The diagnoses in each major diagnostic category (MDC) correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. MDC 1 to MDC 23 are grouped according to principal diagnoses. Patients are assigned to MDC 24 (Multiple Significant Trauma) with at least two significant trauma diagnosis codes (either as principal or secondaries) from different body site categories. Patients assigned to MDC 25 (HIV infections) must have a principal diagnosis of an HIV Infection or a principal diagnosis of a significant HIV related condition and a secondary diagnosis of an HIV Infection.
MDC 0, unlike the others, can be reached from a number of diagnosis/procedure situations, all related to transplants. This is due to the expense involved for the transplants so designated and because these transplants can be needed for a number of reasons which do not all come from one diagnosis domain. DRGs which reach MDC 0 are assigned to the MDC for the principal diagnosis instead of to the MDC associated with the designated DRG.
Of course, many different conditions can take place at the same time or have underlying causalities. Consider the pneumonic M.U.S.I.C., which you may have heard before, used as a reminder to document the:
- M for Manifestation: e.g., sepsis, heart failure, chest pain, angina
- U for Underlying cause or pathology: e.g., UTI, alcoholic cardiomyopathy, GERD, coronary atherosclerosis
- S for Severity or specificity: e.g., severe sepsis, diabetes out of controlled, systolic or diastolic heart failure
- I for Instigating or precipitating causes: Indwelling Foley cath, NSAID use, carbon monoxide poisoning
- C for Consequences or complications: Septic shock, diabetic neuropathy
When given a diagnosis, place it one of these categories and then look for the other four, linking them with terms such as “due to,” “resulting in,” and the like.
Let’s follow this process using the example of chest pain
- Manifestation: Describe the nature of the pain such as pleuritic or “with respiration”, angina, heartburn, biliary colic, radicular
- Note that phrases such as musculoskeletal, chest wall, atypical pain do not change the DRG
- Underlying cause: Angina pectoris (as an example)
- Coronary atherosclerosis or thrombosis, coronary spasm, hypertrophic cardiomyopathy, complication of coronary stent or previous CABG, etc.
- Note that the code for coronary syndrome X was removed from ICD-10
- Severity or specificity: Stable angina, accelerated angina (a complication/comorbidity [CC]), myocardial infarction (manifested by elevated troponins, a major complication/comorbidity [MCC])
- Note that the code for angina decubitus was removed from ICD-10
- Instigating or precipitating causes: Cocaine abuse, trauma, anemia, hyperthyroidism, atrial fibrillation, accelerated or malignant hypertension
- Consequences or complications: Ventricular tachycardia, shock, acute systolic heart failure due to “stunned myocardium”
Now let’s look at another example of how one might document the condition of altered mental status, again using the M.U.S.I.C. pneumonic.
- Manifestation: Dementia, delirium, psychosis, stupor, coma
- Note that the phrase unresponsive does not have a code
- Underlying cause: Various encephalopathies such as stroke, Transient Ischemic Attack (TIA), Alzheimer’s disease, Lewy-body dementia, encephalitis
- Severity or specificity: Correlates with manifestation and underlying cause
- Note that acute states (e.g., acute delirium) are more likely to be CCs
- Instigating or precipitating causes: Drug toxicity (document whether the drug was an overdose or not properly taken as prescribed), cerebral embolus due to atrial fibrillation
- Consequences or complications: Acute respiratory failure, syndrome of inappropriate antidiuretic hormone secretion (SIADH) leading to hyponatremia resulting in a metabolic encephalopathy
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.
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
An average rule of thumb is for a CDI program to employ one CDI specialist for every 1,250 to 1,500 discharges per year. Consider higher staff ratios for programs that expect CDI specialists to perform multiple functions (core measures review, utilization management, etc.) and a lower ratio for programs that perform condition clarifications only. Other considerations include the amount of vacation time staff have available; programs that hired tenured CDI staff may have to adjust for higher weeks of vacation availability. As program expectations change, review staffing requirements to ensure that existing staff can accomplish the new goals with the resources available.
In general, a dedicated CDI specialist should have an average daily census of 12-15 new patients and between five and 10 established and follow-up cases. This census will allow for appropriate query follow-up and daily reconciliation of discharged cases. Therefore, the decision of how many new staff members to hire can be made by dividing the average daily census by 15. CDI leaders can further quantify that number by obtaining the average daily admission numbers.
Another variable to consider is if the CDI specialist is allowed to determine at what point they stop reviewing a case or if they are required to re-review the case periodically until discharge. This can also have an impact on the number of cases per CDI staff member.
