Q: We have a patient who received a pancreas transplant for the treatment of diabetes. The patient was later admitted to the hospital for treatment of an unrelated kidney stone. Would it be appropriate to assign the ICD-10-CM code for diabetes as a chronic condition based on the patient’s medical history?
The estimated annual cost of sepsis readmissions is more than half the annual cost of all Medicare Hospital Readmissions Reduction Program conditions combined, according to a study published in CHEST Journal .
Patients who use oxygen at home for a primary respiratory condition typically present with some degree of respiratory failure. Howard Rodenberg, MD, MPH, CCDS , describes common documentation issues related to oxygen requirements for the diagnosis of acute respiratory failure.
Diagnosis coding for neoplasms can be particularly challenging, as neoplasms are classified by site, behavior, and morphology. Review ICD-10-CM coding and guidelines for reporting solid organ tumors and cancers affecting the bone marrow and lymphatic system. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adriane Martin, DO, FACOS, CCDS, reviews recent Coding Clinic, First Quarter 2019, advice, which includes guidance on reporting abdominal aortic aneurysm (AAA) repairs, spinal fusions, Whipple procedures, midline and central venous catheters, and more.
Sarah Nehring, CCS, CCDS, says that from the inpatient coding and CDI perspective, sepsis can be one of the trickiest diagnoses. In this article, she reviews 10 things coders wish physicians knew about sepsis documentation and coding.
CMS released the fiscal year 2020 IPPS proposed rule in April, which addressed various requests for MS-DRG designations, and in particular, the request for a new MS-DRG designation for chimeric antigen receptor T-cell (CAR-T) therapies that CMS subsequently denied.
Q: Our department has been having trouble reporting comas in ICD-10-CM. Are there any tools we can use to help us report these diagnoses more accurately?
Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , writes that due to the frequency of diagnoses and treatments for breast cancer, it’s more important than ever for inpatient coders to make sure they are reporting these diagnoses and procedures with the utmost accuracy. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , reviews the background of MS-DRGs, as frequently revising MS-DRG basics will ensure that inpatient coders have a thorough understanding of the MS-DRG intricacies, thus perfecting overall assignment and reimbursement accuracy.
Although computer-assisted coding and natural language processing software has improved many aspects of daily CDI work, the technology requires ongoing oversight to ensure efficacy and accuracy. Therefore, CDI professionals, and even inpatient coders, need to be aware of the software’s potential pitfalls within the CDI department and develop tactics to overcome them.
Adriane Martin, DO, FACOS, CCDS, writes that treatment of peripheral arterial disease (PAD) is variable and includes both medical and surgical therapy. Given the frequency of this condition, it is imperative that inpatient coding professionals have a clear understanding of the surgical treatment of PAD to avoid costly ICD-10-PCS errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released the fiscal year (FY) 2020 IPPS proposed rule Tuesday, April 23, which included the annual ICD-10-CM/PCS code update proposals, significant changes to CC/MCC and MS-DRG designations, and a proposed increase to hospital payment rates.
Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I assign the ICD-10-CM code for diabetes with hyperglycemia?
Keeping up with changing coding guidance adds to the complexity of reporting digestive procedures. In this article, Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews ICD-10-PCS reporting for common digestive procedures including the Whipple procedure and lysis of adhesions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Researchers analyzed reports and clinical data from a community hospital for malnourished patients and concluded that of the 1,817 records for malnourished adult patients examined, 1,171 (64.4%) of them were not coded for malnutrition, according to the study published in the Journal of the Academy of Nutrition and Dietetics.
Laura Legg, RHIT, RHIA, CCS, CDIP, takes a look at some common questions asked about MS-DRG optimization and reviews how inpatient coding and documentation plays a large role in the process.
Q: Which ICD-10-PCS code should be reported for an incision and drainage of a perianal abscess of the left buttocks? We are confused about which body part value should be captured since the physician documented both “perianal” and “left buttocks.”
Kay Piper, RHIA, CDIP, CCS, details the process of submitting ICD-10-CM codes to the ICD-10 Coordination and Maintenance Committee meeting by sharing the experience a medical coding educator and a CDI physician adviser had when submitting a proposal for the March 2018 meeting.
