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Q&A: A recap of the ACDIS Quarterly Conference Call


James P. Fee, MD, CCS, CCDS

Editor’s Note: The ACDIS Quarterly Conference Call was held on November 19, and featured a roundtable discussion with 12 of our ACDIS Advisory Board members. The following questions were submitted by audience members after the call, and were answered by advisory board member, James P. Fee, MD, CCS, CCDS, Vice President at Enjoin.

Q: We are struggling with the definitions of acute respiratory failure and chronic respiratory failure issue. My clinicians are asking me for the clinical indicators. Any ideas where to turn? 

A: It is difficult to give a single source. Most medical textbooks define using arterial blood gases criteria and now some P/F ratios. However, true respiratory failure incorporates patient findings and symptoms, impaired oxygenation and ventilation, and intensity of treatment.

Q: I am wondering what the doctor has to say in order for the coder to take a fracture to the traumatic section. If the provider documents that the patient comes in with a “fracture from a fall,” and the patient doesn’t have a history of osteoporosis documented, can the coder take this to traumatic?

A: There are two separate entries in the code set Alphabetic Index: one for pathological and one for traumatic, at the same level. There is no default code in ICD-10, as in ICD-9, should the physician neglect to provide that additional detail, so the type of fracture must be specified. I recommend looking at the code book.

Q: In ICD-10, can you code chronic obstructive pulmonary disease (COPD) exacerbation with aspiration pneumonia?

A: There is no excludes 1 or 2 note under aspiration pneumonia (J69.0) or COPD with acute exacerbation (J44.1). Now there is a confusing note, under J44.0, to assign an additional code to identify the infection, but this would imply sequencing issues and really only applies to bronchitis or bronchiolitis (based on the instructional notes under those code categories).

Sunday Reading: Physician communication scenarios

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

The CDI specialist must be both positive and professional in his or her interactions with physicians. But they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician.

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example:  The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids.  For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Do you think the patient’s pneumonia may be due to aspiration?

The physician responds, “It is certainly a possibility.”  The CDI specialist thanks the physicians and asks: “Could you please clarify that possible cause-and-effect relationship in the record?”  She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”

Approach #2 (verbal query): “Good Morning, Dr. Smith, looks like you are busy today. I have a documentation clarification for you if you have a minute.” The physician responds, “Yes, I am busy and would appreciate it if we could talk later.” The CDI specialist responds: “Thank you. I will leave a written query on the chart for you in case we do not see each other before you leave. I hope your day gets calmer.”

In both scenarios, the CDI specialist had the chance to talk to the physician and express the need for documentation clarification. However, the first scenario had the advantage of the physician immediately documenting an answer. In this case the CDI specialist could have also taken the opportunity to educate the physician on the importance of consistent terminology and could have asked him to use the term aspiration pneumonia throughout the rest of the stay and in the discharge summary.

In the second scenario, the CDI specialist informed the physician of the need to clarify documentation but additional follow-up is required to ensure the physician provided the clarification in the medical record. As the saying goes, “don’t win the battle only to lose the war.” In this situation it was probably better to back off politely. Insisting that the physician do it immediately risks angering and alienating the provider, which would make him or her less likely to cooperate in the future.

Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.

ICD-10 Tip of the Week: Altered Mental Status

Confused about altered mental status?

Confused about altered mental status?

Altered mental status (AMS) is a vague system within both ICD-9-CM and ICD-10-CM. The role of the CDI specialist is to equate this ambiguous symptom with a more definitive diagnosis that better represents the mental status and/or level of consciousness of the patient and accurately captures the associated severity of illness.

When code 780.97 was introduced in October 2006, the American Hospital Association’s Coding Clinic for ICD-9-CM described the condition as “a symptom of a number of different types of illnesses” and listed a variety of possible etiologies, including trauma, infection, neurological disorders, and substances, to name a few.

Just as Coding Clinic noted, physicians incorporate many different considerations in their assessment of a patient’s mental status, including their assessment of altered levels of consciousness, orientation, perception abnormalities, and abnormal thought content.

