In this issue:
Coding News
Are You Seeing a Reduction in Medicare Denials in Your ED?
Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management
Historically, FIs have edited claims or line items on claims based on diagnosis (medical necessity) or frequency of service provided (multiple lab tests, etc), which sometimes resulted in denials of all or a portion of billed ED charges. LYNX has worked with several ED and HIM managers that have experienced these medical necessity denials for such things as lab work, x-rays, CTs, Ultrasounds and MRIs performed for ED patients. In effort to stem the revenue loss, LYNX has helped physicians improve documentation of the correct diagnoses or symptoms for each of these tests and LYNX coders have used Medicare’s Local Medical Review Policies (LMRPS) and Local Coverage Decisions (LCDs) to make sure they coded the correct ICD-9 codes.
Under the new MMA requirements, Medicare is now stressing to providers the importance of documenting and coding presenting symptoms in addition to diagnoses for ED encounters. LYNX coders identify and code these symptom ICD-9 codes and they are then reported on the UB 92 claim form as either the ED “Reason for Visit” or as additional ICD-9 diagnosis codes. Medicare initially gave providers the option of reporting the Reason for Visit ICD-9 code, but they have recently changed their policy to require that it be reported. Medicare edits look for this code in Form Locator 76 on the UB-92 claim for many bill types including 13X—outpatient. Of benefit to providers, CMS rules now require that Medicare systems scan all diagnosis fields on the claim for payable codes.
The MMA further requires that decisions about an ED service being “reasonable and necessary” be based on:
- The information available to the ED Clinician at the time of the visit
- The patient’s presenting problem or symptoms, and not only on the principal diagnosis.
The MMA specifically requires that denial for tests not be based on the number of tests performed and FIs have been instructed to turn off the LMRP/LCD frequency edits in their claims processing software for revenue code 45X (ED), among others. If a denial based on an LMRP or LCD is made, FIs must report the LMRP/LCD number associated with the denial. The law further states that “contractors may continue to target their data analysis on EDs to ensure that there are not aberrant patterns of outliers.”
The FIs have been instructed to reopen any ED claim denied on or after January 1, 2004, if requested by a provider. It may be financially beneficial for hospitals to review last years ED Medicare claims for denials and submit them for appeal under these new rules.
Smooth Operations
Yearly Chargemaster Update Reminder
By Shannon Weintraub, MBA
Director of Coding Operations/QM
It is that time of year again and many facilities choose January 1 as the date to implement fee schedule updates or other changes to their CDM. If your facility has made a recent change to your Chargemaster, either by adding/deleting CPT’s or DP codes or changing/updating fees, please remember to contact LYNX and provide a copy of the updated chargemaster.
It is important that our CDM reflect any changes made by the facility in order for us to provide the best possible service as well as accurate reporting. If your facility has not yet made a change and you would like assistance in your Chargemaster review, please contact your LYNX Coding Operations Manager and they can assist you with that process.
If you have questions or would like to discuss recent changes to your Chargemaster, please feel free to contact your LYNX Coding Operations Manager or myself by email or phone.
Compliance Corner
2005 OPPS Final Rule brings Changes to Infusion and Observation Services
By Ann Florer, RN, CCS-P
Coding Compliance Manager
Hospital Infusion Services
CPT® Codes 90780 and 90781 (IV infusion each additional hour) will replace the often problematic HCPCS level II code Q0081 starting January 1, 2005. 90780 will crosswalk to the same APC (0120) Q0081 previously did, and will continue to be paid on a per visit basis. However, CMS in the final rule states it is critical for hospitals to bill the charges for the packaged CPT codes for drug infusion, each additional hour (90781 SI=N) even though no separate payment for them will be made in CY 2005. For 2007 OPPS, CY 2005 claims data will be used as the basis for setting median costs. Failure to report code both 90780 and 90781 will jeopardize CMS’s ability to make accurate payment determinations for services billed under these codes in 2007.
Observation Services
CMS, admitting that they may have been imposing unreasonable reporting burdens on hospitals, and in some cases, may be requiring that unnecessary tests be performed, changed the OPPS Observation payment rule as follows:
- In an effort to clarify confusion cited by providers regarding observation care that exceeds 48 hours, the descriptor for HCPCS code G0244 was changed to read as follows:
G0244, Observation care provided by a facility to a patient with
CHF, chest pain or asthma, minimum 8 hours.
- CMS has removed the requirement that specific diagnostic tests (e.g. two sequential ECGs for patients with chest pain), be performed in order to qualify for observation payment.
- The counting of time in observation care will no longer end at the time of the physicians discharge order but rather the time the outpatient is actually discharged from the hospital or admitted as an inpatient. However, CMS reiterated that they do not expect observation time to include time spent by the patient in the hospital subsequent to the conclusion of therapeutic, clinical or medical interventions, such as time spent waiting for transportation to go home.
To read the entire 2005 OPPS Final Rule, click here
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.