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Final regular ICD-9-CM code update continues trend of increased specificity
Beginning October 1, coders will have 17 additional
V codes to report personal history of various conditions,
as well as 40 new diagnosis codes for skin malignancies.
The new ICD-9-CM codes are part of the final regular
update to ICD-9-CM before the switch to ICD-10-CM
on October 1, 2013. The Centers for Disease Control and
Prevention (CDC) will make limited updates to both the
ICD-9-CM and ICD-10-CM codes in 2012, and will only
update the ICD-10-CM codes beginning in 2013.
In addition, the CDC revised the code descriptions for
41 ICD-9-CM diagnosis codes and deleted 31 ICD-9-CM
codes altogether.
“The most noticeable trend with these changes has to
be the specificity of the code descriptors,” says Shelly
Cronin, CPC, CPMA, CANPC, CGSC, CGIC, CEU
vendor department manager for the AAPC in Salt Lake
City. “The revised codes as well as the newly created
codes include a specificity level that has not been seen
in previous incarnations of the ICD-9-CM manual.”
Codes add specificity
The increased specificity for a number of codes and
code categories could be the biggest challenge for coders.
“As coders, we tend to fall into habitual coding pat-
terns; we become used to using the same code repeat-
edly,” says Cronin. “These changes will require us
to change our
thinking and to
be vigilant of the
documentation
specificity in rela-
tion to the codes
they choose—
again, a great
precursor to the
ICD-10 changes that is right around the corner.”
The CDC added six new codes for thalassemia that
include additional specificity:
➤ 282.40, Thalassemia, unspecified
➤ 282.43, Alpha thalassemia
➤ 282.44, Beta thalassemia
➤ 282.45, Delta-beta thalassemia
➤ 282.46, Thalassemia minor
➤ 282.47, Hemoglobin E-beta thalassemia
In the past, coders could only report sickle-cell thalas-
semia without crisis (282.41), sickle-cell thalassemia with
crisis (282.42), and other thalassemia (282.49).
In addition to the thalassemia codes, new codes in
the 999.- series indicate the reason for an anaphylactic
or other reaction:
➤ 999.41, Anaphylactic reaction due to administration
of blood and blood products
“ The revised codes as well
as the newly created codes
include a specificity level
that has not been seen in
previous incarnations of
the ICD-9-CM manual.”
—Shelly Cronin, CPC, CPMA,
CANPC, CGSC, CGIC
October 2011 Vol. 12, No. 10
IN THIS ISSUE
p. 4 APC Panel debates codes for packaged servicesShould CMS require facilities to report HCPCS codes for packaged services?
p. 6 Proposed IPPS-based payment cap raises concernsAPC Panel meeting attendees are concerned about CMS’ plan to cross payment systems to set maximum reimbursement.
p. 8 ICD-10-CM anatomy refresher: SpineCheck out the first in our occasional series of anatomy and physiology refreshers.
p. 10 This month’s Q&AOur experts answer your coding questions about charging for triage-only ED visits, the timing of status and written discharge orders, assigning modifier -59 for multiple tests, billing compression wrap and debridement together, and reporting admit and discharge codes on the same day.
Page 2 Briefings on APCs October 2011
© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
➤ 999.42, Anaphylactic reaction due to vaccination
➤ 999.49, Anaphylactic reaction due to other serum
➤ 999.51, Other serum reaction due to administration
of blood and blood products
➤ 999.52, Other serum reaction due to vaccination
➤ 999.59, Other serum reaction
Skin malignancies
The CDC significantly expanded code series 173.x
(other malignant neoplasms of the skin) by adding a
fifth digit to each code in the series. For example, coders
currently report a malignant neoplasm of the lip with
code 173.0. After October 1, coders will need to know
the type of malignancy in order to choose between the
following codes:
➤ 173.00, Unspecified malignant neoplasm of skin of lip
➤ 173.01, Basal cell carcinoma of skin of lip
➤ 173.02, Squamous cell carcinoma of skin of lip
➤ 173.09, Other specified malignant neoplasm of skin
of lip
The series still includes one code for unspecified
malignant neoplasm, but coders should start asking
physicians for additional information so they can select
a more specific code.
“In previous years, the coding has been limited
because the codes were not specific to a particular type
of malignancy despite the specific documentation pro-
vided by physicians,” says Cronin. “Having the ability to
report a code that specifically states that the patient has
a squamous cell carcinoma will bring us closer to the
specificity required for ICD-10 coding.”
