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Guest Post: Addressing unspecified codes

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less conscientious about their diagnosis coding, leaving them to focus only on the first three characters of the code for medical necessity purposes. In actuality, some providers took the compromise as a license to map their superbill codes and submit “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes to all payers.

Matthew Menendez of White Plume Technologies estimated in 2016 the average rate of unspecified code use at the time was 31.5%.

“Payers want the more detailed diagnosis information available in ICD-10. The reason that both government and commercial payers advocated for the migration to ICD-10 and invested millions of dollars to rewrite their adjudication processes was for the granular diagnosis data on their insured patient populations. Payers want to leverage detailed ICD-10 codes to drive down the cost of healthcare in the United States and if the provider community does not supply this data they will begin to deny claims,” Menendez said.

The NEC cases, the NOS cases previously accepted by Medicare are now perfect targets for a retrospective review by any of the government contractors.

Since the grace period between CMS and the AMA ended September 30, 2016, CDI and HIM program managers should review physician practice records both prospectively and retrospectively.

Prospectively, audit a sampling of records to identify documentation deficiency trends pulling NEC and NOS records specifically and offering tips to physicians for documenting the necessary specificity. Target these records for the physician prior to the patient’s return, so the physician can be prepared to capture the necessary information concurrently while the patient’s being seen.

In some situations, though, a more specific condition may not be possible. If unspecified codes are applied to accounts, they should go through a second review process (pre-bill) by a more senior coder or the coding manager.

Retrospectively, coding managers should monitor the continual use of NEC and NOS codes to determine the magnitude of the issue. If greater than 5% of the claims fall into an unspecified bucket in any single payer group, it should be concerning and spur additional CDI educational outreach.

Editor’s note: This article is adapted from JustCoding’s Practical Guide to Coding Management. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q&A: Rejections for claims for removing impacted cerumen

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Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

Many times in the ED, codes for services provided are driven by the chargemaster structure in cooperation with either a charge sheet or a menu in the electronic health record. When this is the driver, it is very easy for the person entering the charges/services to enter a line item for the right ear and one for the left ear. This could be because they are not versed in coding rules (modifiers -RT and -LT equal -50) for the surgical procedures. They may not be thinking of this as a “surgical procedure” as clinically it was “just an irrigation.” Or, there may not be an option for a bilateral procedure on the menu. It may be that the system is responsible for changing two unilateral procedures to report as a bilateral procedure, and this translation is broken. Follow the process through and see where the disconnect is.

CMS also changed the medically unlikely edit (MUE) number for CPT code 69209 as of April 1, 2017. Prior to April 1, the MUE was 2; however, this was changed to 1 as of April 1. You may want to check your claims prior to April 1 dates of service to insure that the payment you received was correct based on the bilateral payment methodology under the OPPS.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question. This Q&A originally appeared in Revenue Cycle Advisor.

Note from the Instructor: Take a road trip this summer

road trip

Take a CDI road trip this summer!

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

I recently taught a CDI Boot Camp at a large, multi-site organization, with attendees coming from CDI, HIM, and quality departments from four different sites. We began the week discussing the Official Guidelines for Coding and Reporting, moving through each Major Diagnostic Category (MDC), and talking about concerns related to code assignment and sequencing.

This discussion was very much a review for the attendees who hailed from the CDI and coding departments. The quality staff, however, coming from a variety of roles related to core measures, patient safety indicators, inpatient quality reporting, and hospital value-based purchasing, had continuous lightbulb moments.

One individual literally hit the side of her head and said, “This explains so much. How come we were not taught this before?”

After the first few days, I asked the quality department staff if they have ever told a coder or a CDI specialist that they “coded it wrong.” Almost every attendee raised their hand. I then asked the CDI specialists and the coders if they have ever been told they had coded a record incorrectly by an individual who had no understanding of coding guidelines. Every one of them raised their hands.

