dial-in instructions - hcpro · hip fractures f. urosepsis, ... as president of maps, ... rhia,is a...

$: Dial-In Instructions - HCPro · Hip fractures f. Urosepsis, ... As president of maps, ... RHIA,is a health information consultant for transitional care units in hospitals, skilled$
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Master the 2007 SNF ICD-9 Codesand Most Difficult Coding Scenarios:

Essential Guidance for NursingHome Coding

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ii Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

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iiiMaster the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

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iv Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

Dear Colleague,

Thank you for participating in our "Master the 2007 SNF ICD-9 Codesand Most Difficult Coding Scenarios: Essential Guidance for NursingHome Coding" audioconference with Mary H. Marshall, PhD, and AnneCook, RHIA, moderated by Joanne Finnegan. We are excited about theopportunity to interact with you directly and encourage you to take advan-tage of the opportunity to ask our experts your questions during the audio-conference. If you would like to submit a question before the audioconfer-ence, please send it to [email protected] and provide the programdate in the subject line. We cannot guarantee your question will beanswered during the program, but we will do our best to take a good crosssection of questions.

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vMaster the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Presentation by Anne Cook, RHIA

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Presentation by Mary H. Marshall, PhD

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Outpatient therapy caps: Exceptions process required by the DRASource: Centers for Medicare & Medicaid Services

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Common abbreviations, provided by Mary H. Marshall, PhD

Exhibit E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53Diagnosis history sheet, provided by Anne Cook, RHIA

Exhibit F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55Medicare communication worksheet, provided by Anne Cook, RHIA

Exhibit G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57UB-92 Form provided by HCPro, Inc.

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

Contents

vi Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

Agenda

I. Overview: Using the ICD-9 coding books II. How to use 'V' codesIII. The new 2007 ICD-9 codes explained IV. Case scenarios from the field

a. Infections b. Pneumonia c. UTIs d. Dehydration e. Hip fractures f. Urosepsis, septicemia, and sepsis

V. Definitions of primary and principal diagnoses

VI. Coding importance to MDS, billing, and therapy

VII. Coding process from admission to billing a. Impact of flow for the SNF b. Resolving codes

VIII. Part B coding for the therapy cap exceptions a. Coverage b. Complexities c. KX modifier

IX. Live Q&A

viiMaster the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

Speaker profiles

Mary H. Marshall, PhD

Mary H. Marshall has over twenty-five years’ experience in healthcare, including an extensive background inplanning, implementation, and management of healthcare services and programs. Marshall is president ofManagement and Planning Services, Inc. (maps), a national healthcare consulting firm based in FernandinaBeach, FL. As president of maps, her involvement with her clients gives her a unique opportunity to understandfully the daily operations and challenges of managing a skilled nursing facility or a rehabilitation company.

She consults and speaks throughout the U.S. on business startup, practice management, operations, billing,reimbursement, Medicare, and Medicaid. Medicare is a specialty focus for her. She has worked with programsin long-term care since 1974. She contributes regularly to professional publications on marketing, trade topics,management, regulation compliance, Medicare, Medicaid, managed care, and rehabilitation.

Anne Cook, RHIA

Anne Cook, RHIA, is a health information consultant for transitional care units in hospitals, skilled nursing facilities, and dialysis centers. Cook conducts workshops on ICD-9 coding, HIPAA, and records managementsystems throughout the southeastern U.S. She also contributes to professional publications on ICD-9 codingissues.

Exhibit A

Presentation by Anne Cook, RHIA

EXHIBIT A

2 Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

HCPRO Audio Conference

Master 2007 SNF ICD-9 Codes

and most Difficult Coding Scenarios:Essential Guidance for Nursing Facility

Coding

August 23, 2006

Why do we code?

• Internal uses

– Statistical collection of disease information

– Quality assessment/improvement

– Infection control

– Continuity of care

1

2

3Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding

EXHIBIT A

Introduction to ICD-9 CM

• ICD-9:

– International Classification of Diseases

– 9th revision, clinical modification

• Published by W.H.O. (World Health

Organization)

• Used internationally to communicate

disease/procedure data

Introduction to ICD-9 CM

• FYI…10th revision, ICD-10 is being

developed/discussed for future implementation

• Date effective TBD- possibly 2007

3

4

EXHIBIT A


The Coding Book

• ICD-9 CM coding book arrangement

– Note that different publishers may have variations to

punctuation and color coding within the ICD-9 CM

coding book but codes and descriptions are standard

regardless of publisher

Volume 1 Tabular List

• Introduction

– Volume 1 Tabular List of Diseases and Injuries:

• Numerical list of codes

• 17 chapters-by body system

• Supplementary classifications

– E codes

– V codes

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EXHIBIT A

Volume 2 Index to Diseases

• Introduction

– Volume 2 Index to Disease:

• Alphabetical list of conditions

• Hypertension Table

• Neoplasm Table

• Table of Drugs and Chemicals

• Index to External Causes of Injury and Poisoning (E codes)

Volume 3 Index and Tabular List

of Procedures

• Introduction

– Volume 3 Alphabetical index and Tabular list of

Procedures

– ICD-9 procedure codes are NOT used by LTC

facilities- Do not assign codes from this section

– All procedure codes have xx.xx 2 digits before the

decimal point

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EXHIBIT A


Code Assignment

When searching in the index to Disease (alpha

Index):

