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Tag Archives: 2016

Top 4 Payer Priorities for 2016




Health Leaders Media


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  February 17, 2016 Follow us on FacebookFollow us on TwitterJoin us on LinkedInRSS feed

Top 4 Payer Priorities for 2016

Rene Letourneau, Senior Editor for HealthLeaders Media

A new payer survey offers insights for providers as both deal with a common challenge: technology. >>>

 

Editor’s Picks

Value-Based Care Shifts into High Gear

Guideposts for the paths to participating in value-based healthcare models come into focus at a payment innovation summit held in Tennessee. >>>

CMS Finalizes Medicare Overpayment Reporting Rule

An overpayment is considered identified by Medicare when an employee using "reasonable diligence" has, or should have, determined it was received and quantified the amount, according to the final rule. >>>

Incoming Carolinas HealthCare CEO Driven by Community, Mission

The newly named CEO of Carolinas HealthCare System, Eugene A. Woods, talks about his legacy at Christus Health and the challenges that await him when he takes the helm at one of the nation’s largest public health systems. >>>

CMS, AHIP Standardize Quality Measures

Seven measure sets aim to alleviate the burden and cost of measuring clinical quality and will "support multi-payer alignment, for the first time, on core measures primarily for physician quality programs," says CMS. >>>

Dignity Health Announces Urgent Care Partnership

The urgent care centers will be a 50/50 partnership, with Dignity Health Medical Foundation providing the clinicians, GoHealth providing the organizational infrastructure and expertise, and both entities equally sharing the capital investment. >>>

ONC: Time to Get Busy with Value-based Payment Models

"We’re in a little bit of a we-don’t-know-what-we-don’t-know state as an industry. And it’s going to dawn on people really quickly that MACRA is a really big deal," says a co-chair of ONC’s Health IT Standards Committee. >>>

The Healthcare Partnership Midrange

The middle ground of the healthcare partnership continuum is dotted with a variety of relationships that feature varying degrees of shared governance. >>>

Intelligence Report:
The Analytics Challenge—Gaining Critical Insight into Risk-Based Models

As providers undertake contracts with increasing levels of downside risk, their need for advanced analytics to manage decision making and monitor results will only grow. >>>

LIVE Webcast

Webcast: Integrating Behavioral Health: Decreasing Costs and Improving Care

Date: March 15, 2016, 1:00–2:00 p.m. ET
In this expert webcast, hear how Carolinas HealthCare System developed a strategy to optimize resources to create a truly integrated model.
Register Today >>>


News Headlines

Community Health stock slumps after surprise loss, rivals also hit

Fox Business, February 17, 2016

When a brain surgeon becomes a malpractice lawyer

ProPublica, February 17, 2016

High cost of cancer care may take physical and emotional toll on patients

The Wall Street Journal, February 17, 2016

Christ Hospital seals surgery deal with UnitedHealth Group division

Cincinnati Business Courier, February 17, 2016

Aetna gets FL insurance regulator’s approval for Humana deal

CNBC / Reuters, February 16, 2016

Cancer patients snagged in health law’s tangled paperwork

Chicago Tribune, February 16, 2016

Hacking of healthcare records skyrockets

WRCB-TV / NBC News, February 16, 2016

Top hospitals likely are available on a marketplace plan, study finds

Kaiser Health News, February 15, 2016

With end of ‘doc fix’, effort to craft a new payment system underway

The Hill, February 12, 2016

Healthcare battle brewing between governors in KY

ABC News / Associated Press, February 12, 2016

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Multimedia/Events

HealthLeaders Media LIVE at NCH Healthcare System: Population Health

Date: February 23, 2016 | 11:00–2:00PM ET
In this live e-conference, discover how NCH Healthcare System has expanded its population health program with a multi-layered strategic plan.
Register Today >>>

From HealthLeaders Magazine

Changing Patient Behavior Through Technology

Software and hardware developments are opening new ways to get patients more involved in their own care. >>>

 

Cancer: Aligning Costs and Care

 

The Healthcare Partnership Midrange

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HCPro.com – Health Plan Insider

Top Takeaways from the 2016 AHIMA Convention

Attending the 2016 AHIMA Annual Convention and Exhibit in Baltimore, MD had its pros and cons.

The pros: unbeatable networking opportunities and the chance to hear astronaut Captain Mark Kelly and former US Congresswoman Gabby Giffords deliver their inspiring message.

The cons: jetlag and responding to the avalanche of work e-mails upon arrival back in the office.

“This is our future,” said Lynne Thomas Gordon of AHIMA’s new strategy.

“This is our future,” said Lynne Thomas Gordon of AHIMA’s new strategy.

The good news is that if you weren’t able to travel to Baltimore, the Journal has you covered—and you time to spare since you’re caught up on your e-mails. The convention closed a little over a week ago, which has given AHIMA’s top subject matter experts—presenters and organizers of many of the convention’s events—time to reflect on all that they learned during the action-packed week. We’ve broken down convention takeaways by HIM domain.

Privacy and Security

This year marked the 10-year anniversary of AHIMA’s Privacy and Security Institute, which attendees helped celebrate with cake, champagne, and a slate of top-tier speakers, according to Angela Rose, MHA, RHIA, CHPA, FAHIMA, a director of HIM practice excellence at AHIMA. The Institute is held on the Saturday and Sunday prior to the formal kickoff of the convention.

Baltimore’s proximity to Washington, DC, and federal agencies such as the Department of Health and Human Services’ Office for Civil Rights (OCR) and the Office of the National Coordinator for Health IT (ONC) helped Rose recruit speakers such as Deven McGraw, Esq., OCR’s deputy director of health information and privacy. Rose says Institute attendees were hanging on to McGraw’s every last word “because she makes all the decisions about their privacy and security programs,” Rose said.

McGraw also touched on recurrent compliance issues, business associate agreements, risk analysis, and failure to manage identified risk, as well as insufficient data backup and contingency planning, among other privacy and security topics.

Click here for the AHIMA Today article on McGraw’s presentation.

Coding and Clinical Documentation Improvement

While attendees of the 2015 AHIMA convention were literally counting down to the October 1, 2015 go-live of ICD-10-CM-PCS, this year coding-focused convention goers were more concerned with ICD-10 updates for 2017 and with how the recently finalized MACRA final rule would impact providers.

In addition to coding and clinical documentation improvement (CDI) sessions held throughout convention, AHIMA also convened the Clinical Coding Meeting held on the Saturday and Sunday prior to the convention’s official launch.

“We had a great crowd for both days of the Clinical Coding Meeting,” said Donna Rugg, RHIT, CCS, CDIP, a director of HIM practice excellence at AHIMA. “We also had more registrants listening via live streaming than last year… Attendees were anxious to hear about ICD-10 post-implementation and CDI—both of these tracks were well attended and we had good Q&A sessions with presenters and the attendees.”

Tammy Combs, MSN, RN, CCS, CCDS, CDIP, a director of HIM practice excellence at AHIMA, said it was exciting to see so much interest in outpatient CDI from those who attended the coding meeting.

“It was exciting to see how interested CDI specialists are in outpatient CDI and expanding CDI into specialty areas such as skilled nursing facilities, pediatrics, home health, and critical access hospitals,” Combs said. “The outpatient CDI workshop had a great response. We had several people come up afterwards making comments about how they enjoyed it and they would like to have more outpatient information from AHIMA.”

Information Governance

Information governance (IG) had a high profile at this year’s convention, with events including the Information Governance Leadership Forum, which was held on the Sunday of convention, as well as the “Building the Case for Information Governance—IG Roundtable,” which took place that Monday.

Ann Meehan, RHIA, director of information governance at AHIMA, felt that attendees were interested and engaged in learning more about IG, and that IG knowledge among convention goers ranged from people who weren’t familiar with the term “information governance” to individuals that are actively implementing IG programs.

“It’s always a learning experience to hear from others who are on the IG journey and to learn new ways that people are going at it. The IG Roundtable and the IG Leadership Forum on Sunday, allowed attendees to interact and share their experiences,” Meehan said.

Meehan said that throughout the convention a theme she kept hearing is that the role of the HIM professional—whether a coder, a CDI manager, or other—is evolving.

