All Entries in the "Coding" Category
Q&A: Credentialing for outpatient CDI
Have CDI questions?
Q: I’ve heard lately that outpatient CDI specialists are less likely to be registered nurses. Is there a reason there may be more coders in this arena?
A: While many outpatient CDI specialists do hold an RN credential, there are good reasons for having coders fill the roll, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for HCPro in Middleton, Massachusetts.
“There are a lot of very specific documentation requirements for evaluation and management (E/M), observation codes, interventional radiology, etc., which RN CDI specialists don’t typically learn,” he says. Additionally, coders may already be comfortable working in a physician practice setting and have a familiarity with hierarchical condition categories (HCC). [more]
Guest post: 2018 ICD-10 codes—when the heart needs a helping hand
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS
Congestive heart failure (CHF) is a commonly diagnosed condition where the ventricles or the lower chambers of the heart do not work effectively. The heart serves as a pump to get blood in and then out of the heart to circulate to the rest of the body. When any type of pump doesn’t work efficiently backups can occur.
The most common form of CHF is left ventricular failure, however left-sided failure can also lead to right ventricular failure as a ripple effect. There are two common types of CHF, one whereby the ventricle cannot contract normally, known as systolic heart failure, and one where the ventricle cannot relax normally due to stiffness, known as diastolic failure. Some patients may have a combination of both systolic and diastolic failure.
The causes of heart failure include hypertension, coronary artery disease, and valvular diseases, as well as cardiomyopathies. [more]
Guest Post: Communication eases challenges of fiscal year 2018 code changes
On October 1, over 800 code changes take effect!
by Crystal Stalter, CDIP, CCS-P, CPC
It’s that time of year again—time to wonder just how the 2018 IPPS final rule will affect CDI and coding efforts.
The 2018 IPPS final rule includes more than 800 ICD-10-PCS changes. Previously recognized operating room codes have become non-operating room codes, affecting DRG assignment, changing surgical DRGs to medical DRGs, and thus affecting reimbursement. Some diagnoses are gaining new definitions and explanations that will result in new ICD-10-CM code assignments and shift DRGs as well.
Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2
by Elizabeth Lamkin, MHA, ACHE
by Elizabeth Lamkin, MHA, ACHE
To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.
Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.
Guest Post, Part 2: Where do we stand with clinical validation?
According to an ACDIS poll, 70% conduct clinical validation reviews.
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:
- Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
- Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.
Summer reading: Defining documentation and coding standards in the revenue cycle, part 1
Elizabeth Lamkin, MHA, ACHE
by Elizabeth Lamkin, MHA, ACHE
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.
It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes why documentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.
Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2
James Kennedy, MD, CCS, CDIP
By James Kennedy, MD, CCS, CDIP
Determine the underlying cause of the altered mental status
Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:
- Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.
Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus
Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question
Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?
A: Let’s break down the documentation.
CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.
Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1
James Kennedy, MD, CCS, CDIP
By James Kennedy, MD, CCS, CDIP
In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.
Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]
Q&A: Electronic query formatting
Have CDI questions?
Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?
A: This is going to be contingent on the system your facility uses.
Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.
