All Entries in the "Questions from the Mailbox" Category

Determining the benefit of flesh-and-blood CDI vs. computer-assisted coding

Don't fear advent of computer assisted coding.

I received an interesting question following the February ACDIS Quarterly Conference Call about the impact of new technology on the CDI profession. It read: “Do you think computer-assisted coding (CAC) will reduce or eliminate CDI jobs?”

Several members of the ACDIS advisory board formulated answers worth sharing (read a few of their comments in the April edition of the CDI Journal.)

Here’s how I feel about CAC. It can be a valuable tool in the box of a CDI specialist, like a hammer or saw, but it does not replace the CDI specialist. At times I too react to new technologies with skepticism and defensiveness, wondering if this or that new gadget will sound the death knell for my own job. But machines will never replace the human element.

In short, summarizing the sentiments of the ACDIS Advisory Board:

• As long as physicians require education as to why accurate, complete, and legible documentation is important, CDI will be here to stay.
• As long as doctors respond to a face instead of an electronic prompt, CDI will be here to stay.
• As long as medicine remains part art and part science, CDI will be here to stay.

In short, CDI is not going anywhere anytime soon. View these new technologies as a new and exciting challenge to master, not as an enemy to fear. What do you think about CAC and the impact it will have on CDI? Send me an e-mail with your thoughts.

Q&A: Potential post-surgical encephalopathy

Q: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.

A: I wouldn’t necessarily query for encephalopathy in this situation. However, I might ask whether the patient had “acute confusion” or “acute drug-induced delirium and/or hypoxia due to narcotics,” and I would want the physician to clearly link the condition to the underlying cause.

Definitions of encephalopathy are easily found by performing a search on the Internet. One such definition, from MedicineNet.com states:

“Encephalopathy: Disease, damage, or malfunction of the brain. In general, encephalopathy is manifested by an altered mental state that is sometimes accompanied by physical changes. Although numerous causes of encephalopathy are known, the majority of cases arise from infection, liver damage, anoxia, or kidney failure. The term encephalopathy is very broad and, in most cases, is preceded by various terms that describe the reason, cause, or special conditions of the patient that leads to brain malfunction. . .”

When an altered mental state is due to a reversible cause (e.g., drugs), the specific condition is what should be reported. The situation you describe sounds potentially like an adverse effect of medications more than encephalopathy. Report an adverse effect by coding the condition (e.g., confusion, delirium, somnolence) along with an additional code (E935.2, Other opiates and related narcotics: codeine [methylmorphine], morphine, opium (alkaloids), meperidine [pethidine]) and indicating the adverse effect of the drug.

Reporting encephalopathy as the only MCC could also trigger an audit. Assigning the most appropriate descriptor (e.g., confusion, delirium, hypoxia) as the adverse effect and ensuring that the documentation clearly links the condition and the cause is important. That way, the record is clear.  As the above definitions states, most cases of encephalopathy are due to underlying diseases rather than anesthesia. Another definition from Mosby’s Medical Dictionary states:

“Encephalopathy: any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions, as Wernicke’s encephalopathy or Schilder’s disease.”

Both the above definitions appear to agree that encephalopathy is due to underlying disease pathology rather than being a reaction to anesthesia or medication.

In the current climate of increased audit scrutiny I would never query for encephalopathy without also asking for the etiology: “encephalopathy due to…” First, this allows the coder to assign the most appropriate ICD-9-CM code.  Second, since encephalopathy is often a source for provider queries and may result in the only MCC on a record, I recommend that CDI staff also query for the etiology as this may provide additional support for the diagnosis.

Editor’s note: Lynne Spryszak, RN, CCDS, CPC, an AHIMA-approved ICD-10-CM/PCS trainer and independent HIM consultant based in Rosell, IL, answered this question, which was originally published in CDI Strategies.

This answer was provided based on limited information submitted to HCPro, Inc. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Q&A: Resolving the case load, productivity question

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Q: For a newly trained CDI specialist, what is the approximate number of reviews (both concurrent and follow up) one should expect him/her to be able to handle per day? I recall from the CDI Boot Camp that the starting number was about 10, but I can’t remember how many new versus follow-up cases CDI staff should expect to review. I assume that the base number of 10 records increases as the weeks goes on, right?

