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Q&A: Sequencing a diagnosis when the phrase ‘versus’ is used

Have a question that is troubling you and your team? Ask us!

Have a question that is troubling you and your team? Ask us!

Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”

When I first started as a CDI specialist I was told we could not use diagnosis when “versus” was stated, and that we had to query for clarification.

A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure of how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.

The first guideline states:

“In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.”

However, let’s review another guideline from the same section which states:

“When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.”

In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.

If there is no symptom diagnosis documented–for example the physician documents NSTEMI versus GERD–the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes, and other testing.


ACDIS Advisory Board releases new ICD-10 timeline

Time flies so try to make the most of it.

Time flies so try to make the most of it; check out the latest ICD-10 implementation advice from the ACDIS Advisory Board.

Not sure where you should be in your ICD-10 implementation? The ACDIS Advisory Board created a revised training timeline specifically for CDI professionals. And “stay the course” is its overarching message.

The revised ICD-10-CM/PCS training and implementation timeline which includes quarter-by-quarter and then month-by-month recommendations for preparedness activities. It makes recommendations such as emphasizing PCS coding and record reviews during the fourth quarter of 2014, developing organizational strategies to identify and prioritize documentation risks by January 2015, and incrementally increasing the scope of coders’ and CDI staff members’ dual coding and communication efforts.

Although the ACDIS revised timeline includes many recommended actions, one of the most important elements is fostering facility-wide communication, says Michelle McCormack, RN, BSN, CCDS, CRCR, ACDIS advisory board member and director of CDI for Stanford Hospital & Clinics in Palo Alto, California.

Stanford Hospital & Clinics, for example, has a number of ICD-10 focused working committees that meet regularly, on separate schedules, then come together monthly with organizational leadership to review key activities and accomplishments and jointly tackle barriers to progress.

While dual coding is a big component of the revised ACDIS timeline, if you haven’t begun dual coding, McCormack says that you can make significant  progress by simply revising your electronic templates and query forms for ICD-10.

Editor’s Note: ACDIS members received an exclusive first look at the new timeline via email July 14. Click here to download the timeline and related article.

Medicare Compliance Review provides new blueprint for CDI efforts

Glenn Krauss

Glenn Krauss

If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.

What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.

The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.

CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.

“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”

Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.


Book Excerpt: Address AMI changes in ICD-10-CM with alternative queries

CDI Specialist's Guide to ICD-10

CDI Specialist’s Guide to ICD-10

One of the most significant changes within the ICD-10-CM Official Guidelines for Coding and Reporting is the definition of a subsequent myocardial infarction, found in Section I.C.9.e.1, which states:

For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 [ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction] may continue to be reported. For encounters after the four-week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.

This is a change from ICD-9-CM, where the fifth digit of “2” designated an episode of care following the initial episode of care within eight weeks of the MI. In other words, the time frame associated with a new AMI will decrease from eight weeks to four in ICD-10-CM.

Tip: Rather than aggravate providers by explaining to them that as of October 1, 2014, the length of time an MI can be defined as “acute” decreases from eight to four weeks, educate providers to document the age of an MI using the number of weeks (not months) for any MI that occurred within the past three months. Once ICD-10-CM is implemented, if the provider documents a patient had an MI within the past month, a query will be necessary to clarify if it was within the last 28 days, as most months contain 30 or 31 days, which could lead to inaccurate coding. Employing the strategy of documenting the age of the MI in weeks will allow for accurate code assignment in both ICD-9-CM and ICD-10-CM.

The codes within I21 will be associated with an AMI. Codes within the I22, however, are used only when another AMI occurs within four weeks/28 days of the initial AMI. Official Guidelines for Coding and Reporting state:

A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction is to be used when a patient who has suffered an AMI has a new AMI within the four-week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.

The timing change also affects codes in category I23: “Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period).” The tabular list notes state:

A code from category I23 must be used in conjunction with a code from category I21 or category I22. The I23 code should be sequenced first, if it is the reason for encounter, or, it should be sequenced after the I21 or I22 code if the complication of the MI occurs during the encounter for the MI.

Many ICD-10-CM diagnosis codes require documentation of the relationship between conditions. The I23 codes require documentation linking the current condition to the precipitating AMI (that occurred within the prior 28 days). Most of the I23 codes are CCs, but a few are MCCs.

Tip: When communicating with providers, either via query efforts or educational sessions, emphasize the importance of accurately identifying the age of an MI as well as the type, anatomic location, and any consequences of the AMI, as most I23 codes can also be captured when not a complication. Perhaps the most challenging code to accuracy capture within this category will be I23.7: “Postinfaraction angina.”