• Review the diagnostic statement

• Identify the main term which are diseases or

conditions and are often nouns

• Do not start with anatomical site

• Generally, review diagnostic statement from right

to left

Code Assignment

Example: COPD

Chronic Obstructive Pulmonary Disease

•Start with diseases

•Then, pulmonary

•Next, obstructive

•Last, chronic

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10


EXHIBIT A

Structure of Codes

• Sections are groups of 3 digit codes

• Categories are 3 digit codes

• Subcategories are 4 digit codes

• 5th digit sub-classifications are 5 digit codes

• ICD-9 codes should be used at their highest

level of specificity or highest number of digits

available

Steps to Accurate Coding

• Locate the main term in the diagnostic statement

• Locate that same main term in the Alphabetic

Index

• Refer to all notes under the main term

• Examine any modifiers in parentheses

• Carefully follow the sub-terms indented under

the main term

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EXHIBIT A


Steps to Accurate Coding

• Follow any cross reference instructions

• CONFIRM THE CODE IN THE TABULAR LIST

• Read and be guided by instructions in the

Tabular List

• Assign the code number

V-Coding

• Supplementary Classification of factors

influencing health status and contact with health

services

• Official Coding Guidelines allow the use of V

codes

• Coding Clinic Dec. 1999 advises the use of V

codes for LTC

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EXHIBIT A

V Codes (V01-V85)

• Assign a V code as the main reason for the

resident’s admission when it is for:

– Rehab services (V57)

– Fracture aftercare (V54)

– Aftercare surgery (V58)

V Codes (V01-V85)

• Assign a V code as a secondary dx when:

– Drug resistance is present (V09)

– S/P or History that interacts or affects the current care

of the resident (V10-V15 = personal HX, V16-V19 =

family HX)

– Attention and management of openings (V55)

– Organ replacement status (V42 or V43)

– Acquired absence of organ/body part (V49.7x)

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EXHIBIT A


V Codes (V01-V85)

• Assign a V code as a secondary dx when:

– Other conditions influencing health status, eg.

Amputations (V49.7x)

– Long term use of drug (current) (V58.6x)

V Codes (V01-V85)

• Key words for locating V codes:

– Absence

– Admission for

– Aftercare

– Attention to

– History of

– Replacement

– Resistance

– Status post

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EXHIBIT A

Aftercare V Codes

• Aftercare visit code situations:

– When initial treatment of disease or injury has been

performed at hospital

– Patient requires continued care during the healing or

recovery phase, or for the long-term consequences of

the disease

• Aftercare V code should not be used if

treatment is directed at a current, acute disease

or injury; the diagnosis code is to be used in

these cases

Tips on Coding Wounds

879.8 Open Wound (Injury)

998.59 Postoperative wound infection

707.0x Pressure Ulcer (Decubitus)

454.0 Stasis Ulcer of Leg

707.1x Chronic Ulcer secondary to Diabetes

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EXHIBIT A


Tips on Coding Sepsis

• Sepsis as principal or secondary diagnosis:

• Code underlying systemic infection:

Septicemia 038.xx or Candidiasis 112.5 firstfollowed by code 995.91 for Sepsis

• With an underlying condition other thanSepticemia, such as pneumonia or UTI, a Codefrom category 038 must be assigned first, thencode 995.91 followed by code for initial infection

• Codes from subcategory 995.9 can never beused as a principal diagnosis

Tips on Coding Severe Sepsis

• Follow same rules for Sepsis but change 5th digit

to indicate organ dysfunction 995.92

• Codes for organ dysfunctions must be assigned

also

Acute respiratory failure: 518.81

Septic shock: 785.52

Acute renal failure: 584.5-584.9

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EXHIBIT A

2007 ICD-9 Codes that impact

SNFs (effective 10/1/2006)

• Mild Cognitive Impairment: 331.83

• Acute Dystonia: 337.72

• Acquired Torsion Dystonia: 333.79

• Subacute dyskinesia due to drugs: 333.85

• Central Pain Syndrome: 338.0

• Acute pain due to trauma: 338.11

• Acute postthoracotomy pain: 338.12

• Chronic postthoracotomy pain: 338.18



• Other acute pain: 338.19

• Chronic pain due to trauma: 338.21

• Other chronic pain: 338.28

• Neoplasm related pain: 338.3

• Chronic pain syndrome: 338.4

• Acute bronchospasm: 519.11

• Other diseases of bronchus and trachea: 519.19

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2007 ICD-9 Codes that impactSNFs (effective 10/1/2006)


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EXHIBIT A




• Complex febrile convulsions: 780.32

• Generalized pain: 780.96

• Altered mental status: 780.97

• Postnasal drip: 784.91

• Urinary hesitancy: 788.64

• Straining on urination: 788.65

• Aftercare for change or removal of nonsurgical

wound dressing: V58.30

• Aftercare for change or removal of surgical

wound dressing: V58.31

Case Scenarios: Psychiatric

Situation

• Resident admitted to SNF after a qualifying

hospital stay for the treatment of delirium,

hallucinations and depression secondary to

vascular dementia. Resident is also blind

secondary to Diabetes and takes Insulin daily.

Receiving physical therapy for generalized

weakness


Case Scenarios: PsychiatricSituation

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EXHIBIT A

Case Scenario: Psychiatric

Situation (continued)

• 290.41 – Vascular dementia with delirium

• 290.42 – Vascular dementia with depression

• 780.79 – Generalized weakness

• V57.1 – Aftercare involving physical therapy

• 250.50 – Diabetes with ophthalmic

manifistations

• V58.67 – Current use of insulin

• 369.4 – Blindness

Case Scenario: Infection with

antibiotics

• Resident readmitted to SNF after qualifying

hospital stay with diagnosis of aspiration

pneumonia due to dysphagia secondary to

Alzheimer’s dementia. Resident continued to

receive antibiotics and was also receiving

physical and speech therapies for generalized

weakness and dysphagia.

