Hemorrhoid Coding Made Easy
Hemorrhoids are simply blood vessels, which require attention only if they become inflamed. Correct hemorrhoid coding depends on documentation that specifies the type (internal, external, or “mixed”) and number of hemorrhoids treated, as well as the treatment method.
Codes to identify treatment for internal hemorrhoids have undergone minor descriptor revisions to clarify application, while two codes have been resequenced from the “Destruction” subhead to appear more appropriately under the “Excision” subhead. Other relevant codes are unchanged for 2010, but CPT® has added specific instruction for appropriate code application, as outlined below, just after the “Anus” subhead.
Surgical Treatment: Internal Hemorrhoid Coding-at-a-Glance
Treatment Single Column/Group Multiple Columns/Groups
Rubber band ligation 46221*
Other Ligation (suture) 46945 46946
Sclerosing Injection 46500*
Thermal energy 46930*
* Report only a single code unit, regardless of how many hemorrhoids are treated
Surgical Treatment: External Hemorrhoid Coding-at-a-Glance
Thrombosed? Single Column/Group Multiple Columns/Groups
Yes 46320 46320 x number of hemorrhoids excised
No 46999 46250
Note that a surgeon may choose to treat a thrombosed external hemorrhoid simply by draining (by incision) the clot only, after which the varicose hemorrhoid may resolve on its own. Report such a procedure using 46083 Incision of thrombosed hemorrhoid, external.
An external thrombosed hemorrhoid may resolve into a skin tag or papilla, which the surgeon may remove. Removal of a single tag/papilla is reported with 46220 Excision of single external papilla or tag, anus, while removal of two or more tags/papillae is reported with 46230 Excision of multiple external papillae or tags, anus. Report only a single unit of 46230 per claim, and never report 46220 and 46230 on the same claim.
Surgical Treatment: Mixed Hemorrhoid Coding-at-a-Glance
Coding for so-called “mixed hemorrhoid” treatment depends on both the number of groups/columns treated, as well as any related procedures performed at the same time.
Excision Alone With Fissurectomy With fistulectomy (fissurectomy when performed)
46255 46257 46258
Excision Alone With Fissurectomy With fistulectomy (fissurectomy when performed)
46260 46261 46262
CMS Releases Proposed IPPS/LTCH Rules for 2017
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update fiscal year (FY) 2017 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The proposed rule, which CMS says would apply to approximately 3,330 acute care hospitals and approximately 430 LTCHs, would affect discharges occurring on or after October 1, 2016.
CMS will accept comments on the proposed rule until June 16, 2016, and will respond to comments in a final rule to be issued by August 1, 2016. The proposed rule can be downloaded from the Federal Register.
The IPPS pays hospitals for services provided to Medicare beneficiaries using a national base payment rate, adjusted for a number of factors that affect hospitals’ costs, including the patient’s condition and the cost of hospital labor in the hospital’s geographic area.
The proposed rule reflects CMS’ plan to shift Medicare payments from volume to value. The agency has a mandated timeline to move the Medicare program toward paying providers based on the quality rather than the quantity of care they give patients.
CMS pays most acute care hospitals for inpatient stays under the IPPS and long-term care hospitals under the LTCH PPS. Under these two payment systems, CMS generally sets payment rates prospectively for inpatient stays based on the patient’s diagnosis and severity of illness. A hospital receives a single payment for the case based on the payment classification – MS-DRGs under the IPPS, and MS-LTC-DRGs under the LTCH PPS – assigned at discharge. CMS is required to update payment rates for IPPS hospitals annually and to account for changes in the costs of goods and services used by these hospitals in treating Medicare patients. This is known as the hospital “market basket.” Payment rates to LTCHs are typically updated annually according to a separate market basket based on LTCH-specific goods and services.
The proposed rules addresses payments, reduction in acquired conditions, fewer readmissions, and other activities that help bring facilities closer to the overall vision of the Affordable Care Act and other movements.
Proposed Changes to Payment Rates under IPPS
The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users is 0.9 percent. This reflects the projected hospital market basket update of 2.8 percent adjusted by -0.5 percentage point for multi-factor productivity and an additional adjustment of -0.75 percentage point in accordance with the Affordable Care Act. This also reflects a proposed 1.5 percentage point reduction for documentation and coding required by the American Taxpayer Relief Act of 2012 and a proposed increase of approximately 0.8 percentage points to remove the adjustment to offset the estimated costs of the Two Midnight policy and address its effects in FYs 2014, 2015, and 2016.
