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Q&A: PCS coding for perineal laceration

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Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Would you please clarify the correct ICD-10-PCS code for a second degree obstetrical (perineum) laceration that includes muscle?

A: This is a challenging area of ICD-10-PCS coding. Repair of obstetric lacerations documentation can often lead to miscoding, so we need to clearly document perineal lacerations and related treatments.

There is conflicting guidance online regarding this procedure, but the Coding Clinic, Fourth Quarter 2013, p. 120 does provide a definitive example to clarify appropriate code assignment. It discusses the case of a 25-year-old patient who had a normal spontaneous vaginal delivery at 39 weeks gestation and suffered a second degree perineum laceration. The repair involved suturing of the muscle.

In this instance, Coding Clinic says to assign code 0KQM0ZZ, repair perineum muscle, open approach. In ICD-10-PCS, an “open” approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. In this case, “open approach” is assigned because the laceration has cut through the external body layers, exposing the muscle (i.e. site of the procedure).

Although the laceration occurred spontaneously, it is nevertheless the means by which the procedure site is exposed. The same principle would apply for a laceration repair caused by other means, such as a knife wound that lacerates the liver.

Editor’s Note: Mark Morsch, MS, AHIMA-Approved ICD-10-CM/PCS Trainer, vice president of technology for Optum360, and Tom Darr, MD, chief medical officer for Optum360, answered this question. To access their free webcast, “Beyond the Planning: Post-Implementation Strategies for CDI and ICD-10,” presented by Optum360 and hosted by ACDIS, click here.

Q&A: Physician advisor collaboration with CDI


Thomas W. Huth, MD, MBA, FACP,

Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Thomas W. Huth, MD, MBA, FACP, Vice President of Medical Affairs at Reid Hospital & Health Care Services in Richmond, Indiana, answered the following questions regarding physician advisor’s role in CDI. With more than 20 years of clinical practice experience and a Master of Business Administration degree, Huth has served in a variety of medical staff, organized medicine, and community leadership roles. Contact him at

Q: Can you describe your role as a physician advisor to CDI?

A: I give expert guidance to the CDI specialists when they have questions about what to query, and how to do it, and how to approach the doctors in an effective manner.

Q: Can you describe the engagement and collaboration of your medical staff in CDI?

A: We work to establish a cultural expectation of engagement and collaboration of the medical staff with the CDI specialists. We provide constant feedback to the doctors and to the medical staff leaders about performance. We also ask the medical staff leaders to send the message to the individual doctors about the importance of CDI to the quality of care for patients and the objective performance of the organization on severity adjusted metrics.


Q: What has been your most successful approach for obtaining physician buy-in?

A: We have had good success by providing physician-specific feedback on the impact of complete and thorough documentation to measures of quality and efficiency. When doctors are shown their own data they usually become much more engaged in the process.


Q: Does your medical executive committee have an escalation policy or other policy requiring physicians to respond to queries/CDI clarifications in a set timeframe? Can you describe its effectiveness?

A: We have an analytics team which gathers in-depth data on physician response rates and we provide that to doctors on a weekly basis. Consequently, our response rates have improved to above 90% in most weeks. There is a comparable rate of agreement with the CDI specialist’s assessment. We don’t emphasize agreement rates to the doctors and we don’t report the rates to them individually. Instead, we use agreement rates as a measure of the quality and appropriateness of the CDI specialists’ queries.


Q: What are your biggest challenges with getting physician buy-in?

A: Keeping doctors engaged in improving the processes and quality of documentation since they have a lot of other priorities.


Q: What do you think the role of the CDI physician advisor is/should be in terms of program advancement and analysis?

A:  It’s very important to have a physician advisor with advanced training in CDI available to the CDI team. The advisor should be an effective liaison to, and teacher of, the medical staff. The physician advisor can provide many useful insights into the data and help plan improvement projects.

Q&A: The Role of the Physician Advisor in CDI


Rebecca Hernandez, RN, BSN


Zachary Fainman, MD

 Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Zachary Fainman, MD, co-medical director and physician advisor of care management at Advocate Luther an General Hospital in Park Ridge, Illinois, offered his insight into the role of the physician advisor in CDI. Fainman provides oversight over care management, social work, utilization management, government audit and CDI, a position he has held since 2011. Fainman is also the founder of the physician advisor committee at Advocate System. Contact him at Rebecca Hernandez, RN, BSN, CDI program supervisor works with and educates CDI specialists, nurses, physicians, and other healthcare practitioners to ensure accuracy and timely clinical documentation in the medical record. Contact her at

Q: Can you describe your role as a physician advisor to CDI?

