Can I Code Arthroscopic Plica Removal and Arthroscopic Meniscectomy in the Same Episode?

I was recently asked about the appropriateness of coding both CPT codes 29875 (arthroscopic plica removal) and 29881 (arthroscopic meniscectomy) for the same episode of care.  This “In the kNOW” installment will provide the answer and examine the rationale behind it.
 
CPT code 29875 is assigned for a limited synovectomy.  This procedure is often referred to as a plica resection or shelf resection, and within CPT, it carries a designation of being a “separate procedure”.  This “separate procedure” designation is often where the confusion lies.  In general, when a procedure is designated as a “separate procedure” it means it is considered to be fundamental component of a larger or more total procedure and is therefore, not to be coded additionally.  However, as every coder knows, there are exceptions to every guideline provided, and the “separate procedure” is not exempt because, in circumstances where the “separate procedure” is clearly distinct from other procedures, it may be reported with modifier 59.  In order for the exception to apply, the “separate procedure” must meet one of the following conditions:

• It represents a different session
• It was a different procedure/surgery
• It represents a different site or body system
• It required a separate surgical approach
• It was a different lesion
• It was a separate injury

Armed with this information, let’s now look at the coding question posed above.  Our main procedure will be the arthroscopic meniscectomy as it is the more extensive procedure performed.  In order to code the plica resection, it would have to meet one of the exceptions listed above, which normally it does not.  These plicectomy procedures are usually performed through the scope insertion, at the same time as the more extensive procedure, and don’t represent a different lesion/injury.  So this becomes the first clue that we shouldn’t code both of these procedures at the same time. 

If we dig even deeper and find a copy of the procedure-to-procedure edits from the Centers for Medicare and Medicaid Services (CMS), we can identify that 29881 is the column 1 procedure with 29875 the column 2 procedure and an edit rationale that states 29881 is considered to be the more extensive procedure.  We do find that we could bypass the edit with the use of an appropriate modifier, but again, keep in mind, that we would need to meet one of the exceptions that we mentioned above, which we don’t.  However, if the plica resection was done in the left knee and the meniscectomy was done in the right knee, a modifier would be appropriate to indicate that both procedures should be paid in this instance since they meet the exception of different body site. 

Further investigation takes us to the National Correct Coding Initiative (NCCI) edit manual.  In Chapter 4 which addresses the musculoskeletal codes in the range of 20000-29999, we go to Section E-Arthroscopy, and then to #8.  Here we are told that 29875 is not to be coded when any other procedure is also performed via arthroscopy in the same knee.

Our final confirmation is addressed in the CPT Assistant from January 2016 on page 11.  That document reiterates the information related to “separate procedures” and states that 29875 is not to be coded with 29881.

It is clear from four different sources that coding of both 29875 and 29881 is not normally going to be reportable.  Should a coder have a situation where one of the exceptions mentioned applies, use of an appropriate modifier will bypass the edit and trigger reimbursement.

 Now you are in the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Texting of Patient Information Among Healthcare Providers - Memo from CMS

• Texting patient information among members of the health care team is permissible if accomplished through a secure platform.
• Texting of patient orders is prohibited regardless of the platform utilized.
• Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.

 
CMS recognizes that the use of texting as a means of communication with other members of the healthcare team has become an essential and valuable means of communication among the team
members. In order to be compliant with the CoPs or CfCs, all providers must utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and
confidentiality as per HIPAA regulations and the CoPs or CfCs. It is expected that providers/organizations will implement procedures/processes that routinely assess the security
and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.

Read the full memo here: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-10.pdf

Statewide Standard Authorization Form - We Need Your Input!

In 2012, Governor Kasich proposed and the Ohio General Assembly enacted legislation to harmonize state privacy law with federal law (RC 3798.02). Prior to the change, state law applied standards for information sharing that in some cases were inconsistent with federal privacy law, which created barriers to electronic health information exchange and care coordination.

The new law also required Ohio Medicaid to develop a standard authorization form for the use and disclosure of protected health information (RC 3798.10).  The purpose of the standard form is to improve care coordination for a patient across multiple providers by making it easier to share protected health information in a secure manner. The form is not required to be used, but a properly executed form must be accepted by the entity receiving it.

Ohio Medicaid developed the standard authorization form (draft below) as part of the broader statewide initiative to integrate physical and behavioral health care services within Medicaid managed care. The form was developed as a partnership among state agencies, behavioral health providers, hospitals, health plans, health information exchanges, and criminal justice, including the Attorney General’s Task Force on Criminal Justice and Mental Illness.

The form is currently being field-tested at several hospitals.  The next step is for Ohio Medicaid to submit a draft rule, including the form and instructions how to use it, to the Common Sense Initiative for review.  At the same time, outreach will occur to a broader group of stakeholders (OHIMA included) for input on the form itself and to test and refine technical assistance documents that support using the form in a broad variety of circumstances and settings. The goal is to have the standard authorization form and rule adopted and in use before the end of the year.

