a deteriorating patient.
    • Plan
      • Document a clear plan, including further investigations, referrals procedures, new medications to be charted.
      • If possible, include an estimated discharge date.
      • Information for your Nursing Unit Manager to plan for the week.
  • Documentation Examples:
    • Documenting a phone conversation
      It is important to document phone conversations with other medical teams and relatives of patients or clinical staff involved in the care of your patient.  After the phone conversation, write a note clearly stating who was involved in the conversation including their role. Document the clear question that was posed, and summarize the main information and points that were gained from the conversation. It’s important to note the pager number/telephone number of the person who was contacted to facilitate further contact if they need to be contacted again.
    • Documenting a family meeting
      Clear documentation is especially crucial in this setting as often key management discussions take place which can change the course of a patient’s care. Begin by documenting exactly who is present in the meeting, and their roles (family members, medical staff, and/or social worker). Document if a translator is present for the meeting. List each point as it was discussed and the general decisions that are made about each. Use quotations where relevant, using quotation marks. Summarize with the key agreements that were made at the conclusion of the meeting. Then, clearly document a plan forward – whether there has been a change in the patient’s treatment plan, or whether it is for ongoing discussion at a later stage.
    • Documenting a mistake
      Rather than brushing over them or attempting to hide them, all mistakes must be formally documented to maintain transparency and so that the appropriate action can be taken. Document exactly what happened, including all persons involved. Document your assessment of the patient immediately afterwards (this is particularly relevant in the case of medication errors). Document if an incident report was logged.

      • Principal diagnosis – the condition which after investigation was found to be the cause for the admission.
      • Co-morbidities – any conditions present on admission and treated. These conditions resulted in a change to the patient’s treatment, care or length of stay.
      • Complications – conditions which arose during the admission and affected the patient’s treatment and length of stay.
      • Procedures – surgical, non-operative, diagnostic, therapeutic procedures which required anesthesia, sedation or injected contrast.

Please contact Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org if you would like more information related to diagnosis capture or documentation requirements.

Coding Corner - November 2019 Edition

CPT Coding Updates Effective January 1, 2020

Effective on January 1, 2020 are the new CPT code updates.  There are 394 changes, including 248 new codes, 71 deletions and 75 revisions. It is important to be aware of these changes as they impact correct coding and reimbursement for provided services. NEPHO is in the process of researching guidelines to ensure accurate education rollout of these new updates. Please contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you would like to have an education session at your practice and/or have questions related to these 2020 updates. There are many new updates to the Surgery Section of CPT and having a solid understanding of the changes is necessary for accurate coding and billing.