A: As physician advisor to CDI, I act as an interface with physicians and CDI specialists. I also give my input on issues where CDI and coding may approach clinical situations from different perspectives.

I work hand in hand with Rebecca Hernandez, our CDI supervisor, in reviewing CDI department and physician metrics, and troubleshooting physician/CDI dynamics. In addition, Rebecca and I provide individualized physician education using their real time clinical cases and translating the case into quality data metrics to explain why CDI is critical to their practices as well as to the institution.

Q: Can you describe the engagement and collaboration of your medical staff in CDI?

A: The issues of trust, respect, and credibility are paramount in achieving engagement and collaboration.  My 20-plus years of clinical experience, as well as my knowledge of regulatory requirements from both governmental and private payors, has been helpful in gaining credibility.

Rebecca’s experience as a critical care nurse, as well as her exposure to multiple healthcare systems as a travel nurse, has gained her respect along with credibility. Thanks to the hard work of our CDI specialists, coders, and leadership, I believe our medical staff is extremely well engaged and collaborative.

Q: What has been your most successful approach for obtaining physician buy-in?

A: I sincerely believe our most successful approach has been individualized and data-driven education.  Rebecca, in collaboration with our medical directors and coding manager, has put together succinct straightforward clinical case studies which provide a clear and relevant picture of how CDI impacts not only revenue, but quality metrics as well.

As in any CDI program, one of the challenges is to get the physician to attend an educational meeting to gain buy-in. One way we get physicians to attend is by respecting their time constraints. So, we remain flexible with our meeting times and venues. Once we get the physicians to attend, they are grateful for the explanation and will actually seek out CDI specialists for their input.

Q: Does your medical executive committee have an escalation policy or other policy requiring physicians to respond to queries/CDI clarification in a set time?  Can you describe its effectiveness?

A: Yes, queries are expected to be answered within 24 hours. If not, the physician receives follow up communication (method of their choosing) from CDI specialists. If there is still no response, within an additional 24 hours, the physician advisor will contact physician and he is unable to obtain response, will escalate the situation to the chief medical officer. So far, this process has been very effective. With a medical staff of about 1,400 physicians, only a few have been escalated to the chief medical officer level.

Q:  What are your biggest challenges with getting physician buy-in?

A: Again, trust is a big issue. At first, physicians believe only the institution will benefit from CDI by realizing an increase in revenue. Once the CDI/physician advisor staff establishes credibility with the medical staff, this issue is abated.

Fear of litigation or government audit is also a barrier. Once the physician is convinced that accurate documentation may in fact positively impact these issues, these barriers are also mitigated. Physicians must be shown that staff and leadership of the institution really do care about them and demonstrating that CDI can aid in presenting an accurate picture of physician performance is one way to prove this.

Q: What do you think the role of the CDI physician advisor is/should be in terms of program advancement and analysis?

A: This again is a dual role between physician advisor and CDI leadership. Data must be available as to the impact on metrics such as length of stay, risk of mortality, severity of illness, case mix index, and complications among other measures. Also, this is a continuous process and does not involve a “one time” meeting. The accuracy of the data is crucial, if not accurate, credibility is at risk.

Q&A: Expanding into quality reviews

Mary Kay Brooks, RN, MSN, CPHQ

Mary Kay Brooks, RN, MSN, CPHQ

Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Mary Kay Brooks, RN, MSN, CPHQ, the director of CDI at the University of Iowa Hospitals & Clinics, in Iowa City, answered the following questions regarding CDI expansion into quality reviews specifically regarding the improvement of her facility’s capture of patient safety indicators. Contact her at

Q: What was the impetuous for shifting your CDI program alignment under the chief medical officer (CMO)?

A: Shifting the program helped to signify the importance of CDI to our physicians and physician extenders. CDI-related metrics are included in our provider performance evaluation data.

Q: Is there any dotted line alignment of the CDI program with quality or HIM?

