2011
CODING & DOCUMENTATION
UPDATE
Healthcare Services Group
October 2010
Overview of Topics
• Coding Changes Reminder
• 2011 Diagnosis Code Changes
• 2011 ICD-9-CM Procedure Code Changes
• 2011 CPT Code Changes
• RAC Audits – Physician & Hospital
• 2011 OIG Work Plan – Physician & Hospital
2
Coding Changes Reminder
• Remember to change the following to reflect the new
diagnosis and procedure codes for 2011:
– Superbill / Encounter Form
– Practice Management Software
• Update ICD-9-CM and CPT Books
3
2011 Diagnosis Code Changes
Effective 10/1/10
New Diagnosis Codes
Additional Digits Required
Deleted Diagnosis Codes
4
2011 Diagnosis Code Changes
• Neoplasms
– Schwannomatosis - 237.73
• One form of a genetic disorder called neurofibromatosis (NF) that
has only been recently recognized
– Neurofibromatosis, NEC - 237.79
• Endocrine, Nutritional & Metabolic, Immunity
– Deleted
• Disorders of Iron Metabolism – 275.0
– Additional 5th Digit Required
» Hereditary Hemochromatosis – 275.01
» Hemochromatos – RBC transfusions – 275.02
» Hemochromatosis NEC - 275.03
» Other Disorders of Iron Metabolism – 275.09
5
2011 Diagnosis Code Changes
• Endocrine, Nutritional & Metabolic, Immunity
– Deleted
• Fluid Overload 276.6
– Additional 5th Digit Required
» Transfusion associated circulatory overload – 276.61
» Other fluid overload – 276.69
– New Code
• Obesity hypoventilation syndrome – 278.03
6
2011 Diagnosis Code Changes
• Blood and Blood-Forming Organs
– Deleted
• Secondary Thrombocytopenia - 287.4
– Additional 5th Digit Required
» Post-transfusion purpura - 278.41
» Other secondary thrombocytopenia – 278.49
• Mental Disorders
– New Code
• Childhood onset fluency disorder – 315.35
7
2011 Diagnosis Code Changes
• Circulatory System
– New Codes
• Other disorders of arteries and arterioles - 447.7
• Aortic Ectasia - 447.71 – 447.73
• Respiratory System
– Deleted
• Influenza due to identified avian influenza virus – 488.0
– Additional 5th Digit Required
» Influenza due to identified avian influenza virus with:
» Pneumonia – 488.01
» Other Respiratory Manifestations – 488.02
» Other Manifestations – 488.09
8
2011 Diagnosis Code Changes
• Respiratory System
– Deleted
• Influenza due to identified novel H1N1 influenza virus – 488.1
– Additional 5th Digit Required
» Influenza due to identified novel H1N1 influenza virus
with:
» Other Respiratory Manifestations – 488.12
» Other Manifestations – 488.19
9
2011 Diagnosis Code Changes
• Digestive System
– New Code
• Fecal impaction – 560.32
• Musculoskeletal System
– New Code
• Spinal stenosis, lumbar region, with neurogenic claudication –
724.03
• Congenital Anomalies
– Deleted
• Other anomalies of uterus – 752.3
– Additional 5th Digit Required:
» 752.31 – 752.47
10
2011 Diagnosis Code Changes
• Symptoms, Signs and Ill-Defined Conditions
– New Codes
•
•
•
•
•
Post traumatic seizures – 780.33
Febrile non-hemolytic transfusion reaction – 780.66
Fluency disorder in conditions classified elsewhere – 784.52
Jaw pain – 784.92
Signs and Symptoms involving cognition
– Attention or concentration deficit – 799.51
– Cognitive communication deficit – 799.52
– Visuospatial deficit – 799.53
– Psychomotor deficit – 799.54
– Frontal lobe and executive function deficit – 799.55
– Other signs and symptoms involving cognition – 799.59
11
2011 Diagnosis Code Changes
• Symptoms, Signs and Ill-Defined Conditions
– Deleted Codes
• Hemoptysis – 786.3
– Additional 5th Digit Required:
» Acute idiopathic pulmonary hemorrhage in infants –
786.31
» Other hemoptysis – 786.39
• Incontinence of Feces – 787.6
– Additional 5th Digit Required:
» Incomplete defecation – 787.61
» Fecal smearing – 787.62
» Fecal urgency – 787.63
12
