Coding and Documentation 2010 Update

1. Coding and Documentation 2010 Update Presented by Healthcare Services Group

2. Overview of Topics • 2010 Diagnosis Code Changes • 2010 CPT Code Changes • CMS Enrollment Forms • Preparing for the RACs • Office of Inspector General (OIG) Work Plan

3. 2010 Diagnosis Code Changes 344 New Diagnosis Codes Effective 10/1/09

4. 2010 Diagnosis Code Changes • Neoplasms – 33 New Codes • Malignant Poorly Differentiated Neuroendocrine Tumors • Merkel Cell Carcinoma of: • Face 209.31 • Scalp & Neck 209.32 • Upper Limb 209.33 • Lower Limb 209.34 • Trunk 209.35 • Other Sites 209.36 • Secondary neuroendocrine tumors (209.70-209.79) • Code first associated multiple endocrine neoplasm syndrome (258.1 – 258.03) • Use additional code to identify associated endocrine syndrome (i.e. carcinoid syndrome 259.2)

5. 2010 Diagnosis Code Changes • Nervous System & Sense Organs – 6 New • Circulatory System – 25 New Codes • Chronic Pulmonary Embolism - 416.2 • Late effects of Cerebrovascular Disease • 438.13-438.14 • Chronic Venous Embolism and Thrombosis • 453.50 – 453.79 • Acute Venous Embolism and Thrombosis • 453.81 – 453.89

6. 2010 Diagnosis Code Changes • Respiratory System - 2 New Codes • Influenza Due to Identified Avian Influenza Virus (488.0) • Influenza Due to Identified Novel H1N1 Influenza Virus (488.1) • Digestive System – 3 New Codes • Complications of Intestinal Pouch (569.71 & 569.79) • Vomiting of Fecal Matter (569.87)

7. 2010 Diagnosis Code Changes • Genitourinary System – 2 New Codes • Benign Endometrial Hyperplasia (621.34) • Endometrial Intraepithelial Neoplasia (EIN) (621.35) • Complications of Pregnancy, Childbirth and Puerperium – 16 New Codes • Puerperal Endometritis (670.10 – 670.14) • Puerperal Sepsis (670.20 – 670.24) • Puerperal Septic Thrombophlebitis (670.30 – 670.34) • Other Major Puerperal Infection (670.80 – 670.84) • Congenital Anomalies – 2 New Codes

8. 2010 Diagnosis Code Changes • Perinatal Period – 8 New Codes • Hypoxic-Ischemic Encephalopathy (768.70 – 768.73) • Newborn Feeding Problems (779.31 – 779.34) • Symptoms, Signs & Ill-Defined Conditions – 15 New Codes • Non-specific (Abnormal) Findings on Radiological and Other Examination of Body Structure; Inconclusive Mammogram (793.82) • Nervousness (799.21) • Irritability (799.22) • Other Signs and Symptoms Involving Emotional State (799.29) • Apparent Life Threatening Event in Infant (799.82)

9. 2010 Diagnosis Code Changes • External Causes of Injury & Poisoning – 170 New Codes • E Codes • Activities Involving: • E000.0 – E000.9 External Cause Status • Civilian Activity Done for Income or Pay • Military Activity • E001.0 – E001.1 Walking and Running • E002.0 – E002.9 Swimming • E003.0 – E003.9 Ice and Snow • E004.0 – E004.9 Climbing, Rappelling and Jumping Off • Rock Climbing • Bungee Jumping

10. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E005.0 – E005.9 • Dancing and Other Rhythmic Movement • Yoga • Cheerleading • E006.0 – E006.9 • Sports & Athletics Played Individually • Skateboarding • Bike Riding • Golf • E007.0 – E007.9 • Other Sports & Athletes Played as a Team or Group • Flag or Touch Football • Soccer, Football, Basketball, etc • Volleyball (beach or court) • Physical Games at School Recess or School Camp

11. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E008.0 – E008.9 • Other Specified Sports and Athletics • Boxing • Martial Arts • Frisbee • E009.0 – E009.9 • Exercise Machines Primarily for Cardiorespiratory Conditioning • E010.0 – E010.9 • Exercise Machines Primarily for Muscle Strengthening

12. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E011.0 – E011.9 • Computer Technology & Electronical Devices • Hand held interactive electronic device • Computer Keyboarding • E012.0 – E012.9 Arts and Handcrafts • E013.0 – E013.9 • Personal Hygiene or Household Maintenance • Bathing and Showering • Vacuuming

13. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E014.0 – E014.9 • Person Providing Caregiving • E015.0 – E015.9 • Food Preparation, Cooking and Grilling • E016.0 – E016.9 • Property and Land Maintenance • E017.0 – E017.9 • Roller Coasters and Other Types of External Motion

14. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E018.0 – E018.9 • Playing a Musical Instrument • E019.0 – E019.9 • Animal Care • E016.0 – E016.9 • Property and Land Maintenance • E017.0 – E017.9 • Roller Coasters and Other Types of External Motion

