Your Double-Headed Dragon Requires Attention Wrangling Compliance and Documentation

  • Gretchen Dixon
  • Volume 06 - Issue 1
Working with compliance and documentation - your double-headed dragon - can call to mind the expectation of a challenge; however, getting both of these heads to work together is vital to each provider’s business survival. Often discovered through revenue cycle audit results is a valley of missing information necessary to bridge these components and ensure our patient care services are accurately reported. This valley affects the accuracy of your patient’s acuity level and intensity of services with complexity of care provided. This article will discuss the activities you need to embrace and the specific documentation details required for ac-
curate ICD-10 code assignments related to wounds.
 
ICD-10-CM implementation is less than 9 months away—what have you done during last year’s reprieve in preparation? Many provider practices, as well as small- to mid-size hospitals, continue to squander this time. The compliance section of this article is to be used as an evaluation tool to determine your current status and readiness towards implementing ICD-10-CM. An additional section will provide key clinical documentation verbiage to assist in providing the specific details necessary to ensure selected ICD-9-CM or ICD-10-CM codes accurately reflect the patient’s level of acuity and intensity of service with complexity of care provided.
 
Topics in this article affecting wound care services include:
  • Compliance and documentation
  • Changes with Modifier 59 when reporting evaluation and management services
  • CMS Model for pre-authorization of non-emergent hyperbaric oxygen therapy
  • New HBO HCPCS Level II code

Begin by Understanding Compliance

To simplify the definition of COMPLIANCE™, this mnemonic device uses each letter to identify the clinical documentation improvement activities necessary to meet today’s and tomorrow’s regulatory guidelines, which will involve providers and payers sharing service accountability through the Affordable Care Act.

Evaluate your clinical documentation activities. How does COMPLIANCE™ fit into your everyday patient care documentation activities?

C = CHANGE begins by recognizing old documentation habits and building new habits through understanding the requirements of detailing information to support the level of acuity and intensity of service with complexity of care.

O = OPTIMIZE your clinical documentation details to provide an accurate, concise, and complete story of the patient’s encounter.

M = MENTOR your peers by encouraging their clinical documentation improvement (CDI).

P = PRACTICE daily adding details to your clinical documentation.

L = LEARN with enthusiasm how to incrementally add details in a patient’s medical record. Start with the most common diagnosis in your office and learn the specific details ICD-10-CM expects. This endeavor should improve your current ICD- 9-CM code selection and prepare you for the code change on October 1, 2015.

I = INSTILL a positive outlook towards changes along with the long-term benefits to your practice. Long-term benefits could be as simple as knowing you complied with federal, state, and local regulations; reducing the number of held claims, which require timely re-work; or experiencing a decrease in AR days as well as an increase in timely reimbursement.

A = ACTION includes addressing weak areas in your clinical documentation. Enlist the assistance of your coders or internal auditors who have reviewed your documentation. Listen to their suggestions and then help your peers to understand the value of clinical documentation change.

N = NEVER ASSUME health care professionals involved with your patients’ medical records will be able to interpret your documentation for patient services if the information is not accurate, clear, concise, and complete.

C = COMPLY with clinical documentation improvement to better represent the acuity of patient care and intensity of services with complexity of care. Without detailed clinical information available, often the acuity of care and intensity of services with complexity of care are not supported. This data can affect your patient care profile monitored by third-party payers and external agencies as well as patients.

E = EDUCATE yourself and peers by seeking opportunities to learn new clinical documentation elements. It can be as simple as how you select verbiage for a sentence. Changing verbiage or re-aligning thoughts often.  

 

Compliance Summary

Evaluating your current habits, staff skills, and level of ICD-10-CM understanding; preparing with education, both formal and informal (on-the-job); and interacting with payers and systems for their ICD-10-CM readiness will all be vital to a successful transition. Mitigating discovered weaknesses in your processes now will help to reduce the last minute scurry and re-work load as we approach October 1, 2015. Will there continually be opportunities before and after October 1, 2015? Absolutely. However, by working through affected staff education, answering questions objectively, ensuring processes are current and technology is up to date for the implementation of ICD-10-CM, you will be in a better position for the change, thus managing your two-headed dragon. Your bridge of preparedness will be stronger for this dynamic change.

