medicare improper payment level at an all-time...

February 2008 Vol. 11, No. 2

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR

As part of its goal to reduce improper payments for

services provided to Medicare beneficiaries, CMS has

embarked on numerous initiatives through contracted

carriers, fiscal intermediaries (FI), durable medical equip-

ment regional carriers, and quality improvement organi-

zations (QIO) to identify improper payments.

On November 16, 2007, CMS released a report in

which it announced it had successfully achieved its goal

of reducing the Medicare improper payment rate to

3.9%, which is the lowest it has been since CMS estab-

lished the claims payment error-rate measurement pro-

tocols in 1996.

Aggressive oversight efforts have resulted in a con-

tinued reduction in the rate of improper Medicare claims

Medicare improper payment level at an all-time lowStress medical necessity and coding compliance for continued success in 2008

payments, which declined from 14.2% in 1996 to 4.4%

in 2006 and 3.9% in 2007.

This solid improvement is a result of efforts that CMS

and its contractors have initiated to use detailed data anal-

ysis in targeting areas where erroneous claims processing,

inaccurate billing, and provider error result in waste, fraud,

and abuse.

CMS calculated the published improper payment error

rate based on a detailed review of randomly sampled Medi-

care fee-for-service

claims submitted

between April 1,

2006, and March

31, 2007. Approx-

imately 140,000

claims spanning all

types of Medicare

fee-for-service pay-

ments were included in the Medicare error-rate testing pro-

gram. Using this data, CMS can identify where problems

exist and target improvement efforts to address them.

Identifying hospital-setting errors

Hospital claims errors identified as part of the chart

review include the following:

No documentation—The provider did not supply any

medical record documentation to support the services

provided.

Insufficient documentation—The provider did not in-

clude pertinent patient facts (e.g., the patient’s overall

condition, diagnosis, and extent of services performed)

in the medical record.

Medically unnecessary services—The provider did not

perform medically necessary services. In the case of in-

patient claims, the QIO and FI make the determination

as to whether the services were medically necessary,

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IN thIs Issue

p. 5 Open Door Forum updateCMS discusses the NPI, the POA, and retroactive inpatient admissions during its most recent call.

> continued on p. 2

the Medicare improper

payment rate is at 3.9%,

which is the lowest it has

been since CMs established

the error-rate measurement

protocol in 1996.

––CMS report,

November 16, 2007

p. 6 Present-on-admission indicatorRead how hospitals have been handling the POA indicator since its October 1, 2007, implementation. Includes a sample POA physician query form.

p. 9 Quality measuresLearn more about the Reporting Hospital Quality Data for the Annual Payment Update (RHQDAPU) program and how it may affect your hospital’s payment under the IPPS.

p. 11 Clinically speakingRobert S. Gold, MD, discusses when you can code ‘possible,’ ‘probable,’ and ‘likely’ conditions.

enclosed: Coding Q&A

Briefings on Coding Compliance Strategies February 2008

© 2008 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

Briefings on Coding Compliance Strategies (ISSN: 1098-0571) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $249/year. • Postmaster: Send address changes to Briefings on Coding Compliance Strategies, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2008 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected compa-nies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorse-ment. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

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editorial Advisory Board Briefings on Coding Compliance Strategies

Group Publisher: Lauren McLeod, CPC

Executive Editor: Ilene MacDonald, CPC

Managing Editor: Lisa eramo, CPC

Arlene F. Baril, Ms, RhIAExecutive Vice President, HIM ServicesPHNS, Inc. Dallas, TX

DeAnne Bloomquist, RhIt, CCs Chief ConsultantMid-Continent Coding, Inc. Wichita, KS

sue Bowman, RhIA, CCsDirector, Classification and CodingAmerican Health Information Management Association Chicago, IL

Gloryanne Bryant, RhIA, CCsDirector, Coding/HIM Compliance Catholic Healthcare West San Francisco, CA

Darren Carter, MDPresident/CEO Provistas New York, NY

William e. haik, MDDirectorDRG Review, Inc. Fort Walton Beach, FL

Lyn henry Director, Billing ComplianceUniversity Medical Associates University of Nebraska Medical Center Omaha, NE

Diane Jepsky, RN, MhA, LNCPresident and CEOJepsky Healthcare Associates Sammamish, WA

James s. Kennedy, MD, CCsDirectorFTI Healthcare Brentwood, TN

shannon McCall, RhIA, CCs, CPCDirector, Coding and HIMHCPro, Inc. Glen Allen, VA

J. eric sandhusen, ChC, CPC, MPh Director of Reimbursement, HIPAA, and Fiscal Compliance Columbia University Dept. of Surgery New York, NY

based on whether the provider rendered those ser-

vices in the correct place of service given the patient’s

acuity level. For example, medical necessity comes up

frequently relative to observation versus inpatient ad-

missions. The provider must determine whether he

or she can provide patient care on an outpatient basis

(e.g., observation) based on the patient’s acuity level

and risk of morbidity and mortality, or whether the pa-

tient’s condition truly warrants an inpatient admission.

Incorrect coding—The assigned codes were not sub-

stantiated, resulting in overcoding or undercoding.

