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.
The digestive system includes the gastrointestinal tract and accessory organs. The gastrointestinal track or alimentary canal consists of the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus. Digestion is the mechanical and chemical breakdown of foods into nutrients that are absorbed while waste products are excreted.
Accessory organs that assist with digestion are the liver, gallbladder, and pancreas. The liver’s role is bile production and further breakdown of ingested nutrients. The gallbladder’s role is storing and releasing bile into the small intestine to facilitate the chemical breakdown of nutrients. The role of the pancreas is further breakdown of carbohydrates, fats, and proteins.
Digestive conditions can be medical or surgical diagnoses. Digestive conditions can be the principal diagnosis that necessitates inpatient admission and/or secondary comorbid conditions that affect the complexity of patient care, severity of illness (SOI), and/or risk of mortality (ROM).
A clinical documentation specialist (CDS) should compare the surgical report list of procedures performed to the surgeon’s narrative description for potential discrepancies (e.g., common bile duct [CBD] exploration, CBD dilated, sphincter of Oddi dilation, ampulla of Vater hepatotomy, running of bowel, accidental operative laceration, liver bed repair, or extensive lysis of adhesions). If documentation in the surgeon’s procedural list and the surgeon’s narrative description conflict a CDS should query the surgeon for clarification.
A CDS who encounters a patient suffering from advanced liver disease, who is experiencing a progressive onset of dyspnea and hypoxia, should assess the medical record for documentation of the etiology. If the etiology is not clearly documented a CDS should query a physician to clarify whether the patient has hepatopulmonary syndrome. This is a complication of advanced liver disease which has progressed to the extent that it affects the lungs.
Digestive conditions may have been present at time of admission but not diagnosed until after admission or after surgery. A review of the medical record is necessary to determine the following:
- Present on admission status
- Cause-and-effect relationship between a condition and surgical procedure or other etiology
Digestive conditions can have a neurological etiology. Neurogenic bowel is a disorder that is due to a neurological etiology such as a spinal code injury. Neuropathies such as impaired esophageal motility can cause swallowing disorders. Diabetic gastroparesis is a neurological disorder that delays the process in which the stomach empties food into the small intestine. A query that seeks etiology is necessary to ensure compliant and accurate code assignment for these diagnoses.
Specificity with respect to the anatomical location of a digestive condition is necessary to ensure accurate code assignment (e.g., gastritis versus esophagitis, fecal impaction versus impaction of intestine).
Specificity with respect to principal and secondary digestive conditions is necessary to ensure coding compliance and to accurately and completely reflect the SOI and ROM.
Based on the 2008 AHIMA query practice guidance “Managing an Effective Query Process” many in the CDI industry believed that yes/no queries were acceptable only for those queries related to present on admission diagnosis. At times, this left CDI specialists in the awkward position of asking what may have seemed like a silly question using really poor grammar.
For example, physicians frequently neglect to cross-document findings from the surgical pathology report. For most CDI specialists, the easiest way to deal with this situation would have been to query the physician and ask whether he or she agrees with the path report. Concerned that such a yes/no question violated industry guidance, CDI specialists wrote open-ended queries such as “please clarify the clinical diagnosis associated with the stage 3 malignant ovarian cancer on the pathology report” or multiple choice queries that included limited options or findings different from the pathology report such as benign, pathology aberration, etc. In both cases, the phrasing tended to annoy physicians.
In the 2013 ACDIS/AHIMA physician query guidance the use of yes/no queries was expanded to include:
- Substantiating or further specifying a diagnosis already present (i.e., findings in pathology, radiology, and other diagnostic reports)
- Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus, and chronic kidney disease)
- Resolving conflicting documentation from multiple practitioners (i.e., asking the attending physician who is documenting “renal failure” if he agrees with “CKD stage 4″ documented by the renal consultant.
Based on the above guidelines, a yes/no query would never be appropriate for a new diagnosis. Moreover, to ensure a yes/no query is not leading, non-POA queries should include “other” and “clinically undetermined” options. The use of these options allows this format to meet the standard of not being leading.
Historically, healthcare organizations have been operating under the belief that when it comes to communicating with physicians, more is better. The tendency is to “cover the bases” and make sure they are sent details on everything, just in case. This is not effective. More is simply more. At high-performance institutions, teams carefully scrutinize the message and the target audience. This discipline demonstrates respect for the physician’s time, knowledge of their professional specialization, and an understanding of their needs.
Often the number of department within an organization sending messages to practices confounds the “relevance” challenge… A useful first step is to audit the current volume of outbound messages, the relevance for the practice, the timing and overlap… Next, find out what doctors need to know. Too often, physicians are not asked what they want or need to know; instead messages are “pushed out” with little regard for the physician’s needs.
