Volume 3, #1

March 2006

In this issue:

• Thorough documentation will help ensure that your non-manipulated fracture care is coded appropriately!
• Documentation and coding for hydration infusions for professional services?
• Pay for Performance (P4P): Are you ready to survive or thrive in the upcoming climate of physician P4P?
• Critical Care/Documentation Refresher

Thorough documentation will help ensure that your non-manipulated fracture care is coded appropriately!

Candace E. Shaeffer, RN, MBA, RHIA
Vice President of Coding Policy

Based on recent clarifications from AMA and discussions with ACEP, LYNX will be revising our coding policy for non-manipulated fractures effective 4/1/2006. The change will be that when an ED MD does not perform and document the definitive fracture treatment and the patient is referred to another physician for that care–restorative or definitive, LYNX will code only the ED E/M and the splint or strapping codes as appropriate. LYNX coding of manipulated fractures will remain the same.

Coding and billing for manipulated fracture care in the ED, when properly documented, is reasonably straightforward. Non-manipulated fracture care, on the other hand, can be problematic because there is not always a clear understanding or definition of what the definitive care is for treatment of these fractures or what the documentation requirements are.

An understanding of the terms used by CPT and others relative to fracture treatment helps. Fracture codes can be coded for restorative care but what is restorative care? Or partial restorative care? What is definitive care? And where does supportive or comfort care fit in? Coders often find it difficult to differentiate these types of care based on the physician’s documentation.

• Restorative care involves manipulation and the restoring of a fracture to its normal anatomic alignment. Most of these fractures will require follow-up care and therefore the treatment provided in the ED is rarely considered “definitive.”

• Fracture treatment for non-manipulated fractures provided in the ED can be definitive—meaning that the treatment is complete or nearly complete and is the same care that a specialist would provide. In this case follow-up may not be required. In the case of non-manipulated fractures, this definitive care might mean stabilization and support, relief of pain and provision of patient education and instructions.

• Differentiate the fracture treatment described above from supportive or comfort care where comfort and protection is the focus of care provided. In this case a splint might be applied for stabilization and patient comfort and then the patient is referred to an orthopedist or other physician for further fracture treatment.

The coding of non-manipulated fracture care in the ED is increasingly problematic, especially when the care is not definitive. Questions that need to be asked are described below:

• Is the treatment/documentation definitive and comparable to what a specialist would provide and document –complications ruled out, treatment and plan described—stabilization, pain relief, patient education, instructions for care and follow-up?

• Was the patient referred to an orthopedist for more definitive or restorative care?

• What are the politics in the hospital—some EDs leave the coding of this service to the orthopedists and code only an ED E/M and splint if placed.

If non-manipulated, but definitive fracture care is to be coded, thorough documentation is required. Best practice documentation might include a separately headed procedure note with the following:

• Future location in detail and notation if the fracture is open or closed, and discussion of complications or potential complications, if any. Treatment provided in the ED

• Post treatment assessment of fracture or treatment—CMS guidelines require that a patient’s progress, response to, and changes in treatment be documented.

• Instructions for care and follow-up.

The following example is from the AMA-CPT Assistant (12/2005):

Case: A patient presents to the ED with a non-displaced scaphoid wrist fracture, is referred to his PMD for follow-up, and then is referred to ortho surgeon for fracture treatment.

Solution: For the ED physician, an E/M and splint code, if appropriate, should be reported. The PMD should report an outpatient E/M code, and the orthopedic surgeon would report the appropriate fracture treatment code.

An example from ED Coding Alert (11/2005 pg.81):

Case: A patient presents to the ED with a non-displaced and minor impacted fracture of the proximal radial head. An x-ray was taken, a short arm splint and sling are placed, and the patient was given instructions to continue wearing the splint for the next 3-4 weeks.

Solution: Because the ED physician provided all of the care that this patient will receive for the injury, the fracture code 24650 (closed treatment of radial head or neck fracture, without manipulation) would be coded along with the ED E/M code.

Another example from ED Coding Alert (11/2005, pg 83):

Case: A patient presents to the ED with a Colles fracture with significant impaction. The MD documentation states that she applied a long arm posterior splint. She discussed the case with the orthopedist who plans further operative treatment in several days.

Solution: The ED visit level and splint should be coded. The orthopedist’s operative treatment will constitute the restorative care. The ED physician’s splint application was for stabilization and comfort.

