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August 2009 Edition

Hot Topics:

Coding Set Updates:

AMA Coding Guidance:

General Coding News

  • Using modifier 50 and add-on codes for facet joint injection services.
  • Payment of bilateral procedures in a method II critical access hospital.
  • Using the CR modifier and DR condition codes on disaster and emergency related claims.

    Hot Topics:

    Implementing Coding Updates: A Checklist for Success

    By Kathy Lindstrom, RHIT


    Beginning in 2005, after the signing of the Medicare Modernization Act of 2003 (MMA) by then President George W. Bush, ICD-9-CM codes are updated twice a year, on April 1 and October 1. Although the majority of updates still occur on October 1, if a new code is needed to describe new technologies or diseases, strong consideration will be made by the ICD-9-CM Coordination and Maintenance committee to release a new code on April 1st. These codes are summarized on the CMS website: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage and are also maintained on the CDC website: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm. The official ICD-9-CM guidelines may also be downloaded from this website page. CPT codes are copyrighted by the American Medical Association (AMA) and are updated once a year, in the fall, with updates effective January 1st. Changes are published and discussed in the AMA book CPT Changes: An Insider’s View.

    Review and Categorize: As soon as codes are released, review and categorize them into one of three categories: Deleted, New, and Revised. CMS conveniently provides the ICD-9-CM codes in these categories at the link provided above.

     Review the frequency of use for deleted and revised codes and create a prioritized list based upon the use of the codes for staff education purposes.

    • Gather Data. For new codes, determine how your organization is currently coding these scenarios. Are you using an unlisted code for CPT? An NOS or NEC code for ICD-9-CM? Use the current code to review the frequency of use in the past year. Review a sampling of these notes. Is there enough detail in the current note to sufficiently utilize the new code? Use these notes to create scenarios to use as test cases for training staff.

    • Review. From the new and revised code lists, review any changes within the description of the code and determine what specifically needs to be documented for proper use of the code. Review any new guidelines released on the codes use (i.e. CPT Changes or the ICD-9-CM official guidelines).
    • Delegate! Starting with your highest use codes, review the pertinent guidelines for their use and create a document that highlights the information to use for training purposes. To break up the work, delegate and distribute the review process amongst the coding staff. Being involved with the research will assist the coders in learning the complexities of the new codes.

    Train: Train staff based upon the use of the codes and any additional documentation that is needed. Meet with the coding staff first to clarify any questions they might have. Since they also might have ideas on what providers currently document or will need to document, this is an excellent starting point.

    • Get on meeting agendas now. A quick review of new codes should be a standing agenda item for provider meetings for September (ICD-9-CM) and December (CPT).
    • Think outside of your department. Reach out to other teams within your organization that use codes, i.e. registry staff, data reporters, forms coordinators and billing staff. Make sure to include this staff in your training sessions. If your facility imbeds codes within forms, make sure these are included in your coding update plan. Again, these should be standing agenda topics for September and December meetings.
    • Feedback. Create a feedback loop between coding staff and health care providers and billing staff if questions arise during implementation. If additional documentation is necessary for coding clarification, verify whether there is an existing process in place for feedback that this could piggyback or mirror.

     Implement: Since 2004, Medicare (and most insurance companies) no longer allows a grace period for accepting code changes.

    •  Make sure start days are clear for everyone. Does your staff clearly understand what code set to use and what date to use (discharge date, date of service) as a basis for their decision? Do you have a way to flag charts within the coding queue so coders are more easily aware which charts need which code sets applied?
    • Flag denials for review. Does your claims staff understand the denial codes to flag for coding review if a discontinued code is used or a new code is used to soon?

    Make a Plan! Coding updates can seem like a daunting task, but by starting with the right plan and by breaking down the work into segments, coding updates can become a normal part of your yearly operational plan.

    Editor’s Note: You can search via keyword or code, current and archived editions of the AMA Changes: An Insider’s Guide book in the CCH & MediRegs Audit and Revenue Resource Center, which is part of the new Coding Suite!

    What is ‘Meaningful Use’ of an EHR?