Editor’s Note: This excerpt was adapted from The Complete Guide to Physician Relationships: Strategies for the Accountable Care Era, by Kriss Barlow, RN, MBA.
Another significant change within ICD-10-CM is the creation of two types of excludes notes. In ICD-9-CM, determining when to apply and excludes note frequently confuses coders and CDI specialists. ICD-10-CM uses the term “Excludes1″ when the two codes cannot be used simultaneously. It is represented by a black box beneath the code in the tabular index. In other words, it is a true exclusion, as the code following the Excludes1 note will never be used on the same claim.
An “Excludes2″ note is represented by a gray box and means “not included here.” When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together, when appropriate. The condition following the excludes note is not part of the condition represented by the code but a patient may have both conditions at the same time. For example, J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation, has an Excludes2 note directing the coder to “Chronic obstructive pulmonary disease with acute bronchitis (J44.0).”
The CDI specialists should think of Excludes2 notes as potential query opportunities, as these notes list conditions commonly associated with a particular diagnosis not already captured by an ICD-10-CM code. The CDI specialist should review the health record for clinical indicators of any condition listed under an Excludes2 note and query, when appropriate, to add this missing diagnosis.
The Excludes 2 note also clarifies whether two conditions are integral or interrelated. For example, there has often been confusion when applying ICD-9-CM codes concerning the diagnosis of acute renal failure with chronic kidney disease; however, the ICD-10-CM tabular list notes for “I12: Hypertensive chronic kidney disease” has an Excludes2 note for acute kidney failure (N17.-). Therefore, the CDI specialist should be looking for clinical indicators within the health record to support the diagnosis of acute kidney failure and query for the diagnosis if applicable and if it is not already documented.
According to the National Institutes of Health’s definition, malnutrition is the condition that occurs when your body does not get enough nutrients. According to The Merck Manual, 19th Edition, malnutrition includes both under nutrition and over nutrition. If left untreated, it can lead to mental or physical disability, illness, and possibly death.
Many hospitals use the lab values for albumin and pre-albumin as indicators for coding/querying physicians in regard to the condition. Recent guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics represent a consensus statement of the American Academy of Nutrition and Dietetics and the American Society for Perental and Enteral Nutrition and essentially made those indicators obsolete. The article provides a table with more detailed clinical criteria which providers can refer when documenting severity levels.
The guidelines advocate for provider use of a standardized set of diagnostic characteristics to identify and document adult malnutrition. The guidance says malnutrition should be diagnosed when at least two or more of the following six characteristics are identified:
- Insufficient energy intake
- Weight loss
- Loss of muscle mass
- Loss of subcutaneous fat
- Localized or generalized fluid accumulation that may sometimes mask weight loss
- Diminished functional status as measured by hand grip strength
Providers must assess these six characteristics in the context of an acute illness or injury, a chronic illness, or social or environmental circumstances to determine whether malnutrition is present and whether it is severe or non severe (moderate). CDI specialists can get a jump on ICD-10 documentation needs by querying physicians now to substantiate whether malnutrition is mild, moderate, severe, or undetermined when documentation is not clear. Facilities should adopt clinical guidelines for diagnosing and coding different degrees of malnutrition and apply them consistently.
The easiest way to ensure that CDI specialists submit queries to physicians only when clinically appropriate is through the use of clinical indicators–a written set of guidelines based on the most current medical literature.
Historically, coders received mixed messages regarding the use of clinical evidence in their queries. On one hand, guidance (and physician staff) point out coders’ lack of medical experience–they are told they are not physicians, not entitled to “practice” medicine, and that they should simply code the diagnoses written by the physician. One the other hand, various agencies and payers opine that coding a diagnosis without clinical evidence is a coding error.
When querying, avoid diagnostic indications but provide objective clinical information and documentation from the medical record, identify where in the medical record such indicators originated and reference the documentation concern at issue. Address the document and date where the issue was found. The physician will not cooperate if he/she thinks the coder or CDI specialist is trying to practice medicine.
Those who query typically use textbook and Web-based references to contextualize the clinical evidence (or lack thereof) for a given diagnosis in the record. Such literature helps the CDI specialist determine when a clinical picture as described in the medical record is indicative of a particular diagnosis.
Standard peer-reviewed physician journals are the most effective. A few recommended resources include:
- Journal of American Medical Association
- The New England Journal of Medicine
- Annals of Internal Medicine
Other journals devoted to specific clinical sub-specialities can be effective as well. Common best practice, however, is for CDI specialists to first conduct diligent research on clinical indicators and then bring their findings forward to physician leaders in that specialty to get their input. When physicians assist in standardizing clinical definitions within the facility for their own use as well as for consistency within the query process they tend to support query efforts more readily.
Editor’s Note: This excerpt comes from The Physician Queries Handbook, Second Edition, by Marion Kruse, MBA, RN.