by Lisa Roat, RHIT, CCS, CCDS
If I were asked to rank exactly what documentation and coding issues facilities struggle with most, I would definitely say that bacteremia, Systemic Inflammatory Response Syndrome (SIRS), and sepsis would be high on the list. Quite honestly, I don’t think there is a question regarding the documenting and coding of bacteremia, SIRS, and/or sepsis in ICD-9-CM that we haven’t been asked.
Considering ICD-9-CM has been in use for more than 30 years and we still receive numerous questions about these topics, I can only imagine to what degree adding ICD-10-CM to the mix will add to the uncertainty. Let’s go through a few of the common terms and discuss concerns as they relate to ICD-10-CM.
Bacteremia is the presence of bacteria in the blood as evidenced by a positive blood culture. It is often transient and of no consequence; however, sustained bacteremia may lead to widespread infection and sepsis. The ICD-10-CM code for bacteremia, R78.81, can be found in Chapter 18, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings.
There are no ICD-10-CM official guidelines for coding and reporting that specifically pertain to bacteremia. However, because bacteremia is classified in the signs and symptom chapter, if a related definitive diagnosis is established by a provider, that definitive diagnosis either would be coded alone or sequenced first, depending on whether the bacteremia was considered an integral part of the disease process. Based on the “Excludes1” note, bacteremia should never be coded with sepsis.
The 2001 International Sepsis Definition Conference opted to omit the term “septicemia” in its official position statement. The updated terminology includes “sepsis” and “systemic inflammatory response syndrome,” and this practice is replicated in ICD-10-CM.
There is only a single reference to septicemia in ICD-10-CM, found under the code for sepsis, unspecified organism, A41.9. The draft ICD-10-CM Official Guidelines for Coding and Reporting removed all references to septicemia.
The idea behind defining SIRS was to establish a clinical response to a nonspecific condition of either infectious or noninfectious origin. SIRS criteria include:
- Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
- Heart rate of more than 90 beats per minute
- Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
- Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10 percent immature [band] forms)
There are two codes for SIRS of a non-infectious origin in ICD-10-CM, with assignment depending on the presence or absence of associated organ dysfunction: R65.10, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11, systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.
What many of us perhaps would consider one of the most significant classification changes related to sepsis in ICD-10-CM can be found in the SIRS category of codes. There is no longer a code for SIRS occurring due to an infectious process. The only references to SIRS in the ICD-10-CM Official Guidelines for Coding and Reporting are those specifically related to SIRS due to a non-infectious process. Instructional notes in ICD-10-CM tell us to code the underlying condition first, meaning the underlying condition should be sequenced before the SIRS code from subcategory R65.1.
Sepsis can be defined as the presence of both an infection and a systemic inflammatory response. The clinical features include two or more of the SIRS criteria occurring as a result of a suspected or documented infection, taking into consideration the entire clinical picture of the patient.
In the ICD-10-CM world, in order to accurately reflect the severity of illness and risk of mortality for patients who present with a localized infection, SIRS, and a clinical picture of sepsis, the provider must document sepsis as a diagnosis. A localized infection with clinical documentation of SIRS only can be coded and reported as the localized infection.
When a patient has sepsis with evidence of organ dysfunction, this is known as severe sepsis, and it is classified in ICD-10-CM either with the code R65.20, severe sepsis without septic shock, or R65.21, severe sepsis with septic shock. According to the ICD-10-CM Official Guidelines for Coding and Reporting, an acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the clinical documentation is not clear as to whether acute organ dysfunction is related to the sepsis or another medical condition, querying the provider is recommended.
The coding of severe sepsis requires a minimum of two codes. The first code will identify the underlying systemic infection, followed by a code from subcategory R65.2, severe sepsis. The codes for severe sepsis from subcategory R65.2 can never be assigned as a principal diagnosis. Don’t forget to add the codes for any associated organ dysfunction in order to reflect accurate severity of illness and risk of mortality.
Any article on clinical documentation and coding related to sepsis would not be complete without mentioning urosepsis. The ICD-10-CM Official Guidelines for Coding and Reporting indicates quite clearly that urosepsis is a nonspecific term that is not synonymous with sepsis. There is no default code for urosepsis in ICD-10-CM, and the provider must be queried for clarification when this term is documented.
However, based on the recently published American Health Information Management Association (AHIMA) recommendations regarding diagnosis options for providers, the options available in such a case must be clinically significant and reasonable, as supported by clinical indicators in the health record. A statement of urosepsis should not automatically generate a clarification for sepsis if there are no clinical indicators, risk factors or treatment documented to substantiate a clinical diagnosis of sepsis.
