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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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