First into the Fix ‘em Up Clinic today is Jeff. He took part in a s’more eating contest at camp last night. I’ve personally never understood the appeal of burned marshmallows, but Jeff, well he was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.
Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips. The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.
The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).
ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.
We also find the following note under pretty much all of the burn codes:
- Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)
We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).
The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.
The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.
For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.
Why in the world is Mr. Grinch so mean? Maybe the problem is his health. Let’s see if we can diagnose the Grinch’s health woes.
First, he is as cuddly as a cactus. What does that mean? He’s covered in spines? A better explanation is he suffers from eczema, which causes redness, skin edema (swelling), itching and dryness, crusting, flaking, blistering, cracking, oozing, or bleeding. Great, we have a condition. Now we need a code. And ICD-10-CM has a lot of codes for eczema to specify the type, including:
- B00.0, eczema herpeticum
- H01.13, eczematous dermatitis of eyelid (subcategories identify which eye and which lid)
- H60.54, acute eczematoid otitis externa (again, we need to specify right, left, bilateral)
- L20, atopic dermatitis (with an associated list of subcategories)
What else is wrong with the Grinch? One friend calls him “a bad banana with a greasy black peel.” A black peel (skin) could be necrosis and we need to know the exact location in order to code for it. If Mr. Grinch suffers from skin necrosis only, we would report I96 (gangrene, not elsewhere classified).
Or maybe he has necrotizing fasciitis (M72.6), in which case we need to use an additional code (B95.-, B96.-) to identify causative organism.
Further reports claim Mr. Grinch’s head is full of spiders. Literally? Let’s hope not. I don’t think medical science could do much for him. Perhaps Mr. Grinch is suffering from a psychological condition that makes his behavior erratic.
He could be suffering from borderline personality disorder (F60.3, note this code excludes antisocial personality disorder [F60.2]).
Or maybe he’s bipolar. If that’s the case, we need a lot more specific information. For example, is he in a manic or depressive phase? Is he displaying psychotic symptoms? Is he in full remission or partial remission?
The Grinch also suffers from termites in his smile, better known as dental caries. Well, we still need to know what kind of dental caries:
- K02.3, arrested dental caries
- K02.5-, dental caries on pit and fissure surface
- K02.6-, dental caries on smooth surface
- K02.7, dental root caries
- K02.9, dental caries, unspecified
Although several of these categories includes more specific subcategories, sadly, termite-induced is not one of our choices.
The Grinch also suffers from seasickness, T75.3- (motion sickness). Two things to note here. One, we need a seventh character to identify the episode of care. To make sure it shows up in the seventh position, we also need two placeholder Xs. We also need to report an additional external cause code to identify vehicle or type of motion (Y92.81-, Y93.5-).
Mr. Grinch is further described as “a crooked jerky jockey.” A-ha! He suffers from scoliosis! Oh dear, we need some more specific information to choose between our scoliosis codes (isn’t that always the case?):
- M41.2-, other idiopathic scoliosis (with subcategories specifying the spinal region affected)
- M41.3-, thoracogenic scoliosis
- M41.4-, neuromuscular scoliosis (this is scoliosis secondary to cerebral palsy, Friedreich’s ataxia, poliomyelitis and other neuromuscular disorders and we need to code also the underlying condition)
- M41.5-, other secondary scoliosis
- M41.8-, other forms of scoliosis
- M41.9, scoliosis, unspecified
Mr. Grinch reported consuming a three-decker sauerkraut and toadstool sandwich with arsenic sauce (yuck!). Perhaps he was poisoned by the arsenic. In order to code for the poisoning, we need to know whether it was:
- Accidental, T57.0X1
- Intentional self-harm, T57.0X2 (not likely given the patient)
- Assault, T57.0X3 (much more likely)
- Undetermined, T57.0X4 (always a popular fallback)
Don’t forget to include the seventh character for the encounter. Hopefully, Dr. Seuss can successfully sift through the Grinch’s conditions and prescribe the correct treatment to get him back in the holiday spirit!
Q: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?
A: These are just my predictions, but I think that inpatient cases are going to drop to 2.5–3 records per hour. Currently we’re upwards of 3–3.5 per hour in non-teaching/tertiary environments.
On the ambulatory surgery side, I think those are going to drop to 5.5-6.5, and I really think it will be closer to the 5. HCPro’s 2011 Coder Productivity survey results show coders completing 6 -7 cases per hour at the time. So the reason I give these estimate is because we’re going to have more of a challenge with the surgeons being able to provide coders the information needed. So I really do think it will be the lower end of that range.
And if you’re one of those facilities that codes today in both ICD-9 and CPT® and if you can continue that practice in ICD-10 and CPT, then you’re going to have more of a reduction, closer to 4 cases per hour just because of the two different thinking patterns for the two coding classifications.
For non-interventional radiology outpatient testing cases, we’re averaging approximately 25–30 per hour right now. I think we’ll that also go down slightly to a range of 23–26.
Editor’s Note: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of St. Louis–based First Class Solutions, Inc., answered this question during the February 29-March 2, 2012 “JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS, ” and was originally published on JustCoding.com.
