coding implications of coding medical necessity and core...

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Coding Implications of Coding Medical Necessity and Core Measures

NCHIMA Coding Roundtable Webinar

February 20, 2013

Kou Yang, RHIA

Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM

February 2013

Medical Necessity

Presented to the NCHIMA Coding Roundtable by

Kou L. Yang, RHIA

Medical Necessity

Presented to the NCHIMA Coding Roundtable by

Kou L. Yang, RHIA

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Key Objectives:

Define Medical Necessity

Identify key areas in the Revenue Cycle that Medical

Necessity edits can be worked

Components necessary to quantify Return on Investment

Explore options available to work medical necessity

Medical Necessity

[Services or supplies] that are justified as reasonable, necessary, and/or appropriate, based on evidence based clinical standards of care.

FIs, Carriers, and Medicare Administrative Contractors (MACs) are Medicare contractors that develop and / or adopt Local Coverage Determinations (LCD)s. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD.

https://www.cms.gov/medicare-coverage-database/indexes/national-and-

local-indexes.aspx

Centers for Medicare & Medicaid Services

https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx











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NCD

NCD

NCD Cardiac Rehab Programs

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Sections of an NCD Policy

Tracking Information

Publication Number

Version Number

Manual Section Number

Effective Date of said Version

Title

Implementation Date

Description Information

Claims Processing Instructions

Sections of an NCD Policy

Transmittal Information

Revision History

National Coverage Analyses (NCAs)

Original consideration for the policy & any additional considerations

Additional Information

NCD for Cardiac Rehab Programs 20.10

Claims Processing Instructions

TN 1974 (Medicare Claims Processing)

Provides specific requirements

HCPCs Detail

Modifier Detail

Diagnosis Detail

Providers requirements

Contractor requirements

Denial Codes

Payment guidance

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LCD

List LCDs by State

LCD MAC Part A / FI / Palmetto GBA (110501, MAC – Part A)

LCD – 61 Records

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LCD Cardiac Rehab (L32872)

LCD

LCD

LCD Sections Document Information

LCD Number

Title

Geographic Jurisdiction

Revision effective date

CMS National Coverage Policy

Coverage Indications Limitations and/or Medical Necessity

Coding Information Bill type codes

Revenue codes

CPT / HCPCs Codes

ICD 9 Codes

General Information Documentation Requirements

Utilization Guidelines

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Medical Necessity Components

• Physician Order

Dated & Signed

Identify service being ordered

The medical condition requiring the service / signs & symptoms

Coverage Indications

May detail required services needed to render prior to LCD service being ordered and performed

• Patient’s medical record / results

• Advance Beneficiary Notice (ABN)

New form CMS-R-131 mandatory use date November 1, 2011

Advance Beneficiary (A) Notifiers to include name, address, and telephone number

(B) Patient Name

(C) Identification Number – medical record #

(D) Body – Items / Services believed to be non-covered

(E) Reason Medicare may not pay

“Medicare does not pay for this test for your condition.”

“Medicare does not pay for this test as often as this (denied as too frequent).”

“Medicare does not pay for experimental or research use tests.”

(F) Estimated Cost – good faith estimate

(G) Options – 3 options for patient

(A) Understand service may be denied but want the procedure and request the claim be submitted to Medicare and beneficiary may appeal

(B) Want the procedure but do not submit claim to Medicare and bill patient

(C) Do not want the procedure

(H) Additional Information

(I) Signature

(J) Date

ABN

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Opportunities in the Revenue Cycle that

Medical Necessity can be assessed

Services Ordered

Services Performed

Charges Entered

Claim Coded

Claim Processed thru Claims Editing

Claim Submitted to

A/B MAC

Revenue Cycle – Opportunity for Medical

Necessity

Point of service ordered

Point of charge entry

Point of coding

Claims edit

Point of Service Order & Charge Entry Options

Manual process would involve identifying commonly adjusted and denied services for medical necessity and familiarize physician and staff of covered indications

Automated process would involve investing in a resource(s) that is capable of flagging for services that do not meet medical necessity.

