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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.

 

Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.

AMI

Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q&A: Finding focus for CC/MCC reviews

haik

William Haik, MD, FCCP, CDIP

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version of the webinar, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q: I’m having trouble with querying physicians for complication codes. Could you please provide guidance?

A: This is difficult. Unless there is an (coding) index directive, query the attending physician to determine if a condition occurring after surgery is due to, or caused by, the surgical procedure (such as atelectasis following surgery). From a medical perspective, the conditions which occur after surgery are not typically due to the surgery, but are due to other factors such as in atelectasis, operative pain, sedation, supine position, etc. Therefore, when I ask, it is when there is a high probability of being related to the surgical procedure (hematoma, excess hemorrhage which is addressed intraoperatively or immediately post-operatively). 

Q: Does systemic inflammatory response syndrome (SIRS) with pneumonia qualify for sepsis or should this be queried?

A: Unfortunately, in ICD-10-CM, there is no coding index entry for SIRS, and the previous index entry in ICD-9-CM for SIRS with infection no longer leads to sepsis. Therefore, the physician must be queried to clarify the documentation and assign an appropriate code.

Q: Should we query when the physicians use accelerated or malignant hypertension (HTN) in regards to hypertensive emergency/urgency?

A: Yes, as the former terms now are considered unspecified, a more specific condition should be sought.

Q: Would a physician query be necessary if the physician documentation indicates malnutrition (CC) and the dietician’s assessment documents mild to moderate malnutrition (CC)?

A: It is unnecessary to query a physician regarding the non-specific documentation of malnutrition. If the physician documents mild or moderate malnutrition, one would assign malnutrition, not otherwise specified, unless the physician specifies further.

Q: Do you have any suggestions for what CDI professionals should do if the physician documents a diagnosis but it is not supported by documentation in the chart or by clinical indicators?

A: I would ask the physician to review the record along with enclosed medical criteria regarding the condition in question. I have developed a handbook which provides evidence-based clinical indicators for common medical conditions. (For a copy, email Behaik@aol.com.)

Q: Should we query for electrolyte abnormalities on gastric bypass patients. We are told imbalances are normal due to diet restrictions.

A: Although electrolyte disturbances are common in gastric bypass patients, they are not normal and not integral to the procedure. The physician would typically would treated the patient if the levels were significantly clinically deranged. In this setting, I would query the attending physician to determine if the levels are merely lab abnormalities or if they should be clinically significant and reportable.

Q: When acute respiratory failure is reported in the postop period and is integral to the procedure (for example, the patient remains on mechanical ventilation for less than two days following post op), do we have to query to see if it is significant or should we code without a query?

A: From a clinical perspective, I assume major surgery (cardiopulmonary, esophageal, gastrointestinal resection surgery) often require prolonged ventilation. In minor surgeries, such as prostate biopsies, extremity surgeries, etc., if the patient is on mechanical ventilation longer than 24-hours and assuming the patient is awake, then I would tend to query regarding post-operative respiratory failure, particularly if there is a medical complication such as aspiration pneumonia, pulmonary edema, etc.

Q: What’s the difference between acute respiratory failure and acute pulmonary insufficiency? Would oxygen dependent Chronic Obstructive Pulmonary Disease (COPD) be insufficiency instead of failure?

A: Acute respiratory failure is a life-threatening condition which is typified by a pO2 of less than 60 on room air (in patients with previously normal lungs) in the clinical situation of a patient with rapid respirations and increased work of breathing in the acute setting. Acute pulmonary/respiratory insufficiency is a poorly defined term merely meaning non-life-threatening impairment of gas exchange. Therefore, it does not represent a pO2 of less than 60 (in patients with previously normal lungs), but not a completely normal pO2. Oxygen-dependent COPD is consistent with chronic respiratory failure as to obtain oxygen (via Medicare) one must have a pO2 of less than 60.

Q: Post-operative pulmonary insufficiency is an MCC, but post-operative respiratory insufficiency is neither a CC/MCC. Is there a way to differentiate these two diagnoses?

A: There is no medical differentiation between pulmonary and respiratory insufficiency. This is merely an idiosyncrasy of ICD-10-CM.

Q: According to resources, a lactate less than 1.0mmol/L, which is normal, is considered a sepsis indicator. Why is this an appropriate indicator if it is within normal limits rather than greater than 2 which is abnormal?

A: Despite the “normal” limits of lactate up to 2.2 in most hospitals, it has been determined, retroactively, a lactic acid level of greater than 1 is a finding seen in sepsis. It is not specific as there are other hypoperfusion states and/or chronic liver disease which may result in an elevated lactic acid level. Therefore, it must only be interpreted in the appropriate clinical circumstances.