CDI specialists need to review the health record for clinical indicators that suggest a definitive diagnosis of which altered mental status is a symptom. Because there are several different pathways to obtaining a diagnosis associated with the symptom of altered mental status, we must consider the most common differential diagnoses, which requires knowledge of the patient’s baseline mental status, including substance use status, the presence or absence of infection, and/or the presence or absence of trauma.

If a patient with altered mental status has a history of dementia, the CDI specialist should review the record to determine if this is the patient’s baseline mental status or a change. Many of the diagnoses associated with dementia are classified within the Mental, Behavioral, and Neurodevelopmental Disorders Chapter, which is signified by codes that begin with the letter “F,” or Diseases of the Nervous System, where the codes begin with the letter “G.”

Coding for degenerative diseases like Alzheimer’s disease requires knowledge of the age of onset to select the most accurate code, as these diagnoses are differentiated by early and late onset.

Encourage providers to include the age of onset for these conditions as part of their new patient history and/or history and physical forms to avoid extraneous queries.

Editor’s Note: For more information, check out the following: The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

TBT: Documentation for care quality

Glenn Krauss

Glenn Krauss

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. This week, we’re throwing it back to a April 2011 article in the CDI Journal, A CDI program’s purpose: Documentation for care quality,” written by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI.

The overarching goal of a documentation improvement program is not to improve reimbursement for the hospital, but to effect a positive change in the behavior of those who document in the medical record. These can include:

  • Treating physicians
  • Consulting physicians
  • ER physicians
  • Nutritionists
  • Floor nurses
  • Wound care nurses
  • Respiratory therapists
  • Physical/occupational therapists

The medical record should accurately depict the acuity of the care provided. It should demonstrate whether all tests and procedures were medically necessary and ordered and performed based on sound evidence-based medicine. It should explain why more resources were spent to treat one particular patient, compared to another patient with a similar diagnosis who was managed and treated with less resources and intensity.

Most CDI specialists focus purely on CC/MCC capture by asking for clarification of specific diagnostic statements, often a single word such as “diastolic” or “sepsis.” Their efforts should be on educating physicians to document a holistic picture of a patient’s illness and the reason for admission to the hospital, not single words in isolation.

Q&A: How can we ensure the right documentation for a level of care recommendation?

Have a question? Leave a comment below!

Have a question? Leave a comment below!

Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?

A: The recent Outpatient Prospective Payment System rule states:

”The physician’s decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”

But another important consideration should be whether the patient requires hospital-level care.

This is the crux of the review. For example, a patient may have an exacerbation of a chronic illness, but the ACC or case manager then needs to ask whether hospitalization is required to resolve the problem. If this is a new illness, does it require hospitalization to find out the source? (Auditors inevitably deny so-called work up hospitalizations if the testing could be performed on an outpatient basis.) Finally, the ACC or case manager must see medical documentation that states that the care the patient requires is expected to exceed two midnights.

Reviewers should consider the history of present illness, the severity of the signs and symptoms of the patient’s current medical condition, and the expectation of a two midnight stay, in addition to:

  • The patient’s age
  • Disease processes
  • The medical predictability an adverse event

Also look at admitting orders. What are the patient’s current needs that require hospital-level care? What is the risk of not admitting the patient? I call this the “because clause”—if the patient is not admitted, given his history of pre-existing condition, he may be at risk for complication.

Editor’s Note: This question was answered by Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida. It was originally published in Case Management Insider.

Guest post: Understand physicians’ perspectives on ICD-10

Sam Antonios, MD

Sam Antonios, MD

by Sam Antonios, MD, FACP, FHM, CCDS

Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar terms, efficiency, or income. How can coders, HIM professionals, and clinical documentation improvement (CDI) specialists engage with physicians to help them now that ICD-10 has been implemented?

Let’s explore some strategies.

Time crunch: The main reason physicians have been concerned about ICD-10 is time, or more specifically the lack of it. In the ambulatory setting, providers–who are in a chronic time crunch–will need to pick a code, or an alias of a code, on every patient encounter. Acclimating to the change will take time, but most physicians will eventually only have to deal with what pertains to their specialty.

