Here comes Peter Cottontail, hopping down the bunny trail—and right into a gopher hole. Stupid rodents.Poor Peter limped his way into the Fix ‘Em Up Clinic to see Dr. Hop A. Long for an initial visit. After a thorough exam and some x-rays, Dr. Long diagnosed Peter with a broken right foot. That’s a big foot on that bunny, Dr. Long. Can you be a little more specific?
Actually, we need Dr. Long to be a lot more specific. If we look up Fracture, foot in the ICD-10-CM Alphabetic Index, we find the following choices:
- astragalus—see Fracture, tarsal, talus
- calcaneus—see Fracture, tarsal, calcaneus
- cuboid—see Fracture, tarsal, cuboid
- cuneiform—see Fracture, tarsal, cuneiform
- metatarsal—see Fracture, metatarsal
- navicular—see Fracture, tarsal, navicular
- talus—see Fracture, tarsal, talus
- tarsal—see Fracture, tarsal
- toe—see Fracture, toe
So before we can even get to any code, we need to know which bone Peter broke. After consulting the x-rays, Dr. Long documents fractures of the cuboid, lateral cuneiform, and medial cuneiform.
For these injuries, we need three different ICD-10-CM codes—one for each bone. We also need to know whether the fractures are displaced or non-displaced and open or closed.
We do have some defaults, though, for coding fractures. If the physician does not document displaced or nondisplaced, code it as displaced. If the physician does not document whether the fracture is open or closed, code it as closed. (Of course you could always query for the additional specificity, too.)
For now, we can use those defaults to code Peter’s fractures as:
- S92.211A, displaced fracture of cuboid bone of right foot, initial encounter
- S92.221A, displaced fracture of lateral cuneiform of right foot, initial encounter
- S92.231A, displaced fracture of intermediate cuneiform of right foot, initial encounter
Dr. Long also notices that Peter suffered a dislocated right ankle. That was some hole he hopped into. For an ankle dislocation, we need to know whether the injury is a dislocation or subluxation, laterality, and encounter.
We know all of that information—dislocation, right ankle, initial encounter. That gives us ICD-10-CM code S93.04XA, dislocation of right ankle joint.
Notice that we do need a placeholder X so our seventh character ends up in the seventh spot.
Dr. Long also documented a sprained right ankle. In order to code the sprain, we need to know which specific ligament is involved.
In case you are not up on your ankle anatomy, we could be coding for the:
- Calcaneofibular ligament
- Deltoid ligament
- Tibiofibular ligament
- Internal collateral ligament
- Talofibular ligament
The internal collateral and talofibular ligaments are grouped into one code for other ligaments. Dr. Long thankfully documented that Peter sprained the anterior tibiofibular and calcaneofibular ligaments. That leads us to codes:
- S93.431A, sprain of tibiofibular ligament of right ankle, initial encounter
- S93.411A, sprain of calcaneofibular ligament of right ankle, initial encounter
Dr. Long puts a cast on Peter’s foot, gives him some crutches, and tells him to avoid hopping on that foot for six to eight weeks.
Now it’s time for us to hop on out of the clinic to enjoy a long weekend!
Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.
Every year (around this time) the CDI Search Group does something extra to make the professionals they work with feel special – something to boost CDI morale, something to make the ACDIS Annual Conference even more exciting. In Nashville, they gave away a trip to Hawaii. In San Diego they chartered a boat and treated 200-plus people to a night of dining and dancing.
This year they are holding four drawings for Vegas show tickets worth up to $500! The first raffle was held last Friday and congratulations go out to Holly Romero, CDI physician advisor at Seattle Children’s Hospital. If you are attending the ACDIS conference in Las Vegas, you can get in on a chance to win one of the remaining three drawings being held April 18, April 25, and May 2.
Whether you’re into musicals, magic shows, or people in tights dangling from the ceiling, they want to make sure you have a good time! Whether or not you win stop by booth #124 during the conference to chat and find out who else won!
