The HIM Reporter Volume 1, Issue 3 October 2010
The Future is Bright for HIM Professionals
by Judy Terry RHIA, Director of Review Services
According to the Bureau of Labor Statistics, (BLS) the current unemployment rate is staying
around 9.3%. This is a devastating time for many Americans who have either lost jobs or have
experienced pay cuts due to the economy. However, the BLS is projecting a bright future for
HIM professionals due to implementation of the electronic record and other health data needs.
According to the Occupational Outlook Handbook for 2010-2011, employment for health infor-
mation technicians is expected to grow at least 20% through 2018 which is much faster than
average for most occupations. More HIM professionals will be needed not only to meet this
Judy Terry RHIA, CCS demand but to fill openings left by retirees.
Judy has more than 30
The job responsibilities for HIM will also change with more emphasis placed on data analysis,
years of experience in the
field of Health Informa- data collection, and management of electronic record systems. With the meaningful use provi-
tion Management and sions of the HITECH act, data will be needed to show improvements in patient outcomes, track
earned her Bachelor’s quality indicators, and demonstrate the value of electronic information upon patient care. The
Degree at Loma Linda 60 regional extension centers that are set up to help providers implement their electronic health
University. She is certi- record systems will need personnel to fill these positions. Data analysis is also important for
fied as an RHIA and cancer research and pharmaceutical companies, both of which can utilize the skills of HIM pro-
CCS. Since that time she fessionals. A new credential for data analysis professionals has been established through
has enjoyed working as AHIMA which focuses on data management, data analytics, and data reporting. Assisting pa-
an HIM Director and a
tients navigate a complicated healthcare system is a new emerging role which can utilize the
consultant both to long
term care facilities and knowledge and experience of HIM professionals on reimbursement issues as well as typical
hospitals. She lives in workflow in the healthcare system. This is an advocacy role to help patients better manage their
Vancouver, Washington health by navigating through various requirements, forms, and deadlines. Of course, coders will
and is currently pursuing still be in demand as the government expands its Recovery Audit Contractor (RAC) program
a Master’s Degree in into Medicaid and other compliance areas. Although computerized coding may become more
Public Health. prevalent, the need for editing and ensuring accuracy of the codes will still be imperative for
appropriate reimbursement. Performance improvement programs will also need HIM profes-
sionals to collect and analyze data for quality care initiatives. With skills in managing data,
critical thinking, planning, and problem solving, the quality improvement area is perfect fit.
Inside this New programs such as Clinical Documentation Improvement (CDI) are also tapping into the
issue: skills of HIM professionals. With a concrete knowledge of coding and documentation, partner-
ing with nursing professionals to improve reimbursement and quality provides a good combina-
Cover story 2 tion of specialized skill sets.
With the impending implementation of ICD-10, trainers will be needed to teach the new coding
Impact New Law 2- system. Ensuring accurate mapping of ICD-9 codes to ICD-10 codes will be important to
has on Three-Day 3
bridge data that is already being collected through the use of these codes. It will be important
Payment Window for someone such as an HIM professional to monitor this transition in terms of reporting and
trending data for continuity of care and information.
Time Based Coding 4
for Evaluation & Community colleges are scrambling to develop training programs to meet the demand. A new
Management Service six-month health IT program has been started with funds from the Office of the National Coor-
dinator (ONC) which is designed to meet the demand for health IT workers. These programs
Influenza Type A vs. 5 will require competencies for graduates with potential for certification. These technicians will
not only need a clear understanding of computers but also medical terminology, security, data
For your 6
analysis patterns, and outcomes information. For more information visit http://healthit.hhs.gov.
Entertainment For HIM professionals, there are many opportunities for career development. Learning new
Contact us! 7 skills and exploring non-traditional roles can be an exciting time as it will only help in secur-
Continued on following page...
ing a fulfilling and long-lasting career. For information on career development visit: http://www.ahimastore.org.
If you have any questions, concerns, or would like further information on this topic, please contact firstname.lastname@example.org.
Faith is taking the first step even when you don't see the whole staircase."
-Martin Luther King
Bureau of Labor Statistics. (2010). Occupational Outlook Handbook 2010-2011, Retrieved from: From: http://www.bls.gov/cps/#news
Dolan, M., Wolter, J., & Heet, R. (2010). Patient navigators, Journal of AHIMA, 81(10).
Eramo, L. (2010). Basic training. Journal of AHIMA, 81(10).
Hyde, L. (2010). The health data analyst’s to-do list. Journal of AHIMA, 81(10).
Rollins, Genna. (2010). Forces of change. Journal of AHIMA, 81(10).
Spath, P. (2009). The role of HIM professionals in quality management. Perspectives in Health Information Management, Summer (6).
