What is a physical examination and what determines its extent? According to CMS’ Evaluation and Management Billing Guide, “The examination is the process of collecting diagnostic information through physical applications such as palpation, ausculation, and inspection. The extent of the examination performed depends on clinical judgement and on the nature of the presenting problem(s).”
Body areas recognized for the purpose of Current Procedural Terminology (CPT) definitions are the abdomen, back, chest, extremities, genitalia, groin and buttocks, head and neck. Organ systems recognized for the purposed of CPT definitions are cardiovascular, ears, nose, mouth, and throat, eyes, gastro-intestinal, genitourinary, hematologic/lymphatic/immunologic, musculoskeletal, neurologic, psychiatric, respiratory and skin.
The levels of E/M services are based on four types of examination defines as follows:
- Problem focus: A limited examination of the affected body area or organ system.
- Expanded problem focus:A limited examination of the affected body area or organ system and any other symptomatic or related organ system. This consists of an examination of two to four systems clinically relevant tot he nature of the presenting problem and history of present illness (HPI).
- Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ systems(s). This consists of an examination of five to seven systems clinically relevant to the nature of the presenting problem and HPI.
- Comprehensive: A general multi-system examination of eight or more systems clinically relevant to the nature of the presenting problem and HPI.
The importance of incorporating medical necessity when determining the extent of a physical exam cannot be overemphasized. CMS contractor Trailblazer Health Enterprises states in Documenting Components of an Established Office E/M Service that “when determining the level of examination, consider the clinical circumstances of the encounter. Do not select the type of examination of excessive and unnecessary information recorded solely to meet the requirements of a higher-level service to medically appropriate.”
Editor’s Note: This excerpt is adapted from The Documentation Improvement Guide to Physician E/M by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI.
One of the most convincing reasons for establishing a concurrent documentation review program is the ability to discuss a patient’s record while the details of the patient’s case are still fresh in the physicians’ mind. Such interactions are as important for resolution of the medical record documentation as it is for providing ongoing education for the physician. Not surprisingly then, many experts encourage facilities to maximize opportunities for verbal interactions between the CDI team and the physician staff, whether it is on the patient care unit or through meetings in the physician lounge. To do so, however, CDI specialists need to exhibit a unique set of interpersonal skills. the CDI specialist must be both positive and professional in his or her interactions with physicians but they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Such skills may be summarized by the colloquialism “know your audience.”
For example, Dr. Smith may respond well to e-mail communication but become visibly uncomfortable, aggressive, or reclusive when approached on the floor of a nursing unit. Conversely, Dr. Adams consistently ignores written queries left in the medical record and does not return phone calls. Approach him during his routine rounds, however, and he will answer multiple CDI questions happily.
Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician. A process-orientated physician, for example, may respond positively to a CDI specialist who explains how his or her documentation in the medical record translates through the HIM department, billing, and, ultimately, reimbursement and quality data reporting. A results-orientated physician, however, would see such discussions as a waste of time, preferring to understand how the process will affect him or her directly, instead. The ability of the CDI staff member to not only be aware of these different dynamics, but also to adjust their queries and education accordingly can appease wary physicians and earn physician support for the CDI program overall.
The healthcare system in the United States is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation. This relationship then makes documentation and coding truly dependent upon each other; without one you don’t have the other. It sounds plain and simple, but of course it is not.
The use of coded data continues to be very important as the healthcare industry works to obtain information for quality measures, outcomes, research, management of resources, reimbursement methodologies, and payment. Such important data require accurate clinical coding, which requires complete and accurate clinical documentation. Indeed, more specific documentation will lead to more specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and soon ICD-10-CM and ICD-10 Procedure Coding System (PCS) code assignment. The result will be more accurate severity of illness (SOI), acuity, and risk of mortality (ROM) -patient data.
