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PCS Coding 2

Intro to E&M

Documentation

and Coding 3-4

The Dialysis

Circuit 4

RMC News 6-7

Vol.7 Issue 2 2nd Quarter 2017

I N S I D E T H I S I S S U E :

Effective Leadership in your CDI Program By Barb Brant MPA, RN, CDIP, CCDS, CCS

In May 2017, the Association of Clinical Documentation Improvement Specialists (ACDIS)

published a position paper called, “Developing effective CDI leadership: Amatter of effort

and attitude”. This position paper addresses the widespread concerns, frustrations, and

challenges that clinical documentation specialists face in their day-to-day roles. However,

while acknowledging the challenges clinical documentation improvement (CDI)

professionals face, the position paper also provides a 5-step process CDI leaders can follow

to overcome these challenges.

Here are some excerpts on ACDIS’s outlined 5-step process for effective leadership:

Step 1: Establish your mission, values, and goals. This means developing your own values,

comparable to a personal mission statement. A leader should be able to identify what their

leadership skills are such as accountability, reliability, teamwork, and excellence. The article

encourages leaders to actually write out a personal mission statement identifying these

leadership qualities and how they are applied on the job.

Step 2: Establish your department’s mission and goals. This step cannot be done in isolation

and a CDI leader needs to understand the organizational expectations from the CDI program.

The mission and goals should be outlined in the SMARTER format: specific, measureable,

attainable, realistic, timely, evaluation, reviewed. The departmental mission statement

should answer three questions: what do we do, whom do we do it for, and how do we do

what we do?

Step 3: Recognize your strengths and weaknesses. This involves looking at the current CDI

program situation and identifying any gaps. Gaps can be in identified such as lack of

enthusiasm for staff, increased educational needs, or unmet requests for assist from other

departments. The mission statement for the program can assist with identifying any gaps in

the program. Short and long term program goals can then be developed.

Step 4: Building a guiding coalition. This process requires support from all those that are

impacted by the CDI program such as HIM leaders, physicians, nurses, ancillary

departments, and senior medical leadership. An example of this would be collaborating with

dietitians for development of queries and criteria for physician education. Another example

would be regular meetings with coding staff discussing AHA Coding Clinic or Official

Coding Guideline updates and/or any changes with the CDI staff.

Step 5: Monitor your progress and share your experiences. Tracking improvements and

milestones is necessary to identify program growth and will encourage a sense of accom-

plishment for the CDI staff. This process should also be shown to other departments so other

leaders in the organization will understand the reason for their involvement with the CDI

program. Continued...

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In summary, the challenges CDI professionals experience should not discourage them from feeling a sense of pride in their roles.

It is imperative for CDI leaders to be effective and listen to these struggles, take action, and align goals which meet the needs of

the overall organization and the CDI staff.

As we move into 2017-2018, we can see the coding progress that we’ve made. Though there were many horror stories about

how productivity would likely drop by as much as 50% with the implementation of ICD-10, studies show that hasn’t been the

case. Our productivity levels have rebounded, as well as our accuracy, as we have moved beyond the basics and gained a

comfort level with the more challenging parts of our job. We have a much better overall understanding of ICD-10 codes and

we’ve seen the addition of many Coding Clinics this past year which has provided additional guidance. However, we are still

seeing a need for additional provider education to document the specificity we need for coding and we’ve been helped along the

way by an increase in the number of clinical documentation improvement (CDI) programs.

In the presentation, we talk about what’s changed for 2017-2018 including new tables, devices, and body part values. We’ve

seen a number of changes across the board especially in the way of new PCS codes.

Two root operations, control and creation, went through a change in description, expanding the way the root operations are used.

This year also brought a major overhaul to the cardiovascular system including the way we count the number of sites when

coding angioplasty and bypass procedures. New devices codes were also added for coronary and peripheral arteries procedures,

endografts to treat aneurysms, intra-cardiac pacemaker, and the addition of a zooplastic tissue substitute qualifier.