Q: I know that the tumor, nodes, and metastasis (TNM) staging system can be used for ICD-10-CM coding purposes, but I’ve never used it before. As an inpatient coding professional, should I know how this system works and how to apply it?
A transcatheter aortic valve replacement (TAVR) is an interventional cardiology procedure that has proven to be an important life-saving cardiac intervention frequently seen by inpatient coders. In this article, Stephen Houlahan, RN, MSN, MBA, CCDS, reviews TAVR history, clinical background, and documentation and reimbursement methodologies to ensure proper education and compliance for facilities.
Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, writes that proper reporting and documentation of chronic obstructive pulmonary disease (COPD) will help ensure accurate MS-DRG assignment and strengthen cases during inpatient audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Cheryl Manchenton, RN, explains CMS’ Hospital-Acquired Condition Reduction Program (HACRP) and says inpatient coding professionals can play a significant role in HACRP success by understanding the basis for hospital-acquired condition scores and ensuring that documentation and coding accurately and fully captures patient conditions and complications.
Sepsis is a leading cause of death in U.S. hospitals, but in most of cases, sepsis alone may not be the true cause of the majority of inpatient, septic hospital deaths, according to recent research published by the Journal of the American Medical Association.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, reviews the clinical validation of acute congestive heart failure (CHF) exacerbation and shares his hospital’s coding and documentation strategy to help in appeal battles.
During CMS’ two-day Coordination and Maintenance Committee meeting March 5 and 6, various stakeholders presented ICD-10-PCS proposals for consideration for future ICD-10-PCS code updates.
With March declared National Endometriosis Awareness Month, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, details endometriosis-related procedure reporting for inpatient coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adriane Martin, DO, FACOS, CCDS, details the updates found in the 2019 ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” and writes that thorough knowledge of query guidelines is essential for inpatient coders and staying abreast of these guideline updates is crucial.
Not many clinical conditions cause more consternation for inpatient coders and CDI specialists than acute and chronic respiratory failure. In this article, William E. Haik, MD, FCCP, CDIP, details acute and chronic respiratory failure and the critical elements in the health record that validate their reporting.
A recent study showed that CMS’ Hospital Readmissions Reduction Program (HRRP) may be causing an increase in the 30-day mortality rate for certain conditions. Now, a second study published by Health Affairs claims that the reductions in readmission rates are themselves “illusory or overstated.”
Q: We had a patient with hemorrhagic cystitis. Our preprocedural plan was a cystoscopy with a bladder biopsy and cauterization. How should this be reported in ICD-10-PCS? We are having trouble choosing between Control or another root operation, and we are getting different MS-DRGs depending how the procedure is reported.
Laurie L. Prescott, MSN, RN, CCDS, CDIP , details the basics of ICD-10-CM/PCS for newer inpatient coders including a review of the ICD-10-CM seventh-character extension, placeholder use, and ICD-10-PCS root operations. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The benefits outweigh the difficulties when it comes to retrospective reviews. How do you get started with this new venture? Like many aspects of CDI, there are many ways to approach the problem. This article details these approaches, including how to enhance coder and CDI collaboration for these reviews.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, reviews ICD-10-CM/PCS cardiac coding for American Heart Month and writes that since accurate coding improves data quality for these conditions, which in turn is used for statistics and tracking trends, ensuring the disease process is captured correctly is imperative. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, explains that reporting sepsis has long been a challenge for many coders even with the continual release of Coding Clinics and guideline revisions. In this article, Rivet reviews common coding traps for this condition including reporting urosepsis, severe sepsis, and sepsis on admission.
CDI professionals can improve documentation and data scores via a mortality review process. This article discusses the various types of mortality reviews and publicly reported data and gives tips on how to implement a successful mortality review process.
CMS recently released an MLN Matters article to inform hospitals and Medicare Administrator Contractors of new system changes, effective July 1, that ensure organ acquisition costs are not included in the IPPS payment calculation for claims that group to a non-transplant MS-DRG.
