EMPOWERING PEOPLE TO IMPACT HEALTH

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EMPOWERING PEOPLE TO IMPACT HEALTH

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©2020-2021 | AHIMA.ORG

CCS Exam Prep WebinarDomain 1

Gina Sanvik, MS, RHIA, CCS, CCS‐PAHIMA‐Approved ICD‐10‐CM/PCS TrainerAHIMA‐Approved Revenue Cycle Trainer

Practice Director, Revenue Cycle ManagementAHIMA


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Domain 1 – Coding Knowledge and SkillsTasks1. Apply diagnosis and procedure codes based on provider's

documentation in the health record2. Determine principal/primary diagnosis and procedure 3. Apply coding conventions/guidelines and regulatory guidance 4. Apply CPT/HCPCS modifiers to outpatient procedures 5. Sequence diagnoses and procedures 6. Apply present on admission (POA) guidelines7. Address coding edits8. Assign reimbursement classifications 9. Abstract pertinent data from health record10.Recognize major complication and co-morbidity (MCC) and

complication and co-morbidity (CC)


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Inpatient CodingICD-10-CM/PCS

Definitions, Guidelines, Conventions, and Reimbursement

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Uniform Hospital Discharge Data Set (UHDDS)• Minimum, common core of data on individual

hospital discharges in the Medicare and Medicaid programs

• Purpose – improve uniformity and comparability of hospital discharge data

• Definitions of data elements can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40. https://www.govinfo.gov/content/pkg/FR-1985-07-31/pdf/FR-1985-07-31.pdf


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Uniform Hospital Discharge Data Set (UHDDS)• UHDDS elements coding professionals should have good understanding of:• Diagnoses• Procedures• Disposition of Patient


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ICD-10-CM Guidelines• Issued by

• Centers for Medicare and Medicaid Services (CMS)

• National Center for Health Statistics (NCHS)• Approved by Cooperating Parties

• American Hospital Association (AHA)• American Health Information Management

Association (AHIMA)• CMS• NCHS

• Instructions and conventions of ICD-10-CM take precedence over guidelines

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ICD-10-CM Guidelines

Sections

I. Conventions, General Coding Guidelines and

Chapter Specific Guidelines

II. Selection of Principal Diagnosis

III. Reporting Additional Diagnoses

IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

Appendix I. Present on Admission Reporting

Guidelines


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Sections



A. Conventions

Applies to ALL ICD‐10‐CM code assignment,

regardless of setting, unless otherwise

indicated

B. General Coding Guidelines

C. Chapter‐Specific Coding Guidelines



IV. Diagnostic Coding and Reporting Guidelines for

Outpatient Services


Guidelines


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Sections



Applies to ALL ICD‐10‐CM code assignment,

regardless of setting, unless otherwise indicated


Applies to inpatient


Applies to inpatient

IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

Applies to outpatient


GuidelinesApplies to inpatient

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Section II. Selection of Principal Diagnosis• Applies to all non-outpatient settings (acute

care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.) as well as hospice services (all levels of care)


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ICD-10-CM GuidelinesUHDDS:• Diagnoses – All diagnoses that affect the

current hospital stay• Principal diagnosis: The condition established

after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

• Other diagnoses: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.


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II.A. Codes for symptoms, signs, and ill-defined conditions

• Patient with pneumonia has symptoms of cough, shortness of breath and hemoptysis.

II.B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis

• Patient admits with diastolic CHF and atrial fibrillation. Both conditions were treated

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II.C. Two or more diagnoses that equally meet the definition for principal diagnosis

II.D. Two or more comparative or contrasting conditions

• Patient admitted with CAUTI and aspiration pneumonia and becomes septic.


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ICD-10-CM GuidelinesOther diagnoses

Clinical evaluation; or

Therapeutic treatment; or

Diagnostic procedures; or

Extended length of hospital stay; or

Increased nursing care and/or monitoring


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Section III. Reporting Additional Diagnoses

Guideline III.A ‐Previous conditions

Guideline III.B ‐Abnormal findings

Guideline III.C ‐Uncertain diagnosis

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ICD-10-PCS Coding GuidelinesA. ConventionsA. Conventions

• B2. Body System

• B3. Root Operation

• B4. Body Part

• B5. Approach

• B6. Device

B. Medical and Surgical Section GuidelinesB. Medical and Surgical Section Guidelines

C. Obstetrics Section GuidelinesC. Obstetrics Section Guidelines

D. Radiation Therapy GuidelinesD. Radiation Therapy Guidelines

E. New Technology Section GuidelinesE. New Technology Section Guidelines

F. Selection of Principal ProcedureF. Selection of Principal Procedure


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ICD-10-PCS Guidelines

UHDDS:• Procedures – All significant procedures are to be reported• Surgical in nature, or • Carries a procedural risk, or• Carries an anesthetic risk, or• Requires specialized training


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ICD-10-PCS Guidelines

UHDDS:• Designate principal procedure if more than one

is reported• The principal procedure is one that was

performed for definitive treatment rather than one performed for diagnostic or exploratory purposes or was necessary to take care of a complication. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure.

