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Guest Post: Tips for new Recovery Audit program denial defense

Laura Legg

Laura Legg

By Laura Legg, RHIT, CCS, CDIP

CMS recently announced the award of a new round of contracts for the Medicare fee-for-service Recovery Auditors (RA). As the new round of RAs roll out, even the most experienced RA response team will need to understand the new challenges we face with CMS’ 2017 changes. Make every effort to ensure your teams are centralized, efficient and organized with excellent communication skills. Also, it is very important to educate your RA response team on changes to the RA rules. Following are a few tips to help you stay on top of the changes.

Compose complete medical records: Your facility should include all required documentation necessary to support each case. If a physician orders a test, make sure the order, results, and interpretation are all included with the medical record and are legible and easily found. Also make sure the discharge summary is as complete as possible. The discharge summary should accurately reflect all confirmed diagnoses and all care administered during the patient’s hospital stay without introducing new information.

Avoid EHR cloning: Cloning, or copy and paste, is being seriously addressed by CMS. RAs may be looking at progress notes for confusion among caregivers due to copy and paste overuse.

Focus on challenging inpatient diagnoses: What diagnoses and procedures challenge coders the most? Some tricky diagnoses are, but are not limited to, sepsis, respiratory failure, renal failure, congestive heart failure, pneumonia, spinal surgeries, and skin procedures. Make sure the medical record documentation support these diagnoses and that coders can easily identify the correct code assignment for them.

Follow RA websites: CMS requires RAs  to keep an updated provider portal which includes a list of issues under review. This resource shows the issue name, type of review, provider type, status impacted, date posted and a detailed description of the issue. It is a good idea to build your internal audit plan around this list and the Office of Inspector General’s (OIG) work plan. CMS will require RAs to broaden their review topics and they must include all provider claim types and may include required reviews based on referrals from the OIG report.

Audit: Be sure that all diagnoses are coded to the highest level of specificity. Ensure that all medical documentation entries are consistent. Be sure internal auditors look at the same data elements reviewed by the RA including principal diagnosis, secondary diagnosis, procedures affecting or potentially affecting diagnosis-related groups, present on admission indicators, and discharge disposition codes.

Reduce denial rates—Under the new rules, additional documentation request (ADR) rates will be affected by your denial rate. More denials will result in more requests and denials still mean a lot of work on the provider end and a drawn-out appeals process. You can improve response rate and efficiency simply by following RA timelines and responding to record request appropriately. Takebacks due to lack of response to ADRs are more common that you think.

Editor’s Note: Legg is the director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. This article was adapted from the original published in Opinions expressed are that of the author and do not represent HCPro or ACDIS.

Conference Update: ACDIS achievement awards nomination deadline extended

achievement awards

ACDIS Achievement Awards

Every year, the ACDIS Achievement Awards are presented at the annual ACDIS conference. There’s still time to nominate someone! The deadline has been extended to Friday, February 17, 2017, to allow more nominations.

Please nominate a colleague who has made significant contributions to the CDI field, who makes a difference in the profession, or is an outspoken advocate of CDI. We are still accepting nominations in the following categories. Click on the links to view each award’s criteria.

All nominations will be reviewed and voted on by the ACDIS Conference Committee in conjunction with ACDIS administration. You may upload supporting material with your nomination. Only one document upload is permitted per nomination. There are three question fields relating to attaching supporting material and if you want to upload files for multiple fields, please combine them into one document or zip them together.

Please fill out the nomination form by Friday, February 17, 2017. Click here:

Conference Q&A: Hirsch offers insight into CDI utilization review contributions


Ronald Hirsch, MD

Editor’s Note: Over the comings weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada.  Today, we’ve reached out to Ronald Hirsch, MD, FACP, CHCQM-PHYADV, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who will present “Medicare Regulation Update: Practical Application for CDI Professionals.” Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians and serves on the Advisory Board of the American College of Physician Advisors. He is the co-author of The Hospital Guide to Contemporary Utilization Review, published in 2015.

Q: What’s the biggest challenge you’ve encountered related to implementing Medicare regulations?
Regulations and guidance from CMS are often vague and occasionally contradictory. These regulations affect everyone, including the doctor, the patient, the bedside nurse, the case managers, CDI staff, the billing and coding staff, and the C-suite (those working in upper administrative roles). Understanding the regulations and implementing them compliantly across the many affected groups is a challenge for hospitals.

