Physician Supervision in the Hospital Outpatient Setting

  By Robin Miller Zweifel, BS, MT (ASCP)

In today’s healthcare environment the word – audit – has become part of our day to day conversation, as well as the subject of multiple team meetings, the cause of work-a-rounds and the basis for revised processes. At the end of the day, the goal is to learn from the errors or weaknesses identified and hopefully improve upon documentation, develop efficient processes and insure compliant claims processes.

A key weakness frequently identified during the audit of infusion services is the inconsistency with which procedures are documented in the outpatient patient record. Regardless of whether your facility currently utilizes a manual documentation system or if you are utilizing an electronic health record for entry of nursing notes and completion of medication administration records there are probably variances in the documentation formats used by clinical staff. Consider an encounter that initiates in the Emergency Department with a patient who presents with fever of unknown etiology, and 3+ nausea and vomiting.

Probable UTI requiring admission to observation for administration of antibiotics:

A primary IV line is initiated in the Emergency Department and hydration therapy is begun. To alleviate the patient’s complaint of nausea and vomiting Zofran is administered by IV push injection through a port in the IV line. Orders are sent to the pharmacy for IV antibiotic and a short stay observation room is requested. The patient is subsequently transferred from the Emergency Department (with hydrating fluids continuing) to the medical unit for observation.

Upon arrival to the medical unit a brief nursing assessment is completed; physician orders for IV antibiotic over 1 hour each 8 hours are noted. The patient’s IV line is assessed and patency noted. The first dose of IV antibiotic is prepared and hung for infusion.

In this scenario patient care has crossed from one department to another with at least three – maybe more – persons notating services and care provided. This is where standardized documentation formats improve efficiency by enhancing coding accuracy and insuring accurate claims processing.

1. In the Emergency Department IV hydration (96361) was initiated and an IV push injection (96374) was performed.

Applying the AMA CPT hierarchy logic for infusion services - at this point - the primary procedure will be the IVP injection of Zofran. Depending on the total time recorded for hydration therapy the secondary service may be billable, but only if the start and stop time support a time increment of 31 minutes or more.

Did documentation from the E.D. transfer with the patient to the medical unit?

2. The patient is transferred to the medical unit where the IV line patency is checked; however, there is no notation of hydrating fluids continuing during the observation stay. Without complete documentation for determining time increment and calculation of billable units of service for hydration therapy there will be no billable charge for CPT 96361.

Why is there no documentation of the stop time for hydration recorded by clinical staff on the medical unit?

Are injections and infusions that are performed on the medical and surgical units documented with start and stop times?

3. Based on the physician order we know that the antibiotic will be administered by IV infusion over a period of one hour. Again, referencing the AMA coding hierarchy the antibiotic therapy (96365) now replaces the IV push injection as the primary procedure. At this point, the IVP becomes a secondary service and the procedure should be billed with CPT 96375 instead of 96374.

Is clinical staff expected to differentiate between inpatient and outpatient encounters and document differently for billable procedures performed during an observation stay?

4. If each department’s charge capture procedures are performed independent of one another the potential is high for incorrect billing of two primary services. If two primary / initial CPT codes appear on the same date of service on the outpatient claim there are correct coding initiative (CCI) edits that will reject the claim. Edit resolution necessitating revision of procedure coding will require validation against the patient record.

When claim edits are encountered what processes are in place for compliant resolution?

At discharge it will be necessary to close the record and confirm that all billable charges have been fully documented and accurately captured for billing of the outpatient encounter. Will the complete record be reviewed and CPT selection and unit of service calculations be validated before the claim is generated?

Clinical staff must be reminded of the need for complete and accurate documentation of an encounter – including communication with physician, verbal orders and authentication of revised treatment – to support billed charges. Every entry in the medical record must be dated and timed. Intravenous infusions and IVP injections require documentation of start and stop time for each procedure. Any late entry to the chart occurring subsequent to the date services were provided should reference the date of service in the text of the entry, but use the current date to denote date entered in the record.

Editor's Note: You can view CCI Edits via the NCCI Code Pair Checker tool available via the NCCI tab in either the Audit and Revenue Resource Center or Coding and Revenue Resource Center; or via the Code Book tab in the Coder’s Resource Center—all of which are part of The Coding Suite!

The Dilemma of Post Inpatient Hospital Care

   By Georgeann Edford, RN, MBA, CCS-P, CPC

Gone are the days when patients stayed in the hospital for a week following major surgical procedures, particularly orthopedic procedures. Both the Centers for Disease Control and Prevention (“CDC”) and the World Health Organization (“WHO”) report that approximately 30% of people over 65 fall each year, and for those over 75 the rates are higher. (Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community–dwelling older persons: results from a randomized trial. The Gerontologist 1994:34(1):16–23.) Between 20% and 30% of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death. (Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.) Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes. (Ibid.)

