hot topics in coding

1. Hot Topics in Coding TxHIMA Winter Meeting November 30, 2007 Salado, TX

3. Documentation Impacts CCs Documentation of whether condition is acute or chronic. Chronic diseases were removed from the CC list unless there was a significant acute manifestation: CHF as a secondary condition is no longer a CC. However, acute systolic heart failure is an MCC. Etiology of condition Causative organism Degree of severity Example: Malnutrition (Mild? Moderate? Severe?) Accompanying conditions such as hemorrhage, coma, heart failure

4. MCC�only if patient lives Major Complications/Comorbidities if patient is discharged alive Cardiac arrest* Respiratory arrest* Cardiogenic shock* Other shock without trauma* Ventricular fibrillation* *If patient expires, these diagnoses are not even CCs

5. Hot Topics � Some Payors Using V. 24 Some payors (Blue Cross) are using the old DRG, v. 24. Why is this an issue? Prior to October 1, 2007, DRG 001 was a craniotomy. After October 1, 2007, MS-DRG is a heart transplant. How are you reporting this data on the UB-04? What are you doing about your facility reports?

6. Hot Topics � MS-DRG Inconsistencies More specificity does not always group to a higher DRG! Malnutrition, unspecified, is a CC. Malnutrition, mild, is not a CC. CMS bases its conclusions on data. Secondary diagnoses that contributed to higher costs were identified as CCs�more cases were coded as unspecified, so it became a CC. CMS bases its conclusions on data. Secondary diagnoses that contributed to higher costs were identified as CCs�more cases were coded as unspecified, so it became a CC.

7. Hot Topics � MS-DRG Inconsistencies Transfer DRGs: A short stay for a DRG with MCC may be less reimbursement than for the same DRG without CC, due to the ALOS. Ex: 2 day stay, transferred to Home Health DRG 195 � Simple pneumonia and pleurisy w/o CC/MCC ALOS 4.1 Payment $3,652.11 Assume patient has secondary diagnosis of ESRD DRG 193 � Simple pneumonia and pleurisy w MCC ALOS 6.9 Payment $3,460.64

8. Hot Topics � CC Changes - Morbid obesity 278.01 � Morbid obesity is no longer a CC for acute care inpatients V85.4 � BMI 40 and over, adult, is a CC Do you have a Rehab unit??? 278.01 is a comorbidity that will group to a higher tier

9. Hot Topics � CC Changes - BMI Documentation: Look for physician documentation of morbid obesity. However, you may code the BMI from the dietician�s notes! Coding Clinic, 4th Q. 2005, pp. 96-98 Coders should not calculate the BMI. The BMI code assignment should be based on medical record documentation, which may be found in a dietitian's note. Please note that this is an exception to the guideline that requires that code assignment be based on the documentation by the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis. While BMI may be reported on the basis of a dietitian's documentation, the codes for overweight and obesity should be based on the provider's documentation. Coders should not calculate the BMI. The BMI code assignment should be based on medical record documentation, which may be found in a dietitian's note. Please note that this is an exception to the guideline that requires that code assignment be based on the documentation by the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis. While BMI may be reported on the basis of a dietitian's documentation, the codes for overweight and obesity should be based on the provider's documentation.

10. Hot Topics � V45.1 and 585.6 Coding Clinic 1998, 3rd Q. 1998, p.3 advises not to code the V-code for status post transplant when there is a complication of the transplanted organ. Since 585.6 (ESRD � chronic kidney disease requiring chronic dialysis) includes dialysis, do you code V45.1 postprocedural renal dialysis status? If you have a Rehab Unit, V45.1 is a comorbidity that will put the patient in a higher tier, but ESRD 585.6 will not.

11. Hot Topics � CC Changes - Rehab To review the latest list of comorbidities for Rehab Units: http://www.cms.hhs.gov/InpatientRehabFacPPS/07_DataFiles.asp#TopOfPage

12. Hot Topics � CC Changes - CHF CHF is no longer a CC with MS-DRGs. Are you having issues at your facility with physician documentation of heart failure: acute/chronic/combined? systolic/diastolic? Decompensated vs. acute