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Other errors—This category encompasses a variety

of other errors made in the hospital setting, includ-

ing quality of care and billing errors. One example

includes outpatient services billed as inpatient ser-

vices when the patient’s acuity level, intensity of

service, and severity of illness warrant outpatient

treatment.

Interpreting hospital error rates

From a coding perspective, HIM directors and cod-

ing managers should take note of medically unnecessary

services and incorrect coding. Focus your efforts on the

following familiar DRGs, each of which CMS referenced

in its November 16 report:

DRG 296—Nutritional and miscellaneous metabolic

disorders, age > 17

DRG 143—Chest pain

DRG 182—Esophagitis, gastroenteritis, and miscel-

laneous digestive disorders, age > 17 with complica-

tion/comorbidity (CC)

DRG 243—Medical pack problems

DRG 416—Septicemia, age > 17

DRG 320—Kidney and urinary tract infection,

age > 17 with CC

DRG 89—Simple pneumonia and pleurisy, age > 17

with CC

DRG 88—Chronic obstructive pulmonary disease

Keep in mind that these CMS-DRGs have changed

under the Medicare Severity DRG (MS-DRG) system,

which took effect October 1, 2007. These DRGs have

been replaced by new DRGs under MS-DRGs. The cod-

ing department should identify the replacement codes

and monitor accuracy of code assignment under these

new DRGs. To view a crosswalk between CMS-DRGs

and MS-DRGs, visit the CMS Web site at www.cms.hhs.

gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage.

These same DRGs are currently under the spot-

light in the Program for Evaluation Payment Patterns

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Improper payment < continued from p. 1

© 2008 HCPro, Inc.

February 2008 Briefings on Coding Compliance Strategies


Electronic Report (PEPPER), a program initiated by the

Hospital Payment Monitoring Program. Hospitals receive

quarterly reports that benchmark their claims submis-

sion within each DRG to other hospital state median

and other percentiles.

Analyzing PePPeR reports

Incorrect coding continues to be a problem in the

hospital setting because some hospitals have developed

a false sense of security based on the results of their indi-

vidual hospital PEPPER quarterly reports. If the PEPPER

report shows that the hospital is within the median range

for each measure, this does not relieve the hospital of its

duty to maintain a vigilant compliance review of the cod-

ing process throughout the year. If anything, the volume

and intensity of clinical coding reviews has taken on even

more importance and necessity in the uncharted territory

of MS-DRGs.

MS-DRGs require a heightened level of clinical aware-

ness and clinical competencies in medicine to promote

complete and accurate coding. Accurate ICD-9 code and

DRG assignment under MS-DRGs is predicated on a clear

understanding of clinical medicine and proper interpre-

tation of official coding rules and guidelines, often in the

face of incomplete and ambiguous physician (consider

“clinical” instead of just physician) medical record doc-

umentation. This is exactly why hospitals should partic-

ipate in clinical coding audits regularly and consistently

throughout the year.

Defining medical necessity

Medical necessity is defined under Title XVII of the

Social Security Act, section 1862 (a)(1)(a), as services

that are reasonable and necessary for the diagnosis and

treatment of an illness or injury, or to improve the func-

tioning of a malformed body member. Services that are

covered under the program may be limited in coverage

due to the following:

Diagnosis requirements—A service may be covered

but limited to certain diagnoses. For example, vitamin

B-12 injections are covered, but only for diagnoses

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such as pernicious anemia and dementias secondary

to vitamin B-12 deficiency.

Frequency/utilization parameters—A service may be

covered but limited depending on whether the ser-

vice is provided more frequently than allowed under

a national coverage policy, a local medical policy, or

a clinically accepted standard of practice. For exam-

ple, CMS may pay for a screening colonoscopy (code

G0105) once every 24 months for beneficiaries who

are at high risk for colorectal cancer.

Proven clinical efficacy—If a service is considered in-

vestigational, experimental, or of questionable useful-

ness, the service may be denied as not reasonable and

necessary. For example, acupuncture (codes 97780

and 97781) is considered experimental/investigational

in the diagnosis or treatment of illness or injury. Payers

will deny claims because they have deemed the proce-

dure/treatment to be ineffective.

Although the bullet points above pertain primarily to

services that are outside the realm of DRGs, this does not

relieve the inpatient coder of the responsibility to under-

stand medical necessity rules that govern the assignment

of ICD-9 codes.

For example, the concept of medical necessity has rel-

evance to inpatient coding when discussing the “two or

more” diagnosis coding rule that governs the assignment

of a principal diagnosis. Section II, “Selection of Principal

Diagnosis,” Part C, “Two or more diagnoses that equally

meet the definition of principal diagnosis,” of the ICD-9-

CM Official Guidelines for Coding and Reporting states:

In the unusual instances when two or more diagnoses equally

meet the criteria for principal diagnosis as determined by the

circumstances of admission, diagnostic workup and/or therapy

provided, and the Alphabetical Index, Tabular List, or another

coding guidelines does not provide sequencing direction, one of

the diagnoses may be sequenced first.

The coder should interpret this guideline with cau-

tion and take the time to review the medical record

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> continued on p. 4

Page � Briefings on Coding Compliance Strategies February 2008

© 2008 HCPro, Inc.


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thoroughly, assimilate the clinical presentation of the pa-

tient with the clinical management, and then consider

whether more than one diagnosis truly meets the criteria

for principal diagnosis.