Benefits Minimizes medical necessity adjustments

Access to physician

Retain revenue

Decrease A/R days

Challenges Limited staffing resources

Limited funds to invest for screening software

Limited time resources

Implemement new processses

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Point of Coding Options

Have Coders resolve Medical Necessity

All charges have to be entered into the system and carried over to the Coding software. This in turn will flag any services / charges subject to policies for review for covered indications.

The Coding software will have to include a medical necessity screening tool – which may be available at additional expenses.

Benefits of implementing screening process Minimize medical necessity adjustments

Decrease A/R days

Documentation available

Retain Revenue

Challenges Productivity based

Not all charges are entered by point of Coding

Expense attached to screening software not available

Claims Edit

Options

The claims management tool will have the software available to screen for Medical Necessity

Benefits of the claims management tool screening edits out

Provides an opportunity to review documentation and add onto the claim to avoid adjustments

Minimize adjustments due to medical necessity

Retain revenue

Challenges

Determining where and who will be processing and resolving the edits

Expenses associated

Documentation availability

Claims Edit

Challenges (continued…)

Medical diagnosis documented does not support the service(s)

rendered in accordance to the policy

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Return on Investment

To show return on investment on developing a process to

minimize medical necessity adjustments

Quantify adjustments due to medical necessity

Gross Total Charges

Reimbursement Total Charge

Take a sample of those adjusted and identify where the

opportunity exists.

Coding Omission (Documentation had supporting indication but not

reported)

Ordered for an un-covered sign or symptom

Documentation not available


Quantify those adjustments for comparison

Total Gross Charges

Reimbursement Total

Quantify expenses

Coding Software

Medical Necessity Software

FTE

CEUs

Benefits

Inter-department expenses


Once final numbers have been identified and ROI is

promising

Solicit the support of Senior Leadership

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Options for working edits post charge entry

Direct accounts back to Coding

Direct accounts back to ordering department

Centralize efforts by developing a team to work edits

Outsource

Adjust without review


Direct accounts back to Coding &

Develop a process to communicate the potential recoveries

and ensure it supports tracking

Spreadsheets

Share Files

Benefits of Coding working the edits

Familiar with the documentation, locating in the documentation the

covered indications

Provides Coders the information and insight of post Code processes

Provides accountability

Challenges

Limited in FTE and Time Resources


Direct accounts back to Ordering Department

Develop a process to communicate the accounts that edit out

for medical necessity and ensure it supports tracking

Spreadsheets

Share Files

Benefits

Provides Accountability

Provides Feedback

Documentation availability

Challenges

Staff (charge entry staff)

Time resource

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Develop a team RHIA, RHIT, CCS, CPC

Require a screening tool

Access internal systems Documentation

Claims management

Department specific software (Radiology / lab software)

Imperative to have Senior Leadership support

Develop good rapport with departments

Benefit of this is decreasing adjustments and the process will be centralized to one team

Challenge would be the expense necessary to develop and maintain the team FTE

CEUs

Benefits

What can you do?

Keep the Physician Orders and make sure that it identifies what service is requested with covered indications, physician’s signature, and dated – Comprehensive Error Rate Testing

Identify the most commonly ordered services, review the applicable policy and provide education to staff

Benchmark adjustments

ROI

ABNs

Develop a process to ensure that the documentation is continuous from practice to the facility

If available - scan orders, results, medical record to be part of the electronic medical record.

Look at possible option to invest in software to identify medical necessity up front

References

https://www.cms.gov/BNI/02_ABN.asp#TopOfPage

http://palmettogba.com/palmetto/palmetto.nsf/DocsCat/Jurisdiction%2011%20AB%20MAC%20and%20HHH%20MAC%20Jurisdiction%20C%20Implementation%20Dates?open&cat=events

http://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx

http://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

https://www.cms.gov/BNI/02_ABN.asp

http://palmettogba.com/palmetto/palmetto.nsf/DocsCat/Jurisdiction 11 AB MAC and HHH MAC Jurisdiction C Implementation Dates?open&cat=events

















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Core Measures/Quality

NCHIMA

Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM

2/20/13

Objectives

Review current Core Measures

Understand the impact of Coding on Core

Measures

Obtain steps to become about of the Core

Measure Team

A National Quality Initiative

Mandated by the Center for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) to monitor specific hospital clinical processes and how well hospitals provide recommended care.

