Stakeholders Urge CMS to Drop Proposed ACO Quality Changes

Recently, stakeholders have come forward to urge CMS to drop their proposed ACO quality changes. Since this is a time of uncertainty and challenges, many believe these changes are significant and are concerned with mandating these changes during a pandemic. Read the article below to find out more.nnCiting concerns about mandating sweeping new reporting requirements in the middle of a pandemic, some of the nation’s largest physician and hospital associations on Wednesday asked the federal government to drop changes on how Medicare accountable care organizations are assessed for quality.nn”The ACO quality changes proposed are significant and come at a time when ACOs are continuing to deal with challenges and uncertainty caused by the COVID-19 pandemic,” the American Medical Association and nine other stakeholder groups wrote in a joint letter to Centers for Medicare & Medicaid Services Administrator Seema Verma.nn”Just as CMS has proposed to delay moving forward with the MIPS Value Pathways approach due to concerns with COVID-19, CMS should also postpone such a drastic and significant change to the way ACO quality is measured, assessed, reported and scored for purposes of both the MSSP and MIPS programs,” the letter said.nn”The proposed rule, set to take effect in 20201, mandates of how ACOs and other alternative payment models are assessed on quality in the Medicare Shared Savings Program and Merit-Based Incentive Payment System.nnThe stakeholders also complain that the delayed release of the final rule cuts into the time ACOs and other APMs would have to implement the changes.nnSpecifically, the stakeholders urged Verma to reconsider:n

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  • Ending the use of the Web Interface reporting mechanism, which has been used since the MSSP’s inception.
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  • Removing the pay-for-reporting year currently provided to ACOs beginning an initial MSSP contract as well as individual measures that are newly introduced to the measure set.
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  • Changes to the quality measure set ACOs must report under the APM Performance Pathway.
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  • Replacing the existing MIPS APM Scoring Standard, which the stakeholders claim “allows each APM to have its own set of unique quality measures and scoring approaches that best fit the particular model.”
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nThe letter was signed by the AMA, American College of Physicians, America’s Essential Hospitals, America’s Physician Groups, AMGA, Association of American Medical Colleges, Federation of American Hospitals, Medical Group Management Association, National Association of ACOs, and Premier.nnOriginal article published on healthleadersmedia.com

September is International Update Your Resumé Month

It is always a good idea to update your resume, so why not take the initiative now since September is international update your resumé month. Read below for more!nnOne of my favorite things to wake up to in the morning is our local newscasters telling us what is today’s “Nation Day of”. As a connoisseur of mac n’ cheese, and French fries, I especially like to keep an eye on when these days are coming up so that indulgence is less guilt-ridden. In addition to these seemingly underappreciated days, we all know of some of the greater know awareness months out there like breast cancer in October and Heart disease in February. But with so many worthy causes, each month is stacked with a plethora to choose from. Here is one I bet you were not aware of.nnSo be sure to mark your calendars moving forward and use September to reflect on your accomplishments over the previous year and update your resume to include all of your achievements!nnFor more information on updating your resumé, click here!

AMA Introduces New COVID-19 CPT Codes

The AMA has released new COVID-19 CPT codes that healthcare providers can use as a response to additional expenses. Read below for more information on the CPT codes and what each code entails.nnThe American Medical Association (AMA) on September 8 published two new CPT codes for novel coronavirus (COVID-19)-related services, including one that accounts for additional supplies and clinical staff time used to mitigate spread of the virus.nnHealthcare providers can now use CPT code 99072 (additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease) to describe the additional supplies and staff time required to support safe in-person interactions with patients during the COVID-19 public health emergency (PHE).nnThis new code was established in response to the significant, additional practice expenses related to activities required to safely provide medical services to patients during the PHE, according to the AMA.nnAs explained in a special edition of CPT® Assistant, providers should use code 99072 only when safety measures are over and above those usually included during an office visit or service. Notably, the new code may only be reported for services rendered in the non-facility place of service settings.nnThe AMA also released a new laboratory testing code 86413 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [COVID-19] antibody, quantitative) for laboratory testing that provides quantitative measurements of SARS-CoV-2 antibodies.nnOther laboratory testing codes for COVID-19 describe qualitative assessments (positive/negative) of SAR-CoV-2 antibodies.nnBoth new codes went into effect immediately and remain effective until end of the COVID-19 PHE.nnHealthcare professionals can find additional information, including clinical examples for the appropriate use of the new codes, in the accompanying CPT Assistant.nnOriginal article published on healthleadersmedia.com

