All Entries in the "Book Excerpt" Category

Book Excerpt: Coding guidelines for diabetes under ICD-10

The age of a patient is not the sole determining factor for the type of diabetes, although most Type 1 diabetics develop the condition before reaching puberty. For this reason, Type 1 diabetes mellitus is also referred to as juvenile diabetes. If the physician does not document the type of diabetes mellitus in the medical record, the default category of codes is E11 (type 2 diabetes mellitus).

If the physician does not document the type of diabetes but does indicate that the patient uses insulin, assign a code from category E11; also report code Z79.4, long term (current use insulin to indicate that the patient uses insulin. Do not report code Z79.4 if a Type 2 patient is given insulin temporarily to bring  his or her blood sugar under control during an encounter. In situations where diabetes occurs during pregnancy and for cases of gestational diabetes, refer to the ICD-10 Official Guidelines for Coding and Reporting Section I.C.15, Diabetes mellitus in pregnancy and gestational (pregnancy-induced) diabetes.

The codes under category E08 (diabetes mellitus due to underlying condition) and E09 (drug or chemical induced diabetes mellitus) identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition of event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drugs, poisoning.)

The sequencing of the secondary diabetes codes in relation to codes for the cause of the diabetes is based on the tabular instructions for categories E08 and E09. For category E08, first code the underlying condition. For category E09 first code the drug or chemical (T36-T65). For a patient with diabetes ketoacidosis without coma due to cirrhosis of pancreas, report K86.8 (cirrhosis of pancreas) and E08.10 (diabetes mellitus due to underlying condition with ketoacidosis without coma).

Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

Book Excerpt: Look to others for advice when starting a new CDI program

The Clinical Documentation Improvement Specialist's Handbook, Second Edition

A savvy CDI steering committee looking to implement a new CDI program should seek the opinion of other facilities in their vicinity, perhaps even visiting other programs and shadowing CDI professionals on their rounds. Such engagement provides anecdotal first-hand experiences to help shape the roles and responsibilities of the CDI staff and it helps the CDI steering committee gauge potential problems.

The group may also decide to enlist the assistance of professional associations; both the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) help foster local meetings in various states where members freely discuss program troubles and triumphs. Furthermore, ACDIS surveys its members annually regarding the structure, staffing, and focus of CDI programs.

For example, two studies (an April 2010 CDI Staffing Survey featuring responses from 85 CDI department directors and a July 2010 CDI Program Benchmarking Survey featuring 482 responses from a variety of CDI professionals) indicate that a majority of CDI programs employ registered nurses as CDI specialists who report to the HIM director.

Whether a facility uses coders, nurses, or some combination of both, and regardless of to whom the CDI staff reports, the goal of capturing complete and accurate documentation should not be compromised in favor of other agendas. Without clearly defined responsibilities, a case manager who also performs some CDI work may push one set of responsibilities aside for another given the limitations of time, experience, and administrative expectation. Conversely, a coder might not pursue a query if tasked with concurrently coding a chart, meeting productivity standards, and maintaining discharged, not final billed (DNFB) goals.

Editor’s Note: This article is an excerpt from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

Book Excerpt: Build better relationships with appropriate physician queries

The Physician Queries Handbook

There are consequences for failing to understand the critical link between patient treatment and the documentation and coding for such treatment. ICD-9-CM coding based on nonspecific physician documentation has led insurers to raise patient co-payments for certain “inefficient” providers.

In the same light, coding from nonspecific physician documentation has led to negative outcomes as seen via publicly reported mortality data posted on the CMS’ Hospital Compare website or other public websites. Here, some providers have high risk-adjusted death rates for community acquired pneumonia, heart failure, myocardial infarction, or other conditions based on ICD-9-CM coded data.

Communities have witnessed their local hospitals close in part as a result of providers’ and coders’ inability to negotiate the code-based reimbursement systems that are integral to establishing medical necessity, which is required for accurately assigning diagnosis-related groups for inpatient reimbursement. As the government and the public demand for improved quality of care and transparency of data increases, the physician documentation and coder translation of the medical record becomes almost as vital as the physical care the patient receives.