Using financial penalties to reduce hospital readmissions has been linked to a significant rise in post-discharge mortality for patients with heart failure and pneumonia, according to a recent study by the Journal of the American Medical Association.
Denise Wilson, RN, MS, RRT, and Karla Hiravi, RN, BSN, explore why coding and clinical denials for acute kidney injury (AKI) and acute tubular necrosis (ATN) are different and the importance of different appeal strategies.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, reviews Coding Clinic , Fourth Quarter 2018, advice surrounding body mass index reporting and how new advice conflicts with previous guidance. McCall also reviews payment methodologies and the official guideline updates for this condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Julian Everett, BSN, RN, CDIP, details her experience reviewing pediatric mortality cases for the first time and gives tips on how the different revenue cycle departments can work together to improve their processes and outcomes.
Q: What is the difference between ICD-10-CM code I24.8 (other forms of acute ischemic heart disease) and code I21.A1 (myocardial infarction type 2)? In which situation would each of these codes be reported?
Training new inpatient coders and CDI staff is a big job that often takes several months to conclude, but the end of orientation doesn’t mean that staff members never have to undergo education ever again. As most are keenly aware, the ground is always moving under our feet. From new regulations, to coding guideline changes, to new clinical definitions, education never truly ends.
Q: I would like to add encephalopathy due to urinary tract infection to our quick coding tips, but our CDI specialists disagree on how this condition should be coded and want us to query for metabolic encephalopathy. How should this condition ultimately be reported?
The mechanics of the concurrent coding process can cause headaches for both CDI and coding professionals. Plus, one could argue that CDI’s presence itself limits the number of necessary post-discharge clarifications without the process of concurrent inpatient coding. This article reviews ways that CDI programs can get involved with this process and work collaboratively with coders.
Adriane Martin, DO, FACOS, CCDS, reviews Coding Clinic’s Third and Fourth Quarter 2018 advice including reporting for coronary artery bypass grafting, drainage of an abscess in the submandibular space, and diabetes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Average hospital costs and mortality rates are significantly higher for patients diagnosed with sepsis after hospital admission when compared with patients diagnosed prior to admission, according to a retrospective analysis recently published in Critical Care Medicine.
This article reviews HCPro’s 2018 coding productivity survey and reviews data on factors that have affected coder productivity, remote coders, and collaboration between coders and CDI specialists, including charts coded per hour and coding accuracy standards.
CMS recently made several updates in its latest version of its Hierarchical Condition Category (HCC) list, including revisions to the mental health and chronic kidney disease categories. And, while HCCs may not be a common review focus for inpatient coders and CDI professionals, capturing HCCs for these conditions is paramount for accurate reporting and reimbursement.
Q: A physician documented that a pregnant patient is obese, and the patient’s chart has a listed body mass index (BMI) score. Can we assign an ICD-10-CM BMI code in this instance or should this never be done for an obstetrics patient?
The Office of Inspector General (OIG) has been conducting a series of studies about adverse events in various healthcare settings since 2008 and will be publishing more of its corresponding reports throughout 2019, the OIG said in a statement.
Assigning the appropriate ICD-10-PCS code for spinal procedures can be a challenge for inpatient coders as they need to correctly identify each character of the seven-character code. In this article, Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS , offers coding tips for reporting spinal surgery cases in ICD-10-PCS and examines the correct use of each character. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adriane Martin, DO, FACOS, CCDS, writes that with the complexity of malnutrition—and the complexity of updated criteria—even the most seasoned inpatient coder should review ICD-10-CM malnutrition coding guidelines and criteria frequently to ensure compliant reporting.
Sepsis has been notoriously hard to report in ICD-10-CM, which means coders should not only fully understand coding guidance and guidelines for sepsis, but they should also have a thorough knowledge of its clinical aspects as well. Cesar M. Limjoco, MD , breaks down these clinical aspects and sheds light on the various sepsis definitions coders have encountered over the years.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes that while reporting mental illness is on the radar for outpatient coders, inpatient coders should be up to date with these diagnoses as well. Capturing this data in the inpatient setting not only substantiates reimbursement, it is also used to identify national trends for tracking and understanding these serious conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A preliminary study found that a new point-of-care troponin assay safely ruled out acute myocardial infarction (AMI) in a large proportion of patients with symptoms suggestive of acute coronary syndrome, according to the report published in the Journal of the American Medical Association.
