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Haunted Coding: The tell-tale chart

The month marked the 165th anniversary of Edgar Allan Poe’s death. We’re still not sure of the cause of Poe’s demise but there are have plenty of theories.

Raven

No more poor Poe.

First is the popular “he drank himself to death” theory that many people have heard. Poe was found “in great distress” outside of a polling place in Baltimore and died four days later. If Poe, who couldn’t really hold his liquor, did succumb to alcohol poisoning, how would we code it? First, we head to the Table of Drugs and Chemicals, then find alcohol and its 28 related entries. Apparently you can be poisoned by a lot of different types of alcohol.

In Poe’s case, it was probably ethanol (T51.0X-). In fact, 13 of the terms under alcohol in the Table of Drugs direct you to T51.0X-.

Now we need the intent behind the poisoning. We have specific codes for:

  • Accidental (unintentional)
  • Intentional self-harm
  • Assault
  • Undetermined

We also need a seventh character to denote the encounter. We have three choices:

  • A, initial encounter
  • D, subsequent encounter
  • S, sequela

Most likely, the alcohol poisoning (if that’s what put an end to the poet) was accidental, so we would report T51.0X1A.

However, we are faced with a more sinister possibility. Some have speculated that Poe was actually the victim of cooping, a method of voter fraud practiced by gangs in the 19th century. The gangs would kidnap people and take them around to various polling places so they could vote multiple times. After each successful casting of the ballot, the gang would reward their victim with alcohol.

You might be able to make a case for this being an assault, although that is probably a tough sell. You could also make a case for undetermined.

You’ll also find the following note under T51.01X-:

Excludes2:

  • Acute alcohol intoxication or ‘hangover’ effects (F10.129, F10.229, F10.929)
  • Drunkenness (F10.129, F10.229, F10.929)
  • Pathological alcohol intoxication (F10.129, F10.229, F10.929)

An Excludes2 note tells us that the conditions listed are not part of T50.1X-, but a patient could be suffering from one of these conditions as well. So if Poe’s doctor documented pathological alcohol intoxication, we would code it in addition to the alcohol poisoning.

Sadly Poe’s medical records have gone missing and shall be seen nevermore.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.

Halloween Extra: A play on Poe, “Nevermore a Delay”

Once upon a midnight dreary, as I labored on a query

monter under bedTo send to the doc whose documentation was a source of constant woe

As I nodded, nearly napping (that darn G47.411 again)

Suddenly there came a tapping

As of someone gently rapping, rapping at my cubicle wall

Tis just my manager, I muttered, coming for the query

Only this and nothing more

 

The silken, sad, muffled rustling of each chart that I sat shuffling

Thrilled me—filled me with fantastic terrors never felt before (oh wait, that’s just F41.1);

So that now, to still the beating of my heart, I stood repeating,

“Tis just my manager coming for the query

Just my manager looking for the query”

This it is and nothing more.

 

Presently my soul grew stronger; hesitating then no longer,

“Jill,” said I, “or Shannon, truly your forgiveness I implore;

But you know my lack of hearing (H90.0) caused by this incessant ringing (H93.13)

Left me thinking there was no one tapping at my cubicle door,

I scarce was sure I heard you”—here I opened wide the door—

Darkness there and nothing more.

 

Deep into that darkness peering, long I stood there wondering, fearing (more F41.1),

Doubting, dreaming dreams no mortal ever dared to dream before;

But the silence was unbroken (or am I just suffering H91.23?), and the stillness gave no token,

Until I heard this one word spoken—ICD-10

This I whispered and an echo murmured back—ICD-10

Merely this and nothing more.

Back into the chamber turning, all my soul within me burning (maybe it’s really R12 and not my soul),

Soon again I heard a tapping somewhat louder than before.

Open here I flung the door, to see a Raven of the days of yore;

Perched above the neighboring cubicle door

Perched contently above my next-door neighbor’s cubicle door

Then he spoke—ICD-10—and nothing more.

