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Updated 2017 ICD-10-CM guidelines come ‘with’ controversial changes

Updated 2017 ICD-10-CM guidelines come ‘with’ controversial changes

by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS


Just like the lyrics to the popular Gap Band song say, "You dropped a bomb on me… I won’t forget it," there are definitely some changes in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting that some of us may wish the Cooperating Parties will forget were ever mentioned.

Generally, changes to the guidelines are minor and rarely cause the chaos and confusion that will certainly ensue with the most recent release, effective October 1. This release includes some contradictory guidance and downright concerning statements that appear as if no one really thought through the repercussions. These revisions will certainly have an impact not only on code assignment, but also specifically on reimbursement.


The guidelines state:

The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.


I consider this paragraph the most controversial addition to the guidelines. We’ll look at the impact the guideline has on previous examples relating to conditions such as diabetes mellitus, hypertensive heart disease, and some other conditions.

The guidance most commonly discussed is that for "diabetes with," which was stated in the AHA’s Coding Clinic for ICD-10-CM/PCS, First Quarter 2016, and reconfirmed in the following quarter. To summarize, the AHA guidance stated:

The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system and ANY condition listed under the term "with" in the Alphabetic Index is intended to be interpreted as a related condition/manifestation.


It appears that someone has never looked in the actual ICD-10-CM index file, because all conditions related to diabetes mellitus are indented under the word "with," not just isolated ones as in the ICD-9-CM manual.

Here is the comparison (from the ICD-9-CM index):

Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0

Compare to this excerpt from the ICD-10-CM Alphabetic Index:

The most surprising aspect to me in the repeated guidance is the contradiction to not assume a relationship between osteomyelitis and diabetes mellitus, which Coding Clinic originally stated in Fourth Quarter 2013 and reiterated in First Quarter 2016, writing:

ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.


Coders understood back in 2013 to not assume relationships between diabetes and other conditions that coexist in a diabetic patient. But this recent guidance creates more questions than answers. This very specific guidance about osteomyelitis leads me to imagine the scenario of a patient who has a relationship created between osteomyelitis and diabetes mellitus by a provider documenting "osteomyelitis due to diabetes mellitus." What codes would be reported?

The correct answer would be to assign the code for other specified complication (e.g., E11.69) since there is no entry specifically for osteomyelitis under diabetes mellitus. It would be classified to the "other" category per the ICD-10-CM conventions. If we examine this a bit closer, E11.69 is listed under the word "with" in the Alphabetic Index.

So, is it assumed or not? The guidance and guidelines directly contradict each other.

Some have argued that the ICD-9-CM index included a specific entry for diabetes with osteomyelitis, and I agree that the word "osteomyelitis" is there in black and white, but take a look at the code title: 250.8 (other specified manifestation of diabetes mellitus). There wasn’t a specific code in ICD-9-CM that said "diabetes with osteomyelitis," just like there isn’t in ICD-10-CM.

Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0

I suggest if the Cooperating Parties truly plan on keeping osteomyelitis separate, there should be a separate entry in the Alphabetic Index where it is not at the second indentation level under the word "with," but is under diabetes as a main term with a singular indentation.

The "with" guidance extends much further than I think the Cooperating Parties have considered. For risk-adjusted plans, the assumption of linking diabetes and other related conditions (acute and/or chronic) without necessitating providers document it will have a direct impact on a patient’s overall risk score.

The risk score uses many factors, but chronic conditions like diabetes mellitus are a key component in determining how much CMS should pay an insurance plan for care for Medicare beneficiaries covered under plans like Medicare Advantage (i.e., Part C). Being able to assume a relationship is a major change and will ultimately have a big impact on spending for any risk-adjusted plan, considering diabetes is such a common condition.

The reason this hasn’t really been considered an issue yet is that Medicare Advantage data is compiled based on the previous year’s diagnosis codes to prospectively estimate spending in the upcoming year.

Therefore, CMS is currently using ICD-9-CM data for encounters through September 30, 2015. Hopefully, this new guidance valid for encounters as of January 1, 2016, will be considered a factor, because patients with diabetic complications are certain to increase.

If the word "with" couldn’t get any more controversial, it ventured out of the endocrine system to the very "heart" of every coder’s cardinal rule. We learned, as fledgling coders, to never assume heart disease (like heart failure) is directly related to hypertension unless the provider documents the two conditions as related, like hypertensive heart failure or heart failure due to hypertension.

Well, no more, my friends?this is the dawn of a new age of coding. We can assume away, not only for hypertension and (chronic) kidney involvement, but also for hypertension and heart involvement because they are both indented under the word "with" in the Alphabetic Index.

The revised guideline states (bolding is mine)’:

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.


Please notice that the past statement does identify that if the provider specifically states another cause, the conditions should be coded as unrelated.