New V codes
The CDC added new personal history V codes for
gestational diabetes (V12.21); other endocrine, metabolic,
and immunity disorders (V12.29); pulmonary embolism
(V12.55); anaphylaxis (V13.81); and other specified dis-
eases (V13.89).
Coders can also report two new family history V codes:
family history of glaucoma (V19.11) and family history
of other specified eye disorder (V19.19).
Other new V codes include the following:
➤ V23.42, Pregnancy with history of ectopic pregnancy
➤ V23.87, Pregnancy with inconclusive fetal viability
➤ V54.82, Aftercare following explantation of joint
prosthesis
➤ V88.21, Acquired absence of hip joint
➤ V88.22, Acquired absence of knee joint
➤ V88.29, Acquired absence of other joint
New E. coli codes
E. coli (code 041.4) is currently covered by a single
code. However, beginning October 1, coders will need to
select the appropriate E. coli code from the following list:
➤ 041.41, Shiga toxin-producing Escherichia coli
[E. coli] (STEC) O157
➤ 041.42, Other specified Shiga toxin-producing
Escherichia coli [E. coli] (STEC)
Editorial Advisory Board Briefings on APCs
Dave Fee, MBAProduct Marketing Manager, Outpatient Products3M Health Information Systems Murray, UT
Frank J. Freeze, LPN, CCS, CPC-HPrincipalThe Wellington Group Valley View, OH
Carole L. Gammarino, RHIT, CPURRecruiting Management, HIM ServicesPrecyse Solutions King of Prussia, PA
Susan E. Garrison, CHCA, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPARExecutive Vice President of Healthcare Consulting Services Magnus Confidential Atlanta, GA
Kimberly Anderwood Hoy, JD, CPCDirector of Medicare and ComplianceHCPro, Inc.Danvers, MA
Diane R. Jepsky, RN, MHA, LNCCEO & PresidentJepsky Healthcare Associates Sammamish, WA
Lolita M. Jones, RHIA, CCSLolita M. Jones Consulting Services Fort Washington, MD
Jugna Shah, MPHPresidentNimitt Consulting Washington, DC
Briefings on APCs (ISSN: 1530-6607 [print]; 1937-7649 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. Copyright © 2011 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. For editorial comments or questions, call 781/639-1872 or fax 781/639-7857. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. Visit our website at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be on this list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BAPCs. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of American Medical Association; no fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
Editorial Director: Lauren McLeod
Associate Editorial Director: Ilene MacDonald, CPC
Senior Managing Editor: Michelle Leppert, CPC-A, [email protected]
October 2011 Briefings on APCs Page 3
© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
➤ 041.43, Shiga toxin-producing Escherichia coli
[E. coli] (STEC), unspecified
➤ 041.49, Other and unspecified Escherichia coli
[E. coli]
Stages of glaucoma
The CDC added codes to specify the stage of glaucoma
in a patient. These five codes, listed below, are completely
new and require a fifth digit:
➤ 365.70, Glaucoma stage, unspecified
➤ 365.71, Mild stage glaucoma
➤ 365.72, Moderate stage glaucoma
➤ 365.73, Severe stage glaucoma
➤ 365.74, Indeterminate stage glaucoma
Additions to influenza
The CDC expanded subcategory 488.8 ( influenza
due to certain identified influenza viruses) to include a
fifth digit identifying pneumonia and other manifestations
that occur as a result of the viral infection. The fifth digit
specifies with pneumonia (488.81), with other respira-
tory manifestations (488.82), and with other manifesta-
tions (488.89).
Pulmonary codes
The CDC added 15 new codes in the 516.- series for
diagnosis of lung diseases. Thirteen of the new codes
require a fifth digit for added specificity:
➤ 516.30, Idiopathic interstitial pneumonia, not
otherwise specified
➤ 516.31, Idiopathic pulmonary fibrosis
➤ 516.32, Idiopathic non-specific interstitial
pneumonitis
➤ 516.33, Acute interstitial pneumonitis
➤ 516.34, Respiratory bronchiolitis interstitial lung
disease
➤ 516.35, Idiopathic lymphoid interstitial pneumonia
➤ 516.36, Cryptogenic organizing pneumonia
➤ 516.37, Desquamative interstitial pneumonia
➤ 516.4, Lymphangioleiomyomatosis
➤ 516.5, Adult pulmonary Langerhans cell histiocytosis
➤ 516.61, Neuroendocrine cell hyperplasia of infancy
➤ 516.62, Pulmonary interstitial glycogenosis
➤ 516.63, Surfactant mutations of the lung
➤ 516.64, Alveolar capillary dysplasia with vein
misalignment
➤ 516.69, Other interstitial lung diseases of childhood
Pneumonitis refers to inflammation of lung tissue.