A: Not officially. I ran the quality/safety department for eight years, so I was already very familiar with the publicly reported quality/safety metrics, and had a solid working relationship with HIM. We definitely closely team with HIM.

Q: Can you provide a brief scenario/description of what PSIs are and why documentation failures might affect this reporting?

A: PSIs are a set of risk‐adjusted metrics for adult and pediatric patients that identify potential hospital complications or adverse events after surgery, procedures, and childbirth. They’re used to evaluate and/or reward hospital or physician performance.

Q: Why did you focus on PSI 15 and 90?

A: We focused on the metrics that had the biggest impact (particularly related to Medicare’s value based purchasing initiative) and opportunity for improvement. PSI 15 is for accidental puncture and laceration (APL) rate.

We realized that there was no consensus between physician documentation and coding guidelines for certain types of injuries and that those situations where the condition was inherent, intended, or routinely expected were being coded as APL, which in turn led to a complication report. So we focused on educating physicians about APL to increase their awareness of the metric and how it is being used.

Then we asked the physicians for assistance and cooperation during reviews. Additionally, we establish a feedback mechanism so we can show them when their data improved and they share with us any problems or difficulties they have.

The PSI 90 is a composite metric and includes:

  • PSI 03 – Pressure Ulcer Rate
  • PSI 06 – Iatrogenic Pneumothorax
  • PSI 07 – CVC‐Related Bloodstream Infection
  • PSI 08 – Postoperative Hip Fracture
  • PSI 09 – Postoperative Hemorrhage or Hematoma
  • PSI 10 – Postoperative Physiological and Metabolic Derangement
  • PSI 11 – Postoperative Respiratory Failure
  • PSI 12 – Postoperative Pulmonary Embolism or Deep Vein Thrombosis
  • PSI 13 – Postoperative Sepsis Rate
  • PSI 14 – Postoperative Wound Dehiscence
  • PSI 15 – Accidental Puncture or Laceration Rate

Q: What was the biggest challenge you faced as you expanded your CDI program’s focus?

A: Educating the CDI nurses on the quality metrics specifications and finding the balance of accurately identifying and coding true complications.

Q: What “ah-ha” moments did the CDI team realized as they began their record reviews?

A: I would say learning to look beyond what simply impacts the quality scores versus what should truly be considered a complication.

Q: What tracking/monitoring data did you use and how often did you review that information?

A: We have an audit set up with HIM to target cases of interest. We look at information retrospectively/comparatively through Hospital Compare and University HealthSystem Consortium data.

Q: What other quality measures/areas might your facility look at investigating?

A: We are primarily targeting hospital acquired conditions and PSIs for adult and pediatrics.

Q: Is there a danger that CDI programs focus on a topic, switch focus and then lose ground they previously gained? (So, if you made progress on PSI 15/90 and move onto HAC focus will physicians go back to their previous poor documentation ways?)

A: Not so far. We routinely monitor or performance, and conduct mini reviews to identify failures.

Q: What staffing considerations should CDI programs evaluate prior to expanding review efforts?

A: Well, certainly your program should be fully staffed. You should also identify some early physician CDI adopters to enlist as “helpers” and “educators” for your physicians and targeted staff.

Q: What advice would you offer to CDI programs/staff looking to possibly expand their reviews?

A: Pick one or two metrics to start with. Don’t go overboard.


Q&A: How should we prepare for PCS?  

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Q: How can our CDI team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes (PCS)? Should we consider hiring additional staff, or staff with a surgical background?

A: I agree that use of ICD-10 will affect coding productivity, and also CDI productivity, primarily due to the technical features of PCS.  However, I feel adoption of [new diagnosis codes] (CM) by coders and CDI staff will be fairly easy.

Using surgical templates for high-volume procedures can make the transition to PCS easier. These templates could ask the surgeon to identify devices, grafts, and other qualifying information [that CDI and coders need to document to the highest specificity]. For example, was the stent bare metal or drug-eluting? Or was cement used for the arthroplasty?

I do not think we need to use people with surgical experience to help us with the PCS coding, as knowledge of anatomy and physiology should suffice. I have found that the extremely granular requirements of PCS coding can make proper MS-DRG assignment challenging in certain situations. This factor will impact CDI and coding DRG match efforts.

