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Guest Post: An obligation to report noncompliance

Rose Dunn

Rose Dunn


One of the many coder/CDI obligations is to report noncompliant activities. Your employer’s compliance plan may direct you to report these noncompliant observations to the compliance officer or a compliance hotline.

When you report your observations, you may do so anonymously or by identifying yourself. It is your decision which approach you take, but regardless, you still have the obligation to report.

Commonly reported coding-relating issues are:

  • Documenting services long after the service was provided and possibly never provided
  • Routinely reporting high-level evaluation and management or MS-DRG codes (upcoding) when the documentation does not support the high level
  • Failure to code to the highest level of specificity when the documentation is present
  • Queries that encourage or lead a physician to add documentation which would increase the level of reimbursement for a particular case
  • Adding charges to a claim for services provided
  • Providing services that are not medically necessary

When a coder/CDI specialist observes actions inconsistent with quality healthcare, the more detail provided to the compliance officer will help in the investigation. Depending on investigation findings, major, minor, or no changes may result. Sometimes, actions observed may appear inappropriate, but upon investigation, the actions were consistent with clinical practice.

For example, a coder/CDI specialist may consider the actions of another staff member to be too zealous in optimizing the codes to achieve higher reimbursement. The term optimization is defined as a procedure used to make a system or design as effective or functional as possible.

When coders “optimize” the coding process, they attempt to make coding for reimbursement as accurate as possible. This process may involve querying the physician for clarification of conditions or augmenting conditions documented. If done in a nonleading way, the organization will obtain the highest entitled reimbursement.

When the investigation illustrates the need to make changes, you will probably see activities such as reeducation, updating of policies, and possibly the removal of staff members.

Qui tam

Unfortunately, there are times when an individual reports legitimate compliance concerns and does not see actions being taken to correct the concern. In these situations, a person may wish to “blow the whistle” and contact an agency outside of the organization to file a lawsuit. This type of lawsuit is known as a qui tam lawsuit.

Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government. Qui tam is an abbreviation of the Latin phrase meaning “who as well for the king as for himself sues in this matter.”

Qui tam cases are different from other types of lawsuits, such as those involving personal injuries, because the person bringing the lawsuit is not the one who has been harmed.

A recent example of qui tam is the South Florida case where physician Mario Baez, a partner in a physician practice, turned whistleblower on his partner when he determined that his partner was submitting fraudulent claims. Nearly all the patients seen at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only 1 in 1,000 people truly have this disorder, according to Baez. The disorder increased the risk score for the physicians who were participating in a Medicare Advantage health plan reimbursement arrangement with Humana. The higher the risk score, the greater the reimbursement. The interesting twist on this qui tam is that Baez was not just whistleblowing on his partner but also on Humana. Humana should have been able to detect this fraudulent activity.

Taking a qui tam action requires much consideration, because often the whistleblower is identified during the legal proceedings. Having legal counsel guidance will be beneficial. If the case is lost, the situation can be embarrassing.

However, if the case is won, there may be financial rewards for the whistleblower depending on how much the whistleblower’s details of the situation contributed to the success of the suit. Regardless, following your convictions to surface inappropriate care should result in better care for patients thereafter, and that is the right thing to do.

Editor’s note: Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. For questions please contact editor Amanda Tyler at This article is excerpted from JustCoding’s Practical Guide to Coding Management.

Q&A: ‘Code first’ versus ‘in diseases classified elsewhere’

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I can’t distinguish between “code first” and “in diseases classified elsewhere.” Both are used with manifestations and both can’t be sequenced as principal diagnosis, and both need etiology codes so what is the difference?

A: Technically, not all “code first” notes are mandatory, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HCPro’s Certified Coder Boot Camp® programs, based in Middleton, Massachusetts. For example, ICD-10-CM category I50 includes a “code first” note but it is only used if applicable since heart failure can be a principal diagnosis.

The “code first” note informs us of two things, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist at ACDIS. First, it informs you that two codes may be required. Second, it provides sequencing direction. There are some “code first” notes that are only applicable in certain instances, such as McCall mentions, at “heart failure” the note talks about assigning codes for hypertensive heart failure, pregnancy related heart failure etc., first, if applicable.  Secondly, if, for example the CDI specialist reviews a Parkinson’s manifestation, such as a dementia, and they see “code first Parkinson’s,” in the tabular list then first code Parkinson’s disease (G20) followed by the code for the dementia F02.80. In this example, the “code first” note is positioned next to the manifestation code to remind you to code the etiology first.

