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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


Q&A: Pneumonia sequencing

Submit your inpatient coding and CDI questions reply to this post .

Submit your inpatient coding and CDI questions reply to this post .

Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy? I thought that the pneumonia would be the primary and the respiratory failure as secondary as the severity of illness/risk of mortality (SOI/ROM) as well as the MS-DRG would all increase. Yet, I’m getting some push back on this train of thought and I’m not sure where the error in my logic may lay. Any insight you could offer would be much appreciated!

A: This is an interesting and common question. I believe you are asking why would we choose the acute respiratory failure as the principal diagnosis when, if we choose the pneumonia with a secondary diagnosis of acute respiratory failure, we have an MCC and it would provide both higher reimbursement and SOI/ROM. Coders and CDI specialists were once taught that when two or more competing diagnoses are present on admission and they could choose the one providing the highest relative weight/increased reimbursement.

In our CDI Boot Camp we explore the concerns around code sequencing in depth and part of our in-class discussion challenges that traditional thought a bit and perhaps spurs our students to think about the matters differently. The traditional choice, to simply code the highest weighed MS-DRG as the principal diagnosis, often gets challenged by auditors. Which condition, they rightfully ask, actually occasioned the admission? Does a typical patient with pneumonia require an inpatient admission? Not usually. When will the physician discharge this patient; when the pneumonia is resolved, or when the acute respiratory failure is no longer a concern?

My bet is that the physician will send this patient home on antibiotics (treatment for the pneumonia) so the pneumonia is not exactly resolved on discharge is it?

I recently assisted an organization with two DRG validation denials from recovery auditors. The auditors agreed with all coded diagnoses but argued the sequencing choices involved. One such account was acute systolic heart failure and acute respiratory failure. Their argument was the choice for admission was based on the acute respiratory failure, not the heart failure. I could not defend against that logic. Once the patient was able to breath without intervention or assist, she was discharged. She was sent home with adjusted medication for her heart failure continuing and follow up with the cardiologist.

I am not saying you should always sequence one way or another, rather, as a CDI specialist it’s your role to closely review the circumstances of admission and carefully consider which conditions meet the definition of principal diagnosis as “That condition after study that occasioned the admission.”

The Official Guidelines for Coding and Reporting tells us it should be a rare instance that two or more diagnoses qualify as the principal and we believe this guideline is used much more frequently than it should be.

Lastly, just to throw another log on the proverbial fire, depending on the circumstances in your example perhaps the encephalopathy could be the principal admission. Again it would depend on the circumstances of this patient and the treatment rendered.  This example is a great one to discuss with your fellow CDI specialists and coders.

Coding Clinic for CDI: Review of Third and Fourth Quarter 2016

Sharme Brodie

Sharme Brodie

by Sharme Brodie, RN, CCDS
The AHA’s Coding Clinic for ICD-10-CM/PCS had both its third and fourth quarter 2016 editions published at the same time this fall. The combined publication is very long—the longest I have ever reviewed—so let’s start by looking at some of the changes to the ICD-10-CM Official Guidelines for Coding and Reporting.

Trouble with ‘with’
As many of you have probably heard, Section A.15 of the new Guidelines states that any time the word “with” appears, either in the Alphabetic Index or in an instructional note not in the Tabular List, the classification presumes a causal relationship and the conditions will be linked even in the absence of provider documentation. Coding Clinic reiterates this fact. For CDI specialists, this may seem like a good thing, but it also means we need to do our homework and make sure all these assumed relationships are truly related. We may find we need more queries to verify these cases with the providers. So be careful and go over each case to make sure it is an accurate representation of what is going on with your patients.

Providers’ prerogative
Coding Clinic (p. 119) stresses the new Guidelines found in Section A.19, which state that assignment of a diagnosis code must be based on the provider’s diagnostic statement that the condition exists, not on clinical criteria used by the provider to establish the diagnosis. That’s not to say the clinical criteria don’t matter, but that coders and CDI specialists cannot decide when a condition exists based on whether we feel certain criteria are appropriate for a condition.

According to Coding Clinic (p. 8), coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This Coding Clinic states “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone.”

Editor’s Note: There’s a lot more to cover in these oversized editions of the fall 2016 Coding Clinic, and Brodie explores the highlights in an extended white paper available in the Resources section of the ACDIS website. Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Q&A: Refuting obesity denials

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 wanted to write you, concerning a denial letter I have received, regarding  morbid obesity. The letter states:

“Although morbid obesity and BMI were documented, from the information received [we] could not verify documentation that supported obesity required increased monitoring, evaluation, diagnostic/therapeutic treatment or increased length of stay, therefore it does not meet criteria for assignment as an additional diagnosis code assignment.”