Updates include the following:  Click here to print this information

  • 6 new CPT codes to report online digital E/M service: These codes are for use when Evaluation and Management (E/M) services are performed, types that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by providers who bill E/M services. 99421, 99422 and 99423 describe patient-initiated digital communications with a physician or other qualified health professional and 98970, 98971 and 98972 represent patient-initiated digital communications with a nonphysician health professional.
  • Additional requirements for 99421, 99422 and 99423:
    •  The interaction must be documented in the permanent record.
    •  If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
    • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
    • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
    • This is for established patients, per CPT.
    • This may not be billed by surgeons during the global period.
    • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.
  • 2 new codes for home blood-pressure monitoring: Also spurred by the popularity of digital health tools, new codes 99473 and 99474 will allow reporting self-measured blood pressure monitoring. Tracking blood pressure at home helps patients take an active role in the process and enables physicians to better diagnose and treat hypertension.
  • Updates for health and behavior assessment and intervention services: New codes 96156, 96158, 96164, 96167, and 96170, and add-on codes 96159, 96165, 96168, and 96171 for health and behavior assessment and intervention services will replace six older codes. This update is
    intended to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.
  • Significant enhancements for reporting long-term electroencephalographic (EEG) monitoring services (95700-95726): Monitoring the electrical activity of the brain is critical to diagnose epilepsy. Four older codes have been deleted to make way for 23 new codes for long-term electroencephalographic (EEG) monitoring services.
  • Surgical Section Updates:
    • Grafting: Watch for four new codes for grafting of autologous fat harvested by liposuction, 15771-15774. The codes vary based on the amount of injectate and the grafting site. The 2020 code set deleted 20926 for other tissue grafts, but added 15769 (Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)).
    • Needle insertions: Dry needling will have two new codes with 20560 (1-2 muscles) and 20561 (3 or more muscles) representing needle insertion without injection.
    • Drugdelivery devices: There will be six new add-on codes, +20700-+20705, related to drug-delivery devices. Three codes are for manual preparation and insertion, varying based on deep, intramedullary, or intra-articular placement. There will be three additional codes for removal based on those same locations. Report these codes along with the appropriate primary surgical procedure.
    • Chest wall tumor excision: New codes for chest tumor excision are 21601-21603 and deleted are 19260, 19271 and 19272.
    • Nasal/sinus endoscopy: Several nasal/sinus endoscopy codes will carry the triangle symbol that indicates a revision for 2020. The AMA reworked the descriptors so the codes can be arranged into more specific families. 31295-31298 will no longer have just “Nasal/sinus endoscopy, surgical” before the semicolon in the descriptor. All will start with the phrase “Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation)” before the semicolon.
    • Pericardial services: The 2020 code set will replace pericardiocentesis codes 33010 and 33011 with 33016, which includes any imaging guidance. Code 33015 for tube pericardiostomy is deleted. Pericardial drainage codes include 33017-33019.
    • Pacemaker removal: A revision to 33275 brings the existing guideline that the code includes imaging guidance into the descriptor for this leadless pacemaker removal code.
  • Surgical Section Update (cont.)
    • Aortic arch grafts: Ascending aorta graft code 33860 will be replaced by 33858 (for aortic dissection) and 33859 (not for dissection). In place of 33870, watch for more detailed code 33871 (Transverse aortic arch graft, with cardiopulmonary bypass, with profound hypothermia, total circulatory arrest and isolated cerebral perfusion with reimplantation of arch vessel(s) (eg, island pedicle or individual arch vessel reimplantation)).
    • Endovascular repair: Deleted 0254T for iliac artery bifurcation endovascular repair. CPT 2020 will have +34717 and 34718 for deployment of an iliac branched endograft. You’ll use +34717 as an add-on code with iliac endovascular repair codes 34703-34706. Code 34718 will be a standalone code for iliac repair “not associated with placement of an aorto-iliac artery endograft at the same session.”
    • Artery exploration: Artery exploration without surgical repair has updated but there is still 35701, but it will change from carotid only to cover any neck artery, with carotid and subclavian. 35702 for the upper extremity and 35703 for lower extremity services. Codes 35721 (femoral), 35741 (popliteal), and 35761 (other) will be deleted.
    • Hemorrhoidectomy: Internal hemorrhoidectomy coding has changes for 2020 that include; Ligation codes 46945 and 46946 will have the phrase “without imaging guidance” added to the descriptors. A new code, 46948, provides a specific option for transanal dearterialization of two or more hemorrhoid columns or groups, including ultrasound guidance.
    • Pelvic packing: New codes for preperitoneal pelvic packing with exploration are 49013 and re-exploration of the wound with packing removal and any repacking 49014.
    • Orchiopexy: Code 54640 has been updated in 2020. Before 2020, the descriptor referred to inguinal orchiopexy with or without hernia repair, suggesting the code included hernia repair. But CPT guidelines instructed you to report the services separately: “For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525.” The 2020 code set keeps that guideline to report the services separately and clarifies the descriptor by removing the hernia reference: “Orchiopexy, inguinal or scrotal approach.”
  • Spinal puncture: There will be an imaging guidance update for spinal puncture. Continued codes are 62270 (lumbar diagnostic) and 62272 (therapeutic), but you’ll also have new options 62328 and 62329 for when those services respectively use fluoroscopic or CT guidance.
  • Nerve injection: The update is that the descriptor wording before the semicolon changes from “Injection, anesthetic agent” to “Injection(s), anesthetic agent(s) and/or steroid.” This change affects every code in the code family. Some of the codes within the code family will see individual updates, such as deletion of 64402 (facial nerve), 64410 (phrenic nerve), and 64413 (cervical plexus).             
  • Additional revisions include:
    • Code 64400 will change from “trigeminal nerve, any division or branch” to “trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)”
    • Codes 64415 (brachial plexus), 64445 (sciatic nerve), and 64447 (femoral nerve) will remove “single” from their descriptors
    • Code 64420 will add “level” to become “intercostal nerve, single level”
    • Code 64421 will become an add-on code for 64420 and change from “multiple, regional block” to represent “each additional level”
    • There will be two new codes, 64451 for “nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)” and 64454 for “genicular nerve branches, including imaging guidance, when performed.”
  • Nerve destruction: The sacroiliac (SI) joint and genicular nerves mentioned above get additional attention in two more new codes: 64624 for genicular nerve branch destruction by neurolytic agent, including imaging guidance if used and 64625 for radiofrequency ablation of nerves innervating the SI joint, with imaging guidance.
  • Ciliary body destruction: Code 66711 will add “without concomitant removal of crystalline lens” to the end of the current descriptor, “Ciliary body destruction; cyclophotocoagulation, endoscopic.” When there is lens removal, guidelines will direct to new codes 66987 and 66988.
  • Cataract removal: Code 66984 and complex removal code 66982 will each have “without endoscopic cyclophotocoagulation” added to the ends of their descriptors. This change makes room for the addition of 66987 (complex) and 66988 for the removal procedures with endoscopic cyclophotocoagulation.

 

Coding Corner - October 2019 Edition

The ICD-10 CM changes and updates will be effective on October 1, 2019.

The new changes include the following updates:

  • 273 new codes
  • 30 revised codes
  • 21 deleted codes
  • 1500 changes to complication or comorbidity/major complication or comorbidity (CC/MMC) designation
  • Most severity changes are downgrades

Areas that have significant changes include; pressure-induced deep tissue damage, acute versus chronic embolism and thrombosis, fractures of the facial bones around the eye, among other changes highlighted below:

