Review your electronic order templates to protect against audits and ensure compliance
by Valerie A. Rinkle, MPA
Orders for services are a vital component of ensuring Medicare coverage. With the advent of computerized provider order entry (CPOE), it is important to review order templates in the electronic medical record (EMR) and the resulting order produced or printed in the formal legal medical record to ensure the templates meet requirements.
Due to increased audit scrutiny, including resumption of inpatient status reviews by Quality Improvement Organizations (QIO) as of late September, it is vital to "audit proof" your organization’s EMR and legal medical record so that the orders substantiate coverage of services. The QIOs are auditing to ensure validity of inpatient orders as well as to ensure cases meet the benchmark for at least two nights of hospital-level care. These determinations are dependent on valid orders.
CMS has published numerous resources on orders for both outpatient services and inpatient admission. Requirements for orders vary based on the type of service, such as inpatient admission, outpatient admission, observation services, diagnostic laboratory services, and other diagnostic tests. A good resource is the CMS article, "Complying With Medical Record Documentation Requirements."
Orders must be signed or otherwise legitimately authenticated. Transmittal 327 contains detailed information concerning physician signature/authentication.
Elements of a valid order
To be considered a valid order, several elements must be present. Elements required in statute or regulations by Medicare are bolded:
- Authentication of the ordering provider (signature or valid electronic signature and credentials)
- Clinical indication/justification/reason for the test, using medical terminology (e.g., sign, symptom, diagnosis) and/or ICD-10-CM codes
- Date of the order
- If a drug is ordered, the drug name, dosage, route of administration, and rate for infusions
- Name of the ordering provider?this must be a treating provider, meaning he or she has conducted an exam and intends to use the results of that exam in continued treatment of the patient
- Patient name?best practice also calls for another identifier, such as date of birth
- Test or service ordered, by name?best practice also calls for the HCPCS/CPT code of the test
Format of orders
There is no requirement regarding the format of orders. For providers not linked to a hospital’s EMR, orders may continue to be delivered in writing or via facsimile. Often, the beginning of the workflow for the hospital EMR is to transcribe the order into the EMR for the patient. If this step occurs, it is vitally important that the original order be scanned and linked to the EMR to substantiate the information transcribed.
What if the staff transcribing the order incorrectly enters the information? What if the test is not logical or valid for the indication? The clinical staff providing the service should be able to view the original order and make any corrections, or obtain an updated order, as appropriate. Auditors expect to see the original order. If the order is not entered via CPOE, there will be no documentation in the EMR regarding the origination of the order, which is why scanning and not just transcribing the order is so crucial.
Orders missing elements
What does your hospital do if one of the elements is missing from the order? Ideally, if there were elements missing, no test or service would be performed. However, the current emphasis on improving patient experience may lead hospitals to move ahead and perform the service anyway. Recall that the EMR will clearly document the time of the test and the time that the diagnosis or other information is obtained, making it very clear to auditors whether the indications for the test were missing prior to its performance.
Further, because of prior authorization requirements as well as national coverage determinations (NCD) and local coverage determinations (LCD) that establish the medical necessity for outpatient tests, diagnostic indications obtained after test performance will be questioned: Did they actually exist prior to the test being performed?
If the hospital proceeds with testing prior to obtaining all the required elements of the order, it is recommended that the original chart note of the provider ordering the test be obtained, scanned, and linked to the EMR. The original chart note should clearly document that the test is needed along with the indication for the test. Documenting this information will prevent the appearance that the indication has been added after the test solely to justify meeting prior authorization or NCD/LCD requirements. Merely updating the EMR order with a diagnosis, or calling the provider and annotating the addition of a diagnosis on a written or faxed order, will open up the account to scrutiny and allegations of invalid documentation to support services.
ED protocols
What about testing initiated via protocol in the ED prior to the patient being seen by the treating provider? Protocols need to be vetted very carefully with the medical staff and with the MAC in your region.
Typically, an order is initiated as a verbal order in the EMR based on the presenting signs and symptoms of the patient. Once the provider sees the patient and uses the test results to treat the patient, the verbal order is authenticated by the treating ED provider in the EMR.