Baby Boomers approaching the bewitching age of 65 as well as children of aging parents will both have to struggle with the dilemma of making the decision regarding what type of care will be needed after hospitalization. Working through the maze of choices can be daunting. The options are inpatient rehabilitation facility (“IRF”), a skilled nursing facility (“SNF”), home with or without a care giver and Home Health care, or outpatient therapy for physical, occupational or speech therapy. However, not all options are available for each patient as every option has qualifications that must be met.

Admission to an IRF requires the presence of one of 13 conditions specified by CMS. If an individual does not have one of these conditions, admission to an IRF is not a certainty. An IRF provides the intensity of care seen in the inpatient hospital setting with an emphasis on restoring the level of functionality the patient had prior to the illness or injury. In contrast, admission to a SNF provides skilled care which is less intense but still focused on restoring function albeit at a slower pace. In both instances, the patient must have medical conditions that requirement treatment beyond physical, occupational and speech therapy. The following chart represents a comparison of the differences in the type of care provided by an IRF and a SNF:

 

Inpatient Rehab Facility	Skilled Nursing Facility
-        Realistic potential for rehab	-        Realistic potential  for rehab
-        Close medical supervision by a physician with specialized training in rehab or experience in rehab	-        Physician certification of the need for a skilled level of care.
-        24 hour rehab nursing care	-        24 hour skilled or rehab nursing care based on physician order
-        Intense level of therapy – typically up to 3 hours of therapy per day	-        Level of therapy ranges from zero to 2.5 hours per day
-        Multi-Disciplinary Team Approach	-        Multi-Disciplinary Team Approach
-        Coordinated Program of Care	-        Coordinated Program of Care
-        Significant Practical Improvement	-        Significant Practical Improvement
-        Realistic Goals	-        Realistic Goals

Patients requiring therapy who also have medical conditions who are home bound may benefit from home health care if there is no family member willing or able to assist in the providing care.

 Summary

The benefits of a healthy life-style that includes exercise and a balanced diet are critical factors in preventing falls in both the middle age and older adults. Preserving independence and taking steps to reduce the risk of falling should be ingrained in the mindset of aging adults and children taking care of aging parents. The CDC recommends the following steps toward preventing falls in the elderly:

• Exercise regularly; exercise programs like Tai Chi that increase strength and improve balance are especially good.
• Ask their doctor or pharmacist to review their medicines–both prescription and over-the counter–to reduce side effects and interactions.
• Have their eyes checked by an eye doctor at least once a year.
• Improve the lighting in their home.
• Reduce hazards in their home that can lead to falls.

At the end of the day, Ben Franklin said it best—“An ounce of prevention is worth a pound of cure.”  

Editor's Note: The regulations at 42 CFR 412.23(b), 412.25, 412.29, and 412.30 specify the criteria for a provider to be classified as an IRF. Further, to calculate specific reimbursement for SNF and IRF patient claims, click on IRF or SNF under the “Special Topics” heading in the gray left static pane of the Audit and Revenue Resource Center tier of The Coding Suite.

2010 CPT® Update

   By Jennifer Ridell, CPC

The 2010 CPT® annual update has been released and is now reflected in CCH Coding Comply and will be reflected in The Coding Suite HCPCS and CPT Code Book by the end of October. The update, effective January 1, 2010, includes: over 150 new codes—21011-21016, 51727-51729, and 78451-78454; over 170 modified—99304-99318, which relate to nursing facility care, initial and subsequent; and over 60 deleted codes—64470-64476, 75558, 75560, 75562, and 75564.

In addition to the code updates noted above, the AMA released additional information pertaining to H1N1 codes and data format. In a response to an urgent request from the Department of Health and Human Services, the CPT Editorial Panel voted to create a new code, and to revise another, to be used for reporting related to the H1N1 virus. These changes were approved by the Panel on September 25 and have an effective date of September 28, 2009. The new code, 90470 covers the administration of the H1N1 immunization and the revised code; and 90663 now refers directly to the H1N1 vaccine product. The creation of these H1N1 specific codes should make reporting and reimbursement a lot easier on everyone, considering the large volume of vaccinations expected to be administered in the coming months. Note: since these changes were made so late in the year, they will not be included in the 2010 CPT® Code Book but are expected in the 2011 CPT® Code Book.