Medical necessity comes into play when coders must

decide whether to assign one condition over another as

the principal diagnosis. Coders may be tempted to as-

sign one condition as principal when it may not meet

the definition of a principal diagnosis in light of medical

necessity.

For example, a patient may be admitted for cellulitis

of the leg with a chronic draining ulcer on the confrater-

nal leg. The patient receives IV antibiotics for the cellulitis

and wound care consisting of wet to dry dressing changes

and nonexcisional debridement if indicated. Although the

ulcer may require nursing care, the medical necessity for

inpatient admission may be questionable. The cellulitis is

unquestionably the principal diagnosis because that is the

chief reason, after study, as to why the patient was admit-

ted to the hospital for care.

using error rates

In its Executive Summary—Improper Medicare Fee-For-

Service Payment Report, published in November 2007, CMS

stated that it will use the error-rate findings described in

the report to determine the underlying reasons for claim

errors and to adjust its action plans to improve compli-

ance in payment, documentation, and provider billing

practices.

The tracking and reporting of error rates also helps

CMS identify emerging trends and implement corrective

actions designed to accurately manage the performance

of all Medicare fee-for-service contractors.

In addition, the error rates will provide all Medicare

fee-for-service contractors with the guidance necessary to

direct claim review activities and provide education efforts

and data analysis.

Under the “Corrective Actions” section of the report,

CMS points out that each FI has been tasked with devel-

oping an error-rate-reduction program that targets incor-

rect coding errors in its jurisdiction. QIOs will continue

to work with hospitals to reduce coding errors through

educational efforts.

The bottom line of this report is that hospitals can

expect renewed QIO and FI focus on identification of

potential coding and medical necessity issues through

data analysis, and resulting request and review of records

on a pre- and postpayment basis.

Devise a formal educational program to meet the

requirements of expanded clinical knowledge to succeed

with accurate and complete coding under the new MS-

DRG system. n

Improper payment < continued from p. 3

© 2008 HCPro, Inc.

February 2008 Briefings on Coding Compliance Strategies Page �


CMS Hospital Open Door Forum update

CMs ODF addresses NPI, POA, and retroactive admissionsCMS hosted its most recent Hospital Open Door Forum

(ODF) call on December 20, 2007, in which it addressed

several inpatient topics. Following is a summary of the call.

NPI update

Effective January 1, 2008, all claims—including the

837I electronic claim form and the UB-04 claim form—that

providers submit must contain either a National Provider

Identifier (NPI) only or an NPI and legacy identifier. If pro-

viders do not submit claims in this manner, CMS will not

process those claims. CMS urged providers to send small

batches of claims with a legacy identifier and NPI number.

Once those claims have been paid, try sending claims with

an NPI only, a CMS official stated during the call. “If the

results are positive, we encourage you to increase the num-

ber of claims using the NPI only,” he added.

Introduction of IACs-PC

CMS announced that it will release a new online en-

terprise application that will allow Medicare fee-for-service

providers to access, update, and submit information over

the Internet. It released more detailed information about

this new application in its special edition Medlearn Matters

article SE0747. The article, which you can view at the CMS

Web site, www.cms.hhs.gov/MLNMattersArticles/downloads/

SE0747.pdf, outlines details of the Individuals Authorized

Access to CMS’ Computer Services—Provider Community

(IACS-PC)—the security system that will allow providers

to safely and confidentially access this information.

Although CMS did not state a specific date on which

the enterprise application would be available, it did state

that the launch would take place in the near future.

“Providers should take the time to set up an account

so that they can access the information when it is made

available,” a CMS representative stated.

For more information about how to register, visit the

CMS Web site at www.cms.hhs.gov/MMAHelp/downloads/

IACS_Individual_Practitioner_Registration_QRG_111607.pdf.

POA listening session

As of October 1, 2007, hospitals were required by

statute to begin submitting present-on-admission (POA)

information. On December 17, CMS and the Centers for

Disease Control and Prevention sponsored a listening ses-

sion, during which CMS provided information about the

following:

Its value-based purchasing initiative

Conditions that it is considering to select for the fiscal

year 2009 payment provision

Challenges associated with selecting hospital-acquired

conditions (HAC)

Additional HACs that it is currently considering

POA coding and reporting

The role of providers regarding documentation of

the POA

For more information, visit the CMS Web site at

www.cms.hhs.gov/HospitalAcqCond/, and click on Educa-

tional Resources.

Retroactive inpatient admissions

As it did in the November 2007 ODF, CMS also ad-

dressed retroactive inpatient admissions. A representative

stated that CMS is working on a series of questions and

answers devoted entirely to this topic.

The representative also clarified that backdating or ret-

roactively editing admission orders to add missing data or

alter confusing orders is never permissible under Medicare;

however, there are certain circumstances in which a pro-

vider may perform a procedure on an outpatient and then,

at the conclusion of the procedure, complete the inpatient

order. “This would not be considered backdated or retro-

active. We’re continuing to work on specific language for

Q&As,” a CMS representative stated.

For more information about retroactive inpatient

admissions, e-mail Daniel Schroder at Daniel.Schroder@

cms.hhs.gov. n

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© 2008 HCPro, Inc.


