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CPT Changes for 2020 – Part Two

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CPT Changes for 2020 – Part Two

 

2020 CPT Code Changes CPT 2020 updates took effect on January 1, 2020. In Part 1 of our series on these changes, we discussed the overall revisions, as well as the specific changes for the Surgery section.

In Part 2, we continue with a discussion of changes in the Evaluation and Management, and Medicine sections, along with an overview of updates in the Radiology, Pathology and Laboratory, and the new Category III codes.

Evaluation and Management Section

The Evaluation and Management Section had minimal changes with 6 new codes, 1 revision, and 1 deletion (AAP News, 2019). An ongoing theme of these changes is online medicine and patient instituted health monitoring. For example, 3 of these new codes and the code deletion are for online digital evaluation and management (E/M) services. These new codes are found in a new heading within the Non-Face-to-Face-Services subsection. Code 99444 for online E/M services was deleted and replaced with 3 time-based codes: 99421, 99422, and 99423 for 5-10, 11-20, and 21 or more minutes cumulative time, respectively. Note that these codes are used for patient-initiated digital communications that require a clinical decision that would usually be provided in the office setting. There are extensive guidelines and parenthetical notes on the elements of the codes and what can and cannot be included in determining the cumulative time. For example, clinical staff time is not calculated as part of the cumulative time.

CPT UpdatesThere are also 2 new codes for self-measured blood pressure using a device that has been clinically validated for accuracy. Code 99473 is used for patient education and training on calibration of the device and is used only once for the same device. Code 99474 is used for the review and averaging of individual readings, and communication of a treatment plan for the patient. Note that this code may only be reported once in a calendar month.

The final E/M changes are for remote physiological monitoring treatment management services. Code 99457 was added in 2019 for these services and was revised for 2020 to include the first 20 minutes of service, with add-on code 99458 created for each additional 20 minutes. These services are provided when the results of the remote monitoring are used to evaluate and update a given treatment plan. Interactive communication with the patient and/or caregiver during the month is essential to these codes, and the device must be ordered by the provider and be FDA-approved.

While the changes to E/M codes were not extensive for 2020, look for significant changes in 2021, as the Office and Other Outpatient Services codes are completely revamped with extensive additions of guideline additions, revisions, and restructuring of codes (AMA, 2019). The selection of codes in 2021 will be based on either medical decision making or time. More details on these changes will become available later into 2020.

Medicine Section

This section had a total of 10 revisions, 21 deletions, and 47 new codes. A brief review of these changes is listed; see your CPT book for more information and important guideline and note additions.
• 2 new vaccine codes, 90694, for influenza, and, 90619, Meningococcal conjugate, are pending FDA approval.
• 2 new time-based biofeedback codes, 90912 and 90913, replace code 90911.
• 2 extended ophthalmoscopy codes, 92201 and 92202, were added.
• Code 92548 was revised, and new code 92549 added for computerized dynamic posturography sensory organization test with motor control (MCT) and adaptation test (ADT).
• The new add-on code 93356, which replaces Category III code 0399T, was added for myocardial strain imaging using speckle tracking.
• 2 new codes, 93985 and 93986, were added for duplex scan of arterial inflow and venous outflow. These services are performed for vessel assessment prior to creation of hemodialysis access.
• Coding for EEG services was completely revamped, with code deletions, guideline changes, and 23 new codes, 95700-95726. The codes are subdivided by professional and technical services and duration. See the Long-Term EEG Monitoring Table in CPT. Also, note that there is an error in the table; the 10th row, 4th column, should read 95708 X 2 (per errata for 2020).
• Multiple code deletions in the Health Behavior Assessment and Intervention heading made way for 9 new codes to reflect current clinical practice. The codes, 96156-96171, are for assessment- and time-based interventions for individual, group, and family services.
• 2 new codes, 97129 and 97130, replace deleted code 97127. These are time-based codes tor therapeutic interventions that focus on cognitive function.
• 3 new codes, 98970, 98971, and 98972, were added for Qualified Nonphysician Health Care Professional Online Evaluation and Management Services. These descriptions mirror the codes found in the Evaluation and Management section for these services performed by a physician or other QHP discussed in the E/M changes above.

Radiology Section

CPT UpdatesThere were a total of 12 new, 18 revised, and 15 deleted codes for this section. There were 2 new codes in upper gastrointestinal tract imaging; 74221 for double-contrast radiological exam of the esophagus, and add-on code 74248 for radiologic small intestine follow-through. This caused the revision of 5 codes and the deletion of 4 in this area. A new coding structure was put in place for myocardial PET scan codes as technology for these studies has changed substantially; often, PET scans are done concurrently with CT transmission scans for better anatomical visualization. The changes include 3 revised, 2 deleted, and 6 new codes for myocardial PET or PET/CT scans; 78429, 78430, 78431, 78432, 78433, 78433. The last change in the radiology section is for radiopharmaceutical localization of tumors and inflammatory processes. These codes have been restructured with 5 code revisions, 3 deletions, and 4 new codes. Code selection is based on whether planar or SPECT imaging is used, how many areas are imaged, the number of days of imaging, and whether CT transmissions are performed at the same time. The 4 new codes report this localization of tumor or inflammatory process; 78830, 78831, 78832, and add-on code 78835.

