The Proposed Inpatient Prospective Payment System (IPPS) Rule was published on April 23, 2019. The ICD-10-CM code changes contained in the FY 2020 Proposed Rule Tables revealed 273 new codes, 21 deleted codes, and 30 code title revisions. The rule also proposes nearly 1,500 changes to complication or comorbidity/major complication or comorbidity (CC/MMC) designation and most of the severity changes are downgrades. The number of new codes by chapter can be viewed in Table 1 below.

New Codes

Table 1

Chapter #	Chapter Title	New Codes
3	Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)	5
8	Diseases of the ear and mastoid process (H60-H95)	1
9	Diseases of the circulatory system (I00-I99)	30
12	Diseases of the skin and subcutaneous tissue (L00-L99)	25
14	Diseases of the genitourinary system (N00-N99)	3
17	Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)	31
18	Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)	3
19	Injury, poisoning and certain other consequences of external causes (S00-T88)	87
20	External causes of morbidity (V00-Y99)	75
21	Factors influencing health status and contact with health services (Z00-Z99)	13
	TOTAL	273

Significant changes for some of the chapters are highlighted below.

Chapter 9: Diseases of the circulatory system (I00-I99)

There are four new atrial fibrillation codes and two existing codes (I48.1, I48.2) have been deleted. The new codes are:

• 11, Longstanding persistent atrial fibrillation
• 19, Other persistent atrial fibrillation
• 20, Chronic atrial fibrillation, unspecified
• 21, Permanent atrial fibrillation

There are eight new codes added to subcategory I80.2, Phlebitis and thrombophlebitis of other and unspecified deep vessels of lower extremities, to identify phlebitis and thrombophlebitis of the peroneal vein and calf muscle veins. Specific codes for these lower extremity veins have also been added to subcategories:

• 4-, Acute embolism and thrombosis of deep veins of lower extremity
• 5-, Chronic embolism and thrombosis of deep veins of lower extremity

Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99)

Category L89, Pressure ulcer, has been expanded with a sixth character of “6” which indicates pressure-induced deep tissue damage of various anatomic sites. Currently, deep tissue injuries code to “pressure ulcer unstageable,” but there can be significant clinical differences between unstageable ulcers and deep tissue injuries. Unstageable ulcers occur when eschar obscures the ability to stage the ulcer, but once removed a stage 3 or 4 ulcer is typically revealed. Deep tissue injuries often have dual etiology that include pressure and ischemia and do not always result in tissue loss. These new codes will have a severity status of Complication/Comorbidity (CC).

Chapter 17: Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)

Several codes have been added to category Q66, Congenital deformities of feet, to provide specificity for laterality. Subcategory Q79.6, Ehlers-Danlos syndrome (EDS) has added a fifth character to specify the most common and severe types of EDS.

Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)

Several new subcategories have been added to specify fractures of the orbital roof and individual orbital walls frequently seen in facial trauma cases. Poisoning codes have been added for poisoning by multiple medicaments (T50.91-) and heatstroke/sunstroke (T67.0-).

Chapter 20: External causes of morbidity (V00-Y99)

Currently ICD-10-CM category Y35, Legal intervention, does not completely capture mechanisms of injury in encounters between civilians and law enforcement. Codes have been added to when the injured person is not specified as either law enforcement, bystander, or suspect. Some legal intervention codes fail to provide the necessary specificity to track for public information, law enforcement, and morbidity and mortality data collection and reporting purposes. Subcategory Y35.8, Legal intervention involving other specified means, has been expanded to capture injuries caused by conducted energy devices (CED) such as TASER devices.

CMS has been hard at work to address the burden placed on clinicians by federal health care regulations. Through our “Patients over Paperwork” initiative we are collecting feedback and updating policies in Medicare and Medicaid that are outdated, duplicative, or overly burdensome. Over the past year I have traveled the nation and met with clinicians, and the feedback I have heard has guided my efforts at the agency.