I think the most pertinent value and mission for CDI professionals is accurate documentation of diagnoses, but we can selectively query for some PCS procedures.

Editor’s Note: Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager of Regional Clinical Documentation & Coding Integrity at Sutter West Bay in San Francisco, answered this question. Contact him at, or connect with him and other CDI professionals on CDI Talk.

Q&A: Exploring HCAP, A Physician Documentation Dilemma

Richard D. Pinson, MD, FACP, CCS

Richard D. Pinson, MD, FACP, CCS

Q: If the physician documents “HCAP” is that sufficient to be able to code a gram negative and/or pneumonia?

A: If the physician documents “HCAP” the code defaults to 486, unspecified pneumonia. When this is the principal diagnosis, it results in DRG 193-195, simple pneumonia. Documentation of suspected/likely/etc. gram negative pneumonia, or organisms, results in code 482.83, other gram negative pneumonia. This is assigned to DRG 177-179, respiratory infections.

Q: Can you please clarify whether or not HCAP and CAP can be used for coding purposes, and if we should query for the specific organism?

A: In both ICD-9 and ICD-10 classifications, HCAP and CAP default to code 486, unspecified pneumonia, and therefore DRG 193-195, simple pneumonia, is assigned if it is the principal diagnosis. CAP belongs in DRG 193-195, and therefore does not require further specification of causative organism for a clinically correct DRG assignment. HCAP represents a much more complex, severe type of pneumonia caused primarily by staph and gram negative organisms, most appropriately described by DRG 177-179, respiratory infections. The most probable/suspected/likely organism(s) causing HCAP must be documented to allow correct coding to these DRGs.

Q: Is there any coding guideline that states you must have a positive sputum culture to code gram negative PNA, even when documented by a physician?

A: No, although in that case one would expect the diagnosis to be qualified with some term expressing the degree of certainty such as probable, suspected, likely, etc. Code assignment is based on consideration of all the documentation and information contained in the medical record taken in its full context and the “clinical validity” of documented diagnoses, meaning the findings are consistent with medical professional diagnostic and treatment standards and/or evidence-based medical literature.

Q: When the physician does not mention the organism in the final impression, can we consider the labs, or does the physician have to document it in the final impression?

A: Culture results alone cannot be used for code assignment. The documentation of the probable/suspected organism(s) is not required in the discharge diagnoses if documented elsewhere in the record, is clinically consistent with the diagnosis, if there is no evidence that the probable/suspected cause has changed “at the time of discharge,” and it was treated with a full course of indicated antibiotics for staph and/or gram negatives.

Editor’s Note: Richard D. Pinson, MD, FACP, CCS, co-founder and Principal of HCQ Consulting, answered these questions, as part of a supplement to our July 9, 2015 webinar, “Exploring HCAP: A Physician Documentation Dilemma.” For more information and access to a complete version of this Q&A, click here.

Q&A: How many cases should CDI review each day?

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Q: Is there an industry standard metric goal for CDI specialist reviews of Medicare cases? Should a CDI team strive to review, for example, 80% of all Medicare discharges in a given month?

A: As most CDI programs operate on a Monday through Friday basis, we cannot review 100% of Medicare admissions concurrently. Some patients may come and go without a review. If your organization has a high number of admissions that are short stays (two to three days or less), even if they arrive on a week day, the CDI team may not actually have time for a review prior to discharge.

Many organizations have begun to expand CDI reviews to seven days a week, and also have CDI specialists perform retrospective reviews for short-stay admissions. If a facility wants to cover more admissions by adding retrospective reviews, they must consider whether the time spent performing retrospective reviews will remove staff from their concurrent review efforts and whether that will negatively affect those expectations. There is no right answer.

The second issue that affects your ability to review a specific percentage of Medicare records is staffing. Do you have enough support to cover a specific percentage of records? If your facility has a high turnover each day, you will be asked to review a higher volume of admissions. The larger the population, the more difficult it will be to review, for example, 90% of the admissions. If you are a one-person-shop, you cannot possibly review a specific percentage of patients, as your population will wax and wane throughout the year.

Lastly, the mission of your CDI department, or the identified purpose of your reviews, might also affect your productivity or the number of reviews you can realistically complete. If you review records primarily for CC/MCC capture, your reviews may be quicker, and therefore your target number of reviews can be higher. However, reviews to capture SOI/ROM or other quality metrics may require more time and detail, and therefore your goal would have to be a bit lower.

