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When coders for inpatient rehabilitation facilities were instructed to use a code from the V57.xx series to indicate principal diagnosis, there was a loud howl of protest from those who felt that these codes did not represent diagnoses but rather the treatment a patient would receive.

It was inconsistent, as staff did not report a code to admit for medical care or a code to admit for surgery. However, this was an efficient method through which to group a patient to DRG 462 for rehabilitation. Rehabilitation facilities excluded from the DRG payment methodology also were instructed to use this code to indicate principal diagnosis.

The 2002 implementation of the IRF PPS included completion of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI). The IRF PAI required code assignment for the etiology, comorbid conditions, complications and reasons for interrupted stays or death.    The IRF PAI instructions for code assignment mandated the etiology-advised coders to report the diagnostic code for the acute condition that was responsible for the impairment. This was unusual, and ran contrary to how the official guidelines instructed coders to operate.

Once again, coders had to accept change, although they did not understand why code V57.89 couldn’t be reported as the etiology, as it was appropriate for the billing form. The response to this was that the billing form and the IRF PAI are separate documents. The IRF PAI is a separate data set, meaning the Official ICD-9-CM Guidelines for Coding and Reporting do not apply to code assignment for it.

Then Came MS DRGs

With the introduction of Medicare Severity – Diagnostic Related Groups (MS –DRGs), the rehabilitation DRGs changed to DRG 946, rehabilitation with major complication/comorbidity (MCC), and DRG 945, Rehabilitation without CC or MCC.

ICD-9-CM codes for the principal diagnoses that assign DRGs 945 or 946 include:

V52.8            Fitting and adjustment of other specified prosthetic device

V52.9    Fitting and adjustment of unspecified prosthetic device

V57.1    Other physical therapy

V57.2            Occupational therapy and vocational rehabilitation

V57.3    Care involving use of rehabilitation speech-language therapy

V57.89 Other specified rehabilitation procedure

V57.9            Unspecified rehabilitation procedure

It is possible to map codes V52.8 and V52.9 to ICD-10-CM codes in the Z44 series of codes. These codes seldom are used as a principal diagnosis by inpatient rehabilitation facilities.

The official ICD-9-CM coding guidelines indicate that only one code from the V57 series of codes should be reported. Inpatient rehabilitation facilities report code V57.89 for inpatient admissions to indicate that a patient will receive therapy in multiple therapy disciplines.

Mapping Won’t Get You There

A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification.  Inpatient rehabilitation coders will need to be flexible, as change is inevitable. How to assign the inpatient rehabilitation DRGs when ICD-10-CM is implemented is a matter still being studied.

One possible solution for assignment of the rehabilitation DRGs is to add additional codes to the ICD-10-CM classification, replacing the current V codes used for ICD-9-CM. Another possible solution would be to map to the rehabilitation DRGs the ICD-10-PCS procedure codes for Physical Rehabilitation and Diagnostic Audiology, F00-F15.

A solution will need to be found prior to Oct. 1, 2013.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience.  As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH).  Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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This is my third article for ICD10monitor, and after the first two I suspect that some of you may be wondering why I’m even a contributor. After all, my entire work history (at least since 1977) has fallen under provider financial responsibilities, and my dominant focus now is Medicare payments. I’ve never worked in health information management (HIM, or “medical records,” its understated former name), and I generally am a useful addition to any room full of HIM professionals. Add to that the fact that I consider ICD-10 to be a monumental bore and perhaps a prime example of the term “necessary evil,” and I can understand why you might question my involvement.

The problem with the notion that I really have nothing of value to say lies in ignoring the synergistic and co-dependent relationships among clinical care professionals, HIM professionals and patient financial services (formerly “business office” or “patient accounting”) professionals. Let’s consider this for a moment as I seek to defend my role.

I ride a “trike:” a Harley-Davidson Ultra Classic with a Roadsmith conversion kit from The Trike Shop in Minnesota. Wait, I think I have a photo somewhere … ah, yes, here it is:

While I readily concede that my trike is little more than a manifestation of one form of mid-life crisis, it does serve to make a key point, to wit:

The one thing that distinguishes a trike from all other forms of transportation are those three round hunks of rubber, steel, aluminum and various other materials on each corner. It’s a funny thing about something with three wheels: if any one of them doesn’t do its job, the vehicle won’t go. That is, it won’t succeed in doing what it’s meant to do.

