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Q&A: Compliant queries  

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Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?

Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition being treated with a nicotine patch and nicotine gum in this patient referred to as a “smoker” in the history and physical documentation.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

A: I like your query but, unfortunately, when treating something prophylactically, by definition we are preventing it from occurring. A condition that is being prophylactically treated should not be coded.

According to the 2016 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, we only need to provide “reasonable options” in a query. “Reasonable options” are determined based on the clinical indicators present in the medical record and, sometimes, there is only one appropriate response based on the clinical indicators present.

We want the documentation to accurately reflect the true picture of what is going on with the patient during the episode of care that is under review, so if the patient is not experiencing withdrawals, and is only being treated prophylactically to prevent the withdrawals, that is what we want the documentation to reflect.

Here are some sample queries for this scenario:

Documentation indicates a 25-year history of smoking cigarettes. Patient admitted to unit after six hours in the ED. Nursing notes describe increased irritability and continued requests to be allowed to smoke. Vital signs indicate elevated heart rate and blood pressure readings as described by nursing notes. Upon admission telephone order obtained for nicotine patch. Please clarify the indication for nicotine patch.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

You have ordered the application of a nicotine patch for this patient with a history of smoking cigarettes for 10 years. The H&P indicates a “habit of 2.5 packs a day”.  Nursing documentation in the ED and admitting unit describe the patient exhibiting anger and threatened discharge against medical advice. Nicotine patch applied 2 hours after admission. Later nursing notes indicate the patient is presenting in much calmer manner and cooperative with plan of care. Please clarify the condition you are treating with the application of the nicotine patch.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

Editor’s note: Sharme Brodie, RN, CCDS answered this question. Brodie is a CDI education specialist for ACDIS and HCPro in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Q&A: Interdepartmental collaboration

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As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Susan Lapp, RN, MSW, a clinical documentation improvement specialist for Community Hospital, South, in Indianapolis, Indiana.answered these questions about interdepartmental collaboration.

Q: How often to get to collaborate with the coding team?

A: We’re a hospital-based network of several facilities, each facility has a CDI staff member. If someone is off, we can cover. We report up through case management and help with length of stay needs.

We each work as a team with a remote coder. We get used to each other’s work habits and patterns. We use a program called “Jabber” that allows us to share each other’s computer screens and chat. We meet once a month with all the coders and all the CDI specialists for group discussion and education. The CDI team also meets once a month.

We have an escalation policy that we can use if the coder and the CDI specialist disagree on an issue. The case gets bumped up to our managers and they get the final say. It’s a good process that allows us to not take it personally and lean on someone else with more experience for a determination.

Q: What type of other groups do you work with?

A: Our physician advisor was working on denials and identified malnutrition as a frequent cause of denials. So we reached out to dietitian and started working on guidelines for documentation. Once we had that in place we were able to go out and provide physician education.

Within the case management team, we spend a lot of time discussing what the principal diagnosis of the case should be. Sometimes what needs to be the principal diagnosis isn’t the diagnosis with the longest length of stay but that’s what the coding rules call for.

A couple months ago, there was a case (case description altered to protect HIPAA requirements) where an elderly gentleman wasn’t correctly taking his medication. He came in once for an overdose and was discharged and when he came back again for a similar situation shortly thereafter, I was able to get the case management team together to re-evaluate their discharge plans.

We disagreed about what the documentation seemed to indicate, so we brought the treating physician in and determined that the patient indeed wasn’t able to self-monitor the medications any more. They found placement for him and his elderly wife. I think this is a perfect example of what a positive effect we can have when we collaborate.

Q: Are you doing any work with other departments on quality measures or that type of reviews?

A: We automatically get notified if the same patient comes back within the 30-day window, so we review those records and identify any clarification opportunities. This helps with NSTEMI documentation and with quality.

We also always look to see if the condition is present on admission or if it’s a hospital acquired condition. If we’re not sure we query the physician.

Complications are another area related to quality that we look at. I don’t know why they can’t just write whether it’s an expected outcome or not. I’ve been in nursing for 39 years and I never thought they’d pay me for this type of work but it’s great. I want my patients to have the best treatment possible and I help the record reflect that.

Q: What advice do you have for others who may be wishing they could collaborate a bit closer with other departments?

A: Be comfortable with the resources you have and be willing to ask questions. I’m not a coder, I’m a nurse. I don’t know what my coders know, that’s why they’re coders. You have to know your limitations as well as your expertise. There might be a difference in opinion as to how you interpret two little words but that difference might mean a patient gets sent home when they really shouldn’t be.


