Uncovering the Mystery behind the RAC Complex Coding Reviews

by Donna D. Wilson, RHIA, CCS

Connolly Healthcare (recovery audit contractor for Region C) recently published the first set of Centers for Medicare and Medicaid Services (CMS) Approved Audit Issues for complex reviews. The complex reviews will request medical records to validate coding and DRG assignment, as well as the discharge status code assignment, for the MS-DRGs/DRGs displayed in figure 1.1. (It should be noted that these complex reviews approved by CMS do not include medical necessity determination.)

On December 3, 2009, coding experts in Region C started analyzing the patterns in the above listed MS-DRG pairings. Below are some questions to consider as to why these MS-DRGs were chosen for review. Read more.

Coding Nasal Sinus Endoscopies

Nasal sinus endoscopy procedures are coded with CPT codes 31231 through 31294. These procedures allow the physician to visualize the interior of the nasal cavity, the middle and superior meatus, the turbinates, and the sphenoethmoid recess. The purpose of the procedures may be either diagnostic or surgical in nature. A surgical endoscopy may be performed to control a nosebleed or to perform a maxillary antrostomy or sphenoidotomy. The coding professional should always review the documentation carefully to clarify the extent of the procedure. A surgical endoscopy includes the diagnostic component. The diagnostic endoscopy should not be reported separately when performed during the same operative episode. Also, if performed, a sinusotomy is considered part of the endoscopic procedure and not reported separately.

Unless otherwise stated, codes in the 31231 through 31294 range are assumed to be unilateral. When the documentation indicates that a bilateral procedure was performed and the specific code does not state bilateral, modifier 50 may be assigned. Key points to remember include:

•    Separate codes should not be assigned to identify a diagnostic nasal/sinus endoscopy when it is performed in conjunction with a surgical nasal/sinus endoscopy.
•    A surgical endoscopy includes a sinusotomy. Only the code for the surgical endoscopy should be assigned when both are performed during the same operative episode.
•    Modifier 50 should be assigned to identify a bilateral procedure only if the code does not specify bilateral.

References

American Medical Association. AMA CPT, 2010.

Smith, Gail. Basic Current Procedural Terminology/HCPCS Coding, 2010 edition. Chicago, IL: AHIMA, 2010.

Healthcare Finance News Warns: Be Wary of Zone Program Integrity Contractors

HIM professionals may be caught unaware when zone program integrity contractors (ZPIC) arrive in their organizations. While most HIM professionals understand RAC auditors, they may be unaware that a second set of auditors has been approved by CMS. ZPICs are the former program safeguard contractors. They are considered by CMS to be the first identifiers of potential fraud and abuse. CMS will utilize the ZPIC program to identify cases of suspected fraud, investigate them, and then proceed with immediate action. The ZPIC will have the authority to report directly to the Office of Inspector General (OIG) for possible criminal or civil prosecutions as a result of investigations. Read this article from Healthcare Finance News article for more information on ZPICs.

AHIMA RAC/Coding Conference

2010 is the year that everyone will experience automated and complex RAC reviews. A clear understanding of the RAC process and how each organization manages this is essential to success. AHIMA is sponsoring the Coding Quality and RAC: Partnering for Long Term Success conference in Washington, DC, March 24-25. Featured speakers will include Melanie Combs-Dyer, RN, BSN, health insurance specialist technical advisor at CMS, and Pamela Durbin, RN, BSN, CDS, nurse consultant at CMS, who will discuss the specifics of the RAC program from the CMS perspective. Pat Brooks, RHIA, senior technical advisor at CMS, will discuss the data issues related to the ICD-10 conversion and how this will impact RAC reviews.

Additional speakers include Donna Wilson, RHIA, CCS, and Pat Maccariella-Hafey, RHIA, CCS, CCS-P, CIRCC, speaking on RAC issues related to outpatient and inpatient coding, respectively. Also presenting will be Sharon Easterling, MHA, RHIA, CCS, Jugna Shah, MPH, and Tasha Green, MS, RHIA. 

ICD-10 Checkpoint

Check your knowledge. Compare ICD-9-CM codes to ICD-10-PCS codes.

What is the correct code for Open Right Arterial Bypass Common Iliac to Femoral using left autologous greater saphenous vein, harvested endoscopically?

