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ICD-Trainer: Burnt marshmallows at summer’s end

Be careful at your end-of-summer camp out!

Be careful at your end-of-summer camp out!

First into the Fix ‘em Up Clinic today is Jeff. He took part in a s’more eating contest at camp last night. I’ve personally never understood the appeal of burned marshmallows, but Jeff, well he was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.

Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips. The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.

The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).

ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.

We also find the following note under pretty much all of the burn codes:

  • Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)

We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).

The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.

The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.

For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.

Dr. Daze is done for the day and so are we. Remember to make sure your food isn’t on fire before you eat it.Editor’s Note: This article is an excerpt from the ICD-10 Trainer Blog

Dual coding/CDI highlights holes in ICD-10 education, documentation, and program efficiencies

Have you started dual coding for ICD-9 and ICD-10? Two facilities shared their experiences during a July AHA webinar. The first task is to determine what dual coding means for your facility, said Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA. Are you coding records concurrently in ICD-9 and ICD-10, or are you coding in ICD-9 and then going back and coding in ICD-10? Figure out which approach will work best at your facility.

Also, are you coding natively in ICD-9 and ICD-10 or are you using some type of crosswalk? Again, that’s up to each facility to decide. One caution about crosswalks, though. You can’t code from a crosswalk alone. That’s not their purpose. A crosswalk can get you to the correct area of the codebook, but it won’t give you the precise code in most cases. Most ICD-9 codes map to multiple ICD-10 codes because the ICD-10 codes are more specific. If every code had a one-to-one match, we wouldn’t need to move to ICD-10.

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Join us to learn more about CDI’s role in dual coding on 9/10/14.

A third point to consider: Is one person coding the same record in ICD-9 and ICD-10 or is one coding it in ICD-9 and someone else coding it in ICD-10? Cindy Hutchinson, CCS, CCS‐P, corporate director of coding services for Intermountain Healthcare in Utah, shared that her coders are coding the same record in both systems. Initially, different coders were coding the record in ICD-9 and ICD-10; once the same coders started coding the records in both systems, it made them more efficient, she said.

Nine months into dual coding, most coders are back to their baseline productivity, with the exceptions of complex surgical cases and Intermountain’s children’s hospital.

Linda M. DiGregorio, RHIA, CCS, associate director clinical documentation, coding, and reimbursement for Winthrop University Hospital in New York, said her coders began dual coding with obstetrics cases in January. In February, they added concurrent dual coding of all hip and knee replacement surgeries, in addition to open reduction internal fixation cases. This month, they also began concurrently dual coding cardiac cases.

DiGregorio said coding productivity has dropped 60%.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.  Join Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA; Rebecca “Ali” Williams, RN, MSN, CCDS; and Tara L. Bell, RN, MSN, CCM, on September 10, 1 p.m., Eastern, for the webinar “Dual Coding/CDI: Practical Steps to Advance your Facility’s ICD-10-CM/PCS Readiness.”

Guest Post: Have you had a CDI check-up lately?

Kelli Estes

Kelli Estes

By Kelli Estes, RN, CCDS

A large number of hospitals across the country have some version of a CDI program in place. With ICD-10 implementation on our heels, it is recommended by AHIMA that all hospitals have a “mature” CDI program in place by October 1, 2014.

In October 2013, I attended the AHIMA pre-conference coding meeting in Atlanta. An informal polling of the audience led to some interesting revelations regarding CDI program maintenance and growth through audits. Most everyone in the room professed to having an internal and external audit process in place for coding, but only a few hands went up when asked about having a CDI-specific audit process. Additionally, recommendations were made to have outside auditors assess CDI programs currently operating under ICD-9 to leverage their stability during the transition to ICD-10.

A thorough, CDI-specific audit can illustrate how viable any CDI program will be come ICD-10, particularly considering projections of a 25% decrease in productivity as a result of ICD-10. Let’s face it!  If you have CDI problems with ICD-9, you will have those same problems with ICD-10. So don’t delay  developing policies and procedures for CDI audit processes including conducting your own internal audits and hiring an external audit team.