2021 ICD-10CM Update Effective October 1, 2020

nnOne of the biggest changes to our ICD-10-CM books for the upcoming new year will be the addition of Chapter 22: Codes for special Purposes (U00-U85). Although this new chapter only consists of two codes and these codes were actually created and valid as early as April 2020, the creation of this chapter is proof that lessons from our current pandemic have been learned. Read below for more!nnHere are the codes, and their guidelines as printed in the Official ICD-10-CM FY 2021 Guidelines;nn

2021 E/M Office Visit Changes-Sign Up for Training Today!

As 2021 approaches and new E/M changes are being implemented, it’s time to prepare your practice and sign up for training. Contact Welter Healthcare Partners and sign up today to have these new policies under your belt before 2021.nn Ginger Avery, CPC, CPMA, CRC, is the Coding and Compliance Manager at Welter Healthcare Partners, Inc. Below, she is providing fourteen operational extremities on how to plan ahead in order to be ready for these administrative 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) revisionsnnTable 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM)nn10 tips to prepare your practice for E/M office visit changes

Transcatheter Aortic Valve Replacement (TAVR) Report

The report below describes a patient undergoing a transcatheter aortic valve replacement. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn– Click Here to Submit Redacted Surgery Case Study –nnDate of Procedure: XX/XX/20nnReferring Physician: A.M., MDnnPerforming Physicians: L. V., MD and S. P., DO. Both co-surgeons participated jointly in this catheter-based procedure.nnAssisting Physician: S. L., MD. A second interventional cardiologist was required for this procedure due to complex anatomic factors resulting in the need for a second operator with complex catheter training.nnAnesthesiologist: A. T., MD and R.S., MDn

Pre-Procedure Diagnoses:

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  1. Severe, symptomatic aortic valve stenosis
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Post-Procedure Diagnoses:

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  1. Successful transcatheter aortic valve replacement 23 mm Sapien Ultra
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  3. No significant paravalvular regurgitation.
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  5. Transvalvular mean gradient was reduced from 57 mmHg to 3 mmHg
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  7. Aortic valve pathology: Tricuspid
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Procedures Performed:

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  1. Transfemoral transcatheter aortic valve replacement
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  3. Balloon aortic valvuloplasty using an 18 mm Z-med balloon
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  5. Ultrasound guidance for arterial and venous access.
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  7. Aortography
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  9. Perclose Proglide deployment
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nIndications 89 year old female with a history of severe, symptomatic aortic stenosis. The patient was evaluated by a multidisciplinary team and deemed an appropriate candidate for TAVR.n

Description of Procedures:

nThe patient was brought to the hybrid operating room in the fasting and non-sedated state. The patient underwent monitored anesthesia care and was prepped in the usual sterile fashion. Transthoracic echocardiography was obtained for baseline assessment. Using ultrasound guidance and a micropuncture needle, the left femoral artery and left femoral vein were punctured and a 6 Fr sheath and 6 Fr sheath were, respectively, placed using the Seldinger technique. The right femoral artery was punctured and pre-close with Perclose devices was performed. Unfractionated heparin (UFH) was administered to achieve a goal activated clot time (ACT) > 250 sec. A 14 Fr E-Sheath was placed without difficulty.nnA transvenous pacemaker was placed in the right ventricle and threshold testing was performed. A pigtail catheter was advanced into the aortic root and aortography was performed to confirm co-planar angles. The aortic valve was crossed with a AL1 catheter and simultaneous aortic and ventricular pressures were obtained. Next, a Safari wire was placed in the left ventricle. After aortography was performed, an 18-mm Z-med balloon was delivered. After rapid pacing started, balloon aortic valvuloplasty was performed using the Z-med balloon, which was inflated at nominal pressure, and deflated. This was removed via the sheath.nnA 23 mm Sapien Ultra Valve was prepped according to manufacturer’s recommendations. The delivery system was introduced into the descending aorta and the valve was mounted onto the balloon in the usual fashion. The Sapien valve was then advanced across the stenotic aortic valve and carefully positioned during aortography. The valve was deployed during rapid pacing at 180 bpm. The delivery system was removed and transthoracic echocardiography revealed no significant paravalvular leak and a mean gradient of 3 mmHg.nnThe pacemaker was removed and iliofemoral aortography revealed absence of vascular complications (e.g. dissection, perforation). The E-sheath was removed and hemostasis was achieved with application of the Perclose Proglide devices. The contralateral arterial sheath was removed and hemostasis was achieved with application of a Perclose Proglide device. The venous sheath was removed and hemostasis was achieved with application of a Perclose Proglide device.n

