RPA NEPHROLOGY CODINGRPA NEPHROLOGY CODING AND BILLING SEMINARSAND BILLING SEMINARS 20122012
1 Coding and Billing for Coding and Billing for Nephrology PracticesNephrology Practices
Debra Lawson, CPC, PCSDebra Lawson, CPC, PCS Nephrology Billing & Management Services, LLC. Rogersville, Tennessee 2 Breaking NewsBreaking News ……...... ......
CRIME RATES RISECRIME RATES RISE
Perpetrators caughtPerpetrators caught Accomplices namedAccomplices named Details at 11Details at 11
3 IT CANIT CAN ’’T HAPPEN TO ME!T HAPPEN TO ME!
Been in practice for years and every time Been in practice for years and every time they look itthey look it ’’s been OKs been OK II’’ll ll ““fly under the radarfly under the radar ”” so they wonso they won ’’t look at t look at meme It happened to Dr. Joe, but everyone knows It happened to Dr. Joe, but everyone knows hehe ’’s a crooks a crook II’’m a small fish, they will go after the big m a small fish, they will go after the big guysguys
4 WHAT MAKES YOU A WHAT MAKES YOU A TARGET?TARGET? Time lapse in getting to the documentationTime lapse in getting to the documentation Lack of documentationLack of documentation Sloppy documentationSloppy documentation Lack of knowledge of the documentation rulesLack of knowledge of the documentation rules Thinking documentation is Thinking documentation is ““just for billingjust for billing ”” and and is not important is not important –– it has nothing to do with it has nothing to do with medical caremedical care II’’m a specialist m a specialist –– all my services are high levelall my services are high level
5 WHO IS LOOKING?WHO IS LOOKING?
The Audit Alphabet SoupThe Audit Alphabet Soup –– CMSCMS –– CERTCERT –– RACRAC Isn’t it amazing…..they can look –– OIGOIG at us, but who is looking at them! –– MICMIC –– ZIPZIP
6 WHY WOULD THEY LOOK AT WHY WOULD THEY LOOK AT ME?ME?
Billing for services not renderedBilling for services not rendered Intentional upcoding or downcoding servicesIntentional upcoding or downcoding services Billing one provider under another providerBilling one provider under another provider ’’s s numbernumber Billing Billing ““incident toincident to ”” services when the services when the physician is not in the suitephysician is not in the suite ““MonotoneMonotone ”” billingbilling
7 WHO ARE THE TARGETS?WHO ARE THE TARGETS?
Large practicesLarge practices Small practicesSmall practices Hospital owned practicesHospital owned practices Teaching practicesTeaching practices Joint venturesJoint ventures YOU!YOU!
8 WHO ARE THE HIRED GUNS?WHO ARE THE HIRED GUNS?
RAC RAC –– As of March 27, 2008 CMS reported As of March 27, 2008 CMS reported that the RAC had that the RAC had ““succeededsucceeded ”” in correcting in correcting more than $1 billion in improper payments more than $1 billion in improper payments from Medicare from Medicare –– 96% ($992.7 million) in 96% ($992.7 million) in overpayments and 4% (37.8 million) in overpayments and 4% (37.8 million) in underpayments returned to providersunderpayments returned to providers – www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
9 WHEN WILL THEY COME FOR WHEN WILL THEY COME FOR YOU?YOU? The Tax Relief and Health Care Act of 2006 The Tax Relief and Health Care Act of 2006 made the RAC permanent and mandated made the RAC permanent and mandated that CMS expand the program to all 50 that CMS expand the program to all 50 states by 2010states by 2010 Third party auditors hired by CMS will Third party auditors hired by CMS will conduct the auditsconduct the audits They will keep a percentage of what is They will keep a percentage of what is collectedcollected
10 HOW DO THEY IDENTIFY HOW DO THEY IDENTIFY PROBLEM CLAIMS?PROBLEM CLAIMS? Automated review Automated review –– conducted without conducted without review of the medical record supporting the review of the medical record supporting the claimclaim Complex review Complex review –– analyzes actual medical analyzes actual medical records supporting claims under records supporting claims under investigationinvestigation Cannot review any claims prior to Oct. 2007Cannot review any claims prior to Oct. 2007
11 COMPLEX REVIEWSCOMPLEX REVIEWS
OnOn --site reviews look at the providersite reviews look at the provider ’’s s records in personrecords in person May request a mail or secure transmission May request a mail or secure transmission of the records to the RACof the records to the RAC May review 10 records per 45 days for solo May review 10 records per 45 days for solo practitionerspractitioners If not received within 45 days RAC may If not received within 45 days RAC may render a overpayment decision without render a overpayment decision without reviewreview 12 PROVIDERPROVIDER ’’S RIGHTSS RIGHTS
May request an extension to secure and May request an extension to secure and forward records to the RACforward records to the RAC RAC must follow Medicare policies, RAC must follow Medicare policies, regulations, national and local carrier regulations, national and local carrier determinations and manual instructionsdeterminations and manual instructions Must follow Medicare coverage, coding and Must follow Medicare coverage, coding and billing policies and may not apply their ownbilling policies and may not apply their own
13 APPEAL OF A RAC DECISIONAPPEAL OF A RAC DECISION
Redetermination Redetermination –– 120 days from denial120 days from denial Reconsideration Reconsideration –– 180 days from 180 days from redetermination by Qualified Independent redetermination by Qualified Independent Contractor (QIC)Contractor (QIC) Administrative Law Judge hearing (60 days after Administrative Law Judge hearing (60 days after QIC)QIC) Medicare Appeals Council (MAC) hearing (60 Medicare Appeals Council (MAC) hearing (60 days after ALJ)days after ALJ) Federal District Court (60 days after MAC)Federal District Court (60 days after MAC)
14 SUCCESS RATE IN APPEAL?SUCCESS RATE IN APPEAL?
Providers have been successful 34% of the Providers have been successful 34% of the time the claims were challengedtime the claims were challenged This may be low given the number of This may be low given the number of appeals still pendingappeals still pending Because of the incentive given the RAC to Because of the incentive given the RAC to find errors, providers should consider an find errors, providers should consider an appeal if they think the RAC is erroneousappeal if they think the RAC is erroneous
15 ARE THEY ALWAYS RIGHT?ARE THEY ALWAYS RIGHT?
Just because you have gotten information Just because you have gotten information about a RAC determination, donabout a RAC determination, don ’’t always t always assume it is the correct decisionassume it is the correct decision Recently there was an erroneous decision Recently there was an erroneous decision by Connolly Consulting Associates (Region by Connolly Consulting Associates (Region ““CC”” RAC) that involved numerous providers RAC) that involved numerous providers from West Virginia to Texas. This decision from West Virginia to Texas. This decision was involving hospital admissions during a was involving hospital admissions during a month the MCP was providedmonth the MCP was provided
16 HOW DO WE PREPARE FOR HOW DO WE PREPARE FOR AN AUDIT?AN AUDIT? ““An ounce of prevention is worth a pound of An ounce of prevention is worth a pound of curecure ”” applies to auditing as much as to applies to auditing as much as to medicinemedicine Look at how things are doneLook at how things are done …….objectively .objectively not just in how is should be donenot just in how is should be done EducationEducation Corrective action Corrective action –– if you are not going to if you are not going to take the steptake the step ……dondon ’’t do the auditt do the audit
17 DOCUMENTATIONDOCUMENTATION GUIDELINESGUIDELINES
18 ICD 9ICD 9
What is the patients problem that YOU are What is the patients problem that YOU are addressing?addressing? Is it a symptom or a diagnosed condition? Is it a symptom or a diagnosed condition? Is it singular or multiple?Is it singular or multiple? Is the clinical picture reflected complete?Is the clinical picture reflected complete? How is it recorded?How is it recorded? –– In the chartIn the chart –– On the billOn the bill
19 CPTCPT What is the physician service What is the physician service YOU YOU performed?performed? –– Are the elements of documentation guidelines Are the elements of documentation guidelines reflected?reflected? –– Where did you do it? (site of service)Where did you do it? (site of service) –– How is it categorized? (screening or treatment)How is it categorized? (screening or treatment) –– How is it recorded?How is it recorded? In the chart On the bill
20 INTRODUCTIONINTRODUCTION
““The proof is in the detailThe proof is in the detail ”” The medical record is not only a document The medical record is not only a document for billing but also a chronological record of for billing but also a chronological record of the care that is rendered to the patientthe care that is rendered to the patient The medical record protects both the patient The medical record protects both the patient and the provider in the event of a and the provider in the event of a malpractice case malpractice case In an audit, the medical record is the only In an audit, the medical record is the only thing an auditor will reviewthing an auditor will review 21 DOCUMENTATION DOCUMENTATION GUIDELINES FOR GUIDELINES FOR EVALUATION AND EVALUATION AND MANAGEMENT MANAGEMENT SERVICESSERVICES
22 DOCUMENTATION DOCUMENTATION E/M SERVICESE/M SERVICES Descriptors for the levels of E/M services Descriptors for the levels of E/M services recognize seven components:recognize seven components: HistoryHistory ExamExam Medical Decision MakingMedical Decision Making CounselingCounseling Coordination of CareCoordination of Care Nature of Presenting ProblemNature of Presenting Problem TimeTime 23 E/M DOCUMENTATIONE/M DOCUMENTATION HISTORYHISTORY History includes some or all of the History includes some or all of the following elements:following elements: Chief Complaint (CC)Chief Complaint (CC) History of Present Illness (HPI)History of Present Illness (HPI) Review of Systems (ROS)Review of Systems (ROS) Past, Family and/or Social History Past, Family and/or Social History (PFSH)(PFSH) –– DG: The CC, ROS, and PFSH must DG: The CC, ROS, and PFSH must be listed as separate elements of be listed as separate elements of history, or may be included in the history, or may be included in the description of the recorded history of description of the recorded history of the present illnessthe present illness
24 E/M DOCUMENTATIONE/M DOCUMENTATION HISTORYHISTORY
–– DG: An earlier ROS and/or PFSH need DG: An earlier ROS and/or PFSH need not be renot be re --recorded if evidence shows recorded if evidence shows update. The review and update may be update. The review and update may be documented by:documented by: Describing any new ROS and/or PFSH Describing any new ROS and/or PFSH or noting no change in info; and/oror noting no change in info; and/or Noting the date and location of the Noting the date and location of the earlier ROS and/or PFSHearlier ROS and/or PFSH
25 E/M DOCUMENTATIONE/M DOCUMENTATION HISTORYHISTORY
–– DGDG : The ROS and/or PFSH may be : The ROS and/or PFSH may be recorded by staff or on a form completed recorded by staff or on a form completed by patient. There must be a notation by patient. There must be a notation supplementing or confirming the info supplementing or confirming the info recorded by others to document that the recorded by others to document that the physician reviewed the info physician reviewed the info –– DGDG : If the physician is unable to obtain : If the physician is unable to obtain history, history, the recordthe record should describe should describe condition or circumstance which precludes condition or circumstance which precludes obtaining history **IMPORTANT**obtaining history **IMPORTANT** 26 DOCUMENTATION DOCUMENTATION CHIEF COMPLAINTCHIEF COMPLAINT The CC is a concise statement describing The CC is a concise statement describing the symptom, problem, condition, diagnosis, the symptom, problem, condition, diagnosis, physician recommended return, or other physician recommended return, or other factor that is the reason for the encounterfactor that is the reason for the encounter –– DGDG : The medical record should clearly reflect : The medical record should clearly reflect the chief complaintthe chief complaint Without a chief complaint there is no element of history
27 DOCUMENTATION DOCUMENTATION HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS HPI HPI –– chronological description of development chronological description of development of patientof patient ’’s present illness from first sign to the s present illness from first sign to the presentpresent Location Location –– pain in legpain in leg Quality Quality –– aching, burning, radiatingaching, burning, radiating Severity Severity –– 10 on a scale of 110 on a scale of 1 --1010 Duration Duration –– started 3 days agostarted 3 days ago Timing Timing –– comes & goescomes & goes Context Context –– lifted large object @ worklifted large object @ work Modifying factors Modifying factors –– better with heatbetter with heat Associated signs and symptoms Associated signs and symptoms –– numbnessnumbness
28 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Describe the history of the present illness Describe the history of the present illness fully and in such a way that the nature of the fully and in such a way that the nature of the presenting problem in clear.presenting problem in clear. –– The documentation guidelines specify elements The documentation guidelines specify elements that must be recorded. Higher services require that must be recorded. Higher services require four or more elements. four or more elements. –– Medical necessity of an E/M encounter is often Medical necessity of an E/M encounter is often viewed through the characteristics captured in viewed through the characteristics captured in specific HPI elements.specific HPI elements.
29 DOCUMENTATION GUIDELINESDOCUMENTATION GUIDELINES ELEMENTS OF HISTORYELEMENTS OF HISTORY
A A problem pertinentproblem pertinent ROS relates directly to ROS relates directly to the problem(s) identified in the HPIthe problem(s) identified in the HPI –– DGDG : The patient: The patient ’’s positive responses and s positive responses and pertinent negatives for the system related to pertinent negatives for the system related to the problem should be documentedthe problem should be documented An An extendedextended ROS inquires about system ROS inquires about system directly related to problem(s) identified in directly related to problem(s) identified in the HPI and a limited number of additional the HPI and a limited number of additional systemssystems
30 DOCUMENTATION GUIDELINESDOCUMENTATION GUIDELINES ELEMENTS OF HISTORYELEMENTS OF HISTORY
–– DGDG : The patient: The patient ’’s positive responses and s positive responses and pertinent negatives for two to nine systems pertinent negatives for two to nine systems must be documentedmust be documented A A completecomplete ROS inquires about the ROS inquires about the system(s) directly related to problem(s) system(s) directly related to problem(s) identified in HPI identified in HPI plusplus all additional body all additional body systemssystems
31 DOCUMENTATION GUIDELINESDOCUMENTATION GUIDELINES ELEMENTS OF HISTORYELEMENTS OF HISTORY
–– DGDG : : At least ten organ systems must be At least ten organ systems must be reviewed. Those systems with positive or reviewed. Those systems with positive or pertinent responses must be individually pertinent responses must be individually documented. For the remaining systems, a documented. For the remaining systems, a notation indicating notation indicating ““all other systems all other systems reviewed and are negativereviewed and are negative ”” is permissible. is permissible. In the absence of such a notation, at least In the absence of such a notation, at least ten systems must be individually ten systems must be individually documented.documented.
32 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Record the ROS appropriate for the clinical Record the ROS appropriate for the clinical circumstance of the encounter. Expansive circumstance of the encounter. Expansive ROS is unnecessary for lowerROS is unnecessary for lower --level level services.services. – When using “negative ” notation, always identify which systems are queried and found to be negative DonDon ’’t record unnecessary information t record unnecessary information solelysolely to to meet documentation requirements for a highmeet documentation requirements for a high --level level service when the nature of the presenting problem service when the nature of the presenting problem dictates a lowerdictates a lower --level of service to be medically level of service to be medically appropriate appropriate
33 PAST, FAMILY AND/OR SOCIAL PAST, FAMILY AND/OR SOCIAL HISTORY (HISTORY ( PFSH)PFSH) The PFSH consists of a review of three The PFSH consists of a review of three areas:areas: Past HistoryPast History Family HistoryFamily History Social HistorySocial History For sub. Hospital care, established pt For sub. Hospital care, established pt visits, and sub. Nursing facility care, CPT visits, and sub. Nursing facility care, CPT requires only interval history (not requires only interval history (not necessary to record PFSH)necessary to record PFSH)
34 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING DonDon ’’t use the terms t use the terms ““unremarkableunremarkable ””, , ““nonnon -- contributorycontributory ”” or or ““irrelevantirrelevant ””.. Record information about all three realms to Record information about all three realms to document document ““completecomplete ”” PFSH for these PFSH for these services:services: –– New patient, new consults, initial hospital, New patient, new consults, initial hospital, observation, nursing homeobservation, nursing home DonDon ’’t record unnecessary information t record unnecessary information solelysolely to meet requirements for higherto meet requirements for higher --level level service.service.