The larger issue I have with assuming anything under "with" is seen in the ICD-10-CM Alphabetic Index and is yet another direct contradiction to the guidelines. If the guidance regarding "with" is truly universal within the Alphabetic Index, then it implies a relationship for diseases extending beyond just diabetes mellitus and hypertensive heart disease. For example, it seems that coders could begin to assume, based on the guidelines, that patients who have sepsis with a coexistence of organ dysfunction have severe sepsis, even though the guidelines specifically state "an acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code."

Who knew that a little word like "with" could cause so many issues?


Excludes1 notes

The guidelines also include an update on reporting Excludes1 conditions. The updated guidelines state:

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.


The Excludes1 conventions clarify what was addressed in the interim guidance provided in October 2015 and in the AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2015, to address situations where Excludes1 notes should be considered Excludes2 or had other exceptions. Category I63 (cerebral infarction) excludes subcategory I69.3- (sequela of cerebral infarction). This guidance directly contradicted the guidelines for Chapter 9, which state: "Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease."

For 2017, subcategory I69.3- has been revised to be included in an Excludes2 note. Exceptions have been added to the guidelines when the exclusion was for a category that may include a number of different conditions, like the "other" category. Some of those inclusive conditions should never be coded with the diagnosis the Excludes1 note appears under, others may be completely unrelated.

This opens the door for a third-party auditor to debate the application of the Excludes1 note if coding the two conditions separately creates a financial impact.


Edito’?s note

McCall is the director of HIM and coding for HCPro, a division of BLR, in Middleton, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see – Briefings on APCs

Hormone Pellet Insertion

My Doctors are wanting to allow an RN we have on staff to do pellet insertions which is in the scope of practice for TN. My question is, what are the billing ramifications of this? Would this be billed in a different way than if it were done by the Doctor? Thanks in advance for any help!

Medical Billing and Coding Forum

Is the 2-midnight rule going away and when will short-stay audits resume?

Is the 2-midnight rule going away and when will short-stay audits resume?

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify updates to CMS’ 2-midnight rule and best practices for compliance.


Every couple months, it seems questions arise about the 2-midnight rule and there are rumors that it may be going away. Below are some questions with answers from our expert Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago, to clarify where things stand today with regard to the 2-midnight rule.


Q: I heard the 2-midnight rule is now gone based on changes to Medicare payment rates under the 2017 inpatient prospective payment system (IPPS) final rule. Is this true, and if not, what changed?


A: No, this is not the case. The 2-midnight rule is still alive and kicking. What the FY 2017 IPPS final rule did is finalize two adjustments in addition to updating the annual rate for inpatient hospital payments.

"First, CMS is finalizing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $ 11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008," states the CMS Fact Sheet. "For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments. For FY 2017, CMS calculates that $ 5.05 billion of the $ 11 billion requirement remains to be addressed. Therefore, CMS is finalizing a -1.5 percent adjustment to complete the statutorily specified recoupment."

And the second part of the change, which seems to be causing the confusion, is CMS took action on a -0.2 percent adjustment it implemented in the FY 2014 IPPS final rule.

This adjustment was initially made to account for an estimated increase in Medicare spending due to the 2-midnight policy. "Specifically, in the FY 2014 IPPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2% to the payment rates," states the fact sheet.

While CMS thought this adjustment was reasonable at the time, a recent review led CMS to permanently remove this adjustment, "and its effects for FYs 2014, 2015, and 2016 by adjusting the 2017 payment rates. This will increase FY 2017 payments by approximately 0.8%," stated CMS.

Hirsch says this move is "purely about money." "They are leaving the 2-midnight rule itself completely intact," he says.

The bottom line: Pay attention to 2-midnight compliance and ensure your organization has good systems in place to support it.


Q: When are Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) short-stay reviews going to resume?


A: Back in May, CMS put a hold on short-stay inpatient audits related to the 2-midnight rule. That hold was lifted effective September 12, 2016, according to a FAQ published by CMS (

According to the FAQ, CMS decided to lift this temporary suspension for five reasons, which are as follows:

  1. BFCC-QIOs were successfully retrained on 2-midnight rule
  2. BFCC-QIOs finished a re-review of claims that were formally denied
  3. CMS "examined and validated the BFCC-QIOs peer review activities related to short-stay reviews"
  4. BFCC-QIOs reached out to providers on claims that were affected by the temporary suspension
  5. BFCC-QIOs started provider outreach and education on the 2-midnight rule

It appears that based on the five points, the temporary audit suspension accomplished its goal of helping BFCC-QIOs sort out the challenges they faced during the initial round of audits.