Pathology and Laboratory Section

There were extensive changes in this section, and a brief overview of the changes follows as the codes are generally assigned via chargemaster. See Appendix B of CPT for a comprehensive list of the new, deleted, and revised codes. There were 6 new therapeutic drug assay codes, along with 4 new Tier I molecular pathology codes, 3 new multianalyte assay codes with algorithmic analyses (MAAA) codes, and 1 new microbiology code. The area with the most significant number of changes was for the Proprietary Laboratory Analyses (PLA) codes, which had 1 revision, 5 deletions, and 75 new codes. These codes are released on a quarterly basis and consist of 4 numerals and the letter U. A comprehensive list of all codes is found in Appendix O.

Category II and III Codes

Category II codes are supplemental tracking codes used for performance measures; the use of the codes is optional. This year, there were 3 code revisions, 1 deletion, and 5 new Category II codes. The changes related to eye exams for people with diabetes and specific reporting of A1c measures for diabetes management.

Category III codes are temporary tracking codes for emerging technology. The codes may be listed for a maximum of 5 years, unless special circumstances apply. This year, there were a total of 51 new Category III codes, with 11 deletions and 1 revision. See Appendix B for a complete listing of codes.

ICD-11 Overview

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ICD-11 Overview

 

The World Health Organization (WHO) recently released the 11th edition of the International Classification of Diseases (ICD-11). This release was presented at the World Health Assembly on May 25, 2019 for adoption by member states, and will come into effect on January 1, 2022. However, before we all go into panic mode, note that it is still unknown when ICD-11 will be ready for implementation in the United States. But, it is not too early to review where we’ve been and overview what’s in store for the future!

Background review on ICD revisions

The table below displays the various revisions of ICD timelines. It is important to note that ICD-10 was adopted by the WHO and the World Health Assembly in 1989. But, ICD-10-CM was not fully implemented in the United States until 2015.

ICD-11

Why did the WHO move on from ICD-10?

Unfortunately, despite the updating process, ICD-10 is clinically outdated, and structural changes were needed in some chapters. There is also an increasing need to operate in an electronic environment, as well as the need to capture more information for morbidity-use cases. ICD is the international standard for systematic recording, reporting, analysis, interpretation, and comparison of mortality and morbidity data. According to the WHO, the 11th revision is the result of a collaboration with clinicians, statisticians, epidemiologists, coders, classification, and IT experts from around the world. ICD-11 is a scientifically rigorous product that accurately reflects contemporary health and medical practice, and represents a significant upgrade from earlier revisions.

The WHO ICD-11 revision goals included to:

1. Ensure that ICD-11 will function in an electronic environment by:
• Presenting a digital product
• Providing linkage with terminologies (e.g., SNOMED)
• Defining ICD Categories by “logical operational rules” on their associations and details
• Supporting electronic health records & information systems

2. Provide a multi-purpose and coherent classification for:
• Mortality, morbidity, primary care, clinical care, research, public health
• Consistency & interoperability across different uses

3. Deliver an international, multilingual reference standard for scientific comparability:
• English, French, Spanish, Russian, Chinese, Arabic

Basic Code Structure of ICD-11

ICD-11The diagnostic codes of ICD-11 are alphanumeric and cover the range from 1A00.00 to ZZ9Z.ZZ. The coding scheme always has a letter in the second position to differentiate from the codes of ICD-10. Chapters are indicated by the first character. For example, 1A00 is a code in Chapter 1, and BA00 is a code in Chapter 11.

ICD-11 has an explicit way of marking codes that are post coordinated to describe one condition, called cluster coding. This is a notable new feature in ICD-11 that creates an ability to link core diagnostic concepts (i.e. stem code concepts) when desired, and/or to add clinical concepts captured in extension codes to primary stem code concepts. Either way, it should be emphasized that the clustering ability inherent to ICD-11 is one of the significant changes relative to ICD-10. And the WHO is indicating that there may not be a need for an ICD-12 version, as ICD-11 is comprehensive and very expandable.

In addition, for the first time, ICD-11 will be fully electronic, providing access to 17,000 diagnostic categories, with over 100,000 medical diagnostic index terms. The index-based search algorithm interprets more than 1.6 million terms. Per the WHO, ICD-11 is easy to install and use online or offline, using free “container” software.

Implementation in the U.S.

There is no definite ICD-11 implementation timeline established yet. However, the National Center for Vital and Health Statistics (NCVHS) notes that there are numerous steps needed to move towards ICD-11 implementation including:

• Evaluation of ICD-11 for U.S. purposes (2018 – 2021? 2022?)
• NCVHS Hearings (2021-2027?)
• Notice of Proposed Rulemaking (NPRM) from HHS published in the Federal Register (? date unknown)
• Final Rule published in the Federal Register (? Date unknown)

It is also very important to note that ICD-11 is only for diagnoses. ICD-10-PCS is completely separate from ICD-10 and will not be updated with the transition of ICD-10 to ICD-11. ICD-10-PCS is not a WHO-developed or maintained vocabulary. ICD-10-PCS is a procedure classification system designed by CMS for coding hospital-based procedures. This development was undertaken, because the WHO retired its procedure coding system with the 10th revision of ICD. The ICD rubric was attached to the new U.S. system. Updates to the U.S. procedure classification system do not need to be tied to updates to ICD and vice versa.