Hemodynamics:

nBaseline aortic valve gradient: Mean 57 mmHg Final aortic valve gradient: Mean 3 mmHgnnEchocardiography: Refer to the separate TTE note for full details of the findings. Briefly, there is severe aortic stenosis at baseline. Following implant of a 23 mm Sapien Ultra valve, the gradient improved from 57 mmHg (from previous echo) to 3 mmHg. There is no significant paravalvular regurgitation. No new pericardial effusion at the conclusion of the procedure.nnEstimated Blood Loss: < 50 cc nnComplications: None apparent nnImplantations: 23 mm Sapien Ultra Valve nnContrast:  100 ccn

Summary:

nThe patient underwent successful balloon aortic valvuloplasty and transfemoral transcatheter aortic valve replacement for severe, symptomatic aortic stenosis using a 23 mm Sapien Ultra valve. The procedure was without apparent complication.n

Recommendations:

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  • Transfer to the ICU in stable condition.
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  • Bedrest for 6 hours.
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  • Aspirin 81 mg daily starting tomorrow morning.
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  • Restart Eliquis 5 mg po BID in 6 hours if no bleeding issues.
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  • Transthoracic echocardiogram to be performed tomorrow to re-evaluate valvular hemodynamics
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Colorado COVID-19 Telehealth Updates

Please find the latest updates from the major commercial health insurance payers in Colorado with more information on how they will be handling COVID-19 moving forward. As you very well know, the health plans have been changing their policies and procedures in response to COVID-19 as the Public Health Emergency (PHE) continues to unfold. These rolling changes will impact benefits for members and will also influence some of the services you may provide.

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This update has information from each health plan to keep you informed on any updated timelines, member cost-sharing responsibility, and covered services for the remainder of the PHE. As you can see, most of the dates for telehealth services have been pushed back to allow continued services for members at home.

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Your team at WHP will continue to monitor the coming changes to keep you up to date any new timelines or rule updates. Based on the current track record, we suspect this will all change again. Click here to download and print the PDF.

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Pain Management During COVID-19

It is not breaking news that COVID-19 is affecting every aspect of society and our overall health. In an August 14, 2020 release from the American Medical Association (AMA), the under-reported issue of opioid-related overdoses is discussed. Read below to find out more.nnAccording to this brief, “More than 40 states have reported increases in opioid-related mortality as well as ongoing concerns for those with a mental illness or substance use disorder in counties and other areas within the state”. Included in this brief are links for individual state reports regarding substance abuse and the AMA’s request for action by governors and state legislatures.nnWhen managing patients with chronic pain who have been prescribed opioid treatments there are certain requirements these patients must adhere to in order to remain on opioid treatment. These requirements, like almost every other aspect of our lives has been interrupted. What is your practice and clinical staff doing to stay compliant with opioid prescriptions?nnClick here to read more from the American Medical Association