2011 Diagnosis Code Changes
• Injury and Poisoning
– Deleted
• Poisoning by other specified central nervous system stimulants –
970.8
– Additional 5th Digit Required:
» Poisoning by cocaine – 970.81
» Poisoning by other central nervous system stimulants –
970.89
• ABO incompatibility reaction – 999.6
– Additional 5th Digit Required:
» ABO incompatibility with hemolytic transfusion reaction
not specified as acute or delayed – 999.61
» Acute – 999.62
Delayed – 999.63
» Other ABO incompatibility reaction - 999.69
13
2011 Diagnosis Code Changes
• Injury and Poisoning
– Deleted
• Rh incompatibility reaction – 999.7
– Additional 5th Digit Required:
» Rh incompatibility with hemolytic transfusion reaction not
specified as acute or delayed – 999.71
» Acute – 999.72
Delayed – 999.73
» Other Rh incompatibility reaction – 999.74
– Non-ABO Incompatibility
» Non-ABO incompatibility reaction, unspecified – 999.75
» Not specified as acute or delayed – 999.76
» Acute – 999.77
Delayed – 999.78
» Other non-ABO incompatibility reaction – 999.79
14
2011 Diagnosis Code Changes
• Injury and Poisoning
– New Codes
• Transfusion reaction, unspecified – 999.8
• Hemolytic transfusion reaction, incompatibility unspecified –
999.83
• Acute hemolytic transfusion reaction, incompatibility unspecified 999.84
• Delayed hemolytic transfusion reaction, incompatibility unspecified
– 999.85
• External Causes of Injury and Poisoning
– New Codes
• Volunteer Activity – E000.2
15
2011 Diagnosis Code Changes
• Factors Influencing Health Status (V Codes)
– New Codes –
• Personal History of:
– Combat & operational stress reaction – V11.4
– Vaginal dysplasia – V13.23
– Vulvar dysplasia – V13.24
– Other (corrected) congential malformations of:
» Genitourinary system – V13.62
» Nervous system – V13.63
» Eye, ear, face and neck – V13.64
» Heart and circulatory system – V13.65
» Respiratory system – V13.66
» Digestive system – V13.67
» Integument, limbs and musculoskeletal – V13.68
16
2011 Diagnosis Code Changes
• Factors Influencing Health Status (V Codes)
– New Codes –
• Personal History of:
– Retained foreign body fully removed – V15.53
• Do not resuscitate status – V49.86
• Physical restraints status – V49.87
• Homicidal ideation – V62.85
• Acquired absence of pancreas – V88.1
– Total – V88.11
Partial – V88.12
17
2011 Diagnosis Code Changes
• Factors Influencing Health Status (V Codes)
– New Codes –
• Retained:
– Foreign body – V90
» Radioactive fragment – V90.0
» Depleted uranium fragments – V90.01
» Other radioactive fragments – V90.09
– Metal fragments – V91
» Metal fragments, unspecified – V90.10
» Magnetic metal fragments – V90.11
» Non-magnetic metal fragments – V90.12
– Plastic fragments – V90.2
– Organic fragments – V90.3
– Animal quills or spines – V90.31
18
2011 Diagnosis Code Changes
• Factors Influencing Health Status (V Codes)
– New Codes –
• Retained:
– Tooth – V90.32
– Wood fragments – V90.33
– Other organic fragments – V90.39
– Other specified foreign body – V90.8
– Glass fragments – V90.81
– Stone or crystalline fragments – V90.83
– Other specified foreign body, NEC – V90.89
– Foreign body, unspecified material – V90.9
• Multiple Gestation Placenta Status
– Codes V91.0 – V91.99
19
2011 Diagnosis Code Changes
• Factors Influencing Health Status (V Codes)
– Deleted
• Encounter for insertion of intrauterine contraceptive device (IUD) –
V25.1
– Insertion of IUD – V25.11
– Removal of IUD – V25.12
– Removal and re-insertion of IUD – V25.13
• Body Mass Index (BMI) 40 and over, adult – V85.4
– BMI 40.0 – 44.9, adult – V85.41
– BMI 45.0 – 49.9, adult – V85.42
– BMI 50.0 – 59.9, adult – V85.43
– BMI 60.0 – 69.9, adult – V85.44
– BMI 70 and over, adult – V85.45
