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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.


TBT: CDI role in audit defense

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media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms.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 October 2012 edition of the CDI Journal. 

When hospitals appeal their denials they typically win. The AHA’s RACTrac report indicates that hospitals appeal more than 40% of their denials with a roughly 75% success rate. That’s where CDI professionals come in.

CDI specialists know how to piece the various components of the medical record together, says Mary Smith (her name has been changed at her facility’s request) a Florida-based RAC denials coordinator. Smith joined her facility’s CDI team in 2007 during the program’s inception. She worked as the CDI coordinator for four years before making the leap to the RAC denials team. Smith, who also spent two years in the case management role, says she has “the perfect blend of professional backgrounds for this line of work. [She] can look at the record and see the different pieces of it and use that knowledge to
formulate an appeal.”

To get a head start on preparing for a possible full-time prepayment review process, ensure the completeness of medical records before they go out the door Make sure that the records do not have any signature issues, have been prereviewed, and contain all the necessary documentation. CDI specialists can also help with audit defense simply by being “aware of the targeted areas and [paying particular attention] when reviewing charts with those DRGs,” says Melanie Haycraft, RN, CCDS, RAC/government audit coordinator for North Oakes Health Systems in Hammond, La. “Consistent documentation with the appropriate criteria met is the only way to audit-proof the chart.”

Q&A: Sepsis, septic shock, still cause for query confusion

Ask your question!

Ask your question!

Q: If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?

A: You are not alone if you find the coding of sepsis to be challenging. In the case you describe above the documentation of septic shock would support both codes for the septicemia and the severe sepsis. (Septic shock cannot occur without sepsis and severe sepsis being present). You would need to add codes for the underlying condition (local infection) as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis. It is also a good practice to assign the code for causal organism if known.

The septic shock would provide the MCC as the secondary diagnosis.

The Official Guidelines of Coding and Reporting specifically outline the coding practices for sepsis, severe sepsis, and septic shock very clearly in the chapter Specific Coding Guidelines- Chapter 1: Certain Infectious and Parasitic Diseases. I always suggest that new CDIs take time to read the guidelines to assist with the special considerations related to this diagnosis.

Again, you are not the only one who has struggled with this difficult topic. For some additional reading please take a look at these previous articles and recommendations from the ACDIS website:

Guest Post: CDI benefits? Money, teddy bears, and more

Use teddy bear inspiration to promote your CDI efforts!

Use teddy bear inspiration to promote your CDI efforts!

By Vicki Sullivan Davis, RN

Doesn’t it burn you up when someone says that CDI programs are all about reimbursement? I can feel my face get red when I hear that statement! Of course, I remain composed, smile, and provide politically correct education to the individual. But deep down I have always wanted to say, “You are darn right CDI is about reimbursement! I work hard every day to make sure you and everyone else continue to have a place to work. I make sure our patients have the most updated equipment for imagining, the most advance surgical suites, a bigger emergency department, adequate nurses on the units, food to prepare, patients to see and E/Ms to bill!”

I want to say, “Yes, my job is to help make money for hospital and so is yours!” Every person in this industry needs be concerned with reimbursement; our survival depends on having money to provide resources for our patients! We provide for our futures through cost containment, efficiency monitoring, billing, staffing to volume, charging for supplies, and even decreasing the number of linens stocked in each room. All staff should be concerned with cost containment and revenue growth. CDI specialists are no different! Reimbursement is reimbursement, we just call it different things in different departments. Budgets, staffing, billing levels, supplies, etc.

Without bringing in adequate reimbursement, the hospital would have to close their doors despite anyone’s best efforts to control efficiency and quality. If we are not worried about reimbursement, we would not have the resources to provide services that are important to the community. We would not be able to sit and hold the hand of a dying patient. We would not be able to give out teddy bears to a scared child getting a chemo treatment. We would not be able to provide a warm blanket for a frail, confused, and aging patient. The impact of healthcare reform is so significant that we all must worry about the almighty dollar if we truly care about people.

But just because I say my job has an impact on reimbursement, doesn’t mean that I only focus on reimbursement.

The heart of our program focuses on the patient. As CDI specialists, making sure we capture severity of illness and risk of mortality (SOI/ROM) is essential, and the outcome of capturing SOI/ROM correctly happens to equate to reimbursement. CDI specialists are just charged with finding innovative ways to perpetuate our hospital’s future (for the patient’s sake!) So next time the next someone rants that your CDI program is “all about the money,” be proud he or she took time to notice your program, then smile and hand them a teddy bear.

Editor’s Note: Vicki Sullivan Davis is CDI manager at Cone Health System at Alamance Regional in Burlington, North Carolina, and past-speaker at ACDIS National Conference. Contact her at

Guest Post: EHR just one piece of the documentation puzzle

by Alexandra Wilson Pecci

EHRs alone don't solve documentation problems.

EHRs alone don’t solve documentation problems.

How nurses and doctors communicate—or don’t communicate—using health information technology is the focus of a multi-year study funded by the federal Agency for Healthcare Research and Quality.

The life-and-death importance of nurse-physician communication and the use of electronic health records came to a frightening, critical head last week when a nurse noted in a sick patient’s EHR that the patient had recently traveled to the United States from Africa.

Despite the note, the patient was sent home. He later returned to the hospital and was eventually diagnosed with the Ebola virus.

Revising an earlier statement that blamed the bungled incident on a “flaw” in its (Epic) EHR system, Texas Health Resources backtracked last Friday saying, “As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”

In either event if the nurse used the EHR alone to communicate that critical piece of patient information, it obviously didn’t work. According to Milisa Manojlovich, PhD, RN, CCRN, associate professor at the University of Michigan School of Nursing, it’s a case of the medium not matching the message.

Editor’s Note: This article originally published in HealthLeaders Media, October 7, 2014.

News: CMS allows ‘meaningful use’ hardship exception applications

CMS offers IPPS proposal.

CMS offers EHR extension.

CMS recently announced that it will once again allow eligible hospitals and professionals to submit meaningful use hardship exception applications. The new deadline for submitting applications is November 30, 2014. The previous deadlines were April 1, 2014, for eligible hospitals, and July 1, 2014, for eligible professionals.

Eligible hospitals and professionals can submit a hardship application by the new deadline if they were unable to fully implement 2014 edition certified EHR technology (CEHRT) due to delays in the availability of the technology. In addition, the application process is open to eligible professionals that could not attest to meaningful use by October 1, 2014, and eligible hospitals that could not attest by July 1, 2014, using the options in the CMS 2014 CEHRT Flexibility Rule.
The Recovery and Reinvestment Act of 2009 requires that CMS apply payment adjustments for eligible hospitals, eligible professionals, and critical access hospitals that are not meaningful users of CEHRT. However, the act also permits CMS to conduct case-by-case reviews of organizations that apply for hardship exceptions.