“Man, I really like Vegas.” ~Elvis Presley
After the big news about the ICD-10 delay, you may be wondering what it means for the 7th Annual ACDIS Conference. Perhaps you may even be debating whether it’s still worth coming to Vegas at all.
If so, I urge you to think again. As Elvis (patron saint of Las Vegas) might have said, “We can’t build our dreams on suspicious minds.”
CDI remains critically important, regardless of the code set being used. You’re still faced with difficult clinical discussions with your physicians, interrogating the record for a host of reasons—those related to code set and those regarding how the codes relate to so many quality improvement, healthcare research, and reimbursement reform efforts.
ACDIS continues to be the only association for CDI specialists—focused on the variety of ways documentation improvement efforts help address these concerns.
This year’s conference includes sessions such as “SOI/ROM Queries: Why is that “Healthy” Patient Dead in the Bed?” Where you’ll learn how to improve your quality metrics, along with “Integrating Quality into Your CDI Program: The Case for All Payer Review.”
To get physicians on board, we’re offering sessions like “Physician Partners for CDI: Strategies for Goal Alignment,” a case study of Novant Health’s successful techniques for engaging physicians. In “Changing Medical Culture and Influencing New Ideas: CDI for Medical Students” you can join the Mayo Clinic CDI team for a presentation on how it partnered with its medical school to create a CDI training program.
On top of sessions like these, it would be a mistake to forgo the ICD-10 sessions we’re offering. You still have to be ready for the (projected) Oct. 1, 2015 compliance date, and attendees will get that information straight from one of the nation’s foremost authorities on ICD-10, Nelly Leon-Chisen of Coding Clinic.
As of today we have our largest ever turnout with more than 950 attendees already registered. What better way is there to learn than from your peers? As always, ACDIS remains the go-to event for dedicated CDI networking.
Despite our large numbers, Vegas is a very big place and Bally’s Hotel still has vacancy. We’d love to have you out to enjoy our first-ever pre-conference cocktail reception on Tuesday evening, May 6, where we’ll be presenting the 2014 CDI Professional of the Year awards and starting out the conference in style.
To close with one final quote from the King: “The joint is always crowded, but you still can find some room.”
If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her child?
ICD-10-CM divides the codes into two different chapters:
- Chapter 15, Pregnancy, Childbirth and the Puerperium (O00-O9A). These codes are only used on the mother’s record.
- Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). These codes are only reported for the newborn. These codes include conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later.
Make sure you code all clinically significant conditions noted on a routine newborn examination. A condition is clinically significant if it requires any of the following:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Extended length of hospital stay
- Increased nursing care and/or monitoring
- Has implications for future health care needs
What types of problems can newborns have? Well, the baby may arrive too early. We would use codes from category P07.3- to report 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.
We have nine different choices to specify exactly how early our bundle of joy arrived, plus an unspecified code. If the newborn arrives at 31 weeks, four days, we would report P07.34.
Maybe our baby is underweight for gestational age. ICD-10-CM includes codes for:
- P07.0-, extremely low birth weight newborn
- P07.1-, other low birth weight newborn
The codes in these categories specify weight ranges. So if the newborn weighs 850 grams at birth, we would report P07.03 (extremely low birth weight newborn, 750-999 grams).
So we have a preemie with a low birth weight. Which condition do we sequence as the principal diagnosis for the birth encounter? It’s a trick question because the answer is neither. When coding the birth episode in a newborn record, we will always assign a code from category Z38.- (liveborn infant) as the principal diagnosis. Birth takes precedence.
Z38.- still gives us plenty of options and we need some specific details to choose the correct code. First, how many babies? Where did the baby arrive? How was the baby delivered? You could conceivably have a different place and method if mom is delivering more than one baby.
For example, if mom gives birth to twins in the hospital, she could deliver one vaginally (Z38.30) and one by cesarean (Z38.31).
Alternately, she could have one on the way to the hospital (Z38.4, twin liveborn infant, born outside hospital) and one vaginally in the hospital. Don’t assume it will be the same for each infant in a multiple birth.
Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
Editor’s Note: This article was first published on the ICD-10 Trainer Blog.
Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?
A: There are two basic situations that support the need for a query. The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis based on clinical indicators in the medical record. The other situation is when a diagnosis is documented that is not supported by clinical evidence. There is a nuance to this type of situation.
It isn’t for the CDI or coder to define the condition with particular clinical indicators nor is Coding Clinic a definitive source for clinical indicators, rather my litmus test is whether or not other providers would come to the same conclusion based on the same clinical evidence.
For example, although many providers are using American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to support the diagnosis of malnutrition, it is not incorrect for a provider to make that diagnosis based on albumin levels as that was an accepted clinical indicator for years so other providers would likely come to the same conclusion based on the same evidence. Remember CDI and coders are not diagnosticians and our role is not to judge the quality of care, but to ensure that a diagnosis meets the definition of a reportable diagnosis before assigning a code (e.g., meets the definition of a principal or secondary diagnosis, is documented by a provider who is delivering direct patient care, is related to this episode of care, is not integral to another condition, etc.)
I cannot think of a situation where it would be acceptable to alter a query or remove a query once the provider addresses it. I would go one step further and suggest even if the provider does not answer the query, it would be inappropriate to alter or remove it. Although organizations are not required to keep the query as part of the legal health record, they are at a minimum, supposed to keep it as part of the business record. A query is discoverable and should be made available to auditors as requested. Verbal queries should be memoralized in the same format as written queries for the purpose of transparency.
My recommendation is to refer to the various AHIMA physician query practice briefs, which discuss standards of when to issue and how to construct a query. The latest industry standards developed in partnership with ACDIS, (Guidelines for Achieving a Compliant Query Practice) builds on the briefs and collective knowledge of government payment, compliance, and auditing practices. This 2013 document stresses that the reason for the query is as much, if not more, significant than the construction of the query.
Queries are vulnerable to scrutiny for several reasons. Below are a few examples.
- Were there sufficient clinical indicators to justify the query?
- The threshold I use for this type of query is would other providers come to the same conclusion based on the same evidence. It is important that CDI use evidence based criteria that is consistently throughout the health record when asking for a diagnosis to be added to the health record especially if that diagnosis would impact reimbursement or quality data
- Is the documentation open to interpretation?
- Would all coders reviewing the record come to the same conclusion and apply the same codes or would it be subjective? If there is too much variability among how the documentation could be translated then a query is necessary for clarification.
- Do coding guidelines require specific documentation like a cause-and-effect relationship?
- Is it clear which condition is the principal diagnosis or is it an unusual occasion where more than one diagnosis could be the principal diagnosis?
- This is a more recent phenomenon as CMS further clarifies what kinds of conditions can support an “admission” to inpatient care compared to a condition that can be treated in the outpatient/observation setting
- There are several references throughout the coding guidelines and from CMS educational tools that state if it is not clear which is the principal diagnosis the provider should be queried
Additionally, the 2013 document recommends if the provider documents on the query form itself, then it should be retained as part of the permanent health record. If the query is part of the health record then it must comply with all authentication requirements associated with the medical record. I know of no situation where a record can be altered following provider validation except by the provider when it is clearly identified as an addendum or alternation. Your CDI program/organization in consultation with the medical staff should determine whether to keep queries as a permanent part of the legal health record or not. I do recommend, though, if the coder’s query are part of the health record then the CDI queries should also be part of the health record as it would be difficult from a compliance standpoint to justify why one is part of the health record and the other is not.