20
2011 ICD-9-CM Volume 3
Procedure Code Changes
• ICD-9-CM Volume 3 Procedure Code Changes
– 22 New Codes & 1 Deleted Code
• Insertion of drug-eluting stent(s) of superficial femoral artery –
00.60
• Cranial implantation or replacement of neurostimulator pulse
generator – 01.20
• Removal of cranial neurostimulator pulse generator – 01.29
• Non-coronary intra-operative fluorescence vascular angiography
(IFVA) – 17.71
• Bronchoscopic bronchial thermoplasty, ablation of airway smooth
muscle – 32.27
• Percutaneous mitral valve repair with implant – 35.97
• Excision or destruction of other lesion or tissue of heart,
thoracoscopic approach – 37.37
21
2011 ICD-9-CM Volume 3
Procedure Code Changes
• ICD-9-CM Volume 3 Procedure Code Changes
– 22 New Codes & 1 Deleted Code
• Central venous catheter placement with guidance – 38.97
• Implantation or replacement of carotid sinus stimulation device
– Total system – 39.81
– Lead(s) only – 39.82
– Pulse generator only – 39.83
• Revision of carotid sinus stimulation
– Lead(s) only – 39.84
– Pulse generator – 39.85
22
2011 ICD-9-CM Volume 3
Procedure Code Changes
• ICD-9-CM Volume 3 Procedure Code Changes
– 22 New Codes & 1 Deleted Code
• Removal of carotid sinus stimulation
– Total system – 39.86
– Lead(s) only – 39.87
– Pulse generator – 39.88
• Other operations on carotid body, carotid sinus and other vascular
bodies – 39.89 (Deleted 39.8)
• Reverse total shoulder replacement – 81.88
• Insertion of sternal fixation device with rigid plates – 84.94
• Fat graft to breast – 85.55
• Fat graft of skin & subcutaneous tissue – 86.97
• Extraction of fat for graft or banking – 86.90
23
2011 CPT Code Changes
Effective 1/1/11
New Codes
Deleted Codes
24
2011 CPT Code Changes
• Evaluation and Management – 3 New Codes
– Code added and resequenced
• Subsequent Observation Care, Low Severity - 99224
• Subsequent Observation Care, Mod. Severity - 99225
• Subsequent Observation Care, High Severity - 99226
• Integumentary System – 3 New & 2 Deleted
– Code added and resequenced – (Add-on Codes)
• Debridement, each additional 20 sq cm
– Subcutaneous Tissue - 11045
– Muscle/Fascia - 11046
– Bone – 11047
– Deleted
• Debridement; skin; partial & full thickness – 11040 & 11041
25
2011 CPT Code Changes
• Musculoskeletal System – 5 New Codes
– Neck & Spine Fusion, Additional – 22551
– Add’l Neck & Spine Fusion (Add-On Code) - 22552
– Code added and resequenced
• Hip Arthroscopy with
– Femoroplasty – 22914
– Labral Repair – 22915
– Acetabuloplasty - 22916
• Respiratory System – 4 New Codes
– Nasal Sinus Endoscopy with Dilation of:
• Maxillary Sinus – 31295
• Frontal Sinus – 31296
• Sphenoid Sinus – 31297
– Bronchoscopy with Balloon Occlusion - 31634
26
2011 CPT Code Changes
• Cardiovascular System – 20 New & 23 Deleted
– New Codes
•
•
•
•
Application of Pulmonary Artery Bands - 33620
Transthoracic Insertion of Catheter or Stent - 33621
Reconstruction Complex Cardiac Anomaly - 33622
Revascularization with Stent
– Iliac, Femoral/Popliteal Artery, Tibial/Peroneal Artery
» 37220 - 37235
• Intraoperative Identification of Sentinel Lymph Nodes - 38900
– Deleted Codes
• Transluminal balloon angioplasty - 35454 – 35474
• Transluminal peripheral atherectomy – 35480 - 35495
• Repair, diaphragmatic hernia – 39520 - 39531
27
2011 CPT Code Changes
• Digestive System – 18 New & 4 Deleted
– New
•
•
•
•
•
•
•
•
Laparoscopy, Esophageal Lengthening (Add-On) - 43283
Esophagogastric Fundoplasty - 43327 – 43328
Hiatal Hernia Repair - 43332 – 43338
Gastric Intubation & Aspiration, Necessitating Physician Skill - 43753
Gastric/Duodenal Intubation & Aspiration- 43754 - 43754
Laparoscopy Placement of Interstitial Device - 49327