What should should you audit for? Good question. Here are some of the items we recommend:

  • CDI specialists’ query writing skill/compliance
  • Missed opportunities to capture MCCs/CCs as well as further severity of illness and risk of mortality
  • Query trends to identify educational opportunities for physicians
  • Productivity when reviewing patient records

Most models of CDI look similar on the surface, but when assessing the detail in the various moving parts you will find differences that could cost your organization big in the long run. You want to make sure you are working smarter, not harder. You also need to identify process improvement needs such as collaboration with other healthcare team members involved in the care of the patient  (i.e., nutrition, wound care, care management, core measures). The only way to capture this type of information best is by reviewing a random selection of CDI cases and overall processes.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.

For additional information on performing program audits read these related articles from ACDIS:

Eight ICD-10 diagnoses to examine for CDI opportunities at your facility

Adelaide LaRosa

Adelaide LaRosa

There are many conditions you need to have on your radar as you think about ICD-10 documentation. We already know physicians will need to do a better job at documenting laterality in ICD-10, says Adelaide La Rosa, RN, BSN, CCDS, director of HIM, CDI, and clinical data management at Catholic Health Services of Long Island in New York. La Rosa advises CDI and HIM professionals to be on the lookout for documentation of laterality in cancers, cerebral infarction, pressure ulcers, extremity atherosclerosis, arthritis, fractures, sprains, joint pain and effusion, dislocations, and tears.

In addition to laterality, La Rosa recommends working with physicians to document information specific to the following conditions:
  1. Urinary tract infections (UTI). Discuss how documentation of a UTI corresponds with how it’s coded, La Rosa said. “In coding, it’s one word that’s missed and the whole coding changes,” she said. Documentation of a UTI will result in coding for a UTI. However, documentation of a UTI with evidence of systemic infection results in coding for sepsis, and documentation of a UTI with evidence of systemic infection and organ dysfunction results in coding for severe sepsis, according to La Rosa.
  2. Arteriosclerotic heart disease (ASHD). Make sure physicians document the location of ASHD and its associated symptoms, La Rosa said. The new code set will break things down based on whether ASHD exists without angina pectoris, with unstable angina pectoris, with angina pectoris with documented spasm, with other form of angina pectoris, or with unspecified angina pectoris, La Rosa says.
  3. Myocardial infarction (MI). Documentation for MI must include whether it was an ST-elevation MI or a non-ST-elevation MI, according to La Rosa. ICD-10 codes require documentation of the coronary artery involved and the site of the MI, so physicians should start including this information in patient records now, she says.
  4. Asthma. Medication requirements and documentation of symptoms help determine the severity of asthma, according to La Rosa. In ICD-10  we will see codes for mild intermittent, mild persistent, moderate persistent, and ­severe persistent asthma, according to La Rosa. HIM and CDI professionals should meet with their organization’s chief pulmonologist to clarify these categories and determine what information needs to be in the record to capture disease severity, La Rosa says.
  5. Diabetes mellitus. Work with your physicians to ensure they are documenting the underlying conditions associated with diabetes mellitus, La Rosa says. Documentation should include complication and manifestation information so you’re not missing patient data when coding in ICD-10, she adds.
  6. Gout. Specific documentation is required when coding for gout in ICD-10. Make sure physicians document the cause, the specific site, and whether it is acute or chronic, La Rosa said. “If this is obviously documented in the charts, the coder, [or the] CDI specialist, will get to the highest level of coding based on that documentation,” she says.
  7. Dementia. Physicians should document the cause of a patient’s dementia, but also any behavioral disturbances that may reflect the severity of the illness, according to La Rosa. This added documentation is especially important for patients transferred to another facility for additional care, she says.
  8. Cerebral infarction. Ensure physician documentation captures the severity, acuity, location, and laterality of this condition as well as the affected side (dominant or nondominant) and residual effect, La Rosa said. If the precerebral artery caused the cerebral infarction, physicians must document the location or origin of the thrombosis, embolism, and occlusion or stenosis, because this information will “drive the code,” according to La Rosa.

Editor’s Note: This article was originally published in our sister website JustCoding.com

Guest Post: ICD-10 delay provides CDI teams time to find hidden documentation solutions

kelli(new photo)

Kelli Estes

Taming the ICD-10 Extraneous Query Beast!

