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Modifier 24 not required for Unrelated Antepartum Visit

30th June 2016

In case a pregnant patient visits an obstetrician/gynecologist during the antepartum for a problem unrelated to pregnancy then a question often arises that can the provider bill separately for that visit, or is the service bundled into the maternity care? If the provider can bill, is it necessary to append modifier 24 “Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period to the E/M code?”

In obstetrics, antepartum haemorrhage (APH), also prepartum hemorrhage, is genital bleeding during pregnancy from the 24th week (sometimes defined as from the 20th week gestational age to term. In regard to treatment, it should be considered a medical emergency (regardless of whether there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead to death of the mother and/or fetus.

The answer to the above question is billing can be done separately but modifier 24 is not required. Billing can be even done for a problem during the antepartum if the condition is complicating the pregnancy.

The Office of Inspector General (OIG) released a mid-year update to its 2016 Work Plan

The changes to the Office of Inspector General (OIG) work plan has been released which includes several new reviews the OIG plans to begin in the near future and many revisions to ongoing reviews, in nearly every sector. The agency tasked with detecting Medicare fraud, waste, and abuse also lists reviews it has completed or removed since releasing the initial 2016 Work Plan.

The main purpose of OIG is to detect Medicare fraud, waste, and abuse.

The OIG will initiate the following new reviews in Medicare Parts A and B

  • • Outpatient Outlier Payments for Short-Stay Claims
  • • Intensity-Modulated Radiation Therapy (IMRT)
  • • Skilled Nursing Facility Prospective Payment System Requirements
  • • National Background Checks for Long-Term Care Employees
  • • Potentially Avoidable Hospitalizations of Medicare and Medicaid Eligible Nursing Home Residents for Urinary Tract Infections
  • • Accountable Care Organizations: Beneficiary Assignment and Shared Savings Payments
  • • Medicare Home Health Fraud Indicators
  • • CMS’ Implementation of New Medicare Payment System for Clinical Diagnostic Laboratory Tests

Revised ongoing reviews include:

  • • Medicare Oversight of Provider-Based Status
  • • Analysis of Salaries Included in Hospital Cost Reports
  • • Home Health Prospective Payment System Requirements
  • • Histocompatiblity Laboratories – Supplier Compliance with Payment Requirements
  • • Covered Uses for Medicare Part B Drugs
  • • Inpatient Rehabilitation Facility Payment System Requirements

Completed reviews include:

  • • Medicare Did Not Pay Select Inpatient Claims for Bone Marrow and Stem Cell Transplant Procedures in Accordance with Medicare Requirements.
  • • Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care.
  • • CMS Has Not Performed Required Closeouts of Contracts Worth Billions.
  • • Enhanced Enrollment Screening Process for Medicare Providers: Early Implementation Results
  • • Part B Payments for 340B Purchased Drugs

Removed Reviews:

  • • Imaging Services (Payments for Practice Expenses)
  • • End-Stage Renal Disease Facilities (Payment System for Renal Dialysis Services and Drugs)
  • • Contract Management at the Centers for Medicare & Medicaid Services

Regulations on surprise medical bills being studied by Texas Lawmakers

Texas consumers getting unexpected bills from doctors who are not in the consumers’ health care network are largely growing. A public policy group told state legislators recently that consumers need more protection from surprise medical bills, particularly those arising from emergency room visits.

According to a senior policy analyst with the Center for Public Policy Priorities, consumers can’t choose which doctor treats them in an emergency room, and often have no choice in which hospital an ambulance takes them. Patients are at their most vulnerable during medical emergencies and should not face a financial emergency later because of a surprise bill.

The Center for Public Policy Priorities told the legislators that they should protect consumers by eliminating surprise bills from emergencies, eliminating bills from out-of-network doctors that patients do not choose, and improving and expanding the mediation system for out-of-network bills as consumers lose due to the current billing system.

2017 ICD-10 CM codes released by CDC

CDC (Centers for Disease Control and Prevention) has released 2017 ICD-10 CM codes with the Index and Tabular files. There are 1,974 additions, 311 deletions, and 425 revisions. The resulting total for diagnosis codes is 71,486. The addenda for the Index (90 pages), Table of Drugs and Chemicals (2 pages), Neoplasm Table (11 pages), External Cause Index (9 pages), and Tabular (160 pages) are included in this release. Two additional files include the Code Descriptor in Tabular Order file and Duplicate Code file.

The Code Descriptor in Tabular Order provides the code descriptor at each level of the code set. One important file that is missing from the update is the 2017 ICD-10-CM Official Coding and Reporting Guidelines as well as the General Equivalence Mappings (GEMs).

Brief description of the changes includes:

