Aug 5, 2020 | Uncategorized
As we move closer to 2021 and our new E/M guidelines, now is the perfect time to educate our clinicians on the importance of documenting their encounters to include medical necessity.nnIn the January 2020 issue of CMS MLN on Evaluation & Management under the General Principles of E/M Documentation, we see this guidance; Clear and concise medical record documentation is critical to providing patients with quality care and is required for you to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation helps physicians and other health care professionals evaluate and plan the patient’s immediate treatment and monitor the patient’s health care over time.nnThe key here is “record pertinent facts, findings, and observations” and the big word that we as auditors focus on most is pertinent. So often we see clinicians mark review of systems as “negative”, what is pertinent with a mark of negative? How does this tell us pertinent facts about the patient presentation of help to tell the story about how the patient is feeling?nnMoving forward, the nature of the presenting problem will become more pertinent to our coding and we will be seeing far less emphasis on things like counting ROS statements or physical exam elements. CMS will re-release their MLN next year on Evaluation and Management so be sure to make sure you are getting these updates as they become available.nnFor more information on the evaluation management guide, click here.
Jul 29, 2020 | Uncategorized
Last week, members of the House of Representatives Telehealth Caucus introduced the bipartisan Protecting Access to Post-COVID-19 Telehealth Act. Check out the article below for 7 things to consider with this new Telehealth legislation. nnThe legislation “seeks to expand the use of telehealth beyond the current national health crisis, including permanently eliminating obsolete geographic originating site restrictions,” according to the American Telemedicine Association (ATA).nnAs this legislative initiative moves forward, what do health systems, hospitals, and providers need to consider? Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS); ATA; the Healthcare Information and Management Systems Society (HIMSS); and experts at other organizations are weighing in with insights and predictions. Here’s a look at the current zeitgeist:nn1. IS THE PROPOSED HOUSE LEGISLATION ENOUGH?nThe proposed legislation addresses most priorities outlined in a June 29 letter to Congress signed by the ATA and 340 national and regional organizations last month, urging Congress to make telehealth flexibilities created during the COVID-19 pandemic permanent, according to a statement issued by the telehealth association. These priorities include:n
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- Removing geographic restrictions and allowing the patient’s home as an originating site
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- Maintaining and enhancing the Department of Health and Human Services’ (HHS) authority to determine appropriate telehealth services and providers
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- Ensuring Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) can continue to furnish telehealth
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- Making HHS’ temporary waiver authority for future emergencies permanent
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n”This legislation is an important step towards breaking down discriminatory geographic restrictions and modernizing our healthcare delivery system,” said ATA CEO Ann Mond Johnson.nn2. EVALUATING THE CLINICAL APPROPRIATENESS OF TELEHEALTHnIn a Health Affairs blog written by Verma and published on July 15, the CMS administrator said, “First, it is important to assess whether the mode of telehealth service delivery is clinically appropriate and safe for patients, as compared to an in-person visit.” For example, before the declared public health emergency, CMS restricted telemedicine visits to patients who already had an established relationship with a practitioner. To reduce exposure risks, those limitations were then lifted to encompass new patients. “As the health care system enters a new normal,” Verma writes, “it is important to consider whether allowing people with particularly acute needs to be seen by a clinician for the first time via telemedicine, instead of in-person, will result in the best possible outcomes.”nn3. WILL PARITY PAYMENT CONTINUE?nDuring the public health emergency, Medicare has reimbursed providers the same rate for telehealth visits as it would pay for in-person visits. One question on many minds is whether this practice will continue.nnIn her blog post, Verma said, “Further analysis could be done to determine the level of resources involved in telehealth visits outside of a public health emergency, and to inform the extent to which payment rate adjustments might need to be made.” She cited both savings and increased costs related to telehealth. “For example,” Verma wrote, “supply costs that are typically needed to enable safe in-person care (e.g., patient gowns, cleaning, or disinfectants) and built into the in-person payment rate are not needed in a telehealth visit. On the other hand, there are new processes that clinicians must create for telehealth visits, with associated costs.”nnThe surge in telehealth activity during the pandemic should provide ample data to evaluate its effectiveness, said Tom Leary, vice president of government affairs for HIMSS, during a media briefing on July 16. Through April, Medicare beneficiaries experienced 1.7 million telehealth visits. “That’s plenty enough data now for the CBO [Congressional Budget Office] to be able to really, truly understand the impact … as well as the potential cost savings or cost drivers,” he said.nn”Clearly, CMS is not going to want to increase their spend,” said