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Note from the CCDS Coordinator: Over the Y92.838 and through the Y92.821 to Grandmother’s Y92.01 we go

Penny

CCDS Coordinator Penny Richards

By Penny Richards

Ah. Thanksgiving. While the ACDIS team will be out of the office for the Thanksgiving holiday and Black Friday, we know that the opportunities for mishaps requiring medical attention are far too plentiful to mention. We wouldn’t want to leave you without ACDIS’ guidance in this trying time, so here is a short list of codes that might prove helpful to the on-duty clinical documentation specialist. [more]

Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 3: Right heart failure

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part three in a three-part series. Click here to read parts one and two!

Right Heart Failure

Notice that we now have new codes for acute, chronic, and acute-on-chronic right heart failure. Remember also that Coding Clinic, Third Quarter, 2013, p. 33, states that the documented term of “decompensated” indicates that there has been a flare-up (acute phase) of a chronic condition. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018: [more]

Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97. [more]

Q&A: Reporting right-sided heart

SharmeBrodie_May2017

Sharme Brodie RN, CCDS, answered this week’s CDI question.

Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein distension, swelling of ankles and feet, etc.

A: ICD-10-CM has codes associated with the documentation of right-sided failure and for left-sided failure. Each ventricle supplies different portions of the circulation, so heart failure can be described as either right or left depending on the symptoms. When the right ventricle fails, we call it right-heart failure. In this case, fluid backs up into the peripheral circulation, into the legs, head, and the liver. Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. [more]

Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 1: Myocardial infarction

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part one in a three-part series. Return to the blog next week for the next installment! [more]

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]

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.

[more]

Guest Post: Improving the selection of a principal diagnosis

Commeree_Adrienne_web_106x121

Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.

But while code selection may seem fairly straightforward in some cases, it can seem like throwing a dart at a board in others. Multiple factors must be considered and reviewed before a coder can assign a diagnosis as principal. There may be many reasons a patient went to the hospital, and multiple conditions may have been treated during that patient’s stay. Because of these complicating factors, relying solely on a software program to discern the principal diagnosis might lead to errors. A thorough review of the documentation, along with a solid understanding of the Official Guidelines for Coding and Reporting, instructional notes, and Coding Clinic issues, is imperative.

The ICD-10-CM Official Guidelines for Coding and Reporting state:

The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS collects data on patients related to race and ethnicity and is issued by the Centers for Disease Control and Prevention. Its definitions are used by acute care hospitals to report inpatient data elements that factor in the DRG classification system, which is how the hospital receives reimbursement for the inpatient admission.

Coders and CDI professionals must review all the documentation by the physician or any qualified healthcare practitioner who, per the coding guidelines, is legally accountable for establishing the patient’s diagnosis.

Parts of the medical record include the history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary. While reading through a provider’s documentation, coders must ask themselves: “Is this condition requiring any diagnostic evaluation, therapeutic work, treatment, etc.?”

Once a medical record has been completely reviewed, coders must decide which code identifies the reason the patient was admitted and treated: What condition “bought the bed”?

But our work isn’t done after that. Are there any instructional notes or chapter-specific guidelines that give sequencing direction for coding? For example, if a patient is treated for decompensated diastolic congestive heart failure and also has hypertension, instructional notes within Chapter 9 of the ICD-10-CM manual, Diseases of the Circulatory System, give sequencing directives for the coding of these conditions.

“Decompensated,” according to Coding Clinic, Second Quarter 2013, indicates that there has been a flare-up (acute phase) of a chronic condition. I50.33 is the ICD-10-CM code for acute-on-chronic congestive heart failure. However, before assigning that code as the principal diagnosis, you must check the instructional notes directly under category I50 for heart failure. These notes, usually printed in red, give sequencing guidance for codes in this category.

Per the Official Guidelines for Coding and Reporting, “code first” informs coders that these conditions have both an underlying etiology and multiple body system manifestations due to that etiology:

“For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a ’use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

To code for the hypertension, the instructional notes guide the coder to reference code I11.0 (hypertensive heart disease with heart failure). More instructional guidance following the code helps the coder correctly assign the principal diagnosis for this patient.

But we’re still not done. Are there any issues of Coding Clinic that give more information regarding the assignment of a principal diagnosis? In reference to the example above, congestive heart failure with hypertension, documentation guidelines for reporting these two conditions have changed for 2017.

The Third Quarter 2016 Coding Clinic reiterates the documentation requirements and sequencing by stating that “the classification presumes a causal relationship between hypertension and heart involvement.”

The preceding example is one of many. A coder can have more than one diagnosis that fits the definition of a principal diagnosis, or possibly two diagnoses that are contrasting (either/or). If there are no chapter-specific guidelines for sequencing (is the patient pregnant? Does the patient have an HIV-related illness?), then refer to Section II, subsections B, C, D, and E, in the ICD-10-CM coding guidelines.

Editor’s note: This article originally appeared in JustCoding. Commeree is a coding regulatory specialist at HCPro in Middleton, Massachusetts. Contact her at acommeree@hcpro.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.