Proactive Documentation Direction

Our focus is to provide specific information as it relates to describing the specific wound characteristics that need to be documented in detail in the medical record. It is the details that will direct either the provider or coder to select specific ICD-10-CM codes to accurately support services provided.

NOW: Currently, providers are paid for services using CPT codes with a limited focus on the diagnosis, which most likely is represented by an unspecified diagnostic ICD-9-CM code. Payers reimburse by service provided as long as the diagnostic code is reasonable or within the diagnosis coding category. Your data is being messaged now by third-party payers.

THEN: Starting October 1, 2015 under the Affordable Care Act (ACA) there is a transition that needs to be understood and engaged. Providers and payers will be held equally accountable for accurately providing, reporting, and reimbursing healthcare services based on clinical documentation. The ACA with HIPAA continues reforming ambulatory patient care to include provider risk sharing. This involves a transparency and accountability movement toward value-based purchasing (providers managing patient care) with a focus on improving health conditions. How you treat your patient’s medical condition(s) and results/outcomes will be more closely monitored by your payers.

NOTE: Payers can remove you from their contracts if the clinical information reported with ICD-10-CM codes and CPT codes do not align to support the level of acuity and intensity of services with complexity of care based on your data or the data of your peers for the same specialty.

Transition

Part 1: After the implementation of ICD-10, providers will no longer be paid just for the service they provided; there must be a clear reason (diagnosis) stating why the service was provided. Presently, part one of the equation looks like this: S=P

Service = Payment

(as long as there is a diagnosis code in the broad category to support why the service was performed)

Part 2: There must be a level of certainty with each diagnosis, which means specificity in the details of the clinical documentation. The specific diagnosis provides a more accurate selection of ICD-9-CM/ICD-10-CM codes, thus avoiding the selection of unspecified codes. We have always been paid for unspecified ICD-9-CM codes, so why is it necessary to change? On October 1, 2015 the equation will become: D + S = P

Diagnosis code(s) [Why] + Service [What was provided] = Payment

Data Collection after October 1, 2015

Tracking of Unspecified Code Usage

Why is it suddenly necessary to reduce the use of unspecified diagnosis codes that have commonly been used in the past? Starting on the ICD-10-CM go-live date, the Centers for Medicare & Medicaid Services (CMS) will be gathering data on the use of unspecified diagnosis codes. It is anticipated the data collection will be conducted for up to two years and may result in changes to Relative Value Unit calculations, which may affect your reimbursement of services.

Also, it is anticipated there will be a reduction in payments for a low level of acuity and low intensity of services with a low level of complexity of care related to the diagnosis and services provided. While there are times when an unspecified diagnosis code may be appropriate to report conditions of uncertainty, using unspecified diagnosis codes will also be viewed as a reflection of low acuity and low intensity of services with low complexity of care. The above chevron provides a visual effect.

Third-party payers have already begun to monitor providers’ use of unspecified codes. As they build their data banks, each provider’s frequency in reporting unspecified codes may cause additional claim and documentation scrutiny. Identifying unspecified code usage could have a negative outcome for providers - this includes audits of clinical documentation to determine if there is specific medical necessity information for the services provided.

Profiling will escalate with like peers comparing this data of unspecified codes routinely reported on claims. Continued routine use of unspecified codes could result in the provider being removed from certain health plans with a possible negative financial outcome on a provider’s business.

When to Use an Unspecified Code1

The use of unspecified codes is tracked in most data collection systems and identifies these codes by specialty, resulting in a list of the top ten reported unspecified codes. However, it is a known fact there are times when an unspecified code is acceptable or even necessary to report signs or symptoms and is the best choice to accurately reflect what is known about the patient’s medical condition at the time of the visit. Coding guidelines instruct coding to the level of certainty known for the visit; if a definitive diagnosis has not been established by the time the patient visit has concluded, it is then appropriate to select an unspecified code. Every code selected by a provider or coder must be supported by clinical documentation, as it would be inappropriate to select codes that are not supported by medical record documentation or that are medically unnecessary, such as for diagnostic testing.

Clinical Documentation Improvement

The following example uses the documentation of a common wound care patient diagnosis coded in ICD- 9-CM and then in ICD-10-CM. The reader should note the complexity of the information documented in the patient’s medical record; this is absolutely necessary to select the most accurate diagnosis code that reflects the level of acuity and intensity of services and complexity of care.