With this workflow, the requirements for orders are met. The concern with this workflow is whether the hospital has controls in place for patients who leave without being seen (LWBS) by the provider and for tests the provider does not agree were needed.
Providers do, at times, disagree with the protocol initiated by the nursing staff. There must be a clear workflow for the provider to do one of the following:
- Not authenticate the order with which the provider disagrees.
- Authenticate the order, but annotate the tests the provider disagrees with within the order. In these cases, the disputed tests should be billed and written off as noncovered.
Also, if tests are ordered via protocol and the patient is LWBS by a provider, the tests are not usually authenticated by the provider, and they are billed and written off as noncovered.
Billing for tests and services
ICD-10-CM codes included on outpatient claims for services typically come from the provider order. For certain imaging, cardiology, and other tests (i.e., nonclinical laboratory tests) where a physician makes a separate report of interpretation, the final impression on the report may be a different diagnosis from that on the order. In this case, the coder should code the final diagnosis from the report of interpretation. This diagnosis should be the diagnosis code billed on the claim. However, a large volume of accounts are billed from the order, and there may not be a process to ensure the diagnosis from the report of interpretation is included on the claim. In the past, some billing and coding departments coded solely from the indication that patient access staff transcribed from the order onto the patient account, meaning the departments did not review the reports of interpretation.
It is critical for compliance that outpatient accounts be coded from the original order if the report of interpretation does not have a more specific diagnosis (i.e., the report states "routine" or "no finding"). Proper coding requires that the staff applying the codes either view the original order in CPOE or via the scanned image.
With today’s gains in automation and productivity, more workflows now pull a code directly from the transcribed information or the data entered into CPOE to the outpatient account for billing. If this is the preferred workflow of the hospital, a sample of accounts should be audited quarterly to ensure that the codes billed match the original order and that the automated workflow is viable for compliance coding and billing and does not bypass reports of interpretation that include more specific diagnoses.
One of the best program memoranda (albeit an older one) that explains CMS policies concerning coding for diagnostic tests is contained in Transmittal PM AB 01-144.
Including ICD-10-CM codes
There is a lot of debate regarding whether the codes themselves (versus terminology) should be included in the order. Coders typically emphasize that they can arrive at the most appropriate code if medical terminology, rather than a less specific ICD-10-CM code, is included on the order. Meanwhile, patient access staff and other employees who must apply NCDs and LCDs and check for prior authorization prefer the actual ICD-10 code to be on the order because it facilitates checking for coverage and authorization in electronic tools designed for that purpose.
CPOE can improve the specificity of orders if the drop-down menus used by providers are customized to be as specific as possible and avoid more nonspecific codes. Consider also the greater specificity present in ICD-10-CM. If certain order sets for high-volume patients include indications for drugs and other tests at their greatest specificity, documentation can be better captured in more routine workflows to support ICD-10-CM coding, thereby avoiding time-consuming provider queries.
Conclusion
EMRs enable workflows that should be scrutinized completely, from the initiation of the order with the treating provider to the order’s appearance in the retained legal medical record.
Other related processes should also be scrutinized, including the workflow used to check orders for medical necessity and prior authorization, as well as the workflow used by staff and/or coders to apply the codes from the orders to the account and the resulting claim. Detailing these workflows and enhancing the processes that go along with them will ensure compliant orders.
Editor’s note
Rinkle is a lead regulatory specialist and instructor for HCPro’s Medicare Boot Camp®?Hospital Version, Medicare Boot Camp?Utilization Review Version, and Medicare Boot Camp?Critical Access Hospital Version. She is a former hospital revenue cycle director and has over 30 years in the healthcare industry, including over 12 years of consulting experience in which she has spoken and advised on effective operational solutions for compliance with Medicare coverage, payment, and coding regulations.
Updated 2017 ICD-10-CM guidelines come ‘with’ controversial changes
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS
Just like the lyrics to the popular Gap Band song say, "You dropped a bomb on me… I won’t forget it," there are definitely some changes in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting that some of us may wish the Cooperating Parties will forget were ever mentioned.