Hospitals that do not successfully participate in the Hospital IQR Program and do not submit the required quality data will be subject to a one-fourth reduction of the market basket update. Also, the law requires that any hospital that is not a meaningful EHR user will be subject to a three-fourths reduction of the market basket update in FY 2017.
CMS projects that the rate increase, together with other proposed changes to IPPS payment policies, will increase IPPS operating payments by approximately 0.7 percent and that changes in uncompensated care payments will decrease IPPS operating payments by an additional 0.3 percent. Other additional payment adjustments will include continued penalties for excess readmissions, a continued 1 percent penalty for hospitals in the worst performing quartile under the Hospital Acquired Condition Reduction Program, and continued bonuses and penalties for hospital-value based purchasing. In sum, CMS projects that total Medicare spending on inpatient hospital services, including capital, will increase by about $539 million in FY 2017.
This projected increase in spending includes an estimated $350,000 increase in FY 2017 payments to hospitals located in Puerto Rico under the proposal to make IPPS payments for capital-related costs based solely on the national capital Federal rate (rather than the current blend of the national capital federal rate and Puerto Rico-specific capital rate), consistent with the recent statutory change in the payment methodology for operating IPPS payments to those hospitals.
IPPS Rate Adjustments for Documentation and Coding and Two Midnight Policy
In the FY 2017 IPPS proposed rule, CMS is proposing two adjustments in addition to its annual rate update for inpatient hospital payments.
First, CMS is proposing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008. For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments. For FY 2017, CMS calculates that $5.08 billion of the $11 billion requirement remains to be addressed. Therefore, CMS is proposing a final -1.5 percent adjustment to complete the statutorily-specified recoupment.
Second, CMS is proposing to take action regarding the -0.2 percent adjustment it implemented in the FY 2014 IPPS/LTCH PPS final rule to account for an estimated increase in Medicare expenditures due to the Two Midnight Policy. Specifically, in the FY 2014 IPPS/LTCH PPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2 percent to the payment rates. CMS believes the assumptions underlying the -0.2 percent adjustment were reasonable at the time they were made. Additionally, CMS does not generally believe it is appropriate in a prospective payment system to retrospectively adjust rates. However, in light of recent review and the unique circumstances surrounding this adjustment, for FY 2017, CMS is proposing to permanently remove this adjustment and also its effects for FYs 2014, 2015, and 2016 by adjusting the FY 2017 payment rates. The impact of this proposal is to increase FY 2017 payments by approximately 0.8 percent.
Medicare Uncompensated Care Payments
CMS distributes a prospectively determined amount to disproportionate share hospitals based on their relative share of uncompensated care nationally. As required by the Affordable Care Act, this amount is equal to an estimate of 75 percent of what otherwise would have been paid as Medicare disproportionate share hospital payments, adjusted for decreases in the rate of uninsured individuals and other factors. In this rule, subject to additional data updates, CMS is proposing to distribute roughly $6.0 billion in uncompensated care payments in FY 2017, a decrease of $400 million from the FY 2016 amount.
For FY 2017, CMS proposes to continue to distribute these funds using a methodology based on insured low income days, which include inpatient days for patients eligible for Medicaid and inpatient days for patients entitled to Medicare and Supplemental Security Income (SSI), and proposes two changes to this methodology. First, CMS proposes to use data from three cost reporting periods instead of one cost reporting period to limit major fluctuations in uncompensated care payments from year-to-year. Second, CMS proposes to apply a proxy to estimate Medicare SSI inpatient days for Puerto Rico hospitals since hospitals since residents of Puerto Rico are not eligible for SSI benefits.
For FY 2018, CMS proposes to begin incorporating uncompensated care cost data from Worksheet S-10 of the Medicare Cost report in the methodology for distributing these funds. CMS proposes to define uncompensated care costs as the costs of charity care and non-Medicare bad debt and to incorporate Worksheet S-10 data over a three-year period, where insured low income day data will be averaged with uncompensated care cost data. For FY 2018, CMS proposes to use Worksheet S-10 data from FY 2014 cost reports in combination with insured low income days from the two preceding periods for determining the distribution of uncompensated care payments. To the extent that hospitals have either not submitted a Worksheet S-10 with their FY 2014 cost report, or find errors on a submitted Worksheet S-10, we encourage hospitals and Medicare Administrative Contractors (MACs) to work together to complete and/or revise their FY 2014 Worksheet S-10 as soon as possible.
