CONNECT WITH US!

www.rmcinc.org 800.538.5007

REIMBURSEMENT MANAGEMENT

CONSULTANTS, INC. 12042 SE Sunnyside Rd #452

Clackamas, OR 97015

Adult Critical Care Overview –Part 1

continued 2

Psychiatric Diagnostic Testing

2-3

What the Russian Indictment

teaches us about cybersecurity

4

Avoid Conflicts in Reported Diagnoses

4-5

RMC News 6-7

Vol.8 Issue 3 3rd Quarter 2018

I N S I D E T H I S I S S U E :

Adult Critical Care Overview - Part 1 of 4 Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGS

Chris Breithoff, CPC, CPCO, CRC

As coding professionals, it’s important to get back to the basics on our challenging areas! Many of us

can attest to the fact that “critical care” is a problematic area in coding. So…let’s start off the four-part series of articles with a fundamental question. What is the definition of Critical Care? Per American Medical Association (AMA) CPT Professional 2018 codebook, critical care is defined as “…the direct delivery by a physician(s) or other qualified healthcare professional of medical care for a critically ill or critically injured patient.” The critical illness or injury would acutely impair one or more vital organ systems (i.e. central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure) to such a degree where there is high likelihood of imminent or life-threatening deterioration in the patient’s condition.1 The provider would treat the critical illness using “high complexity decision making to assess, manage, and support vital systems to treat single or multiple vital organ system failures and/or prevent further life-threatening deterioration of the patient’s condition.“ (AMA CPT Professional codebook 2018, p.23) Critical care services require the personal attention of the provider and must be provided at the patient’s bedside or on the floor/unit where the patient is located (immediately available and doing work related to the patient). Critical care services can be provided anywhere as long as the definition of critical care is met. Although critical care typically requires interpretation of multiple physiology parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.1 Being called to the bedside emergently is not the only requirement to support reporting critical care services and the provider’s documentation should clearly reflect the severity of the illness/injury and what services were provided at that moment to support the billing of critical care.

There are two primary adult critical care codes:

• 99291 Critical care, evaluation and management of the critically ill or critically injured

patient, first 30 to 74 minutes

• + 99292 Critical care, evaluation and management of the critically ill or critically injured

patient; each additional 30 minutes (list separately in addition to the code for the primary service)

(If less than 30 minutes of critical time is documented then an appropriate E/M code would be reported)

99291 may be used only once per day by a single provider or by multiple providers within the same

group, even if the time spent is not continuous. The initial 30 minutes of critical care (99291) needs to be performed by a single provider. Code 99292 is an add-on code and may be used for additional time spent providing critical care after the first 74 minutes. The CPT book provides a grid to help coders determine how many units of 99292 are billed based on the total time documented and has been copied at the end of this article.

Keep in mind, critical care is a time-based service1 and can be continuous, intermittent, or accumulated. More than one provider (usually different specialties) can provide critical care services as long as their service meets the requirements of critical care and is medically necessary. It cannot, however, be a duplication of care; documentation must reflect how the two physicians focused on different issues of care and clearly state their individual time (time cannot overlap). Physicians of the same specialty within the same group practice may bill and are paid as though they were a single physician (NPP and physician time cannot be combined) and each provider’s critical care time needs to be documented separately. If two physicians of the same group provide critical care throughout the day then their time is added together and reported under a single provider or broken out with 99291 for Dr. A and 99292 for Dr. B if time is over 74 minutes. It is recommended that each provider document a note and time for each critical care session they perform during a calendar day.

Continued...

99291 and 99292 have good reimbursement rates and are scrutinized by Medicare and other payors. Make sure your documentation supports the code(s). Stay tuned for more Critical Care Overview in our next Compliance Connection Newsletter.

DOCUMENTATION IS KEY!!!!

