Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and edema?
Quality measures, such as the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program, form the basis of the 2015 IPPS final rule, released August 4.
CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
Q: How would the following be viewed if it was included in a cardiology consult note: Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
Spinal fusion is a procedure to join, or fuse, two or more vertebrae and can be performed in both the inpatient and outpatient settings. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, review spinal anatomy before discussing correct ICD-9-CM Vol. 3 and ICD-10-PCS coding for inpatient spinal fusions.
Q: ICD-9-CM includes Pott’s fracture as an alternate term for a bimalleolar fracture. However, ICD-10-CM doesn’t include that term in either the Alphabetic Index or the Tabular List. If the physician documents a Pott’s fracture, can we automatically use the code for bimalleolar fractures in ICD-10-CM, even though the term is not in the index?
In ICD-10-CM, you need to communicate with the medical staff about the specific elements that are important for pathologic fractures, because the coding is different than it used to be and it's so different from traumatic fractures.
Q: We know that we can look at the radiology report to get some specifics about a fracture. When it comes to an open fracture in ICD-10-CM, can you determine the Gustilo-Anderson classification, whether it's I, II, IIIA, IIIB, or IIIC, based on a description of the wound? Or does the physician actually have to document, “It's a Gustilo type I" or "type III”?
CMS designates certain procedures as inpatient-only, meaning it will only reimburse the facility when the procedure is performed on an inpatient. However, CMS identifies these procedures using outpatient CPT ® codes. Beverly Cunningham, MS, RN, and Kimberly A.H. Baker, JD, CPC, discuss the process for identifying and coding inpatient-only procedures.
Physician documentation drives quality measures, but physicians often don't understand how the quality of their documenation relates to their quality of care.
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
The April 1 confirmation of the delay in implementing the ICD-10 code set until at least October 1, 2015, certainly took the wind out of many healthcare organizations' sails.
CMS' 2015 IPPS proposed rule, released April 30, focuses on quality measures, such as HAC reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
Q: We had a question regarding documentation in a record of SIRS due to acute peritonitis without sepsis. Our critical care physician on that case called it severe sepsis as well. What would you do in a situation like that?
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
At the time of this publication, the Protecting Access to Medicare Act of 2014 bill was recently passed. The status quo regarding physician reimbursement from Medicare has been maintained. So what? That system has been broken for 20 years. ICD-10 will be postponed for provider billing for another year. So what? Life will go on as it has for the past 36 years with ICD-9-CM. In other words, nothing has changed. We're good for another year. Pressure's off! ...Right?
A diabetic patient is admitted with gangrene. The physician does not specifically link the diabetes and the gangrene, but also does not document any other potential cause of the gangrene. Should you code both conditions?
Congress needed just a week to throw a huge monkey wrench into the healthcare industry's plans for ICD-10 implementation. On March 26, House leadership introduced H.R. 4302, "Protecting Access to Medicare Act of 2014." By April 1, the bill had passed the Senate and been signed into law by President Obama.
When Congress passed the Protecting Access to Medicare Act of 2014, it mandated at least a one-year delay in ICD-10 implementation. Members of the Briefings on Coding Compliance Strategies editorial board, who represent a wide range of industry stakeholders, offered their thoughts on two questions related to the delay.
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chills. The blood culture shows positive for methicillin-resistant Staphylococcus aureus (MRSA). The attending physician documents MRSA sepsis in the progress notes. Antibiotics are changed based on the blood culture and the patient is treated with appropriate antibiotics. Due to poor vascular access, a central venous catheter (CVC) is inserted and antibiotics are infused through this access. The patient responded slowly to treatment and CVC access becomes red and inflamed. The catheter is removed and cultured. The physician documents this to be an infection due to MRSA. What’s the diagnosis code for this?
Cheryl Ericson, MS, RN, CCDS, CDIP, discusses the difference between “after study” and “due to” when it comes to choosing the correct principal diagnosis .
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
ICD-10-CM includes more specificity than ICD-9-CM, but it still includes unspecified codes. Adele Towers, MD, MPH, Joanne Schade-Boyce, BSDH, MS, CPC, ACS, PCS, Michael Gallagher, MD, MBA, MPH, Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain when reporting an unspecified ICD-10-CM code is a good option.
