Notice to our ACDIS members: ACDIS has recently learned that some minor procedures coded in ICD-10-PCS lead to surgical DRG assignments and unexpectedly high payments. This has led to some facilities opting not to code these procedures, believing that it may result in future recoupments from CMS.
Please take a moment to answer this anonymous six question survey. ACDIS plans to alert regulatory coding authorities with these findings in hopes to attain clarification.
By, Robert S. Gold, MD
Although we have gone through years of confusion regarding “cardiac arrest” and probably came to some conclusions about when it gets coded and when it doesn’t, this Ghost of CDI Past has come back to haunt us.
The code for cardiac arrest in ICD-9-CM was 427.5. In ICD-10-CM, it has expanded to include elements of the I46 series, where I46.2 represents cardiac arrest due to an underlying cardiac condition, I46.8 represents cardiac arrest from some other underlying condition and I46.9 is for “I have no idea why” cardiac arrest (also known as cause unspecified).
Well, first things first (again): In the process of dying of some chronic or acute disease or traumatic process, the heart stops. No cardiac arrest code is applied for these circumstances at all.
On the other hand, if the patient is not expected to be in the process of dying and something happens and the heart stops, whether it’s called sudden cardiac death or cardiac arrest, then the cardiac arrest code is assigned.
If the cause is known, or pretty clear even if it’s not known, then the specific code is assigned. Cardiac arrest due to ventricular fibrillation gets the I46.2 code as well as the specific code for ventricular fibrillation (I49.01) for the added specificity.
When the cause is hypercalcemia or hyperkalemia, then we have the I46.8 code plus the specific code for the electrolyte disturbance that led to the cessation of heartbeat. OK, that’s one. We code it when it’s appropriate to code it.
But, as I have heard in ICD-9-CM and am now starting to hear in ICD-10-CM, “We’re giving CPR, which is ‘cardiopulmonary resuscitation,’ and the patient’s oxygen saturation is 60%, so obviously the patient has acute hypoxic respiratory failure, right?” Wrong!
When the heart stops, whether while dying from lung cancer or responding to a massive ST elevation myocardial infarction at the origin of the left anterior descending coronary artery, breathing stops, renal function stops, the brain function stops—the patient dies—unless circulation can be restored. So all this advice of getting doctors to document “acute hypoxic respiratory failure” just because the oxygen saturations are low is bogus.
Does this mean that the two can never be coded together? Not at all! If the acute hypoxemic event precedes the cardiac arrest, as in drowning or smoke inhalation or acute pulmonary edema, and that is followed by a fatal arrhythmia or a myocardial infarction which stops the heart suddenly, then it is quite proper to look at having both events documented and coded. But you don’t shoot for a diagnosis just because of a lab result and your opinion that “it just makes sense.”
Editor’s Note: This post was originally published in Just Coding.
Once a physician documents heart failure, CDI specialists should look for evidence to support the type—either systolic or diastolic.
The terms systolic and diastolic heart failure describe the pathology of the heart failure, which can affect both the left and right sides of the heart, resulting in symptoms associated with either and/or both of these conditions. Consequently, it is difficult to diagnosis the pathological cause of heart failure by symptoms alone.
The CMS quality measure (HF-2) for inpatient care requires that any patient admitted with heart failure has documentation of a left ventricular systolic (LVS) function study in which the evaluation occurred before arrival or during hospitalization or is planned for after discharge. As such, it is likely that the medical record will contain this value, and that can assist with determining the type of heart failure.
Although codes cannot be assigned based on documentation from a previous visit, this information can be used as a clinical indicator for a specificity query. Remember that a new diagnosis cannot be introduced in the current record; the old record would only be a source to support the clinical indicators within a query.
Editor’s Note: For information, check out The Clinical Documentation Improvement Specialist’s Guide to ICD-10.
The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS included some new language, which could help clear up confusion for CDI specialists and HIM/coding professionals regarding use of prior ICD-9 guidance.
