|
Procedure
Practice 07/15/00 - Coding
Recommendations
Hospital Outpatient
Coding Issues
Outpatient coding is the hot topic in hospitals
across the country. This month we provide an overview of several
key outpatient coding issues:
 |
Diagnosis Coding
|
|
The Outpatient Code Editor
(OCE)
|
|
Correct Coding Initiative
(CCI) Edits
|
|
Ambulatory Payment Classification
(APC) System
|
Because of the nature of the information provided
in this month's articles, a coding quiz rather than the usual
medical report or coding scenarios can be found on our Procedure
Coding Practice page.
Diagnosis
Coding - The
Outpatient Code Editor (OCE)
Correct Coding
Initiative (CCI) Edits - Ambulatory
Payment Classification System (APCs)
Outpatient diagnosis coding presents some unique
challenges for coders because of the many types of outpatient
encounters and the various methods in which these encounters
are documented.
Official Outpatient Coding
Guidelines
| 1. |
Search for the correct code in the Alphabetic
Index first before referring to the Tabular List of
your ICD-9-CM coding book. |
| 2. |
Any code in the range 001.0 through V82.9
may be used to report illness, injury, symptoms, conditions,
problems, complaints, or other reasons for the outpatient
encounter. |
| 3. |
Documentation of the outpatient encounter
must describe the patient's condition and support code
selection. |
| 4. |
V-codes may be used to report outpatient
encounters for circumstances other than disease or injury;
for example, a clinic visit for a wound dressing change. |
| 5. |
Always code to the highest level of specificity
by using all digits required for a specific code.
|
| 6. |
Code first the diagnosis, symptom, problem,
condition, or other reason for the encounter that is
documented to be chiefly responsible for the services
provided. Coexisting conditions are coded as secondary
diagnoses. |
| 7. |
Code the condition to the highest degree
of certainty for the particular encounter. Many times
the correct code will report a sign, symptom, or abnormal
test result since diagnoses are often not established
at the time of initial outpatient encounter. |
| 8. |
Do not code any diagnosis documented as
"probable", "suspected", "rule
out", "questionable", or "working
diagnosis". |
| 9. |
Chronic diseases treated on an ongoing
basis may be coded as many times as the patient receives
care for the condition(s). |
| 10. |
Code all conditions that coexisted at
the time of the patient encounter and required or affected
the patient's care, treatment, or management. Do not
code conditions that were previously treated and no
longer exist. |
| 11. |
For ancillary diagnostic testing services,
code the reason for the test based upon medical record
documentation. Codes for other diagnoses such as chronic
conditions may be sequenced as additional diagnoses
codes. |
| 12. |
For ancillary therapeutic services, code
the reason for which the service was provided. |
| 13. |
The appropriate V-code may be listed first
for patients who receive outpatient chemotherapy, radiation
therapy, or rehabilitative therapy (e.g., physical,
occupational, or speech therapy). The diagnosis or problem
for which the service was being provided is listed as
the second code. |
| 14. |
For preoperative evaluation only, select
a code from category V72.8, Other specified examinations.
Code the reason for surgery as a secondary diagnosis.
Also code any findings related to the pre-operative
evaluation.
Please note:
Coders must know their 3rd-party payer rules
regarding guidelines
13 and 14. As many coders know, payers'
policies do not always follow coding guidelines.
Some 3rd-party payers require that the diagnosis
or problem be coded first with the V-code
listed second. This situation is frustrating
for coders who strive for coding consistency
and accuracy. While efforts should be made
to educate the payer regarding correct coding
practice, if they are unsuccessful, coders
must comply with special payer requirements
to avoid fraud and abuse issues. |
|
15. |
For ambulatory surgery, code the diagnosis for which
the procedure was performed. Select the postoperative
diagnosis if it differs from the preoperative diagnosis
since it is more definitive.
|
Laboratory, Pathology, and Radiology
Issues
Given the above official coding guidelines, many coders still
have questions about the correct way to code diagnoses for
outpatient ancillary services. An article published in the
first quarter 2000 issue of Coding
Clinic for ICD-9-CM specifically addressed
many of these coding issues. The following examples demonstrate
some of the key points of that article.
| 1. |
A patient presented to the radiology department
for a chest x-ray. The reason for the x-ray was documented
as wheezing and cough for two weeks. The radiologist’s
diagnosis was right upper lobe pneumonia. Again, depending
upon when the coder assigns a code and what documentation
exists at that time, two equally valid coding scenarios
exist. The coder must either assign symptom codes for
the wheezing and cough, 786.07 and 786.2, if the radiologist's
diagnosis is not available; or, if the radiologist's
diagnosis is documented, then 486, Pneumonia,
may be coded. |
| 2. |
A patient was seen in a physician's office
for excision of a skin lesion on her back. The pathologist's
diagnosis was benign nevus. Again, two coding scenarios
may occur. The coder may need to code the diagnosis
prior to the pathologist's tissue diagnosis. Therefore,
it would be correct to assign a code for skin lesion
709.9, Unspecified disorder of skin and subcutaneous
tissue. If the coder has the pathology report with
the diagnosis of benign nevus, then it is appropriate
to code 216.5, Benign neoplasm of skin of trunk,
except scrotum.