Generally, changes to the guidelines are minor and rarely cause the chaos and confusion that will certainly ensue with the most recent release, effective October 1. This release includes some contradictory guidance and downright concerning statements that appear as if no one really thought through the repercussions. These revisions will certainly have an impact not only on code assignment, but also specifically on reimbursement.
With
The guidelines state:
The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.
I consider this paragraph the most controversial addition to the guidelines. We’ll look at the impact the guideline has on previous examples relating to conditions such as diabetes mellitus, hypertensive heart disease, and some other conditions.
The guidance most commonly discussed is that for "diabetes with," which was stated in the AHA’s Coding Clinic for ICD-10-CM/PCS, First Quarter 2016, and reconfirmed in the following quarter. To summarize, the AHA guidance stated:
The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system and ANY condition listed under the term "with" in the Alphabetic Index is intended to be interpreted as a related condition/manifestation.
It appears that someone has never looked in the actual ICD-10-CM index file, because all conditions related to diabetes mellitus are indented under the word "with," not just isolated ones as in the ICD-9-CM manual.
Here is the comparison (from the ICD-9-CM index):
Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0
Compare to this excerpt from the ICD-10-CM Alphabetic Index:
The most surprising aspect to me in the repeated guidance is the contradiction to not assume a relationship between osteomyelitis and diabetes mellitus, which Coding Clinic originally stated in Fourth Quarter 2013 and reiterated in First Quarter 2016, writing:
ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.
Coders understood back in 2013 to not assume relationships between diabetes and other conditions that coexist in a diabetic patient. But this recent guidance creates more questions than answers. This very specific guidance about osteomyelitis leads me to imagine the scenario of a patient who has a relationship created between osteomyelitis and diabetes mellitus by a provider documenting "osteomyelitis due to diabetes mellitus." What codes would be reported?
The correct answer would be to assign the code for other specified complication (e.g., E11.69) since there is no entry specifically for osteomyelitis under diabetes mellitus. It would be classified to the "other" category per the ICD-10-CM conventions. If we examine this a bit closer, E11.69 is listed under the word "with" in the Alphabetic Index.
So, is it assumed or not? The guidance and guidelines directly contradict each other.
Some have argued that the ICD-9-CM index included a specific entry for diabetes with osteomyelitis, and I agree that the word "osteomyelitis" is there in black and white, but take a look at the code title: 250.8 (other specified manifestation of diabetes mellitus). There wasn’t a specific code in ICD-9-CM that said "diabetes with osteomyelitis," just like there isn’t in ICD-10-CM.
Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0
I suggest if the Cooperating Parties truly plan on keeping osteomyelitis separate, there should be a separate entry in the Alphabetic Index where it is not at the second indentation level under the word "with," but is under diabetes as a main term with a singular indentation.
The "with" guidance extends much further than I think the Cooperating Parties have considered. For risk-adjusted plans, the assumption of linking diabetes and other related conditions (acute and/or chronic) without necessitating providers document it will have a direct impact on a patient’s overall risk score.
The risk score uses many factors, but chronic conditions like diabetes mellitus are a key component in determining how much CMS should pay an insurance plan for care for Medicare beneficiaries covered under plans like Medicare Advantage (i.e., Part C). Being able to assume a relationship is a major change and will ultimately have a big impact on spending for any risk-adjusted plan, considering diabetes is such a common condition.
The reason this hasn’t really been considered an issue yet is that Medicare Advantage data is compiled based on the previous year’s diagnosis codes to prospectively estimate spending in the upcoming year.
Therefore, CMS is currently using ICD-9-CM data for encounters through September 30, 2015. Hopefully, this new guidance valid for encounters as of January 1, 2016, will be considered a factor, because patients with diabetic complications are certain to increase.
If the word "with" couldn’t get any more controversial, it ventured out of the endocrine system to the very "heart" of every coder’s cardinal rule. We learned, as fledgling coders, to never assume heart disease (like heart failure) is directly related to hypertension unless the provider documents the two conditions as related, like hypertensive heart failure or heart failure due to hypertension.
Well, no more, my friends?this is the dawn of a new age of coding. We can assume away, not only for hypertension and (chronic) kidney involvement, but also for hypertension and heart involvement because they are both indented under the word "with" in the Alphabetic Index.