Hospital Acquired Conditions (HAC) Reduction Program
The HAC Reduction Program creates an incentive for hospitals to reduce the incidence of hospital-acquired conditions by requiring the Secretary to make an adjustment to payments to hospitals that are in the worst performing quarterile for prevalence of hospital-acquired conditions. In the FY 2017 IPPS/LTCH PPS Proposed Rule, CMS is proposing to make five changes to existing HAC Reduction Program policies:
- Establish NHSN CDC HAI data submission requirements for newly opened hospitals;
- Clarify data requirements for Domain 1 scoring;
- Establish performance periods for the FY 2018 and FY 2019 HAC Reduction Programs;
- Adopt the refined PSI 90: Patient Safety for Selected Indicators Composite Measure (NQF # 0531); and
- Change the Program scoring methodology from the current decile-based scoring to a continuous scoring methodology.
Hospital Readmissions Reduction Program (HRRP)
The HRRP requires a reduction to a hospital’s base operating DRG payment to account for excess readmissions associated with selected applicable conditions. For FY 2017 and subsequent years, the reduction is based on a hospital’s risk-adjusted readmission rate during a three-year period for acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), total hip arthroplasty/total knee arthroplasty (THA/TKA), and, effective for FY 2017 (pursuant to previous rulemaking) coronary artery bypass graft (CABG). To align with other quality reporting programs and allow the posting of data as soon as possible, CMS is proposing to update the public reporting policy so that excess readmission rates will be posted to the Hospital Compare website as soon as feasible following the hospitals’ preview period. CMS is not proposing any changes to the HRRP measures in the FY 2017 IPPS rule.
Notification Procedures for Outpatients Receiving Observation Services
Enacted August 6, 2015, the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals receiving observation services as outpatients for more than 24 hours.
- Hospitals and CAHs would be required to furnish a new CMS-developed standardized notice, the Medicare Outpatient Observation Notice (MOON), to a Medicare beneficiary or enrollee who has been receiving observation services as an outpatient for more than 24 hours. The notice must be provided no later than 36 hours after observation services are initiated;
- The MOON will inform nearly one million beneficiaries annually of the reason the individual is an outpatient receiving observation services and the implications of observation services on cost sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility (SNF) services; and
- An oral explanation of the MOON must be provided, ideally in conjunction with the delivery of the notice, and a signature must be obtained from the individual, or an individual qualified to act on their behalf, to acknowledge receipt and understanding of the notice (or in cases of refusal of signature by such individual, signature by the staff member of the hospital or CAH providing the notice).
The standardized notice, MOON, is required to go through the Paperwork Reduction Act process, thus affording the public an opportunity to comment on the proposed MOON.
Electronic Health Record Incentive Programs and Quality Reporting
This proposed rule also includes the requirements for eligible hospitals and CAHs reporting clinical quality measures (CQMs) for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program. CMS is proposing modifications to some of the CQM reporting and submission requirements, including the proposed removal of certain CQMs to align with the Hospital IQR Program. No new CQMs are proposed.
Hospital Inpatient Quality Reporting (IQR) Program
The Hospital IQR Program is a pay-for-reporting program established by the Medicare Prescription Drug, Improvement, and Modernization Act. In the FY 2017 IPPS/LTCH PPS Proposed Rule, CMS is proposing to add a total of four new claims-based measures for the FY 2019 payment determination and subsequent years (three clinical episode-based payment measures, and one communication & coordination-of-care measure). CMS is also proposing to remove 15 measures for the FY 2019 payment determination and subsequent years. Of these 15 measures, 13 are electronic clinical quality measures (eCQMs), two of which CMS is also proposing to remove in their chart-abstracted form, and two others are structural measures. CMS is also proposing to refine two previously adopted measures beginning with the FY 2018 payment determination. Furthermore, CMS is inviting public comment on potential new quality measures and other areas for future inclusion in the Hospital IQR Program.
CMS is proposing a number of changes in relation to eCQMs:
- To require hospitals to report four quarters of data for all eCQMs included in the Hospital IQR Program measure set for the FY 2019 payment determination and subsequent years in order to align with the Medicare and Medicaid EHR Incentive Programs;
- To require several related technical eCQM submissions requirements beginning with the FY 2019 payment determination; and
- To modify the current validation process to include the validation of eCQM data beginning in the spring of CY 2018 for the FY 2020 payment determination.
CMS is also proposing to update its Extraordinary Circumstances Extensions/Exemptions (ECE) policy by:
- Extending the ECE request deadline for non-eCQM circumstances from 30 to 90 calendar days following an extraordinary circumstance; and
- Establishing a separate submission deadline of April 1 following the end of the reporting calendar year for ECEs related to eCQMs.