A: From my experience, a newly hatched CDI specialist working solo should be able to review about 10 cases/day for the first few weeks. I typically give a new person just one unit to cover, which would mean that on Monday she/he would have about 5-10 new admissions from the weekend (depending on the size of the unit –for example, our units were about 20 beds each) plus their re-reviews. Thereafter that person could have two or three new admits per day which would make about 10 or so total reviews.

After a month, I would add a second unit, thereby doubling the reviews from 10 to 20. A full assignment for my reviewers was four units. I tried to give people similar clinical units to cover so there might be some overlap. For example, whoever covered the cardiovascular intensive care unit (CVICU) would also cover the post-coronary artery bypass graft (CABG) units. That way,

if she didn’t get to review the CVICU record that patient would eventually be hers in the CABG unit and she could review the case then.

As the manager I really scrutinized the number of admissions on each unit (from a data perspective) so that everyone’s assignments were about equal and that everyone had similar query-opportunity units. This way the CDI specialist could not only learn different areas and become more professionally versatile for the benefit of the hospital but enable him/her to build additional physician relationships and a broader understanding of conditions based on the range of physician perspective.

At the six-month mark a CDI specialist would assume a full assignment. Again, as a manager, I understood that it would still be a while before he/she was able to identify documentation improvement opportunities with 100% ability. Our program had processes for prioritizing reviews as well as clearly defined query follow-up policies. Our physician response rate goal was 100% and our policies and processes were designed to make that happen.

My team only had documentation responsibilities, however. We did not perform utilization review, case management, or other measures. If these additional tasks are added to a CDI specialist’s to-do list, I would recommend you adjust your program’s expectations accordingly.

If you have utilization review tasks also included in your CDI duties, and find it inhibiting your ability to follow-up on outstanding CDI reviews, track the number of cases that you are unable to review or follow up on for one-to-three months. This ensures you have data to support your position—that the additional role of utilization review hampers your ability to effectively complete CDI reviews of the records.

Your data should also show potential lost opportunities such as reductions in captured severity of illness/risk of mortality scores, DRG change, missed queries, etc. so that you can show how the lack of complete record review negatively affects the facility and patient care.

Editor’s Note: This article first appeared in the February 16 edition of CDI Strategies. For additional information regarding productivity metric for CDI specialists see also:

• Survey: Production expectations for reviews, re-reviews
• CDI Productivity Benchmarks (A CDI Talk topic)
• Q&A: Productivity measures for CDI specialists
• Additional thoughts on CDI staff productivity
• Metrics ideas and thoughts
• Q&A: Maintaining CDI productivity under the SOI/ROM system
• Chart reviews: Best practices from three perspectives

Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

• Consider NKF definitions when documenting renal disease
• Column: AKI and the mess we’re in
• Acute kidney injury: The crossroads of ICD-9-CM and medical literature
• Q&A: Two query alternatives for acute on chronic renal insufficiency
• Use kidney key-words to sooth your documentation troubles
• Sample queries and educational posters in the Forms & Tools Library

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at christine.Mobley@dimensionshealth.org.

Q&A: Choosing the most appropriate principal diagnosis

Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an

Discerning the principal diagnosis is difficult at best.

outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature of 102°, his blood pressure is 94/60.

His urine is cloudy and brown. A bolus of fluid is given in the emergency room (ER) with subsequent dramatic improvement in the patient’s mental status. The ER physician admits the patient for “fever workup and UTI” and documents urosepsis. Patient is treated with IV antibiotics, Tylenol, and continued IV fluids.

Given the rule of “when a symptom is followed by contrasting /a comparative diagnosis, the symptom code is sequenced first,” should the principal diagnosis be fever with the UTI as the MCC/CC?

A: The provider documentation said “fever workup and UTI.” “Fever workup” is just a comment about what is planned, not a diagnosis. In addition “fever” is a symptom code and coding guidelines state that a symptom should not be sequenced as the principal diagnosis when a definitive diagnosis is known. In this case, “urosepsis”—which has been documented, is a diagnosis (599.0—the same code as UTI).