Clinical coding makes possible the reporting of mortality data in the United States and to the World Health Organization (WHO). Coded data also allow government and other third-party payers to reimburse healthcare providers for the care and services given in all settings. Coded data and information are also the primary sources for -administrative management of medical services and are sources of epidemiologic research and statistical data pertaining to inpatient stays. The National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS) are the U.S. government agencies responsible for overseeing all changes and modifications to ICD-9-CM and for implementing ICD-10-CM and ICD-10-PCS.
As the healthcare industry in the United States transitions to ICD-10, awareness of the need for greater clinical documentation specificity and the code specificity that correlates to it is increasing. The ICD-10-CM diagnosis coding system and ICD-10-PCS procedural code system were designed to provide more clinical information via coded data. A strong understanding of specific coding challenges and areas that require more attention can facilitate a strategic approach to ICD-10 success.
Editor’s Note: This excerpt was adapted from ICD-10 Coding and Physician Language Strategies for Complete Documentation, Third Edition by Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS.
ICD-9-CM provided few codes to capture an altered level of consciousness as the cause of altered mental status (AMS), as the only significant available diagnosis was coma; however, patients can have severe impairment without being in a coma (R40.20). ICD-10-CM codes allow for the capture of significant impairment when the patient does not have a coma through codes associated with the Glasgow Coma Scale.
The most common use of the Glasgow Coma Scale is assessing the severity of an acute brain injury, such as one associated with trauma or stroke. The draft ICD-10-CM Official Guidelines for Coding and Reporting Section C.18.e states that these codes “can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes.”
The Glasgow Coma Scale is comprised of three scores that evaluate the patient’s level of consciousness by noting under what circumstances they open their eyes, their best verbal response, and their best motor response at the time of the assessment. According tot he guidelines, “one from each subcategory [is] needed to complete the scale.” the lower the score on any subsection of the scale, the greater the level of impairment.
Most organizations document the total score from the scale, which can range from three to 15, rather than the score for each sub scale. Unfortunately, there are no CCs or MCCs currently associated with the total score, even though a total score between three and eight (R40.243-) represents significant impairment. Furthermore, the scale is typically completed as part of the nursing assessment rather than documented by the provider, which makes it difficult for coders to use the documentation for coding purposes.
Lastly, ICD-10-CM requires a 7th character for the timing of the assessment. This can be difficult to obtain since the scores are frequently determined by someone other than the provider. Additional guidance indicating that scores can be obtained from sources other than the provider would alleviate this difficulty. Frequency of the determination may also be cause for some concern as the draft Official Guidelines for Coding and Reporting state that facilities should report the patient’s initial score, assessed and documented at the time he or she presented for care. However, organizations can report the score as often as they choose, and best practice would be to report a score whenever there is a deterioration in the patient’s level of consciousness.
Tip: Review and revise, if necessary, trauma and neurological assessment forms to ensure that the score for each sub scale of the Glasgow Coma Scale is documented. Consider adding these scales to physician assessment forms so the scores can be coded without queries.
Physicians in the United States are becoming more aware of the value of clinical data and the relationships between their professional profiles and the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT®) codes they assign, or those assigned for them by others. Certainly, internists are aware of the value of personal professional billing codes, and surgeons are aware of their morbidity and mortality rates. These all relate to the ICD codes assigned for diagnoses, treatments, and procedures performed.
If the clinical documentation and, thus, the codes do not accurately and specifically represent the work a physician does, someone can be inconvenienced—if not actually hurt—with data that poorly reflects on the practitioner’s quality of care.
