spencerCIncorrect coding continues to be an area of risk for hospitals under the Recovery Audit Contractor program, and the Centers for Medicare & Medicaid Services recently provided guidance to address commonly made billing errors in three types of procedures.


As you’ll see below, the two procedures related to inpatient hospital-tracheostomies and excisional debridements-are errors that can be corrected as long as the provider’s documentation is clear. (If not, coders must query the provider.) The other procedure that CMS reviewed, which relates to outpatient providers and physicians, may not be as straightforward: chemotherapy administration and non-chemotherapy injections and infusions. (These and other issues can be found in CMS’s February 2011 issue of Medicare Quarterly Provider Compliance Newsletter at: http://www.cms.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN905712.pdf.)


Inpatient Coding of Tracheostomies


Providers are inappropriately billing for the creation of a new tracheo­stomy when services performed only involve revising an existing tracheo­stomy. Instead of assigning 31.1 for a temporary tracheostomy or 31.29 for a permanent tracheostomy, hospitals should assign the following for the revision:


31.74   Revision of tracheostomy


A check of the issues posted, as CMS indicates in its newsletter, shows that all four RACs are performing validations on one or more of the following MS-DRGs. (Note, however, that, according to the issues listed on their web sites, medical necessity is excluded from review.)


004      Tracheostomy with mechanical ventilation 96+ hours or principal diagnosis except face, mouth & neck without major operating room

011      Tracheostomy for face, mouth and neck diagnoses with major complications and co-morbidities (MCCs)

012      Tracheostomy for face, mouth and neck diagnoses with comorbidities (CCs)

013      Tracheostomy for face, mouth and neck diagnoses without CCs or MCCs


Inpatient Coding of Excisional Debridements


Here’s another straightforward coding error cited by CMS: Do not code non-excisional debridement as excisional debridement. Hospitals are incorrectly reporting this procedure when the wound is debrided using autolytic, enzymatic or mechanical (whirlpool) debridement.


Excisional debridement of a wound, infection or burn (86.22) is defined as the “surgical removal or cutting away of devitalized tissue, necrosis, or slough.” Code 86.28 should be assigned for nonexcisional debridements of wound, infection, or burn. Ensure that the provider documentation supports and describes the procedure of excisional debridement performed.  If the documentation is not clear, be sure the coder queries the provider for clarification.

RACs are performing validation for the following related MS-DRGs. Again, at this time, medical necessity is excluded from these reviews.


463      Wound debridement and skin graft except hand, for musculo-connective tissue disorders with MCCs

464      Wound debridement and skin graft except hand, for musculo-connective tissue disorders with CCs

465      Wound debridement and skin graft except hand, for musculo-connective tissue disorders without CC/MCC

573      Skin graft and/or debridement for skin ulcer or cellulitis with MCC

574      Skin graft and/or debridement for skin ulcer or cellulitis with CC

575      Skin graft and/or debridement for skin ulcer or cellulitis without CC/MCC

901      Wound debridements for injuries with MCC

902      Wound debridements for injuries with CC

903      Wound debridements for injuries without CC/MCC


Diagnostic Coding Refresher


If coding problems are identified at your hospital, the following guidance should be passed along to inpatient coders. For most, it will not be new information but, instead, an opportunity to remember the basics.


When a patient is admitted to the hospital, the health condition that the physician deter­mines, after study, is chiefly responsible as the cause for the admission should be sequenced as the principal diag­nosis.  The other diagnoses that are identified should also include all MCCs and CCs present during the admission that impact the MS-DRG assignment, and the present on admission (POA) indicator for all diagnoses reported must be assigned correctly.



Also do the following:


  • Ensure that all medical documenta­tion entries are consistent with other parts of the medical record (assess­ments, treatment plans, physi­cian orders, nursing notes, medica­tion and treatment records, etc. and other facility documents such as admission and discharge data and pharmacy records). If an entry is made that contradicts documenta­tion found elsewhere in the record, the attending physician should clarify and document it.
  • Make sure that all diagnoses are coded to the highest level of specificity.
  • The hospital’s claim must match both the attending physician’s description and diagnosis and the information con­tained in the beneficiary’s medical record.


