Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM, explains the definition of acute ischemic syndrome and the clinical indicators that make a difference when reviewing a medical record. In part two of this two-part series, Kuqi takes a look at myocardial infarctions (MI), treatments for MIs, and clinical documentation concepts.

CMS recently released the FY 2021 IPPS final rule, which increased hospital payment rates, created new MS-DRGs, and finalized the FY 2021 ICD-10-CM/PCS code sets and CC/MCC designations to be implemented October 1.

Julian Everett, RN, BSN, CDIP, reviews ICD-10-CM reporting and clinical criteria for pneumonia and its causative agents and associated comorbidities. Everett also details documentation recommendations for providers to ensure inpatient coders can report this disease with the utmost accuracy.

Q: When is it appropriate to report both flash or acute pulmonary edema and acute on chronic heart failure (diastolic, systolic, or other) in ICD-10-CM? What other etiologies lead to flash pulmonary edema and how do I know when to query?

Sharme Brodie, RN, CCDS, CCDS-O , writes that the cost of new technologies can lead to an overwhelming financial burden to hospitals and patients, which is why accurate reporting of ICD-10-PCS codes in the new technology section of the ICD-10-PCS manual is more important than ever.

Q: We have an elderly patient admitted in our hospital who is also presenting with glaucoma. Since we don’t report glaucoma on a regular basis, can you explain any background, guidelines, or tips for reporting glaucoma in ICD-10-CM?

In July, the Office of Inspector General (OIG) released a report regarding the incorrect assignment of ICD-10-CM codes for severe malnutrition on inpatient hospital claims. In this article, Yvette M. DeVay, MHA, CPC, CPMA, CIC , reviews these findings and explains how to better document and report malnutrition.

Heart disease is a broad category, but for this article Julian Everett, RN, BSN, CDIP , takes a look at ICD-10-CM reporting for myocardial infarctions (MI). It is essential to understand what defines an MI, current quality initiatives for MIs, and documentation and coding requirements for this diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O, writes that it’s important for inpatient coders to acquaint themselves with any underlying conditions related to novel coronavirus (COVID-19) in order to ensure accurate reporting, reimbursement, and data gathering.

According to a recent audit by the Department of Health and Human Services’ Office of Inspector General (OIG), Ohio State University Hospital received millions in overpayments during an audit period due to errors in coding, MS-DRG assignment, and billing.

To deal with the rising rate of infection and increased hospital admissions for extraordinarily sick patients due to the novel coronavirus (COVID-19), CDI teams have had to act quickly by adapting to remote work, modifying CDI practices, and more.

Q: We have a patient who gave birth while admitted for novel coronavirus (COVID-19). How should this be reported and sequenced in ICD-10-CM and which MS-DRG would this be assigned to?

Q: We have a patient that was admitted with sepsis due to COVID-19 who also has human immunodeficiency virus (HIV). How should we report this in ICD-10-CM, and which MS-DRG would this be assigned to?

The ICD-10-CM Coordination and Maintenance Committee recently released the fiscal year (FY) 2021 ICD-10-CM code set, which includes 490 new, 58 deleted, and 47 revised ICD-10-CM codes. Along with updates to the Tabular index, these changes include new codes for reporting chronic kidney disease and body mass index.

Julian Everett, RN, BSN, CDIP, writes that as some hospitals see revenue continue to decline due to the current COVID-19 pandemic, inpatient coders and CDI specialists need to brush up on the criteria, treatment, and ICD-10-CM reporting for malnutrition diagnoses to avoid any more loss in revenue.

CMS’ recently released the fiscal year (FY) 2021 IPPS proposed rule which included proposals for the creation and revision of various MS-DRGs. In particular, CMS proposed the creation of a new MS-DRG for cases involving chimeric antigen receptor T-cell (CAR-T) therapies.

Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC , gives guidance to CDI teams working on clinical validation, denials prevention, and appeals processes to help ensure proper reimbursement for their hospitals.

Sarah A. Nehring, CCS, CCDS, writes that an inpatient coder’s first concern regarding the reporting of novel coronavirus (COVID-19) is to code all confirmed cases and only confirmed cases. In this article, Nehring details guidelines on how to accomplish this.

CMS recently released the fiscal year (FY) 2021 ICD-10-PCS code set and ICD-10-PCS Official Guidelines for Coding and Reporting . The ICD-10-PCS code update includes new codes for Fragmentation and Drainage, while the guidelines update includes new and revised guidelines for certain root operations, approach values, and device combinations.

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, details MS-DRG updates found in the fiscal year (FY) 2021 IPPS proposed rule, including the proposed creation of MS-DRG 521 (Hip Replacement with Principal Diagnosis of Hip Fracture with MCC) and MS-DRG 522 (Hip Replacement with Principal Diagnosis of Hip Fracture without MCC). Note : To access this free article, make sure you first register here if you do not have a paid subscription.

CMS recently released the FY 2021 IPPS proposed rule, which includes updates to CC/MCC designations as well as hundreds of ICD-10-CM/PCS updates.

Emmel Golden, MD, FCCP, CCDS, Brandy Kline, RHIA, CCS, CCS-P, CCDS, CDIP , and Katy Good, RN, BSN, MHA, CCDS, CCS , review the clinical indicators, ICD-10-CM reporting, and financial impacts of the novel coronavirus (COVID-19) and associated diagnoses, including hypoxia.