It went on to say that the diagnosis code does not meet criteria for reporting on the claim due to the ICD-9-CM Official Guidelines for Coding and Reporting rules for assignment of other (additional) diagnosis, UHDDS’ definations of other diagnoses, and other Guidelines (they cited Section I, General Coding Guidelines and Section III, Reporting Additional Diagnoses).

We fought the denial from two angles. One the physician did recommend weight loss and dietitian was monitoring the patient. Second, Coding Clinic address this question specifically.  Coding Clinic, Third Quarter 2011, pp. 3-4. This addresses the question of the clinical significance of obesity. Also, Coding Clinic, Third Quarter 2007, pp. 13-14, addresses the issue of coding of chronic conditions. I am still waiting on an answer, but wanted to see if you would share your opinion regarding this situation.

A: I agree with you fully on the obesity. Coding Clinic states:

“Individuals who are overweight, obese, or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider.”

This statement is fairly definitive and I would encourage you NOT to make any facility specific policy changes based on this inappropriate audit finding.

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Hospital-acquired conditions versus hospital-acquired pneumonia

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Have a question? Leave a comment below!

Q: Why is hospital-acquired pneumonia not considered a CMS hospital-acquired condition (HAC)?

A: This is confusing to a lot of people because of the similarity of terms used. Hospital-acquired pneumonia is a clinical descriptor. However, CMS’ hospital-acquired conditions are more of a payment classification than a clinical classification. Thus, those conditions that are certainly hospital acquired from a clinical perspective may or may not be a CMS hospital-acquired condition.

Hospital-acquired conditions are conditions that CMS has classified as preventable, and thus are not subject to additional payment coverage. At this time, hospital-acquired pneumonia is not considered a HAC by CMS.

Here are some links for further reading:

I hope this helps!

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Community-acquired pneumonia

Q: How do we determine if a patient’s pneumonia is community acquired or not? What documentation should we look for to support this?

A: To be honest, any type of pneumonia can be acquired in the community. However, physicians often use the term “community acquired” to signify a simple pneumonia. Simple pneumonia is usually easily treatable, although the term is somewhat self-limiting. The diagnosis causes unique problems for CDI specialists.

In general, simple pneumonia cases would not and should not be admitted to the hospital for inpatient status. They could be admitted, however, if they have a number of other medical problems that further complicate the care of their pneumonia, or are becoming acute themselves—for example, a congestive heart failure (CHF) patient getting fluid overloaded, a diabetes patient with an out-of-control blood sugar level, or a very elderly patient who also has a urinary infection and has now become confused.

We certainly would not want to make a blanket statement that any patient admitted to the hospital probably has a gram-negative or complex pneumonia. But, oftentimes, the pneumonia by itself does not support the admission.

“Atypical” is a term used by physicians to describe a unique presentation of pneumonia that has its own set of chest x-ray findings, history, and treatment requirements. Generally, atypical pneumonia is usually caused by one of the organisms classified as a complex pneumonia for DRG assignment purposes. Unfortunately, the term “atypical” codes to one of the simple pneumonia types.

Interestingly enough, “hospital acquired” and “healthcare acquired” are almost always written when the physician is attempting to describe a more complex pneumonia, resistant to treatment, in a patient who has a higher acuity illness. Unfortunately, these terms code to simple pneumonia classifications, too. Physicians are almost always surprised (and often disagree) with these phrases being classified as “simple.”

For this reason, what I teach CDI specialists to ask for the specific organism, and to either document that organism as either confirmed or suspected at discharge. Getting the exact organism is not always possible. Nevertheless, physicians need to document their assessment based on the same clinical evidence that caused them to treat that patient in one manner versus another.

For CDI specialists, the moral here is that when physicians document “atypical,” “hospital-acquired,” and “healthcare-acquired” you may need to craft a query, so providers don’t get an inappropriate downgrade.

Furthermore, CDI specialists may need to query the physician regarding patients sick enough to be admitted to the hospital for community-acquired pneumonia, particularly if the physician did not include any additional documentation regarding comorbidities. It may be that the patient actually has sepsis, or reveal a more specific causative organism which changes the classification to a more complex pneumonia.

Worst case scenario, a reassessment of the utilization procedures may need to occur if a large population of simple pneumonias is actually being admitted with no complications, no co-morbidities, no risk factors, and they genuinely do have simple gram positive type pneumonias.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Morbid obesity

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

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

Q: Coding Clinic, Third Quarter 2011, p. 4 states:

“…morbid obesity is a chronic condition and; therefore, can be coded as a secondary diagnosis without treatment.” (emphasis added)

An article in the CDI Journal, “From the Forum: Manage denials for BMI morbid obesity,” seems to indicate that providers should document how the obesity affects patient care.

What level of patient care needs to be documented?

A: The Coding Clinic you are referring to states:


If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.


Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.