Domenic Segalla, principal, healthcare advisory services, of tax advisory company, Withum, during the same HIMSS briefing. “This is something that they’re really going to dig into to see what the current rate will be going forward and the impact on both outcomes and healthcare spend,” he said.nn”We work a lot with large health systems, independent hospitals, and even physician groups,” said Segalla. “The one thing that is clear from all of the providers and health systems is they do not believe they can go back [in time].”nn4. LICENSURE ACROSS STATE LINESnTemporary waivers have enabled Medicare providers to practice across state lines during the public health emergency, said Leary, while each state had to apply for similar exceptions for Medicaid. While there is a movement to continue these endeavors moving forward, endorsed by organizations such as the American Nursing Association and the American Medical Association, the process is complicated, said Leary. “I don’t think that’s as high on the priority list as some of the other waivers,” he said.nnMedicare will look to Congress to help them solve the issue, Leary predicted, and Medicaid will continue to work with states on individual requests.nn5. THE IMPACT OF FRAUDnCMS is closely examining fraud as it relates to telehealth, said Leary. ” The last thing we want … is for bad actors to spoil what has been a very positive experience [with telehealth} during the pandemic,” he said.nnFraudulent practices, according to Verma, might include practitioners who offer shorter telehealth visits to maximize payment, or bill more visits than are possible in a day. “It is vital that beneficiaries and taxpayer dollars are protected from unscrupulous actors,” she wrote. CMS is examining data from many angles, including monitoring program integrity. “We know the path forward to expanding telehealth relies on CMS addressing the potential for fraud and abuse in telehealth, as we do with all services,” she said.nn6. INCENTIVES TO INVEST IN TELEHEALTH TECHNOLOGYnBecause telehealth requires an investment in technology, Bill Kinney, CPA, senior manager at Withum, who also spoke at the HIMSS press briefing, suggested that it might be necessary to create incentives to encourage technology expenditures.nn”In order to incentivize this … what other parts and pieces of legislation unrelated to this could be put into place?” he asked. “Is there a way to incentivize health groups, physician groups, or anyone to invest in the technology that might be necessary?” He mentioned accelerated depreciation as one approach that would enable organizations to expense things immediately, as opposed to depreciating over a specified period of time. “There are a lot of opportunities there,” he said.nnChris Cooper, managing director of the BDO Center for Healthcare Excellence and Innovation, which is part of the accounting group BDO USA, suggests that perhaps a new form of legislation could be enacted to encourage adoption of telehealth that would work similarly to the way meaningful use provide incentives for providers to adopt EMRs. During the transitional phase, incentives would be provided to close any gaps between in-person and virtual visit reimbursement.nn7. LEGISLATION TO EXPAND BROADBAND SERVICESnThe pandemic has exposed inequities in access to healthcare, said Leary. “We’ve certainly seen anecdotal issues around minority and rural communities having less access because there isn’t as much broadband exposure.” As a result, he said he anticipates Congress may address this dilemma possibly by providing additional funding for broadband services in these areas.nnOriginal article published on healthleadersmedia.com
Jul 29, 2020 | Uncategorized
We have all seen water bottles with times listed on the sides reminding you to continue drinking water throughout the day. As you spend time outside this summer and temperatures continue to increase, staying hydrated is just as important as wearing your sunscreen.nnDo you know the warning signs that you are dehydrated? Spend just a moment on an internet search and there are more articles about this topic then you will have the desire to read.nnHere are some signs to be aware of, it might just be your body telling you it needs more water. The first symptoms of dehydration include thirst, darker urine, and decreased urine production. As the condition progresses to moderate dehydration, symptoms include:n
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- Dry mouth or bad breath
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- Lethargy
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- Weakness in muscles or muscle cramps
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- Headache
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- Dizziness
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- Dry or flushed skin
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- Fever and chills
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- Food cravings, especially for sweets
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nHere are just a few quick-read articles on the importance of hydration:nneverydayhealth.comnnmedicalnewstoday.com
Jul 22, 2020 | Uncategorized