However, even if the query form is not governed by authentication requirements associated with the legal health record because it is only part of the business record, it would be inappropriate to alter a document validated by another. I think it would also be an ethical issue as the integrity of the CDI and the provider could be affected by altering a document that was already addressed. The impact of a query is usually recorded as a CDI performance metric. Most CDI departments monitor queries for:
- Response rate
- Did the provider responded even if they disagreed
- Agreement rate
- Did the query result in a change in the health record
- Effect on the claim
- Did the query impact reimbursement and/or quality
Therefore, altering a query could alter CDI metrics. It could also mask CDI performance issues such as not understanding when a query is warranted as well as issues with query construction. The best course of action would probably be to “close” the query and then reissue a new query with the new and/or updated information; however, this may be frustrating to the provider if they already responded once to a similar query. A query that requires additional revision after submitting it to the provider may be a learning opportunity for the CDI constructing the query so they are able to be more precise and accurate the next time they construct a similar query.
Hope this helps!
Dear ACDIS Member,
As you doubt have heard this week the Senate and House of Representatives approved–and the President signed–H.R. 4302 (“Protecting Access to Medicare”).
So, it’s now official: ICD-10 will be delayed at least another year.
The actual language in the bill does not include a new enforcement date, but says “no earlier” than October 1, 2015.
H.R. 4302 primarily addresses Medicare payments to physicians and the Sustainable Growth Rate. But buried in it is section 212, a seven line section that calls for a delay in implementation of the ICD-10 code set until October 1, 2015. The actual language reads as follows:
The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.
Some see a silver lining in the delay, as it means another year to prepare physicians, coding staff, and CDI for ICD-10.
But the delay also creates considerable turmoil. Staff will need to be retrained or take refresher courses. Implementation and staffing plans will be put on hold. CMS estimates that a one year delay could cost between $1 billion to $6.6 billion, according a statement from AHIMA officials. In addition, credibility with physicians will be strained.
The best advice we at ACDIS can offer is to stay the course, and do your job to the best of your ability. Since you are clarifying diagnoses and procedures to their highest level of specificity, and ensuring that all diagnoses/procedures are supported by clinical indicators, the codes will take care of themselves, regardless of whether they are ICD-9 or ICD-10. Continue educating providers on the importance of complete and specific documentation in the health record.
In short, try not to be discouraged, and know your job as CDI specialists remains as important as ever.
We at ACDIS are committed to providing you with the best and only dedicated support network for CDI, regardless of what the future holds. And we will continue to provide you with the latest news and guidance on ICD-10, both on the ACDIS website and at our annual conference in May.
Join me and a host of fellow healthcare industry leaders including Rhonda Buckholtz from the AAPC, Margarita Valdez from AHIMA, Robert Tennant from the MGMA, Jim Daley of WEDI among others as we discuss the implications on next week’s Talk Ten Tuesday April 8.
Brian Murphy, CPC
We’re nearly down to the wire–there’s little more than a month left before the 7th Annual ACDIS Conference and pre-conference events. The ACDIS team begins to arrive on Saturday and Sunday and the Physician Advisor and ICD-10 for CDI Boot Camp sessions start first thing Monday morning, May 5. The main event kicks off Tuesday evening, May 6, with the award reception and welcome networking event with dozens of sessions, exhibitors, poster presentations, after hours activities, and other events taking place throughout the remainder of the conference May 7-9.
More than 900 attendees already signed up and we’re excited to welcome new CDI professionals and to network with those individuals we’ve come to regard as friends as we’ve met and networked at the conference over the past six years. While we like to think we’ve done our very best to make the conference a welcoming, informative event, it’s the past attendees who typically say it best. So we’ve gathered a few comments and thought we’d share them here.
- “The conference gives attendees time to connect and network with others and recharges your batteries. There is just such a great level of excitement here.” Robin Jones
- “I have been to the conference three times and [the 2013 event] was by far the best one. The speakers were all great and the material is so relevant and helpful in my day-to-day work. Where else can we get such a wealth of CDI information in a few days? It’s fabulous.” Laura Bohls
- “This was my first conference and the speakers were excellent and the material covered was relevant. It was a great conference.” Alex Gilman
- “I have been involved in CDI since October 2007 and ACDIS has always been my ‘go to’ resource. As programs across the country mature, I believe seasoned CDI specialists would appreciate a greater number of advanced presentations.” Kimberly Mineroldi
- “Great conference!! Loved the opportunity and will be back next year!! Networking in our field of expertise is priceless. There is no better way to achieve this than here at the conference. Thanks to all who pulled this together.” Kimberly Ogle
Have you registered yet? #Vegasbaby! #ACDIS2014
Q: Over the years I have heard differing opinions regarding whether clinical or coding expertise should be weighed more during the concurrent record review process. I have been told many times to “think like a coder,” and “not get to clinical when you looking at the chart.”