Coding of joint replacements saw updated body part values for hip and knee procedures. Additionally, AHA Coding Clinic

provided clarification on qualifiers for joint replacements. Coding Clinic also provided much needed advice on take down and

creation of colostomies/ileostomies procedures as well as advice on the different types of stomas we may see while coding.

As many coders still struggle with assigning the approach, we’ve provided some clues to look for. These clues include the

following:

Know the intent or objective of the procedure. What is the physician’s rationale or reason for performing the

procedure; what clues can be found in the body of the report? Procedures such as paracentesis, thoracentesis, and

laminectomy with discectomy may have multiple intents so clues as well as precise documentation are critical.

Is the procedure considered therapeutic (removing fluid from the lung to make the patient’s breathing more

comfortable), diagnostic (is that lung mass a benign lesion or cancer), or eradicating/treating disease

(removing the colon to cure the patient’s sigmoid carcinoma)?

Use your body part references, including the body part key in the back of the ICD-10 PCS codebook and reliable on-

line sources including graphics. Review and know the body part guidelines including those related to separate body

part values (fingers and toes), upper and lower intestinal tract, prefix “peri”, branches of body parts, and contralateral

body parts.

Know the difference when coding procedures performed on supporting structures near a joint (tendons, ligaments,

bursae) and the different layers that may be involved in a procedure (skin, subcutaneous tissue and fascia, muscle,

bone).

Refresher on qualifiers (diagnostic, vertical, bifurcation, bypassed to and from) and device guidelines (what qualifies as

a device, device key, materials that are integral to the main procedure) help keep all of us on the right tract.

Some procedures such as lavage, brushing and biopsies, lavage versus extraction, and non-excisional debridement continue to be

problematic.

“Effective Leadership in CDI” continued...

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PCS Coding By Karen Stokes, CCS

Karen Stokes, CCS is RMC’s Senior Coding Auditor, and joined RMC in 2015. Karen has been working in the field of HIM for more than 25 years. With a background in both physician offices and hospitals, Karen has over 15 years inpatient coding and auditing experience.

Karen has extensive experience coding, auditing, educating and training. Karen has worked and/or provided services for a variety of facilities

across the country. With a focus on working closely with coders, Karen transitioned to an auditing and education role in 2012. Karen is an AHIMA approved ICD-10-CM and ICD-10-PCS Train the Trainer, and has been actively involved with RMC’s ICD-10 Training and

education program. Karen resides in Florida and can be reached at kstokes@rmcinc.org

Barb Brant, MPA, BSN, RN, CCS, CDIP, CCDS is RMC’s Senior Clinical Documentation Specialist and Auditing Consultant, joining RMC in 2016. Barb received her BS in Nursing at York College of PA, and her Master’s in Public Administration at Pennsylvania State

University. In addition to her nursing background, Barb has extensive experience in Clinical Documentation Improvement. Barb has lead in

the development, implementation, auditing and performance improvement efforts of numerous CDI programs. Additionally, Barb assisted health systems with ICD-10 Gap Analyses by creating and presenting ICD-10 CM educational materials for physicians, coders and CDI

specialists. For RMC Barb has provided CDI services, chart documentation analyses, and clinical direction for coding reviews. Barb resides

in Camp Hill, PA and can be reached at BBrant@rmcinc.org.

Introduction to Evaluation & Management Documentation and Coding By Monique Vanderhoof RHIT, CPC, CCA, CRC

Proper Evaluation and Management (E&M) coding is important for accurate and timely claims review and payment, but any

E&M coder knows that proper documentation is key to accurate coding. E&M coding is one of the most difficult coding

concepts to master! Provider documentation can vary greatly but then again, so can interpretation of the E&M guidelines.

According to CMS, in 2014 over 50% of hospital visits and between 8-15% of office visits contained coding errors. Many of

these errors were due to insufficient documentation and no proof of medical necessity. Too often we see a chief complaint listed

as “recheck” or “follow-up” without any elaboration of symptoms, diagnosis, etc. This simple statement does not meet medical

necessity and leaves the documentation lacking right from the beginning. Here are some helpful terms/concepts to help you

increase your knowledge of E&M coding.

