Podcast: Unlocking the Value of Medicare’s Internet Only Manuals

In my most recent episode of Compliance Conversations, I sat down with Tyler Griffeth, a Technical Manager of Professional Documentation and Coding at Intermountain Healthcare, to discuss a couple of his favorite Medicare Internet Only Manuals (IOMs), specifically the National Correct Coding Initiative (NCCI) Policy Manual and the Claims Processing Manual.

His passion for the manuals (and coding and documentation in general) is evident, and based in no small part because they solve most coding conundrums, so long as “You know where to look.”

The National Correct Coding Initiative (NCCI) Policy Manual, which he jokingly said, “I’ve got mine laminated, I can read it in the tub with a little bit of bubbly” is just one of his favorites. Another, of course, is the Claims Processing Manual, about which he says, “It’s a really great resource if you’re dealing with things like denials, but also if you’re involved in a RAC audit.” I then spent the remainder of our conversation, listening to Griffeth tell me all about pprvu files.

Tune in to my most recent episode of Compliance Conversations, How to Earn a Huge ROI from Medicare’s IOMs, and learn how to:

• Use the NCCI Manual to Clarify Procedure Codes to Physicians
• Leverage the Claims Processing Manual to Avoid Denials
• Apply Situational Modifiers in Conjunction with Codes

And be sure to bookmark Medicare’s Internet Only Manuals, and our podcast today.

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations. I’m CJ Wolfe, I’m Healthicity's Sr. Compliance Executive, and today I have a wonderful expert from the documentation and coding world, Tyler Griffeth. Welcome Tyler.

Tyler: Thanks, thanks for having me CJ.

CJ: Tyler is a technical manager of professional documentation and coding at Intermountain Healthcare. Many years ago, I worked at Intermountain Healthcare. It’s a very large health system with hospitals and doctors and health plans and all sorts of fully-integrated healthcare in the intermountain west, mainly here in Utah. Tyler is one of the managers there. We thought we would talk about some things, but before that, Tyler, I usually want to have my guests tell the listeners how they ended up doing what they are doing. A lot of us don’t grow up thinking, “Oh, when I grow up I want to be a coder, or a compliance person, or something.” How did you end up where you are?

Tyler: Right, I mean we talk to Dr.’s every day that are like [with sarcasm], "You know, I got involved in this thing because I wanted to practice expert coding principals." So, I don’t know what you’re talking about there, CJ.

CJ: Exactly, right? Doctors just love coding . . .

Tyler: Like a lot of people, I studies silly things in college like history. I actually started out thinking I would be a physician, so I had some pre-med classes, but I got a job as a part time security officer, here in Intermountain Healthcare, and one of the directors of my current department saw me as the security guard and asked me what the heck I was doing there.

CJ: Yeah.

Tyler: Because she figured a guy, I guess like me, shouldn’t sit around as a security guard as a career, which by the way, I thought it was a noble profession. You are making the world safe one hospital facility at a time. But, it’s true, it wasn’t my career path. I thought I would teach. Well, our director said, "Why don’t you come work for me and teach doctors?" and I said, “Teach doctors about what…? They already know everything.” And so she knew I was a good candidate for working the doctors, because I believed that already.

CJ: Exactly.

Tyler: I looked at what they had. I did an interview like everybody else. I just kind of fell into this, then. They did an in-house training thing for me, I got all the coding certifications, and have just really worked with about every different kind of physician since then. And that is in the last twelve years.

CJ: Yeah, so you’ve been doing this for about twelve years now, is that right?

Tyler: That’s right, everything from plastics, hand surgeons, to primary care, working with those guys.

CJ: Cool.

Tyler: That’s the thing about Intermountain Healthcare, there are doctors of pretty much every flavor here.