Editor’s Note: The above excerpt was written by James S. Kennedy, MD, CCS, in the introduction to The Physician Queries Handbook: Guide to Compliant and Effective Communication.

Book Excerpt: Training new CDI staff members

Because CDI is still a relatively new and emerging profession…finding seasoned professionals can be difficult and it may be necessary to provide between three to six months of on-the-job training before the new hire can effectively conduct all aspects of the role.

Many new hires require some coding or clinical education. Initial and ongoing education represents an important aspect of successful CDI programs. Generally speaking, CDI specialist education should include:

• Revenue cycle overview and case-mix index basics
  

  The Clinical Documentation Improvement Specialist's Handbook, Second Edition

• Introduction to hospital and medical staff profiling
• Basics of ICD-9-CM principals and Medicare Severity Diagnosis-Related Group (MS-DRG) methodology
• MS-DRG definitions and sequencing guidelines
• Major diagnostic category (MDC)-specific documentation guidelines and strategies
• Present on admission basics
• Core measure basics
• Compliant and effective physician querying strategies
• Orientation to the ICD-9-CM Official Guidelines for Coding and Reporting and Coding Clinic for ICD-9-CM
• Basic tenets of ICD-10
• In-depth review of CC/MCC
• Review of AHIMA and ACDIS Code of Ethics
• Review of AHIMA physician query guidances and tools
• Mentoring with seasoned staff for three to four weeks to allow for accurate application of core CDI principals
• Orientation to physician groups and hospital medical staff structure

Lastly, regardless of the educational and professional background of those chosen to staff the CDI program, it bears repeating that successful programs require the support of HIM, quality management, and case management. Moreover, the support of the hospital administration, the compliance department, and the medical staff leadership is crucial to the immediate and long-term viability of a CDI program.

Editor’s Note: This post was taken from The Clinical Documentation Improvement Specialist’s Handbook by Marion Kruse, MBA, RN and Heather Taillon, RHIA.

Book Excerpt: Tailor ICD-10 documentation education to top MS-DRGs

CDI Specialist's Guide to ICD-10

When tackling ICD-10 training for physicians, speak to them about the current ICD-9 systems as a segue to the transition to ICD-10. Focus on the top 10 common clinical diagnoses that CDI specialist at your facility consistently identify as problematic from a clinical specificity standpoint. If physicians are motivated and conditioned to include specificity in these top clinical diagnoses, the road to a successful transition of clinical documentation under ICD-10 can be established.

Another approach is to run a report of the top 20 MS-DRGs for the most recent fiscal year and review the diagnoses that comprise them. Then tailor ICD-10 training to common clinical diagnoses that physicians manage on a regular basis. Common MS-DRGs that will appear on this list relate to diagnoses such as:

• Chest pain
• gastroenteritis/esophagitis
• Congestive heart failure
• Pneumonia
• Kidney and urinary tract infection
• Cellulities
• Stroke and cardiovascular accident
• Cardiac arrhythmia and other conduction disorders
• Sepsis
• Seizure disorder
• Gastrointestinal bleed and obstruction
• Renal failure
• Acute myocardial infarction

Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

Book Excerpt: Documentation needs to support severity of illness for pulmonary edema

Documentation Strategies to Support Severity of Illness, Second Edition

Fluid in the interstitial spaces in the lung or fluid in the alveoli can be interpreted as pulmonary edema. With severe shortness of breath, it is likely acute pulmonary edema. Chronic pulmonary edema is usually a manifestation of end-stage heart failure. Patients with acute pulmonary edema may present with acute respiratory failure.