Case Scenarios: PsychiatricSituation (continued)

Case Scenario: Infection withantibiotics

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EXHIBIT A



antibiotics (continued)

• 507.0 – Aspiration pneumonia

• 787.2 – Dysphagia


• V57.89 – Aftercare involving multiple therapies

• 294.10 – Dementia in condition classified

elsewhere without behavioral disturbance

• 331.0 – Alzheimer’s disease


antibiotics (continued)

• 507.0 – Aspiration pneumonia

• 787.2 – Dysphagia


• V57.89 – Aftercare involving multiple therapies

• 294.10 – Dementia in condition classified

elsewhere without behavioral disturbance

• 331.0 – Alzheimer’s disease

Case Scenario: Infection withantibiotics (continued)

29

Case Scenario:

Infection without antibiotics

Residents readmitted to SNF after a qualifying

hospital stay with diagnosis of UTI but was not

receiving antibiotics. Resident is receiving physical

therapy for generalized weakness.

V57.1 – Aftercare involving physical therapy

V13.02 – History of UTI

780.79 – Generalized weakness

Case Scenario: Infection without antibiotics

30


EXHIBIT A

Case Scenario: Dehydration

Resident admitted to SNF after qualifying

hospital stay with diagnosis of dehydration and

malnutrition. Gastronomy tube was surgically

inserted. Resident is receiving physical therapy

for generalized weakness.

• V55.1 - Attention to Gastrostomy

• V12.2 – History of metabolic disorder

• V57.1 – Aftercare involving physical therapy


OR

Case Scenario:

Dehydration (continued)

• 276.51 – Dehydration

• 263.9 – Malnutrition

• V55.1 – Attention to gastronomy

• V57.1 – Aftercare involving physical

therapy


Gastrostomy

31

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Gastrostomy

EXHIBIT A


Case Scenario: Hip Fracture

Resident admitted to SNF after qualifying hospitalstay for aftercare of healing traumatic hip fracturesecondary to fall at home. ORIF surgeryperformed. Resident is receiving aftercareinvolving gait training from physical therapist.

• V54.13 – Aftercare of healing traumatic hip fracture

• V15.88 – History of fall

• V58.78 – Aftercare following surgery to musculoskeletal system

• V57.1 – Aftercare involving gait training from physical therapy

Definition of principal (Primary)

diagnosis in federal register

Primary (principal) diagnosis is defined in the

Uniform Hospital Discharge Data Set (UHDDS)

as “That condition established after study to be

chiefly responsible for occasioning the

admission of the patient to the hospital for care.”

(Federal Register July 21, 1985)

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EXHIBIT A

Definition of principal (Primary)

diagnosis in federal register

(continued)

Since that time, the application of the UHDDS

definition has been expanded to include all non-

outpatient settings (Acute care, Short-Term,

Long-Term and psychiatric hospitals; Home

health agencies; Rehab facilities; Nursing

Homes, etc.)

Definition of principal diagnosis

for SNF Medicare billing

When it comes to the UB-92, Reference Section

50 of the SNF Manual defines Field 67 (Principal

Diagnosis) as the condition for which the

resident was admitted or readmitted to a SNF to

receive skilled services and must be one of the

conditions or a related condition for which the

resident received hospital care during the

qualifying hospital stay.

35

36

Exhibit B

Presentation by Mary H. Marshall, PhD


EXHIBIT B

OUTLINE

VI. CODING IMPORTANCE TO BILLING, MDS, AND

THERAPY

VII. CODING PROCESS

VIII. PART B CODING FOR THERAPY CAP

EXCEPTIONS

THE TEAM

MUST WORKTOGETHER

EXCEPTIONS

Agenda continuation

1

2

EXHIBIT B


SECTION VI

CODING IMPORTANCE

� ADMISSIONS

� MDS

� BILLING

� THERAPY

CODING IMPORTANCE

� Coding reflects conditions that affect the resident’s current

ADL status, mood and behavioral status, medical

treatments, nursing monitoring or risk of death.

� Coding reflects conditions that support the reasons that the

resident is being covered for Medicare.

3

4


EXHIBIT B

CODING IMPORTANCE

ADMISSIONS

� Identify the reasons for Medicare coverage.

� Order the reasons related to the conditions in the hospitaland the level of importance in supporting the Medicarelevel of care (LOC).

� Obtain the ICD-9 codes from the Medical RecordsCoordinator or Coder.

CODING IMPORTANCE

MDS

� Must be diagnosis codes to support the other information on

the assessment

� Codes must be related to the resident’s current conditions

that drive the care plan.

� Ensure that each code has a physician documented

diagnosis in the clinical record. Physician involvement in

coding is critical.

5

6

EXHIBIT B


CODING IMPORTANCE

MDS

� Do not include conditions that have been resolved or no

longer affect the resident’s functioning or care plan.

� Only include the “active” diagnosis that generate an

updated, accurate picture of the resident's health status.

CODING IMPORTANCE

BILLING

� Must support the services that are billed on the UB-92

� Must be updated as conditions change

� Must reflect the key reasons for which the resident isbeing covered for Medicare.

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EXHIBIT B

CODING IMPORTANCE

BILLING

� Principal diagnosis is defined as the chief condition forwhich the resident was admitted to the SNF (Medicare).Should be one of the conditions or a related condition forwhich the resident was in the hospital.

� Other diagnoses are codes which help support coverage.

CODING IMPORTANCE

BILLING

� Must be ordered to reflect the primary and other reasons

that the resident qualifies for Medicare coverage.

� When the narrative of the codes is written, a picture of

the resident's condition, which supports coverage is

clear.

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10

EXHIBIT B


CODING IMPORTANCE

BILLING

� Identify codes that trigger the rejection of a claim andbring to the attention of medical records coordinator orfacility coder.

� Remember: Inaccurate coding can trigger a suspension orrejection of a claim resulting in delayed payments.

CODING IMPORTANCE

THERAPY

� Must have medical and treatment diagnoses.

� Medical Diagnosis. Resulted in the therapy disorder and

most closely relates to the current POC for therapy. May

change related to an acute condition or exacerbation of a

secondary diagnosis requiring intensive services not

identified on initial or previous POC.