CJ: That’s right. Well that’s great, we all kind of come to this world a little bit differently, but we’re all here now. I know you have some expertise and some other questions I want to talk about. I think for our listeners these are really good resources when it comes to coding and documentation practices. We’re going to be a little bit of a hodge-podge or stew on resources. The first question that I wanted to ask you, Tyler, it has to do with the National Correct Coding Initiative, or NCCI policy manual. A lot of us know about the NCCI edits, but there is a manual. Tell us about how you, you know, why is is that manual is important. How do you guys use it? Tell us a little bit about that manual.

Tyler: Right. The manual contains your pair procedure to procedure coding edits, right? And about every payor follows them, so knowing about what procedures they consider hitting against each other is a really important thing to understand, because people get denials all the time. And they have pretty much no idea because they have a person who’s not involved with knowing actual medicine trying to deal with edits, trying to describe why a very complex procedure has some aspects of another very complex procedure included with it.

CJ: Yeah.

Tyler: The main part of the NCCI policy manual contains procedure to procedure coding edits, and that’s what the NCCI edits are.

CJ: Right.

Tyler: A good example that I see of this all the time is exactly what I’m talking about, for me. I work with plastics doctors a lot, and so we’ll see them wanting to code for a mild cutaneous flap, that’s a muscle flap that you usually transpose from one place to another, and it’s code 15734. All right, now they will want to do that with a free flap breast reconstruction, for example, and that’s 19364, oh I think I said the mild cutaneous flap, that’s 15734, and the recons . . .

CJ: Yeah, I think you said that.

Tyler: Did I say it right? Okay, good, so the free flap breast reconstruction, 19364, will include a mild cutaneous flap, and a physician will say, “Well, I clearly did both of these.” And you need to be able to explain, “Yeah, that’s right, but the NCCI policy manual straight up . . .” I’ll give you direct chapter and verse, and this is what’s great about this policy manual. I mean, I’ve got mine laminated, you know . . .

CJ: Yeah.

Tyler: I can read it in the tub. A little bit of bubbly, a little bit of bubble bath, you know, some candlelight, I’m in for a good night, CJ, with my NCCI policy manual.

CJ: That’s pretty sick, man.

Tyler: Hey, it’s a good time, it’s a good time. Anyway, so, in chapter 3, point 7, it actually says straight up, “CBG code 15734, which is the . . . cutaneous flap, shall not be reported with breast reconstruction codes 19357 through 19364 . . .” and a couple of other codes, or breast processes codes. Since a flap is performed using the reconstruction or prostheses procedure. So, it’s that clear sometimes.

CJ: Right.

Tyler: Which is fantastic because there is just no way that is an understood by a physician, as well as by most people who are familiar with plastic surgery type coding.

CJ: Right, yeah. You know, I remember, so I didn’t do a lot in plastics but I did a lot in interventional radiology and there were examples as well. I’m sure the coding has changed a little bit, but when you’re doing a, like, a heart catheterization and you pull the catheter out of the aorta down through the leg arteries and you do what’s known as a drive by renal aortography . . .

Tyler: Right.

CJ: I remember specifically the CCI manual saying, "Look, this is an example where if you’re doing it in conjunction with this greater procedure, the smaller procedure, we’ve worked the work and the reimbursement in the greater procedure code." I know a lot of people complain that the reimbursements are not enough, but from their perspective they say that is an inclusive code. It’s just chock full of those examples, depending on the specialty, right?

Tyler: You bet, and again, that clear. I think it’s a fantastic resource for people to understand a denial and then, like you say, to be able to go back to your physician and say, “Doctor, look, you actually are getting paid.”Because that is a big concern with most providers.

CJ: Right.

Tyler: “Hey, I want to get paid. I want to get paid for what I’m doing, man, it’s a lot of work.” Well that’s true, doctor, but look, you are getting paid, because yes, the lesser procedure has the reimbursement built into the greater procedure to cover that lesser procedure.

CJ: Yeah. The manual is available for free online, is that correct? You can download the chapters as PDF’s or something?