13. Hot Topics � Aborted stroke? Aborted MI? Clarification regarding aborted stroke: Coding Clinic 3rd q. 2007, p. 12, because the cases of aborted stroke and aborted MI were clinically different. The MI was aborted by the use of tPA and there was no myocardial injury so it was not coded as an MI (Coding Clinic 2nd Q. 2001, pp. 7-8) With a stroke, although the patient received tPA, he still had a cerebral infarction, so it is coded as an infarct. Aborted Stroke The Central Office on ICD-9-CM has received several questions concerning the validity of advice about "aborted stroke" published in Coding Clinic, First Quarter 2007, pages 23-34. Although this advice appears to conflict with information published in Coding Clinic, Second Quarter 2001, pages 7-8, regarding "aborted myocardial infarction (MI)," these cases are clinically different. In terms of the aborted MI, the patient presented with severe chest pain resembling an acute MI. After tissue plasminogen activator (tPA) was administered, the MI was averted with no evidence of injury to the myocardium. Code 411.1, Intermediate coronary syndrome, was assigned for the aborted MI. Conversely, "aborted stroke," is a distinct clinical situation. Although the patient received tPA, he still suffered a cerebral infarction, and evidence of the infarction (i.e., brain damage) would be visible microscopically. Therefore, based on the documentation and further medical review, it was the consensus of the clinicians on the Editorial Advisory Board (EAB) for Coding Clinic, that patients who present with symptoms of an acute cerebral infarction and receive tPA have actually had an infarct. Assign code 434.91, Cerebral artery occlusion, with cerebral infarction. Selection of the correct code assignment for a condition described as averted or aborted depends on whether the condition actually occurred. Aborted Stroke The Central Office on ICD-9-CM has received several questions concerning the validity of advice about "aborted stroke" published in Coding Clinic, First Quarter 2007, pages 23-34. Although this advice appears to conflict with information published in Coding Clinic, Second Quarter 2001, pages 7-8, regarding "aborted myocardial infarction (MI)," these cases are clinically different. In terms of the aborted MI, the patient presented with severe chest pain resembling an acute MI. After tissue plasminogen activator (tPA) was administered, the MI was averted with no evidence of injury to the myocardium. Code 411.1, Intermediate coronary syndrome, was assigned for the aborted MI. Conversely, "aborted stroke," is a distinct clinical situation. Although the patient received tPA, he still suffered a cerebral infarction, and evidence of the infarction (i.e., brain damage) would be visible microscopically. Therefore, based on the documentation and further medical review, it was the consensus of the clinicians on the Editorial Advisory Board (EAB) for Coding Clinic, that patients who present with symptoms of an acute cerebral infarction and receive tPA have actually had an infarct. Assign code 434.91, Cerebral artery occlusion, with cerebral infarction. Selection of the correct code assignment for a condition described as averted or aborted depends on whether the condition actually occurred.

14. Hot Topics � Chronic Conditions Chronic conditions with no active treatment See Coding Clinic, 3rd Q. 2007, p. 13-14. Inpatient Coding: Chronic conditions, such as, but not limited to hypertension, Parkinsons disease, COPD, and diabetes..should be coded even in the absence of documented intervention or further evaluation. Some chronic conditions affect the patient for the rest of this or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization.� Outpatient Coding: Chronic conditions that require or affect patient care treatment or management should be coded. The coding advice for inpatients in this coding clinic states that these types of chronic conditions should be coded, even if they are only listed in the history section of the H&P, as long as there is no contradictory information. The Official Guidelines for Coding and Reporting for Outpatient Services state, �Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment or care for the condition. �Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.� Do not code conditions that were previously treated and no longer exist. �This information was previously published in Coding Clinic Fourth Quarter 2006, pp. 236-240. Conversely conditions that do not require or affect patient care, treatment or management are not reported. The coding advice for inpatients in this coding clinic states that these types of chronic conditions should be coded, even if they are only listed in the history section of the H&P, as long as there is no contradictory information. The Official Guidelines for Coding and Reporting for Outpatient Services state, �Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment or care for the condition. �Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.� Do not code conditions that were previously treated and no longer exist. �This information was previously published in Coding Clinic Fourth Quarter 2006, pp. 236-240. Conversely conditions that do not require or affect patient care, treatment or management are not reported.

15. Hot Topics � Core (Quality) Measures CHF is a Core Measure. Coding Clinic 2nd Q. 2001, p. 13 gives advice on the PDX for a patient admitted in CHF due to fluid overload and noncompliance with treatment. PDX: CHF. Coding Clinic 3rd Q. 2007, p. 11 clarifies fluid overload due to dialysis noncompliance when the physician states the CHF is not decompensated. PDX: Fluid overload. Reason: The physician has clarified the distinction between fluid overload and CHF.