Without doubt, the sepsis conundrum will continue to plague us regardless of whether we are using the ICD-9-CM or ICD-10-CM code set. As professionals within this ever-changing world of healthcare, it is imperative that we continue to work toward enhancing our clinical knowledge levels and critical thinking skills. We need to remind ourselves, perhaps repeatedly, that the true representation of the quality of care provided to a patient, along with acuity of that patient and outcome data, still rests upon the quality of clinical documentation and coding.
Improved data will help improve the quality of healthcare, and isn’t that what it’s really all about?
Editor’s Note: Roat is the manager of HIM product development and compliance for J.A. Thomas & Associates, a Nuance Company. She is an AHIMA-approved ICD-10 CM/PCS Trainer. This article originally published on the ICD-10 Monitor and is reprinted here with permission. Contact Roat at email@example.com.
Too many CDI specialists live for the immediate satisfaction of today. Their primary focus is upon getting a diagnosis documented in the record once and then moving on to the next chart, looking to secure another diagnosis and score a “win,” as measured by number of queries generated and number of queries positively responded to by physicians.
The medical record must clearly articulate the physician’s clinical rationale and judgment in support of conclusive diagnostic statements. These statements alone, however, are no longer sufficient in support of diagnosis code assignment from both the physician and hospital perspective, not to mention establishment of medical necessity for inpatient admission as well as physician evaluation and management (E/M) assignment. The clinical facts of the case explicitly documented in the record, supported by the physician’s thoughts and updated plan of care, serve to best reflect the patient’s true clinical condition, acuity, and ICD-9-CM diagnosis code assignment.
If you get this added documentation in the chart, it deprives third-party reviewers of their widely pervasive stand to refute a once documented diagnosis on the basis of its clinical significance and recouping money from the hospital. This is I what I coin the “vision to see beyond immediate results.”
What do I mean by this statement? Let me demonstrate with an example.
What is stronger documentation: A physician responding to a multiple-choice query and writing the term “neuropathy” once in the record, or documenting as follows?
Neuropathy related to prior oxaliplatin dosing. Symptoms have not dissipated despite using a vitamin B complex. This may be a limiting factor in choosing future chemotherapy agents. If the chemo related neuropathy continues, consider stopping the current chemo regimen altogether and see if a short chemo holiday improves the patient’s severe neuropathic pain and then, perhaps, begin a new regimen. My immediate concern right now is to get the patient over the hurdle of her relentless pain in the legs and arms, then discharge the patient and see how she does, bring her back into the office for evaluation in a week and hopefully start a new chemo regimen.
This example, taken from an actual chart, shows the diagnosis of neuropathy with clinical support beyond the typical diagnostic conclusion statement. While neuropathy, aside from acute infectious polyneuritis, is not considered a “CC,” the level of documentation including discussion of the physician’s clinical judgment, thought processes, and medical decision making goes a long way in supporting the medical necessity for inpatient admission and continued stay in the hospital. Helping physicians incorporate explicit documentation of clinical facts undoubtedly adds value to our roles and responsibilities as CDI specialists. Yet this benefit is not immediately measurable in results the hospital’s chief financial officer can equate to in terms of revenue and return on investment for CDI staff.
Nevertheless, even if a condition is not a CC, we should still be seeking specificity from the physician—especially with ICD-10-CM/PCS implementation on the horizon. If we take the time to work with the doctors today on documentation that impacts their payment—i.e., reflects their medical decision-making and ensures medical necessity for procedures and services—they’ll be willing to help us tomorrow.
Keep in mind that taking the extra time with a doctor today might result in a short term loss of productivity. Maybe you only get to 22 charts instead of 25. But you’ll also be ready for when ICD-10 comes, and your physicians will have bought into your CDI program.
Speaking of ICD-10, here is an excellent link comparing ICD-9 to ICD-10 for several commonly-used codes. Use this to focus your CDI efforts on specific code sets: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals-Items/R1199OTN.html.
In short, get the extra specificity today. Strive for clinical support and documentation of all diagnoses, regardless of whether or not something is a CC with such efforts you will find the “vision to see beyond immediate results.”
DCBA started working with Atlanta Idea Studio marketing firm back in 2012. When they proposed we create educational content via video the entire DCBA team thought that would be a great approach to CDI education, as well as being a little entertaining. The project turned out fantastic and we are all excited and proud of our new video series. So far I have discussed topics like stroke and acute myocardial infarction and plans are in place to create additional videos discussing many more topics.
