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Cover story continued 2

Ancillary Coding Tips & Reminders

2

Adult Critical Care Overview: Part 3 of 4

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Phishing: Help Good Employees Avoid a Cybersecurity

Nightmare

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RMC News 5-6

Vol. 9 Issue 1 1st Quarter 2019

I N S I D E T H I S I S S U E :

An abscess is a collection of pus, WBC’s, dead tissue, and bacteria (like staph), or foreign material, such as a stitch. An abscess can be located on any part of the body, external and internal. Abscesses located on the skin are easy to see and diagnose, while those that are internal might not be so readily apparent. People with acne or eczema, diabetes, and Immunodeficiency are at an increased risk of developing abscesses. Poor hygiene and direct contact with an infected person are also risks. Treatment for an abscess consists of warm compresses, antibiotics, and sometimes Incision and Drainage. To locate the ICD-10-CM code for an abscess you will need to know the type, if specified, and the site. You must first index “abscess”, followed by type if known, followed by site. An example would be an abscess of the foot. Index abscess, foot. If the abscess involves the tendon you would need to index abscess, tendon, foot. An abscess of the bone might be coded as osteomyelitis (per “see also” instructions in index). Some examples for type would include stitch abscess (abscess, stitch) and amebic abscess of the brain (abscess, amebic, brain). Remember, if the provider documents cellulitis and abscess at the same site, both conditions would be coded.

A Laceration is tearing of the skin or soft tissue and is usually jagged and irregular. Lacerations can be contaminated with debris depending on the circumstances of the injury. Many lacerations will require repair which could consist of Tissue adhesive, sutures, staples, or even skin flaps or grafts. There are several types of lacerations: traumatic (with or without foreign body), obstetrical, neonatal (birth injury), lacerations complicating abortion and ectopic or molar pregnancies, and accidental lacerations occurring during surgical procedures. To code your laceration in ICD-10-CM you will need to index the term laceration, followed by site. Some sites have even more specificity, such as the finger. Index laceration, finger and you will have options such as with foreign body and with damage to nail, damage to nail, with foreign body, or damage to nail without foreign body. Traumatic laceration codes will require a 7th character for treatment, A=Initial (active) treatment, D = subsequent encounter (routine healing), and S = sequela. For obstetrical lacerations you will need to index laceration, perineum, female, during delivery or delivery complicated by laceration. Obstetrical lacerations are further broken down by degree. To locate codes for lacerations that occur during surgery you will need to index complication, surgical, accidental puncture or laceration. Nerve lacerations are not found under laceration, instead you will index Injury, nerve, by site. When coding your repairs in CPT you will need to know the location of the repair and the size of the wound in cm’s, as recorded before repair. You will need to add together the lengths of all wounds of the same complexity (simple, intermediate, complex), that are in the same anatomic category. Multiple wounds of different complexity are not added together. Likewise, multiple wounds of the same complexity but located in different anatomical groups are not added together. Multiple wound repair codes may require modifier 59 so pay attention to your CCI edits.

A fracture is a broken bone that can range from a thin crack all the way to a complete break. The fracture can be crosswise or lengthwise, and can occur in many places and many pieces. Most fractures occur as a result of a sudden, very intense pressure or force impacting the bone, one that it cannot support. The strength of that force or pressure will determine the severity of the fracture. Anyone can experience a fracture, but you are more likely to develop one if you have brittle bones, or low bone density. You are more likely to develop brittle bones if you have any of the following risk factors: age, osteoporosis, endocrine or nutritional disorders, coritco-steroids, physically inactive, or you use alcohol or tobacco. When coding fractures the more information you have, the easier code selection will be. In order to locate your ICD-10-CM code for a fracture, you will need to know the type (traumatic or patho-logic), location (specific bone, proximal, distal, shaft, etc), laterality, and is the fracture open/closed, displaced/non-displaced.

Continued...

Coding of Abscesses, Lacerations, Fractures, and Nail Procedures in the Outpatient Setting

By Stacy Hartstine, RHIT, CCS

Nails are horn-like envelopes covering the tips of the fingers and toes and are made of a tough protective protein called alpha-keratin. A healthy nail functions to protect the fingertip, or toe, and surrounding soft tissue from injury. The nail also enhances precise delicate movements and sensitivity. It is a tool that enables precision grip, such as pulling out a splinter, and for cutting or scraping action. Common nail conditions include Ingrowing nails, fungal and bacterial infections, and subungual hematomas. CPT has several procedures that deal with nail procedures. These procedures can be found in range (11719-11765).