Q: What are three things attendees can expect from your session?
Let me just list some of these out:

  1. To hear a simple explanation of the two-midnight rule
  2. To understand the practical application of medical necessity guidelines for CDI professionals
  3. To be familiarized with the required patient notifications

Q: What is one tool CDI professionals cannot live without?
A: If they learn the two-midnight rule as I teach it, they will become the hero of their institution.

Q: In what ways does your session challenge CDI professionals to think outside the box?
A: CDI professionals work hand in hand with case managers but often do not understand their work. Gaining an understanding of that work makes them a more indispensable part of the team.

Q: What are you most looking forward to about this year’s conference?
A: As a physician advisor expert, my CDI knowledge is quite cursory. With the breadth of courses available at the conference. I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference Boot Camp for physician advisors. It will be an honor to hear from Erica Remer, MD, and James Kennedy, MD, two of the most renowned physicians in CDI.

Q: Fun question: Do you have any pets?
My wife and I just got a new kitten three weeks ago. Leopold is a little wild thing during the day between naps but he loves to cuddle with us at night in bed.

Guest Post: Documentation for chronic care management

Lori-Lynne Webb

Lori-Lynne Webb

As CDI specialists and coders, it is our job to document and code appropriately for the care being provided. For CDI professionals working with physician practice settings, identifying documentation to support chronic care management codes under the Current Procedural Terminology (CPT) code system can be difficult. 

CPT code 99490, regular (“non-complex”) chronic care management assumes 15 minutes of work by the billing practitioner, according to a January 18, 2017 Frequently Asked Questions publication from CMS. The code incentivizes providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions. In addition to charting the time, the diagnoses for the two (or more) chronic conditions must be documented and clearly connected as medically necessary for this oversight care.

In the 18 months since code 99490 has been implemented, one of the biggest problems is physician reluctance to document and bill for it. Many providers have the basic criteria built into their electronic health records (EHR), yet do not use it. The EHR is the most effective way to meet the  criteria for billing of this code but a basic table in a hard copy chart or file can be just as effective and easy to use.


According to CMS, in fiscal year 2015, only 275,000 Medicare beneficiaries received (and CMS paid for) this service. Considering how many Medicare beneficiaries are enrolled and receiving Medicare services (approximately 54 million), 275,000 services provided with code 99490 is a very small percentage.


An area of continued concern from providers is they must also allow the patient to “opt in” and consent for this care. This can be problematic, as this is a non-face-to-face coordination of care and patients may view this as a charge for a service not rendered appropriately, as they did not physically “see” the provider. I’ve heard of patients complaining to their providers for having to pay for this “invisible” service. Again, it is imperative that the provider communicate clearly to the patient regarding this service and allow them to opt in or out. Physicians have also stated concern about whether they would be able to ensure or maintain 24/7 access to care management services as required by the CMS guidelines.

As a coder, billing code 99490 is one way to help your physician actually get paid for time spent performing this care management service. This service can include telephone calls, coordination of continuing services, and collaboration with specialty physicians which are services that are not normally paid for, or bundled in traditional E/M services. In addition to providing good patient care, the billing/coding of chronic care management code 99490 can also help the practice revenue stream and enhance the patients overall care.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at or find current coding information on her blog: Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article originally appeared on

Breaking News: The Surviving Sepsis Campaign releases new guidelines for Management of Sepsis and Septic Shock, 2017

Allen Frady

Allen Frady

By Allen Frady, RN, BSN, CCDS, CCS

Management and practice guidelines are not often at the forefront of CDI focus and training. As quality and revenue reviewers, we more often find ourselves involved in clinical definitions and criteria, as we simply try to determine if a diagnosis exists.

As clinical validation and audit activities push CDI specialists closer to denial defense efforts, we must also be aware of the most current recommendations with regards to treatment. Last week in the both Journal of American Medical Association (JAMA), and a number of critical care publications such as the Society of Critical Care Medicine, we got our first peek at newly updated treatment recommendations coming out of the Surviving Sepsis Campaign. Although these publications represent more of an evolutionary update (compared the revolutionary change of definition we saw with last year’s release of Sepsis-3 definition changes) there are some noteworthy talking points here for CDI specialist.

The publication takes a rather comprehensive approach, covering every possible facet of monitoring and treating patients in sepsis (that is, after all, part of the Surviving Sepsis Campaign’s mission). Starting with the initial resuscitation, the update includes a shortening of the initial time for the early directed therapy treatments (for some components such as administering IV fluids) from six hours to three hours.