The revised guideline states (bolding is mine)’:
The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.
Please notice that the past statement does identify that if the provider specifically states another cause, the conditions should be coded as unrelated.
The larger issue I have with assuming anything under "with" is seen in the ICD-10-CM Alphabetic Index and is yet another direct contradiction to the guidelines. If the guidance regarding "with" is truly universal within the Alphabetic Index, then it implies a relationship for diseases extending beyond just diabetes mellitus and hypertensive heart disease. For example, it seems that coders could begin to assume, based on the guidelines, that patients who have sepsis with a coexistence of organ dysfunction have severe sepsis, even though the guidelines specifically state "an acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code."
Who knew that a little word like "with" could cause so many issues?
Excludes1 notes
The guidelines also include an update on reporting Excludes1 conditions. The updated guidelines state:
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.
The Excludes1 conventions clarify what was addressed in the interim guidance provided in October 2015 and in the AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2015, to address situations where Excludes1 notes should be considered Excludes2 or had other exceptions. Category I63 (cerebral infarction) excludes subcategory I69.3- (sequela of cerebral infarction). This guidance directly contradicted the guidelines for Chapter 9, which state: "Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease."
For 2017, subcategory I69.3- has been revised to be included in an Excludes2 note. Exceptions have been added to the guidelines when the exclusion was for a category that may include a number of different conditions, like the "other" category. Some of those inclusive conditions should never be coded with the diagnosis the Excludes1 note appears under, others may be completely unrelated.
This opens the door for a third-party auditor to debate the application of the Excludes1 note if coding the two conditions separately creates a financial impact.
Edito’?s note
McCall is the director of HIM and coding for HCPro, a division of BLR, in Middleton, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see www.hcprobootcamps.com.a
Making a checklist to prepare for the OPPS final rule
Editor’s note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
The 2017 OPPS final rule will not be out for a couple of weeks, but that doesn’t mean providers can’t be thinking about what their action plan will be once the rule is released.
With only 60 days between the final rule’s release and the January 1 implementation date, providers will be ahead of the curve by spending time now and thinking about the processes they may need to review, change, or implement based on what CMS finalizes and the sort of financial impact the final rule is likely to have.
While I don’t know with 100% certainty what CMS will finalize, revise, delay, or back away from, I offer providers this list of what they should look at immediately upon the rule’s release.
Section 603
With Congress mandating payment changes for all non-grandfathered (those not billing under OPPS prior to November 2, 2015) off-campus, provider-based departments (PBD) starting January 2017, it was no surprise that CMS discussed this issue in the proposed rule. But it was a huge surprise to read CMS’ proposals, which, if finalized, would greatly impact otherwise protected grandfathered locations under Congress’ Section 603.
For example, CMS proposed that if an off-campus PBD moves, changes ownership, or expands its services beyond what it was providing as of November 2, 2015, as defined by APC-based clinical families, then its grandfathered status would be impacted. While this may sound relatively simple, the payment and operational impact would be a nightmare.
There is another aspect of Section 603 and CMS’ proposal to use the Medicare Physician Fee Schedule (MPFS) as the "applicable payment system" for Medicare Part B services provided at non-grandfathered locations or deemed "non-excepted." Specifically, there are many services for which the MPFS has no facility component for the facility costs associated with performing the procedure because they are only provided in hospital outpatient departments or ambulatory surgery centers. For these services, the industry has to wonder what CMS was thinking, as the agency cannot possibly expect to pay nothing for services that would continue to be rendered in off-campus PBDs.
CMS’ unexpected and hastily configured proposals create such large operational and financial problems that the industry is hoping the agency will simply retreat and delays the implementation of Section 603, or at a minimum revert to paying grandfathered facilities under the OPPS for all of their services, regardless of clinical service expansion, site relocation, or ownership changes. There is precedent for CMS to postpone implementation beyond statutory deadlines. If there were ever a situation where delay is advised, this is one.