There is no one prototype of what a CDI program or department is. Each organization defines the responsibilities of their CDI specialists differently, depending upon their culture and identified needs. Some programs focus on patient safety indicators (PSIs) and quality, some focus on medical necessity, and others focus on reimbursement—t he number of cases reviewed will be different for each organization. Take into consideration the patient population to compute an expected number, or percentage of reviews.

If you are an ACDIS member, you may wish to throw this question out to CDI Talk and see what other facilities require for an expected number of reviews each day, just be sure to preface the question with a description your CDI specialists’ responsibilities and your CDI department’s mission. CDI specialists from other organizations may be able to weigh in and help you set a realistic standard for your facility.

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

Q&A: Query rate metrics

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Q: I noticed that several programs do not seem to have a query percentage rate that they must meet. My facility has a goal of 35%, which was set by a consulting company about five years ago when our program was started. Is there a more realistic query rate percentage we should aim for? What do other programs set as a goal?

A: There are several concerns with having a set query rate. Query opportunities vary through the “life” of CDI efforts. Initially, there may be a high query rate (i.e., type of heart failure with CHF), but once physicians become educated—which should be the goal of CDI efforts—those “clarification” queries should decrease in volume.

As a CDI department matures, the type of queries often become more sophisticated, moving from queries that clarify an existing diagnosis to identifying missing diagnoses and/or clinical validation of documented diagnoses, which may be less prevalent.

A continued high query rate among seasoned CDI specialists could actually be seen as a potential performance issue, because it could indicate the CDI specialists is not effective in establishing relationships with providers and delivering education. The goal of CDI is to reduce the query rate over time, as improved documentation practices become ingrained in the culture of the organization. [more]

Q&A: Preadmission Bundling of Certain Inpatient Only Procedures

Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.

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Q: A March transmittal from CMS allows payment for certain preadmission inpatient only procedures bundled into a subsequent inpatient claim under the so-called three- (or one-) day window rules. How will these changes affect coding and billing on the inpatient hospital side as far as MS-DRGs go? If the inpatient order is written after the procedure, would the principal reason for admission be post-operative aftercare, rather than the condition that caused the surgery?

A: Under its recent clarification, CMS’ expansion of coverage applies to the following:

  • All preadmission inpatient-only procedures performed on the date of admission
  • All preadmission inpatient-only procedures performed during the relevant window (one or three day[s] preceding the date of admission) that would otherwise be deemed related to the inpatient stay

For purposes of the preadmission bundling rules, a procedure is deemed to be related to the subsequent inpatient stay if it is clinically associated with the reason for a patient’s inpatient admission. The relevant preadmission window is three days for IPPS and Maryland hospitals and one-day for all non-IPPS hospitals, except for critical access hospitals (CAHs). CAHs are not subject to these preadmission bundling rules.

Presumably, [more]

Q&A: Unrelated surgical procedure DRGs

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

Q: Could you please explain unrelated surgical procedure DRGs? Also can you explain how we can differentiate between extensive operating room (OR) procedure and non-extensive OR procedure.  

A: Many CDI specialists with a clinical background are “encoder dependent,” trained to “code” using an encoder and taught to create a working MS-DRG based on “grouper” software. However, CDI specialists should understand how to manually assign a MS-DRG, too. The basics steps for assigning a MS-DRG are.

  1. Identify all the reportable diagnoses in the health record and assign their applicable ICD code (we currently use ICD-9-CM, but will transition to ICD-10-CM)
  2. Identify the principal diagnosis (the condition “after study” determined to be chiefly responsible for occasioning the admission), the remaining diagnoses are secondary diagnoses some of which may be classified by CMS as a complicating or comorbidity (CC) or major complication or comorbidity (MCC)
  3. Use the alphabetic index of diagnoses in the DRG Expert to identify the base/medical MS-DRG noting its Major Diagnostic Category (MDC)/body system (the MDC is necessary to assign the surgical MS-DRG when applicable) by scanning the MS-DRGs associated with the listed pages to see which applies to the particular scenario
  4. Identify any/all reportable procedures and their associated procedure code (ICD-9-CM Vol. 3 until we transition to ICD-10-PCS)