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.
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.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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: 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 .
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.
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?
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.
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.
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 .
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?
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.
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.
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.
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.
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: 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.
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.
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.
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.