35 DOCUMENTATIONDOCUMENTATION EXAMINATIONEXAMINATION
Problem FocusedProblem Focused
Expanded Problem FocusedExpanded Problem Focused
DetailedDetailed
ComprehensiveComprehensive
36 ORGAN SYSTEMS RECOGNIZEDORGAN SYSTEMS RECOGNIZED EXAMINATIONEXAMINATION
Constitutional (e.g., vital signs, general Constitutional (e.g., vital signs, general appearance)appearance) EyesEyes Ears, Nose, Mouth, and ThroatEars, Nose, Mouth, and Throat CardiovascularCardiovascular RespiratoryRespiratory Gastrointestinal Gastrointestinal
37 ORGAN SYSTEMS RECOGNIZEDORGAN SYSTEMS RECOGNIZED EXAMINATIONEXAMINATION
GenitourinaryGenitourinary MusculoskeletalMusculoskeletal SkinSkin NeurologicNeurologic PsychiatricPsychiatric Hematologic/Lymphatic/Immunologic Hematologic/Lymphatic/Immunologic
38 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Understand the difference in “Expanded Problem Focused ” and “Detailed ” exams under 1995 guidelines – The difference is not the number of systems required (2 -7 for both exams) – The difference is in the detail in which the examined system is described Always examine the system(s) related to the presenting problem – Use “normal ” or “negative ” and “WNL ” notations only to describe unaffected or asymptomatic organ systems Code the Physical Exam by the clinical circumstances of the encounter, not to meet high -level requirements
39 DOCUMENTATIONDOCUMENTATION COMPLEXITY OF MEDICAL DECISION MAKINGCOMPLEXITY OF MEDICAL DECISION MAKING
Medical Decision Making is measured by:Medical Decision Making is measured by: The number of possible diagnoses and/or The number of possible diagnoses and/or the number of management options that the number of management options that must be consideredmust be considered The amount and/or complexity of medical The amount and/or complexity of medical records, diagnostic tests, and/or other records, diagnostic tests, and/or other information that must be obtained, information that must be obtained, reviewed and analyzedreviewed and analyzed The risk of significant complications, The risk of significant complications, morbidity and/or mortalitymorbidity and/or mortality
40 NUMBER OF DIAGNOSES OR NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONSMANAGEMENT OPTIONS
––DG: For each encounter, an DG: For each encounter, an assessment, clinical impression, or assessment, clinical impression, or diagnosis should be documenteddiagnosis should be documented For a presenting problem with an established For a presenting problem with an established diagnosis, the records should indicate diagnosis, the records should indicate whether the problem is: improved, well whether the problem is: improved, well controlled, resolving or resolved or controlled, resolving or resolved or inadequately controlled, worsening, or failing inadequately controlled, worsening, or failing to change as expectedto change as expected
41 NUMBER OF DIAGNOSES OR NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONSMANAGEMENT OPTIONS –– For a presenting problem without an established For a presenting problem without an established diagnosis, the assessment or clinical impression diagnosis, the assessment or clinical impression may be stated in the form of a differential may be stated in the form of a differential diagnoses or as diagnoses or as ““possiblepossible ””, , ““probableprobable ”” or or ““rule rule outout ”” (R/O) diagnoses(R/O) diagnoses –– DGDG : The initiation of, or changes in treatment : The initiation of, or changes in treatment should be documented. Treatment includes should be documented. Treatment includes patient instructions, nursing instructions, therapypatient instructions, nursing instructions, therapy and medsand meds (NOTE: All changes in meds and refills must be documented)
42 AMOUNT AND/OR COMPLEXITY OF AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWEDDATA TO BE REVIEWED Test or procedures ordered or scheduled must be Test or procedures ordered or scheduled must be documenteddocumented Review of diagnostic tests should be documentedReview of diagnostic tests should be documented Decision to obtain additional info/records should bDecision to obtain additional info/records should be e documenteddocumented Relevant finds from review of records/info should Relevant finds from review of records/info should be documentedbe documented Discussion of findings from tests with performing Discussion of findings from tests with performing physician should be documentedphysician should be documented Direct interpretation of tests previously interpretDirect interpretation of tests previously interpreted ed should be documentedshould be documented
43 RISK OF COMPLICATIONS, MORBIDITY RISK OF COMPLICATIONS, MORBIDITY AND/OR MORTALITYAND/OR MORTALITY Co morbidities/underlying diseases that Co morbidities/underlying diseases that increase the complexity of Medical Decision increase the complexity of Medical Decision Making must be documentedMaking must be documented If procedure is ordered at time of E/M If procedure is ordered at time of E/M encounter, that test must be documentedencounter, that test must be documented If procedure is done at time of E/M service, If procedure is done at time of E/M service, that must be documentedthat must be documented The referral for procedure must be The referral for procedure must be documenteddocumented
44 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Record relevant impressions, tentative Record relevant impressions, tentative diagnosis, confirmed diagnoses and all diagnosis, confirmed diagnoses and all therapeutic options chosen related to every therapeutic options chosen related to every problem for which E/M is clearly problem for which E/M is clearly documented in the record of the other key documented in the record of the other key componentscomponents –– DonDon ’’t count existent old diagnoses unless the t count existent old diagnoses unless the record clearly demonstrates their presence record clearly demonstrates their presence increased physician work related to the increased physician work related to the encounter encounter
45 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Summarize old records or other outside Summarize old records or other outside information reviewed and incorporated into information reviewed and incorporated into decisiondecision --making.making. Beware of templatesBeware of templates that overthat over --estimate estimate decisiondecision --making. Understand the logic of making. Understand the logic of templates and/or computer programs used templates and/or computer programs used for E/M service coding.for E/M service coding.
46 DOCUMENTATIONDOCUMENTATION ENCOUNTER DOMINATED BYENCOUNTER DOMINATED BY COUNSELING / COORDINATION OF CARECOUNSELING / COORDINATION OF CARE
If counseling and/or coordination of care If counseling and/or coordination of care dominates more than 50% of the dominates more than 50% of the physician/patient and/or family encounter, physician/patient and/or family encounter, time is considered the key or controlling time is considered the key or controlling factor to qualify for a particular level of E/M factor to qualify for a particular level of E/M servicesservices
47 DOCUMENTATIONDOCUMENTATION ENCOUNTER DOMINATED BYENCOUNTER DOMINATED BY COUNSELING / COORDINATION OF CARECOUNSELING / COORDINATION OF CARE
–– DGDG : If the physician elects to report the level : If the physician elects to report the level of care based on time, the total length of time of of care based on time, the total length of time of the encounter must be documented along with the encounter must be documented along with the amount of time spent in counseling and the the amount of time spent in counseling and the content of the counseling sessioncontent of the counseling session Who was present What was discussed Conclusions met
48 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Subsequent hospital services Subsequent hospital services –– Pay attention to Pay attention to medical necessity medical necessity –– strongly consider the strongly consider the ““nature nature of the presenting problemof the presenting problem ”” – 99231 – usually the patient is stable, recovering or improving A problem focused interval history A problem focus examination (a limited examination of the affected body area or organ system) Medical decision making that is straightforward or of low complexity
49 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING –– 99232 99232 –– usually the patient is responding usually the patient is responding inadequately to therapy or has developed a inadequately to therapy or has developed a minor complicationminor complication An expanded problem focused interval history An expanded problem focused examination (a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Medical decision making of moderate complexity
50 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING –– 99233 99233 –– usually the patient is unstable or has usually the patient is unstable or has developed a significant complication or developed a significant complication or significant new problemsignificant new problem A detailed interval history A detailed examination (an extended examination of the affected body area(s) and other symptomatic or related organ system(s) Medical decision making of high complexity
51 CONSULTATIONCONSULTATION SERVICESSERVICES
52 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS
Consult codes 99251Consult codes 99251 --99255 are no longer 99255 are no longer recognized for Medicare Part B paymentrecognized for Medicare Part B payment In the inpatient hospital setting the initial In the inpatient hospital setting the initial evaluation by any physician will be 99221evaluation by any physician will be 99221 -- 9922399223 This change will result in multiple billings This change will result in multiple billings of the initial hospital codeof the initial hospital code
53 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS
Modifier Modifier ““--AIAI ”” will be utilized by the admitting will be utilized by the admitting or attending physician and is identified as or attending physician and is identified as ““Principal Physician of RecordPrincipal Physician of Record ”” Each time the patient is admitted to the Each time the patient is admitted to the hospital and a physician provides an initial hospital and a physician provides an initial evaluation, this code may be usedevaluation, this code may be used
54 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Even for an established dialysis patient, where a Even for an established dialysis patient, where a consultation code would not have been consultation code would not have been appropriate, 99221appropriate, 99221 --99223 can be used99223 can be used If the patient also has dialysis on the day of the If the patient also has dialysis on the day of the initial evaluation (not necessarily the day of initial evaluation (not necessarily the day of admission) both the 99221admission) both the 99221 --99223 99223 and and 90935/37/45/47 can be used 90935/37/45/47 can be used –– append modifier append modifier ““--2525 ”” to the 99221to the 99221 -- 9922399223
55 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Providers must pay close attention to the Providers must pay close attention to the complexity level performed when choosing complexity level performed when choosing the level of service billedthe level of service billed A crosswalk from the consultation codes A crosswalk from the consultation codes would be:would be: –– 9925199251 --99253 = 99221 (watch documentation 99253 = 99221 (watch documentation requirements)requirements) –– 99254 = 9922299254 = 99222 –– 99255 = 9922399255 = 99223
56 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Follow up care in the hospital settings use Follow up care in the hospital settings use the subsequent visits appropriate for the the subsequent visits appropriate for the locationlocation 9923199231 --99233 are used for inpatient 99233 are used for inpatient hospital followhospital follow --up careup care
57 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Reminder Reminder –– when using the higher levels of the initial when using the higher levels of the initial hospital visit codes (99222hospital visit codes (99222 --99223) there must be a 99223) there must be a comprehensive history and physical examcomprehensive history and physical exam For the history of present illness there must be at least four of the elements: Location Severity Quality Timing Context Modifying factors Associated signs & symptoms Past, family and social history obtained at this visit At least a 10 organ system review At least an 8 organ system physical exam
58 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Observation care presents some different issuesObservation care presents some different issues Only the physician who Only the physician who ordered ordered the outpatient the outpatient observation admission may bill the observation observation admission may bill the observation admission codes 99218admission codes 99218 --9922099220 Other physicians providing care in the observation Other physicians providing care in the observation setting are to bill 99201setting are to bill 99201 --99205 new 99205 new office/outpatient visit code or 99211office/outpatient visit code or 99211 --99215 99215 established office/outpatient visit code depending established office/outpatient visit code depending on the status of the patienton the status of the patient ’’s relationship with the s relationship with the evaluating physicianevaluating physician
59 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Office/outpatient consultation codes (99241Office/outpatient consultation codes (99241 -- 99245) are also not recognized for Medicare 99245) are also not recognized for Medicare Part B paymentPart B payment Unlike the hospital codes that allow physicians Unlike the hospital codes that allow physicians to bill the inpatient initial hospital care code to bill the inpatient initial hospital care code each time the patient is admitted to the hospital, each time the patient is admitted to the hospital, in the outpatient setting, the provider must in the outpatient setting, the provider must determine if the patient is new or establisheddetermine if the patient is new or established If the patient has been seen by any member of If the patient has been seen by any member of the group during the past 3 years, the patient is the group during the past 3 years, the patient is establishedestablished 60 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS
This care could have been provided in the This care could have been provided in the inpatient or the outpatient settinginpatient or the outpatient setting If the patient is new to the practice bill 99201If the patient is new to the practice bill 99201 -- 99205 as appropriate based on the elements and 99205 as appropriate based on the elements and nature of the presenting problemnature of the presenting problem If the patient has been seen within three years, If the patient has been seen within three years, regardless of the diagnosis, the patient is regardless of the diagnosis, the patient is established and you must use 99211established and you must use 99211 --9921599215
61 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS There is a direct crosswalk to these codes There is a direct crosswalk to these codes making the billing simpliermaking the billing simplier –– 99241 = 9920199241 = 99201 –– 99242 = 9920299242 = 99202 –– 99243 = 9920399243 = 99203 –– 99244 = 9920499244 = 99204 –– 99245 = 99205 99245 = 99205 –– remember at this level the remember at this level the intensity of the visit is high intensity of the visit is high
62 BILLING FOR BILLING FOR CONSULTATIONSCONSULTATIONS Documentation of all elements are required Documentation of all elements are required including the chief complaint (reason for the visitincluding the chief complaint (reason for the visit)) I also suggest that the provider continue to I also suggest that the provider continue to document who requested the document who requested the ““consultationconsultation ”” if this if this is an initial encounter either new or establishedis an initial encounter either new or established If any portion of the encounter is performed by a If any portion of the encounter is performed by a NPP, and the billing is done under the physicianNPP, and the billing is done under the physician ’’s s provider number, the physician would have to be provider number, the physician would have to be physically present in the suite and see the patientphysically present in the suite and see the patient as a as a ““sharedshared ”” visitvisit
63 OIG TARGETSOIG TARGETS
““What the What the inspectorsinspectors are looking forare looking for ””
64 OIG WORK PLANOIG WORK PLAN
““The size and scope of the Medicare system The size and scope of the Medicare system places it at high risk for payment errorsplaces it at high risk for payment errors ”” OIG audits help to avoid fraud and protect OIG audits help to avoid fraud and protect the solvency of the Medicare Trust.the solvency of the Medicare Trust. These reviews have revealed payments for These reviews have revealed payments for unallowable services, improper coding, and unallowable services, improper coding, and other types of improper payments. other types of improper payments.
65 2012 TARGETS2012 TARGETS
Place of Service ErrorsPlace of Service Errors Incident to ServicesIncident to Services Impact of Opting out of MedicareImpact of Opting out of Medicare Trends in Coding of ClaimsTrends in Coding of Claims E&M during Global Surgical PeriodsE&M during Global Surgical Periods
66 2012 TARGETS2012 TARGETS
Modifiers During Global Surgical Modifiers During Global Surgical PeriodsPeriods
Potentially Inappropriate PaymentsPotentially Inappropriate Payments
67 2012 TARGETS2012 TARGETS Place of Service ErrorsPlace of Service Errors – OIG will determine whether physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments. – Medicare regulations provide for different levels of payments to physicians depending on where the service is performed. – Medicare makes higher payments for physician office services.
68 2012 TARGETS2012 TARGETS Incident to ServicesIncident to Services –OIG will review physician billing for “incident -to ” services to determine whether payment for such services had a higher error rate than that for non -incident -to services. We will also assess CMS ’s ability to monitor services billed as “incident -to. ” Medicare Part B pays for certain services billed by physicians that are performed by non - physicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians ’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician.
