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Answered: - Application Exercises 1. You are the CDM Coordinator at Anywhere
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Application Exercises
1. You are the CDM Coordinator at Anywhere Hospital. Answer the
following questions about the IPPS new technology add-on payment
items/devices for the new fiscal year.
1.1
When would these items/devices be incorporated into the CDM?
1.2
How would these items/devices be incorporated into the CDM?
1.3
Which departments/units within Anywhere Hospital would you
provide educational sessions?
1.4
How would you explain the importance of the new technology
add-on payment to various department/unit managers?
2. Read the article ?Diagnosis Coding and Medical Necessity: Rules and
Reimbursement? by Janis Cogley, located on the AHIMA Body of
Knowledge (BoK) at www.ahima.org.
2
This article discusses how Medicare administrative contractors (MAC) use
coverage determinations to establish medical necessity. When the
condition(s) of a patient are expected not to meet medical necessity
requirements for a test, procedure, or service, the provider has the
obligation under the Beneficiary Notices Initiative to alert the Medicare
beneficiary prior to rendering the service. The Medicare beneficiary is
notified via the Advance Beneficiary Notice (ABN).
The Medicare beneficiary may choose to complete the ABN and provide
out-of- pocket reimbursement for the service, or may elect to not have
the service performed. If the provider fails to alert the Medicare
beneficiary with an ABN, then the facility may not balance bill the patient
for the non-covered charges denied by the MAC.
Scenario
You are the revenue cycle coordinator for Anywhere Hospital. The decision
support department at Anywhere Hospital is concerned because the volume
of remittance advice remark code #M39 (The patient is not liable for payment
for this service because the advance notice of non-coverage you provided the
patient did not comply with program requirements.) on Medicare remittance
advice logs has increased over the past three months. Further analysis of the
denied claims shows that 75 percent of the claims have code 93798
(physician services for outpatient cardiac rehabilitation with continuous ECG
monitoring) present. Therefore, they are requesting that the revenue cycle
team perform further investigation for this issue.
After auditing the remittance advice logs and medical records for a sample
of cardiac rehabilitation claims, the revenue cycle team has determined that
medical necessity is not being met for code 93798. Further, they have
discovered that a new LCD was issued for code 93798 in October (three
months ago). The only ICD-9-CM diagnosis codes that support medical
necessity for code 93798 are
410.00?410.92 Acute myocardial infarction of anterolateral wall
episode of care unspecified through acute myocardial infarction
of unspecified site subsequent episode of care
412 Old myocardial infarction
413.0?413.9* Angina decubitus through other and unspecified angina pectoris
V45.81 Post surgical aortocoronary bypass status
* There is no specific code assigned to stable angina. Therefore,
these codes should be used to identify stable angina and
documentation should support that diagnosis.
Further, around $20,790.00 has been written off due to ABNs not being
issued for this cardiac rehabilitation service.
2.1
What went wrong in the revenue cycle?
2.2
How would you suggest rectifying this issue?
2.3
How will your team monitor improvements?
3. Review the following excerpt from the charge description master file at
Anywhere Hospital. Closely examine the line items and identify and
correct the elements that need to be updated or revised.
ITEM CODE
12345
12347
12350
12351
12348
12346
12349
12352
12353
SERVICE DESCRIPTION
BILIRUBIN TOTAL & DIRECT
CHROMOSOME STUDY - AMNIOTIC FLUID
SKIN TEST CAND
TRANSCATHETER PLACEMENT.IVSTENT
VESSLE
CT CHEST W/WO ABD&PELVIS W/CONTRAST
CATHETERIZATION URETHRA COMPLICATED
OPERATING ROOM-III 1ST 30 MINUTES
HOT/COLD THERAPY PT
LEVEL 2 DRUG
REVENU
E
CODE
310
CPT
CODE
PRICE
82251
300
300
320
86458
95960
$25.00
$0.00
$20.00
$1,125.00
352
360
360
430
250
53675
4. The executive finance team at Anywhere Hospital is reviewing charge levels
for various surgical units. The team leader has requested a CDM
management report from the CDM coordinator. She would like the report to
include the Medicare reimbursement, cost, and profit for procedures
performed during first quarter 20XX. Additionally, she would like third-party
payer average reimbursement, cost, and profit for the same time period.