We discussed communications with providers, compliant queries, and practices of leading versus non-leading interactions when speaking to providers. Many of those who worked under the umbrella of quality spoke up to say that perhaps their discussions with providers had been leading. They never received education about how to compliantly query a provider for a diagnosis or how to query for removal of a diagnosis.

When we discussed sequencing new rules related to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, I noticed the quality folks looking at each other and making faces. I stopped the class to ask what was wrong. They responded by asking when the change occurred. When I told them late last year—per guidance from AHA Coding Clinic, Third Quarter 2016—they all sighed and one expressed frustration about not knowing about the change earlier. They had been struggling to understand why admissions for COPD suddenly sky rocketed. One simple discussion answered a question they had been struggling with for months. And, as an added bonus, they learned why the coders were sequencing these diagnoses as they were.

As the week progressed, we talked about the specifics of a number of quality monitors—discussing what populations were included, exclusions, and the adjustments applied to organizations related to reimbursement. Now the coders and the CDI staff were asking why they hadn’t been taught this material before. They began to understand why the quality department was so concerned about the presence or absence of specific diagnoses. The quality staff were saying, “we need your help.” There was a purpose to this class: to knock down silos, learn from each other, and support each other.

I often describe our efforts as a group of individuals driving down a five lane highway. We have coders, CDI specialists, quality staff, case managers/utilization review staff, and denials management all traveling in their own lane. But, we are all heading to the same destination. We are all working to bring success to our organization. We wish to be recognized for the high caliber of care we provide, and consequently reimbursed appropriately for the resources we lend to that effort. Documentation is the key to this successful road trip. The providers are working to navigate safely on this busy highway with only the drivers to direct them.

As we travel down this road, we often swerve into each other’s lane. Often we are forced to swerve because the provider looks for guidance from us, assuming we understand the driver’s manual for the other cars on the road. If we do not understand every other driver’s role and their specific manual, we cannot support each other. We need to keep all our vehicles traveling in the same direction at a safe speed and ensure that as the providers try to cross the road we don’t run them down. It is confusing to providers if the CDI specialists instructs them one way and the denial management team tells them the complete opposite. Then they seek clarification from the quality coordinator and get a third interpretation of the “rules.” The providers are bound to give up and just navigate in the bike lane, never making any actual progress.

So, how do we learn to support each other? We need to step out of our comfort zones and spend some time with the other disciplines driving down that highway. We need to ask questions and answer other’s questions in return. We need to recognize that what we do affects the other’s work and work to support them. Large organizations often foster silos more than smaller organizations as they separate out the job functions more definitively. Often smaller organizations expect one person to wear a number of hats. Even though there are issues with overwhelming one individual, it also breaks down barriers.

Before you panic, I am not suggesting one person does it all. I am suggesting, though, that we intermingle a bit more, shadow different job roles, invite others to shadow us.

Take the road trip together—it’s more fun that way!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

Q&A: Best practices in time documentation

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Got CDI questions? Ask ACDIS!

Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.

A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague description of time amount requirements out there. So often, I end up having to query the physicians for time spend performing a procedure. I always like to have them explain the time. For example, he or she could say, “I spent 20 minutes of our 30-minute visit explaining how to properly use a new asthma inhaler.” That explains, how the physician met with the patient for 30 minutes and out of that time, used 20 minutes to explain how to use the new inhaler rather than just saying, “I spent 20 minutes discussing counseling or coordination of care.”

The other area that I always like to mention is sometimes time is best documented as “time in, time out.” Physicians are going to add that time up all day, especially if it’s a critical care patient. Physicians may want to get in the habit of documenting, “I walked in the patient’s room at 9:05 a.m. and we did our full thorough E/M exam and medical decision-making. I walked out of the patient’s room at 9:45 a.m.” So now coders have 40 minutes that a physician spent with the patient. And then a physician may go back into the room three hours later and document, “Patient was not responding well to those previous interventions. I now am back in the room at 11:18 a.m. and I spent from 11:18 a.m. until 1 p.m. with the patient and we’re still working on these interventions.” Then coders can add up all those time increments.

