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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Don’t Wait to Implement April Code Update

Code changes for the April update to the 2019 Medicare Physician Fee Schedule Database (MPFSDB) are effective for dates of service on and after Jan. 1, 2019. Medicare Administrative Contractors (MAC) will not search their files to retract payment for claims already paid or to retroactively pay claims. To ensure proper claims payment, providers will […]

The post Don’t Wait to Implement April Code Update appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Learn to Implement CDI in Your Practice at HEALTHCON

HEALTHCON 2019 (April 28-May 1 in Las Vegas) is for everyone in the business side of healthcare, and provides cutting-edge education, networking, and other opportunities to attendees. Expert speakers, such as Dr. Lisa L Campbell, PhD, COC, CPC, CPC-I, help make this a professional event you can’t miss. AAPC asked Dr. Campbell about her presentation, […]

The post Learn to Implement CDI in Your Practice at HEALTHCON appeared first on AAPC Knowledge Center.

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2017 OPPS proposed rule looks to implement provider-based changes

2017 OPPS proposed rule looks to implement provider-based changes

CMS is looking to implement the Section 603 provisions of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments (PBD) by January 1, 2017, according to the 2017 OPPS proposed rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16098.pdf). The agency is proposing to pay the nonfacility or office Medicare Physician Fee Schedule (MPFS) amount to the performing/supervising physician and preclude hospitals from billing on a UB-04 form or receiving OPPS payment for services performed at these locations for 2017, but plans to explore other options for 2018 and beyond.

Physicians would be paid at the higher nonfacility rate of the MPFS, but only hospitals that have employed or contracted physicians that reassign their billing to the hospital would get paid under the MPFS for these services.

Hospitals would be able to bill claims on CMS-1500 forms for physicians who have already reassigned their billing to the hospital, as in the case of employed physicians. Otherwise, hospitals would have the option of enrolling the location as the type of provider or supplier it wishes to bill to meet the requirements of that payment system (e.g., ambulatory surgery center or group practice).

"This proposal will be very challenging for hospitals that have community physicians practice at their off-campus outpatient departments that will no longer be paid under OPPS," says Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro, a division of BLR, in Middleton, Massachusetts.

"These physicians would bill with the office place of service code and the hospital would have to figure out how to get compensated," she says. "This will likely require hospitals to rewrite their agreements with these physicians."

CMS’ proposal for operationalizing Section 603 comes as somewhat of a surprise since the burden is being placed squarely on providers, with CMS’ own systems not ready to allow existing billing practices, says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc.

"Some providers hoped CMS would delay implementation and others speculated that modifier ?PO might get repurposed for CY 2017," says Shah. "Perhaps commenters will be able to offer CMS solutions that will minimize provider operational burden."

CMS writes in the proposed rule:

We intend the policy we are proposing in this proposed rule to be a temporary, 1-year solution until we can adapt our systems to accommodate payment to off-campus PBDs for the non-excepted items and services they furnish under the applicable payment system, other than OPPS.

 

CMS would allow certain excepted items and services to still be billed under the OPPS:

  • All items and services furnished in a dedicated emergency department
  • Items and services furnished in a hospital department within 250 yards of a remote location of the hospital and within 250 yards of the main hospital (i.e., on-campus)
  • Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015

Hospitals could also continue to bill for services at these facilities that are not paid under the OPPS, such as laboratory services.

Off-campus PBDs built and billing before November 2, 2015, would retain grandfathered status or what CMS calls "excepted" status and continue billing under the OPPS, but the proposed rule includes some caveats. While the agency proposes that a change in ownership would not change an off-campus PBD’s excepted status as long as the new owner assumes the same provider agreement, a change in location would. However, CMS is requesting comments on this provision and whether certain exceptions should apply for situations beyond a hospital’s control such as a natural disaster.

Off-campus PBDs that expand services beyond those offered and billed before November 2, 2015, will not be allowed to bill them under the OPPS. CMS has proposed clinical families based on APCs that would determine whether those expanded services would continue to be excepted (see Table 21 on page 342 of the proposed rule).

CMS also proposed a 90-day Medicare EHR incentive program reporting period in 2016 for all eligible professionals, eligible hospitals, and critical access hospitals (CAH). If passed, the reporting period would be 90 continuous days between January 1, 2016, and December 31, 2016. CMS proposed the elimination of clinical decision support and computerized order entry objectives and measures for eligible hospitals and CAHs attesting under the program. The thresholds for the modified stage 2 for 2017 and stage 3 for 2017 and 2018 would be reduced. These proposed changes do not apply to the Medicaid EHR incentive program.

CMS proposed that EHR incentive program participants that have not yet demonstrated meaningful use attest to the modified stage 2 by October 1, 2017. This is in part due to the fact that after publishing the 2015 EHR Incentive Programs Final Rule, CMS realized it was not possible for new incentive program participants to attest to stage 3. However, any eligible hospital, eligible professional, or CAH that has attested to meaningful use in the past will report to different systems.

The proposed rule states that some eligible professionals who have not demonstrated meaningful use but intend to attest in 2017 and transition to MIPS should be granted a hardship exception.

CMS also proposed modifying the measure calculations for the EHR incentive program. Under the proposal, actions in the numerator must occur during the reporting period when the period is a full calendar year. If the reporting period is not a full calendar year, the numerator must be reported in the same calendar year as the reporting year.