By way of background, in 2010 the AHA stated that previous issues of Coding Clinic would not be translated to ICD-10-CM/PCS. The announcement led many to question if Coding Clinic advice could even be applied to ICD-10 coding practices, and if auditors will deny claims based on advice from AHA Coding Clinic for ICD-9-CM.
Previously, the AHA responded stating that past advice has focused on what documentation could be used and has not been specific to a coding system. However, in the December 2015 Coding Clinic, the AHA wrote:
In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD-9-CM, and remain applicable to ICD-10-CM with some caveats. For example, Coding Clinic may still be useful to understand clinical clues when applying the guideline regarding not coding separately signs and symptoms that are integral to a condition. Users may continue to use that information, as clues—not clinical criteria.
As far as previously published advice on documentation is concerned, documentation issues would generally not be unique to ICD-9-CM, and so long as there is nothing new published in Coding Clinic for ICD-10-CM and ICD-10-PCS to replace it, the advance would stand.
In response, Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, says any ICD-9 Coding Clinic that describes clinical situations or general guidance that is consistent with the ICD-10-CM/PCS Official Guidelines for Coding and Reporting can likely be applied.
Coders and CDI specialists may come across scenarios where guidance is consistent, and other situations where guidance is contradictory, Prescott says. Stop and reflect when using ICD-9 Coding Clinic guidance, and ask yourself if the ICD-9 guidance in any way conflicts with the new code set, coding conventions, and guidelines.
If there is a conflict, Prescott says do not rely on the ICD-9 Coding Clinic and instead follow the guidance within the ICD-10-CM/PCS Official Guidelines for Coding and Reporting.
This past weekend marked the one-month anniversary of ICD-10-CM/PCS implementation. The date that many feared would destroy their organization came and went—without much to-do. In fact, a recent poll on the ACDIS website indicated that 42% of respondents said their facility it handling ICD-10 implementation fine with no real problems, and 36 % are handling implementation okay with only a few minor documentation or coding hiccups. Less than 15% say implementation has been “not great.”
While it’s still too early to call ICD-10 implementation a success, some facilities are already asking “what’s next?”
Facilities may be eager to move ahead with the next project, but don’t rush. Depending on issues identified throughout this first month, ICD-10 response teams—IT, HIM, and CDI staff, at minimum— should continue to meet once or twice a week to address and answer questions that arise relating to documentation, CDI, and coding.
If your team hasn’t started one, create a log of questions, resolutions, and outstanding concerns. Develop a plan for continued education for physicians, coding, and CDI staff, which targets newly identified problem areas.
Be sure to include the physician champions or medical staff leadership in these discussions, and address physician concerns in a timely manner. The goal should be to resolve documentation issues as they occur, so physicians can learn and the problem doesn’t arise again.
B early 2016 response teams and/or leadership should start to identify system issues and a corrective action plan if problems exist. Run reports for an MS-DRG shifts and analyze for potential opportunities and improvements in areas such as case-mix index, DRG volumes, and MCC/CC capture. Determine financial impact of ICD-10 on outpatient services and use national coverage determinations for assessments.
Editor’s Note: This post was compiled using a number of ACDIS resources. For more information, check out the following:
Physician education has been a challenge for CDI specialists long before ICD-10 implementation. Now that we’re nearly three weeks in, some physicians may start to feel that they don’t need continuing ICD-10 education. The reality is ICD-10 will be an ongoing learning process for everyone. But, how do you keep physicians interested in what you to say?
Erica Remer, MD, FACEP, CCDS, clinical documentation integrity officer of University Hospitals in Cleveland, Ohio, said CDI specialists need to view this time as an opportunity to not only continue ICD-10-related education, but to embed standard CDI information to keep them engaged. “This is a great opportunity to go through the things that [the physicians] weren’t doing right in ICD-9 and reinforce it with ICD-10 education,” she said during the October 14 ACDIS Radio call. “This is a fresh start and one we should be capitalizing on.”
When placing a query, teach them why you had to query in the first place, Remer suggests. Educate them so you don’t have to query them and so they document properly—fewer queries is certainly an incentive to document correctly!