“We must all step up and prepare ourselves to evolve with it. We don’t want to become the next ‘Blockbuster Video’ as Lynn [Thomas Gordon] said. That was absolutely the pervasive theme throughout the convention… and IG is part of that,” Meehan added.

Click here for more Journal coverage on IG at convention.

Standards

The mission of AHIMA’s standards team at this year’s convention was to was to raise awareness about AHIMA’s role in standardization of HIM practices and guiding the development of Health IT standards for interoperable health information systems, according to Anna Orlova, PhD, senior director of standards at AHIMA.

Orlova and her team were thrilled to find that attendees at standards-related sessions were engaged and interested in learning about the concepts, processes, and entities of standards development activities. Additionally, Orlova received several inquiries from individuals who were interested in joining AHIMA’s Standards Task Force.

“There is growing interest in participating on the AHIMA Standards Task Force. Those who already participate in the Task Force strongly advocated for continuation of AHIMA involvement in standardization efforts both nationally and globally,” said Orlova.

At the session “Data on the Go: Keeping up with mHealth,” presenters shared success stories about improving patient engagement with people with chronic illnesses via mobile devices.

The question Orlova and her team heard the most often was “How can I get involved?” and “How would I use standards in my organization?”

Mary Butler is the associate editor at The Journal of AHIMA.


Event Coverage | Journal of AHIMA

Case Management Monthly, November 2016

Accountable care units can help streamline communication and reduce length of stay

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify the potential advantages and challenges involved with establishing a hospitalist accountable care unit

 

Opening the lines of communication between clinicians and specialists to make care more efficient can be a sizable challenge.

At many facilities, hospitalists shuttle from floor to floor to see patients, each time trying to track down the nurse and other professionals working on each case. Information is typically transferred through an inefficient system of pages and phone calls?sometimes taking hours at a time to deliver crucial pieces of information.

Enter the accountable care unit?a new way of configuring care systems that can help to uncoil tangled communication wires between clinicians and support staff to provide care that is more efficient and streamlined.

In this model, hospitalists work with patients in a specified geographical area of the hospital in conjunction with interdisciplinary teams.

Having patients in one area helps make care more efficient, and as one hospital system in New Mexico learned, can also reduce length of stay and increase cost-efficiency.

 

A push toward regionalization

Regionalization of hospitalist patients is becoming more common today, because of the benefits it’s been shown to bring, says Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. Those benefits include:

  • Improved teamwork, care coordination, and communication
  • Fewer readmissions
  • Improved resource management to lower cost of care
  • Improvements in patient satisfaction
  • Reduction in inefficiencies

"I’m pushing accountable care units at all my hospital clients," says Daniels. But while the will is there in many cases to make the change, it’s not always an easy conversion.

Sometimes these initiatives face pushback from physicians concerned about personnel or scheduling issues.

Other challenges include:

  • The lack of diagnostic diversity that results from having set teams on a unit
  • The challenge of deciding whether teams should be flexible or static
  • Hammering out logistical issues, such as how patients should be triaged and how beds are managed

 

Despite the challenges these initiatives can face, Presbyterian Medical Group in Albuquerque, New Mexico successfully implemented a unit-based model with multidisciplinary rounds about six years ago, says David J. Yu, MD, MBA, FACP, SFHM, medical director of adult inpatient medicine service for Presbyterian Healthcare Services.

The initiative was prompted by a desire to improve inefficiencies and streamline care. "We basically needed to improve patient flow and communication," says Yu. "But we also realized it was a very large process because it involved almost every department, including case managers, physical therapy, nursing, and ancillary services."

To overcome that daunting multi-departmental challenge, officials enlisted the hospital’s Lean Six Sigma group to help coordinate the project.

Presbyterian sought to trade its outmoded care model for something more efficient; one that would improve communication and eliminate delays related to breakdowns in this area.

The changes began as a unit-based project with multidisciplinary whiteboard rounds, a daily meeting that included the hospitalist, nursing staff, care coordination, physical therapy, and other specialists. They discuss the treatment plan and the goals related to the patient care both for that day and the hospitalization for each patient, he says.

The success of that pilot program led officials to implement the same unit-based model in eight of the medical floors at the hospital.

The payoff for the organization has not only been a huge boost in the efficiency of communication, but reduced length of stay for patients. "We’ve seen significant improvements in the average length of stay. This is not because we’ve reduced therapeutic time, but because we’ve reduced inefficiencies," says Yu. Lag time created by communication gaps has been tightened up, allowing patients to move through the system more quickly and efficiently.

To ensure that these new efficiencies weren’t resulting in quality reductions, Yu says the organization also tracked readmissions, which remained steady, confirming that faster discharges weren’t compromising patient care.

 

Overcoming obstacles

Presbyterian has managed to overcome many hurdles that can make this model a challenge. Although these changes have been successful, they have not necessarily been quick.

"I think in many cases people are just interested in a quick fix," says Yu. This process has been anything but. More than half a decade in, Yu says the program is still a work in progress and the team is continually looking to make improvements.

The initiative took time because it addressed the underlying structure of the organization and didn’t just make surface changes that can’t be sustained.

"I like to use the analogy of painting a wall. The painting is the easiest part. What takes time is all the prep work getting the surface ready," he says.

Most organizations just want the paint on the wall?they aren’t willing to address work needed to fix the underlying structure. "This really is a foundational project that takes months and years to develop and mature," he says.

This project not only solved many communication problems at the organization, but it also helped to ready the facility for the new era in healthcare ahead?one where revenue is driven by quality, not volume.

Organizations that want to thrive in this new model will need to rethink antiquated processes and systems going forward, he says. Those that don’t may not survive in this model.

 

Steps to success

For an initiative like this one to be successful, it has to be well designed and have support?both in commitment and in terms of dollars?from upper management.

"A lack of resources is another reason why a lot of these projects fail," says Yu. "The hospital doesn’t want to fund it. If only one department is very excited about the project, it won’t work."

The model involves a major change that requires support from multiple disciplines. "Without the support of leadership it’s not going to succeed," he says.

You also have to give hospital staff members a reason to support it, which may be the biggest challenge.

"It has to successfully answer the question, ‘What’s in it for me?’ " says Yu.

If the changes are onerous and provide little benefit to the people they affect, there’s little incentive for anyone to support it.

"Understand your worker and your project," he says. And overcoming barriers may involve system and even contract changes, he says.

If you can get that support, you can make changes that will improve communication and consequently care at your organization?and help ready it for the changing healthcare landscape of the future.

 

Commonwealth Fund study shows insurance gaps remain

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify potential risk factors and interventions for patients who still don’t have health insurance under the Affordable Care Act

 

While some 26 million Americans have gained insurance since the Affordable Care Act (ACA) became effective in 2010, another 24 million U.S. adults are still living without coverage, according to a new report by the Commonwealth Fund, a private, nonprofit organization that supports health policy research and reform.

This is a concern because not only are uninsured adults likely to skip needed health services due to the cost, but a lack of insurance is also a risk factor for preventable hospitalizations and health declines due to chronic diseases, according to the Henry J. Kaiser Family Foundation (http://ow.ly/Bs3a304bJR7).

So who are these uninsured Americans? According to The Commonwealth Fund survey (http://ow.ly/I8uZ304cB2b), 88% are Latinos under the age of 35 who earn less than $ 16,243 and/or work for a small business. "Half (51%) of the remaining uninsured live in one of the 20 states that had not yet expanded Medicaid at the time of the survey," states a press release issued by the Commonwealth Fund (http://ow.ly/gqsB304bJZk).

Case managers should take note of the survey findings.

"The Commonwealth Fund analysis is beneficial to all case managers, because the uninsured population compromises our most at high-risk groups of patients," says June Stark, RN, BSN, Med, director of care coordination at St. Elizabeth’s Medical Center in Boston. "Most hospitals today seem to be the primary source of healthcare provision to the patients in their communities. Expanding the case manager’s understanding of this population can contribute to the development of successful strategies for managing this group."

 

About the study

The study, called The Commonwealth Fund Affordable Care Act Tracking Survey, consisted of 15-minute telephone interviews. Interviewers conducted the interviews in two languages, either English or Spanish, between February and April 2016. The data was collected by calling a random, nationally representative sample of nearly 5,000 adults ages 19?64.