Keep in mind that the CDI staff generally work Monday through Friday so their actual daily census will be higher, especially on Mondays. Increasingly, however, facilities appear willing to adopt a more flexible schedule. These schedules may include a rotating day of the weekend and/or different staggered shifts to make CDI specialists more available to the medical staff.
In the children’s classic by Lewis Carroll, Through the Looking-Glass the Red Queen tells Alice that in Wonderland “It takes all the running you can do to keep in the same place.” The quote has been adapted to evolutionary biology, whereby organisms must continuously evolve to survive since the environment continuously changes. The same can be said of healthcare and the role of the CDI department within the facility. At the onset of the CDI profession, many believed there was limited value in CDI efforts over time. CDI staff members needed only to educate physicians, set them on the right path, and recede into the background.
Constantly changing healthcare regulations, reimbursement methods, coding regulations, clinical practice and facility business focus render such thinking moot. So much changes continuously that the CDI [staff and program] must, like Alice and the Red Queen, run the race without end–maintains an awareness of such changes and effectively communicating with physicians on the most salient aspects as they affect their documentation.
Being able to have a CDI presence at grand rounds may take a year to come to fruition. It may take five years to convince administration that new surgical residents should receive two hours of training on CDI. And it may take two years to earn the support of the urology physicians, or more than three years to research and target vascular surgery with enough information to win them over to your ways.
CDI is a marathon. The goal of the program and the aim of the physician advisor in it is to improve the capture of the patient’s SOI/ROM for physicians and their facilities. These goals should not be judged on a single month, quarter or year but averaged over time. A single missed query or an non-compliant physician will not destroy CDI efforts. There will be other opportunities and the program’s success will come over time.
Editor’s Note: This excerpt comes from The Physician Advisor’s Guide to Clinical Documentation Improvement by Trey La Charité, MD, and James S. Kennedy, MD, CCS, CDIP.
A CDI program should be implemented because of the disconnect between physician documentation in the medical record and its translation to a coded data set for analysis. This coded data–ICD-9 and ICD-10-CM/PCS–and its corresponding Medicare reimbursement systems are the foundation used to measure and compare hospital outcomes. This data is used to make decisions regarding regulatory changes that affect medical necessity requirements, standards in quality of care, and reimbursement. Because CDI programs help make physician documentation more precise it also makes data more reliable so accurate decisions can be made regarding clinical best practices and financial compensation.
To this end, many programs have begun to analyze how CDI efforts affect the severity of illness and risk of mortality (SOI/ROM) scores at their facility. Programs have also turned to public healthcare data sites such as HealthGrades.com and CMS website Hospital Compare to examine how their facility fares when compared to the outcomes of similarly sized facilities.
Prior to CDI implementation a hospital should determine the status of its current documentation needs and identify any predominant facility concerns. Accomplish this through interviews with coding and quality staff members and perform a retrospective chart review. Set up a series of individual interviews and/or group sessions and ask the coders to outline common documentation concerns and the potential impact on MS-DRG and SOI/ROM assignments. Then perform a random chart review to quantify the issues noted. The person(s) performing this chart review should have a working knowledge of clinical indicators and an understanding of the rules which govern how documentation translates into ICD-9-CM codes. These chart reviews provide examples to help illustrate the need for a CDI program. The review should also provide a list of concrete target areas from which to start a facility-wide CDI education process.
Professional organizations have begun working to help their physician members understand how clinical documentation and ICD codes derived from that documentation affect quality of care. Physicians must understand that these codes explain the mental work they do to determine their patient’s current health problems and ongoing health status. The complexity of a physician’s medical decision-making reflects the complexity of the patient and the terms that physicians use in the medical record–whether in the hospital, the office, or in a skilled nursing facility–lead to cod assignments that either do or do not inform the database that they know their patients.
All physicians took courses in pathology and physiology and learned about causes of symptoms and specific etiologies of disease manifestations. However, physicians often take shortcuts with respect to the clinical documentation in their patient’s medical records, and those shortcuts hurt not only their profiles but the the over healthcare system.
The Uniform Hospital Discharge Data Set (UHDDS) requires hospitals to report conditions that affect patient care and require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, and increased nursing care/monitoring. Identifying these components of the conditions adds to the complexity of medical decision-making and enhances severity profiles.
Physicians and the hospital health information management (HIM) department must communicate and collaborate with each other. The HIM coding staff must have an opportunity to ask physicians questions or to request clarification when clinical documentation is not specific. A strong partnership between physicians, HIM staff, and clinical documentation improvement staff is also an imperative for success.
Due to increased regulatory scrutiny of clinical documentation to support medical necessity and coding, documentation that is complete, specific and detailed will serve as a good defense.
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.