It’s the same with healthcare finance as practiced in provider settings (hospitals, physician offices, ASCs, ESRD facilities, you name it). If the front wheel represents patient care, the back wheels are HIM and PFS. While it’s true there is no money without good patient care, it’s no less true that HIM significantly impacts the collectible revenues on any given claim, and PFS has to be at the top of its game – all the time – to collect those revenues. My favorite maxim is no less true than when it first was stated: “No Margin, No Mission.” And neither caregivers nor HIM nor PFS can claim they are the most important part of the equation. In fact, the system only works, it only thrives, when all three components of the revenue cycle perform at their best.

While my interest and expertise lie in the area of payments, that simply means that my focus is on the PFS third of this relationship. But I readily embrace the reality that my success depends in large measure on HIM providing the best records and coding possible, and, as always, on the clinicians providing the best possible care. Think of my trike as “the Revenue Cycle.” It’s neither a unicycle nor a bicycle; it’s a tricycle, and it succeeds only because of that distinguishing fact.

Quite simply, it is impossible to separate the three core functions of the revenue cycle and operate on the presumption that one or the other (or the other) is “the most important.”  As a payer watchdog, someone who helps providers identify when they are underpaid by FIs and MACs, I depend on HIM to give me an accurate bill, on patient financial services to collect it and on the clinical care professionals to generate the next day’s revenue. It’s a funny thing about cycles: they repeat. So with every new day the clinicians must do as well as they did the day before, as must the HIM and PFS professionals.

Those of us who live, breathe, succeed and prosper working on the provider side of healthcare are not standing in three corners of a wrestling ring waiting for a fight to begin. Rather we are the three keys to any provider’s long-term financial success: the front wheel (clinicians, leading the way), one rear wheel (HIM, assuring that billing is accurate and timely) and the other rear wheel (PFS, generating the bill, following up with payers and collecting everything to which the provider is entitled).

Because we all depend on each other, we also have the right and responsibility to consider each other’s priorities and preferenc­­­­es as we pursue our own. Thus my role is not to be focused on the technical aspects of ICD-10 implementation and conversion; there are many people here who are far more capable in that area than I. Rather, my role is to contribute some small insights into one of the other two-thirds of the ICD-10 milieu: patient financial services (and perhaps to serve as a counterpoint to all the “tech talk”). I also reserve the right to be tongue-in-cheek any time I feel like it.

So let us know if you have a topic you’d like me to address. I have opinions about almost everything!

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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As hospitals begin preparations for ICD-10, it should be recognized that a parallel process will be taking place in the physician office setting. Fully integrated systems will produce the benefit of providing integrated education to physicians. In fragmented systems, physicians will be responsible for purchasing new IT systems, providing training for office billing staff and in many, many instances hiring new staff due to the anticipated attrition of professional billers as we transition to the new system.

What kind of awareness training should physicians receive now? The first step should be fostering awareness of the complexity of the system from a very high level to persuade physician leaders to begin preparations. In this article, I’ll focus on the diagnosis side of ICD-10.

Most healthcare leaders are aware that the number of diagnosis codes increases dramatically from ICD-9 to ICD-10. However, while the raw aggregate number of codes increases from approximately 13,500 to 70,000, the increase is not consistent across all categories.

Consider one localized group of fractures, those occurring in the femoral head and neck region. Under ICD-9 there are 12 available codes such as 820.02 Midcervical Femoral Neck Fracture, Closed or 820.11 Epiphyseal Fracture Transcervical, Open. These fractures are distinguished from peritrochanteric and shaft fractures.

In ICD-10-CM, Chapter XIX: Injury, poisoning and certain other consequences of external causes (including subchapter S00-T98, Injuries to the Hip and Thigh) are addressed in sections S70-S79. S72 is titled Fracture of Femur and is subdivided into S72.0 Fracture of the Neck of the Femur, S72.1 Pertrochanteric Fracture, S72.2 Subtrochanteric Fracture, S72.3 Fracture of the Shaft of the Femur, and so on.