Tyler: Absolutely. It comes out as a .zip file for us, but yeah, it is, it’s really easy. It’s set up by chapter as you are saying, somewhat like how the CPG book is setup by chapter.

CJ: Yeah, I remember that . . .

Tyler: So really easy to reference or bookmark. If you want to bookmark it, you just have to make sure you’re bookmarking it and then using the updated because they will update that every year. You need to make sure that you’re using your most updated version. You can bookmark the exact section that you work with, if you work with a specific doctor. If you’re part of a huge health system like us, then you’ll have to just look through the chapter and codes that you’re using.

CJ: Yeah. I remember you were telling us a little bit about how you got into the department you’re in. I don’t know if the director at the time was the same director I had when I got into coding at Intermountain.

Tyler: It was.

CJ: She’s a wonderful mentor, a wonderful person. She gave an example once when we were trying to teach doctors about this, so I try to credit her whenever I use this example . . . it’s kind of the value meal at a fast food restaurant. You can order the burger, the fries, and the drink as separate items, and you pay more than if you order the whole meal. And so we always use to say CCI edits are kind of like that. If you order the whole meal, or the greater procedure, the burger is included, the fries are included, the hamburger is included, and so all of that is included as one bundled price. You can’t bill for those other codes separately, but, in some circumstances, maybe you went through the drive-through and I ordered a value meal and my passenger in the car ordered a drink. So on the receipt a separate line item of a drink looks like you’ve un-bundled the drink from the value meal, but in in reality the documentation would show, nope, I did both. Because there are times when you can bypass those edits with a 59 modifier, right? Or other modifiers . . .

Tyler: Correct.

CJ: But the documentation has to support it.

Tyler: Absolutely, because if not, essentially, you are lying. You are saying, “Hey, I did a completely separate complex repair with this breast procedure.” But if it’s in the same exact spot, and the closure for that procedure, you’re telling a falsehood there.

CJ: That’s right.

Tyler: Saying, “Yeah, there was a separate complex repair.” No no, there was not a separate complex repair with that 59 modifier. It’s the repair that’s included with that breast reconstruction procedure, because the idea, if you make a hole in somebody, you’re going to need to close it up.

CJ: That’s right.

Tyler: That’s even bigger than I want fries and a shake with my burger, you know?

CJ: Yeah.

Tyler: If you make a hole in me doctor, I want you to close it up, okay?

CJ: That’s right. That’s exactly right. That’s a good kind of scenario on the NCCI manual There’s another manual that I find useful, and I know you do too, the Medicare Claims Processing Manual. This is also, if, correct me if I’m wrong, is still a publicly available manual online, you can download it. It has all sorts of documentation and requirements that are specific to Medicare, is that right?

Tyler: It absolutely does, yeah, and it’s a great resource, again, if you’re dealing with things like denials. But also, let’s say you’re involved with like a RAC audit.

CJ: Okay.

Tyler: That can be a real scary type of situation.

CJ: Yeah.

Tyler: They are going to follow your Medicare guidelines, and, one example I can think of was, a whole bunch of 99239’s, that’s the higher-level in-patient discharge code.

CJ: Okay.

Tyler: So, these higher level patient discharge codes are being denied, and of course, immediately you go, “Well, that’s because you didn’t document greater than 30 minutes spent on the discharge services for that patient that day.”

CJ: Okay.

Tyler: Well, well, looking at the documentation in this instance, they did document. They were documenting really well that they spent 35 minutes, or 45 minutes, or an hour in the discharge services for these patients for that day. So, we’re kind of scratching our heads with this, going, “Well I guess they are denied as part of this RAC audit and we just gotta accept that I guess . . .” And then we decided, well, let’s take a little bit closer look. Let’s look at the processing manual and let’s see what’s up. Have you ever heard of a swing bed?

CJ: Yeah.

Tyler: Okay, now it’s not a hammock, or . . .

CJ: Yeah, so some of our listeners might not know, why don’t you tell us about it, define it for us.