IMPACT NEW LAW HAS ON THREE-DAY PAYMENT WINDOW
By Marcia Vaqar, MPH, RHIA, CCS, CCS-P Director Coding Services
Hospitals will need to become familiar with the new legislation that President Obama signed into law on June 25, 2010. The
“Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010”, which is to clarify Medicare’s
policy for payment of services provided in hospital outpatient departments on either the day of or during the three days prior to
an inpatient admission. It is well known as the “3-day payment window” or “3-day rule”.
The new law makes the policy pertaining to admission-related nondiagnostic services more consistent with common hospital
billing practices. Section 102 is effective for services furnished on or after the date of enactment, June 25, 2010.
Before the new law enactment:
Previously, hospitals have struggled to correctly apply the rule in their billing operations. Confusion has surrounded this area
for many years. Because of the grey area surrounding the 3-day payment window not only the hospitals had problems but there
was confusion for the MACs/FIs too. This all came to light during CMS’ Hospital Quality Open Door Forum conference calls,
during which the provider community posed numerous questions about the rules. Due to a lack of clarification providers/
hospitals were found to be doing some things different.
Before June 25 of this year the 3-day payment window required that all outpatient diagnostic and any “related” non-diagnostic
medical services provided to a Medicare beneficiary by the admitting hospital including any services received from an entity
wholly owned or operated by the admitting hospital done within three days prior to the beneficiary’s hospital admission were
deemed to be inpatient services, and were included in the inpatient payment. “Related” meant that only when there was an
exact match between the principal diagnosis code assigned for the preadmission services and the inpatient stay was the outpa-
tient non-diagnostic services perceived as “related to” the inpatient admission. The codes had to be exact matches including the
fifth digit of code and this would determine if they were related services.
Hospitals could submit a separate outpatient claim to Medicare Part B for the non-diagnostic services when the non-diagnostic
services were not related to the inpatient admission. In the event that hospitals incorrectly included unrelated outpatient non-
diagnostic services on an inpatient Medicare claim, CMS allowed hospitals to unbundle the non-diagnostic services and submit
separate bills for those unrelated outpatient claims.
After new law enactment of June 25, 2010
One of the changes adopts a new definition for “other services related to the admission”. The related services are no longer
determined by the fact that the ICD-9-CM codes are exact matches.
Now the hospital will need to demonstrate that the services are “unrelated” to the admission. Right after the June 25 enact-
ment of the law, CMS announced that they planned in the near future to provide instructions to the hospital community through
its contractors advising them on how to bill for related services provided during the 3-day payment window.
CMS instructed hospitals that pending future guidance they should continue to bill Medicare separately for services provided
prior to June 25, 2010 that were unrelated to an inpatient stay provided that the claim would meet all applicable filing deadlines
Continued on following page...
HIM Reporter October 2010
and the hospital had supporting documentation showing that the services is unrelated to the inpatient stay. Of note ambulance
and maintenance renal dialysis services provided to patient within the 3-day window are excluded from preadmission services.
Another difference with the new Act that CMS wanted to make clear is Section 102 (c) also prohibits Medicare from re-opening,
adjusting or making payments when hospitals (or an entity wholly owned or operated by the hospital) submit new claims or ad-
justment claims for any services that were provided prior to June 25, 2010 in order to separately bill outpatient non-diagnostic
services. This provision will also stop RAC-related re-openings and also does not allow any recoupment's related to the 3-day
rule. Time will tell what effect the new law has on the RACs focus on the 3-day window issues.
Interim Final Rule for 3-day Window
On July 30, 2010 the 2011 IPPS Final Rule included an interim final rule (IFR) on the 3-day window. CMS published the IFR
with a comment period implementing the recent changes to the 3-day window which became a law on June 25, 2010. Com-
ments will be accepted until September 28, 2010.
CMS guidance was in line with prior guidance which was released shortly after Congress adopted the new provisions. Hospitals
should take note that CMS reiterated that nothing had changed for diagnostic services provided before an inpatient admission.
CMS defines unrelated as being “clinically distinct and independent from the reason for the beneficiary’s admission.
It should be noted that the 3-day payment window will not be applicable to Critical Access Hospitals (CAH). The new law did
not create any new obligations that would apply more broadly which would add more types of hospitals that would need to
monitor the 3-day window rule.
CMS indicated that they would be establishing a “condition code, modifier, or some other indicator” for hospitals to use to attest
that a service is unrelated to inpatient admission and would allow separate billing. CMS instructed hospitals to bill for services
they believe to be unrelated and covered under the beneficiary’s Part B to Part B until the indicator is developed. Hospitals will
be responsible for maintaining documentation in the beneficiary’s medical record establishing that the service was unrelated.