In comparison to the 12 available codes for all femoral head and neck fractures in ICD-9, consider S72.0 Fracture of the Neck of the Femur. This appears to be a specific code, but under S72.0, using the appropriate additional digits S72.0xyz allows for markedly increased specificity.

There are, in fact, 576 subtypes of fracture within S72.0. There are 48 specific codes for Fracture of Unspecified Part of Neck of Femur, another 48 specific codes for Unspecified Intracapsular Fracture (of the femur), 96 codes for epiphyseal fractures (48 displaced, 48 undisplaced), 96 codes for mid-cervical fractures (again half displaced, half non-displaced), 96 codes for fractures of the base of the neck (same pattern), 48 codes for unspecified fractures of the head of the femur, 96 codes for articular fractures of the femoral head (displaced and non-displaced, and 48 codes for “other fractures of the head and neck of the femur.” If one considers all codes for femoral fractures from the proximal to distal aspects bilaterally, by my calculations there are 2,466 codes (though I may have missed a few).

The level of specificity required appears daunting. Can we expect coders currently using12 different codes to find the detail necessary to specify one of 576 codes? Further, do we expect orthopedic surgeons to provide all the necessary detail for this specificity? The challenge may not be as insurmountable as it initially appears.

ICD-10-CM diagnosis codes have 3-7 characters (compared to 3-5 in ICD-9) laid out in a specific format, with each character organized within any subchapter in a specific manner (see ICD-9-CM diagnoses/ICD-10-CM sidebar comparison).

The first three digits indicate the category. The first character is always alphabetic, the second is always numeric and the third can be either. Consider the following specific diagnosis code listed below (it’s one of the 576 codes):

S72031K Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with nonunion.

The category of fracture is S72 – femoral fracture; S72.0 narrows the description to those of the head and neck. The remaining digits indicate, in this example, the subsequent encounter for a non-union in a fracture that originally was closed. This level of detail typically is included in the clinical record, though it may not be summarized succinctly by the orthopedic surgeon at this point.

By developing a collaborative educational approach for physicians as well as coders and documentation specialists, ICD-10 at least can be demystified partially. The anticipated benefits of ICD-10, according to CMS, are listed in the sidebar. Successful implementation will require peer-to-peer discussions to provide the motivation and knowledge necessary for physicians to collaborate in the inpatient ICD-10 process.

BENEFITS OF ICD-10-CM

ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practices. The modern classification system will provide much better data needed for:

- Measuring the quality, safety and efficacy of care;
- Reducing the need for attachments to explain the patient’s condition;
- Designing payment systems and processing claims for reimbursement;
- Conducting research, epidemiological studies and clinical trials;
- Setting health policy;
- Performing operational and strategic planning;
- Designing healthcare delivery systems;
- Monitoring resource utilization;
- Improving clinical, financial and administrative performance;
- Preventing and detecting healthcare fraud and abuse; and
- Tracking public health and risks.

Source: Quick Reference Information: ICD-10-CM Classification Enhancements, available at https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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EDITOR’S NOTE: This is a continuation of an article from Michael G. Calahan appearing in last month’s edition of ICD-10monitor e-news entitled, “It’s Time to Get to Work!”

Last month we provided an introduction into how practice NPPs (physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, nurse midwives) can assist in the ICD-10 conversion process preliminarily without the benefit of having gone through ICD-10-CM classes and without access to special ICD-10 software. This preliminary preparation step involves the performance of a baseline medical record (MR) documentation assessment. The practice NPP is perfectly suited to perform or assist with this endeavor.

The baseline assessment will help expose areas where a practice’s various providers might need to shore up their MR documentation so practical conversion from ICD-9 to ICD-10 will be more efficient. Various additional benefits can be realized as well: as you perform the MR documentation assessment you may come across missed opportunities (that is, services that should have been “captured” but were missed) as well as services reported but under-documented enough so that the billing for these services could be questioned by an outside reviewer such as an OIG, RAC or CERT auditor. The focus, however, will be on the documentation of diagnostic statements supporting the final assigned ICD-9-CM codes and how well that documentation would support the ICD-10-CM codes. Case selection, or determining what dates of service to review (as stated in last month’s article) should be accomplished by analyzing frequency reports generated by a billing software system to assess, at a minimum, the top 25 ICD-9-CM codes reported to payers during the last year.