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

TBT: Salary surveys show industry/profession growth

Here is a "what if" scenario to help illustrate CDI specialists' return on investment.

Take the 2014 CDI Salary Survey.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely 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 rather than our fashion sense (or lack there-of). 

Today, we’ve chosen to take a look at our previous salary surveys and ask you to please participate by taking the 2014 survey. ACDIS members have access to them all in the CDI Journal section of the website. Once you’re on the Journal page simply type “Control F” and add the search word “salary” to locate the articles.

When ACDIS put out the call for participation in its 2014 CDI Salary Survey last week more than 700 people responded. We need you to take a few minutes to complete the survey, too. Why? Because these surveys provide us with a snapshot view of how changes in the profession affect how you get paid for the work you do. And, you can use the results to make the case for changes in your own compensation! It’s true. We’ve heard from a number of ACDIS members who’ve analyzed the data against their own circumstances and got the compensation they deserved. But let’s take a look at what previous salary surveys have illustrated

  • The 2013 CDI Salary Survey garnered more than 700 responses. 25% of respondents said they earned $60,000–$69,999 annually; but the number of individuals earning $50,000-$59,999 decreased by 4% and the number of those earning $70,000-$79,999 increased by about 4%.
  • The 2012 CDI Salary Survey garnered more than 900 responses. 26% earned $60,000–$69,999 annually. Those earning $70,000–$79,999 rose from 16% in 2010 to 20% in 2012.
  • The 2010 CDI Salary Survey (published in January 2011) garnered more than 900 responses. 31% earned $60,000–$69,000 annually. 77% earned between $50,000 and $89,000.
  • The 2009 CDI Salary Survey garnered 330 responses. 32% earned $60,000–$69,999 annually. Only one respondent claimed a salary of less than $30,000, and only one respondent claimed a salary of more than $120,000.
  • The 2008 CDI Salary Survey (the first year the survey was administered) garnered 132 responses. 30% earned $60,000–$69,999 annually.

How have salary rates changes since last year’s survey? You tell us! Please complete the 2014 CDI Specialist’s Salary Benchmarking Survey. We will share the results in a special report later this year.

Q&A: Identifying the MS-DRG for unreleated surgical procedures

Ask your question!

Ask your question!

Q: Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between extensive operating room (OR) procedure and non-extensive OR procedure.

A: Many CDI specialists with a clinical background are what I like to call, encoder dependent. What I mean by that is we’ve been trained to “code” using an encoder and create our working MS-DRGs based on “grouper” software. It is often helpful to understand how to manually assign a MS-DRG. The basics steps for assigning a MS-DRG are as follows:

  1. Identify all the applicable diagnoses in the health record
  2. Identify the principal diagnosis (the condition after study to be chiefly responsible for occasioning the admission)
  3. Determine its associated ICD code (we currently use ICD-9-CM, but we’ll eventually use ICD-10-CM)
  4. Identify the base/medical DRG noting its Major Diagnostic Category/body system
  5. Identify any/all procedures

This is where it can get a little tricky. The UHDDS (Uniform Hospital Discharge Data set) defines the principal procedure as

  • One that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication
  • If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure

If there was a procedure performed take the following steps:

  1. Determine the associated procedure codes (currently based on ICD-9-CM Vol. 3 codes and soon to be ICD-10-PCS) and determine if the procedure code associated with the principal procedure as listed in the DRG Expert?
  2. If the code isn’t in the DRG Expert index of procedures, it is for one of two reasons: Either it is not a “reimbursable” procedure (i.e., one that will affect the MS-DRG assignment) or is it a major OR procedure
  3. If there isn’t a procedure or it doesn’t impact DRG assignment, does the medical DRG allow for movement i.e., can patients be put into different groups based on the presence or absence of a complicating condition (CC) or major complicating condition (MCC)
  4. If so, check to see if any of the remaining diagnoses, which are now considered “secondary diagnoses” are CCs or MCCs
  5. Finalize the working DRG
  6. If the procedure code is in the same MDC/body system as the principal diagnosis assign the new surgical MS-DRG (this is the most common scenario and is often referred to as a “match”)
  7. If the procedure code is not in the same MDC/body system a different process is used to assign the surgical MS-DRG

The MS-DRG system is based on the assumption that if there is a “reimbursable” medical intervention/procedure that the case/claim will remain in the same body system (MDC) as the principal diagnosis will apply. However, there are occasions when the principal procedure is not related to the principal diagnoses because it is associated with a different MDC/body system as in the example you describe, which will require you to take some additional steps, including:

  1. Turn to the start of “DRGs Associated with All MDCs.”
  2. Scan the procedure codes listed under DRG 984 Prostatic O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code.  These are codes that range from 60.0 to 60.99 within ICD-9-CM Vol. 3. If the applicable code is found under DRG 984 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 986 and 984

Your example of a principal diagnosis of pneumonia (respiratory system MDC) with a procedure of a TURP will fall into one of these DRGs because the TURP is not a procedure located within the respiratory MDC/body system, but is classified as a prostate procedure and found under DRG 984. Your final MS-DRG assignment will depend on the presence or absence of secondary diagnose classified as a CC or MCC.