Explanation:
The above two coding situations follow the
same logic as the ambulatory surgery coding
guideline, which states that a postoperative
diagnosis is more definitive than a preoperative
diagnosis. In the examples, an ordering physician
documented signs or symptoms that required
further investigation and then referred the
patient (or tissue specimen) to the hospital
for an outpatient service. Following the service,
another physician (either a pathologist or
radiologist) provided more specific diagnostic
information than the ordering physician. If
the coder does not have this information available,
then signs and symptoms must be coded. If
the radiology or pathology report is available
to the coder, then it is correct to code the
more specific diagnosis documented on that
report. The basic rule remains unchanged:
code based upon the physician documentation
available at the time of code assignment. |
|
3. |
A patient underwent urinalysis for complaints of dysuria
and left flank pain. The urinalysis revealed greater
than 100,000 white cells and was positive for bacteria.
A subsequent culture and sensitivity revealed E. coli
urinary tract infection. The correct diagnosis codes
are 788.0 and 789.04, Dysuria and left lower quadrant
abdominal (flank) pain. It is incorrect to code
the urinary tract infection based upon only a laboratory
test that has not been interpreted by a physician. |
| 4. |
A chest x-ray was done on a patient referred
for hemoptysis and weight loss. The radiologist reported
no acute intrathoracic disease. Incidental note was
made of a small hiatal hernia. The correct diagnosis
codes for this case are 786.3, Hemoptysis,
and 783.2, Abnormal loss of weight. The hiatal
hernia is an incidental finding unrelated to the reason
for the service and is not coded.
|
Emergency Department:
Signs and Symptoms vs. Diagnoses
Patients often present to the Emergency Department (ED) with
a constellation of signs and/or symptoms that may point to
several different diagnoses. The ED physician then orders
multiple tests to arrive at the final diagnosis, but should
the final diagnosis be the only one coded and reported?
Most coders have been trained to report the most specific
diagnosis available and to code signs and symptoms only if
a final diagnosis is unknown to the physician. However, other
coders believe that because the physician was unsure of the
final diagnosis at the time the diagnostic tests were ordered,
it is appropriate to code the patient's presenting signs and
symptoms. The resultant disagreement and confusion raises
serious coding compliance and quality concerns.
Recently, the National
Uniform Billing Committee (NUBIC) approved dual
use of the admitting diagnosis field on the UB92 hospital
billing form. This field may now be used to report the presenting
sign, symptom, or diagnosis for ED visits. In addition, the
Central Office
for ICD-9-CM has advised coders that signs and
symptoms may be reported as secondary conditions to document
the reasons for certain diagnostic testing. Codes for signs
and symptoms appear on the hospital UB92 billing form in field
locator 76. The thoroughness of this coding process presents
a more detailed picture of the patient's need for treatment,
the justification for the ED physician's diagnostic work-up,
and the final patient diagnosis.
Medical Necessity
In the past few years "medical necessity" has become
an issue for coders, billers, payers and patients. Simply
put, health insurance companies do not pay for an outpatient
service without clear documentation of the need (i.e., medical
necessity) for that service. Coders need to see the "big
picture" of coding, billing, and reimbursement in order
to understand the complexity of this issue.
Who determines medical necessity?
The Medicare program defines medical necessity as a service
that is "reasonable and necessary for the diagnosis
or treatment of illness or injury." As with all Medicare
coding and billing issues, the Health
Care Financing Administration (HCFA) is ultimately
responsible for the process of medical necessity determination.
Recognizing differences in regional practice patterns and
outpatient service utilization, HCFA delegates the development
of medical necessity guidelines to its local contractors.
The contractors then create Local Medical Review Policies
(LMRPs) that serve as the basis for local coverage decisions.
LMRPs are constantly being developed and modified. Newly
proposed LMRPs are subjected to a 45-day comment period
during which physicians may offer comments and opinions.
Once finalized, LMRPs become effective 30 days following
publication by the local Medicare carrier.
