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Examine Your Definition of Professionalism

By Deborah M Cooper, CPC, CPMA, CFPC, CGSC There are ways to represent professionalism, but what does it really mean to you? Is it: How  you dress, where you work, the places you go, or the people you associate with? The level of education you’ve accomplished, the school you attended, or the number of credentials […]

The post Examine Your Definition of Professionalism appeared first on AAPC Knowledge Center.

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95165 Definition of Doses

I have to code 4 vials for one allergy as following:

– 3 vials with each 2.75 cc (10 doses each)
– 1 vial with 5.75 cc (16 doses)

The administration will be weekly over 46 weeks. I read a lot from other coders that they charge by the doses no matter the total cc, in this case 95165 x 46.

Per Medicare guidelines a dose is defined as one (1) cc. Please see below:

Allergen Immunotherapy (Medicare excerpts)
Billing Guidelines:
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January
1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial.
When billing code 95165, providers should report the number of units representing the number of 1 cc
doses being prepared.

In my case that would mean 95165 x 14 cc total.

Doesn’t this guideline apply to commercial insurances as well? There is a big difference between 14 vs 46 units.

Medical Billing and Coding Forum

Provider documenting ICD-10 codes in lieu of text definition

I have a NeuroPsych Provider that documents the actual ICD-10 code on testing reports in lieu of a text definition. I think I read something from CMS a few years back about this, and I believe it said that the actual text definition must be in the note. However, I have been searching for this guidance and cannot find anything. Do any of you have an official guidance on this?

Much appreciated!!

Medical Billing and Coding Forum

Definition of “significant” for modifier 25

What makes an E/M "significant" enough to warrants a claim with modifier 25 the same day as a minor procedure?

Humana has informed us that they will only pay an E/M with modifier 25 if the problem was significant enough to require a prescription, lab order, surgery recommendation, or something like that. If it only requires counseling or OTC medication, it is not "significant" enough to bill a separate E/M.

Example: Pt came in for evaluation of a rash, and the provider examined the area and recommended an OTC cream. The provider happened to notice an unrelated suspicious lesion and performed a biopsy. So we billed 11100 for the lesion and 99212-25 for the rash. Humana denied the 99212-25 stating that the rash was not a "significant" enough problem to bill separately because the recommendation was only for OTC medication.

Is this appropriate?

Medical Billing and Coding Forum

A new sepsis definition: Finding coding compliance at a crossroads

A new sepsis definition: Finding coding compliance at a crossroads

This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS.

 

In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’ SEP-1 core measure), and ICD-10-CM coding compliance.

We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a "life-threatening organ dysfunction caused by a dysregulated host response to infection," differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term "severe sepsis," and discussed that the definition change impacted ICD-10-CM code assignment and compliance.

Definitions and clinical indicators in Sepsis-2 are available at http://tinyurl.com/SepsisTwo, and definitions for Sepsis-3 are available at www.jamasepsis.com. CMS’ definition of sepsis and severe sepsis for the SEP-1 core measure is available at http://tinyurl.com/2017SEP1.

 

Coding Clinic update

Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated "coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis)."

Coding Clinic went on to write (emphasis mine):

 

In my opinion, this means that Coding Clinic is saying ICD-10-CM still embraces the coding of infections without sepsis, with sepsis but without organ dysfunction, and with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis), if the diagnosis is incorporated by the documenting physician. The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.

Alternatively, while Sepsis-3 states that the word "sepsis" requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents "severe sepsis" or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term "sepsis" (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.

 

Coding Clinic, Fourth Quarter 2016

As we discussed last month, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):

 

In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147?149 stated (emphasis mine):

 

Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI. Access these at http://tinyurl.com/2016AHIMAclinicalvalidation and www.hcpro.com/content/327466.pdf.

 

Coding Clinic then went on to say that (emphasis mine) "a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system."

While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in the literature.

As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded. I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.