2020 ICD-10 CM Coding Highlights:

  • Eye wall fractures. Sixty new acute fracture codes for closed and open fractures of the orbital wall surrounding the eye, specific to laterality and position around the eye. Example: New code S02.831B will report fracture of medial orbital wall right side, initial encounter for open fracture.
  • Deep tissue injuries. A total of 25 new codes are proposed to be added to specifically capture deep tissue injuries, such as L89.026 (Pressure-induced deep tissue damage of left elbow) and L89.156 (Pressure-induced deep tissue damage of sacral region). Deep tissue injuries currently are coded as unstageable pressure ulcers, which is incorrect by definition, according to the proposal.
  • Atrial fibrillation. Four new codes in the I48.- category are proposed to capture different forms of persistent and chronic atrial fibrillation, such as I48.11 (Longstanding persistent atrial fibrillation) and I48.21 (Permanent atrial fibrillation).
  • Phlebitis and thrombophlebitis. Eight new codes for phlebitis and thrombophlebitis that will allow more specific coding for laterality and location, such as I80.241 (Phlebitis and thrombophlebitis of right peroneal vein).
  • Embolism and thrombosis. New codes to allow reporting of chronic embolism and thrombosis of the peroneal vein and calf muscular vein as well as new codes for acute embolism and thrombosis of those veins. The codes will also be selected based on laterality. For example: Code I82.451 describes acute embolism of right peroneal vein, while I82.562 describes chronic embolism and thrombosis of left calf muscular vein.
  • Poisoning, adverse effects and underdosing. The proposed update includes 18 new T codes for poisoning, adverse effects or underdosing of multiple unspecified drugs, medicaments and biological substances. You’ll use the appropriate seventh character to describe the encounter: initial, subsequent or sequela. The new poisoning codes are divided into four causes: accidental, intentional, assault and undetermined. For example, T50.913S (Poisoning by multiple unspecified drugs, medicaments and biological substances, assault, sequela).
  • Heatstroke. Summer will be over when the new codes go live, but you’ll have options for heatstroke and sunstroke (T67.01X-), exertional heatstroke (T67.02X-), and other heatstroke and sunstroke (T67.09X-).
  • Legal intervention. There will be 75 new codes for injuries sustained during a legal intervention. Many of the additions are to be used to indicate that an unspecified person was injured. For example, Y35.319A (Legal intervention involving baton, unspecified person injured, initial encounter). The current code set describes injuries to law enforcement officers, bystanders or suspects. In addition, there are new codes for injuries caused by conducted energy devices, such as tasers. Codes Y35.831A-Y35.839S describe injuries to law enforcement officials, bystanders, suspects or unspecified individuals.
  • New Z codes. You’ll find a handful of new codes for factors influencing health status and contact with health services. Proposed codes include Z01.020 (Encounter for examination of eyes and vision following failed vision screening without abnormal findings), Z22.7 (Latent tuberculosis), six new personal history of in-situ neoplasms codes (Z86.002-Z86.007) and one code for the presence of a neurostimulator (Z96.82).

Revisions:

  • Codes under T40.906– (Underdosing of unspecified psychodysleptics) and T40.996– (Underdosing of other psychodysleptics) were revised to include the term “[hallucinogens]” in the title.
  • Codes under T44.1×6– (Underdosing of other parasympathomimetics) were revised to include the term “cholinergics” in the title.
  • Codes M77.51 (Other enthesopathy of right foot) and M77.52 (Other enthesopathy of left foot) were revised to include the terms “and ankle” in the title.
ICD-10-CM chapter New Revised Invalid
Chapter 1: Certain infectious and parasitic diseases (A00-B99) 0 3 0
Chapter 2: Neoplasms (C00-D49) 0 0 0
Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 5 0 1
Chapter 4: Endocrine, nutritional and metabolic diseases (E00-E89) 0 0 0
Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99) 0 0 0
Chapter 6: Diseases of the nervous system (G00-G99) 0 2 0
Chapter 7: Diseases of the eye and adnexa (H00-H59) 0 0 4
Chapter 8: Diseases of the ear and mastoid process (H60-H95) 1 0 0
Chapter 9: Diseases of the circulatory system (I00-I99) 30 2 2
Chapter 10: Diseases of the respiratory system (J00-J99) 0 1 0
Chapter 11: Diseases of the digestive system (K00-K95) 0 0 0
Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99) 25 0 0
Chapter 13: Diseases of the musculoskeletal system and connective tissue (M00-M99) 0 6 0
Chapter 14: Diseases of the genitourinary system (N00-N99) 3 1 0
Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A) 0 0 0
Chapter 16: Certain conditions originating in the perinatal period (P00-P96) 0 0 0
Chapter 17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 31 0 10
Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 3 1 1
Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) 87 9 3
Chapter 20: External causes of morbidity (V00-Y99) 75 3 0
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) 13 2 0
Total 273 30 21

Please contact Shawn Bromley at  Shawn.M.Bromley@Lahey.org or 978-236-1704 with questions regarding new ICD-10 CM changes and updates or if you would like to schedule an onsite overview meeting.

Coding Corner - September 2019 Edition

Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020.  The proposed rules will be announced sometime in November 2019.

The calendar year (CY) 2020 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.

Background on the Physician Fee Schedule
Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service.  These services include, but are not limited to, visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service.  Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice.  These RVUs become payment rates through the application of a conversion factor.  Payment rates are calculated to include an overall payment update specified by statute.

PAYMENT PROVISIONS

CY 2020 PFS Rate setting and Conversion Factor
CMS is proposing a series of standard technical proposals involving practice expense, including the implementation of the second year of the market-based supply and equipment pricing update, and standard rate setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).

With the budget neutrality adjustment to account for changes in RVUs, as required by law, the proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services
For CY 2020, CMS is adding the following codes to the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

Payment for Evaluation and Management (E/M) Services
Consistent with goals of burden reduction, CMS is proposing to align E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits.  The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions.  The CPT changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate.  The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time.

Physician Supervision Requirements for Physician Assistants (PAs)
CMS is proposing to modify the regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice.  In the absence of State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

To reduce burden, of re-documentation CMS is proposing broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or  other members of the medical team.

Care Management Services
CMS is proposing to increase payment for Transitional Care Management (TCM), which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

Another proposal includes a set of Medicare-developed HCPCS G codes for certain Chronic Care Management (CCM) services.  CCM is a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period.  CMS is proposing to replace a number of the CCM codes with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time.  CMS is also proposing to adjust certain billing requirements and elements of the care planning services.  These changes would also reduce burden associated with billing the complex CCM codes.

Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions, CMS is also proposing to create new coding for Principal Care Management (PCM) services, which would pay clinicians for providing care management for patients with a single serious and high risk condition.

Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act established a new Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs).  To meet this statutory requirement, CMS is specifically proposing:

  • Definitions of OTP and OUD treatment services
  • Enrollment policies for OTPs
  • Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks
  • Adjustments to the bundled payments rates for geography and annual updates
  • Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate
  • Zero beneficiary copayment for a time limited duration

CMS intends to implement this benefit beginning January 1, 2020, as required by the SUPPORT Act.

CMS is proposing to create new coding and payment for a bundled episode of care for management and counseling for OUD.  The new proposed codes describe a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling.  One code describes the initial month of treatment, which would include administering assessments and developing a treatment plan; another code describes subsequent months of treatment; and an add-on code describes additional counseling.  CMS is proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate.

Please contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you have questions Medicare proposed changes coming in 2020 and 2021.

Coding Corner - August 2019 Edition

ICD-10 Clinical Modification (CM) 2020 Updates – Effective 10/1/2019

The ICD-10 CM changes and updates will be effective on October 1, 2019. The new changes include the following updates:

  • 273 new codes
  • 30 revised codes
  • 21 deleted codes
  • 1500 changes to complication or comorbidity/major complication or comorbidity (CC/MMC) designation
  • Most severity changes are downgrades

Areas that have significant changes include; pressure-induced deep tissue damage, acute versus chronic embolism and thrombosis, fractures of the facial bones around the eye, among other changes highlighted below:

2020 ICD-10 CM Coding Highlights:

  • Eye wall fractures. Sixty new acute fracture codes for closed and open fractures of the orbital wall surrounding the eye, specific to laterality and position around the eye. Example: New code S02.831B will report fracture of medial orbital wall right side, initial encounter for open fracture.
  • Deep tissue injuries. A total of 25 new codes are proposed to be added to specifically capture deep tissue injuries, such as L89.026 (Pressure-induced deep tissue damage of left elbow) and L89.156 (Pressure-induced deep tissue damage of sacral region). Deep tissue injuries currently are coded as unstageable pressure ulcers, which is incorrect by definition, according to the proposal.
  • Atrial fibrillation. Four new codes in the I48.- category are proposed to capture different forms of persistent and chronic atrial fibrillation, such as I48.11 (Longstanding persistent atrial fibrillation) and I48.21 (Permanent atrial fibrillation).
  • Phlebitis and thrombophlebitis. Eight new codes for phlebitis and thrombophlebitis that will allow more specific coding for laterality and location, such as I80.241 (Phlebitis and thrombophlebitis of right peroneal vein).
  • Embolism and thrombosis. New codes to allow reporting of chronic embolism and thrombosis of the peroneal vein and calf muscular vein as well as new codes for acute embolism and thrombosis of those veins. The codes will also be selected based on laterality. For example: Code I82.451 describes acute embolism of right peroneal vein, while I82.562 describes chronic embolism and thrombosis of left calf muscular vein.
  • Poisoning, adverse effects and underdosing. The proposed update includes 18 new T codes for poisoning, adverse effects or underdosing of multiple unspecified drugs, medicaments and biological substances. You’ll use the appropriate seventh character to describe the encounter: initial, subsequent or sequela. The new poisoning codes are divided into four causes: accidental, intentional, assault and undetermined. For example, T50.913S (Poisoning by multiple unspecified drugs, medicaments and biological substances, assault, sequela).
  • Heatstroke. Summer will be over when the new codes go live, but you’ll have options for heatstroke and sunstroke (T67.01X-), exertional heatstroke (T67.02X-), and other heatstroke and sunstroke (T67.09X-).
  • Legal intervention. There will be 75 new codes for injuries sustained during a legal intervention. Many of the additions are to be used to indicate that an unspecified person was injured. For example, Y35.319A (Legal intervention involving baton, unspecified person injured, initial encounter). The current code set describes injuries to law enforcement officers, bystanders or suspects. In addition, there are new codes for injuries caused by conducted energy devices, such as tasers. Codes Y35.831A-Y35.839S describe injuries to law enforcement officials, bystanders, suspects or unspecified individuals.
  • New Z codes. You’ll find a handful of new codes for factors influencing health status and contact with health services. Proposed codes include Z01.020 (Encounter for examination of eyes and vision following failed vision screening without abnormal findings), Z22.7 (Latent tuberculosis), six new personal history of in-situ neoplasms codes (Z86.002-Z86.007) and one code for the presence of a neurostimulator (Z96.82).