Since the ACA went into effect, the uninsured population shifted from mostly white adults to Latinos, according to the Commonwealth Fund press release. Results also show that renewed efforts to help uninsured individuals gain coverage might also be in order.

"The ACA held promise for many, especially those with incomes that could bear new market sticker prices, and as can be seen from the study, diverse populations benefitted from targeted reform marketing efforts," says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the director of case management and bed management for RWJBarnabas Health in Toms River, New Jersey. "Yet it is very apparent that while there has been success with some at-risk populations, those with the lowest incomes who do not qualify for Medicaid are still struggling."

This study, she says, shows it may be time for a revival of the initial efforts to enroll Americans in health plans, which have become less prominent over time. There may also be a role for case managers and social workers to help guide uninsured patients they encounter in the hospital to seek coverage.

"The case manager has an active role in helping patients acquire insurance coverage," says Stark. "A mainstay of the traditional case manager role is, during the admission assessment, to determine if the patient has insurance and if so, to validate if it is correct and active. This is accomplished by interviewing the patient, viewing their insurance card, and checking further with the help of the hospital’s financial counselors."

If a patient is uninsured, case managers should refer him or her to financial counselors to determine the patient’s eligibility and to help him or her secure insurance during the hospital stay, she adds.

"The case manager’s efforts to secure insurance is essential, as the specific insurance benefits drive what discharge options are available for the patient, and therefore, helps secure a safe discharge plan," says Stark.

Social workers, too, play a role.

"It is often the social work partner in a case management relationship who provides the under-insured and uninsured the counseling, available tools and resources, and sometimes the hands-on, step-by-step training to explore with patients and families their income/assets/spending and eligibility for entitlement programs or market products," says Kates. "It is a continuous conversation that has been rooted in a long history of patient intervention by social work. Possessing expert knowledge in federal and state eligibility requirements, financial/social access limits, and having strong relationships with county and state providers, the social worker will connect services with patients."

In their role as patient advocates, case managers and social workers can help to break down cultural and social barriers, such as language and access based on geography, she adds.

 

Action points from the Commonwealth Fund

The Commonwealth Fund study authors agree with Kates that enhancing efforts to reach the uninsured and help them enroll in health plans should be a goal based on these findings. Only 62% of people without insurance said they knew about insurance marketplaces.

They also recommend a number of other steps that they say could help more of these uninsured individuals gain coverage. Their recommendations are as follows:

  • Expand state eligibility for Medicare coverage, a move that Commonwealth Fund authors say would "immediately extend health insurance to millions of uninsured people." Twenty states had not yet expanded Medicaid coverage at the time of the survey. If they had, one-third of all adults without insurance would qualify for Medicaid coverage. "This especially affects uninsured young adults, of whom 38% or an estimated 4 million, have incomes that would qualify them for Medicaid but live in non-expansion states," states the press release.
  • Enhance subsidies and lower cost-sharing in marketplace plans to help more people afford insurance. Many people without insurance believe they can’t afford it?even if they might qualify for financial help under the ACA. Some 85% of those without insurance who did shop for a plan said they couldn’t find an affordable option. "A large majority of this group, who were also uninsured, had incomes qualifying them for subsidies or Medicaid, though some may not have been eligible due to their immigration status," states the press release.
  • Promote immigration reform. Changing immigration rules would help more people gain insurance coverage. "A loosening of the law’s restrictions on eligibility for undocumented immigrants would also help," states the Commonwealth Fund press release. While the survey data didn’t definitely prove that this is the case, study authors suspect that many Latinos lack insurance coverage because they may be undocumented and not eligible for coverage under the ACA. Other risk factors that may also be at play: Latinos make up nearly half of adults who are earning less than 138% of the poverty level?$ 16,243 for one person or $ 33,465 for a family of four.

 

Ultimately, using a combination of local and federal interventions can help the U.S. move closer to its goal of helping get coverage for all its citizens.

 

Is the 2-midnight rule going away and when will short-stay audits resume?

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify updates to CMS’ 2-midnight rule and best practices for compliance.

 

Every couple months, it seems questions arise about the 2-midnight rule and there are rumors that it may be going away. Below are some questions with answers from our expert Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago, to clarify where things stand today with regard to the 2-midnight rule.

 

Q: I heard the 2-midnight rule is now gone based on changes to Medicare payment rates under the 2017 inpatient prospective payment system (IPPS) final rule. Is this true, and if not, what changed?

 

A: No, this is not the case. The 2-midnight rule is still alive and kicking. What the FY 2017 IPPS final rule did is finalize two adjustments in addition to updating the annual rate for inpatient hospital payments.

"First, CMS is finalizing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $ 11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008," states the CMS Fact Sheet. "For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments. For FY 2017, CMS calculates that $ 5.05 billion of the $ 11 billion requirement remains to be addressed. Therefore, CMS is finalizing a -1.5 percent adjustment to complete the statutorily specified recoupment."

And the second part of the change, which seems to be causing the confusion, is CMS took action on a -0.2 percent adjustment it implemented in the FY 2014 IPPS final rule.

This adjustment was initially made to account for an estimated increase in Medicare spending due to the 2-midnight policy. "Specifically, in the FY 2014 IPPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2% to the payment rates," states the fact sheet.

While CMS thought this adjustment was reasonable at the time, a recent review led CMS to permanently remove this adjustment, "and its effects for FYs 2014, 2015, and 2016 by adjusting the 2017 payment rates. This will increase FY 2017 payments by approximately 0.8%," stated CMS.

Hirsch says this move is "purely about money." "They are leaving the 2-midnight rule itself completely intact," he says.

The bottom line: Pay attention to 2-midnight compliance and ensure your organization has good systems in place to support it.

 

Q: When are Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) short-stay reviews going to resume?

 

A: Back in May, CMS put a hold on short-stay inpatient audits related to the 2-midnight rule. That hold was lifted effective September 12, 2016, according to a FAQ published by CMS (http://ow.ly/DQxW304bCa6).

According to the FAQ, CMS decided to lift this temporary suspension for five reasons, which are as follows:

  1. BFCC-QIOs were successfully retrained on 2-midnight rule
  2. BFCC-QIOs finished a re-review of claims that were formally denied
  3. CMS "examined and validated the BFCC-QIOs peer review activities related to short-stay reviews"
  4. BFCC-QIOs reached out to providers on claims that were affected by the temporary suspension
  5. BFCC-QIOs started provider outreach and education on the 2-midnight rule

It appears that based on the five points, the temporary audit suspension accomplished its goal of helping BFCC-QIOs sort out the challenges they faced during the initial round of audits.

Prior to the suspension, hospitals complained about inconsistencies in the review process, which triggered the suspension. The BFCC-QIO audits began in October 2015, and hospitals reported a number of surprises including:

  • Auditors requested records as far back as May 2015 when many believed the audits would only look at records from 2015 forward
  • BFCC-QIOs missed deadlines, and provided audit results late
  • Failure by BFCC-QIOs to schedule timely education for providers

 

These problems made it difficult for hospitals to hit filing deadlines, and they were consequently reporting problems because they missed the window to appeal denied claims. Hospitals also didn’t have a chance to get education to understand what they were doing wrong to fix the problem.

There were also rumored problems related to benchmark admissions. Hospitals reported that BFCC-QIOs were routinely and in some cases inappropriately denying inpatient admissions when the patient spent one night as an outpatient in the emergency department or in observation services before he or she was admitted?even when the patient spent a second night in the hospital as an inpatient.

To prevent future problems, CMS said in its FAQ that it will continue to provide oversight for BFCC-QIO efforts by:

  • Reviewing a sample of completed claim reviews each month
  • Monitoring provider education calls
  • Responding to individual provider inquiries and concern. Providers may send questions to the CMS Open Door Forum Mailbox at ODF@cms.hhs.gov.

 

CMS also said that BFCC-QIOs will continue tofollow the guidance called, "Reviewing Short-Stay Hospital Claims for Patient Status." To see a copy ofthe guidance, go to www.cms.gov/research-statistics- data-and-systems/monitoring-programs/medicare-ffs- compliance-programs/medical-review/inpatienthospitalreviews.html.   