Physicians want to know what’s in it for them—what they get out of documenting more specifically, Remer says. When approaching physicians with an ICD-10 subject, reiterate things like quality scores, or physician ratings on sites like HealthGrades.com and HospitalSafetyScore.org. Make sure they know how documentation affects not just the hospital but their individual jobs and reputations. This helps get physician buy-in, says Remer.
CDI specialists should also take ICD-10 implementation as a “fresh start,” an opportunity to evaluate their own practices. At University Hospitals, CDI specialists make a point to query in a more timely fashion and stay on top of operative notes to make sure they are completed quickly, Remer says. “You can’t do procedures (PCS) without an op[erative] note,” says Remer. “It’s crucial now [for documentation]. What we would really like to prevent is having to query [the physician] twice.”
Editor’s Note: This post was written using a number of ACDIS resources, including:
Labor Day marks the unofficial end of summer, and hopefully, the end of patients with picnic-induced problems at the Fix ‘Em Up Clinic.
Dr. Sunni Daze sees Sam and diagnoses Sam with a torn medial collateral ligament and a torn lateral collateral ligament.
Unfortunately, Dr. Daze didn’t specify which knee in the diagnosis. She did, however, document that she examined his left knee, so we have laterality. We also know she is seeing Sam for the first time for these injuries, so we would report:
- S83.412A, sprain of medial collateral ligament of left knee, initial encounter
- S83.422A, sprain of lateral collateral ligament of left knee, initial encounter
She refers Sam to an orthopedist for further treatment. When Sam sees the orthopedist for the first time, we will report the exact same codes, even the same seventh character. Seventh character A is used when the patient is receiving active treatment, including when the patient sees a new physician.
Our second patient, Jake, fell victim to a vengeful squirrel during his family’s picnic in the park. The squirrel made a move to steal Jake’s potato chip for a snack. When Jake reached for it, the squirrel got a mouthful of Jake’s hand instead of the tasty treat. The squirrel took off, leaving Jake with a bleeding bite wound.
Dr. Daze documents the following:
Patient presents for initial treatment of open bite wound on hand caused by squirrel. Cleaned and irrigated wound. Placed five stiches in left hand. Applied sterile bandages. Prescribed antibiotics. Sent patient home with instructions for keeping the wound clean.
Again, we know laterality and encounter, so we would report S61.452A (open bite of left hand, initial encounter).
If your payer requires external cause codes, we do have one for bitten by squirrel (W53.21). Don’t forget the placeholder and seventh character.
Editor’s Note: This article originally published on the ICD-10 Trainer Blog.
A couple of weeks ago, CMS and the American Medical Association (AMA) released a series of questions and answers regarding the July 6, 2015 joint announcement on ICD-10-CM/PCS implementation flexibilities. CMS answered 13 questions that a lot of CDI specialists and coders had been asking.
For the first year of ICD-10 use, CMS will not deny or audit physician claims based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family of codes. What is family of codes, you ask? According to CMS, a “family of codes” means any code from the same ICD-10 three-character category.
Here’s an example: Take category H25 (age-related cataract): this category, according to CMS, is a family. The family contains a number of specific codes that capture information on the type of cataracts, as well as information on the eye involved.
If a coder were to report H25.9 (Unspecified age-related cataract) when the patient really suffered H25.031 (Anterior subcapsular polar age-related cataract, right eye), CMS would not audit or deny this claim because a valid code was reported within the correct family.
What does this mean for CDI? Well, for one, CMS never said it wouldn’t deny claims for medical necessity. Additionally, this “deal” with the AMA only pertains to private physician practice, not hospital claims. This means CDI needs to work especially hard to make sure the documentation is as specific as possible, and clearly supports why the patient required the treatment they received. Some things you can do to ensure specific and accurate documentation include:
- Make sure the documentation includes all conditions that were clinically evaluated, that were therapeutically treated, that were studied, that extended the length of stay, or that increased nursing care or monitoring.
- Ask questions and query—if something isn’t clear to you, or if you think it can be documented to a higher specificity, do not hesitate to get a second opinion from a CDI or coding peer, and/or query the physician.