The following sources of information may be used in the
development of LMRPs:
- Carrier data, such as reports identifying significant
utilization of a service in the past year
- National claims history
- Information from state medical societies and individual
physicians
- Recommended model policy developed by national or regional
medical director workgroups
- LMRPs established by other carriers in reaction to abusive
or aberrant practices
- Complaints from beneficiaries
- Recommendations from other sources, such as Office of
Inspector General
A specific LMRP may determine:
- Whether or not a service is covered by Medicare
- Under what medical conditions a covered service is reimbursed
- The allowable frequency of a specific service
- The acceptable ICD-9-CM diagnosis codes for a given
service
- Other Health Insurance Carriers
Most other 3rd-party payers have similar processes in place
to determine what constitutes a medically necessary service.
While many payers model their coverage decisions on the
local Medicare carrier's LMRPs, they are under no obligation
to do so and can develop their own guidelines for covered
and noncovered services, frequency of service, and acceptable
ICD-9-CM diagnoses.
How does medical necessity apply to coding and claims processing?
A hospital outpatient service is reported on the billing
form as a CPT code. The medical reason for that service
is reported as an ICD-9-CM diagnosis code. The insurance
carrier then makes a reimbursement determination based upon
those codes. The process for making this determination can
be rather complicated. The service may be covered or noncovered,
medically necessary or medically unnecessary. Depending
upon the diagnosis code, a service that is normally covered
may be considered noncovered if the diagnosis does not justify
the carrier's interpretation of "medically necessary."
Let's see an example to demonstrate:
A 38-year-old patient who is scheduled for minor surgery
insisted on having a preoperative EKG despite his physican's
reassurances that the test was not needed. The EKG was performed
and read as normal. Although the insurance carrier may cover
preoperative EKGs for patients over 50 or patients with
specific diagnoses, this patient did not have a diagnosis
that warranted this service and, therefore, the carrier
considered the service medically unnecessary in this instance.
The coder must report the reason for the service, in this
case V72.81, Preoperative cardiovascular examination.
The Coder's Role
It's easy for coders to become the scapegoats in a billing
system that everyone, especially patients, finds confusing.
Have you ever received a phonecall from a patient whose physician
has told him/her that the hospital (you!) "coded it wrong"
after the insurance company has declined payment for medically
unnecessary services? It's not a pleasant situation, but coders
cannot allow pressure from any outside party to alter sound
coding practices simply to "get the bill paid."
As always, the guiding principle for correct coding is to
code based upon the available physician documentation. Code
the appropriate sign, symptom, or diagnosis as documented
by the physician. If the service is for screening purposes
only (i.e., no signs, symptoms, or diagnoses are documented),
assign the appropriate V-code. (See V-code
sequencing discussion above.)
Communication is the key to finding a solution to many outpatient
coding dilemmas. Unfortunately, communication between physician
practices and hospitals regarding coding and billing issues
is often nonexistent. Consider working with your hospital
billing department to develop training and education materials
for physician practices. Explain documentation needs and coding
guidelines. Share copies of Medicare LMRPs. Think about placing
bound copies of collected LMRPs in physician lounges, the
HIM department, dictating stations, and other areas where
physicians may have a minute for some "light reading."
Many physicians aren't aware of the multitude of Medicare
hospital coding and billing regulations. Their understanding
of the system not only improves communication, but may encourage
physician participation in future LMRP development and modification.
Diagnosis
Coding - The
Outpatient Code Editor (OCE)
Correct Coding
Initiative (CCI) Edits - Ambulatory
Payment Classification System (APCs)
The OCE is a software package supplied to Medicare carriers
by HCFA. Historically, the OCE edited outpatient hospital
claims for billing data and to determine if the Ambulatory
Surgery Center (ASC) limit should apply to each claim. The
OCE also reviewed each CPT and ICD-9-CM code for validity
and Medicare coverage.
For the implementation of the Outpatient Prospective Payment
System (OPPS), major modifications to the OCE were made. The
new OPPS version of the software not only detects errors,
it also provides edit descriptions and claim dispositions.
The edits also determine Ambulatory Payment Classification
(APC) assignment and provide pricing data. Effective with
OPPS implementation, all outpatient hospital claims must pass
through the OCE.