Prior to the suspension, hospitals complained about inconsistencies in the review process, which triggered the suspension. The BFCC-QIO audits began in October 2015, and hospitals reported a number of surprises including:

  • Auditors requested records as far back as May 2015 when many believed the audits would only look at records from 2015 forward
  • BFCC-QIOs missed deadlines, and provided audit results late
  • Failure by BFCC-QIOs to schedule timely education for providers


These problems made it difficult for hospitals to hit filing deadlines, and they were consequently reporting problems because they missed the window to appeal denied claims. Hospitals also didn’t have a chance to get education to understand what they were doing wrong to fix the problem.

There were also rumored problems related to benchmark admissions. Hospitals reported that BFCC-QIOs were routinely and in some cases inappropriately denying inpatient admissions when the patient spent one night as an outpatient in the emergency department or in observation services before he or she was admitted?even when the patient spent a second night in the hospital as an inpatient.

To prevent future problems, CMS said in its FAQ that it will continue to provide oversight for BFCC-QIO efforts by:

  • Reviewing a sample of completed claim reviews each month
  • Monitoring provider education calls
  • Responding to individual provider inquiries and concern. Providers may send questions to the CMS Open Door Forum Mailbox at [email protected]


CMS also said that BFCC-QIOs will continue tofollow the guidance called, "Reviewing Short-Stay Hospital Claims for Patient Status." To see a copy ofthe guidance, go to data-and-systems/monitoring-programs/medicare-ffs- compliance-programs/medical-review/inpatienthospitalreviews.html.   

The BFCC-QIOs will also be charged with providing provider education going forward. "The BFCC-QIOs were directed to use comprehensive outreach and communication approaches (i.e., website, newsletter, one-on-one training, and town hall type events) to continue to educate providers on when payment under Medicare Part A is appropriate under the 2-midnight policy," states the FAQ. "BFCC-QIOs are required to educate providers using quality improvement core principles that facilitate continuous learning and promote greater provider understanding of the appropriate application of the 2-midnight policy in accordance with the revisions in the CY 2016 OPPS Final Rule (CMS-1633-FC):"

Now that audits have resumed, organizations should maintain a focus on 2-midnight compliance. Below are some tips Hirsch has recommended in the past, including:

  • Reviewing every short-stay admission?those between zero and one day?prior to billing.
  • Ensuring that every patient’s status is appropriate up front. Reviewing the chart of every patient that goes upstairs.
  • Using the physician advisor to check compliance on cases that are murky to ensure that they meet one of the exceptions under the 2-midnight rule. Changing cases that don’t meet an exception using condition code 44. If the problem isn’t discovered until after discharge, self-deny and rebill the claim.
  • Ensuring that the case managers and the physicians are up to date about any potential changes to the 2-midnight rule and how to comply. – Case Management Monthly

Report to Congress Recommends MIPS Overhaul

The Medicare Payment Advisory Commission’s (MedPAC) June Report to the Congress addresses (among other things) issues it sees with the Merit-based Incentive Payment System (MIPS) — one of two paths in the Centers for Medicare & Medicaid Services’ (CMS) Quality Payment Program, and a provision of the Medicare Access and CHIP Reauthorization Act (MACRA). “As […]
AAPC Knowledge Center

Medicare myths

Medicare myths

Editor’s note: This article is excerpted from the book Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement, by Elizabeth Malzahn-McLaren.


Throughout my years of educating providers on the inner workings of the Medicare program, whether it was a boot camp class for newcomers or a refresher course for those in the business for years, there are always instances where I am able to "myth-bust" Medicare. With any program, especially one that has been in existence for 60 years, there are bound to be some myths out there about how the program works.


Myth #1: A psychiatric resident will not qualify for Medicare Part A skilled services.

Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify coming straight from the hospital, at least for a short period of time.

First you need to determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.

The resident may need to have his or her medications adjusted; there also can be potential for an adverse drug reaction if medications were changed. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may have therapy orders upon discharge from the hospital. Other areas to review include hearing, speech, and vision (Section B of the Minimum Data Set [MDS]); ­cognitive patterns (Section C); mood (Section D); behavior (Section E); functional status (Section G); and medications (Section N) … just to name a few!


Myth #2: You can cover a resident for the first five days to observe and assess his or her condition.

The Centers for Medicare & Medicaid Services (CMS) provides no time frame of minimum or maximum time covered; however, there is the ability to use administrative presumption of coverage. Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD), if no skilled need is identified on the initial admission/readmission MDS. The regulation indicates that a resident can be skilled "until the condition of the patient is stabilized." Typically, skilled care for observation and assessment lasts for a few weeks or less.


Myth #3: A new diagnosis triggers a new benefit period.

This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service, and it can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under SNF Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria:

  • Determining when skilled services ended
  • Counting days

There is no magic formula to earning a new benefit period. Let us review an example to illustrate how the calculation should work.

