Volume 1, #3

September 2004

In this issue:

• Coding News
  • How Might the Proposed Medicare Fee Changes Affect Your Reimbursement in 2005?
  • Emergency Medicine Billing Facts from Part B News
• Smooth Operations
  • 2005 ICD-9 Update Required for October 1, 2004 Visits
• Compliance Corner
  • Reconciling the Dilemma between ICD-9-CM Diagnosis Coding Guidelines and EMTALA

Coding News

How Might the Proposed Medicare Fee Changes Affect Your Reimbursement in 2005?

By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

The proposed Medicare Fee Schedule changes for 2005 were published in the August 5, 2004 Federal Register. Thanks to language in the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA), the conversion factor (CF) change for 2005 will be “not less than 1.5%.” If left to the calculations mandated in the Social Security Act, the CF would have decreased approximately 3.6% from the 2004 value.

The 2004 CF is $37.3374 and with an almost certain 1.5% increase, the 2005 CF will be $37.8975. The final rule will be published in the Federal Register by November 1, 2004 and we will confirm the final value for you. In the meantime, you can access additional information on the CMS Web site under physician services at http://www.cms.gov.

In addition to a change in the CF, relative value units for most services were adjusted. Taking into account the CF and RVU changes, CMS estimates that the total payments to Emergency Medicine will increase approximately two percent. A comparison of 2004 and estimated 2005 RVUs, payment rates and % change for ED E/M codes and select procedures is listed below. The complete list is available on our Web site. To view, click here.

Comparison of Relevant ED CPT, RVUs and Payments: 2004 versus 2005

If you are interested in more information about how the 2005 changes will impact your group’s reimbursement, contact your LYNX coding manager to schedule an in-depth fee analysis by our LYNX consulting team.

Emergency Medicine Billing Facts from Part B News

According to a Part B News analysis of Medicare claims data comparing Emergency Medicine utilization and payments from 2003 to 2002, a total of 21,968,834 ED physician services were provided to Medicare beneficiaries in 200, a 9.9% increase over 2002. The overall denial rate was 9.3%. A total of $1,269,003,523 was paid to ED physicians in 2003—a 16% increase over 2002 and represented 2.5% of total Medicare payments to physicians.

Smooth Operations

2005 ICD-9 Update Required for October 1, 2004 Visits

By Shannon Weintraub, MBA
Director of Coding Operations/QM

It is that time of year again. The new 2005 ICD-9 codes will be effective October 1 and per HIPAA Transactions and Code Sets rules, the 90-day grace period for this transition has been eliminated. Candace Shaeffer, vice president of Coding Operations, has sent emails to our primary contacts on both the professional and facility side discussing the change as well as the implications that will result from this change.

Efforts are already underway at LYNX to code as many records as possible that are in suspend status or require further documentation. As the date approaches, we would like to enlist your help to clear out any records with DOS prior to October 1. In order to minimize the effects of this ICD-9 change, we are requesting that you and your staff complete all corrections, suspensions and addendums for your September and past months’ records as soon as possible.

If you would like to obtain a listing of any patients that are suspended and you are not sure how to do so, please contact one of our regional coding operations managers:

Bellevue, Washington
Toll-Free #800.767.5969 or email:

• Stacy Land
• Wendy Gravely
• Laura Bennett

Tampa, Florida
Toll-Free #800.921.9587 or email Sally Strand

The timely completion of documentation for all pre-October 1 ED visits will minimize the volume of records that will require manual processing in order to generate the bill/claim. Your assistance is greatly appreciated.

Compliance Corner

Reconciling the Dilemma between ICD-9-CM Diagnosis Coding Guidelines and EMTALA

By Ann Florer, RN, CCS-P
Coding Compliance Manager

The more specific a diagnosis, the greater the probability an ICD-9-CM code will support the E/M services and procedures provided and will hasten coding, billing and payment.

Background

The original objective for ICD-9 coding was to facilitate data collection (classified by diagnosis) for research, education and administration. Today, ICD-9 codes serve a number of other purposes. They are used to evaluate utilization patterns and to study health costs. They are also used to facilitate payment and provide a basis for denying it when standards of medical necessity are not met.