While we wait for the 2022 implementation of the 11th edition, read up on the 2020 ICD-10-PCS Guideline Changes for Coding and Reporting.

YES HIM Consulting, Inc. will keep up-to-date on any and all changes to the implementation dates. In the meantime, if you wish to review the online ICD-11 coding tool, please refer to:

ICD-11 Coding Tool

ICD-11 Coding Tool Help

End of The Fiscal Year Push!

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End of The Fiscal Year Push!

 

Every organization associated with Health Information Coding has felt the pressure to catch everything up at the end of the Fiscal Year. It helps to understand what is at stake and how you can help.

Fiscal YearFiscal Years (FY) vary depending on the organization. Some correspond to the calendar year, while others start/end at times established for taxing and accounting purposes (The Balance, 2019). Annual Financial reports are generated during this time to show the success or failure of the organization to meet its goals and expectations. Banks and Financial Institutions look at these reports to evaluate their investment and decide whether to raise or lower the rates they charge based on the perceived risk. Administration will use the data to plan for future expansion or contraction. Finance can identify weaknesses in the Revenue Cycle and negotiate contracts with Third-Party Payers. Raises and bonuses rely heavily on positive results. The positive and negative consequences are dependent on collections, cash reserves, and bad debt – all items influenced by timely and accurate coding.

DNFB (discharged, not final billed) is the accumulation of charges for accounts that have not been coded or cleared the Billing edits. This number can get out-of-hand with unnecessary delays that cripple the cash flow and rob the organization of interest it could earn from cash reserves. If bad enough, the organization will have to pay interest on money borrowed to cover expenses that should have been covered by reserves. Rejected/denied accounts can further erode the financial well-being of the organization: billing/appeal deadlines missed, underinsured may pay the first accounts submitted and have nothing left for the late bills, old accounts may be lost and never processed, etc. Community goodwill may also suffer if patients are billed for items or services that should have been covered by Third-Party Payers.

An expensive remedy for delays from coding backlog is to use overtime. Forcing employees to work weekends and evenings may be helpful to their pocketbooks, but can exhaust them, resulting in errors, lower productivity, and disruption of personal plans. The extra cost will also have to be covered in the budget somehow.

Fiscal YearRejected/denied accounts can result in long payment delays from the Payers. To avoid this, it may be better to suffer a short delay by scrubbing the account clean before billing. Edits for missing charges, incorrect dates, wrong physicians, and coding errors can be corrected upfront. However, if these delays are not followed up and fixed in a timely fashion, it can result in other losses: billing deadlines missed, funds may dry up when the patient is underinsured, and old accounts may never get attention.

After the crunch of “dropping everything” is over at the end of the FY, it is an opportune time to look at fixes for these problems. An ounce of prevention is worth a pound of cure. Setting productivity standards and monitoring coding quality will ameliorate some of the mad rush next year. Preventative measures to decrease and monitor holds is another step in an effective, efficient Revenue Cycle program.

New Year, New Codes: CPT Changes for 2020

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New Year, New Codes: CPT Changes for 2020

 

2020 CPT Code ChangesAs we turn the calendar to a new decade, the 2020 CPT code changes take effect. This year there are a total of 394 changes to CPT, bringing the total number of codes to 10,471. This includes 248 new codes, 71 deletions, and 75 code revisions, according to the American Medical Association (AMA). In this article, we will discuss the changes in the Surgery Section. And in Part 2, we will discuss changes in the Evaluation and Management, Medicine, Radiology, and Pathology and Laboratory sections, along with an overview of the new Category III codes. Visit YES HIM Consulting’s Education Portal for courses on the 2020 CPT updates. Stay up-to-date on the 2020 ICD-10-PCS guideline changes.

Surgery Section

The Surgery section had a total of 38 new codes with 37 revisions and 17 deletions.

Integumentary Subsection

The Integumentary subsection had 5 new codes and 4 deletions. Though there were no code revisions, the guidelines for intermediate and complex repair were revised to clarify the differences between the two types of repair. Please see the CPT handbook for the detailed definition of intermediate repair, and note that this definition now includes limited undermining, which is specifically detailed in the description. Complex repair includes all the requirements for intermediate repair, as well as one additional element. One of these 4 potential elements is extensive undermining, which is specifically defined in the guidelines, and an image was added to the CPT handbook to illustrate extensive undermining. Additionally, the references to scar revision and stents were removed from the complex repair guidelines. Carefully review these revised guidelines.