A resident completed a 100-day Medicare benefit period on December 31. The resident remained skilled under Medicare Part B, receiving therapy services until January 31. Beginning February 1, the resident was no longer at a skilled level of care. Based on the counting of 60 days, the resident would be eligible for a new benefit period on April 2 (assuming 28 days in February). However, we need to review each day between February 1 and April 2 to make sure none of the following occurred:

  • Did the resident receive any services that would qualify the resident under a Medicare skilled level of care while in the SNF during that time period? For example, was the resident picked back up under a Medicare Part B plan of care that met the skilled level of care requirements?
  • Did the resident have any inpatient admissions to the hospital during that time period?


If the answer to either of these questions is yes, then the resident did not earn a new 100-day benefit period based on either the provision of skilled services or failure to meet the 60-day period of wellness requirement.

There is one small wrinkle in this calculation of benefit periods. If a resident leaves the SNF and continues to receive a skilled service while residing at home, for example, this would not impact the benefit period. When reviewing skilled services received, Medicare is only looking at skilled services received while in a SNF or as an inpatient of a hospital. Skilled services rendered to a beneficiary in the home setting do not impact the Medicare Part A SNF benefit period calculation.


Myth #4: All residents who are receiving tube feeding are always skilled and always will be skilled.

This statement is both true and false. The caveat lies with the level of calories and fluid the resident is taking in through the tube. Residents who meet the 26%?50% of calories and 501 cc of fluid per day via the feeding tube, or residents who receive 51% or more of calories via the feeding tube will automatically qualify for ­Medicare Part A benefits in a SNF. Additionally, they are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS. These levels will also continue that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.

Residents who meet the caloric and fluid requirements of 26%?50% of caloric intake and 501 cc of fluid daily via the tube or residents who receive 51% of more of caloric intake from the tube will remain at a skilled level of care for a full 100 days, as long as they remain at those levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she:

  • Drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF or inpatient hospital stay
  • Remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days


Myth #5: As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, we can pick the resident back up on Medicare Part A.

Although this is partly true, the most important criteria to using the 30-day window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.


Myth #6: A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.

Often, a resident is unable to leave the SNF due to the complexity of the services being rendered in the SNF. That said, a couple of items need to be reviewed before determining if an overnight leave of absence (LOA) is feasible:

  • Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF?
  • Are the absences infrequent in nature and not for prolonged periods of time?


Obviously, the first question is important to make sure the resident can be properly cared for during the LOA. It is always necessary to consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible. The second question relates more to being sure that the practical matter criteria also discussed in Chapter 3 is being met. If a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, for example, it is doubtful that the practical matter criterion is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02):

As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (see §30.7).


That said, although a resident may safely be able to go on LOAs frequently or for prolonged periods of time, the question becomes: Is the SNF the most appropriate place for that resident to receive those skilled services?


Myth #7: You never have to issue more than one notice regarding a Medicare stay at the same time.

If only that were a true statement. There are so many notices that it can be confusing trying to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Chapter 30, Section 261 of the Medicare Claims Processing Manual:

Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs. Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per §1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.


This same manual section notes the following example of when both notices would be issued:

A beneficiary’s Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverage. A SNFABN must also be delivered before custodial care begins.


Myth #8: There is never an instance where no notice is required at the end of Medicare coverage.

This is untrue! When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and have the ability to appeal decisions being made by providers in relation to their Medicare coverage; the end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. That said, it is recommended to communicate the end of the 100-day benefit period to the beneficiary, but no formal notice or form is required. – Billing Alert for Long-Term Care

SNF therapy contracts: Your risks and what you need to know Q&A

SNF therapy contracts: Your risks and what you need to know Q&A

Editor’s note: The following Q&A was written by Reginald Hislop III.


Q: When we receive proposals from various therapy companies, they all represented that they would increase our Part A and Part B billings. Should this somehow be incorporated into the ­contract?


A: Yes. Absolutely. If they’re willing to say that to you and they tell you, "That’s the reason why you’re going to go with us is because we’re going to do this," I am going to hold them accountable for that, and I first want to know how you determine that and how are you going to do that because I’m going to tell them right there before we even get to a contract, I’m going to say that they need to fundamentally prove it. How do you know it, how’s it going to happen, and be prepared because yeah, you’re going to put in the contract, you’re going to represent it, it’s going to be legal and you’re going to do it over what period of time? I’m then going to hold them accountable for it.

Otherwise, it becomes a common game of therapy contractors: "We’re going to make your world so much better than the last group that was in here." I’ve never seen a contractor come in and say, "We looked at your last experience with your last therapy contractor and the amount of stuff that they were doing, and by the way, we got to tell you, it really makes us nervous, and fundamentally if you go with us, we’re going to shrink your revenue by 15% because we think there’s a whole bunch of erroneous and falsely billed claims." I’ve never seen that happen. Everybody comes in and says, "Yes, we can improve your performance over this group, and we’re going to do it by a pretty impressive margin, and your revenue is going to go up, your claims are going to go up." I want to know how they’re going to do that, I want it in the contract, and I want full transparency. I want to know over what time period, because without that, they haven’t actually validated they will be able to do that. That’s a standard pitch, and they have never yet been expected in many cases to be accountable for those kind of numbers. It’s just a sales pitch, but, if they’re going to say it, I want it in the contract.