Tyler: You betcha. Okay, so not a hammock, no ropes involved, it’s nothing like that. A swing bed is what happens sometimes in a rural hospital, or rural location, where you don’t have enough in-patient beds to appropriately care for patients along with patients that need lesser attention. Like those patients that would normally be transferred to a skilled nursing facility bed.

CJ: Right.

Tyler: There is actually, this is the Medicare benefit policy manual, chapter eight, again I’ve got the chapter and verse here. Chapter eight, it’s 10.3.

CJ: Gotcha.

Tyler: A hospital, known as a swing bed facility can swing its beds between hospital and skilled nursing facility levels of care on an as-needed basis So again, really specific knowledge in these IOM’s, internet only manuals.

CJ: Right.

Tyler: That Medicare publishes, so super helpful. It goes on to say when a hospital is providing extended care services it can not be treated as a skilled nursing facility for the purposes of applying coverage rules. You don’t have to change the location of the patient even, it says.

CJ: Yeah.

Tyler: It just needs to have their status changed, and what was happening for us is they were in this type of situation, when they were all ready to leave, they are feeling great, they are ready to leave the hospital. Our providers are billing a 99239. Well, that’s not appropriate for a patient who is a skilled nursing facility.

CJ: Right.

Tyler: A skilled nursing facility discharge code is 99316.

CJ: Is different.

Tyler: Exactly. All we needed to do; we didn’t need accept the loss of all the money. We didn’t need to do that. We just needed to resubmit, with the appropriate code for that situation and we found out about the policy by looking at the Medicare claims processing.

CJ: Yeah, and so those manuals, correct me if I’m wrong, but as I remember, those manuals are published by CMS nationally, because CMS will contract with regional carriers, or Medicare administrated contractors, and those mac’s are suppose to follow these national policy manuals. Is that right?

Tyler: Absolutely. Everybody who is, like you said, a MAC, all the MAC’s have an agreement to follow these.

CJ: Yeah, and so this is, what’s interesting, you know, and sometimes, you know, the MAC’s are independently owned, you know, there may be like a health insurance company or something, but they are independent contracts . . .

Tyler: Sure, sure.

CJ: And if they are new at the process, they might not be aware, and you might know better, you know, chapter and verse like you said, if you’re studying these manuals.

Tyler: Right.

CJ: Yeah.

Tyler: Exactly. All you’d really need to do is know where to look and know, quote to them the chapter and verse for Medicare.

CJ: Exactly.

Tyler: But to let them know.

CJ: Yeah, and they know they are supposed to follow that, that’s right. The other topic we’re getting kind of close to the end of our time, but I wanted to cover one more question for you, kind of a topic, on the PPRVU files. You know, those can be valuable files, but they also can be misused by some payors. Tell us what PPRVU files are and maybe an example of problems that can arise with how some people misuse those.

Tyler: Right, okay. PPRVU file is essentially a list of all the codes, the RVUs that are assigned to them by Medicare, and there are a bunch of indicators in this chart, that show what kind of situational modifiers can be used in conjunction with the codes.

CJ: Yeah.

Tyler: So, you’ve got a zero indicator that says you can not use this bilateral surgery modifier with this code, or a co-surgeon modifier, or a team surgery.

CJ: Right.

Tyler: One interesting situation that we had, and maybe some people listening have had this problem and they don’t know why this is such a problem, but we were seeing a whole bunch of denials on an ‘s’ code, s-2068. S-2068 is a specific code, for a DIEP flap reconstruction. Sorry, again for the plastics example.

CJ: No, that’s good.

Tyler: It’s where I do a lot. This is a very complex surgery, it’s where you take a free flap piece of somebody’s abdomen and you transpose that to the breast You use microvascular and neurologic anastomosis to connect up this flap. It makes a good-looking breast, but it also makes a breast that gains and loses weight with the patient.

CJ: Okay.