One key initiative that we have launched involves streamlining the measures that clinicians report; a recent Health Affairs study found that U.S. medical practices in four common specialties on average spend, per physician, a striking 15.1 hours per week and over $40,000 per year reporting quality metrics. The litany of regulations in healthcare contributes to the consolidation we’re seeing in the system. According to a survey by the American Medical Association, the percent of clinicians with ownership status in their practice declined from 53 percent in 2012 to 47 percent in 2016, with younger physicians more than three times as likely as older physicians to be employed by hospitals.

As one example of a common sense regulatory change that we have made this year, we changed our policy on medical student documentation, so patient notes written by a medical student can now be used for billing purposes after the attending physician signs off. Through our implementation of MACRA, we have worked to ensure a gradual transition for clinicians to the new payment system. And more recently, we addressed payment differentials between sites of service that reduce competition in the system.

In the 2019 proposed rule for the Physician Fee Schedule, CMS recognized another opportunity to act on the feedback that we have been receiving regarding clinician burden and the burnout that can come as a result. We have heard repeatedly that a major source of burnout is the documentation burden associated with evaluation and management (E/M) coding, and that a change is long overdue.

The current 1995/1997 E/M framework was built upon a model of clinical care involving complaint or symptom-based face-to-face encounters between a patient and a clinician. Since the 1990s, the nature of clinical work has evolved, including greater emphasis on patient centered, collaborative models of care with clinical teams working together to manage chronic conditions. The intensity of this work, which often requires complex medical decision-making and care coordination, is not well represented in the current E/M framework. As a result, clinicians find themselves having to perform and document clinical activity that may be of only marginal relevance to the visit, but is required in order to receive the level of payment that their effort deserves. 2 CMS sought to update documentation requirements and propose a new model of payment for E/M services. In response to our proposals, the agency received more than 15,000 comments, which reaffirmed the need to reduce burden on clinicians and provided us with specific feedback on how to improve our proposal. We appreciate the input and have responded. Effective January 1, 2019, we will: •

• Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to re-document information.

• Clarify that for both new and established E/M office visits, a Chief Complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered.

• Eliminate the requirement for documenting the medical necessity of furnishing visits in the patient’s home versus in an office.

• Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.

Beginning in 2021, we will implement payment and coding changes to achieve additional burden reduction. Billing for visits will be simplified and payment will vary primarily based on attributes that do not require separate, complex documentation. For 2021, we intend to:

• Implement a single payment rate for visits currently reported as levels two, three, and four. These represent a majority of office/outpatient visits with clinicians. This means that for the majority of visits, the required documentation related to payment will be limited to what is required for a level two visit.

• Retain a separate payment rate for the most complex patients – those currently reported through use of the level five codes. Also we will retain the current separate code for level one visits, which are predominantly used for visits with clinical support staff.

• Introduce coding that adjusts rates upward to account for additional resource costs inherent and routine in furnishing certain types of non-procedural care. These codes would only be reportable with level two through four visits, and their use generally would not impose new per-visit documentation requirements.

• Introduce coding that adjusts rates upward for use with level two through four visits to account for the additional resource requirements when practitioners need to spend extended time with a patient.

• Allow for flexibility in how level two through five visits are documented – specifically introducing a choice to use the current framework, medical decision-making, or time.

We acknowledge that there is a great deal of work to do to further modernize the payment structure for office/outpatient visits and associated documentation requirements. We are 3 committed to getting this right in order to reflect the evolving nature of clinical practice, respect the work of physicians and other clinicians, and support the best experience of care for every patient. A two-year delay for the payment and coding changes will give clinicians more time to integrate changes in workflow that may be required. In addition, the extra time will allow CMS to continue working with the clinician community on this effort.

CMS is committed to reducing administrative burden. We need clinicians to be able to leverage their full skill set and provide high-quality patient care, instead of being consumed by paperwork. We welcome your feedback and look forward to continuing engagement with clinicians to improve the framework through which we understand and value the care that they provide.