Q: Would the indemnification clause you mentioned, indemnification not just for the therapy component but the whole amount?how can the therapy company indemnify money they did not receive?


A: How can they indemnify money they did not receive? We’re not talking about necessarily indemnification for money they received. We’re talking about indemnification for services that they provided as part of the representation that all of our services that we provide are going to be compliant and in concert with the law. Since the SNF is responsible for that, my responsibility then is to negotiate with that company and say, "By the way, if in fact we’re involved in this work and you’re going to be part of this process and you’re going to have input in terms of what we RUG, what we bill, part of our triple check and all the rest of that other kind of stuff, there is dollars on the table, and anything that you did that was illegal, unethical, or improper that caused us to lose revenue as a result of your actions and your documentation, all those other kinds of things because you’re going to represent to me that you’re going to do this, you’re going to properly manage and supervise your employees and all those other kinds of things, that if in fact you didn’t do that, you’re going to be responsible not just for what we paid you but also for what your bad acts caused this facility." Yes, I can indemnify them for that because they are part and parcel to that. They’re going to represent to me that they’re going to do this the right way, and if they don’t, then they’re going to have shared risk for anything that occurs that they were responsible for or could be tied to them that cost my facility money or my organization money.


Q: How do we hold the therapy provider accountable for an 80% productivity level?


A: You actually monitor their productivity levels. Their treatment records should be open. Their minutes should be open. I should be able to see when they were on-site, what their time was spent on this site, what I was billed for because I’m being billed for their time. And I should be able to go to treatment logs and treatment records and look at what their billing time was and their documentation time was, and I can quickly do a simple calculation that says if I had a physical therapist here for eight hours and she was here for four days a week or five days a week, I ought to be able to convert that based on treatment records and treatment logs to what her productivity percentage was, what her care percentage time was, and it better not be more than 80%.


Q: Our present contract doesn’t include much of anything you mentioned. How do we change it or get the therapy provider to go along with your recommendation?


A: There are two ways to do that. One is basically to tell them you attended this seminar and their contract stinks and you want to renegotiate it. I don’t know what your out clauses look like in your contracts. Typically there will be some kind of out clause that will allow you some leverage. If not, when your contract comes up for renewal, make them well aware that these are all going to be key components of your RFP process. You’re going to put it out there, you’re going to bid them unless they’re going to come to the table and do it, they’re not going to have this contract anymore, and generally I have suggested providers to tell them this in advance, good advance. Tell them, "[We] might be six months away from when our contract renews, but here’s a list of the things that we’re going to require of you going forward. So, if you want to keep this contract, we can talk about this now or you can basically be assured that if you’re not going to do this now or have some conversation with us now, chances are relatively poor that you will retain this contract." I haven’t seen a contractor yet that won’t under certain circumstances if you raise most of these issues, at least be willing to start conversations with them about them.


Q: What tools do you suggest in guiding SNF therapists into making appropriate decisions regarding choosing a RUG?

A: Again, the best process for this is your triple check. There are some very good software programs out there, and I’m not going to try to pitch too many companies, but most software programs, AOD does a good job. Rehab Optima also does a good job. Develop a good triple-check process, have good education, make sure your MDS coordinator is certified, RAC certified as part of this process. The RAC certification and staying current on the certification is amajor help in terms of appropriate RUGs based on the documentation. Use your triple check, have everybody together in terms of being able to access and identify your MDSs, what your sections mean, what your documentation is to support your RUG categories. It’s not that difficult, but it does require some work, and it’s really critical that you have good software and a good MDS coordinator who’s RAC certified.

If you don’t have a good MDS coordinator or a coordinator that is RAC certified, rent one. There are services out there that you can go to that will in fact help you through that process on a monthly basis. It will cost you a little money up front, and in the interim get somebody on your staff RAC certified.


Q: Can you explain the in-house hybrid model in greater detail?

A: Sure. The in-house hybrid model works exactly like this: For all intents and purposes we bifurcate the issues. We say, "All right, what we need is we need staff therapists or we need access to staff therapists, and we can do that, but we don’t know how to do that as a facility." We’re not sure where to go, we’re not sure how to recruit, we don’t know how much they should be paid, job descriptions, all the rest of that other kind of stuff, and the one thing that we definitely don’t have expertise in maybe is managing a therapy department, is managing a therapy company. And we’ve heard horror stories about how hard it is to find good rehab directors, how much you pay, you know, all that kind of stuff.