HHS Delays Stark Law Reforms One Year

Laws regarding physician self-referral and anti-kickback have been delayed due to the need for revisions. This delay has prevented physicians from being able to implement new solutions without the concern that they could be in violation of the law. Read the article below to learn more.nnThe much-anticipated final rule updating physician self-referral and anti-kickback laws has been pushed back for one year, the Department of Health and Human Services announced this week.nn”We are still working through the complexity of the issues raised by comments received on the proposed rule,” HHS Deputy Executive Secretary Wilma M. Robinson wrote in a public notice, “and therefore we are not able to meet the announced publication target date.”nnInstead, she said, the timeline has been pushed back to August 31, 2021.nnThe news was a disappointment for the American Hospital Association, which earlier this month had urged the Office of Management and Budget for an “expeditious review and release of the Physician Self-Referral and Anti-Kickback Statute final regulations” that the Centers For Medicare & Medicaid Services had submitted in July.nnThe AHA has long complained that the Stark Law prohibiting physician self-referrals is a major hindrance in the transition to value-based care, and that the proposed reforms would “provide space for the types of innovative arrangements among hospitals and physicians that can enhance care coordination, improve quality and reduce costs.”nnThe proposal would create new and permanent exceptions to the 30-year-old Stark Law for value-based arrangements, permitting physicians and other providers to try innovating solutions without fear that their legitimate efforts to coordinate care might violate the law, according to an agency fact sheet.nnThose new exceptions would apply for Medicare and non-Medicare populations alike.nnAHA General Counsel Melinda Hatton on Wednesday “strongly urged CMS to move more quickly to finalize these improvements.”nn”This is an extremely disappointing setback for hospital and health system efforts to continue to innovate coordinated care arrangements, which have great potential to benefit patients, lower costs and make care more accessible for everyone,” she said.nnThe proposed rule was first unveiled in October 2019, as part of the Trump administration’s “Patients Over Paperwork” initiative.nn”We serve patients poorly when government regulations gather dust in the attic: they become ever more stale and liable to wreak havoc throughout the healthcare system,” CMS Administrator Seema Verma said at the time.nnOriginal article published on healthleadersmedia.com

Back to School With COVID-19

With COVID-19 being a huge concern when considering sending your kids back to school, educational facilities are advised to be extra diligent in their cleaning, disinfecting, and social distancing procedures. Still though, sending your child to school during a pandemic can cause your stress levels to increase. Take a look at the articles provided below to gather some back to school advice from medical professionals.nnAny parent will tell you that stress levels leading up to the start of a new school year are bad enough in a normal year. Now enter COVID-19, and parents, teachers, administrators and even students can increase stress levels to dangerous levels.nnSo here are a few great links we think can help you make informed decisions regarding your children.n

2021 ICD-10-CM Guidelines Clarify Reporting Of COVID-19 Manifestations

nnCMS got a jumpstart on the 2021 ICD-10-CM guidelines regarding COVID-19, releasing these new regulations just a few weeks ago. The guidelines cover reporting COVID cases that are respiratory, non-respiratory, in pregnancy, and in newborns. Keep reading for more details on these guidelines.nnCMS released the 2021 ICD-10-CM Official Guidelines for Coding and Reporting on July 8, several weeks earlier than usual. The coding guidelines, which take effect October 1, include new instructions for reporting manifestations of the novel coronavirus (COVID-19), among other changes.nnThe guidelines include a new section for COVID-19 that expands on the temporary coding guidelines posted in April by the ICD-10-CM Coordination and Maintenance Committee. Coders should note that the temporary guidelines will expire September 30.nnNew instructions for reporting ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease) include the following:nnAcute respiratory manifestations of COVID-19.n

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  • Code U07.1 should be assigned as the principal diagnosis if the reason for the encounter or visit is a respiratory manifestation of COVID-19. Codes for the respiratory manifestations should be assigned as additional diagnoses.
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  • Code J96.0 (acute respiratory failure) was added as another respiratory manifestation that may be coded secondary to U07.1.
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nThe non-respiratory manifestation of COVID-19n

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  • If the reason for the encounter or admission is a non-respiratory manifestation of COVID-19, code U07.1 should be assigned as the principal diagnosis and codes for the manifestations should be assigned as additional diagnoses.
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nCOVID-19 in pregnancyn

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  • According to new guidance in Chapter 15: Pregnancy, Childbirth, and the Puerperium, if a patient tests positive for COVID-19 during an encounter that is unrelated to the disease, the reason for the encounter should be coded first, 098.5 (other viral diseases complicating pregnancy, childbirth, and the puerperium). The coder would then report U07.1 and any appropriate COVID-19 manifestation codes.
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nCOVID-19 in newbornsn