There are 5 new codes for tissue grafting. The first code, 15769, is used for grafting of autologous soft tissue via an excisional technique and placement in a defect for reconstruction. The remaining 4 codes are for adipose cell harvesting using liposuction, also known as lipofilling. In these services, the cells harvested via liposuction are minimally prepared and injected in small aliquots, or a portion of a larger whole, into the defect. The codes are differentiated by anatomical sites that receive the graft and the amount of injectate; with 15771 for grafting to the trunk, breasts, scalp, arms, and/or legs for 50 ccs or less of injectate, with add-on code 15772 for each additional 50 ccs or part thereof. For the anatomic sites of face, eyelids, mouth, neck, ears, orbits, genitalia, hands and/or feet, code 15773 is used for the first 25 ccs or less of injectate, with add-on code 15774 for each additional 25 ccs or part thereof.

2020 CPT Code ChangesCode 20926 for tissue grafts other was deleted with references to these codes. The 3 codes for excision of chest wall tumor were deleted, though these codes were added to the musculoskeletal subsection, which is a more logical placement. There was one deletion for breast procedures, 19304, for subcutaneous mastectomy. See the revised guidelines for breast biopsy, mastectomy, and other breast procedures in the anatomic heading for Breast in CPT.

Musculoskeletal Subsection

The Musculoskeletal subsection has a total of 11 new codes. Of these additions, 3 codes for excision of chest wall tumor were in the Integumentary subsection and have been moved to 21601, 21602, and 21603, depending on the extent of the excision. There are 2 new codes for needle insertion(s) without injections, also known as dry needling or trigger-point acupuncture. The codes 20560 and 20561 are distinguished by the number of muscles involved, and there are new guidelines and parentheticals for these codes. Finally, there are 6 new add-on codes, 20700-20705, for preparation/insertion and removal of drug-delivery devices. The codes are distinguished based on the location: deep, intramedullary, or intraarticular, and whether this is preparation and insertion, or removal of the device. These codes are not used for prefabricated or “out of the box” devices; important new guidelines accompany the codes.

Respiratory and Cardiovascular Subsections

There were no new codes in the Respiratory subsection, with 9 code revisions and updated guidelines for nasal/sinus endoscopy codes. As always, there were several changes in the Cardiovascular subsection, with 2 revisions, 11 new codes and 8 code deletions. There are 4 codes for procedures on the pericardium, 33016-33019 were added, with the codes distinguished by whether or not an indwelling catheter is inserted. Other factors guiding code selection are the type of imaging guidance, age of the patient, and the presence of a congenital cardiac anomaly. This is accompanied by the deletion of 3 codes; 33010, 33011, and 33015, with parentheticals referencing the new codes. Code 33275, established in 2019 for removal of a leadless pacemaker, was revised to include imaging guidance when performed.

New codes for ascending aorta grafts, 33858 and 33859, replace deleted code 33860, with the latest codes distinguishing between these grafts for aortic dissection versus other aortic diseases, such as an aneurysm. Code 33870 for transverse arch graft was deleted and replaced with 33871, which added descriptions of additional procedures included in the code. There are parentheticals and guidelines that specify 33871 is used for a complete versus hemiarch graft procedure. New codes 34717 and 34718 for iliac branched endograft (IBE) placement replace deleted Category III code 0254T. The code 34717 is an add-on code when the IBE placement is done at the same time as an aortoiliac artery endograft placement, while 34718 is used when the IBE placement is done on its own. There are important notes, guidelines, and parentheticals for both of these codes.

2020 CPT Code ChangesCodes for exploration of an artery were revised with code deletions, a revision, and two new codes. The codes now are organized by the neck, upper extremity, and lower extremity arteries, and the description of with or without lysis of the artery has been removed. Existing parent code 35701 now describes exploration of neck artery rather than specifically the carotid. The new code 35702 is for upper extremity artery, and 35703 for lower extremity artery. This resulted in the deletion of codes 35721, 35741, and 35761 for exploration of the femoral, popliteal, and other vessels. Important notes and parentheticals accompany new guidelines for these codes.

Digestive Subsection

In the Digestive subsection, code 43401 for transection of the esophagus with repair for esophageal varices was deleted due to low utilization, and the service does not represent current practice. Codes for transanal hemorrhoidal dearterialization were updated, with conversion of Category III codes, code revisions, and new codes. Codes 46945 and 46946 were revised to indicate that imaging guidance is not included in the code. New code 46948 is the converted code for deleted Category III code 0249T for transanal hemorrhoidal dearterialization of two or more hemorrhoid columns, including ultrasound guidance. This is a distinct procedure from traditional hemorrhoidectomy that includes the removal of the hemorrhoid bundle. Finally, 2 new codes for preperitoneal pelvic packing were added. Code 49013 is for this packing associated with pelvic trauma, while 49014 is for re-exploration. Note that a laparotomy is not associated with these codes; instead, a low-horizontal Pfannenstiel is used.

Male Genital and Nervous System Subsections

There is only 1 change in the Male Genital System; a code revision for 54640 that deleted the mention of with or without hernia repair and adding the scrotal approach to the code descriptor. The first group of changes in the Nervous System subsection are on spinal puncture. Codes 62270 and 62272 were revised with the addition of a semi-colon to become parent codes. This allows for the addition of 2 new codes; 62328 for diagnostic and 62329 for therapeutic lumbar puncture with fluoroscopic or CT guidance.