In the hospital, physicians will need to document more. However, by now, CDI programs should have been strengthened. It’s more important than ever to explain the underlying goal of the new code set: better documentation will mean more accurate data, which will mean better risk adjustments for quality measures. Better documentation also means a more appropriate DRG that justifies the length of stay or resource utilization for each patient.

Avoid the cliché: ICD-10-CM/PCS is not used in the rest of the world, and the U.S. is not the last nation to implement ICD-10. That’s because ICD-10-CM is modified to fit the needs of the U.S. and is therefore different than the World Health Organization’s ICD-10. ICD-10-PCS is new, unique to the U.S., and untested anywhere else. Furthermore, ICD-10 in the rest of the world is not used for direct physician reimbursement. However, the rest of the world’s countries have implemented their own versions of ICD-10. So their data is already more precise than ours.

Explain the added codes: When ICD-10 became a reality, the first thing everyone focused on was the number of new codes. There should not be a strict emphasis on this fact. Although it is true that the number of codes has increased, the increase can be explained in the context of the concepts that have been added to each coding element. About one-third of the new codes are due to added laterality. Also, a single additional concept for a combination code will have a multiplicative effect. As an example, Crohn’s disease can be of the large intestine, the small intestine, both the large and small intestine, or an unspecified intestine (four locations). Adding one of seven complication concepts to each location of Crohn’s disease will multiply these four codes by seven, resulting in 28 codes. Yet Crohn’s disease did not change, nor did ICD-10-CM add 24 new types of Crohn’s disease pathology.


Sunday Reading: Case-mix index metrics

The Physician Queries Handbook

The Physician Queries Handbook

Almost every program uses the case-mix index as one metric of CDI program performance. The case-mix index is the sum of all your facility’s MS-DRG relative weights, divided by the number (volume) of Medicare cases for the year. A low case-mix index may denote MS-DRG assignments that do not adequately reflect the resources used to treat Medicare patients, but it is important to remember that the case-mix index is also affected by:

  • Types of services provided by the hospital
  • Volumes of medical and surgical cases
  • DRG assignments
  • Quality of documentation
  • Changes in federal guidelines, (e.g., the reassignment of diagnoses as CC/MCCs, such as when acute renal failure was reassigned from an MCC to a CC

Of the previous factors, only one can be influenced by the CDI team—documentation. And due to the variability that exists from month to month, the case-mix index should be considered a measurement over time rather than a barometer of a particular month’s performance. If you decide to review your case-mix index for short periods of time (e.g., per quarter), make sure you compare the quarter of interest to the previous year, as seasonal variation in healthcare affects the results.

Because surgical MS-DRGs are higher weighted than medical MS-DRGs (because the cost of the surgery is typically higher and therefore represented in higher relative weight), an increase in the volume of surgical cases can increase the overall case-mix index. Conversely, when the volume of surgical cases is flat, and the case-mix index increases, such an increase represents an increasing complexity of medical patients seen by the facility.

Keep in mind economic factors as well. During the recent recession, many people postponed elective surgeries and delayed healthcare, which negatively affected hospitals’ case-mix index, especially if they were considered a more elite or expensive healthcare provider in the community, as consumers looked for lower-cost alternatives.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

ICD-10 Tip of the Week: Acute Myocardial Infarction


Don't let documentation for AMI give you a heart attack.

Don’t let documentation for AMI give you a heart attack.

Many people present to the emergency department with complaints of chest pain, fearing they are having an acute myocardial infarction (AMI), more commonly referred to as a heart attack. Because of the seriousness of an AMI, many patients are admitted to the hospital while the provider verifies if the person is having, or has had, an AMI.

Documentation in the health record should clearly confirm or rule out the diagnosis of an AMI. CDI specialists should question the validity of the diagnosis when all documentation of an AMI abruptly ceases, as the provider may not always state when it has been ruled out.