Monitoring suggestions have also gotten more specific, changing from general parameters for urinary output, mean arterial pressure, and invasive cardiac monitoring to a recommendation of frequent perfusion reassessment and adjustment made on an increased number of data points and focusing on dynamic parameters rather than static ones. The specific IV fluid recuitation recommendation is now 30ml/lg of crystalloid fluids over three hours (assuming stable renal and cardiac function of course).

Reassessment now includes an evaluation of everything from heart rate, to general blood pressure, arterial oxygen saturation, respiratory rate, with the continued recommendation of maintain the map of at least 65 or greater and introducing invasive monitoring for central venous pressure etc. in patients who are in critical status.

It makes further recommendations using lactate levels as part of the ongoing data to measure the amount and effectiveness of necessary fluid therapy.

Studies show that facilities who establish comprehensive sepsis protocols and performance standards have better outcomes. Doing so has become a recommendation across the board. If possible, patients should get blood cultures before starting antibiotic therapy as long as it does not delay antimicrobial administration any significant length of time. Another recommendation is to immediately test for and repeat monitor lactate levels.

The guidelines go on to address the specific antimicrobial selections, vasopressor escalation, source identification and recommendations for things like blood transfusion, anticoagulant administration, use of mechanical ventilation, management of ARDS patients, DVT prophylaxis, nutritional support and use of corticosteroids.

There new guidelines contain a vast amount of treatment information (too much to detail here) but as I mentioned, the recommendations are evolutionary in nature, not revolutionary.  I have been teaching CDS the 30ml/kg guideline along with the importance of lactate and procalcitonin for a few years now.  It is nice to see it in the practice guidelines.

One noteworthy point I want to mention, is the subject of de-escalation of therapy. In some cases, auditors will use a change or drop in antibiotics or a decrease in IV fluid administration as evidence that sepsis was ruled out. Nothing could be further from the truth. One of the reasons they suggest that blood cultures and wound cultures be performed early is so that they can appropriately de-escalate antimicrobial therapy in light of possible findings of the organism. In the era of increasing antimicrobial resistance with the over prescription of antibiotics, and in a critical care scenario when certain antibiotics may be nephrotoxic or hepatotoxic, this is likely to be more a sign of responsible stewardship than an indicator of diagnostic value.

The Surviving Sepsis Campaign specifically mentions the following recommendations:

  • De-escalation to the narrowest effective antimicrobial agent for most serious infections.
  • A thoughtful de-escalation of antimicrobials based on adequate clinical improvement in spite of the possible initial culture findings.
  • De-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement or evidence of infection resolution in septic shock patients.
  • De-escalation of early multidrug therapy is associated with equivalent or superior clinical outcomes in sepsis and septic shock in some observational studies. This one needs more study however.
  • They recommend, daily assessment for de-escalation of antimicrobial therapy in patients with both sepsis and septic shock.
  • Various procalcitonin-based algorithms have been used to direct de-escalation of antimicrobial therapy in severe infections and sepsis. This also needs further study however. In total, the phrase “de-escalation” appears in the article no less than 30 times.

The next time you hear someone argue that a decreasing of vasopressors, IV fluid, or antimicrobial therapy proves there was no sepsis or shock, remind yourself that this has largely been debunked. De-escalation is in fact, a responsible part of sepsis management. Not every patient’s presentation would merit early de-escalation of course.

If physicians are abruptly stopping (not de-escalating) therapy such as antibiotics and or IV fluid and monitoring early in the episode, that could be a sign that either the sepsis was in fact ruled out, or could be that the early goal directed therapy worked exceptionally well. In such a case, a query is in order to ascertain the proper physician documentation that the sepsis was either ruled out, or was an atypical case which resolved early.

The goals here are clearly stated by the Surviving Sepsis Sampaign however—that antibiotic therapy should if at all possible, start being reduced within about three days if the patient is responding well to treatment. What you would likely see here is a change from multi therapy to a single IV antibiotic. In some cases, with antibiotics which have good PO absorption in a patient with no GI pathology, a change to PO antibiotics is possible. In other cases, antibiotics might be discontinued entirely. This is not evidence that there was no sepsis. The same goes for the fluid therapy. These practice reference repeatedly describe the time period as a “few” days. For most people “few” means around three. They further mention an early therapeutic window of only three to five days. Some studies in fact are cited in this paper which show that the shorter treatment periods of three to five days can be just as effective as seven and 10-day treatment protocols. These shorter treatment windows have also been associated with improved outcomes in some studies.