Original documentation: This is an established patient with a chronic ulceration of the calf (which calf). Ulcer measurements noted. Necrotic or devitalized tissue is estimated to be present in 75% of the ulcer bed with 25% beefy granulation in the wound bed. Debridement performed.

As you can see, the diagnosis codes have different descriptions based on the limited information in the provider’s documentation. ICD-9-CM coding definitions are less descriptive than the ICD-10-CM codes, and the detail within the new code descriptions will more accurately reflect the level of acuity thus supporting the level of intensity for services and complexity of care.

ICD-9-CM

ICD-10-CM

707.12 – Ulcer of calf

L97.209 – Non-pressure chronic ulcer of unspecified calf with unspecified severity

Since ulcers involve the integumentary system the level of documentation needs to include laterality (right, left or bilateral), ulcer characteristics, and level of severity. Ulcers are divided into two categories in ICD-10-CM: non-pressure chronic ulcer and pressure ulcer. Codes for non-pressure chronic ulcers of the lower limb include those documented as:
  • Chronic ulcer of skin
  • Non-healing ulcer of skin
  • Non-healing infected sinus of skin
  • Trophic ulcer
The following illustration provides reference information easily located in any vendor’s ICD-10-CM mappings manual. These manuals create a crosswalk between ICD-9-CM diagnostic codes and all of the relative ICD- 10-CM codes, which provides options for a diagnosis code to be selected based on the details within the provider’s documented information. Using this type of manual will allow you to review those codes frequently used by your specialty and begin to add the level of details in the documentation to avoid an unspecified code selection. This example of code selection in ICD-10-CM demonstrates the need to document certain elements as related to an ulcer of the calf to avoid an unspecified ulcer code selection.
  • State status: acute versus chronic (in this instance chronic will be used)
  • Type of ulcer: pressure versus non-pressure (in this instance non-pressure will be used)
  • Anatomical location: calf
  • Laterality: right, left, bilateral
  • The severity of ulcer must be documented
    • Limited to the breakdown of skin or
    • With fat layer exposed or
    • With necrosis of muscle or
    • With necrosis of bone or
    • With unspecified severity (this should never be selected for a diagnosis in a wound care department)
Improved documentation: This is an established patient with a chronic ulceration of the left lateral calf. This ulcer was caused by an injury during a vacation 3 months ago and would not heal while under treatment from the primary physician. The patient has been in treatment by this clinic for 3 weeks and the ulcer measurements have made only minimal improvement for healing from the last visit. Agree with clinical wound assessment measurements. Necrotic devitalized tissue of the subcutaneous tissue remains and is estimated to be present in 75% of the ulcer bed with 25% pinkish granulation in the wound bed. Debridement performed.
 
The following table lays out the amount of information required to code the diagnosis of ulcer of the calf in ICD-10- CM accurately portraying the patient’s medical condition which supports the level of acuity with the intensity of services and complexity of care. The color coding refers to where the Improved Documentation scenario supports the appropriate ICD-10-CM code.
 

ICD-9-CM

ICD-10-CM

707.12 – Ulcer of calf

L97.201 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin

L97.202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed

L97.203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

L97.204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone

L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity (Should not be selected as a diagnosis in a wound care department)

L97.211 Non-pressure chronic ulcer of Right calf limited to breakdown of skin

L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed

L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle

L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone

L97.219 Non-pressure chronic ulcer of right calf with unspecified severity (Should not be selected as a diagnosis in a wound care department)

L97.221 Non-pressure chronic ulcer of left calf with a limited breakdown of skin

L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed

L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle

L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone

L97.229 Non-pressure chronic ulcer of left calf with unspecified severity (Should not be selected as a diagnosis in a wound care department)

Based on the clinical documentation in this example, ICD-10-CM code L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed should be reported to accurately reflect the level of patient acuity with intensity of services and complexity of care.