15. 2010 Diagnosis Code Changes • E Codes • Activities Involving: • E018.0 – E018.9 • Playing a Musical Instrument • E019.0 – E019.9 • Animal Care • E029.0 – E029.9 • Other Activity • Refereeing a sports activity • Spectator at a sports activity • Rough housing or horseplay • E 990.0 - E998.9 • Military / War Operations

16. 2010 Diagnosis Code Changes • V Codes – 33 New Codes • Personal History: • V10.90 – V15.83 • Unspecified Malignant neoplasm • Other Personal History Presenting Hazards to Health; Injury; • Traumatic Brain Injury • Failed Moderate Sedation • Under-immunization Status • V20.31 – V20.32 • Health supervision of infant or child • V26.42 – V26.82 • Procreative management – fertility preservation procedure • V53.50 – V53.9 • Fitting and adjustment of intestinal appliance and device • Lap Band • V60.81 – V60.89 • Housing, Household and Economic Circumstances; Foster Care (Status) • V61.07 – V61.42 • Other Family Circumstances; Parent-Child Problems

17. 2010 Diagnosis Code Changes • V Codes – 33 New Codes • Personal History: • V60.81 – V60.89 • Housing, Household and Economic Circumstances; Foster Care (Status) • V61.07 – V61.42 • Other Family Circumstances; Parent-Child Problems • V72.60 – V72.69 • Special Investigations and Examinations • Laboratory • V80.01 – V80.09 • Special Screening for Neurological, Eye and Ear Diseases • V87.32 – V87.46 • Other Specified Personal Exposures and History Presenting Hazards to Health • Estrogen Therapy • Steroid Therapy

18. 2010 CPT CODE CHANGES CPT Changes Effective 1/1/10 159 New Codes 66 Deleted Codes

19. 2010 CPT CODE CHANGES • Integumentary – 2 New Codes • Musculoskeletal – 42 New Codes • Excision of Soft Tissue Tumors • Radical Resection of Soft Tissue Tumors • Codes 21011 – 28047 • Respiratory– 14 New Codes • Bronchoscopy – 2 New Codes (31626 & 31627) • Instillation(s), via Chest Tube/Catheter, Agent for Fibrinolysis (32561 & 32562) • Replacement of Ventricular Assist Device (33981 – 33983)

20. 2010 CPT CODE CHANGES • Digestive – 7 New Codes • Laparoscopy, Repair of Paraesophageal Hernia (43281 & 43282) • Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (43775) • Urinary – 3 New Codes • Complex Cystometrogram; with Voiding Pressure Studies (51727 – 51729) • Male Genitourinary – 1 New Code • Female Genitourinary – 1 New Code

21. 2010 CPT CODE CHANGES • Nervous – 10 New Codes • Removal of Spinal Neurostimulator Electrode • Revision Including Replacement of Spinal Neurostimulator Electrode • CPT Codes 63661 – 63664 • Injection(s), Diagnostic or Therapeutic Agent, Paravertebral Facet Joint • CPT Codes 64490 - 64495

22. 2010 CPT CODE CHANGES • Radiology – 14 New Codes • CT, Colonography (74261 & 74262) • CT, Heart (Previously Category III Codes) • CPT Codes 75565 – 75574 • Myocardial Perfusion Imaging • CPT Codes 78451 - 78454 • Pathology & Lab – 15 Codes

23. 2010 CPT CODE CHANGES • Medicine – 10 New Codes • AMA announced on 9/28/09 that they have created a new code specific to vaccine administration and revised existing code 90663 to include the H1N1 vaccine • 90470 – H1N1 Immunization Administration (intramuscular, intranasal) Including Counseling When Performed • 90663 – Influenza Virus Vaccine, Pandemic Formulation, H1N1

24. 2010 CPT CODE CHANGES • Category III Codes – 20 New Codes • Sleep Study – Unattended (0203T – 0204T) • Audiometry (0208T – 0212T) • Injections, Diagnostic or Therapeutic Agent, Paravertebral Facet Joint With Ultrasound Guidance (0213T – 0218T) • Placement of Posterior Intrafacet Implant(s) (0219T – 0222T)

25. 2010 CPT CODE CHANGES • Category II Codes – 21 Codes • F Codes (Quality Measures) • Plan for follow-up care for major depressive disorder, documented (0545F) • Seizure type(s) and current seizure frequency, documented (1200F) • Etiology of epilepsy or epilepsy syndrome(s) reviewed and documented (1205F) • Patient interviewed directly by evaluating clinician on or before date of diagnosis of major depressive disorder (2060F) • Body Mass Index (BMI), documented (3008F) • Cervical cancer screening results documented and reviewed (3015F)