Read more.

Coding Challenges for Discussion

Nasal Sinus Endoscopy Case Study

Ambulatory Surgery Setting

Preoperative diagnosis: Nasal septal deviation, hypertrophic inferior turbinates, nasal airway obstruction, chronic frontal ethmoid, and maxillary sinusitis with sinus polyposis.

Postoperative diagnosis: Same

Procedure:  Nasal/sinus endoscopy, surgical, with frontal sinus exploration, right.
Nasal/sinus endoscopy, surgical, with frontal sinus exploration, left.
Nasal/sinus endoscopy, surgical, with anterior and posterior ethmoidectomy, right.
Nasal/sinus endoscopy, surgical, with anterior and posterior ethmoidectomy, left.
Septoplasty.
Nasal/sinus endoscopy, surgical, with maxillary antrotomy and polypectomy, right.
Nasal/sinus endoscopy, surgical, with maxillary antrotomy and polypectomy, left.
Submucous resection of inferior turbinate, right.
Submucous resection of inferior turbinate, left. Read more.

CodeWrite Continuing Education Quiz

To purchase this month’s CodeWrite quiz, visit the AHIMA Store and select “Quizzes” followed by CodeWrite Community News, January 2010 from the list of available items. Once you have completed your purchase you will be directed to the quiz page.

Quality Measure Reporting: A Guide to Greater Efficiency

Virtual Meeting | March 3

Quality measure initiatives continue to accelerate in the healthcare industry. Organizations are challenged by the number of required measures, qualified staff, and methods of reporting the measures. This virtual meeting gives attendees the opportunity to review best practices regarding quality measure reporting and obtaining up-to-date industry information regarding efforts to improve the efficiency of measure reporting. Register by February 9 to save $50. Earn two continuing education units.

New Books from AHIMA Press

Updated to reflect code changes effective January 1, 2010, both AHIMA Press books offer hands-on coding exercises and examples for on-the-job training and classroom use.

Beginning and intermediate coding students will excel with the 2010 edition of Basic Current Procedural Terminology and HCPCS Coding. Delivering basic training and practice in the application of procedural codes from the Current Procedural Terminology (CPT®) and the Healthcare Procedural Coding System (HPCPS), this book explains CPT® codes effective January 1, 2010, and HCPCS codes as of October 1, 2009. It offers a thorough learning experience through real-world exercises, detailed specifics and subsets of coding, and demonstration of code use in reimbursement.

Procedural Coding and Reimbursement for Physician Services: Applying Current Procedural Terminology (CPT) and HCPCS, 2010 Edition, introduces the basic principles and conventions of CPT coding, and delivers experience-based knowledge needed for confident, efficient coding.

2010 ICD-10 Summit: Beyond Compliance to Strategic Advantage

Washington, DC | April 12-13

The Second Annual ICD-10 Summit is dedicated to the exploration of the challenges and opportunities of the transition to the ICD-10-CM/PCS coding systems and the 5010 HIPAA transaction. The Summit gathers thought leaders from all segments of the healthcare industry to meet this challenge, because all segments are affected by this transition. The industry at large is strengthened through transparency in the exchange of information between every community. Register by March 15 to save $100. Earn twelve continuing education units.

Physician Practice Fast Facts: Information You Need Now!

Do you work in physician practice? Do you need continuing education that is quick, affordable and meaningful? You can have all this and maintain your credentials with important CEUs on crucial topics for everyday management of the physician practice environment. Harness the learning benefits of audio seminars faster! These 30-minute pre-recorded physician practice topics will boost your knowledge and experience in half the time of an audio seminar. Fast Facts seminars are available via pre-recorded Webcast or CD. An assessment is included with each seminar. Earn one CEU for each seminar and assessment completed. Prices start as low as $49 per seminar! Get more information, including a complete list of topics.            

AHIMA General Information

The coding roundtable process is designed to meet the needs of coding professionals by providing educational and networking opportunities. Our process is designed to be interactive—on the Internet and around the table where you work. AHIMA is the association of professionals engaged in or interested in the practice of health information management. The association, through its component state associations, provides support to members and strengthens the healthcare industry and profession by providing a voice that is 53,000-members strong. AHIMA members strive to ensure that healthcare is based on accurate and timely information.