As more and more education and pressure is put on physicians about the dangers of antimicrobial resistance, and as we analyze the impacts long term to the kidneys and liver of hard to metabolize antibiotic therapy and as we see the impacts of over treating patients with antibiotics actually leading to increased readmissions due to the extinguishment of the natural healthy flora and the breeding of resistant organisms, we are likely going to see a trend towards these shorter treatment periods as standard sepsis care.

Link to Abstract:

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

Guest Post: Pneumonia coding compliance critical for success

James S. Kennedy

James S. Kennedy

by James S. Kennedy, MD, CCS, CDIP

In ascertaining pneumonia’s clinical validity, I like the criteria established by a work group of physicians convened by the Maryland Hospital Association that support compliant coding. Essential elements to diagnose pneumonia include one of each of the following three elements:

  • Temperature > 38°C or < 36°C and/or leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
  • Purulent sputum, cough, dyspnea, tachypnea, supportive findings through physical exam (e.g. bronchial breath sounds, dullness to percussion), and/or worsening gas exchange
  • Supportive imaging

There are many others, such as those from the Annals in Internal Medicine in 2003. These authors state that a negative chest x-ray is an imperfect gold standard in ruling out pneumonia, thus when a physician documents pneumonia with a negative chest x-ray, we must ascertain its clinical validity. If a provider maintains that a patient has pneumonia, especially when it is documented with uncertainty at the time of an inpatient discharge or in response to a clinical validation query, then we are on solid ground to code the condition. Coding Clinic, Fourth Quarter, 2016, page 149, is a valid defense of this principle.

Even though ICD-10-CM classifies pneumonia by its causative organism, querying for the underlying cause is tricky. The AHIMA Standards of Ethical Coding state that coding professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query, and cites that querying for gram-negative pneumonia on every pneumonia case regardless of clinical indicators is an example of unethical coding. Therefore, coders and their compliance personnel must know the clinical indicators supporting a query for the underlying cause of pneumonia as to target them appropriately and judge the validity of the documented response.

In my opinion, the best article addressing this dilemma is the 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society on hospital-acquired and ventilator-associated pneumonia.

In my reading, if a patient requires more than 2–3 days of an antibiotic other than ceftriaxone (Rocephin®), levofloxacin (Levaquin®) at 250–500 milligrams per day, azithromycin (Zithromax®), or similar agents, depending on the agent used that’s described in this article, the provider can support at the time of discharge that the pneumonia was likely due to the associated organism with hospital-acquired or ventilator-associated pneumonia. These include:

  • Staph aureus – vancomycin or linezolid
  • Pseudomonas – ciprofloxacin, levofloxacin (750 mg/day, not lower doses of 250–500 mg/day), aminoglycosides (gentamicin) or colistin – pseudomonas
  • Other gram-negatives – Zosyn®, cefepime, imipenem, or azotrenam

Community-acquired pneumonia is a challenge, given that we often do not know what the causative organism is or that it is often viral in nature. Many physicians will still treat with an antibiotic, even though a study in the New England Journal of Medicine demonstrated an organism in only half of the cases studied and bacterial agent in only one out of seven hospitalized cases.

IDSA also published a guideline for community-acquired pneumonia which has a table of what antibiotics should be used in special circumstances. Options that influence DRG or HCC assignment include:

  • Anaerobes (aspiration pneumonia) – Zosyn®, Unasyn®, or clindamycin
  • Influenza – oseltamivir or zanamivir

Whether to query the physician for the bacteria justifying the use of Rocephin®, Zithromax®, or Levaquin® is an issue that will challenge all of us, especially if we’re working to manage our HCC-related risk-adjustment factor score. I’m open to suggestions if you have strategies that work in your facilities.

One final reminder: inpatient pneumonia cases with sepsis on admission are counted in the CMS mortality and readmission measures cohorts. However, the same cases with a secondary diagnosis of severe sepsis or sepsis with an associated organ dysfunction, are not. As we discussed in my previous sepsis columns, I hope that you’ve worked with your medical staff to define exactly what severe sepsis is and how to identify it at the time the inpatient order is written so that it may be properly documented and coded.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

Guest Post: An obligation to report noncompliance

Rose Dunn

Rose Dunn


One of the many coder/CDI obligations is to report noncompliant activities. Your employer’s compliance plan may direct you to report these noncompliant observations to the compliance officer or a compliance hotline.

When you report your observations, you may do so anonymously or by identifying yourself. It is your decision which approach you take, but regardless, you still have the obligation to report.