11

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EXHIBIT B

CODING IMPORTANCE

THERAPY

� Treatment Diagnosis. Diagnosis supporting the therapy

services. E.g. CVA may be the primary medical diagnosis,

but aphasia may be the SLP treatment diagnosis.

� Reference the list of therapy diagnosis from A. Cook, as

well as the codes listed in the guidelines for therapy cap

exceptions. All in the Exhibits.

CODING IMPORTANCE

THERAPY

� Must support that the level of complexity of services andcondition of the patient require a qualified therapist forservices to be safely and effectively performed.

� Key is -- do the services require the skills of a qualifiedtherapist? ICD-9 codes support the illness or injury(medical condition) requiring these services.

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EXHIBIT B


CODING IMPORTANCE

THERAPY

� Codes should change as the medical condition andservices needed change.

� Codes on all parts of the documentation must agree andflow, e.g. evaluation, plan of care, physician certification,services logs.

� Codes must be reflected on the UB-92 claim form.

CODING IMPORTANCE

RESOURCES

� Long-Term Care Resident Assessment Instrument (RAI)

User’s Manual. Version 2.0. Updated March 2006.

� CMS Pub 100-2, chapter 5, §§220 and 230.

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EXHIBIT B

SECTION VII

CODING PROCESS FROM ADMISSION TO

BILLING

� IMPACT OF FLOW FOR THE SNF

� RESOLVING CODES

CODING PROCESS

IMPACT OF THE CODING FLOW

�Admissions.� Identify and order.

� Assign ICD-9 codes.

� Input into software or communicate to appropriatestaff.

� Discuss at Medicare Meetings.

�MDS� Include in Section I of each assessment.

� May have more codes than are on the UB-92.

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EXHIBIT B


CODING PROCESS


�Therapy

� Identify medical and treatment diagnoses.

� Coordinate with other TEAM members to ensure that

these codes are included on the UB-92, on the MDS

and in the physician's orders.

� Ensure that the therapy codes support and complement

the other diagnoses.

CODING PROCESS


� Ensure that the Care Plan reflects intervention related tothe diagnoses.

� Ensure that there is continuity with the various entities thatare assigning and reviewing codes.

� Resolve and update codes as resident condition changes.

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EXHIBIT B

CODING PROCESS

RESOLVING CODES

� ENOUGH SAID ALREADY!!!!

� CRITICAL THAT CODES ARE ACCURATE FOR THE

RESIDENT’S STAY IN THE SNF.

�CONSEQUENCES:

� Inaccurate MDS assessments.

� Inaccurate documentation

� Inaccurate billing.

� Denied or slowed payments.

SECTION VIII

PART B CODING FOR THE THERAPY CAP

EXCEPTION

� COVERAGE

� CONDITIONS AND COMPLEXITIES

� KX MODIFIER

21

22

EXHIBIT B


PART B THERAPY CAP EXCEPTIONS

This is not a thorough presentation of Part B therapy

cap exceptions. Rather the focus is on the ICD-9

codes that have been published as “complexities”

which support the “automatic” exception process.


COVERAGE – BRIEFLY

� Must be “medically necessary.”

� Must be covered by Medicare.

� Documentation must support the medial necessity.

Reference CMS Pub 100-02, chap 15, §220.3 and CMS

Pub. 100-4, chap. 5, §§10.2 and 20.

� Must be “justification” for continued service.

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24


EXHIBIT B



� ICD-9 codes must support the “medically necessity” andthe “extended” therapy.

� Number of services that can be provided on a given day isnot limited.

� Number of visits or treatment encounters per treatmentday per discipline is not limited.

� Treatment days for PT, OT and SLP are separatelyapproved.



� Exceptions are for current conditions being treated during

this episode of care.

� Even though services may meet criteria for an exception,

they are still subject to “Progressive Corrective Action”

(PCA) and Medical Review to determine services are

covered and appropriately provided.

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26

EXHIBIT B



CONDITIONS AND COMPLEXITIES

“Automatic Exception”

� No specific documentation is submitted to the FiscalIntermediary or Carrier though treatment is for an activecondition and documentation justifies medicallynecessary services above the caps.

� A summary that specifically addresses the “justification”for the therapy cap exception is recommended.




� ICD-9 codes for “conditions” and “complexities” is in theExhibits. Source: CMS Pub. 100-4, chap. 5, §10.2, C3.

� “Conditions” do not have an asterisk (*).

� “Conditions” must be related to the therapy goals andmust directly and significantly impact the rate ofrecovery.

27

28


EXHIBIT B




� “Complexities” are identified on the list with asterisks (*).

� “Complexities,” in combination with other conditions thatare not on the list, will directly and significantly impact therate of recovery of the condition being treated.




� Documentation should indicate that the progress wasaffected by the complexity and the extend services arenecessary.

� Only use ICD-9 codes that describe a specific underlyingcondition or specific body part(s) affected that resulted inthe current episode of care.

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30

EXHIBIT B





� Presence of a diagnosis code on the list does not meanthat all services for the “condition” or “complexity” areexcepted from the caps.

� It is important to understand that most of the conditionon the list would not ordinarily result in servicesexceeding the caps.



“Manual Exception”

� Remember that the documentation of “medical

necessity,” the use of appropriate ICD-9 and CPT-4

codes, documentation of functional gains, the

justification for the need for continued services based

on demonstrated gains and all comments on the

“automatic” exception process should be applied to the

“manual” exception process, as well.

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32


EXHIBIT B



Potential Problems

(Misrepresentation, Abuse and Fraud)

� Routine application for exceptions after the cap.

� Expectation that if the resident’s condition is on the “list”

it will be covered as an exception.



Potential Problems

� Lack of documentation explaining why or how thecomplexity affects treatment.