Placement of Interstitial Device (Add-On) - 49412
Insertion of Tunneled Intraperitoneal Catheter – 49418
– Deleted
• Esophagogastric fundoplasty – 43324 & 43326
• Biopsy of Stomach - 43600
28
2011 CPT Code Changes
• Urinary System – 1 New Code
– Transurethral Radiofrequency Treatment for Stress Incontinence 53860
• Female Genitourinary System – 1 New Code
– Insertion of Vaginal Brachytherapy Device - 57156
• Nervous System – 8 New & 2 Deleted
– Stereotactic Computer Assisted Cranial Procedures –
• 61781 -61783
– Posterior Tibial Neurostimulator - 64566
– Cranial Nerve Neurostimulator Electrodes - 64568 – 64570
– Chemodenervation of Parotid & Submandibular Glands - 64611
29
2011 CPT Code Changes
• Eye and Ocular Adnexa – 4 New Codes
– Placement of Amniotic Membrane on Ocular Surface –
• 65778 – 65779
– Transluminal Dilation of Eye Canal - 66174 - 66175
• Radiology – 5 New Codes
– CT Angioplasty Abdomen/Pelvis
• Without Contrast – 74176
• With Contrast – 74177
• Without Contrast 1+ Body Regions – 74178
– Ultrasound Extremity Non-Vascular
• Complete - 76881
• Limited – 76882
• Pathology & Laboratory–15 New & 13 Deleted
30
2011 CPT Code Changes
• Medicine – 40 New & 41 Deleted
– New Codes
• Immunization Administration thru 18 years
– First Vaccine/Toxoid – 90460
– Each Additional – 90461
• H1N1 Immunization Administration, including counseling - 90470
• Meningococcal Vaccine, 2-15 months - 90644
• Influenza Virus Vaccine
– Intranasal – 90664
– Intramuscular, Preservative Free – 90666
– Intramuscular, Split Virus, Adjuvanted – 90667
– Intramuscular, Split Virus – 90668
31
2011 CPT Code Changes
• Medicine – 40 New & 41 Deleted
– New Codes
• Therapeutic repetitive transcranial magnetic stimulation treatment;
planning – 90867
– Delivery and management, per session - 90868
• Esophageal Motility (Add-On Code) – 91013
• Sleep Study 95800 - 95801
– Deleted Codes
• Immunization Administration – 90465 – 90468
• Esophageal/Gastric Intubation/Motility – 91000-91105
• Telephonic Transmission of Post-Symptom EKG strips
– 93012 & 93014
• Holter Monitors
– 93230 - 93233
– 93235 - 93237
32
2011 CPT Code Changes
• Medicine – 40 New & 41 Deleted
– New & Deleted Heart Catheterization Codes
• New
– 93451 - 93464
– 93563 - 93568
• Deleted
– 93501
– 93508 - 93511
– 93514
– 93524
– 93526 - 93529
– 93539 - 93545
– 93555 - 93556
33
2011 CPT Code Changes
• Category II Codes (F Codes) – 31 New Codes
–
–
–
–
–
–
–
–
–
Major Depressive Disorder
Parkinson’s Disease
Epilepsy
Body Mass Index
Cervical Cancer Screening
BloodTyping
ClinicalTumor Staging
Anesthesia
Tobacco Use & Cessation Counseling
34
2011 CPT Code Changes
• Category III Codes (T Codes)
– 52 New Codes & 13 Deleted Codes
–
–
–
–
–
–
–
Cryopreservation Ovary Tissue / Oocyte – 0058T & 0059T
Audiometry and Speech Audiometry – 0208T – 0212T
Injection Paravertebral Facet Joint – 0213T – 0218T
Placement Posterior Intrafacet Implants – 0219T – 0222T
Transluminal Peripheral Atherectomy – 0234T – 0239T
Esophageal Motility – 0240T – 0242T
Measurement of Wheeze Rate for Bronchodilator
• 0243T & 0244T
– Open Treatment of Rib Fractures – 0245T – 0248T
– Ligation Hemorrhoid with Ultrasound – 0249T
35
2011 CPT Code Changes
• Category III Codes (T Codes) – 52 New Codes
– 52 New Codes & 13 Deleted Codes
– Bronchial Valve Procedures – 0250T – 0252T
– Endovascular Repair – 0254T – 0256T
– Aortic Heart Valve Replacement with and without Cardiac Bypass –
0258T & 0259T
– Hypothermia, Neonate, 28 days or less – 0260T & 0261T
36
RAC Audits – Region A
Outpatient Hospital - Physician
• Untimed Codes
– Certain untimed codes are billed for more than one unit
• i.e. Physical Therapy
• Newborn/Pediatric Codes