69 2012 TARGETS2012 TARGETS
Incident to ServicesIncident to Services – We also found that unqualified non -physicians performed 21 percent of the services that physicians did not perform personally. Incident -to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality.
70 2012 TARGETS2012 TARGETS
Impact of Opting Out of MedicareImpact of Opting Out of Medicare – OIG will review the extent to which physicians are opting out of Medicare and determine whether physicians who have opted out of Medicare are submitting claims to Medicare. We will also examine whether specific areas of the country have seen higher numbers of physicians opting out and its potential impact on beneficiaries. Physicians are permitted to enter into private contracts with Medicare beneficiaries. (Social Security Act, § 1802(b).) As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.
71 2012 TARGETS2012 TARGETS Trends in Coding of Claims Trends in Coding of Claims – OIG will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000 -2009. We will also identify providers that exhibited questionable billing for E/M services in 2009. Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. (CMS ’s Medicare Claims Processing Manual, Pub. No. 100 -04, ch. 12, § 30.6.1.) 72 2012 TARGETS2012 TARGETS Evaluation and Management Services Evaluation and Management Services Provided During Global Surgery PeriodsProvided During Global Surgery Periods – OIG will review industry practices related to the number of E/M services provided by physicians and reimbursed as part of the global surgery fee to determine whether the practices have changed since the global surgery fee concept was developed in 1992. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E/M services provided during the global surgery period. Medicare Claims Processing Manual, Pub. 100 -04, ch. 12, § 40.
73 2012 TARGETS2012 TARGETS Use of Modifiers During the Global Use of Modifiers During the Global Surgery Period Surgery Period – OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements. Prior OIG work has shown that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. Medicare Claims Processing Manual, Pub. 100 -04, ch. 12, § 40.1. 74 2012 TARGETS2012 TARGETS Potentially Inappropriate PaymentsPotentially Inappropriate Payments – OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported.
75 END STAGE RENAL DISEASEEND STAGE RENAL DISEASE PHYSICIAN COMPENSATIONPHYSICIAN COMPENSATION
BILLING FOR THE MONTHLY BILLING FOR THE MONTHLY CAPITATION PAYMENTCAPITATION PAYMENT
MCPMCP
76 REGULATIONSREGULATIONS
Conditions of coverage?? orConditions of coverage?? or MCP??MCP?? Are there conflicting regulations?Are there conflicting regulations? Which should be followed?Which should be followed?
77 MEDICARE AND ESRDMEDICARE AND ESRD
““A match made in CongressA match made in Congress ””
78 ESRD DEFINEDESRD DEFINED
Medicare regulations define ESRD as Medicare regulations define ESRD as ““that that stage of kidney impairment that appears stage of kidney impairment that appears irreversible and permanent and requires a irreversible and permanent and requires a regular course of dialysis treatment or kidney regular course of dialysis treatment or kidney transplantation to survivetransplantation to survive ””.. 1972, Congress changed the Social Security 1972, Congress changed the Social Security Act to instruct CMS to pay the cost of treating Act to instruct CMS to pay the cost of treating ESRD via Medicare eligibilityESRD via Medicare eligibility
79 MEDICARE ENTITLEMENT DATE MEDICARE ENTITLEMENT DATE -- ESRDESRD
Entitlement begins after completion of three Entitlement begins after completion of three month waiting period for inmonth waiting period for in --center patientscenter patients
Waiting period waived for home dialysisWaiting period waived for home dialysis
Waiting period also waived for transplantsWaiting period also waived for transplants
80 MEDICARE SECONDARY PAYERMEDICARE SECONDARY PAYER (MSP)(MSP)
Beneficiary is workingBeneficiary is working Beneficiary is disabledBeneficiary is disabled Completion of coordination periodCompletion of coordination period –– 30 months as Medicare Secondary 30 months as Medicare Secondary –– Primary coverage must be an employer group Primary coverage must be an employer group planplan
81 MONTHLY CAPITATION PAYMENTMONTHLY CAPITATION PAYMENT
CMS method to reimburse Nephrologists CMS method to reimburse Nephrologists for all outpatient care of patients with for all outpatient care of patients with ESRDESRD MCP is comprehensive, per patient, per MCP is comprehensive, per patient, per month payment for month payment for allall outpatient renaloutpatient renal -- related carerelated care
82 MONTHLY CAPITATION PAYMENTMONTHLY CAPITATION PAYMENT Not included in MCP:Not included in MCP: NonNon --renal related evaluation and renal related evaluation and managementmanagement Hospital inpatient servicesHospital inpatient services All nonAll non --renal proceduresrenal procedures Evaluation for transplant or LRD evaluationEvaluation for transplant or LRD evaluation Training of patients to perform home Training of patients to perform home dialysisdialysis
83 MONTHLY CAPITATION PAYMENTMONTHLY CAPITATION PAYMENT Included in the MCPIncluded in the MCP All renalAll renal --related related outpatientoutpatient services rendered services rendered to the dialysis patientto the dialysis patient Interpretation of ancillary testing (nerve Interpretation of ancillary testing (nerve conduction studies, bone density, doppler conduction studies, bone density, doppler studies)studies) Services rendered to the dialysis patient while Services rendered to the dialysis patient while on dialysison dialysis Physicals required by the dialysis facility for thePhysicals required by the dialysis facility for the renal patientrenal patient
84 MONTHLY CAPITATION MONTHLY CAPITATION PAYMENTPAYMENT Included in the MCPIncluded in the MCP Certification of the need for items & Certification of the need for items & services such as DME & home health careservices such as DME & home health care Care plan oversight services described by Care plan oversight services described by CPT code 99375 CPT code 99375
85 MONTHLY CAPITATION PAYMENTMONTHLY CAPITATION PAYMENT Included in the MCPIncluded in the MCP Periodic visits to the patient during dialysis to Periodic visits to the patient during dialysis to determine if the dialysis is working well both determine if the dialysis is working well both physiologically & psychologically. During this physiologically & psychologically. During this encounter the physician will determine if any encounter the physician will determine if any elements of the plan need to be revised to elements of the plan need to be revised to optimize the patientoptimize the patient ’’s treatment and/or care. s treatment and/or care. Coordination & direction of the multiCoordination & direction of the multi -- disciplinary team involved in the patientdisciplinary team involved in the patient ’’ss care.care.
86 OUTPATIENT SETTINGSOUTPATIENT SETTINGS
The MCP covers all The MCP covers all outpatientoutpatient services services related to the patientrelated to the patient ’’s renal conditions renal condition Services may be rendered in the inServices may be rendered in the in --center center dialysis unit, patientdialysis unit, patient ’’s home, practitioners home, practitioner ’’s s office, outpatient hospital, observation care, office, outpatient hospital, observation care, emergency room and outpatient surgeryemergency room and outpatient surgery –– Inpatient services cannot count as MCP Inpatient services cannot count as MCP encountersencounters
87 PRACTITIONER DEFINITIONSPRACTITIONER DEFINITIONS
MCP physician is the MCP physician is the physician physician who performs who performs the the ““majormajor ”” (care plan) visit during the month. (care plan) visit during the month. This physician is the billing physicianThis physician is the billing physician NonNon --physician practitioner physician practitioner –– NP/PA who is NP/PA who is employed by the same entity as the physicianemployed by the same entity as the physician – Must be able under statute to furnish services that would be physician services NonNon --MCP physician MCP physician –– must have a relationship must have a relationship with the MCP physician such as partnerwith the MCP physician such as partner
88 USE OF NONUSE OF NON --PHYSICIAN PHYSICIAN PRACTITIONERSPRACTITIONERS MCPMCP physician (billing physician) must provide physician (billing physician) must provide the visit with the complete assessment of the the visit with the complete assessment of the patient, establish the plan of care, and submit patient, establish the plan of care, and submit the bill for the monthly servicethe bill for the monthly service –– Must see the Must see the patient at least once a monthpatient at least once a month – Non -physicians can provide some of the visits to equal total # submitted – Non MCP physician can provide some of the visits – Non -physician must have a relationship with the physician (employee)
89 PARTIAL MONTH RULEPARTIAL MONTH RULE 9096790967 --90970 ESRD related services for dialysis 90970 ESRD related services for dialysis less than a full month of service less than a full month of service Use limited to:Use limited to: – Transient patients – Home dialysis patients – Patients who have a permanent change in their MCP physician during the month – Partial month with one or more face -to -face visits without the complete (care plan) visit but only in patients with Dialysis stopped due to death. Dialysis patient transplanted Dialysis patient hospitalized during the month
90 PARTIAL MONTH RULEPARTIAL MONTH RULE (cont.)(cont.) Partial month rule Partial month rule does notdoes not apply to apply to patients who start dialysis during the monthpatients who start dialysis during the month Without a complete (care plan) visit, these Without a complete (care plan) visit, these patients cannot be billed for this first month patients cannot be billed for this first month on dialysison dialysis Cannot bill 90967Cannot bill 90967 --9097090970
91 TRANSIENT PATIENTSTRANSIENT PATIENTS
Only one physician can bill for the management of Only one physician can bill for the management of a patient per montha patient per month Bill 90970 for the number of days the patient is Bill 90970 for the number of days the patient is under the transient physicianunder the transient physician ’’s cares care If the transient patient is in the transient dialysIf the transient patient is in the transient dialysis is unit for a full month, then the same rules apply asunit for a full month, then the same rules apply as with any other inwith any other in --center patient. Transient MD center patient. Transient MD becomes MCP physicianbecomes MCP physician
92 PATIENTS WITH LESS THAN A PATIENTS WITH LESS THAN A FULL MONTH MCPFULL MONTH MCP Bill as if the patient had a full month of Bill as if the patient had a full month of dialysis with the appropriate CPT code for dialysis with the appropriate CPT code for the number of encounters if:the number of encounters if: –– Dies during the monthDies during the month –– Transplants during the month Transplants during the month –– Transfers during the monthTransfers during the month –– HospitalizedHospitalized Patient must have Patient must have complete (care plan) visitcomplete (care plan) visit to to bill using the appropriate CPT codebill using the appropriate CPT code
93 HOSPITAL OBSERVATION HOSPITAL OBSERVATION STATUSSTATUS ESRDESRD --related visits furnished in hospital related visits furnished in hospital observation status count as an MCP observation status count as an MCP encounter encounter Visit will count towards the total number of Visit will count towards the total number of encounters submitted (CPT code)encounters submitted (CPT code) Describe (document) in the medical record Describe (document) in the medical record the type of ESRDthe type of ESRD --related service rendered related service rendered in observation statusin observation status
94 HOSPITALIZATION & THE MCPHOSPITALIZATION & THE MCP ININ --CENTER PATIENTSCENTER PATIENTS ESRD patients, other than home dialysis patients, ESRD patients, other than home dialysis patients, hospitalized during the month will be billed for thhospitalized during the month will be billed for the e number of facenumber of face --toto --face encounters that occurred face encounters that occurred when the patient was when the patient was notnot in the hospitalin the hospital Since the MCP is no longer Since the MCP is no longer ““timetime ”” dependent, but dependent, but based on encounters facebased on encounters face --toto --face, the face, the practitioners no longer practitioners no longer ““carve outcarve out ”” hospital days.hospital days. Bill inpatient care Bill inpatient care andand the CPT code for the the CPT code for the number of outpatient facenumber of outpatient face --toto --face encountersface encounters
95 HOME DIALYSISHOME DIALYSIS
Payment based on 2Payment based on 2 --3 visit payment level 3 visit payment level approximately $221.66approximately $221.66 Monthly visit is the Monthly visit is the REQUIREDREQUIRED in 2011 in 2011 –– bill using bill using full month code 90966 for 20+ years old)full month code 90966 for 20+ years old) If patient has less than full month at homeIf patient has less than full month at home –– bill bill using by day code 90970 for 20+ years old)using by day code 90970 for 20+ years old) Home patients are billed similarly to how MCP was Home patients are billed similarly to how MCP was billed historicallybilled historically
96 HOME DIALYSIS HOME DIALYSIS (cont)
If the home patient receives inIf the home patient receives in --center center dialysis during the month, the provider dialysis during the month, the provider would still bill the management fee for the would still bill the management fee for the month under the home dialysis provisionmonth under the home dialysis provision The physician cannot bill the inThe physician cannot bill the in --center CPT center CPT code code oror CPT 90935CPT 90935 --90937 for the 90937 for the encounters inencounters in --centercenter
97 HOSPITALIZATION & THE MCPHOSPITALIZATION & THE MCP HOME DIALYSISHOME DIALYSIS Home patients continue to be billed in a Home patients continue to be billed in a full month or partial month format similar full month or partial month format similar to prior codes to prior codes If the patient is home for the 1If the patient is home for the 1 st --1010 th hospitalized from the 11hospitalized from the 11 th --2020 th , then back , then back home from the 21home from the 21 st --3030 th , you would bill for , you would bill for the 90970 (adult) for the 1the 90970 (adult) for the 1 --10 (10 days), 10 (10 days), inpatient codes for 11inpatient codes for 11 --20, then 90970 for 20, then 90970 for the 21the 21 --30 (10 days)30 (10 days)
98 MODALITY CHANGESMODALITY CHANGES
If a patient switches modalities during the If a patient switches modalities during the month, bill the entire month using the month, bill the entire month using the appropriate appropriate HOMEHOME dialysis code 90963dialysis code 90963 -- 9096690966 If partial month care bill using 90967If partial month care bill using 90967 --9097090970
99 DOCUMENTATION DOCUMENTATION REQUIREMENTSREQUIREMENTS
CMS stopped short of dictating CMS stopped short of dictating documentation requirements however were documentation requirements however were very specific on what was necessaryvery specific on what was necessary With requirements now for verification of With requirements now for verification of physicianphysician ’’s face to face visits, s face to face visits, documentation of encounters will be documentation of encounters will be necessarynecessary RPA documentation tool has been revised RPA documentation tool has been revised to meet CMS recommendationsto meet CMS recommendations
100 DOCUMENTATION REQUIREMENTS DOCUMENTATION REQUIREMENTS (cont)(cont)
Document what is clinically relevant iDocument what is clinically relevant i ncludingncluding but but not limitednot limited to:to: – patient's current status and complaints, – a clinically appropriate physical examination, assessment of the patient's treatment for ESRD that includes assessment of the adequacy of the dialysis treatment, the status of the patient's vascular access, assessment and treatment of the other conditions associated with ESRD, such as anemia, electrolyte management, and bone density, as well as changes to the patient's management
101 ADDITIONAL DOCUMENTATION ADDITIONAL DOCUMENTATION NEEDED FOR PEDIATRIC NEEDED FOR PEDIATRIC PATIENTSPATIENTS In addition to the requirements for adult In addition to the requirements for adult patients, pediatric nephrologists also need to:patients, pediatric nephrologists also need to: –– Monitor the patient for adequacy of nutritionMonitor the patient for adequacy of nutrition –– Assess for growth and developmentAssess for growth and development –– Counsel parentsCounsel parents
Documentation must show these elements Documentation must show these elements In addition to the adult documentation In addition to the adult documentation requirementsrequirements
102 CHANGES IN DOCUMENTATION CHANGES IN DOCUMENTATION REQUIREMENTS (cont)REQUIREMENTS (cont) Documentation of the complete (care plan)Documentation of the complete (care plan) visit is requiredvisit is required Documentation that the physician Documentation that the physician performed a service for the patient is performed a service for the patient is required for the other encountersrequired for the other encounters Signing a dialysis flow sheet or any other Signing a dialysis flow sheet or any other form if not enoughform if not enough ……the physician must the physician must document they are performing a service at document they are performing a service at each encountereach encounter
103 MCP CONCLUSIONSMCP CONCLUSIONS
Documentation will be key in managing new Documentation will be key in managing new MCP changesMCP changes
Administrative challenges will create additional Administrative challenges will create additional requirements for excellent record keepingrequirements for excellent record keeping
Complete visit, including disease appropriate Complete visit, including disease appropriate physical exam is necessary to bill the inphysical exam is necessary to bill the in --center center CPT codeCPT code
104 NEPHROLOGYNEPHROLOGY SPECIFICSPECIFIC CPT CPT CODINGCODING
105 INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODES
9093590935 -- Single physician evaluation of Single physician evaluation of hemodialysishemodialysis 9093790937 -- Multiple physician evaluation of Multiple physician evaluation of hemodialysishemodialysis 9094590945 -- Single physician evaluation of Single physician evaluation of continuous forms of dialysiscontinuous forms of dialysis 9094790947 -- Multiple physician evaluation of Multiple physician evaluation of continuous forms of dialysiscontinuous forms of dialysis Includes E&M services rendered on the same day
106 INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODES
To bill physician must meet the following:To bill physician must meet the following: Be present Be present duringduring the dialysis treatmentthe dialysis treatment Documentation must reflect presence during Documentation must reflect presence during the treatmentthe treatment The need for repeated visit should be noted The need for repeated visit should be noted in the patientin the patient ’’s chart. The note should s chart. The note should include the problem or anticipated problem include the problem or anticipated problem which required the physicianwhich required the physician ’’s repeat s repeat evaluationevaluation 107 INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODES Four E/M services that can be billed on the Four E/M services that can be billed on the same day as dialysis services rendered same day as dialysis services rendered in the inpatient settingin the inpatient setting Hospital admissionHospital admission Hospital dischargeHospital discharge Inpatient consultation (for commercial Inpatient consultation (for commercial payers only)payers only) Critical CareCritical Care –– Most carriers require the use of a Most carriers require the use of a ““--2525 ”” modifier modifier on the E/M code on the same day as a on the E/M code on the same day as a procedure procedure
108 HOSPICEHOSPICE SERVICESSERVICES
109 WHAT IS HOSPICE?WHAT IS HOSPICE? Hospice is a program of care and support for Hospice is a program of care and support for people who are terminally illpeople who are terminally ill To get Hospice benefits from Medicare the patient To get Hospice benefits from Medicare the patient must meet must meet all all of the following conditionsof the following conditions : : – Be eligible for Medicare Part A (Hospital Insurance). – The patient ’s doctor and the hospice medical director certify that the patient is terminally ill and has 6 months or less to live if th eir illness runs its normal course. – The patient must sign a statement choosing hospice care instead of other Medicare -covered benefits to treat the terminal illness. *Medicare will still pay for covered benefits for any health pro blems that aren ’t related to the terminal illness. – Care comes from a Medicare -approved hospice program.
