Even through ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze, c oders and CDI specialists still need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs.
The physician documented “encephalopathy” in the progress note of a patient who was admitted with a cerebrovascular accident (CVA) and/or possible seizures. James S. Kennedy , MD, CCS, CDIP, discusses what to consider when determining whether to code the encephalopathy.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
Many coders and CDI specialists memorized previous Official Guidelines for Coding and Reporting , Coding Clinic for ICD-9-CM and do not have to give them a lot of forethought before applying correctly to their day-to-day reviews. Although many of the Official Guidelines for Coding and Reporting remain the same in ICD-10, none of Coding Clinic's previous advice can be applied to the new code set. Without years of new Coding Clinic advice under their belts, it may take some time before the staff exhibits the same ease when applying ICD-10-CM/PCS codes to the documentation provided.
Coding tells a patient's story, based on the narrative the physician provides in his or her documentation. Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and payment.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
In order to identify patients with a CC or MCC, coders need to know when to report additional diagnoses. William E. Haik, MD, FCCP, CDIP, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, discuss when to report a secondary diagnosis.
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
Auditors continue to scrutinize inpatient wound care services. Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, reviews the importance of documenting medical necessity for these services.
The reason a patient comes in is to a facility not always the same as the reason the physician admitted the patient. Brush up on the guidelines for principal diagnosis selection.
In some cases, coding professionals can—and should—report ancillary services provided to inpatients. Denise Williams, RN, CPC-H, and Valerie A. Rinkle, MPA, explain when and how to bill for ancillary bedside services.
CMS proposed that a new HCPCS modifier be appended to every code for a service furnished in a hospital's off-campus provider-based department on both the CMS-1500 claim form for physicians' services and the UB-04 form (CMS Form 1450) for hospital outpatient services in the 2015 OPPS proposed rule. Despite many detailed comments opposing this change, no consensus emerged; therefore, CMS is moving forward with implementing a slightly modified policy.
Coronary artery bypass graft (CABG) procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Surgeons can create bypasses in other vessels of the body.
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
Despite all the uncertainty surrounding the implementation of ICD-10-CM/PCS, the Cooperating Parties (i.e., the American Hospital Association, AHIMA, CMS, and the National Center for Healthcare Statistics) nevertheless decided that the farewell issue of Coding Clinic for ICD-9-CM (which was published in the first quarter of 2014) will remain the farewell issue.
Q: If the physician writes septic shock instead of sepsis, do I need to query for sepsis? Is this an integral part of the diagnosis and sepsis would be the principal diagnosis, with septic shock a secondary diagnosis, making it an MCC?
The anatomical definition of a body part may not be the same as the ICD-10-PCS identification of a body part. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the guidelines for selecting the appropriate body part and how body parts can affect root operation selection.
Q: We’ve heard that ICD-10-CM does not include a diagnosis code to show that a laparoscopic procedure was converted to an open procedure. How will we report this in ICD-10?
ICD-10-PCS will change the way coders count sites for coronary artery bypass graft (CABG) procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Nena Scott, MS, RHIA, CCS, CCS-P, explain how coders will report CABG in ICD-10-PCS.
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for at least 20 days or the case is an outlier.
Malnutrition is at its most basic level any nutritional imbalance and it is often underdiagnosed. James S. Kennedy, MD, CCS, William E. Haik, MD, FCCP, CDIP, and Mindy Hamilton, RD, LD , explain the clinical indicators and coding basics for malnutrition.
Q: We have a problem getting our physicians to understand what we are querying for chronic respiratory failure when a patient is on home oxygen continuously with documented supplementary oxygen of less than 90%, or arterial blood gas with hypoxemia. The physicians tell us chronic obstructive pulmonary disease (COPD) is chronic respiratory failure by definition. Can you help us clarify this situation or give us some tips on how to educate our physicians?
Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not, since the term “subacute” doesn’t really fall anywhere.
ICD-10-CM is similar to ICD-9-CM, but coders need to watch out for differences which could lead to incorrect coding. Nelly Leon-Chisen, RHIA, Gretchen Young-Charles, RHIA, and Sarah A. Serling, CPC, CPC-H, CPC-I, CEMC, CCS-P, CCS , discuss possible pitfalls for coding myocardial infarctions, neoplasms, and external causes in ICD-10-CM.
Many physicians remain reluctant to admit when a complication occurs as the direct result of the medical care they provide. Trey La Charité, MD , reviews hypothetical situations to help illustrate how coders and clinical documentation improvement specialists can handle complications.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.
Malnutrition is at its most basic level any nutritional imbalance. While it can be overnutrition, such as being overweight, obese, or morbidly obese, providers more commonly equate malnutrition with undernutrition, which is a continuum of inadequate intake, impaired absorption, altered transport, and altered nutrient utilization.
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
Q: How specific does the physician have to be for the location of the acute myocardial infarction (MI) in ICD-10-CM? We don’t do catheterizations at my facility .
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.
Q: My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart be listed in the discharge summary for them to be coded?
Clinical auditors are often not able to translate from ICD-9 to CPT ® to determine a procedure is inpatient-only, which leads to denials. Kimberly A.H. Baker, JD, CPC, and Beverly Cunningham, MS, RN, reveal common causes of denials and what hospitals can do to overturn incorrect denials.
CMS designates a certain set of procedures as inpatient-only, meaning it will only reimburse facilities for these procedures when they are performed in the inpatient setting. Inpatient-only procedures present numerous problems for hospitals.
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).” When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
Not feeling well? The problem could be in your small intestine. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews common conditions related to the small intestine.
ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
The 2015 IPPS final rule focused on quality measures. James S. Kennedy, MD, CCS, CDIP, and Cheryl Ericson, MS, RN, CCDS, CDI-P, highlight the changes and explain the role of coding in quality scores.