Tyler: It’s hot and cold with the patient, you never have these issues where you have a problem with the capsule around your prostheses that needs to be revised. Ten years later they don’t need to go in and revise your augmentation of your beast with a prosthetic because of a multiple of problems.

CJ: Yeah.

Tyler: So, it’s an amazing service, and the fact that there are providers that are this skilled to do it is just an incredible thing. And holy cow, why you wouldn’t want to pay for this service for your beneficiary.

CJ: Right.

Tyler: Considering it is the best way to perform a reconstruction, basically, for most patients, why you wouldn’t want to do that, we didn’t know. So, we started looking into this, and of course Medicare never accepts an ‘s’ code. They have their ‘d’ codes, third party payers have their ‘s’ codes.

CJ: Yeah.

Tyler: So, the PPRVU file puts a little indicator of ‘9’ next to all the ‘s’ codes.

CJ: Okay.

Tyler: The ‘9’ indicator concept does not apply. Essentially, it’s just kind of a placeholder digit to say, “Hey listen, we just don’t want to have blank spaces in our chart.”

CJ: Right.

Tyler: The concept does not apply because Medicare will never accept an ‘s’ code. It will never accept one. So, the problem is you have a third-party payor that does accept ‘s’ codes, and they are looking at this ‘9’ indicator next to . . .

CJ: Ohhhh.

Tyler: Assisted, or co-surgeon, and they are denying, saying, “Hey sorry, you can’t have a co-surgeon for S-2068. Medicare says the concept does not apply.” And you’re just going, “Guys, guys, you do accept ‘s’ codes, the concept does apply.”

CJ: Right.

Tyler: So, with an appeal on a denial like that, we do have, you can have a physician who writes a letter, who explains this procedure and the benefits that are incredible to their beneficiary, the patient.

CJ: Right.

Tyler: So, you can do that. There’s also a few scholarly articles, meaning they are published in journals that are peer reviewed, that talk about doing microvascular anastomotic procedures with multiple physicians in order to cut down OR time. In order to cut down on the amount of time the patient is under anesthetic, in order to cut down on physician fatigue, because if a physician is trying to do this deep flap breast reconstruction, it can take them up to 16 hours.

CJ: Yeah, wow.

Tyler: If you have an assistant, you can cut that time at least in half, if not . . . You know I’ve seen that providers can do it in as short as 7 hours, doing bilateral deep flap breast construction. Of course, the way to appropriate to code that is S-2068, with a 62 modifier for a co-surgeon type situation. Now of course, there are unilateral procedures, so if you’re in a situation where one provider does the left breast, and one does the right breast.

CJ: Yep.

Tyler: Then, go ahead with S-2068 LT, and the other provider . . .

CJ: Does the RT.

Tyler: Does the RT, exactly. So, it’s easy to get by that way, but lots of times they are doing pieces of each of the procedures in truly a co-surgeon style situation.

CJ: Yeah, that’s a really interesting example, so it was a non-Medicare payor, using the RVU file the way Medicare would use it, instead of the way they were supposed to use it as a 3rd party payor.

Tyler: That’s absolutely right, and so, we on appeal will sometimes help them realize that.

CJ: Yeah, exactly.

Tyler: I can’t say that it works every time, but it does work.

CJ: Well, this is awesome, Tyler. We are out of our time for today. I just want to review what we’ve talked about. Three great resources that you’ve shared with us, the NCCI policy manual, the claims processing manual from Medicare, and the PPRVU files. All great resources.

Tyler: You bet.

CJ: They can be used, they can be misused, and doing our own homework on them on them can make a big difference for our reimbursement revenue cycle in complains of course. Tyler, thank you for taking some time to share your expertise with us today.

Tyler: Well you’re perfectly welcome, and I really appreciated the opportunity to be here. It’s really an honor, CJ.

CJ: Awesome. Well thanks, Tyler, and thank you to all our listeners for listening to another episode. Until next time, take care.