Outpatient Coding of Chemo


The problem presented by CMS for chemotherapy administration and non-chemotherapy injections and infusions is less straightforward than the above. RACs have discovered errors involving claims containing the following HCPCS codes. (Note that CMS provided the effective date range in parenthesis following the code description.)


90765 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (Effective Date Range: Through 12/31/2008);


96365 – initial, up to 1 hour (01/01/2009-present);


90769 – initial, up to 1 hour, including pump set-up and establishment of subcutaneous infu­sion site(s) (Effective Date Range: 01/01/2008-12/31/2008); and


96369 – initial, up to 1 hour, including pump set-up and establish­ment of subcutaneous infusion site(s) (Effective Date Range: 01/01/2009-present)


With only one exception, states CMS, providers should report initial infusion codes only once per day. The exception is when protocol requires that two separate in­travenous sites are necessary.


RACs are finding that providers are making two primary errors:


  • Billing more than one initial infusion code per day and failing to append a modifier that signifies the need for different access sites on the same date of service; and
  • Incor­rectly coding chemotherapy administra­tion and non-chemotherapy injections and infusions more than once per day without an appropriate modifier. (See below for guidance on modifier 59.)


CMS offers the following advice to physicians and nonphysician practitioners, which hospital staff may want to pass on to them:


  • Review section 30.5 E in Chapter 6 of the Medicare Claims Processing Manual regarding billing for infusion chemo: http://cms.gov/manuals/downloads/clm104c12.pdf.
  • Document drug orders and the dosage-administration information adequately.


More on Modifier 59


First, coders should review the instructions provided in the professional edition (page 504) of the AMA’s 2011 CPT manual for what constitutes an “initial” service code. Providers also need to know when it is appropriate to assign modifier 59 with the above CPT codes. In its February 2011 newsletter, CMS quotes the following directly from the American Medical Association’s Coding with Modifiers 3rd Edition.


“Chemotherapy codes include codes for the administration of chemotherapeutic agents by multiple routes, the most common being the intravenous route. Separate payment is allowed for chemotherapy administra­tion by push and by infusion techniques on the same day, but only one push administration is allowed on a single day. It is recognized that combination chemotherapy is frequently provided by different routes at the same ses­sion. Modifier 59 can be appropriately used when two different modes of chemotherapy administration are used. Modifier 59 is used in this situation to indicate that two separate procedures were used to administer chemothera­peutic drugs, not to indicate that two separate drugs were administered.”


The AMA continues: “When the sole purpose of fluid administration is to maintain patency of the access device, the infusion is neither diagnostic nor therapeutic; therefore, the injection, infusion, or chemotherapy administration codes are not to be sep­arately reported. If fluid administration is medically necessary for therapeutic reasons (e.g., correct dehydration or prevent nephrotoxicity) in the course of a transfusion or chemotherapy, it could be separately reported with modifier 59 because the fluid administered is medically necessary for a different diagnosis.”



What RACs Review


The purpose of contractors’ reviews’ of the medical record for medical necessity and DRG validation is to ensure that diagnostic and procedural information and the beneficiary’s discharge status, as coded and reported by the hospital on its claim, matches both the attending physician’s description and the information contained in the beneficiary’s medical record. Reviewers validate principal diagnosis, secondary diagnoses, and procedures affecting or potentially affecting the DRG.


Note, however, that, currently, RACs are reviewing medical records of the above MS-DRGs only for validation but not medical necessity. The dates of service being reviewed vary so be sure to check your RAC’s web site for details of these reviews and others.


About the Author


Carol Spencer, RHIA, CHDA, CCS, is a senior consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. She brings more than 20 years of experience in health information management, coding, teaching, data quality and revenue integrity. She is an accomplished local, regional, and national speaker and author covering topics such as recovery audit contractors (RACs), payment audits, MS-DRG reimbursement systems, ICD-9-CM coding, and is an AHIMA-approved ICD-10-CM/PCS Trainer. Ms. Spencer is a thought-leader in data analytics and an expert on compliance in coding, query, and clinical documentation improvement strategies.

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