There were code revisions, deletions, and additions in the Somatic Nerve heading for Introduction/Injection of Anesthetic agents for diagnostic or therapeutic purposes. About 18 codes were revised to include the word “steroid” in the code description. The 3 codes, 64402, 64410, and 64413, for facial nerve, phrenic nerve, and cervical plexus were deleted, as the procedures are not commonly performed. Codes 64451 and 64454 were added for these procedures on the nerves of the sacroiliac joint and genicular nerve branches, respectively. In the Destruction by Neurolytic Agent subheading, 2 codes were added; 64624 describes this destruction in the genicular nerve branches, and 64625 is for radiofrequency ablation of nerves of the sacroiliac joint. A new chart is found in CPT directly after code 64451 to assist with code selection, indicating the nerves involved, number of injections, and whether image guidance is included.

Eye and Ocular Adnexa Subsection

Finally, in the Eye and Ocular Adnexa subsection, 3 codes were revised, and 2 codes added. Code 66711 was revised to include without concomitant removal of crystalline lens, and 66982 and 66984 for extracapsular cataract removal were revised to include without endoscopic cyclophotocoagulation. This allows for the creation of new codes 66987 and 66988 for extracapsular cataract removal procedures with endoscopic cyclophotocoagulation. Important guidelines and notes accompany the revised and new codes.

Remaining code changes will be covered in Part 2 of this series.

Medicare Advantage Insurers Use Reviews to Get Higher Payments

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Medicare Advantage Insurers Use Reviews to Get Higher Payments

 

The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) has flagged payments billed by health insurance companies to the federal Medicare Advantage program after an investigation revealed they might be overstating patients’ diagnoses without the proper documentation to receive larger payments (oig.hhs.gov, 2019). Based on the 2016 Medicare Advantage encounter data analyzed by the OIG, it was found that “Medicare Advantage Organizations almost always used chart reviews as a tool to add – rather than delete – diagnoses; over 99% of chart reviews in our analysis added diagnoses” (oig.hhs.gov, 2019).

Medicare AdvantageAs a result, insurers were able to get an extra $6.7 billion in payments in 2017 from the Centers for Medicare and Medicaid Services (Modern Healthcare, 2019). The OIG stated in its report that for a diagnosis to qualify for a risk-adjusted payment, it must be documented and supported by a medical record from a face-to-face doctor visit. The study found that many of these diagnoses were unsupported by the necessary documentation (oig.hhs.gov, 2019).

In a previous article, YES HIM Consulting discusses the background of Medicare Advantage and how the payments are calculated: “The Centers for Medicare and Medicaid Services pays each Medicare Advantage Organization (MAO) a monthly per-person amount for each beneficiary enrolled in its plan. The plan payment rates are determined by the plan’s bid, which is submitted to CMS on an annual basis. The per-person amount paid to each plan for enrolled beneficiaries is adjusted to account for differences in health status between enrolled beneficiaries.”

Medicare AdvantageAnd, since MAOs are paid more for sicker patients due to the higher medical costs, insurers will go to great lengths to find as many diagnoses to tack on for greater payments, including hiring third-party vendors to audit medical charts and identify additional diagnoses. The OIG report found that in 2016, “a total of 553 Medicare Advantage Organizations submitted 52.6 million chart reviews for risk-adjustment purposes, for an average of more than 95,000 reviews per insurer” (Modern Healthcare, 2019).

However, a spokesperson for America’s Health Insurance Plans says the report from the OIG may be inaccurate, because it analyzed encounter data, which is often considered incomplete or incorrect, and not the actual medical records (Modern Healthcare, 2019). This method would potentially reduce insurers’ payments.

This instance is not the first time that MAOs’ risk-adjusted payments have come under scrutiny. A different audit by the OIG revealed that Medicare Advantage plans were overpaid by millions of dollars due to over-exaggerated, unsupported risk scores (Modern Healthcare, 2014). In the OIG’s latest report, 40.6 million chart reviews were submitted, ultimately adding diagnoses, and almost half of those reviews (41%) had no records of an office visit, test, procedure or other methods to justify such diagnoses (Modern Healthcare, 2019). In addition, an OIG report from 2018 found that MAOs inappropriately denied medical claims to increase profits (The New York Times, 2018).

Medicare AdvantageTo more accurately support these risk adjustments going forward, the OIG laid out several recommendations: First, the Centers for Medicare and Medicaid Services oversee the MAOs that received payments from unlinked chart reviews and no service records; Next, they conduct audits that confirm the diagnoses listed on chart reviews; And lastly, scrutinize the risks and benefits for accepting unlinked chart reviews for risk adjustment consideration (oig.hhs.gov, 2019).