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  • If a newborn tests positive for COVID-19 and a specific method of transmission is not documented, U07.1 should be assigned and any appropriate codes for associated manifestations, according to a new section in Certain Conditions Originating in Perinatal Period. If a newborn tests positive for COVID-19 and the provider documents that the newborn contracted the disease in utero or during birth, P35.8 (other congenital viral diseases) should be coded followed by U07.1. The guidance clarifies that Z38 (liveborn infants according to place of birth and type of delivery) is the principal diagnosis when coding the birth episode in a newborn record.
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nA section on coding “presumptive positive” COVID-19 cases was not included in the 2021 guidelines because it refers to cases awaiting a second, confirmatory CDC laboratory test—a practice that is no longer required.nnOriginal article published on healthleadersmedia.com

CMS Seeking Comment on E/M Add-on Code GPC1X

CMS is looking for public comments on the changes of the 2021 E/M codes. The added code focuses on services and resources suited to individual patients regarding ongoing and long-term illness. Keep reading to learn more about the addition of this code.nnWith the proposed 2021 Evaluation & Management (E/M) changes final rule on track to be released November 1, 2020, CMS is currently seeking public comment regarding the addition of code GPC1X [Complex visit w med care svs].nnCMS is looking for comment on the codes intended use as previous descriptions were found to be “unclear”. This code was created with the intent of supporting the longitudinal care of patients, however, CMS has received several concerns that the description could be interpreted as applicable to every office or outpatient E/M visit.nnIn the proposed rule, the agency states “We continue to believe that the time, intensity, and PE involved in furnishing services to patients on an ongoing basis that result in a comprehensive, longitudinal, and continuous relationship with the patient and involves the delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape, are not adequately described by the revised office/outpatient E/M visit code set. We believe the inclusion of HCPCS add-on code GPC1X appropriately recognizes the resources involved when practitioners furnish services that are best suited to patients’ ongoing care needs and potentially evolving illness. We also believe the work reflected in HCPCS add-on code GPC1X is inherently distinct from existing coding that describes preventive and cares management services.”nnSubmissions are due before 11:59 PM on October 5, 2020.nnClick here for more information on code GPC1X. 

ABN Use Extension

The Advance Beneficiary Notice of Noncoverage (ABN) is widely used to help out those who will be denied Medicare payments. The renewal deadline has recently been extended as a result of the COVID-19 pandemic. Here you’ll find more information regarding the details of the ABN use extension.nnDue to COVID-19 concerns, CMS is going to expand the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023). At this time, the renewed ABN will be mandatory for use on 1/1/2021. The renewed form may be implemented prior to the mandatory deadline. The ABN form and instructions may be found at cms.gov