110 WHO DO YOU BILL FOR WHO DO YOU BILL FOR SERVICES?SERVICES? Hospice pays for all care related to the Hospice pays for all care related to the hospice conditionhospice condition The patient must use standard Medicare to The patient must use standard Medicare to cover any health care not related to the cover any health care not related to the terminal conditionterminal condition ““GVGV ”” modifier is used to bill Medicare by the modifier is used to bill Medicare by the attending physician not employed by a attending physician not employed by a hospice for the evaluation and treatment of hospice for the evaluation and treatment of a terminal conditiona terminal condition
111 WHO DO YOU BILL FOR WHO DO YOU BILL FOR SERVICES?SERVICES? Any physician providing services to the Any physician providing services to the hospice patient for the terminal condition hospice patient for the terminal condition other than the attending must have a other than the attending must have a contract with the hospice and bill to the contract with the hospice and bill to the hospicehospice ““GWGW ”” modifier is used to report all physician modifier is used to report all physician services to services to MedicareMedicare that are unrelated to a that are unrelated to a patientpatient ’’s terminal conditions terminal condition
112 HOME DIALYSIS HOME DIALYSIS TRAININGTRAINING
113 HOME TRAINING DIALYSIS HOME TRAINING DIALYSIS MANAGEMENTMANAGEMENT
9098990989 -- Dialysis training, patient, including Dialysis training, patient, including helper where applicable, any mode, helper where applicable, any mode, complete coursecomplete course 9099390993 -- Dialysis training, patient, including Dialysis training, patient, including helper where applicable, any mode, course helper where applicable, any mode, course not completed, per training session (billed not completed, per training session (billed by units completed)by units completed) Physician Physician mustmust have direct participation in have direct participation in the training to bill the training to bill
114 HOME TRAINING DIALYSIS HOME TRAINING DIALYSIS MANAGEMENTMANAGEMENT Example of billing for trainingExample of billing for training –– Patient on hemodialysis March 1Patient on hemodialysis March 1 --15, 201115, 2011 Seen with comprehensive visit 2 times –– Patient began home PD training March 16 Patient began home PD training March 16 continued through March 21, 2011. continued through March 21, 2011. Physician participated directly in training – 90989, PD training complete, March 16,17,19,20,21, 2011 –– Patient at home for the full month (90963Patient at home for the full month (90963 -- 90966)90966)
115 HOME TRAINING DIALYSIS HOME TRAINING DIALYSIS MANAGEMENTMANAGEMENT A completed course is reimbursed with a A completed course is reimbursed with a maximum $500 allowablemaximum $500 allowable A completed course should be reported with A completed course should be reported with 90989 with a quantity of 90989 with a quantity of ““oneone ”” For a training course not completed bill For a training course not completed bill 90993 for the number of sessions completed 90993 for the number of sessions completed and reimbursed at a $20 per session and reimbursed at a $20 per session allowableallowable
116 BILLING FOR BILLING FOR ERYTHROPOIETIC STIMULATINGERYTHROPOIETIC STIMULATING AGENTSAGENTS
117 CAUTION!CAUTION!
POLICIES CHANGE QUICKLY!!POLICIES CHANGE QUICKLY!! Please review your own carriers LCD on a Please review your own carriers LCD on a monthly basis.monthly basis. Knowledge in this arena is vital. Knowledge in this arena is vital. An ounce of preventionAn ounce of prevention ………………..
118 INITIAL PROCRITINITIAL PROCRIT ® (Epoetin Alfa) & (Epoetin Alfa) & ARANESPARANESP ® (Darbepoetin Alfa)(Darbepoetin Alfa) ADMINISTRATION ADMINISTRATION EXAMPLEEXAMPLE GUIDELINESGUIDELINES
Pretreatment HCT Pretreatment HCT PatientPatient ’’s current s current Level of less than 30Level of less than 30 weight in kilogramsweight in kilograms Creatinine of 3.0 or Creatinine of 3.0 or Date of lab (within 7 Date of lab (within 7 greater greater OROR days days -- this may vary this may vary Documented renal Documented renal by location)by location) Please understand this is an example insufficiency (stage insufficiency (stage & not intended to be taken as 33--5)5) policy! 119 FOLLOWFOLLOW --UP PROCRITUP PROCRIT ® (Epoetin Alfa) (Epoetin Alfa) ARANESPARANESP ® (Darbepoetin Alfa)(Darbepoetin Alfa) ADMINISTRATION ADMINISTRATION EXAMPLE EXAMPLE GUIDELINESGUIDELINES
Current HCT level to max of 30 or multiply of Current HCT level to max of 30 or multiply of Hgb x 3 (watch the LCD, this level varies by Hgb x 3 (watch the LCD, this level varies by state)state) Date of Laboratory Data (within the last 30 Date of Laboratory Data (within the last 30 days)days) ICDICD --9 code appropriate for state9 code appropriate for state
120 BILLING FOR ADMINISTRATION OF BILLING FOR ADMINISTRATION OF PROCRIT AND ARANESPPROCRIT AND ARANESP
Drug and administration is covered Drug and administration is covered ““incident incident toto ”” physician service physician service If the purpose of the visit is for an injection, If the purpose of the visit is for an injection, use 96372 for the subcutaneous use 96372 for the subcutaneous administration of either Procrit or Aranespadministration of either Procrit or Aranesp 99211 is only used when another service, 99211 is only used when another service, not protocol for the injection, is providednot protocol for the injection, is provided
121 BILLING FOR ADMINISTRATION OF BILLING FOR ADMINISTRATION OF PROCRIT AND ARANESPPROCRIT AND ARANESP When the drug is administered When the drug is administered ““incident toincident to ”” a a physicianphysician ’’s visit, bill the appropriate level of s visit, bill the appropriate level of E&M for the physician visit with a E&M for the physician visit with a ““--2525 ”” modifier (CCI edit effective 10/1/05), the modifier (CCI edit effective 10/1/05), the administration fee 96372 and the drug. administration fee 96372 and the drug. REMEMBERREMEMBER : The provider must be : The provider must be physically present in the suite when the physically present in the suite when the injection is given to bill for the administration injection is given to bill for the administration or the drugor the drug
122 ““INCIDENT TOINCIDENT TO ”” AND AND ““SHAREDSHARED ”” SERVICE SERVICE BILLINGBILLING ““GETTING THE MOST FROM GETTING THE MOST FROM THE WORK PHYSICIAN THE WORK PHYSICIAN EXTENDERS PERFORMEXTENDERS PERFORM ””
123 BILLING OPTIONS FOR NPPsBILLING OPTIONS FOR NPPs
NPPs own provider number receiving 85% NPPs own provider number receiving 85% of the MPFS (Medicare Physicianof the MPFS (Medicare Physician ’’s Fee s Fee Schedule) amountSchedule) amount ““IncidentIncident --toto ”” the physician receiving 100% of the physician receiving 100% of the MPFSthe MPFS Split/Shared service rendering 100% of Split/Shared service rendering 100% of MPFSMPFS
124 WHAT IS WHAT IS ““INCIDENT TOINCIDENT TO ””
Incident to services are:Incident to services are: – Services performed by non -physician practitioners – Services paid as physician ’s services ““Furnished as a Furnished as a partpart of the physicianof the physician ’’s personal, s personal, professional service in the course of diagnosis or professional service in the course of diagnosis or treatment of an injury or illnesstreatment of an injury or illness ”” – Medicare Benefits Policy Manual, Chapter 15, Section 60.1
125 REQUIREMENTS FOR REQUIREMENTS FOR ““INCIDENT INCIDENT TO BILLINGTO BILLING ”” Services must be of the type that would be Services must be of the type that would be covered by Medicare if rendered by a covered by Medicare if rendered by a physicianphysician Services must be of the type that an NP or Services must be of the type that an NP or PA can perform under state statute as PA can perform under state statute as defined in scope of practicedefined in scope of practice Services must be performed under direct Services must be performed under direct supervision by the physiciansupervision by the physician
126 REQUIREMENTS FOR REQUIREMENTS FOR ““INCIDENT INCIDENT TO BILLINGTO BILLING ”” Cost of the Cost of the ““Incident toIncident to ”” services must be services must be incurred by the entity that bills for the incurred by the entity that bills for the serviceservice Medicare does not cover services that are Medicare does not cover services that are not medically necessary or are not of the not medically necessary or are not of the type of service that would normally be type of service that would normally be performed in the physicianperformed in the physician ’’s offices office
127 REQUIREMENTS FOR REQUIREMENTS FOR ““INCIDENT INCIDENT TO BILLINGTO BILLING ”” NP or PA must be an employee of the NP or PA must be an employee of the physician or groupphysician or group Applies only to office servicesApplies only to office services Physician must be physically present in the Physician must be physically present in the office suite to qualify, even if the physician office suite to qualify, even if the physician does not personally see the patientdoes not personally see the patient
128 REQUIREMENTS FOR REQUIREMENTS FOR ““INCIDENT INCIDENT TO BILLINGTO BILLING ”” ““The availability of a physician by telephone The availability of a physician by telephone and the presence of the physician and the presence of the physician somewhere in the institution does not somewhere in the institution does not constitute direct supervisionconstitute direct supervision ”” –– Medicare Benefit Policy Manual, Chapter 15, Medicare Benefit Policy Manual, Chapter 15, Section 60.1.BSection 60.1.B
If the nonIf the non --physician practitioner outpatient service physician practitioner outpatient service does not meet all the qualifications of does not meet all the qualifications of ““incident incident toto ”” bill under the NP or PA at 85%bill under the NP or PA at 85%
129 REQUIREMENTS FOR REQUIREMENTS FOR ““INCIDENT TO BILLINGINCIDENT TO BILLING ”” RememberRemember …….. Incident.. Incident --to cannot be for new to cannot be for new patient visitspatient visits ““Incident toIncident to ”” must be an integral part of the must be an integral part of the physicianphysician ’’s established plan of care for the s established plan of care for the patientpatient Does not apply cover new problems Does not apply cover new problems
130 SHARED SERVICE BILLINGSHARED SERVICE BILLING Services provided by both the physician and the Services provided by both the physician and the extender in the hospital settingextender in the hospital setting Each provider must document the faceEach provider must document the face --toto --face face services renderedservices rendered If NP or PA does dictation for services, If NP or PA does dictation for services, documentation must show that both providers saw documentation must show that both providers saw the patient and the patient and ““sharedshared ”” in the patientin the patient ’’s cares care Statement of Statement of ““Sally Jones, NP for Dr. Sam SmithSally Jones, NP for Dr. Sam Smith ”” is not adequate to show physicianis not adequate to show physician ’’s involvements involvement
131 SHARED SERVICE BILLINGSHARED SERVICE BILLING
Cannot report shared service in the skilled Cannot report shared service in the skilled nursing facility (SNF) or nursing facility (NF) nursing facility (SNF) or nursing facility (NF) settingsetting Each provider (physician & NPP) must Each provider (physician & NPP) must personally perform a substantive portion of personally perform a substantive portion of the E/M visitthe E/M visit ……faceface --toto --faceface ……with the same with the same patient on the same daypatient on the same day The physician & the NPP must be a member The physician & the NPP must be a member of the same practiceof the same practice
132 SHARED SERVICE BILLING SHARED SERVICE BILLING EXAMPLESEXAMPLES
NPP sees the hospital inpatient early in the NPP sees the hospital inpatient early in the day and the physician follows with a later day and the physician follows with a later faceface --toto --face encounter. This service may be face encounter. This service may be reported by either the physician or the NPPreported by either the physician or the NPP
133 DOCUMENTATION OF DOCUMENTATION OF SPLIT/SHARED BILLINGSPLIT/SHARED BILLING Each physician/NPP should personally Each physician/NPP should personally document in the medical record his/her document in the medical record his/her portion of the E/M split/shared visitportion of the E/M split/shared visit The physicianThe physician ’’s documentation must show s documentation must show faceface --toto --face componentface component ……suggest examsuggest exam Documentation must support the combined Documentation must support the combined service level reported on the claimservice level reported on the claim Staff may document ROS & PFSH but the Staff may document ROS & PFSH but the physician & NPP must show reviewphysician & NPP must show review 134 EXAMPLES OF UNACCEPTABLE EXAMPLES OF UNACCEPTABLE DOCUMENTATIONDOCUMENTATION Agree with aboveAgree with above Rounded, reviewed, agreeRounded, reviewed, agree Discussed with NPP agreeDiscussed with NPP agree Seen & agreeSeen & agree Patient seen and evaluatedPatient seen and evaluated Legible CountersignatureLegible Countersignature
135 EXAMPLES OF ACCEPTABLE EXAMPLES OF ACCEPTABLE DOCUMENTATIONDOCUMENTATION I performed a history & PE of the patient and I performed a history & PE of the patient and discussed his management with the NPP. I discussed his management with the NPP. I reviewed the NPP note & I agree with the reviewed the NPP note & I agree with the documented findings and plan of care.documented findings and plan of care. I saw and evaluated the patient. I reviewed I saw and evaluated the patient. I reviewed the NPPthe NPP ’’s note and agree except that s note and agree except that picture is more consistent with acute tubular picture is more consistent with acute tubular necrosis. Will begin XYZ therapy.necrosis. Will begin XYZ therapy.