Commonly reported coding-relating issues are:

  • Documenting services long after the service was provided and possibly never provided
  • Routinely reporting high-level evaluation and management or MS-DRG codes (upcoding) when the documentation does not support the high level
  • Failure to code to the highest level of specificity when the documentation is present
  • Queries that encourage or lead a physician to add documentation which would increase the level of reimbursement for a particular case
  • Adding charges to a claim for services provided
  • Providing services that are not medically necessary

When a coder/CDI specialist observes actions inconsistent with quality healthcare, the more detail provided to the compliance officer will help in the investigation. Depending on investigation findings, major, minor, or no changes may result. Sometimes, actions observed may appear inappropriate, but upon investigation, the actions were consistent with clinical practice.

For example, a coder/CDI specialist may consider the actions of another staff member to be too zealous in optimizing the codes to achieve higher reimbursement. The term optimization is defined as a procedure used to make a system or design as effective or functional as possible.

When coders “optimize” the coding process, they attempt to make coding for reimbursement as accurate as possible. This process may involve querying the physician for clarification of conditions or augmenting conditions documented. If done in a nonleading way, the organization will obtain the highest entitled reimbursement.

When the investigation illustrates the need to make changes, you will probably see activities such as reeducation, updating of policies, and possibly the removal of staff members.

Qui tam

Unfortunately, there are times when an individual reports legitimate compliance concerns and does not see actions being taken to correct the concern. In these situations, a person may wish to “blow the whistle” and contact an agency outside of the organization to file a lawsuit. This type of lawsuit is known as a qui tam lawsuit.

Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government. Qui tam is an abbreviation of the Latin phrase meaning “who as well for the king as for himself sues in this matter.”

Qui tam cases are different from other types of lawsuits, such as those involving personal injuries, because the person bringing the lawsuit is not the one who has been harmed.

A recent example of qui tam is the South Florida case where physician Mario Baez, a partner in a physician practice, turned whistleblower on his partner when he determined that his partner was submitting fraudulent claims. Nearly all the patients seen at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only 1 in 1,000 people truly have this disorder, according to Baez. The disorder increased the risk score for the physicians who were participating in a Medicare Advantage health plan reimbursement arrangement with Humana. The higher the risk score, the greater the reimbursement. The interesting twist on this qui tam is that Baez was not just whistleblowing on his partner but also on Humana. Humana should have been able to detect this fraudulent activity.

Taking a qui tam action requires much consideration, because often the whistleblower is identified during the legal proceedings. Having legal counsel guidance will be beneficial. If the case is lost, the situation can be embarrassing.

However, if the case is won, there may be financial rewards for the whistleblower depending on how much the whistleblower’s details of the situation contributed to the success of the suit. Regardless, following your convictions to surface inappropriate care should result in better care for patients thereafter, and that is the right thing to do.

Editor’s note: Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. For questions please contact editor Amanda Tyler at This article is excerpted from JustCoding’s Practical Guide to Coding Management.

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


Guest Post: AMI 30-day mortality measures and CDI – Is your approach ischemic?

Shannon Newell

Shannon Newell

by Shannon Newell, RHIA, CCS

The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP) in fiscal year 2013. In February 2016, CMS announced that 70% of commercial payers agreed to use the measure as one of the cardiology outcomes linked to payment.

The Medicare Episode Payment Bundle for AMIs, proposed to begin in July 2017, will further link reimbursement to measure performance. Traditional CDI approaches to strengthen data quality in the name of risk of mortality are not sufficient enough to capture the documentation needed under the CMS mortality risk adjustment methodology.

CMS includes any discharges with the principal diagnosis of an AMI in the mortality outcome measure (except for a few exclusions outlined in the methodology, such as discharged against medical advice). The final group of included discharges is referred to as the “cohort.” Consider the following case studies:

Case Study 1

  • Scenario:
    • Admitted with severe unstable angina and diaphoresis with the finding of ST elevation in the anterior leads on an EKG with the initial set of cardiac enzymes being negative
    • Because of the suspicion of acute transmural myocardial infarction (MI), receives TPA infusion
    • Subsequent cardiac enzymes are negative, and at the time of discharge, the physician documents an aborted transmural MI
  • Principal diagnosis:
    • The principal diagnosis would be unstable angina because the AMI was aborted
    • If coronary artery disease is documented, coding guidelines would require selection of this condition as the principal diagnosis
  • AMI mortality cohort:
    • This discharge would be excluded from the AMI mortality cohort with the correct application of coding guidelines for principal diagnosis selection