Spinal Decompression

The report below describes a patient undergoing spinal surgery. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed. nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn– Click Here to Submit Redacted Surgery Case Study –nnOPERATIVE REPORTnnDATE OF OPERATION: 06/XX/2020nnOPERATING SURGEON: A.K. M.D.nnPREOPERATIVE DIAGNOSES:nC4-5 subluxation with spinal cord compression.nC4-5 anterior cervical osteomyelitis and diskitis.nnPOSTOPERATIVE DIAGNOSES:nC4-5 subluxation with spinal cord compression.nC4-5 anterior cervical osteomyelitis and diskitis.nnOPERATION PERFORMED:nC4 and C5 posterior cervical decompression with resection of epidural phlegmon.nC4-C5 posterior cervical arthrodesis with allograft and autograft.nC4-5 posterior cervical instrumentation with lateral mass screws and rods.nnFIRST ASSISTANT: B. J., P.A.nnANESTHESIA: General.nnDESCRIPTION OF OPERATION: The patient was brought into the operating room. He was intubated. Appropriate lines were placed and he was placed into Mayfield head fixation. Using strict log roll precautions, he was then turned prone onto an OR table with gel rolls going across his chest and across the iliac crest. Arms were tucked after pressure points were padded and he was positioned with his neck in a neutral position slightly extended to try to counteract to the subluxation.nnImmediate C-arm imaging was obtained to ensure good positioning. The midline neck was now shaved, prepped, and draped and surgery was begun.nnIncision was marked out over the midline what was felt to be the C4 and C5 spinous processes. Incision was made and carried down through the subcutaneous tissues remaining in the median raphe until the spinous processes were identified.nnC-arm was brought back in to positively identify the C4 and C5 levels. We now continued exposure until we had exposed from inferior C3 to superior C6 encompassing the lateral masses bilaterally of C4 and C5. We first performed the instrumentation using a drill guide and drill with C-arm to guide angle of trajectory. Standard landmarks were used to place lateral mass screws, that is the lateral mass was bisected both in a rostral-caudal and left-right fashion and the entry point 1 mm inferior and lateral was chosen. We then angled approximately 5 to 10 degrees laterally. Rostrally, the angle for the screws was determined by the C-arm. 14 mm pilot hole was drilled and then sounded with a ball probe to make sure we had not perforated, following which the 14 mm polyaxial lateral mass screws were placed. This was done into the bilateral C4 and bilateral C5 lateral masses.nnWe now decorticated. The curette was used to curette out the facet at C4-5, both the inferior articulating facet of C4 and the superior articulating facet of C5 bilaterally. We additionally used the drill to drill the lateral lamina that remained after decompression and a combination of allograft and autograft, which had been harvested with the decompression, were used to fill the facet and do an onlay lateral laminar arthrodesis.nnPrior to the arthrodesis, the decompression was done. Leksell rongeur was used to remove the spinous process of C4 and C5 as well as the lamina, which was further removed with Kerrison rongeurs. The lamina was thinned using the high- speed drill and ligamentum flavum was also removed from the C3-4, C4-5, and C5-6 interspaces.nnOf note, there was an organized vascular collection, which was unusual to see at the level of C4-5. This may have been inflammatory reaction to the infection on the opposite side. Although no clear infection was seen, this phlegmon was adhesed to the dura and had to be removed as a separate piece. It was sent half of it to pathology and half of it to microbiology for evaluation. We also took cultures in this area.nnOnce the decompression was completed, arthrodesis was done as mentioned and finally, the instrumentation was completed by placing rods into the lateral mass screws, which were then affixed with set screws and final tightening done.nnWe now thoroughly irrigated. Bleeding was controlled with Floseal, bipolar, and Bovie as well as bone wax to the bleeding bone edges. Given the patient’s renal failure and cirrhosis and low starting hematocrit, we elected to place a drain, which was tunneled out a separate incision. Finally, the wound was closed in multiple layers, first closing the cervical fascia with interrupted 0 Vicryl sutures, placing some inverted 2-0 and 3-0 Vicryl sutures and then staples were applied to the skin. Wound was cleaned, dressed with Telfa, 4x4s, and Tegaderm. The patient then turned back supine, placed back into a C-collar, extubated, and sent to the recovery room. Estimated blood loss was 20 to 25 cc. Sponge and needle counts were correct. There were no complications.nnSPECIMEN SENT: Epidural phlegmon, half to pathology, half to microbiology and cultures were also obtained.