For hospitals to know how the 3-day window will affect billing of these cases we will have to see how CMS responds to the
comments that will be submitted to the IFR. One area of large interest will be the definition of “unrelated”. Hospitals will not
be able to finalize policies for implementation. Until CMS does address the comments received hospitals should make sure they
are adjusting their billing practices for any services after June 25, 2010 which will ensure non-diagnostic services on the day of
admission are not billed separately. During this time frame while hospitals are waiting for more guidance they should be work-
ing on developing a process that allows for a review of services in the three days before for clinical related services and docu-
mentation of services that are unrelated, to support separate billing.
If you have any questions or would like more information on this topic, please contact Marcia@rmcinc.org.
For more information on the 3-day window, please visit the CMS website 2011 IPPS final rule which includes the Interim rule.
Marcia Vaqar, MPH, RHIA, CCS, CCS-P is a healthcare medical auditor and coding consultant who works with hos-
pitals and healthcare organizations to help insure accurate and correct coding through education, auditing, and coding
support. Before venturing out as a consultant and joining the staff of RMC, Inc. Marcia spent over twenty years as a
coding manager, project manager/coordinator of Health Information Management Operations, Inpatient/Outpatient
Coder, Health Information Coordinator, and Medical Record Administrative Aide. Today Marcia offers her extensive
knowledge background to healthcare systems in cooperation with RMC, Inc. which includes but is not limited to coding;
severity of illness data collection and verification; clinical documentation improvement; and coding management skills .
Please stay tuned for information on our upcoming audio conferences...
Our next series is scheduled to start in January 2011!
Time-Based Coding for Evaluations & Management Service
By Connie Eckenrodt RHIT, CHC Director of Physician Services
Evaluation and management (E/M) services refer to visits and consultations furnished by physicians. Billing Medicare for a
patient visit requires the selection of a CPT code that best represents the level of E/M service performed.
CPT recognizes seven components which are used to define the levels of E/M services:
2. Physical Examination
3. Medical Decision Making
4. Patient Counseling
5. Coordination of Care
6. Nature of Presenting Problem
The first 3 components - history, physical examination and medical decision making - are considered the key components in
selecting a level of E/M service.
The next 3 components - counseling, coordination of care, and nature of presenting problem - are considered contributory
factors in the majority of encounters.
When counseling and/or coordination of care dominates (more than 50%) of the visit, then time may be considered the key or
controlling factor in selecting the level of some E/M services. Counseling is defined as a discussion with a patient and/or fam-
ily concerning one or more of the following areas:
Diagnostic results, impressions, and/or recommended diagnostic studies When coding based on time, there are
no specific documentation require-
ments for history, physical exam and
Risks and benefits of management (treatment) options medical decision making. However, it
Instructions for management (treatment) and/or follow-up is recommended that the physician
Importance of compliance with chosen management (treatment options) document pertinent information about
these components in the chart.
Risk factor reduction
Patient and family education
In the outpatient setting, only time spent face-to-face with the patient counts toward total visit time. In the inpatient setting,
total time spent includes face-to-face time and unit/floor time.
Face-to-face time is defined as the time the provider spends directly with a patient.
Unit/floor time is defined as the total time the provider spends with the patient, the patient's family or the patient's other providers, and
the time spent coordinating a patient's care on the unit/floor.
When billing E/M services based on time, the documentation must contain the following four elements:
1. Reason for the encounter (chief complaint)
2. Total time spent (face-to-face for outpatient encounters, unit/floor for inpatient encounters)
3. Total time spent in counseling and/or coordination of care (must be greater than 50% of total time) and,
4. Brief description of the counseling and/or coordination of care provided
Example: “The patient returns today for follow-up on her diagnosis of diabetes, with recent weight gain. Patient was
counseled on importance of good nutrition and exercise habits and we discussed goals for daily food intake. Total face
-to-face time with the patient was 25 minutes, of which greater than 50% was spent in counseling.”
In this example, the visit would be billed based upon the total time of 25 minutes, or 99214 for an established patient.
Ms. Eckenrodt is the Director of Physician Coding & Compliance at RMC. With over 15 years in the HIM field, Ms.
Eckenrodt’s focus has been on outpatient coding, with particular emphasis on professional fee coding and documenta-
tion improvement. Areas of expertise include: new provider coding orientations; individual and group coding education
for providers and professional fee coders; pre-bill and retrospective coding audits; and risk assessment and focus review
audits for internal compliance initiatives and compliance initiatives pursuant to federal investigations. Consulting has been
provided in myriad settings, from small practices to large multi-specialty practice groups.