At my facility we designate the initial/queried MS-DRG as part of our concurrent process and we review all the final MS-DRGs to be sure that our queried diagnoses have been captured. A secondary benefit to doing this is to discuss differences in our views and to substantiate where we might have found something perhaps they didn’t or vice versa. It seems odd to me that one set of experience should be weighed more than another when we all work together and seem to bring different skill sets to the table.
A: In my opinion, the clinical thought process is just as important as coding awareness for CDI professionals. I view it as a collaborative process between CDI and coding staff so I think it is great that your organization allows for discussion and differing opinions.
Since the coder is the one who releases the record to billing, in some organizations their opinion does supersede that of CDI as they are able to release a record without consultation with CDI and/or prior to completion of CDI review (e.g., while there is an outstanding query) unless processes are in place to require reconciliation of disagreements between the two departments.
I think the management model of CDI has a huge impact on potential disparity among the “value” of CDI and coding opinions. My preference is for CDI and coding to be independent yet equal departments so both departments have an equal voice. Specifically, each department would have the same management structure e.g., their own supervisor and/or manager rather than reporting to the same manager. It is also important when implementing a CDI department that the expectation from the beginning is collaboration. The workflow process should support communication between the CDI and coding staff so the coders consider CDI reviews prior to releasing a bill and/or referring records back to CDI, as necessary, rather than coding the record independent of the CDI process.
Additionally, there should be a process for reconciliation that allows the views of both CDI and coding to be considered when disagreements occur such as use of the facility compliance officer or HIM director as a mediator.
In my opinion the role of CDI is to ensure the documentation in the health record is clear and precise so that anyone who reviews the record comes to the same conclusion. The “think like a coder” comment addresses the nurse’s tendency to assume the provider’s intent. While this helps when delivering clinical care it can be problematic in terms of coding. As such, nurses need to be sure the documentation is explicit rather than presumptive. Coding does not allow for assumptions so although coders know “Na with an up arrow” is hypernatermia, they can’t code it as such unless the provider has made the diagnosis and it is supported as a reportable secondary diagnosis. Asking the CDI specialist to “think like a coder” is asking the CDI specialist to be sure the documentation supports the code assignment and if it doesn’t, to obtain clarification.
The goal of CDI should not be how many records they can “pre-code,” rather how can they make a record’s documentation explicit through provider education and the query process to ensure consistency in coding. If two coders could come to different conclusions when coding the record then CDI has not done its job.
It sounds like your organization has a good process in place for working together with the coding staff. It is best practice to examine coder/CDI DRG assignment agreement rates. The focus of the CDI specialist is to look for what is missing in the medical record as the coders will still be coding the record.
At roughly 6:30 p.m. last night, Monday, March 31, the U.S. Senate voted to approve a bill to temporarily “fix” the Sustainable Growth Rate (SGR). However, tucked into the bill was one sentence that could cost the healthcare industry upwards of $6 billion and shake a number of healthcare improvement initiatives to their core:
The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.
What this means is that, barring a Presidential veto of the bill, ICD-10 will be delayed until at least Oct. 1, 2015
The delay of ICD-10 impacts much more than just coded medical bills, but also quality, population health, and other programs that expected to start using ICD-10 codes in October. The extent of the logistical challenges and costs associated with “dialing back” to ICD-9-CM are not yet fully understood but are expected to be extensive, according to a statement from AHIMA officials in the Journal of AHIMA.