� Codes that only are used when the services are over thecap.

� Omission of ICD-9 codes on the UB-92 that reflect the“condition” or “complexity.”

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34

EXHIBIT B




Potential Problems

� Functional gains are not clearly documented. These

gains will help support the need for continued service.

“Justification.”

� Lack of documentation before and after the cap is

reached to justify the medical necessity of the services.


“The ‘condition’ or ‘complexity’ mustdirectly and significantly affect thetype, frequency, intensity and/orduration of required, medicallynecessary, skilled services overthe cap.”

35

36


EXHIBIT B


NOTE:

There are also other clinical complexities in addition

to the underlying medical conditions that qualify for

an automatic cap exception. Reference the CMS

Pub. 10-4, chapter 5, §10.2 for detail.


RECOMMENDATION

Carefully audit and review your documentation and

ICD-9 coding. There must be more detail and

support of the “medical necessity” of the treatments

– before and after the therapy caps.

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38

EXHIBIT B



KX MODIFIER, CPT-4 CODES

� KX modifier must be attached to services over the cap.

Modifier alerts the contractor to override a denial for that

service due to the cap.

� CPT-4 (HCPCS Level I) codes continue to be used to

identify the services rendered.


NOTE:

Routine use of the KX modifier for all patients with

the “conditions” on the list will likely show up on data

analysis as aberrant and invite inquiry.

39

40

Exhibit C

Outpatient therapy caps: Exceptions process required by the DRA Source: Centers for Medicare and Medical Services.

reprinted with permission from Mary H. Marshall, PhD

EXHIBIT C


OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA

TopicsSearchMediaReleases

PressReleases

FactSheets

Testimony

Fact SheetFor Immediate Release: Contact:

Wednesday, February 15, 2006 CMS Office of Public Affairs 202-690-6145

For questions about Medicare please call 1-800-MEDICARE or visit www.medicare.gov.


Background: Section 4541 of the Balanced Budget Act of 1997 (BBA) required the Centers for Medicare & Medicaid Services (CMS) to impose financial limitations or caps on outpatient physical, speech-language and occupational therapy services by all providers, other than hospital outpatient departments. The law required a combined cap for physical therapy and speech-language pathology, and a separate cap for occupational therapy. Due to a series of moratoria enacted subsequently to the BBA, the caps were only in effect in 1999 and for a few months in 2003. With the expiration of the most recent moratorium, the caps were reinstated on January 1, 2006 at $1,740 for each cap.

The President signed the Deficit Reduction Act of 2005 (DRA) into law on February 8, 2006. The DRA directs CMS to create a process to allow exceptions to therapy caps for certain medically necessary services provided on or after January 1, 2006. The law mandates that if CMS does not make a decision within 10 days, the services will be deemed to be medically necessary. This fact sheet describes the exceptions process which will be implemented by our claims processing contractors.Until contractors are able to implement the exceptions process, they are required to accept requests for adjustment of claims for services in 2006 that were denied for exceeding the caps.

Exceptions Process: CMS has established an exceptions process that is effective retroactively to January 1, 2006. Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception. In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap.

The exceptions process allows for two types of exceptions to caps for medically necessary services:

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782 (1 of 9)7/27/2006 4:04:08 PM

Search now


EXHIBIT C


� Automatic Exceptions. Automatic exceptions for certain conditions or complexities are allowed without a written request. A request to the contractor for an exception is not required when services related to these conditions and complexities, which are described below, are appropriately provided and documented. We anticipate that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.

� Manual Exceptions. Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims. If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps--the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap. A treatment day is a day on which one or more services are provided. The request must include certain documentation, including a justification for the request. Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days. These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.

Automatic Exceptions to the Therapy Caps: Certain diagnoses qualify for an automatic exception to the therapy caps, if the condition or complexity has a direct and significant impact on the need for course of therapy being provided and the additional treatment is medically necessary. A list of these diagnoses is attached. For a condition or complexity to qualify the beneficiary for an exception to the caps, the therapy must be related to one of the listed conditions.

In addition to conditions, there are clinically complex situations that can justify an automatic exception to the therapy caps for any condition that necessitates skilled therapy services. As in all exceptions, the services rendered above the caps must be documented, covered by Medicare, and medically necessary services. Those complex situations include:

� The beneficiary was discharged from a hospital or skilled nursing facility (SNF) within 30 treatment days of starting this episode of outpatient therapy. The claim should indicate the date of discharge and name of hospital or SNF.

� The beneficiary has, in addition to another disease or condition being treated, generalized musculoskeletal conditions or a condition affecting multiple sites that is not listed as qualifying for an automatic exception that will have a direct and significant impact on the rate of recovery.

� The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will have a direct and significant impact the rate of recovery.

For the above complexities, the provider should include in the documentation all relevant disorders or conditions and describe the impact. For example: A sprained ankle does not qualify for exception by


EXHIBIT C



condition, but if the patient also has a dysfunctional wrist on the opposite side that precludes the use of a cane, it could cause a direct and significant impact on the patient’s need for skilled physical therapy, and might cause services in that calendar year to exceed caps.

� The beneficiary requires physical therapy (PT) and speech-language pathology (SLP) services concurrently. If the combination of the two services causes the cap to be exceeded for necessary

� services, the services are excepted from the PT/SLP cap. There is no effect on the occupational therapy cap.

� The beneficiary had a prior episode of outpatient therapy during this calendar year for a different condition. If services are medically necessary and would be payable under the cap, an exception is allowed if prior use of services for a different condition caused the cap to be exceeded and the medically necessary services to be denied. In cases where the beneficiary was treated in the same year for the same condition, a written request and contractor approval is required for use of the KX modifier if the condition does not qualify for an automatic exception.