 

Wonderful, I muttered, now I’m seeing birds, I shuttered

I’ve started hallucinating a creepy bird of yore (R44.1, too bad it doesn’t specify what I’m seeing)

I really want to write this query

So I can code this record, I am weary (R53.83)

Weary of worrying when ICD-10 will be implemented

Quoth the raven, 2015

This he said and nothing more.

 

Listen bird, I said with feeling, please don’t let me be dreaming

Please tell me that ICD-10 is really coming soon

Currently our codes are lacking

We can’t even tell what’s catching

We don’t know what diseases we’re not tracking

Quoth the raven, 2015

This he said and nothing more.

 

“Be that word our sign of parting, bird my friend!” I grinned, upstarting—

“Get thee back into the tempest and spread the word to every coder!

Leave one black plume as a token of that joy thy beak hath spoken!

Leave my hopefulness unbroken!—quit the perch above my neighbors door!

Take thy beak from out my heart (S26.19, W61.99XA), and take thy form from off my neighbor’s door!”

Quoth the raven, 2015

This he said and nothing more.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog

TBT: Get with the (CDI) program, doc!

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the July 2012 edition of the CDI Journal.

Trey La Charite, MD

Trey La Charite, MD

by Trey La Charité, MD

We all agree: Better medical record documentation helps the patient, the physician, and the hospital. So why do we have so much trouble getting physicians to implement suggestions made by the CDI staff ? If your facility is anything like mine, provider compliance varies greatly. What always amazes me and our CDI specialists here is which physicians participate and which do not. Let’s look at some reasons why physicians choose not to adopt CDI goals and what remedies we might implement to gain wider acceptance of CDI principles.

First, the inescapable elephant in the room that must be effectively and decisively crushed is money. Unfortunately, the gut reaction of most doctors is that CDI is something that benefits only the hospital through an increased profit margin. While CDI professionals know this is not true, this initial reaction is understandable. After all, from where does the impetus for most CDI programs originate? The chief financial officer’s (CFO) office, of course! And, frequently, the CFO has jumped onto the CDI bandwagon because he or she learned how another facility improved their case-mix index (CMI) by implementing CDI  initiatives. Although the CMI is merely a reflection of how sick the patients are in a hospital, to a CFO, a higher CMI simply equals greater revenue.

Unfortunately, this means that your fledgling CDI program may have a public relations problem before it ever gets off the ground.

How do we remedy this problem? Education, education, education! The majority of doctors do not understand the increasing availability of their performance data to the general public, the insurance companies, and our government. Why is this important? Our government (via new Medicare payment rules) has  embarked on a strategy of healthcare reform through forced competition between healthcare providers. The theory is that patients will choose the doctors and facilities that have better outcomes and fewer complications at a lower cost.

Additionally, insurance companies and employers will intentionally steer their beneficiaries and employees toward the providers who display these same qualities. The ultimate question becomes whether new patients will want (after reviewing performance data on the Internet) or be able (through reduced copays to see the better providers) to be treated by your physicians in your hospitals. Yes, the probable short-term goal of any new CDI program is increased revenue at the CFO’s behest. The long term goal of all CDI programs is to ensure the flow of new patients through your doors through better performance data.

Q&A: Using clinical indicators from previous encounters

Ask your question by leaving a comment below.

Ask your question by leaving a comment below.

Q: Although I understand that a coder cannot code from a previous encounter’s documentation but can the CDI specialist bring such information to the physician’s attention such as laboratory results in order to obtain a baseline for renal failure/chronic kidney disease (CKD)?

A: It is true coders cannot assign codes based on documentation from a previous encounter. Code assignment must be based solely on the present episode of care.

And yet, as you suggest in your question, a historical perspective is often needed for the physician to determine the most accurate diagnosis such as in determining the stage of CKD as well as determining the type of heart failure (diastolic, systolic, or combined).

Let’s look at both cases. To accurately stage CKD, the physician must have access to the trending estimated glomerular filtration rate (eGFR). Typically, the CDI specialist would query the provider to determine the stage of CKD since advanced stages affect severity of illness/risk of mortality and may constitute a CC if captured as a secondary diagnosis.