If you were to go ahead and code the fever the code would be 780.61, Fever presenting with conditions classified elsewhere. However, any code from the 780 range is considered a symptom, another clue to look elsewhere for the principal diagnosis. If you were to look up 780.61 in the code book here is what you’d find:

780.61, Fever presenting with conditions classified elsewhere

Code first underlying condition when associated fever is present, such as with:

leukemia (codes from categories 204-208)

neutropenia (288.00-288.09)

sickle-cell disease (282.60-282.69)

The phrase “code first” means that you would first code the condition/disease causing the fever and a few examples, not the complete list, are provided.  In other words, due to the coding direction “code first” this code (780.61) could never be the first-listed or principal diagnosis. So, here’s how the scenario plays out:

• Principal diagnosis: UTI
• Procedure: None
• MCC/CC: None
• MS-DRG Assignment:  MS-DRG 690, UTI without MCC
• Query opportunity? Yes. Query the physician to clarify the term “urosepsis.” There won’t be a code for urosepsis in ICD-10 so start making this diagnosis an educational priority, if you haven’t done so already.  You would want to ask the physician (if appropriate) if he/she is treating the patient for a localized infection (urosepsis/UTI) or a systemic infection (sepsis due to a urinary tract infection or from a urinary source).
  Before you query, investigate the clues of failed outpatient antibiotics, hypotension, and altered mental status.  Evaluate additional lab results, assess how “sick” the patient is and include that information in your query.  The scenario above stated that the patient’s mental status improved with hydration, so I wouldn’t necessarily jump on the “sepsis” bandwagon. And although the blood pressure appears somewhat low, this may be within normal parameters for this patient. Assess what this patient’s baseline is, a very important step prior to querying for any diagnosis.
• Query/potential DRG (only if the patient meets clinical parameters and the documentation and treatment plan support the diagnosis): DRG 872, Sepsis with UTI as a secondary diagnosis

Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, AHIMA-Approved ICD-10 CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com.

Q&A: Incorporating CDI efforts in the outpatient arena

Q: Do you recommend carving out time for outpatient [documentation] review, or dedicating someone to this

Industry experts answered a series of questions regarding program growth during CDI Week.

role?

A: We actually carve out time for outpatient review. We started with two initiatives in our ED. One was injections/infusions and documentation for our RNs, and the other was medical necessity documentation. The way we built a case for injections/infusion was our outpatient ED coders audited 100% of records for two weeks. They gave us a loss in charge analysis—what we would have recouped in charges had the RNs documented appropriately—and then we extrapolated that out over a year.

With medical necessity, we worked with the patient accounts department. They had to write off charges for things like CTs, EKGs, BNPs, and  PT/INRs because there wasn’t a diagnosis or symptom to support the need for certain outpatient radiological tests and labs. Patient accounts tracked those charges that were being written off.

If you’re a newer program, [now may] not the time [to start outpatient record reviews]. But if you’re an established program and you have the manpower, definitely it’s a good time to expand into outpatient areas. Compliant documentation is a big deal with RAC and other regulatory agencies [who are] making sure you’re supporting all your treatments and clinical thought processes.

We have four total CDI [specialists], including myself. We’re all RHIAs. Two are scheduled to be down in the ED during the week, each for two-hour increments, on top of going up to the inpatient units. We then switch off every other week. That way if someone goes on vacation, everyone has coverage and knows the process. It also switches up your day a little bit. You get to see different things outside of your normal routine with the inpatient reviews.

Editor’s Note: The above Q&A was adapted from responses provided by Avery E. Trickey, RHIA, manager of the HIM department at Advocate BroMenn Medical Center in Normal, IL,  as part of the first annual Clinical Documentation Improvement Week celebrated in September. All the Q&As from the week are available on the ACDIS website www.acdis.org.

Q&A: Resection or excision in ICD-10

Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a resection or an excision and why. The coder coded the following record to total ostectomy-rib.  If you crosswalk the ICD-9-CM Level 3 code to ICD-10-PCS, it maps to a resection. I think that is correct, but I’m not sure if we should query the physician to find out if the physician considers the procedure an excision. Here is summary of the key findings from the report:

A female developed a left arm DVT [deep vein thrombosis], was treated with anticoagulation and a

Probably an excision.

subsequent venogram revealed compression of the left axial subclavian vein with elevation of the arm. With the arm in neutral position, the vein flow was normal. Her arm swelling subsequently resolved and DVT then resolved. She was then referred for first rib resection.

During the operation, an incision was made in the axilla and dissection proceeded down onto the chest wall. The chest wall dissection proceeded up to the first rib. The first rib was cleared of its surrounding tissue using Bovie cautery. The scalene muscles were resected off of the rib. Once we adequately cleared the rib of surrounding tissue posteriorly beyond the edge of the nerve and anteriorly to the junction with the manubrium, the rib was cut posteriorly and avulsed anteriorly.