Revisions:

  • Codes under T40.906– (Underdosing of unspecified psychodysleptics) and T40.996– (Underdosing of other psychodysleptics) were revised to include the term “[hallucinogens]” in the title.
  • Codes under T44.1×6– (Underdosing of other parasympathomimetics) were revised to include the term “cholinergics” in the title.
  • Codes M77.51 (Other enthesopathy of right foot) and M77.52 (Other enthesopathy of left foot) were revised to include the terms “and ankle” in the title.
ICD-10-CM chapter New Revised Invalid
Chapter 1: Certain infectious and parasitic diseases (A00-B99) 0 3 0
Chapter 2: Neoplasms (C00-D49) 0 0 0
Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) 5 0 1
Chapter 4: Endocrine, nutritional and metabolic diseases (E00-E89) 0 0 0
Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99) 0 0 0
Chapter 6: Diseases of the nervous system (G00-G99) 0 2 0
Chapter 7: Diseases of the eye and adnexa (H00-H59) 0 0 4
Chapter 8: Diseases of the ear and mastoid process (H60-H95) 1 0 0
Chapter 9: Diseases of the circulatory system (I00-I99) 30 2 2
Chapter 10: Diseases of the respiratory system (J00-J99) 0 1 0
Chapter 11: Diseases of the digestive system (K00-K95) 0 0 0
Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99) 25 0 0
Chapter 13: Diseases of the musculoskeletal system and connective tissue (M00-M99) 0 6 0
Chapter 14: Diseases of the genitourinary system (N00-N99) 3 1 0
Chapter 15: Pregnancy, childbirth and the puerperium (O00-O9A) 0 0 0
Chapter 16: Certain conditions originating in the perinatal period (P00-P96) 0 0 0
Chapter 17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 31 0 10
Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) 3 1 1
Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) 87 9 3
Chapter 20: External causes of morbidity (V00-Y99) 75 3 0
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) 13 2 0
Total 273 30 21

Please contact Shawn Bromley at  Shawn.M.Bromley@Lahey.org or 978-236-1704 with questions regarding new ICD-10 CM changes and updates or if you would like to schedule an onsite overview meeting.

Coding Corner - July 2019 Edition

Accurate Coding of Opioid Diagnoisis Improves Risk Adjustment Capture

ICD-10 gives us the opportunity to improve public health intervention related to drug abuse. Where are the other links between mental illness and drug use, abuse, or dependence? It’s about finding and targeting the root cause of drug problems, and coded data can help us get answers.  The major changes for the CMS HCC 2019 Risk Adjustment Model included the addition of four new risk-generating HCCs in chronic conditions related to substance abuse and mental health, and severity of chronic kidney disease.

  • The four new HCCs include:
    • HCC 56: Drug Abuse, Uncomplicated, Except Cannabis
    • HCC 58: Reactive and Unspecified Psychosis
    • HCC 60: Personality Disorders
    • HCC 138: Chronic Kidney Disease, Moderate (Stage 3)
  • Statistical data depends on coded data, and coded data depends on documentation specificity. Encourage physicians to:
    • Document the intent of the overdose carefully
    • Choose one term (use, abuse, or dependence) to use throughout the note consistently
    • Document any complications
    • Identify any and all other drug use, abuse, or dependence
    • Document any manifestations and link them to the drug use (when appropriate)
  • According to the ICD-10 coding guidelines for coding opioid use, abuse and dependence, when the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis) only one code should be assigned to identify the pattern of use based on the following hierarchy:
    • If both “use” and “abuse” are documented, assign only the code for abuse.
    • If both “abuse” and “dependence” are documented, assign only the code for dependence.
    • If “use,” “abuse,” and “dependence” are all documented, assign only the code for dependence.
    • If both “use” and “dependence” are documented, assign only the code for dependence.
  • The diagnosis of Opioid Use Disorder can be applied to someone who has a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
    • Taking more opioid drugs than intended.
    • Wanting or trying to control opioid drug use without success.
    • Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs.
    • Cravings opioids.
    • Failing to carry out important roles at home, work, or school because of opioid use.
    • Continuing to use opioids, despite use of the drug causing relationship or social problems.
    • Giving up or reducing other activities because of opioid use.
    • Using opioids even when it is physically unsafe.
    • Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway.
    • Tolerance for opioids.
    • Withdrawal symptoms when opioids are not taken.
Opioid Abuse
HCC ICD-10 Codes
F11.10 Opioid abuse, uncomplicated
F11.11 Opioid abuse, in remission
F11.120 Opioid abuse with intoxication uncomplicated
F11.121 Opioid abuse with intoxication, delirium
F11.122 Opioid abuse with intoxication with perceptual disturbance
F11.129 Opioid abuse with intoxication, unspecified
F11.14 Opioid abuse with opioid-induced mood disorder
F11.150 Opioid abuse with opioid-induced psychotic disorder with delusions
F11.151 Opioid abuse with opioid-induced psychotic disorder with hallucinations
F11.159 Opioid abuse with opioid-induced psychotic disorder, unspecified
F11.181 Opioid abuse with opioid-induced sexual dysfunction
F11.182 Opioid abuse with opioid-induced sleep disorder
F11.188 Opioid abuse with other opioid-induced disorder
F11.19 Opioid abuse with unspecified opioid-induced disorder
                                                        Opioid Dependence
HCC ICD-10 Codes
F11.20 Opioid dependence, uncomplicated
F11.21 Opioid dependence, in remission
F11.220 Opioid dependence with intoxication uncomplicated
F11.221 Opioid dependence with intoxication, delirium
F11.222 Opioid dependence with intoxication with perceptual disturbance
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid dependence with opioid-induced mood disorder
F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions
F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.281 Opioid dependence with opioid-induced sexual dysfunction
F11.282 Opioid dependence with opioid-induced sleep disorder
F11.288 Opioid dependence with other opioid-induced disorder
F11.29 Opioid dependence with unspecified opioid-induced disorder

Opioid Use, Unspecified    HCC ICD-10 Codes
F11.920 Opioid use, unspecified with intoxication, uncomplicated
F11.921 Opioid use, unspecified with intoxication delirium
F11.922 Opioid use, unspecified with intoxication with perceptual disturbance
F11.929 Opioid use, unspecified with intoxication, unspecified
F11.93 Opioid use, unspecified with withdrawal
F11.94 Opioid use, unspecified with opioid-induced mood disorder
F11.950 Opioid use, unspecified with opioid-induced psychotic disorder with delusions
F11.951 Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations
F11.959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified
F11.981 Opioid use, unspecified with opioid-induced sexual dysfunction
F11.982 Opioid use, unspecified with opioid-induced sleep disorder
F11.988 Opioid use, unspecified with other opioid-induced disorder
F11.99 Opioid use, unspecified with unspecified opioid-induced disorder

Coding Corner - June 2019 Edition

Medicare Annual Wellness Visits Review 

  • Annual Wellness Visits (AWV) are covered by Medicare annually, but they are often confused with other types of examinations, so the Centers for Medicare & Medicaid Services (CMS) has published an MLN booklet Click here to help office staff and their providers keep them all straight.