The concept of medical necessity becomes important when considering the mandates of the Emergency Medical Treatment and Active Labor Act (EMTALA). Hospitals that participate in the Medicare program are subject to the emergency care requirements of this law, which require them to provide an appropriate medical screening examination to any person (not just those who receive Medicare benefits) who comes to the hospital emergency department (ED) and requests treatment or an examination for a medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or a transfer to another medical facility as appropriate. Hospitals that violate EMTALA may have their Medicare participation terminated and may be subject to civil money penalties (“CMPs”) of up to $50,000 per violation.

EMTALA employs a standard of medical necessity known as the Prudent Layperson Standard, and compels payers to cover emergency services “if the patient presents with symptoms that a ‘prudent layperson,’ possessing an average knowledge of health and medicine, could reasonably expect to result in serious impairment to his or her health.” However, the practical application of this standard does not make payment for ED services automatic.

Due to the high cost of providing ED services, many payers have established stringent rules for determining ‘emergent’ conditions. These rules use ICD-9 diagnosis coding as a foundation. Many payers have lists of non-emergent diagnoses that they consider inappropriate reasons for being seen in the ED. Even if a patient presents to the ED with acute symptoms, the payer may deny the claim if the physician documents one of these diagnosis. Otitis Media is found on the payers non-emergent list. The physician is required to see the patient under EMTALA, yet the payer may deny the claim as non-emergent. One way to potentially circumvent this denial is to document the diagnosis as “acute” Otitis Media as appropriate.

Using ICD-9 codes to support the Prudent Layperson Standard

LYNX will assign a sign or symptom code to support the evaluation and management level provided, if the final diagnoses does not support the reason for the encounter/visit for the services provided.

Diagnosis Documentation Tips

• If a patient presents to the ED with an acute problem, always document the final diagnosis as “acute,” (this includes diagnosis of chronic conditions such as sickle cell disease, schizophrenia, angina, low back pain, gastroenteritis, bronchitis etc).

• If a patient presents with a worsening of a chronic condition, document the diagnosis as an “acute” or as an “exacerbation.” For example, patient with chronic obstructive asthma, (COPD) presents extremely SOB. Instead of documenting “Asthma,” document “Acute exacerbation of chronic asthma.”

• If you have not arrived at a definitive diagnosis after evaluation of the patient’s condition, do not list the final diagnosis as “probable,” “rule out,” suspected,” “questionable,” “possible,” one diagnosis “vs.” different one or “working diagnosis” etc. ICD-9-CM outpatient coding guidelines do not allow the coding of non-definitive diagnoses. Instead, list the diagnosis to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reason for the visit, e.g., acute chest pain.

• Always document diabetes as “controlled” or “uncontrolled” (for the current encounter) and either Type I or Type II. Do not list a diabetic diagnosis as only “insulin-dependent” or not, since both Type I or Type II may be insulin-dependent at some point during the course of their disease. If a condition is a manifestation of diabetes, the diagnosis should indicate this, e.g., Type I DM with ketoacidosis, diabetic coma, chronic renal failure, peripheral neuropathy, retinopathy, gangrene, etc. or Type II diabetic with hyperosmolar coma.

• For further information, refer to the ICD-9-CM guidelines for coding signs and symptoms if an established diagnosis has not been established at http://www.cdc.gov/nchs/data/icd9/icdguide.pdf.

How the 2005 ICD-9 Code Changes affect Documentation Requirements

October 1, 2004 is the release date for new and revised ICD-9-CM diagnosis codes. As with previous years, the new and improved codes require diagnoses of greater specificity for correct code assignment. Some of the changes that will have the most impact on ED coding include:

• A diagnosis of decubitus ulcers, now needs to include the location, e.g., hip, buttock, lower back, ankle, etc.
• A patient encounter for treatment of venous embolism and thrombosis — deep vein of lower extremity — now requires specificity as to whether the location is proximal (upper leg and thigh, popliteal vein and above) or distal (calf and lower leg). When no thrombosis or embolism is found at this encounter, the diagnosis should include the statement “history of venous thrombosis and embolism” if the patient has had one in the past.
• Obstructive Chronic Bronchitis has a new code if this condition occurs “with acute bronchitis.”
• Psychiatric Diagnosis Code Terminology has been revised this year to more closely align with DSM-IV, the Diagnostic and Statistical Manual of Mental Disorders (DSM).
• For a complete list of all ICD-9 code additions/revisions and deletions, refer to the following online publications: http://www.aan.com/professionals/coding/2005_coding.pdf or http://www.cms.hhs.gov/providers/hipps/frnotices.asp.