    By Marianne Russo, CPC, CMC

    Beginning in 2015, Medicare will begin to penalize providers by reducing their payments by one percent if they have not started to use an Electronic Health Record (EHR). The EHR must be certified and used in compliance with the guidelines defined as “meaningful use” by Medicare. 

    President Obama signed The American Recovery and Reinvestment Act of 2009 (ARRA) on February 17, 2009. The purpose of the act is to improve the health of Americans by transforming the health care delivery system. The Act authorized the Centers for Medicare & Medicaid Services (CMS) to offer hospitals and physicians a financial incentive if they become a “meaningful user” of an EHR. ARRA allotted approximately $19B in Medicare incentive payments to aid physicians in adopting an electronic medical record. The incentive payments are scheduled to begin in 2011 and go through 2016. ARRA also allotted additional funds for states to provide incentive payments to eligible Medicaid providers. A physician can be eligible for either the Medicare or Medicaid incentive payment, but not both. 

    The Meaningful Use Workshop was formed to establish the definition of “meaningful use.” The following 2011 goals and objectives were discussed during the June meeting. 

    1.      Improve quality, safety, efficiency, and reduce health disparities – To satisfy this objective, a provider must utilize a Computerized Provider Order Entry system (CPOE). The system must include a method to generate and transmit electronic prescriptions, maintain an active medication list, allergy listing, and an up-to-date problem list. The CPOE should also have the ability to record patient vital signs, create a progress note for each visit, and send reminders for follow-up care to patients. The CPOE should have the ability to create reports that can be sorted by gender, race, and insurance, etc.

    CMS will monitor the percentage of eligible providers (EP) that meet the objectives by utilizing quality measures using certified EHR technology. Some of the measures that will be monitored are similar to the current PQRI measures, e.g. patients who were administered the flu vaccine, patients with recorded BMI, smoking cessation counseling, and diabetics with A1c under control.

    2.      Engage patients and their families – A physician must provide either the patient or a family member with an electronic copy or electronic access to their clinical information. CMS will monitor compliance of this objective with reportable quality measures.

    3.      Improve care coordinationPhysicians will be required to share clinical information, including medication reconciliation, among all providers of care. Similar to the prior two goals, CMS will require quality measures to be reported.

    4.      Improve population and public health – Electronic data must be required to be submitted to immunization registries.

    5.      Ensure adequate privacy and security protections for personal health information – Providers must ensure that all HIPAA privacy and security rules are satisfied by conducting and/or updating security risk assessments. If a provider is currently under investigation for a HIPAA violation, unless the violation is resolved, the provider cannot meet “meaningful use.”

    CMS is expected to expand on these objectives for 2013 and 2015. For 2013, the goal of each objective is to “guide and support care processes and care coordination.” In 2015, CMS’ goal is to “achieve and improve performance and support care processes and on key health system outcomes.”

    A provider who implements a qualified EHR will be eligible for a maximum bonus payment of $44,000 over a five year period starting in 2011. The incentive payment will be based on an amount equal to 75 percent of certain allowable charges. Hospital-based providers are not eligible for the incentive payments. The following is a breakdown of the distribution of bonus incentive payments:












    Incentive $










    Penalties will be assessed starting in 2015 for providers who have not implemented a qualified EHR. In 2015, Medicare payments will be reduced by one percent, by two percent in 2016, and three percent thereafter. If less than 75 percent of eligible providers utilize an EHR by 2018, the reduction may increase to four percent then five percent.

    Detailed descriptions of the goals and objectives can be found at: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11113_872719_0_0_18/Meaningful%20Use%20Matrix.pdf..

    Editor’s Note:  To read more about the ARRA changes to Medicare and Medicaid you can go to the CCH Medicare and Medicaid Guide Explanations and Annotations or purchase the new CCH e-Book “Health Provisions of the American Recovery and Reinvestment Act of 2009.”

    Emergency Dialysis Services vs. EMTALA


    According to an article published in the September 2009, Dennis Barry’s Reimbursement Advisor, “Emergency Dialysis Services and Medicare Coverage,” under the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital is required to stabilize a patient and, presumably, that would include dialyzing a patient if the hospital had the capacity of doing so. However, prior to 2002, if the hospital was not certified by Medicare as a dialysis facility, it could not bill for an outpatient dialysis service since Medicare only paid a certified dialysis facility for that service.