136 EXAMPLES OF ACCEPTABLE EXAMPLES OF ACCEPTABLE DOCUMENTATIONDOCUMENTATION I saw and evaluated the patient. Agree with I saw and evaluated the patient. Agree with the NPPthe NPP ’’s note but lower extremity edema is s note but lower extremity edema is increased. Will increase lasix and monitor increased. Will increase lasix and monitor closelyclosely
137 EXTENDERS AND THE MCPEXTENDERS AND THE MCP
Can provide some of the visits to equate to the Can provide some of the visits to equate to the total billedtotal billed Watch any state regulations that may applyWatch any state regulations that may apply If extender providers the If extender providers the ““Care PlanCare Plan ”” visit, then the visit, then the MCP must be billed under the extenderMCP must be billed under the extender ’’s provider s provider number at 85% of physiciannumber at 85% of physician ’’s fees fee For 100% reimbursement, physician must see the For 100% reimbursement, physician must see the patient for the major patient for the major ““Care PlanCare Plan ”” visitvisit
138 BILLING PHYSICIANS AS BILLING PHYSICIANS AS ““INCIDENT TOINCIDENT TO ”” DO NOT bill an uncredentialed physician DO NOT bill an uncredentialed physician ““incident toincident to ”” another physiciananother physician CMS policy prohibits use of CMS policy prohibits use of ““incident toincident to ”” billing from one physician to anotherbilling from one physician to another
139 CODING FOR CODING FOR OBSERVATION CAREOBSERVATION CARE
23 Hour short stay23 Hour short stay Observation StatusObservation Status
140 OBSERVATION STATUS CAREOBSERVATION STATUS CARE
““23 hour23 hour ”” short stay short stay –– can extend depending can extend depending on hospitalon hospital ’’s interpretation s interpretation Outpatient hospital servicesOutpatient hospital services Bill using outpatient hospital place of service Bill using outpatient hospital place of service ““2222 ”” RenalRenal --related services are part of the MCPrelated services are part of the MCP Outpatient consult codes will be subject to Outpatient consult codes will be subject to practice expense adjustment practice expense adjustment –– 25% of 25% of reimbursementreimbursement 141 OBSERVATION STATUS CAREOBSERVATION STATUS CARE
For services that cross over more than one For services that cross over more than one calendar daycalendar day Billed by supervising or admitting MDBilled by supervising or admitting MD –– 9921899218 --99220 for observation admission day99220 for observation admission day –– 99217 for observation discharge day services99217 for observation discharge day services Obs encounters by other physicians bill Obs encounters by other physicians bill 9924199241 --99245 or 9922499245 or 99224 --99226 as 99226 as appropriateappropriate
142 OBSERVATION STATUS CAREOBSERVATION STATUS CARE
When observation care is within same When observation care is within same calendar day calendar day –– but exceeds 8 hoursbut exceeds 8 hours Bill 99234Bill 99234 --99236 only99236 only Do not bill discharge care Do not bill discharge care –– 9921799217 Other services such as Emergency room Other services such as Emergency room services are part of the observation status services are part of the observation status codecode
143 OBSERVATION STATUS CAREOBSERVATION STATUS CARE
For observation care of less than 8 hours, For observation care of less than 8 hours, bill only the appropriate observation admit bill only the appropriate observation admit code 99218code 99218 --9922099220 Do not bill a discharge codeDo not bill a discharge code
144 SUBSEQUENT OBSERVATION SUBSEQUENT OBSERVATION CARECARE
9922499224 --99226 are used to bill subsequent 99226 are used to bill subsequent observation care by any physicianobservation care by any physician Document changes in the history, physical Document changes in the history, physical condition and response to management condition and response to management since the last assessment by the physiciansince the last assessment by the physician
145 CODING FOR CRITICAL CODING FOR CRITICAL CARECARE
146 9929199291
Critical care, evaluation and management of Critical care, evaluation and management of the critically ill or critically injured patient; the critically ill or critically injured patient; first 30first 30 --74 minutes74 minutes
147 9929299292
Critical care, evaluation and management Critical care, evaluation and management of the critically ill or critically injured patientof the critically ill or critically injured patient; ; each additional 30 minutes each additional 30 minutes
148 CPT DEFINITIONCPT DEFINITION CRITICAL ILLNESS OR INJURYCRITICAL ILLNESS OR INJURY
““A critical illness or injury acutely impairs A critical illness or injury acutely impairs one or more vital organ system(s) such one or more vital organ system(s) such that there is a high probability of imminent that there is a high probability of imminent or life threatening deterioration in the or life threatening deterioration in the patientpatient ’’s condition.s condition. ””
149 CPT DEFINITIONCPT DEFINITION CRITICAL CARE SERVICESCRITICAL CARE SERVICES ““Critical care is the Critical care is the direct deliverydirect delivery by a by a physician(s) of medical care for a critically ill physician(s) of medical care for a critically ill or injured patient.or injured patient. ”” ““Involves decision making of high Involves decision making of high complexity to assess, manipulate, and complexity to assess, manipulate, and support system function(s), to treat single or support system function(s), to treat single or multiple vital organ system failure and/or to multiple vital organ system failure and/or to prevent further life threatening deterioration prevent further life threatening deterioration of the patientof the patient ’’s condition.s condition. ”” 150 CPT DEFINITIONCPT DEFINITION CRITICAL CARE SERVICESCRITICAL CARE SERVICES
Examples of Vital Organ System FailureExamples of Vital Organ System Failure Central nervous system failureCentral nervous system failure ShockShock Circulatory failureCirculatory failure Renal failureRenal failure Hepatic failureHepatic failure Respiratory failureRespiratory failure Metabolic failureMetabolic failure
151 WHERE IS CRITICAL CARE WHERE IS CRITICAL CARE PROVIDEDPROVIDED
Critical care is usually, but not always, given Critical care is usually, but not always, given in a critical care area, such as the coronary in a critical care area, such as the coronary care unit, intensive care unit, pediatric care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or intensive care unit, respiratory care unit, or the emergency care facility.the emergency care facility.
152 TREATMENT CRITERIONTREATMENT CRITERION
Critical care services require direct Critical care services require direct personal personal management by the physician. They are life management by the physician. They are life and organ supporting interventions that and organ supporting interventions that require frequent, personal assessment and require frequent, personal assessment and manipulation by the physician.manipulation by the physician. Failure to provide these interventions on an Failure to provide these interventions on an urgent basis would result in life threatening urgent basis would result in life threatening deterioration in the patientdeterioration in the patient ’’s condition.s condition.
153 ““FULL ATTENTIONFULL ATTENTION ”” REQUIREMENTREQUIREMENT ““Critical care is used to report the total Critical care is used to report the total duration of time spent by a physician duration of time spent by a physician providing critical care services to a critically providing critical care services to a critically ill or injured patient, even if the time spent ill or injured patient, even if the time spent by the physician on that date is not by the physician on that date is not continuous. For the time spent, the continuous. For the time spent, the physician must devote his or her physician must devote his or her fullfull attention to the patientattention to the patient …”…”
154 WHERE IS THE CARE PROVIDEDWHERE IS THE CARE PROVIDED
Time spent with the individual patient Time spent with the individual patient mustmust be be recorded in the patientrecorded in the patient ’’s record.s record. Time spent can be reported if spent is at the Time spent can be reported if spent is at the bedside or on the unit or floor, i.e.. Coordinatingbedside or on the unit or floor, i.e.. Coordinating care, but care, but cannotcannot be in caring for another patient. be in caring for another patient. Can include time spent with family, etc. when the Can include time spent with family, etc. when the patient cannot make decisions for self.patient cannot make decisions for self.
155 DOCUMENTIONDOCUMENTION FOR MEDICAL REVIEWFOR MEDICAL REVIEW
Must indicate full attention providedMust indicate full attention provided Since time based, must contain documentation of Since time based, must contain documentation of total time involved total time involved Time involved with family to gain pertinent historyTime involved with family to gain pertinent history or make decisions must be documentedor make decisions must be documented Telephone calls to family members to be Telephone calls to family members to be considered must meet same criteria as faceconsidered must meet same criteria as face --toto -- faceface
156 SERVICES SERVICES NOTNOT INCLUDED IN INCLUDED IN CRITICAL CARE TIMECRITICAL CARE TIME
Time spent providing services not bundled into critical care tim e such as dialysis or access placement are not included
Services rendered earlier in the day prior to the patient ’s need for critical care. This service can be reported separately, but documentation needs to be sent with the claim and a modifier (-25) needs to be appended to this service. CR 5792 Time spent updating patient ’s family about status not meeting previous criteria regardless of how lengthy
157 CRITICAL CARE & DIALYSISCRITICAL CARE & DIALYSIS
Dialysis (90935, 90937, 90945, 90947) is Dialysis (90935, 90937, 90945, 90947) is not included in Critical Care timenot included in Critical Care time Make sure a separate note is made for Make sure a separate note is made for dialysis and all the criteria for billing dialysis and all the criteria for billing dialysis are metdialysis are met ……physical presence physical presence during the treatmentduring the treatment Append a Append a ““--2525 ”” modifier to the Critical modifier to the Critical Care codeCare code
158 CRITICAL CARE TIDBITSCRITICAL CARE TIDBITS
99291 is used to report first hour (3099291 is used to report first hour (30 --74 minutes) 74 minutes) of critical careof critical care 99292 is used to report each additional 30 99292 is used to report each additional 30 minutesminutes 99292 is used to report final 1599292 is used to report final 15 --30 minutes of 30 minutes of critical carecritical care Critical care of less than 30 minutes is reported Critical care of less than 30 minutes is reported using appropriate E/M code using appropriate E/M code Only one physician may bill for a given hour of Only one physician may bill for a given hour of critical care even if more than one physician is critical care even if more than one physician is providing careproviding care
159 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Critical CareCritical Care –– Does the documentation demonstrate all of the Does the documentation demonstrate all of the following?following? Direct personal management. Frequent personal assessment and manipulation (not just the general once -a-day visit). High -complexity decision -making to assess, manipulate and support vital system function(s) to treat single or multiple organ system failure or to prevent further deterioration.
160 TIPS FOR PREVENTING CODING TIPS FOR PREVENTING CODING ERRORS WITH E/M CODINGERRORS WITH E/M CODING Critical Care Critical Care –– cont.cont. Interventions of a nature that failure to initiate these interventions on an urgent basis would likely result in sudden clinically significant or life -threatening deterioration in the patient ’s condition. – What about the time spent providing critical care? Is specifically recorded? Is it reasonable considering the documented work provided? Does it exclude time spent performing procedures separately billable? If it includes time spent with family, was the family members operating as a surrogate decision -maker because the patient was unable to make decisions?