The regular segments on DCBAtv include “ICD-10 Insights” and “Ask DCBA.” In “ICD-10 Insights” we give an example of the specificity that is required for ICD-10. The “Ask DCBA” segment is inspired by our CDI forum CDItalk.com. We encourage CDItalk members to ask questions and we illustrate our responses through video. There is a lot of work that goes into these productions so we hope the CDI community enjoys them. Let us know what you think!
by Michelle A. Leppert, CPC
We all know that procedure coding will change considerably on October 1, 2014 with the implementation of ICD-10-PCS. But what about change as an ICD-10-PCS root operation?
In ICD-10-PCS, you will use the root operation change for procedures that involve:
- Removing a device then immediately inserting a similar device
- Exchanging the device without making an incision or puncturing the skin or mucous membrane
So, if the physician removes a patient’s percutaneous endoscopic gastrostomy (PEG) tube and immediately inserts a new one, report 0D20XUZ (change feeding device, upper intestinal track, external approach).
A change procedure always involves a device, but you need to make sure you are coding the correct device. For a change involving the upper intestinal track, we have three device possibilities:
- 0, drainage device
- U, feeding tube
- Y, other device
The approach for a change procedure is always external.
Other change procedures include:
- 0S2YX0Z, exchange of drainage tube from right hip joint (the body part for this code is very general—simply lower joint, so regardless of which joint is involved, you’ll report this code)
- 0B21XFZ, tracheostomy tube exchange
- 0W29X0Z, Change chest tube for right pneumothorax
- 0020X0Z, exchange of cerebral ventriculostomy drainage tube
- 0T2BX0Z, foley urinary catheter exchange (the device is a drainage tube because a foley catheter drains urine)
Editor’s Note: Michelle A. Leppert, CPC, is a senior managing editor specializing in outpatient coding for JustCoding.com, and wrote this article for the ICD-10 Trainer Blog.
Editor’s Note: I couldn’t help but “borrow” this post from my friend Michelle A. Leppert, CPC, a senior managing editor specializing in outpatient coding for JustCoding.com and editor of the ICD-10 Trainer Blog. If you haven’t had a chance to read her posts, you are missing out. Enjoy!
It’s Valentine’s Day and love is in the air. So are Cupid’s arrows.
Does ICD-10-CM include a code for assault by Cupid’s arrow? Not quite. The arrow itself would leave a puncture wound (probably), so we need to know where the arrow struck.
Since it’s Valentine’s Day, we’ll credit Cupid with excellent aim and we’ll say he shot me through the heart. ICD-10-CM includes two possible codes for a puncture wound to the heart:
- S26.09, other injury of heart with hemopericardium
- S26.19, other injury of heart without hemopericardium
Both codes require a seventh character to denote the encounter and since they are only five characters long, we’ll need to add an X placeholder.
We can also add an external cause code for being shot with an arrow:
- X99.8, assault by other sharp object (note that we need two placeholders and a seventh character for encounter with this code)
All three of our codes seem very unspecific, but keep in mind, we’re reporting “other” injuries and weapons. We know what the specific injury is and what caused it, we just don’t have a code specific enough.
In the aftermath of Cupid’s assault, my heart is beating fast at the sight of my true love. Oh, wait, maybe I’m actually experiencing palpitations—R00.2 (palpitations).
I’m so excited, I swoon. (That’s fainting in case you’re not a fan of romance novels). And fainting is also known as syncope.
That gives us ICD-10-CM code R55 (syncope and collapse). Before you report R55, make sure you review the extensive list of excluded codes and conditions.
Fortunately, my true love is fast on his feet and saves me from a nasty concussion from hitting the floor. (It’s about time he’s useful).
And he brought me flowers, how sweet. Achoo! Or not. It seems I’ve suffering from an allergic reaction to the flowers. Achoo!
My pollen allergy (J30.1, allergic rhinitis due to pollen) is in full force, but I’ll take the flowers anyway. Oh look, roses! With thorns. Great, now I have puncture wounds to my hands.
In order to code those wounds, we need to know:
- Which hand—left or right? Maybe it’s both. If so we’ll need to code for each separately.
- Where specifically are the punctures–palm or fingers?
- If the fingers are involved, which ones?
- Is the nail involved?
- Did part of the thorn remain?
Really, can this get any worse? Wait until I get my hands on that demonic angel of love!
by Laura Legg
Now is the best time to consider the clinical documentation initiatives you need to implement in 2013. The preparation for ICD-10 has documentation needs first and foremost on everyone’s mind. Start now and you have time for an effective and well planned set of initiatives.