A 1-centimeter hole in the pleura was discovered upon inspection. After attempting to simply close this we continued to have a small air leak, therefore, a 24-French chest tube was selected and placed into the pleura with a purse-string of 3-0 Vicryl around it. The chest tube was secured through a separate stab incision on the lateral chest wall.

The wound was copiously irrigated and closed in multiple layers with 2-0 and 3-0 Vicryl sutures in the soft tissues and 4-0 Monocryl in the skin.

A: In reviewing my ICD-10-CM/PCS training materials, I believe this is a resection. The ICD-10-PCS coding guidelines (section B3.8) indicate:

“PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestines…”

Also, in the 2011 edition  of AHIMA’s ICD-10-PCS training manual, it states:

“Resection is similar to Excision except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part…”

In reviewing the root operation table for 0PT , it has the body part value of rib, right and rib, left. If it had said ribs, then my answer would be different because one rib would be only part of ribs so I would go with excision.

In my opinion, the correct ICD-10-PCS code would be:

• 0PT10ZZ for the right rib
• 0PT20ZZ for the left rib

Editor’s Note: Heather Taillon, RHIA, manager of coding compliance at Franciscan St Francis Health in Beech Grove, IN, answered this question following the September 27 audio conference “ICD-10 for CDI: Improve Documentation Now for Effective Transition Later.” Taillon is an AHIMA- Approved ICD-10-CM/PCS Trainer.

Q&A: Aspiration without pneumonia

Q: Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he

When to code for aspiration pneumonia

said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia, he said the patient doesn’t have pneumonia. He said the patient also doesn’t have a foreign body. What should I do?

A: It is difficult to answer without more information. Mendelson’s syndrome is a bronchitis or pneumonitis resulting from macroaspiration of acidic stomach contents usually associated with endotracheal intubation. When patients have this condition, coders should report ICD-9-CM code 997.39 (other respiratory complications) plus a code for the pulmonary condition. Aspiration pneumonia and aspiration bronchitis both map to the same ICD-9-CM code, 507.0 (pneumonitis due to inhalation of food or vomitus).

Because ICD is an international classification system maintained by the World Health Organization, it tends to group similar conditions under the same code. This is unlike CPT^®, with which physicians may be more familiar. The AMA maintains CPT, which includes more procedure- and encounter-specific codes. In this case, the physician must provide clarification so a coder can report the most accurate ICD-9-CM code.

Editor’s Note: William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, answered this question in the June issue of Briefings on Coding Compliance Strategies

Q&A: Where to find CC/MCC designations

You've got questions? Lynne's got answers.

Q: How do you know when a condition has a complication comorbidity (CC) or major CC (MCC) designation?

A: Initially, you’ll have to refer to the current fiscal year CC and MCC lists which are published as part of the Inpatient Prospective Payment System Final Rule by CMS, typically the first week in August. CMS lists CC/MCCs by codes, numerically, so every year I take CMS’ lists and reorganize them alphabetically, by condition, so non-coders will have an easier time finding what they need.

The new, FY 2012, CC and MCC lists (alphabetical) have been uploaded to the ACDIS web site in the Forms & Tools Library under “Policies, Procedures, Regulations, and Job Descriptions.” You must be an ACDIS member to access this link.  I have also uploaded a document showing the new CC and MCC diagnoses as well as the deleted/changed CC/MCC conditions in the same location.

Over time, you may consider developing your own “short list” of CC and MCC conditions to use for reference. After reviewing charts for several months, you will probably memorize the conditions you see most frequently, or if you are unit-based, consider developing lists for the types of patients you see: cardiac, respiratory, neuro, ortho, etc.

Q&A:When is combination code reporting permitted?

Q: I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart

Send your questions to mvarnavas@cdiassociation.com

failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to indicate not to combine these without an expressed link by the physician. Renal disease is an assumed link, but not heart disease. I’d also like to know the thought process behind tracing this diagnosis to DRG 316 for stress-related chest pain. When I code chest pain with anxiety or acute stress reaction I get DRG 880 or 882.

A: A combination code is a single code used to classify:

• Two diagnoses, or
• A diagnosis with an associated secondary process (manifestation)
• A diagnosis with an associated complication

Combination codes are identified by referring to sub-term entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Coders should only assign the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

To simplify if a physician documents two conditions as being related to each and there is a combination code, the combination code should be used instead of two separate codes.

The code that relates to stress related chest pain is code 306.2 cardiovascular malfunction arising from mental factors, which groups to DRG 316.