The BFCC-QIOs will also be charged with providing provider education going forward. "The BFCC-QIOs were directed to use comprehensive outreach and communication approaches (i.e., website, newsletter, one-on-one training, and town hall type events) to continue to educate providers on when payment under Medicare Part A is appropriate under the 2-midnight policy," states the FAQ. "BFCC-QIOs are required to educate providers using quality improvement core principles that facilitate continuous learning and promote greater provider understanding of the appropriate application of the 2-midnight policy in accordance with the revisions in the CY 2016 OPPS Final Rule (CMS-1633-FC): www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1633-FC.html."

Now that audits have resumed, organizations should maintain a focus on 2-midnight compliance. Below are some tips Hirsch has recommended in the past, including:

  • Reviewing every short-stay admission?those between zero and one day?prior to billing.
  • Ensuring that every patient’s status is appropriate up front. Reviewing the chart of every patient that goes upstairs.
  • Using the physician advisor to check compliance on cases that are murky to ensure that they meet one of the exceptions under the 2-midnight rule. Changing cases that don’t meet an exception using condition code 44. If the problem isn’t discovered until after discharge, self-deny and rebill the claim.
  • Ensuring that the case managers and the physicians are up to date about any potential changes to the 2-midnight rule and how to comply.

 

HCPro.com – Case Management Monthly

Briefings on Coding Compliance Strategies, November 2016

Navigating the 2017 pressure ulcer coding changes in newly released guidelines

By Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

As if coders and clinical documentation improvement specialists aren’t under enough pressure as it is, the advent of the 2017 Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding. The guidelines can be viewed here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.

Considering that these conditions impact length of stay, require additional monitoring and nursing care, and ultimately affect reimbursement for facilities, it’s no wonder coding for these conditions is under increased scrutiny. However, with a solid understanding of these types of ulcers, taking the time to read and understand the coding requirements can alleviate the "pressure" of ulcer codes.

 

New terminology

In April, the National Pressure Ulcer Advisory Panel (NPUAP) revised the pressure injury staging system, which can be found here: www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury. Since then, the NPUAP has received positive feedback regarding the system, and in August, The Joint Commission adopted the new terminology.

 

The definitions for each type of pressure injury are now:

  • Stage 1 pressure injury: Non-blanchable erythema of intact skin
  • Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis

 

  • Stage 3 pressure injury: Full-thickness skin loss

 

  • Stage 4 pressure injury: Full-thickness skin and tissue loss

 

  • Unstageable pressure injury: Obscured full-thickness skin and tissue loss

 

  • Deep tissue pressure injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration

 

The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer. These are similar to the codes from the L89 category in ICD-10-CM, however, the system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.

The NPUAP no longer uses the term "pressure ulcer," and has replaced it with "pressure injury," since stage 1 and deep tissue injuries describe intact skin, not open ulcers. The system also introduced the new term DTPI with this update.

 

Incorporating these changes in ICD-10

CMS has been in discussion with the NPUAP to in-corporate the new terminology, however, these terms are not used in the 2017 ICD-10-CM/PCS code update. The incorporation of the pressure ulcer terminology will be directed by both CMS and The Joint Commission, and NPUAP is currently working to introduce the changes to the code definitions.

 

According to the NPUAP:

 

Some documentation requirements for pressure ulcer coding, such as using non-physician documentation for identifying pressure ulcer stages, hasn’t changed from 2016 to 2017. What has changed for 2017 is the requirements for coding the progression of stages.

For ulcers that were present on admission (POA) but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. Furthermore, if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

These new coding requirements differ greatly from 2016 guidance which required only the highest stage of the pressure ulcer to be reported for pressure ulcers that evolve into a higher stage during the admission.

These new requirements could have an impact on hospital-acquired condition (HAC) reporting, considering stage 3 and stage 4 pressure ulcers with POA indicators of either a N- No or U-Documentation is insufficient are considered to be HACs, and also are classified as major complications or comorbidities.

American Hospital Association Coding Clinic guidance from First Quarter 2009 stated that the National Quality Forum excludes progression of pressure ulcers that were present on admission as a serious reportable event (SRE), also called a "never event." The intent was not to penalize facilities for progression of a pressure ulcer that was POA, as these are difficult conditions and even with the best preventive measures in effect, ulcers may evolve to a higher degree. The revised guidance for 2017, which is necessitating that two codes be used to identify the different stages of a site, feels as if it’s changing the standpoint of whether the pressure ulcer evolution is now an SRE.

The latest Coding Clinic, Third Quarter 2016, has updated guidance for pressure injury terminology. They acknowledge the changes in definition by the NPUAP from pressure ulcer to injury and advise:

For a DTPI, there is an entry in the Alphabetic Index under "injury, deep tissue," with further guidance which states: "meaning pressure ulcer ? see ulcer, pressure, unstageable, by site." Therefore, per Coding Clinic, code a DTPI as an unstageable pressure ulcer by site.

 

What is in the future for coders?

Can coders expect to see changes in pressure ulcer terminology soon? The most recent Coding Clinic did not give a time frame for updates, thus the potential impact on hospital reimbursement is something we can only speculate on at this point. If a pressure ulcer evolves from a stage 1, 2, 3, or 4 during an inpatient admission, these ulcers could be identified as an HAC and therefore impact the diagnosis-related group.

 

Editor’s Note: 

Commeree is a coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts. She has many years of experience in the healthcare industry involving coding, auditing, training, and compliance expertise. This article originally appeared on JustCoding, and opinions expressed are that of the author and do not represent HCPro or ACDIS. For questions, contact editor Amanda Tyler at atyler@hcpro.com.

 

A new sepsis definition: Finding coding compliance at a crossroads

This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS.

 

In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’ SEP-1 core measure), and ICD-10-CM coding compliance.

We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a "life-threatening organ dysfunction caused by a dysregulated host response to infection," differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term "severe sepsis," and discussed that the definition change impacted ICD-10-CM code assignment and compliance.

Definitions and clinical indicators in Sepsis-2 are available at http://tinyurl.com/SepsisTwo, and definitions for Sepsis-3 are available at www.jamasepsis.com. CMS’ definition of sepsis and severe sepsis for the SEP-1 core measure is available at http://tinyurl.com/2017SEP1.

 

Coding Clinic update

Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated "coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis)."

Coding Clinic went on to write (emphasis mine):

 

In my opinion, this means that Coding Clinic is saying ICD-10-CM still embraces the coding of infections without sepsis, with sepsis but without organ dysfunction, and with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis), if the diagnosis is incorporated by the documenting physician. The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.

Alternatively, while Sepsis-3 states that the word "sepsis" requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents "severe sepsis" or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term "sepsis" (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.

 

Coding Clinic, Fourth Quarter 2016

As we discussed last month, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):

 

In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147?149 stated (emphasis mine):

 

Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI. Access these at http://tinyurl.com/2016AHIMAclinicalvalidation and www.hcpro.com/content/327466.pdf.

 

Coding Clinic then went on to say that (emphasis mine) "a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system."

While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in the literature.

As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded. I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.

Solving the problem

In developing a sepsis strategy in light of these Coding Clinics, allow me to remind all of you that there are three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock unless he or she states what environment they are in. These are:

  • Clinical language ? Physicians have a language that we use in direct patient care that communicates well with other physicians; we learned this language in medical school, in residency training, and in reading our literature. Every physician knows what "urosepsis," "unresponsiveness," and "neurotoxicity" is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so that we can report them using the ICD-10-CM conventions. Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT) is a clinical language we use in our problem lists and so is Sepsis-3. ICD-10-CM is not. Not all physicians embrace Sepsis-3, thus some may wish to label a patient as having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them. See the articles listed above.
  • Coding language ? As discussed, Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without and with organ dysfunction, bases coding on the individual physician’s criteria and documentation, and requires clinical validation using reasonable criteria prior to code assignment.
  • Core measure language ? Defining cohorts with core measures, such as SEP-1, is a clinical abstraction based on clinical criteria and not necessarily based on what a physician writes. For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than that of Sepsis-3. Remember, however, that in 2017, if a physician documents severe sepsis and R65.20, and severe sepsis is coded, that record will be held accountable for the SEP-1 even if it doesn’t meet the SEP-1 criteria. View this regulation at http://tinyurl.com/jlau9ms.