Annual Wellness Visit Components 

  • AWVs are only provided annually. The AWV is a visit to perform a health risk assessment (HRA) and develop or update a personalized prevention plan.
  • The IPPE differs in that it’s a review of the beneficiary’s medical and social health history, and includes preventive services education.

To be able to bill for an AWV the provider should fulfill these steps the first time a patient has an AWV:

  • Perform an HRA
  • Establish the beneficiary’s medical and family history
  • Establish a list of current providers and suppliers
  • Measure height, weight, BMI, and blood pressure
  • Detect any cognitive impairment the beneficiary may have
  • Review the beneficiary’s potential risk factors for depression, including current or past experiences with depression or other mood disorders
  • Review the beneficiary’s functional ability and level of safety
  • Establish an appropriate written screening schedule for the beneficiary. (CMS recommends a checklist for five to 10 years)
  • Establish a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or already underway
  • Furnish the beneficiary personalized health advice and appropriate referrals to health education or preventive counseling services or programs
  • At the beneficiary’s discretion, furnish advance care planning services

In subsequent years, the provider should follow these steps:

  • Review and update the HRA
  • Update the beneficiary’s medical/family history
  • Update the list of current providers and suppliers
  • Measure height, weight, BMI, and blood pressure
  • Detect any cognitive impairment
  • Update the written screening schedule
  • Update the list of risk factors and conditions
  • Furnish the beneficiary’s health advices and referral to health education and counseling programs
  • At the beneficiary’s discretion, furnish advance care planning services

Coding Annual Wellness Visits

In addition to the appropriate diagnosis codes, report the following HCPCS Level II codes:

Click table to enlarge

Eligibility

Medicare Part B covers the Annual Wellness Visit if:

  • The patient had Part B for over 12 months
  • The patient has not received an AWV in the past 12 months
  • Patient’s cannot receive an AWV within the same year as their Welcome to Medicare preventive visit.
  • To be covered, the Medicare beneficiary must have been covered by Part B for more than 12 months.

Please contact Shawn Bromley from NEPHO at shawn.m.bromley@lahey.org or 978-236-1704 if you have questions regarding Medicare Annual Wellness Visits.

 

Coding Corner - May 2019 Edition

The Importance of Understanding Medical Necessity

Medical necessity documentation, or lack of it, is one of the most common reasons for claim denials. For a service to be considered medically necessary, it must be reasonable and necessary to diagnosis or treat a patient’s medical condition. When submitting claims for payment, it is the diagnosis codes reported with the service that tells the payer “why” a service was performed. The diagnosis reported can be the determining factor in supporting or not supporting the medical necessity of the procedure.

Example:

  • If the patient came in with an earache and was diagnosed with Otitis Media (H66.91), and the provider billed for a chest x ray, insurance would not pay for it. This is because it is not medically necessary to perform a chest x ray on a patient who is not having any breathing or chest related symptoms or problems.
  • Medical necessity is based on “evidence based clinical standards of care”. This means that there is evidence to support a course of treatment based on a set of symptoms or other diagnostic results.
  • Not all diagnoses for all procedures are considered medically necessary. CMS (Centers for Medicare and Medicaid Services) and also commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures.
  • It is important to note that a diagnosis code should never be altered to match one of the diagnosis codes listed in a coverage policy as supporting medical necessity. The diagnosis code submitted must be supported and reflected in the medical documentation. It would be inappropriate to report a diagnosis just because it is on an approved list of diagnosis codes that meet medical necessity by a payer.

Medical Necessity and Evaluation and Management Services:

  • Per CMS; Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.
  • It may be appropriate to perform a highly detailed history and physical even when the patient presents with an uncomplicated problem and no workup is planned. However, in these cases it is best to base the final E/M code selection on the level of medical necessity, even if a coding tool suggests a higher level of service based on what is documented.
  • Medical necessity documentation from a physician and/or provider should include the following:
  • Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is the diagnosis driver, and multiple diagnoses may be involved.
  • Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.
  • Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition.

Providers should continually enhance their documentation to improve overall coordination between medical record, coding accuracy, payer reimbursement. Up front communication with the billing team and/or insurance payers will help avoid claim denials. Some examples of what payers look for when reviewing support of medical necessity include:

  • Treatment is consistent with symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.
  • Treatment is necessary and consistent with generally accepted professional medical standards (not experimental or investigational).
  • Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician of supplier.
  • Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.
  • The disbursement of medical care and/or treatment must not be related to the patient’s or the payer monetary status or benefit.

Medical necessity is the base to support the service provided. CMS provides a specific definition under the Social Security Act: “no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Please contact Shawn Bromley at 978-236-1704 or shawn.m.bromley@lahey.org if you have questions related to coding, billing and/or medical necessity documentation requirements.