Cardiac causes of acute pulmonary edema include:

• Exacerbation of left ventricular heart failure with volume overload in end-stage renal disease (ESRD) patients who have chronic heart failure
• Acute MI whether from coronary occlusion or demand MI
• Accelerated (or malignant) hypertension including the severe hypertension that may occur with thyrotoxicosis, pheochromocytoma, carcinoid syncrome, eclampsia
• Tachyarrhythmia (AF with RVR, supraventricular tachycardia, ventricular tachycardia)
• Takotsubo syndrome (stress cardiomyopathy or apical ballooning syndrome)

Non-cardiac causes of acute pulmonary edema include:

• Pulmonary embolism (venus thrombi, fat or air embolism)
• Aspiration of gastric acid
• Sepsis (ARDS)
• Rapid decompression
• Drowning
• Volume overload in ESRD patients who do not have chronic heart failure

Documentation needs

Was this an acute MI (including non-Q wave MI due to ventricular tachycardia, pulmonary embolism, or fat embolus? If so, document it as the cause of the pulmonary edema.

Was there chest trauma, rapid deceleration, sepsis, or ARDS? If so, document that as the cause of the pulmonary edema.

Did the patient aspirate fumes, vapors, gastric acid, or food? If so, document that as the cause of the pulmonary edema.

Is this volume overload related to renal failure with an otherwise stable heart? If so, document it as non-cardiac pulmonary edema.

If this is an ESRD patient with heart failure due to volume overload, state so. For example, write: “Noncompliant patient missed dialysis two days ago, admitted now in volume overload causing exacerbation of chronic diastolic heart failure.”

Editor’s Note: This excerpt was adapted from Documentation Strategies to Support Severity of Illness: Ensure an Accurate Professional Profile, second edition, written by ACDIS Advisory Board member Robert S. Gold, MD.

Book Excerpt: Tips for hypertension documentation

The 2012 edition of The CDI Pocket Guide was recently released.

The term “accelerated” hypertension is an archaic term but necessary for the correct documentation and coding of severe hypertension when it occurs as a secondary diagnosis. Unfortunately, coding terminology hasn’t caught up with the currently-accepted clinical diagnostic terms for severe, uncontrolled hypertension.

Terms such as “hypertensive emergency,” “hypertensive crisis,” “hypertensive urgency,” “severe hypertension,” “malignant hypertension,” and “accelerated hypertension” are all used in the literature and often overlap. Yet “accelerated,” and “malignant,” or “necrotizing” hypertension are the only terms that will result in coding as a comorbidity/complication: 401.0 or Categories 402-405 with 4th digit = 0.

Using only the terms “hypertensive emergency,” “hypertensive crisis,” and/or “hypertensive urgency,” will result in assignment of non-specific hypertension codes that do not accurately reflect the seriousness of the patient’s condition or the complexity of care required to treat it.

Clinical definition: A patient with hypertension that is consistent with “accelerated” or “malignat” should require urgent treatment (either IV or STAT oral dosing), have the same risks and clinical implications as urget or emergent hypertension and meet one of the following criteria:

• Systolic blood pressure (BP) > 180 mm Hg, or
• Diastolic BP > 110 mm Hg, or
• End-organ involvement/damage (e.g., neurologic, renal, or cardiac damage)

The following examples compares the criteria for accelerated hypertension with the more current terminology:

• “Hypertensive urgency” is defined as having BP > 180/110 mm Hg, with or without symptoms such as severe headache, shortness of breath and anxiety; and no end-organ involvement.
• “Hypertensive emergency” is usually symptomatic with BP of at least > 180/120 mm Hg; often it exceeds 22/140 mm Hg. There is end-organ involvement, with possible symptoms including chest pain and neurologic deficits.
• “Hypertensive crisis” is used to describe the spectrum of severe, uncontrolled hypertension that includes both urgent and emergent hypertension, as described above.

Editor’s Note: This excerpt was taken from The 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS and Cynthia L. Tang, RHIA, CCS.

