All Entries in the "Coding" Category

Supplement to October 2009 CDI Journal: Coding Clinic update

Hi ACDIS members, if you go to our CDI Journal home page you will find a special supplement to the October 2009 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, third quarter 2009. The source of the article is James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook.

In this article Dr. Kennedy breaks down the latest Coding Clinic as it pertains to CDI specialists, reviewing important sequencing considerations, query opportunities, and more. Going forward, ACDIS plans to make this a regular feature exclusively for our membership. Coding Clinic for ICD-9-CM is a vital component of every CDI specialists’ toolbox, and we hope you find the article useful.

If you have any feedback for Dr. Kennedy, please feel free to post it right here.

Take care,

Brian

Talk about documentation catches, simple mistakes cause profound costs

Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect date. I recently came upon this news brief from New York Injury News which outlined the trials of HIV patient who lost his coverage due to inaccurate documentation of a blood-test date.

You find vital information in the medical record everyday. Tell us about some of your 'best find' stories.

As compassionate people living day-to-day it’s easy to vilify the insurance company for dropping a sick person from its coverage rosters, or point the finger at the patient for not keeping better tabs on his or her clinical and coverage information. Yet CDI professionals well know the costs of seemingly simple mistakes. This particular case ended up costing the insurance company, Fortis, $10 million for inappropriate denial of healthcare coverage and added untold difficulties to a young man’s life.

Well, I know that CDI specialists catch these seemingly simple mistakes all the time. So here’s a special request to ACDIS Blog readers—wouldn’t it be nice to receive recognition for those otherwise unseen documentation catches you make everyday? Send me your funniest, most heart wrenching, or simply ‘best catch’ documentation stories by the end of October. We’ll run them by our editorial panel and pick the best to publish. E-mail  me at mvarnavas@cdiassociation.com.

Much ado about the flu vaccine

You probably know all the pros and cons of getting the yearly flu vaccination far better than me.  I’ve been inundated with propaganda from both sides of the argument—to get the flu shot or not (yes, I’m struggling to avoid another Shakespeare reference). In fact, just this morning someone sent me a clip from a Fox News video of a physician stating the vaccine for H1N1 is deadlier than the disease. It listed nine reasons not to get vaccinated.

In the interest of self-disclosure I have not (to my knowledge) ever received the flu shot. It is offered here as a benefit of my employment. They even offer them on-site. But I never get one. I’m not

Alien tripod illustration by Alvim Corréa, from the 1906 French edition of H.G. Wells' "War of the Worlds".

sure why. I guess I believe in the wives tales—that the shot makes some people sick. And, besides if H.G. Well’s virus helped humans defeat an alien race, I could withstand a little sniffle in favor of the greater good of planet Earth. (Yes, I am that strong.)

In the fall of 2009, however, we’re not just talking about the annual incarnation of the seasonal flu that receives its share of the—vaccinate, don’t vaccinate—hype. This year receiving an inoculation for the seasonal flu and the potential pandemic of H1N1 “swine flu” seems more important than ever.

Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) urges healthcare facilities to require staff vaccinations for flu.  The group made its recommendation August 31 as predictions from a presidential panel suggested that half of all Americans may be infected with the H1N1 virus during the upcoming flu season.

Just this week Indiana and Tennessee became the first to offer the H1N1 shots. At the end of September the swine flu swept through Austin, TX.

Rates of healthcare provider vaccinations for the simple seasonal shot, however, hover at the 42% mark, a rate that has not budged much in the last decade, according to the APIC. The Centers for Disease Control and Prevention, as well as APIC, recommend that all healthcare workers in direct contact with patients get a flu vaccination to keep patients safe.

My husband, a special education teacher here in Massachusetts, gets his vaccinations every year religiously. My elderly relatives to do too. For some reason I’m still not sold.

Let me know you feel about this season’s various flu threats.  Tell me about any flu-type challenges you see specific to CDI specialists regarding complications, documentation, and/or simple staffing considerations. If you have already had to deal with an H1N1 case, I’d love to hear from you.

Most of all, stay healthy.

To read more about required flu vaccination for healthcare workers, go to HealthLeadersMedia.com. (There’s an interesting Blog post from my friend and co-worker Gienna Shaw that shows how one hospital engaged its staff in a video about the importance of the H1N1 flu shot. It’s really cute. Definitely worth a watch.)

Don’t forget to read the CDC’s “flu facts,” too. They may seem like simple common knowledge but they’re always worth a quick review.

Oh, and I just got this in my e-mail inbox from CMS!

Flu Season is upon us! CMS encourages providers to begin taking advantage of each office visit to encourage your patients with Medicare to get seasonal flu shots. Flu shots are their best defense against combating flu this season. And don’t forget—health care workers also need to protect themselves.

Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient as a part B benefit. No deductible or copayment/coinsurance applies. Note that influenza vaccine is NOT a Part D covered Drug.

For more information about Medicare’s coverage of the seasonal influenza vaccine and its administration, as well as related educational resources for health care professionals, please go to  the CMS Web site. For information on Medicare policies related to H1N1 influenza, please go to www.cms.hhs.gov/H1N1 on the CMS Web site.

Q&A: Coding from NP documentation

Question: If a CDI specialist puts a sticker in the chart and a nurse practitioner (NP) signs it, can the coder code that diagnosis legally?

