A Lisa Selman-Holman blog
Just a reminder of a few codes that became invalid Oct. 1. Don’t code!
A few we’ve seen:
The HHS Office of the Inspector General conducted a study looking at home health claims from 2002-2008 and found that$432 million in Medicare monies were inappropriately paid either because medical necessity was not established or coding was inaccurate. Millions more dollars were lost to CMS or HHAs because of upcoding or downcoding.
The number of HHAs grew from 7,052 to 9,801, and increase of 39 percent. Medicare spending on home health increased 84 percent from $8.5 billion in 2000 to $15.7 billion in 2007. The sharp rise in payments created the push to investigate payments.
HHS reviewed the claims of almost 500 beneficiaries to see whether Medicare coverage requirements were met.
The office found that 22 percent of claims were in error because services were not medically necessary or claims were coded inaccurately, resulting in $432 million in improper Medicare payments. Also, HHAs upcoded about 10 percent ($278 million) of claims and downcoded about 10 percent ($184 million) of claims.
OIG believes it needs to investigate more to determine what services are met and what potential for fraud is involved.
Read the complete report.
Several questions in CMS’s 3rd quarter Q&As deal with pressure ulcers and M1308.
The highlights (in my words, not CMS’s!):
CMS has clarified that payment changes relative to the removal of the hypertension codes will be effective with M0090 dates of 1/1/2012.
“Beginning with M0090 dates of January 1, 2012, 401.1 Benign essential hypertension codes and 401.9 Unspecified essential hypertension are removed from the HH PPS case-mix system. Specifically, 401.1 and 401.9 diagnosis codes will no longer result in additional points when computing the HIPPS codes”
Providers should not change the codes they use for hypertension unless they have been coding the 401 codes in error. Changing the codes just to get points is upcoding and we certainly do not want to prove CMS correct about case mix creep. You can be sure that they will be watching for trends in hypertension coding as a result of the case mix change.
Remember hypertension with chronic kidney disease (585) or renal sclerosis (587) changes the hypertension code to the 403 category. There is a presumed relationship between CKD and HTN with HTN causing the CKD.
However, a relationship between heart disease and HTN cannot be presumed. The physician must either state (e.g., heart failure due to hypertension) or imply the relationship (e.g., hypertensive heart disease).
Even if you do not have the information to be able to change the hypertension code to some other category besides 401, do not despair! Remember that hypertension and heart disease are together in Table 4. Even if you do not earn points with the hypertension codes, think how many of your patients with 401 codes also have codes from the 414 category (coronary atherosclerosis and chronic ischemia), 410 (acute myocardial infarction) and 428 (heart failure). Those codes are case mix, too, so you will not be losing any points!
I am already getting questions on dementia coding … here we go!
Question: Now that the new dementia codes (294.10, 294.11) have come out, do we only use them for a dementia related to another condition that was coded and use 290.0 for straight senile dementia OR do we have to use 294.1x for all dementia?
As codes change Oct. 1, we need to think about which set of codes, 2011 or 2012, we need to use for our patients whose episodes cross over the code change period.
Actually, we need to look at what episodes or assessments cross the code change period. The choice of codes, and CMS confirmed this to me, is based on M0090, the completion of assessment. Soooo…
If the assessment is not complete by Oct. 1, we use 2011 codes for the RAP and EOE. If the assessment is complete by Oct. 1, use the 2012 codes.
What about payment changes over the fiscal year change? CMS has a formula that factors in payment issues. It’s not something for us to worry about.
All 173 codes are now 5th digits, following the recent trend in neoplasm codes. The bigger issue with these five-digit codes is that CMS has only designated 173.09 as a case-mix code, not the other codes. This takes away our case-mix codes. Almost all neoplasm 173 codes were all case-mix before the 2012 list came out. That should not be done without rulemaking, so there are may queries in to CMS about this issue.
Remember that the codes follow a patter with the 5th digit:
0 = unspecified
9 = other specified (and this is the case-mix code)
Also remember that the codes affected are not melanoma codes.
Effective Oct. 1, watch the E. coli codes …. they now need 5th digits.
041.49 is the code we are most likely to use. Watch the use additional code instruction that is now attached to this group of codes.
Quick scenario: Your patient is being treated for a bladder infection caused by E. coli.
M1020: 595.0, acute bladder infection
M1022: 041.49, E. coli unspecified
My new codes webinar is Fridat Aug. 19 (TODAY!) at noon central time!
Learn everything you need to know about new codes and guidelines effective Oct. 1.
http://selmanholmanblog.com/2011/08/04/new-codes-seminar/#entry
Intermediate coders, get all the latest information on changes and the best coding education around. I’m
Highlights include:
I will be in Dallas Aug. 24-25; McAllen Aug. 31-Sept. 1; Houston, Sept. 7-8