Many CDI programs include documented the trending information within the clinical indicators of the query when asking for the stage. This is a practice that I always felt comfortable with; we were not applying a code based on documentation from a previous record, we were pulling clinical indicators to support a query. The provision of the trending information saved the physician the time required to access previous data and provided the information needed to determine an accurate diagnosis for the patient. The provision of the trending information usually assisted in motivating the physician to answer the query.

However in order to include this information, the provider first must supply the underlying diagnosis. For example, the provider must state the patient has chronic congestive heart failure, before the CDI specialist could place a query using an ECHO report from a previous encounter. If the provider does not state chronic CHF, you would not want to include that previous information since it may not be relevant to this particular episode of care and could be seen as an attempt to lead the physician to document a condition not currently being treated.

It may be best to lean on the side of caution.

News: AHIMA outlines steps for data governance

AHIMA releases recommendations for data governance

AHIMA releases recommendations for data governance

AHIMA unveiled its recommendations for healthcare information governance during its annual conference in San Diego earlier this month.

Information governance (IG) or data governance refers to the management, compliance, and control of health information in a given organization. AHIMA principally focuses on the management of medical records but the release of its recommendations broadens its scope to coverage of data information of all types within the healthcare setting, according to a Modern Healthcare report.

AHIMA’s recommendations state that IG efforts maybe more lax than necessary and that HIM professionals should work to educate stake holders on the need for interdisciplinary collaboration on policies and procedures, including engaging administrators to set strategies and priorities for the overall effort, according to a report in For the Record magazine.

According to an article in Fierce HealthIT, the framework focuses on the following eight principles:

  1. Accountability: An accountable member of leadership will oversee the program.
  2. Transparency: IG processes and activities will be documented in an open and verifiable manner.
  3. Integrity: Information will be managed in a way to provide a reasonable guarantee of reliability.
  4. Protection: Appropriate levels of protection will be provided from breach, corruption, and loss.
  5. Compliance: The program will be designed to comply with applicable laws, standards, and organizational policies.
  6. Availability: Information will be managed to ensure timely, accurate, and efficient retrieval.
  7. Retention: Data will be kept for the appropriate period based on legal, regulatory, and other requirements.
  8. Disposition: Data that is no longer required will be disposed of in an appropriate and secure manner.

Reveal the fact(s) behind the funny

Don't delay!

Don’t delay!

If I hear one more person poke fun at ICD-10-CM code V97.33XD (sucked into a jet engine, subsequent encounter), I am going to develop a very strong case of R45.850. (That’s homicidal ideation in case you don’t have your code book handy.)

First of all, most of the people making fun of this code don’t actually understand what the code is conveying. See the New York Times, an Alabama physicians group, Healthcare Dive, The Boston Globe, and on and on and on.

The subsequent encounter part is not saying the person was sucked into a jet engine twice (what are the odds of that?). It’s telling us that the person is being seen for a subsequent encounter for injuries suffered when he or she was sucked into the jet engine. (And you can indeed survive being sucked into a jet engine as long as you are not on that television show Lost.)

The seventh character is one of the main new concepts in ICD-10-CM. Maybe we need to do a better job of explaining what it means.

In most cases the seventh character indicates the episode of care. If the patient is receiving active treatment, you use seventh character A in most cases.

If the patient is being seen for routine follow up, the seventh character becomes D, again in most cases.

When the patient develops a complication or a condition that arises as a direct result of a condition, that’s a sequela reported with seventh character S (always).

Fracture codes have some additional seventh characters for nonunions, malunions, delayed healing, and open fractures. Most injury codes only give you three choices: A, D, and S.

Do the physicians at your organization know what the seventh character actually means? If not, here’s a perfect example you can use to explain it. V97.33XD doesn’t mean sucked into a jet engine twice. It means the patient is actually recovering from injuries sustained by his or her sole encounter with a jet engine.

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