All Entries Tagged With: "Coding"
Incorporate awareness of transfer DRGs into CDI record review efforts
CMS never met a dollar it didn't want back.
CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.
(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)
For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.
You can download the current list here.
Why do you need to know about transfer DRGs?
The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.
When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.
Clarification regarding Coding Clinic publication
The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.
The American Hospital Association (AHA) has not made any formal decisions regarding when it will begin publishing a separate Coding Clinic for ICD-10, contrary to what was reported in December 1 edition of CDI Strategies, according to Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA.
Those with questions pertaining to ICD-10 can submit them to the AHA now. Those who submit inquiries must have working knowledge of the new code set and questions must pertain to the application of the codes and the interpretation of the medical record.
The AHA is beginning to collect questions regarding the new code set and will include some of those questions starting with its 4th Quarter 2012 edition of Coding Clinic for ICD-9-CM, Leon-Chisen told ACDIS.
“This service is for coding advice only not for advice about ICD-10 implementation,” Leon-Chisen said during CMS’ “ICD-10 Implementation Strategies and Planning National Provider Call” on November 17.
The AHA has no plans to translate guidance from previous volumes of Coding Clinic for ICD-9-CM, as the increased specificity of the new code set is expected to make much of the guidance obsolete. However, it has not made a decision just yet about when it will stop publishing Coding Clinic for ICD-9-CM, or when it might begin publishing a specific Coding Clinic for the new code set.
Pediatric reviews: Know the rules before you play the game
by Robert S. Gold, MD
Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric
Don't throw the baby out with the proverbial bathwater when it comes to documentation and coding improvement associated with pediatrics.
diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.
Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.
Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.
Book Excerpt: Tips for hypertension documentation
The 2012 edition of The CDI Pocket Guide was recently released.
The term “accelerated” hypertension is an archaic term but necessary for the correct documentation and coding of severe hypertension when it occurs as a secondary diagnosis. Unfortunately, coding terminology hasn’t caught up with the currently-accepted clinical diagnostic terms for severe, uncontrolled hypertension.
Terms such as “hypertensive emergency,” “hypertensive crisis,” “hypertensive urgency,” “severe hypertension,” “malignant hypertension,” and “accelerated hypertension” are all used in the literature and often overlap. Yet “accelerated,” and “malignant,” or “necrotizing” hypertension are the only terms that will result in coding as a comorbidity/complication: 401.0 or Categories 402-405 with 4th digit = 0.
Using only the terms “hypertensive emergency,” “hypertensive crisis,” and/or “hypertensive urgency,” will result in assignment of non-specific hypertension codes that do not accurately reflect the seriousness of the patient’s condition or the complexity of care required to treat it.
Clinical definition: A patient with hypertension that is consistent with “accelerated” or “malignat” should require urgent treatment (either IV or STAT oral dosing), have the same risks and clinical implications as urget or emergent hypertension and meet one of the following criteria:
- Systolic blood pressure (BP) > 180 mm Hg, or
- Diastolic BP > 110 mm Hg, or
- End-organ involvement/damage (e.g., neurologic, renal, or cardiac damage)
The following examples compares the criteria for accelerated hypertension with the more current terminology:
- “Hypertensive urgency” is defined as having BP > 180/110 mm Hg, with or without symptoms such as severe headache, shortness of breath and anxiety; and no end-organ involvement.
- “Hypertensive emergency” is usually symptomatic with BP of at least > 180/120 mm Hg; often it exceeds 22/140 mm Hg. There is end-organ involvement, with possible symptoms including chest pain and neurologic deficits.
- “Hypertensive crisis” is used to describe the spectrum of severe, uncontrolled hypertension that includes both urgent and emergent hypertension, as described above.
Editor’s Note: This excerpt was taken from The 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS and Cynthia L. Tang, RHIA, CCS.
Q&A: Resection or excision in ICD-10
Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a resection or an excision and why. The coder coded the following record to total ostectomy-rib. If you crosswalk the ICD-9-CM Level 3 code to ICD-10-PCS, it maps to a resection. I think that is correct, but I’m not sure if we should query the physician to find out if the physician considers the procedure an excision. Here is summary of the key findings from the report:
A female developed a left arm DVT [deep vein thrombosis], was treated with anticoagulation and a
Probably an excision.
subsequent venogram revealed compression of the left axial subclavian vein with elevation of the arm. With the arm in neutral position, the vein flow was normal. Her arm swelling subsequently resolved and DVT then resolved. She was then referred for first rib resection.
During the operation, an incision was made in the axilla and dissection proceeded down onto the chest wall. The chest wall dissection proceeded up to the first rib. The first rib was cleared of its surrounding tissue using Bovie cautery. The scalene muscles were resected off of the rib. Once we adequately cleared the rib of surrounding tissue posteriorly beyond the edge of the nerve and anteriorly to the junction with the manubrium, the rib was cut posteriorly and avulsed anteriorly.
A 1-centimeter hole in the pleura was discovered upon inspection. After attempting to simply close this we continued to have a small air leak, therefore, a 24-French chest tube was selected and placed into the pleura with a purse-string of 3-0 Vicryl around it. The chest tube was secured through a separate stab incision on the lateral chest wall.