Although many pointed to the AMA—a longtime opponent of ICD-10 implementation—as leading the charge to include the delay language, AMA President Ardis Dee Hoven, MD, said in a statement that the Association is “deeply disappointed by the Senate’s decision to enact a 17th patch to fix the flawed Sustainable Growth Rate (SGR) formula. Congress has spent more taxpayer money on temporary patches than it would cost to solve the problem for good.”
The SGR is the CMS’ way to control costs for physician services. It attempts to cap the yearly increase in expense per beneficiary to less than the growth of the GDP, but nearly every year Congress votes to negate the measure in bills typically dubbed the “doc fix.”
This year, physicians were expecting a 24% reduction in Medicare payments at the turn of the year, but lawmakers extended the previous fix until March 31, according to Kaiser Health News.
The ICD-10 language was not included in an earlier version of the bill, according to the ICD-10 Trainer Blog.
During the vote in the House of Representatives the ICD-10 measure was not referenced but some members of Congress opposed passage of the bill as being rushed through. Later in the Senate a new bill without the ICD-10 measure was introduced but opposed.
The ACDIS advisory board recommends CDI professionals stay the course, clarify diagnoses and procedures to their highest level of specificity, and ensure that all diagnoses/procedures are supported by clinical indicators. When we do this, the codes should take care of themselves, regardless of whether they are ICD-9 or ICD-10.
There is no doubt about it—CDI specialists will be taking on more work and a greater complexity related to that work in 2014 due to the implementation of ICD-10. The question for many CDI managers around the country is: How do I keep my staff intact, given that they’re facing a greater workload, competing pressures, and increased career opportunities from other facilities and consulting firms looking to hire?
“I know my staff is juggling responsibilities and doing so much more than simple chart reviews,” says Samantha Joy, one Illinois-based CDI director whose name has been changed at the request of her facility. Joy took over the program two years ago and grew its staff by 50%. She now has 12 full-time CDI specialists. One has been working at Joy’s facility for eight years; the newest staff member started a few months ago. There are no plans to hire additional staff members due to the ICD-10-CM/PCS implementation.
Although Joy hasn’t had any trouble with staffing turnover in the past, and salaries are in line with the ranges reported in her area (read the 2013 Salary Survey results in the October edition of the CDI Journal), she understands how valuable CDI expertise will be in 2014 and wants to be ahead of the curve. So when her facility’s ICD-10-CM/PCS steering committee began discussing retention bonuses for coding staff, Joy began researching similar trends in the industry for her staff as well.
She found only a few facilities who had developed retention bonuses for CDI staff, but that was enough to convince her it was a good idea. So she drafted a proposal, and received approval in December. According to the proposal, CDI specialists will receive an incentive payment for remaining on as staff, staggered and delivered in the following increments:
- 25% of the incentive payment once they start their ICD-10-CM/PCS training
- 25% of the payment once they complete their training, based on an 85% or higher proved competency rate
- 50% of the payment one year post-ICD-10 implementation
If these staff members leave the facility for any reason they will have to pay back the money they’ve received; and, of course, they must remain in good standing while on staff, completing their regular workload and performing their duties as appropriate, says Joy. Training is expected to begin early in 2014 and take about four or five months to complete. CDI specialists will also review the components of physician training so they understand what physicians have learned and have the ability to fill in the gaps if necessary.
“The question is how to reward my staff for taking on all this additional information, and how can I retain them once I’ve trained them,” says Joy. “There are not a lot of facilities doing this yet—either that or they haven’t thought through to this level of planning so far. So I feel like I am just one more step ahead.”
Editor’s Note: Download a free ICD-10-CM/PCS CDI survey results and analysis. Also, don’t forget to register for the free webinar Six Months until ICD-10 Hits: Last Minute Tips for Coding and Improving Physician Documentation, which takes place Tuesday, April 1 at 1-1:45 p.m., with Coding Boot Camp Instructor Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP, and CDI Boot Camp instructor Laurie Prescott, MSN, RN, CCDS, CDIP.