� The beneficiary requires this treatment in order to return to a previous place of residence. Document that environment and what is needed to return. For example: “Patient is progressing (see initial and current objective measurement scores) and has a good potential for completing goals for independent use of the toilet which is required for discharge from the nursing home setting and return to the assisted living facility where she resided prior to the stroke.”

� The beneficiary requires this treatment plan in order to reduce Activities of Daily Living assistance or Instrumental Activities of Daily Living assistance to previous levels. Document prior level of independence and current assistance needs.

� The beneficiary indicates he/she does not have access to outpatient hospital therapy services. List reasons that justify why the patient cannot obtain necessary services from a hospital outpatient department. Reasonable justifications include residents of skilled nursing facilities prevented by consolidated billing from accessing hospital services, debilitated patients for whom transportation to the hospital is a physical hardship, or lack of therapy services at hospital in the beneficiary’s county.

Use of Modifier: When services qualify for either an automatic or manual exception, provider/suppliers should add a KX modifier to each line of the claim that contains a service that exceeds caps. This modifier represents the provider/supplier’s attestation of medical necessity. Medical records continue to be subject to review for possible misrepresentation, fraud or patterns of abuse. If the contractor determines that the provider/supplier has inappropriately used the modifier, the provider/supplier may be subject to sanctions resulting from providing inaccurate information on a claim.

Further Information: Further information regarding automatic exceptions and the process for requesting and documenting manual exceptions is published on the CMS website at: www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage.



EXHIBIT C


The therapy caps are discussed in Pub 100-04, chapter 5, section 10.2, Pub.100-8, chapter 3.4.1.2, and Pub 100-02, chapter 15, section 220.3. Other information concerning the process can be found in CR4364, at www.cms.hhs.gov/Transmittals/2006Trans/list.asp#TopOfPage.

ATTACHMENT

Diagnosis Codes That Qualify for an Automatic Exception to the Caps

Note: On this table, conditions are represented in normal type and complexities are bold with asterisks.

ICD-9 Description

V43.64 Joint replacement, hip

V43.65 Joint replacement, knee

V43.61 Joint replacement, shoulder

V49.63-49.67 Upper limb amputation status

V49.73-49.77 Lower limb amputation status

250 – 250.93 Diabetes mellitus*

278.01-278.02 Overweight, Obesity, and other hyperalimentation *

290.0-290.4 Dementias*

294.0-294.9Persistent mental disorders due to contions classified elsewhere*

311 Depressive disorder NEC*

323.0-323.0 Encephalitis, myelitis, and encephalomyelitis*

331.0-331.9 Other cerebral degenerations


EXHIBIT C



332.0-332.1 Parkinson's disease

333.0-333.99 Other extrapyramidal diseases and abnormal movement disorders

334.0-334.9 Spinocerebellar disease

335.0-335.9 Anterior horn cell disease

336.0-336.9 Other diseases of spinal cord

337.20-337.29 Reflex Sympathetic Dystrophy

340 Multiple sclerosis

342.00-342.9 Hemiplegia and Hemiparesis

343.0-343.9 Infantile cerebral palsy

344.00-344.9 Other paralytic syndromes

348.9-348.9 Other conditions of brain

349.0-349.9 Other and unspecified disorders of the nervous system

353-357 Neuropathies

359.0-359.9 Muscular dystrophies and other myopathies

386.0-386.9Vertiginous syndromes and other disorders of vestibular system*

401.0-401.9 Essential Hypertension*

402.00-402.91 Hypertensive heart disease*

414.00-414.9 Other forms of Chronic Ischemic Heart Disease*

415.0-415.19 Acute pulmonary heart disease*

416.0-416.9 Chronic pulmonary heart disease*

427.0-427.9 Cardiac dysrhythmias*



EXHIBIT C


428.0-428.9 Congestive Heart failure*

430-432.9 Intracranial hemorrhages

433.0-434.9Occlusion and stenosis of precerebral and cerebral arteries (forocclusion only)