Although present-on-admission (POA) indicator

assignment is going smoothly for most hospitals, a cou-

ple of problems have hindered some facilities’ overall

success.

“There are some challenges and struggles along the

way,” says June Bronnert, RHIA, CCS, CCS-P, manag-

er of professional practice resources at the American Health

Information Management Association in Chicago. “The big-

gest challenge revolves around physician documentation.

I’ve also heard about some systems issues.”

Many echo Bronnert’s sentiments and agree that some

hospital systems simply weren’t ready.

“For the most part, hospitals have been aggressive

with staff training and education on Medicare Severity

DRGs [MS-DRG] and POA indicators. Facilities started

preparing for the POA indicators months ago, and some

of the vendors have just not caught up,” says Arlene F.

Baril, MS, RHIA, executive vice president of HIM ser-

vices at PHNS, Inc., in Dallas.

Some hospital systems have not been able to accept

all of the POA indicators. Other hospital systems have not

been able to properly interface with them.

“Having had so many things hit at the same time—

MS-DRGs, POA, and the National Provider Identifier to

name a few—I think POA reporting took a backseat for

some of the vendors because they know there’s a grace

period before the claims will be denied for payment,”

Baril says. “Facilities need to get aggressive with their

vendors.”

Focus on physician documentation

Obtaining proper physician documentation contin-

ues to challenge hospitals. Some facilities have taken extra

steps to educate physicians about the required documen-

tation, a measure that Baril recommends.

“When we conducted MS-DRG education, we in-

cluded medical staff,” she says. Other hospitals incorpo-

rate POA documentation education into various medical

staff meetings, and others choose to approach physicians

one-on-one and tackle ongoing documentation prob-

lems for that physician. “It’s important for each facili-

ty to know how to go about educating its physicians,”

Bronnert says. “What works for one physician might

not work for another.”

The focus on clinical documentation improvement pro-

grams has intensified as facilities try to be more proactive

than reactive with regard to documentation shortcomings.

“Facilities are really evaluating their need for a clini-

cal documentation improvement program if they don’t

already have one,” Bronnert says. “They are also spend-

ing more time with providers, stressing, for example, that

when a patient is admitted, they should document any-

thing that is suspected or probable at that time.”

For example, documentation for pressure ulcers that

are POA is a common challenge. Many times, a wound

care nurse conducts a thorough exam, but the documen-

tation is not sufficient to assign the condition as POA,

Bronnert says. As a result, this documentation will likely

lead to a physician query unless the provider follows up

with his or her own documentation. (See the sample POA

“Physician documentation query” form on p. 8.) “Queries

are the last thing the provider or the HIM professional is

striving for,” Bronnert says. “They’re striving to have it

done right at the outset.”

hospitals experience POA snags due to systems problems, insufficient documentation

As of January 1, 2008: Hospitals that fail to report the

present-on-admission (POA) indicator for discharges will

begin receiving remittance advice remark codes inform-

ing them that the information is missing.

Beginning with discharges on or after April 1, 2008: Medi-

care will return claims to the hospital if it does not report

the POA indicator. The hospital must supply the correct

POA indicator and resubmit the claim.

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POA reporting deadlines

© 2008 HCPro, Inc.

February 2008 Briefings on Coding Compliance Strategies Page �


Monitor the physician query process

If physicians don’t document conditions that are POA

until days into the admission, the HIM staff will most likely

have to query the provider to determine whether the con-

dition was POA, Bronnert says.

“The POA indicator is really getting at when was the

condition present—not when was it diagnosed,” she says.

“The longer you go into admission, if the documentation

isn’t there, then it’s harder to know whether the condi-

tion was POA or whether it happened during the stay.”

One of the best ways to cut back on physician queries

is to track and trend queries by individual physicians. This

allows a hospital to determine which physician may require

one-on-one work to improve his or her documentation.

A joint effort between clinical documentation special-

ists and coding staff members is imperative for success.

The two need to work in tandem so nurses really under-

stand the coding rules, Baril says. “Pick the right people

to be champions of the program and have the ability to

educate the physicians,” she says. “I think physicians are

more willing to join this effort because they are becom-

ing accustomed to having to supply additional data them-

selves. I think this makes them a little more cognizant.” For

example, the Physician Quality Reporting Initiative allows

physicians to supply additional quality data to receive an

increase of 1.5% in their Part B Medicare payments.

Coordinate hIM and business office staff

As facilities work through POA reporting problems,

it’s important to monitor the back end to ensure that the

POA indicators are being properly billed, Bronnert says.

With the workaround for reporting POA conditions elec-

tronically, it is particularly important to ensure that data

are leaving the facility the way you expect them to.

Maintain communication between your HIM staff

members and the business office. Even if you have the

ability to report the POA indicators, there could be a

glitch in the software that prevents the data from trans-

lating to the business office, Baril says.

“Make sure you’re doing concurrent auditing to ensure

that the information is passing correctly to the bill,” she

says. “I would also recommend that coders know what

they need to assign and key [the information] in manually

if there is not a prompt built into the system.”

Provide your coders with two lists of codes—one that

specifies the ranges of codes that do require POA report-

ing and a second list that specifies the ranges that do not.