– Patients that exceed the age limit defined by CPT code
• Global Surgery
– Pre- and Post-Operative visits
• New Patient Visits
– Guidelines for a new patient
• New to practice
• Has not been seen in practice for 3 years
37
RAC Audits – Region A
Outpatient Hospital - Physician
• Technical Component of Radiology
• Neulasta
– Drug that reduces risk of infection in cancer patients
• Commonly reported with a chemotherapy drug administration code
rather than a therapeutic administration code which creates an
overpayment
• Global Billing of Radiology or Diagnostic Tests in
Facility Setting
• Add-On Codes
– Add-on code reimbursed when primary procedure either was
not billed or not paid
• NCCI Edits
38
RAC Audits – Region A
Outpatient Hospital - Physician
• Duplicate Claims
• IV Hydration
– When billed for more than one unit per date of service
• Once in a Lifetime
– i.e. Removal of organs; genetic testing; dialysis training etc.
• Bronchoscopy Services
– When billed for more than one unit per date of service
• Global vs. TC/PC Split Reimbursements
– Reimbursement for global and then additional
reimbursement for TC or PC
39
RAC Audits – Region A
Inpatient Hospital
• MS-DRG Validation –
– Currently Medical Necessity Excluded
•
•
•
•
•
•
•
•
•
•
•
•
Tracheostomy
Coronary Bypass, Cardiac & Cardiac Valve Procedures
Extensive & Non-Extensive OR Procedures
Joint Disorders
Major Chest Procedures
Major Large & Small Bowel Procedures
Hip & Femur Procedures
Intracranial Hemorrhage or Cerebral Infarction
Pulmonary Edema & Respiratory Failure
Ventilator Support of 96+ Hours
Craniotomy & Endovascular Intracranial Procedures
Excisional Debridement
40
RAC Audits – Region A
Inpatient Hospital
• MS-DRG Validation
– Currently Medical Necessity Excluded
•
•
•
•
•
•
Severe Sepsis
Complications of Cholecystectomy
Seizures
Lysis of Adhesions
Pathological Fractures
Cardiac Defibrillator
– Diagnostic and procedural information and the discharge status
of the beneficiary, as coded and reported by the hospital on its
claim, matches both the attending physician description and the
information contained in the beneficiary's medical record
41
RAC Audits – Region A
Inpatient Hospital
• DRG Coding and Medical Necessity Validation
– Diseases of Blood, Blood Forming Organs & Immunological
Disorders
• Currently for MS-DRG 811
– Red Blood Cell Disorders with MCC
– Endocrine, Nutritional & Metabolic Disorders
• Currently for MS-DRG 640
– Nutritional & Miscellaneous Metabolic Disorders with MCC
– Nervous System Disorders
• Currently for MS-DRG’s 056 & 057
– Degenerative Nervous System Disorders with MCC
– Degenerative Nervous System Disorders w/o MCC
42
RAC Audits – Region A
Inpatient Hospital
• DRG Coding and Medical Necessity Validation
– Musculoskeletal Disorders
• Currently for MS-DRG’s 551 & 552
– Medical Back Problems with MCC
– Medical Back Problems w/o MCC
– Gastrointestinal Disorders
• Currently for MS-DRG’s 391 & 393
– Esophagitis, Gastroenterology & Miscellaneous Digestive
Disorders with MCC
– Other Digestive System Diagnoses with MCC
– Kidney and Urinary Tract Disorders
• Currently for MS-DRG’s 683 & 684
– Renal Failure with CC
– Renal Failure w/o MCC
43
RAC Audits – Region A
Inpatient Hospital
• DRG Coding and Medical Necessity Validation
– Respiratory
• Currently for MS-DRG’s 190, 191 & 192
– COPD with MCC
– COPD with CC
– COPD w/o CC and MCC
– Cardiovascular Procedures
• Currently for MS-DRG 249
– Percutaneous Cardiovascular Procedure with Non-Drug Eluting
Stent w/o MCC
44
RAC Audits – Region A
Inpatient Hospital
• IPPS Hospital to Hospital Transfers
– Per diem rate should be paid for transferring hospital
– Full MS-DRG payment to final discharge hospital