If the procedure code is not found under DRG 984, scan the procedure codes listed under DRG 987 Nonextensive O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code. These codes span several pages within the DRG Expert. If the applicable code is found under DRG 987 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 987 and 989.

If the procedure code is not found under DRG 984 or DRG 987 and it was not associated with a page when referencing a procedure index or if it was found, it was in a different MDC/body system than the PDX then the assumption is the case/claim belongs in DRGs 981-983. This final step requires a leap of faith since it is based on a process of elimination where this is the “last resort” for DRG assignment. These DRGs are heavily scrutinized by external auditors as assignment within these DRGs can erroneously inflate reimbursement if the case was improperly assigned. As above, this is a DRG is a “triplet” where either a CC or a MCC can “move” the DRG. So check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit

CDI Journal released: Focus on ROI, quality, ICD-10, pediatric malnutrtion, and other clinical indicators

Join ACDIS. Get the Journal. Get informed.

Join ACDIS. Get the Journal. Get informed.

The July edition of the CDI Journal includes a number of news-related information for CDI professionals related to expectations for programs’ return on investment (ROI), ICD-10 preparation, and new information from Coding Clinic.

Of particular note, a recent ACDIS poll had more than 1,500 participants answering the question “How much of a financial impact does your CDI program have on its facility annually?”  Although most respondents indicate the CDI program only returns about $500,000 annually, those ACDIS spoke to to analyze the data called that number “disappointing.” In the article “CDI program financial value often lost of staff,” sources suggest that ROI should typically be in the $2 million range depending, of course, on the facility’s Medicare blended rate, bed size and other factors.

In the article, ” With 2015 date set, ‘stay the course’ mantra reinforced,” experts suggest that not only should CDI and coding departments work out their differences and begin to work more collaboratively, but they should also begin dual coding/CDI efforts as soon as possible. Feeding each other information about how documentation affects ICD-10-CM/PCS code assignment and identifying documentation and coding gaps helps illuminate trouble spots, puts any pre-existing training into practices, and helps prepare organizations in terms of implementation preparation overall, the article states.

In “Beware of vendor promises regarding CDI/coder results,” Trey La Charité, MD, discusses compliance concerns related to vendor promises.”I have found that a healthy skepticism needs to be applied within the realm of clinical documentation integrity. In fact, I am thinking of hanging ‘Caveat Emptor’ (Latin for ‘buyer beware’) sign over my desk,” he writes.
ACDIS’ newest CDI Boot Camp instructor Sharme Brodie, RN, CCDS, explores the first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. The latest publications include some important reminders as to whose documentation can be used for what purposes.
Finally this quarter’s Journal also includes a number of articles which discuss troublesome diagnoses such as hypoxemic respiratory failure, pediatric malnutrition, and cardiorenal syndrome.

OPPS developments shift toward MS-DRG-style payments; eliminates physician certification for inpatient stays


OPPS proposed rule released

After last year’s OPPS proposed rule debacle, which included a later-than-usual release, data errors that required corrections and a comment extension, and radical changes to E/M, the 2015 OPPS proposed rule released by CMS last week seems relatively benign.

At less than 700 pages, it’s also shorter than most proposed rules, but does include a new concept to the OPPS in the form of “complexity adjustments” for Comprehensive APCs.
As promised, CMS reintroduced the concept of Comprehensive APCs for device-dependent APCs first seen in last year’s proposed rule. With Comprehensive APCs, a single payment will be made rather than separate, individual APC payments.
CMS has refined the concept to include some lower-cost device-dependent APCs and two new APCs for other procedures and technologies that are either largely device dependent or represent single session services with multiple components. CMS is now proposing 28 Comprehensive APCs for 2015 after consolidating and restructuring the 29 proposed last year.
The most significant change to the policy is a proposed “complexity adjustment.” The adjustment is applied when a primary procedure assigned to a Comprehensive APC is reported with other specified procedures also assigned to Comprehensive APCs or with a specified packaged add-on code. When the facility reports one of these combinations, CMS will increase the payable APC to the next higher APC in the clinical group, similar to DRGs on the inpatient side.
“This is the first time in OPPS history where we have something like severity adjustment,” says Kimberly Anderwood Hoy Baker, JD, director of Medicare and Compliance for HCPro, a division of BLR, in Danvers, Massachusetts.
Editor’s Note: This article originally published in the APCs Insider. ACDIS members received additional information via email in a special news alert last week.

