In this issue:
Coding News
CMS Outpatient Prospective Payment Systems (OPPS) Coding Guidelines
Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management
Providers of ED services are still waiting to see what CMS decides to do with the AHA-AHIMA Expert Panel recommendations for coding ED and Clinic visits. The CMS APC Advisory Panel met in February and discussed the Expert Panel recommendations.There are several sticking points to the AHA proposed guidelines, namely whether the number of visit levels should be three or five, the role of “contributing factors” or clinical data elements that increase a visit level by one level (but not from a high level visit into critical care), and patient education and discharge instructions and how they will be accounted for in the coding model. There was much debate and according to some present, we may not see any CMS OPPS coding guidelines until well into 2005 or later. CMS has promised 6-12 months notice before any changes are implemented and plenty of time for providers to comment on a proposed rule.
Also of note, at the same APC Advisory meeting the panel decided to recommend to CMS that payment for observation services be expanded beyond the three currently reimbursed diagnoses-chest pain, asthma and CHF. Their recommendation will include coverage for “all clinical conditions” for which observation status is appropriate based on medical necessity (AHA Coding Clinic for HCPCS Second Quarter 2004, p 6.)
HIPAA Transaction Code Sets (TCS) Rules Require Provider Changes
Certain HIPAA TCS Rules related to Coordination of Benefits are set for July 6, 2004 implementation. The UB-92 claim form is used for both inpatient and outpatient claims submission and unfortunately, the data requirements and edits can be different for each. In order to comply with HIPAA rules several changes are required. A few of these mandatory changes follow; if these conditions are not met the claim will be rejected:
- For outpatient claims each line item must have a date(s) of service reported for each revenue code on the claim
- Outpatient claims should not report anything in the Covered Days field
- Any reported E code must be valid, even though they are not required by Medicare
- All ED and Urgent Care Clinic (freestanding or hospital based) claims must contain a patient “Reason For Visit” ICD-9 code (usually a symptom).
Many hospitals have continued to report ICD-9 procedure codes for outpatient services which is not compliant under the TCS rules. CMS has decided not to reject claims for this reason in July but will do so in the near future. LYNX will work with clients to establish a process for mapping CPT procedure codes to ICD-9 procedure codes using the chargemaster. Contact your LYNX coding manager for more information.
Click here for additional information on the CMS TCS changes.
Smooth Operations
Operations Insight: New & Familiar Faces
By Shannon Weintraub, MBA
Director of Coding Operations/QM
As many of you are aware, we have recently undergone a reorganization of our management structure within the Coding Services Department at LYNX Medical Systems. As a result, we have added additional personnel to better serve the needs of our clients. I would like to take this opportunity to introduce you to the new and reacquaint you with those that you’ve come to depend upon:
New :: Wendy Gravely, MBA comes to LYNX with 10 years of healthcare experience, managing decision support, finance and internal consulting functions within Group Health Cooperative’s delivery system and at Premera Blue Cross.
Stacy Land has past experience as a practice manager and consultant for individual medical practices, including creation of two new clinics. She has been a Coding Operations Manager with LYNX for two years.
Laura Bennett, RHIT has worked at LYNX for more than 6 years. During her time at LYNX, she has taught both coder and physician education classes, managed our QM Department and has worked with our Coding Review Services (CRS) Clients as client manager.
Sally Strand, RN has been with LYNX for 15 years. She brings a clinical background in the Emergency Department, coding expertise and a solid foundation for providing consistently outstanding service to her clients.
Speaking of customer service—this is a top priority at LYNX as we are consistently looking to enhance the service we provide for you. Should you have any questions, please feel free to contact anyone of the managers above, Candace Shaeffer or me at 1.800.767.5969.
Compliance Corner
Thorough ED Staff Documentation Enhances ED Revenue
By Ann Florer, RN, CCS-P
Did you know that if you fail to document the route by which you administered a medication, you could be costing your Emergency Department revenue? Physician, Nursing and ED ancillary staff documentation determines what is billed for during an ED patient’s visit. Under Medicare’s reimbursement system for outpatient hospitals (facility), known as the Outpatient Prospective Payment System (OPPS), a resource-based charging structure determines patient charges.
In the past, nursing services and outpatient surgical procedures were used to determine the level of service charged. For example, patients who required IV therapy were often placed in a “higher acuity level” than those not requiring this therapy. Under the OPPS, procedures such as IV infusion therapy, IV injections, laceration repairs and splint applications, are separately charged. Absent or incomplete documentation of the services performed during the ED patient’s visit can result in failure to be able to bill the service. Below are some examples where missing or incomplete documentation can cost your ED revenue:
- Physician orders Morphine 10mg, a nurse documents Morphine 10mg on medication administration record. Neither the physician nor the nurse document whether the medication was given IV, IM or PO.
For medication administrations always document whether the medication was given, IVP, IVPB, IM or oral, sublingual etc.
- Nurse documents that an IV of 1000cc NS was hung. There is no documentation in the record as to whether any fluid was infused or whether this IV was present just to keep the vein open (KVO).
In order to bill for IV infusions, there must be documentation supporting that fluid was infused for therapeutic or diagnostic reasons.
- A plastic surgeon is called to the ED to perform a complicated laceration repair. The surgeon writes nothing but follow-up instructions for the patient on the ED record. The ED loses the revenue for the procedure performed and all the resources included in it (nursing and technician time, suture trays dressing etc.) because there is no documentation available at the time of billing to support what, if any, procedure the plastic surgeon performed.
Having PMDs document the procedures they perform in the ED on the ED records helps to ensure these resources are captured.
- In order to bill for the highest ED service, Critical Care, there must be documentation or other evidence in the record that at least 30 minutes of Critical Care management was provided.
Caring for patients who are critical often results in multiple tasks being accomplished in a short period of time. Thorough documentation for critical patients is very important in order to bill for critical care services. Please remember to document times for patient arrival, transfers, cardioversion, administration of medications, starting of IV infusions, dispositions, times of assessment, start and stop times for CPR, etc.
The information contained herein is provided for informational and educational purposes only, and nothing contained herein should be construed as advice. All information contained herein is obtained by LYNX Medical Systems (LYNX) from sources believed by LYNX to be accurate and reliable. Because of the possibility of human and mechanical error as well as other factors, LYNX is not responsible for any errors or omissions. LYNX makes no representations and disclaims all expressed, implied, and statutory warranties of any kind to user and/or any third party including warranties as to accuracy, timeliness, completeness, merchantability or fitness for any particular purpose.