So to me, the best way I’ve found for providers to calculate E/M time is to document how many minutes of the total visit time that he or she spent counseling, doing coordination care, or what the provider talked to the patient about. But when I’m auditing inpatient records, I like to see the time in and time out and a bulk amount of time at the end of the day that I can add up to bill for that full-time increment and to know it’s all accounted for.

Editor’s Note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, answered this question during the HCPro webinar “Coding and Reporting Medical Necessity: Essentials for Coders and Other Healthcare Professionals.” This Q&A originally appeared in JustCoding

Guest Post: Improving the selection of a principal diagnosis

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Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.

But while code selection may seem fairly straightforward in some cases, it can seem like throwing a dart at a board in others. Multiple factors must be considered and reviewed before a coder can assign a diagnosis as principal. There may be many reasons a patient went to the hospital, and multiple conditions may have been treated during that patient’s stay. Because of these complicating factors, relying solely on a software program to discern the principal diagnosis might lead to errors. A thorough review of the documentation, along with a solid understanding of the Official Guidelines for Coding and Reporting, instructional notes, and Coding Clinic issues, is imperative.

The ICD-10-CM Official Guidelines for Coding and Reporting state:

The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS collects data on patients related to race and ethnicity and is issued by the Centers for Disease Control and Prevention. Its definitions are used by acute care hospitals to report inpatient data elements that factor in the DRG classification system, which is how the hospital receives reimbursement for the inpatient admission.

Coders and CDI professionals must review all the documentation by the physician or any qualified healthcare practitioner who, per the coding guidelines, is legally accountable for establishing the patient’s diagnosis.

Parts of the medical record include the history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary. While reading through a provider’s documentation, coders must ask themselves: “Is this condition requiring any diagnostic evaluation, therapeutic work, treatment, etc.?”

Once a medical record has been completely reviewed, coders must decide which code identifies the reason the patient was admitted and treated: What condition “bought the bed”?

But our work isn’t done after that. Are there any instructional notes or chapter-specific guidelines that give sequencing direction for coding? For example, if a patient is treated for decompensated diastolic congestive heart failure and also has hypertension, instructional notes within Chapter 9 of the ICD-10-CM manual, Diseases of the Circulatory System, give sequencing directives for the coding of these conditions.

“Decompensated,” according to Coding Clinic, Second Quarter 2013, indicates that there has been a flare-up (acute phase) of a chronic condition. I50.33 is the ICD-10-CM code for acute-on-chronic congestive heart failure. However, before assigning that code as the principal diagnosis, you must check the instructional notes directly under category I50 for heart failure. These notes, usually printed in red, give sequencing guidance for codes in this category.

Per the Official Guidelines for Coding and Reporting, “code first” informs coders that these conditions have both an underlying etiology and multiple body system manifestations due to that etiology:

“For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a ’use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

To code for the hypertension, the instructional notes guide the coder to reference code I11.0 (hypertensive heart disease with heart failure). More instructional guidance following the code helps the coder correctly assign the principal diagnosis for this patient.

But we’re still not done. Are there any issues of Coding Clinic that give more information regarding the assignment of a principal diagnosis? In reference to the example above, congestive heart failure with hypertension, documentation guidelines for reporting these two conditions have changed for 2017.

The Third Quarter 2016 Coding Clinic reiterates the documentation requirements and sequencing by stating that “the classification presumes a causal relationship between hypertension and heart involvement.”

The preceding example is one of many. A coder can have more than one diagnosis that fits the definition of a principal diagnosis, or possibly two diagnoses that are contrasting (either/or). If there are no chapter-specific guidelines for sequencing (is the patient pregnant? Does the patient have an HIV-related illness?), then refer to Section II, subsections B, C, D, and E, in the ICD-10-CM coding guidelines.

Editor’s note: This article originally appeared in JustCoding. Commeree is a coding regulatory specialist at HCPro in Middleton, Massachusetts. Contact her at acommeree@hcpro.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

 

Guest Post: Creating an inpatient coding compliance plan

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.