What we do is essentially bifurcate the issues. We say, "All right, here’s the deal. Let’s go get a company who isn’t going to provide the therapy and has no interest in doing that or billing us for that, but is going to help us set up our program." So we’re going to go to one of the qualified companies that are out there that do this, and what they’re going to do is they’re going to come in, they’re going to do an assessment for us, which should be very low cost, to look at our operations, look at what we’re billing, look at our Medicare utilization, and give us a proposal that basically says, "Hey, here is what our department from our perspective would look like. Here’s how many PT hours you need, OT hours, speech therapy, staffing requirements, you know, rates of pay and all that other kind of stuff. We’re going to help you do that. We’re going to put this together and give you a pro forma, show you how this pays for itself and all this other kind of stuff.

"In the meantime, what we’re going to do as well is if you want to proceed down this path, we’re going to do that for you in concert with you. We will recruit, we will hire, we’ll give you job descriptions which we have. We have policies, we have procedures, we can give you a turn-key therapy company, and what we will do is we will be your therapy director fundamentally. We’ll be the folks who manage your therapists. We’ll watch those productivities. We’ll do the education. We’ll do all those kinds of things for you and in partnership with you, and the therapists that will be on site will be 100% your skilled nursing facility employees. They are your employees. You pay them. They’re your benefits. They’re subject to all your rules and regulations and all that kind of stuff, and we’ll just help you manage them. We’ll provide better oversight, and we’ll provide the infrastructure that’s necessary for a therapy department and a therapy program including ongoing education and RUG support and QA and all that kind of stuff. And we do that for a flat fee each month or a percentage of your ultimate therapy department revenue, etc." – Billing Alert for Long-Term Care

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Bolster billing compliance: Implement a Medicare Part A triple-check process

Bolster billing compliance: Implement a Medicare Part A triple-check process

Medicare billing is a domain rife with payer offshoots and evolving regulations that can be difficult to navigate without a strategy to weather claim scrutiny and withstand the gaze of CMS’ various auditing contractors.

Enter the triple-check process, a time-tested internal auditing strategy used by proactive long-term care providers to facilitate billing accuracy and compliance the first time a UB-04 claim form is submitted. As its name suggests, triple check is a layered verification process that involves staff members from billing, nursing, and therapy departments?the three core disciplines required to submit a clean claim. But this sturdy foundation is also pliable, allowing a facility to easily adapt the procedure to the various types of claims it files.

Read on for an expert iteration of the triple-check process, which is modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC. This specific triple-check procedure is designed to mobilize key staff to ensure accuracy and timely submission of Part A claims.



Each month, the SNF will collect all Medicare Part A billing information ready for submission and enlist the following individuals to carry out their designated roles in verifying the accuracy of these items: administrator, director of nursing, MDS coordinator, facility rehab director or designee, business office manager, medical records personnel, and central supply staff.

The following is a breakdown of each of these staff members’ responsibilities in the triple-check process:

Business office manager and medical records personnel

  • Verify that the qualifying stay information recorded on the UB-04 aligns with that on the medical records face sheet.


Business office manager

  • Verify that each resident has benefit days available in the HIPAA Eligibility Transaction System.
  • Verify the admit date on the UB-04 aligns with the date in the manual census log.
  • Verify covered service dates listed on the UB-04 align with those in the Medicare and manual census logs.
  • Verify that a resident’s financial file contains a signed and completed Medicare Secondary Payer form whenever applicable.


Business office manager and MDS coordinator

  • Verify that ADLs are correct and are supported by documentation. Confirm that staff have coded all other contributory items (e.g., mood, IVs).
  • Verify that ARDs on each MDS align with the occurrence dates found at form locators (FL) 31?34 on the UB-04.
  • Verify that the RUG level listed on each MDS aligns with that found at FL 44 on the UB-04.
  • Verify that the assessment type for each MDS aligns with the modifier found at FL 44 on the UB-04.
  • Verify that the number of accommodation units listed on the UB-04 aligns with the assessment type for each MDS. Verify that the total number of accommodation units aligns with corresponding covered service dates.


Facility rehab director, MDS coordinator, and business office manager

  • Verify that physical therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes documented in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that each principal diagnosis is accurate, that all secondary diagnoses support skilled care, and that every ICD-9 code corresponds to an appropriate diagnosis.
  • Verify that occupational therapy minutes recorded on the daily treatment grid align with those in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that speech therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.


DON and medical records personnel

  • Verify each resident’s need for Medicare skilled intervention by reviewing supporting clinical documentation that corresponds with the dates of service listed in the manual census log.
  • Verify that each (re)certification form has been completed and signed by the appropriate physician.
  • Verify that each physician order has been obtained and implemented.
  • Verify that each chart reflects appropriate charting guidelines. Confirm that charting has been completed at least once in every 24-hour period, relates to skilled service provided, and supports therapy.


Facility rehab director

  • Verify that physician orders include rehabilitation.
  • Verify that each evaluation notes the prior level of function.
  • Verify that clinical documentation contains a progress note establishing the need for continued skilled intervention.