Although pneumonia is a type of pneumonitis because
the infection causes inflammation, physicians use pneu-
monitis to refer to other causes of lung inflammation.
Revised code descriptions
In the 317–319 series of codes, the words “ intellectual
disabilities” replaced “mental retardation.” Intellectual
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Page 4 Briefings on APCs October 2011
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Should CMS require hospitals to report HCPCS codes
for all packaged services that have HCPCS codes? That
topic generated plenty of discussion during the August
12 APC Advisory Panel on Ambulatory Payment Clas-
sification Groups meeting.
The requirement would benefit CMS by allowing it
to set more accurate rates and pay more accurately for
packaged services, especially drugs. But many are con-
cerned the burden would outweigh that benefit.
Currently, facilities generally do not need to report
HCPCS codes for packaged services, including drugs,
even when a HCPCS code exists. The exception is for
devices and radiopharmaceuticals, for which CMS
has instituted edits to ensure that packaged codes are
reported.
Attendees intensely debated whether the panel
should recommend CMS require providers report
HCPCS codes for all services that have codes, regard-
less of whether they are separately paid, according to
Kimberly Anderwood Hoy, JD, CPC, director of
Medicare and compliance for HCPro, Inc., in Danvers,
MA.
“It was really hotly debated,” says Hoy, adding that
she made her only comment during the discussion.
“Some people had really strong opinions.”
Although CMS does not currently require hospitals
to report HCPCS codes for packaged services, including
drugs, it strongly encourages providers to do so because
this data influences the APC rate-setting process, says
Jugna Shah, MPH, president of Nimitt Consulting in
Washington, DC.
HCPCS codes for packaged services
One of the attendees at the meeting suggested that
instead of worrying about reporting HCPCS codes for
packaged services, hospitals should focus on clini-
cal software to help clinicians do their job. After the
clinical piece is in place, the commenter argued, then
hospitals can worry about integrating the reporting of
HCPCS codes for packaged services.
Hoy responded with a comment based on her expe-
rience with hospital software contracts. “If you make
something required, the software vendors will add it to
the software,” Hoy says. “Until you make it required,
you’ll never have that integration where the clinical
piece will be integrated.”
Other attendees expressed concern that reporting
HCPCS codes would represent a burden to hospitals,
Hoy says. Hospitals don’t receive additional reimburse-
ment for packaged services even when they report
HCPCS codes for them.
“Interestingly, everyone from the provider side who
was there and commented said it wouldn’t be a heavy
burden on hospitals, but that hospitals probably would
not do it unless required,” Hoy says.
Kathy Dorale, RHIA, CCS, CCS-P, vice president of
HIM at Avera Health System in South Dakota, noted
during the meeting that hospitals end up coding the
National Drug Code anyway on many drugs.
Although providers said reporting HCPCS codes
wouldn’t be a burden for them, several members of the
panel disagreed, Hoy says. Other panel members rec-
ognized the burden but said that without accurate and
APC Panel debates requiring codes for packaged services
disabilities can be mild, moderate, severe, profound,
or unspecified. The same change was made in V codes
V18.4 (family history of intellectual disabilities) and
V79.2 (special screening for intellectual disabilities).
Three influenza codes, 488.11, 488.12, and 488.19,
now specify “2009 H1N1 influenza” within their code
descriptions instead of using the phrase “identified
novel.”
The codes in series 995.5x now denote “anaphylactic
reaction” instead of anaphylactic shock. Coders still
need to select the appropriate fifth digit to denote the
substance that caused the reaction. n
October 2011 Briefings on APCs Page 5
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complete data, rate setting will continue to be compro-
mised. In the end, the panel did not approve any recom-
mendation to CMS on the issue because they weren’t
sure how or whether CMS would enforce it, Hoy says.
Reporting HCPCS codes for all packaged services
could lead to better reimbursement down the line, Hoy
says.
“If hospitals report these packaged services, it will
give CMS better data about the costs of services and
ensure their costs are incorporated into separately paid
items,” she says. “We’ve got the codes and we can dif-
ferentiate things, so we should provide the data to CMS,
which should lead to better payments.”
Once a hospital adds the HCPCS codes to the charge-
master, it will only have to update the codes each year.