“Not all E codes require POA reporting, for example, but

I still see coders report POA indicators on all codes,” Baril

says. “I would strongly recommend that facilities conduct

ongoing audits and ensure their coders understand POA

indicator assignment and are cognizant of the codes that

are exempt from POA reporting.” n

OIG report reveals NhIC overpayments

The National Heritage Insurance

Company (NHIC) inappropriately

paid more than $13,000 for outpa-

tient lab services provided to Medi-

care beneficiaries during inpatient

stays at prospective payment system

hospitals during calendar year (CY)

2005, according to a November 2007

report from the Office of Inspector

General (OIG).

will help identify and deny payments

for all lab services that providers bill

with an inpatient hospital place of ser-

vice code, the OIG states.

To view the OIG report Medicare

Part B Payments Made by National

Heritage Insurance Company for Out-

patient Laboratory Services Provided

During Inpatient Stays in Calendar Year

2005 (A-01-07-00512), visit the OIG

Web site at www.oig.hhs.gov/oas/reports/

region10/10700512.pdf. n

The OIG estimates that NHIC

paid lab suppliers $292,524 for the

technical component of lab services

that were provided to hospital inpa-

tients during CY 2005, the report

states. This resulted in a double pay-

ment—one payment to the hospital

(as part of the DRG payment) and

one to the lab supplier under Part B.

The OIG report emphasizes the

need for internal control systems as

well as prepayment edits. These edits

News in brief


© 2008 HCPro, Inc.


Source: Arlene F. Baril, MS, RHIA, executive vice president, HIM Services, PHNS, Inc., One Lincoln Centre, 5400 LBJ Freeway, Suite 200,

Dallas, TX 75240; [email protected]. Reprinted with permission.

Physician documentation query

POA diagnosis clarification

Encounter number: ___________________ Discharge date: _____________

Patient’s name: _________________________________

Physician’s name: __________________________________ Query date: ________________

In order to meet federal and state present-on-admission (POA) guidelines, it is necessary to ascertain whether a diagnosis was

POA or whether it developed subsequent to admission.

The criteria are as follows:

Y: Yes, the condition is POA at the time of the order to admit to

inpatient status

N: No, the condition is not POA and developed during the inpatient stay

W: Condition is clinically undeterminable whether POA

Were the following diagnoses POA?

___________________________________ Y _____ N _____ W _____

___________________________________ Y _____ N _____ W _____

___________________________________ Y _____ N _____ W _____

___________________________________ Y _____ N _____ W _____

___________________________________ Y _____ N _____ W _____

___________________________________ Y _____ N _____ W _____

___________________________________________ ________________

Physician’s signature Date

******************** This form is a permanent part of the medical record. ******************

© 2008 HCPro, Inc.



For the past several years, hospitals nationwide have

been becoming familiar with inpatient quality measures.

These measures help determine which facilities dem-

onstrate a commitment to improving and standardiz-

ing patient care for conditions such as acute myocardial

infarction, heart failure, pneumonia, and postoperative

infections.

To receive full payment under the IPPS in 2008, hos-

pitals must participate in the Reporting Hospital Quality

Data for the Annual Payment Update (RHQDAPU) pro-

gram. CMS will now reduce the payment to hospitals

paid under IPPS by 2% each fiscal year (FY) if they don’t

submit specific quality data.

Although 2% may not seem like a weighty penalty,

Kimberly Anderwood Hoy, Esq., director of Medicare

and compliance for HCPro, Inc., in Marblehead, MA, says

that the money can add up, and she recommends that

hospitals who wish to participate in the program submit

their quality data in the correct form and manner.

“Consider that Medicare barely pays cost as it is, and

that 2% is a considerable amount,” Hoy says. “We’re talk-

ing about inpatient stays with payment amounts worth

thousands of dollars.”

CMS also added six new quality measures to the 21

preexisting measures, bringing the total to 27. The new

measures include the following:

Surgical Care Improvement Project (SCIP)

– SCIP venous thromboembolism (VTE) 1: VTE pro-

phylaxis ordered for surgery patients

– SCIP-VTE 2: VTE prophylaxis within 24 hours pre-/

postsurgery

– SCIP infection 2: Prophylactic antibiotic selection

for surgical patients

Mortality measures

– Acute myocardial infarction 30-day mortality

(Medicare patients)

– Heart failure 30-day mortality (Medicare patients)

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Patients’ experience of care

– Hospital Consumer Assessment of Healthcare

Providers and Systems (HCAHPS) patient survey

In addition to these six measures, CMS addressed

RHQDAPU program procedures for data submission, data

validation, and public display of quality data in the IPPS

final rule.

Know quality measure categories

For 2008, the 27 quality measures are split into two

main categories—measures related to the process of care

and measures related to 30-day risk-adjusted mortality

rates.

Hospital process of care measures are comprised of

medical information from patient records converted into

a percentage that illustrates how well hospitals care for

their patients.

The IPPS final rule includes the following types of

process of care measures:

Eight measures related to heart attack care

Four measures related to heart failure care

Seven measures related to pneumonia care

Five measures related to surgical infection

prevention

The new SCIP measures also fall under the process of

care measures. According to the CMS/SCIP official Web

site (www.medqic.org/scip), SCIP is “a national quality part-

nership of organizations interested in improving surgical

care by significantly reducing surgical complications.”