Therefore, allow me to suggest the following strategy to ensure a balance of compliance with all three of these environments:

1.Standardize the definition and documentation of severe sepsis first. I believe that the Recovery Auditors (RA) are looking for records with sepsis codes that do not have R65.20 or R65.21 (septic shock) as a secondary diagnosis as to deny these codes and their resultant DRGs. In so doing, I believe that the definition of severe sepsis should be negotiated with and standardized by the medical staff, which could incorporate any or all of the following three criteria:

 

No matter what criteria is used, be sure to coordinate its development and deployment with your quality, clinical documentation integrity, and coding staff so that if a physician documents severe sepsis or septic shock, the SEP-1 algorithm can be implemented.

Also, be sure that physicians explicitly link organ dysfunctions to sepsis, or preferably, use the term "severe sepsis" so that R65.20 is not inadvertently missed by the coders. If a clinical documentation specialist or coder obtains a record supporting R65.20, be sure to notify the SEP-1 manager to determine if it qualifies for the SEP-1 core measure.

 

2.Develop a facilitywide definition for sepsis without organ dysfunction. As noted last month, many physicians do not believe that organ dysfunction is required to diagnose sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, we must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding validation purposes. When it is documented by a provider without evidence of acute organ dysfunction, this statement can be used to rebut the RA’s denials. These will be handy if we are appealing beyond the first level.

3.Remind the RA that the ICD-10-CM guidelines are part of HIPAA and that coding is based on provider documentation. I’m sure that all of our contracts with private payers state that we will comply with federal laws, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign codes based on provider documentation, and not so much on what the RA thinks, and that Coding Clinic, First Quarter 2014, pp. 16?17, states that "the official guidelines are part of the HIPAA code set standards," we don’t want the RAs to violate HIPAA or our contracts with payers. This may require that our hospital attorneys or compliance officers weigh in, given that RAs have been known to deny codes based on provider documentation and want us to do the same.

 

Summary

Please recognize that this topic is very controversial and that the opinions expressed here are solely my own. I encourage all of us to discuss Sepsis-2, Sepsis-3, SEP-1, the 2017 Official ICD-10-CM Guidelines, and these Coding Clinics with our compliance officers and/or attorneys so that we can best support policies and procedures ensuring complete, precise, and compliant coding of sepsis in light of Sepsis-3. If you have success stories, please share them with me and the editor here at BCCS.

 

Editor’s note:

This article was part two of a two-part series. You can read part one in BCCS’ October issue. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at atyler@hcpro.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

 

Has your CDI program shifted its focus for optimal PSI 15 performance?

by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer

The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).

Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.

A fundamental understanding of patient safety indicator measures

Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:

  • The numerator: The numerator for PSI 15, also called the "outcome of interest," reports the actual number of cases which experienced the accidental puncture/laceration.
  • The denominator: The denominator for PSI 15, also called the "cohort," establishes the population which is screened to identify the outcome of interest.
  • Risk adjustment: Denominator comorbidities, which have a statistically demonstrated impact on the likelihood of a patient incurring the patient safety event. The risk adjustment methodology establishes the expected number of discharges with the outcomes of interest.

 

The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.

For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.

 

The new PSI 15?what counts?

The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).

The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.

From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.

 

PSI 15: Are you focused on risk adjustment?

Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.

The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.

The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.

 

Summary

Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.

 

 

Editor’s note:

Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or shannon.newell@enjoincdi.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

 

New clinical criteria definitions in 2017 Official Guidelines up the ante for coders

by Laura Legg, RHIT, CCS, CDIP, and AHIMA-approved ICD-10-CM/PCS trainer

The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.

Up the ante means to increase the costs, risks, or considerations involved in taking an action or reaching a conclusion. With the new coding guideline for clinical validation that went into effect October 1, the stakes remain high for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.

It is not that the information was not there before, but now the issue is finally getting attention. When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present. But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this has been a haunting issue for a very long time.

The ICD-10-CM Official Guidelines for Coding and Reporting are the foundation from which coders assign codes. Coders need to review the new guidelines in detail to understand the changes and implications for their facilities.

The Centers for Disease Control and Prevention published these new guidelines which can be read in their entirety here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.

 

Taking a closer look

The coding guideline for section A.19 (code assignment and clinical criteria) has been labeled as controversial and, at this point, we have more questions than answers. Denials issued by payers due to the absence, or perceived absence, of clinical indicators by which the payer lowers the DRG is now being called DRG downgrading and it’s getting attention.

The code assignment and clinical criteria states:

 

Physicians and other providers document a patient’s condition based on past experience and what the clinician learned in medical school, which often differs from clinician to clinician. When you put a patient in front of a group of clinicians you will most likely get differing documentation. So how do we fix that?

The diagnosis of sepsis is a good example. There does not appear to be a universally accepted and consistently applied definition for the condition of sepsis.

In a patient record with the principal diagnosis code of sepsis, followed by the code for the localized infection, pneumonia, a payer denial could occur.

Payer denials often deny the sepsis diagnosis code stating that "the diagnosis of sepsis was not supported by the clinical evidence. Therefore, as a result of this review, the diagnosis code A41.9 [sepsis, unspecified organism] has been removed and the principal diagnosis re-sequenced to code J18.9 [pneumonia, unspecified organism] for pneumonia and to the lower paying DRG 193." This is now being referred to as a DRG downgrade. DRG downgrades can occur for different reasons including both DRG coding changes and clinical validation downgrades.

 

What is a coder to do?

What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart? Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of this coding guideline to coding practices.

Remember the section that reads: "the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient."

This represents a catch-22. If the diagnosis is not clinically validated, both recovery auditors (RA), as well as commercial insurance auditors, are going to deny the claim. On the other hand, if coders or the facility decide not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.

AHIMA’s 2016 Clinical Documentation Toolkit offers this advice:

The toolkit is available here: http://bok.ahima.org/PdfView?oid=301829.

 

Increasing clinical documentation

As the healthcare industry experiences an increased number of external audits, both federal and private, the need to up the ante on clinical documentation has become essential. The answer is not to let this guidance prompt lazy documentation, which has far reaching consequences, but to use it as a catalyst for improvement.

The goal of any clinical documentation improvement (CDI) program is to ensure a complete and accurate patient record, and this cannot be done without the presence of documentation supporting the clinical indicators and clear and consistent documentation regarding the condition. The provider’s documentation of their full thought process will accomplish this. If medical staff can come together and agree upon a definition for a certain condition, they can begin the process of being consistent with how the description is presented in the patient record.

CDI specialists and coders should not use the new guideline as an excuse not to query. Coders are not clinicians and, therefore, should not be expected to evaluate clinical criteria. Coding and CDI were separate functions, but, as audits from outside organizations expand, there is more emphasis on correct coding, DRG assignment, and the use of clinical criteria to support the reported codes, which means these entities need to work together.

The American Hospital Association’s Coding Clinic for ICD-10 instructs coders not to use background clinical information contained in their responses for code assignment. This information is only provided so the coders can make a judgment to query where there is incomplete documentation. Coders and CDI staff should review all chart documentation and data, and query when necessary to clarify inconsistencies in physician documentation.