Coding Clinic's Third and Fourth Quarter 2013 issues focus considerable attention on ICD-10-PCS procedure coding. On p. 18, Coding Clinic Third Quarter 2013 states that the coding of a peripherally inserted central catheter (PICC) depends on the end placement of the PICC line?that is, where the device ends up.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
Heather Taillon, RHIA, Cheryl Collins, BS, RN , and Andrea Clark, RHIA, CCS, CPC-H , explain the basic rules regarding principal diagnosis selection in general and for neoplasms in particular in ICD-9-CM.
Coders may need to have a conversation with physicians about how changes in ICD-10-CM could require additional documentation for mental disorders due to a known physiological condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, compares coding for these conditions in ICD-9-CM and ICD-10-CM.
When it comes to coding malnutrition, coders need to see very specific information in the physician documentation. James S. Kennedy, MD, CCS, William E. Haik, MD, FCCP, CDIP , and Mindy Hamilton, RD, LD, review the clinical factors for malnutrition and how to assign the correct ICD-9-CM codes.
Whether you work in a dedicated children’s hospital or a general hospital with a pediatric service line, you will likely come into contact with coding charts of kids. Sometimes they are easy (e.g., an inguinal hernia repair without obstruction or gangrene is an inguinal hernia repair without obstruction or gangrene—except it has to be identified as right or left in ICD-10). Sometimes they are not so easy (e.g., complex congenital diseases and their manifestations and complications).
Inpatient coders will see an entirely new coding system October 1 when they begin officially using ICD-10-PCS. However, MS-DRGs are not changing. The only thing that is changing is what codes map to a particular MS-DRG.
The UHDDS defines principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. That means the principal diagnosis is not always the condition that brought the patient into the hospital.
Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
Codes for epilepsy and migraine headaches are getting a makeover for ICD-10-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews the additional specificity in the new ICD-10-CM codes.
Physicians can biopsy numerous body sites and structures, including muscles, organs, and fluids. Mark N. Dominesey, MBA, RN, CCDS, CDIP, and Nena Scott, MSEd, RHIA, CCS, CCS-P, dig into biopsy coding in both ICD-9-CM and ICD-10-CM.
Q: Can you explain when a neoplasm should be listed as the principal diagnosis? We have some coders who believe the neoplasm should always be the principal diagnosis.
Coders are often in the difficult position of trying to determine whether to report a CC. William E. Haik, MD, FCCP, CDIP, and Kathy DeVault, RHIA, CCS, CCS-P, discuss problems areas in documentation of CCs and what clinical indicators coders should use to help with CC reporting.
Coders live in a very difficult world. They want to do what is best for their organization based on the documentation they have, but sometimes the documentation is incomplete. The patient’s clinical picture can help coders decide when a condition rises to the level of a CC.
Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
Problems can occur anywhere along the alimentary canal or in any of the accessory organs. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses some common diagnosis and procedure codes for digestive diseases and procedures.
Yeah, ICD-10 is all different, isn't it? Well, the appearance of the codes may change, but the diseases don't. Some things you're used to may be truly different, but what we think about while coding doesn't totally change.
The Cooperating Parties made the last regular update to the ICD-9-CM codes October 1, 2011, but they are still adding codes for new technologies each year. The updates are considerably smaller than the regular updates, but coders still need to be aware of them.
ICD-10-PCS is a whole new ball game for inpatient coders. Everything will change. Coders have been hearing that almost constantly since CMS announced the first ICD-10 implementation date in 2009.
Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Robert S. Gold, MD , and Gloria Miller, CPC, CPMA , review anatomy and documentation for wounds and explain how to code for wound care in ICD-9 and ICD-10.
Recovery Auditors are data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay. Robert S. Gold, MD, and Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, provide tips for correct sepsis coding to avoid auditor takebacks.
Over and over, one gets frustrated that professional coders are told that they are smart and educated and know about anatomy, physiology, and pharmacology, and then the same people turn around and say, "You code what the doctor documented and it's not up to you to question the physician."
Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.
CMS released its FY 2014 IPPS final rule in August, and with it comes a whole slew of changes for inpatient hospitals. Set aside a good amount of time to scroll through the 2,000-plus page document. Yes, that's right: There are more than 2,000 pages of information to absorb before the rule goes into effect on October 1, 2013.
Does the patient really have sepsis? Experts say coders often struggle with this question because physicians don't sufficiently document clinical indicators.
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
Q: A patient undergoes placement of a MediPort ® to receive chemotherapy for lung cancer. What principal diagnosis should we report? Should we report V58.81 (fitting and adjustment of vascular catheter) or 162.9 (malignant neoplasm of bronchus and lung unspecified)?