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ICD-10-PCS Coding Guidelines

1. Definitive treatment of both principal and secondary diagnosis:• Sequence the procedure done for definitive treatment

most related to principal diagnosis as principal procedure

2. Definitive treatment and diagnostic procedures for both principal and secondary diagnosis:• Sequence the procedure done for definitive treatment

most related to principal diagnosis as principal procedure


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ICD-10-PCS Coding Guidelines

3. Diagnostic procedure done for principal diagnosis and definitive procedure for secondary diagnosis:• Sequence the diagnostic procedure as principal since

it’s related to the principal diagnosis

4. Both diagnostic and definitive procedures performed for secondary diagnoses only: • Sequence procedure performed for definitive

treatment of secondary diagnosis as principal procedure, there are no procedures related to principal diagnosis.


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Abstracting “The process of extracting information from a document to create a brief summary of patient’s illness, treatment and outcome.”• Data may be manually or automatically collected• Research & other organization specific data collected• Statistical analysis of medical record for

administrative & clinical decision making• Produces disease & procedure indices, vital

statistics, registries, health care statistical information, provider information, state reporting

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CMS DefinitionsDiagnosis-Related Group (DRG): A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.

Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services).


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CMS DefinitionsCase Mix: The distribution of patients into categories reflecting differences in severity of illness or resource consumption.

Case Mix Index: The average DRG relative weight for all Medicare admissions.

https://www.cms.gov/apps/glossary/default.asp?Letter=C&Language=English


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Inpatient Prospective Payment System (IPPS)

Hospital reimbursement under Medicare Part A

• Relative weight (RW)

• Payment level

• Used to calculate Case‐Mix Index (CMI)

• Calculated by adding the MS‐DRG relative weight for every inpatient discharge (sum of the RWs) and dividing by the number of discharges

Diagnosis‐Related Group (DRG)

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Medicare Severity – Diagnosis Related Groups (MS-DRGs)

Levels of Severity

Major Complication/ Comorbidity (MCC)

Highest level of severity

Complication/ Comorbidity (CC)

Lower level of severity than MCC

Non‐CCDo not significantly affect severity of illness and

resource use


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Medicare Severity – Diagnosis Related Groups (MS-DRGs)• 25 Major Diagnostic Categories (MDC)• 01 Nervous System• 02 Eye• 03 Ear, Nose, Mouth & Throat• 04 Respiratory System• 05 Circulatory System

Version 38 can be found at:https://www.cms.gov/icd10m/version38-fullcode-cms/fullcode_cms/P0001.html


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• 25 Major Diagnostic Categories (MDC)• Surgical or Medical


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• 25 Major Diagnostic Categories (MDC)• Surgical or Medical


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https://www.cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-page#Tables

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Case Mix Calculation Example

1. Add RW for every discharge – to get the sum of all RWs2. Divide by the number of discharges

MS‐

DRG

Title RW # of

DC

Sum of RW

186 Pleural effusion w/ MCC 1.5432 10 15.4320

187 Pleural effusion w/ CC 1.0322 35 36.1270

188 Pleural effusion w/o CC/MCC 0.7281 30 21.8430

189 Pulmonary edema & respiratory failure 1.2248 6 7.3488

190 Chronic obstructive pulmonary disease w/ MCC 1.1239 22 24.7258

191 Chronic obstructive pulmonary disease w/ CC 0.8831 25 22.0775

192 Chronic obstructive pulmonary disease w/o

CC/MCC

0.6949 40 27.7960


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1. Add RW for every discharge – to get the sum of all RWs2. Divide by the number of discharges

MS‐

DRG

Title RW # of

DC

Sum of RW








CC/MCC

0.6949 40 27.7960

x

x

x

x

x

x

x

=

=

=

=

=

=

=


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1. Add RW for every discharge – to get the sum of all RWs = 155.3501

2. Divide by the number of discharges

MS‐

DRG

Title RW # of

DC

Sum of RW








CC/MCC

0.6949 40 27.7960

155.3501

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1. Add RW for every discharge – to get the sum of all RWs = 155.3501

2. Divide by the number of discharges = 168

MS‐

DRG

Title RW # of

DC

Sum of RW








CC/MCC

0.6949 40 27.7960

168 155.3501


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1. Add RW for every discharge – to get the sum of all RWs = 155.35012. Divide by the number of discharges = 168