References: AMA’s Current Procedural Terminology 2018 Medicare Claims Processing Manual Society of Critical Care Medicine 1 https://www.cms.gov/Medicare/Medicare-Contracting/ContractorLearningResources/downloads/JA5993.pdf

Who knew that psychiatric diagnostic coding could be so complex? Psych providers use the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), which provides diagnostic criteria for providers to use when assigning mental health diagnoses, which was created by the American Psychiatric Association. Both DSM-5 and ICD-10 have a place in the world of behavioral health care, treatment, diagnosis and coding, but sometimes the DSM-5 and the ICD-10 manuals do not speak the exact same language.

The trick is to not get caught between the two resources. Though clinicians will use DSM-5 to diagnosis and classify mental/behavioral health disorders, it is our responsibility as coders to take that information and assign an appropriate/corresponding ICD-10 diagnosis code to the condition or disease.

Often the wording used in DSM-5 diagnostic statements are not going to mirror the wording found in ICD-10 code descriptions. As coders, learning about the DSM-5 classification will provide an additional layer of understanding but ultimately we are still going to be using our ICD-10 coding classification system for code assignment.

Page 2 C O M P L I A N C E C O N N E C T I O N S

Psychiatric Diagnostic Coding By Cindy S. Allred, RHIA & Jennifer Jones, CCS

“Critical Care” continued...

Chris Breithoff, CPC, CPCO, CRC is the Director of Physician Coding Services at RMC. She has worked in the medical arena since 1985 with an emphasis on coding & compliance for 18 years. Chris has a diverse background which includes managing large private practices, additionally, managing a physician coding department for a large teaching hospital. In these roles, Chris’ was responsible for the day to day coding, education of coders and providers, as well as overall compliance of the revenue cycle. Chris’ areas of expertise include Evaluation and Management coding, Critical Care, Emergency, Gastroenterology, Pulmonary, Cardiology and Sleep Medicine. Chris joined RMC in 2012 as an Auditor. In 2015 Chris took the helm of the Physician Coding Services and has done an outstanding job assuring exceptional services to our client and focusing on RMC staff engagement. Chris can be reached at cbreithoff@rmcinc.org.

Continued...

Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC is a Manager of Physician Coding Services at RMC. Susan has been working in the medical field since 1996, within physician offices. In addition being a Certified Professional Coder, she also holds specialty certifications in Evaluation and Management, General Surgery and OB/GYN. She is also a certified AAPC instructor. She has experience in professional fee coding, provider auditing (retrospective and prospective) and coder/provider education. Her experience ranges from small to large multi-specialty groups and large teaching hospitals. Susan also has experience coding Ophthalmology (to include Optho-plastics), Infusions for Chemotherapy, General Surgery (to include bariatric surgery), and Dialysis. Susan can be reached at smorton@rmcinc.org.

TOTAL DURATION OF

CRITICAL CARE CODES CODE TO REPORT

Less than 30 minutes 99232 or 99233 or other appropriate E/M code

30-74 minutes 99291 x 1

75-104 minutes 99291 x 1 and 99292 x 1

105-134 minutes 99291 x 1 and 99292 x 2

135-164 minutes 99291 x 1 and 99292 x 3

165-194 minutes 99291 x 1 amd 99292 x 4

194 minutes or longer 99291 x 1 as appropriate (per the above illustrations)

• DSM-5 was created to most closely follow ICD-11 codes, so some ICD-10 codes don’t translate well.

• ICD-10 is the designated code set to be used for coding and billing purposes in a psychiatric facility. As always, coding should be done to the highest level of specificity based on the documentation.

• If documentation is unclear or not specific enough to assign an ICD-10 code, a query should be sent to the provider for clarification.

• Providers may want to quote DSM-5 codes, but coders must follow ICD-10 rules for assigning codes. Remember to review the quarterly Coding Clinics as soon as they are released, as questions relating to Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (codes F01-F99) are being addressed (for example, see Coding Clinic 2Q 2018 pages 10-11). The 2019 release of ICD-10-CM includes new, updated and deleted codes that will affect the coding of several DSM-5 Disorders, it will be important for us to be aware and be prepared. The coding changes will go into effect October 1, 2018.

