Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Audits this week prove to be interesting. As we focus on the accurate coding of HIV, there seems to be opportunity with understanding the definition and the significance in the reimbursement.
Often times the need for additional supportive documentation in determining the appropriate ICD-10 for HIV. Limited information is in the medical record. To code B20, the condition is active and meets criteria versus Z21, asymptomatic HIV.
CMS applies the 128% add‐on to the per diem payment for patients with Acquired Immune Deficiency Syndrome (AIDS). Currently, the AIDS clinical indication is based on the ICD‐10‐CM coding of B20.
However, the ICD‐10 B20 Code, unlike ICD‐9 code 042, does not include “AIDS Like Syndrome” among the symptoms applicable to this code, and therefore, payment for these patients would not include the AIDS per diem adjustment described above.
Validation that patient qualifies for B20 is necessary to properly bill and the medical record demonstrates physician support for coding for the appropriate AIDS add-on.
Per the CDC Definition, a patient has AIDS if he or she is infected with HIV and has one of the following:
- CD4+ T-cell count below 200 cells/µL
- CD4+ T-cell percentage of total lymphocytes of less than 15%
- One of the defining illnesses
The AIDS case definition was expanded in 1985 to include a total of 20 conditions.
- Four of these conditions were cancers: Kaposi's sarcoma and three distinct types of lymphoma.
- The remaining conditions were opportunistic infections, those caused by bacteria, fungi, protozoa, and other infectious agents that an intact immune system can usually manage but which take advantage of the "opportunity" provided by weakened immunity to proliferate in the body.
- Candidiasis of bronchi, trachea, or lungs (see Fungal Infections)
- Candidiasis, esophageal (see Fungal Infections)
- Cervical cancer, invasive‡
- Coccidioidomycosis, disseminated (see Fungal Infections)
- Cryptococcosis, extrapulmonary (see Fungal Infections)
- Cryptosporidiosis, chronic intestinal (>1-month duration) (see Enteric Diseases)
- Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
- Cytomegalovirus retinitis (with loss of vision)
- Encephalopathy, HIV-related† (see Dementia)
- Herpes simplex: chronic ulcer(s) (>1-month duration) or bronchitis, pneumonitis, or esophagitis
- Histoplasmosis, disseminated (see Fungal Infections)
- Isosporiasis, chronic intestinal (>1-month duration) (see Enteric Diseases)
- Kaposi's sarcoma
- Lymphoma, Burkitt's
- Lymphoma, immunoblastic
- Lymphoma, primary, of brain (primary central nervous system lymphoma)
- Mycobacterium avium complex or disease caused by M. Kansasii, disseminated
- Disease caused by Mycobacterium tuberculosis, any site (pulmonary‡ or extrapulmonary†) (see Tuberculosis)
- Disease caused by Mycobacterium, other species or unidentified species, disseminated
- Pneumocystis carinii pneumonia
- Pneumonia, recurrent‡ (see Bacterial Infections)
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent (see Bacterial Infections)
- Toxoplasmosis of brain (encephalitis)
- Wasting syndrome caused by HIV infection
As stated above, the rate for the accurately coded ICD‐10 B20 Code pays 128% of the actual RUG level. For example, if the patient classifies into an HE2:
HE2 Rate= $589.03 (Barnstable County, MA)
$589.03 x 128% = $753.96
$589.03 + $753.96 = $1,342.99 per day
As you can see from above, the reimbursement level is significant as it is reflective of the resources utilized to care for patients within this classification.
Harmony HealthCARE International (HHI) recommends auditing your current caseload and determining if all patients are coded properly to ensure accurate and appropriate reimbursement.
Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have regarding coding and/or regulatory changes. You can contact us by clicking here. Looking to train your staff? Join us in person at one of our our upcoming Competency/Certification Courses. Click here to see the dates and locations.
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