Healthcare providers typically start with an evaluation of the patient’s chief complaint and work toward specifying the cause of the symptom. Coding from documentation where the physician notes the patient’s symptoms but documents no working medical diagnosis is a definite “don’t.” Signs or symptoms of an underlying condition should be coded only if no definitive diagnosis is determined, according to the ICD-9-CM Official Guidelines for Coding and Reporting. However, when the workup of the condition is not clear-cut and a medical diagnosis cannot be definitively made, the symptom then becomes the final diagnosis. Most signs and symptoms codes are identified in Chapter 16 of the coding manual.
Take the following situation for example. A patient is admitted for evaluation of abdominal pain. The physician rules out all acute diagnoses. the medical record contains no underlying diagnosis. The appropriate code assignment would be 789.00, which groups to MS-DRG 392, esophagitis, gastroenteritis, and miscellaneous digestive disorders. however, if there is documentation to support an underlying disease process, such as ulcerative colitis, an appropriate code for ulcerative colitis, 556.9, would be used and MS-DRG 387 would be assigned.
Editor’s Note: This excerpt was adapted from The CCDS Exam Study Guide by Fran Jurcak, RN, MSN, CCDS.
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?
A: No, tremors in an alcoholic cannot be assumed as DTs. If the provider documents “tremor” without additional specification it defaults to code 781.0, abnormal involuntary movements (tremors, NOS – not otherwise specified). The provider would need to specifically refer to the condition as DTs or they could document “alcohol withdrawal delirium” or “alcoholic delirium” both of which map to code 291.0, which is a CC. The key word is “delirium” not tremors. The code set can also differentiate between acute and chronic alcoholic delirium (alcohol induced persisting dementia a.k.a. alcoholic dementia), but both are CCs.
Additionally, the documentation would need to be clear that the patient was experiencing DTs rather than preventing DTs. A condition that is being prevented does not qualify as a secondary diagnosis so it would not be appropriate to assign a code based on this documentation. Documentation of alcohol withdrawal (291.81) is also a CC as a secondary diagnosis.
The key here is for the provider to document the patient has alcohol “dependence” rather than alcohol abuse. The code set only recognizes withdrawal as a condition that occurs with dependence of any substance, which is a physiological response to cessation of use of the substance. Therefore, alcohol dependence with withdrawal symptoms also supports use of code 291.81.
Something else you can consider if trying to add a CC to an alcoholic case is that these patients usually receive a “banana bag” in the emergency room, which is IV fluids with multi-vitamins including thiamine. If the provider documents “evidence of thiamine deficiency” as a diagnosis associated with the treatment of a “banana bag” (it is appropriate to query when treatment is documented without documentation of the condition being treated), then this maps to a 265.* code.
However, if the “banana bag” is a prophylactic treatment then it would not be appropriate to assign a code. A multiple choice query with prophylactic treatment as an option may be a compliant way to approach such a query. For example:
Dear Dr. Z:
Please provide a diagnosis associated with the administration of an IV “banana bag” in the emergency department on (date/time) for Mr. X who has a history of “alcoholism” in the next 24 hours or next progress note by documenting your response below:
- Evidence of thiamine deficiency due to chronic alcohol use/alcoholism
- Prophylactic treatment of potential thiamine deficiency associated with chronic alcohol use/alcoholism
- Unable to determine
- Other: ______________
And be sure to have the physician provide his/her authentication per your organizational guidelines if documentation occurs on query form.
Hope this helps!
The American Medical Association (AMA) has pushed to defeat the ICD-10 code set transition since 2012. During its recent House of Delegates meeting, this November, the AMA reinforced its position that ICD-10 implementation should be delayed by two years. It initially put forth that resolution in June.
The AMA’s stance was a contributing factor in the implementation delay implemented in 2012–the one that pushed the “go-live” date from October 1, 2013, to October 1, 2014. That may not have been a great thing for physicians, according to Paul Weygandt, MD, JD, MPH, MBA, CCS, vice president of physician services for J.A. Thomas and Associates in Atlanta.
“The worst thing for physicians was that the AMA delayed ICD-10 by one year,” he told AHIMA Convention attendees in October. Why? Because it provided physicians a convenient illusion that the AMA could stop ICD-10 implementation again. And why should physicians bother understanding the documentation needs of ICD-10 if they think the change will never actually come to pass?
The question for CDI specialists is how to get physicians on board for ICD-10 when the AMA is not? Remind them that ICD-10 doesn’t change the way they practice medicine. They will still treat patients the same way they do now. We’re just asking them to document a little more specifically.
