All Entries Tagged With: "Coding"

Don’t let surgical complication documentation get complicated

There’s still time to sign up for Friday’s (November 20, 1 p.m. EST) audio conference: Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures with Robert S. Gold, MD, and Lena N. Wilson, RHIA, CCS.

Wilson is the HIM operations manager of the clinical documentation improvement program (CDIP) and inpatient coding at Clarian Health Partners in Indianapolis. In her current role, Wilson is responsible for the CDI program at Clarian’s three facilities in downtown Indianapolis, and the inpatient coding operations for the downtown facilities and the two suburban hospitals.

And while many in the CDI world think that Dr. Gold requires no introduction, let me nevertheless tout his expertise as founder and CEO of DCBA, Inc., in Atlanta, GA, a consulting firm that provides physician-to-physician education programs in clinical documentation improvement. He has more than 42 years of experience as a physician, medical director, and consultant.

Surgery documentation is an area rife with concern from both the physician point-of-view as well as from the CDI and coding perspective, like Dr. Gold points out in this Friday’s presentation. Too often CDI programs improve a facility’s risk adjusted mortality index but negatively impact a surgeon’s physician profile. Such outcomes make it difficult to get physician support for CDI. He outlines the following three “Golden Rules:”

1. If it is a complication of surgery, it is either a complication or surgery
2. If it is a manifestation of a disease unrelated to the surgery it is not a complication of the surgery
3. If it is not treated it may not be codable—but it may

Dazed and confused? Or Encephalopathy?

Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?

The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.

Don't let dementia documentation confuse you.

The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.

So what is encephalopathy?

As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.

The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.

Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):

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Audio conference: Annual MS-DRG program Tuesday

You already understand the importance of MS-DRG selection. Picking the most appropriate principal diagnosis as well as valid secondaries is critical to ensure accurate MS-DRG assignment. New challenges such as Recovery Audit Contractors (RAC) scruitney coupled with increased focus on present on admission (POA) indicators and quality measures increases the need for comprehensive understading of changes to MS-DRGs.

Two of our favorite speakers— Gloryanne Bryant, BA, RHIA, RHIT, CCS, CCDS, regional managing director HIM (Revenue Cycle N. California) for Kaiser Permanente in Oakland, CA and Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta, GA— team up this coming Tuesday, September 29, at 1 p.m. EST, for the seventh annual DRG Update audio conference 2010 IPPS MS-DRG Update: Analyze the Rule and Understand the Impact.

The program examines changes in the 2010 MS-DRG list, defines various rules and regulations, and illustrates ideas to manage coding for MS-DRGs and documentation improvement.

HACs set for October 1: Are you ready?

When a hospital-acquired-condition (HAC) is not present on admission (POA), and it is the only complication/comorbidity (CC) or major CC (MCC) on the claim, the case will group to a lower-weighted Medicare Severity DRG (MS-DRG). That means less reimbursement for your hospital.

“It could have a financial impact on the hospital’s bottom line,” says DeAnne W. Bloomquist, RHIT, CCS, a coding and compliance consultant and the president of Mid-Continent Coding, Inc., in Overland Park, KS.

The following eight HAC conditions take effect October 1:

1. Foreign object retained after surgery. Codes 998.4 (foreign body accidentally left during a procedure) and 998.7 (acute reaction to a foreign substance accidentally left during a procedure) denote this HAC.
2. Air embolism. Code 999.1 (air embolism to any site, following infusion, perfusion, or transfusion) denotes this HAC that refers to a condition in which air inadvertently passes through an open blood vessel.
3. Blood incompatibility. Code 999.6 (ABO incompatibility reaction) denotes this HAC.
4. Stages III and IV (decubitus) pressure ulcers. Code 707.23 indicates a stage III decubitus ulcer, and code 707.24 indicates a stage IV decubitus ulcer.
5. Falls and trauma. This includes fractures, dislocations, intracranial injuries, crushing injuries, and burns. The following codes denote this HAC:
   • Codes 800–829: Fractures
   • Codes 830–839: Dislocations
   • Codes 850-854: Intracranial injuries
   • Codes 925–929: Crushing injuries
   • Codes 940–949: Burns
   • Codes 991–994: External causes (i.e., heat, air pressure, light, frostbite)
6. Catheter-associated urinary tract infections (UTI). Code 996.64 (infection due to indwelling urinary catheter) denotes this HAC.
7. Vascular catheter-associated infections. Code 999.31 (infection due to central venous catheter—catheter-related bloodstream infection, not otherwise specified) denotes this HAC.
8. Mediastinitis after coronary artery bypass graft (CABG). Code 519.2 (mediastinitis) and a CABG procedure code from the 36.10–36.19 range denote this HAC.

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

Get all the information on anemia documentation

I’m just sticking my foot into a wicked pile of super sticky unknown substance by bringing this topic of ‘acute blood loss anemia’ back up. But there’s been so much back and forth with our own ACDIS Advisory Board to iron out the details published in this week’s CDI Strategies, that I was quite surprised when one of our readers e-mailed shortly after publication to ask another question based on the brief.

Another question? I thought we couldn’t possibly write anything more on the topic! Well, I was wrong. Our friend from Washington, DC, asked: “If  ‘precipitous drop in hematocrit’ is documented, must the baseline be known? What are the parameters and is it facility specific?”

So I’m throwing the whole thing out here  to blog land. Please help me by posting any (and all) information you might have regarding how you approach physicians with queries for anemia.

Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

• History
• Examination
• Medical decision making

History:  The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

• Problem focused
• Expanded focus
• Detailed
• Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

• The number of possible diagnosis and or management options
• The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
• -The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

Some important points that should be kept in mind when documenting level of risk are:

• Comorbidities/Underlying disease
• Surgical or invasive diagnostic procedures ordered, planned or scheduled.
• Surgical or invasive diagnostic procedure performed.
• The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

1. Minimal: Minor problems such as colds, insect bites, etc.
2. Low:  Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
3. Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
4. High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.

Few IPPS changes final rule could cause CDIs trouble

There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.

Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”

The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.

Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.

Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.

Don’t cut out ‘excisional’ when considering debridement queries

This is one case when you can't 'cut it out.'

Recently a client contacted me regarding a surgeon who asked the coding department to stop querying him about excisional debridements. His comment was that all his debridements are excisional. He’s a surgeon and he cuts. Bottom line.  So please stop pestering him with the queries.

As most of us know, this clearly isn’t enough to code a record and has been the reason for a significant number of concurrent and retrospective queries across country in many, many hospitals. The simplest solution, of course, is for the physician to use the words excisional debridement but as we all know, that simple solution doesn’t always translate into simple reality.

What the client wanted to know was if they could make the assumption based upon his comment, that whenever he documented debridement, that he meant excisional and code to excisional. Again, I believe most of us would say that the documentation doesn’t indicate excisional and needs further clarification. So how do we get the documentation and not irritate the physician?

In an attempt to help clear the water surrounding the word “excisional,” many coding departments and documentation teams have made attempts to develop policies and procedures for clarifying this procedure. This became especially important with Recovery Audit Contractors (RACs) and other auditing agencies focusing on this specific procedure. Add to the mix the increasing number of elderly patients that are admitted with wounds that require care and then the number of non-excisional methods of treating these wounds. Clearly there is much to consider.

So what’s the best approach? Of course education is important. Physicians must understand the importance of their documentation and how a single word (or lack thereof) impacts the severity of illness, risk of mortality, and reimbursement. Communication of coding guidelines and definitions becomes an important function of a documentation improvement team.

Whether through queries, newsletters, posters or presentations, it is important for a documentation team to recognize the need for an ongoing method to provide support and resources to healthcare providers regarding documentation. We need to help providers learn the vocabulary that best represents the diagnosis and care they provide to the patient. Making assumptions or creating policies that allow for ambiguous interpretation of documentation will only create other problems.

So, clearly this particular surgeon needs to understand that if he performed an excisional debridement then he needs to document “excisional debridement.” Providing him with the information that defines an excisional versus non-excisional debridement is also important. Hopefully, once this information is shared, he will understand the need to include the appropriate words in his documentation. If not, that leaves the query process as an important part of the documentation process.

In answer to the question of whether it’s okay to eliminate queries for excisional debridement if the physician documents just debridement, only the provider knows the depth to which he or she cut and therefore it becomes the responsibility of that healthcare provider to document accurately and appropriately. I know this answer doesn’t necessarily make a CDI specialist’s day, but look at the bright side; it’s another opportunity to have a conversation with a physician and spread the word of complete and consistent documentation!

Fall intro to ICD-9-CM offered in Boston

Gee, it seems like I’m all about the local trivia recently—from hazelnuts to evergreens, state flags to historic settlements. Well, since I’m apparently on a roll. Let’s talk about my hometown Boston.

• The first American lighthouse was built in the Boston Harbor in 1716.
• The first public school system was founded in Boston in 1635.
  

  Boston Common is the center piece of the Olmstead designed Emerald Necklace of parks.

• When you take a stroll on the Boston Common, you are visiting the nation’s first public park, established in 1634.
  • Boston Common is part of the larger Emerald Necklace parkway designed by landscape architect Frederick Law Olmstead who also designed Central Park in New York City and a little place call Moraine Farm in Beverly, MA, where yours truly married the love of her life five years ago. (By the way, according to the US Census Bureau, Massachusetts has the lowest divorce rate in the country with 2.2 divorces per 1000 people.)
• The Hyatt Harborside Hotel in Boston is the site of the next stellar program “ICD-9-CM Coding Essentials: What Every CDI Specialist Needs to Know,” on September 21.

Now I’m not saying Shannon McCall’s class is as exciting as my wedding nor as relaxing as a stroll along Boston Common, it’s definitely a day full of invaluable information. I participated in this program during the 2009 ACDIS conference in Las Vegas and was nearly overwhelmed with the depth and breadth of tools she was able to cover. And for once I’m not just playing my own tune. Many CDI specialists who attended also found it beneficial.

“I would recommend this seminar to colleagues,” said Pamela Lindsey, RN, BSN, MCRMC, Fraser, MI. “It provides a good base of information for a CDS (RN) program. It was helpful to gain information on navigating through the ICD-9 manuals along with the other materials.”

They’ve extended the early bird registration rate through August 24, which saves you $100, and if you are currently an ACDIS member be sure to ask for member discounts too. To register, visit www.hcmarketplace.com.

Query tip for principal diagnosis of fall admissions

by Joel Moorhead, MD, PhD

An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.

Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:

• Select a principal diagnosis from established conditions the physician has clearly documented.
• Query the physician to obtain a principal diagnosis when documentation is not explicit.

Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.

Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.

When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.

Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.

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