“They are mostly chargemaster-driven items, so it’s
really a one-time thing,” Hoy says. “It’s not an ongoing
burden. Once you get the codes in your chargemas-
ter, when the item is billed the code is automatically
reported.”
Many individuals at the meeting acknowledged that
it would be best to report HCPCS codes for all packaged
services that have them. However, because reporting is
seen as a “nicety” rather than a requirement that must
be implemented, making it a priority for hospitals will
be difficult, says Shah.
Audience members agreed with this sentiment,
repeatedly commenting that if CMS does not require
reporting of HCPCS codes, it will fall by the wayside for
most hospitals because other, bigger projects will take
center stage, Hoy says.
Drug payments
The first day of the APC Panel meeting featured a
discussion of how to pay more appropriately for sepa-
rately payable drugs. Alpha-Banu Huq, a member of
CMS’ division of outpatient care, discussed the proposed
payment for drugs. A pharmacy stakeholder group pre-
sented ways in which CMS’ methodology for reimburs-
ing hospitals for separately payable drugs is woefully
inadequate.
CMS must allocate additional dollars from packaged
drugs (those reported with HCPCS codes as well as those
reported without HCPCS codes; called coded and uncod-
ed packaged drugs respectively in the proposed rule) to
separately payable drugs. This would allow the agency
to appropriately reimburse hospitals for drug acquisition
costs as well as the drug handling/overhead costs associ-
ated with preparation, storage, mixing, quality checks,
and safe disposal of drugs. “These costs are not insig-
nificant, yet CMS has continued to provide inadequate
reimbursement for them,” says Shah.
By reallocating a greater proportion of packaged drug
costs to separately payable drugs, CMS would be able
to increase the current proposed payment rate of the
average sales price (ASP)+4% to ASP+6%, which would
provide more adequate compensation to hospitals for
their drugs.
One reason CMS is hesitating on this reallocation is
because hospitals do not report the drug HCPCS codes
on claims, which means CMS doesn’t really know what
packaged drugs hospitals are using or whether the drug
has more overhead costs associated with it than appro-
priate, say Hoy and Shah.
In addition, some facilities may not be reporting all
of the drugs that are eligible for separate payment based
on the packaging threshold. As a result, some packaged
drugs may actually qualify for separate payment because
they exceed the packaging threshold, but CMS is unable
to make that determination due to lack of data. n
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Page 6 Briefings on APCs October 2011
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Proposed IPPS-based payment cap raises concernsCMS’ plan to cap payment for cardiac resynchroniza-
tion therapy (CRT) based on Medicare severity diagnosis-
related group (MS-DRG) 227 payment drew plenty of
discussion at the August 12 APC Advisory Panel on Am-
bulatory Payment Classification Groups meeting.
As part of the 2012 OPPS proposed rule, CMS an-
nounced plans to create a new composite APC for CRT
defibrillator (CRT-D) and CRT pacemaker (CRT-P) proce-
dures. CMS proposes capping payment for those services
at the lesser of the newly established APC median cost or
the inpatient standardized payment for MS-DRG 227.
The issue was not whether CMS should create a
composite, says Kimberly Anderwood Hoy, JD, CPC,
director of Medicare and compliance for HCPro, Inc.,
in Danvers, MA. Everyone who spoke seemed to agree
that CRT was perfect for an APC composite. Instead, the
debate focused on CMS’ plan to cap the payment based
on MS-DRG 227. Many commenters opined that CMS’
proposal to cap an outpatient payment based on an in-
patient rate is a radical and inappropriate departure from
the usual rate-setting process, Hoy says.
Jugna Shah, MPH, president of Nimitt Consulting in
Washington, DC, commented that CMS has never before
been willing to look across payment systems—even
when asked to do so, as in the case of drug payment
parity with the physician office setting.
Historically, CMS has been unwilling to compare one
payment system to another because IPPS, OPPS, and the
physician payment system are very different. Rather,
CMS has relied on Congress to cross payment systems—
for example, with mammograms—and has shied away
from doing so itself.
Crossing payment systems
Shah asked the APC Panel to think about CMS’
proposal in two ways. First, she posed a philosophi-
cal question of whether the agency should look across
payment systems. If CMS decides to do so for its CRT-D
proposal, then it must consider doing it for all services,
including drugs and biologicals. ”If CMS wants to walk
through the door of comparing payment systems, then
it must do so for other services as well, such as drugs,”
says Shah.
If CMS’ proposal is finalized, she said the panel
should recommend that CMS also finalize the repeated
requests to eliminate the drug packaging threshold and
provide separate payment for all drugs as it does in the
physician office setting.