“Resequencing” CPT Codes. The AMA further announced their plan to minimize the confusion that has been created in the past when a new code has been added in a section that has run out of numbers in a sequence. This used to be handled by deleting the existing codes and assigning the entire section to a new code range with the required space. This new process is being called “resequencing” by the AMA and is expected to be used on rare occasions. “Resequencing” basically means that instead of moving a whole group of codes, a code that is out of numeric order might be used in an entirely different section if that section has run out of space but needs to accommodate a new code. Also, this will allow the AMA to put in place a new rule for deleted codes which will be to not reuse a deleted code for a period of ten years. As we move to an electronic world, the benefits of this new policy are great. The old process resulted in codes being deleted just to accommodate a new code and this practice made researching historical information more difficult. Providers and payers struggled when a code was deleted and then reappeared somewhere else with a different code number but the same code description. These changes should help to ensure data quality and integrity in the future.

When “resequencing” is used, there will be multiple steps taken by the AMA to make sure it is clear to everyone what is happening. In the print version of the CPT data, the resequenced number will be out of numeric order but grouped with the other codes in the content section it pertains to. A new symbol (#) will be added to the code to make it easy to identify it as a resequenced code and a place holder at the proper spot in numeric order will be added to direct users to the range where the code can be found. These changes will also have an impact on any area where in the past, a range of codes was referenced. This mainly applies to cross-references, parentheticals, and introductory notes and it will be addressed by using specific lists of codes instead of ranges. There is no impact expected to AMA electronic versions of the CPT data as that will still be provided in numeric order as it always has been released in the past.

To view these updates to the CPT code set on IntelliConnect or the IRN, go to the Search Code Sets tab in CCH Coding Comply, select the CPT code set, select added, modified, and/or deleted in the Filter Actions and in the Start Date field enter 01/01/2010. Via the search results, you will be able to export all or some codes by checking the box next to individual codes or the “Select All” box; and then clicking on the “Export” icon in the upper right corner of the screen. The exported results will contain the CPT code, long description and projected revenue codes in either Excel or a text format.

August 2009 CPT® Assistant

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

Therapeutic Apheresis: Codes 36511-36522.

CPT codes 36511-36522 are used to report therapeutic apheresis procedures. This procedure is used to separate and remove one or more blood constituents and then return the treated blood to circulation. Therapeutic apheresis is performed to treat disorders like acute Guillain-Barré syndrome and sickle cell anemia. Specifically, CPT code 36516 is used to report the selective removal of low density lipoprotein (LDL)-cholesterol from the plasma of patients with familial hypercholesterolemia. Specialists in internal medicine, cardiology, pathology, nephrology, endocrinology, and hematology primarily perform this procedure. There are strict eligibility requirements for this procedure, including the determination that the serum lipids can not be controlled with diet and drug therapy and the FDA has LDL-apheresis eligibility requirements as well. When billing for this service, modifier 26 is used to report physician evaluation of the patient. The physician is not expected to operate the apparatus used during the procedure, as that is typically done by a nurse or other health professional, but the physician does need to remain on the premises to respond to emergencies and to periodically assess the status of the patient.

Cataract Extraction/Intraocular Lens Insertion (IOL): Codes 66840-66985.

There are two main types of cataract extraction, extracapsular or intracapsular. Extracapsular extraction is the most common procedure for cataract removal and it is reported with CPT codes 66840-66852, 66940, 66982, and 66984. This procedure includes the removal of lens material while leaving the posterior capsule in tact. Intracapsular extraction is less commonly used and it includes the removal of the entire lens including the posterior capsule. This procedure should be reported with CPT codes 66920, 66930, and 66983. It is important to report modifier LT or RT with the codes listed above along with modifier 51 for the physician services related to the code for a secondary procedure.

Coding Communication: Haemophilus influenzae type b (Hib) Vaccine Booster Dose.

Due to a shortage of the Haemophilus influenzae type b (Hib) vaccine in the United States, the Advisory Committee on Immunization Practices (ACIP) recommended that the administration of the Hib vaccine booster be deferred. Just this past June, the U.S. Centers for Disease Control and Prevention, ACIP, the American Academy of Pediatrics, and the American Academy of Family Physicians recommended the reinstatement of the booster vaccine for children ages 15 months through four years of age that had completed the primary series of the Hib vaccine (first through third doses). On August 19, the Food and Drug Administration approved the use of an additional PRP-T conjugate vaccine from GlaxoSmith-Kline called Hiberix® as a booster vacine because the anticipated supply of the Hib vaccine is expected to be insufficient to vaccinate all children with deferred Hib boosters. CPT code 90648, hemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use to report Hiberix® for the booster dose (4th dose) of the Hib -vaccination series, has been approved for use in reporting the booster by the Vaccine Coding Caucus which is a committee of the CPT Editorial Panel. Additionally, the proper administration code (90465, 90466, 90471, or 90472) should also be reported, based on the age of the patient.