Hopefully, providers sent in a surfeit of comments regarding these and other issues and outstanding questions related to the agency’s Section 603 implementation proposals. I hope CMS will acknowledge its proposals have administrative, operational, and financial gaps that are so large, it will be impossible to move forward by January. But even if CMS does choose to put off its proposals until proper payment mechanisms are developed, Congress was clear in its language requiring changes by January 1, 2017, so something is likely going to have to occur.
CMS’ proposals, if finalized, would have drastic long-term implications for all providers, including those who believe that their grandfathered status would protect them; the sad reality is that under CMS’ proposals, there will be massive operational and financial impact, so this is the first topic in the final rule that everyone should review.
Packaging proposals
Providers have gotten used to CMS expanding packaging in each OPPS rule, as the agency calls packaging an essential part of a prospective payment system. With CMS’ expansion of lab packaging from date of service to claim level this year, we should not be surprised if the agency finalizes its proposal of expanding the conditional packaging logic of CPT codes assigned to status indicators Q1 and Q2 to the claim level.
Claim-level packaging of these types of ancillary services will have a huge financial impact on providers submitting multiday claims, such as those for chemotherapy and radiation therapy services, despite the fact that multiday claims for these types of services are not required.
Currently, status indicators Q1 and Q2 are packaged into other OPPS services when provided on the same date of service, even when submitted on a claim that spans more than one day. If CMS finalizes its proposal, providers that continue submitting multiday claims when monthly or series claims are not required should not be surprised when they find themselves no longer receiving separate payment for many services.
This is the time for providers to assess whether they submit multiday claims for any services beyond the required repetitive services listed in the Medicare Claims Processing Manual, Chapter 1, section 50.2.2. While it is true the manual states that is is an option to bill nonrepetitive services on multiday claims, it did not have financial implications. At least, until this year, with the claim-based packaging of labs and proposal for claim-based packaging of Q1 and Q2 services. Providers should determine why they are billing multiday claims and what it would take to change their billing processes. If they elect not to move away from multiday claims, then assessing the financial impact that will occur is an important exercise to go through prior to January 1.
The other packaging proposal providers should look for in the final rule involves the use of modifier -L1 for reporting unrelated laboratory tests when they occur on a claim with other OPPS services. CMS proposes to delete the modifier for CY 2017 as it believes that the vast majority of labs should be packaged regardless of whether they are unrelated to other OPPS payable services.
This would have a big impact on providers who provide reference laboratory or nonpatient services, which the agency requires to be reported on the same claim as other OPPS services performed on the same date. Today, the use of the -L1 modifier allows providers to identify these services as separate and unrelated to the other OPPS services so that payment is received from the Clinical Laboratory Fee Schedule.
If CMS finalizes its proposal to eliminate modifier -L1, we can hope the agency will also update its instructions for reporting reference laboratory services so they can be separately paid even when provided on the same date of service or claim as other OPPS services. If CMS does not make a change, then providers can again expect to see a large financial impact. Both of these packaging proposals should be looked at immediately in the final rule.
Device-intensive procedures
The final set of proposals providers will want to review relates to the changes proposed for device-intensive procedures. This is a place where we hope to see CMS finalizing changes as proposed.
For example, CMS proposes to use the implantable device cost-to-charge ratio (CCR) to calculate pass-through device payments for hospitals that file cost reports designating that cost center, as this is a more accurate CCR for determining separate pass-through payment. Currently, only about two-thirds of hospitals use the implantable device CCR, which means the remaining one-third need to examine their cost reporting process.
Providers should determine whether they are in the group that reports the implantable cost center; if a provider is not reporting, it should find out why and begin making changes. This will have an impact on facilities’ ability to generate much better pass-through payment going forward, when applicable. It will also ensure future payment rates for device-intensive procedures reflect more accurate payment of the device.
Finally, it will be interesting to see whether CMS finalizes the addition of another 25 comprehensive APCs (C-APC) encompassing 1,844 additional status indicator T services; if it does, a financial impact analysis of these services will also be important, as this will be a large increase in C-APCs for a one-year span.
I plan to discuss these and other final rule changes in my next column, as well as in HCPro’s annual OPPS final rule webcast December 1 (see www.hcmarketplace.com for details), but in the meantime I hope the above checklist will be useful to providers now and in the first weeks of the rule’s release.