Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
Coders need to understand the clinical presentation of sepsis to report it accurately. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review how to identify sepsis and tips for coding it in ICD-10-CM.
Garry L. Huff, MD, CCS, CCDS, and Brandy Kline, RHIA, CCS, CCS-P, CCDS, provide an overview ofkey information providers need to document for coders to assign proper codes for chronic kidney disease and acute kidney injury.
Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures.
Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
Q: I am having trouble with ICD-10-PCS coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Could you please clarify the correct ICD-10-PCS code for a second-degree obstetrical (perineum) laceration that includes muscle?
A 12-year-old male developed umbilical discomfort Monday and didn't eat much dinner. On Tuesday, he started vomiting at school and the pain shifted to his right lower quadrant. His parents brought him to the ED, where his vital signs showed:
Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by coders and CDI specialists to identify any potential impact on documentation capture and code assignment processes.
Q: How can our team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes? Should we consider hiring additional staff or staff with a surgical background?
Q: In my facility, we are supposed to send an email to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
The 2016 IPPS final rule continues CMS’ plan to shift Medicare payments from volume to quality. Shannon Newell, RHIA, CCS, and James S. Kennedy, MD, CCS, CDIP, analyze the rule and the impact it could have on providers.
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on their preparations. In the rush to complete coding education, documentation improvement, and system updates, HIM managers may not have looked at looming MS-DRG shifts.
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
Although CMS did not propose any changes to the 2-midnight rule in the fiscal year 2016 IPPS proposed rule, it signaled its intention to address short stays in the calendar year (CY) 2016 OPPS proposed rule. CMS followed through by introducing several proposed changes to the 2-midnight rule.
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart or leading the physician by introducing a new diagnosis. Do you have any suggestions?
Coders and CDI specialists often rely on the encoder to determine the MS-DRG. Cheryl Ericson, MS, RN, CCDS, CDIP, reviews the steps necessary to determine the MS-DRG on your own.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that is reversible within three months of loss of function. Garry L. Huff, MD, CCS, CCDS, and Kim Yelton, RHIA, CCS, CDIP, review the clinical definition of AKI and coding for both ICD-9-CM and ICD-10-CM.
Q: Can “in the setting of”' be interpreted as “due to” in ICD-10-CM? For example, the physician documented that the patient has a urinary tract infection in the setting of a urinary catheter.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA's Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
PSI 12 evaluates the hospital's risk-adjusted rate of perioperative deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in surgical discharges for patients 18 years and older. Performance for PSI 12 contributes 25.8% of the PSI 90 composite score under the Hospital-Acquired Condition Reduction Program.
Physicians often use the terms acute renal failure (ARF) and acute kidney injury (AKI) interchangeably to describe an abrupt decrease in kidney function that is reversible within three months of loss of function.
Respiratory failure, whether acute or chronic and whether following surgery or not, is one diagnosis that is always an easy target for those who abuse the documentation and assignment of ICD codes.
Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines. James S. Kennedy, MD, CCS, CDIP, Kyra Brown, RHIA, CCS, and Nelly Leon-Chisen, RHIA, discuss the best ways to use this additional guidance.
Q: In ICD-9-CM, sprains and strains fall under the same codes. Will that also be the case in ICD-10-CM or are we going to report these injuries separately?
Shannon Newell, RHIA, CCS, Steve Weichhand, and Sean Johnson conclude their four-part series on PSI 90 with an in-depth look at PSI 12, which evaluates a hospital’s risk adjusted rate of perioperative deep vein thrombosis and/or pulmonary embolism in surgical discharges for patients 18 years and older.
Q: When I started as a coder, I learned that the complication code, such as from ICD-9-CM series 998 or 999, takes precedence as the reason of admission when present with another contributing condition. Is this correct, and is there any written guidance from AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS that discusses this?
CMS provided plenty of proposed refinements to quality measures in the 2016 IPPS proposed rule, but did not suggest any changes to the 2-midnight rule. Kimberly A.H. Baker, JD, CPC, James S. Kennedy, MD, CCS, CDIP, and Shannon Newell, RHIA, CCS, highlight the most significant proposed changes.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
The 2016 OPPS proposed rule is likely to continue CMS' trend of expanded packaging and feature refinements and expansion of comprehensive APCs based on comments CMS has made in prior rules.
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
Patient Safety Indicator 15 tracks events during surgical procedures that can hurt patients, but not whether the patient actually suffers harm from the event. Robert S. Gold, MD, identifies some of the challenges involved with this quality measure.
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘"with’" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
Coders tell a patient’s story with a principal diagnosis and additional diagnoses, some of which are CCs or MCCs. William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and Cheryl Ericson, MS, RN, CCDS, CDIP, explain the value of educating physicians and coders about CCs and MCCs.
Coders and clinical documentation improvement specialists need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs. Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, discuss some common CCs and MCCs.
PSI 15 measures the hospital's risk-adjusted rate of accidental punctures and lacerations. PSI 15 has the highest weight in the PSI 90 composite under both the Hospital-Acquired Condition Program and the Hospital Value Based Purchasing Program. Coders and CDI specialists can improve performance for PSI 15 by ensuring complete documentation and correct ICD-9-CM code assignment for PSI 15?pertinent inclusions, exclusions, and risk adjustment variables.
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