Physicians are likely documenting much of the necessary information already, such as laterality, because it’s good patient care. The physician wants to know where an injury occurred so when the patient comes back for a follow up, he or she is checking the correct area.
ICD-10 is also written in more clinical terms and less coder speak, which means docs will need to learn less than coders. For example, many pulmonologists already describe asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
ICD-10-CM now uses those terms.
For myocardial infarctions, physicians have been documenting STEMI and non-STEMI for years, Weygandt says. In ICD-10-CM, coders will be able to report it that way.
Don’t tell physicians what they need to document. Tell them what they aren’t documenting. Give them a (figurative) pat on the head for the things they are doing correctly. And ask them if they would accept their documentation if it came from a resident.
“Good documentation for ICD-10 is what we should be teaching residents because it’s good clinical care,” Weygandt says.
ICD-10 is coming, whether the AMA wants it to or not. Work with your physicians now so you are all ready for the change.
Editor’s Note: This article was originally published on The ICD-10 Trainer Blog.
Date: Friday, December 6
Time: 9:30 a.m. to 2 p.m.
Location: Dekalb Medical Center, Decatur
Agenda: Celina Guardiola, JD, RN, Assoc. Director CDI Consulting at Optum discusses “ICD-10: Maximizing the opportunities and mitigating the risks.” CEUs will be offered
Contact: Maria Mann, Georgia.email@example.com; or visit the Georgia Facebook page.
Cost: $10; $25 for membership
Date: Friday, December 13
Time: 12:30 p.m.
Location: Maryland Hospital Association,Elkridge
Agenda: Holiday pot luck and “Toys for Tots” drive
Contact: Andrea Norris, firstname.lastname@example.org
Date: Thursday, December 19
Time: Noon to 1 p.m.
Contact: Susan Haley, email@example.com
Date: Thursday, January 9
Time: 1:30 to 3 p.m.
Location: The Hospital of Central Connecticut, New Britain Campus
Contact: MaryAnn Shanley, firstname.lastname@example.org
Date: Wednesday, January 15
Time: 6 p.m.
Location: Lucille’s in Tempe Town Marketplace (Hwy 101, McClintock, & Rio Salado).
Contact: Gloria Richardson, email@example.com
CMS has designated almost 1,600 diagnostic codes as MCCs, and more than 3,300 codes as CCs. For a complete list of these go to the CMS website at www.cms.hhs.gov/AcuteInpatientPPS.
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Increased nursing care/monitoring
- Extended length of stay
A feral flock of wild turkeys has invaded New York City. Seriously. And with them, they bring all sorts of code-ready diseases and mishaps.
First, turkeys can transmit fun infections such as chlamydiosis, salmonellosis, arizonosis, and colibacillosis.
When we look up chlamydiosis in the ICD-10-CM Alphabetic Index, we are directed to see chlamydia. That doesn’t sound good.
On a clinical note, however, chlamydiosis in birds is different from the human venereal disease chlamydia. Patients who contract chlamydiosis from birds often experience fever, headache, and loss of appetite. They may also experience painful or difficult breathing.
Chlamydiosis in birds, such as our Big Apple party crashers, is caused by a bacterial organism, Chlamydophila psittaci. And it just so happens we have a specific ICD-10-CM code for it: A70 (Chlamydia psittaci infections).
We all know not to eat raw eggs and I certainly don’t want to fight a wild turkey for one (the grocery store ones come with much less hazard to my hands). Odds are, we won’t contract salmonellosis from the NYC flock.
Colibacillosis is caused by our old friend Escherichia coli. E. coli can cause all sorts of unpleasant conditions, including:
- A04.0, enteropathogenic Escherichia coli infection
- A04.1, enterotoxigenic Escherichia coli infection
- A04.2, enteroinvasive Escherichia coli infection
- A04.3, enterohemorrhagic Escherichia coli infection
- G00.8, meningitis due to Escherichia coli
- J15.5, pneumonia due to Escherichia coli
- P36.4, sepsis of newborn due to Escherichia coli
Those all sound like awesome reasons to avoid the meandering turkeys and their droppings. So if you’re flocking to New York for the holidays, watch out for those wild birds.
Editor’s Note: This article was originally posted on the ICD-10 Trainer Blog.