Second, Shah cautioned the panel about assuming that
CMS’ cost calculations for one care setting are more or less
accurate given that the rate-setting processes for inpatient
and outpatient charges are completely different. “You sim-
ply cannot compare apples and eggplants and ask every-
one to believe the comparison is valid,” Shah says.
Valerie Rinkle, MPA, revenue cycle director for
Asante Health System in Medford, OR, reminded the
panel that CMS stated it always makes payment deci-
sions based on data from hospitals. In the past, when
CMS made decisions that negatively affected hospital re-
imbursement, its reasoning was always that the hospital
data reflected those revised costs or APC assignment.
With this proposal, however, CMS would not be
relying on hospital claims data to set reimbursement.
Instead, it would be crossing over to the inpatient pay-
ment system, which may be completely inapplicable to
the outpatient side or not as accurate as the outpatient
data, Rinkle says.
One factor that makes the outpatient data potentially
more accurate are edits that CMS implemented to ensure
that the costs of devices are reported on outpatient claims
even though they are not paid separately. No such edits
are in place in the inpatient billing system, and claims
could be submitted without reporting the cost of devices,
a significant portion of the cost of these procedures.
APC Panel recommendation
The panel voted almost unanimously to recommend
that CMS’ base payment for new proposed composite
October 2011 Briefings on APCs Page 7
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APC 8009 and APC 0108 (insertion/replacement/repair
of cardioverter-defibrillator leads) be set on the outpa-
tient claims data only.
The concern among providers is not just about new
composite APC, Hoy says. CMS seems willing to cross
payment systems for its own advantage, but chose not to
do so in the past when it would have raised rates for pro-
viders. Providers worry that this opens the door for CMS
to adopt this method in other places, lowering reimburse-
ment if a lower rate exists in another payment system,
without regard to the cost providers report. “It’s definitely
a slippery slope that no one wants CMS to start down.”
The thing that many in the provider community are
questioning is why CMS is beginning to make compari-
sons across sites of service. “Is it only because limiting
payment in this instance benefits the agency?” asks
Shah. Where else will CMS limit the payment based on
the inpatient rate or limit inpatient payment based on
the outpatient rate? Will the agency ever increase pay-
ments? The answers to these questions are still unclear.
New APCs
The APC Groups and Status Assignments Committee
recommended creation of new APCs. The panel adopted
the committee’s recommendation to support the cre-
ation of two new APCs (0331 and 0334) for the HCPCS
codes for reporting combined abdominal and pelvic CT
scans (74176–74178). When these codes were intro-
duced, CMS assigned them to existing APCs for indi-
vidual CT scans.
Providers argued that these codes represented the
combination of predecessor codes and that assigning
them to the same APC as single exams did not sufficient-
ly compensate providers for what are effectively multiple
exams. The new APCs would raise the payment for these
codes from a range of $193–$334 in calendar year (CY)
2011 to $402–$571 in CY 2012.
The panel also adopted the committee’s recommenda-
tion to support CMS’ proposal to create a new APC for
upper gastrointestinal (GI) procedures. This new APC
would result in three levels of upper GI procedures.
However, the subcommittee recommended that two
codes—43227 (endoscopic esophageal repair) and 43830
(placement of gastronomy tube)—be assigned to the Lev-
el III APC rather than Level II because their median costs
are closer to the median costs of Level III procedures.
Magnetoencephalography payment
CMS currently uses claims data from electroencephalo-
grams (EEG) to set the cost-to-charge ratio for magneto-
encephalography (MEG), which is incorrect according to
one presenter. The presenter argued that MEG costs more,
but did not provide data showing that hospitals charged a
proportionally different amount for this service, Hoy says.
MEG currently falls under revenue code 086x, but
many facilities don’t report it there because CMS does not
require them to, Hoy says. Instead, they report it under
the regular EEG revenue center. Even if hospitals use the
separate revenue code, MEG does not have a cost center
where CMS and hospitals can compare cost data.
The APC Panel recommended that CMS require
facilities to report MEG under revenue code 086x with
appropriate edits to make sure facilities report it there. Al-
though the presenter argued that MEG is more expensive
than it looks on paper, CMS’ average cost data showed
that the procedure had been priced too high. As a result,
the panel recommended CMS move MEG from APC 67
to APC 66, which is a lower payment, Hoy says.
