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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?

Go ahead, ask us!

Go ahead, ask us!

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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Have a question? Leave a comment below!

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

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: 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)


Q&A: Creating a compliant query for SIRS and/or sepsis

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

Submit your CDI questions by replying to this post .

Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), Pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart, leading the physician, by introducing a new diagnosis. Do you have any suggestions?

A: Although many CDI and coding professionals feel offering a new diagnosis as a choice in a multiple choice query or clarification is considered introducing new information, the 2013 Guidelines for Achieving a Compliant Query Practice states,

“[P]roviding a new diagnosis as an option in a multiple choice list, as supported and substantiated by referenced clinical indicators from the health record, is not introducing new information.”

Thus, if you have a patient that demonstrates clinical indicators to support the diagnosis of sepsis, you may submit a query to clarify if this diagnosis is appropriate. In the body of the query, you would also include those clinical indicators and evidence of treatment that supports your rational for querying the physician.

That said, use the SIRS criteria to support sepsis, with caution. The criteria cannot be explained by another existing condition—for example, tachycardia when the patient has atrial fibrillation.  Review the Surviving Sepsis Campaign’s nationally supported clinical criteria and treatment bundles that can be used to support the diagnosis of sepsis.

Here’s an example query that you might use:

Dear Doctor;

Patient 2345 was admitted with a UTI. The ED record indicates patient was febrile with a temperature of 102.7, heart rate of 98, Laboratory results showed a white blood cell count of 13,500 with 12% bands, hyperlactatemia, and altered mental status. Blood cultures pending. Antibiotics ordered with fluid bolus.

Based on these clinical indicators, can the patient’s status be further clarified as:

  1. UTI with sepsis
  2. UTI only
  3. Other _____________________
  4. Unable to determine

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: Documenting uncertain diagnoses

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Ask your question by leaving a comment below.

Q: If the physician says “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the “uncertain diagnosis” terms “yet to be ruled out?”

A: Yes, the terms “concerning for” and “considering” would be interpreted as an uncertain diagnosis, so they would only be reportable if they appear at the time of discharge. The Official Guidelines for Coding and Reporting doesn’t limit the terminology that can be associated with an “uncertain” diagnosis. It states:

“If the diagnosis documented at the time of discharge is qualified as ‘’probable,’ ’suspected,’ ‘likely”, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

The AHA’s Coding Clinic for ICD-9-CM/ICD-10-CM/PCS has also addressed this topic.  Encourage providers to use the phrase “evidence of” when they feel comfortable that a diagnosis is relevant, but may be lacking certainty through diagnostics. Please see below (the text is taken from slides featured in our CDI Boot Camp):

Querying for Organism:

  • Coding Clinic 3rd Quarter 2009 provides clarification regarding use of the verbiage “evidence of
  • When the provider documents “evidence of” a particular condition, it is NOT considered an uncertain diagnosis and should be appropriately coded and reported.
  • If the provider documents “evidence of” a condition and/or causative organism in the progress notes or on a query, a code can be assigned without further documentation; however, the CDI should monitor the record for evidence of the condition being ruled out and query the status of the diagnosis if applicable.

Coding Clinic ICD-10-CM 1st Qtr. 2014

  • Is it appropriate to report codes for diagnoses reported as “evidence of cerebral atrophy” and “appears to be a nasal fracture,” …
  • ANSWER: The phrase “appears to be,” listed in the diagnostic statement fits the definition of a probable or suspected condition and would not be coded in the outpatient setting… However, when the provider documents “evidence of” a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported…

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 responded to this question.

Q&A: Getting surgeons on board with PCS

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Do you have a CDI-related question? Leave us a comment below.

Q: What information do you have about physician response to ICD-10-PCS? I am getting some push-back from surgeons. The response I received from a surgeon was, “I want to choose my own words for the surgery that I performed” and “I don’t want a coder picking the words, ‘removal or extraction or insertion.’ I want them to code my words.” He went on to state that he wasn’t going to change his language, which I reassured him that he didn’t have to do, according to the directive from CMS. Have you heard any complaints about the coders translating what the surgeon writes into the appropriate ICD-10-PCS code?

A: I think it is too soon to ascertain the overall reaction to ICD-10-PCS by surgeons. They may be unaware of how their documentation codes out in the inpatient setting under PCS, since their reimbursement works differently. You are right that the provider doesn’t have to use the root operation terms—the coder must interpret the surgeon’s documentation into one of the root operations. I guess it may become an issue for the surgeon if it affects a quality measure. Until then, who knows?

I think PCS is going to be a big challenge for most organizations, but they may not realize it, yet. Also, remember that, traditionally, CDI has been able to work around surgeons, because we often query about diagnoses, which can be based on the documentation of other providers as long as the surgeon is silent. So it might be helpful to go back to basics with the surgeon to let them know what CDI does, why it can and does affect them, what a query is, etc.

Further, in the Physician Advisor’s Guide to Clinical Documentation Improvement, Trey LaCharite, MD, writes (pp. 193-194):

“Surgeries/surgeons represent the largest financial drivers at most facilities and yet these individuals are notorious for providing limited documentation regarding their efforts and for non-compliance with CDI initiatives. Any increase in documentation from this physician group represents a total paradigm shift since a once universally perceived benefit of a career in surgery was less note writing. As the old joke goes, “where do you hide $100 from a surgeon? In the medical record!”…

“To win them over, focus on their nature. Surgeons are data driven, competitive, and worried about their public quality report cards. Show them, both individually and as a group how the facility down the street seems to have better performance scores (higher SOI/ROM, higher expected-to-observed mortality ratios, lower LOS, etc.) for a given procedure than your facility does. Additionally, if you have multiple surgeons or groups of physicians within your own facility performing the same procedure, show how one of them seems to be doing a better job than his or her colleague. The surgeons will do the rest since they are not used to being anything but ‘top of the class.’”