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Uses of Core Measure Data

Medicare Pay for Performance/Value Based Purchasing All major payers moving toward using Core Measure results to benchmark & for contract negotiations As of 2013, also the basis for Physician reimbursement

Goal of Core Measures

High Quality of Care by use of

− “inclusion” criteria

− “exclusion” criteria

− with guidelines for “acceptable” documentation

Quality Measure Information

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13)

http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx






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The Specifications Manual for National Hospital Quality Measures

The Joint Commission

Inpatient

Outpatient


Acute Myocardial Infarction (AMI)

Heart Failure (HF)

Pneumonia (PN) Hospital

Venous Thromboembolism (VTE)

Stroke (STK)


Children’s Asthma Care (CAC)

Surgical Care Improvement Project (SCIP)

Hospital Outpatient Measures (HOP)

Perinatal Care (PC)

Hospital-Based Inpatient Psychiatric Services (HBIPS)

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Emergency Department (ED)

Immunization (IMM)

Tobacco Treatment (TOB) Substance Use (SUB)


Readmission and Mortality Measures

− Age > or = to 65

− 30 day measures

− Utilize medicare claims data

AMI, CHF, Pneumonia

What is done with the Data?

Data is transmitted on all measures you select via a vendor software based on the Specifications Manual for that criteria set

− Internal

− External

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Oryx – implemented in 1997

Hospitals are required to collect and transmit data to The Joint Commission for a minimum of four core measure sets or a combination of applicable core measure sets and non-core measures


Data is publicly reported

The Joint Commission website at Quality Check

http://www.hospitalcompare.hhs.gov

CMS

http://www.hospitalcompare.hhs.gov

http://www.hospitalcompare.hhs.gov/






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2/19/2013 55

Core Measure Overview

Indicators

Acute MI ASA w/in 24 hrs of arrival

ASA at discharge ACE/ARB at discharge, if LVSD

Fibrinolytic within 30 min of arrival

PCI within 90 minutes of arrival

Beta Blocker at discharge

Statin prescribed at discharge, if LDL>100

Heart Failure D/C Instructions Evaluation of LV

systolic function ACEI/ARB for LV systolic dysfunction

Pneumonia

Blood Culture prior to Antibiotic Administration

Blood Culture <24 hrs prior to or 24 hrs after arrival for pts transferred or admitted to ICU

Antibiotic Selection ICU/non-ICU

Surgical Care Improvement Program (SCIP)

Antibiotic given within one hour of incision time

Prophylactic Antibiotic selection

Antibiotic d/c w/in 24 hrs of anesthesia end time

Appropriate Hair Removal

Removal of Foley Catheter Post-op Day #1 or #2

Peri-op Temp Management

VTE ordered & given w/in 24 hrs of anesthesia end time

Beta Blocker in Peri-op period

Pneumococcal Vaccine

Pts age 65 & older are screened for vaccine and receive, if indicated

Pts age 6-64 years with high risk condition-screened for vaccine and receive, if indicated

2/19/2013 56

Core Measure Overview

Indicators

Influenza Vaccine

Patients 6 months & older-screened for & receive vaccine in season if indicated

ED Throughput-Admitted Patients

ED Arrival Time to ED Departure for Admitted Patients

Admit Decision Time to ED Departure for admitted pts

ED Throughput – Discharged Patients

ED Arrival time to ED Departure Time Door to Diagnostic Evaluation by MD/NP/PA

Left Without Being Seen

Time to Pain Medication Administration for Long Bone Fracture

Head CT scan results for Stroke (acute ischemic or hemorrhagic) interpreted within 45 minutes of arrival

