In this issue:

• Coding News
  • LYNX Monitoring for Coding Quality
  • Documentation Reminders
• Compliance Corner
  • CMS releases Clarifying Manual Instructions for Coding and Payment for Drug Administration under the Hospital Outpatient Prospective Payment System (OPPS)

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Coding News

LYNX Monitoring for Coding Quality

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

In order to ensure coding quality, LYNX coding managers and Quality Management staff monitor several parameters of hospital and professional coding every two weeks. They employ the tools built into our E/Code coding system to check your visit level and procedural frequencies. LYNX managers compare the actual coded visit level frequency distribution to prior months and to the typical frequencies for the presenting problems seen in your ED. This latter comparison tells us if there are variations from what we would expect to see. If a significant variation is found, an audit of the records is performed. The visit level frequency distribution is also assessed relative to the hospital admit rate for the period. If the admit rate increases, your frequency distribution is expected to shift commensurately to the right or toward the higher acuity levels.

Several other data points are compared, analyzed and trended. Managers look at the average charge compared to previous months, the percentage of levels 4 and 5 relative to the full volume of patients, and the number of procedures coded per 100 visits. In addition, coders provide their managers with a weekly report containing any unusual circumstances that the manager should be aware of and that might change the distribution of visits and procedures.

Coding is not an exact science. Coding guidelines for facilities are not standardized and reimbursement policies vary by payer. There are also many factors that contribute to the determination of the final visit level in a given record. LYNX hires credentialed or credential eligible coders and each under goes an extensive training program of didactic learning and auditing. We provide continuing education and assessment of understanding on a monthly basis. This is all part of our coding compliance plan and our commitment to you to deliver the highest possible quality of coding.

Despite the very best efforts, in any coding practice coding can get off track. The monitoring described above is one of the best methods to detect and correct errors early. We view coding as a partnership with each of our clients and if you have questions about any aspect of coding your feedback and input will be welcomed. We provide you with reports so you can review coding performance and also compare coding results to what you expect based on the services provided in your ED. If you need more information, contact your LYNX coding manager.

Documentation Reminders

• For IV infusions, start and stop times, the rate, route/location and type of infusion (solution, mediations) are all required data elements for coding.
• An ED facility charge for critical care may be coded in certain circumstances when it can not be coded for the physician. Documentation of at least 30 minutes of critical care is required for coding 99291 for each but the rules and circumstances for counting this time are different. Two examples of when this critical care time variance might occur are when a trauma team assumes care from the ED physician and the critical care situation moves forward with the trauma team and nursing staff or because the physician has performed separately billable procedures for which the performance time must be deducted from the total critical care time. This time deduction for procedures is not a requirement for facility critical care time calculation. Make sure nurses consistently document time when patient acuity and treatment require critical care.
• Any coordination with another department or service in the process of completing orders should be documented—this might include social services, HIM (Medical Records), interpreters, security, chaplains, etc. Each of these represents work performed/resource utilization by your nursing staff and can potentially increase the visit level coded for a particular encounter.

Compliance Corner

CMS releases Clarifying Manual Instructions for Coding and Payment for Drug Administration under the Hospital Outpatient Prospective Payment System (OPPS)

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

CMS released Transmittal 557 on May 6, 2005 clarifying manual instructions for coding and payment for drug administration codes for Medicare patients. The original transmittal #404 left several unanswered questions which CMS has now addressed. Changes are effective June 1, 2005.

Highlights of the Clarification Transmittal include:

Hospitals will report CPT code 90780 (IV infusion therapy, up to 1 hour) to indicate infusion of drug other than anti-neoplastic drugs (including hydration solutions).

CPT codes 90780 and 90781 should not be reported when the infusion is a necessary and integral part of a separately payable OPPS procedure.

CPT codes 90780 and 90781 report the duration of an infusion, regardless of the number of drugs infused; therefore hospitals may bill one unit of CPT code 90780 for each encounter, but not for each drug infused.

• Hospitals are to report first hour infusion (90780) after 15 minutes of infusion.
• IV Infusions, (not anti-neoplastic), lasting 15 minutes or less should be billed as intravenous pushes and coded accordingly (90784).
• Hospitals are to bill push code 90784 for services that meet existing CPT guidelines and meet either of the following criteria:
  
  
  • A healthcare professional administering an injections is continuously present to administer and observe the patient; and
  • An infusion is administered lasting 15 minutes or less.
• Hospitals are to report additional hours of infusion (90781) (beyond the first hour) only after more than 30 minutes have passed from the end of the previously billed hour (90780). This means you must provide an infusion of greater than 90 minutes before you can bill the add-on infusion code.
• Providers are limited to reporting a maximum of eight units of service for eight additional hours for each add-on infusion code. If the infusion is greater than nine hours, providers must report it with an additional add-on code.
  
  
  • For example, a 10-hour infusion, report one unit of the first hour (90780), eight units of the add-on code (90781) and one unit of the same add-on code (90781).

Use of the Distinct Procedural Service Modifier -59

• With respect to drug infusions Transmittal 557 clarifies that the use of the -59 modifier Indicates a distinct encounter on the same date of service meeting the following criteria
  
  
  • The drug administration occurs during a distinct encounter on the same date of service or previous drug administration service; and
  • The same HCPCS code has already been billed for services provided during a separate and distinct encounter earlier on the same day.
• CPT modifier 59 is NOT to be used when a beneficiary receives infusion therapy at more than one site or when an infusion is stopped and then started again in the same encounter.
  
  
  • The use of modifier -59 lets CMS know that multiple payments should be made and
  • That multiple separate encounters occurred on the same date of service.

To view the entire transmittal, click here.