Coders when coding ER encounters you are reviewing all the information before entering your codes, right! In doing so, your encounter should look like so….(Scenario in my head)

“16 year old male who presents with a complaint of left elbow injury/pain after falling PTA(prior to arrival). He has some swelling and unable to bend at the elbow joint. He denies………

A/P: Fall (NO! NO! NO! PHYSICIANS), sprain of left elbow…………NOW CODE”

Admit Dx: Left Elbow Injury S59.902A

Reason Dx 1: Left elbow Injury S59.902A

Reason Dx 2

Reason Dx 3

Primary Dx: Sprain of Left Elbow S53.402A

Dx: Fall W19.XXXA

Please educate your physicians and let them know they are not TREATING a fall. Ask yourself……How can they do that? All accidents, falls happened already so they weren’t there. The physician must TREAT the result of the fall i.e left elbow injury, burns, lacerations, gunshot wounds etc. It is imperative as a coder, we seek these trends and make sure we are letting our supervisors, managers, coding educators etc know this so that proper education is given to the physician.

CODERS TIP: For some coders I know that External Cause of Injury(NEVER PRIMARY DIAGNOSIS) coding is rather difficult. Please just keep it simple when coding. We must remember the end of our ABC’s and the sequencing of codes all in one. Just think…..

Injury: Usually S and T codes

How?-V and W Codes- How did the injury happen…..falls, accidents, burns, injuries…….Look in the ECI section in ICD-10Cm

What?-X or Y codes- What activities they were indulging in…..athletics, riding, exercises….Look under activities in the ECI section in ICD-10Cm

Where?-Y codes-Where were they….home, school, highway, jail……..Look under place of occurrence in the ECI section in ICD-10CM (if you know the work status you can also code it as well)

Z codes– This is usually tetanus shots(common), statuses, histories…..according to documentation.

Now you’ve conquered the end of your ABC’s and sequencing in coding!

Happy ER Coding!

1. What are some of your weaknesses? Learning how not to say no because you want to be a team player.

2. What are some of your strengths? I can adjust well to any environment, handle multitasking, work well with others, very detailed/organized, and I’m a fast learner and a team player.

3. Why should we hire you? In this career change I am capable and adaptable. Open minded to new things and eager to learn them.

4. Where do you see yourself in 5 years? I will be an established successful medical coder and enjoying my career.

5. What is the role of Medical Billing and coding? The main duties of the individuals involved in medical billing and coding jobs are to manage and document the medical related paperwork, create invoices regarding the bill for patients to insurance companies, providing necessary codes for each diagnosis/procedure followed in the billing system, and cross checking the patients bill coverage with relevant insurance company.

10 coding tips to help you solve the case of a patient encounter

1. Propose Relevant Questions-The first thing to ask yourself is, “What was done for the patient?” (laboratory visit, a surgery, a diagnostic, or a therapeutic)
2. Analyze Data from Different Source Documents-In the medical record there may be lab reports, radiology reports, medication lists, encounter notes, and visit summary reports, all of which can lead you to the correct code(s).
3. Research Unfamiliar Medical Procedures, Diagnosis, and Terms-The worst thing a coder can do is GUESS. If there is a diagnosis or procedure code that you have not come across before, LOOK IT UP.
4. Develop the Critical Thinker from Within-Critical thinking is at the core of being a professional coder, as you must make important coding decisions based on the information in the medical documentation.
5. Rely on Proven Resources-A good detective understands the power of reliable information.
6. Pay Attention to Detail and Accuracy-Taking the time to carefully review the documentation in the medical record is beneficial in diagnosis and procedure coding. The quality of your resources will directly affect the outcome of your coding.
7. Maintain Strong Communication Skills-There will be many times when you must query the physician to accurately code a case. Effective written and verbal communication skills will be helpful in querying a physician.
8. Use Robust Coding Software-ALL facilities have their own software packages.
9. Keep Up-to-date on Insurance Carrier Guidelines-Insurance carriers update guidelines often, and it is important for you to know the myriads of changes that can affect coverage.
10. Administer the Coding Process-Using the data, now that you have uncovered the who, what, when, where, and why along all coding guidelines and conventions, select your codes with confidence!

Ark-La-Tex In-depth: Health Care Fraud

They come to your home. They come to your schools — claiming to be licensed behavioral health care providers.