The original DRG system aimed to categorize similar patients with theoretically similar treatments and charges based on the patient’s principal diagnosis and up to eight secondary diagnoses. As time has gone by this system has expanded and become more complicated, making it essential for inpatient coders to understand to ensure accurate reporting and facility reimbursement.
Q: Considering the fiscal year 2019 update to the ICD-10-PCS Official Guidelines for Coding and Reporting for Transfer procedures, how should we now report a pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure in ICD-10-PCS?
As the task of query creation is becoming more prevalent in coding departments, reviewing essential query requirements is a must for all inpatient coders. This article covers these essential requirements including the growing adoption of electronic medical records, when to query, and pointers for submitting queries to physicians. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Humbert, RHIA, and Catrena Smith, CCS, CCS-P, CPCO, CPC, CIC, CPC-I, CRC, CHTS-PW, explore three scenarios for onboarding new inpatient coders and provide valuable advice to prepare them for success.
Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, review the recently published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community” and help coders apply this criteria in ICD-10-CM.
CMS and the Office of Inspector General (OIG) claims to have identified unspecified upcoding in hospital billing—either accidentally or intentionally reporting higher severity codes than supported by documentation to increase payment. Because of this, these entities will conduct a two-part study to assess inpatient hospital billing, according to the OIG.
For patients who suffer from frequent symptoms of gastroesophageal reflux disease (GERD), the provider may have to increase to prescription strength medications and possibly consider surgical intervention for severe cases. In this article, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, reviews ICD-10-CM/PCS coding for these GERD diagnoses and procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adriane Martin, DO, FACOS, CCDS, explains the confusion behind the various sepsis definitions and provides guidance to coders when reporting sepsis in ICD-10-CM.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that by reviewing common electronic health record (EHR) challenges, a CDI program can formulate appropriate mitigation strategies to minimize potential negatives of the system.
Among patients ages 65 years and older, the rate of opioid-related hospitalizations increased more than the rate of nonopioid-related hospitalizations between 2010 and 2015, according to the recent statistical brief published by the Healthcare Cost and Utilization Project.
A new risk model provides a simple way to determine whether acute myocardial infarction (AMI) patients are at a high risk for hospital readmissions, says a study published in the Journal of the American Heart Association.
Q: Can an ICD-10-CM body mass index (BMI) code be used as a standalone code? If not, what documentation should we look for to justify the use of a BMI code?
Sharme Brodie, RN, CCDS, reviews recent guidance published in Coding Clinic , Third Quarter 2018, including advice on diabetes, acute myocardial infarctions (AMI), pressure ulcers, and more.
Crystal R. Stalter, CPC, CCS-P, CDIP, says that there is still confusion around documenting patient stays to show quality, especially in the inpatient realm. Is it really as simple as documenting conditions to their fullest specificity or does it involve a more complex approach?
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that understanding spinal anatomy, the reporting of detailed spinal diagnoses, and the selection of applicable procedure codes can ensure that these complicated claims are reimbursed correctly and in compliance with coding guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Cheryl Manchenton, RN, BSN, CCDS , details the recent updates to patient safety indicator (PSI) 90 and says that these changes are the reason why it’s more important than ever to ensure that PSI metrics are complete and accurate.
The rate of most hospital-acquired conditions (HAC) continued to decline from 2014 to 2016, according to the latest national scorecard released by the Agency for Healthcare Research and Quality.
Q: We have a patient admitted with a history of chronic heart failure (CHF) and end-stage renal disease (ESRD) who was admitted with volume overload due to acute kidney injury and dialysis noncompliance. How should we report this in ICD-10-CM?
Adriane Martin, DO, FACOS, CCDS , reviews some of the ICD-10-CM/PCS code and CC/MCC updates that made the final cut in the fiscal year 2019 IPPS final rule.