The healthcare industry has entered a new era of value based -purchasing (VBP), in which a healthcare provider’s statistics will determine whether the provider is preferred or to be avoided. Medicare started the initiative a few years ago, and in 2012, it took its first giant steps. Private insurance companies have jumped aboard and are making their determinations of selection of physicians and hospitals to be used by their clients based on data. The elements of this data include:
- Cooperation with official practice guidelines for acute myocardial infarction (AMI), heart failure (HF), pneumonia (PNA), postoperative wound infections, and avoidance of deep vein thrombosis (DVT) after surgeries
- Severity-adjusted mortality rates
- Severity-adjusted complication rates (patient safety)
- Frequency of patient safety indicators occurring
- Frequency of “never” events
- Frequency of postoperative and postprocedural complications
- Severity-adjusted length of stay and patient costs
- Appropriate venue for delivery of healthcare
- Avoidance of preventable readmissions to hospital
- Bundled payments
- Combined payments between hospital and physician for inpatient care
- Combined payments for outpatient element of patients after hospitalization
- Combined payments for global care of patients
- Combined, severity-adjusted payments between surgeons
All of these measures are determined through analysis of ICD codes, and an understanding of how the physician’s documentation justifies assignment of the correct ICD codes is paramount for future success of a practice.
Finally, on October 1, 2014, the United States joins the other nations that already use the International Classification of Diseases system, 10th revision (ICD-10), which requires even greater attention to documentation and assignment of ICD codes than ever before. Physician survival in this new value-based world will depend on documentation and assignment of accurate and specific ICD-10 codes. Both will be paramount to success.
Editor’s Note: This excerpt was adapted from ICD-10 Documentation Strategies to Support Severity of Illness Ensure an Accurate Professional Profile, Third Edition, written by Robert S. Gold, MD.
The ICD-9-CM Official Guidelines for Coding and Reporting state that not otherwise specified (NOS) “is equivalent to ‘unspecified’ and should only be used when the coder lacks the information necessary to code a more specific four-digit subcategory.” In Section 1.A.5.b, the Guidelines direct coders to limit the use of unspecified codes as follows:
“Codes (usually a code with a 4th digit of 9 or a 5th digit of 0 for diagnosis codes) titled ‘unspecified’ are for use when information in the medical record is insufficient to assign a more specific code.”
These are very strong admonitions that “unspecified” codes should not be casually assigned. Coders frequently assign NOS codes even when more specific detail is documented in the medical record. To avoid this pitfall, the medical record should be searched carefully for any additional information that might permit assignment of a more specific code, thereby giving a more accurate and complete account of the patient’s condition and treatment. Two of the most commonly assigned unspecified codes are:
- Pneumonia, organism unspecified (486)
- Congestive heart failure, unspecified (428.0)
For pneumonia, if there is any documentation whatsoever by any provider that suggests the actual, probable, or suspected organism or other cause being treated, this ought to provide sufficient information to assign a more specific code. A positive culture alone in the absence of provider documentation is not sufficient to assign a specific organism but deserves a query for clarification (Coding Clinic, Second Quarter, 1998, p. 3).
The term “congestive heart failure” is considered nonspecific, outdated, and inadequate to describe this condition. finding documentation of systolic and/or diastolic failure or dysfunction and the acuity anywhere at all in the medical record by a provider should permit assignment of the correct and more specific codes. If the necessary information isn’t there, a query would be appropriate.
In ICD-10, the Guidelines state that “codes titles ‘unspecified’ are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided the ‘other specified’ code may represent both other and unspecified. However, unspecified codes for the above diagnosis are:
- Pneumonia, organism unspecified (J18.9)
- Congestive heart failure, unspecified (150.9)
Healthcare providers typically start with an evaluation of the patient’s chief complaint and work toward specifying the cause of the symptom. Coding from documentation where the physician notes the patient’s symptoms but documents no working medical diagnosis is a definite “don’t.” Signs or symptoms of an underlying condition should be coded only if no definitive diagnosis is determined, according to the ICD-9-CM Official Guidelines for Coding and Reporting. However, when the workup of the condition is not clear-cut and a medical diagnosis cannot be definitively made, the symptom then becomes the final diagnosis. Most signs and symptoms codes are identified in Chapter 16 of the coding manual.