Q: Is healthcare associated pneumonia (HCAP) synonymous with hospital acquired pneumonia?

A: They are similar, but not synonymous. HCAP includes nursing homes, long-term acute care facilities, chemotherapy, and dialysis centers. Hospital-acquired pneumonia requires a hospitalization of at least a three-day stay. The pathogenic organisms are similar as is the treatment.

Q&A: ‘Code first’ versus ‘in diseases classified elsewhere’

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I can’t distinguish between “code first” and “in diseases classified elsewhere.” Both are used with manifestations and both can’t be sequenced as principal diagnosis, and both need etiology codes so what is the difference?

A: Technically, not all “code first” notes are mandatory, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HCPro’s Certified Coder Boot Camp® programs, based in Middleton, Massachusetts. For example, ICD-10-CM category I50 includes a “code first” note but it is only used if applicable since heart failure can be a principal diagnosis.

The “code first” note informs us of two things, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist at ACDIS. First, it informs you that two codes may be required. Second, it provides sequencing direction. There are some “code first” notes that are only applicable in certain instances, such as McCall mentions, at “heart failure” the note talks about assigning codes for hypertensive heart failure, pregnancy related heart failure etc., first, if applicable.  Secondly, if, for example the CDI specialist reviews a Parkinson’s manifestation, such as a dementia, and they see “code first Parkinson’s,” in the tabular list then first code Parkinson’s disease (G20) followed by the code for the dementia F02.80. In this example, the “code first” note is positioned next to the manifestation code to remind you to code the etiology first.

In contrast, the phrase “in diseases classified elsewhere” informs coders that two codes are required and means this code must be sequenced as the second code. If you see “in diseases classified elsewhere” in a code description, then you know you are looking at a manifestation code. These codes should never be used as a principal diagnosis and must be reported in conjunction with a code for the underlying cause/diagnosis.

While these terms may seem very similar, Frady says, the “code first” terminology represents an instructional note while “in diseases classified elsewhere” is actually a part of the code title itself. You would only see the “code first” note if you look up the code in the tabular list and review the instructional notes, whereas you would see “in diseases classified elsewhere” if you were simply reading the code title or description in the alphabetic index.

Interestingly enough, if you index Dementia in a current 2017 code book, these conventions are not used.  The index entry is Dementia (with) Parkinson’s disease:   G20 [F02.80]. In this case the formatting of code first [bracketed code second] provides the sequencing.

Caution is warranted, if you index this condition by looking up the keyword “Parkinson’s,” you get an entirely different code as you get an instructional note to “See Parkinsonism” and following that pathway in either a book or an encoder you will arrive at codes G31.83 and F02.80.

Editor’s note: This answer was provided based on limited information submitted to ACDIS. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. For information regarding coding or CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.

 

Thanksgiving mishaps? There’s an ICD-10 code for that!

It's Thanksgiving! Time to celebrate all the ICD-10 codes you (hopefully) won't actually encounter this holiday.

It’s Thanksgiving! Time to celebrate all the ICD-10 codes you (hopefully) won’t actually encounter this holiday.

As we prepare for the Thanksgiving holiday with family and friends and give thanks for all of our blessings, it is important to be ready with appropriate codes to accurately document any holiday mishaps.

Here’s a short list to help you quickly and efficiently communicate the information required to file a complaint claim:

For incidents with a fresh (live, not saucy) turkey:

  • W61.42 Struck by turkey
  • W61.43 Pecked by turkey
  • W61.49 Other contact with turkey

For general kitchen and meal prep actions:

  • Y93.G1 Activity, food prep and cleanup
  • Y21.2 Undetermined event involving hot water
  • Y93.G3 Activity, cooking and baking

For dealing with obnoxious Uncle Leo who insisted on pushing his way to the dessert table:

  • Y04.2 Assault by strike against or bumped into by another person

For your mother-in-law’s criticism of the lumpy gravy (which we know was not lumpy):

  • Z63.1 Problems in relationship with in-laws

For activities post-meal to work off effects of R63.2 Polyphagia (overeating):

  • W21.01 Struck by football

For Friday morning:

  • W72.820 Sleep deprivation

Editor’s note: The ACDIS office will be closed for the Thanksgiving holiday and will reopen on November 28. Please send along your most common documentation improvement opportunities either in the comment section or via email to mvarnavas@acdis.org.

Guest Post (Part 2): Solving the documentation difficulties for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part two of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

In developing a CDI strategy for dealing with new sepsis-3 criteria, remember three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock documentation without considering the environment in which such documentation is to be interpreted.

Clinical language
Physicians use a language in direct-patient care that communicates (easily translates) well with other physicians. Every physician knows what “urosepsis,” “unresponsiveness,” and “neurotoxicity” is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so coders can assign the correct coding conventions.

Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is a clinical language; so is sepsis-3. ICD-10-CM is not.

Not all physicians embrace sepsis-3, thus some may wish to label a patient has having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them.

Coding language
In a landmark article published in the Journal of AHIMA in 2014, Sue Bowman, senior director of coding policy and compliance for AHIMA in Chicago, Illinois, makes it very clear that ICD-10-CM is not for clinical care but for administrative purposes.

“The standard vocabulary afforded by SNOMED CT supports meaningful information exchange to meet clinical requirements, Bowman says. “ICD-10-CM and ICD-10-PCS, with their classification structure and conventions and reporting rules, are useful for classifying healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous,” she wrote.

Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without organ dysfunction and sepsis with acute organ dysfunction (severe sepsis) and is based on the individual physician’s criteria.

Core measure language
Defining cohorts with core measures, such as SEP-1, is an abstraction based on clinical criteria and not necessarily based on what a physician writes.  For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than Sepsis-3. We must remember, however, that in 2017, if a physician documents severe sepsis and R65.20 is coded, that record will be held accountable for the SEP-1 core measure even if it doesn’t meet the SEP-1 criteria. View this regulation here.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at jkennedy@cdimd.com.

Guest Post (Part 1): Documentation and coding challenges abound for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part one of four, excerpted from an article originally published in JustCoding. Click here to read the original. The comments and opinions represent those of Kennedy

by James S. Kennedy, MD, CCS, CDIP

There are a number of coding compliance challenges with sepsis-3 and with sepsis or severe sepsis in general. In this article, I’ll review my top four concerns.

First, sepsis-3 states that patients with an infection meeting the new sepsis criteria should be coded as R65.20, severe sepsis. This is impossible in the United States, given that ICD-10-CM code R65.20 can only be assigned if the physician documents “severe sepsis,” not sepsis alone, or if the physician documents that an acute organ dysfunction is associated with sepsis, though many coders fail to assign R65.20 when these links are made. Its apparent that the sepsis-3 authors are not familiar with Coding Clinic for ICD-10-CM/PCS, the Department of Justice, or our friendly neighborhood recovery auditors (RA).

Secondly, ICD-10-CM still has a multitude of codes for sepsis without organ dysfunction (e.g., A40-A41). The 2017 ICD-10-CM Official Guidelines for Coding and Reporting states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. It states:

The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (Emphasis added.)

Recent advice from Coding Clinic supports the concept that if an individual physician documents sepsis using his or her own criteria (that may differ from sepsis-3 or that of a RA), coders are obligated to code it. Therefore, if a physician documents sepsis, can we still defend the coding of an A40-A41 code if there is no documented organ dysfunction? I believe that the Guidelines and Coding Clinic say that we can, even if the RA doesn’t like it.

Thirdly, the ICD-10-CM table instructions for code R65.20, severe sepsis, tell us to use an “additional code to identify specific acute organ dysfunction.” If a physician documents severe sepsis based on the sepsis-3 criteria of a lactate over 2 milliequivalent per liter (mEq/L), or sepsis-3’s changes in the Glasgow Coma Scale, what is the organ dysfunction that should also be coded or queried for? Without an organ dysfunction documented and coded, a RA may claim that the severe sepsis code is invalid.

Finally, in my own personal review of the CMS 2015 MedPAR, approximately 45-55% of MS-DRGs 871 or 872 (septicemia or severe sepsis) do not have a code for severe sepsis, yet a number of patients have acute organ dysfunctions present on admission which I believe should have been linked to the patient’s sepsis to render the severe sepsis code.

RAs look at sepsis DRGs without R65.20, severe sepsis, or R65.21, septic shock, as opportunities to take money away from facilities who coded sepsis (e.g., A40-A41) as present on admission and sequenced it as a principal diagnosis without an additional R65.20 or R65.21 code. To take these records out of the RA data mining pool, CDI professionals must make every effort to query providers if the clinically valid indicators of organ dysfunction due to sepsis are present but the record does not have the documentation interpreting these indicators as to report R65.20 and R65.21 and their associated organ dysfunctions. This effort, however, must be coordinated with the SEP-1 or quality manager, given that any coding of R65.20 or R65.21 subjects the record to the SEP-1.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at jkennedy@cdimd.com.

Membership Update: Important ICD-10-PCS survey

Do you have what it takes to become a CDI specialist?

Take our survey!

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.

Click here to take the survey. 

Thank you.

Gold’s Gospel: Arrested development

Dr. Robert S. Gold

Dr. Robert S. Gold

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.

ICD-10 Tip of the Week: Systolic and diastolic heart failure

Don't let documentation for AMI give you a heart attack.

CDI specialists should look for evidence to support the type of heart failure. 

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.