    Accordingly, the only way a hospital that was not a Medicare-certified dialysis facility could be paid for emergency dialysis services was to admit the ESRD patient and bill the service as an inpatient service. The medical necessity of the stay, however, was typically subject to challenge because a patient in this condition would not, in many instances, be expected to need an inpatient stay of 24 hours or more.

    Policy revision. To address this conflict, CMS revised the Medicare Claims Processing Manual, Pub. 100-04, Ch. 4, sec. 200.2, in 2002 to allow Medicare coverage for outpatient dialysis furnished in an emergency situation in an outpatient hospital setting when the hospital is not an approved dialysis facility. In analyzing the conflict, CMS thought it was appropriate to pay for “emergency dialysis” when it was not “routine;” yet if routine, there is a presumption of coverage that a patient who is enrolled in Medicare as an ESRD patient and, therefore, would ordinarily be receiving routine dialysis on a scheduled basis. “Routine” dialysis is defined by CMS as the three times per week maintenance treatment the same patient would normally receive at his or her home facility. They would consider a patient to be receiving routine dialysis if the claims received from the outpatient department indicated that the same patient received dialysis treatment more than once a week in this setting.

    State law conflicts. Unfortunately, CMS’s policy revision does not completely eliminate the problem. Under the state hospital licensure laws in some states, a hospital may not furnish outpatient dialysis services unless licensed to do so, and obtaining and maintaining such licensure is not practical for a hospital that only performs emergency dialysis services. Thus, state law may require hospitals to admit patients for emergency dialysis. If a hospital, however, were to admit a Medicare dialysis patient for emergency dialysis in order to avoid violating state law, Medicare may not reimburse for a bill for an inpatient admission that was not medically necessary. In such instances, it is recommended that hospitals follow Medicare’s instructions for “condition code 44” billing, and bill the case as an outpatient service even though the patient had been admitted as an inpatient. Condition code 44 (inpatient admission changed to outpatient) is used on outpatient claims when the physician ordered inpatient services but, upon internal utilization review before the claim was originally submitted, the hospital determined the services did not meet its inpatient criteria.

    Dennis Barry’s Reimbursement Advisor, Emergency Dialysis Services and Medicare Coverage, Vol. 25, No. 1, Sept. 2009. To view this newsletter electronically, you can go to IntelliConnect where it accessible under “News” or on the IRN on the Health Care Reimbursement Tab, under the Reimbursement Integrated Library blue bar.

    Code Set Updates:

    FY 2010 MS-DRG Update


    The fiscal year (FY) 2010 MS-DRGs have been released by CMS. These code updates become effective October 1, 2009. This update includes changes to relative weight values for most MS-DRGs. To view all modifications to this code set, go to the Search Code Sets tab in CCH Coding Comply, select the DRG code set, in the Refine Search box, de-select the Return active codes effective as of: box, then select Modified for Filter by Actions, in the Start Date enter 10/01/2009 and click Search.

    AMA Coding Guidance:

    July 2009 CPT® Assistant


    The CPT® Assistant newsletter for July 2009 has been released and is now reflected in CCH Coding Comply and the CCH & MediRegs Coding Suite.

    Coding Communication: Nursing Facility Services.


    The current codes that are used to report Nursing Facility Care Services are 99304-99310 and 99318. In 2008, typical time spent by a physician for these services was added to the codes in this section. Time was added to help physicians choose the appropriate level of care but should not be the sole deciding factor unless counseling and/or coordination of care dominated the encounter with the patient and/or family. Initial Nursing Facility Care codes (99304-99306) should be reported when a new or established patient is admitted or readmitted to the nursing facility. Subsequent Nursing Facility Care codes (99307-99310) should be reported for all care at the nursing facility after the initial nursing facility visit and Nursing Facility Discharge Services codes (99315 and 99316) should be used to cover an emergency transfer to an acute care setting, death, or the discharge assessment and planning that occurred in the days immediately before the actual discharge. Other Nursing Facility Care Services (99318) is used to report an annual nursing facility assessment which the facility would complete to aid in creating a multi-disciplinary care plan.