Using the information in table 1 complete the data elements provided in
table 2. Table 1 and 2 are also provided in Excel format. The average
reimbursement rate for all third-party payers at Anywhere Hospital is 62
percent of billed charges. The outpatient ratio of cost to charge for
revenue code 360 is 0.4043. The outpatient ratio of cost to charge for
revenue code 320 is 0.5267. Is either of the payers profitable for Anytime
Hospital in this outpatient surgical area?
$1.00
$270.00
$2,267.00
$75.00
$3,000.00
Table 1
CHARGE
CODE
CODE DESCRIPTION
CPT CODE
REV CODE
REVENUE
AREA
CHARGE
MEDICARE
VOL
TPP VOL
49213
BIOPSY BREAST PERCUT W/O IMAGING GUIDANCE
19100
360
1137
826.80
58
115
49214
BIOPSY OF BREAST, OPEN
19101
360
1137
3944.25
37
76
49217
CRYOSURG ABLATE FIBROADENOMA, EACH
19105
360
1137
6059.85
21
32
49218
NIPPLE EXPLORATION
19110
360
1137
3944.25
12
14
49219
EXCISE BREAST DUCT FISTULA
19112
360
1137
3944.25
14
17
49220
REMOVEAL OF BREAST LESION
19120
360
1137
3944.25
76
87
49221
EXCISION, BREAST LESION
19125
360
1137
3944.25
45
90
49222
EXCISION, ADDL BREAST LESION
19126
360
1137
3944.25
36
54
49223
REMOVAL OF CHEST WALL LESION
19260
360
1137
3076.44
22
43
49224
PREOP PLACE NEEDLE LOCAL WIRE BREAST
19281
320
1196
65.00
43
98
49225
PREOP NEEDLE LOCALIZATION ADD'L LESIONS
19282
320
1196
65.00
10
65
49227
PLACE BALLOON CATHETER FOR RADIOELEMENT APP
19296
360
1137
10810.92
5
24
49228
PLACE BALLOON CATHETER WITH PART MASTECTOMY
19297
360
1137
10810.92
8
12
49229
PLACE BRACHYTHERPAY CATHETER
19298
360
1137
10810.92
10
32
49230
REMOVAL OF BREAST TISSUE
19300
360
1137
3944.25
21
68
49231
PARTIAL MASTECTOMY
19301
360
1137
3944.25
24
45
49232
P-MASTECTOMY W LYMPHADENECTOMY
19302
360
1137
7608.72
21
65
49233
MASTECTOMY, SIMPLE, COMPLETE
19303
360
1137
6059.85
18
47
49234
MASTECTOMY, SUBCUTANEOUS
19304
360
1137
6059.85
17
56
49235
MASTECOMY, MODIFIED RADICAL
19307
360
1137
7608.72
15
63
49236
SUSPENSION OF BREAST
19316
360
1137
6059.85
11
2
49237
REDUCTION OF LARGE BREAST
19318
360
1137
7608.72
9
12
49238
ENLARGE BREAST
19324
360
1137
7608.72
0
23
49239
ENLARGE BREASE WITH IMPLANT
19325
360
1137
10810.92
0
25
49240
REMOVAL OF BREAST IMPLANT
19328
360
1137
6059.85
5
13
49241
REMOVAL OF BREAST IMPLANT MATERIAL
19330
360
1137
6059.85
0
16
49242
IMMEDIATE BREAST PROSTHESIS
19340
360
1137
7608.72
0
34
49243
DELAYED BREAST PROSTHESIS
19342
360
1137
10810.92
17
27
49244
BREAST RECONSTRUCTION
19350
360
1137
3944.25
4
47
49245
CORRECT INVERTED NIPPLE(S)
19355
360
1137
6059.85
0
3
49246
BREAST RECONSTRUCTION
19357
360
1137
10810.92
6
25
49247
BREAST RECONSTRUCTION
19366
360
1137
6059.85
7
24
49248
SURGERY OF BREAST CAPSULE
19370
360
1137
6059.85
5
12
49249
REMOVAL OF BREAST CAPSULE
19371
360
1137
6059.85
6
9
49250
REVISE BREAST RECONSTRUCTION
19380
360
1137
7608.72
4
8
49251
DESIGN CUSTOM BREAST IMPLANT
19396
360
1137
6059.85
0
23
49252
BREAST SURGERY PROCEDURE
19499
360
1137
3944.25
2
1
Table 2
CHARGE
CODE
CODE DESCRIPTION
CPT CODE MCR REIMB
49213
BIOPSY BREAST PERCUT W/O IMAGING GUIDANCE
BIOPSY OF BREAST, OPEN