Inpatient-only procedures
Panel members also stated they would need addi-
tional clinical information before determining whether
to recommend removing 43279 (Laparoscopic esoph-
agomyotomy [Heller type], with fundoplasty) from the
inpatient-only list and deciding which APC it should be
grouped to as an outpatient procedure.
Rinkle suggested that the panel consider Medicare Ad-
vantage Plan data to determine how often a procedure is
performed on an outpatient basis when deciding whether
to remove it from the list. A CMS representative con-
firmed that CMS currently reviews OPPS data only and
does not consider Medicare Advantage Plan data. n
Page 8 Briefings on APCs October 2011
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ICD-10-CM anatomy refresher: SpineEditor’s note: With the increased specificity required for
ICD-10-CM coding, coders need a solid foundation in anatomy
and physiology. To help coders prepare for the coming switch,
we will provide a series of occasional anatomy and physiology
refreshers for different parts of the body. This month we start
with the spine.
The spine is only one part of the musculoskeletal
system, but its interwoven bones, nerves, and muscles
make it a very complicated section. To make matters
even more confusing, a single vertebra is more than just
a bone; it is a complex segment of anatomical structures.
“It’s important for a coder to understand all of these
individual segments of the vertebrae because these de-
tails are necessary for accurate coding in both diagnoses
and procedures,” says Shelley C. Safian, PhD, MAOM/
HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved
ICD-10-CM/PCS trainer of Safian Communications Ser-
vices in Orlando, FL.
That complexity can make it difficult to accurately
assign ICD-9-CM diagnosis codes for the wide range of
spinal conditions—coding these conditions in ICD-10-
CM could be challenging as well.
Spinal column
A knowledge of spinal anatomy provides the founda-
tion necessary to assign codes both before and after the
switch to ICD-10-CM.
The spine is essentially a stack of bones (known as
vertebrae) that run down the posterior of the torso from
the brainstem to the tailbone. The spinal column is broken
into five separate areas, based on location from the top of
the spine to the bottom:
Figure 1
Figure 2
October 2011 Briefings on APCs Page 9
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➤ Cervical, known as C1–C7
➤ Thoracic, known as T1–T12
➤ Lumbar, known as L1–L5
➤ Sacral, known as S1–S5
➤ Coccyx, known as CX
The first cervical vertebra, usually known as C1, is
also called the atlas. C2, the second cervical vertebra,
is also known as the axis. “The good news is these are
the only two vertebrae that have alternate names,” says
Safian.
The sacral vertebrae, or sacrum, start out as five
separate bones at birth. By the time an individual
reaches his or her mid-20s, the bones fuse into one
bony section. After the bones fuse, the S1–S5 desig-
nation refers to the location on the single bone, says
Safian.
Similar to the sacrum, the coccyx also fuses into one
bone as a person ages; it starts out as three to five indi-
vidual bones at birth.
Vertebral body
Each vertebra includes a vertebral body that sur-
rounds the spinal cord to protect it in the front. The
spinous process and the pedicle protect the spinal cord
in the back.
The pedicles are short stout processes that attach to
the superior part of the vertebral body on each side.
These extend posteriorly to meet the laminae, which are
broad flat plates of bone. The pedicles also overlap the
laminae of the vertebrae below.
The articular processes arise from the junctions of the
pedicles and laminae. These bony projections have a
small smooth surface known as a facet. Each vertebra in-
cludes four articular processes, two upper and two lower,
that comprise the facet joints.
Coders also need to understand the difference be-
tween an interspace and a segment, says Kim Pollock,
RN, MBA, CPC, consultant with KarenZupko & Associ-
ates, Inc., in Chicago. A vertebral segment represents a
single complete vertebral bone with its associated articu-
lar processes and laminae.
Although the bones of the vertebral column are stacked
on top of each other, they don’t actually rest on each
other. The vertebral interspace is the non-bony compart-
ment between two adjacent vertebral bodies that contains
the intervertebral disc and includes the nucleus pulposus,
annulus fibrosus, and two cartilagenous endplates.
“Think of the segment as two bones and the space
between,” says Pollock. n
Figure 3
Figure 4
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Charging for triage-only ED visits
Q A patient presents to the ED and is triaged and
assessed by a nurse, but leaves before being seen
by the ED physician. Is there a CPT code we can use for
the nursing assessment, and can we charge the patient
for the nursing assessment?
A These visits are often referred to as triage-only
or nurse-only visits. Medicare contractors vary in
their policies for reimbursing such visits. CMS published
an FAQ on this issue in 2008, ID 8810, but it does not
clearly answer the question of a patient leaving the ED
before he or she sees the physician:
FAQ Q: Is it appropriate for a hospital to bill a visit code
under the Outpatient Prospective Payment System (OPPS)
for care provided to a registered outpatient if the patient was
not seen by a physician?