The American Psychiatric Association™ has released a handy quick-reference guide to the changes, which is located on their website and can be found at the following location:

https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5/coding-updates

*Note: Prior to May 2018, a "no diagnosis or condition" category had been omitted in DSM-5. The DSM-5 Steering Committee subsequently approved the inclusion of this category, and its corresponding ICD-10-CM code, Z03.89 "No diagnosis or condition," is available for immedi-ate use.

Page 3 C O M P L I A N C E C O N N E C T I O N S

“Psychiatric Diagnostic Coding” continued...

As Ordered in the ICD-10-CM Classification

Disorder*

DSM-5 Recommended

ICD-10-CM Code for use

through September 30,

2018*

DSM-5 Recommend-

ed ICD-10-CM Code

for use beginning

October 1, 2018*

Opioid withdrawal, Without moderate or severe use disorder Not in DSM-5 F11.93

Cannabis withdrawal, With moderate or severe use disorder F12.288 F12.23

Cannabis withdrawal, Without moderate or severe use disorder Not in DSM-5 F12.93

Sedative, hypnotic, or anxiolytic withdrawal delirium, Without moderate or

severe use disorder

Not in DSM-5 F13.931

Sedative, hypnotic, or anxiolytic withdrawal, With perceptual disturbances,

Without moderate or severe use disorder

Not in DSM-5 F13.932

Sedative, hypnotic, or anxiolytic withdrawal, Without perceptual disturb-

ances, Without moderate or severe use disorder

Not in DSM-5 F13.939

Amphetamine or other stimulant withdrawal, Without moderate or severe

use disorder

Not in DSM-5 F15.93

Other (or unknown) withdrawal, Without moderate or severe use disorder Not in DSM-5 F19.939

Factitious disorder, Imposed on another F68.10 F68.A

No diagnosis or condition* Not in DSM-5* Z03.89*

Cindy S. Allred, RHIA has over 16 years of experience as a Director of Health Information Management for a 135 bed State Psychiatric Institution covering civil, forensic & voluntary patient populations for adolescent, adult and geriatric psychiatric units. She has oversight and responsibility for all aspects of coding, both facility and pro-fee, for those patient populations. She has also instructed college level Medical Law and Ethics courses for over 10 years as an adjunct faculty staff and serves as a Privacy Specialist for Privacy, Confidentiality, Security and Breach Notification related matters. Cindy joined RMC in 2017 and is currently the Project Manager of Coding Services for RMC. Cindy can be reached at callred@rmcinc.org.

Jennifer Jones, CCS is one of RMC’s Manager of Coding Services and also a CDI Specialist. Jennifer has been with RMC since 2009. Jennifer has over 27 years of experience in the Health Information Management field and has held such positions as Manager of Coding Services, Inpatient & Outpatient Coding Specialist, Medical Transcriptionist, Medical Assistant, Medical Biller, and Medical Receptionist. Jennifer also has experience Clinical Documentation Improvement starting in 2010. Jennifer has worked in 25-bed Critical Access Hospitals, midsize hospitals, and large trauma level 1 medical centers. Jennifer is currently working on obtaining her RHIT, completion toward the end of 2017. Jennifer is an AHIMA approved ICD-10-CM and ICD-10-PCS Train the Trainer, and has been actively involved with RMC’s ICD-10 Training and education program. Jennifer resides in Oregon and can be reached at jjones@rmcinc.org

Aside from the sensationalism of alleged espionage by a foreign power, the cybercrime accusations listed in the Mueller investigation’s indictment document should be a warning to businesses everywhere. It’s an object lesson in “this could happen to you.” The Russia cyberwarfare debacle notwithstanding, nation state attacks on US entities are common. The US CERT site has a running list of North Korean “malicious cyber activity” to prove it.