Documenting Underlying Conditions

Any associated underlying medical condition such as atherosclerosis, gangrene, chronic venous hypertension, varicose ulcer, and post-phlebitic or post-thrombotic syndromes affecting the lower extremities requires additional details. In ICD-10-CM many code descriptions may now combine medical conditions. The following example shows the specific information needed to accurately identify an ICD-10-CM diagnosis code for atherosclerosis. This example of code selection in ICD-10-CM demonstrates the need to document additional specific elements as related to the underlying condition.

  • Anatomical location of ulcer—include the terms lateral, medial, inferior, superior as needed
    • Thigh
    • Calf
    • Ankle
    • Heel and mid-foot includes the plantar surface of the foot
    • Other part of foot includes toes
    • Other part of lower leg
    • Unspecified site (should not be selected as a diagnosis)
  • Laterality: right, left, bilateral or unspecified (should not be selected)
  • Atherosclerosis of native arteries of lower extremity or
    • Atherosclerosis of autologous vein bypass graft(s) of extremity or
    • Atherosclerosis of non-autologous biological bypass graft(s) or
    • Atherosclerosis of non-biological bypass graft(s) or
    • Atherosclerosis of other type of bypass graft(s)
    • Atherosclerosis of other type of bypass graft(s) of extremities with gangrene
  • An additional ICD-10-CM code is required to describe the severity of the ulcer tissue per coding guidelines which must be supported with documentation to include one of the below
    • Limited to breakdown of skin or
    • With fat layer exposed or
    • With necrosis of muscle or
    • With necrosis of bone or
    • With unspecified severity (should not be selected as a diagnosis)

Improved documentation with underlying condition: This is an established patient with a chronic ulceration of the left lateral calf due to atherosclerosis of autologous vein bypass (lower extremities) for over 1 year and would not heal while under treatment from several provider specialists, thus supporting the referral to the wound care department. The patient has been in treatment by this clinic for 3 weeks and the ulcer measurements have only made minimal improvement for healing from last visit. Agree with clinical wound assessment measurements. Necrotic devitalized tissue of the subcutaneous tissue remains and is estimated to be present in 85% of the ulcer bed with 15% some light pinkish granulation in the wound bed. Debridement performed.

ICD-9-CM

ICD-10-CM*

707.12 – Ulcer of calf

I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf

I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf

I70.332 Atherosclerosis of unspecified type of bypass graft(s)native arteries of right leg with ulceration of calf

I70.342 Atherosclerosis of unspecified type of bypass graft(s)native arteries of left leg with ulceration of calf

I70.432 Atherosclerosis of autologous vein bypass graft(s) type of right leg with ulceration of calf

I70.442 Atherosclerosis of autologous vein bypass graft(s) type of left leg with ulceration of calf

I70.532 Atherosclerosis of biological non- autologous vein bypass graft(s) type of right leg with ulceration of calf

I70.542 Atherosclerosis of biological non- autologous vein bypass graft(s) type of left leg with ulceration of calf

I70.632 Atherosclerosis of non-biological bypass graft(s) type of right leg with ulceration of calf

I70.642 Atherosclerosis of non-biological bypass graft(s) type of left leg with ulceration of calf

I70.732 Atherosclerosis of other type of bypass graft(s) of right leg with ulceration of calf

I70.742 Atherosclerosis of other type of bypass graft(s) of left leg with ulceration of calf

*Each of these codes requires an additional code to identify the severity of the ulcer)

These codes require an additional  ICD-10-CM  code to complete an accurate picture of the ulcer’s level of severity and intensity of service from the L97–L97.49 category of ICD-10-CM diagnostic codes. Without the L97 codes, the diagnosis code would not be complete, causing a possible claim denial or hold for further information. The necessary supplemental codes are noted below.

 

ICD-10-CM codes identifying ulcer severity

L97.201 Non-pressure chronic ulcer of unspecified calf limited to skin breakdown

L97.202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed

L97.203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

L97.204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone

L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity*

Laterality + Severity

Additional Detail for Right calf ulcer

L97.211 Non-pressure chronic ulcer of right calf limited to skin breakdown

L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed

L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle

L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone

L97.219 Non-pressure chronic ulcer of right calf with unspecified severity*

Laterality + Severity

Additional Detail for Left calf ulcer

L97.221 Non-pressure chronic ulcer of left calf limited to skin breakdown

L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed

L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle

L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone

L97.229 Non-pressure chronic ulcer of left calf with unspecified severity*

*Unspecified codes should not be selected in a wound care clinic

 

Based on the clinical documentation in this example, ICD-10-CM codes I70.442 Atherosclerosis of autologous vein bypass graft(s) type of left leg with ulceration of calf and L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed should be reported to accurately reflect the level of patient acuity with intensity of services and complexity of care.