Chris Simons, MS, RHIA , outlines tasks that generally fall within the CDI department’s realm and writes that to ensure that inpatient CDI specialists can thoroughly complete these tasks, they must have strong clinical skills and a working knowledge of ICD-10-CM and MS-DRG assignment. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Creating a query and knowing when to query can be complicated, and there are a number of continued training tactics that prove successful for the coder when trying to improve upon physician query practices. This article looks at a few of the official sources that offer query guidance for coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: We recently had a patient admitted for syncope workup. The workups were negative except for incidental findings of acute kidney injury (AKI). The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels and hydration.” Would the AKI or hypovolemia be sequenced as the principal diagnosis?
Cesar M. Limjoco, MD, writes that although different literature has become available on principal diagnosis selection through the years, questions and disputes keep popping up. In this article, he revisits the issue and provides additional insight to code selection for conditions such as acute respiratory failure and congestive heart failure.
Acute heart failure patients in an emergency department's clinical pathway program had a 13.1% lower readmission rate, according to a report published in the American Journal of Emergency Medicine.
Adriane Martin, DO, FACOS, CCDS, reviews Coding Clinic guidance published in the first and second quarters of this year as it pertains to coding guidelines, severity of illness, and MS-DRG assignment for the inpatient setting.
Allen Frady, RN-BSN, CCDS, CCS, CRC, says that defending code assignment against denials requires more than reviewing the denial to determine if the condition was coded and reported according to the coding guidelines; it requires an understanding of payer requirements as well.
Inpatient coding audits need to be tailored to the type of record being reviewed, the time it may take to complete the audit, and any compliance-related issues that may crop up. This article focuses on how coding managers can streamline these aspects to ensure a successful audit. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Our team is having a hard time determining a principal diagnosis for a patient with a history of stage 5 chronic kidney disease (CKD) who is receiving chronic hemodialysis and is in acute renal failure (ARF) with volume overload. Which ICD-10-CM code should be the principal diagnosis?
William E. Haik, MD, FCCP, CDIP, writes that complex pneumonias can segregate to a higher-weighted MS-DRG than other pneumonia types, so reviewing clinical elements with your physician staff may help improve documentation and avoid adverse determinations by external reviewers for these conditions.
Early readmissions were more likely to be preventable and amenable to hospital-based interventions, according to a recent study published in the Annals of Internal Medicine.
Q: If a CDI specialist doesn’t enter the queried diagnosis in his or her working DRG, but the physician responds favorably to the queried diagnosis at the time of coding (or during the retrospective query process), would you consider this in the reconciliation process? If yes, how would we capture this type of data?
The fiscal year (FY) 2019 IPPS final rule contains extensive changes pertaining to MS-DRGs. This article details some of the most notable MS-DRG updates including revisions to epilepsy with neurostimulators and pacemaker insertion classifications. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Cathy Farraher, RN, BSN, MBA, CCCM, CCDS , details the basics of the All Patient Refined Diagnosis Related Groups (APR-DRG), the system developed to allow for a more specific analysis of outcomes in the non-Medicare population, and shows coders and CDI teams how to better capture quality metrics through documentation.
Adriane Martin, DO, FACOS, CCDS , writes that abdominal aortic aneurysms (AAA) are the most common type of aortic aneurysm, and the complexities surrounding AAAs make reporting procedures related to them difficult for even the most skilled inpatient coder.
The European Heart Journal recently published the fourth universal definition of myocardial infarction (MI). The newest definition, which supersedes all previous versions, includes new and updated clinical concepts as well as new sections of guidance.
CMS recently released the fiscal year (FY) 2019 IPPS final rule with significant reductions to reporting requirements for quality initiatives, updates to payment rates, changes to CC/MCC designations, and revisions to various MS-DRGs.
Q: We have a patient who is diagnosed as having acute renal insufficiency due to dehydration with decreased urinary output and was admitted for IV hydration. What diagnosis codes should we assign?
Jennifer Cayce, RHIT, CCS, CCS-P, CPC , explores the conundrums of reporting acute kidney disorders due to confusing clinical terminology and addresses some of the problematic areas of nephrology diagnoses.