By Kelli Estes, RN, CCDS

Whether ICD-10-CM/PCS implementation is six or 18 months away, the code set expanding from 14,000 to 73,000 codes will create a query volume of epic proportion if we don’t bring things down to a 10,000-foot view and get some much needed perspective. It is simply not the intent of a CDI program to query providers for everything from soup to nuts considering such code volumes.

CDI specialists cannot possibly be productive if they are expected to be the gatekeeper for capturing all clinical documentation drilling down to the deepest level of ICD-10 specificity with an exponential growth in code volume. It just won’t happen in the real world.

I think we have to remember ICD-9-CM already provides “some” specificity in certain conditions that many physicians never tap into resulting in the use of unspecified codes, as things currently stand today. There will still be unspecified codes available in ICD-10. While I am certainly not suggesting we brush off the urgent need for being more specific, I do caution against getting stuck in some apocalyptic thought process that workflow will gridlock once ICD-10-CM/PCS goes live in all hospitals across the country. There will still be a learning curve that lingers after the “go live” date for ICD-10.  We prep and plan, but we have to actually “go there” before we can get a realistic grasp on all of this.

CDI Tip: Besides educating providers with issues common to their practice, we need to also take a collaborative approach and start developing smart assessment tools to be used within or as an adjunct to the EHR (electronic health records). This will help providers improve documentation specificity pro-actively by providing choices that lead to the necessary words for depicting a really accurate clinical picture useful for ICD-10 code selection.

For example, the following choices are necessary for drilling down to the most specific fracture code:

  • Traumatic, Pathologic, Stress
  • Anatomical specificity
  • Laterality:  Right, Left
  • Open, Closed
  • Displaced, Nondisplaced
  • Initial encounter, subsequent encounter, sequelae
  • Gustilo-Anderson Fracture Scale

Changes to note from ICD-9-CM to ICD-10-CM include:

  1. Fractures not indicated as displaced or non-displaced in documentation will be coded as displaced
  2. Fractures not indicated as closed or open in documentation will be coded as closed

With the delay of ICD-10-CM/PCS implementation it only makes sense for CDI teams to embrace the additional time to fine tune strategies for educating providers and develop useful tools to enhance documentation improvement. Learn ICD-10-CM/PCS now. Practice ICD-10 CDI now. That way, when everybody else is scrambling at the last minute, you’ll be ready.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.

ACDIS Advisory Board releases new ICD-10 timeline

Time flies so try to make the most of it.

Time flies so try to make the most of it; check out the latest ICD-10 implementation advice from the ACDIS Advisory Board.

Not sure where you should be in your ICD-10 implementation? The ACDIS Advisory Board created a revised training timeline specifically for CDI professionals. And “stay the course” is its overarching message.

The revised ICD-10-CM/PCS training and implementation timeline which includes quarter-by-quarter and then month-by-month recommendations for preparedness activities. It makes recommendations such as emphasizing PCS coding and record reviews during the fourth quarter of 2014, developing organizational strategies to identify and prioritize documentation risks by January 2015, and incrementally increasing the scope of coders’ and CDI staff members’ dual coding and communication efforts.

Although the ACDIS revised timeline includes many recommended actions, one of the most important elements is fostering facility-wide communication, says Michelle McCormack, RN, BSN, CCDS, CRCR, ACDIS advisory board member and director of CDI for Stanford Hospital & Clinics in Palo Alto, California.

Stanford Hospital & Clinics, for example, has a number of ICD-10 focused working committees that meet regularly, on separate schedules, then come together monthly with organizational leadership to review key activities and accomplishments and jointly tackle barriers to progress.

While dual coding is a big component of the revised ACDIS timeline, if you haven’t begun dual coding, McCormack says that you can make significant  progress by simply revising your electronic templates and query forms for ICD-10.

Editor’s Note: ACDIS members received an exclusive first look at the new timeline via email July 14. Click here to download the timeline and related article.

Tip: Brush up on heart anatomy as related to ICD-10-CM/PCS

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You’ve got heart, kid! Don’t let A&P get you down.

Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are pretty good, especially considering it was first published in 1858.

Not surprisingly, anatomy hasn’t really changed since then. Our understanding of certain things–like what parts of the brain are involved in which functions—has changed, but the structures themselves have stayed the same for the last many thousands of years.