436 Acute, but ill-defined, cerebrovascular disease

437.0-437.9 Other and ill-defined cerebrovascular disease

438.0-438.9 Late effects of cerebrovascular disease

443.0-443.9 Other peripheral vascular disease*

453.0-453.9 Other venous embolism and thrombosis*

457.0-457.1 Postmastectomy lymphedema syndrome and other lymphedema

478.30-478.5 Disesases of vocal cords or larynx

486 Pneumonia, organism unspecified*

490-496 Chronic Obstructive Pulmonary Diseases*

710.0-710.9 Diffuse diseases of connective tissue

707.99-707.9 Chronic ulcer of skin*

711.00-711.99 Arthropathy associated with infections*

713.0-713.8Arthropathy associated withother discorders classified elsewhere*

714.0-714.9Rheumatoid arthritis and other inflammatory polyarthropathies*

715.09 Osteoarthritis and allied disorders


EXHIBIT C



715.11 Osteoarthritis, localized, primary, shoulder region

715.15 Osteoarthritis, localized, primary, pelvic region and thigh

715.16 Osteoarthritis, localized, primary, lower leg

715.91 Osteoarthritis, unspecified id gen. or local, shoulder

715.96 Osteoarthritis, unspecified if gen. or local, lower leg

718.44 Contracture of hand

718.49 Contracture of joint, multiple sites

719.7 Difficulty walking*

721.91 Spondylosis with myelopathy

723.4 Other disorders of the cervical region, brachia neuritis or radiculitis NOS

724.02 Spinal stenosis, lumbar region

724.3 Other and unspecified disorders of the back, sciatica*

724.4 Other and unspecified disorders of the back, thoracic or lumbosacral neuritis or radiculitis, unspecified*

726.10-726.19 Rotator cuff disorder and allied syndromes

727.61-727.62 rupture of tendon, nontraumatic

733.00 Osteoporosis with wedging of vertebra

780.93 Memory Loss

781.2 Abnormality of gait



EXHIBIT C


781.3 Lack of coordination

781.8 Neurologic neglect syndrome

781.92Symptoms involving nervous and musculoskeletal symptoms, abnormal posture*

784.3-784.69 Aphasia and other speech disturbances

787.2 Dysphasia

806.00-806.99 Fracture of vertebral Column with Spinal Cord Injury

810.00-810.13 Fracture of clavicle

811.00-811.19 Fracture of scapula

812.00.812.59 Fracture of humerus

813.00-813.93 Fracture or radius and ulna

820.00-820.9 Fracture of neck of femur

821.0-821.39 Fracture of other and unspecified parts of femur

828.0-828.1Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum

852.00-852.59Subarachnoid, subdural, and extradural hemorrhage, following injury

853.00-853.19 Other and unspecified intracranial hemorrhage following injury

854.00-854.19 Intracranial injury of other and unspecified nature

881.0-881.2 Open wound of elbow, forearm, and wrist

882.0-882.2 Open wound of hand with tendon involvement

884.0-884.2Multiple and unspecified open wound of upper limb with tendon involvement

887.0 – 887.7 Traumatic amputation of arm and hand (complete) (partial)


EXHIBIT C



897.0-897.7 Traumatic amputation of leg(s) (complete) (partial)

952.00-952.9 Spinal cord injury without evidence of spinal bone injury

941.00-952.9 Burns

959.01 Head Injury

# # #


Exhibit D

Common abbreviations, reprinted with permission from Mary H. Marshall, PhD

EXHIBIT D


MAPS, Inc.·8/21/05 904-491-3114

COMMON ABBREVIATIONSABN Advanced Beneficiary Notice

ARD Assessment Reference Date

ARP Assessment Reference Period

BNI Beneficiary Notice Initiative

CMI Case Mix Index

CPS Cognitive Performance Scale

CMS Centers for Medicare and Medicaid Services

CPT-4 Current Procedural Terminology – 4th Edition

CWF Common Working File

DON Director of Nursing (Nurses)

ER Emergency Room

FI Fiscal Intermediary

HCFA Health Care Financing Administration (now CMS)

HIPPS Health Insurance Prospective Payment System (code for billing Part A)

HIPAA Health Insurance Portability and Accountability Act

HIM Health Insurance Manual

ICD-9-CM International Classification of Diseases – 9th Edition

LOA Leave of Absence

MDS Minimum Data Set (Assessment tool which is a part of the RAI)

MSP Medicare Secondary Payer

OMRA Other Medicare Required Assessment

PM Program Memorandum (Transmittals from CMS giving Medicare regulations)

QI Quality Indicators

RAI Resident Assessment Instrument

RUG Resource Utilization Group

SCPA Significant Correction of Prior Assessment

SCSA Significant Change in Status Assessment

SNF Skilled Nursing Facility (Medicare certified facility or part of a facility)

SNFABN Skilled Nursing Facility Advanced Beneficiary Notice

UB-92 Uniform Billing (UB-92 claim form)

Exhibit E

Diagnosis history sheet, reprinted with permission from Anne Cook, RHIA

EXHIBIT E


DIAGNOSIS HISTORY SHEET

LAST FIRST MIDDLE ADMITTED PHYSICIAN MR NUMBER

DATE NO. DIAGNOSIS ICD-9 CODE

Exhibit F

Medicare communication worksheet, reprinted with permission from Anne Cook, RHIA

EXHIBIT F


MEDICARE COMMUNICATION WORKSEET

RESIDENT ______________________ MEDICARE ADMIT DATE __________

ACUTE HOSPITAL STAY (UB-92 field 36): FROM _______ THROUGH ______

PRINCIPAL DIAGNOSIS FOR CURRENT BILLING CYCLE (UB-92 field 67) ICD-9 CODE__________________________________________ ________________ ADDITIONAL DIAGNOSES (UB-92 fields 68-75)___________________________________________ ________________ ___________________________________________ ________________ ___________________________________________ ________________ ___________________________________________ ________________ ___________________________________________ ________________ ___________________________________________ ________________ ___________________________________________ ________________ PHYSICAL THERAPY: TREATMENT DX. ________________ ___________________________________________ ________________ OCCUPATIONAL THERAPY: TREATMENT DX. ________________ ___________________________________________ ________________ SPEECH THERAPY: TREATMENT DX. ________________ ___________________________________________ ________________

PRINCIPAL DIAGNOSIS ON INITIAL ADMISSIONTO NURSING FACILITY (UB-92 field 76)___________________________________________ ________________

BILLING MONTH ____________________________ YEAR___________

ARD_______________RUG____________________ MDS ASSESS TYPE ____

ARD_______________RUG____________________ MDS ASSESS TYPE ____

NOTES: _________________________________________________________ ________________________________________________________________

100TH DAY ____________ DATE DISCHARGED FROM MEDICARE _________

TERMINATION OF MEDICARE LETTER DATE: _________________________

SIGNED: ___________________________________ DATE: __________ MEDICARE NURSE

E-40 Rev. 06-05 Anne Cook & Associates770-578-9422

Exhibit G

UB-92 Form provided by HCPro, Inc.

EXHIBIT G


AB

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3 PATIENT CONTROL NO. 4 TYPE

5 FED. TAX NO. 6 STATEMENT COVERS PERIOD 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D.

12 PATIENT NAME 13 PATIENT ADDRESS

14 BIRTHDATE 15 SEX 16 MS

42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE53 ASG52 REL

58 INSURED’S NAME 59 P. REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO.

OF BILL117 DATE

ADMISSION18 HR 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO.

