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Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

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.

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Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

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.

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Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

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?

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.

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Q&A: Documenting excisions in dermatologic settings

ask ACDIS

Have CDI questions?

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

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Guest Post: Addressing unspecified codes

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less conscientious about their diagnosis coding, leaving them to focus only on the first three characters of the code for medical necessity purposes. In actuality, some providers took the compromise as a license to map their superbill codes and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Matthew Menendez of White Plume Technologies estimated in 2016 the average rate of unspecified code use at the time was 31.5%.

“Payers want the more detailed diagnosis information available in ICD-10. The reason that both government and commercial payers advocated for the migration to ICD-10 and invested millions of dollars to rewrite their adjudication processes was for the granular diagnosis data on their insured patient populations. Payers want to leverage detailed ICD-10 codes to drive down the cost of healthcare in the United States and if the provider community does not supply this data they will begin to deny claims,” Menendez said.

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Q&A: Rejections for claims for removing impacted cerumen

ask ACDIS

Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

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Measuring the effect of HCCs, part 3

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the first part of this article, click here. To read the second part of the article, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

The effect of hierarchical condition categories (HCCs) may double as hospitals buy physician practices and form health systems made up of a spectrum of different types of providers. Physician reimbursement has become increasingly complex and some physicians find it easier to operate with the support of a larger organization. Organizations that were once solely hospital-based now have to grapple with the complexities of a different set of billing and reimbursement regulations, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee and a hospitalist at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

Fee’s seen a lot of interest in HCCs from large multi-practice groups affiliated with a larger organization and some smaller physician practices have also started to pay attention to HCCs, particularly if they work with a larger organization for EHR assistance to support meaningful use. “I think we’re at a tip of an iceberg in terms of interest in HCCs. I think providers have a lot more to learn about HCCs,” he says.

As provider organizations grow, they should create a program to collect and merge patient data for analysis just as payers do. This will give the provider insight into what reimbursement they can expect for certain patient populations and it can help pinpoint what departments need more help.

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Measuring the effect of HCCs, part 2

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the third part of this article, come back to the blog next week. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Separate rumors from facts in relation to risk-adjustment

Organizations may mistakenly believe that hierarchical condition categories (HCCs) are currently being applied to all reimbursement models and CDI program staff may not understand the nuances of how risk adjustments get calculated for certain claims-based outcomes such as mortality or readmissions, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee.

Organizations need to begin understanding HCCs and what their risk-adjustment factor (RAF) is, but these codes do not currently affect all reimbursement models across the board. For example, HCCs primarily affect the cost category of MIPS. The relative category weighting for cost is 0% for 2017 but will be 30% for 2019 and will not begin to affect payment until 2020. Evaluate what metrics and reimbursement are affected by HCCs and target resources.

“All of these risk-adjustment methodologies and HCCs in particular are being used in compensation in ACOs and in the value-based purchasing models that we’re looking at for future reimbursement,” says Monica Pappas, RHIA, president of MPA Consulting, Inc., in Long Beach, California. “So we really have to learn more about the system and be more informed about the impact of some of these codes that we typically don’t pay attention to.”

Organizations already specify if codes are complications or comorbidities or major complications or comorbidities and make calculations based on Medicare Severity-Diagnosis Related Groups. The same general principles can be applied to HCCs, Pappas says. Although the sheer number of codes can seem overwhelming, hospitals can work with vendors to create systems to track and flag the codes, and many HCCs fall in the same category, she says.

Coders and CDI professionals can use that as a shortcut to help them remember common targets. As demand rises, vendors will likely develop more sophisticated tools to assist in identifying these codes, flagging documentation for physicians and CDI specialists, and analyzing data.

“I don’t think any human being is capable of knowing all this,” she says. “The amount of information is massive and if we don’t look to some technology solutions, we’ll never win.”