CRYOSURG ABLATE FIBROADENOMA, EACH
NIPPLE EXPLORATION
EXCISE BREAST DUCT FISTULA
19112
49220
REMOVEAL OF BREAST LESION
19120
49221
EXCISION, BREAST LESION
19125
49222
EXCISION, ADDL BREAST LESION
19126
49223
REMOVAL OF CHEST WALL LESION
19260
49224
PREOP PLACE NEEDLE LOCAL WIRE BREAST
19281
49225
PREOP NEEDLE LOCALIZATION ADD'L LESIONS
19282
49227
PLACE BALLOON CATHETER FOR RADIOELEMENT APP
19296
49228
PLACE BALLOON CATHETER WITH PART MASTECTOMY
19297
49229
PLACE BRACHYTHERPAY CATHETER
19298
49230
REMOVAL OF BREAST TISSUE
19300
49231
PARTIAL MASTECTOMY
19301
49232
P-MASTECTOMY W LYMPHADENECTOMY
19302
49233
MASTECTOMY, SIMPLE, COMPLETE
19303
49234
MASTECTOMY, SUBCUTANEOUS
19304
49235
MASTECOMY, MODIFIED RADICAL
19307
49236
SUSPENSION OF BREAST
19316
49237
REDUCTION OF LARGE BREAST
19318
49238
ENLARGE BREAST
19324
49239
ENLARGE BREASE WITH IMPLANT
19325
49240
REMOVAL OF BREAST IMPLANT
19328
49241
REMOVAL OF BREAST IMPLANT MATERIAL
19330
49242
IMMEDIATE BREAST PROSTHESIS
19340
49243
DELAYED BREAST PROSTHESIS
19342
49244
BREAST RECONSTRUCTION
19350
49245
CORRECT INVERTED NIPPLE(S)
19355
49246
BREAST RECONSTRUCTION
19357
49247
BREAST RECONSTRUCTION
19366
49248
SURGERY OF BREAST CAPSULE
19370
49249
REMOVAL OF BREAST CAPSULE
19371
49250
REVISE BREAST RECONSTRUCTION
19380
49251
DESIGN CUSTOM BREAST IMPLANT
19396
49252
BREAST SURGERY PROCEDURE
TPP PROFIT
19110
49219
MCR
PROFIT
19105
49218
TPP COST
19101
49217
MCR COST
19100
49214
TPP REIMB
19499
5. Identify five new CPT codes for the upcoming calendar year. Create a
workflow to ensure that all data elements required in the CDM are
identified, verified, and signed off on for inclusion in the CDM. Identify any
compliance issues for these new CPT codes.
6. The health information management team at Anywhere University
Hospital (AUH) contracted with an auditing firm to perform full
assessment coding review. The results from this baseline assessment are
provided in four tables:
Variation Log by Type of Error
Variation Log by Coder
Variation Log by MS-DRG
MS-DRG Relationship Assessment
You are the inpatient coding manager at AUH. Your director has asked you
to develop an ongoing review and monitoring schedule for the next year
based on the results from the outside review.
Include internal and external reviews, coding in-services, physician
workshops, and external seminars/educational sessions that will be
performed and or provided for your staff. The schedule should be specific
(include volumes and/or percentages of charts to be reviewed). Keep in mind
that on average it takes 18 minutes to review one inpatient chart. Budget
provides for $65,000 for external reviews. The average cost for reviewing one
inpatient record by an external review team is $55.00 (fully loaded).
In addition to preparing the schedule, outline how you will maintain
coding quality statistics and report them back to the HIM Director and
Compliance Committee at your facility.
How will you reward your staff members who show great improvements?
How will you reward and/or recognize that your staff has made
improvements overall?