Coding Corner - April 2019 Edition

E/M Coding and the Documentation Guidelines: Putting It All Together:

Key components that make up an established patient visit are History (HPI), Exam and Medical Decision Making (MDM). An established patient visit will need to have 2 of 3 key components and must meet medical necessity.

The underlying problem for wrong billing of these services includes the following:

  • Lack of understanding on how the coding system for E/M works
  • Inaccurate and incomplete documentation to support the code billed
  • Supporting medical necessity
  • Downcoding (documentation supports a higher level service code)
  • Upcoding (documentation supports a lower level service code)c

Comparison coding and billing for level 99213 and 99214:

Click to enlarge/print

Many providers are consistently undercoding for their services because they have a limited understanding of the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding. Providers who understand the process of E/M documentation can optimize a higher rate of return for their services. If you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

Changes Coming in 2021

  • New rules for coding based on time
  • Code based on MDM alone
  • New blended payment structure for new and established office patients
  • New minimum documentation threshold for new and established office patients
  • New G code for increased reimbursement for primary care physicians
  • New G code for increased reimbursement for non-procedural specialty care services
  • New outpatient prolonged services code with decreased time threshold
  • A great resource for E/M coding guidance is: https://emuniversity.com/2019.html.

Please contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you have questions regarding E/M coding and billing.

Coding Corner - March 2019

Coding News from NEPHO
The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) recommend that health care providers routinely enlist independent parties to audit coding practices. Chart audits are a way to obtain feedback regarding your coding program and help in measuring quality.

Although the goals may generally be the same, coding audits can differ in several ways, including methodology type, accuracy definitions, and cost.

Coding Audit Methodologies
Coding audits can be retrospective, which is a review of submitted claims, or prospective, an analysis of pre-billed claims. They can also be random, targeted, or a mix of both, and a code-for-code or full-record analysis.

Establishing a regular external coding audit will have a high return on investment (ROI), helping you maintain the best coding practices for the well-being of your practice. Most importantly, it will help identify potential coding and documentation problems and reduce risk of lost revenue from denials.

Coding Audits Help To:

  • Determine if day to day operating procedures are compliant with current regulations
  • Prevent non-compliance issues from occurring
  • Reduce potential for over or underpayments
  • Reduce risk of improper documentation
  • Minimize risk of fraud
  • Ensure compliance with Medicaid and Medicare standards
  • Address areas of coding education opportunity

NEPHO Coding Audit Findings:
In an ongoing effort to ensure accuracy and compliant coding NEPHO performed an outpatient service chart audit review on three NEPHO physician practices. The findings addressed areas of opportunity for provider education. A trend identified included missing preventative screening ICD-10 diagnosis codes that were released October 1, 2018.  The initial review was done in January 2019 and follow-up review was completed in February 2019. The follow-up coding review found that all 3 practices had improved with capture of the new ICD-10 diagnosis codes for screening encounters.

 Z00-Z99 Factors influencing health status and contact with health services

  • 81 Encounter for examination and observation of victim following forced sexual exploitation (ruled out)
  • 82 Encounter for examination and observation of victim following forced labor exploitation (ruled out)
  • 89 Encounter for examination and observation for other specified reasons (ruled out)
  • 30 Encounter for screening examination for mental health and behavioral disorders, unspecified
  • 31 Encounter for screening for depression
  • 32 Encounter for screening for maternal depression
  • 39 Encounter for screening examination for other mental health and behavioral disorders
  • 40 Encounter for screening for unspecified developmental delays
  • 41 Encounter for autism screening
  • 42 Encounter for screening for global developmental delays (milestones)
  • 49 Encounter for screening for other developmental delays
  • 821 Contact with and (suspected) exposure to Zika virus
  • 83 Immunization not carried out due to unavailability of vaccine
  • 430 Family history of elevated lipoprotein(a)
  • 438 Family history of other disorder of lipoprotein metabolism and other lipedemia

Please contact Shawn Bromley at shawn.m.bromley@lahey.org  and/or 978-236-1704 if you would like to have a coding audit performed at your practice or have questions related to coding.

Coding Corner - February 2019 Edition

CPT Coding and Billing Updates for 2019
Here are the most recent 2019 coding updates that physician’s should be aware of to ensure accuracy in coding and billing for MRI Breast Exams and new codes of Chronic Care Management.

MRI-Based Breast Exams Contrast Updated Codes:
The 2019 change deleted codes 77058 and 77059 and resulted in an expansion associated with four codes:

  • 77046: Unilateral MRI breast exams without contrast
  • 77047: Bilateral MRI breast exams without contrast
  • 77048: Unilateral MRI breast exams, with/without contrast
  • 77049: Bilateral MRI breast exams, with/without contrast

    Codes 77046
     and 77047 encompass computer-aided detection (CAD), including CAD real-time lesion detection, characterization and pharmacokinetic analysis. This change has eliminated the need to separately add the HCPCS code 0159T for situations involving CAD.

New Code for Chronic Care Management:
CPT code updates for 2019 include chronic care management (CCM). This update allows providers to bill for at least a half hour of their time.

  • 99491: Chronic care management services provided personally by a physician or other qualified healthcare professional for at least 30 minutes.
  • This code is billed for CCM coordination sessions that are more than 20 minutes but less than an hour.

Coding Corner - January 2019 Edition

Modernizing Medicare Physician Payment by Recognizing Communication
Technology-Based Services

  • CMS has issued its final 2019 Physician Fee Schedule and Quality Payment Program, opening the door to reimbursement for connected care services that enable providers to manage and coordinate care at home. The changes are focused on three new CPT codes that separate Remote Patient Monitoring (RPM) services from telehealth.

