Donna D. Wilson,RHIA,CCS

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Getting it Right the First Time Inpatient and
Outpatient Coding

• Donna D. Wilson,RHIA,CCS
• Senior Director
• Compliance Concepts, Inc.

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Objectives

• List the improper payments due to coding.
• Outline documentation requirements in correct
  coding.
• Review official resources.
• Develop an effective coding compliance program.
• Educate physicians ,coders and ancillary staff.
• Appeal with supporting documentation.

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Coding Improper Payments

• Inpatient

• Outpatient

• Excisional debridements
• Lysis of adhesions
• Wrong Principal Diagnosis
• Coagulation Disorders
• DRGs/MS-DRGs with only one CC or MCC
• Discharge disposition

• Units of service
• Neulasta, Speech, Infusion, Blood Transfusions.
• Duplicate service-Colonoscopies
• New vs. Established E/M

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Inpatient Coding Improper Payments

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Excisional Debridements

• RAC Findings
• Reporting of excisional debridement (86.22)
  without supporting documentation to meet the
  definition of excisional debridement.
• Per the CMS RAC Status Document 2007 In the
  medical record the physician documents
  debridement was performed and the coder assigned
  86.22 (excisional debridement).
• Debridement must meet documentation requirements
  as outlined in AHA Coding clinic 3rd Qtr. 1991 or
  coded to the non-operative ICD-9-CM code 86.28
  (non-excisional debridement).

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Documentation Requirements/References-Debridements

• Documentation Requirements

• Reference AHA Coding clinic for ICD-9-CM

• Size
• Depth
• Removal of devitalized tissue
• Instruments used.
• Definite cutting away of tissue- not the minor
  scissors removal of loose fragments.
• Query physician.

• 1st Qtr 2008 Vol. 25 p. 3.
• 4th Qtr 2004 Vol. 21 p. 137.
• 2nd Qtr 2004 Vol. 21.
• 2nd Qtr 2000 Vol.17 p. 9.
• 3Rd Qtr 1991 Volume 8
• 4th Qtr 1988 Volume 5.

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Lysis of Adhesions

• RAC Findings
• According to AHA Coding clinic 4th Qtr. 1990
  Coders should not code adhesions and lysis
  thereof, based solely on mention of adhesions or
  lysis in an operative report. Determination as to
  whether the adhesions and the lysis are
  significant enough to code and report must be
  made by the surgeon.
• Minor adhesions may exist without being
  organized, causing any symptoms or additional
  difficulty of performing the procedure. Coding
  the lysis of adhesions is inappropriate on these
  cases-since this is an approach.

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Documentation Requirements/References-Lysis of
Adhesions

• Documentation Requirements

• Reference-AHA Coding Clinic

• Dont code if used as an approach unless
  documented as extensive in the operative note.
• Documented as extensive by the surgeon, then code
  both the lysis of adhesions and the definitive
  surgery.

• 4 Qtr. 1996 Pgs. 65-67.
• 3 Qtr. 1994 Pg. 8.
• 4 Qtr. 1990 Pgs. 18-19.

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Wrong Principal Diagnosis

• RAC Findings
• Principal Diagnosis on claim didnt match
  Principal Diagnosis on the medical record.
• (Example Respiratory listed on claim but
  medical record supports Sepsis as Principal
  Diagnosis.)
• Clinical documentation must support principal
  diagnosis-example Sepsis vs. Urosepsis (UTI).
• Overpayment request letter is issued by the RAC
  for the DRG difference.

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Documentation Requirements/References-Wrong
Principal Diagnosis

• Documentation Requirements

• References

• The principal diagnosis is defined in the Uniform
  Hospital Discharge Data Set (UHDDS) as that
  condition established after study to be chiefly
  responsible for occasioning the admission of the
  patient to the hospital for care.