In each case, the physician performing the definitive or restorative care was the one to report the fracture treatment code. When the definitive care is provided in the ED, the patient may still be referred to an orthopedist or other MD for general follow-up care if needed. This “if necessary” referral would not preclude assignment of fracture care code for the ED physician.

Because it’s never certain what the patient will do for follow-up care, a 54 modifier for “surgical care only” will be appended to the fracture care codes when these services are reported by ED physicians.

Documentation and coding for hydration infusions for professional services?

Candace E. Shaeffer, RN, MBA, RHIA
Vice President of Coding Policy

In a letter to ACEP dated 1/9/06 CPT clarified that ED physicians could bill for hydration infusions, “There is no language in the 2006 CPT book that prohibits emergency physicians from reporting the hydration codes if that is the service they are providing. As long as they meet the requirements as stated, emergency physicians may use the hydration codes.”

Medicare will not pay for these infusions for professional services but some payers might. In order to optimize the chances of this, good documentation addressing medical necessity and the services provided is essential. A general coding/billing principle is that all billed services should have documentation to support the medical necessity for providing them. A physician’s order for the infusion is one way to establish the medical necessity. Although there are no specific MD documentation requirements listed in CPT for the hydration infusion codes, best practice documentation for a hydration infusion should include a separately headed procedure note with the following:

• the rationale for the infusion with documentation that it is a “hydration” infusion
• the type of infusion fluids and the length of time over which it will infuse
• the patient’s response to the infusion

Under “Principles for Medical Record Documentation” in the CMS documentation guidelines, item 6 states, “the patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.” This requirement applies to hydration infusions as well as other forms of treatment. If you have questions about the coding and billing of non-manipulated fractures or hydration codes, contact Shannon Weintraub or Candace Shaeffer toll-free at 800.767.5969.

Pay for Performance (P4P): Are you ready to survive or thrive in the upcoming climate of physician P4P?

Jeffery L. Wajda DO, MS, FACEP
Associate Medical Director

In Remember the Institute of Medicine (IOM) Report from 2001 entitled Crossing the Quality Chasm? The IOM declared the U.S. health system to be in need of fundamental change. Among the many ailments identified was the failure to “align payment incentives with quality improvements.” The IOM is the same organization that in 1999 estimated that as many as 98,000 American’s die every year as a result of avoidable patient safety errors.

In an attempt to create an environment that fosters and rewards improvement, over 100 health care pay for performance (P4P) initiatives are up and running in the U.S. These programs work on the premise that Hospitals, Physicians, Insurance Companies and Employers align efforts to advance quality through collaboration.

Medicare Hospital Pay for Performance quality outcome indicators are well established for Community Acquired Pneumonia, STEMI Treatment, CABG care and Hip Fracture care. Additionally Medicare, JAHCO and the AMA have agreed to work together to produce 100 “physician quality outcome indicators” by 2007. The American Medical Association echoed physician discomfort, writing that P4P is a “tsunami building offshore in a sea of stakeholder unrest, threatening those who are not prepared.” As the P4P trend gains momentum, both hospital and physician reimbursement will be in part based on their ability to meet defined quality benchmarks.

The California Pay for Performance Program has become the largest program of its kind. Over 200 participating physician organizations and the 35,000 physicians whom they represent have responded to the challenge of improving the quality of healthcare and patient experience for over six million Californians in the last five years.

The California P4P stakeholders are often asked, “What is your experience and what have you learned?” Some key points of consensus among California stakeholders were:

• Set ambitious long-term quality improvement objectives, but modest short-term process goals. Trust is the glue that binds collaboration.
• Start with a small number of initial quality measures and increase the numbers over time.
• Performance measures are the “tip of the iceberg,” with detail underlying it in the form of data metrics, barriers to data collection, and inevitable confounding factors leading to inconsistencies. Therefore, test measures prior to implementation.
• Payment incentives are a powerful motivator and catalyst. Public and peer recognition are also important and not to be underestimated.
• There is no substitute for actively engaged physician leaders in the decision making and governance process. Consensus decision making can be painfully slow, but necessary. Physicians must be confident that measurement is fair and payers must believe that payment is justified.