So why do you need to brush up on anatomy and physiology before ICD-10? The best reason I’ve heard so far comes from Gerri Walk, RHIA, CCS, senior manager of technical training for HRS in Baltimore.

“The vessels of the heart are like roads in Texas,” Gerri says. “Turn a corner and you’re on a different road or in a different vessel.”

ICD-10-CM and ICD-10-PCS both require specific vessels for cardiac conditions and procedures. For example, a patient suffers an acute MI. Where was the infarction? ICD-10-CM includes specific sites, such as:

  • Left main coronary artery
  • Left anterior descending coronary artery
  • Diagonal coronary artery
  • Other coronary artery of anterior wall
  • Right coronary artery
  • Other coronary artery of inferior wall

Some of those are easy (if the physician documents it). Some could be a little trickier. Do you know which smaller arteries are on the inferior wall and which are on the anterior wall?

For Dilation procedures (balloon angioplasty and stents) in ICD-10-PCS, you only need to know the number of coronary sites treated. For Bypass procedures, you need to know the number of sites bypassed from and where the bypass is going:

  • 3, coronary artery
  • 8, internal mammary, right
  • 9, internal mammary, left
  • C, thoracic artery
  • F, abdominal artery
  • W, aorta

Although some coders and CDI specialize to particular units or concentrations of care, you still need to know arteries even if you don’t focus on cardiac cases. For a procedure involving an artery, for example, you will need to know which artery is involved, where it is located in the body, what approach the physician used, what type of repair he or she performed, and whether the physician used a device.

Consider a patient with septic thrombosis of the choroid vein. If you know that the choroid vein is an intracranial vein, you’re all set. You can report ICD-10-CM code G08 (intracranial and intraspinal phlebitis and thrombophlebitis). You’ll notice all of the intracranial veins and sinuses are lumped into this one code. If you don’t know where the vein belongs and your physician simply documents septic thrombosis of the choroid vein, you’ll need to research the vein. This decreases productivity, which slows down cash flow and so on and so forth.

You don’t need to take a full-blown anatomy course. Figure out what anatomy you already know well. Odds are you know some of it very well. Identify areas where you aren’t as strong and do some focused training. It can be as simple as looking at Gray’s Anatomy (again, the book, not the TV show).

Find ways to make it fun. An anatomy version of Jeopardy! could be interesting. You can find a lot of free resources online, just make sure you choose ones from a reputable source.

Editor’s Note: This article first published on the ICD-10 Trainer Blog.

 

Fabulous Fourth of July ICD-10-CM coding

Be careful out there this 4th! Whether you are coding, querying, or enjoying the holiday.

Whether you are coding, querying, or enjoying the holiday, be careful out there this 4th!

Ah, the Fourth of July, picnics, parades, and pryotechnics. What could be better? Well, not having your family and friends end up at Fix ‘Em Up Clinic the next day would be a good start.

Ralph, apparently did not pay attention to the “do not try this at home” warning. He attempted to create his own backyard extravaganza and ended up blowing off two fingers. Ralph immediately traveled to the Acme ED for initial treatment by Dr. Boom and with a follow-up by Dr. Sam.

We know that Ralph suffered a traumatic amputation. In order to code his accident we also need to know:

  • Was the amputation complete or total?
  • Which hand was involved?
  • Which specific fingers were involved?

Dr. Sam documents he is seeing Ralph for a follow-up visit for complete traumatic amputation of the right index finger and partial amputation of the right middle finger caused by exploding fireworks.

That gives us codes:

  • S68.110A, complete traumatic metacarpophalangeal amputation of right index finger, initial encounter
  • S68.122A, partial traumatic metacarpophalangeal amputation of right middle finger, initial encounter

This is a follow-up treatment for Ralph’s injuries, so why are we calling it an initial visit? Because the ICD-10-CM Official Guidelines for Coding and Reporting tell us to add the seventh character of A when a patient is receiving active treatment including:

  • Surgical treatment
  • ED encounter
  • Treatment by a new physician

Dr. Boom saw Ralph in the ED, today Dr. Sam is treating him at the clinic. An initial visit with a doctor means you append A as the seventh character.

And with that, we will close the clinic for the day and hope you all stayed safer during your holiday celebrations.