The new CPT codes are:

  • CPT code 99453:“Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
  • CPT code 99454:“Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each
    30 days.”
  • CPT code 99457:“Remote physiologic monitoring treatment management services, 20
    minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
  • CMS has finalized two newly defined physician’s services utilizing communication technology. These two services are the brief communication technology based service, or virtual check in (HCPCS code G2012), and the remote evaluation of recorded video and/or images submitted (HCPCS code G2010). These services will allow practitioners to decide whether an office visit or other medical service is needed, improving efficiency and convenience for both the practitioner and beneficiary.
  • HCPCS code G2012: CMS states the code allows “audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.”  (Note: telephone calls that involve only clinical staff cannot be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.)
  • HCPCS code G2010: CMS defines this code as; remote evaluation of recorded video and/or images submitted by an established patient.

Evaluation and Management (E/M) 2019 Documentation Updates

  • Beginning January 1, 2019, Medicare will allow ancillary staff to perform and record the chief complaint and history of present illness.
  • Additionally, for established patient office/outpatient visits, when the medical record already contains relevant information, Medicare will allow physicians to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and not re-record the defined list of required elements. Physicians will still need to review prior data, update it as necessary, and indicate in the medical record that they have done so.
  • These updates were approved to help improve physician’s workflow to provide more focus on the patient during the office visit.
  • CMS has delayed additional E/M additional documentation changes until 2020 and 2021. Updates will be made available as more information is released from CMS.

Contact Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you are interested in more information regarding the new Telehealth services or need additional guidance on the updated E/M documentation requirements.

2018 Coding Corner

Coding Corner - December 2018 Edition

ICD-10- CM Diagnosis Codes Reset January 1, 2019

  • A major component of the Hierarchical Condition Categories (HCCs) model is that the individual HCCs are only valid for one year. Regardless of the HCCs fundamental chronicity, on January 1, 2019 the patient’s HCC listing will be blank.
  • For example, a patient with diabetes with complications would need to have a face-to-face encounter with a provider where diabetes is discussed and documented for the appropriate
    HCC to be reported in the new base year.
  • There are two important aspects to remember when HCC coding:
  • Analyzing health record documentation to identify reportable conditions
  • Accurately assigning ICD-10-CM codes to these conditions
  • Providers and risk adjustment professionals need to work together to ensure quality and thorough documentation of patient conditions to support risk adjustment and quality reporting initiatives. With such an emphasis on yearly code capture, provider education becomes a higher priority early in the year to prevent the loss of HCC diagnosis.
  • The NEPHO will be working to educate providers beginning early 2019 to help continue efforts to impact the patient’s health status.
  • The following coding education will be a focus for 2019:
  • Risk Adjustment Accurate Documentation and Coding Practices
  • Importance of Risk Adjustment
  • Risk Adjustment Auditing and Monitoring
  • The NEPHO will be working with providers directly to address education opportunities and to ensure accurate coding and reporting of HCCs is continued through the year. Working together can help ensure compliance and optimal financial results under HCC risk adjustment contract models.
  • Please reach out to NEPHO directly if you would like to review risk adjustment education opportunities for your practice. Contact Shawn Bromley at shawn.m.bromley@lahey.org or call 978-236-1704.

Coding Corner - November 2018 Edition

Risk Adjustment Coding is a Joint Effort

Risk adjustment coding requires health plan management, provider group management, physicians, nurse practitioners and physician assistants, and skilled coding professionals to work together to capture the health status of their patients and ensure their documentation complies with the Hierarchical Condition Categories (HCC) reporting requirements on a yearly basis.

Here are some common errors made in coding and documentation. By working to address these, physician practices will have a better opportunity to meet the requirements for Risk Adjustment Coding that will impact the future budget.

Missed diagnosis that are not reported on a claim or recorded in the chart:

  • Example: A male patient was seen by PCP for 3 month follow-up, BMI is over 40, he has diabetes and high blood pressure, recent weight is 100 pounds over his ideal weight.
    • Common Error: Diabetes and high blood pressure are coded but provider does not code morbid obesity (E66.01) and BMI (Z68.4).
    • Solution: Make sure to code E66.01 and Z68.5 to ensure full risk adjustment capture.

Not documenting “due to” – including this phrase will support the causal relationship, allowing for proper reporting of diagnosis:

  • Example: A patient is admitted with cellulitis (L03.90) around a recent operative wound site.
    • Common Error: The cellulitis is due to or the result of the surgical procedure but not documented.
    • Solution: Code the Cellulitis (L03.90) and Complication of surgical and medical care (T88.9) with detail in documentation related to the surgical procedure.

Misuse of the phrase “history of” – only use this phrase for a condition that has been completely resolved. If the condition is active, do not use this phrase:

  • Example: Patient is being seen and has a history of cancer.
    • Common Error: Provider codes diagnosis C44.20 (unspecified malignant neoplasm).
    • Solution: There is only “history of” which would be coded Z85.9 (history of malignant neoplasm).

Ambiguity – Physicians must be clear on their documentation:

  • Example: Patient seen for sick visit regarding cough. Provider listed chronic conditions; diabetes, COPD and asthma but does not provide update in documentation related to the status of chronic conditions and/or relationship to the current visit for cough.
    • Common Error: Provider codes cough and all chronic conditions.
    • Solution: Accurate coding is for cough only (R05). The chronic conditions should not be coded as part of the sick visit.