In contrast, the phrase “in diseases classified elsewhere” informs coders that two codes are required and means this code must be sequenced as the second code. If you see “in diseases classified elsewhere” in a code description, then you know you are looking at a manifestation code. These codes should never be used as a principal diagnosis and must be reported in conjunction with a code for the underlying cause/diagnosis.

While these terms may seem very similar, Frady says, the “code first” terminology represents an instructional note while “in diseases classified elsewhere” is actually a part of the code title itself. You would only see the “code first” note if you look up the code in the tabular list and review the instructional notes, whereas you would see “in diseases classified elsewhere” if you were simply reading the code title or description in the alphabetic index.

Interestingly enough, if you index Dementia in a current 2017 code book, these conventions are not used.  The index entry is Dementia (with) Parkinson’s disease:   G20 [F02.80]. In this case the formatting of code first [bracketed code second] provides the sequencing.

Caution is warranted, if you index this condition by looking up the keyword “Parkinson’s,” you get an entirely different code as you get an instructional note to “See Parkinsonism” and following that pathway in either a book or an encoder you will arrive at codes G31.83 and F02.80.

Editor’s note: This answer was provided based on limited information submitted to ACDIS. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. For information regarding coding or CDI Boot Camps visit


Guest Post: AMI 30-day mortality measures and CDI – Is your approach ischemic?

Shannon Newell

Shannon Newell

by Shannon Newell, RHIA, CCS

The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP) in fiscal year 2013. In February 2016, CMS announced that 70% of commercial payers agreed to use the measure as one of the cardiology outcomes linked to payment.

The Medicare Episode Payment Bundle for AMIs, proposed to begin in July 2017, will further link reimbursement to measure performance. Traditional CDI approaches to strengthen data quality in the name of risk of mortality are not sufficient enough to capture the documentation needed under the CMS mortality risk adjustment methodology.

CMS includes any discharges with the principal diagnosis of an AMI in the mortality outcome measure (except for a few exclusions outlined in the methodology, such as discharged against medical advice). The final group of included discharges is referred to as the “cohort.” Consider the following case studies:

Case Study 1

  • Scenario:
    • Admitted with severe unstable angina and diaphoresis with the finding of ST elevation in the anterior leads on an EKG with the initial set of cardiac enzymes being negative
    • Because of the suspicion of acute transmural myocardial infarction (MI), receives TPA infusion
    • Subsequent cardiac enzymes are negative, and at the time of discharge, the physician documents an aborted transmural MI
  • Principal diagnosis:
    • The principal diagnosis would be unstable angina because the AMI was aborted
    • If coronary artery disease is documented, coding guidelines would require selection of this condition as the principal diagnosis
  • AMI mortality cohort:
    • This discharge would be excluded from the AMI mortality cohort with the correct application of coding guidelines for principal diagnosis selection

Case Study 2

  • Scenario:
    • Admitted with subendocardial MI with acute systolic heart failure and cardiogenic pulmonary edema
    • Treated with supplemental oxygen and IV Lasix therapy, and because of the patient’s age, the MI is treated conservatively
  • Principal diagnosis: Two principal diagnosis options exist:
    • Option 1: Acute systolic heart failure
    • Option 2:  Subendocardial MI
  • AMI mortality cohort:
    • Coding guidelines permit the selection of either option as the principal diagnosis
    • Today’s CDI teams typically select the option which will result in the highest MS-DRG relative weight, which will result in attribution of the discharge to the AMI mortality cohort in this case


Once a hospital claim goes out the door with the principal diagnosis of AMI, CMS analyzes claims databases to determine if that Medicare beneficiary died within 30 days of discharge (for any reason). If a mortality is identified, CMS attributes the death to the hospital that reported a claim with AMI as the principal diagnosis within 30 days preceding the death.

Each discharge included in the AMI mortality cohort is then risk adjusted to determine the expected rate of mortality. The CMS methodology uses CCs/MCCs, not hierarchical condition categories, to determine the likelihood of death for each discharge.

