Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or H&P documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
A: There are a few issues to consider here. First, can you code from EMT documentation, such as trip sheets? No. Although these documents are often included in the health record, these documents are not “owned” by the hospital. They are usually classified as external correspondence. If the claim is selected for complex review, the EMT trip sheet cannot be released. As such, it can’t be used to support code assignment.
There is one caveat to this statement. In ICD-10-CM, when implemented, the code for Glasgow coma requires a character that indicates when the assessment was made, which can include those made by an EMT. Coding Clinic from 1st Quarter 2014 states:
“. . . If the EMT documents the patient’s initial GCS core in the field, can the EMT’s documentation be used? Coders are concerned there is no official advice or guideline that allows the use of nonphysician documentation for Glasgow coma scores. . . “The response was, “It would be appropriate to use the pre-hospital report containing the EMT’s documentation and other nonphysician documentation to determine the Glasgow coma score.”
Second, there could be an issue with how the provider is reiterating the EMT findings in the health record. The provider is expected to provide a history of present illness as part of the history and physical. However, conditions not related to the current episode of care should not be reported. The documentation by the provider needs to clearly show the conditions that exist at the time of admission, rather than just listing an overall history.
Sometimes a coder’s perspective is different than a clinician’s regarding what they define as a history of a condition. Often, if a provider fails to carry a diagnosis throughout the health record, and doesn’t include it in the discharge summary, it may not be perceived as reportable by a coder. Many coders begin the coding process with the discharge summary, because it is the final word of the attending provider. However, it is important to note that Coding Clinic 1st Qtr. 2014 states “documentation is not limited to the face sheet, discharge summary, progress note, history and physical, or other report designed to capture diagnostic information. This advice only refers to inpatient coding.”
Just because the provider doesn’t mention a diagnosis more than once does not mean it isn’t reportable. Oftentimes, the provider’s focus changes daily, so they may not feel the need to summarize conditions that are no longer a focus of their efforts. If there is a disagreement between CDI and coding, it is best to clarify with the provider, assuming the totality of health record supports the condition as reportable.
If the provider only mentions the condition(s) in the history and physical, it might be helpful to query for the status of the condition to see if it should be reported. For example, if the provider, in their history and physical, documents “early clinical sepsis” and it is never documented again, be sure there are clinical indicators that support it as a reportable diagnosis. If there are clinical indicators to support it as a reportable condition than your query may be as follows:
Please clarify the status of the condition “early clinical sepsis” as documented in the H&P in this patient who presented with (give specific s/sx) and was treated with (give specifics) or had the following diagnostics (give specifics), etc. Was the “early clinical sepsis”
- Confirmed and ongoing
- Confirmed and resolved
- Ruled out
- Without clinical significance
- Unable to determine
Also note, the multiple choice format would only work well if your organization maintains the query as part of the health record so it would need to be validated by the provider. If the provider responds, by confirming the diagnosis (either ongoing or resolved), it would be reportable. If the provider responds with any other choice, it would not be reportable.
Keep in mind that you can use clinical indicators obtained from EMT documentation to query the provider if there appears to be an undocumented, reportable condition relevant to the current episode of care, if the current provider documentation doesn’t support code assignment.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass, contributed to this post.
Q: Our facility is considering having our coders and CDI specialists “go–live” with ICD-10-CM/PCS on July 1, for practice to help off-set the impact of ICD-10. The system will would then code backwards into ICD-9-CM for billing. Is this “backward mapping” method appropriate?
A: The biggest issue is how your ICD-10-CM/PCS coding will be “translated” into ICD-9-CM for claims processing until CMS accepts ICD-10-CM/PCS codes to process claims. If you the system is coding backward code, the resulting code will likely be based on GEMs, which CMS discourages.
CMS specifically states the GEMS are not for coding purposes, but rather to help build coding databases. Backward mapping—going from an ICD-10-CM/PCS code to an ICD-9-CM code—could be problematic, and could result in assigning many nonspecific codes, which may have reimbursement ramifications. The GEM mappings were not intended to be used for coding purposes, but rather to help build coding databases.
Many codes have a “one to many” ratio, resulting in either a nonspecific code or, in some cases, a “no map” option. Ideally, we would like to think if we convert documentation to ICD-10-CM/PCS that it would automatically backward map to the correct ICD-9-CM code, but it may not.
For example, if the documentation states “severe persistent intrinsic asthma,” the ICD-10-CM assigned code would be to J45.50 (severe persistent asthma, uncomplicated), because the term “intrinsic” in ICD-10-CM/PCS is now an included term not previously factored into category selection in ICD-9-CM. So, if you backwards map the code J45.50, it will translate to 493.00 or 493.10 in ICD-9-CM.