They say they’ll help your kids and it won’t coast you a penny. Everybody assumes proper vetting has been done and entrust their kids to these so-called professionals.

Trouble is once the Louisiana Department of Health dropped a credentialing requirement from its handbook, the scammers came out in droves.

“What our agency is tasked to do,” said Louisiana Deputy Attorney General Bill Stiles, “is investigate Medicaid fraud by providers.”

There are active fraud investigations underway in Northwest Louisiana. And because the probe is ongoing, Stiles could not provide details.

But the bloated billing and questionable healthcare practices here and across the state had state Rep. Dodie Horton of Bossier Parrish fighting back.

“I have concern and outrage about the Louisiana Department of Health in closing the hole; in permitting a lot of this fraud from happening with the behavioral health program,” Horton said.

Here’s what she’s talking about: people claiming to be mental health professionals working with students, and apparently providing no real help at all.

“There’s no real credentialing and verifying being done,” Horton said.

Meaning, anybody can claim to be a licensed behavioral health professional.

“When the DOH removed the credentialing, verifying and background portion of the requirement out of their book then the floodgates opened to fraud,” Horton said.

These numbers were compiled by Louisiana’s Legislative Auditor in October 2017:

• 45 percent of 3,400 listed mental health providers did not meet requirements.
• 319 clinical social workers were not licensed.
• 714 professional counselors were not licensed.
• 113 marriage and family therapists were not licensed.

“You have people out there who are unlicensed,”  Stiles said.

“People assume this is all being vetted, but it isn’t,” Horton said.

Follow the money; here’s a taste:

• One provider paid more than $12,000 for 245 service hours on Christmas Day.
• Another received $9,000 for 179 service hours on New Year’s Day.
• Another got $35,000 for 729 hours in a single day.

“It’s impossible. I’m sure taxpayers are saying how is this even possible?”

“I can’t live with the fact that millions of dollars are going out; children improperly diagnosed,” Horton said, “that is going to stay with them the rest of their lives,” Stiles said.

As far as closing the loophole at DOH, Horton says, “For two years there’s been no action.”

That’s why Horton carried HB211 proposing basic Medicaid reforms, requiring LDH to furnish complete claims for behavioral sciences and imposing a 12-hour/per day/per patient limit.

“There’s no accountability,” said Horton. “We need to bring back accountability in the behavioral health department.”

“How do you diagnose a two-year-old with PTSD?” asks Horton. “How do you diagnose a 4-year-old as bi-polar?”

“Roughly 10 percent of all Medicaid dollars are spent fraudulently. That’s $1.5 billion in Louisiana,” said Stiles.

Added Horton: “It’s mind boggling this has been allowed to happen. I’m outraged, and I feel the public will be too.”

Have you ever thought someone had touched your left arm when, in fact, they had reached for your right one? Scientists know this phenomenon as a phantom sensation, and it may help shed light on how the human brain processes touch.

Have you ever experienced a phantom sensation? A new study begins to unravel the mystery.

The human brain holds many mysteries, and this is illustrated most clearly by the existence of a range of phenomena, such as phantom limb pain. This particular phenomenon occurs when a person believes they can detect pain or other tactile sensations in a limb that they have lost through amputation.

Some people experience tactile hallucinations, in which they mistakenly believe they feel a sensation when, in fact, no factors could have induced it.

Tactile hallucinations usually occur in individuals living with a psychological condition, such as schizophrenia. However, people who are entirely mentally and physically healthy can also experience a similar phenomenon.

For instance, when a person receives a touch on their left hand, they may believe that they felt this touch in their left foot or vice versa. Scientists call this a phantom sensation, and researchers are still puzzled as to why this phenomenon occurs.

In a new study, whose findings appear in Current Biology, a team of researchers from New York University and the Universities of Hamburg and Bielefeld in Germany explain in more detail what characterizes phantom sensations. They argue that a better understanding of this phenomenon could help specialists decipher similar mysteries, including phantom limb pain.