New vs Established Patient - Many E&M codes distinguish between a new vs. an established patient.

New Patient = Any patient that has NOT received professional services from the provider or another provider of the

exact same specialty who belongs to the same group practice within the past 3 years.

Established Patient = Any patient that has received professional services from the provider or another provider of the

exact same specialty who belongs to the same group practice within the past 3 years.

Chief Complaint – Explanation or concise statement describing the symptom, problem, condition, diagnosis or other reason

why a patient presented to your office/facility. *Establishes medical necessity!

History of Present Illness (HPI) – Description of how a patient developed the present illness, from first sign/symptom to the

present. Used to determine the extent of exam and medical decision making necessary. Includes information about Location,

Duration, Timing, Severity, Quality, Context, Modifying Factors, and Associated Signs & Symptoms.

Review of Systems (ROS) – An inventory of up to 14 body systems obtained by asking a series of questions in order to better

define the problem, clarify the diagnosis, identify any necessary tests, or define a baseline.

Past, Family, and Social History (PFSH) –

Past History = Information about a patient’s past illnesses, allergies, operations, injuries, current medications, etc.

Family History = Information about medical events, diseases, and hereditary conditions in a patient’s blood relatives

that place a patient at risk.

Social History = Information about a patient’s social habits, such as use of drugs/alcohol/tobacco, marital status,

living arrangements, occupation, etc.

Physical Exam – Two sets of guidelines that can be followed.

1995 Guidelines

Count the number of organ systems/body areas

Single system exams are not well defined

Better for general examinations

1997 Guidelines

Count the number of elements (bullets) performed

Single system exams are well defined

Better for specialty exams

Most often used to build EHR templates

Medical Decision Making (MDM) – The provider’s mental and physical work based on the presenting problem. Driven by the

nature of the presenting problem(s) and how the problem(s) are addressed. There are three main elements to MDM.

Number of possible diagnoses and/or treatment options

Risk of complications and/or morbidity or mortality associated with the presenting problem(s) and/or possible treat-

ment options.

Amount and complexity of data to be analyzed.

Two out of three of the elements above must meet or exceed criteria to choose the appropriate level of E&M code. The four

levels of MDM are:

Straightforward

Low Complexity

Moderate Complexity

High Complexity

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Continued...

This basic terminology should help you begin to understand E&M coding, but there is so much more to it! Want more detailed

information? Need help with E&M coding in your facility? Give us a call and let us help you out!

You have probably noticed that there was a significant change when coding dialysis interventions in Current Procedural Termi-

nology (CPT) for 2017! As a result of a survey performed by the CPT Editorial Panel and the RVS Update Committee (RUC),

nine new codes were created. The survey looked at frequently billed arteriovenous (AV) graft and fistula intervention codes and

determined that combination codes would be a welcome change.

What is a dialysis circuit?

The dialysis circuit begins at the arterial anastomosis and extends to the right atrium. It is further divided into two segments;

peripheral and central. The dialysis circuit codes include interventions performed within both AV fistula and AV grafts.

We have a base code!

CPT 36901 is the base code. Additional codes are based on a hierarchy where codes containing more intensive services, such as

stent placement, include services provided within less intensive codes. Only one code is required to capture the full service

provided. Hooray!

What is included?

All dialysis circuit codes include direct percutaneous access to the circuit, catheterization for performance of fistulograms, angi-

ography, fluoroscopic guidance, roadmapping, radiological supervision & interpretation and closure of the puncture site.

What is not included?

Per CPT, the arterial inflow to the dialysis circuit is considered a separate vessel. If a proximal inflow artery, separate from the

peripheral dialysis segment, requires imaging or intervention, this is separately reportable. Ultrasound guidance for access to the

dialysis circuit and moderate sedation are also not included.