Book Excerpt: Coronary Artery Disease

Learn about documentation for  SOI from Robert Gold, MD.

Learn about documentation for SOI from Robert Gold, MD.

Identifying atherosclerosis of the coronary arteries as the cause of either a presenting symptom or of the disease process being treated is important. Specificity of the particular vessel involved, when known, is also crucial for data analysis. Coronary artery disease (CAD) is categorized as follows:

Native vessel (always the correct designation when the patient has had no coronary artery surgery)

  • Vein bypass
  • Synthetic bypass
  • Artery bypass (internal mammary)
  • Native vessel of transplant heart
  • Bypass vessel of transplant heart
  • Unknown, native, or bypass vessel

Sometimes, long-term atherosclerotic disease of the coronaries can lead to long-term functional abnormality of the entire heart and result in heart failure (ischamic cardiomyopathy).

When a stent has been inserted in a coronary artery, designating whether obstruction at the stent is likely due to a progression of the atherosclerosis in the stent of premature blockage occurred due to malpositioning of the stent (in-stent stenosis or end-stent stenosis) is important. Some stents will develop late obstruction due to the body’s attempt to line the stent with cells usually found in the inner lining of native arteries; this is neointimal hyperplasia or overgrowth of the lining cells bridging the interior of the stent.

Documentation requirements include the following:

  • Specify/document whether the obstructive disease in the coronaries is the cause of the patient’s chest pain or is suspected to be the cause.
  • Specify/document whether the cause of the patient’s documented cardiomyopathy is coronary occlusive disease (ischemic cardiomyopathy) or some other known cause (e.g. hypertension, valvular cardiomyopathy, viral cardiomyopathy, amloid).
  • Specify/document in the medical record of a patient with documented coronary artery bypass grafting (CABG) whether the symptoms are due to disease of the remaining native vessels or due to occlusion of bypass vein or artery or other graft. Identify the vessel or graft material, if known.
  • Specify/document whether your patient has had angioplasty and a stent, and whether the current symptoms are due to occlusion of other native vessels or of the stent.
  • Specify/document the cause if a patient with CAD developed unstable angina because  of anemia or tachyarrhythmia or other secondary cause (demand ischemia causing unstable angina) and not new narrowing of the coronary arteries.

Editor’s Note: This excerpt comes from ICD-10 Documentation Strategies to Support Severity of Illness
Ensure an Accurate Professional Profile, Third Edition

Q&A: Querying for CHF for systolic/diastolic specificity

Got a question? Ask us!

Got a question? Ask us!

Q: After reviewing Coding Clinic for ICD-9-CM, First Quarter 2014, p. 6, regarding heart failure and preserved or reduced ejection fraction the coding department began querying for a direct link between congestive heart failure (CHF) and the systolic/diastolic dysfunction that is often times noted in the medical record, but not directly linked to the CHF diagnosis.

For example, CHF is documented in the history of present illness as the reason for admission. The attending consults cardiology and cardiology’s progress note states severe systolic dysfunction. Our coders are now directed to query for the type of CHF and not just acuity in this example. Also going forward, if documentation in the electronic health record states acute CHF on line 1 and systolic dysfunction is on line 4, coding will query for systolic CHF.

Our coding department did submit a related question on this matter to AHA Coding Clinic for ICD-9-CM Editorial Board but they are no longer accepting questions related to ICD-9-CM since they have already transitioned to ICD-10-CM/PCS advice.

So we were hoping that you might have some advice as to whether such queries were actually necessary or whether the coders can go ahead and code for the type without a query.

A: There is no need to query when the chars states the type of dysfunction(systolic, diastolic, or combined) concurrently with a diagnosis of CHF, according to Coding Clinic for ICD-9-CM, First Quarter 2009, p. 8. If CHF is documented by a clinician in notes, history of present illness, consult, etc., and ‘systolic dysfunction’, as one example, is written in a similar fashion during the same episode of care, we do not query for linkage.

Editor’s Note: Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity at Sutter West Bay, in  San Francisco, answered this question in the ACDIS discussion forum CDI Talk.