“The limitations of the previous explanations for how and where our brain processes touch become apparent when it comes to individuals who have had parts of their bodies amputated or suffer from neurological diseases,” notes study coauthor Prof. Tobias Heed. He emphasizes that to this day, scientists know surprisingly little about how the human brain processes the sensation of touch.

Posted: Jun 03, 2019 / 02:44 PM CDT / Updated: Jun 03, 2019 / 11:16 PM CDT

AUSTIN (KXAN) — Governor Greg Abbott signed House Bill 18, an omnibus bill meant to get more mental health services to students in Texas public schools. 

Amarillo Republican Representative Four Price and Austin Democratic Senator Kirk Watson shepherded the bill through the legislature. It would require school districts to offer mental health and suicide prevention curricula if they do the same with physical health. 

The curricula and training will include signs of mental health conditions and substance abuse, strategies for maintaining student to student positive relations, conflict resolution, and information about how grief and trauma affect student learning. 

School districts will be partnering with local mental health authorities for specific content. 

Advocates hope these curricula and training will help identify and respond to mental health issues and bullying before they become larger problems. 

HB 18 now allows school districts to employ or contract with one or more non-physician mental health professionals: a psychologist, registered nurse with a masters degree in psychiatric nursing, or a licensed social worker.

It also requires online training in mental health first aid to be public and encouraged in schools. 

Next school year, training videos will be offered in public schools around the state as part of new coursework, teaching students what to look for in their classmates and how to get them help. The focus is on suicide prevention and grief counseling.

“Often times we wait until it reaches a crisis point or other negative outcomes arise before we really do anything about it. And that needs to change. It’s a whole paradigm shift. It’s a philosophy change,” said Greg Hansch, from the Texas chapter of the National Alliance on Mental Illness.

Last year’s school shooting at Santa Fe sparked this effort at the Texas capitol. Hansch said advocates have pushed for similar measures for years; but it took Governor Abbott including items in his school safety action plan and calling mental health a legislative emergency item, to get it into law.

Next school year, schools will partner with local mental health providers to offer services in every school. 

“That word offered is critical there. It doesn’t mean that every single student in public school is going to receive education around mental health. It means they’ll have the opportunity to receive that through – like an elective,” said Hansch.

Per the new law: schools will partner with their local mental health district. Williamson County will partner with Bluebonnet Trails Community Services. Hays County will partner with Hill Country Mental Health & Developmental Disabilities Centers.

There is no additional state money to go with this new curriculum, but the Texas Council of Community Centers (a coalition of local mental health authorities) are expected to hire additional staff to implement the bill. 

There will be $2.3 million in general revenue funds used as grants to support non-physician mental health professionals.

Staff for the Texas Education Agency suggests there could be possible costs to local school districts for coordinating school health programs and yearly training. 

Lesion excision coding may seem complex, but reporting excision of benign (11400-11471) and malignant (11600-11646) skin lesions can be mastered in five steps.

Step 1: Measure First, Cut Second

When assigning CPT® codes 11400-11646, you must know both the size of the lesion(s) excised and the width of the margins (the area surrounding the lesion that is also removed). Per CPT® instructions, “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that [most narrow] margin required for complete excision.”

The provider should measure the lesion and margins prior to excision. This is because the lesion will “shrink” as soon as the incision releases the tension on the skin.

Step 2: Wait for the Pathology Report

CPT® codes for lesion excision (as well as ICD-10-CM diagnostic codes) require that you identify a lesion as either benign or malignant. For this reason, you should wait for the results of the pathology report before making a code selection. Only those lesions specifically identified as malignant may be assigned a code for malignancy.

Exception: If a surgeon performs a re-excision to obtain clear margins at a later operative session, you may report the same malignant diagnosis that you linked to the initial excision because the reason for the re-excision is malignancy.

Step 3: Location Matters

You need to know the anatomic location from which the lesion(s) is excised to determine proper coding. Multiple areas may be grouped together within a single set of codes: pay careful attention to code descriptors.

Step 4: Bundle Simple Repairs with Excision

Per CPT® guidelines, all lesion excision codes include simple wound closure. CPT® allows separate coding for intermediate (12031-12057) and complex (13100-13153) repairs; however, payers who follow National Correct Coding Initiative (NCCI) edits will bundle intermediate and complex repairs into excision of benign lesions of 0.5 cm or less (11400, 11420, and 11440).

