AAPC Comments on Quality Reporting

The National Quality Forum (NQF) is seeking comments on its report, Health IT Enablement of Quality Measurement – The Quality Data Set (QDS) and Dataflow. The deadline for comments is June 30. If you would like to read the report or comment upon it, links are provided below.

AAPC sent the following comment to NQF out of concern for EMR coding practices as discussed in this report:

The National Quality Forum Health Information Technology Expert Panel Report Health IT Enablement of Quality Measurement-the Quality Data Set (QDS) and Dataflow falls prey to flawed logic in its plans for quality measures as outlined in Health IT Enablement of Quality Measurement – the Quality Data Set (QDS) and Dataflow.

The flawed logic occurs as IT treats CPT and ICD-9-CM codes as independent and discreet bits of data, which they are not. Instead, each CPT or ICD-9-CM code has a chain of rules and relationships that must be followed during the code selection process.  These rules are found in disparate places: in the code books’ indexes, notes, chapter beginnings and under other related codes or in associated publications. Without all the linked information, it is very easy to miscode a claim. The selection of CPT and ICD-9-CM codes is quite different from the other HIT codes in the proposal – LOINC, NDCs, etc because codes in those coding systems have definitions that are precise and unambiguous.

For example, the National Drug Code is a 10-digit code. The first segment of the code identifies the manufacturer, the second segment identifies the strength, dosage form and formulation, and the third segment identifies package size. In this way, NCD 00006-0117-30 provides complete information, identifying:

• Merck Singular tablets, 10 mg, in a bottle of 30 for oral administration, prescription required.

Continuing on this theme, codes in CPT and ICD-9-CM are not as simple to select. Consider the following scenarios, covered in rules that reside outside the official descriptions:

• If two lesions are removed with one excision, do you report a code for each lesion? The rules tell us to report only one lesion excision by combining the size of the lesions to report size. (CPT Assistant, June 2008, Pages 14-15). To do otherwise could be perceived as abuse or fraud.
• When a primary malignancy has been eradicated from its site and there is no further treatment directed to that site, a code from category V10 Personal history of malignant neoplasm, should be used to report the former malignancy. Any mention of extension, invasion, or metastasis to another site is code as a secondary malignant neoplasm . The secondary site may be the first listed diagnosis code with the V10 code being a secondary code. (ICD-9-CM Official Guidelines for Coding and Reporting,1.C.2.d.) To continue reporting a malignancy in the patient could create coverage issues for the patient, and skews national data.
• Bedside pulmonary function testing is included in inpatient pediatric critical care (2009 CPT Guidelines, page 34). To separately report this service would be abuse or fraud. This may well be caught by an internal claim scrubber before being reported. However, endotracheal intubation may be reported separately with inpatient pediatric critical care. How would the physician know to report it?
• Diabetes due to pancreatectomy is not reported with secondary diabetes codes, but with the code for post-surgical hypoinsulemia. (ICD-9-CM Guidelines, 2009 I.C.3.a.7.d.i.) To report the wrong code could result in a claim denial based on medical necessity.

EMRs typically provide pull-down pick lists to access subsets of code sets from which physicians make their selection. Pick lists do not provide physicians with the chain of rules and relationships needed for dependable code selection. Their use often results in bad data, charges of fraud, and denied claims.

With all the talk about granularity and the need for details in coding; with the money that the government is willing to put on the table to bring about ICD-10-CM and -PCS; and with all the emphasis the government and private payers are placing upon the future of  risk adjustment, we should be developing a healthcare information system that allows for the selection of the right code, each time. ICD-9-CM codes require all of the back-up information so that the right code can be found.  Even in their sample document, the National Quality Forum defaulted to the nonspecific code for diabetes – 250.00. There seems to be no understanding of the complexity of code selection or the importance of correct code selection.

If the systems contain code pick lists, they are promoting poor coding. If, however, the EMR systems are restricted from supplying pick lists that allow coders, autocoding software, or physicians to enter codes using outside sources, the data will be accurate.

NQF’s Recommendation 1 seems to recognize the need for greater understanding of the data elements of the QDC.  With this observation in mind, AAPC would be happy to work with the NQF or its workgroup to bring about understanding of the billing codes of CPT and ICD-9-CM, to ensure that these codes are used properly in any system developed. Similarly, AAPC stands ready to provide the workgroup with any coding assistance it needs.

To access the report on IT and quality measures, go to http://www.qualityforum.org/projects/ongoing/HITEP2/comments/index.asp and to access the template to comment on the draft, go to http://www.qualityforum.org/projects/ongoing/HITEP/. Thanks for your interest in Upholding a Higher Standard in coding.

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