ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Sue Bowman, RHIA, CCS, and Donna Smith, RHIA, clear up some misconceptions about ICD-10 implementation and use.
Recovery Auditors have uncovered incorrect secondary diagnoses in patients who underwent amputations for musculoskeletal and circulatory system disorders. CMS revealed the findings in its Quarterly Compliance Newsletter .
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 .
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.
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.
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?
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
Heart failure is one of the top MS-DRGs, so Recovery Auditors have focused on identifying potential coding problems with MS-DRGs 291, 292, and 293. Recovery Auditors identified errors related to sequencing of the principal diagnosis and improper coding of secondary diagnoses, according to the Medicare Quarterly Compliance Newsletter .
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: 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.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
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?
When a patient comes in contact with a drug or chemical that has an unhealthy effect, coders will have an easier time reporting it in ICD-10-CM than in ICD-9-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer reviews poisoning and adverse effect coding in both code sets.
The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures. Kim Carr, RHIT, CCS, CDIP, CCDS , and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight some of the most significant changes for fracture coding.
ICD-10-PCS includes three root operations that involve taking out or eliminating solid matter, fluids, or gases from a body part. Donna Smith, RHIA, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, review root operations Drainage, Extirpation, and Fragmentation.
The 2015 IPPS final rule , released August 4, focuses on quality initiatives and includes no ICD-9-CM diagnosis or procedure code changes. However, CMS did finalize some MS-DRG changes for Fiscal Year 2015.
Improper ICD-9-CM code assignment led to incorrect grouping of claims to MS-DRG 857 (postoperative or posttraumatic infections with operating room procedure with complications and comorbidities), according to Recovery Auditors. CMS released the findings in the July 2014 Medicare Quarterly Provider Compliance Newsletter .
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”?
Physician documentation drives quality measures, but physicians often don’t understand the link between the two. James Fee, MD, CCS, CCDS, Kristi Stanton, RHIT, CCS, CPC, CIRCC, and Jane Bonewell, RHIT, offer suggestions for ways to educate providers and improve documentation.
Coders now incorporate consideration of medical necessity when coding for inpatient admissions. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI , explains the importance of understanding the concept of medical necessity as it relates to coding.
Coders use different codes to report traumatic and pathologic fractures. Robert S. Gold, MD, and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight the differences in coding for the two etiologies of fractures in both ICD-9-CM and ICD-10-CM.
Chronic kidney disease (CKD) is a manifestation of many different chronic disease processes, including diabetes, hypertension, and immune complex diseases. Garry L. Huff, MD, CCS, CCDS , and William E. Haik, MD, FCCP, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, explain the clinical indicators of CKD as well as coding and documentation problem areas.
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
As part of the 2015 OPPS proposed rule , released July 3, CMS is considering eliminating the requirement for a signed physician certification for most short inpatient stays. CMS would still require a signed physician certification for stays that last 20 days or longer, as well as outlier cases.
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.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
CMS focused on quality measures in the 2015 IPPS proposed rule, released April 30. Kimberly A.H. Baker, JD, Cheryl Ericson, MS, RN, CCDS, CDIP, James S. Kennedy, MD, CCS, CDIP ,and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, highlight the most significant proposed changes.
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.
For anyone who has not yet started ICD-10 training, CMS posted a transcript, audio file, and slide presentation from the June 4 More ICD-10 Basics MLN Provider call on its website.
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.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
ICD-10-PCS root operations Occlusion, Restriction, and Dilation involve changing the diameter of a tubular body part. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Angie Comfort, RHIT, CDIP, CCS, review the definitions of these root operations and examine when they should be used.
Reporting codes for use, abuse, and dependence isn’t completely new for ICD-10-CM. Coders can report them in ICD-9-CM. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, reviews the meaning of use, abuse, and dependence and how to code these conditions.
Coders can only use the documentation they have to code in ICD-9-CM and ICD-10-CM. Adelaide La Rosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, discuss the importance of good documentation when coding for fractures and congestive heart failure in both systems.
Q: We had a question regarding documentation in a record of SIRS due to acute peritonitis without sepsis. Our critical care physician on that case called it severe sepsis as well. What would you do in a situation like that?
Some conditions, such as gangrene due to diabetes, require two codes to correctly report in ICD-9-CM. In ICD-10-CM, coders will only need one code. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and William E. Haik, MD, FCCP, CDIP, explain how these combination codes act as their own CC or MCC in ICD-10-CM.
Pneumonia is an inflammatory process that affects the lung tissue. Robert S. Gold, MD , and Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, explain the clinical and documentation pieces of pneumonia coding.
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
Four ICD-10-PCS root operations involve procedures that put in, put back, or move some or all of a body part. Gerri Walk, RHIA, CCS, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, highlight the differences among Reattachment, Reposition, Transfer, and Transplantation.
Cheryl Ericson, MS, RN, CCDS, CDIP, discusses the difference between “after study” and “due to” when it comes to choosing the correct principal diagnosis .