The wound was copiously irrigated and closed in multiple layers with 2-0 and 3-0 Vicryl sutures in the soft tissues and 4-0 Monocryl in the skin.
A: In reviewing my ICD-10-CM/PCS training materials, I believe this is a resection. The ICD-10-PCS coding guidelines (section B3.8) indicate:
“PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestines…”
Also, in the 2011 edition of AHIMA’s ICD-10-PCS training manual, it states:
“Resection is similar to Excision except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part…”
In reviewing the root operation table for 0PT , it has the body part value of rib, right and rib, left. If it had said ribs, then my answer would be different because one rib would be only part of ribs so I would go with excision.
In my opinion, the correct ICD-10-PCS code would be:
- 0PT10ZZ for the right rib
- 0PT20ZZ for the left rib
Editor’s Note: Heather Taillon, RHIA, manager of coding compliance at Franciscan St Francis Health in Beech Grove, IN, answered this question following the September 27 audio conference “ICD-10 for CDI: Improve Documentation Now for Effective Transition Later.” Taillon is an AHIMA- Approved ICD-10-CM/PCS Trainer.
Collaboration: Coding and me
A Venn Diagram helps illustrate where overlapping interests lay.
I realize that many of the faithful members of ACDIS are, indeed, coders, but most of us have a nursing background, so I’m going to give my two-cents on the coding/CDI specialist relationships from a nursing perspective and hope that the coders among us will forgive me.
The first thing and the last thing that coders and nurses need to understand is that nobody knows everything. If you remember a Venn diagram—yes, those big bubbles with the overlap in the middle that you learned in 7th grade math—and apply it here, we have the coding world, and we have the nursing world, and we have that great big space in the middle where we cross paths. Nevertheless, we also must bear in mind that there is space on the left and right where never the twain shall meet.
Both nurses and coders have studied anatomy and physiology, we all know medical terminology, and we all have some understanding of coding guidelines and principles. That’s where we meet.
But coders have studied coding, and they typically can code up to 30-40 charts or more per day with staggering precision. The average nurse doesn’t spend the time assigning CPT codes, or E-codes, or worrying about whether the femur fracture is of the head, the shaft, or the condyle part of the bone, the way coders do.
Likewise, the average coder has never been in the room with the hundreds or thousands of patients that the nurse has seen, has not personally observed or helped treat the signs and symptoms associated with the myriad medical conditions people can acquire, and does not have the in-depth knowledge of intricacies of medical management that nurses have.
When I first started as a CDI specialist, it took time for the coders to get used to me and what I could do for them—and to them. Because my orientation was bare bones and my preceptor was literally in the next state, I had to learn by mistake. And boy, did I make mistakes.
I can’t tell you how long it took me to grasp that hypertension in a patient with chronic renal disease codes out differently than it does for hypertension in the general population. I’m still embarrassed to admit that I nagged a coder to take a vascular ulcer as a CC on a patient with peripheral vascular disease because I didn’t understand how to apply the combination code.
It took persistence and patience but eventually the coders realized that not only was I a fast learner, but that there were some things that I could teach them. One coder was coding atrial fibrillation (AF) with rapid ventricular response (RVR) as ventricular tachycardia, which not only added CCs to the coding summaries, but drastically altered the dynamic of those charts. As a former cardiac care unit (CCU) nurse, I knew that AF with RVR is absolutely not “v-tach.” I argued my case, and even enlisted one of our electrophysiologists to help me explain the situation.
The electrophysiologist was able to verify that AF w/RVR is definitely not v-tach, and further emphasized that if v-tach were to be coded, it would completely change the treatment protocols he would have been expected to perform. By pressing the issue, I might have lost our facility some CCs, but I think I saved us a lot of heartache in future audits.
I have tremendous respect for the work that coders do. It pains me to see adversarial relationships between coders and nurses. Everybody wants to be right, especially if their work is going to be graded negatively if they’re not officially right. But some nurses are just determined to prove that they know more than coders—and vice-versa.
I really miss the days when I could just call a coder for a consult on a complex case while the patient was still in-house, and when the coder could call me to ask my take on a confusing chart they were coding.
It may be difficult for more experienced coders to understand the need for a CDI program when they have been sending back-end queries for years without help. So those CDI specialists who do have a nursing background may be in a situation where they need to prove their value—not by fighting with coders but by sharing our clinical expertise in a nonjudgmental manner.
We need to remember that everyone’s goal is an accurate, pristine chart, regardless of who gets credit.
I suppose there are some relationships that will always be sticky. Let’s just make this one stick.
Book Excerpt: Coding and physician languages
This handbook regarding documentation tips comes in packs of 10 so it can be delivered to physicians, CDI staff, or coders.
Clinical documentation for coding purposes continues to be highly important as we work to obtain data for quality measures and payment. Such data rely on accurate coding, which relies on complete and accurate clinical documentation; they are dependent on each other. Indeed, the more specific the documentation, the more specific the ICD-9-CM (and in the future the ICD-10) code(s) will be, and in turn, the more accurate the severity, acuity, and risk of mortality (ROM) data will be.