This year, the SCIP will focus on four surgical areas in

which the rate of surgical complication is high. In partic-

ular, surgical site infections (SSI) make up a considerable

percentage of hospital infections. If prevented, hospi-

tals will not only garner reimbursement, but they will

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Report hospital quality measures to ensure an accurate public profile and full reimbursement

> continued on p. 10


© 2008 HCPro, Inc.


see a reduction in the length of patient stays. Similarly,

deep VTE occurs frequently after surgeries, especially

when the procedures are performed without preventive

measures.

By participating in the RHQDAPU program hospi-

tals will:

Receive the full update for FY 2008

Provide a broader view of care for their facility

Be able to measure their performance and com-

mence quality improvement efforts where needed

Recognize opportunities to improve processes and

reduce occurrences of SSIs and VTE

The inclusion of mortality measures in the quality

measure set is also new for 2008. The 30-day risk-adjusted

death rates are based on a model that relies on Medicare

claims and enrollment information. Using this data, the

model predicts patient deaths for any cause within 30 days

of hospital admission for heart attack or heart failure. It

also forecasts patient deaths that may occur during hos-

pitalization or after discharge.

The 30-day designation is significant because this is

the time period during which deaths are most likely to

relate to the care that patients receive while in the hos-

pital. The designation also includes patients who die out-

side of the hospital within 30 days.

According to the Hospital Compare Web site (www.

hospitalcompare.hhs.gov), mortality rates are only for pa-

tients who receive coverage under the Original Medicare

Plan, a fee-for-service plan that covers several healthcare

services and some medications. However, rates for the

process of care measures reflect care for people in Medi-

care Advantage plans or people who do not have Medi-

care at all.

The patients’ experience of care measure makes

use of the HCAHPS. CMS defines HCAHPS as, “A

standardized survey instrument and data collection

methodology for measuring patients’ perspectives of

hospital care.”

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Although many hospitals collect information on pa-

tient satisfaction, a national standard for collecting or

publicly reporting such information did not exist prior

to HCAHPS’ implementation. Public display of patient

opinion enables prospective patients to make informed

choices about their hospital care.

understand reporting requirements

In order to receive a full market basket update for FY

2008, a hospital must fulfill the following requirements:

Complete the registration process specified on www.

QualityNet.org, regardless of how the hospital ulti-

mately submits data.

Begin collecting data on the expanded set of qual-

ity measures, submit data for each quarter on time,

and pass all edits and consistency checks that quality

improvement organizations (QIO) require.

Submit data to the QIO Clinical Warehouse using an

approved method, such as the online authorization

process from QualityNet Exchange.

Submit a sample or a complete population of cases

for the following topics: acute myocardial infarction;

heart failure; pneumonia; SCIP; mortality measures

for Medicare patients; and patients’ experience of

care.

Submit a withdrawal of participation form to the

QIO if it chooses to withdraw from the RHQDAPU

program. If a hospital elects to withdraw from the

RHQDAPU program, it will receive a 2% reduction

in its payment update.

Submit the RHQDAPU Completeness of Data Trans-

mission form, which establishes that it has reviewed

the QualityNet Exchange QIO Clinical Warehouse

feedback reports. It must also attest to the fact that it

submitted complete provider data.

Pass CMS validation requirements with submitted

data meeting a minimum of 80% (combined) reli-

ability. This is based on chart audits for data from the

first three quarters of the year. n

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5.

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7.

Quality measures < continued from p. 9

© 2008 HCPro, Inc.



Clinically Speaking

to code or not to code: that is the questionby Robert S. Gold, MD

ICD-9-CM diagnostic and procedural

code assignment usually follows certain

patterns. But despite this familiarity, assigning diagnostic

codes is sometimes muddy at best.

For example, a patient presents to the hospital with

a set of signs or symptoms that may represent several dif-

ferent disease processes. The admitting physician usually

documents one of the following three items:

Abnormal lab findings, symptoms, or physical findings

A list of differential diagnostic considerations

“Rule out (R/O)”

Then, either alone or with the help of additional tests

and a group of consultants, the physician comes to one of

the following four conclusions:

The patient clearly has the condition that everyone

has agreed upon

The patient has a differential diagnosis, each element

of which has been a proven contributor to the pre-

senting signs and symptoms

The patient has a differential diagnosis, but the cause

of the presenting signs and symptoms is unclear

The patient’s condition is unclear (no diagnosis found),

and the physician cannot reach a conclusion

Coders understand that the principal diagnosis is the

diagnosis made after workup that led to the need for the

inpatient hospital stay. Sometimes secondary diagnoses

may fall under the same decision tree. This is why it is im-

portant to make the determination only after workup.

Under MS-DRGs, there are a decreased number of

diagnoses that CMS still considers to be complications/

comorbidities (CC). A hospital’s finances depend on cod-

ers who can accurately identify a principal diagnosis, as

well as a CC or a major CC, which means that coders may

be under additional pressure to capture all conditions that

1.

2.

3.

1.

2.

3.

4.

will help yield a higher-paying MS-DRG. And sometimes

one specific coding guideline gets in the way of truth and

honesty.