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“Abcesses, Lacerations, Fractures, Nail Procedures” continued...

Stacy Hartstine, RHIT, CCS is the Director of Coding Services at RMC. Stacy started in healthcare in 1994, working in various clinics and hospital settings. Holding positions as office manager, coder, Director of Health Information and Privacy Officer. In 2006 Stacy joined RMC as a Manager over the Texas Region. Stacy has proven herself to be an accomplished coder, auditor, manager, and now Director of Coding Services at RMC. In this position, Stacy is ultimately responsible for the overall success of the Hospital Division at RMC. Assuring exceptional client satisfaction with excellent services and exceptional customer service. Additionally, RMC staff engagement is a top priority.

Jennifer Jones, CCS is one of RMC’s Manager of Coding Services and also a CDI Specialist. Jennifer has been with RMC since 2009. Jennifer has over 27 years of experience in the HIM field and has held such positions as Manager of Coding Services, Inpatient & Outpatient Coding Specialist, Medical Transcriptionist, Medical Assistant, Medical Biller, and Medical Receptionist. Jennifer also has experience Clinical Documentation Improvement starting in 2010. Jennifer has worked in 25-bed Critical Access Hospitals, midsize hospitals, and large trauma level 1 medical centers. Jennifer is currently working on obtaining her RHIT, completion toward the end of 2017. Jennifer is an AHIMA approved ICD-10-CM and ICD-10-PCS Train the Trainer, and has been actively involved with RMC’s ICD-10 Training and education program. Jennifer resides in Oregon and can be reached at jjones@rmcinc.org

Ancillary coding to some seems to be so easy, but ancillary coding is actually very problematic. A lot of new coders are started out on ancil-lary encounters/visits, but in reality these are some of the more difficult encounters/visits to work with. A lack of documentation or minimal documentation, inconsistent guidance, and a lack of facility standards for ancillary encounters/visits are some of the factors that contribute to the problem.

Source documents should always include a provider order, signed documents such as radiology and pathology reports, and some nursing/therapy documentation for BMI and pressure ulcers if correlating documentation is noted. Do not forget that laboratory and microbiology reports are not typically signed by a provider and should not be used for coding. Facility guidelines are a must, and these should specify what is actually coded (first listed diagnosis only or chronic conditions as well?), what source documents are required (provider order, face sheet, proof of services provided, radiology or pathology reports), whether or not queries are permitted on ancillary encounters/visits, and a proce-dure for returning encounters/visits with missing documentation.

Potholes for coding ancillary encounters/visits include the words “mild” or “moderate”, coding only from the “impression” in a radiology report or coding from the body of the report, having no diagnosis or reason for a visit or test and lack of documentation in general, as well as receiving diagnosis codes on an order without the diagnosis written out. According to Coding Clinic 4Q 2015, pg 34, “it is not appropriate for providers to list the code number or select codes in lieu of a written diagnostic statement”, therefore the account may have to be routed back to the provider for a written diagnostic statement. Some facilities do not want to query on ancillary encounters/visits, however compliance is important for all types of encounters/visits, and this includes ancillary. Facilities should also clarify if mild or only moderate diagnoses are being coded, coding from the impression alone or coding the whole report.

The ground rules for ancillary coding include having the first listed diagnosis. This is the diagnosis, condition, problem or other reason for the encounter/visit that is shown in the medical record to be chiefly responsible for the ancillary services provided. Assign a diagnosis if one has been established, however assign signs and symptoms if a definitive diagnosis has not been established (confirmed). As ancillary encounters/visits are outpatient services, follow outpatient coding guidelines and do not code uncertain diagnosis such as possible, probable, suspected or similar terminology. If encounters are for routine lab or radiology, assign Z01.89 encounter for other specific special examinations, only in the absence of any signs, symptoms or associated diagnoses. Borderline diagnoses are not considered to be uncertain, and conditions that a pro-vider has documented as borderline are to be coded as confirmed (unless the condition has a specific subentry for borderline, as in borderline diabetes). Chronic conditions that are treated on an ongoing basis may be coded on ancillary encounters/visits if they coexist at the time of the encounter/visit and they require or affect patient care, treatment or management. However, this needs to be addressed in facility guidelines as noted above. Historical codes may also be used as secondary codes if the information has an impact on current care or influences treatment.