Crafting Your Organization’s Strategic Plan For A Successful Year

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Crafting Your Organization’s Strategic Plan For A Successful Year

 

The healthcare and health information management industry is no stranger to constant changes and evolutions. To successfully navigate the future – and be prepared for anything – healthcare organizations need to craft a strategic plan. But what does strategic planning entail? “Strategic planning is the process of documenting and establishing a direction of your company – by assessing where you are and where you’re going” (The Hartford/Small Biz Ahead, 2018).

strategic planningA strategic plan is beneficial for everyone: It allows the company owner to identify which goals will help grow the organization, and it helps the employees foster that growth by accomplishing the necessary objectives and increasing productivity. By including your employees in the planning process, you create a sense of ownership and accountability for the plan to succeed. Bottom line: Everyone is on the same page about the company’s direction and goals.

The strategic planning process should include:

  • Company Goals, Values, and Mission: Setting your company goals, values, and mission provides the framework of a strategic plan, and may be the most important step of the process. To successfully execute your strategic plan, you need to set performance benchmarks, and identify the initiatives to achieve that growth. For an example, review AHIMA’s strategic objectives they planned for 2018-2022.
  • Establishing Partnerships and Securing Clients: Without partners and clients, your organization would not be a success. It is paramount to dedicate a portion of your strategic plan to making new connections that will help your business grow. Identify all stakeholders in your industry, and develop a proposal that demonstrates your value and how your companies could work together for a profitable future for both parties.strategic planning
  • Creating a Budget: Your organization likely does not have unlimited financial resources, so it is crucial to set monetary boundaries that allow you to achieve your goals and meet all objectives without breaking the bank. Your company partnerships may help increase your budget, giving you flexibility on how you meet your goals.
  • Continuing Education for Coders and Auditors: There is a plethora of organizations that are in constant need of skilled, qualified medical coders and auditors. Build time into your plan for continuing education to ensure your team maintains the knowledge they need to make your organization successful. In addition, by encouraging ongoing education, you will increase your coder and auditor retention, as well as your return on investment.
  • Communication and Brand Guidelines: According to the Journal of AHIMA, one of the 10 best practices of strategic planning is communication. “Develop coherent strategic plan messaging using tools such as blogs and social media, newsletters, brown-bag [informal] meetings, conference presentations, collaborative tools, and FAQs. Execute outreach relentlessly” (Journal of AHIMA, 2013). Use trade shows to get your organization’s name in front of the companies with which you want to do business. Establish your brand guidelines, and adhere to them in all internal and external communications.

Most importantly, remain flexible and ready to adapt your plan to fit your current situation as needed.

Optimal Quality Coding Prevents Medical Claims Denials

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Optimal Quality Coding Prevents Medical Claims Denials

 

Medical billing denials generate significant cost for providers and hospitals that could be avoided by improving claims data management and optimizing medical coding processes. According to the American Medical Association National Health Insurer Report Card (2013), the five most common reasons for medical billing denials include missing information, duplicated claims or services, services already being adjudicated, services not being covered by payer, and the limit for filing has already expired. Optimal quality coding effectively prevents medical claims denials by reducing the potential for manual error and addressing concerns over fast approaching time limits.

How to prevent future claims denials, increase reimbursement, and maximize revenue? 

Optimal Quality CodingIn retrospect, many claims denials are preventable with more careful data management and improved quality coding. Even a single blank field on a claims form can be sufficient for immediate claim denial, with technical errors cited as being responsible for 61% of initial claims denials, as well as 42% of denial write-offs. Furthermore, “duplicates, which are claims resubmitted for a single encounter on the same date by the same provider for the same beneficiary for the same service item, are among the biggest reasons (up to 32%) for Medicare Part B claim denials” (Change Healthcare, 2016). The cost of an individual service may fall under another claim that has been previously satisfied, resulting in denial. Providers should always refer to individual patient insurance policies to confirm that services are covered prior to seeing patients to avoid denial due to services not being covered. Finally, with a limited window available to submit medical claims, the time-consuming process of correcting manual errors ultimately leads to unnecessary billing delays, with 81% of complex claim denials occurring as a result of expired filing limits.

Improved quality coding as a targeted strategy for process optimization

Multiple strategies exist to achieve optimal quality coding in an attempt to reduce costs associated with medical claims denials and maximize revenue. Effective management of patient claims data is crucial towards this goal; medical claims denials should be properly measured, categorized, and organized for efficient analysis, and the quality of data entered initially upon admission must be greatly improved. The creation of dedicated resources focused on continued statistical analysis of trends inpatient claims data can identify potential solutions and provide documentation of ongoing progress. Determination of the reason for each denial by root-cause analysis offers further valuable insight towards preventing future denials for similar reasons. Additional opportunities for improved reimbursement include the introduction of an effective denials management program, and implementation of insurance claims management software to automate portions of the claims process, used in combination with automated predictive analytics, as well as the option to outsource revenue cycle management to independent, third-party consulting services.

Top 5 Common Myths of Coding Outsourcing

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Top 5 Common Myths of Coding Outsourcing

 

Assigning coding and auditing needs to outside companies allows providers to focus on the tasks that they enjoy doing, and leaves the other functions for experts who can get them done quickly and accurately, especially if the organization’s in-house staff is not trained in coding. But, due to the sensitive nature of the materials at hand, providers can be a little hesitant to sign away their coding responsibilities.