Query the provi

HCPro.com – Briefings on Coding Compliance Strategies

2016 Deleted CPT codes


0099T   Implantation of intrastromal corneal ring segments

0103T   Holotranscobalamin, quantitative

0123T   Fistulization of sclera for glaucoma, through ciliary body

0182T   High dose rate electronic brachytherapy, per fraction

0223T   Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; single, with interpretation and report

0224T   Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter, AV or VV delays only, with interpretation and report

0225T   Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter, AV and VV delays, with interpretation and report

0233T   Skin advanced glycation endproducts (AGE) measurement by multi-wavelength fluorescent spectroscopy

0240T   Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with high resolution esophageal pressure topography

0241T   Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion during high resolution esophageal pressure topography study (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)

0243T   Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluation(s), with interpretation and report

0244T   Continuous measurement of wheeze rate during treatment assessment or during sleep for documentation of nocturnal wheeze and cough for diagnostic evaluation 3 to 24 hours, with interpretation and report

0262T   Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach

0311T   Non-invasive calculation and analysis of central arterial pressure waveforms with interpretation and report

21805   Open treatment of rib fracture without fixation, each

31620   Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure[s])

37202   Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive)

37250   Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List separately in addition to code for primary procedure)

37251   Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; each additional vessel (List separately in addition to code for primary procedure)

39400   Mediastinoscopy, includes biopsy(ies), when performed

47136   Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age

47500   Injection procedure for percutaneous transhepatic cholangiography

47505   Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T-tube)

47510   Introduction of percutaneous transhepatic catheter for biliary drainage

47511   Introduction of percutaneous transhepatic stent for internal and external biliary drainage

47525   Change of percutaneous biliary drainage catheter

47530   Revision and/or reinsertion of transhepatic tube

47560   Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy

47561   Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy

47630   Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique)

50392   Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous

50393   Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous

50394   Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter

50398   Change of nephrostomy or pyelostomy tube

64412   Injection, anesthetic agent; spinal accessory nerve

67112   Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques

70373   Laryngography, contrast, radiological supervision and interpretation

72010   Radiologic examination, spine, entire, survey study, anteroposterior and lateral

72069   Radiologic examination, spine, thoracolumbar, standing (scoliosis)

72090   Radiologic examination, spine; scoliosis study, including supine and erect studies

73500   Radiologic examination, hip, unilateral; 1 view

73510   Radiologic examination, hip, unilateral; complete, minimum of 2 views

73520   Radiologic examination, hips, bilateral, minimum of 2 views of each hip, including anteroposterior view of pelvis

73530   Radiologic examination, hip, during operative procedure

73540   Radiologic examination, pelvis and hips, infant or child, minimum of 2 views

73550   Radiologic examination, femur, 2 views

74305   Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation

74320   Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation

74327   Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique), radiological supervision and interpretation

74475   Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

74480   Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

75896   Transcatheter therapy, infusion, other than for thrombolysis, radiological supervision and interpretation

75945   Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel

75946   Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; each additional non-coronary vessel (List separately in addition to code for primary procedure)

75980   Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation

75982   Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation

77776   Interstitial radiation source application; simple

77777   Interstitial radiation source application; intermediate

77785   Remote afterloading high dose rate radionuclide brachytherapy; 1 channel

77786   Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels

77787   Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels

82486   Chromatography, qualitative; column (eg, gas liquid or HPLC), analyte not elsewhere specified

82487   Chromatography, qualitative; paper, 1-dimensional, analyte not elsewhere specified

82488   Chromatography, qualitative; paper, 2-dimensional, analyte not elsewhere specified

82489   Chromatography, qualitative; thin layer, analyte not elsewhere specified

82491   Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase

82492   Chromatography, quantitative, column (eg, gas liquid or HPLC); multiple analytes, single stationary and mobile phase

82541   Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), non-drug analyte not elsewhere specified; qualitative, single stationary and mobile phase

82543   Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), non-drug analyte not elsewhere specified; stable isotope dilution, single analyte, quantitative, single stationary and mobile phase

82544   Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), non-drug analyte not elsewhere specified; stable isotope dilution, multiple analytes, quantitative, single stationary and mobile phase

83788   Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen

88347   Immunofluorescent study, each antibody; indirect method

90645   Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use

90646   Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90669   Pneumococcal conjugate vaccine, 7 valent (PCV7), for intramuscular use

90692   Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use

90693   Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military)

90703   Tetanus toxoid adsorbed, for intramuscular use

90704   Mumps virus vaccine, live, for subcutaneous use

90705   Measles virus vaccine, live, for subcutaneous use

90706   Rubella virus vaccine, live, for subcutaneous use

90708   Measles and rubella virus vaccine, live, for subcutaneous use

90712   Poliovirus vaccine, (any type[s]) (OPV), live, for oral use

90719   Diphtheria toxoid, for intramuscular use

90720   Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Haemophilus influenzae b vaccine (DTwP-Hib), for intramuscular use

90721   Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Haemophilus influenzae b vaccine (DTaP/Hib), for intramuscular use

90725   Cholera vaccine for injectable use

90727   Plague vaccine, for intramuscular use

90735   Japanese encephalitis virus vaccine, for subcutaneous use

92543   Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording

95973   Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)



Coding Ahead

2016 New CPT codes


0381T   External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0382T   External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0383T   External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0384T   External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0385T   External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0386T   External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0387T   Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular

0388T   Transcatheter removal of permanent leadless pacemaker, ventricular

0389T   Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system

0390T   Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

0391T   Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

0392T   Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band)

0393T   Removal of esophageal sphincter augmentation device

0394T   High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed

0395T   High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed

0396T   Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure)

0397T   Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure)

0398T   Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed

0399T   Myocardial strain imaging (quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics) (List separately in addition to code for primary procedure)

0400T   Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; one to five lesions

0401T   Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; six or more lesions

0402T   Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

0403T   Preventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day

0404T   Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency

0405T   Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-to-face time

0406T   Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant;

0407T   Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement

10035   Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion

10036   Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for primary procedure)

31652   Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures

31653   Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures

31654   Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])

33477   Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed

37252   Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)

37253   Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)

39401   Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed

39402   Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging)

43210   Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed

47531   Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access

47532   Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access (eg, percutaneous transhepatic cholangiogram)

47533   Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; external

47534   Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; internal-external

47535   Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

47536   Exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal-external to external only), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

47537   Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (eg, with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

47538   Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; existing access

47539   Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; new access, without placement of separate biliary drainage catheter

47540   Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation, each stent; new access, with placement of separate biliary drainage catheter (eg, external or internal-external)

47541   Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (eg, rendezvous procedure), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation, new access

47542   Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, each duct (List separately in addition to code for primary procedure)

47543   Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (eg, brush, forceps, and/or needle), including imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, single or multiple (List separately in addition to code for primary procedure)

47544   Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction of calculi by any method (eg, mechanical, electrohydraulic, lithotripsy) when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

49185   Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed

50430   Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access

50431   Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; existing access

50432   Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

50433   Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access

50434   Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, via pre-existing nephrostomy tract

50435   Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

50606   Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

50693   Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; pre-existing nephrostomy tract

50694   Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter

50695   Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, with separate nephrostomy catheter

50705   Ureteral embolization or occlusion, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

50706   Balloon dilation, ureteral stricture, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

54437   Repair of traumatic corporeal tear(s)

54438   Replantation, penis, complete amputation including urethral repair

61645   Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)

61650   Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory

61651   Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition to code for primary procedure)

64461   Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)

64462   Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure)

64463   Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)

65785   Implantation of intrastromal corneal ring segments

69209   Removal impacted cerumen using irrigation/lavage, unilateral

72081   Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view

72082   Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views

72083   Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views

72084   Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views

73501   Radiologic examination, hip, unilateral, with pelvis when performed; 1 view

73502   Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views

73503   Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views

73521   Radiologic examination, hips, bilateral, with pelvis when performed; 2 views

73522   Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views

73523   Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views

73551   Radiologic examination, femur; 1 view

73552   Radiologic examination, femur; minimum 2 views

74712   Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation

74713   Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)

77767   Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

77768   Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions

77770   Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel

77771   Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels

77772   Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels

78265   Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit

78266   Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, multiple days

80081   Obstetric panel (includes HIV testing) This panel must include the following: Blood count, complete (CBC), and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result (87389) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)

81162   BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis

81170   ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain

81218   CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence

81219   CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9

81272   KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18)

81273   KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s)

81276   KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146)

81311   NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)

81314   PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18)

81412   Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1

81432   Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53

81433   Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11

81434   Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A

81437   Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL

81438   Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL

81442   Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1

81490   Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score

81493   Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score

81525   Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score

81528   Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

81535   Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination

81536   Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedure)

81538   Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival

81540   Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype

81545   Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)

81595   Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score

88350   Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)

90620   Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intramuscular use

90621   Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for intramuscular use

90625   Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use

90697   Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use

92537   Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations)

92538   Caloric vestibular test with recording, bilateral; monothermal (ie, one irrigation in each ear for a total of two irrigations)

93050   Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive

96931   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion

96932   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion

96933   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion

96934   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure)

96935   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure)

96936   Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure)

99177   Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis

99415   Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

99416   Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service)


Coding Ahead

2016 G-Codes, Definitive Drug Testing, G0480, G0481, G0482, & G0483 OPINIONS PLEASE!

When using codes G0480, G0481, G0482, & G0483 it’s my understanding that you do not and can not bill these codes with more than one unit.
I’ve read the description for all codes and that’s the only way I understand it. Please tell me if I am wrong!