As you can see, there are a lot of factors to take into consideration when coding ancillary encounters/visits. It is not as “easy” as some may think. Make sure there are facility guidelines in place for ancillary encounters/visits, that also includes a query policy, and this will help avoid falling into some of the ancillary coding potholes.

Ancillary Coding Tips and Reminders By Jennifer Jones, CCS

In this third installment of critical care services, we will discuss how split shared and teaching services affects reporting critical care services and billing telehealth consultations.

Split/Shared Visits:

Critical care services reported should reflect the evaluation, treatment and management of the patient by the physician or the NPP and cannot be a combined service between them. When the requirements for critical care services are met by the NPP, the service would be billed under the NPP with their individual NPI number. As usual for NPP billing, reimbursement would be at 85% of the fee schedule. If the NPP sees a patient for 45 minutes in the morning and a physician, in the same group practice, sees the patient in the afternoon for 50 minutes the charges submitted would be 99291 for the NPP (at 85%) and 99291 for the physician at (100%). The claim could still be rejected and in order to appeal any denials both providers should specifically document the medical necessity and time requirements for the critical care service each rendered.

Teaching Physicians:

When providing critical care in the teaching facility, the teaching physician must be present for the entire period of critical care time. Time spent teaching the resident may not be counted towards critical care time. Only the time that the teaching physician spends with the patient (either alone or together with the resident) can be counted towards critical care time. The teaching physician may refer to the resident’s documentation for patient history, exam and medical assessment BUT the teaching physician’s documentation must provide substantial information including:

• Time the teaching physician spent providing critical care

• That the patient was critically ill when the teaching physician saw the patient

• Why the patient was critically ill and the treatment and management provided by the teaching physician

An example of an acceptable teaching documentation is listed below:

• Patient developed hypotension and hypoxia. I spent 45 minutes of critical care providing treatment with (insert detailed description of care provided i.e... …..pressors, oxygen, fluids) of what was done from the teaching physician). The teaching physician can then reference the resident note saying I reviewed the resident’s documentation and I agree with the resident’s A/P.

Telehealth Consultation Critical Care Coding:

G0508 and G0509 represent professional consultations furnished via an interactive telecommunication system. An interactive telecommunica-tion system is defined as multimedia communication equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site provider. A good example where this may be utilized is for a stroke patient at a rural hospital.

• G0508 – Critical Care, initial, physician typically spend 60 minutes communicating with the patient and providers via telehealth

• G0509 – Critical Care, subsequent physicians typically spends 50 minutes communicating with the patient and providers via telehealth

− Do not report G0508 or G0509 more than once per day

− CMS feels that the overall work for G0508 and G0509 is not as great as the critical care codes 99291-99292 but that this service involves more work than G0427 (Telehealth consultation, ER or initial inpatient typically 70 minutes or more communicating with the patient via telehealth)

References:

AMA’s Current Procedural Terminology 2019 codebook

Medicare Claims Processing Manual

Adult Critical Care Overview - Part 3 of 4 Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC

Chris Breithoff, CPC, CPCO, CDEO, CRC

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Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC is a Manager of Physician Coding Services at RMC. Susan has been working in the medical field since 1996, within physician offices. In addition being a Certified Professional Coder, she also holds specialty certifications in Evaluation and Management, General Surgery and OB/GYN. She is also a certified AAPC instructor. She has experience in professional fee coding, provider auditing (retrospective and prospective) and coder/provider education. Her experience ranges from small to large multispecialty groups and large teaching hospitals. Susan also has experience coding Ophthalmology (to include Optho-plastics), Infusions for Chemotherapy, General Surgery (to include bariatric surgery), and Dialysis. Susan can be reached at smorton@rmcinc.org.