These are 5 common myths of outsourcing, and how YES HIM Consulting debunks these concerns with a skilled team of consultants, coders, and auditors:

coding outsourcing myths1. Outsourcing means working with companies outside of the United States. While it is the norm for most companies to outsource services overseas, that is not the case for YES HIM Consulting. Our entire organization is U.S.-based, and all of our team members live and operate domestically, so you won’t have to work around odd operating hours and different time zones. In a previous article, we discuss additional benefits of hiring YES HIM Consulting’s team of fast, reliable, and skilled coders and auditors.

2. There are liabilities of potential data leaks and breaches. Companies that operate in the U.S. must comply with HIPAA, so certain security measures are taken to safeguard sensitive medical records. YES HIM Consulting is no different, and regularly undergoes security checks to maximize the safety of this data. Additionally, consulting companies should make sure that their coding support team is operating accurately and efficiently. YES HIM Consulting upholds a standard of 95% accuracy, and develops and provides coding education with CEUs, so our team’s skills stay sharp. We take pride in our coders’ and auditors’ experience, which helps us maintain a reputation for excellence.

3. It can cost more than in-house services. Since outsourcing is also consulting, companies tend to negotiate prices that work better for hospitals’ budgets. YES HIM Consulting is ready to work with you to fit your needs and budget.

4. Outsourcing requires a lot of hand-holding. Consultants are accustomed to rapid change and fast turn-around, so they know how to deliver for their clients. And, remember: It is always best to look for a partner – not just a vendor. A partner, like YES HIM Consulting, will deliver incredible results quickly. Outsourcing introduces you to coding outsourcing mythsthe most talented coders in the industry. “Outsourcing can be a way to tap a broader talent pool without incurring the higher cost and risk of bringing on additional full-time employees” (Physicians Practice, 2019).

5. There’s a tedious on-boarding process involved. Consultants need what you need – to start working immediately. Our team is ready to go as soon as you need us. Look for a partner who has a dedicated team for IT access, data analysis, and report building – not just a one-trick pony for “coding outsourcing.” Our consultants are experts in their field, fueled by ongoing training with our company. They stay up-to-date on the latest coding updates and requirements with resources like the “2019 Consulting and Outsourcing Guide” from the Journal of AHIMA (Journal of AHIMA, 2019).

Still don’t know if outsourcing could work for your organization? Consider these other points as to why YES HIM Consulting is the right fit to handle all your coding and auditing needs.

Clinical Documentation Integrity Significance in Revenue Cycle Management Success in Healthcare

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Clinical Documentation Integrity Significance in Revenue Cycle Management Success in Healthcare

Revenue Cycle Management (RCM) can be thought of as the method of transportation to take an organization from one place to where it needs to go. For the transport to occur successfully and be operationally sound, the processes in place to support it must be accurate and deliberate. The chances of the vehicle making it to the destination with a missing tire would predispose the outcome to failure. So is the case with clinical documentation deficiencies.

The Healthcare Financial Management Association (HFMA) defines the revenue cycle as “All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.” Clearly, what this description is stating is that the success of this operation of people and processes being successful is dependent upon the vital information being accurately recorded for claim generation, claim submission, and full payment recompense. Anything short of these two operational necessities working collaboratively, will predispose the organization to denials.

Best Practices for Getting it Right the First Time

Perhaps the most vulnerable of issues in the RCM process is the potential for incorrect information creation in a patient’s chart. Data disparities duplicate or inaccurate medical record number recording, and unverified insurance verifications processes in place can potentiate claim denials. By the establishment of best practice procedures designed for guidance at registrations time, the opportunity for errors and oversights can decrease significantly. As a best practice, providing accurate claims data to assist in the appropriate coding, has a direct impact on decreasing denials and improving financial cash flow.

In short, a better way to say it: error-free claims + accurate coding = denials avoided = money unlost!

An important best practice decision that your organization can undertake is to work with YES HIM Consulting, Inc. as their professional coding partner. Successful results take proactive measures, and YES auditors can identify outliers that can have an impact on your organization’s coding accuracy, revenue, and data quality. YES auditors keenly identify potential deficiencies upfront and create a custom quality improvement plan per coding challenges. Working with our partners in order to establish streamlined processes with built-in measures, to capture and alert of a potential error before claim submission. The objective is clear: revenue “protection” while maintaining compliance standards. We have provided a brief overview of the importance of ICD-10 coding in the RCM process here.

The Final Important Takeaway

The objective and need for sound clinical documentation integrity cannot be overstated. The key to effective error reduction and claims denials in any organization may be as simple as to identify them before they occur. This standard set of safeguard protocols put in place early on will further mitigate any significant unbilled list of claims. This guiding rule employed early on will help to eliminate the potential slowing of cash flow for the organization.

2020 ICD-10-PCS Guideline Changes: Make Room for Exceptions

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2020 ICD-10-PCS Guideline Changes: Make Room for Exceptions

 

On April, we provided an overview of the upcoming ICD Code Revisions for FY2020. In July, we covered in detail the 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P, which was published in the Federal Register, May 3, 2019.