161 CKD EDUCATION CKD EDUCATION BENEFITSBENEFITS
IMPLEMENTATION IMPLEMENTATION JANUARY 1, 2010JANUARY 1, 2010
162 CKD EDUCATION BENEFITCKD EDUCATION BENEFIT
Limited to beneficiaries with Stage IV CKDLimited to beneficiaries with Stage IV CKD Defined as six, 60 minute sessionsDefined as six, 60 minute sessions Allows for individual or group sessionsAllows for individual or group sessions –– G0420 G0420 –– for individualsfor individuals –– G0421G0421 –– for group sessionsfor group sessions The RVUs for G0420 was multiplied by 4 and The RVUs for G0420 was multiplied by 4 and G0421 was multiplied by 2G0421 was multiplied by 2 G0420 would pay approximately $108.18G0420 would pay approximately $108.18 G0421 would pay approximately $25.60G0421 would pay approximately $25.60
163 CKD EDUCATION BENEFITCKD EDUCATION BENEFIT
““Incident toIncident to ”” does not apply does not apply –– education must education must be rendered by a physician, physician be rendered by a physician, physician assistant, nurse practitioner or clinical nurse assistant, nurse practitioner or clinical nurse specialistspecialist Dialysis facilities expressly are excluded from Dialysis facilities expressly are excluded from providing this serviceproviding this service
164 EDUCATION TALKING POINTSEDUCATION TALKING POINTS
Basic information regarding CKD, how the Basic information regarding CKD, how the kidneys work, what happens when the kidney kidneys work, what happens when the kidney fail and the permanence of the diseasefail and the permanence of the disease Survival rates with and without renal Survival rates with and without renal replacement therapy and survival rates if the replacement therapy and survival rates if the patient refused treatment for the CKDpatient refused treatment for the CKD The need for kidney transplantationThe need for kidney transplantation
165 EDUCATION TALKING POINTSEDUCATION TALKING POINTS •• Unbiased information about RRT options Unbiased information about RRT options including advantages and disadvantages for including advantages and disadvantages for all modalitiesall modalities •• Adequate information regarding why some Adequate information regarding why some RRT options were not viable for a patientRRT options were not viable for a patient •• How different RRT options affected the How different RRT options affected the patientpatient ’’s cos co --morbid conditionsmorbid conditions •• Effects of RRT choices on lifestyle such as Effects of RRT choices on lifestyle such as treatment flexibility & session lengthtreatment flexibility & session length
166 EDUCATION TALKING POINTSEDUCATION TALKING POINTS
Whether a patient will need assistance based on Whether a patient will need assistance based on RRT modality choice and training requirements for RRT modality choice and training requirements for helpershelpers The right to refuse treatmentThe right to refuse treatment Effects of the disease and the subsequent Effects of the disease and the subsequent treatment on the patienttreatment on the patient ’’s physical appearances physical appearance Patient recognition of the symptoms that would Patient recognition of the symptoms that would empower the patient with the knowledge to seek empower the patient with the knowledge to seek helphelp
167 EDUCATION TALKING POINTSEDUCATION TALKING POINTS
Disease and treatment complications related to Disease and treatment complications related to renal replacement therapy such as renal replacement therapy such as hypertension, catheter migration, temporary/ hypertension, catheter migration, temporary/ permanent loss of dialysis access and risk of permanent loss of dialysis access and risk of infection at the access siteinfection at the access site How to control and manage consequences of How to control and manage consequences of complications and symptoms (for example: complications and symptoms (for example: treatment for itchy skin or insomnia)treatment for itchy skin or insomnia)
168 EDUCATION TALKING POINTSEDUCATION TALKING POINTS
The ability to travel and organize holidays The ability to travel and organize holidays depending on RRT choicedepending on RRT choice Maintenance of social relationships, activities andMaintenance of social relationships, activities and commitmentscommitments How the disease and RRT may affect the patientHow the disease and RRT may affect the patient ’’s s ability to continue workingability to continue working Available support servicesAvailable support services Medication management Medication management
169 POSTPOST -- EDUCATION EDUCATION ASSESSMENTASSESSMENT
Requires beneficiaries to be assessed at the Requires beneficiaries to be assessed at the conclusion of the sessionsconclusion of the sessions Providers must develop outcome assessments Providers must develop outcome assessments tailored to beneficiariestailored to beneficiaries At this point CMS is seeking comment on the At this point CMS is seeking comment on the factors to include in the outcomes assessmentfactors to include in the outcomes assessment
170 DOCUMENTATIONDOCUMENTATION Although the regulations did not address Although the regulations did not address specific documentation requirements, it will specific documentation requirements, it will be necessary to documentation the elements be necessary to documentation the elements covered in each sessioncovered in each session Maintain the documentation in the patientMaintain the documentation in the patient ’’s s chartchart RPA has developed a documentation tool to RPA has developed a documentation tool to assist our physicians in this taskassist our physicians in this task
171 Kidney Disease Education Documentation Tool
Patient Name: ______Identification Number: ______
Kidney Disease Education (KDE) Session 1 Session 2 Ses sion 3 Session 4 Session 5 Session 6 Qualified Person Notes Session Date G0420-Individual >31 minutes G0421-Group >31 minutes Topics Reviewed:
Discuss management of co-morbities
Diabetes Mellitus
Hypertension
Therapeutic Options Discuss Treatment Modalities (advantages/disadvantages and settings of each)
Hemodialysis/HomeHD/Nocturnal
Peritoneal
Transplantation
Dialysis Access Options
Participating in choice of treatment/tailoring of treatment
Prevention of uremic complications
Smoking Cessation
Avoidance NSAIDS
Anemia
Bone Disease
Blood Transfusion Impact
Nutrition
Conservative Management/Palliative Care
Advanced Directives
Outcomes Assessment Date: ______Conducted By: ______Attending/Supervising MD Signature: ______172 MEDICARE PREVENTIVE MEDICARE PREVENTIVE SERVICESSERVICES
Section 4103 of the Affordable Section 4103 of the Affordable Care Act of 2010Care Act of 2010 Annual Wellness VisitAnnual Wellness Visit
173 WELCOME TO MEDICARE WELCOME TO MEDICARE PHYSICALPHYSICAL
G0402 G0402 –– Initial preventive physical exam Initial preventive physical exam (IPPE)(IPPE) –– Within first 12 months of having Part B MedicareWithin first 12 months of having Part B Medicare –– No deductible applies but coinsurance appliesNo deductible applies but coinsurance applies –– Can bill separate E&M service with modifier Can bill separate E&M service with modifier ““--2525 ”” –– EKG no longer is required (deductible & EKG no longer is required (deductible & coinsurance do apply if performed)coinsurance do apply if performed)
174 WELCOME TO MEDICARE WELCOME TO MEDICARE PHYSICAL (IPPE)PHYSICAL (IPPE) Review of medical & social history with Review of medical & social history with emphasis on disease detectionemphasis on disease detection Review of risk for depressionReview of risk for depression Review of functional ability & level of safetyReview of functional ability & level of safety PE including height, weight, BP, visual screenPE including height, weight, BP, visual screen Referral, education & counseling as needed Referral, education & counseling as needed including written plan for appropriate including written plan for appropriate screening and other preventive services screening and other preventive services
175 ANNUAL WELLNESS VISIT ANNUAL WELLNESS VISIT (AWV)(AWV) G0438 G0438 -- beneficiary is no longer within 12 beneficiary is no longer within 12 months after effective date of first Medicare months after effective date of first Medicare Part B coverage period and did not receive Part B coverage period and did not receive the IPPE benefit during the 1the IPPE benefit during the 1 st 12 months12 months Once in a lifetime benefitOnce in a lifetime benefit G0439 G0439 –– subsequent AWV annually subsequent AWV annually thereafterthereafter
176 ANNUAL WELLNESS VISIT ANNUAL WELLNESS VISIT (AWV) ELEMENTS(AWV) ELEMENTS Establishment of medical/family history Measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other measurements as deem appropriate List of current providers and suppliers used regularly for beneficiary Detection of any cognitive impairments Review of risk for depression using screening tests Review of functional ability & level of safety based on observation and screening questions or questionnaires
177 ANNUAL WELLNESS VISIT ANNUAL WELLNESS VISIT (AWV) ELEMENTS(AWV) ELEMENTS Establishment of written screening schedule such as a check list for the next 5 to 10 years, include immunizations and health screening as age appropriate Personalized health advice and referrals as appropriate for health education and preventive counseling services or programs to reduce risk and promote self -management and wellness including weight loss, smoking cessation, fall prevention & nutrition Voluntary advance care planning Any other elements as deemed appropriate through the National Carrier Determination process (NDC)
178 ANNUAL WELLNESS VISIT ANNUAL WELLNESS VISIT (AWV)(AWV) May be performed by MD, DO, or qualified May be performed by MD, DO, or qualified NPP, health educator, registered dietitian, NPP, health educator, registered dietitian, nutrition professional or other licensed nutrition professional or other licensed practitioner or a team of such professionalspractitioner or a team of such professionals As a result of the Affordable Care Act, the As a result of the Affordable Care Act, the deductible and coinsurance for the AWV is deductible and coinsurance for the AWV is waivedwaived
179 SUBSEQUENT AWV SUBSEQUENT AWV ELEMENTSELEMENTS Update the individual ’s medical/family history Measure the patients weight, BP and other routine measurements Update list of patient ’s current providers and suppliers Detection of any cognitive impairments that the patient may have Update the individual ’s written screening schedule developed at the first AWV providing PPPS (personal preventive plan services) Update the list of risk factors and conditions
180 SUBSEQUENT AWV SUBSEQUENT AWV ELEMENTSELEMENTS Furnish appropriate personalized health advice to the individual and referrals as necessary to health education or preventive counseling or programs Voluntary advance care planning upon agreement with the patient Other elements that may be added through the National Carrier Determination process (NCD) Deductible and coinsurance are waived for the Deductible and coinsurance are waived for the subsequent AWV as well as the initialsubsequent AWV as well as the initial
181 PAYMENT FOR AWVPAYMENT FOR AWV
Payment for G0438 AWV is approximately Payment for G0438 AWV is approximately $155.19$155.19 Payment for G0439 subsequent AWV is Payment for G0439 subsequent AWV is approximately $103.88.approximately $103.88.
182 ICDICD --99--CM CODINGCM CODING
WHY YOU DID WHAT YOU DIDWHY YOU DID WHAT YOU DID
183 ICDICD --9 Coding9 Coding
Detail is very important today in billing the Detail is very important today in billing the diagnosis our patients havediagnosis our patients have But as we approach October, 2013 detail But as we approach October, 2013 detail becomes far more importantbecomes far more important Diseases that are associated with Kidney Diseases that are associated with Kidney disease are sometimes more challenging disease are sometimes more challenging than CKD or ESRDthan CKD or ESRD LetLet ’’s take a different approach at ICDs take a different approach at ICD --99
184 DIABETES INSIPIDUSDIABETES INSIPIDUS
Diabetes insipidus (DI) is an uncommon Diabetes insipidus (DI) is an uncommon condition that occurs when the kidneys are condition that occurs when the kidneys are unable to conserve water as they perform unable to conserve water as they perform their function of filtering blood. The their function of filtering blood. The amount of water conserved is controlled by amount of water conserved is controlled by antidiuretic hormone (ADH), also called antidiuretic hormone (ADH), also called vasopressin. (ICDvasopressin. (ICD --9 253.5)9 253.5) DIABETES INSIPIDUSDIABETES INSIPIDUS ADH is a hormone produced in a region of the brain called the hypothalamus. It is then stored and released from the pituitary gland, a small gland at the base of the brain. DI caused by a lack of ADH is called central diabetes insipidus. When DI is caused by a failure of the kidneys to respond to ADH, the condition is called nephrogenic diabetes insipidus. (ICD -9 588.1) DIABETES INSIPIDUSDIABETES INSIPIDUS
Nephrogenic DI involves a Certain drugs such as defect in the parts of the lithium kidneys that reabsorb water High levels of calcium in the back into the bloodstream. It body (hypercalcemia) occurs less often than central (275.42) DI. Nephrogenic DI may DI. Nephrogenic DI may Kidney disease (such as occur as an inherited occur as an inherited polycystic kidney disease) disorder in which male Symptoms children receive the Symptoms abnormal gene that causes – Excessive thirst (783.5) May be intense or uncontrollable the disease from their May involve a craving for ice mothers. water Nephrogenic DI may also be – Excessive urine volume caused by: (788.42) SIADHSIADH Syndrome of Inappropriate Anti diuretic Hormone secretion or SIADH The body normally maintains very tight control over its total amount of water and its concentration of sodium Certain disease states can upset the delicate balance of water and salt in the body If there is too much ADH in the body, or if the kidneys overreact to the ADH they receive, the body retains excess water and the serum sodium concentration becomes diluted and falls to abnormal levels Treatment includes water restriction and salt administration and diagnosis of the underlying cause of the SIADH, usually a neoplasm (ICD -9 Code 253.6) HYPERTENSIONHYPERTENSION
Hypertension Table found under the main Hypertension Table found under the main term term ““hypertensionhypertension ”” in the index, contains a in the index, contains a complete listing of all conditions due to or complete listing of all conditions due to or associated with hypertension and classifies associated with hypertension and classifies them according to malignant, benign, and them according to malignant, benign, and unspecified.unspecified.
189 HYPERTENSIONHYPERTENSION
Hypertension, essential, or NOSHypertension, essential, or NOS –– Assign hypertension to category code 401 with Assign hypertension to category code 401 with the appropriate fourth digit to indicate malignant the appropriate fourth digit to indicate malignant (0), benign (1), or unspecified (9). Do not use (0), benign (1), or unspecified (9). Do not use either .0 malignant or .1 benign unless the either .0 malignant or .1 benign unless the medical record documentation supports such a medical record documentation supports such a designationdesignation
190 HYPERTENSIONHYPERTENSION
Hypertension with heart diseaseHypertension with heart disease –– Heart conditions (425.8, 429.0Heart conditions (425.8, 429.0 --429.3) are 429.3) are assigned to a code from category 402 when a assigned to a code from category 402 when a causal relationship is stated (due to causal relationship is stated (due to hypertension) or implied (hypertensive). Use hypertension) or implied (hypertensive). Use an additional code from category 428 to identify an additional code from category 428 to identify the type of heart failure in those patients with the type of heart failure in those patients with heart failure. More than one code from heart failure. More than one code from category 428 may be assigned if the patient has category 428 may be assigned if the patient has systolic or diastolic failure and CHFsystolic or diastolic failure and CHF
191 HYPERTENSIONHYPERTENSION
Hypertension with heart disease (cont.)Hypertension with heart disease (cont.) –– The same heart conditions with hypertension The same heart conditions with hypertension without a stated causal relationship are coded without a stated causal relationship are coded separately. Sequence according to the separately. Sequence according to the circumstances of the encountercircumstances of the encounter
192 HYPERTENSIONHYPERTENSION
Hypertensive chronic kidney diseaseHypertensive chronic kidney disease –– Assign codes from category 403 when Assign codes from category 403 when conditions classified in categories 585conditions classified in categories 585 --587 587 are present. Unlike hypertensive heart are present. Unlike hypertensive heart disease, there is a presumed cause and effect disease, there is a presumed cause and effect relationship between hypertension and CKDrelationship between hypertension and CKD –– Fourth digit is type of hypertensionFourth digit is type of hypertension –– Fifth digit Fifth digit ““00”” is stage 1is stage 1 --44 –– Fifth digit Fifth digit ““11”” is stage 5is stage 5 --66
193 HYPERTENSIONHYPERTENSION
Hypertensive chronic kidney diseaseHypertensive chronic kidney disease –– If the physician states that the hypertension and If the physician states that the hypertension and CKD are unrelated code the conditions CKD are unrelated code the conditions separately sequencing according to the separately sequencing according to the encounterencounter
194 HYPERTENSIONHYPERTENSION
Hypertension secondary Hypertension secondary –– two codes are two codes are required; one to identify the underlying required; one to identify the underlying etiology and one from category 405 to etiology and one from category 405 to identify the hypertension. Sequencing of the identify the hypertension. Sequencing of the codes is determined by the reason for the codes is determined by the reason for the encounter.encounter. Elevated blood pressure reading without a Elevated blood pressure reading without a diagnosis of hypertension is coded 796.2diagnosis of hypertension is coded 796.2
195 DIABETIC NEPHROPATHYDIABETIC NEPHROPATHY
During diabetic nephropathy the kidney becomes damaged and more protein than normal collects in the urine. As the disease progresses, more of the kidney is destroyed. Over time, the kidney's ability to function starts to decline, which may eventually lead to chronic kidney failure. DIABETES MELLITUSDIABETES MELLITUS
250 is the main category for diabetes250 is the main category for diabetes The fourth digit is the manifestation of the The fourth digit is the manifestation of the diabetes such as 250.4X is diabetes with diabetes such as 250.4X is diabetes with renal manifestationsrenal manifestations The fifth digit defines the type of diabetesThe fifth digit defines the type of diabetes –– ““00”” is type II or unspecified not stated as is type II or unspecified not stated as uncontrolleduncontrolled –– ““11”” is type I not stated uncontrolledis type I not stated uncontrolled –– ““22”” is type II uncontrolledis type II uncontrolled –– ““33”” is type I uncontrolledis type I uncontrolled 197 DIABETES MELLITUSDIABETES MELLITUS