Q&A: Coronary stent

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Go ahead, ask us!

Q: The 2016 CDI Pocket Guide states that four or more stents or vessels is equivalent to an MCC and changes the DRG. I understand that Coding Clinic, Second Quarter 2015 defines the number of individual sites instead rather than anatomical vessels. The DRG Expert states four vessels or four plus stents changes the DRG. It was my understanding that when four stents are used in three vessels or sites, the DRG would not change. Could you please clarify if it is the number of stents or the number of sites that changes the DRG?

A: The coronary stent question has plagued the entire coding and CDI community since Oct. 1, 2015. There is much self-contradiction in the DRG titles, which includes vessels and stents, and the meaning of “sites” (implying stent locations) in the ICD-10-PCS Official Guidelines for Coding and Reporting. The Coding Clinic advice published in Second Quarter 2015 helped some, and I believe intended to clarify that the number of coronary arteries treated determines the code assigned, which then drives the DRG.

Because of the confusion and contradictions, the 2017 ICD-10-PCS Official Guidelines for Coding and Reporting sections B3.6, B3.7, B4.4 have been modified to indicate that procedures performed on coronary arteries are classified by the number of arteries treated, not the number of coronary artery sites.  The number of stents does impact code assignment or DRG classification, but the code titles for DRGs 246 and 248 still perplexingly retain “4+ vessels/stents.”

Editor’s note: Richard D. Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, and author of the CDI Pocket Guide answered this question. Contact him at

Q&A: Procedure code for esophagogastroduodenoscopy

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Q: What is the correct procedure code for an esophagogastroduodenoscopy with placement of clips to control bleeding? Our coder coded 0DQ68ZZ, which groups to DRG 326, the same as an esophagectomy. The relative weight (RW) is 5.45. This does not seem right. Could you please clarify?

A: This was addressed in AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2014. The coder is correct in their assignment. The only difference is that this was in the esophagus, but the intent is the same. I am assuming it is because the clips act as a “suture” to stop the bleed, and therefore it is considered a “repair,” much like suturing for the integumentary system.

Coding Clinic states:


A patient presents with bleeding duodenal ulcer and an esophagogastroduodenoscopy was carried out. Multiple clips were applied to the vessels to control the multiple hemorrhaging ulcers. Should “control” be assigned for the root operation? What is the ap­propriate ICD-10-PCS procedure code?


The root operation “control” is defined as only applicable for procedures to correct postoperative bleeding, and so it does not apply to this procedure. This procedure is a repair of the duodenum. Most of the body’s organs and tissues are vascular, and they bleed when cut or eroded. Repair of a cut or eroded body part is coded to the body part repaired, rather than to a vascular system body part. In this case, the duodenal ulcers are being repaired via an endoscop­ic approach, with clips placed on vessels eroded by the ulcers. Assign the following ICD-10-PCS code: 0DQ98ZZ Repair duodenum, via natural or artificial opening endoscopic.

I think why this seems so problematic is that in ICD-9-CM, the code would likely be 42.33, endoscopic excision or destruction of lesion or tissue of esophagus, which includes control of esophageal bleeding and was considered a non-operating room procedure. The ICD-9-CM code was very generic. When translating to an ICD-10 code, the intent of the procedure seems to have been taken into consideration. This procedure is the same intent as suturing sites like the duodenum and stomach for bleeding, which was assigned to a surgical DRG. This would be my guess as to why it maps to DRG 326, though I agree that the RW seems very high.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of HIM/Coding for HCPro in Middleton, Massachusetts answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: SOI/ROM impact

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Q: I am with a CDI program that is starting to explore the severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do.

I was told that regardless of the actual final impact on SOI/ROM we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?

A: I very much agree with your practice of claiming those in which you see a change in SOI/ROM related to your query. I believe you are being encouraged to claim impact for any query that allows for an increase in SOI/ROM. So, for example, if you query for MCC capture, that would likely affect SOI/ROM and I would claim the impact for both MCC capture and SOI.

Say you have a patient that is admitted for COPD exacerbation with heart failure and diabetes. When you query to capture the MCC of the acute respiratory failure, and the physician responds appropriately, you would claim the credit for the MCC capture. But this query likely would also increase your SOI/ROM (I do not have access to an APR grouper but my guess is that it likely would).

I would think that although your goal in the query was not to increase SOI/ROM, if it did indeed do so, I would take the credit for this as well.