  • Each CC is comprised of related ICD-10 codes
  • There are a variety of CCs which affect AMI mortality risk adjustment
    • These categories are weighted; some have a more significant effect on risk adjustment than others
    • 12 categories drive 90% of strengthened risk adjustment opportunity
    • Only about 25% of these conditions serve as MS-DRG CCs/MCCs
  • CMS looks for the presence of these conditions in the AMI admission as well as all Part A and (face to face) Part B claims for the 12 months prior to that admission
  • Some of the conditions must be documented prior to the patient’s admission for AMI management or there is no “credit” for risk adjustment

Performance for the CMS 30-day AMI mortality measure adjusts payments received for the Medicare and commercial patient population. This reimbursement is not limited to hospitals; under the Episode Payment Model other providers will be affected as well. Although this is a hospital-centric measure, meaning the measure assesses the hospital’s management quality for the AMI population, documentation and reported codes across the continuum affect the expected risk of mortality, and in turn impact measure performance.

A few questions for CDI and quality programs to consider as they shift initiatives to support value based payments:

  • Does your principal diagnosis selection process consider attribution of discharges to quality measures in addition to MS-DRG relative weights?
  • Does your record review process to support the capture of CCs/MCCs related to mortality only on actual deaths or on the entire denominator included in the measure?
  • Are you focused on the capture of CCs/MCCs which have an effect on CMS’ mortality methodology?
    • The comorbidities in this algorithm differ from those used in other mortality risk adjustment methodologies commonly used in CDI programs today
    • The broad number of comorbid categories requires the CDI and quality teams focus on point of care capture
  • Do the clinical documentation and reported codes in your system’s outpatient settings support the capture of comorbid conditions related to risk adjustment?

Editor’s note: Newell is a Managing Director with CCDI-DQ with extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. Reach her at

Q&A: Be wary of over reliance on nurse practitioners for documentation

Deanne Wilk

Deanne Wilk

Q: We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for patients and we have great success with them.

The difference here is that the orthopods want us to send all queries to their NP, even if he/she is not caring for the patient. The ACDIS/AHIMA query guidelines tell us to query the provider that documented whatever needs clarification (though because we have a team approach with hospitalists, we often query the attending caring for the patient now, not necessarily the documenting provider). Our coding department has said they will not accept query responses from a non-treating provider. What do you think?

A: I have seen this happen at a number of facilities. They are using the NP/PA to do the “dirty work.”  There are varying opinions on this:

  1. NP will become very good at documentation and become your best friend
  2. Queries will get answered in a timely manner
  3. If they are going to respond to queries they must see the patient.  If not, they are a potential liability for the medical group and hospital.

I also wanted to respond to the group regarding who/where you can obtain documentation from:

  • Pathology = no
  • Echo = no
  • Radiologist = no (however,  CDI/coding can pull the specific fracture site and/or vessel sites directly from reports as long as the diagnosis is stated in the H & P/PN/Consult/ER, etc.
  • EKG = no
  • Cath report = yes

However, remember that in a query you can “refer” to that information.

 Editor’s note: Deanne Wilk, BSN, RN, CCS, CDI Manager at Penn State Health in Hershey answered this question. Make sure to work with your facility compliance and coding departments in incorporating any recommendations as advice provided is general in nature. Contact Wilk at

Guest Post: Tips for appealing MS-DRG denials

Sam Antonios, MD

Sam Antonios, MD

by Sam Antonios, MD, FACP, FHM, CPE, CCDS

Over the last 18–24 months, health- care organizations have seen a surge in MS-DRG denials, sometimes referred to as clinical validation denials.

When reviewers from Medicare Advantage health plans, Recovery Auditors, or other private or contracted health plans analyze a clinical case submitted for reimbursement, they may determine that a particular disease should be removed from the claim. They argue that the clinical documentation in the medical record does not support the diagnosis submitted. In the vast majority of these cases, the removed diagnosis is a CC or MCC, which causes the MS-DRG to shift to a lower payment.

MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In some circumstances, the volumes have been over- whelming. There have also been reports of cases where denials have been egregious, unjustified, or made with disregard for the treating physician’s opinion.

Although there is no surefire way to win an appeal, here are some tips to increase the likelihood of overturning MS-DRG denials.

One: If you believe the case has merit, file an appeal, even if the variance in dollar amount is insignificant. It may be tempting to let go of denials that minimally affect the reimbursement, but when the treating provider’s documentation is available, complete, and accurate, and the coding is correct per official coding guidelines, organizations should appeal. This maintains consistency and makes the appeals about data integrity, rather than payment.

Two: Write clearly and summarize first. The appeal reader will likely not want to spend a lot of time figuring out the intent of the appeal. The first few lines need to describe the clinical case and need for appeal succinctly. Additional details can be included in later paragraphs.

Also, remember to reference review articles, clinical guidelines, or other findings to support your appeal.