    On-Line Medical Evaluation.


    Category III code 0074T was deleted in 2008 and replaced by Category I code 99444, On-line evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network. This code is not intended for new patients or established patients with an emergent medical issue or a condition whose diagnosis and treatment could only be accomplished by visual inspection. This CPT code should only be reported once and should not be reported at all if the on-line service refers to E/M services performed and reported by the same physician in the last seven days or if the service falls within the postoperative global period of a previously completed procedure. To report on-line medical evaluations by a non-physician, 98969 should be reported.

    Preventive Medicine Services.


    CPT codes 99381-99397 are used to report preventative medicine E/M services in infants, children, adolescents, and adults. There are two subcategories of care within this range of codes:

    • Initial preventive medicine E/M service for new patient visits (99381-99387); and
    • Periodic preventive medicine reevaluation and management services for established patient visits (99391-99397).
    These codes include an age and gender appropriate comprehensive history and examination for both new and established patients. Also included in the services is the ordering of laboratory and diagnostic procedures. The performance of immunization administrations and ancillary studies involving laboratory, radiology, other procedures, or screening tests should be reported separately with the appropriate CPT code.

    Revisions to Prolonged Services (Codes 99354-99357).


    In 2009, revisions were made to the Prolonged Physician Service codes (99354-99357) to better clarify the reporting of these services. These codes are to be used in addition to the designated E/M service for the visit and any other physician services provided at the same session. CPT codes 99354 and 99355 are used to report face-to-face time by the physician in the office or any other outpatient setting and 99356 and 99357 are used to report services provided by a physician in an inpatient setting. For both the inpatient and outpatient setting the time spent by the physician does not need to be continuous to be reported as prolonged services, it is reported as a total amount of time on a specific date. Codes 99354 and 99356 should be reported only once per date of service. With the revision of these codes, Modifier 21 was deleted because the CPT coding system recognized there were two ways to report prolonged services, which goes against the principle of having a single way to report an individual service.

    Coding Consultation: Questions and Answers.


    An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of evaluation and management: home services and surgery: digestive system and musculoskeletal system. The responses answer multiple questions including: our physician is coordinating and supervising the care of a patient who is at home; what is the appropriate code to report and our gastroenterologist performed an endoscopic pancreatoscopy (code 43273) and a sphincterotomy (code 43262); should the sphincterotomy be separately reported or is this procedure inherent and inclusive to the endoscopic pancreatoscopy?

    To view these articles via CCH Coding Comply, search from the Search Code Sets tab in Coding Comply for any of the codes listed above, view the Related Documents by clicking on the paper icon next to the code, then select the article. To view these articles on REX go to the CPT® Assistant Archives folder and in the Search field within this folder and enter “July 2009.”

    General Coding News


    Using modifier 50 and add-on codes for facet joint injection services.

    A review of facet joint injection services performed in 2006 was completed by the Office of the Inspector General (OIG). The review found that physicians were often reporting an inappropriate add-on code to represent bilateral facet joint injection instead of using modifier 50. The full report was released by the OIG as "Medicare Payments for Facet Joint Injection Services,” OEI-05-07-00200.

    The two primary codes that should be reported for this type of service are 64470 (Injection; anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) and 64475 (Injection; anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar/sacral, single level). The difference between these two primary codes is that one applies to cervical or thoracic areas of the spine while the other covers the lumbar/sacral areas. Both of the primary codes are used to report a single level of injection. There are two add-on codes that can be reported in addition to primary codes 64470 and 64475. The two codes are: 64472 (Injection; anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level) and 64476 (Injection; anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar/sacral, each additional level). These codes should be reported when an additional joint level receives an injection, not when the same joint level receives an injection on the right and left side. If an injection is done on both the right and left sides of the same joint level, then modifier 50 should be reported to cover the bilateral procedure. One-Time Notification Manual, Pub. 100-20, Transmittal No. 526, July 31, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,263 in the August 10, 2009 CCH Coding Comply What’s New newsletter; or on Rex via the Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the title “R526OTN Appropriate Use of Modifier 50 and Add-On Codes for Facet Joint Injections Services.”

    General Coding News


    Payment of bilateral procedures in a method II critical access hospital.