The occurrence of an OCE edit triggers one of six different
claim dispositions. The entire claim may be:
- Rejected (provider may resubmit if data entry errors were
made)
- Denied for noncovered service (provider may not resubmit)
- Returned to provider (provider may resubmit after correcting
errors)
- Suspended for further carrier review
A single line item or specific line items on the claim may
be:
- Rejected (provider may resubmit if data entry errors were
made)
- Denied for noncovered service (provider may not resubmit)
The OCE contains 42 individual edits, excluding the CCI edits
discussed below. While providers will not see the OCE edits
on returned or rejected claims, they will receive a reason
or error code related to the edit. Pertinent coding edits
include:
- Invalid diagnosis, including edits for 4th and 5th digits
as appropriate
- Diagnosis and age conflict
- Diagnosis and sex conflict
- E-codes submitted as principal diagnosis
- Invalid CPT procedure codes
- Procedure and age conflict
- Procedure and sex conflict
- Inpatient only procedure
- Invalid CPT modifier
Other edits include verification of dates of service and
revenue codes as well as the Correct Coding Initiative (CCI)
edits discussed below.
Diagnosis
Coding - The
Outpatient Code Editor (OCE)
Correct Coding
Initiative (CCI) Edits - Ambulatory
Payment Classification System (APCs)
On January 1, 1996, HCFA implemented its CCI to identify
and eliminate incorrect CPT coding of outpatient medical services.
The initiative installed a set of coding edits into each Medicare
Part B carrier's computerized claim processing system. The
edits were designed to prevent erroneous payments to physicians
and ambulatory surgical centers due to inappropriate CPT code
assignments.
HCFA contracts with AdminaStar Federal to maintain and revise
the CCI edits, and revisions to the edits are generally made
on a quarterly basis. Medicare has applied the CCI edits to
physician claims since 1996. Since their implementation, the
edits have saved Medicare over $700 million in payments. With
APC implementation, the same edits will be applied to hospital
outpatient claims.
The CCI edit file is a table of CPT-4 codes within the Medicare
Part B claim processing system. The table consists of code
pairs or "edits" separated in two columns. Column
one contains the correct code (i.e., the "payable"
code) while column two contains the incorrect or inappropriate
code in relation to the code in column one. Approximately
11,000 edits represent mutually exclusive codes, i.e., codes
that represent services that cannot be reasonably performed
at the same session. The remaining 109,000 edits are classified
as comprehensive code edits. The service represented by the
comprehensive code is paid and the component code disallowed.
Modifiers may be added to explain the circumstances of the
procedures performed if a valid reason exists for separate
reimbursement.
Hospital coders must understand CCI edits and know how to
implement edit overrides with modifiers as appropriate. If
the coder determines that a modifier is appropriate, it may
be attached to either code (but not both codes); however,
the modifier is usually attached to the column 2 code. Remember,
modifiers provide explanatory billing information to the payer.
Just because you can override an edit with a modifier doesn't
mean that you should do so inappropriately.
The following modifiers may be used to over-ride CCI edits
and should be used whenever appropriate to clearly describe
the service provided:
| E1 through E4 |
FA, F1-F9 |
TA, T1-T9 |
| LT, RT |
LC, LD, RC |
-58 |
| -59 |
-78 |
-79 |
Example: In a CCI edit for mutually
exclusive codes, the column 1 code will be paid
and the column 2 code will be denied
unless an appropriate modifier is appended to one
of the codes on the claim.
|
| Column
1 Code |
Column
2 Code |
| 63047:
Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral) with decompression of spinal
cord, cauda equina and/or nerve root(s) (e.g., spinal
or lateral recess stenosis), single vertebral segment,
lumbar. |
63042:
Laminotomy (hemilaminectomy) with decompression
of nerve root(s), including partial facetectomy, foraminotomy
and/or excision of herniated intervertebral disk,
reexploration, lumbar. |
|
Example:
In a comprehensive code edit, the column 1 code will
be paid
and the column 2 code will be denied,
unless an appropriate modifier is appended to one
of the codes on the claim.
|
| Column
1 Code |
Column
2 Code |
| 14000:
Adjacent tissue transfer or rearrangement, trunk,
defect 10 sq cm or less |
13101:
Complex repair of trunk, 2.6 cm to 7.5 cm |
|
Diagnosis
Coding - The
Outpatient Code Editor (OCE)
Correct Coding
Initiative (CCI) Edits - Ambulatory
Payment Classification System (APCs)
HCFA's Outpatient Prospective Payment
System (OPPS)
On August 1, 2000, or shortly after, HCFA will implement
the Medicare Outpatient Prospective Payment System (OPPS).
The OPPS affects reimbursement to almost all facilities that
participate in the Medicare program and bill for hospital
outpatient services. Additional regulations affect the amount
of patient copayment. Facilities that are excluded from the
OPPS include Indian Health Service Hospitals, Critical Access
Hospitals, and Maryland hospitals reimbursed under their state
payment system. A transition period extending through January
1, 2004, will allow hospitals to adjust to the new system
without suffering substantial financial loss. Rural hospitals
of fewer than 100 beds and cancer hospitals will be "held
harmless." Although their services will be grouped to
APCs, these hospitals will not receive less than cost-based
amounts for procedures performed. These facilities must still
submit their charge data according to OPPS requirements.