There are big changes coming to the E/M codes in 2021! These updates will help to ease the processes that medical office workers handle daily. Ginger Avery, CPC, CPMA, CRC, is the Coding and Compliance Manager at Welter Healthcare Partners, Inc. Below, she is providing fourteen tips on how to plan ahead in order to be ready for these code changes!nnThe 2021 E/M code changes are set to deliver a powerful mix of updates to help streamline documentation practices and reduce administrative burden. Medical practices are encouraged to start planning now for operational and administrative workflow adjustments that will be a result of this momentous occasion.nn1. Identify/Assign Project Lead. This transition will affect everyone in the organization including coders, billers, other non-clinical staff, clinical staff, and clinicians. A designated project lead will help assure your clinic is prepared to streamline processes before the changes take effect on January 1, 2021.nn2. Make Time for Meetings. Schedule time for meetings to review the changes and address questions. Track goals and milestones during the transition process. Organizations are encouraged to recognize the significance of this event and prioritize time to prepare for changes.nn3. Make a List of Necessary Changes. Forms, templates, and contracts need updated, electronic health records and practice management systems need upgraded, several experts will be noted.nn4. Update Policies, Procedures, Practice Protocols & Compliance Plan. Policies, Procedures, Protocols should all be in alignment with the new guidelines.nn5. Review Medical Malpractice Liability. Although the “counted” documentation requirements have lessened with the updates, clinicians are reminded to tell clear stories, documenting the clinically relevant details of each encounter. The new guidelines state that office visits include “a medically appropriate history and/or physical examination when performed.” Regardless of the changes, it is important to remember that the burden of proof lies within the documented details. Supportive documentation will help guard against fraud & abuse law infractions.nn6. Assess Financial Impact. Guard against an unanticipated financial impact by understanding the rules in advance and performing a prospective payment analysis. Be prepared to adjust business practices depending on practice needs.nn7. Check with EHR vendors. Check with EHR vendors to assure their systems are updated appropriately prior to Jan 1st.nn8. Consider Coding Support. Establish strong coding/auditing resources and expertise early in the planning process.nn9. Conduct Current Coding/Documentation Assessment. Review current documentation practices and system functionality to address specific areas of interest for education development. This small audit sample should be conducted by an outside auditing source to provide an unbiased evaluation with appropriate recommendations.nn10. Provide Education. Educate clinicians appropriately about documentation that impacts medical decision making and how to become proficient with recognizing complexity in alignment with the new guidelines. The new guidelines provide definitions and descriptions that clarify many details that were previously left subject to interpretation. For example, an Undiagnosed new problem with uncertain prognosis is defined in the 2021 guidelines as, “A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.”nn11. Conduct a Time Study. Have clinicians track the total time related to each patient encounter for the day to determine whether current processes are set to capture total encounter time appropriately.nn12. Understand Employer and Payor Requirements. Employers or payors may still require documentation of additional information above and beyond the new E/M office visit coding guidelines. Careful evaluation of the flexibilities allowed under the new guidelines will ensure that the documentation satisfies any other obligations and requirements that they may be expected to fulfill within their contracts.nn13. Consider How the New E/M Guidelines Impact Your Specialty. For example, pain management practices will use the new E/M guidelines for office visits, but they’ll need to stick to the current guidelines for codes such as subsequent hospital visit code 99232 and subsequent nursing facility code 99308, which were among the top 10 E/M visit codes for the specialty according to the latest Medicare Part B utilization data.nn14. Download and study the materials the AMA has published. The guidance includes a new medical decision making (MDM) table, new coding guidelines for office visits and prolonged service codes and a detailed list of relevant definitions.nnResourcesnnImplementing CPT® Evaluation and Management (E/M) revisions nnTable 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM)nn10 tips to prepare your practice for E/M office visit changes
Jul 16, 2020 | Uncategorized
For the upcoming year, the FY 2021 ICD-10-CM Official Guidelines have made over 500 significant changes. These updates, set to take effect on October 1, 2020, include 490 new codes, 47 revised codes, and 58 codes deemed invalid. The upcoming changes are some of the biggest yet, as they address hundreds of new policies. See Welter Healthcare Partners’s summary of these changes in the information below!nnWith over 500 diagnosis coding changes just around the corner, the FY 2021 ICD10CM Official Guidelines bring updates that are set to be significantly larger than the FY2020 update brought to us last year. nnUpdates that are set to take effect October 1st, 2020 include: 490 new codes, 47 revised codes and 58 codes deemed invalid (see table below), additional instructions on reporting manifestations of COVID-19, as well as new guidance on social determinants of health, insulin use and acute kidney failure, among several other changes. nnBelow is a summary of the anticipated FY2021 ICD10CM Updates by Chapter: nnChapter 1: Certain Infectious & Parasitic Disease brings a new section 1.g for reporting Coronavirus infections. nnChapter 3: Diseases of Blood & Blood-forming organs has eighteen new, detailed codes available for sickle cell anemia. These new codes describe complications associated with sickle- cell and hemoglobin-C (Hb-C) diseases. For example, a note for new sickle-cell thalassemia code D57.418 (Sickle-cell thalassemia, unspecified, with crisis with other specified complication) instructs the coder to code any identified complications such as cholelithiasis (K80.