Begin your search for a neoplasm code first in the alphabetic index by looking under the tumor’s histology, and then consult the neoplasm table if necessary, or risk assigning an incorrect code for a patient’s cancer diagnosis. If you instead jump immediately into the neoplasm table, you could easily end up choosing an incorrect code, says Sherri Parson, HCS-D, director of staff education for Floral Park, N.Y.-based coding outsourcer Quality in Real Time. Learning how to use the alphabetic index and the neoplasm table correctly is a common source of confusion among coders. “We see our novice coders struggle with this so much,” Parson says.
Consider a diagnosis of melanoma of the skin of the left breast. Correct procedure would involve first looking in the index under “melanoma,” which is the tumor’s histology or cell type, scrolling to “skin” and then “breast (female)(male),” which leads to C43.52 (Malignant melanoma of skin of breast).
By contrast, if you first went to the neoplasm table and based on melanoma being a type of skin cancer searched under “skin” and then scrolled to “breast,” you’d end up at C44.501 (Unspecified malignant neoplasm of skin of breast).
Furthermore, note that the C44.- category (Other and unspecified malignant neoplasm of skin) provides codes for basal cell carcinoma and squamous cell carcinoma, two distinct types of skin cancer, as well as unspecified skin cancer codes. Codes for melanoma aren’t found there.
Tip: Remember that the procedure of first looking in the alphabetic index before verifying the code in the tabular is instruction that’s taken directly from official coding guidelines [I.B.1]. For neoplasms that aren’t specified by their histology and that are generally referred to as neoplasms or cancer, the index will lead you to the neoplasm table.
CMS has released five scenarios to help clinicians correctly answer new OASIS medication questions that have been added to comply with the IMPACT Act and will be publicly reported.
CMS discussed this information as part of an Aug. 17 Home Health Quality Reporting call about the new OASIS items and how to properly respond.
M2001 (Drug regimen review), M2003 (Medication follow-up) and M2005 (Medication intervention) are quality measures needed to meet IMPACT Act requirements, and data collection for home health agencies began Jan. 1, 2017. The Drug Regimen Review measure will appear on Home Health Compare in October 2018.
With drug regimen review, three conditions must be met for the care episode to have a favorable result: Completion of a drug regimen review at the beginning of the episode, physician contact and follow-up if medication issues are identified and physician contact and follow-up each time significant medication issues are identified throughout the episode.
The numerator is the number of episodes where the desired process was provided, and the denominator is the number of episodes eligible for the desired process. The measure rate is the percentage of successful patient episodes.
Data collection on the items for long-term care hospitals, inpatient rehab facilities and skilled-nursing facilities begins in 2018, with public reporting in 2020, according to CMS’ slides from the call.
Many home health clinicians don’t fully understand M2003 in particular, so the scenarios CMS has outlined will be valuable for agencies to use to educate staff, says Jennifer Sandel, co-owner of Home Care Services Solutions in Battle Creek, Mich.
A common reason why clinicians mark “0 - No” on M2003 is the challenge of getting physicians to respond by midnight of the next calendar day.
But there are simple steps agencies can take to increase their odds of accomplishing what CMS expects of providers and physicians as part of the OASIS item, industry experts contend. For instance, stress the need for clinicians to follow up with physicians’ offices if they haven’t heard back by the next day.
Two scenarios discussed during the call involve agencies that identified a medication issue and tried alerting the doctor in a timely manner but didn’t get a timely response. Clinicians in these scenarios should mark “0 – No” on M2003, CMS indicated.
Consider scenarios for M2001, M2003
Scenario 1: Late Friday afternoon during your resumption of care (ROC) visit, you identify a potential clinically significant medication issue you believe needs timely attention. You leave a message with the physician’s answering service before you leave the patient’s home, and you leave a second message Saturday.
The physician calls back Monday morning, telling you to have the patient discontinue the medication. You relay the information to your patient by phone and confirm he understood the direction during a home visit Monday afternoon.
Answer: Respond “1 – Yes, issues found during review” because the medication issue was clinically significant, CMS says. Respond “0 – No” on M2003 because even though the physician was notified and the issue was resolved, completion of recommended actions didn’t occur by midnight of the next calendar day.
Scenario 2: During the start-of-care (SOC) comprehensive assessment, the RN completes the drug regimen review and identifies a potential clinically significant medication issue. On that day of admission, the RN leaves a voicemail with the physician’s office about the issue.
The physician responds after midnight the next calendar day. No other medication issues arise during the episode, and the patient is discharged.
Answer: On M2001, respond “1 – Yes, issues found during review,” CMS says. Answer “0 – No” on M2003 and M2005.
The issue was potentially significant and required physician contact by midnight of the next calendar day, CMS notes. Again, while the clinician tried to speak with the physician’s office about the issue, contact didn’t occur timely.
Forum details frequency of responses
On M2001, clinicians responded “0 – No” on 76% of SOC and ROC assessments in the first quarter of OASIS data collection for the item, officials said during the webinar.