FAQ A: Under the OPPS, unless indicated otherwise, we
do not specify the type of hospital staff (for example, nurses,
pharmacists, etc.) who may provide services in hospitals
because the OPPS only makes payments for services provided
incident to physicians’ services. Hospitals providing services
incident to physicians’ services may choose a variety of staff-
ing configurations to provide those services, taking into ac-
count other relevant factors such as State and local laws and
hospital policies.
Billing a visit code in addition to another service mere-
ly because the patient interacted with hospital staff or
spent time in a room for that service is inappropriate. A
hospital may bill a visit code based on the hospital’s own
coding guidelines, which must reasonably relate the inten-
sity of hospital resources to the different levels of HCPCS
codes. Services furnished must be medically necessary and
documented.
If a hospital provides a distinct, separately identifiable
service in addition to the test, the hospital is responsible
for billing the code that most closely describes the service
provided.
Querying CMS’ MACs provided these responses:
➤ In order for incident-to requirements to be in
effect, there first must be an established physician-
patient relationship. In order to provide services
incident to the physician, the physician must have
seen the patient and established some type of plan
for the patient’s care.
➤ In the rare instance when a medically necessary ser-
vice is well documented and meets the definition of
an emergency service, a facility charge may be ap-
propriate. However, one CMS FI/MAC has provided
guidance to bill a low-level clinic visit 99211, which
is the only E/M service that does not require the
presence of a physician. Additional guidance states
that a visit level should not be assigned when only
administrative services are provided.
➤ If the services are not otherwise separately pay-
able, the hospital may charge the lowest-level
emergency room visit charge.
Noridian has stated that a low-level visit may be re-
ported in this “triage-only” scenario. Highmark has stated
that it will not pay for an ED service when the patient
has not been seen by the physician. TrailBlazer, the MAC
for Colorado, New Mexico, Oklahoma, and Texas, has
published an FAQ on its website (see below) stating that it
will pay for a triage-only visit:
Question: Is it appropriate for a hospital paid under
OPPS to bill a low-level visit code for care provided to a regis-
tered outpatient if the patient was not seen by a physician?
Answer: Under the OPPS, unless indicated otherwise,
CMS does not specify the hospital staff who may provide ser-
vices in hospitals because the OPPS only makes payment for
services provided “incident to” physicians’ services. Hospi-
tals providing services incident to physician’s services may
choose a variety of staffing configurations to provide those
services, taking into account other relevant factors such as
state and local laws and hospital policies.
October 2011 Briefings on APCs Page 11
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➤ Facilities should code a level of service based on facility
resource consumption, not physician resource consump-
tion. This includes situations where patients may see a
physician only briefly or not at all.
➤ If a visit and another service are also billed, the visit must
be separately identifiable from the other service since the
resources used to provide non-visit services including staff
time, equipment, supplies, etc., are captured in the line
item for that service.
➤ Billing a visit in addition to another service merely be-
cause the patient interacted with hospital staff or spent
time in a room for that service is inappropriate.
➤ All services furnished must be medically necessary and
documented.
See www.trailblazerhealth.com/Publications/ Questions%20
and%20Answers/OPPSQandA.pdf?DomainID=1 for more
information.
Chapter 4 of the Medicare Claims Processing Manual pro-
vides the following guidance:
CMS has acknowledged from the beginning of the OPPS
that CMS believes that CPT Evaluation and Management
(E/M) codes were designed to reflect the activities of physi-
cians and do not describe well the range and mix of services
provided by hospitals during visits of clinic and emergency
department patients. While awaiting the development of a
national set of facility-specific codes and guidelines, provid-
ers should continue to apply their current internal guide-
lines to the existing CPT codes. Each hospital’s internal
guidelines should follow the intent of the CPT code descrip-
tors, in that the guidelines should be designed to reasonably
relate the intensity of hospital resources.
Each hospital must clearly document its internal
guidelines and apply them consistently following its
MAC’s payment policies. Since the responses vary by
contractor, each hospital must understand the payment
policy that applies in its area. Working with the local FI
or MAC and your internal compliance team, consider the
following questions when deciding whether to bill for a
“triage-only” ED visit:
➤ Was the visit medically necessary?
➤ Did the visit meet the definition of an ED service?