It’s rare that the general public gets to see the “how” of a breach. Organizations typically stick to generalities when they own up to data breach-es. Notice that the cyber-attackers used every tool at their disposal to locate and exploit vulnerabilities at the DNC and Clinton campaign: spear phishing to steal passwords and gain network access, spoofed security notifications and email accounts, hacking tools and malware. This single-minded cyber-attack is a prime example of how things really play out when hackers want to get in your back door.

Every organization needs to take the cautionary message to heart. Because to mitigate the risk of a data breach recurrence, you not only need to know what happened, but also how and why it did. Think about it. What if you’re a healthcare provider? People’s lives are at stake.

3 Fundamental Tips for Risk Mitigation

• Implement perimeter controls to detect breaches and other cyberattacks such as ransomware. How else will you know a phishing attack has occurred? When the system takeover happens? Use appropriate technical perimeter controls to detect an attack early on so you can take immediate action.

• Launch system redundancy while you resolve the breach or security incident. You need to take the system down to root out every instance of malware, which means business continuity measures come into play. If you can launch your backup, business operations can continue with only a small blip.

• Engage computer forensic experts to get an image of the drives. Sure, maybe you can wipe drives as part of eliminating ransomware. Now what? You have no way to find out how it happened or why.

The above tips make the assumption that you have the basics in place, like security incident response and business continuity plans (which go hand-in-hand, by the way). If you don’t have functioning fundamentals, the ensuing scramble after a data breach or security incident starts to look like that classic vaudeville sketch “Who’s on first?”

Due to recent scrutiny by regulatory agencies of possible “up-coding” by Clinical Documentation Improvement (CDI) programs, it is more important than ever to ensure clinical validation for all reported diagnoses, and need for physician query clarifications. The goal of all CDI programs should always be to capture accurate, complete and comprehensive documentation for all conditions reported during a patient encounter. Every diagnosis should be clinically valid, and evidenced by the documentation and treatment, to withstand outside audit reviews.

Each CDI program should develop a policy and procedure that is specific to their needs as longs as it does not conflict with Official Coding Guidelines, AHA Coding Clinics or AHIMA Practice Briefs. In reviewing the medical record, each diagnosis should be validated for active treatment and management of the condition and consistency in provider documentation.

Without a doubt, outside reviewers often target conditions which are major comorbid conditions (MCCs). The most commonly targeted diagnoses include; sepsis, severe malnutrition, encephalopathy and respiratory failure. Here are a couple considerations for two of these problematic diagnoses:

• Sepsis – debate as always surrounded the definition of sepsis. In 1992, the American College of Chest Physicians and the Society of Critical Care Medicine published guidelines basically equating sepsis with a known infection plus two SIRS criteria. More recently in 2016, The Third International Consensus Definition for Sepsis and Septic Shock published their recommendations which is known as Sepsis 3. These new recommendations use the Sequential Organ Failure Assessment (SOFA) score to differentiate sepsis from other non-systemic infections. Many physicians like the SOFA scoring since it does take a patient’s chronic conditions into consideration. Whichever criteria a facility endorses, documentation problems for sepsis include: lack of consistent documentation throughout the medial record to discharge, conflicting physician documentation of the condition, and lack of clinical indicators supporting a systemic effect from the site of infection.

Page 4 C O M P L I A N C E C O N N E C T I O N S

Chris Apgar, founder of Apgar & Associates is a Certified Information systems Security Professional (CISSP). He is one of the country’s foremost experts and spokespersons on healthcare privacy, security, regulatory arriafs, state and federal compliance and secure and efficient electronic health information exchange. Chris has more than 19 years of experience in regulatory compliance and is a leader of regional and national privacy, security and health information exchange forums. As a member of Workgroup for Electronic Data Interchange, and serving on the Board of Directors since 2006, Chris is an honest, reliable, trustworthy expert in the field of privacy and security.

Apgar & Associates helps you discover privacy and security vulnerabilities so you can manage risks before a breach occurs. Contact us to schedule your assessment today: 503-384-2583 or email capgar@apgarandassoc.com for more details.