    If a physician has rendered his or her billing rights to a Method II Critical Access Hospital, bilateral procedures are payable by Medicare when the procedure is authorized as a bilateral procedure. Bilateral procedures are generally reported by appending modifier 50 to the HCPCS code for the procedure. Modifier 50 would not be reported if the procedure is identified in the description as bilateral or unilateral. If modifier 50 is being used to report a bilateral procedure then modifiers LT and RT should not be reported. Medicare uses the payment policy indicators from the Medicare Physician Fee Schedule to determine if a particular HCPCS/CPT code is authorized as a bilateral procedure. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1777, July 24, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,246 in the August 3, 2009, CCH Coding Comply What’s New newsletter; or on Rex via the Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the title “R1777CP 2009 Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH).”

    General Coding News


    Using the CR modifier and DR condition codes on disaster and emergency related claims.

    In response to Hurricane Katrina, CMS developed a condition code (DR) and modifier (CR) to help in the processing of claims affected by the hurricane. In addition to helping with Hurricane Katrina, the DR condition code and the CR modifier were approved for use on claims or items and services affected by future emergencies. The CR modifier should be appended to claims for Part B items or services in either institutional or non-institutional billing. Modifier CR is required if an item or service is affected by an emergency or disaster. If an emergency or disaster impacts an item or service, a formal waiver is required for Medicare payment. A formal waiver can be defined as a waived program requirement that would otherwise apply by statute or regulation. Additionally, if a contractor or CMS determines that modifier CR is required to efficiently process claims or to administer the Medicare fee-for-service program, the modifier must be applied. In the event of an officially declared emergency, contractors should advise providers and suppliers which HCPCS codes and dates of service are impacted by the mandatory use of the CR modifier. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1784, July 31, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,257 in the August 10, 2009, CCH Coding Comply What’s New newsletter; or on Rex via the Coding Suite in the CMS Transmittals and MLN Matters Articles folder under the titles “R1784CP The Use of the CR Modifier and DR Condition Code on Disaster/Emergency-Related Claims.”


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    Editor's Note

    The August edition of the Coding Compliance Advisory newsletter kicks off the inclusion of “Hot Topic” stories by the CCH & MediRegs Coding Advisory board members. These board members are leading experts in the health care industry who are skilled at explaining complex coding, billing, reimbursement, and compliance topics with practical knowledge. This month’s edition includes hot topics by board member, Kathy Lindstrom, RHIT, who discusses best practices for implementing annual coding updates so that your facility can avoid denied claims and improper reimbursement; and board member, Marianne Russo, CPC, CMC, who discusses what “meaningful use” of an electronic health record requires based on The American Recovery and Reinvestment Act of 2009. As we wrap up summer and head into the busy season for the health care industry, we will be bringing you stories from our board members on such topics as: prescreening for IRFs; CAH billing, coding and compliance issues; the nuances of knee coding; explanation of modifiers and the global package; and much more!

    Best Regards,

    Nicole Stone, Managing Editor

    About the Authors

    Kathy Lindstrom is a professional coder for Provation, a Wolters Kluwer Health company, where she primarily focuses on physician clinical coding, ICD-9, ICD-10, and CPT coding. Kathy also focuses on terminology coding, which involves analyzing data from SNOMED, RxNorm, LOINC and MEDCIN. She is a member of the CCH & MediRegs 2009 Coding Advisory Board.

    Marianne Russo is the Reimbursement Manager for Clinical Practice Management Plan, where she has been employed for over 25 years. She currently manages the regulatory guidelines of the Medicare and Medicaid programs for 18 multi-specialty clinical practices. She is a member of the CCH & MediRegs 2009 Coding Advisory Board.

    Upcoming Free Webinars

    Introducing the Coding Suite. Held on 9/16/2009 at 2pm EDT and 10/14/2009 at 2:30pm EDT. To register, click here.

    Special Topic Webinar – “Evaluation and Management.” Held on 9/30/09 at 1pm EDT. Registration TBD.

    Upcoming future special topic webinars include: IPPS Coding Changes in 2010 held in October; OPPS Coding Changes in 2010 held in November; and 2010 Coding Changes held in December.

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