➤ Was the visit a distinct and separately identifiable ser-
vice from a test or procedure provided and billed?
➤ Were the resources expended entirely administrative?
Timing of status and written discharge orders
Q Is a status order valid if the physician writes it after
the discharge order while the patient is still in the
bed? Where can I find this Medicare guideline?
A The order must be written to change the status
from inpatient to outpatient while the patient is still
in the facility, as required by condition code 44 criteria.
Medicare does not permit retroactive orders as noted in
the Medicare Claims Processing Manual, Chapter 1, section
50.3.2. If the patient has been discharged and the status
Contributors
We would like to thank the following contributors for
answering the questions that appear on pp. 10–12:
Andrea Clark, RHIA, CCS, CPC-H
President
Health Revenue Assurance Associates, Inc.
Plantation, FL
Shelley C. Safian, PhD, MAOM/HSM, CCS-P,
CPC-H, CPC-I CHA
Safian Communications Services
Orlando, FL
Candace E. Shaeffer, RHIA, RN, MBA
Chief Compliance Officer
LYNX Medical Systems, Inc.
Bellevue, WA
Denise Williams, RN, CPC-H
Director of Revenue Integrity Services
Health Revenue Assurance Associates, Inc.
Plantation, FL
Page 12 Briefings on APCs October 2011
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was still inpatient, there are certain services that can be
billed on an inpatient Part B–only claim. The information
concerning such a claim is also found in section 50.3.2 of
the Claims Processing Manual:
When Condition Code 44 is appropriately used, the hos-
pital reports on the outpatient bill the services that were
ordered and provided to the patient for the entire patient
encounter. However, in accordance with the general Medi-
care requirements for services furnished to beneficiaries and
billed to Medicare, even in Condition Code 44 situations,
hospitals may not report observation services using HCPCS
code G0378 (Hospital observation service, per hour) for ob-
servation services furnished during a hospital encounter
prior to a physician’s order for observation services. Medi-
care does not permit retroactive orders or the inference of
physician orders. Like all hospital outpatient services, ob-
servation services must be ordered by a physician. The clock
time begins at the time that observation services are initiat-
ed in accordance with a physician’s order.
Assigning modifier -59 for multiple tests
Q When could we use modifier -59 (distinct proce-
dural service) if all the following procedures are
performed in one session:
➤ 92541, Spontaneous nystagmus test
➤ 92542, Positional nystagmus test
➤ 92544, Optokinetic nystagmus test
➤ 92545, Oscillating tracking test
A All of these codes bundle to 92540. However, per
the CPT Manual and Medicare CCI edits, combi-
nations of three or fewer of codes 92541, 92542, 92544,
and 92545 are allowable on the same date of service and
modifiable as appropriate. If a physician orders all four of
the above procedures (92541, 92542, 92544, and 92545)
and the tests are performed on the same date, report
comprehensive code 92540 (basic vestibular evaluation)
instead of the individual codes.
The American Speech-Language-Hearing Association
website provides a helpful table explaining this at www.
asha.org/practice/reimbursement/ medicare/Aud_coding_rules.htm.
Billing compression wrap and debridement
Q Are you allowed to bill a compression wrap along
with a debridement (any level) on the same day?
Also, must a culture specimen be performed with every
debridement at any level (e.g., 97597, 97598)?
A The compression wrap CPT code (29581) billed
with the debridement code will hit an NCCI edit.
They should not be assigned together unless the wrap
was applied to a different site not involving the debride-
ment. Under the Medicare NCCI edits this is incorrect
separate reporting of codes if the codes are billed for ser-
vices provided to the same beneficiary by the same physi-
cian on the same day.
Reporting admit, discharge codes on same day
Q A patient is in a swing bed in the hospital and
is seen by the physician. The physician admits
the patient as an inpatient. The physician writes a dis-
charge summary note and an interval progress note.
Can we bill a nursing facility discharge day manage-
ment code 99315 from the swing bed and admit to
inpatient code 99222?
A The CPT guidelines located directly above code
99221 state the following:
When the patient is admitted to the hospital as an
inpatient in the course of an encounter in another site of
service (e.g., hospital emergency department, observation
status in a hospital, physician’s office, nursing facility),
all evaluation and management services provided by
that physician in conjunction with that admission are
considered part of the initial hospital care when performed
on the same date as the admission.
Within the same facility on the same date of service,
the discharge and admission become part of the initial
hospital (admission) management. Therefore, you may re-
port only 99222. You should query the physician and ask
him or her complete the appropriate documentation. n