You are the Revenue Cycle Coordinator for Anywhere Hospital. The Decision Suppor

Question

You are the Revenue Cycle Coordinator for Anywhere Hospital. The Decision
Support department at Anywhere Hospital is concerned because the volume of remittance advice remark code #M39 (The patient is not liable for payment for this service because the advance notice of non-coverage you provided the patient did not comply with program requirements.) on Medicare remittance advice logs has increased over the past three months. Further analysis of the denied claims shows that 75 percent of the claims have code 93798 (physician services for outpatient cardiac rehabilitation with continuous ECG monitoring) present. Therefore, they are requesting that the Revenue Cycle Team perform further investigation for this issue.

After auditing the remittance advice logs and medical records for a sample of cardiac rehabilitation claims, the Revenue Cycle Team has determined that medical necessity is not being met for code 93798. Further, they have discovered that a new LCD was issued for code 93798 in October (three months ago). The ICD-10-CM diagnosis codes that support medical necessity for code 93798 are

I20.1 Angina pectoris with documented spasm
I20.8 Other forms of angina pectoris
I20.9 Angina pectoris, unspecified
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending
coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of
anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of
inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary
artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with
documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina
pectoris
I25.2* Old myocardial infarction
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina
pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms
of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified
angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina
pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other
forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with
unspecified angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina
pectoris with documented spasm
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other
forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with
unspecified angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with
angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with
other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with
unspecified angina pectoris
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina
pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified
angina pectoris
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with
angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with
unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina
pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with
documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina
pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina
pectoris
I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without
angina pectoris
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
I50.22 Chronic systolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
Z48.21 Encounter for aftercare following heart transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z94.1 Heart transplant status
Z94.3 Heart and lungs transplant status
Z95.1 Presence of aortocoronary bypass graft
Z95.2 Presence of prosthetic heart valve
Z95.3 Presence of xenogenic heart valve
Z95.4 Presence of other heart-valve replacement
Z95.5 Presence of coronary angioplasty implant and graft
Z98.61 Coronary angioplasty status
Z98.89 Other specified postprocedural states

**Note: ICD-10 code I25.2 (old myocardial infarction) refers to a MI that has occurred more than eight weeks prior to cardiac rehabilitation services.

Further, around $20,790.00 has been written off due to ABNs not being issued for this cardiac rehabilitation service.

What went wrong in the revenue cycle?                    

How would you suggest rectifying this issue?                     

How will your team monitor improvements?

Explanation / Answer

This is a case study related wrong diagnosis entry , which resulted in revenue loss of writing off $20790. The code of 93798 is wrongly entered in many of the cases.

The isse can be solved only by proper training to bill entry staff. Only experienced staff who had knowledge of Hospital Activities as well from the field of Medical are the right persons to the job. Other wise same mistake will repeat again.

Improvements can be verified by looking into to the finacial figures as well the number of edited bills. How many of them are coming for the financial re imbursement or are coming to change the diagnosis code.

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