Consider the following reference from Coding Clinic,

May/June 1984:

If the diagnosis at the time of discharge is stated as suspected,

questionable, likely, or probable, code the condition as if it

existed or was established. A diagnosis at the time of discharge

prefaced by the term “rule out” is to be translated as “sus-

pected.” A diagnosis stated as “Suspected _______, but not

confirmed” needs further consideration to determine whether

it refers to a “suspected condition” at the time of discharge

or a “suspected condition” at the time of admission but not

established during the episode of hospitalization.

And we know the following from Coding Clinic, Second

Quarter 1988:

Coding guidelines for inconclusive diagnoses (probable, sus-

pected, rule out, etc.) were developed for inpatient reporting

and do not apply to outpatients.

We also know about the rules for comparative and

contrasting conditions published in the ICD-9-CM Official

Guidelines for Coding and Reporting, which state the following:

Two or more comparative or contrasting conditions

In those rare instances when two or more contrasting

or comparative diagnoses are documented as “either/or” (or

similar terminology), they are coded as if the diagnoses were

confirmed and the diagnoses are sequenced according to the

circumstances of the admission. If no further determina-

tion can be made as to which diagnosis should be principal,

either diagnosis may be sequenced first.

A symptom(s) followed by contrasting/comparative

diagnoses

When a symptom(s) is followed by contrasting/

comparative diagnoses, the symptom code is sequenced first.

> continued on p. 12


© 2008 HCPro, Inc.


All the contrasting/comparative diagnoses should be coded as

additional diagnoses.

Each of these references can spark discussion and

potentially lead to controversy.

When a physician admits a patient and documents,

“rule out MI [myocardial infarction],” the problem is

that the patient has presented with signs and symptoms

that might represent an MI, but they could also be due

to a lot of other conditions. If the presentation is “typi-

cal,” it involves chest pain. If the presentation is “atypi-

cal,” it could manifest itself as shortness of breath or

weakness.

It is up to the physician to determine whether the

presentation—either typical or atypical—actually rep-

resents an acute MI. The physician may perform EKG

interpretation, cardiac enzyme determinations, and echo

and stress tests to determine whether an acute condition

is occurring.

But in order for the coder to assign an accurate ICD-9-

CM code, the physician—in the face of normal enzymes,

no change in the EKG from former tracings, and no signs of

acute ischemic damage on the scans—must tell us whether

the MI was ruled in or ruled out. But what should a coder

report when he or she receives no information except

“Discharge—return to the office in two days”?

Do we code this as an MI? Not at all. We are not

allowed to assume that just because there is no evidence

whatsoever that the patient did not have any heart prob-

lems that the physician ruled out an MI. We have to go

back to the physician and ask, “After all is said and done,

what condition do you believe caused the patient’s pre-

senting signs and symptoms?” If the physician is proac-

tive, you’ll get the answer.

I received a question similar to the above just the

other day. When a patient is admitted with “R/O ACS

(acute coronary syndrome)” and there is no conclusion,

the coders had been advised to assign code 411.1 because

the physician used the term “rule out.” That’s wrong!

There are professionals out there who will tell you

to assign certain codes because the “coding guidelines

say you can do it.” But if you read the citation more

carefully, you’ll determine that this is not always the

case. Consider the following excerpt from the ICD-9-CM

Official Guidelines for Coding and Reporting:

Uncertain diagnosis

If the diagnosis documented at the time of discharge is

qualified as “probable,” “suspected,” “likely,” “question-

able,” “possible,” or “still to be ruled out,” or other similar

terms indicating uncertainty, code the condition as if it existed

or was established. The basis for these guidelines are the diag-

nostic workup, arrangements for further workup or observa-

tion, and initial therapeutic approach that correspond most

closely with the established diagnosis.

This reference states that you should only code uncer-

tain diagnoses as if they existed, or as if the physician

had established them when, after workup, he or she still

believes at the time of discharge that the condition existed,

even though it could not be proven. If a coder is left with

no conclusion, he or she has to go after one. The coder

must encourage the physician to validate that the condition

was or was not ACS. If the physician suspects it was gastro-

esophageal reflux disease (GERD), for example, a coder can

code that when it is stated that this was probably due to

GERD. If he or she thinks that it was probably the patient’s

costochondritis, you can code that when it is stated that

way. This is where the possible/probable/likely comes into

play. The physician believes, after workup, that the symp-

toms were caused by this disease or condition, even though

he or she wasn’t able to use a test result to prove it. n

Editor’s note: Dr. Gold founded DCBA, Inc., in Atlanta, a

consulting firm that provides physician-to-physician programs in

clinical documentation improvement. The goals are data accura-

cy, profile management, and compliance, either in the inpatient

or outpatient arenas. He can be reached by phone at 770/216-

9691 or by e-mail at [email protected].

Clinically speaking < continued from p. 11

Coding Q&AA monthly service of Briefings on Coding Compliance Strategies

We want your coding and compliance questions!The mission of Coding Q&A is to help you find answers to your urgent coding/compliance questions. To submit your questions, contact Briefings on Coding Compliance Strategies Managing Editor

Lisa Eramo at [email protected] or 781/639-1872, Ext. 3802.

February 2008

I code the majority of obstetric and neonatal charts

at my hospital. Can you explain how present on

admission (POA) relates to nuchal cords?