I would also suggest you seek out your peers on the ACDIS Forum as they likely could share with you how they analyze their metrics.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: CKD relationship

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

Q: The coders at my facility have stated auto linking congestive heart failure (CHF), hypertension (HTN), and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” HTN. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record. I referenced the Coding Clinic, Fourth Quarter 2008, which states that unless a causal relationship exists between the heart condition and the hypertension—and the physician documents this relationship in the record—each condition requires its own code, and if the documentation does not make that link, an HIM/coding professional must code the two conditions separately.

I understand that ICD-9 Coding Clinics may not apply in ICD-10, but I cannot find any updated guidance. Our coders are going by the Coding Clinic, First Quarter 2016, which still uses the phrase “due to.”

A: I know of no updated instruction that allows heart disease and hypertension to be an assumed relationship. We teach that the provider must clearly state the heart disease is due to (related to, secondary to, etc.) the hypertension.

Of course, the relationship between CKD and hypertension is a combination that can be assumed if found to be present.

For the patient that has the trifecta—is hypertensive, and has heart failure and kidney disease—we still need the provider to clearly state the relationship between the heart disease and the hypertension.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: Mortality rate, observed/expected

Discerning the principal diagnosis is difficult at best.

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Q: Do you have any information about mortality rate, observed/expected, or can you direct me to where I might get additional information to better understand this metric?

A: The mortality index is defined by the number of patient deaths in a hospital within a ratio that compares actual deaths within a specific time period to expected deaths pulled from risk of mortality data. This is often referred to as the “O” to “E” death rate.

The observed to expected mortality rate is an example of a risk adjusted measure.

The observed mortality is represented by the actual number of patients that died in the hospital in a specific time frame (month, quarter, year etc.)

The expected mortality is the average expected number of deaths based upon diagnosed conditions, age, gender, etc. within the same timeframe.

The ratio is computed by dividing the observed mortality rate by the expected mortality rate.

The lower the score the better. For example, if the score is a one—it demonstrates that the actual mortality rate is equal to the expected rate. If the ratio is 1.25 it demonstrates the fact that more patients died than what might be expected. If the ratio is .75 it demonstrates that less patients died than were expected to.

This ratio can be affected by the quality of care provided and/or the quality of documentation captured in the medical record. If the CDI team does not help capture the highest severity of illness and risk of mortality appropriate for the physician or facility’s patient population through complete documentation, then the risk adjustment applied to this ratio will not be accurate. If the patient dies, it may appear as though the death could have been prevented.

Many CDI programs perform “death reviews” of these records to ensure that that the documentation clearly reflects severity of illness and risk of mortality. The goal of these reviews is to capture an APR-DRG (all-payer refined diagnosis related group) risk of mortality score of a 4. The higher level of risk of mortality demonstrates that there is a high probability of patient death.

There are a number of software programs that can compute the expected mortality of your patient population. Likely your quality department can assist you in in obtaining your observed to expected ratio and help you identify the ratio for specific service lines (cardiovascular, neurosurgery, etc), specific conditions (heart failure, specific surgical procedures etc.), or by provider.

Although there are many factors that can influence your O to E mortality ratio, it can be used to assess the effectiveness of your documentation improvement efforts as well. But we must ensure that the interpretation of this metric does take into consideration other possible influencing factors as well.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her For information regarding CDI Boot Camps

Q&A: Defining “repair”

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Have a question that is troubling you and your team? Ask us!

Q: When I try to code Ileostomy takedown of the small bowel, with small bowel resection, and end-to-end anastomosis, I get to code 0DBB4ZZ.  However, I am not sure if this would this be a repair of the ileum, and therefore coded to 0DQB3ZZ? Coding Clinic notes code 0DBB4ZZ, but “repair” means “restore to previous function.” What is your advice for this scenario?

A: The Coding Clinic you are referring to reads:

The ileostomy takedown is coded as “Excision” because part of the ileum is removed, and the anas­tomosis is considered inherent to the surgery and not coded separately. The ICD-10-PCS Official Guide­lines for Coding and Reporting state “Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.” Assign the following ICD-10-PCS codes:

0DBB0ZZ Excision of ileum, open approach (for the ileostomy takedown)

0WQF0ZZ Repair abdominal wall, open approach (for parastomal hernia repair and stoma closure

You are absolutely correct; the definition of “repair” is “repairing to the extent possible, a body part to its normal anatomic structure and function.”