Source Documents

In preparing source documents for the MR documentation review, remember that the final reported ICD-9-CM codes for each selected case may need to be compared with information contained in the practice superbills or encounter forms (also known as “charge tickets”), since physician practices often utilize this type of form as a charge-capture tool.

This form is typically the source document and data facilitator for billing information, which in turn gets translated to the CMS-1500 claim forms submitted to payers for reimbursement. However, errors in the translation of data from the MR documentation to the superbill are not rare. And even though this is a documentation review for ICD-9-to-ICD-10 comparison purposes, the CMS-1500 claim forms for each date of service also should be on hand.

The CMS-1500 claim forms are important source documents that can be used for comparing what was reported to the payers versus what the MR documentation states as actual case data. The true crux of an audit is ultimately a comparison of the MR documentation against the CMS-1500 claim forms.

At a minimum then, you will require the following source documents to carry out a full MR documentation assessment for diagnosis comparison purposes:

- Original MR documentation (i.e. an office visit note)
- Ancillary documents such as provider orders, operative reports, pathology reports, radiology reports, etc., if germane to the office visit
- Practice superbills or encounter forms (i.e. the “charge tickets”)
- CMS-1500 claim form copies.

To perform a comparison and contrast of ICD-9-CM-to-ICD-10-CM codes, an ICD-10 tool also will be needed. This can be a pre-2013 ICD-10-CM book, an encoder with ICD-10 mapping or the public CMS files that include listings of the ICD-10-CM/PCS codes as well as “GEM” files (general equivalency mapping spreadsheets) that tie ICD-9 and ICD-10 together.

Review Process

It’s time to begin the review. Select a patient date of service, arranging in front of you the original MR documentation, ancillary documents, the superbill and a copy of the CMS-1500 claim form. Scan the progress (office visit) note for the recorded diagnostic data. Most of the current reportable ICD-9-CM codes found on the CMS-1500 claim form and encircled on the practice superbill will arise out of the diagnostic statement(s) listed under the “assessment” section (if providers follow the SOAP note format), or alternatively this section can be labeled “impressions” or “diagnoses.” There should be uniformity in terms of provider note organization and final documentation of patient data.

Also scan the ”history” section of the office visit note. Within the history component of the typical patient office encounter you will find four distinct elements required to be documented for most evaluation and management (E/M) services: chief complaint (CC); review of systems (ROS); past, family and social history (PFSH); and history of present illness (HPI). A chronic but current/ongoing diagnosis impacting current care also commonly will be listed within the elements of the history, but not carried down or relisted in the diagnostic area found under the assessment section.  This practice should be avoided as it is often confusing for coders as well as outside medical reviewers. Chronic but ongoing (and therefore reportable) diagnoses frequently are missed when they are buried in the history component of an E/M service file and not relisted under the assessment.

At this juncture let’s look at a case study to demonstrate the comparison process. For illustration purposes we will use a patient with essential hypertension (HTN) coded to ICD-9-CM code 401.9; consider that no other ICD-9-CM codes were assigned or are listed on the CMS-1500 claim form for this particular office visit. In this scenario the patient’s CC is “Here for F/U of HTN,” and in fact the “impression” line states “HTN, doing well on current meds.” However, the patient also has generalized osteoarthritis and is undergoing active treatment for this condition, as evidenced by a note under the “plan” section reading “Increase Celebrex to 100mg b.i.d.” A quick glance at the history reveals the physician had documented a correlating diagnosis in the ROS as “Musculoskeletal - gen OA w/noctural multi-jt. pain.” Your conclusion in reviewing these notes is that the OA did in fact impact the current date of service, and therefore two diagnoses for this office visit should have been coded: the HTN and the OA.