155.3501/168 = 0.92470298carry out to 4 decimal places

MS‐

DRG

Title RW # of

DC

Sum of RW








CC/MCC

0.6949 40 27.7960

168 155.3501

Case Mix Index 0.9247


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CMS MS-DRG vs 3M APR-DRG

• MS-DRGs – did not classify severity levels for non-Medicare patients such as:• Newborns• Pediatric patients• High risk pregnancies• HIV-related co-morbidities• Mental disorders• Drug and alcohol dependence• Burns• Organ transplants

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MS DRG• Data Source - Medicare• Coverage - 65+ years

old• 3 levels of severity• Not all conditions

contain 3 levels of severity

• No risk categorization for risk of dying

• Intended for reimbursement only

APR DRG• Data Source - All payer• Coverage includes all ages• 4 levels of severity• All conditions have 4 levels

of severity• 4 levels of risk of mortality

for every condition.• Used in both

reimbursement and quality performance measurement

CMS MS-DRG vs 3M APR-DRG

http://www.fha.org/showDocument.aspx?f=DRG‐Overview‐of‐All‐Patient‐Refined‐Diagostic‐Related‐Groups.ppt


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All Patient Refined (APR) DRGs

NOTE: The following information on APR-DRGs was pulled from a 3M presentation that can be found at:https://www.forwardhealth.wi.gov/kw/pdf/handouts/3M_APR_DRG_Presentation.pdf• Assignment to a “Base” APR-DRG based on: - Principal Diagnosis, for Medical patients, or - Most Important Surgical Procedure

(performed in an O.R.) The “Base” DRG for both MS-DRGs and APR-DRGs are grouped into the MDCs


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• Each Base APR-DRG is divided into subclasses - Two types of Subclasses: • Severity of Illness (SOI) • Risk of Mortality (ROM)

- SOI and ROM assignment take into account the interaction among principal & secondary diagnoses, age, and, in some cases, procedures

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• Severity of Illness (SOI) - Minor- Moderate- Major- Extreme

• Risk of Mortality (ROM) - Minor- Moderate- Major- Severe


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• Both an admission APR DRG and discharge APR DRG are computed - Discharge APR DRG – classification of the

reason for admission, severity of illness and risk of mortality of a patient at discharge.• Uses all the ICD codes on the record to

account for classification • Used for prospective payment, risk

adjustment in quality reporting


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(cont.)- Admissions APR DRG - classification of the

reason for admission and the severity of illness and risk of mortality of a patient when they entered the admission. • Uses a subset of ICD codes on the record

based on Present on admission indicator, and

• Seven additional steps in criteria to account for the codes used in Admissions APR DRG classification.

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Present on Admission (POA)

• Section 5001(c) of the Deficit Reduction Act of 2005 requires reporting present on admission• Effective for discharges on or after October 1, 2007• Required by CMS• Reported to distinguish among conditions actually present at admission and those conditions that develop during an inpatient admission


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POA Reporting Requirements

• All claims involving inpatient admissions • Present on admission defined as present at the

time the order for inpatient admission occurs • conditions that develop during an outpatient

encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission

• POA indicator is assigned to principal and secondary diagnoses


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POA Reporting Requirements

• Inconsistent, missing, conflicting or unclear documentation must be resolved by provider• If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported

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POA Guidelines

• Appendix I of the ICD-10-CM Official Guidelines for Coding and Reporting• Not intended to replace any guidelines • Complete and accurate documentation, code assignment, and reporting of diagnoses and procedures


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POA Reporting Definitions

• Y = present at the time of inpatient admission• N = not present at the time of inpatient admission• U = documentation is insufficient to determine if condition is present on admission • W = provider is unable to clinically determine whether condition was present on admission or not• Unreported/Not used – (Exempt from POA reporting)


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Medicare Code Editor• Invalid diagnosis or

procedure codes• External cause code as

principal diagnosis• Duplicate of PDX• Age conflicts• Sex conflicts• Manifestation code as a

principal diagnosis• Questionable admission

Medicare Code Editor• Unacceptable principal

diagnosis• Non-covered procedure• Invalid age• Invalid sex• Invalid discharge status• Limited coverage• Wrong procedure

performed• Procedure inconsistent

with length of stay

Coding Edits - MCE

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Outpatient CodingICD-10-CM & CPT/HCPCS

Definitions, Guidelines, Conventions, and Reimbursement


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Outpatient ICD-10-CM Coding Guidelines

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services• Used for reporting hospital-based outpatient services and provider-based office visits. • Guidelines in Section I.A-C also apply• Encounter and visit used interchangeably


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First Listed Diagnosis

• Instead of principal diagnosis• Conventions of ICD-10-CM take precedence• Diagnosis may not be established at first encounter• Codes for symptoms are common• Two or more visits may be necessary to determine diagnosis

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Outpatient Surgery and Observation• Outpatient Surgery