  • Chair the triple-check meeting (detailed below), and ensure that the entire process is completed by appropriate staff each month before Medicare claims are submitted. Participation in the triple check will allow the administrator to monitor the effectiveness of key operational processes carried out by the facility’s ­interdisciplinary team (IDT) on an ongoing basis.

Triple-check meeting and audit tool

Each of the SNF’s triple-check participants should complete their respective duties prior to the Medicare triple-check meeting, which will be held monthly before the SNF bills for a given batch of services. In other words, the meeting is not an occasion for staff to complete their initial claim component(s). Instead, it’s a chance for IDT members to cross-check the work of their colleagues by verifying the accuracy of claim items that others have completed, thereby ensuring each element has been studied by multiple sets of eyes.

The triple-check meeting will also serve as the platform for the SNF’s business office manager to document the completion of each integral item on a billing claim using the triple-check audit tool, an internal checklist-type document that will be included in every month-end closing report.

Using this audit tool, the manager will denote items verified as correct during the triple-check meeting with an "X." He or she will mark items identified as incorrect with an "O" and, in the remarks section of the document, record the steps the team will take to obtain the correct information. Items initially found to be incorrect but rectified during the meeting should still be marked with an "O" to better track any practice patterns that could lead to billing slipups and inform future training activities.

The business office manager will call for any claim found to have errors during the triple-check meeting to be put on hold until it is amended. Once staff have made necessary revisions, the manager will indicate these correction(s) and the corresponding date(s) in the remarks section of the audit tool. He or she will then contact a corporate entity to review the changes and ultimately grant approval to submit the claim. – Billing Alert for Long-Term Care