Step 5: Report Each Lesion Separately

When the physician excises multiple lesions, code each lesion separately, assigning a specific CPT® and ICD-10-CM code for every lesion treated. When coding for multiple excisions, you should append modifier 59 Distinct procedural service to the second and all subsequent codes describing lesion excision in the same anatomic location.

To demonstrate our rules at work, let’s consider two examples:

Example 1: The surgeon excises a lesion from a patient’s right shoulder (location). Prior to excision, the lesion measures 1.5 centimeters at its widest; to ensure complete removal the surgeon allows a margin of at least 1.5 cm on all sides. Adding the largest diameter of the lesion (1.5 cm) to the narrowest margin (1.5 cm on each side, or 3.0 cm total) results in an excised diameter of 4.5 cm (size before excision). Subsequent to excision, the pathology report identifies the lesion as malignant. The correct code is 11606 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter over 4 cm.

Example 2: The physician removes three lesions from the right arm. Pathology determines that two of these (with excised diameters of 1 cm and 1.5 cm) are benign. The third lesion (excised diameter 2.5 cm) returns malignant. First, report the excision of the malignant lesion (the “most extensive” procedure) using 11603 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm. Next, report the benign lesion excisions using 11402-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm and 11401-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm.

By Deborah M Cooper, CPC, CPMA, CFPC, CGSC

There are ways to represent professionalism, but what does it really mean to you? Is it:

• How  you dress, where you work, the places you go, or the people you associate with?
• The level of education you’ve accomplished, the school you attended, or the number of credentials behind your name?
• How much education does it take to be a professional? Is professionalism complete at a bachelor’s degree, or even a master’s degree?
• Do you magically become a professional when you obtain a certificate that says you attended school for a stated number of years?

Let’s examine what it means to be professional.Photo by rawpixel.com from Pexels

Define Professionalism

Merriam-Webster Dictionary defines professionalism as “the conduct, aims, or qualities that characterize or mark a profession or a professional person;” and it defines a profession as “a calling requiring specialized knowledge and often long and intensive academic preparation.” Being a professional is potentially a combination of acquired education in addition to a few other qualities. Not all professionals have the top degrees in their field of expertise; however, these individuals have dedicated many hours of time and effort to master the knowledge they need to be successful and they recognize the importance of sustaining that knowledge by keeping it up to date. For example, Certified Professional Coders (CPCs®) seek ways to earn continuing education units (CEUs) to maintain their credentials and to keep current with medical coding changes and healthcare regulations

Look Professional

Another important step to professionalism is to look the part that you are trying to emanate. This means portray your outward appearance in the best possible light. Dress for success does not always require a three-piece suit. It just means to be polished and dressed appropriately for the environment you work in.

Exemplify Professionalism

Being a professional not only requires a specialized knowledge, but also the highest level of competency. You can depend upon a professional to accomplish the task set before them. They hold themselves accountable for both word and deed, and they do the right thing for the right reason. They have learned the secret of forming good relationships by treating others with the same level of respect and dignity they desire to be treated. They recognize that we’re all in this game called of life together, and they thrive on the ability to help others succeed. They know that when they lend a helping hand to someone else, it’s one step closer to their own success.

Professionals exhibit qualities such as honesty and integrity. They are true to their values, even when it means taking the road less traveled.

Achieve Professionalism

Being a certified medical coder provides the opportunity to achieve professionalism every day. We learn from each other; but even more importantly, there’s always a chance to pass what we have learned on to someone else. We demonstrate excellence in how we relate with others, as well as how we perform our responsibilities. We recognize teamwork as an important component of our professional conduct. We show diversity that enhances learning and knowledge which is so important to professionalism

Medical coders succeed even through the most difficult obstacles because we are determined to identify as professionals. Although being a certified medical coder is only one of many professions, all professions have their own criteria to demonstrate professionalism ― but the root definition of professionalism in each one remains consistent.