10/8/2015

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Billing & Coding

“What Compliance Officers Need to or Should know?”

Coding and Compliance

� Why should Compliance Officers be coders?

� Coding is critical driver for hospitals and clinics

� Except for physician arrangements, probably one of

the most critical areas for fraud, waste, and abuse

� Critical part of auditing & monitoring

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Top Billing and Payment

Issues� Two-midnight rule

� Bundled payments

� ICD-10 implementation

� IPPS, OPPS, MPFS Updates

IPPS

� “Inpatient Prospective Payment System”

� ICD-10: Still happening

� 2-Midnight rule

� Disproportionate Share Hospital (DSH) payment

� New DRGs for Medicare Severity Diagnosis Groups

� Quality of care initiatives

� Changes in hospital readmission requirements

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OPPS

� “Outpatient Prospective Payment System”

� Changes in E & M services

� Payment rate changes for drug and

radiopharmaceutical reimbursement

� Payments for outpatient services and ambulatory

medical centers

� Changes in codes—specifically “bypass codes”

MPFS

� “Medicare Physician Fee Schedule”

� RVUs, pricing amounts, payment policy indicators

� Stronger link to quality and PQRS (Physician Quality

Reporting System)

� Physician compare benchmark

� EHR incentive program revision

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OIG Work Plan

� Good source for “hot topics in all areas

� Coding and Billing are certainly key areas of concern

and focus

“Incident-To” payments

� “Incident to” payments—huge issue for mid-level providers

� Risk Assessment

� Documentation needed

� License verification and scope of practice

� Supervision: Direct, Personal, General/Indirect

� Which payers will pay what for what?

� Medicare rules

� Hawaii’s rules

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Place of Service (POS)

� Key for documentation

� Allowable depending on rules and coding policies

� Different payments depending on POS

� Higher in non-hospital settings

� Outpatient department POS pay less

National Correct Coding

Initiative (NCCI)� Reviews included in OIG Work Plan

� Goal is to promote correct coding. Automatic

computer edits and consistent policies

� Federal law required States to incorporate

methodologies compatible with NCCI for Medicaid

claims 10/1/10

� Could be deferred until 9/1/11

� After 9/1/11 only conflict with state laws allow

deactivation

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Outpatient Drugs and

Administration� Overbilling of units

� Correct documentation of units

� Particular interest in chemotherapy drugs

ICD-10

�IT’s FINALLY

HERE!!!

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ICD-10

� Increase from approximately 9000 codes to over 68,000 codes

� Specificity: Trimesters and weeks of gestation

� More Combination codes

� Episode of care (7th character)

� X placeholders

� Laterality must be documented

� Use of unspecified codes limited and more documentation required

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The Wonderful World of

ICD-10� V97.33XD: Sucked into jet engine, subsequent

encounter

� W51.XXXA: Accidental striking against or bumped

into by another person, sequela

� V00.01XD: Pedestrian on foot injured in collision with

roller-skater, subsequent encounter

� Y93.D: Activities involved arts and handcrafts

� Z99.89: Dependence on enabling machines and

devices, not elsewhere classified

And they keep coming…

� Y92.146: Swimming-pool of prison as the place of occurrence of the external cause

� Also a code for “day spa of the prison”

� Z99.89: Dependence on enabling machines and devices, not elsewhere classified

� S10.87XA: Other superficial bite of other specified part of neck, initial encounter

� W55.41.XA: Bitten by pig, initial encounter

� W61.62.XD: Struck by duck, subsequent encounter

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And just when you

thought it was safe….� Z63.1: Problems in relationship with in-laws

� W22.2XD: Walked into a lamppost, subsequent encounter

� Y93.D: V91.07XD: Burn due to water-skis on fire, subsequent encounter

� W55.29XA: Other contact with cow, subsequent encounter

� W22.02XD: V95.43XS: Spacecraft collision injuring occupant, sequela

� W61.12XA: Struck by macaw, initial encounter

� R46.1: Bizarre Personal appearance

www.healthcaredive.com

Coding Complexity

� Both ICD-9 and ICD-10 coexist for quite a while

� Hospitals must keep both systems going until all

payments made

� Keep documentation for ICD-9 around for reviews,

audits, challenges

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ICD-10: Proposed

Transitions� HR 2652: Provides 2-year grace period for physicians

to transition to ICD-10

� HR 2126: Prohibits implementing, administering, or enforcing regulations to replace ICD-9 with ICD-10

� HR 2247: Requires comprehensive end-to-end testing to assess whether ICD-10 claims process is fully functional

� HR 3018: Requires that claims submitted with iCD-9 codes continue to be paid during the transition—a safe harbor

EMR: Coding

Challenges� Charge Slips: automatically generated with the

presumed codes as physicians document the patient

visit.

� Systems have tools with built-in calculators for visits

and procedures and automated selection of diagnosis

codes.

� Can result in upcoding

� Physician ends up being a coder by default

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EMR: Templates!!!

� EHR templates are designed with a particular launch point, such as a chief complaint, chronic diseases, or preventive exams.

� Within the templates are pre-defined generic statements that are associated with a particular treatment plan.

� Other systems may include pick lists, evaluation and management (E/M) tools, even pop-up messages that remind physicians of appropriate actions they “should” take to achieve a higher level.

EMR: Auto-generated

Claims� Auto-generated claims sent to payers, bypassing the

coder.

� Physicians and software designers don’t understand

the technical side of coding that goes beyond

choosing codes.

� Commercial payer rules, local coverage

determinations, etc. all factor into proper claim

submission and are not integrated into EHR’s

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2-Midnight Rule

� Controversial from its inception

� New proposed rules and clarification

� Greater deference to physician decision-making in

determining appropriateness for inpatient admission

� New Medicare part A rule that allows case-by-case

basis:

� Documentation!!

� Determination (DOCUMENTED) that visit will require formal admission

2-Midnight Rule

� Proposed Rule:

� Severity of the signs and symptoms

� Predictability of something adverse happening to patient

� Need for diagnostic services that are appropriately outpatient

� Elimination of routine RAC audits

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Coding Compliance

� Policies, policies, policies

� Despite ICD-10 specificity and despite EMR making

coding more “automatic” there will still be decisions

that need to be made

� Hospitals must have consistent rules in place to

support consistent coding processes

Coding Compliance

� Coding reviews

� Physician education

� Coder education and individual reviews

� Outside monitoring

� RAC reviews and feedback

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In conclusion….

� Coding remains a huge compliance risk

� Compliance Officers must pay increased attention to

coding during this time of major transition

� As coding becomes more automated, pressure will be

on to ensure the documentation supports the medical

necessity

� Compliance and Coding---BOTH begin with “CO”

Partners with coders, HIM, is vital