  • • Conditions that were added throughout the code set is postoperative seroma
  • • Code A92.5 has been added to Chapter 1 (Infectious and Parasitic Diseases) which has been assigned by the World Health Organization (WHO) for the Zika Virus.
  • • Five new codes added to Chapter 2 (Neoplasms)
  • • Five new codes added in Chapter 3 (Diseases of Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism).
  • • Chapter 4 (Endocrine, Metabolic, and Nutritional Diseases) includes further specificity of diabetic retinopathy (proliferative vs. non-proliferative and severity of mild, moderate, or severe) and the ability to capture that macular edema has resolved after treatment with laterality.
  • • Changes included in Chapter 5(Mental, Behavioral, and Neurodevelopment Disorders) are additions to capture hoarding, various obsessive-compulsive disorders, and social pragmatic communication disorder.
  • • Chapter 6 (Diseases of the Nervous System) include carpal tunnel disorder, tarsal tunnel disorder, and various lesions of specific nerves.
  • • Chapter 7 (Diseases of the Eye and Adnexa) include addition of central occlusion of the retinal vein, nonexudative and exudative age related macular degeneration, expansion of stages of primary open angle glaucoma, and amblyopia suspect.
  • • Chapter 8 (Diseases of the Ear and Mastoid Process) include addition of hearing loss with additional information in relationship to the contralateral ear and pulsatile tinnitus.
  • • Chapter 9 (Diseases of the Circulatory System) updates include the addition of hypertensive urgency, emergency, or crisis; reducing specificity of non-traumatic subarachnoid hemorrhage and the communicating artery; expansion of the cerebral infarction and sequel of stroke codes; addition of aneurysm of precerebral and vertebral arteries; and addition of dissection of unspecified arteries.
  • • Codes related to mediastinitis and other diseases of the mediastinum added to Chapter 10 (Diseases of the Respiratory System)
  • • Numerous dental conditions, ischemia or acute infarction of the intestines, megacolon types, and more specific pancreatitis codes added to Chapter 11 (Diseases of the Digestive System)
  • • Codes related to preorbital cellulitis and excessive and redundant skin and subcutaneous tissue added to Chapter 12 (Diseases of the Skin and Subcutaneous Tissue)
  • • Bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and periprosthetic fractures added to Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue)
  • • Chapter 14 (Diseases of the Genitourinary System) have a few title changes as well as the code additions for specific urinary incontinence conditions, various prostatic dysplasia, testicular and scrotal pain, erectile dysfunction, ovarian cysts, conditions of the fallopian tubes, and complications of the urinary tract including fistulas, hemorrhage, infection, malfunction, etc.
  • • Various conditions involving ectopic pregnancy; pre-eclampsia, severe pre-eclampsia, and eclampsia complicating childbirth and puerperium; gestational edema; gestational diabetes controlled by oral medications; partial or low lying placenta previa; and expansion of third degree perineal laceration added to Chapter 15 (Pregnancy, Childbirth, and Puerperium)
  • • Chapter 16 (Certain Conditions Originating in the Perinatal Period)-Updates to code title and two new codes added that include newborn light for gestational age greater than 2500 grams and newborn light for gestational age other.
  • • Chapter 17 (Congenital Malformations, Deformations, Chromosomal Abnormalities) include addition of new congenital cardiac conditions and various longitudinal vaginal septum conditions.
  • • Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings) include addition of the National Institute of Health Stroke Scale (NIHSS) scores, microscopic hematuria, expansion of total Glasgow Coma Score, bacteriuria, abnormal radiologic findings on diagnostic imaging, and expansion of abnormal Prostate Specific Antigen (PSA).
  • • Chapter 19 (Injuries, Poisoning, and Certain Other Consequences of External Causes) changes include significant number of additions regarding the specific fractures to bones of skull, various fracture types of the foot; title revisions to complications involving prosthetic devices; new stenosis of cardiac stent codes, and additions to complication types including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage.
  • • Chapter 20 (External Causes of Morbidity) include updation of some of the vehicular accident codes, added contact with paper or sharp objects, overexertion, and an activity of the choking game.
  • • Chapter 21 (Factors Influencing Health Status and Contact with Health Services) include addition of a variety of observation of newborn for various conditions, hormone malignancy status, encounter for prophylactic medications, encounter for contraceptives, gestational carrier status, conversion of endoscopic procedures to open, and long term use of oral hypoglycemic drugs.

New OASIS guidance manual released by CMS

The Outcome and ASsessment Information Set (OASIS) is a group of standard data elements developed, tested, and refined over the past two decades through a research and demonstration program funded primarily by the Centers for Medicare & Medicaid Services (CMS), with additional funding from the Robert Wood Johnson Foundation and the New York State Department of Health. OASIS data elements are designed to enable systematic comparative measurement of home health care patient outcomes at two points in time. Outcome measures are the basis for outcome-based quality improvement (OBQI) efforts that home health agencies (HHAs) can employ to assess and improve the quality of care they provide to patients. Under OBQI, CMS provides HHAs with agency-patient related characteristic (case mix), risk-adjusted outcome, potential avoidable event (adverse event outcome), and patient tally reports for their patients for a 12-month period.

The Centers for Medicare & Medicaid Services (CMS) has released OASIS-C2 Guidance Manual Online which is scheduled to be implemented on 1st Jan 2017, and replaces the version of the data set that was created to conform to ICD-10 coding.

Changes set forth in the new guidance manual are as detailed below:

  • • Several items added in response to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. Passed in 2014, the law requires standardized data to be submitted by various post-acute providers, including skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRFs), in addition to home health agencies. The goal of IMPACT is to get significant comparison of outcomes and costs in various settings, with the ultimate goal of adjusting Medicare reimbursements accordingly.
  • • Appendix G of the new manual summarizes the changes from OASIS-C1/ICD-10 to OASIS-C2, including new items/IMPACT Act items which include but are not limited to:
  • M1028: Active Diagnoses, Co-morbidities and Co-existing Conditions
  • M1313: Worsening in Pressure Ulcer Stats since SOC/ROC
  • M2001: Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
  • • Instructions on how agencies can adopt pressure ulcer guidelines from the National Pressure Ulcer Advisory Panel (NPUAP) are included in the guidance manual. Agencies may adopt NPUAP guidelines but definitions on staging may not align with OASIS scoring instructions. So in that case, agencies are instructed to rely on the OASIS instructions, the manual states.

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