• Reason for surgery is first listed diagnosis• Applies even if surgery is not performed due

to complication• Observation Stay

• Medical condition that caused observation• Medical condition

• Complication of outpatient surgery• Reason for the surgery• Complication that caused observation


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Code the Reason for the Encounter• Diagnostic services

• Reason for the test• Z01.89, Encounter for other

specified special examinations• Therapeutic services

• Reason for the service• Exceptions – Z codes

• Chemotherapy• Radiation• Immunotherapy


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Procedure Coding

• Coding for all outpatient settings and physicians in any setting• HCPCS• CPT®

• Published by AMA• National Codes (HCPCS Level II)• Established by CMS

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Modifiers

• Modified by some circumstance• Bilateral• Less or more services

• CPT® Modifiers• National code modifiers• Appendix A in CPT®


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Procedural Coding• 6 sections

• Surgery largest section• Evaluation and Management for provider

service• Anesthesia, Radiology, Pathology and

Laboratory, Medicine• Chargemaster assignment

• Radiology, Pathology and Laboratory• Coding Guidance

• AMA’s CPT® Assistant• AHA’s Coding Clinic® for HCPCS


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Outpatient Prospective Payment System (OPPS)

• Implemented on August 1, 2000• OBRA of 1986• Mandated development of OPPS

• Balanced Budget Act of 1998• Ambulatory Payment Classifications (APCs)• Based on HCPCS codes• CPT®

• National Codes

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Ambulatory Payment Classifications (APCs)

• Divides services into groups• Fixed Payments for services• Similar characteristics and costs• Some similarities with DRGs• Based on HCPCS codes• More than 850 APCs• Multiple APCs for a given case possible


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Services Included in APCs• Surgical procedures• Radiology, including radiation therapy• Clinic visits (E/M)• ER visits• Partial hospitalization services for the mentally

ill• Chemotherapy• Preventive services and screening exams• Dialysis for other than ESRD• Vaccines, splints, casts and antigens• Certain implantable items


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APC Status Indicators

Examples:• N- Items and Services Packaged into APC Rates• T-Significant Procedure, Multiple Reduction Applies• S- Significant Procedure, Not Discounted When Multiple• C- Inpatient Procedures, not paid under OPPS

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Medical Necessity

• Cover only services that are warranted by the patient’s condition• National Coverage Determinations (NCDs)• Developed by CMS

• Local Coverage Determinations (LCDs)• Developed by Medicare Administrative Contractor (MAC)


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National Correct Coding Initiative (NCCI)• Based on CPT® coding conventions, national and local policies• Updated annually for Medicare services and quarterly for Medicaid services• Procedure-to-Procedure (PTP) edits • Code pairs that should not appear together• Separate procedures• Mutually exclusive


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Outpatient Code Editor (OCE)

• Used by the Medicare Administrative Contractor (MAC) to process claims• Evaluates codes vs edits• Age and sex inconsistencies• Valid codes• Established coding guidelines

• Pass all edits = clean claim

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Resources

• American Medical Association. (2020). CPT 2021 professional edition. Chicago, IL.

• An overview of 3M™ all patient refined diagnostic related groups (3M APR DRG). (2012, July 12). Retrieved from http://www.fha.org/showDocument.aspx?f=DRG-Overview-of-All-Patient-Refined-Diagostic-Related-Groups.ppt

• Casto, A. B. (2021). ICD-10-CM codebook 2021. Chicago, IL: AHIMA.

• Casto, A. B. (2018). Principles of healthcare reimbursement (6th ed.). Chicago, IL: AHIMA Press.


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Resources

• National Archives And Records Administration. (1985). Health Information Policy Council; 1984 Revision of the Uniform Hospital Discharge Data Set. Federal Register: 50 Fed. Reg. 30925. Wednesday. [Periodical] Retrieved from the Library of Congress, https://www.loc.gov/item/fr050147/.

• Pocket Glossary of Health Information Management and Technology. Chicago, IL: AHIMA, American Health Information Management Association, 2017.

• U.S. Dept. of Health & Human Services, Centers for Medicare & Medicaid Services. Glossary, (n.d.). Baltimore, MD. Retrieved from https://www.cms.gov/apps/glossary/


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Resources• U.S. Dept. of Health & Human Services, Centers for

Medicare & Medicaid Services. ICD-10-CM/PCS MS-DRG v38.0 Definitions Manual. (n.d.). Retrieved from https://www.cms.gov/icd10m/version38-fullcode-cms/fullcode_cms/P0001.html

• U.S. Dept. of Health & Human Services, Centers for Medicare & Medicaid Services. Internet -only manuals (IOMs), Medicare claims processing manual, (n.d.). Baltimore, MD. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

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Resources

U.S. Dept. of Health & Human Services, Centers for Medicare & Medicaid Services. National Correct Coding Initiative Policy Manual for Medicare Services. (2021, January 1). Retrieved from: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd


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