The 2014 IPPS Final Rule contains two significant changes that will impact coders: the 2-midnight inpatient presumption and the Part A to Part B rebilling. Marc Tucker, DO, FACOS, FAPWCA, MBA, and Kimberly Anderwood Hoy Baker, JD, CPC, review the key provisions of these changes.
The 2014 OPPS proposed rule is shorter than normal at 718 pages, but the proposed changes are significant and probably the most sweeping changes since the inception of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting.
As meticulous as a coder may be, he or she is bound to make a mistake at some point in his or her career. After all, nobody is perfect. Mistakes aren't necessarily a reflection on one's abilities or attention to detail. Coders know that physician documentation often makes the job much more difficult. Add stringent productivity standards to that, and you've got a potential recipe for disaster.
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?
Does the DRG accurately depict the patient’s story? Does the length of stay and severity of illness correlate with what actually happened? Heather Taillon, RHIA, and Cheryl Collins, BS, RN, offer tips to selecting the correct principal diagnosis.
Q: Which ICD-10-CM external cause code should we report if a patient falls while on an escalator? This is the first time that the patient has been seen for such a fall.
Complete capture of procedure codes in ICD-9-CM helps to ensure accurate translation to ICD-10-PCS. Donna M. Smith and Patricia L. Belluomini, RHIA, reveal coding errors—including omission of procedure codes—that make the translation process more challenging.
Joint replacement surgery is nothing short of a miracle for those experiencing pain due to an arthritic or damaged joint. The surgery is performed not only on the hip and knee, but also on the ankle, foot, shoulder, elbow, or finger. Patients who have undergone this surgery often regain mobility and are able to live pain free.
Although ICD-10-CM resolves some problematic areas of coding, it isn't a panacea. Respiratory insufficiency is one diagnosis that will continue to challenge coders.
For coders, the summer months can be some of the busiest, particularly for those working in areas that attract tourists. Linda Schwab Messmer, RHIT, CCS, and Lori-Lynne A. Webb, CPC, COBGC, CCS-P, CCP, CHDA, review ICD-9-CM codes for common summer injuries and ailments.
Facilities may be reluctant to charge for bedside services beyond the room rate because they fear double-dipping. Kimberly Anderwood Hoy, JC, CPC, and William L. Malm, ND, RN, CMAS, discuss what CMS does—and doesn’t—say about charging for ancillary services .
Q: Some of our providers see patients in our local nursing facilities. When these patients are admitted to our hospital, must we retain this documentation in our own records?
Hospital value-based purchasing (HVBP). It's the latest buzz phrase in the healthcare industry, and it's something in which all insurers are interested.
Upon quick glance, codes for insertion, removal, and revision of pacemakers look quite different in ICD-10-PCS. The good news is that much of the logic that coders use to assign these codes in ICD-9-CM won't change. The silver lining? The procedure itself doesn't change, nor does anatomy.
Charging for inpatient ancillary procedures and supplies has always been confusing. "CMS provides very little guidance ... Its theory is that it's up to the provider to figure it out," says Kimberly Anderwood Hoy, JC, CPC, director of Medicare and compliance at HCPro, Inc., in Danvers, Mass.
E codes are important in a variety of settings. Pamela L. Owens, PhD, Kathy Vermoch, MPH, Leslie Prellwitz, MBA, CCS, CCS-P, and Suzanne Rogers, RHIA, CCS, CCDS, explain the importance of reporting E codes and why every facility should have an internal coding policy that includes E codes.
Q: What advice can you offer for sequencing pulmonary edema and congestive heart failure when both appear to meet the definition of principal diagnosis?
Q: How will I report the initial insertion of a dual-chamber pacemaker device in ICD-10-PCS? The physician inserted two leads—one into the atrium and one into the ventricle–using a percutaneous approach into the patient’s chest.
Auto manufacturers rely on them to make decisions about improving passenger restraints in vehicles. Industrial engineers may reference them when advocating for improved design of staircases to prevent falls. Drug companies use them to bolster support for child-resistant packaging.
Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.
Consider the following: A beneficiary is admitted to a hospital pursuant to a physician order and receives medically necessary care spanning at least two midnights. CMS will consider this appropriate for payment under Medicare Part A, according to the FY 2014 IPPS proposed rule released April 26. Actuaries estimate that this proposal for what constitutes appropriate inpatient care would increase IPPS expenditures by $220 million due to an expected net increase in inpatient encounters. CMS proposes a 2% reduction to offset projected spending increases.