Facilitation of accurate and consistent coding practice is a key element in carrying out this mission, so as an association we provide educational resources and representation in key national groups to support this goal. To ensure that its members meet professional standards of excellence, AHIMA issues professional credentials in health information management, including both entry-level and specialist certification related to coding. Active, associate, and student memberships are available. You can earn credentials through a combination of education, experience, and acceptable performance on national certification exams. Current AHIMA credentials include:

Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Coding Specialist-Physician based (CCS-P)
Certified Coding Associate (CCA)
Certified in Healthcare Privacy and Security (CHPS)
Certified Health Data Analyst (CHDA)

Coding roundtable participation is not restricted to membership in AHIMA. The Internet-based Communities of Practice, containing a wealth of coding information and resources, is one of many membership benefits. For more information on AHIMA membership, visit www.ahima.org or call (312) 233-1100.

Participation in the coding community and the coding roundtables ensures an integrated network of coding professionals working together to raise the standard of excellence in the coding profession. By joining together, coding roundtables can solve common problems and provide input to groups and agencies that make a difference in our workplace and the industry we serve.

CodeWrite is published twelve times a year by the American Health Information Management Association (AHIMA), 233 N. Michigan Ave., 21st Floor, Chicago, IL 60601-5809.

AHIMA respects its members' and nonmembers' Internet privacy and right to choose which communications they want to receive. You are currently subscribed to ahima_list5_codewrite as %%EMAILAddr_%%. If you prefer not to receive AHIMA CodeWrite click unsubscribe and you will be removed.

Copyright © 2010 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher.

January 2010

Calendar of Events

January 12
Resequence or Renumber? Facts of Life in CPT Development audio seminar

January 28
Facility ED Coding and Charge Capture audio seminar

February 4
Injection and Infusion Coding audio seminar

February 18
Modifier Usage in Professional Services audio seminar

February 19–21
AHIMA Academy for ICD-10: Building Expert Trainers in Diagnosis and Procedure Coding
Huntington Beach, CA

March 3
Quality Measure Reporting: A Guide to Greater Efficiency virtual meeting

March 4
Coding for Excisional versus Non-Excisional Debridement audio seminar

March 18
Developing Effective Queries audio seminar

March 24-25
Coding Quality and RAC: Partnering for Long Term Success
Washington, DC

March 25
Procedural Coding for Dialysis Services audio seminar

For more information and full agendas visit www.ahimastore.org or www.ahima.org/meetings/.

Upcoming AHIMA Convention & Exhibit Dates and Locations

September 25–30, 2010
Orlando, FL

October 1–6, 2011
Salt Lake City, UT

Coding Assessment and Training Solutions

Coding Assessment and Training Solutions, one of AHIMA’s Web-based offerings for experience coders, offers two distinct learning elements that may be used together or separately to meet individual or departmental training goals. Assessments are available for each course of study, providing and unbiased tool to determine strengths and weaknesses in coding ability and define a baseline for evaluating progress. Training Solutions are designed to take the most problematic issues per subject area. For more information and registration, visit http://campus.ahima.org.  

Navigate the Transition to ICD-10

Use AHIMA’s ICD-10 Web pages as a resource to help guide you through the transition to ICD-10-CM and ICD-10-PCS.

Connect and Network with Your Peers

AHIMA offers many opportunities for you to network with others online, ask questions and learn from your peers, and hear about the latest news from AHIMA.

Communities of Practice

(Members only)
Answers, support, and career advice are available through this well-established professional network. AHIMA members enjoy a wide continuum of benefits:

• Current coding news and practices
• Online forums
• Practical research materials
• Relevant education resources

The Communities of Practice is a benefit of AHIMA membership. If you are already a member, go to http://cop.ahima.org. Your user name is your AHIMA member ID including the initial zero(s). For information on becoming a member, click here.

Become a Fan of AHIMA

Check out AHIMA’s Official Facebook page. There is also an AHIMA Careers page dedicated to students and recent graduates pursuing a career in the health information field. Become a fan of one (or both) of these pages and join in the discussions.

Follow AHIMA Resources on Twitter

Become a follower of the AHIMA Resources Twitter page