HIM Reporter October 2010
Influenza Type A vs. Avian Influenza
By Stacy Hardin, CCS, CPC-H Regional Manager, Coding Services
Since I’ve been sick for the past 10 days and flu season is upon us, I was reminded of an issue that came up last year regarding
Influenza A coding. After the October 1 st updates, one coder submitted the question of which code to use for Influenza A,
487.1 or new code 488 for Avian Influenza. The facility was instructing coders to use 488 when documentation stated Influ-
enza type A referring coders to Coding Clinic 4 thQ, 2007.
My response to their recommendation was that code 488 was created for Avian Influenza and it is a subtype of Influenza A
but when you read the entire coding clinic from 4Q 2007, it states that "to date there have been no reported cases of Avian
Influenza in the United states." This deadly flu has the potential for a pandemic and CDC would want to monitor/track any
confirmed cases. I am concerned that we would be incorrectly reporting if we use this code. Avian/bird flu has not made it to
the US yet.
It was finally agreed that Influenza type A should continue to be coded using 487.1. It should also be noted that the use of the
new code 488 has an exception to the coding guidelines regarding suspected conditions and should only be reported for con-
CC 4Q 2007:
Effective October 1, 2007, code 488 has been created to identify influenza due to identified avian influenza virus.
Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. Usually, “avian influenza virus” refers to influ-
enza A viruses found chiefly in birds. The risk to humans is generally low because the viruses do not usually infect hu-
Symptoms of avian influenza in humans have ranged from typical human influenza-like symptoms (e.g., fever, cough, sore
throat, and muscle aches) to eye infections, pneumonia, severe respiratory diseases (such as acute respiratory distress), and
other severe and life-threatening complications. The symptoms of avian influenza may depend on which virus caused the in-
Influenza A (H5N1) virus––also called “H5N1 virus”––is an influenza A virus subtype that occurs mainly in birds. Few avian
influenza viruses have crossed the species barrier to infect humans. H5N1 has caused the largest number of detected cases of
severe disease and death in humans. Most of these cases have resulted from people having direct or close contact with H5N1-
infected poultry or H5N1-contaminated surfaces. There have been no human cases reported in the United States to date.
Scientists are concerned that the H5N1 virus could change and be capable of infecting humans and spread easily from one
person to another. There could be little or no immune protection against the virus in the human population. If H5N1 virus
were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could
Similar to the guidelines for coding HIV infection, code 488 should be assigned only for confirmed cases of avian flu. Code
488 is not assigned when the diagnostic statement indicates that the infection is “suspected,” “possible,” “likely,” or
“questionable.” This is an exception to the hospital inpatient guideline that directs the coder to assign a code for a di-
agnosis qualified as suspected or possible as if it were established.
New code 488 Influenza due to identified avian influenza virus
Note: Influenza caused by influenza viruses that normally infect only birds and, less commonly, other animals
Excludes: influenza caused by other influenza viruses (487)
Stacy has 15 years experience in the Health Information Management field. She started her career working for a small
rural Family Practice Clinic where her duties included coding, transcription and nursing assistant. Stacy moved into the
Hospital sector a little over 10 years ago where she began working in a rural 27 bed hospital performing transcription
and coding. It was there that she tested and achieved her CCS credential and she eventually held the position of HIM
Director. She has also worked as Coding Compliance Coordinator for a 150 bed facility and is currently Regional Cod-
ing Manager and Project Manager for RMC. Stacy has been pursuing her Associates Degree in HIM and has plans to
complete those courses and sit for her RHIT exam very soon.
Strictly for your Entertainment…
by Jane Barta, RHIA
5. X-rays of the lower intestine and rectum using contrast material which is introduced rectally by the radiologist.
7. Objective results of examination or diagnostic test, such as x-ray.
10. Lower part of the abdomen, located between the hip bones.
11. An x-ray cannot be billed to Medicare without one of these from a physician.
13. X-ray of the kidneys and ureters, usually done after injection of a radiopaque dye (intravenous).
15. Medically induced insensitivity to pain so that certain radiological procedures can be performed.
17. Exam of an internal body part, using high frequency sound waves.
18. Exam of the upper gastrointestinal tract.
19. Fluids that are administered into the veins are this.
1. Diagnostic test that is a radiographic image produced using a form of electromagnetic radiation.
2. Markers used by radiologists that are a fixed basis of reference or landmark.
3. Computerized axial tomography.
4. Diagnostic and screening tool used for the early detection of developing tumors in the breast.
6. Conditions which the physician believes make a particular procedure or test advisable.
8. Conclusions reached after reviewing the findings.
9. Voiding cystourethrogram.
12. Diagnoses from this physician, who reads x-ray films and completes a dictated report, may be coded.
16. X-ray of the kidney, ureter and bladder.
TIPS: Hyphens (-) that are part of the answer have their own box; e.g., pick-up would be 7 boxes on the puzzle grid.
Answers that are more than one word have a blank box between each word; e.g. top hat would be 7 boxes on the
HIM Reporter October 2010
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