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 responded to this question.

Q&A: Complication codes versus condition codes

You've got questions? We've got answers.

You’ve got questions? We’ve got answers.

Q: When I started as a CDI specialist, I learned that when a complication code, such as 999 or 998 series, happens to be the reason of admission, along with another condition also contributing to the admission, the complication code takes precedence over the other condition code. Is this correct, and is there any written guidance like an AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS that discusses this?

A: First refer to the code set’s alphabetic index and tabular list guidelines related to sequencing, with notes that instruct us to code first or code also. There is instruction within the Official Guidelines of Coding and Reporting as to how to interpret the directional notes found here. For example: “Section I. Conventions, general coding guidelines and chapter specific guidelines.”

Coding Clinic also gives us guidance, however, there is a hierarchy for which piece of guidance supersedes the other. Follow first the instruction within the index and tabular list (coding conventions) as these are the highest, followed by the Official Guidelines of Coding and Reporting, and lastly the Coding Clinic advice.

The Official Guidelines of Coding and Reporting, related to this subject in particular states in “Selection of Principal Diagnosis- Section G”:

Complications of surgery and other medical care. When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

Thus, your understanding of how these should be sequenced is absolutely correct, and now you are able to state where you accessed this instruction.

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: Encephalopathy as a principal diagnosis

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Q: We recently had a patient admitted with acute metabolic encephalopathy due to a urinary tract infection (UTI). Acute metabolic encephalopathy was selected as the principal diagnosis, with the UTI as a CC, due to the understanding that patients are not typically admitted to the hospital for a UTI. However, the chart was audited by Recovery Audit contractors, who insist we make the UTI the principal diagnosis, with acute metabolic encephalopathy as a secondary diagnosis. What are your thoughts? Also, in what cases, if any, can encephalopathy be a principal diagnosis?

A: Encephalopathy is often challenged by auditors as both a principal and secondary diagnosis. Essentially, the definition of encephalopathy is vague at best, and, if the documentation does not support it, it is often denied. But that doesn’t mean we should not take use this diagnosis when appropriate. We need to ensure our documentation supports the diagnosis with appropriate clinical indicators. I would suggest you view the denial to determine whether the denial is based on the sequencing, or whether they are denying the actual diagnosis altogether.

Additionally, work with coders and physicians to develop organizational definitions for encephalopathy to eliminate any uncertainty. Such standard definitions can also be helpful for diagnoses such as acute/chronic respiratory failure, acute kidney injury, and levels of malnutrition severity. If the coders and CDI specialists consistently use defined criteria to support query for this diagnosis, you will be able to identify when it is appropriate to use this diagnosis and when it is not evident.

Let’s talk about encephalopathy. Encephalopathy is always the result of another disease or systemic illness. The Official Guidelines for Coding and Reporting offers guidance concerning etiology/manifestation codes, specifically “code also” and “code first” instructions. In the case of etiology/manifestation conventions, certain pairs of conditions usually occur together. The code set’s tabular list offers sequencing guidance for these specific diagnoses pairs. When you find the manifestation code in the code book, the instructions indicate to “code first the etiology,” and, when you find the etiology, to “use an additional code” to capture the manifestation. A common example of the etiology/manifestation coding convention is diabetes and gastroparesis.

Although encephalopathy always has an underlying cause, it is not considered part of an etiology/manifestation convention. There is no “code first” instruction pertaining to the diagnosis of encephalopathy. So, now we need to look at the definition of principal diagnosis for the patient with encephalopathy and UTI.

The UHDDS defines the principal diagnosis as “the condition established after study to be chiefly responsible for the admission of the patient to the hospital for care.” Let’s look at an example patient: An elderly woman comes to the emergency department for altered mental status, and is diagnosed with a UTI. The CDI specialist asks (just as you may have done in the situation you described), “Does a UTI normally require an inpatient admission?”

The answer to that is typically, no. UTI is one of the most frequently-denied diagnoses for medical necessity. If we ask the same question for encephalopathy, we find it definitely requires an inpatient admission.

I have debated this very same issue with coders. They state we are not treating the encephalopathy, but rather we are treating the UTI. We must remember that to treat encephalopathy, we must treat and eliminate the underlying contributing condition.

We monitor and treat encephalopathy in other ways, as well. For example, a patient arriving to an emergency department with altered mental status will most likely be administered a CT scan of the brain.

Neurological assessments are a provision of care and monitoring. These patients require more nursing care. As a nurse, there is a tendency to focus on the encephalopathy over the UTI, to keep the patient safe, and assign someone to watch over these patients.

Next we need to ask how the decision is made to send the patient home. Is it when the UTI is completely cured (antibiotic regimen is complete/urine is clear), or is it when the patient’s mental functioning clears? My guess is that we send the patient home when the encephalopathy resolves.

Historically, coders have sequenced the UTI first, with encephalopathy supplying the MCC. This will provide more reimbursement, and coders were taught in years past to make the choice that provides the most reimbursement.

However, I encourage you to challenge the status quo, and question what diagnosis actually occasioned the admission. We are not saying encephalopathy would be the choice every time, but we do encourage to not automatically assume.

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 For information regarding CDI Boot Camps