Although MS-DRGs have stolen the spotlight since CMS implemented them in 2007, hospitals are increasingly using All Patient Refined DRGs (APR-DRG) to compile the most accurate assessment of patient severity of illness (SOI) and risk of mortality (ROM). Cheryl M. Manchenton, RN, BSN, and Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, describe why APR-DRGs are the most widely-used SOI and ROM-adjusted DRGs and how organizations can use them to their advantage.
QUESTION: A physician documents in an operative report debridement of a necrotic muscle (not due to an open wound). Must the physician also document how the muscle is removed to report ICD-9-CM procedure code 83.45 (other myectomy)? Is this considered excisional or nonexcisional debridement? What documentation is required to code the removal of a necrotic portion of a muscle?
Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually — reviewing coding guidelines is helpful.
Unfortunately, ICD-10-PCS is not very comparable to the current ICD-9-CM volume 3 codes inpatient coders currently use. But coders shouldn’t despair, according to Sandy Nicholson, MA, RHIA, Jennifer Avery, CCS, CPC-H, CPC, CPC-I and Robert S. Gold, MD —ICD-10-PC coding may even be fun once coders get the hang of it.
As charges become more specific to provide additional concrete and transparent cost data, providers must consider what procedures they routinely provide to patients and what procedures are specifically related to the patient's condition. Denise Williams, RN, CPC-H, and Kimberly Anderwood Hoy, JD, CPC, reveal tips for determining when to separately bill for ancillary bedside services provided to inpatients.
QUESTION: For a healing traumatic finger amputation with concern but no diagnosis of infection at the amputation site (the physician prescribed Bactrim), is it correct to assign code V54.89 (other orthopedic aftercare) and ICD-9-CM code 886.x (traumatic amputation of finger)?
Coders and billers may not completely understand how to charge for inpatient supplies. One misconception is that the room rate incorporates all supplies used for every inpatient. Another misconception is that payers will not separately pay for inpatient supplies.
How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.
QUESTION: We are having a discussion about how to code when the studies section of the history and physical (H&P) indicates that the chest x-ray showed atelectasis or that an electrocardiogram showed right bundle branch block with anterior fascicular block. Some of us believe that it’s okay to code the diagnosis (i.e., atelectasis) if the provider states that the testing “showed” the diagnosis, whereas others believe we cannot code the diagnosis as it is a lab/testing result, and the provider could just be reading the results onto his or her H&P dictation. I realize you cannot go to the testing result itself and code from it directly. However, I argue that it would be okay to code for it because the provider is using this information to make decisions about care, testing, and procedures, and he or she indicates the testing results in the H&P body. What are your thoughts?
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
When a provider notes a diagnosis on the hospital-acquired condition (HAC) list, coders must be diligent about looking throughout the rest of the chart to ensure documentation clearly indicates the presence of a HAC. For example, if the condition is a pressure ulcer, the condition may have been present on admission. Shelia Bullock, RN, BSN, MBA, CCM, CCDS, and Beverly Cunningham, MS, RN, address the importance of coder participation as members of hospital HAC committees and the development of best practices to ensure accurate HAC and HCAC reporting.
QUESTION: Recently, reviewers have denied diagnostic code 584.9 (acute renal failure [ARF]) based on lab values. The diagnosis is well documented and treated by the attending physician, but reviewers are stating the lab values do not support the diagnosis of ARF. The lab values (creatinine/blood urea nitrogen) went from normal to abnormal, and we found no definitive standards for lab parameters to meet the definition of ARF. Following coding guidelines for reporting secondary diagnoses, the ARF was clinically evaluated, the patient received therapeutic and diagnostic procedures, and there was an extended length of stay/increased nursing care. As coders, we feel it is inappropriate to question the physician’s clinical judgment, and reporting the ARF as a secondary diagnosis is correct. Based on the documentation in the record, is it appropriate to code the ARF?
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the official abbreviation list at their hospital. Some don’t. And even if they did, some physicians will use the wrong term. Robert S. Gold, MD, discusses an example that was featured in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD-9-CM coding of a bronchoscopy with biopsy (TBB) vs. a bronchoscopic lung biopsy (TBLB).
What should inpatient coders remember about the three-day payment window requirements? Although it may seem counterintuitive, Debbie Mackaman, RHIA, CHCO, and Marion G. Kruse, RN, MBA, explain that inpatient coders need to be aware of certain outpatient services that they may need to include on inpatient claims, as well as when they need to alert billers to assign condition code 51.
QUESTION: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.