Solving the problem

In developing a sepsis strategy in light of these Coding Clinics, allow me to remind all of you that there are three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock unless he or she states what environment they are in. These are:

  • Clinical language ? Physicians have a language that we use in direct patient care that communicates well with other physicians; we learned this language in medical school, in residency training, and in reading our literature. Every physician knows what "urosepsis," "unresponsiveness," and "neurotoxicity" is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so that we can report them using the ICD-10-CM conventions. Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT) is a clinical language we use in our problem lists and so is Sepsis-3. ICD-10-CM is not. Not all physicians embrace Sepsis-3, thus some may wish to label a patient as having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them. See the articles listed above.
  • Coding language ? As discussed, Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without and with organ dysfunction, bases coding on the individual physician’s criteria and documentation, and requires clinical validation using reasonable criteria prior to code assignment.
  • Core measure language ? Defining cohorts with core measures, such as SEP-1, is a clinical abstraction based on clinical criteria and not necessarily based on what a physician writes. For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than that of Sepsis-3. Remember, however, that in 2017, if a physician documents severe sepsis and R65.20, and severe sepsis is coded, that record will be held accountable for the SEP-1 even if it doesn’t meet the SEP-1 criteria. View this regulation at http://tinyurl.com/jlau9ms.

Therefore, allow me to suggest the following strategy to ensure a balance of compliance with all three of these environments:

1.Standardize the definition and documentation of severe sepsis first. I believe that the Recovery Auditors (RA) are looking for records with sepsis codes that do not have R65.20 or R65.21 (septic shock) as a secondary diagnosis as to deny these codes and their resultant DRGs. In so doing, I believe that the definition of severe sepsis should be negotiated with and standardized by the medical staff, which could incorporate any or all of the following three criteria:

 

No matter what criteria is used, be sure to coordinate its development and deployment with your quality, clinical documentation integrity, and coding staff so that if a physician documents severe sepsis or septic shock, the SEP-1 algorithm can be implemented.

Also, be sure that physicians explicitly link organ dysfunctions to sepsis, or preferably, use the term "severe sepsis" so that R65.20 is not inadvertently missed by the coders. If a clinical documentation specialist or coder obtains a record supporting R65.20, be sure to notify the SEP-1 manager to determine if it qualifies for the SEP-1 core measure.

 

2.Develop a facilitywide definition for sepsis without organ dysfunction. As noted last month, many physicians do not believe that organ dysfunction is required to diagnose sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, we must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding validation purposes. When it is documented by a provider without evidence of acute organ dysfunction, this statement can be used to rebut the RA’s denials. These will be handy if we are appealing beyond the first level.

3.Remind the RA that the ICD-10-CM guidelines are part of HIPAA and that coding is based on provider documentation. I’m sure that all of our contracts with private payers state that we will comply with federal laws, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign codes based on provider documentation, and not so much on what the RA thinks, and that Coding Clinic, First Quarter 2014, pp. 16?17, states that "the official guidelines are part of the HIPAA code set standards," we don’t want the RAs to violate HIPAA or our contracts with payers. This may require that our hospital attorneys or compliance officers weigh in, given that RAs have been known to deny codes based on provider documentation and want us to do the same.

 

Summary

Please recognize that this topic is very controversial and that the opinions expressed here are solely my own. I encourage all of us to discuss Sepsis-2, Sepsis-3, SEP-1, the 2017 Official ICD-10-CM Guidelines, and these Coding Clinics with our compliance officers and/or attorneys so that we can best support policies and procedures ensuring complete, precise, and compliant coding of sepsis in light of Sepsis-3. If you have success stories, please share them with me and the editor here at BCCS.

 

Editor’s note:

This article was part two of a two-part series. You can read part one in BCCS’ October issue. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at [email protected]. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at [email protected]. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

HCPro.com – Briefings on Coding Compliance Strategies

Young and old: Ex-surveyor worries about where CMS applies ligature risk definition

One of the major concerns former Joint Commission surveyor Ernest Allen has with CMS’ new ligature standards is that they don’t distinguish between geriatric and adult behavioral health units.

HCPro.com – Briefings on Accreditation and Quality

Definition of minor surgery vs major surgery in medical decion making E/M

Can someone point me to a CMS definition of what these two terms mean? Is major surgery based on the 90 day global and minor surgery on the 10 day global or no global at all?

If you have a definitive link to something that would point me in the right direction, I would appreciate it since I am working thru audits right now and want to be sure I am interpreting this part of the E/M audit correctly.

Thank you!

Medical Billing and Coding Forum

Definition of Readmission

I’ve searched around but can’t find any definitive information on this and one of my docs asked me for some clarification. Does any one know of any guidelines for a readmission to a nursing home? Specifically, my doc was asking, if an LTC NF patient goes out somewhere, say the hospital, and comes back to the nursing home-is there a specific amount of time that would need to have passed for him to bill an H&P as opposed to a follow up visit? I see rules and regulations regarding the facility billing, but nothing definitive about physician billing when it comes to readmissions. If anyone has any guidance, it would be greatly appreciated!

Medical Billing and Coding Forum