Proposal to Expand Telehealth Benefits Permanently for Medicare Beneficiaries

CMS proposed changes to expand telehealth which would improve healthcare in rural areas. The proposal will also ensure proper reimbursement times and other important changes. Read the article below for more information on this important update.nnTrump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural AreasnnThe Centers for Medicare & Medicaid Services (CMS) is proposing changes to expand telehealth permanently, consistent with the Executive Order on Improving Rural and Telehealth Access that President Trump signed today. The Executive Order and proposed rule advance our efforts to improve access and convenience of care for Medicare beneficiaries, particularly those living in rural areas. Additionally, the proposed rule implements a multi-year effort to reduce clinician burden under our Patients Over Paperwork initiative and to ensure appropriate reimbursement for time spent with patients. This proposed rule also takes steps to implement President Trump’s Executive Order on Protecting and Improving Medicare for our Nation’s Seniors and continues our commitment to ensure that the Medicare program is sustainable for future generations.nnExpanding Beneficiary Access to Care through Telehealth nnOver the last three years, as part of the Fostering Innovation and Rethinking Rural Health strategic initiatives, CMS has been working to modernize Medicare by unleashing private-sector innovations and improve beneficiary access to services furnished via telecommunications technology. Starting in 2019, Medicare began paying for virtual check-ins, meaning patients across the country can briefly connect with doctors by phone or video chat to see whether they need to come in for a visit. In response to the COVID-19 pandemic, CMS moved swiftly to significantly expand payment for telehealth services and implement other flexibilities so that Medicare beneficiaries living in all areas of the country can get convenient and high-quality care from the comfort of their home while avoiding unnecessary exposure to the virus. Before the public health emergency (PHE), only 14,000 beneficiaries received a Medicare telehealth service in a week while over 10.1 million beneficiaries have received a Medicare telehealth service during the public health emergency from mid-March through early-July. For more information on Medicare’s unprecedented increases in telemedicine and its impact on the health care delivery system, visit the CMS Health Affairs blog here.nnAs directed by President Trump’s Executive Order on Improving Rural and Telehealth Access, through this rule, CMS is taking steps to extend the availability of certain telemedicine services after the PHE ends, giving Medicare beneficiaries more convenient ways to access healthcare particularly in rural areas where access to healthcare providers may otherwise be limited Improving Rural and Telehealth Access.nn“Telemedicine can never fully replace in-person care, but it can complement and enhance in-person care by furnishing one more powerful clinical tool to increase access and choices for America’s seniors,” said CMS Administrator Seema Verma. “The Trump Administration’s unprecedented expansion of telemedicine during the pandemic represents a revolution in healthcare delivery, one to which the healthcare system has adapted quickly and effectively. Never one merely to tinker around the edges when it comes to patient-centered care, President Trump will not let this opportunity slip through our fingers.”nnDuring the public health emergency, CMS added 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth. CMS is proposing to permanently allow some of those services to be done by telehealth including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home), and certain types of visits for patients with cognitive impairments. CMS is seeking public input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services such as emergency department visits, for a specific time period, through the calendar year in which the PHE ends. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.nnPrioritizing Investment in Preventive Care and Chronic Disease ManagementnnUnder our Patients Over Paperwork initiative, the Trump Administration has taken steps to eliminate burdensome billing and coding requirements for Evaluation and Management (E/M) (or office/outpatient visits) that makeup 20 percent of the spending under the Physician Fee Schedule. These billing and documentation requirements for E/M codes were established 20 years ago and have been subject to longstanding criticism from clinicians that they do not reflect current care practices and needs. After extensive stakeholder collaboration with the American Medical Association and others, simplified coding and billing requirements for E/M visits will go into effect January 1, 2021, saving clinicians 2.3 million hours per year in burden reduction. As a result of this change, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients.nnAdditionally, last year, the Trump Administration finalized historic changes to increase payment rates for office/outpatient E/M visits beginning in 2021. The higher payment for E/M visits takes into account the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of the Medicare patients, of which two-thirds have multiple chronic conditions. The prevalence of certain chronic conditions in the Medicare population is growing. For example, as of 2018, 68.9% of beneficiaries have 2 or more chronic conditions. In addition, between 2014 and 2018, the percent of beneficiaries with 6 or more chronic conditions has grown from 14.3% to 17.7%.nnIn this rule, CMS is proposing to similarly increase the value of many services that are comparable to or include office/outpatient E/M visits such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services and others. The proposed adjustments, which implement recommendations from the American Medical Association, help to ensure that CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients, like primary care and complex or chronic disease management.nnBolstering the Healthcare Workforce/Patients Over PaperworknnCMS is also taking steps to ensure that healthcare professionals can practice at the top of their professional training. During the COVID-19 public health emergency, CMS announced several temporary changes to expand workforce capacity and reduce clinician burden so that staffing levels remain high in response to the pandemic. As part of its Patients over Paperwork initiative to reduce regulatory burden for providers, CMS is proposing to make some of these temporary changes permanent following the PHE. Such proposed changes include nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law; clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare; allowing physical and occupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings; and allowing physical or occupational therapists, speech-language pathologists and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient’s medical record.nnPublic comments on the proposed rules are due by October 5, 2020.nnFor a fact sheet on the CY 2021 Physician Fee Schedule proposed rule, click here.nnFor a fact sheet on the CY 2021 Quality Payment Program proposed rule, click here.nnFor a fact sheet Medicare Diabetes Prevention Program, click here.nnTo view the CY 2021 Physician Fee Schedule and Quality Payment Program proposed rule, click here.nnOriginal article published on CMS.govnn 

Medical Necessity in E/M

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.

7 Things to Consider with New Telehealth Legislation Proposed

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

Stay Hydrated During These Hot Summer Months

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

Fourteen Tips to Prepare for 2021 E/M Office Visit Changes

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

2021 ICD-10-CM Updates

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).nnnnReferences:nCDC.govnCDC 10 CM GuidelinesnPBN Decision Health