Time for Spring Cleaning

This article is about spring cleaning your coding and billing! There are a few concerns coming to light that need tidying up. These include the following:

1. Increasing Denials

Inconsistent documentation will draw denials if the documentation impacts the reimbursement. Some examples include aspiration pneumonia versus pneumonia, unspecified; chronic diastolic congestive heart failure versus acute-on-chronic diastolic congestive heart failure; and sepsis.

Another issue that may draw a denial is when the documentation does not support the payer’s payment policies. Here are examples:

• Acute respiratory failure with hypoxia, when the patient’s respiratory rate is not 24 or greater (or there is no documentation of increased work in breathing).
• Sepsis with the patient’s platelet level not less than 150.
• Toxic metabolic encephalopathy when the documentation states that the patient is alert and oriented. If you use documentation templates, be careful with default documentation.
• Emergency department evaluation and management level for the hospital, when the payer may have different criteria to determine levels.

2. End of the Public Health Emergency (PHE)

The Centers for Medicare & Medicaid Services (CMS) has published a fact sheet about the end of the PHE. It is important for your revenue cycle to understand how this change will impact your facility – and not just from a CMS perspective. From a coding perspective, update your facility-specific coding guidelines so that you document the expected changes.

3. Inpatient Prospective Payment System (IPPS) FY24

There are proposed changes for MS-DRGs as well as New Technology Add-On Payment (NTAP) items. Make plans to become educated, and communicate those changes.

4. Chargemaster and Revenue Integrity

The Healthcare Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes update on a quarterly basis. It is important to stay on top of the changes to reduce claim rejections or missed revenue. The end of the PHE will impact the chargemaster and revenue integrity as well.

5. Crohn’s Disease and Manifestations

This issue recently came up during a coding review. There was a difference of opinion regarding the coding of Crohn’s disease and its manifestations. According to the coding instruction under K50, an additional code should be assigned to specify the manifestation. The Coding Clinic from the fourth quarter of 2012 also provides the guidance that the manifestation may be separately reported to provide specificity.

Spring always brings with it activity. It may be new codes, new payment rules, or changes in reimbursement methodology. It is important to discuss such changes, develop an action plan, and complete the actions. As healthcare becomes more complicated, communication will be important to be successful.

Programming note: Listen to Laurie Johnson’s live coding report every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.