I do agree with you that the takedown does seem to fit the definition of a repair but, per the Coding Clinic advice, it is coded to the Root Operation of Excision. Until there is different guidance from Coding Clinic, this is how it would be coded.

I wish I could tell you that everything makes sense but, sometimes it does not.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Q&A: Code assignment for hospital acquired/healthcare associated conditions

Discerning the principal diagnosis is difficult at best.

We always want to obtain the etiology of pneumonia.

Q: Is it appropriate to assign code Y95, nosocomial condition, based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAC)? It is appropriate to assign code Y95, nosocomial condition, for documented healthcare associated conditions. Should this still be queried for specificity, and should the HAC condition (i.e. pneumonia) be coded as bacterial, viral, or something else?

A: When the provider uses terms such as “CAP,” “HAP,” or “HCAP,” these would default to code J18.9, pneumonia, unspecified organism, which maps to simple pneumonia MS-DRG 193/194/195.

Community acquired pneumonia (CAP) is typically a simple pneumonia, but could also be atypical pneumonia. Both hospital acquired pneumonia (HAP) and healthcare associated pneumonia (HCAP) can be considered nosocomial infections, and are most commonly caused by a gram negative organism.

Identification of the organism could move any of these from a simple pneumonia—MS-DRG 193, 194, or 195—to a complex pneumonia—MS-DRG 177, 178, or 179.  ICD-10-CM has numerous codes that link the causative organism and the pneumonia. Use of these codes is based on physician documentation linking the pneumonia and the causative organism.

Per AHA’s Coding Clinic, Third Quarter, 1994, we do not assign a code for bacterial pneumonia unless documentation if the medical record supports the presence of a bacteria.

If the physician identifies the pneumonia as a gram positive, mixed bacterial, or bacterial pneumonia without further specification, it would be coded to J15.9, unspecified bacterial pneumonia.

We always want to obtain the etiology of pneumonia. As the MS-DRG assignment will vary based on etiology, this may require a query. The physician’s clinical opinion is sufficient to diagnose the type of infection. Diagnostic data, such as a positive sputum cultures or chest x-ray, are not necessary for the diagnosis.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Q&A: Coding and sequencing clarification

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Have a question that is troubling you and your team? Ask us!

Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially, they thought he had pulmonary nodular amyloidosis (PNA) but when they did an echo-cardiogram on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next day the patient had a cardiac arrest. Given the pericardial effusion, they did a bedside echo during resuscitation. This showed right atrial collapse and performed an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but deemed terminal and later died. No definitive treatment was directed at the lung cancer.

We are discussing two concerns related to this case:

  1. How to code the effusion: Our coder thinks it may be appropriate to only code C7989 (secondary malignant neoplasm) but I think that I39.3 (pleural effusion) should be coded.
  2. Sequencing: Our coder assigned C7989 as the principal diagnosis. If we code I39.3, would that end up being the principal? The Official Guidelines for Coding and Reporting say that complications of neoplasm should be listed as principal.

Any suggestions or thoughts you might have would be greatly appreciated.

A: J91.0 (Malignant pleural effusion) is a manifestation code and cannot be sequenced as the principal diagnosis, says Sharon Salinas, CCS, Health Information Management, at Barlow Respiratory Hospital in Los Angeles. “The underlying condition is to be sequenced first.  Per the National Institutes of Health, malignant pericardial effusion is also a manifestation so I think the lung neoplasm might have to be the principal – if that is the underlying cause.”

Look also at ICD-10-CM code I30.9 for acute neoplastic pericardial effusion present on admission (POA) plus the C code for secondary malignancy POA and finally, pericardial tamponade, not POA, suggests Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

Gold points to a AHA Coding Clinic, Second Quarter 1989, which directs coders to the Alphabetic Index entry for effusion, pericardium, which has a note to “see also pericarditis,” and leads to options of pericarditis (with effusion), neoplastic (chronic), and acute.

“The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor, either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas),” says Gold.

Unfortunately, says Salinas, ICD-10-CM lost some specificity for situations like this.  Code I313, for pericardial effusion isn’t specifically for malignant pericardial effusion but comes close. Code J91.0, is a manifestation code and cannot be sequenced as principal diagnosis.

“I would query for acuity and for underlying cause of effusion (primary, metastatic, other, undetermined. I think you need both queries to determine the principal,” she says.

Editor’s Note: This QA is an example of the information shared daily amongst ACDIS members on CDI Talk. Join the conversation and make the most of your ACDIS membership.