Modifier 59 Morphing Into Subsets

Before closing, HCPCS modifier 59 has been used to tell the payer a service is separate and distinct from the reason for the encounter. As of August 15, 2014, CMS Transmittal 1422 has redefined the application of modifier 59 into four subsets to further define the meaning. CMS felt modifier 59 has been overused, abused, and incorrectly applied, therefore necessitating the change. Part of the issue with modifier 59 is the broadness of its definition to cover many different scenarios. CMS hopes that by redefining modifier 59 with these four subsets more precise coding options will be available to define specific encounter activity and thus reduce errors associated with modifier 59 overpayments, as well as provide a better understand- ing of when and why providers use this modifier.

How will this change affect your practice? Your two-headed dragon, documentation and compliance, continues to be affected by this change in the health- care business. CMS will continue to have the OIG (Office of Inspector General) review the use of modifier 59 over the next several years. Therefore, we need to stay abreast of it, as daunting as it sometimes seems. Within the Transmittal, directions were provided for Medicare Administrative Contracts to review data regarding the application of these modifiers on claims. The following is taken from Transmittal 1422 and defines the new HCPCS modifiers.

xE—Separate encounter, a service that is distinct because it occurred during a separate encounter xS—Separate structure, a service that is distinct because it was performed on a separate organ or structure

xP—Separate practitioner, a service that is distinct because it was performed by a different practitioner xU—Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.

 

Prior Authorization of Non-Emergent Hyperbaric Oxygen (HBO) Therapy

Note: physician documentation requirements and facility prior authorization of Medicare beneficiaries and specific billing processes.

On May 5, 2014, CMS issued a press release titled “Fact Sheets: Prior Authorization of Non- Emergent Hyperbaric Oxygen (HBO) Therapy.” This document appeared low on the radar but set the stage for the implementation of demonstration programs regarding prior authorization for non-emergent HBO in the states of Illinois, Michigan, and New Jersey. This is a test to help ensure HBO services are provided in compliance with Medicare coverage, documentation, coding, and payment rules prior to the anticipated services to be performed, specifically HBO treatments.
 
History for this Decision
CMS is concerned about patients receiving non-medically necessary non-emergent HBO therapy in the identified three states due to their high utilization of HBO therapy and improper payment rates for the services. This falls under the Social Security Act, Section 1115A, allowing that the Secretary has the authority to test innovative payment and service delivery processes to reduce program expenditures while preserving quality of care to beneficiaries/patients.
No new clinical documentation criteria will be required. The objective is to ensure the clinical documentation is sufficiently detailed to support the decision for the HBO treatment and the relevant coverage and coding requirements are met prior to performing HBO treatment and submitting a claim for reimbursement.
 
Prior Authorization Process
This process of prior authorization will allow relevant clinical documentation to be submitted for review prior to providing HBO services. CMS or its contractors (your Medicare Administrative Contractor) will review the request and provide a yes or no decision. Payment will be made as long as there is an affirmative prior authorization decision and all other requirements have been met. Without the affirmative prior authorization decision, the submitted claim will be denied.
 
It is recommended the reader obtain a copy of all related articles noted in the reference section of this article.
Planning ahead for beginning a patient’s HBO therapy will require understanding the decision timeline, which is divided based on whether the request is an initial or subsequent.
  • Initial request: this decision is to be postmarked within 10 business days (2 weeks)
  • Subsequent requests: this type of request will be processed within 20 business days (4 weeks)
  • Provisional affirmative: decision may affirm up to 40 HBO treatments in a year
Six Common Conditions Covered for HBO
 