26. 2010 CPT CODE CHANGES • Category II Codes • F Codes (Quality Measures) • Pulmonary function test performed within 12 months prior to surgery (3038F) • ABO and Rh blood typing documented as performed (3293F) • Group B Streptococcus screening documented as performed during week 35-37 gestation (3294F) • Clinical tumor, node and metastases staging documented and reviewed prior to surgery (Lung/Esop Cx) (3323F) • MRI or CT scan ordered, reviewed or requested (3324F) • Performance status documented and reviewed within 2 weeks prior to surgery (Lung/Esop Cx) (3328F)

27. 2010 CPT CODE CHANGES • Category II Codes • F Codes (Quality Measures) • EEG ordered, reviewed or requested (3650F) • Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user (4004F) • Antidepressant pharmacotherapy considered and not prescribed (4063F) • Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record (4255F) • Duration of general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record (4256F)

28. 2010 CPT CODE CHANGES • Category II Codes • F Codes (Quality Measures) • Counseling about epilepsy specific safety issues provided to patient or caregiver (4330F) • Counseling for women of childbearing potential with epilepsy (4340F) • Consideration of referral for a neurological evaluation of appropriateness for surgical therapy for intractable epilepsy within the past 3 years (5200F) • Patient queried and counseled about anti-epileptic drug side effects (6070F)

29. CMS ENROLLMENT FORMS • Effective 11/30/09 • Must use new CMS-855I (for physicians and non-physicians) and CMS-855B (for medical groups and clinics) • Identify the new forms by looking for the revision date of (02/08) (EF 07/09) in the bottom-left corner • Older versions of the forms with (02/08) only in the bottom-left corner will be denied after 11/30/09

30. Preparing for the RACs • RAC Audits • RACs do not do random reviews • Audit targets are based on: • Data mining • Aberrant billing patterns • Experience of RAC auditors • Many are former Medicare contractor auditors

31. Preparing for the RACs • Identify Risk Areas • Review many risk areas and billing errors such as: • Physical Therapy • PT re-evaluations conducted 30 days after initial evaluation and every 30 days after • Cannot be billed as a matter of routine • Must have documented medical necessity • More than one modality • Each modality reported in units (based on time) • Number of minutes in chart must correspond to the units on the claim • Incorrectly Applying Modifier 59 to Override CCI Edit • Pharmacy and Drug Administration • i.e. Neulasta – drug that reduces the risk of infection in cancer patients • Commonly reported with a chemotherapy drug administration code rather than a therapeutic administration code which creates an overpayment • Drugs are high volume and high dollar • Documentation • Documentation must be carefully maintained in the medical records

32. Office of Inspector General (OIG) Physician Work Plan Physician OIG Work Plan for 2010 • E-Prescribing Incentive Programs • Review of e-prescribing payments will help the OIG prepare for reviews of the even larger incentive programs that will be handed out in the future for implementing electronic medical records (EMR) • Medicare Practice Expenses Incurred by Selected Physician Specialties • Medical & Surgical Procedures • Office Visits & Consultations • Determine whether Medicare payments for physician services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing services and operating their practices

33. Office of Inspector General (OIG) Physician Work Plan • Physicians’ Medicare Services Performed by Non-Physicians • Overutilization of “Incident-to” • Examine the qualifications of non-physician staff that perform “incident-to” services and assess whether these qualifications are consistent with professionally recognized standards of care • Referrals from Excluded Providers • CMS allowed physicians to use their own NPI on claims in place of an ordering or referring physician who didn’t have an NPI or was unable to obtain it • OIG to look for claims that were ordered or referred by a provider excluded from Medicare

34. Office of Inspector General (OIG) Physician Work Plan • Place of Service (POS) Errors • Medicare pays a a physician a higher amount when the service is performed in a non-facility setting • OIG to determine whether physicians properly coded the POS on claims for services provided in ASC’s and hospital outpatient departments • Pain Management • Transforaminal Epidural Injections • Payments increased by 130% between 2003 & 2007 • OIG reviewing for medical necessity • Mismatches Between Date of Service and Date of Death • To review claims and make recommendations to CMS on how they can improve their review process

35. Office of Inspector General (OIG) Hospital Work Plan Hospital OIG Work Plan for 2010 • Hospital Ownership of Physician Practices • To determine whether hospitals have met the Federal requirements to obtain the provider-based designation • To assess the impact of the increased cost to Medicare • Reimbursement under OPPS for physician services in provider-based practices • To determine the extent to which hospital-owned physician practices without provider-based designation improperly received reimbursement under OPPS

36. Office of Inspector General (OIG) Hospital Work Plan • Payments for Diagnostic X-Rays in Hospital Emergency Departments (ED) • Potential overuse of diagnostic imaging services • Continuing to Review: • Coding & Documentation Changes Under the Medicare Severity Diagnosis Related Group System (MS-DRG) • Determine if specific MS-DRG’s are being upcoded • Serious Medical Errors (“Never Events”) • Review key issues, policies and practices regarding never events in hospitals “The material contained in this presentation is for general information and should not be acted upon without prior professional consultation.”