Three: Learn how to navigate the electronic health record (EHR) to find relevant information. The history and physical and the discharge summary may not capture the entire clinical picture.

Learn where to locate, and how to decipher, emergency department documentation, consultant reports, progress notes, nursing notes, and other provider documentation, which can often include vital information to a support an appeal.

Additionally, respiratory notes can reveal the status of the patient, including lung exams, respiratory effort, and need for respiratory treatments. The goal should be to offer a complete and accurate clinical picture of the patient.

Four: If possible, review records from transferring facilities to help describe the patient’s case. These records are likely scanned into the record later in the patient care process, but they should be collected before an appeal. Creatinine levels, electrolytes, and other laboratory findings can help differentiate acute and chronic symptoms and conditions.

Five: Keep track of denials electronically. Preferably, use denial-tracking software. If such software is not available, or too costly for your facility, spreadsheets can be just as effective. Remember to update and back up these records regularly.

Editor’s note: Antonios is the CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. A board-certified internist, he manages the hospital EHR system, works closely with quality leaders to tackle challenging documentation requirements, and engages with physicians on CDI and quality initiatives. This article is an excerpt from its original which appeared in the Sept./Oct. edition of the CDI Journal. Contact him at

Q&A: Pneumonia sequencing

Submit your inpatient coding and CDI questions reply to this post .

Submit your inpatient coding and CDI questions reply to this post .

Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy? I thought that the pneumonia would be the primary and the respiratory failure as secondary as the severity of illness/risk of mortality (SOI/ROM) as well as the MS-DRG would all increase. Yet, I’m getting some push back on this train of thought and I’m not sure where the error in my logic may lay. Any insight you could offer would be much appreciated!

A: This is an interesting and common question. I believe you are asking why would we choose the acute respiratory failure as the principal diagnosis when, if we choose the pneumonia with a secondary diagnosis of acute respiratory failure, we have an MCC and it would provide both higher reimbursement and SOI/ROM. Coders and CDI specialists were once taught that when two or more competing diagnoses are present on admission and they could choose the one providing the highest relative weight/increased reimbursement.

In our CDI Boot Camp we explore the concerns around code sequencing in depth and part of our in-class discussion challenges that traditional thought a bit and perhaps spurs our students to think about the matters differently. The traditional choice, to simply code the highest weighed MS-DRG as the principal diagnosis, often gets challenged by auditors. Which condition, they rightfully ask, actually occasioned the admission? Does a typical patient with pneumonia require an inpatient admission? Not usually. When will the physician discharge this patient; when the pneumonia is resolved, or when the acute respiratory failure is no longer a concern?

My bet is that the physician will send this patient home on antibiotics (treatment for the pneumonia) so the pneumonia is not exactly resolved on discharge is it?

I recently assisted an organization with two DRG validation denials from recovery auditors. The auditors agreed with all coded diagnoses but argued the sequencing choices involved. One such account was acute systolic heart failure and acute respiratory failure. Their argument was the choice for admission was based on the acute respiratory failure, not the heart failure. I could not defend against that logic. Once the patient was able to breath without intervention or assist, she was discharged. She was sent home with adjusted medication for her heart failure continuing and follow up with the cardiologist.

I am not saying you should always sequence one way or another, rather, as a CDI specialist it’s your role to closely review the circumstances of admission and carefully consider which conditions meet the definition of principal diagnosis as “That condition after study that occasioned the admission.”

The Official Guidelines for Coding and Reporting tells us it should be a rare instance that two or more diagnoses qualify as the principal and we believe this guideline is used much more frequently than it should be.

Lastly, just to throw another log on the proverbial fire, depending on the circumstances in your example perhaps the encephalopathy could be the principal admission. Again it would depend on the circumstances of this patient and the treatment rendered.  This example is a great one to discuss with your fellow CDI specialists and coders.

Guest Post: Beyond CC/MCC capture for compliant CDI efforts

Editor’s Note: Let’s call this week’s guest post from “a ghost of ACDIS’ past.” Those who’ve worked in the profession for some time will no doubt remember with some fondness the teachings of founding ACDIS Advisory Board member Robert S. Gold, MD, who sadly passed away in the spring of 2016. The following was a note sent some years before that, encouraging ACDIS and the CDI professionals it represents to advance their efforts beyond traditional CC/MCC capture to ensure complete and accurate medical record. 

