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For other articles and previous issues click here. December 5, 2005 Coding
in a Time of Disaster Many Americans were glued to the news in August and September, keeping up with the hurricanes and floods pounding the Gulf Coast. Hurricane Katrina led the charge, frightening populations into migration and devastating lives and property. The staggering destruction of the first storm was still fresh when Hurricane Rita took aim in the same general direction with winds topping out in excess of 170 mph. Until the 11th hour, it seemed that her single eye was focused directly on the Houston-Galveston metroplex, and another 1 million-plus people hit the highways to escape similar devastation. Among them were evacuees still displaced from Katrina. When Rita finally came ashore, it was to reign more destruction on the Louisiana/Texas coastal communities. Awful, tragic, and certainly disastrous—but what does it have to do with coding? For those affected by the storms, the medical needs of the injured and/or displaced created a serious collateral disaster. These storms wreaked havoc with the social and medical infrastructure of the surrounding cities, and their coding departments will be hustling to clean up in their own way for months to come. First, one must assume that the department was even able to code. Coding software and related computer systems can be wiped out by power shutdowns and server complications; technical intervention to restore electronic capability was often the initial recovery effort. (Lesson: Have an effective, battle-tested back-up coding plan in advance of the need.) The influx of patients has all types of coding departments bursting at the seams with backlog. For providers who combine coding and billing as one entity, the effort to verify identity—much less insurance eligibility—has been a major challenge. Hospitals, nursing homes, and providers of other types have had to evacuate patients to ensure their safety for continuing medical treatment. In many cases, those same patients had to transfer back as soon as the immediate crisis ended. Does the coder from the transferring facility need to consider the multiple admissions to be a “combined” service and code as a single entity? Is the receiving facility going to have any difficulty getting reimbursement from the carrier who may be reluctant to pay for what amounts to three separate admissions (first admission, “transferred to” admission, and “transferred back” admission) instead of one? There are no single answers to these questions. Different carriers have different rules based on their contract for care, and some may even make exceptions for disaster-related circumstances. Admissions with diagnosis-related group (DRG) payors such as Medicaid and Medicare present another potential catastrophe. Even if the coding and DRG do not change, you still may take a financial beating on some of these cases. Because a transfer was involved, it is critical for the discharge disposition code to be correct on the claim. In some contracts, payment can change from the full DRG to a per diem for at least one of the admissions. If a Medicare patient has a “transfer DRG,” the discharge disposition code will determine whether per diem or full payment is made. To circumvent a coding data disaster, review the E-code rules for cause of injury and make sure the staff reports them accurately. If everyone who treats the injured patient uses the current injury E-code, reporting will show multiple episodes of injury instead of an initial injury with subsequent continued care. Refresh your coders on the correct use of “late effect of injury” codes, and know when to use the code for an acute fracture vs. a specific V-code for aftercare of a healing—or healed—fracture. The data you report today will be scrutinized by payors—as well as providers—now and in the future. The Centers for Medicare & Medicaid Services (CMS) recognized the emergency healthcare needs of its beneficiaries and medical providers affected by Hurricane Katrina and acted to speed provision of healthcare services to the patient population it serves. On the CMS Web site for Medlearn Matters, Change Request #4106, dated September 23, addresses multiple issues created by this and subsequent disasters. The CMS promptly created a new condition code and modifier effective for dates of service on or after August 21. The new condition code DR (disaster related) and the new modifier CR (catastrophe/disaster related) are to indicate claims for Hurricane Katrina as well as for victims of other disasters. To allow for circumstances in which the provider has no access to verification of eligibility or healthcare records of the affected patient population, the CMS has acted to waive the normal requirements for eligibility and states that presumption of eligibility should be made. If a healthcare provider furnishes medical services in good faith but cannot, due to Hurricane Katrina or a subsequent similar disaster, fulfill the normal requirements of one of its programs, the CMS is assuring that the provider will be paid for its services and will be exempt from sanctions for noncompliance—as long as there is no discovery of actual fraud or abuse. If you are a physician or supplier and are billing your local carrier or Durable Medical Equipment Regional Carrier (DMERC) for Part B services, report the CR modifier instead of the DR condition code. The condition code is to be used in fiscal intermediary billing on a UB 92 or the electronic 837 claim. For institutions filing a claim covered by these circumstances, either the condition code or the modifier may be reported. If a claim is for a case that is—or may be—impacted by specific payor policies and is related to a national or regional disaster, the condition code DR will accurately identify it as such. When a specific Part B service may be affected by a disaster-related policy, the modifier CR should be used. Medicare contractors began recognizing the new condition code and modifier on October 3, if possible. They were compelled to recognize them no later than October 31. Avoid another disaster at your facility, and be completely versed in the content and requirements for reporting these new condition and modifier codes. Accurately report not only the ICD-9-CM and Current Procedural Terminology codes for the disaster victims, but also verify the discharge disposition codes as well. To review the complete Medlearn Matters article, visit www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM4106.pdf. Be sure to read all the way to the bottom of page 3 and see the link to the official instructions regarding this change. You will see an additional link for toll-free numbers of carriers/DMERCs/fiscal intermediaries in case you have further questions.
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