If I were coding the baby’s chart, I would consider a

nuchal cord to be POA because an “admission” for

a newborn starts at birth. I would query the physician

regarding the POA indicator for the code assignment on

the mother’s chart.

Sandy Nicholson, MA, RHIA, CCS-P, CEO of HCRSolutions,

LLC, in Locust Grove, GA, answered the previous question.

A physician takes an image of the wrist to deter-

mine the patient’s bone age. Which code should

we assign for this?

Physicians often perform bone measurements for

patients who are entering puberty and adulthood.

If this is what the physician intends through his or her

documentation, you could report V21.0, V21.1, or

V21.2.

If there is no further documentation, query the physi-

cian for more information. There is no specific code for

“bone age.”

Sandy Sillman, RHIT, PAHM, DRG coordinator for

Henry Ford Health System in Detroit, answered the pre-

vious question.

Can you describe the difference between a

complication/comorbidity (CC) and a major

CC (MCC)?

A complication is a clinically significant condition

that develops during the patient’s hospital stay. For

example, acute blood loss anemia or metabolic encepha-

lopathy are complications.

A comorbidity is a preexisting condition that the patient

has upon admission to the hospital. Comorbidities may

be chronic, and providers should list them on the medical

record even when they are not acutely symptomatic. For

example, malnutrition and chronic systolic heart failure

are both examples of chronic comorbidities.

The CC list includes those conditions that CMS deter-

mined add at least one day to the length of stay or those

that add significant additional resources in 75% of patient

cases. Increased resources include additional evaluation,

additional treatment, or increased level of care, such as

telemetry or nursing care.

MCCs are those conditions that require double the

amount of resources as a CC. These conditions tend to

include acute major conditions (with some exceptions),

such as pneumonia, acute myocardial infarction, or acute

systolic heart failure.

CMS’ rationale behind creating the CC/MCC designa-

tion was to identify patients based on their severity of

illness.

A team of researchers and physicians at Johns Hopkins

University in Baltimore first determined which conditions

were CCs in the late 1970s. A similar process took place

when CMS updated the CC list this year. CMS dropped

a number of conditions from the list because it deter-

mined that those conditions no longer required increased

resource use. For example, it deleted dehydration and

hypoxia.

A supplement to Briefings on Coding Compliance Strategies

> continued on p. 2

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2008 HCPro, Inc., Marblehead, MA. Telephone: 781/639-1872; fax: 781/639-2982. CPT codes, descriptions, and material only are Copyright © 2008 American Medical Association. CPT is a trademark of the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

CMS deleted other CCs if there was a code that was

more specific to identify the condition. For example, un-

specified congestive heart failure (CHF) is no longer a CC.

The physician must specify whether the CHF is acute or

chronic and whether it is systolic, diastolic, or both, in

order for it to qualify as a CC or MCC.

Deborah Mange, RN, BSN, DRG-DOC specialist for EMH

Regional Medical Center in Elyria, OH, answered the previ-

ous question.

Should we report discharge status code 66 on the

UB-04/837I billing form when staff admits a criti-

cal-access hospital (CAH) ER patient to CAH inpatient

status at the same hospital?

Report discharge status code 66 when an ER patient

leaves the ER and transfers to inpatient status. Pro-

viders may report this code effective for discharges/to

dates on or after January 1, 2006. There will be no pay-

ment implications for the use of this code at this time

for transfers or postacute transfers; however, the patient

status code field is a required field, and you must code it

accurately.

Discharge status code 66 indicates a patient’s status

as of the “to” date of the billing period. The National

Uniform Billing Committee approved patient status code

66 and defined it as “discharges/transfers to a Critical

Access Hospital.” Go to the CMS Web site (www.cms.

hhs.gov/MLNMattersArticles/downloads/MM3829.pdf)

for more information.

Susan Von Kirchoff, MEd, RHIA, CCS, CCS-P, of BKD, LLP,

in Little Rock, AR, answered the previous question.

Where can I find the most up-to-date infor-

mation regarding the three-day payment

window?

Refer to the Medicare Claims Processing Manual,

Chapter 3, section 40.3 for more information. You

can view the manual at the CMS Web site at www.cms.

hhs.gov/manuals/downloads/clm104c03.pdf. Also, refer

to Transmittal A03013 and Transmittal A013054 for more

information.

When a patient transitions from observation to an

inpatient, the billing reflects the number of hours

billed under observation status prior to the patient’s

transfer to inpatient status. Should the facility also bill

the medication and fluid administration services, such

as IV pushes and hours of IV infusions, provided during

the observation portion of the stay? If so, what is the

rationale for doing so given that all payment is includ-

ed under the DRG?

CMS has stated that it believes that everything phy-

sicians or clinical staff members perform should be

reported in order to correct and collect accurate claims

submission data. CMS develops payment policy based

on the information providers submit.

If hospitals arbitrarily determine that they will not in-

clude a representative cost, then claims may be underre-

ported. Report these services in order to accurately report

all of the costs incurred with that patient.

William Malm, ND, RN, practice director for revenue cycle

management for HCPro, Inc., in Marblehead, MA, answered

the previous two questions. ■

BCCS, P.O. Box 1168, Marblehead, MA 01945 Telephone 781/639-1872 Fax 781/639-2982

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