16. Hot Topics �Quality Measure Additions Effective October 1, 2007 SCIP Quality Measures SCIP-VTE1: Venous thromboembolism prophylaxis ordered for surgery patient SCIP-VTE2: VTE prophylaxis with 24 hours pre/post surgery SCIP Infection 2: Prophylactic antibiotic selection for surgical patients HCAHPS Survey Mortality (Medicare Patients only) Acute Myocardial Infarction 30 day mortality Heart Failure 30 day mortality

17. Hot Topics - FY 2009 Quality Measure Additions Pneumonia 30 day mortality (Medicare patients) SCIP Infection 4: Cardiac surgery patients with controlled 6am postoperative serum glucose SCIP Infection 5: Surgery patients with appropriate hair removal SCIP Infection 7: Colorectal patients with immediate postoperative normothermia SCIP Cardiovascular 2: Surgery patients on a beta-blocker prior to arrival who received a beta-blocker during the perioperative period

18. Hot Topics � Outpatient Core Measures!! Proposed Changes to OPPS 2008 include a requirement to report data on 10 outpatient measures starting January 1st in order to receive the full OPPS payment for services provided in CY 2009. Hospitals that fail to comply in 2008 will receive a 2% reduction in their OPPS update factor in 2009. Expect to add 30 additional measures for implementation in CY2010 and beyond.

19. Hot Topics � Outpatient Core Measures (cont�d) The outpatient core measures include: ED AMI � aspirin on arrival ED AMI � median time to fibrinolysis ED AMI � fibrinolytic therapy received within 30 min of arrival ED AMI � median time to ECG ED AMI � median time to transfer for primary PCI Heart Failure � ACE or blocker for LV systolic dysfunction Perioperative care � Timing of antibiotic prophylaxis Perioperative care � Selection of prophylactic antibiotic Empiric antibiotic for community acquired pneumonia Hemoglobin A1c poor control in Type 1 or 2 diabetes mellitus

20. Hot Topics � Present on Admission Requirement Required by CMS Transmittal 1240: http://www.cms.hhs.gov/transmittals/downloads/R1240CP.pdf MLN Matters Article #MM5499: http://www.cms.hhs.gov/MLMattersArticles/downloads/MM5499.pdf Guidelines: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf Texas announcement: http://www.dshs.state.tx.us/THCIC/hospitals/POA.shtm Required for short-term acute care hospitals. The Health Care Information Collection program expects to begin collecting Diagnosis Present on Admission indicators from Texas hospitals beginning in 2008. Rules for the submission of this additional data have been proposed by the Health and Human Services Commission (HHSC) and are published in the September 7, 2007 Texas Register (32 TexReg 6030). The rules will require all hospitals to submit the indicators for selected diagnosis codes. Comments on the proposed rules can be submitted until close of business October 8, 2007. After the program�s response to the comments, HHSC will approve the rules for final publication. This is expected to occur in early December. The rules will be enforced 90 days after final publication in the Texas Register. The Present on Admission indicators are expected to be reported beginning in late first quarter 2008. The quality of the data collected will be reviewed before the indicators are included in the Public Use Data File or used for public reporting. After HHSC approval for final publication, the specifications for submission of the Diagnosis Present on Admission indicators will be added to the Technical Specifications Manual. The selected diagnosis codes will be listed in an Appendix to the Manual. Required for short-term acute care hospitals. The Health Care Information Collection program expects to begin collecting Diagnosis Present on Admission indicators from Texas hospitals beginning in 2008. Rules for the submission of this additional data have been proposed by the Health and Human Services Commission (HHSC) and are published in the September 7, 2007 Texas Register (32 TexReg 6030). The rules will require all hospitals to submit the indicators for selected diagnosis codes. Comments on the proposed rules can be submitted until close of business October 8, 2007. After the program�s response to the comments, HHSC will approve the rules for final publication. This is expected to occur in early December. The rules will be enforced 90 days after final publication in the Texas Register. The Present on Admission indicators are expected to be reported beginning in late first quarter 2008. The quality of the data collected will be reviewed before the indicators are included in the Public Use Data File or used for public reporting. After HHSC approval for final publication, the specifications for submission of the Diagnosis Present on Admission indicators will be added to the Technical Specifications Manual. The selected diagnosis codes will be listed in an Appendix to the Manual.