Hospital Outpatient Surgery

Antibiotic Selection

Timing of Antibiotic Prophylaxis

Hospital Outpatient AMI/CP

Median Time to Fibrinolysis

Fibrinolytic therapy within 30 minutes

Mean time to EKG

ASA at arrival

Median time to transfer for Acute Coronary Intervention

Code Sets for Criteria Appendix A.1 – A.120

ICD-9-CM code Tables

ICD-9 codes for selected core measure sets

Codes drive whether an indicator is within the criteria set or outside of the criteria set

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Strict Documentation Requirements

AMI

− Moderate or severe aortic stenosis

− hyperkalemia, angioedema, renal artery stenosis, hypotension, or worsening renal disease

− Second or third-degree heart block

Strict Documentation Requirements AMI

− 410.00 AMI ANTEROLATERAL,UNSPEC

− 410.01 AMI ANTEROLATERAL, INIT

− 410.10 AMI ANTERIOR WALL,UNSPEC

− 410.11 AMI ANTERIOR WALL, INIT

− 410.20 AMI INFEROLATERAL,UNSPEC

− 410.21 AMI INFEROLATERAL, INIT

− 410.30 AMI INFEROPOST, UNSPEC

− 410.31 AMI INFEROPOST, INITIAL

− 410.40 AMI INFERIOR WALL,UNSPEC

− 410.41 AMI INFERIOR WALL, INIT

− 410.50 AMI LATERAL NEC, UNSPEC

− 410.51 AMI LATERAL NEC, INITIAL

− 410.60 TRUE POST INFARCT,UNSPEC

− 410.61 TRUE POST INFARCT, INIT

− 410.70 SUBENDO INFARCT, UNSPEC

− 410.71 SUBENDO INFARCT, INITIAL

− 410.80 AMI NEC, UNSPECIFIED

− 410.81 AMI NEC, INITIAL

− 410.90 AMI NOS, UNSPECIFIED

− 410.91 AMI NOS, INITIAL

What happens when Patient Falls Out?

Perform chart review

Measures not met

Bring to coding

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What happens when Patient Falls Out?

Example:

Patients presents with chest pain and shortness of breath and fever.

Final diagnoses:

Pneumonia

MI

Strict Documentation Requirements CHF

− 402.01 MAL HYPERT HRT DIS W HF

− 402.11 BENIGN HYP HT DIS W HF

− 402.91 HYP HT DIS NOS W HT FAIL

− q404.01 MAL HYP HT/KD I-IV W HF

− 404.03 MAL HYP HT/KD STG V W HF

− 404.11 BEN HYP HT/KD I-IV W HF

− 404.13 BEN HYP HT/KD STG V W HF

− 404.91 HYP HT/KD NOS I-IV W HF

− 404.93 HYP HT/KD NOS ST V W HF

− 428.0 CHF NOS

Strict Documentation Requirements CHF

− 428.1 LEFT HEART FAILURE

− 428.20 SYSTOLIC HRT FAILURE NOS

− 428.21 AC SYSTOLIC HRT FAILURE

− 428.22 CHR SYSTOLIC HRT FAILURE

− 428.23 AC ON CHR SYST HRT FAIL

− 428.30 DIASTOLC HRT FAILURE NOS

− 428.31 AC DIASTOLIC HRT FAILURE

− 428.32 CHR DIASTOLIC HRT FAIL

− 428.33 AC ON CHR DIAST HRT FAIL

− 428.40 SYST/DIAST HRT FAIL NOS

− 428.41 AC SYST/DIASTOL HRT FAIL

− 428.42 CHR SYST/DIASTL HRT FAIL

− 428.43 AC/CHR SYST/DIA HRT FAIL

− 428.9 HEART FAILURE NOS

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Next Steps

Volunteer to be on Core Measure Team

Assist with EMR in identifying measure sets

Participate in review of charts

Next Steps

Ensure you are capturing diagnoses appropriately

Review abstracting

Educate coders on how coding drives quality

Contact Info

Recovery Analytics

Sharon Easterling, MHA, RHIA, CCS, CDIP, President/CEO

[email protected]

888-474-8023

www.recoveryanalyticsllc.com

mailto:[email protected]

http://www.recoveryanalyticsllc.com/

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