The term AMI is somewhat nonspecific, as myocardial infarctions are often differentiated as an ST segment elevated myocardial infarction (STEMI) or a non-ST segment elevation myocardial infarction (NSTEMI). An electrocardiogram (ECG) translates the heart’s electrical activity into a graph. Typically, a 12-lead ECG, which provides 12 “views” or leads of the heart, is performed in the emergency department when a patient presents with chest pain or angina to evaluate the possibility of an AMI.

The ICD-9-CM code set did not allow differentiation of MIs as STEMI or NSTEMI, as AMIs were coded within the 410 category: “Acute myocardial infarction”; however, the ICD-10-CM code set does.

CDI specialists need to educate providers about the classification of AMIs by STEMI and NSTEMI within the ICD-10-CM code set, as some quality programs, like the American Heart Association Mission Life Line, review the performance of organizations in treating patients with STEMIs.

The ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.9.e.1 states:

“Subcategories I21.0-I21.2 and code I21.3 are used for ST elevation myocardial infarction (STEMI). Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs. If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.”

Cardiologist often have a more stringent threshold for the diagnosis of AMI compared to other types of providers, as some may diagnose an AMI on the basis of cardiac biomarker changes or ECG changes alone. CDI specialists should review the record for clinical indicators supporting the diagnosis of AMI when documented by practitioners other than a cardiologist and referred to as a “silent” AMI or one that does not require treatment.

Editor’s Note: For more information, check out the following: The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

TBT: Unforeseen circumstances and complications

Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility.

Work with physicans and come up with a process to respond to unforeseen circumstances and complications.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. This week, we’re throwing it back to a 2011 ACDIS White Paper, “Principal Diagnosis Selection,” written by Jennifer Avery, CCS, CPC-H, CPC, CPC-I.

If a patient is admitted to the hospital with the intention of a therapeutic procedure or treatment plan, but due to unforeseen circumstances it cannot be carried out, then based on the ICD-10-CM Official Guidelines for Coding and Reporting for FY 2016 “the principal diagnosis is the condition which, after study, was chiefly responsible for the admission to the hospital,” even if the treatment was not carried out.

For example, a patient is admitted for a prostatectomy due to benign prostatic hypertrophy (BPH). However, shortly after admission the patient develops palpitations and the procedure is cancelled due to contraindications. The patient is evaluated and treated for the cause of the palpitations. The principal diagnosis would still be the BPH. An additional code may be assigned to identify the reason the procedure was not carried out.

When a patient is admitted for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. For example, if a patient is admitted for a postoperative seroma, and per the documentation the causative organism is identified as Staphylococcus aureus, the principal diagnosis would be complication of the postoperative seroma with an additional diagnosis to identify the causative organism.

On some occasions, a patient may develop an unrelated condition after admission requiring surgery. If this occurs, the unrelated condition requiring surgery fits the Uniform Hospital Discharge Data Set definition of additional diagnoses (treated, evaluated, diagnostic study, affects length of stay, or increases nursing care/monitoring), and the reason for the admission is still the principal diagnosis. For example, if a patient is admitted for dehydration due to hypermesis from gastroenteritis and receives IV fluids and meds. On day two of the admission, the patient begins to experience dysrhythmia, pulmonary edema, tachycardia, and hypoxia. The physician determines that the patient is in congestive heart failure and schedules him/her for a pacemaker. The reason for the admission is still the dehydration. The congestive heart failure is coded as an additional diagnosis.

Christmas greetings

Twas the night before Christmas and all through the house

All the patient were being discharged accompanied by their spouse

All the doctors were documenting in their charts with care

In the hopes that no queries would soon be there.

When down through the stairwell a CDI nurse did come with a bound

With a bundle of queries still in her hand

With the wink of her eye and a nod of her head

She soon let the doctors know there was nothing to dread.

With her query in hand and her pencil in ready

She completed her message without any worry

And written in red all the doctors did see

Merry Christmas to all and to all a good year.


Happy holiday to you all



Lee Anne Landon, BSN  CCDS