- Try to review every piece of the record, including, but not limited to, physician assessments and orders, ER nursing assessments, EMT records, history and physical, other physician orders, nursing admission assessments, consulting physician documentation, operation reports, diagnostic testing, ancillary staff reports, and progress notes.
- Confirm the principal and any secondary diagnoses, symptoms relating to these diagnoses, surgeries or treatments, and any change in care level.
- Take the time to verify the correct code assignment/sequencing and clinical indicators.
With specific, detailed documentation, coders will be able to report the most specific code. While this may seem basic, these tips could help your facility defend against denials, which are still very possible even if the code is within the correct family.
Editor’s Note: This post was compiled using a variety of ACDIS and HCPro resources. For more information, check out:
- The Clinical Documentation Improvement Specialist’s Guide to ICD-10
- The Clinical Documentation Improvement Specialist’s Complete Training Guide
- family,” originally published on the JustCoding ICD-10 Trainer blog
- “CMS clarifies ’family of codes,’” originally published in CDI Strategies
An experienced CDI specialist should have an average daily census of 12-15 new patients and five to 10 established/follow-up cases. A good rule of thumb is one CDI specialist for every 1,200-1,500 discharges per year. The more functions a CDI specialist is expected to perform, the higher the staff ratio should be. Smaller CDI staff should focus on condition clarification only. However, many CDI programs are understaffed—some only employ one CDI specialist. Such staffing will become even more problematic once ICD-10 implementation begins.
Reviews are going to take more time and require more resources. While CDI staff ratios and productivity expectations depend on the program’s mission, CDI programs need to evaluate whether or not their program’s focus is realistic for their staff size. More importantly, they must start considering whether or not they need to bring on additional staff to bridge those anticipated productivity gaps.
Most programs query to identify incomplete, vague [more]
Those following the episodic turns of the ICD-10-CM/PCS implementation saga witnessed another dramatic plot twist in the narrative this week when the American Medical Association (AMA) and CMS made a joint announcement essentially prioritizing physician ICD-10 education and allowing some flexibility in claims auditing and quality reporting.
“ICD-10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD, in a joint statement with CMS Monday morning, July 6.
Stack’s statement not only marks a sea change in opinion from the AMA. Yet those hoping the agreement might also resolve years of debate and back-room political attempts to delay ICD-10 implementation may just have to keep on hoping until the actual implementation date comes to pass. Last week (July 10) Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-N.C., introduced H.R. 3018, the Code-FLEX Act, to allow submission of ICD-9-CM and ICD-10-CM codes for 180 days after implementation.
W. Jeff Terry, MD, a Mobile, Alabama, urologist, sounded off on the problems of ICD-10-CM/PCS implementation in a HealthLeaders Media article, “AMA Delegate Blasts ICD-10 Implementation Requirements,” on Friday, July 1. And previous AMA leaders described ICD-10-CM/PCS’ detriments in Star Wars terms, Healthcare IT News pointed out this week, recalling that past-AMA President Robert Wah, MD, indicated the group wanted to essentially freeze the code set in carbonite.
Despite the new Code-FLEX Act proposal, the AMA and CMS seem to be moving forward with ICD-10 education. Although the details of their agreement seem simple enough, many news headlines seems to state that CMS gave physician practices permission to code incorrectly. When actually, CMS for its part said Medicare review contractors “will not deny physician… claims …based solely on the specificity of the ICD-10 diagnosis code as long as the physician used a valid code from the right family.” (Emphasis added.)
The problem comes, as Michelle Leppert points out in an an article on the ICD-10 Trainer Blog, that CMS does not define a family of codes. Is it a category of codes, such as 500, superficial injury of head? “That could be interesting,” Leppert writes, since the category includes nine subcategories which each also have further subsections.
While those entrenched in ICD-10-CM/PCS drama may say that these concessions read more like snip-its from the Official Guidelines for Coding and Reporting, getting the AMA to effectively bury its opposition is, for once, a welcome shift in the ICD-10-CM/PCS implementation storyline.
Editor’s Note: Portions of this article originally published in eNewsletter CDI Strategies. Subscribe now, for free.