In relation to the hypertension, there is no annotation or indication of concurrent hypertensive heart disease or chronic kidney disease (or any combination thereof): it is strictly noted as “HTN.” Under the current ICD-9-CM coding structure, because the descriptor “benign” (ICD-9-CM code 401.1) or “malignant” (ICD-9-CM code 401.0) was not recorded in the MR documentation along with the acronym “HTN,” the official coding guidelines and instructions state that the unspecified ICD-9-CM code 401.9 must be reported for “essential hypertension.” Now compare this code with the anticipated requirements and information under ICD-10-CM. Utilize your ICD-10 tool to locate the code for essential hypertension and you find a small surprise: in ICD-10-CM the descriptors “benign” and malignant” no longer apply. The full description mapped to the current ICD-9-CM essential hypertension code series (401.0, 401.1 and 401.9) match up to “I10 Essential (Primary) Hypertension” (see table). What will be required in this case in terms of MR documentation for accurate ICD-10-CM coding of the recorded information? First, establishing the hypertension as “essential” appears tantamount to getting it coded correctly.

This baseline classification should be established in the MR documentation in a highly visible area at some point even if it is not repeated each and every time the hypertension is recorded. Secondly, ensuring that the current state of hypertension is not connected etiologically to hypertensive heart disease, chronic kidney disease or a combination of these two is vital for correct coding (these conditions map to other ICD-10-CM codes).

For the generalized osteoarthritis (OA) that you have uncovered as not being reported but clearly documented and impacting current care, the ICD-9-CM code based on the MR documentation should be “715.00 Generalized osteoarthrosis, unspecified site.” (Note: if the adjective “generalized” was not noted in the MR documentation, then ICD-9-CM code “715.90 Osteoarthrosis, unspecified whether generalized or localized, unspecified site” would be assigned in this case.) Each of these descriptions for OA (715.00 and 715.90) maps to ICD-10-CM code M15.9 Polyosteoarthritis, unspecified.

However, it should be noted ICD-9-CM code 715.90 dually maps to ICD-10-CM code “M19.90 Unspecified osteoarthritis, unspecified site” as well. This particular ICD-10-CM code encompasses numerous other, more specific ICD-9-CM codes for various joints afflicted with OA, whether localized or not specified as “generalized or localized” (see table below). The analysis reveals that osteoarthritis, depending on how specific the provider has been in his or her documentation, can be coded in several ways under ICD-10-CM. As with ICD-9-CM coding now, the more specific the MR documentation, the more accurate the coding – and this holds true in ICD-10-CM coding.

Your Findings

As the NPP “auditor,” you have found upon comparison of the MR documentation to the CMS-1500 claim form that the ICD-9-CM code for OA was not reported at all, and you further find that it was not even encircled on the practice superbill. The lesson buried in this for providers? The MR documentation should be as clear, concise and explicit as possible, especially when summarizing impressions or diagnoses. The lesson herein for coders is that there often is corroborating information between the history and plan sections of the note, and both should be reviewed for possible “missed diagnosis opportunities” for ICD-9 and ICD-10 coding purposes. Lastly, do not rely solely on the superbills for diagnostic information.

Delineating between old (past or no longer under treatment) and current (new or ongoing conditions that impact care) diagnoses is important so that practice coders can benefit from nicely detailed and organized MR documentation. The common denominator in deciding if a diagnosis should be coded for the current encounter is if it impacts care in some way; the condition must be demonstrated in the note to have been evaluated, assessed, managed and/or treated to some extent. This can be accomplished by straightforward statements such as “no change in hypertension; current regimen to be continued,” or it can be made clear by more unassuming statements such as that outlined in the above scenario: “Increase Celebrex to 100mg b.i.d.”

If unconfirmed diagnostic statements are made, such as “ruled out,” “probable,” or “suspected,” then the patient’s signs and symptoms should be demarcated clearly in the notes so the practice coders can assign appropriate ICD-9-CM codes (and, in the future, ICD-10-CM codes) to represent fully the signs and symptoms prompting the patient’s office visit.

General documentation standards should be reviewed while assessing the status of the MR documentation. These standards include legibility, provider signature/authentication, identification/credentials of annotations made by non-provider staff and adequate patient identifiers, including patient name, MR number (if used), date of service, time (if timed services such as prolonged care are being provided), etc.

In many instances ICD-10-CM promises to demand greater specificity on diagnosis code descriptions and assignment, therefore a correlating level of specificity is expected to be found in the MR documentation. Performing a baseline audit and having the practice NPP perform or assist with this audit is often a rewarding exercise.  We will explore more complex “greater specificity” ICD-10-CM coding scenarios in upcoming articles.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

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