Your Coding Team consists of:
Coding Manager (you)
One Data Quality Auditor (1
FTE) Eight Inpatient Coders (8
FTE)
2=RHIA, CCS
3=CCS
3=RHIT
Results of the full assessment coding review for AUH:
Two audits were performed:
1.Coding quality review by MS-DRG
2.MS-DRG Relationship Analysis
Variation Log by Type of Error
Inaccurate sequencing or specificity principal diagnosis,
affect MS- DRG
Inaccurate sequencing or specificity principal diagnosis,
non affect MS-DRG
Omission CC, affect MS-DRG
Omission CC, non affect MS-DRG
Inaccurate principal procedure, affect MS-DRG
Omission procedure, affect MS-DRG
More specific coding of diagnosis or procedure, non affect MSDRG
Inaccurate coding
Missed diagnosis or procedure code
% of
errors
17%
16%
33%
2%
3%
4%
12%
5%
8%
Coder
Coder
Coder
Coder
Coder
Coder
Coder
Coder
Coder
1
2
3
4
5
6
7
8
Variation Log by Coder
Error Rate
3%
9%
8%
2%
4%
16%
12%
3%
Variation Log by MS-DRG*
MS-DRG
Volume
Erro
r
Rat 2%
470
420
313
233
14%
392
232
1%
291
232
17%
247
220
3%
292
216
5%
871
213
12%
641
209
0%
194
195
3%
293
193
1%
885
188
3%
312
177
0%
191
175
7%
287
173
2%
310
171
15%
689
157
11%
603
143
2%
379
137
3%
192
131
9%
683
116
11%
189
114
1%
069
110
2%
190
92
12%
193
87
10%
690
76
4%
065
76
5%
195
72
2%
066
52
2%
064
41
5%
906
35
2%
*MS-DRG descriptions provided below
Standard
5%
5%
5%
5%
5%
5%
5%
5%
Variation Log by MS-DRG*
Set
MS-DRG
Hospital % Nation %
Set
064
24.3%
21.4%
065
45.0%
43.8%
066
30.8%
34.8%
190
191
192
23.1%
44.0%
32.9%
15.2%
33.5%
51.3%
193
194
195
24.6%
55.1%
20.3%
17.5%
54.2%
28.3%
291
292
293
34.6%
36.7%
28.8%
29.2%
38.8%
31.9%
689
67.4%
21.7%
690
32.6%
78.3%
*MS-DRG descriptions provided below
MS-DRG
064
065
066
069
189
190
191
192
193
194
195
247
287
291
292
293
310
312
313
379
MS-DRG Title (FY 2008)
Intracranial hemorrhage or cerebral infarction w MCC
Intracranial hemorrhage or cerebral infarction w CC
Intracranial hemorrhage or cerebral infarction w/o CC/MCC
Transient ischemia
Pulmonary edema & respiratory failure
Chronic obstructive pulmonary disease w MCC
Chronic obstructive pulmonary disease w CC
Chronic obstructive pulmonary disease w/o CC/MCC
Simple pneumonia & pleurisy w MCC
Simple pneumonia & pleurisy w CC
Simple pneumonia & pleurisy w/o CC/MCC
Perc cardiovasc proc w drug-eluting stent w/o MCC
Circulatory disorders except AMI, w card cath w/o MCC
Heart failure & shock w MCC
Heart failure & shock w CC
Heart failure & shock w/o CC/MCC
Cardiac arrhythmia & conduction disorders w/o CC/MCC
Syncope & collapse
Chest pain
G.I. hemorrhage w/o CC/MCC
392
470
603
641
683
689
690
871
885
906
Esophagitis, gastroent & misc digest disorders w/o MCC
Major joint replacement or reattachment of lower
extremity w/o MCC
Cellulitis w/o MCC
Nutritional & misc metabolic disorders w/o MCC
Renal failure w CC
Kidney & urinary tract infections w/ MCC
Kidney & urinary tract infections w/o MCC
Septicemia w/o MV 96+ hours w MCC
Psychoses
Hand procedures for injuries
7.Review the case mix index (CMI) figures in tables 1 and 2, next. Compare
the hospital figures to the state average and the peer facilities.
Facility
Hospital A
Hospital B
Hospital C
Hospital D
State Average
Table 1 - Overall CMI ? Years 1-3
Year 1
Year 2
1.8694
1.9017
1.9662
2.0554
1.6440
1.6873
1.8454
1.7021
1.4480
1.4778
Year 3
2.1473
2.0267
1.7010
1.6250
1.4953
Facility
Hospital A
Hospital B
Hospital C
Hospital D
State Average
Table 2 ? MCD 08 CMI ? Years 1-3
Year 1
Year 2
1.5700
1.4941
1.6917
1.8145
1.7264
1.7812
1.8246
1.8628
1.5461
1.6127
Year 3
1.3914
1.9703
1.7898
2.0187
1.6292
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