CMS administrator Mark B. McClellan, M.D. PhD has been a strong P4P supporter. In his testimony before the House Ways and Means Subcommittee on Health on September 29, 2005, he stated:

“Medicare needs to move away from a system that pays simply for more services, regardless of their quality or impact on patient health…to a system that instead encourages and rewards efficiency and high quality for the Medicare program and its beneficiaries.”

Consistent with this sentiment is the voluntary CMS reporting program where physicians began reporting 16 quality measures in January 2006. Both the AMA and Medical Group Management Association (MGMA) have voiced concerns that this program creates significant administrative reporting burden without reimbursement for data collection.

Pay for Performance is here to stay. Relatively quickly, P4P has become a part of the ongoing debate over how to rein in costs while improving quality. Physicians can use the experience of others and actively advocate for their patients and themselves. Active physician participation will help assure that quality indicators are evidence based. Will the rewards of a broad based Medicare P4P program justify the costs?

At this point three quality indicators are aimed at Emergency Physicians; ASA in STEMI, Beta blockers on arrival in STEMI and Antibiotics within four hours for community acquired Pneumonia. These indicators are linked to the ED visit level CPT codes and specific ICD-9 diagnoses. LYNX Medical Systems is actively pursuing software solutions designed to simplify data management associated with these and future initiatives.

Critical Care Coding/Documentation Refresher

Shannon Weintraub, MBA
Director of Coding Operations

It can sometimes be difficult for both coders and physicians to differentiate between a Level 5 and Critical Care encounter—both require high MDM. Coders must rely on the clear documentation of the physician as the strongest indicator that the care given was critical. So what constitutes Critical Care Services?

CPT Definition of Critical Care Services:

Beginning in 2003 CPT defines a critical illness or injury as an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care services involve decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

CMS adds that in order to qualify as critical care for Medicare patients, “the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.”

(www.acep.org)

Sometimes statements in the documentation seem inconsistent with critical care such as “the patient was in mild pain or no acute distress.” Pain is not a prerequisite for critical care and at times, in a critical care encounter the patient may not be in distress. Admission is also not a prerequisite requirement for critical care. Consider the following CPT example vignette:

A 73 year old presents to the ED with a rapid heart rate, significant shortness of breath and diaphoresis. He is seen by the ED MD and treated with respiratory therapy. The MD diagnoses CHF and spends 45 minutes of critical care time assessing and treating the patient. Subsequently the patient is able to breathe comfortably and his symptoms have decreased. The MD documents a history and exam and performs an extensive work-up and then discharges the patient home.

Because the physician documented that this was critical care time CPT Assistant advises that critical care 99291 should be coded (CPT Assistant July, 2002).

So now that we have determined what constitutes Critical Care, how do you count your time? In order to qualify for Critical Care a physician “must devote his or her full attention to the patient,” however, the time recorded for critical care should not be limited to time spent in direct contact with the patient or at the patient’s bedside. Remember to include time that is spent in work related to the patients care, for example:

• Reviewing lab and diagnostic test results
• Discussing patients care with other physicians
• Reviewing previous medical records
• Documenting in the medical record
• Discussing the patient’s condition and treatment with patient’s family—ONLY IF the patient is unable to participate in these discussions him or herself.

Remember to note all procedures performed, and the time it takes to perform them if they are separately billable. Procedure time must be subtracted from critical care time, with the exception of those procedures which are considered bundled. Only a handful of procedures are considered “bundled” into Critical Care services and are not separately billable:

• the interpretation of cardiac output measurements ( CPT 93561, 93562)
• pulse oximetry ( CPT 94760, 94761, 94762)
• chest x-rays ( CPT 71010, 71015, 71020)
• blood gases
• information data stored in computers (CPT 99090)
• gastric intubation ( CPT 43752, 91105)
• transcutaneous pacing (CPT 92953)
• ventilator management ( CPT 94656, 94657, 94660, 94662)
• vascular access procedures ( CPT 36000, 36410, 36415, 36540, 36600)

To support a critical care service, the physician’s documentation should explain the critical nature of the patient’s condition. It is helpful to document why a particular system was in danger of “failing.” Common indicators of severity are: documentation of unstable vital signs, altered mental status, respiratory distress, changes in the patient’s condition and frequent reevaluations, serious cardiac arrhythmias or multiple injuries. These are examples of the “flags” that help coders differentiate between a level 5 and Critical Care.