Chris Breithoff, CPC, CPCO, CDEO, CRC is the Director of Physician Coding Services at RMC. She has worked in the medical arena since 1985 with an emphasis on coding & compliance for 18 years. Chris has a diverse background which includes managing large private practices, additionally, managing a physician coding department for a large teaching hospital. In these roles, Chris’ was responsible for the day to day coding, education of coders and providers, as well as overall compliance of the revenue cycle. Chris’ areas of expertise include Evaluation and Management coding, Critical Care, Emergency, Gastroenterology, Pulmonary, Cardiology and Sleep Medicine. Chris joined RMC in 2012 as an Auditor. In 2015 Chris took the helm of the Physician Coding Services and has done an outstanding job assuring exceptional services to our client and focusing on RMC staff engagement. Chris can be reached at cbreithoff@rmcinc.org.

Phishing: Help Good Employees Avoid Causing a Cybersecurity Nightmare

By Chris Apgar, CISSP

The sneakiest of cyber-attacks, phishing has grown in sophistication even as organizations work to tighten cybersecurity programs. Phishing attacks have always been an easy backdoor into an organization’s – or individual’s – network. With one click as you’re hurrying through daily emails, you can unleash malicious software into the system.

Phishing fools the best employees. Impersonation has become slick – emails look nearly identical to those you’d get from a bank, shipping service, or online retailer. Even government agencies get used to perpetuate the scam. Links or attachments that look benign, like receipts, tracking links or spreadsheets, contain nasty malware that can bring down a system and halt business operations until it’s contained.

6 Phishing-wary Best Practices

1. Recognize the sender’s email address. Then stop. Look again, and don’t click on the link or open the attachment. If the topic seems even a hair out of character for the sender, it may be coming from a hacked account.

2. Hover your cursor over the suspect link. If the heading says it’s from your bank but the web link that you see when you hover your cursor over the link doesn’t match, don’t click the link! It would be a good idea to report these scams to your bank or other legitimate sender you may communicate with.

3. Don’t recognize the email address or sender? Definitely don’t click. And perhaps let your IT department know a strange email is in your Inbox.

4. Weren’t expecting an email from this sender? Use the telephone! Yes, an old-fashioned call to verify that the email is legitimate could save your company a world of hurt.

5. Pay close attention to emails directing you to websites that look just a little off. Fake sites often impersonate real ones.

6. Update software security and anti-malware software when it’s released. Don’t swipe it off the screen or keep clicking “install later.” That’s the kind of procrastination cyber attackers count on.

7. Backup data frequently, then test those backups. You want to know that a data restore action actually works. If it doesn’t, rethink your backup strategy.

Your best bet to combat phishing attacks? Workforce awareness. Much of the privacy and security training we provide is geared toward helping your workforce recognize phishing attacks, learn how everyday activities can compromise information security, and realize how their particular job function relates to overall cybersecurity, no matter what the position is.

Resource: OS OCR Security List, February 2018 Cybersecurity Newsletter: Phishing

RMC is currently looking for experienced, credentialed, hard-working coding experts to join our team. Positions are all remote, and all RMC staff are issued a company laptop.

Qualified candidates:

• Must have a minimum of 5 solid years of coding experience

• Must be AHIMA/AAPC credentialed

• Must pass RMC's coding test

• Must be reliable, friendly and flexible

• Full-time AND part-time positions available! Some positions qualify for sign-on bonus!

If you want to join our team and LOVE your job, please send your resume to employment@rmcinc.org

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Chris Apgar, founder of Apgar & Associates is a Certified Information systems Security Professional (CISSP). He is one of the country’s foremost experts and spokespersons on healthcare privacy, security, regulatory arriafs, state and federal compliance and secure and efficient electronic health information exchange. Chris has more than 19 years of experience in regulatory compliance and is a leader of regional and national privacy, security and health information exchange forums. As a member of Workgroup for Electronic Data Interchange, and serving on the Board of Directors since 2006, Chris is an honest, reliable, trustworthy expert in the field of privacy and security.

Apgar & Associates helps you discover privacy and security vulnerabilities so you can manage risks before a breach occurs. Contact us to schedule your assessment today: 503-384-2583 or email capgar@apgarandassoc.com for more details.

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Yep. You read that right. Totally free.

Visit our website: www.rmcinc.org to submit your questions today!

Our new website features a “Coding Questions” button. Submit your question, and one of our

RMC coding experts will reply.

*Also - don’t forget to follow RMC on Facebook, LinkedIn and Twitter. We post coding tips, reminders and updates weekly!

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Camille Walker: cwalker@rmcinc.org or Kristin Gibson: kristin@rmcinc.org