Answer: ICD-9-CM guidelines allow code assignment from a NPs documentation so it is important that you seek a compliant policy. I would suggest that you seek the NP scope of practice specific to your state. Although most states have similar scopes of practice, they can differ. I would suggest that you meet with your compliance department to create a facility specific policy regarding the NP scope of practice, and seek medical staff approval on the policy.

A sticker in the chart however is larger source of concern. It is not considered a valid part of a medical record and coding staff cannot report from something that is not part of the legal medical record. Additionally, signing your note as a method of agreement is not clinically valid data entry by a provider of medical care.  There is not enough documented proof that the person did anything other than sign (without reading) the note, and that kind of “validation” would not be supportable as a clinical decision.  A physician who signs the progress note of a medical student or nurse is not a substitute for the physician’s entry of the same verbiage in the medical record and will not stand under legal scrutiny. 

(Robin Holmes and Robert Gold of the ACDIS advisory board answered this question)

CMS posts ICD-10 Fact Sheet

During a recent planning call for the ACDIS 2010 conference in Chicago, the group discussed  creating a session specifically targeting ICD-10 challenges in the clinical documentation improvement world. Opinions on the matter were mixed. (I’ll post later this week with a list of potential topics the committee hopes to cover.)

While most people are aware that CMS plans to implement the new data set for ICD-10 come 2013, they’re unsure about how to proceed with transition planning and whether or not CDI specialists need to get involved in that planning process. General consensus seems to be that HIM leaders need to work closely with other department leaders to communicate the impact of ICD-10 and plan implementation strategies. CDI managers and department leaders should reach out to HIM counterparts and try to stay as informed as possible about ongoing changes.

CMS recently posted a fact sheet regarding ICD-10 that summarizes structural differences between the new system and its predecessor, ICD-9. It also explains how organizations and facilities should plan for the change and provides a list of helpful Web sites.

We also recently received a press release from 3M regarding its new 3M™ ICD-10 Code Translation Tool, a new software application that helps convert ICD-9 based applications to ICD-10. The release says the new program uses menu-driven features to convert existing systems and software applications to ICD-10. It also says the tool can be customized to create mappings for specific facility needs. Aside from its nifty new program, 3M does offer a free .pdf of frequently asked questions regarding ICD-10 that you may find useful for additional background reading.

You can also read more at ACDIS sister Blog ICD-10 Watch.

If all this seems to fall into the category of “too much information,” fear not. We’ll continue to keep you informed of what’s happening in the ICD-10 realm periodically.

Audio conference: Annual MS-DRG program Tuesday

You already understand the importance of MS-DRG selection. Picking the most appropriate principal diagnosis as well as valid secondaries is critical to ensure accurate MS-DRG assignment. New challenges such as Recovery Audit Contractors (RAC) scruitney coupled with increased focus on present on admission (POA) indicators and quality measures increases the need for comprehensive understading of changes to MS-DRGs.

Two of our favorite speakers— Gloryanne Bryant, BA, RHIA, RHIT, CCS, CCDS, regional managing director HIM (Revenue Cycle N. California) for Kaiser Permanente in Oakland, CA and Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta, GA— team up this coming Tuesday, September 29, at 1 p.m. EST, for the seventh annual DRG Update audio conference 2010 IPPS MS-DRG Update: Analyze the Rule and Understand the Impact.

The program examines changes in the 2010 MS-DRG list, defines various rules and regulations, and illustrates ideas to manage coding for MS-DRGs and documentation improvement.

New article of the month: Complications of surgery

Hi ACDIS members, there’s been a lot of talk regarding complications of surgery during our quarterly conference calls. In response, we worked with Dr. Robert Gold of DCBA, Inc. and the ACDIS advisory board, and Mario Perez of J.A. Thomas & Associates, to bring you a new article of the month on the subject.

Please click here to view the article or visit our main page.

As a reminder, you can find an archive of previous articles of the month (as well as many other articles and links) on our helpful resources page.

Take care,

Brian

Get all the information on anemia documentation

I’m just sticking my foot into a wicked pile of super sticky unknown substance by bringing this topic of ‘acute blood loss anemia’ back up. But there’s been so much back and forth with our own ACDIS Advisory Board to iron out the details published in this week’s CDI Strategies, that I was quite surprised when one of our readers e-mailed shortly after publication to ask another question based on the brief.

Another question? I thought we couldn’t possibly write anything more on the topic! Well, I was wrong. Our friend from Washington, DC, asked: “If  ‘precipitous drop in hematocrit’ is documented, must the baseline be known? What are the parameters and is it facility specific?”

So I’m throwing the whole thing out here  to blog land. Please help me by posting any (and all) information you might have regarding how you approach physicians with queries for anemia.

Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

• History
• Examination
• Medical decision making

History:  The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

• Problem focused
• Expanded focus
• Detailed
• Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

• The number of possible diagnosis and or management options
• The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
• -The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

Some important points that should be kept in mind when documenting level of risk are:

• Comorbidities/Underlying disease
• Surgical or invasive diagnostic procedures ordered, planned or scheduled.
• Surgical or invasive diagnostic procedure performed.
• The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

1. Minimal: Minor problems such as colds, insect bites, etc.
2. Low:  Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
3. Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
4. High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.

Few IPPS changes final rule could cause CDIs trouble

There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.

Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”

The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.

Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.

Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.