21. Hot Topics � Present on Admission �Never Events� �Never events� are serious, preventable and costly medical errors. AHRQ (Agency for Healthcare Research and Quality): http://psnet.ahrq.gov/resource.aspx?resourceID=3816 (Click on link �Fact Sheet/FAQ� for more information on �never events�)

22. POA Conditions Affecting Reimbursement � FY 2009 Air embolism Blood incompatability Catheter associated UTI Decubitus ulcers Falls Objects left in during surgery Surgical Site Infections � Mediastinitis after CABG Vascular Catheter Associated Infections

23. Hot Topics � Present on Admission Exempt Field Medicare reporting instructions for conditions exempt from POA differ from information in the Official Coding Guidelines (Coding Clinic, 3rd Q. 2007, pp. 15-16). The guidelines instruct that conditions on the exempt list are to be left blank, while Medicare instructs these conditions should be reported with a �1�.

24. Hot Topics - Devices Sec. 61.3 � Billing for Devices Replaced Without Cost to an OPPS Hospital or Beneficiary for Which the Hospital Receives a Credit and Payment for OPPS Services Required to Replace the Device: http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

25. Hot Topics � Condition Code 44 Use of Condition Code 44: https://cms.hhs.gov/ContractorLearningResources/downloads/JA0622.pdf

26. Hot Topics � RACs Recovery Audit Contractors: http://www.cms.hhs.gov/rac/ What can you do now to prepare? Stay aware of what is happening in other states file:///C:/Documents%20and%20Settings/Sarah%20Glass/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/DOUAA0SC/RACs_042607_-donna%5B1%5D.ppt#259,4,Timeline%20for%20Nation-wide%20RAC%20rolloutfile:///C:/Documents%20and%20Settings/Sarah%20Glass/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/DOUAA0SC/RACs_042607_-donna%5B1%5D.ppt#259,4,Timeline%20for%20Nation-wide%20RAC%20rollout

27. Hot Topics � RACs 61% of highest gross dollars in error, FY 2004, were due to medical necessity. 24% were due to DRG changes.

28. Hot Topics � RACs (continued) General information about the Hospital Payment Monitoring Program: http://www.hpmpresources.org/ Review your PEPPER report Texas: http://www.tmf.org/pepper/

29. Hot Topics � PQRI Similar to CORE measures for hospitals, this program, established by CMS, includes financial incentives for physicians to report on a designated set of quality measures for dates of service from July 1, 2007-December 31, 2007. Physicians may earn a bonus payment, subject to a 1.5% cap, of 1.5% of total allowed charges for covered Medicare fee schedule services.

30. Hot Topics � PQRI (continued) For more information about PQRI: http://www.cms.hhs.gov/PQRI Proposed Rule for Physicians Fee Schedule and for Ambulance Payment Policies (1,481 pages) is at: http://www.cms.hhs.gov/phyicianfeesched/downloads/CMS-1385-FC.pdf

31. Hot Topics � Nursing Homes P4P CMS is considering a pay for performance demonstration in Nursing Homes! More information is available at: http://www.extendedcarenews.com/article/7830# and http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp

32. Hot Topics � Quality Measures for Home Health Did you know there are ten quality measures for Home Health? http://www.medicare.gov/HHCompare/Home.asp?dest=NAV/Home/Datadetails#TabTop

33. Hot Topics � HIM Advocacy � My PHR AHIMA resolution passed September 24, 2007, on HIM Adoption of the Personal Health Record, to charge HIM professionals with the responsibility of creating and maintaining their own personal health record. For more information about creating your own personal health record, see www.myPHR.com This site includes a database of PHR tools. You can select internet-based, paper-based or software, and either purchased or free. Based on your selections, you�ll find links to tools to help you create your own PHR.This site includes a database of PHR tools. You can select internet-based, paper-based or software, and either purchased or free. Based on your selections, you�ll find links to tools to help you create your own PHR.

34. Hot Topics � AHIMA Advocacy � Hill Day Hill Day � April 8, 2008 http://www.ahima.org/dc/hilldayinfo.asp

35. Hot Topics � AHIMA Advocacy - CAC Computer Assisted Coding (CAC) For more information, join the CoP on CAC, and check out the article in the �Resources� section on �Delving into Computer Assisted Coding� AHIMA Coding Workflow Process Model is also available in the CAC Community of Practice