Transurethral Radiofrequency (RF) Micro-Remodeling of the Female Bladder Neck and Proximal Urethra for Stress Urinary Incontinence.

The Food and Drug Administration has approved the use of transurethral radiofrequency bladder neck and urethra micro-remodeling for the treatment of female stress urinary incontinence due to bladder outlet hypermobility. A new Category III code, 0193T, was added to the CPT code set in 2009 to cover this procedure. There may be multiple cycles needed to complete this treatment, but only one unit of 0193T is needed to report all the cycles performed during an encounter. Additionally, this new code includes the insertion of a non-indwelling bladder catheter, so it should not be reported in conjunction with code 51701.

CPT® and RBRVS Annual Symposium 2010.

The American Medical Association is hosting their annual CPT and RBRVS Symposium for 2010 in Chicago on November 11 - 13, 2009. This meeting will provide insight into the coding and physician payment changes for 2010. The topics that will be covered include: CPT 2010 resequencing principles, ICD-10 overview and introduction to claim form 5010, and excision of soft and bone tumors. Registration information can be found at www.ama-assn.org/go/symposia or by calling the AMA Customer Service line at (800) 621-8335.

Coding Clarification: Questions and Answers

An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of evaluation and management: preventive medicine services and surgery: musculoskeletal system. The responses answer questions with information related to CPT codes 27685, 27686 (lengthening or shortening tendon in the leg or ankle procedures) and 99406, and 99407 (smoking cessation E/M codes).

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 in The Coding Suite go to the CPT® Assistant Archives folder and in the Search field within this folder and enter “September 2009.”

Annual update of the influenza vaccine payment allowances.

Effective September 1, 2009, payment allowances were set based on 95 percent of the average wholesale price for the influenza virus vaccines reported with CPT codes 90655, 90656, 90657, 90658, and 90660. The payment allowance of CPT 90660 (FluMist®, a nasal influenza vaccine) is permissible if its use is medically reasonable and necessary. These payment allowances are set annually. Additionally, payment allowances for pneumococcal vaccines are based on 95 percent of the average wholesale price and are updated on a quarterly basis. The current payment allowances for pneumococcal vaccines can be found in the quarterly drug pricing files. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1824, Oct. 2, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,468 in the October 12, 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 “R1824CP Influenza Vaccine Payment Allowances - Annual Update for 2009-2010 Season.”

Information regarding exceptions to the clinical criteria described in a LCD.

Effective October 13, 2009 Medicare administrative contractors, fiscal intermediaries, and carriers have the ability to create an exception to the clinical criteria contained in a LCD. This practice will likely occur under rare and unusual circumstances and will be based on a thorough review of the medical record and relevant evidence in medical literature. When an exception is made, detailed information related to it will be placed in a log maintained by the contractor. If exceptions to a particular LCD are not rare, a thorough review of that particular LCD by the contractor should be conducted to be sure it is as clear and accurate as it can be. Medicare Program Integrity Manual, Pub. 100-09, Transmittal No. 303, Sept. 25, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,461 in the October 5, 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 “R303PI Local Coverage Determinations (LCD) Exceptions.”

Maintenance and update information for hook and hold claims.

Payment for outpatient drugs by CMS is determined by using the Average Sales Price methodology. Drug companies are required to submit data for ASP pricing within 30 days of the close of their fiscal quarter. It takes approximately six weeks to process this information and to issue final ASPs for a specific quarter. The OPPS Pricer is updated the first day of every month but it will not contain the updated ASP data for certain drug HCPCS codes since there is a delay in processing that information. The Fiscal Intermediary Shared System has been instructed to hook and hold claims with dates of service on or after the first day of each quarter with bill types 12x, 13x, or 76x, and with one or more drug HCPCS codes. The drug HCPCS code needs to be found on the list of applicable codes which is updated quarterly. Specifically, the ASP rates for drugs furnished on or after January 1, 2010 will not be available until mid-December 2009 which means Fiscal Intermediaries and A/B Medicare Administrative Contractors would not begin to release hooked claims until January 8, 2010. Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 1820, Sept. 25, 2009. This transmittal can be viewed on the IRN or IntelliConnect at ¶158,457 in the October 5, 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 “R1820CP Maintenance and Update of the Temporary Hook Created to Hold OPPS Claims that Include Certain Drug HCPCS Codes.”