UHC has just started denying the old codes and I am sending corrected claims on them, but my supervisor is telling me to bill for 4 units on G0480 because that’s the number of drugs tested for, I explained my thoughts on it but she is not seeing it that way.

Please tell me your thought!! And if I am wrong then why 4 different codes for different amounts of drug classes???

Please give me opinions, I would greatly appreciate them!!!

Medical Billing & Coding Forum | AAPC

2016 CPT Code Changes


2016 Newly Added Lab Codes List

80081 Obstetric panel (includes HIV testing)

This new code is identical to the 80055 code (Obstetric panel) except the HIV testing was added. In order to bill this code all components of the panel must be performed. The added service for this new panel includes HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result (87389).

MOLECULAR PATHOLOGY TIER 1 MOLECULAR PATHOLOGY PROCEDURES

The following are the new codes for 2016 for gene-specific and genomic procedures. Molecular pathology codes include all analytical services performed in the test. This includes cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection. Any procedures required prior to cell lysis such as microdissection (88380, 88381) are reported separately. AMA instructs coders to use 87149-87153, 87470-87801, and 87900-87904 for any molecular testing done for microbial identification. This means molecular testing for infectious agents, such as HPV are NOT reported in the molecular pathology section of the code book. You should look to the Microbiology section for those codes.

For in situ hybridization, use the 88271-88275 (when interpreted by scientist instead of pathologist) and 88365-88368 when interpreted by a pathologist.

81170 ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain

81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis. Do not report 81162 in conjunction with 81211, 81213, 81214, 81216)

81218 CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence

81219 CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9

81272 KIT (v-kit Hardy-Zukerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18)

81273 KIT (v-kit Hardy-Zukerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variants(s)

81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma gene analysis; additional variants(s) (eg, codon 61, codon 146)

81311 NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)

81314 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18)

GENOMIC SEQUENCING PROCEDURES AND OTHER MOLECULAR MULTIANALYTE ASSAYS

This new section of genomic sequencing procedures (GSPs) are DNA or RNA sequence analysis methods that simultaneously assay multiple genes or genetic regions relevant 

to a clinical situation. Most commonly referred to a “Next Gen Sequencing” (NGS) or “Massively Parallel Sequencing” (MPS) in the laboratory, are tests intended to 

evaluate the genetic material in totality or near totality.

The codes in this section should be used when the components of the descriptor(s) are met regardless of the technique used, unless specifically noted in the code descriptor. 

If all the components are NOT performed, then you must assign code(s) in the Tier 1 or Tier 2 section or if they aren’t listed in the Tier codes, use the unlisted code 

81479. AMA provides two parenthetical statements after this introduction section:

• For cytogenomic microarray analyses, see 81228, 81229, 81405, 81406.
• For long QT syndrome gene analyses, see 81280, 81282 

81412 Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GA, HEXA, IKBKAP, MCOLN1, and SMPD1

81432 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, include ATM, BRCA1, BRIP1, CHD1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53

81433 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11

81434 Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A

81437 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma; genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL

81438 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma; duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL

81442 Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence
analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1

The CPT codes listed above in this section are panels associated with various disorders where the testing is performed by genomic sequence analysis. In each of the CPT panel codes the code descriptors define specifically what genes must be tested in that panel as well as the minimum number of genes that must be tested in order to assign that given CPT code.

MULTIANALYTE ASSAYS WITH ALGORITHMIC ANALYSES

Multianalyte Assays with Algorithmic Analyses (MAAAs) are procedures that utilize multiple results derived from assays of various types, including molecular pathology assays, fluorescent in situ hybridization assays and nonnucleic acid based assays (eg, proteins, polypeptides, lipids, carbohydrates). Algorithmic analysis using the results of these assays as well as other patient information, if used, is then performed and reported typically as a numeric score(s) or as a probability.

MAAAs are typically unique to a single clinical laboratory or manufacturer. The results of individual component procedure(s) that are inputs to the MAAAs may be provided on the associated laboratory report; however, these assays are not reported separately using additional codes. For more information on these codes, please see the MAAA section of the 2016 CPT code book and Appendix O in your 2016 Code book

81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score. Do not report 81490 in conjunction with 86140

81493 Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score

81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score

81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result. Do not report 81528 in conjunction with 81275, 82274

81535 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination

+81536 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; each additional single drug or drug combination (List separately in addition to code for primary procedure) Do not report 81536 in conjunction with 81535

81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival

81540 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype

81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)

81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score

0009M Fetal aneuploidy (trisomy 21, and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy

0010M Oncology (High-Grade Prostate Cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA and human kallikrein 2 [hK2]) plus patient age, digital rectal examination status, and no history of positive prostate biopsy, utilizing plasma, prognostic algorithm reported as a probability score

SURGICAL PATHOLOGY

Immunofluorescence Stains

AMA has added one code for 2016, an add-on code for immunofluorescence stains. This code represents any additional stains that are performed above the initial first stain which is assigned CPT 88346. The “unit of service” is defined as each additional “single antibody stain procedure” from that designated specimen. It is not solely each additional stain performed, it has to be a separate stain procedure for that given stain, hence the descriptor “single antibody stain procedure.”

Also please note in the parenthetical that the AMA specifically states to not report 88346 and 88350 when the stain performed is a multiplex immunofluorescence stain(s)… it directs to the coder to assign the miscellaneous code 88399.

NOTE that 88350 has a + sign denoting an add-on code and can only be billed when 88346 is also billed. 

+88350 Immunofluoroscence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) Report 88350 in conjunction with 88346. Do not report 88346 and 88350 for fluorescent in situ hybridization studies, see 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, and 

88377. Do not report 88346 and 88350 for multiplex immunofluorescence analysis, use 88399

CMS newly added codes

G0475 Hiv antigen/antibody, combination assay, screening

G0476 Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test.


Coding Ahead

Five Documentation Vulnerabilities to Address in 2016


Physician Documentation

Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016

By Dari Bonner, RMC, CCP, CHCA, and Dr. Karen M. Fancher, MD, RMC, CPC, CANPC, CFPC . Originally published in AHIMA.

Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI specialists within their owned or affiliated physician practices to ensure a smooth transition—thereby expanding CDI efforts into outpatient and ambulatory settings.

With the proliferation of accountable care organizations (ACOs) and the rise in healthcare mergers and acquisitions, many hospitals and health systems are looking for ways to continue the ICD-10 educational momentum and expand CDI efforts into outpatient, ambulatory, and physician practice settings. Beyond these hospital-led initiatives, many independent practices and private physicians are also quickly recognizing the importance of documentation quality—and how coded data translates to reportable outcomes. This article takes a deeper dive into implementing effective CDI programs within physician practices. 

Why the Timing is Right

In today’s healthcare environment, documentation is paramount, being used for medical coding and reimbursement. It’s also increasingly used to gauge the quality of care provided. When physicians accurately and thoroughly capture the true clinical picture of a patient’s condition or problem, not only do they justify medical necessity, they may also avoid third-party audit scrutiny and denials. This has a direct positive effect on cash flow and the overall successful operation of the business—for both hospitals and physicians.

Regulatory changes have also forced physicians to take a closer look at clinical documentation. ACOs and bundled payments, for example, incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible. Public outcomes data has also forced physicians to question the efficacy of their coded data, which almost always leads back to a discussion about documentation. In addition, the Physician Quality Reporting System (PQRS) and “meaningful use” Electronic Health Record (EHR) Incentive Program are pushing the need for better physician documentation. 

In the years ahead, the Centers for Medicare and Medicaid Services’ (CMS’) new Merit-Based Incentive Payment System (MIPS) will become a significant regulatory driver behind physician practice CDI. This program, which consolidates the PQRS, value-based payment modifier (VBPM), and meaningful use incentive program, uses data collected during 2017 to determine potential payment adjustments in 2019. Payment adjustments are determined based on a MIPS composite score that is partially driven by the coding of hierarchical condition categories (HCC), making HCC capture vital in the practice setting. 

Negative payment adjustments will be distributed as follows, depending on whether a provider’s composite score falls below a particular performance threshold: four percent in 2018, five percent in 2019, seven percent in 2020, and nine percent in 2021 through 2023. Above-par performance could earn a physician a bonus as high as 12 percent in 2018 and 27 percent by 2021.

