In this issue:
Coding News
Update on the AMA’s Proposed Documentation Guidelines — Clinical Examples
By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management
Several LYNX coders, Quality Management specialists and a few of our managers participated in an ACEP coding trial of ED clinical examples or vignettes, back in September 2002. For the trial, LYNX had test cases and assigned professional E/M codes using the clinical vignettes methodology. Once the ED records were coded, we compared our coding with the coding performed on the same records by another ED coding group in Sacramento, CA. Both groups found the E/M level 1, 3 and 5 examples difficult to generalize and apply to actual ED records for coding. Coding results were highly variable between the coders in each group and between the two groups. Many of the coders wondered how CMS would use these clinical examples in an audit situation. The AMA had the same question. Last month, at the AMA House of Delegates meeting, they voted to officially cancel the clinical vignettes proposal.
For now, LYNX will continue to use the CMS 1995 documentation guidelines for professional coding. It’s unlikely that we will have any new guidelines for pro coding in the near future.
Smooth Operations
Documentation Feedback
By Shannon Weintraub, MBA
Director of Coding Operations/QM
As a LYNX Coding Services client, you are aware that LYNX strives to provide an integrated approach to meeting clients’ emergency medicine management needs. Our service stretches beyond code and charge assignment, to providing documentation feedback when deficiencies exist. Documentation feedback identifies missing information needed for claims processing and contributes to clinician/staff education.
Feedback is provided when your clinical documentation does not support the expected visit level or when insufficient documentation is available to code a procedure.
Most Common Physician Feedback
- Deficiencies in: HPI, ROS, Physical Exam, MDM or procedure documentation
- Missing signature
- Critical care time is not documented
- Handwriting illegible
- Missing final diagnosis
Most Common Nursing Feedback
- Documentation for medication did not indicate route of assignment
- Mode of arrival and/or disposition was not clearly documented
- Handwriting illegible
As a LYNX Coding Service client, you should be receiving documentation feedback on a consistent basis. Since modes of operation may vary from site to site, if you are unsure by what means the feedback is being provided or if you have questions about your feedback, please feel free to contact your Coding Operations Manager by email or phone.
Compliance Corner
Policy Change for Splints and Strapping
By Ann Florer, RN, CCS-P
Coding Compliance Manager
Based on clarification from the Centers for Medicare and Medicaid Services (CMS), LYNX is revising its policy for coding splinting and strapping procedures in the ED and other outpatient settings. CMS directs ED providers to bill for splints only if the splint is personally applied by the physician. CMS Carriers referenced the fact that “incident to” rules do not apply in the hospital setting under Medicare Part B and referred to Chapter 15, Section 60-0B and Section 60.1B (B-3 2050.1) of the Medicare Benefit Policy Manual, which states that a physician may not bill for the services of a hospital employee “incident to” the physician service. The hospital’s intermediary makes payment for these services under Part B to a hospital. Under this direction, effective for August 1 dates of service, LYNX will no longer assign a splint or strapping procedure code for professional services if the emergency department clinician (EDC) does not personally apply the splint or strapping.
Medicare rules do not necessarily apply to all payers. Most payers follow CPT guidelines and code descriptors. The CPT descriptor for splints and straps includes the terms “application of.” Many payers and providers believe that the evaluation of a splint or strap applied by ancillary staff is part of the E/M service. Without guidelines from all other payers, LYNX has adopted a conservative approach and we recommend that if the physician does not apply the splint or strap then it should not be separately coded.
Documentation Tips
Write down, speak up or enter that diagnosis.
At least one diagnosis should be documented on every record-irrespective of the reason for the visit. A case where diagnosis documentation is often deficient is when a patient presents to the ED requesting a medication refill. The physician or provider will document “medication refill” rather than “medication refill for depression” or indicate the diagnosis in the documentation. Payers usually deny ED claims with a V code listed as the primary diagnosis but unless coders know what the medication is for, that is all they can code. To help ensure reimbursement for the visit, remember to document the diagnosis for which the medication is being refilled.
Another case where diagnoses are often missing from ED documentation is when a patient presents to the ED needing attention to a central line or an indwelling tube of some kind. There is often no diagnosis identifying why the patient has the line or tube in place. Unless a complication is diagnosed, a V code must be assigned for the visit. To help ensure reimbursement for the visit, remember to document the diagnosis for which the indwelling tube or catheter was placed.
Working with residents requires specific documentation.
If you involve residents in the care of your ED patients, CMS teaching physician documentation guidelines require that you personally document at least the following:
- That you performed the service or were physically present during the key or critical portions of the service when performed by the resident
- Your participation in the management of the patient (cannot be documented by the Resident)
A counter signature or identification of the teaching physician alone does not meet the requirements necessary to code a service as being performed by a teaching physician. In order to bill for critical care services the teaching physician must be present (located in the same room) for the period of time for which the critical care services are provided.
Report your critical care service time.
LYNX coders look for documentation regarding the amount of time you spent providing critical care services. Without the specific listing of your critical care time, a critical care E/M service cannot be coded. In addition to the time requirement, CMS adds the following criteria to CPT documentation requirements when they perform medical reviews of critical care services:
There is a high probability of sudden, clinically significant or life-threatening deterioration in the patient’s condition, which requires the highest level of physician preparedness to intervene urgently.
Critical care services require direct personal management by the physician. They are life- and organ-supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal from or failure to initiate these interventions on an urgent basis would likely result in a sudden, clinically significant or life-threatening deterioration in the patient’s condition.
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.