The age of the patient is not the sole The age of the patient is not the sole determining factor of the type of diabetesdetermining factor of the type of diabetes All type I diabetics must use insulin All type I diabetics must use insulin However the use of insulin does not mean However the use of insulin does not mean the patient is type Ithe patient is type I Add the code V58.67 for long term insulin Add the code V58.67 for long term insulin useuse
198 DIABETES MELLITUSDIABETES MELLITUS
Assign and sequence manifestation and Assign and sequence manifestation and association conditions with the 250.XX code association conditions with the 250.XX code before associated codes before associated codes For example: 250.40 is diabetes II with For example: 250.40 is diabetes II with renal manifestations, if the patient has renal manifestations, if the patient has diabetic nephropathy add 583.81 diabetic nephropathy add 583.81 (nephropathy) add the stage of CKD (ie. (nephropathy) add the stage of CKD (ie. 585.3) then add V58.67 if there is long term 585.3) then add V58.67 if there is long term insulin useinsulin use
199 SECONDARY DIABETES SECONDARY DIABETES MELLITUSMELLITUS Used to report diabetes when the disease Used to report diabetes when the disease process is process is ““due todue to ”” some other situation some other situation such as drug induced or chemical inducedsuch as drug induced or chemical induced Code the situation that caused the Code the situation that caused the diabetesdiabetes 249.XX is the series of codes249.XX is the series of codes Do not use for sequencing diabetes when Do not use for sequencing diabetes when the primary reason for the encounter was the primary reason for the encounter was another problem another problem 200 SECONDARY DIABETES SECONDARY DIABETES MELLITUSMELLITUS 249.4X 249.4X –– Secondary diabetes mellitus with Secondary diabetes mellitus with renal manifestationsrenal manifestations Fifth digit Fifth digit ““00”” not stated as uncontrolled or not stated as uncontrolled or unspecified or unspecified or ““11”” uncontrolleduncontrolled Use additional code to identify manifestationUse additional code to identify manifestation –– CKD (585.1CKD (585.1 --585.9)585.9) –– Diabetic nephropathy (583.81)Diabetic nephropathy (583.81) –– Intercapillary glomerulosclerosis (581.81)Intercapillary glomerulosclerosis (581.81) POLYCYSTIC KIDNEY DISEASEPOLYCYSTIC KIDNEY DISEASE
: A cyst is a fluid: A cyst is a fluid --filled sac. filled sac. There are two types of There are two types of kidney cysts.kidney cysts. Polycystic kidney disease Polycystic kidney disease (PKD) runs in families. In (PKD) runs in families. In PKD, the cysts enlarge PKD, the cysts enlarge and destroy surrounding and destroy surrounding normal tissue. As the normal tissue. As the cysts enlarge, the kidneys cysts enlarge, the kidneys lose function, leading to lose function, leading to progressive kidney failure.progressive kidney failure. POLYCYSTIC KIDNEY DISEASEPOLYCYSTIC KIDNEY DISEASE
•• PKD can cause kidneys PKD can cause kidneys •• Diagnosis is made with Diagnosis is made with to fail requiring dialysis to fail requiring dialysis imaging and patient imaging and patient or transplantor transplant historyhistory •• PKD can cause blood PKD can cause blood •• Treatments are Treatments are in the urinein the urine medication and RRT medication and RRT •• PKD can cause cysts to PKD can cause cysts to (renal replacement (renal replacement develop on other develop on other therapy)therapy) organsorgans ICD-9 Code 753.12 – Polycystic unspec •• Symptoms of PKDSymptoms of PKD 753.13 PKD, autosomal dominant – Pain in the back and 753.14 PKD, autosomal recessive (rare lower side disease causing cysts on the kidney & – Headache liver causing renal and kidney failure – Urinary tract infections in children and adolescents ACQUIRED CYSTIC KIDNEY ACQUIRED CYSTIC KIDNEY DISEASEDISEASE
Acquired cystic kidney disease (ACKD) Acquired cystic kidney disease (ACKD) happens when people are on dialysishappens when people are on dialysis Unlike PKD, patients with ACKD do not Unlike PKD, patients with ACKD do not develop cysts on other organsdevelop cysts on other organs The kidneys are normal sizeThe kidneys are normal size ACKD usually is symptom freeACKD usually is symptom free ACKD is harmless and does not need ACKD is harmless and does not need treatmenttreatment ICD-9 Code 593.2 NEPHROLITHIASIS (KIDNEY NEPHROLITHIASIS (KIDNEY STONE)STONE) A kidney stone is a A kidney stone is a crystal that forms in crystal that forms in the kidney from the kidney from substances in the substances in the urine. It may get urine. It may get stuck in the urinary stuck in the urinary tract, block the flow tract, block the flow of urine and cause of urine and cause great pain +/or great pain +/or kidney failure. kidney failure. ICD-9 Code 592.0 Uric acid stone 274.11 STAGES OF CKDSTAGES OF CKD eGFR of 90 or above eGFR of 90 or above Stage 1 (585.1)Stage 1 (585.1) is considered normalis considered normal eGFR stays below 60 eGFR stays below 60 Stage 2 (585.2)Stage 2 (585.2) for 3 monthsfor 3 months Moderate decrease in Moderate decrease in Stage 3 (585.3)Stage 3 (585.3) eGFR (30 to 59)eGFR (30 to 59) Severe reduction in Severe reduction in Stage 4 (585.4)Stage 4 (585.4) eGFR (15 to 29)eGFR (15 to 29) Kidney failure (eGFR Kidney failure (eGFR Stage 5 (585.5) or Stage 5 (585.5) or less than 15less than 15 Stage 6 if on dialysis Stage 6 if on dialysis (585.6)(585.6) ACUTE KIDNEY FAILUREACUTE KIDNEY FAILURE
Acute (sudden) kidney Acute (sudden) kidney May have AKF in the May have AKF in the failure is the sudden failure is the sudden setting of CKDsetting of CKD loss of the ability of the loss of the ability of the Code the AKF primary Code the AKF primary kidneys to remove kidneys to remove with the underlying with the underlying waste and concentrate waste and concentrate stage of CKD stage of CKD urine +/or excrete urine +/or excrete secondarysecondary electrolytes.electrolytes. ICD-9 Code 584.9 Physician may list as Physician may list as Acute on Chronic 584.9 followed by the AKI (acute kidney AKI (acute kidney stage of CKD prior to the exacerbation 585.X injury)injury) ACUTE TUBULAR NECROSISACUTE TUBULAR NECROSIS
• Acute tubular necrosis (ATN) • Common in hospitalized is damaging and loss of patients tubular cells usually caused – Blood transfusions by lack of oxygen and/or – Injury or trauma that damages chemical insult to the kidney muscle tissues (ischemia of the – Hypotension > 30 mins kidneys). It may also occur if – Major surgery the kidney cells are damaged – Septic Shock by a poison or harmful – Contrast substance. – Medication Toxicity • Diabetes can make more ATN is often recoverable but susceptible may need short term dialysis to support the body while the kidney recovers.
ICD-9 Code 584.5 ACUTE KIDNEY FAILUREACUTE KIDNEY FAILURE
•• Acute Kidney Failure with lesion of renal Acute Kidney Failure with lesion of renal cortical necrosis (ICDcortical necrosis (ICD --9 584.6)9 584.6) •• Acute Kidney Failure with lesion of renal Acute Kidney Failure with lesion of renal Medullary (papillary) necrosis Medullary (papillary) necrosis (most often (most often diabetic or associated with NSAID use) diabetic or associated with NSAID use) (ICD(ICD --9 9 584.7)584.7) •• Acute Kidney Failure with other specified Acute Kidney Failure with other specified pathological lesion in kidney (ICDpathological lesion in kidney (ICD --9 584.8)9 584.8) •• These lesions may require a biopsy to prove These lesions may require a biopsy to prove presence of which type lesionpresence of which type lesion RENAL BIOPSYRENAL BIOPSY
• In renal biopsy, a small sample of kidney tissue is removed with a needle. The test is used to evaluate a malfunctioning transplanted kidney. It is also used to evaluate an unexplained decrease in kidney function, persistent blood in the urine (ICD -9 599.70), or protein in the urine (ICD -9 791.0). • Many glomerular diseases will need a kidney biopsy for definitive diagnosis CPT Code 50200 ANALGESIC NEPHROPATHYANALGESIC NEPHROPATHY
•• Caused by use of pain Caused by use of pain •• Statistics show that 4 out Statistics show that 4 out killers such as aspirin, killers such as aspirin, of every 100,000 people of every 100,000 people ibuprofen, and naproxen ibuprofen, and naproxen will develop Analgesic will develop Analgesic sodium as well as sodium as well as NephropathyNephropathy prescription NSAIDsprescription NSAIDs •• Blood test should be Blood test should be •• Use can be a single Use can be a single done frequently to done frequently to dose or more long termdose or more long term monitor kidney monitor kidney •• Can cause acute or Can cause acute or involvementinvolvement chronic kidney diseasechronic kidney disease •• A less nephrotoxic A less nephrotoxic •• Most frequent in women Most frequent in women substance should be substance should be over 30over 30 used when possible to used when possible to avoid damageavoid damage
ICD-9 Code 583.89 IgA NEPHROPATHYIgA NEPHROPATHY
• IgA is a protein called an • Risk factors include: antibody that helps the – A personal or family history body fight infections. IgA of IgA nephropathy or nephropathy (Berger's Henoch Schonlein purpura, a form of vasculitis that disease) occurs when too affects many parts of the much of this protein is body deposited in the kidneys. – Caucasian or Asian IgA builds up inside the ethnicity small blood vessels of the – IgA nephropathy most kidney. Structures in the often affects males in their kidney called glomeruli teens to late 30s become inflamed and • Symptoms include: damaged. – Blood in the urine – Repeated blood or dark urine – Swelling of hands and feet ICD-9 Code 583.9 LUPUS NEPHRITISLUPUS NEPHRITIS
•• An inflammation of the An inflammation of the •• Additionally code as a Additionally code as a kidney caused by kidney caused by secondary code for the secondary code for the systemic lupus systemic lupus manifestation of the manifestation of the erythematosus (SLE) erythematosus (SLE) diseasedisease (ICD(ICD --9 Code 710.0) 9 Code 710.0) – Endocarditis (424.91) •• Lupus can affect the Lupus can affect the – Nephritis (583.81) connective tissues of connective tissues of • Chronic (582.81) multisystemmultisystem – Nephrotic Syndrome (581.81) •• Fever, muscle & joint Fever, muscle & joint pain, rash of a butterfly pain, rash of a butterfly Coding Note: Watch use of 583.81 patternpattern This code is a secondary code and cannot be used as a primary code FOCAL SEGMENTAL FOCAL SEGMENTAL GLOMERULOSCLEROSISGLOMERULOSCLEROSIS
• Focal Segmental GS is • FSGS affect children and scar tissue that forms in adults but most frequently the glomeruli African -Americans • Focal means that some of • Known causes are: the glomeruli become – Heroin use damaged while others – HIV remain normal – Inherited genetic problems • Segmental means that – Obesity only part of the individual – Reflux Nephropathy (a glomeruli becomes condition in which urine damaged flows backward from the bladder to the kidney) – Sickle Cell Disease Most are unknown etiology ICD-9 Code 582.1; with Nephrotic syndrome 581.1 GOODPASTUREGOODPASTURE ‘‘S SYNDROMES SYNDROME ICD-9 Code 446.21
•• Is a rare disease that Is a rare disease that •• GoodpastureGoodpasture ’’s may be s may be targets the lungs and targets the lungs and diagnosis using blood diagnosis using blood kidneyskidneys tests, but biopsy of the tests, but biopsy of the •• Is an autoimmune Is an autoimmune lung or kidney may be lung or kidney may be syndrome there the syndrome there the necessarynecessary bodies own defense bodies own defense •• Treatment may be Treatment may be system attacks itselfsystem attacks itself immunosuppressive immunosuppressive •• Symptoms includeSymptoms include therapy or therapy or – Blood in urine (599.70) plasmapheresisplasmapheresis – Protein in urine (791.0) •• Patients may need Patients may need – Fatigue and tiredness dialysis or kidney dialysis or kidney (780.79) transplantationtransplantation – Hemoptysis (786.30) SECONDARY SECONDARY HYPERPARATHYROIDISMHYPERPARATHYROIDISM Kidney failure is a Kidney failure is a Too much phosphate Too much phosphate common cause of common cause of can cause a change in can cause a change in secondary secondary calcium levels in the calcium levels in the hyperparathyroidism. hyperparathyroidism. body. The calcium body. The calcium Kidney failure can Kidney failure can needs to be corrected needs to be corrected interfere with the interfere with the in these patients as in these patients as body's ability to body's ability to well.well. remove phosphate.remove phosphate. ICD-9 Code for Secondary hyperparathyroidism of Renal origin 588.81 ICD-9 Hypocalcemia 275.41 Secondary hyperparathyroidism of non-renal origin 252.02 NEPHROLITHIASISNEPHROLITHIASIS Kidney stones form when a change occurs in the normal balance of water, salts, minerals, and other substances found in urine. Other chemical compounds that can form stones in the urinary tract include uric acid and the amino acid cystine. NEPHROLITHIASISNEPHROLITHIASIS Symptoms and signs Symptoms and signs of a kidney stone of a kidney stone include excruciating, include excruciating, cramping pain in the cramping pain in the lower back and/or side, lower back and/or side, groin, or abdomen as groin, or abdomen as well as blood in the well as blood in the urineurine One out of every 20 people develop a Kidney stones can be Kidney stones can be kidney stone at some time in their life hereditaryhereditary ICD-9 Uric acid stone 274.11; kidney stone 592.0; stone in ureter 592.1 INTRODUCTION TOINTRODUCTION TO ICDICD --10CM10CM
PROPOSED EFFECTIVE DATE PROPOSED EFFECTIVE DATE OCTOBER 1, 2013OCTOBER 1, 2013
219 ICDICD --1010 --CM/PCSCM/PCS
Enacted in the Health Insurance Portability Enacted in the Health Insurance Portability and Accountability Act (HIPAA) of 1996and Accountability Act (HIPAA) of 1996 All covered entities must implement the new All covered entities must implement the new code sets for dates of service or date of code sets for dates of service or date of discharge for inpatients that occur on or discharge for inpatients that occur on or after October 1, 2013after October 1, 2013 Health and Human Services has no plans to Health and Human Services has no plans to extend the implementation dateextend the implementation date
220 ICDICD --1010 --CM/PCSCM/PCS
Consists of two parts:Consists of two parts: –– ICDICD --1010 --CM CM –– The diagnosis classification The diagnosis classification system developed for the CDC and all other US system developed for the CDC and all other US treatment settingstreatment settings –– ICDICD --1010 --PCS PCS –– procedure classification system procedure classification system developed by CMS for use in the US for developed by CMS for use in the US for inpatient hospital settings ONLY. ICDinpatient hospital settings ONLY. ICD --10 uses 10 uses 7 alpha/numeric digits where ICD7 alpha/numeric digits where ICD --9 uses 39 uses 3 --5 5 numeric digitsnumeric digits
221 ICDICD --1010 --CM/PCSCM/PCS
Incorporates much greater specificity and Incorporates much greater specificity and clinical information which allows forclinical information which allows for –– Improved ability to measure health care Improved ability to measure health care servicesservices –– Increased sensitivity when refining groupings Increased sensitivity when refining groupings and reimbursement methodologiesand reimbursement methodologies –– Enhanced ability to conduct public health Enhanced ability to conduct public health surveillancesurveillance –– Decrease need to including supporting Decrease need to including supporting documentation with claimsdocumentation with claims 222 ICDICD --1010 --CM/PCSCM/PCS
Includes updated medical terminology and Includes updated medical terminology and classification of diseaseclassification of disease Provides codes to allow comparison of Provides codes to allow comparison of mortality and morbidity datamortality and morbidity data Provides better data forProvides better data for –– Measuring care furnished to patientsMeasuring care furnished to patients –– Designing payment systemsDesigning payment systems –– Making clinical decisionsMaking clinical decisions
223 ICDICD --1010 --CM/PCSCM/PCS
–– Processing claimsProcessing claims –– Tracking public health Tracking public health –– Identifying fraud and abuseIdentifying fraud and abuse –– Conducting researchConducting research
224 STRUCTURAL DIFFERENCES STRUCTURAL DIFFERENCES BETWEEN THE TWO CODING BETWEEN THE TWO CODING SYSTEMSSYSTEMS ICDICD --99--CM Diagnosis CodesCM Diagnosis Codes –– 33--5 digits5 digits –– First digit is alpha (E or V) or numericFirst digit is alpha (E or V) or numeric –– Digits 2Digits 2 --5 are numeric5 are numeric –– ExamplesExamples 496 – Chronic airway obstruction NEC 511.9 – Unspecified pleural effusion V42.0 – Renal transplant 225 STRUCTURAL DIFFERENCES STRUCTURAL DIFFERENCES BETWEEN THE TWO CODING BETWEEN THE TWO CODING SYSTEMSSYSTEMS
ICDICD --1010 --CM Diagnosis CodesCM Diagnosis Codes –– 33--7 digits7 digits –– Digit 1 is alphaDigit 1 is alpha –– Digit 2 and 3 are numericDigit 2 and 3 are numeric –– Digits 4Digits 4 --7 are alpha or numeric (alpha digits are 7 are alpha or numeric (alpha digits are not case sensitivenot case sensitive
226 STRUCTURAL DIFFERENCES STRUCTURAL DIFFERENCES BETWEEN THE TWO CODING BETWEEN THE TWO CODING SYSTEMSSYSTEMS
–– ExamplesExamples N18.6 – End stage renal disease S52.131a - Displaced fracture of neck of right radius, initial encounter for closed fracture N28.9 – Acute Renal Failure N18.1 -5 – Stages of CKD I12.0 – ESRD due to Hypertension
227 WHAT GENERATES THE WHAT GENERATES THE RESISTANCE?RESISTANCE? Perceptions regarding impact on practice Perceptions regarding impact on practice managementmanagement –– General office staff lack sufficient expertiseGeneral office staff lack sufficient expertise –– May require certified coders and current coders May require certified coders and current coders may need to recertify, incurring costly training may need to recertify, incurring costly training and exam feesand exam fees Costly investment in new infrastructureCostly investment in new infrastructure –– New information technology tools requiredNew information technology tools required –– New billing and collection systems requiredNew billing and collection systems required –– Limited resources for staff trainingLimited resources for staff training
228 WHAT GENERATES THE WHAT GENERATES THE RESISTANCE?RESISTANCE? Impact on reimbursementImpact on reimbursement –– Decreased shortDecreased short --term coding accuracy and term coding accuracy and productivityproductivity Physician practice changesPhysician practice changes –– Greater medical record documentation to Greater medical record documentation to support more detailed codessupport more detailed codes
229 GET PHYSICIAN BUYGET PHYSICIAN BUY --ININ
Provide evidence that simplifies the processProvide evidence that simplifies the process Work with organized medicine to deliver the Work with organized medicine to deliver the messagemessage Partner with key professionals that can help Partner with key professionals that can help facilitate trainingfacilitate training Leverage existing relationships between Leverage existing relationships between health information management health information management professionals and physiciansprofessionals and physicians