-) or priapism (N48.32). nnChapter 4: Endocrine, Nutritional & Metabolic Disease includes new coding instructions to follow for diabetic patients treated with insulin, oral hypoglycemics and injectable non-insulin drugs. For example, if the patient is taking both insulin and an injectable non-insulin antidiabetic drug, assign both Z79.4 (Long term [current] use of insulin) and Z79.899 (Other long term [current] drug therapy). If the patient is taking oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign code Z79.84 (Long term [current] use of oral hypoglycemic drugs) in addition to code Z79.899. nnChapter 5: Mental, Behavioral and Neurodevelopmental Disorders contains twenty-one new codes that describe withdrawal from substances including alcohol, cocaine, and opioids. For example, F10.932 (Alcohol use, unspecified with withdrawal with perceptual disturbance). nnChapter 6: Diseases of the Nervous System has added “pseudotumor” as a clarifying term to G93.2 (Benign intracranial hypertension) and coders are instructed to code G98.81- (intracranial hypotension) with G96.0 (Cerebrospinal fluid leak) when applicable. nnChapter 9: Diseases of the Circulatory System contains many revisions to the includes and excludes notes for existing codes. For example: Atherosclerosis of native arteries of the legs with ulceration (I70.2-) now includes both critical and chronic ischemia of native arteries with ulceration. Hypertensive Heart Disease (I11) has been revised to exclude Takotsubo Syndrome (I51.81), also known as “broken heart” syndrome. nnA new hypertension guideline provides instruction that when a patient has hypertensive chronic kidney disease and acute renal failure, code both conditions and sequence the codes based on the reason for the encounter. nnChapter 10: Diseases of the Respiratory System now has code also instructions for cases of acute laryngitis and tracheitis (J04) and acute obstructive laryngitis (croup) and epiglottitis (J05). Coders are instructed to code also influenza if present, including influenza due to identified novel influenza A virus with other respiratory manifestations (J10.1). This chapter also has a new section 10.e specifically for vaping-related disorders. nnChapter 13: Musculoskeletal System found several updates this year including twelve new codes to capture other pathological fractures (M80.8AX- and M80.0AX-). Updates include an expanded list of codes for rheumatoid arthritis, as well as primary and secondary arthritis, and arthritis caused by trauma. New codes in the M24 category for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture and ankylosis. nnChapter 14: Disease of Genitourinary brings two new sub-stages to Stage 3 chronic kidney disease (CKD). The new codes are: N18.30 (Chronic kidney disease, stage 3 unspecified), N18.31 (Chronic kidney disease, stage 3a) and N18.32 (Chronic kidney disease, stage 3b). nnChapter 15: Pregnancy, Childbirth, and the Puerperium contain new language that warns coders they should not report O85 for sepsis that follows an obstetrical procedure. A note nnpoints them to the Sepsis due to a postprocedural infection of Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99), U07.1. nnA new section 15.s provides instruction on reporting COVID-19 infections in pregnancy, childbirth, and the puerperium. E.g. when a newborn tests positive for COVID-19 and the provider has not documented a specific method of transmission, assign code U07.1 and the appropriate codes for associated manifestations. Code P35.8 (Other congenital viral diseases) followed by U07.1 when the provider documents that the newborn contracted the disease in utero or during birth. nnChapter 16: Certain Conditions Originating in the Perinatal Period has a new section 16.h for reporting COVID-19 Infections in Newborn. nnChapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains several changes. Code R51 (Headache) will be split into two codes: R51.0 (Headache with orthostatic component, not elsewhere classified) or R51.9 (Headache, unspecified). nnAnother source of new headache coding will come from five new codes for intracranial hypotension – the severe orthostatic headache that is a common symptom of a cerebral spinal fluid (CSF) leak: For example, G96.810 (Intracranial hypotension, unspecified), G97.83 (Intracranial hypotension following lumbar cerebrospinal fluid shunting) and G97.84 (Intracranial hypotension following other procedure). Five new codes for CSF leaks can now be found in place of the current code G96.0 (CSF leak). nnChapter 19: Injury, poisoning & certain other consequences holds 128 additions that include new codes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics. nnChapter 21: Factors influencing health status and contact with health services include new observation language. The new language creates a second exception to the rule that observation codes are primary. The GL state, “An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis.” nnNEW Chapter 22: Codes for Special Purposes (U00-U85) includes just two codes: U07.0 Vaping- related disorder and U07.1 COVID-19, these codes took effect in the earlier this year. nnDeletions from the 2021 ICD-10-CM code set include Q51.20 (Other doubling of uterus, unspecified), and the entire code family of T40.4X- (Poisoning by the adverse effect of and underdosing of other synthetic narcotics). nnThe general coding guidelines clarify that social determinants of health may be coded if self- reported by patients, “as long as the patient self-reported information is signed off by and incorporated into the health record by either a clinician or provider.” Social determinants of health, found in code categories Z55-Z65, report potential health hazards related to socioeconomic and psychosocial circumstances that may complicate the care of the patient (e.g., the patient is unemployed).nn
nnReferences:nCDC.govnCDC 10 CM GuidelinesnPBN Decision Health