All services except those on the following short list will
be paid under the OPPS. The listed services are paid under
other existing fee schedules:
- Physical, occupational, and speech therapies
- Epoetin Alpha for End Stage Renal Disease (ESRD)
- Physician services for ESRD patients
- Durable Medical Equipment (DME)
- Clinical laboratory services
- Ambulance services
The OPPS is based on Ambulatory Payment Classifications (APC).
The 664 (originally 451) APC categories were developed based
on the following criteria:
- Resource homogeneity
- Clinical homogeneity
- Provider concentration
- Frequency of service
- Minimal opportunities for up-coding and code fragmentation
Like the inpatient DRG system, a payment rate is set for
each APC. Unlike the DRG system, which assigns a single DRG
per inpatient hospitalization, a single bill for multiple
hospital outpatient services may result in multiple APC payments.
According to HCFA the APC system will simplify payment, ensure
appropriate payment, and encourage efficient delivery of care.
HCFA's final rules were published in the April 7, 2000, Federal
Register and are available online.
Accurate representation of hospital charges depends upon
the following 5 critical elements:
- CPT/HCPCS code
- Revenue code
- Date(s) of service
- Units of service
- Modifier reporting
Payment Status Indicators
Without a CPT/HCPCS code to identify the service provided,
a charge will not be separately paid. Each CPT code listed
in the APC system has a status indicator that determines the
reimbursement method. Categories G, H, and J will be updated
quarterly.
|
| Indicator |
Description of Service(s)
and Reimbursement Method |
| A |
Lab,
ambulance, rehab, durable medical equipment, or other
services paid under separate fee schedule |
| C |
Inpatient
only service, not paid under APC system |
| E |
Payment
not allowed under APC system (code not used by Medicare,
noncovered service, etc.) Corneal tissue acquisition
cost, additional payment allowed |
| F |
Corneal tissue
acquisition cost, additional payment allowed |
| G |
Current
drug or biological item eligible for pass-through
payment |
| H |
Device eligible
for pass-through payment |
| J |
New
drug eligible for pass-through payment |
| N |
Incidental
service, packaged into other services or APC |
| P |
Paid
only in partial hospitalization programs |
| S |
Significant
procedure, no discounting for multiple procedures
|
| T |
Significant
procedure, discounted if other multiple "T"
procedures also performed |
| V |
Clinic or
ED visit, paid under APC rate |
| X |
Ancillary
service, paid under APC rate, no discounting for multiple
procedures |
|
Coder Concerns
The accuracy and appropriateness of CPT coding is the single
most important contribution coders can make as their facilities
transition to the new APC system. Review all available APC
resources and become familiar with the peculiarities of the
system. For example:
- Although most "unlisted" CPT codes have been
grouped to an APC, some of them have not. The four codes
that have not been grouped to an APC are 20999, 39499, 39599,
and 44899. If you must report an "unlisted" CPT
code, be sure that the billing office includes a narrative
description of the surgical procedure in the "remarks"
field of the UB-92. Most Medicare carriers also want an
operative report to accompany the claim with the unlisted
code. Contact your Medicare carrier to verify specific reporting
requirements.
- Procedures described as "complicated" in the
CPT manual sometimes, but not always, group to a higher
paying APC than similar procedures without "complicated"
in their definitions. For example, 10121, Incision and
removal of foreign body, subcutaneous tissues, complicated,
is assigned APC 0020 with a payment rate of $315.65.
Code 10120, Incision and removal of foreign body, subcutaneous
tissues, simple, groups to APC 0006 with
a payment rate of $96.97. However, 10060, Incision and
drainage of abscess, simple, and 10061, Incision
and drainage of abscess, complicated, both
group to APC 0006. Educate physicians on the importance
of their documentation and how it affects hospital reimbursement
under the new OPPS.
Practice
Makes Perfect!
Are you ready for some hands-on
practice? Print the coding quiz on our Procedure
Practice page
and circle your answers. Then compare your answers with our
Answer
Key. Good
luck!
Back to:
Top
- Diagnosis
Coding - The
Outpatient Code Editor (OCE)
Correct
Coding Initiative (CCI) Edits - Ambulatory
Payment Classification System (APCs)
If you have comments or suggestions about our
code selections or about any topic on our Coding Edge® pages,
please e-mail us at codingedge@lagunamedsys.com.
Please
understand, however, that we cannot answer inquiries
unless they relate directly to our published material.
|