CMS also proposed removing six procedures from its inpatient-only list, including four spine procedures as well as two laryngoplasty procedures. CMS is requesting comments on whether to remove total knee arthroplasty from the inpatient-only list in the future.

"The deletion of procedures from the inpatient-only list is long overdue," says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer and founder, First Class Solutions, Inc., in Maryland Heights, Missouri. "It’s unfortunate that the knee arthroplasty wasn’t included. I question whether there is value to the inpatient-only list any longer."

Some conditional packaging status indicators are currently based on the date of service, while others package based on the claim’s from and through dates, meaning packaging crosses all dates encompassed in those fields (FL6) of the claim. For CY 2017, CMS proposes to change its packaging logic for all conditional packaging status indicators so that it occurs at the claim level.

The proposal would change the logic for status indicators Q1 and Q2, which currently package items or services provided on the same date of service as those assigned status indicator S, T, and V. CMS also proposes deleting modifier ?L1 (separately reportable laboratory test), which had been operationally burdensome and confusing to report, led to a billion dollar CMS miscalculation, and was subsequently replaced in functionality with status indicator Q4. If CMS finalizes its proposal, all laboratory tests that appear on a claim with other hospital services would be packaged, even if ordered by a different provider for a different diagnosis than the other services.

For more information, see CMS’ fact sheet, available at: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html.

HCPro.com – HIM Briefings

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.

 

Procedure

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.

 

Administrator

  • 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.

HCPro.com – Billing Alert for Long-Term Care

CMS to Implement Advanced Diagnostic Imaging Monitoring Program

The Centers for Medicare & Medicaid Services (CMS) has a date in mind for implementing the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. In the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule, CMS proposes Jan. 1, 2019, for when ordering professionals would need to consult specified applicable AUC using a qualified clinician decision […]
AAPC Knowledge Center

From the Trainer: ICD-10 FAQ #1 – If the US is the last to implement, why are there so many unknowns?

For the last year, I’ve traveled across the country providing ICD-10-CM and ICD-10-PCS education to coders and clinical documentation specialists.  Our company’s model provides three separate training sessions for our clients: basic, intermediate, and advanced.  This means lots of repeat visits to each client, lots of really hard questions, and tons of professional growth for me.  I thought it was time to start a new series here on my Coder Coach blog: ICD-10 FAQs.  This is a question I’ve been asked a lot lately as we get into advanced trainings and more controversial topics:

If the United States is the last country to implement ICD-10, why are there so many unanswered coding questions and why do we have to wait for Coding Clinic advice?



While it seems logical that someone would have figured out all of this ICD-10 stuff within the last 20 years as we’ve been “messing around” here in the US (please note the sarcasm, because I don’t really think we’ve been messing around; we’ve actually been quite busy), the reality of the situation is that the US version of ICD-10 is different from everyone else’s.  The core ICD-10 code set was developed by the World Health Organization (WHO) and classifies causes of morbidity (i.e., diagnoses) and every country has the ability to adapt it further (e.g., ICD-10-CA in Canada, ICD-10-AM in Australia, ICD-10-CM in the US).  Two things should have jumped out at you based on this statement:

  1. ICD-10 diagnosis codes may be different in Canada, Australia, and the US
  2. The international code set does not  include procedures

Let’s tackle #1 first.  The US version of the ICD-10 diagnosis codes, ICD-10-CM, is a clinical modification (BTW – that’s what the “CM” stands for; it’s not “coding manual” like some people seem to think).  It is based on the WHO version, but has been adapted for use here in the good ole United States of America.  I haven’t had a ton of time to compare it to the original, but what I do know about the CM version is this:
  • The Excludes1/Excludes2 convention, which solves a lot of problems from ICD-9 (and creates a few new ones) is not part of the WHO version
  • The use of 7th character extensions for injuries and poisonings is not part of the WHO version
  • The expansion of the external cause codes, which are not required for reporting, are not nearly as extensive in the WHO version
  • While we have adapted diabetes terminology in the US to Type 1 and Type 2 diabetes, the WHO version still uses the insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) terminology that we’ve worked so hard to banish from our medical record documentation here in the States
Most of the really hard diagnosis questions I get about coding ICD-10 diagnoses revolve around the changes that are unique to the CM version.
As for the procedural component, ICD-10-PCS (which stands for procedure coding system), that was developed in the US by CMS under contract with 3M.  Although I’ve heard that other countries have plans to adopt PCS, right now the US is the only country using it.  Although other countries have procedural coding systems, it’s important to remember that we are the only ones using coding for reimbursement.  For that reason, we will likely place more weight on those procedure codes than other countries and when it comes to PCS, it’s uncharted territory.
Hopefully that answers a couple of questions about the ambiguity of ICD-10.  And may I also just point out that this is nothing new.  Coding has always undergone an evolutionary process.  We have seen it with ICD-9-CM and CPT.  It’s the reason we have official publications like the Coding Clinic and CPT Assistant.  If you are not familiar with these publications, you need to be.  They are official resources that answer a lot of questions.  And as of second quarter of this year, the American Hospital Association has stopped publishing Coding Clinic for ICD-9-CM and is only publishing Coding Clinic for ICD-10-CM/PCS.  My colleagues and I have been monitoring the publication very carefully each quarter because their advice does change some previous assumptions many have made based on what we know about these new coding systems.

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