What the Russian Indictment teaches us about cybersecurity By Chris Apgar, CISSP

Avoid Conflicts in Reported Diagnoses By Barb Brant MPA, RN, CDIP, CCDS, CCS

Continued...

• Encephalopathy – is a term meaning an acute global cerebral/cognitive dysfunction. Numerous conditions can cause this dysfunction,

and the hallmark of the condition is an altered mental status, cognition changes, lethargy and/or delirium. Outside auditors are often attempting to remove the diagnosis of encephalopathy from a claim if the documentation supports this condition is due to the affect from a drug – as in intoxication or withdrawal. ICD-10 now has combination codes in the F10 – F19 range (Mental and behavioral disorders due to psychoactive substances) which include the terms of intoxication, hallucinations, delirium, just to name a few. Documentation problems for encephalopathy include discrepancy between the documentation of the condition and the actual patient assessments. For example, the physician may be documenting encephalopathy in their assessment, yet review of systems noted the patient as awake, alert, oriented x4. This largely is due to the common practice of copying and pasting within the electronic records. Clinical documentation for encephalopathy should support a baseline mental status, a deviation from that baseline, and include possible causes.

It is especially challenging when a physician is documenting a diagnosis which not clinically valid or is a past condition no longer being treated. Again, copying and pasting within the electronic medical record makes these mistakes all too easy. It is important that a CDI specialist demonstrate they are not questioning a physician’s judgment when performing a clinical validation query. The documentation needs to speak for itself and support that clarification is needed. Many CDI programs utilize Physician Advisors for these issues.

Therefore, Clinical Documentation specialists can assist in denial prevention by:

• Looking at all the documentation (ED, attending physician, physician consults, ancillary, and nursing) for any conflicting assessments

• Collaborate with physicians to obtain clinical validation criteria for problematic diagnoses

• Use standardized query formatting to assist with physician compliance and responses

• Understand your facility’s denial data to track for trends and identify education needs

Barb Brant, MPA, BSN, RN, CCS, CDIP, CCDS is RMC’s Senior Clinical Documentation Specialist and Auditing Consultant, joining RMC in 2016. Barb received her BS in Nursing at York College of PA, and her Master’s in Public Administration at Pennsylvania State University. In addition to her nursing background, Barb has extensive experience in Clinical Documentation Improvement. Barb has lead in the development, implementation, auditing and performance improvement efforts of numerous CDI programs. Additionally, Barb assisted health systems with ICD-10 Gap Analyses by creating and presenting ICD-10 CM educational materials for physicians, coders and CDI specialists. For RMC Barb has provided CDI services, chart documentation analyses, and clinical direction for coding reviews. Barb resides in Camp Hill, PA and can be reached at BBrant@rmcinc.org.

Page 5 C O M P L I A N C E C O N N E C T I O N S

“Avoiding Conflict” continued...

Page 6 C O M P L I A N C E C O N N E C T I O N S

Yep. You read that right. Totally free.

Visit our website: www.rmcinc.org to submit your questions today!

Our new website features a “Coding Questions” button. Submit your question, and one of our

RMC coding experts will reply.

*Also - don’t forget to follow RMC on Facebook, LinkedIn and Twitter. We post coding tips, reminders and updates weekly!

Page 7 C O M P L I A N C E C O N N E C T I O N S

Camille Walker: cwalker@rmcinc.org or Kristin Gibson: kristin@rmcinc.org

RMC is currently looking for experienced, credentialed, hard-working coding experts to join our team. Positions are all remote, and all RMC staff are issued a company laptop.

Qualified candidates:

• Must have a minimum of 5 solid years of coding experience

• Must be AHIMA/AAPC credentialed

• Must pass RMC's coding test

• Must be reliable, friendly and flexible

• Full-time AND part-time positions available! Some positions qualify for sign-on bonus!

If you want to join our team and LOVE your job, please send your resume to employment@rmcinc.org