• ICD-9-CM Official Coding
  Guidelines
• 4th Qtr. 2008 AHA Coding Clinic.
• PEPPER reports

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Coagulation Disorders

• RAC Findings
• Coagulopathy due to Coumadin Cases with a
  Principal dx of 286.5 (Hemorrhagic disorder due
  to intrinsic circulating anticoagulants)
• Examples of some of the Secondary diagnosis
  578.x( GI bleed), 784.7, (Epistaxis),599.7,
  (Hematuria), 786.3, (Hemoptysis.)
• Coumadin is not a Circulating anticoagulant.
• Coders may be incorrectly assigning 286.5  to
  describe all patients on anticoagulants whether
  or not there is a resulting hemorrhagic disorder.

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Documentation Requirements/References-Coagulation
Disorders

• Documentation Requirements

• Reference-AHA Coding Clinic

• Code 286.5 is used only when such an adverse
  condition has occurred
• If only an abnormal lab finding was documented
  then 790.92 code should be assigned.
• Query the physician.

• 3rd Qtr. 1990 Volume 7
• 3rd Qtr 1992 Volume 9
• 4th Qtr. 1993 Volume 10
• 3rd Qtr. 2004 Volume 21

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DRGs/MS-DRGs with only one CC or MCC

• RAC Findings
• DRGs/MS-DRGs grouping with a CC (complication or
  comorbidity) or MCC (major complication or
  comorbidity) containing only one secondary
  diagnosis.
• Example of MS-DRG Grouping
• MS-DRG
  Weight
• MSDRG 329 Major Small Large bowel with MCC
  4.5059
• MSDRG 330 Major Small Large bowel with CC
  2.8935
• MSDRG 331 Major Small Large bowel w/o cc/MCC
  1.8415
• (

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Documentation Requirements/References-DRGs/MS-DRGs
with only one CC or MCC

• Documentation Requirements

• Reference-AHA Coding Clinic

• Coders should not  code findings from path.
  reports on inpatient  records w/out
  confirmation of the diagnosis from  the
  attending physician.
• Query the physician regarding the clinical
  significance of radiological findings.

• 1st Qtr. 2004 pgs. 20-21.
• 2nd Qtr. 2002 pgs. 17-18.
• 3rd Qtr. 2008 Volume 25

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Discharge Disposition Codes

• RAC Findings
• RAC identified incorrect discharge disposition
  code assignments such as
• First claim indicated pt went home.
• Second claim indicated pt. transferred to another
  inpatient acute care hospital.
• Two hospitals should split a single DRG payment
  instead of both receiving a full DRG payment.
• Automated review under demonstration will
  become a complex review under the Permanent RAC

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Documentation Requirements/References-Discharge
Disposition Code Assignments

• Documentation Requirements

• References

• Implement effective quality control programs to
  ensure accurate code assignments.
• Work closely with Case Mgmt.
• Follow-up with receiving facility.
• Retain history chart of discharge disposition
  code changes over the years.

• www.scha.org Click on Compliance Finance/Third
  party payors/Patient discharge status code
  history.
• NUBC
• Medicare processing manual

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Outpatient Coding Improper
Payments
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Units of Service

• RAC FINDINGS Incorrect coding on the
  chargemaster
• Injection, pegfilgrastim 6mg (J2505) Neulasta
  Provider billed one service per 1 mg however the
  definition of this code is one service per 6 mg
  vial.
• Speech/hearing therapy (92507)- Provider billed
  one service for each 15 minutes however the
  definition of this code is one service per
  session.
• Blood transfusion service (36430) - Provider
  billed one service per pint of bloodhowever,defin
  ition of this code is one service per transfusion
  session.

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Documentation Requirements/References-Units of
Service

• Documentation Requirements

• References

• Review chargemaster descriptions frequently.
• Educate departments.
• Document services rendered by session.
• Denote correct units administered.

• Transmittal 949 http//www.cms.hhs.gov/transmitta
  ls/downloads/R949CP.pdf (Neulasta).
• CMS Claims Processing Manual 100-4, Chapter 5,
  Section 20.2 http//www.cms.hhs.gov/manuals/downlo
  ads/clm104c05.pdf (Speech)

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Duplicate Services

• RAC Findings
• Search for claims for two or more identical
  surgical procedures for the same beneficiary on
  the same day at the same hospital.
• Example Two colonoscopies billed on the same day
  due to incorrect coding of CPT codes.
• Be more careful when submitting claims for
  colonoscopies (45355, 45378, 45380, 45383, 45384,
  45385) to ensure you do not bill for more than
  one per day per pt.