Let’s look at some of the diagnosis specific initiatives.
Diabetes documentation and coding will need to include the type or cause of diabetes:
- Type I
- Type II
- Due to drugs and chemicals
- Due to underlying condition
- Other specified diabetes.
Pathologic (non-traumatic) fracture documentation and coding will need to include:
- Exact location of fracture-site and laterality
- Etiology of the fracture-osteoporosis, neoplastic disease, other specified
- Encounter type-initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae
Note these OB and pregnancy coding requirements:
- Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred. Some obstetric chapter codes specify trimester but not all.
- If the condition develops prior to admission, assign the trimester at the time of admission.
- If the patient is hospitalized during one trimester and a condition/complication develops during the same hospitalization but in a subsequent trimester, assign the code for the trimester in which the complication developed.
- The provider’s documentation of “weeks” may be used to assign appropriate codes for trimester.
- ICD-10-CM definitions of trimesters:
First trimester=less than 14 weeks, 0 days
Second trimester=14 weeks, 0 days to less than 28 weeks, 0 days
Third trimester=28 weeks until delivery
- Gestational diabetes needs specification of diet controlled or insulin controlled. If both, assign the code for insulin controlled.
Incorporate the following scales into documentation templates or queries.
- National Heart, Lung and Blood Institute asthma severity classification scale of intermittent, mild persistent, moderate persistent, and severe persistent.
- Glasgow Coma Scale will need a score from each of the three assessment areas: eye opening, verbal response and motor response
- Gustilo Open Fracture Classification-I, II, III, IIIB, or IIIC
Additional documentation tips:
- Anticipate needing queries for approach, laterality, and root operation for procedure coding.
- Clarify the relationship between chronic obstructive pulmonary disease, bronchitis, and asthma. ICD-10-CM distinguishes between uncomplicated cases and those in exacerbation. An acute exacerbation is a worsening or decompensating of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition. An additional code can be used regarding exposure to or use of tobacco.
- Physicians will need to document side of dominance: left, right, or ambidextrous.
- Codes in ICD-10-CM include laterality for paired organs or structures.
- General and focal seizures have different codes and general seizures require specific type and identify intractable seizures.
- Provider must identify the substance related to adverse effect, poisoning, or toxic effect.
As we learn more about ICD-10 in the coming months, more clinical documentation issues will be brought forward. Be prepared. I’ve heard it said often in 2012 that the key to successful ICD-10 implementation is improving our clinical documentation to meet the specificity requirements. Propel your ICD-10 preparation by beginning now.
Editor’s Note: This post originally published on our sister blog, ICD-10 Trainer. It was written by Laura Legg, an HIM and coding consultant based in Renton, Wash.
by Melinda Tully, MSN, CCDS, CDIP
My last blog post focused on physician profiling. Time and time again, I’ve seen that once physicians understand how clinical documentation impacts their pay, profiling, medical/legal risk and severity of illness reporting, they realize it is in their best interest to learn the key elements of clinical documentation improvement (CDI), and how that applies to ICD-10.
As we all know, it’s not just physicians getting a grade. Whether it’s Healthgrades, Hospital Compare or Consumer Reports’ Hospital Ratings feature, it is easier than ever to search and find scores for hospital performance. Finding a quality physician or hospital has become as easy and simplified as searching for a favorite restaurant online.
Hospitals and health systems need to make sure their ‘grade’ online is a true reflection of performance. And since that grade is derived from coded data and abstracted from quality measures, CDI has yet another role to play in setting the record straight.
Perhaps the most significant transition facing hospitals is value-based purchasing (VBP). Required by the Patient Protection/Affordable Care Act, VBP shifts payment models so that hospitals will receive value-based incentive payments which start in October 2013 based on performance or improvement on a set of clinical and patient experience-of-care quality measures. It is now more important than ever to document carefully. Hospital reimbursement will not only be based on severity of illness (case mix) but also on the quality of care delivered and patient outcomes.
What’s at stake for hospitals?
- Hospitals face an expected $270 million in readmission penalties
- Stakes increase each year, as these programs increase the percentage of reimbursement at risk across several years
Hospitals face two choices: Make sure revenue stays at least neutral during this transition; or, leverage this focus on accurate documentation for payment to improve its overall case mix index – and turn VPB into a strategic advantage. With ICD-10, hospitals have the opportunity to increase specificity by shifting the Medicare Severity Diagnostic Related Group coding system (MS-DRG), explaining resource consumption patterns, and reporting severity of illness, or risk of mortality.
If a hospital is ready to look at VBP as a strategic advantage, then top-level administrators should ask themselves the following:
- Do you have a CDI program in place now—or plan to ASAP?
