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An auditor asked the question of postoperative sinus debridements while discussing functional endoscopic sinus surgery (FESS). It was asked if postoperative debridements are coded and chargeable when a septoplasty or a turbinate procedure is performed. Auditing Zero Global Days The reason the auditor qualified the question as a FESS surgery performed with a septoplasty or […]
The post Auditing Postoperative Sinus Debridements appeared first on AAPC Knowledge Center.
Operation – Exam under anesthesia, Repair Vaginal Tear, revison of vaginal septum resection ,control of post op hemorrhage
The patient was taken to the OR where general endotracheal anesthesia was induced. The patient was placed in the dorsal lithotomy position with her legs supported using candy cane stirrups. The patient was then prepped and draped in the normal sterile fashion. A time-out was performed to confirm correct patient, correct procedure. A deaver retractor was used to visualized the vagina. A large clot was evacuated. The vagina was then copiously irrigated with sterile water. The vagina was then inspected and a largely intact incision was noted longitudinally, both inferior and superior. Two cervices were noted and appeared normal. An small area of separation was noted, with a small amount of active bleeding. The posterior portion of the incision was oversewn from the apex to the introitus using 3-0 vicryl in a running/locked fashion. One small area about 1 cm above the introitus in this incision line continued a bleed. A figure of 8 was placed using the same suture. Excellent hemostasis was noted. The vagina was then packed the Kerlix with premarin cream. A foley catheter was placed without difficulty. All sponge, lap, and needle counts were correct x 2 at the end of the procedure. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
I am having trouble figuring out the correct diagnosis.
TIA
KAM
Typical post-operative care, including related evaluation and management is not separately reportable; but, an unrelated evaluation and management service during a postoperative period may be. According to the Centers for Medicare and Medicaid Services (CMS), an E/M service provided during the global period of a procedure is unrelated if: • The E/M service is for […]
AAPC Knowledge Center
Is the caring for, and treatment of post-operative complications in the global period coded and billable? To answer this question, You first must know who the third-party payer is because different payers have different rules. What’s the Global Issue? Medicare says they will not pay for any care for post-operative complications or exacerbations in the global […]
AAPC Knowledge Center
Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model
By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized.
In this article we’ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality.
Performance may impact reimbursement in FY 2018
A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals.
If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in:
Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse Events Composite, previously known as the PSI 90 composite measure.
The Patient Safety and Adverse Events Composite measure was reviewed in last month’s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight:
Data quality and PSI 11 performance
PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a risk-adjusted measure evaluated using an observed over an expected ratio.
Discharges included in the measure:
Identification of postoperative respiratory events:
Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.
PSI 11 CDI vulnerabilities
In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts.
How do I recognize acute respiratory failure?
Clinical criteria to identify if not documented and/or to validate a documented diagnosis include:
What is the definition of "prolonged" postoperative mechanical ventilation?
If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure?
In addition to the above, other record review findings which negatively impact PSI 11 data quality include:
Summary
Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested:
Editor’s note
Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA’s ICD-10-CM/PCS coder workforce training in August 2013. Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or [email protected]. Opinions expressed are that of the authors and do not represent HCPro or ACDIS.
Postoperative respiratory failure’s introduction into the CMS value-based reimbursement model
By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized.
In this article we’ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality.
Performance may impact reimbursement in FY 2018
A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals.
If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in:
Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse Events Composite, previously known as the PSI 90 composite measure.
The Patient Safety and Adverse Events Composite measure was reviewed in last month’s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight:
Data quality and PSI 11 performance
PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a risk-adjusted measure evaluated using an observed over an expected ratio.
Discharges included in the measure:
Identification of postoperative respiratory events:
Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.
PSI 11 CDI vulnerabilities
In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts.
How do I recognize acute respiratory failure?
Clinical criteria to identify if not documented and/or to validate a documented diagnosis include:
What is the definition of "prolonged" postoperative mechanical ventilation?
If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure?
In addition to the above, other record review findings which negatively impact PSI 11 data quality include:
Summary
Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested:
Editor’s note: Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA’s ICD-10-CM/PCS coder workforce training in August 2013. Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or [email protected]. Opinions expressed are that of the authors and do not represent HCPro or ACDIS.
Reporting modifiers for services performed in the postoperative period
Modifier -58 describes a staged or related procedure or service by the same provider during the postoperative period. For outpatient hospitals, the postoperative period is defined as the same service date.
Report modifier -58 to indicate the performance of a procedure or service during the same calendar day postoperative period. For example, a scheduled diagnostic procedure might be performed in the morning, resulting in the decision by the surgeon to perform an unscheduled therapeutic procedure on the same patient later on the same day.
Because hospital outpatient reporting represents services performed within a given 24-hour period or a range of dates, the original intent and use of modifier -58 is not altered for hospital outpatient reporting.
Modifier -58 indicates that the reported procedure is related to the original procedure, intended to be performed sometime in the future as a "staged" procedure, and may represent the following:
The use of the modifier -58 enables the fiscal intermediary or other payers/carriers to pay appropriately for the procedure per se and other associated postoperative services performed subsequent to the original procedure on the same calendar date (for outpatient hospital billing).
Modifier -58 is not used to report a related or unrelated procedure performed on the same date as the original procedure. To report this circumstance, use a different, more suitable modifier.
Also remember to check with your fiscal intermediary regarding local policy associated with the use of the modifier -58 for staged procedures on the same date.
Appropriate use of modifier -58
Inappropriate use of modifier -58
For example, a spinal neurostimulator generator is inserted following the insertion of two neurostimulator leads and trial dosing performed earlier on the same calendar day.
Providers should report:
Reporting modifier -78
Modifier -78 describes a return to the operating room for a related procedure during the postoperative period. For outpatient hospitals, the postoperative period is defined as the same service date.
Use modifier -78 to indicate that another procedure was performed during the postoperative period of the initial procedure that was performed earlier in the same day.
For example, an unscheduled breast lumpectomy may be performed after a breast biopsy that took place earlier on the same calendar day or postoperative control of bleeding may occur for a procedure performed earlier on the same calendar day.
Use of modifiers applies to services/procedures performed on the same calendar day; thus, the postoperative period is defined as the calendar day on which the procedure/service was performed.
Ensure that modifier -78 is reported if the subsequent procedure does either of the following:
Below are some of the CPT codes that are likely to be reported with modifier -78 when a patient returns to the operating room to have a postoperative complication treated:
Appropriate use of modifier -78
Inappropriate use of modifier -78
Note that an OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, or an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit.
Reporting modifier -79
Modifier -79 is used to describe an unrelated procedure or service by the same physician during the postoperative period. For outpatient hospitals, the postoperative period is defined as the same service date.
Use modifier -79 to indicate that the performance of a procedure or service by the same physician during the postoperative period was unrelated to the original procedure that was performed earlier in the day.
You may need to use the modifier if the patient accounts/business office generates two bills for the same physician for the same date of service. This modifier would require a single bill and a single patient account number.
Editor’s note: This article is an excerpt from the HCPro book "JustCoding’s Guide to Modifiers: Hospital Outpatient Edition" by Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H. For more information, or to order a copy, see www.hcmarketplace.com.