The following six conditions are most commonly diagnosed in wound care settings and are arranged in order of frequency.
  • Diabetic wounds of the lower extremities in patients who meet the following three criteria
    • Patient has type I or Type II diabetes with a lower extremity wound that is due to diabetes
      • Coding: The physician must document there is a casual relationship between the wound and diabetes by using the term “due to”2
      • Without the casual relationship noted, the two conditions are coded separately3
    • Patient has a wound classified as a Wagner grade III or higher
    • Patient has failed an adequate course of wound therapy as defined in the NCD (reference noted below).
  • Chronic refractory osteomyelitis, unresponsive to conventional and surgical management
  • Osteoradionecrosis as an adjunct to conventional treatment
  • Soft tissue radionecrosis as an adjunct to conventional treatment
  • Preparation and preservation of compromised skin grafts (not for primary management of wounds)
  • Actinomycrosis, only as an adjunct to conventional therapy when the disease process if refractory to antibiotics and surgical treatment

“...in the December 10 presentation there was a change in the HBO HCPCS code to G0277 for per 30-minute intervals of treatment.”

What is the Criteria for Conventional Treatment?
 
For HBO therapy to be covered as an adjunctive therapy, certain minimum criteria must be clear and detailed in the clinical documentation as follows:
  • Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days or
  • There are no measurable signs of healing for at least 30 days of treatment with standard wound therapy
  • HBO must be used in addition to standard wound care
  • HBO therapy is covered as an adjunctive therapy only after there are no measurable signs of health
  • Wounds must be evaluated at least every 30 days during the HBO therapy program
  • Continuing HBO therapy is not covered if there is a lack of measurable signs of healing noted within any 30 day period of treatment.
It would be most prudent to review your understand- ing of what constitutes conventional treatment and the specific documentation required to meet the criteria.
 
Beginning Timeline Involves Two Dates
 
March 1, 2015 is when your Medicare Administrative Contractor for the three listed states will begin accepting prior authorization requests for one of the 6 conditions for HBO treatment to begin on or after April 13, 2015
  • All HBO treatments for one of the six conditions with a date of service on or after April 13, 2015 must have completed the prior authorization process or the claims will be stopped for prepayment review
  • Model data gathering will be for 3 years with annual updates of findings.
  • Anticipate further expansions involving other states with high volume of HBO therapy and high costs.
New HBO HCPCS Code Starting January 1, 2015
 
On November 4 and December 10, 2014, CMS conducted an Open Door Forum to inform the wound care industry of the change for prior authorization of HBO in the three states. CMS documented in the November 4 presentation that the HCPCS code C1300 would continue. However, in the December 10 presentation, there was a change in the HBO HCPCS code to G0277 for per 30-minute intervals of treatment. This code is listed in the most current HCPCS Level II manual for facility reporting of services. Validate your department Charge-master data and update any forms, paper or electronic, which may have the old C1300 HCPCS code.
 
Physician services are still reported with CPT code 99183. However, if the facility does not have prior authorization or has a non-affirmed prior authorization, the associated physician claims with the 99183 code will be subject to medical review related at this time to the three states listed.
 
Summary
 
With all the types of changes in front of healthcare providers for 2015, take a deep breath and exhale slowly, but with gusto, to calm down your two-headed dragon. Approach these changes pro-actively and incrementally: Gather your team, prioritize the issues that need to be addressed and resolved, designate and hold accountable those selected for specific tasks, and entrust your staff to use their knowledge and skill to complete each component in a timely and realistic manner. Working on the issues in small bits with a thorough understanding of the goal will ensure you will be ready to manage the two-headed dragon as you complete your readiness for the implementation of ICD-10-CM on October 1, 2015.

 