Unfortunately, this does not translate to a direct match: 493.00 is for extrinsic asthma and 493.10 is for intrinsic asthma. The ICD-10-CM/PCS code translates to two possible ICD-9-CM codes, and only one can be chosen. But it has to backward map to both because the code for severe persistent asthma does not identify extrinsic or intrinsic in ICD-9-CM.
Most organizations are dual-coding–coding in both ICD-9-CM so their claims can be reimbursed appropriately and in ICD-10-CM/PCS so they can practice the new code set and identify improvement opportunities. However, not all organizations have software that can “hold” both code sets simultaneously. If your software allows you to hold both codes, even though it is time consuming, the best suggestion is to native code in both ICD-9-CM and ICD-10-CM/PCS. If you rely merely on the backwards mapping, it may not achieve the desired result. The systems are not identical, and very few codes have exact maps.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass. and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of HIM and Coding at HCPro in Danvers, Mass. contributed to this response.
Q: Our cardiologists like to document “biventricular heart failure.” Is a query needed to clarify systolic and/or diastolic?
A: A query should be issued for the chronicity and type of heart failure when the physician states only “biventricular heart failure.” Biventricular represents that both ventricles have mechanical problems, but it doesn’t specify which phase of the cardiac cycle (systole or diastole) is encountering a pumping/filling issue.
If you have access to an encoder and type in “biventricular heart failure” you will receive prompts to add in participating factors, and asked to choose what type of heart failure (systolic, diastolic, combined, etc). If you pick “unspecified,” you end up with code “428.0 Congestive heart failure, unspecified.”
Editor’s Note: Vicki Sullivan Davis is CDI manager at Cone Health System at Alamance Regional in Burlington, North Carolina, and past-speaker at ACDIS National Conference. Contact her at firstname.lastname@example.org.
Q: If a is patient admitted with malnutrition and the physician documented the patient to be malnourished from mild to severe, would the CDI team use DRG 641, Severe Malnutrition as a working DRG or should we query the physician to clarify the severity or type of malnutrition.
A: DRG 641, Severe Malnutrition would require use of ICD-9-CM code 261, Nutritional Marasmus, which is a high-risk diagnosis vulnerable to denial. The same is true for ICD-9-CM code 260, Kwashiorkor. These conditions describe a very specific type of severe malnutrition typically found in third-world countries and doesn’t typically exist in the U.S.
Even if it wasn’t a vulnerable diagnosis the difference between mild and severe malnutrition constitutes the difference between a CC and an MCC designation. So first look to see what clinical indicators and treatment support were documented in the record. In my opinion, the treatment is often what separates mild nutrition from severe malnutrition. If the clinical indicators and treatment support severe protein calorie malnutrition (ICD-9-CM code 262), I would query the provider to clarify their documentation as to the type.
The following are some additional articles that might help shed a little more light on these conditions and their relative controversy over the years:
- Q&A: Review clinical criteria for malnutrition
- Tip: Ensure malnutrition documentation and coding meet current clinical standards
- News: Hospital settles allegations of False Claims Act violations related to malnutrition and leading queries
- New malnutrition criteria could help ensure consistent coding
- Dietitian involvement resolves malnutrition query quandary
- Body Mass Index and malnutrition: Interrelated comorbidities
- Take a closer look at clinical indicators of malnutrition
Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:
A: There are many myths concerning compliant query practices so before automatically accepting a dictum of query parameters go back to the official sources to ensure compliance. By this I mean first reference the most recent guidance from the Association of Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS). AHIMA is one of the four cooperating parties (along with CMS, American Hospital Association, and the National Center for Health Statistics) so its recommendations have additional credence should auditors or other investigators question your CDI program practices.
According to the 2013 “Guidelines for Achieving a Compliant Query Practice:”
“Multiple-choice query formats should include clinically significant and reasonable options as supported by the clinical indicators within the medical record, recognizing that there may be only one reasonable option. Multiple-choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”
If you still feel a fourth choice is needed perhaps the choice of “not clinically significant” could be offered. But this would depend on the circumstances of the particular patient encounter.
The 2013 practice brief also provides an option for yes/no queries. However, the brief does recommend that even in yes/no queries that additional options be included, similar to those recommended for multiple-choice queries.
“The ‘yes/no’ query format should be constructed to include the additional options associated with multiple-choice queries (i.e., ‘other,’ ‘clinically undetermined,’ and ‘not clinically significant’ and ‘integral to’). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query.”
Again, refer to the practice brief for additional circumstances where yes/no queries may be warranted and read up on previous practice brief recommendations for a better understanding of how queries should be formatted.