Hospital Value-Based Purchasing (VBP) Program
Established by the Affordable Care Act, the Hospital VBP Program adjusts payments to hospitals for inpatient services based on their performance on an announced set of measures. In the proposed rule, CMS proposes to implement updates to the Hospital VBP Program and to expand the number of measures. Specifically, the rule proposes to expand the number of hospital units to which two National Healthcare Safety Network measures apply beginning with the FY 2019 program year. In addition, CMS proposes to expand the cohort used to calculate the 30-day pneumonia mortality measure beginning with the FY 2021 program year. CMS also proposes to add two condition-specific payment measures (one for acute myocardial infarction and one for heart failure) beginning with the FY 2021 program year and a 30-day mortality measure following CABG surgery beginning with the FY 2022 program year. The rule also proposes changes for determining the policy that governs whether a hospital will be excluded from the program if it is cited for deficiencies that pose immediate jeopardy to the health and safety of patients.
PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
The PCHQR Program collects and publishes data on an announced set of quality measures. In the FY 2017 IPPS/LTCH PPS Proposed Rule, CMS proposes to collect one new measure under this program. Specifically, CMS is proposing to add a measure of Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy. In addition to this measure, CMS is proposing to expand the patient cohort of the previously finalized Radiation Dose Limits to Normal Tissues for Patients Receiving 3D Conformal Radiation Therapy. The new cohort will include breast and rectal cancer patients in addition to the previous cohort of lung and pancreatic cancer patients.
Inpatient Psychiatric Facility Quality Reporting Quality Reporting (IPFQR) Program
The IPFQR Program is a pay-for-reporting program established by the Affordable Care Act. In the proposed rule, CMS is proposing two additional measures to the program. Specifically, CMS is proposing to add Thirty-day All-Cause Readmission Following Psychiatric Hospitalization in an IPF, which is a measure calculated from administrative claims data, and SUB-3: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and the subset measure SUB-3a: Alcohol & Other Drug Use Disorder Treatment at Discharge (NQF #1664): This is a chart-abstracted measure that complements the previously adopted substance abuse measures in the IPFQR Program.
Long-Term Care Hospital Prospective Payment System Changes
Nationwide, most chronically ill patients are treated in acute care hospitals, but some are admitted to LTCHs. In this proposed rule, CMS is continuing to implement the changes required by The Pathway for SGR Reform Act of 2013 that establish two different types of LTCH PPS payment rates depending on whether the patient meets certain clinical criteria. As a result of the continuation of this phase in FY 2017, CMS projects that LTCH PPS payments would decrease by 6.9 percent, or approximately $355 million. Cases that qualify for the higher standard LTCH PPS payment rate under the revised system will see an increase in that payment rate of 0.3 percent in FY 2017. In addition, CMS is proposing to streamline its regulations regarding the 25 percent threshold policy, which is a payment adjustment made when the number of cases an LTCH admits from a single hospital exceeds a specified threshold (generally 25 percent).
Long Term Care Hospital Quality Reporting Program (LTCH QRP)
Beginning in FY 2014, the applicable annual update for any LTCH that did not submit the required data to CMS is reduced by two percentage points. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the continued specification of quality measures for the LTCH QRP, as well as resource use and other measures.
To satisfy the requirements of the IMPACT Act, CMS is proposing one new assessment-based quality measure, and three claims-based measures for inclusion in the LTCH QRP:
- Discharge to Community – Post Acute Care (PAC) LTCH QRP(claims-based);
- Medicare Spending Per Beneficiary (MSPB) – PAC LTCH QRP (claims-based);
- Potentially Preventable 30 Day Post-Discharge Readmission Measure for LTCHs (claims-based); and
- Drug Regimen Review Conducted with Follow-Up for Identified Issues (assessment-based).
CMS is proposing to add four new measures to LTCH QRP public reporting by fall 2017 on a CMS website, such as Hospital Compare. We are clarifying the previously finalized review and correction period for LTCH QRP public reporting in order to emphasize its alignment with the Hospital IQR Program’s policies and practices.
Interim Final Rule with Comment (IFC)
Along with the FY 2017 IPPS/LTCH PPS proposed rule, CMS is issuing an IFC to implement section 231 of the Consolidated Appropriations Act, 2016 that establishes a temporary exception for certain wound care discharges from the site neutral payment rate (that is, the relatively lower payment rate for LTCH discharges that do not meet the statutory patient level criteria) for certain LTCHs.
Pain: ICD-10-CM Coding
The ICD-10-CM Official Guidelines for Coding and Reporting provide extensive notes and instruction for coding pain (category G89). Review these guidelines in full. The following summary identifies key points.
When seeking a pain diagnosis, identify as precisely as possible the pain’s location and/or source. If pain is the primary symptom and you know the location, the Alphabetic Index generally will provide all the information you need.