230 KNOCK IT DOWN TO SIZE!KNOCK IT DOWN TO SIZE!
Although the coding book is huge, we will Although the coding book is huge, we will only use a small segment of the informationonly use a small segment of the information Work with your physicians to develop Work with your physicians to develop crosswalks between ICDcrosswalks between ICD --9 and ICD9 and ICD --10 10 codes they frequently usecodes they frequently use Begin discussions now to reduce anxiety but Begin discussions now to reduce anxiety but train later train later –– needs to be done needs to be done ““just in timejust in time ”” Training should have both a general and Training should have both a general and practice specific focuspractice specific focus 231 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Start to organize your implementation effortStart to organize your implementation effort Establish who will be the lead person in your Establish who will be the lead person in your organization to oversee the implementation organization to oversee the implementation efforteffort Look at all areas that will be impacted by the Look at all areas that will be impacted by the change change –– Practice Management SystemPractice Management System –– Electronic Medical RecordsElectronic Medical Records –– SuperbillsSuperbills –– Clinical areasClinical areas 232 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Schedule regular meetings to keep Schedule regular meetings to keep everyone in the organization informed of the everyone in the organization informed of the progressprogress Develop a budget Develop a budget –– Look at what the costs Look at what the costs will bewill be –– What resources will be required for What resources will be required for implementationimplementation –– Practice management system Practice management system –– disc spacedisc space –– Software costsSoftware costs –– Training Training
233 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Develop a reasonable timeline that can be Develop a reasonable timeline that can be accomplished accomplished –– frustration will only end in frustration will only end in failure and more frustrationfailure and more frustration Keep the physicians involved Keep the physicians involved –– assess the assess the physicianphysician ’’s acceptance to changes acceptance to change Documentation changes will need to be Documentation changes will need to be made to accommodate more specificity in made to accommodate more specificity in codingcoding
234 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Contact your system vendors earlyContact your system vendors early –– Will they be ready to accommodate ICDWill they be ready to accommodate ICD --10 on 10 on schedule?schedule? –– What costs will be involved with the transition?What costs will be involved with the transition? –– Will they be ready to accept the 5010 electronic Will they be ready to accept the 5010 electronic transaction standard required by HIPAA by transaction standard required by HIPAA by January 1, 2012?January 1, 2012? –– What are their plans for implementation?What are their plans for implementation? –– When will they have software ready for testing?When will they have software ready for testing? –– Is your current hardware adequate?Is your current hardware adequate?
235 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Develop your training planDevelop your training plan –– Who needs training Who needs training –– physicians, coders, billing physicians, coders, billing staff, administrative staff, clinical staffstaff, administrative staff, clinical staff –– How much training will each classification of How much training will each classification of personnel needpersonnel need –– Establish your training schedule Establish your training schedule –– be realistic be realistic Determine if temporary staff or overtime will Determine if temporary staff or overtime will be needed during the training processbe needed during the training process What materials will be neededWhat materials will be needed
236 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Analyze your business processesAnalyze your business processes –– Identify all systems that utilize or are tied to Identify all systems that utilize or are tied to ICDICD --99 –– Review existing policies related to ICDReview existing policies related to ICD --99 –– Do you have any payer contracts that are tied to Do you have any payer contracts that are tied to ICDICD --99 –– If so modify those contracts before the payers If so modify those contracts before the payers get wiseget wise –– Carefully review any new contracts that are Carefully review any new contracts that are received during implementation processreceived during implementation process
237 IMPLEMENTATION PLANNINGIMPLEMENTATION PLANNING
Work with vendors to ensure that testing is Work with vendors to ensure that testing is done before implementation datesdone before implementation dates –– Volunteer to be a Volunteer to be a ““betabeta ”” site for testingsite for testing –– Integrate software into your systemsIntegrate software into your systems –– Make internal customizationsMake internal customizations –– Test systems with your clearinghouses, payers, Test systems with your clearinghouses, payers, electronic systems electronic systems –– Ensure vendors will maintain and update codes Ensure vendors will maintain and update codes during the transition periodduring the transition period
238 GEMsGEMs
GEMs are a crosswalk developed by CMS GEMs are a crosswalk developed by CMS and CDC for use by all providers, payers, and CDC for use by all providers, payers, and data users. The mappings are free of and data users. The mappings are free of charge and can be found in the public charge and can be found in the public domaindomain http://http:// www.cms.hhs.gov/MLNProducts/downwww.cms.hhs.gov/MLNProducts/down loads/ICDloads/ICD --10_GEM_factsheet.pdf10_GEM_factsheet.pdf http://www.cms.hhs.gov/MLNProducts/downhttp://www.cms.hhs.gov/MLNProducts/down loads/ICDloads/ICD --10Mappingfctsht.pdf10Mappingfctsht.pdf
239 ICDICD --1010 --CM CODINGCM CODING
WHAT YOUR NEW CODING WORLD WILL WHAT YOUR NEW CODING WORLD WILL LOOK LIKELOOK LIKE
240 HYPERPARATHYROIDISMHYPERPARATHYROIDISM E21.3 E21.3 –– Unspecified HyperparathyroidismUnspecified Hyperparathyroidism E21.0 E21.0 –– Primary hyperparathyroidismPrimary hyperparathyroidism N25.81 N25.81 –– Secondary hyperparathyroidism Secondary hyperparathyroidism (renal)(renal) E21.2 E21.2 –– Secondary hyperparathyroidism Secondary hyperparathyroidism (non(non --renal)renal) E21.2 E21.2 –– Hyperparathyroidism specified, Not Hyperparathyroidism specified, Not elsewhere classifiedelsewhere classified E21.2 E21.2 –– Tertiary hyperparathyroidismTertiary hyperparathyroidism
241 DIABETES MELLITUS DUE TO DIABETES MELLITUS DUE TO UNDERLYING CONDITIONSUNDERLYING CONDITIONS Code first the underlying condition such as Code first the underlying condition such as Malignant neoplasm (C00Malignant neoplasm (C00 --C96)C96) Use additional code for any insulin use (Z79.4)Use additional code for any insulin use (Z79.4) –– E08.21 E08.21 –– DM due to underlying condition with DM due to underlying condition with Diabetic NephropathyDiabetic Nephropathy –– E08.22 E08.22 –– DM due to underlying condition with DM due to underlying condition with Diabetic Chronic Kidney DiseaseDiabetic Chronic Kidney Disease Use additional code for stage of CKD (N18.1 -N18.6) –– E08.29 E08.29 –– DM due to underlying condition with DM due to underlying condition with other Diabetic Kidney Complicationsother Diabetic Kidney Complications 242 DRUG/CHEMICAL INDUCED DRUG/CHEMICAL INDUCED DIABETES MELLITUSDIABETES MELLITUS Code first (T36Code first (T36 --T65) to identify drug or chemical T65) to identify drug or chemical involvedinvolved Use additional code to identify insulin use (Z79.4)Use additional code to identify insulin use (Z79.4) –– E09.21 E09.21 -- Drug or chemical induced DM with Drug or chemical induced DM with Diabetic NephropathyDiabetic Nephropathy –– E09.22 E09.22 –– Drug or chemical induced DM with Drug or chemical induced DM with Diabetic CKDDiabetic CKD Code additionally the stage of CKD (N18.1 -N18.6) –– E09.29 E09.29 –– Drug or chemical induced DM with other Drug or chemical induced DM with other Diabetic Kidney ComplicationDiabetic Kidney Complication
243 TYPE I DIABETES MELLITUSTYPE I DIABETES MELLITUS
E10.21 E10.21 –– Type I DM with Diabetic Type I DM with Diabetic NephropathyNephropathy E10.22 E10.22 –– Type I DM with Diabetic CKDType I DM with Diabetic CKD –– Use additional code to identify the stage of CKD Use additional code to identify the stage of CKD (N18.1(N18.1 --N18.6)N18.6) E10.29 E10.29 –– Type I DM with other Diabetic Type I DM with other Diabetic Kidney Complications such as DM with Renal Kidney Complications such as DM with Renal Tubular DegenerationTubular Degeneration
244 TYPE II DIABETES MELLITUSTYPE II DIABETES MELLITUS Use additional code to identify any insulin use Use additional code to identify any insulin use (Z79.4)(Z79.4) E11.21 E11.21 –– Type II DM with Diabetic Nephropathy Type II DM with Diabetic Nephropathy E11.22 E11.22 –– Type II DM with Diabetic Kidney Type II DM with Diabetic Kidney DiseaseDisease –– Use additional code to identify stage of CKD Use additional code to identify stage of CKD (N18.1(N18.1 --N18.6)N18.6) E11.29 E11.29 -- Type II DM with other Diabetic Kidney Type II DM with other Diabetic Kidney Complications such as DM with Renal Tubular Complications such as DM with Renal Tubular DegenerationDegeneration
245 ESSENTIAL PRIMARY ESSENTIAL PRIMARY HYPERTENSIONHYPERTENSION
I10 I10 –– Includes high blood pressureIncludes high blood pressure Malignant HypertensionMalignant Hypertension Benign HypertensionBenign Hypertension
246 HYPERTENSION CHRONIC HYPERTENSION CHRONIC KIDNEY DISEASEKIDNEY DISEASE I12.0 I12.0 –– Hypertensive chronic kidney disease Hypertensive chronic kidney disease Stage 5 CKD or End Stage Renal DiseaseStage 5 CKD or End Stage Renal Disease –– Use additional code to identify stage of CKD Use additional code to identify stage of CKD (N18.5 or N18.6)(N18.5 or N18.6) I12.1 I12.1 –– Hypertensive chronic kidney disease Hypertensive chronic kidney disease Stage 1Stage 1 --4 or unspecified CKD 4 or unspecified CKD –– Use additional code to identify stage of CKD Use additional code to identify stage of CKD (N18.1 (N18.1 -- N18.4)N18.4)
247 SECONDARY HYPERTENSIONSECONDARY HYPERTENSION
Code also underlying primary conditionCode also underlying primary condition I15.0 I15.0 –– Renovascular HypertensionRenovascular Hypertension I15.9 I15.9 –– Secondary Hypertension, Secondary Hypertension, unspecifiedunspecified
248 CHRONIC KIDNEY DISEASECHRONIC KIDNEY DISEASE
Code first any associated:Code first any associated: –– Diabetic chronic kidney disease (E08.22, E09.22, Diabetic chronic kidney disease (E08.22, E09.22, E10.22, E11.22, E13.22)E10.22, E11.22, E13.22) –– Hypertensive chronic kidney disease (I12.X, Hypertensive chronic kidney disease (I12.X, I13.X)I13.X) Use additional code to identify kidney Use additional code to identify kidney transplant status, if applicable (Z94.0)transplant status, if applicable (Z94.0)
249 CHRONIC KIDNEY DISEASECHRONIC KIDNEY DISEASE N18.1 N18.1 –– Chronic kidney disease, Stage 1Chronic kidney disease, Stage 1 N18.2 N18.2 –– Chronic kidney disease, Stage 2Chronic kidney disease, Stage 2 N18.3 N18.3 –– Chronic kidney disease, Stage 3Chronic kidney disease, Stage 3 N18.4 N18.4 –– Chronic kidney disease, Stage 4Chronic kidney disease, Stage 4 N18.5 N18.5 –– Chronic kidney disease, Stage 5Chronic kidney disease, Stage 5 N18.6 N18.6 –– End Stage Renal Disease requiring End Stage Renal Disease requiring dialysisdialysis –– Use additional code to identify dialysis status Use additional code to identify dialysis status (Z99.2)(Z99.2) 250 ACUTE KIDNEY FAILUREACUTE KIDNEY FAILURE
Code also associated underlying conditionCode also associated underlying condition N17.0 N17.0 –– AKF with tubular necrosisAKF with tubular necrosis N17.1 N17.1 –– AKF with acute cortical necrosisAKF with acute cortical necrosis N17.2 N17.2 –– AKF with medullary necrosisAKF with medullary necrosis N17.8 N17.8 –– Other acute kidney failureOther acute kidney failure N17.9 N17.9 –– Acute kidney failure, unspecifiedAcute kidney failure, unspecified
251 KIDNEY TRANSPLANTKIDNEY TRANSPLANT Z94.0 Z94.0 –– Kidney transplant statusKidney transplant status Do not code with complications of transplantDo not code with complications of transplant –– T86.10 T86.10 –– Unspecified complication of kidney Unspecified complication of kidney transplanttransplant –– T86.11 T86.11 –– Kidney transplant rejectionKidney transplant rejection –– T86.12 T86.12 –– Kidney transplant failureKidney transplant failure –– T86.13 T86.13 –– Kidney transplant infectionKidney transplant infection Use additional code to specify infection –– T86.19 T86.19 –– Other complication of kidney Other complication of kidney transplanttransplant
252 Final ThoughtsFinal Thoughts
The Driving Force The Driving Force -- $$$ $$$ Been thereBeen there --done done that! that! Prove it!Prove it! 253 CONTACT INFORMATIONCONTACT INFORMATION
Debra Lawson, CPC, PCSDebra Lawson, CPC, PCS –– [email protected]@NBandMS.com Renal Physicians AssociationRenal Physicians Association –– 11--800800 --RPARPA --75257525 –– www.renalmd.orgwww.renalmd.org American College of Medical Coding Specialists – 1-800 -946 -9402 – www.acmcs.org . American Academy of Professional Coders – 1-800 -626 -CODE – www. aapc.com
254