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Documentation Requirements/References-Units of
Service

• Documentation Requirements

• References

• Codes 45380 (Colonoscopy w/ bx), 45384
  (Colonoscopy w/ polypectomy hot bx forceps or
  bipolar cautery), and 45385 (Colonoscopy w/
  polypectomy w/ snare) are different techniques
  can only be used once for a single colonoscopy.

• Current CPT Book
• AMA CPT Assistant
• AHA Coding clinic for HCPCS.
• July 2004 AMA CPT Assistant.
• Note -59 modifier may apply

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Evaluation and Management (E/M)

• RAC Findings
• Medicares global surgery payment rules even in
  cases involving E/M services.
• E/M services that are not reasonable
  necessary.
• Duplicate EM codes
• New versus established EM codes
• Units of service (Lupron injections)

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Documentation Requirements/References-Units of
Service

• Documentation Requirements

• References

• Medicare requires that if a physician (or
  practice) has not seen a patient in three or more
  years, he/she can file the claim as a new
  patient.
• If it has been less than three (3) years, the
  physician must charge for an established patient.
  

• Current CPT Book
• AMA CPT Assistant
• Consider Group practices same tax ID same
  specialty.

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Coding Compliance Plan
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Become RAC Ready

• Determine the coding focus for your healthcare
  facility by reviewing the same sources that the
  RAC uses
• OIG Audits/Reports/Annual Work Plan
• CERT Audits/Reports
• PEPPER Reports
• National and local coverage determinations
• Update your Coding compliance plan yearly!

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Educate staff

• EDUCATE,EDUCATE

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Physician Education

• Attend each department to educate physicians.
• Each physician was provided with a listing of
  his/her records reviewed by the RAC and the
  outcome of the reviews.
• Visit physician practices to explain RAC and pt.
  status-give them contact names and numbers.
• Utilize hospital intranet to post most common
  inpatient only procedures/pt. type keys and order
  sets for ease of use in physician practices.

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Hospital staff Education

• Educate coders and clinical documentation
  specialists on RAC targets and process.
• Communicate with Case Management to improve
  discharge disposition code assignment.
• Attend service line director, managers and
  nursing leadership meetings.
• Provide RAC updates to senior leadership,
  internal audit and board.

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Stay abreast share with others

• RAC team participated in monthly conference calls
  in the state of South Carolina demo
• SCHA sponsored call for
• Business Office Managers / Compliance Officers
• Utilization Review/Reimbursement Managers
• Coding/DRG Managers
• CEOs and CFOs also participated .
• SCHA, RAC and CMS were on these calls

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Appeal Your Coding Errors
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Appeal letters

• Responsible department writes the appeal letter.
• Advice from physician advisor and outside
  consulting agency was sought on some cases.
• Cover letter and entire medical record was mailed
  with each appeal.
• Copies of Interqual and AHA Coding Clinic
  accompanied the appeals.
• Flagged the medical record to provide easier
  review for the auditor.

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Hire outside assistance

• Consider hiring external auditors to assist in
  the appeal process.
• Assist at all levels of appeal.
• Allows you to appeal with an unbiased party at
  your side.

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REFERENCES
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Maintain Current Resources

• ICD-9-CM Books Volumes 1-2 -3.
• AHA Coding Clinic
• ICD-9-CM Official Coding Guidelines
• CPT Books
• CPT Assistant

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References

• http//www.cms.hhs.gov/RAC/
• http//www.ahacentraloffice.org/
• www.scha.org
• http//www.ama-assn.org/ama/pub/physician-resource
  s/solutions-managing-your-practice/coding-billing-
  insurance/cpt.shtml

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Contact information

• Donna D. Wilson, RHIA, CCSCompliance Concepts,
  Inc.Senior DirectorStonewood Commons II103
  Bradford Road, Suite 320Wexford, PA
  15090Office [phone]Cell (843)
  345-4653Fax [phone]EMail
  dwilson_at_ccius.comwww.complianceconcepts.com