This years’ updates to the ICD-10-PCS Official Guidelines for Coding and Reporting include a new section, updates to an existing section, new guidance on a body part, some editorial changes and the introduction to the possibility of exceptions for special cases.  In addition, the Guideline changes also included exceptions regarding mastectomy procedures, followed by immediate reconstruction; a welcomed change.

The Exceptions:  Mastectomies Coded in All Circumstances- Immediate Replacement Included

The Introduction includes this new line regarding the guidelines: “They are intended to provide direction that is applicable in most circumstances.  However, there may be circumstances where exceptions are applied.”

  • A dilemma solved for coding professionals. The exceptions that were included in the updated guidelines involve a mastectomy followed by immediate reconstruction. It was a matter or timing that determined whether the mastectomy was coded. If a patient had a mastectomy during the current encounter and a subsequent reconstruction at a different episode, then the mastectomy was coded for the first encounter, and the reconstruction for the next one. This was different in the case of a mastectomy followed by immediate reconstruction during the same encounter.  Before 2020, following the guidelines meant that in the case of immediate replacement, the mastectomy would not be coded as it was necessary to remove the native breast first before replacing it.  The exceptions to the guidelines give coding professionals a solution to this dilemma. They also bring the guidelines in line with the advice published in the Third Quarter 2018 Coding Clinic page 13, in the article:  Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: mastectomy is coded separately, and the harvest of the DIEP graft is not reflected in a separate code.
  • Guideline B3.1b has been updated to state that Components of a procedure specified in the root operations definition or explanation as integral to that root operation are not coded separately. The exception is listed:  Exceptions: Mastectomy followed by breast reconstruction, both resection and replacement of the breast are coded separately. This contrasts the resection of the native breast before replacement to the example given in the guideline: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. As noted in the Third Quarter 2018 Coding Clinic article, “Mastectomy with breast replacement/reconstruction and joint replacement surgery are conceptually very different. In joint replacement, the objective is to restore function by replacing the joint. For a mastectomy with reconstruction, it is important to identify that the primary objective of the surgery is to remove cancerous or potentially cancerous breast tissue, and that the reconstruction is an additional objective.”
  • The changes in guideline B3.9 also relate to these circumstances. 9 instructs that if an autograft is obtained from a different procedure site in order to complete the objective of the procedure, a separate procedure is coded.  Excision of a saphenous vein for a coronary bypass is highlighted as an example.
  • The updated guideline lists the exception to this guideline: Except when the seventh character qualifier value in the ICD-10-PCS table fully specifies the site from which the autograft was obtained.
  • Added to the saphenous vein example is the following: Replacement of breast with autologous deep inferior epigastric artery perforator (DIEP) flap, excision of the DIEP flap is not coded separately. The seventh character qualifier value Deep Inferior Epigastric Artery Perforator Flap in the Replacement table fully specifies the site of the autograft harvest. This updated guideline and example are telling us that including a code for the harvest would not add any information as the source of the graft is listed in the 7th character qualifier, and therefore the additional code is not required.

ICD-10-PCS Guideline ChangesEdits in the Guidelines

While there is no change in guideline A9 that instructs that within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table; the code table used as an example has been updated to include device value Y “other device” that has been added to the 0JH code table.

  • Guideline B2.1a for body systems had some editorial changes, listing the complete titles of the Anatomical Regions body systems and removing the Control example, since this root operation can now be coded in in other body systems. Also added was an example: Amputation of the foot is coded to the root operation Detachment in the body system Anatomical Regions, Lower Extremities.
  • The root operation Extraction was added to B3.5 for overlapping body layers, stating that for root operations such as Excision, Extraction, Repair or Inspection performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.
  • In guideline B4.1b for body part that addresses the prefix “peri,” guidance is given for the periosteum: A procedure site documented as involving the periosteum is coded to the corresponding bone body part.

A New Section of Guidelines, and Updates to New Technology

A completely new section with two guidelines, section D, is added for Radiation Therapy.  The new guidelines concern Brachytherapy and instruct when separate codes are needed from the Medical and Surgical section for Insertion of the brachytherapy source that remains in the body at the end of the procedure.  Also covered is the placement of a temporary applicator for brachytherapy delivery.  Review these guidelines carefully.

  • With the addition of the Radiation Therapy section, the New Technology guidelines from section X have been moved to E, with some edits and the addition of a new guideline.  The updated guidelines specify when a New Technology code may be the only code reported and when they may be additional codes reported along with codes from other sections of ICD-10-PCS.  One example given is for the use of dual filter cerebral embolic filtration, coded as X2A5312 used in conjunction with a transcatheter aortic valve replacement (TAVR); both codes are assigned.

While the updates to the 2020 guidelines are not extensive, there are important changes that warrant careful review. You can find the full document here: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-ICD-10-PCS-Guidelines.pdf

YES HIM Consulting, Inc. Largo, Fl.
Office: (727) 531-3839       Fax: (727) 240-4592