As you know, ACDIS regularly asks for assistance with industry and product related insight. Many of these surveys are then shared with the membership in special benchmarking reports or used to design more useful products and services for you. We currently have a few surveys outstanding and hope you will take a moment or two to participate. Surveys include:
- A 10-question survey regarding ICD-10 query preparation. Your responses will help founding ACDIS Advisory Board member Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, tailor her 2014 ACDIS conference presentation on the subject.
- A 10-question survey regarding online training for CDI professionals. Your responses will help ACDIS provide more useful tools and programs for your CDI department.
- A 19-question survey regarding ICD-10 implementation and preparedness for HIM directors/managers. Your responses will help our sister publication, Medical Records Briefing, compile a benchmarking report in its upcoming edition.
HCPro, Inc. and the Association of Clinical Documentation Improvement Specialists (ACDIS) are currently seeking an individual to serve as a CDI Education
Specialist. The primary function of this role is serving as instructor for the ACDIS-sponsored CDI Boot Camp and ICD-10 for CDI Boot Camp, as well as customized boot camps and other client engagements. Enjoying teaching and education are a must, as are excellent verbal and written communication skills. Candidate must be familiar with PowerPoint use and design. The CDI Education Specialist also serves as in-house support and expertise for ACDIS-related functions, including assisting with articles and related product development. In addition, the CDI Education Specialist is responsible for updating and revising class materials under the direction of the CDI Education Director.
The per diem CDI Education Specialist position is home-based but requires approximately 50% travel. Candidates will preferably have 4 to 10 years experience in the CDI field. Candidates will have a current RN licensure or be a Registered Health Information Administrator (RHIA) through AHIMA. Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credentials preferred.
Compensation: Competitive, based on experience
HCPro offers a competitive salary and an excellent benefits package. Qualified candidates should send a resume to firstname.lastname@example.org HCPro/BLR® is an EEO employer. For additional information contact ACDIS Director Brian Murphy at email@example.com.
Guidelines for assigning principal diagnosis (PDX) remain exactly the same after the change to ICD-10-CM/PCS. UHDDS guidelines define the PDX “as the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.”
Even though the definition remains the same, the healthcare environment has changed dramatically since this definition was first implemented, and accurately assigning the PDX can be complex. MS-DRGs based on a symptom PDX typically have a low relative weight (RW) and therefore lower reimbursement. These types of MS-DRGs are also highly scrutinized by external auditors because diagnostic workups, often associated with a symptom PDX, typically do not meed requirements for inpatient hospital care.
Coders and CDI specialists need to consider medical necessity of setting when assigning the PDX. Typically, medical necessity requires documentation of an acute disease process or an exacerbation of a chronic condition. Capturing PDX documentation is also needed to ensure that what the hospital reports matches what the provider bill.s
Signs or symptoms of an underlying condition should be coded only if no definitive diagnosis is determined, according to the draft ICD-10-CM Official Guidelines for Coding and Reporting. Sign and symptom codes are identified in Chapter 18 of the coding manual, codes R00 through R99.
However, inpatient hospital coding guidelines allow the reporting of uncertain diagnoses if they remain uncertain at the time of discharge. As such, the CDI specialist should review the health record for clinical indicators and query the provider of the “probable,” “suspected,” or “likely” cause of the symptom to avoid defaulting to a symptom PDX. Keep the following two important definitions in mind:
- A sign is objective evidence of a disease that the examining physician can observe
- A symptom is a subjective observation that the patient reports but that the physician does not confirm objectively
Q: I am part of a fairly new CDI department trying to amp-up our physician education/guidelines. To that end, I have been reviewing the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) recent guidelines for malnutrition. The part that is confusing me is that it does not address mild malnutrition. If the physician documents malnutrition but the patient does not meet two out of six criteria (or more) required by the new guidelines, should we not code for malnutrition?
A: Determining when to query for a malnutrition diagnosis can be very tricky. First, make sure it meets the definition of a secondary diagnosis—is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay. Although coding guidelines state that only one of these criteria needs to be met in order for a diagnosis to be considered a secondary diagnoses, there are some diagnoses that I recommend always have supportive treatment—malnutrition is one of them. I recommend you make sure there is some treatment associated with any malnutrition diagnosis and that the type of treatment supports the severity of the malnutrition.
Secondly, determine if the clinical evidence supports the diagnosis of malnutrition and if so, to what specificity. Clinical indicators are important in two different types of situations—where clinical indicators for a condition are present and yet the condition itself is not documented and where the condition is documented but the clinical indicators are missing. [more]