– Validating that both hospitals don’t receive full MS-DRG
payments
45
2011 OIG Work Plan
Physician
• Evaluation and Management (E/M) Coding and Electronic
Health Record (EHR) Bonuses
– Review E/M utilization to identify trends in the level of services
• Certain providers billing lower or higher-level codes
– Review documentation for E/M Services
• To determine if identical or very similar documentation was used for
different E/M codes
– OIG believes the reliance on EHR systems’ automated
documentation features may be causing improper payments
based on identical documentation
46
2011 OIG Work Plan
Physician
• EHR Bonuses and Attestation
– OIG will check that those receiving bonuses have met
meaningful use standards
• Error-Prone Providers
– Providers with high claims denial rates over the last four years
• Will be singled out for medical claims review
• Will receive overpayment demand letters
• Coding of E/M Services
– Providers are responsible for ensuring that the codes they
submit accurately reflect the services they provide
47
2011 OIG Work Plan
Physician
• Place of Service Errors
– Physician’s Office vs. Ambulatory Surgical Center (ASC) /
Hospital Outpatient Departments
• E/M Services Billed During Global Surgery Periods
• Part B Imaging Services
– Review whether the utilization rates reflect industry standards
• Excessive Payments for Diagnostic Tests
– Determine if testing was medically necessary
• Trends in Laboratory Utilization
– Will review types of lab tests ordered and number of lab tests
ordered
48
2011 OIG Work Plan Hospital
• Medicare Excessive Payments
– Hospitals required to report units of service as the number of
times that a service or procedure was performed
• Review outpatient claims in which payments exceeded charges and
selected HCPCS codes for billings that appear aberrant
• Medicare Disproportionate Share (DSH) Payments
– Determine if payments were in accordance with Medicare
methodology
• Medicare Outlier Payments
– Verify that outlier payments are based on the most recent costto-charge ratio from the cost report to properly determine outlier
payments
49
2011 OIG Work Plan Hospital
• Reliability of Hospital-Reported Quality Measure Data
– Review hospitals’ controls for ensuring the accuracy of data
related to quality of care
• Hospital Readmissions
– Readmitted to hospital less than 31 days after being
discharged
– Determine trends in the number of hospital readmission
cases
– Determine if the hospital services met professional
standards of care
• Payments for Diagnostic Radiology Services in Hospital
Emergency Departments
50
2011 OIG Work Plan Hospital
• Hospital Admissions with Conditions Coded Present-onAdmission (POA)
– Determine which types of facilities and specific providers are
most frequently transferring patients with certain diagnoses
that were coded POA
• Responses to Adverse Events in Hospitals
– Determine whether hospitals have taken corrective actions
and are in compliance with Medicare standards
– Will identify and analyze potential overlaps, conflicts and
gaps in responses
• Hospital Reporting for Adverse Events
– Review type of information hospitals’ internal incidentreporting systems capture
51
Contact Information
– Contact Information
• Michael McLafferty CPA, MBA, FACMPE, CHFP
EisnerAmper, LLP Partner, Healthcare Services Group
Michael.McLafferty@eisneramper.com
• Steven Bisciello, MBA
EisnerAmper, LLP Supervising Consultant, Healthcare
Services Group
Steven.Bisciello@eisneramper.com
• Maureen Doherty, CPC, CPC-H
EisnerAmper, LLP Supervising Consultant, Healthcare
Services Group
Maureen.Doherty@eisneramper.com
52
EisnerAmper LLP is an independent member firm of PKF International Limited