- Are you actively monitoring your CDI program?
- Are you benchmarking yourself to your peers with a CDI program?
- Have you set goals for targeted improvements?
- Are you reviewing all payment schemes that base payment on coded data?
- Are you prepared to manage the CDI opportunities afforded by both ICD-10-CM and ICD-10-PCS?
- Have you determined if your CDI program is adequate for both ICD-9 and ICD-10 success?
If a hospital answers ‘no’ to any of the above questions, they are leaving opportunities at the door.
Editor’s Note: Melinda Tully, MSN, CCDS, CDIP, vice president of clinical services and education, joined the Nuance team in October 2012 as part of the J. A. Thomas & Associates acquisition. This post originally published on the Nuance blog “For the Health of IT.” Contact her at firstname.lastname@example.org.
Why is it that a date ending in 2013 seems so much closer to October 2014? Others must feel this way because there seems to be a really flurry of activity at the ICD-10 websites since the new year. Hopefully, this new year is spurring us forward with ICD-10 implementation.
The new year is a good time to take stock of where you are and to think about what needs to happen in 2013. Perhaps we should start with a discussion of physician queries and look at best practices.
(Remember ACDIS and AHIMA will release a joint physician query practice brief in February, so stayed tuned for those guidance updates.)
Queries should be:
- Clearly and concisely written, contain precise language
- Present the facts and why clarification is needed, present the scenario
- Individualized to each patient and contain clinical evidence specific to the case
- Used to clarify the intent of the physician
- Include the option that no additional documentation or clarification can be provided
- Addressed to a specific provider and close with the query author’s name and phone number
- Maintained in the medical record and be used as supporting documentation for coding
- Sent using only approved templates
On the other hand, queries should not:
- Be used as a substitute for appropriate physician documentation in the record
- Indicate to the provider an increase/decrease in payment
- Introduce information not otherwise contained in the medical record
Facilities should have a clear written policy or procedure to address the entire query process. The policy should:
- Explain when it is appropriate to query a physician
- How the query should be conducted
- Address where and how long the query will be kept
Make sure staff members are trained so they are familiar with acceptable query procedure.
Audit completed queries. Queries should be properly completed and appropriately dated and authenticated or they are noncompliant.
Organizations must also develop processes to:
- Notify the provider when a query is placed (email, note, fax)
- Follow up on open queries
Editor’s Note: This article originally published on the ICD-10 Trainer Blog. Laura Legg is an HIM and coding consultant based in Renton, WA . Her interests include ICD-10 CM/PCS, coding compliance, and Recovery Auditors. She has more than 25 years of experience in HIM and has served as an HIM Manager/Director for several acute care/critical access hospitals and a major hospital system.
Q: Can you explain how we would code a percutaneous transluminal coronary angioplasty (PTCA) using ICD-9-CM vs. ICD-10-PCS?
- 36.06 (insertion of non-drug-eluting coronary stent)
- 00.66 (angioplasty [PTCA])
- 00.45 (insertion of one vascular stent)
- 00.40 (procedure on single vessel)
- 00.44 (procedure on vessel bifurcation)
- 0 (medical/surgical [procedure])
- 2 (heart and great vessels [body system])
- 7 (dilation [root operation])
- 0 (coronary artery, one site [body part])
- 3 (percutaneous [approach])
- D (intraluminal device [bare metal stent])
- 6 (bifurcation)
Q: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?
A: These are just my predictions, but I think that inpatient cases are going to drop to 2.5–3 records per hour. Currently we’re upwards of 3–3.5 per hour in non-teaching/tertiary environments.
On the ambulatory surgery side, I think those are going to drop to 5.5-6.5, and I really think it will be closer to the 5. HCPro’s 2011 Coder Productivity survey results show coders completing 6 -7 cases per hour at the time. So the reason I give these estimate is because we’re going to have more of a challenge with the surgeons being able to provide coders the information needed. So I really do think it will be the lower end of that range.
And if you’re one of those facilities that codes today in both ICD-9 and CPT® and if you can continue that practice in ICD-10 and CPT, then you’re going to have more of a reduction, closer to 4 cases per hour just because of the two different thinking patterns for the two coding classifications.
For non-interventional radiology outpatient testing cases, we’re averaging approximately 25–30 per hour right now. I think we’ll that also go down slightly to a range of 23–26.
Editor’s Note: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of St. Louis–based First Class Solutions, Inc., answered this question during the February 29-March 2, 2012 “JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS, ” and was originally published on JustCoding.com.