Clinical coding allows for the reporting of mortality data to the World Health Organization (WHO), the reporting of morbidity data in the United States, and the provision of data to third-party payers so they can reimburse hospitals for care and services provided. Coded information is also the primary source for the administrative management of medical services and a source of epidemiological research and statistical data from inpatient stays.
Editor’s Note: This excerpt was taken from Coding and Physician Language: Strategies for Obtaining Complete Documentation, Second edition, written by Gloryanne Bryant, RHIA, CCS, CCDS.
Book Excerpt: Find a clinical focus when training physicians on ICD-10
Start educating physicians now
When tackling ICD-10 training for physicians, speak to them about the current ICD-9 system as a segue to the transition to ICD-10. Focus on the top 10 common clinical diagnosis that CDI specialists at your facility consistently identify as problematic from a clinical specificity standpoint. If physicians are motivated and conditioned to include specificity in these top 10 clinical diagnoses the road to a successful transition of clinical documentation under ICD-10 can be established.
Another approach is to run a report of the top 20 MS-DRGs for the most recent fiscal year and review the diagnoses that comprise them. Then tailor ICD-10 training to common clinical diagnoses that physicians manage on a regular basis.
…[E]xplore how improved documentation can help physicians with their participation in the Physician Quality Reporting Initiative (PQRI)… which includes incentive payment for [those] who satisfactorily report data on quality measures for covered services.
Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Guide to ICD-10 written by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS,
Q&A: Aspiration without pneumonia
Q: Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he
When to code for aspiration pneumonia
said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia, he said the patient doesn’t have pneumonia. He said the patient also doesn’t have a foreign body. What should I do?
A: It is difficult to answer without more information. Mendelson’s syndrome is a bronchitis or pneumonitis resulting from macroaspiration of acidic stomach contents usually associated with endotracheal intubation. When patients have this condition, coders should report ICD-9-CM code 997.39 (other respiratory complications) plus a code for the pulmonary condition. Aspiration pneumonia and aspiration bronchitis both map to the same ICD-9-CM code, 507.0 (pneumonitis due to inhalation of food or vomitus).
Because ICD is an international classification system maintained by the World Health Organization, it tends to group similar conditions under the same code. This is unlike CPT®, with which physicians may be more familiar. The AMA maintains CPT, which includes more procedure- and encounter-specific codes. In this case, the physician must provide clarification so a coder can report the most accurate ICD-9-CM code.
Editor’s Note: William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, answered this question in the June issue of Briefings on Coding Compliance Strategies
Combination codes add specificity of disease process
Jennifer Avery
by Jennifer Avery, CCS, CPC, CPC-H, CPC-I
One of the things that has concerned me about ICD-10-CM is the lack of guidance regarding sequencing. Since the American Hospital Association announced that it would not be converting Coding Clinic for ICD-9-CM and that we would start with new Coding Clinics for ICD-10-CM, I have been a little freaked out about the amount of confusion this may cause when it comes to sequencing and principal diagnosis selection. However the more I work with ICD-10-CM, I can see that many of the Coding Clinics that we rely on for ICD-9-CM will no longer be necessary due to the make-up of the ICD-10-CM codes.
For example, let’s take a look at coronary artery disease (CAD) and angina. Many Coding Clinics address the sequencing of angina as an additional (subsequent) diagnosis when it is related to CAD. You would list firsICD-9-CM diagnosis code 414.0x (principal), followed by the angina code (either ICD-9-CM code 413.9 or 411.1). However, in ICD-10-CM these Coding Clinics are no longer necessary because we will have a combination code that will identify the disease process (CAD) and the manifestation (angina) all in one code.
Consider ICD-10-CM code I25.110 (Atherosclerotic heart disease of native coronary artery with unstable angina pectoris). The ICD-10-CM code seems to be consistent with the advice that we have in ICD-9-CM, however, without the need for a Coding Clinic to address sequencing. Expect to see more of such code combinations with disease processes and their manifestations in ICD-10. Take, for example, ICD-10-CM code K50.013 (Crohn’s disease of small intestine with fistula) or ICD-10-CM code K71.51 (Toxic liver disease with chronic active hepatitis with ascites).
ICD-10-CM codes have the ability to represent complete disease processes and their manifestations in one complete code, which helps alleviate confusion regarding sequencing disease processes and their manifestations, a sometimes common problem in ICD-9-CM. Where we often require more than one code in ICD-9-CM, we may now be able to use a combination code in ICD-10-CM that will represent the disease process and the complication/manifestation.
Procedural complications further illustrate this. In ICD-9-CM, we have one code that identifies foreign body accidentally left in during surgery (998.4). However, there are 50 ICD-10-CM codes (T81.5x) that identify the specificity for a foreign body accidentally left in during surgery and the “reaction” due to the complication (e.g., adhesions, obstruction, and perforation).
Editor’s Note: Avery is a regulatory specialist for HCPro’s Revenue Cycle Institute based in Danvers, MA. This article first appeared on our sister blog ICD-10 Trainer.