CONDITION CODES

FROM THROUGH

32 OCCURRENCECODE DATE




36 OCCURRENCE SPANCODE FROM THROUGH

39 VALUE CODESCODE AMOUNT



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INFO BEN

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2APPROVED OMB NO. 0938-0279

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63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION

76 ADM. DIAG. CD. 77 E-CODE 78

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OTHER DIAG. CODES

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80 PRINCIPAL PROCEDURE 81 OTHER PROCEDURE OTHER PROCEDURE79 P.C.CODE DATE CODE DATE CODE DATE

84 REMARKS

OTHER PROCEDURE OTHER PROCEDURE OTHER PROCEDURECODE DATE CODE DATE CODE DATE

82 ATTENDING PHYS. ID

83 OTHER PHYS. ID

OTHER PHYS. ID

85 PROVIDER REPRESENTATIVE 86 DATE

I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.UB-92 HCFA-1450 OCR/ORIGINAL

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68 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE67 PRIN. DIAG. CD.

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EXHIBIT G

UNIFORM BILL: NOTICE: ANYONE WHO MISREPRESENTS OR FALSIFIES ESSENTIALINFORMATION REQUESTED BY THIS FORM MAY UPON CONVICTION BESUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW.

the information submitted as part of this claim is true, accurate andcomplete, and, the services shown on this form were medicallyindicated and necessary for the health of the patient;

the patient has represented that by a reported residential addressoutside a military treatment center catchment area he or she does notlive within a catchment area of a U.S. military or U.S. Public HealthService medical facility, or if the patient resides within a catchmentarea of such a facility, a copy of a Non-Availability Statement (DDForm 1251) is on file, or the physician has certified to a medicalemergency in any assistance where a copy of a Non-AvailabilityStatement is not on file;

the patient or the patient’s parent or guardian has responded directlyto the provider’s request to identify all health insurance coverages,and that all such coverages are identified on the face the claim exceptthose that are exclusively supplemental payments to CHAMPUS-determined benefits;

the amount billed to CHAMPUS has been billed after all such coverageshave been billed and paid, excluding Medicaid, and the amount billedto CHAMPUS is that remaining claimed against CHAMPUS benefits;

the beneficiary’s cost share has not been waived by consent or failureto exercise generally accepted billing and collection efforts; and,

any hospital-based physician under contract, the cost of whoseservices are allocated in the charges included in this bill, is not anemployee or member of the Uniformed Services. For purposes of thiscertification, an employee of the Uniformed Services is an employee,appointed in civil service (refer to 5 USC 2105), including part-time orintermittent but excluding contract surgeons or other personnelemployed by the Uniformed Services through personal servicecontracts. Similarly, member of the Uniformed Services does not applyto reserve members of the Uniformed Services not on active duty.

based on the Consolidated Omnibus Budget Reconciliation Act of1986, all providers participating in Medicare must also participate inCHAMPUS for inpatient hospital services provided pursuant toadmissions to hospitals occurring on or after January 1, 1987.

if CHAMPUS benefits are to be paid in a participating status, I agreeto submit this claim to the appropriate CHAMPUS claims processoras a participating provider. I agree to accept the CHAMPUS-determined reasonable charge as the total charge for the medicalservices or supplies listed on the claim form. I will accept theCHAMPUS-determined reasonable charge even if it is less than thebilled amount, and also agree to accept the amount paid by CHAMPUS,combined with the cost-share amount and deductible amount, if any,paid by or on behalf of the patient as full payment for the listed medicalservices or supplies. I will make no attempt to collect from the patient(or his or her parent or guardian) amounts over the CHAMPUS-determined reasonable charge. CHAMPUS will make any benefitspayable directly to me, if I submit this claim as a participating provider.

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

If third party benefits are indicated as being assigned or in participationstatus, on the face thereof, appropriate assignments by the insured/beneficiary and signature of patient or parent or legal guardiancovering authorization to release information are on file.Determinations as to the release of medical and financial informationshould be guided by the particular terms of the release forms thatwere executed by the patient or the patient’s legal representative.The hospital agrees to save harmless, indemnify and defend anyinsurer who makes payment in reliance upon this certification, fromand against any claim to the insurance proceeds when in fact novalid assignment of benefits to the hospital was made.

If patient occupied a private room or required private nursing formedical necessity, any required certifications are on file.

Physician’s certifications and re-certifications, if required by contractor Federal regulations, are on file.

For Christian Science Sanitoriums, verifications and if necessary re-verifications of the patient’s need for sanitorium services are on file.

Signature of patient or his/her representative on certifications,authorization to release information, and payment request, as requiredbe Federal law and regulations (42 USC 1935f, 42 CFR 424.36, 10USC 1071 thru 1086, 32 CFR 199) and, any other applicable contractregulations, is on file.

This claim, to the best of my knowledge, is correct and complete andis in conformance with the Civil Rights Act of 1964 as amended.Records adequately disclosing services will be maintained andnecessary information will be furnished to such governmentalagencies as required by applicable law.

For Medicare purposes:

If the patient has indicated that other health insurance or a statemedical assistance agency will pay part of his/her medical expensesand he/she wants information about his/her claim released to themupon their request, necessary authorization is on file. The patient’ssignature on the provider’s request to bill Medicare authorizes anyholder of medical and non-medical information, including employmentstatus, and whether the person has employer group health insurance,liability, no-fault, workers’ compensation, or other insurance which isresponsible to pay for the services for which this Medicare claim ismade.

For Medicaid purposes:

This is to certify that the foregoing information is true, accurate, andcomplete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State Laws.

1.

2.

3.

4.

5.

6.

7.

8.

Certifications relevant to the Bill and Information Shown on the FaceHereof: Signatures on the face hereof incorporate the followingcertifications or verifications where pertinent to this Bill:

ESTIMATED CONTRACT BENEFITS

9.For CHAMPUS purposes:

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Master the 2007 SNF ICD-9 Codes and Most Difficult Coding Scenarios: Essential Guidance for Nursing Home Coding 63

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