Clinicians responded “1 – Yes, issues found during the review” on 23% of assessments.
Clinicians responded “9 – NA, Patient is not taking any medications” on 0.22% of assessments.
M2001 was reported with a dash on 0.15% of assessments.
Despite the data, a far larger percentage of patients actually do have medication issues, Sandel contends.
Such a low percentage of assessments where “Yes” is marked indicates clinicians don’t completely understand what “clinically significant” medication issues are, don’t understand what M2001 asks and/or don’t properly check medication, Sandel adds.
On M2003, meanwhile, clinicians responded “0 – No” on 15% of SOC and ROC assessments. Clinicians responded “1 – Yes” on 85% of assessments.
The “No” response should be listed more than 15% of the time on M2003, but many clinicians misunderstand the item, Sandel says.
For instance, she contends, many clinicians think they need to contact the physician (or physician designee) timely but don’t realize they also need to hear back and complete prescribed/recommended actions timely.
Do this to avoid a “No” on M2003
Educate field clinicians about how to get doctors’ offices to respond sooner to calls about medication.
If clinicians identify medication issues during an assessment at noon and leave a message that afternoon but don’t hear back, they should call the doctor’s office the next morning, advises Jessica Cook, coding and OASIS manager for BlackTree Healthcare Consulting in Conshohocken, Pa.
Stress a return call is necessary — and give a deadline to respond, Cook says. For instance, the clinician could tell physician’s office staff, “If at all possible could I get some direction on how the doctor wants me to handle this by tomorrow afternoon?”
Don’t expect a timely response if you don’t ask for one when you call and report an issue, says LaDawn Pierce, QAPI administrator for Mays Home Care, which serves Texas and Oklahoma.
Understand that weekends are not an excuse:
If the on-call physician directs you to monitor the patient and wait until Monday when the primary doctor is available, you can answer “yes” on M2003, says Ann Rambusch, president of Rambusch3 Consulting in Georgetown, Texas.
Note that many doctors rotate who is on-call for important issues that must addressed outside regular business hours.
But for doctors who don’t take calls after hours, arrange a meeting with them and explain the process measure, Pierce says. Explain the importance of coordinating care and that it’s vital to improve outcomes and prevent potentially avoidable hospitalizations.
“Ask that physician for a contingency plan and his/her preferred method addressing clinically significant medication issues that occur outside of normal business hours,” Pierce says.
If the patient comes to your agency from a hospital at night or on the weekend, ask the discharge planner who you can contact if you identify clinically significant medication issues, she adds.
Remember the window for a response isn’t 24 hours. Agencies actually have from the visit one day until midnight the following night “for the two-way communication and completion of the recommended actions to occur,” Linda Krulish, president of OASIS Answers, Inc., said while educating providers during the call. CMS wants the response by midnight of the next calendar day, not midnight of the next business day.
Understand the issue must be “significant” or there’s no need to call the doctor. Clinicians should use their judgment to determine if the medication issue is potentially significant, Rambusch says.
“Physicians get lots of calls,” she reminds. “Don’t waste their time if in your judgment this does not rise to a potentially significant issue.”
If you habitually call with insignificant issues, physicians will stop responding, Rambusch says.
If a clinician identifies potential drug interaction issues but believes the physician has previously identified these issues as well and doesn’t have a problem with them, there’s no need to call the doctor, Sandel says.
But life-threatening drug interactions should lead to calls to doctors — and so should issues where there’s a gray area about whether a call is necessary, Sandel says.
Consider calling top referral sources and asking them for examples of situations when they’d want to be called about medication issues and when they would not, Sandel adds.
Conduct drug regimen reviews and assessments in the first part of the day. This gives you more time to get a response from the physician, Rambusch says.
Remind clinicians what to do when the doctor has no new orders or instructions. If clinicians report the issue to a physician timely, and the physician’s office responds timely with no new recommendations, the clinician should mark “1 – Yes,” Krulish says. — Josh
A 57-year-old man is admitted to home health with a primary diagnosis of anemia caused by his hepatocellular carcinoma of the liver. His medical record indicates that he is has chronic hepatitis C infection, is a former IV drug user and that his opioid dependence is currently in remission.
Code the scenario:
|Primary and Secondary Diagnoses||M1025 Additional diagnoses|
|M1021a: Liver cell carcinoma||C22.0|
|M1023b: Anemia in neoplastic disease||D63.0|
|M1023c: Chronic viral hepatitis C||B18.2|
|M1023d: Opioid dependence, in remission||F11.21|
- Even though the focus of care is on the anemia, because it’s caused by cancer, the cancer is coded first, in accordance with tabular instruction.
- The histology of the patient’s cancer is specified as hepatocellular carcinoma, and an index search under those terms leads specifically to C22.0, making that the correct code.
- His chronic hepatitis C infection, as well as his opioid dependence in remission, are relevant to his plan of care and are thus coded as comorbidities.