Begin by reviewing any existing coding policies and procedures to determine whether they are consistent with the organization’s compliance plan, as well as the latest Official Guidelines for Coding and Reporting. If your department lacks compliance policies and procedures, excellent resources are available at JustCoding, ACDIS, AHIMA and the Hospital Corporation of America.

A facility’s coding compliance plan may be a subsection of the policy. If you format your compliance plan as a subsection, the document should be labeled “coding compliance policy and plan.” The plan component should be much more detailed and include the specifics of what, when, and how often. Each organization should tailor its coding compliance plan to its organization.

When developing a new coding compliance plan, managers should begin by asking these questions:

  • Why am I establishing a plan?
  • What will I review?
  • How will I select a sample?
  • How will I assess accuracy?
  • What action will I take when the results are known?
  • How will I monitor progress?

The coding manager should collaborate with the compliance officer in developing the plan. Some components that should be considered when you create your plan are:

Purpose: The purpose of the XYZ Hospital Compliance Plan is to improve the accuracy and integrity of patient data, ensure minimal variation in coding practices, serve as a conduit to improve provider documentation in the electronic patient record, and support XYZ Hospital’s ability to receive its entitled reimbursement for the services it and its providers provide.

Expectation: Staff (employees and, when applicable, contracted staff) will strive to maintain the highest level of professional and ethical standards in the performance of their coding duties. Staff will be trained and oriented in all applicable federal and state laws and regulations that apply to coding and documentation as relates to their positions.

Adherence to these guidelines is imperative. Where any questions or uncertainty regarding these requirements exists, it is the responsibility of the employee to seek guidance from a certified coding specialist, health information administrator, or another qualified coding professional. Staff will be familiar with prohibited and unethical conduct that relates to coding and billing as outlined in the facility compliance plan. Staff will comply with AHIMA’s Code of Ethics.

Education:

  • All coders, billers, and providers will receive orientation and training in the fundamentals of compliant coding and billing. Continuing education will be provided in the form of handouts, memos, journals, in-services, and formal education as available and approved. To keep up with changes in regulatory requirements, coding changes, and proper coding procedures, it is the staff member’s responsibility to further his or her knowledge by reading all handouts, memos, and journals provided, and actively participating in available in-services and formal education workshops.
  • All coders, billers, and providers will receive training in coding, documentation, and billing compliance issues on an annual basis or more frequently as need dictates. The training will be coordinated by the coding compliance subcommittee in conjunction with or in addition to training provided by the compliance office.

Coding resources: Coding staff shall have access to the following resources to facilitate their coding duties:

  • Encoder
  • Computer with dual monitors
  • Coding books: ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; other reference materials will be maintained in the coding manager’s office

Coding conventions and guidelines: The guidelines and conventions to be followed for codes to be reported on claims will be:

  • Coding Clinic published by the American Hospital Association
  • Official Guidelines for Coding and Reporting published by CMS and the National Center for Health Statistics

Editor’s note: This article was originally published in JustCoding. 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. This article is excerpted from JustCoding’s Practical Guide to Coding Management.

 

Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.

AMI

Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Book Excerpt: Teamwork makes the dream work

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Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

CDI specialists do not work alone. They form a team with case management (CM) and physicians for concurrent documentation analysis and improvement. The case manager advises the physician on patient status, the CDI specialist ensures the documentation reflects the status and care, and the physician advisor is there to support CM and CDI if there is conflict with a physician or clinical staff. The physician advisor can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient is scheduled for surgery as an outpatient but the surgery is on the inpatient-only list (CMS, OPPS final rule, 2016). The surgery scheduling department checks the inpatient-only list and notifies the physician that CM is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice.

The CDI specialist checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the physician advisor. The physician advisor contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, coding and billing will clearly know what claim to drop without requiring a bill hold and clinical review.