36. Hot Topics � AHIMA Advocacy � ICD-10-CM AHIMA�s position statement (approved July 2007): http://www.ahima.org/icd10/documents/MicrosoftWord-ICD-10StatementApproved7-18-2007.pdf Legislative Proposals: http://www.ahima.org/icd10/legislative.asp ICD-10-CM and ICD-10-PCS preparation checklist (to use at least three years prior to implementation) resource: http://www.ahima.org/icd10/ICD-10PreparationChecklist.mht The House passed HR 4157, the �Health Information Technology Promotion Act,� with a veto proof vote of 270-148 on July 27, 2006.� Unfortunately, this bill was very different from the Senate version, S 1418 (the �Wired for Health Care Quality Act�), and negotiators were not able to develop a compromise between them.�� Therefore, it is back to the drawing board for 2007, and we do expect Congress to attempt to pass an HIT bill this year.� � Although Congress was not able to pass legislation in 2006, AHIMA and our allies educated Congress for the need to upgrade our outdated and inefficient ICD-9 coding system. As a result, included in HR 4157 was language that called for the implementation and use of ICD-10-CM and PCS by October 1, 2010. Senator Norm Coleman (R-MN) also introduced the �Critical Access to Health Information Technology Act (S. 1952-109th Congress)� which included nearly identical language on ICD-10.� Further, both HR 4157 and S 1952 included additional provisions that would upgrade the HIPAA claims attachment standard and also make changes to the HIPAA standards adoption process to enable more efficient updating.� These are critical components, and we will be advocating for them again in 2007.� The House passed HR 4157, the �Health Information Technology Promotion Act,� with a veto proof vote of 270-148 on July 27, 2006.� Unfortunately, this bill was very different from the Senate version, S 1418 (the �Wired for Health Care Quality Act�), and negotiators were not able to develop a compromise between them.�� Therefore, it is back to the drawing board for 2007, and we do expect Congress to attempt to pass an HIT bill this year.� � Although Congress was not able to pass legislation in 2006, AHIMA and our allies educated Congress for the need to upgrade our outdated and inefficient ICD-9 coding system. As a result, included in HR 4157 was language that called for the implementation and use of ICD-10-CM and PCS by October 1, 2010. Senator Norm Coleman (R-MN) also introduced the �Critical Access to Health Information Technology Act (S. 1952-109th Congress)� which included nearly identical language on ICD-10.� Further, both HR 4157 and S 1952 included additional provisions that would upgrade the HIPAA claims attachment standard and also make changes to the HIPAA standards adoption process to enable more efficient updating.� These are critical components, and we will be advocating for them again in 2007.�

37. Hot Topics � Clinical Data Sets, Vocabularies, Terminologies and Classifications Clinical Data Set: �A data set is a collection of data elements such as age, principal diagnosis, or level of functioning. Each data element should have a single stated definition and purpose. It should also have a unique name or data dictionary established. A data set should also have some interrelationship between the data elements that are defined. Examples of a data set could include something as simple as a master patient index to something more complex such as the Minimum Data Set for long term care.� Source: �Clarification of Clinical Data Sets, Vocabularies, Terminologies, and Classification,� by AHIMA's Coding Policy and Strategy Committee

38. Hot Topics � Clinical Data Sets, Vocabularies, Terminologies and Classifications Clinical Vocabulary: �A clinical vocabulary is a list or collection of clinical words or phrases with their meanings. Examples of clinical vocabularies include the Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) from the College of American Pathologists, the Read Codes from Britain's National Health Service, and the Unified Medical Language System (UMLS) from the National Library of Medicine.� Source: �Clarification of Clinical Data Sets, Vocabularies, Terminologies, and Classification,� by AHIMA's Coding Policy and Strategy Committee

39. Hot Topics � Clinical Data Sets, Vocabularies, Terminologies and Classifications Terminologies: A clinical terminology provides the proper use of clinical words as names or symbols. It is a system of clinical terms of preferred terminology or a nomenclature. Examples include defined terms such as a neuroma or colitis, abbreviations such as SLE for systemic lupus erythematosus or CMV for cytomegalovirus, and synonyms of terms. Source: �Clarification of Clinical Data Sets, Vocabularies, Terminologies, and Classification,� by AHIMA's Coding Policy and Strategy Committee

40. Hot Topics � Clinical Data Sets, Vocabularies, Terminologies and Classifications Classification Systems: �A classification system is clinically descriptive and arranges or organizes like or related entities for easy retrieval. Examples include ICD-9-CM, CPT, ICD-10-PCS, and the North American Nursing Diagnosis Association Taxonomy (NANDA).� Source: �Clarification of Clinical Data Sets, Vocabularies, Terminologies, and Classification,� by AHIMA's Coding Policy and Strategy Committee

41. Hot Topics What are YOUR Hot Topics?