Only report pain diagnosis codes from the G89 category as the primary diagnosis when:
- The acute or chronic pain and neoplasm pain provide more detail when used with codes from other categories; or
- The reason for the service is for pain control or pain management.
Do not report codes from category G89 as the first-listed diagnosis if you know the underlying (definitive) diagnosis and the reason for the service is to manage/treat the underlying condition. You may report the acute/chronic pain code (G89) as a secondary diagnosis if the diagnosis provides additional, relevant information not adequately explained by the primary diagnosis code.
If the patient has a documented, more-comprehensive diagnosis causing the documented acute/chronic pain, but the documentation indicates the primary reason for the visit/service is management/control of the pain, report a diagnosis code from the G89 category as the primary or first-listed ICD-10-CM code.
Per ICD-10-CM Official Guidelines (section I.C.6), you “may use codes from category G89 with codes that identify the site of pain (including codes from chapter 18) if the category G89 code provides additional information. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes should be assigned.”
The Guidelines further tells us, “If the pain is not specified as acute or chronic, post-thoracotomy, postprocedural, or neoplasm-related, do not assign codes from category G89.”
Acute pain is sudden and sharp. It can range from mild to severe and may last a few minutes or a few months. Acute pain typically does not last longer than six months and usually disappears when the physician identifies and treats the underlying cause or condition. Chronic pain may last for months or years, and may persist even after the underlying injury has healed or the underlying condition has been treated. There is no specific timeframe identifying when you can define the pain as chronic. Determine the code assignment based on provider documentation.
Chronic pain syndrome is not the same as chronic pain. Report chronic pain syndrome only if the provider documents that exact condition.
Glaucoma: ICD-10-CM Coding
Excessive pressure from fluid in the eye can lead to a hypertensive condition called glaucoma. When ocular pressure rises, pathological changes occur that can damage vision. The fluid in the front of the eye flows through an anatomical pathway. If this pathway is blocked, pressure against blood vessels can cut off blood to the eye, leading to blindness. The physician can perform surgery to revise the flow of aqueous in the eye and reduce the pressure. Glaucoma codes are found in ICD-10-CM category H40—except for congenital glaucoma, which is found in subcategory Q15.0.
ICD-10-CM codes for Glaucoma include the type and stage
Glaucoma is classified according to the type of angle closure. The angle referenced is along the exterior ring of the iris, where it joins the trabecular meshwork at the base of the cornea. This meshwork collects aqueous that has flowed through the anterior chamber so that it can be recirculated in the eye. If the angle is closed, the flow of aqueous is reduced or shut off, creating a surplus of aqueous and raising the pressure within the eye. Closed-angle glaucoma is also known as narrow-angle. Increased pressure causes the iris to bulge forward, narrowing or blocking the drainage angle formed by the cornea and iris. Acute closed-angle glaucoma occurs quickly; for example, within minutes or hours following an injury to the eye. Chronic closed-angle glaucoma can be due to a defect caused by illness or age. Open-angle (also known as wide-angle) glaucoma (chronic glaucoma), is the most common type of glaucoma, and it is the leading cause of blindness in adults in the United States. It can only be detected by regular eye exams. Gradually the pressure increases in the eye due to clogging of the drainage system or overproduction of aqueous fluid.
A seventh character identifies the stage of disease. Unspecified equals not documented; indeterminate stage means the physician is unable to determine the stage.
0 stage unspecified
1 mild stage
2 moderate stage
3 severe stage
4 indeterminate stage
Laterality is also a factor: Coding Guidelines dictate that when a patient has bilateral glaucoma that is documented as the same type and stage, you should assign a code for bilateral glaucoma with the appropriate seventh character for the stage. When the patient has bilateral glaucoma with different type or different stage, assign a code for each eye, instead of a bilateral code. Specific guidelines exist for subcategories H40.10-, H40.11-, and H40.20- (I.C.7.a.), with attention to how the codes are indexed in the Alphabetic Index.
Vermilionectomy: CPT® Coding in Brief
Vermilionectomy (40500 Vermilionectomy (lip shave), with mucosal advancement) is the shaving or excision of the vermilion border of the lip. This code also includes the repair of the excisional area by mucosal advancement. If more tissue is excised or removed from the lip area, choose from code range 40510-40530. Choose wedge resections or full-thickness excisional codes based on the tissue excised and the reconstruction performed to correct the defect. These reconstructions are built into the code; do not report them separately with any other repair codes. When reporting 40510-40527, do not additionally report codes from the Integumentary System section.