Additionally, this three-part team of CDI specialist, CM, and physician advisor are able to gather real-time feedback on whether the electronic health record (EHR) is user-friendly, and report findings back to the executive team and IT. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM look to ensure appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Guest Post: Clinical validation denial targets

by Erica E. Remer, MD, FACEP, CCDS

Auditors target multiple conditions which for clinical validation denials (CVD). Personally, I found acute kidney injury (AKI) and malnutrition the most commonly defensible targets. On the other hand, I often agreed with auditors on their CVDs for pneumonia and urinary tract infections. Other frequent CVDs included sepsis, encephalopathy, and respiratory failure.

Certain diagnoses are susceptible to CVDs for the following reasons:

  • DRG downgrade: Auditors target medical records with only one CC/MCC because doing so downgrades the DRG and results in less reimbursement.
  • Empiric treatment: Providers start antibiotic therapy early for patients who present with signs of infection (e.g., fever, leukocytosis, altered mental status) on as they seek the infection’s source. Sometimes the physician cannot identify the source or the etiology of the disease turns out to be a different than originally expected. Clinicians also need to be careful to not propagate the original debunked diagnosis via copy and paste, so it gets wrongly coded.
  • Documentation consistency: Physicians should document their medical decision making process throughout the patient’s stay. Best practice is to document when a diagnosis is initially considered (may be in uncertain format), when the diagnosis is definitively ruled in, and when the condition resolves. The physician should recap this information in the discharge summary. Only mentioning a diagnosis once in the medical record, while permissible, raises an auditor’s interest and begs the question of whether the condition really was present.
  • Pursuant to a query: When providers need to be queried to make a diagnosis codable, and they agree without supplying any clinical support, a red flag goes up—and I mean like waving one in front of an auditor like a bull, and not just signaling peril up ahead.

Finally, auditors target diagnoses with uncertain or emerging clinical guidelines. Clinical guidelines change, but it takes time for medical practice to adjust (e.g., malnutrition, sepsis). If a guideline is not universally adopted (for example, discussions regarding the new Sepsis-3 definitions) some variability in medical practice is allowed. That doesn’t necessarily mean a provider is wrong if he or she does not follow the latest guideline. As long as the provider is within the acceptable range of practice, he or she just needs to demonstrate the clinical considerations of the case and the auditor should accept the diagnosis. If a provider deviates from clinical criteria or guidelines, he or she should document the mitigating circumstances (e.g., on beta-blockers, previous antibiotic therapy, contamination).

On the other hand, the provider needs to consider established guidelines. If the average, prudent similarly qualified practitioner wouldn’t call an asymptomatic deviation of sodium by 1 mEq/L, hyponatremia, neither should you.

Similarly, AKI has criteria of change within the previous 48 hours, or deviation from a baseline from seven days ago, but a provider could make a convincing argument that the patient’s serum creatinine (SCr) is always X and the acute derangement is likely to have occurred since the onset of symptoms 36 hours ago. It would be quite serendipitous to randomly have a baseline drawn within seven days of an index visit if AKI preceded hospitalization, wouldn’t it? However, if the SCr is only off by 0.1 mg/dL, you are hard-pressed to spin that as AKI.

While the coder may not really the arbiter of clinical validation, coders should be empowered to refer questionable records for a clinical review either by the CDI specialist, the attending, or a physician advisor/champion, and coders need to know which conditions are vulnerable and which clinical indicators to consider.

Absence of abnormal clinical indicators does not mean the condition is definitively not present; it means the encounter needs clinical review and the condition may require more documentation to support it.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the third part of this article, return to the blog next week!

Guest Post: Protecting documentation from clinical validity denials

by Erica E. Remer, MD, FACEP, CCDS

Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.

If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.

However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.

Thorough documentation

It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.

The ICD-10-CM Official Guidelines for Coding and Reporting for 2017 states:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.

Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.

The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.

Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.

The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.

Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.

Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.

What coders can do

Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.

Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?

The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”

The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.

If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the second part of this article, return to the blog next week!