Book Excerpt:Track physician response rates to assess program effectiveness

If a facility educates its physician stakeholders well, the number of queries left unanswered should be minimal. It is unreasonable to expect 100% query response rate, however, if the facility has not:

The CDI Handbook

• Obtained strong administrative support
• Developed comprehensive physician education
• Established medical staff documentation improvement initiatives
• Created consequences for non-participatory physicians

Generally, facilities set incremental goals. During the beginning of a program, a facility may expect to obtain 60% response rate, which should increase to between 75%-80% by the end of the program’s first year. More mature programs expect query response rates in the 90%-100% range. Although the goal is 100%, some leeway must be given if department funding in involved and if not all physicians within the department are employees of the hospital.

So with a program goal of roughly 90% for physician response to queries, all methods of finalizing queries should be considered. This may include calls to the physician by the CDI specialist and/or physician advisor, or developing an easier way for physicians to comply (e.g., fax query forms, electronic query forms).

Tracking the number of physician query responses helps facilities assess the credibility of the queries posed by the CDI staff as well as measure physician involvement, support, and understanding of the program. Program success stems from obtaining physician documentation in the medical record, not just the discovery and creation of a query. Similarly, just because a physician responds to a query does not necessarily mean he or she agrees with the premise of the clarification request.

When a CDI specialist poses a question and leaves a query that causes the physician to clarify the documentation within the medical record, most hospitals choose to record this as an “agreement” because the physician responded. While facilities should monitor this statistic, the query forms themselves should also be monitored to be sure the queries do not lead the physician or include clinically irrelevant multiple choice options. If the physician agreement rate with CDI queries is low, determine if it relates to a single CDI specialist, a single physician, or the entire program.

Editor’s Note: This post was taken from The Clinical Documentation Improvement Specialist’s Handbook by Marion Kruse, MBA, RN and Heather Taillon, RHIA.

Book Excerpt: Coding and physician languages

This handbook regarding documentation tips comes in packs of 10 so it can be delivered to physicians, CDI staff, or coders.

Clinical documentation for coding purposes continues to be highly important as we work to obtain data for quality measures and payment. Such data rely on accurate coding, which relies on complete and accurate clinical documentation; they are dependent on each other. Indeed, the more specific the documentation, the more specific the ICD-9-CM (and in the future the ICD-10) code(s) will be, and in turn, the more accurate the severity, acuity, and risk of mortality (ROM) data will be.

Clinical coding allows for the reporting of mortality data to the World Health Organization (WHO), the reporting of morbidity data in the United States, and the provision of data to third-party payers so they can reimburse hospitals for care and services provided. Coded information is also the primary source for the administrative management of medical services and a source of epidemiological research and statistical data from inpatient stays.

Editor’s Note: This excerpt was taken from Coding and Physician Language: Strategies for Obtaining Complete Documentation, Second edition, written by Gloryanne Bryant, RHIA, CCS, CCDS.

Book excerpt: Use of clinical indicators in compliant query creation

The updated edition of the CDI Specialist's Handbook.

The easiest way to ensure CDI specialists submit appropriate queries is through the use of clinical indicators. Clinical indicators are a written set of guidelines based on the most current medical literature that help the CDI specialist determine when a clinical picture suggests a particular diagnosis.

Although medicine is both an art and a science a physician’s diagnosis is generally guided by a patient presenting symptoms, physical findings, and the results of diagnostic testing. By understanding the clinical information a physician uses to make a diagnosis, CDI staff members can ensure their queries are relevant and timely.

Consistent definition of conditions and treatments documented in the medical record is critical for accurate capture of coded healthcare data. However, what one physician may term a diagnosis another physician may label differently, which can lead to inconsistent outcomes. Therefore, when crating queries related to specific topics, refer to peer-reviewed physician journals such as:

• Journal of the American Medical Association
• The New England Journal of Medicine
• Annals of Internal Medicine
• Journal of the American College of Cardiology

When creating facility-specific query templates be sure to include clinical indicators for high-volume diseases but also be sure that the medical staff at your facility (or the specialty most closely linked to the condition) vet these queries.

Editor’s Note: This article is adapted from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, byMarion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.