References
  1. CMS Medicare FFS Provider e-News May 16, 2013 refer to page 10 regarding the use of Unspecified codes. http:// www.cms.gov/Outreach-and-Education/Outreach/FF- SProvPartProg/Downloads/2013-05-16-Enews.pdf
  2. ICD-9-CM Coding Handbook with Answers published by the American Hospital Association, Chapter 11: Endocrine, Metabolic and Nutritional Diseases
  3. ICD-9-CM Coding Handbook with Answers published by the American Hospital Association, Chapter 11: Endocrine, Metabolic and Nutritional Diseases
  4. 2015 ICD-9-CM Expert for Hospitals, Volumes 1, 2, 3 published by Optum
  5. 2015 ICD-10-CM Expert for Hospitals: The Complete Official Draft Code Set published by Optum
  6. 2015 ICD-10-CM Mappings published by Optum
  7. 2015 Official ICD-9-CM Coding Guidelines for Coding and Reporting: Section 1, Subsection A, Subsection 5.b titled Unspecified codes
  8. 2012 Best Practice for ICD-10-CM Documentation and Compliance published by Contexo /Media
  9. 2015 Official ICD-10-CM Coding Guidelines for Coding and Reporting http://www.cms.gov/Medicare/Coding/ ICD10/Downloads/icd10cm-guidelines-2015.pdf
  10. CMS Medicare FFS Provider e-News May 16, 2013 refer to page 10 regarding the use of Unspecified codes. http:// www.cms.gov/Outreach-and-Education/Outreach/FF- SProvPartProg/Downloads/2013-05-16-Enews.pdf
  11. CMS ICD-10: It is closer than you think http://www.cms. gov/Medicare/Coding/ICD10/Downloads/CMSReleas- esICD-10-PCSFiles.pdf
  12. HcPro New codes replace modifier 59: http://www. hcpro.com/print/CCP-307987-5091/Note-from-the- instructor-New-Codes-to-Replace-Modifier-59New-Medi- cally-Unlikely-Edits-MUE-Guidance.html
  13. CMS Transmittal 1422 dated August 15, 2014 with Subject: Specific Modifiers for Distinct Procedural Services at http://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/Downloads/R1422OTN.pdf
  14. CMS Prior Authorization of Non-Emergent Hyperbaric Oxygen (HB) Therapy November 4, 2014 http://www. cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/ Prior-Authorization-Initiatives/Downloads/HBO_Prior- AuthSlides_ODF110414.pdf
  15. CMS Prior Authorization of Non-Emergent Hyperbaric Oxygen (HBO) Therapy December 10, 2014: http:// www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Prior-Authorization-Initiatives/Downloads/HBO_ PriorAuthSlides_ODF121014.pdf
  16. CMS Prior Authorization of Non-Emergent Hyperbaric Oxygen (HBO) Therapy February 3, 2015 Open Forum Slide Deck http://www.cms.gov/Research-Statistics- Data-and-Systems/Monitoring-Programs/Medicare- FFS-Compliance-Programs/Prior-Authorization-Initiatives/Downloads/HBO_PriorAuthSlides_ODF020314. pdf
  17. CMS Frequently Asked Questions on the New Prior Authorization Demonstration Projects Non-Emergent Hyperbaric Oxygen Therapy: http://www.cms.gov/ Research-Statistics-Data-and-Systems/Monitoring- Programs/Medicare-FFS-Compliance-Programs/Prior- Authorization-Initiatives/Downloads/HyperbaricOxygen- PriorAuthorization_ExternalFAQ.pdf
  18. CMS Fact Sheets Prior Authorization Process for Non- Emergent Hyperbaric Oxygen Therapy http://www. cms.gov/Newsroom/MediaReleaseDatabase/Fact- sheets/2014-Fact-sheets-items/2014-05-22-2.html
  19. CMS National Coverage Determination for HBO Therapy: http://www.cms.gov/medicare-coverage-database/ details/ncd-details.aspx?NCDId=12&ncdver=3&bc=BA AAgAAAAAAA&
COMPLIANCETM is trademarked by Gretchen Dixon through Best Publishing Company
 

About the Author

Gretchen-Dixon
Gretchen Dixon is the owner of Professional Compliance Strategies LLC and consults on outpatient departments and physician services. She provides revenue cycle compliance reviews of services with the focus on wound care department operations for over 9 years. She holds several credentials: MBA in Healthcare Management, Registered Nurse with practicing licenses in NY and a multi-state license from Virginia, AHIMA Certified Coding Specialist (CCS), AAPC Certified Professional Compliance Officer (CPCO), and is an AHIMA Approved ICD-10-CM/ PCS Trainer/Ambassador. Being a longtime internal healthcare compliance auditor, she identifies issues through audits of D, C, Bs (documentation, coding & billing) of provided services. The outcomes of each audit determines the topics of education to be provided to staff and physicians as she believes education is the KEY to having accurate, complete and consistent documentation for accurate reimbursement of billed services. If you are interested in the services offered, contact her at gm- This email address is being protected from spambots. You need JavaScript enabled to view it. or 615.210.7476.
 

 

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