Let’s talk about the peripheral segment interventions. When coding interventions keep in mind that no matter the number of

angioplasties performed or the number of lesions treated, regardless the number of stents placed, only one code is selected per

session, based on the hierarchy. Only one code assigned per encounter or session.

Diagnostic only, see CPT 36901

Diagnostic with angioplasty, see CPT 36902

Diagnostic with angioplasty and stent, see CPT 36903

If thrombectomy or thrombolysis is performed, reference CPT codes 36904-36906. Keep in mind these codes include all the

services in our base code CPT 36901, so you will not report this separately. The thrombectomy codes are also based on the hier-

archy, where stent placement is greater than angioplasty and angioplasty is greater than thrombectomy alone.

If an additional intervention is performed in the central segment you will want to report an add-on code in addition to your

peripheral segment code. We use the same decision tree as the peripheral codes; you will select one code based on the most

intensive intervention performed, no matter the number of angioplasty sites or the number of stents placed.

There is also an add-on code for when permanent embolization or occlusion is performed. CPT 36909 includes occlusions

within the dialysis circuit and is only reported one time per encounter, per day. If the intervention is performed open, you will

want to reference CPT 37607.

Be sure to reference your CPT Manual for additional notes and instructions when assigning Dialysis Circuit intervention codes.

Happy Coding!

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Monique Vanderhoof, RHIT, CPC, CCA, CRC is Director of Coding Services at RMC. Monique started in healthcare in 1993, working in various roles in the clinic setting. Monique’s aptitude for coding and management was noted and Monique quickly ascended to a position as

office manager of a cardiology clinic which she held for 14 years. In 2011 Monique joined RMC as the Manager of the HCC/Risk Adjustment

Division where Monique’s sharp coding skills and management ability was recognized. In 2016 Monique was promoted to Director of Coding Services. In this new role she is directly responsible for all coding services at a large psychiatric hospital. Additionally, Monique retained the

HCC/Risk Adjustment Division, performing audits, coder and provider education. Monique has done an outstanding job at RMC, focusing on

quality services, and excellent customer service. Monique can be reached at moniquev@rmcinc.org.

The Dialysis Circuit By Sarah Reed, RHIT, CCS

“E&M Documentation” continued...

Sarah Reed, RHIT, CCS is RMC’s Senior Outpatient Auditor. Sarah joined RMC in 2013, and has nearly 10 years of experience in the Health Information Management Field. She has a love for all Outpatient Coding, ER, Outpatient, Profee and specializes in SDS. Prior to joining RMC,

Sarah’s past positions include Surgery Coding Specialist, Senior Coding Compliance Auditor and Revenue Integrity Failed Claims Specialist. She

has worked in a variety of acute care hospitals, ranging from a 25-bed critical access hospitals to large multi hospital networks including trauma level 1 teaching hospitals. Sarah is a multi-talented coder, auditor, educator and trainer. Sarah has been actively involved with RMC’s ICD-10

Training and education program. Sarah resides in Oregon and can be reached at sreed@rmcinc.org

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Yep. You read that right. Totally free.

Visit our website: www.rmcinc.org to submit your questions today!

Our new website features a “Coding Questions” button. Submit your question, and one of our

RMC coding experts will reply.

*Also - don’t forget to follow RMC on Facebook, LinkedIn and Twitter. We post coding tips, reminders and updates weekly!

Page 6 C O M P L I A N C E C O N N E C T I O N S

Camille Walker: cwalker@rmcinc.org or Kristin Gibson: kristin@rmcinc.org

RMC is currently looking for experienced, credentialed, hard-working coding experts to join our team.

Positions are all remote, and all RMC staff are issued a company laptop.

Qualified candidates:

Must have a minimum of 5 solid years of coding experience

Must be AHIMA/AAPC credentialed

Must pass RMC's coding test

Must be reliable, friendly and flexible

Full-time AND part-time positions available! Some positions qualify for sign-on bonus!

If you want to join our team and LOVE your job, please send your resume to employment@rmcinc.org