Coding Clinic clearly states that morbid obesity should be coded when it is documented by the provider. It speaks to the fact this condition is always clinically significant. That said, morbid obesity is almost always addressed by both the provider and the nursing staff caring for the patient. These patients are more prone for infections, musculoskeletal injury, skin breakdown, respiratory compromise, etc., and, therefore, the medical decision making and care for this patient will be more complicated. This is why we are able to code this diagnosis whenever it is documented by the provider.

After this Coding Clinic was released, I have not seen a denial for this diagnosis. If you feel you need to expand documentation related to the condition, ensure your nursing plans reflect care of a morbidly obese patient. Your provider should also include their concerns related to the condition in their assessments.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps visit

Q&A: Query peer-auditing  

Go ahead, ask us!

Go ahead, ask us!

Q: Is it written in ACDIS Code of Ethics that, as CDI specialists, we are to “pull” bad or non-credible queries from patient charts and report them to our manager? This is what I have been taught in my current position.

A: As a manager, I would never ask my staff to be confrontational with each other. Queries should be audited on a regular basis—the manager or designee should regularly perform random audits of queries to ensure they are written compliantly and are appropriately assigned (no queries for unwarranted reasons), as well as identifying missed query opportunities.

Many departments also conduct peer reviews where each CDI specialist performs a selected audit of coworkers reviews and queries against facility and industry standards (such as the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice). The group then discuss their findings and exchange ideas about what may have been missed or how a given query may have been more effectively worded.

I would never ask a CDI specialist to pull a query by another coworker like that. If they found something terribly concerning, it should be reported to the manager, and the manager can determine if the query should be pulled, etc.

This example, in my opinion, is not related to CDI ethics as much as it is management and leadership. Every program should have an established method of query audit.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps visit

Q&A: Compliant queries  

Got a question? Ask us!

Got a question? Ask us!

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: Technology

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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. Joy Coletti, MBA, RN, CCDS, system services director for clinical documentation improvement at Memorial Hermann in Houston, Texas, answered these questions on electronic health records. Contact her at

Q: How long has your facility been using electronic health records? 

A: It was phased in at each hospital over a one to two-year timeframe in early 2000. Two of our smaller community hospitals took the lead with engaged physician champions.

Q: What role did you personally play in the transition? How big a role did the CDI team play?

A: CDI did not really play a role in initial EMR adoption, unfortunately, other than [providing input on] how physicians are electronically prompted when they have a query, and where those query responses reside in the EHR.

Q: What was the impetus for the transition initially (ICD-10? Government imitative?)?   

A: HIPAA was likely a large factor in speeding up the transition. E-queries were implemented in 2010. By 2010 the EMR was more electronic than paper, but still a hybrid of the two.

Q: Can you describe the different systems you use for your EHR and e-Queries? 

A: EHR is a Cerner platform, but also has Intelligent Medical Objects which allows us to search diagnoses. For e-queries, CDI specialist and coders software were developed by Meta Health, now part of Streamline Health.

Q: Has EHR use led to remote CDI capabilities?  

A: Yes, but within each hospital. Records are reviewed from an office location rather than within the units. This has significantly improved productivity levels. Records can also be reviewed across hospitals for coverage capabilities when a CDI specialist is out of the office or when census is very high at certain facilities. I hired three regional float CDI specialists who support multiple hospitals remotely from their offices on one hospital campus. Each CDI float supports multiple facilities and provided backup coverage.

Q: What has been the biggest benefit from EHR implementation in your opinion? 

A: Legibility of documentation, the ability for many disciplines to access the record simultaneously, remote access, and quicker order entry with fewer errors.

Q: What has the CDI team struggled with most in terms of reviewing records in the EHR and helping physicians with their documentation?

A: First, fragmentation of the EHR, which makes it challenging for physicians to “tell the patient’s full story” in an accurate and efficient manner. Providers sometimes produce a lot of copy-and-paste generated notes, which are challenging for CDI specialists and coders to follow and understand the patient’s story.

Second, there are no central diagnosis or problem lists managed by physicians that can be used by CDI specialists and coders.

Q: What advice would you give to CDI specialists who might be just starting EHR implementation or struggling through the process?

A: Continue to use paper queries until the EHR is at least 50% electronic, or at least a majority of history and physicals and progress notes are electronic. Once you transition to e-queries, while the health record is still hybrid, place a paper query “prompter” in the paper record to alert providers they have an electronic query, the basic steps for how to answer that e-query, and, of course, the CDI specialist’s name and contact information.

Q: What contingency plans are in place for when the power goes out or internet goes down? (you can skip this question if you want, I’m just curious in light of the flooding in LA and the fires in CA and knowing what happened in NYC after Sandy.)

A: Luckily, our back-up generators have always kicked in. All generators were moved out of basement level years ago due to the history of flooding in Houston area. Our IT emergency plans kick in when the EHR goes down and “all hands on deck” until the issue is identified and the EHR is back up and running. In the past, we were able to be back up within two hours.