Pulmonary hypertension is a complex, progressive disease that affects both children and adults, and leads to significant morbidity and mortality. In this article, Amy Sanderson, MD , reviews this disease to help ensure proper inpatient reporting and more precise queries.

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that attention must be paid to coding guidelines and instructional notes for blindness, low vision, and laterality when reporting diseases of the eye and adnexa in Chapter 7 of the ICD-10-CM manual. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Q: When would you use the ICD-10-CM codes for opioid or marijuana use when no mental, behavioral, or other disorder is connected?

Trey La Charité, MD, FACP, SFHM, CCS, CCDS , writes that one area of risk unique to CDI and coding staff is the physician query. While the creation of the individual physician query usually garners most of the attention, maintenance of query compliance is equally important and frequently overlooked.

Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O, reviews the latest guidance and ICD-10-CM reporting for common novel coronavirus (COVID-19) scenarios such as reporting for patients who present for testing with symptoms of COVID-19. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Q: Is there is any guidance on ICD-10-CM reporting for screening for COVID-19? For example, a patient was admitted with pneumonia and the physician documented “COVID-19 screening completed–NEGATIVE.” Would it be appropriate to assign ICD-10-CM code Z11.59 (encounter for screening for other viral diseases) for this?

Amy Sanderson, MD , writes that cerebral edema and brain compression are the result of significant brain abnormalities that can be life-threatening, and it’s important for clinicians to recognize and treat these conditions promptly. Properly documenting these diagnoses in the medical record is important to accurately reflect just how sick these patients are.

Q: We are seeing an influx of possible COVID-19 patients at our facility. How can we prepare to query for COVID-19-related documentation and coding issues that are bound to come our way due to the newness of the diagnosis?

Kay Piper, RHIA, CDIP, CCS, says exciting changes to ICD-10-CM are published in an often-overlooked document called the Addenda. It lists additions, revisions, and deletions to the Alphabetical Index and Tabular List. This might seem mundane until you realize the changes’ potential effect on coding and CDI.

Yvette DeVay, MHA, CPC, CPMA, CIC, writes that because novel coronavirus (COVID-19) is a new disease, there is still much to learn about how the disease is spread and what severity of illness it causes. For these reasons and more, many inpatient coders are finding this virus hard to report. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

The Surviving Sepsis Campaign recently published new pediatric sepsis guidelines in Pediatric Critical Care Medicine . This update includes information on a two-phase process for septic shock and guidelines for therapy start times.

William E. Haik, MD, FCCP, CDIP , details guideline changes regarding the diagnosis and treatment of adults with community-acquired pneumonia and provides criteria to clinically validate a diagnosis of Gram-negative and methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.

Q: Our coding department frequently has trouble reporting type 2 myocardial infarctions (MI). Can you share any coding and clinical criteria guidance?

While the premise for quality programs is largely the same across the board, there are many programs and measures that fall under the “quality” banner. From readmissions to present on admission (POA) and patient safety indicators (PSI), CDI programs have a myriad of potential options in terms of record review focus.

Sarah Nehring, CCS, CCDS , writes that because of the complexity and frequency of ischemic stroke admissions, inpatient coders should review clinical criteria and ICD-10-CM reporting regularly for this diagnosis to ensure accurate coding and reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Q: What is your recommendation for pressure-injury querying using the nursing staff’s documentation?

Trey La Charité, MD, FACP, SFHM, CCS, CCDS , writes about conflicting documentation and how coders and clinical documentation integrity specialists can resolve inconsistencies in provider documentation to prevent claim denials.

With the increased focus on clinical validation denials, more and more CDI professionals are finding themselves involved in the appeals-writing process and may initially feel a bit overwhelmed by the magnitude of the job. This article is part two of the two-part series covering best practices and appeal advice for those on the frontlines.

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, analyzes pertinent guidelines and coding dilemmas found within Chapter 1 of the ICD-10-CM Manual: Certain Infectious and Parasitic Diseases. Commeree covers instructional note guidance and other chapter specific guidance for diagnoses such as sepsis and HIV. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

According to the 2019 coding productivity survey recently conducted by HCPro, 36% of inpatient coders indicated that they only coded an average of one to two inpatient charts per hour.

Julian Everett, RN, BSN, CDIP , reviews the background of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) and says that even though the report is only made available through quality or chief financial departments, it is imperative CDI and coding staff have a seat at the table when discussing areas for improvement at a facility.

Q: Our coding department was told there were changes made for fiscal year (FY) 2020 when it comes to reporting healed/healing pressure ulcers and pressure-induced deep tissue damage. Can you explain any recent updates?

Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?

One strategy for handling the confluence of confusion surrounding frequent criteria changes comes in developing a set of organizationwide clinical criteria for targeted, high-risk/high-volume diagnoses. This article discusses others’ experiences in developing standardized clinical indicators and guidelines at their facilities.

Inpatient coders may query to achieve clarity within the medical record and allow for accurate ICD-10-CM/PCS reporting. This article will cover when to query, how to format a query, and review ICD-10-PCS code anatomy to ensure a well-rounded and precise query is submitted. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Safety-net hospitals may not have adequate resources to comply with federal and state sepsis quality improvement standards required of acute care hospitals, according to a recent study published in the Journal of Critical Care .

As of December 4, nearly 2,300 cases of lung injury related to vaping have been reported, according to the Centers for Disease Control and Prevention. In this article, Adriane Martin, DO, FACOS, CCDS , covers guidance, clinical indicators, and ICD-10-CM reporting for vaping-related lung injury.