Past is present: ICD-10-CM clears some ICD-9-CM issues while others persist

By Robert S. Gold, MD
I have been musing recently about things I’ve written for this journal over the past years. Hard to believe I’ve been doing monthly educational articles regarding the clinical aspects of coding since about 2002.
I know that a lot of my pieces had relatively universal appeal. Some had been considered outrageous and seemingly destructive, depending on the view of the reader. But time has proven they were right then, and they are still right in ICD-10. Return with us now to those thrilling days of yesteryear–the Lone Ranger rides again. 
Back in 2002, I objected that the codes for "sepsis" and "septicemia" were the same codes–and they were all described as "septicemia."
In the article, I emphasized that sepsis was a condition that resulted when the body suffered the consequences of a localized infection mediated by chemicals that were released into the bloodstream, but that the infection was a local event. I pointed out that septicemia was an infection of the bloodstream itself–and that both could exist simultaneously, but they were different animals and needed different diagnosis codes to describe them.
Then, in 2003, it was finally published, after adoption of the 995.9x series of codes, that septicemia and sepsis were different (AHA’s Coding Clinic, Fourth Quarter 2003, pp. 79-81) and that the new codes would identify that distinction.
Okay, that being somewhat resolved, I pursued the issue that SIRS plus infection is NOT sepsis in 2009. Why? Because the combination of codes for SIRS plus infection, without or with organ failure, led to a massive proliferation of coding "sepsis" cases when there was no sepsis–and often when there was no SIRS. Nothing changed in the rules or definitions.
I brought along some of the world’s most renowned specialists in infectious disease and critical care who had supported for years (since 2001, actually) that SIRS plus infection is NOT pathognomonic of sepsis. Nothing happened.
Finally, with the coming of ICD-10-CM, the equivalent of 995.91 (SIRS plus infection without organ failure) disappeared. "Sepsis" is now "sepsis." You need the word "sepsis" to code "sepsis." All is right with the world, right?
Nope. Not a chance. Now, instead of all of the codes being "septicemia" codes, they are all "sepsis" codes–and the only "septicemia" code we have is for plague. (There’s actually one for meningococcemia, which is infection of the bloodstream with the meningococcal organism.)
So we have no other codes for septicemia when all of the codes had been for reporting septicemia up until now. If you look up "septicemia," you get A41.9 (sepsis, unspecified organism), equivalent to the 038.9 (unspecified septicemia) of ICD-9-CM.
So sepsis is septicemia again–after all of our work to distinguish that the two are different. And though septicemia is defined as infection of the bloodstream, we have no codes for bloodstream infection in ICD-10-CM except catheter-related bloodstream infection (T80.211-). And infectious disease physicians are calling these "bacteremia," so there’s no chance of determining what the patient has through analysis of diagnosis codes.
One step forward, two steps back.
In November 2002, I wrote an article on syncope. Here I spoke of the myriad of conditions that could led to the symptom of passing out. (Remember, syncope means that the patient actually passed out. When we see "near syncope" written and try to code it, the encoder sees the word "syncope" and assigns that code, recognizing that "near" and "pre-" are nonessential modifiers, so the patient didn’t actually have to pass out.)
I talked about neurogenic syncope causes and cardiogenic causes. I spoke of volume changes (hypovolemia) and autonomic nerve dysfunction and arrhythmias such as bradycardia. In ICD-9-CM, everything went to 780.2 (syncope and collapse) without additional specifics being provided by the physician and the "due to" cause of the syncope if a cause could be found.
Yes, there were syncopes due to lumbar puncture and complicating delivery and such. The arrhythmia codes were arrhythmia codes, and the syncope part disappeared.
Well, in ICD-10-CM, all of the syncopes are now R55 (syncope and collapse). Whether it was a cardiogenic or neurogenic cause or it was attributed specifically to an arrhythmia or to heat or a coughing episode (which is really neurogenic, but it has a code of its own at R05 [cough]), there’s no improvement without the physician getting involved. And the doctor must identify the cause of the syncope and make the link so that the other diagnosis would be the principal diagnosis, not the syncope.
In this article, I noted that the term "orthostatic hypotension" was usually a symptom when provided by the physician and not a diagnosis, but was assigned 458.0 (orthostatic hypotension). That’s when the patient’s blood pressure drops with change in opposition from lying to sitting or standing and causes decreased blood supply to the brain, leading to the patient becoming dizzy or passing out.
It should be called orthostatic changes in vital signs, but the docs and nurses call it orthostatic hypotension. It’s a symptom, and it’s always due to something or other. In ICD-10-CM, we again have a breakdown of codes with I95.0 (idiopathic hypotension) and I95.1 (orthostatic hypotension), which is the equivalent of 458.0 and the code for the symptom complex of orthostatic changes in vital signs.
We also have I95.2 (orthostatic hypotension due to drugs), as often happens with patients on beta blockers; I95.3 (hypotension of hemodialysis); and I95.89 (other specified cause of orthostatic blood pressure changes).
But it’s still not a diagnosis. We still have no better idea about the pathophysiology of the patient’s syncopal episode, with or without measured hypotension. We need this from the doc. That’s the conclusion I wrote in 2002:
Interactions between or among drugs can cause instability of the arteries and veins. The physician might have to change the patient’s beta blocker dosage or switch to a non-beta-blocker drug for treatment of the patient’s hypertension. A patient might have intrinsic autonomic nerve dysfunction, where the arteries and veins cannot maintain the pressures that they normally exert on the column of blood in them, or they can’t respond quickly enough to changes in position. In all of these, the patient stands up and falls down. Immediate testing of pulse rate and blood pressure on position change demonstrates "orthostatic" changes.
Whether it’s dehydration, autonomic dysfunction of diabetes, sick sinus syndrome, or aortic stenosis, the coder must recognize that most of the time the physician knows the cause of the syncope and makes some effort to document that cause. Most of the time, however, the cause of the syncope is not clear. Keep this column nearby and refer to it when you see syncope or orthostatic hypotension documented. If you see one of these causes, a clinically oriented query couldn’t hurt.
I10 is the ICD-10-CM code for hypertension, whether benign or malignant. Too easy, right? I objected, as I seem to do a lot, and wrote my objections and got together with some of the premier physicians in nephrology and hypertension.
We agreed that malignant hypertension kills patients and we must have a code set to demonstrate this potentially lethal condition. Word got to the code gurus in the Coordination and Maintenance Committee, and we all must be ready for this change, though it doesn’t exist–yet.
I’m sure you have all seen documentation of such things as hypertensive emergency, hypertensive urgency, and hypertensive crisis, right? Well, this is a situation where acute onset of exceptionally high blood pressure levels can cause target organ damage, such as hypertensive encephalopathy or hypertensive stroke or seizure, acute renal failure, or acute pulmonary edema.
Blood pressures in the range of 220/110 or higher (it can be lower in children) must be treated quickly to avoid death of the patient. Existence of this situation is called a hypertensive crisis. It’s not slight elevations in blood pressure that happen when you run a half block–it’s real, serious stuff.
If there is target organ damage, as above, it should be referred to as hypertensive emergency. If it is identified that no target organ damage has occurred, the incident was a situation of hypertensive urgency. In future updates, there will be an I16 code for hypertensive crisis that requires specificity with the fifth character to distinguish between hypertensive emergency and hypertensive urgency. They got this almost right.
Instructions will be there to determine if the patient’s hypertensive crisis was associated with endocrine-induced hypertension or renal artery stenosis or other secondary cause of hypertension, or if it was essential hypertension. But the instructions are not there (yet) to "code also" the target organ damage that justifies coding the hypertensive emergency. Maybe one day they will be. 
Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or[email protected] If you have a specific procedure or condition you would like Dr. Gold to address in his column, contact Editor Steven Andrews at ­[email protected]. This article was originally published in the November issue of Briefings on Coding Compliance Strategies. – JustCoding News: Inpatient