Editor’s Note: This article originally published on the ICD-10-Trainer Blog. Read the complete collection of tales from the “Stitch ‘Em Up Hospital” and “Fix ‘Em Up Clinic” in the new book ICD-10 Trainer: Top Coding Scenarios for CM and PCS.

Coding Clinic to review advice highlights

The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.

The AHA published its final Coding Clinic for ICD-9-CM recently.

The AHA recently published its first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. In it, the editorial board reiterated that it has no plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS.

Additionally, this issue reminds readers that clinical information previously published in Coding Clinic—whether for ICD-9-CM or ICD-10-CM/PCS—does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of the patient’s medical condition. CDI staff may still find it helpful to know what signs and symptoms are integral (or not) to a condition; however Coding Clinic cautioned that ICD-10 has new combination codes as well as instructional notes that may or may not be consistent with ICD-9-CM.

The forthcoming edition of the CDI Journal takes a deeper look at the most recent Coding Clinic advise, but for those who cannot wait for July 1st, the AHA presents a review of ICD-10-CM Coding Clinic advise to-date, tomorrow, Wednesday, June 18, noon to 1 p.m., Central.

ICD-10 Trainer says: Too much sun is no fun

Ah, Memorial Day, the unofficial start of summer. And the day after Memorial Day is the unofficial start of summer injury season at Fix ’Em Up Clinic.

Sweating sun

Holidays are no fun unless your using ICD-10 codes to account for Memorial Day mayhem!

Jackee took advantage of the long weekend by heading to the beach. She packed plenty of water, munchies, and books to read, but didn’t pack her sunscreen. As a result, she ended up with a nasty sunburn.

The only information we really need to code Jackee’s sunburn is the degree:

  • L55.0, sunburn of first degree
  • L55.1, sunburn of second degree
  • L55.2, sunburn of third degree
  • L55.9, sunburn, unspecified

The physician does need to specify the degree; you can’t just guess or default to first degree.

We can also add some External Cause codes:

  • X32.XXXA, exposure to sunlight, initial encounter
  • Y92.832, beach as the place of occurrence of the external cause
  • Y99.8, other external cause status

Gina also headed to the beach for the weekend, but she was a little less prepared than Jackee. Gina forgot to pack her water but spent the day anyway. She came into the clinic complaining of nausea, vomiting, vertigo, and muscle cramps. Her temperature was 104°F and her heartbeat was fast and weak.

Dr. Sunni Daze diagnosis sunstroke. That’s pretty easy to code. We have one choice: T67.0 (heatstroke and sunstroke).

However, we do see a note to use additional code(s) to identify any associated complications of heatstroke, such as:

  • coma and stupor (R40.-)
  • systemic inflammatory response syndrome (R65.1-)

Since Dr. Daze didn’t document any complications, we don’t need to report any additional diagnosis codes. We could report the same External Cause codes as we did for Jackee.

Our final post-Memorial Day patient skipped the beach and went camping instead. That also turned out to be a less-than-perfect way to spend the weekend.

Geoff ran afoul of some ticks in the woods, who decided to tag along for his ride home. They also left him with what he thought was a summer cold. Instead, he contracted Lyme disease.

We have five codes for Lyme disease, depending on what condition results from the disease:

  • A69.20, Lyme disease, unspecified
  • A69.21, meningitis due to Lyme disease
  • A69.22, other neurologic disorders in Lyme disease
  • A69.23, arthritis due to Lyme disease
  • A69.29, other conditions associated with Lyme disease

We can still assign External Cause codes for Geoff’s illness. One thing to watch out for is the first code. You may be tempted to assign a code for bitten by an insect. However, ticks are not actually insects. They are arthropods, like spiders. It turns out that we will still report W57.XXXA (bitten or stung by nonvenomous insect and other nonvenomous arthropods) because ICD-10-CM lumps insects and arthropods into one code.

Our additional External Cause codes would be:

  • Y92.821, forest as the place of occurrence of the external cause
  • Y93.01, activity, walking, marching and hiking (camping doesn’t have its own code, but Geoff was also hiking during his trip)
  • Y99.8, other external cause status

So when you head out this summer remember your sunscreen, drink plenty of water, and watch out for small arthropods.

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.