• FORM (draft) - EXPIRED
  
• INSTRUCTIONS (draft) - EXPIRED

Please review the draft form and instructions.  If you have any comments (positive or negative), fill out this SURVEY (EXPIRED) by Monday, June 18th.  Your comments will be reviewed by an OHIMA taskforce who will formally submit our comments to Ohio Medicaid.  If you are interested in serving on OHIMA's taskforce, please indicate your interest within the survey above.  

Staunching The Tide of Medical Necessity Denials

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

The Importance of CDI Involvement in Denials and Appeals

Denials and appeal is a major challenge for hospitals with the Advisory Board’s biennial revenue cycle survey finding that a median 350-bed hospital would have lost $3.5 million to increased denial write-offs from healthcare payers over the past four years. Hospitals wrote off as uncollectable 90% more denials than six years ago, a difference of $3.5 million for a median 350-bed hospital, according to the report. The Advisory Board found that the median for successful denial appeals for hospitals fell from 56% to 45% for commercial payers over the past two years and from 51% to 41% for Medicaid. (Fierce Healthcare Article- November 15, 2017 Denials Rampant. Medical necessity denials continue to grow exponentially as third-party payers become more aggressive in denying care both in the inpatient and outpatient setting as part of a major business strategy to reduce the medical loss ratio, the amount insurance companies pay out for actual care provided compared to the premiums they collect, in the interest of increasing profits and shareholder and C suite annual payouts.

Hospital’s Approach to Addressing Medical Necessity Denials

A hospital’s typical approach to addressing medical necessity denials, DRG down-codes and clinical validation denials is to throw and devote more resources, staff, and acquire more software to manage the onslaught of denials. This approach is a lesson in inefficiencies and futility from the sense the hospital is overlooking and neglecting the addressment of the root cause of these denials, poor and/or insufficient documentation. Claims are placed into this category when the medical documentation submitted is inadequate to support payment for the services billed, as defined by Medicare.  Poor and insufficient spans the gamut from lack of documentation, documentation that adds little if any value to the care of the patient, lack of clarity in documentation, cut and paste of documentation creating issues with situational awareness and carry forwards with concerns of contextual consistency. A contensious area that has a strong tendency to breed DRG down-codes and clinical validation denials is Clinical Documentation Improvement Programs, initiatives heavily ingrained in most hospitals as a means of optimizing inpatient DRG revenue. What Chief Financial Officers fail to realize is that present CDI processes are conduits for denials mainly due to the realized fact that CDI programs were never intended or designed to improve actual documentation. Instead, CDI programs were designed and intended to serve as a band-aid approach to documentation improvement, securing the capture of additional diagnoses and/or clarification of nonspecific diagnoses in the interest of producing “optimal revenue” through the MS-DRG assignment. Optimal DRG assignment translates into case-mix increases that produces enhanced reimbursement for the hospital. Often overlooked by CFOs is the notion that increases in case mix are measured in gross patient revenue versus more accurate and reliable net patient revenue, taking into mounting costly denials and the resources needed to appeal with no assurance of success. The underlying limitations and shortfalls of CDI programs centers on the limited effort and capability of CDI specialists to actually improve physician documentation beyond diagnoses capture through the repetitive transactional reactive query process. What is missing is the general lack of enhancement and improvement of the quality, completeness and accuracy of the physician’s documentation describing, showing and telling the true patient story reflective of the patient’s severity of illness, need for hospital level of care and the potential risks and untoward event to the patient without said hospital level of care. In short, what is required is a clear detailed account of all relevant clinical facts, clinical information and context surrounding the care ordered and/or provided accompanied by clear concise documentation by the physician of his/her clinical judgment, medical decision making and thought processes.

Medical Necessity Denials-A Unique Challenge

Medical necessity denials present unique challenges to mounting a successful effective appeals campaign for lack of supporting clinical documentation in the record. Medicare defines this category of denials as when the contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. This lack of supporting clinical documentation can be appropriately addressed through transformation of current clinical documentation improvement program processes from one predicated upon transactional reactive processes to one more closely aligned with the revenue cycle that embraces proactivity and a tailored balanced approach to documentation improvement that achieves meaningful measurable positive change in physician overall behavioral patterns of documentation. The crucial first step in driving real improvement in documentation is to reengineer, refocus, redirect and rebrand current CDI efforts, recognizing the urgent need for wholesale directional change in CDI.


Effectively staunching the tide of tremendous revenue leakage associated with increasing medical necessity denials requires a refreshing novel approach that gets to the root cause consisting of poor and insufficient documentation. Medicare under its annual CERT program report highlighting the annual Fee-For-Service Improper Payment Rate consistently identifies insufficient documentation as accounting for the majority of medical necessity denials. The best course of action to mount that will directly address these medical necessity denials is to design, organize, plan and execute a focused strategy for transforming present day CDI initiatives into a program that engages physicians in a participatory manner in truly wanting to improve their communication of patient care for all the right reasons. In my next blog, I will outline the steps necessary to initiate this extremely time sensitive strategy. Time is of the essence as medical necessity denials continue to mount in most healthcare facilities contributing to lost net patient revenue opportunities and increased cost to collect associated with the denials and appeals process.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com.