Take the following situation for example. A patient is admitted for evaluation of abdominal pain. The physician rules out all acute diagnoses. the medical record contains no underlying diagnosis. The appropriate code assignment would be 789.00, which groups to MS-DRG 392, esophagitis, gastroenteritis, and miscellaneous digestive disorders. however, if there is documentation to support an underlying disease process, such as ulcerative colitis, an appropriate code for ulcerative colitis, 556.9, would be used and MS-DRG 387 would be assigned.
Editor’s Note: This excerpt was adapted from The CCDS Exam Study Guide by Fran Jurcak, RN, MSN, CCDS.
CMS has designated almost 1,600 diagnostic codes as MCCs, and more than 3,300 codes as CCs. For a complete list of these go to the CMS website at www.cms.hhs.gov/AcuteInpatientPPS.
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Increased nursing care/monitoring
- Extended length of stay
Guidelines for assigning principal diagnosis (PDX) remain exactly the same after the change to ICD-10-CM/PCS. UHDDS guidelines define the PDX “as the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.”
Even though the definition remains the same, the healthcare environment has changed dramatically since this definition was first implemented, and accurately assigning the PDX can be complex. MS-DRGs based on a symptom PDX typically have a low relative weight (RW) and therefore lower reimbursement. These types of MS-DRGs are also highly scrutinized by external auditors because diagnostic workups, often associated with a symptom PDX, typically do not meed requirements for inpatient hospital care.
Coders and CDI specialists need to consider medical necessity of setting when assigning the PDX. Typically, medical necessity requires documentation of an acute disease process or an exacerbation of a chronic condition. Capturing PDX documentation is also needed to ensure that what the hospital reports matches what the provider bill.s
Signs or symptoms of an underlying condition should be coded only if no definitive diagnosis is determined, according to the draft ICD-10-CM Official Guidelines for Coding and Reporting. Sign and symptom codes are identified in Chapter 18 of the coding manual, codes R00 through R99.
However, inpatient hospital coding guidelines allow the reporting of uncertain diagnoses if they remain uncertain at the time of discharge. As such, the CDI specialist should review the health record for clinical indicators and query the provider of the “probable,” “suspected,” or “likely” cause of the symptom to avoid defaulting to a symptom PDX. Keep the following two important definitions in mind:
- A sign is objective evidence of a disease that the examining physician can observe
- A symptom is a subjective observation that the patient reports but that the physician does not confirm objectively
The Major Diagnostic Category (MDC) for multiple significant trauma (MST) includes very particular guiding principals for proper assignment. First, the patient must have a documented trauma associated with his or her reason for admission. Second, two body sites must be affected and the injuries must be significant enough to qualify as a body-site injury. However, the injuries do not have to be present on admission but may occur (although this applies only to non hospital acquired conditions) or be diagnosed after the admission. In other words, there must first be a trauma and then significant injuries in order for a condition to be coded and grouped to these MS-DRGs. The detail of documentation of the injury drives whether the injury groups to this MDC or simply to an injury within another MDC.
For example, if a patient falls off a ladder and suffers a closed fracture of the vault of the skull but does not suffer an intracranial injury, and there is no documentation regarding loss of consciousness, the appropriate code assignment is 800.00 and the care provided does not qualify as a body site for MST. However, if the same patient has documented loss of consciousness for three to five minutes, the correct code assignment is 800.02, which does qualify as a body site for MST. As a single injury, both of these codes group to MDC 4 and MS-DRG 87. However, if there is documentation of two other body-site injuries the MS-DRG is 965. Simple injuries rarely group to this MDC but combinations of injuries may, so it is important to clearly identify the extent of each injury.
Due to the severity of these injuries, most patients require some surgical intervention. Such intervention would move the final MS-DRG assignment to the surgical side. Here again, very specific procedures (and related specific documentation) will force assignment of the final MS-DRG. Don’t forget the surgical hierarchy when reviewing these charts as the patient undergoes multiple procedures. The principal procedure will become the procedure highest on the surgical hierarchy.