Because of this potential negative impact on finances due to lax clinical documentation, CDI programs in physician practices will certainly become the norm. The question today is: How can HIM professionals help support them?

Logistics of CDI in a Physician Practice

Unlike hospitals that have more operational and personnel resources for CDI, physician practices must often rely on a certified coding professional or office manager to perform the task. In addition to overseeing CDI efforts, these individuals may also be responsible for checking patients in and out, obtaining insurance authorizations, responding to audits, coding, billing, performing accounts receivable follow-up, contracting, and much more. 

Given the plethora of responsibilities, CDI must therefore be extremely targeted and thoughtful in the practice setting. Those charged with CDI must audit documentation frequently so they can pinpoint educational opportunities for each individual provider—physicians, nurses, medical assistants, and scribes.

Another challenge is that CDI in a physician practice is often retrospective. Practices typically receive a denial and then perform physician or staff education based on the reason for the denial. Unfortunately, by the time the education occurs most physicians don’t remember making the documentation error or omission, and don’t recall the specifics of the case. Retrospective CDI also permits subsequent errors to snowball, causing a cascade of denials before a correction is provided. 

To be truly effective, practices need a “front-to-back” approach—proactive education and concurrent CDI on the front end of the process. This may require a more dedicated CDI resource within the practice as well as close collaboration with the practice’s EHR vendor to remediate documentation vulnerabilities, tweak templates, and update documentation alerts and prompts. 

Physician Documentation Vulnerabilities

To identify documentation vulnerabilities, one needn’t look further than the “FY 2016 Office of Inspector General (OIG) Work Plan” in which the OIG identifies trends and patterns of compliance risk and fraud. Some of these include non-covered chiropractic and anesthesia services as well as unreasonable use of prolonged services, high use of outpatient physical therapy services, and non-compliant referrals/orders for certain Medicare services, supplies, and durable medical equipment. But there are many other areas ripe for CDI. Consider the following five areas.

1. Cloned notes and assessments

This occurs when nurses or other providers copy and paste information from a previous visit into the current visit without verifying the accuracy of that information. In many cases, details are completely inaccurate or omitted entirely. There’s also often a mismatch between the chief complaint/history of present illness and the assessment. For example, a patient complains of neck pain but the entire assessment addresses the patient’s lower back pain. This incongruence can certainly benefit from a CDI specialist’s analytical eye.

2. Medical necessity

Physicians sometimes don’t understand that medical necessity isn’t synonymous with medical decision making. The specific ICD-10 diagnosis codes that the physician chooses can either make or break a payer’s decision to deem services medically necessary for the patient. Many physicians don’t even realize that local coverage determinations (LCDs) exist, requiring certain diagnoses as a prerequisite for payment. As payers continue to update these LCDs in light of ICD-10, someone focused on CDI can monitor changes and ensure that documentation is updated accordingly. 

3. ICD-10 diagnosis specificity

Certain specialties, such as orthopedics, OB/GYN, internal medicine, and cardiology, saw many more code expansions in ICD-10-CM than others. These specialties could benefit from CDI that prompts greater specificity related to laterality, disease manifestation, anatomical location, and more. An individual trained in CDI can help explain ICD-10 terminology to physicians and create ICD-10 favorite lists and shortcuts to alleviate the burden of sifting through diagnosis codes listed in the EHR—ultimately increasing productivity.

Unspecified codes may prove to be particularly problematic in practices. That’s because CPT codes—not diagnosis codes—drive reimbursement in the practice setting, leaving little incentive for physicians to pay attention to diagnoses. In addition, the American Medical Association/CMS joint announcement made last July indicates that contractors conducting medical reviews (i.e., Medicare administrative contractors, recovery auditors, zone program integrity contractors, and the supplemental medical review contractor) during the 12-month period following ICD-10’s implementation on October 1, 2015 could not deny claims solely for the specificity of the ICD-10 code. This is as long as the code is in the correct family of codes (i.e., the correct ICD-10 three-character category) and there is no evidence of potential fraud. This flexibility applies to both automated and complex medical reviews. 

Many physicians don’t understand that this flexibility pertains only to Medicare and only to retrospective audits. Some have misinterpreted the announcement to mean that they have complete flexibility with all payers for ICD-10 reporting on the front end. Someone well-versed in CDI can ensure compliant coding that won’t subsequently jeopardize reimbursement once the Medicare flexibility has expired.

4. E/M levels

Due to fear of denials and audits, physicians frequently down-code their evaluation and management (E/M) levels (i.e., code a lower-level, lesser paying E/M code). In some cases, a higher level might be justified if the individual trained in CDI can identify opportunities where documentation is lacking—and then query for clarification. In other cases, a CDI specialist can identify patterns of over-coding that could trigger an audit or raise a payer’s red flag. An example is when a physician provides a follow-up office visit or subsequent hospital visit and then bills using a higher level E/M code as though a comprehensive new patient office visit or an initial hospital visit had been provided.

5. Bundling and modifier usage

CDI specialists can help physicians identify when it’s appropriate to use a modifier and when a particular procedure or service is inherent in a more extensive procedure or service performed at the same time. 

How to Get Started with Physician CDI

In this age of documentation scrutiny, physician practices can’t afford to wait for an OIG or CMS audit to reveal noncompliance. Doing so could put a practice out of business. It’s also in the practice’s best interest to improve documentation if it’s part of an ACO, shared-savings initiative, or larger health system. Consider these three strategies:

• Hire a certified coding professional. Several associations, including AHIMA, can point a practice to certified coding professionals. By ensuring that documentation meets regulatory requirements, a certified coding professional is an invaluable asset for any physician practice. A certified coding professional can also use his or her auditing skills to provide CDI feedback. Allow coding professionals to spend time in the clinical areas of the practice so they become more familiar with clinical diagnoses and procedures and can assist with documentation improvement.
• Focus on collaboration. Collaboration among key staff members in the provider practice will help providers document better and more efficiently. Also, quality CDI programs can help a practice streamline processes and procedures that currently create extra work for office staff and providers alike. 
• Seek assistance from hospital-based CDI specialists and HIM directors. These individuals can share valuable resources (i.e., policies, documentation tools/tips) that can help practices launch their CDI efforts.

    Documentation quality begins in the outpatient setting. Physicians who document well in their practices help establish a baseline for patient severity and justify medical necessity for inpatient services. Quality documentation enhances outcomes and ensures accurate revenue. Now is the time to evaluate needs, build partnerships, and begin the important task of improving physician practice documentation. 

    CDI Training

    Healthcare is rapidly changing. Stay in the game by taking a proactive approach to clinical documentation.

    Online Clinical Documentation Improvement Course: Click Here

     

     

    The Medical Management Institute – MMI – Medical Coding News & MMI Updates

    Inpatient Hospital Payment Rate Impacted by the Consolidated Appropriations Act, 2016


    CMS is currently revising the Inpatient Prospective Payment System (IPPS) FY 2016 Pricer to reflect the new payment calculation requirement.  The amount of the payment with respect to the operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for inpatient hospital discharges on or after January 1, 2016, will be based on 0 percent of the applicable Puerto Rico percentage and 100 percent of the applicable Federal percentage. In addition, the IPPS FY 2016 Pricer will include conforming changes to certain FY 2016 IPPS operating rates and factors that result from the application of the new Puerto Rico hospital payment calculation requirement, which are applicable to all IPPS hospital discharges on or after January 1, 2016. We will also incorporate the revised IPPS rates into the Long-Term Care Hospital (LTCH) Pricer, as they are used for certain LTCH claims payments.

    To allow sufficient time to develop and test, CMS will implement the IPPS and LTCH Pricers on April 4, 2016. Medicare Administrative Contractors (MACs) will reprocess IPPS inpatient claims from Puerto Rico and all other IPPS hospitals with a discharge date on or after January 1, 2016. The MACs will also reprocess LTCH claims with a discharge date on or after January 1, 2016, due to the impact of this change.  Puerto Rico hospitals (as well as all other IPPS and LTCH hospitals) do not need to take any action. We expect to reprocess claims no later than June 30, 2016.


    Coding Ahead