It so often seems that all CDI programs have been developed based on MS-DRG maximization. Such short-term focus however defeats the goals (and challenges) of healthcare in today’s society.  When CDI develops from the Medicare revenue perspective, rifts grow quickly between the coders and the CDI because so many of the teachings don’t line up.  Rifts develop between the CDI folks and the docs, too, because docs feel like they are targets and are always wrong. Rifts develop between the CDI team and quality team because CDI queries seem to encourage the reporting of complications even when complications don’t exist. And massive holes exist in the patient’s database because of CC/MCC capture concentration which leaves all of the patient’s chronic conditions unsought after and unreported.

Too many instruments support the old, obsolete concepts and too few encourage people to go beyond their silos. All of the initiatives that are needed to drive us into the future will fail if we don’t expand our expectations beyond these past, financially focused, efforts.

TBT: CMS offers video on ICD-10 coding for diabetes

Check out this video from CMS from last year. How has your facility changed its documentation improvement efforts around diabetes and how have the recent ICD-10-CM/PCS coding updates, Official Guidelines for Coding and Reporting, and new recommendations from Coding Clinic affected those efforts?

Let us know in the comment section. It’s a concern lots of CDI specialists struggle with.

Coding Clinic for CDI: Review of Third and Fourth Quarter 2016

Sharme Brodie

Sharme Brodie

by Sharme Brodie, RN, CCDS
The AHA’s Coding Clinic for ICD-10-CM/PCS had both its third and fourth quarter 2016 editions published at the same time this fall. The combined publication is very long—the longest I have ever reviewed—so let’s start by looking at some of the changes to the ICD-10-CM Official Guidelines for Coding and Reporting.

Trouble with ‘with’
As many of you have probably heard, Section A.15 of the new Guidelines states that any time the word “with” appears, either in the Alphabetic Index or in an instructional note not in the Tabular List, the classification presumes a causal relationship and the conditions will be linked even in the absence of provider documentation. Coding Clinic reiterates this fact. For CDI specialists, this may seem like a good thing, but it also means we need to do our homework and make sure all these assumed relationships are truly related. We may find we need more queries to verify these cases with the providers. So be careful and go over each case to make sure it is an accurate representation of what is going on with your patients.

Providers’ prerogative
Coding Clinic (p. 119) stresses the new Guidelines found in Section A.19, which state that assignment of a diagnosis code must be based on the provider’s diagnostic statement that the condition exists, not on clinical criteria used by the provider to establish the diagnosis. That’s not to say the clinical criteria don’t matter, but that coders and CDI specialists cannot decide when a condition exists based on whether we feel certain criteria are appropriate for a condition.

According to Coding Clinic (p. 8), coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This Coding Clinic states “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone.”

Editor’s Note: There’s a lot more to cover in these oversized editions of the fall 2016 Coding Clinic, and Brodie explores the highlights in an extended white paper available in the Resources section of the ACDIS website. Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Reassess CDI metrics to ensure program progress

Jon Elion, MD

Jon Elion, MD

Just because you can measure something doesn’t mean should measure it, Jon Elion, MD, founder and CEO, ChartWise Medical Systems, told ICD-10 Monitor’s Talk Ten Tuesday back in February of 2016. Specifically, he pondered why CDI programs hold onto legacy targets such as physician response rates as a measurement of program success. Instead, measures need to change as the CDI program itself matures and grows.

As CDI programs begin, managers need to track:

  • physician query rates (how many queries per record reviewed)
  • Physician response rates (how many of those queries receive a response either positive or negative)
  • physician agree rates (how many query responses align with the intent of the CDI specialist)

Such measures help CDI programs assess the competency of its staff as well as the engagement of its physicians with program goals. Yet any assessment tool needs to be analyzed itself and the reason behind the data interrogated, Elion indicated.

For example, if the CDI team sends a query to one physician but a different physician responds should that response count towards the first or second physician’s data? What about the physician who responds to all queries, just not in a timely way? What about the physician who answers all their queries but always needs to be queried on the specificity of his or her patient’s heart failure?

Theoretically, as a CDI program matures its physician engagement and response rates should increase throughout the first year and stabilize in the second or third years. While programs may not expect 100% consistent physician response rates they should expect it to hover in the mid-90% range.

Elion doesn’t mean that CDI managers should toss out those traditional measurements altogether but to use them instead to identify potential trouble spots, educational opportunities, and to nip any provider support concerns in the bud early.

Such measures should not be used to penalize physicians, however. “Clinicians who are always on their toes would suffer from a toe walking gait which most closely maps to ICD-10 code R26.89,” he said.

What types of metrics does your CDI program measure and what items to you think should be retired?