Case Study 2

  • Scenario:
    • Admitted with subendocardial MI with acute systolic heart failure and cardiogenic pulmonary edema
    • Treated with supplemental oxygen and IV Lasix therapy, and because of the patient’s age, the MI is treated conservatively
  • Principal diagnosis: Two principal diagnosis options exist:
    • Option 1: Acute systolic heart failure
    • Option 2:  Subendocardial MI
  • AMI mortality cohort:
    • Coding guidelines permit the selection of either option as the principal diagnosis
    • Today’s CDI teams typically select the option which will result in the highest MS-DRG relative weight, which will result in attribution of the discharge to the AMI mortality cohort in this case


Once a hospital claim goes out the door with the principal diagnosis of AMI, CMS analyzes claims databases to determine if that Medicare beneficiary died within 30 days of discharge (for any reason). If a mortality is identified, CMS attributes the death to the hospital that reported a claim with AMI as the principal diagnosis within 30 days preceding the death.

Each discharge included in the AMI mortality cohort is then risk adjusted to determine the expected rate of mortality. The CMS methodology uses CCs/MCCs, not hierarchical condition categories, to determine the likelihood of death for each discharge.

  • Each CC is comprised of related ICD-10 codes
  • There are a variety of CCs which affect AMI mortality risk adjustment
    • These categories are weighted; some have a more significant effect on risk adjustment than others
    • 12 categories drive 90% of strengthened risk adjustment opportunity
    • Only about 25% of these conditions serve as MS-DRG CCs/MCCs
  • CMS looks for the presence of these conditions in the AMI admission as well as all Part A and (face to face) Part B claims for the 12 months prior to that admission
  • Some of the conditions must be documented prior to the patient’s admission for AMI management or there is no “credit” for risk adjustment

Performance for the CMS 30-day AMI mortality measure adjusts payments received for the Medicare and commercial patient population. This reimbursement is not limited to hospitals; under the Episode Payment Model other providers will be affected as well. Although this is a hospital-centric measure, meaning the measure assesses the hospital’s management quality for the AMI population, documentation and reported codes across the continuum affect the expected risk of mortality, and in turn impact measure performance.

A few questions for CDI and quality programs to consider as they shift initiatives to support value based payments:

  • Does your principal diagnosis selection process consider attribution of discharges to quality measures in addition to MS-DRG relative weights?
  • Does your record review process to support the capture of CCs/MCCs related to mortality only on actual deaths or on the entire denominator included in the measure?
  • Are you focused on the capture of CCs/MCCs which have an effect on CMS’ mortality methodology?
    • The comorbidities in this algorithm differ from those used in other mortality risk adjustment methodologies commonly used in CDI programs today
    • The broad number of comorbid categories requires the CDI and quality teams focus on point of care capture
  • Do the clinical documentation and reported codes in your system’s outpatient settings support the capture of comorbid conditions related to risk adjustment?

Editor’s note: Newell is a Managing Director with CCDI-DQ with extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. Reach her at

Q&A: Be wary of over reliance on nurse practitioners for documentation

Deanne Wilk

Deanne Wilk

Q: We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for patients and we have great success with them.

The difference here is that the orthopods want us to send all queries to their NP, even if he/she is not caring for the patient. The ACDIS/AHIMA query guidelines tell us to query the provider that documented whatever needs clarification (though because we have a team approach with hospitalists, we often query the attending caring for the patient now, not necessarily the documenting provider). Our coding department has said they will not accept query responses from a non-treating provider. What do you think?

A: I have seen this happen at a number of facilities. They are using the NP/PA to do the “dirty work.”  There are varying opinions on this:

  1. NP will become very good at documentation and become your best friend
  2. Queries will get answered in a timely manner
  3. If they are going to respond to queries they must see the patient.  If not, they are a potential liability for the medical group and hospital.

I also wanted to respond to the group regarding who/where you can obtain documentation from:

  • Pathology = no
  • Echo = no
  • Radiologist = no (however,  CDI/coding can pull the specific fracture site and/or vessel sites directly from reports as long as the diagnosis is stated in the H & P/PN/Consult/ER, etc.
  • EKG = no
  • Cath report = yes

However, remember that in a query you can “refer” to that information.

 Editor’s note: Deanne Wilk, BSN, RN, CCS, CDI Manager at Penn State Health in Hershey answered this question. Make sure to work with your facility compliance and coding departments in incorporating any recommendations as advice provided is general in nature. Contact Wilk at