Answered: - Application Exercises 1. You are the CDM Coordinator at Anywhere

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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.

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

CODE

310

CPT

CODE

PRICE

82251

300

320

86458

95960

$25.00

$0.00

$20.00

$1,125.00

352

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

115

49214

BIOPSY OF BREAST, OPEN

19101

360

1137

3944.25

49217

CRYOSURG ABLATE FIBROADENOMA, EACH

19105

360

1137

6059.85

49218

NIPPLE EXPLORATION

19110

360

1137

3944.25

49219

EXCISE BREAST DUCT FISTULA

19112

360

1137

3944.25

49220

REMOVEAL OF BREAST LESION

19120

360

1137

3944.25

49221

EXCISION, BREAST LESION

19125

360

1137

3944.25

49222

EXCISION, ADDL BREAST LESION

19126

360

1137

3944.25

49223

REMOVAL OF CHEST WALL LESION

19260

360

1137

3076.44

49224

PREOP PLACE NEEDLE LOCAL WIRE BREAST

19281

320

1196

65.00

49225

PREOP NEEDLE LOCALIZATION ADD'L LESIONS

19282

320

1196

65.00

49227

PLACE BALLOON CATHETER FOR RADIOELEMENT APP

19296

360

1137

10810.92

49228

PLACE BALLOON CATHETER WITH PART MASTECTOMY

19297

360

1137

10810.92

49229

PLACE BRACHYTHERPAY CATHETER

19298

360

1137

10810.92

49230

REMOVAL OF BREAST TISSUE

19300

360

1137

3944.25

49231

PARTIAL MASTECTOMY

19301

360

1137

3944.25

49232

P-MASTECTOMY W LYMPHADENECTOMY

19302

360

1137

7608.72

49233

MASTECTOMY, SIMPLE, COMPLETE

19303

360

1137

6059.85

49234

MASTECTOMY, SUBCUTANEOUS

19304

360

1137

6059.85

49235

MASTECOMY, MODIFIED RADICAL

19307

360

1137

7608.72

49236

SUSPENSION OF BREAST

19316

360

1137

6059.85

49237

REDUCTION OF LARGE BREAST

19318

360

1137

7608.72

49238

ENLARGE BREAST

19324

360

1137

7608.72

49239

ENLARGE BREASE WITH IMPLANT

19325

360

1137

10810.92

49240

REMOVAL OF BREAST IMPLANT

19328

360

1137

6059.85

49241

REMOVAL OF BREAST IMPLANT MATERIAL

19330

360

1137

6059.85

49242

IMMEDIATE BREAST PROSTHESIS

19340

360

1137

7608.72

49243

DELAYED BREAST PROSTHESIS

19342

360

1137

10810.92

49244

BREAST RECONSTRUCTION

19350

360

1137

3944.25

49245

CORRECT INVERTED NIPPLE(S)

19355

360

1137

6059.85

49246

BREAST RECONSTRUCTION

19357

360

1137

10810.92

49247

BREAST RECONSTRUCTION

19366

360

1137

6059.85

49248

SURGERY OF BREAST CAPSULE

19370

360

1137

6059.85

49249

REMOVAL OF BREAST CAPSULE

19371

360

1137

6059.85

49250

REVISE BREAST RECONSTRUCTION

19380

360

1137

7608.72

49251

DESIGN CUSTOM BREAST IMPLANT

19396

360

1137

6059.85

49252

BREAST SURGERY PROCEDURE

19499

360

1137

3944.25

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%

12%

Coder

Variation Log by Coder

Error Rate

16%

12%

Variation Log by MS-DRG*

MS-DRG

Volume

Erro

Rat 2%

470

420

313

233

14%

392

232

291

232

17%

247

220

292

216

871

213

12%

641

209

194

195

293

193

885

188

312

177

191

175

287

173

310

171

15%

689

157

11%

603

143

379

137

192

131

683

116

11%

189

114

069

110

190

12%

193

10%

690

065

195

066

064

906

*MS-DRG descriptions provided below

Standard

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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