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the physician documents “acquired Schatzki’s Ring” that maps to code 530.3 no CC/MCC. However, how would it be coded if the physician does not document “acquired” and only documents “Schatzki’s Ring”? Could it be considered an MCC or would we need to query the physician?
I am also wondering what clinical criteria needs to be present, does the patient need to have a related esophageal principal diagnosis or would this diagnosis fall into a congenital defect?
SB: If the physician does not specify the condition as “acquired” it defaults to 750.3. To assign a code for this condition it would have to meet one of the following five criteria for reporting a secondary diagnoses:
- clinical evaluation; or
- therapeutic treatment; or
- diagnostic procedures; or
- extended length of hospital stay; or
- increased nursing care and/or monitoring
JK: AHA’s Coding Clinic for ICD-9-CM, 1st Quarter, 2012, pp. 15-16, discussed this very issue. In it, guidance calls for querying the physician for clarification when documentation indicates “newly diagnosed Schatzki Ring in an adult patient without additional information regarding whether the condition is congenital or acquired.”
Coding Clinic states that code 530.3 should be used if the condition is acquired. When the physician is unable to determine the type, then the ICD-9-CM code defaults to congenital.
“However, Schatzki’s Ring would be a reportable condition only if it meets the definition of a secondary diagnosis, in that it must be clinically significant or symptomatic. In most cases, when a Schatzki’s Ring is found, it is an incidental finding,” Coding Clinic states.
Based on this Coding Clinic it appears to me that Schatzki’s Ring documented as an incidental finding should not be coded. If it is “clinically significant” or symptomatic, then a query is required to determine if the condition was acquired or congenital. If so, code 530.3 can be assigned.
Editor’s Note: This question was answered by ACDIS Advisory Board members Susan Belley, M.Ed., RHIA, CPHQ, Project Manager for 3M HIS Consulting Services in Atlanta and James S. Kennedy, MD, CCS, Managing Director at FTI Healthcare in Brentwood, Tenn.
Q: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
A: ICD-9-CM codes for CF (i.e., 277.00-277.03) are combination codes. ICD-9-CM code 277.02 specifically denotes CF with pulmonary manifestations. To report this code, the provider must document a relationship between the pulmonary condition and the CF exacerbation. A query is necessary when the physician doesn’t document this cause-and-effect relationship linking the two diagnoses.
The nature of the admission determines the principal diagnosis. If the treatment focuses on the exacerbation of the CF, then the CF exacerbation is the principal diagnosis. Report the specific pulmonary manifestation as a secondary diagnosis. If the treatment focuses on the pulmonary manifestation, then the pulmonary manifestation is the principal diagnosis. Report the CF as a secondary diagnosis.
Coding Clinic, 4th quarter 2002, states that coders must query the physician to identify the relationship of the manifestation/complication to the CF. The circumstances of the admission dictate the principal diagnosis and sequencing.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, education director at HCPro, Inc. and an AHIMA-approved ICD-10-CM/PCS trainer in Danvers, MA, answered this question. For information about CDI-related Boot Camps taught by Ericson, visit www.hcprobootcamps.com. This article first published in the eNewsletter CDI Strategies.
I’ve been listening to my share of ICD-10 preparation audio conferences and webinars. During a recent free webcast with the topic of combination codes in I-10 came up. A few days later in perusing previous editions of Briefings on Coding Compliance Strategies, I came across the following article which discusses complication of care coding and combination codes in ICD-10. Here is the article:
Coders have always struggled with knowing when to report complications of care, says Nelly Leon-Chisen, RHIA, director of coding and classification at the AHA in Chicago. “It’s understandable that people would have questions because there’s more of an interest in using administrative and coded data to look at complications,” she says. “There’s an interest in reducing readmissions, complications, and hospital-acquired conditions.”
Most coders know that reporting a complication of care requires that the medical record include explicit documentation of the relationship between the condition and the procedure. Previous versions of the ICD-9-CM guidelines include this requirement in Chapter 17 (Injury and Poisoning), suggesting that it applies only to codes within the 996-999 code range. This has confused coders with respect to whether the requirement also applies to codes outside this range.
“There have been many questions posed to AHA’s Coding Clinic over the years on this topic,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. Acute hemorrhagic blood loss anemia (ICD-9-CM code 285.1), a non-Chapter 17 code, has been the focus of many of these questions. “Even though this code is not in the complication series of ICD-9-CM codes, it is still seen at times as a complication regardless of whether it is expected,” she says.
To eliminate confusion, the FY 2012 ICD-9-CM guidelines include the requirement for provider documentation under Section 1 (conventions, general coding guidelines, and chapter-specific guidelines), says Leon-Chisen.
This change confirms that the guideline requiring the presence of a cause-and-effect relationship applies to all complication codes regardless of the chapter in which they appear, says McCall.
”This means the provider should clearly identify and document that the condition is directly related to the procedure performed and not merely a condition that arose during a postoperative period or during an admission/encounter,” she says. Terms such as “due to,” “associated with,” or “secondary to” help clarify this relationship.
Leon-Chisen agrees. “Not all conditions that happen to develop during or after surgery are complications,” she says. “In other words, be careful, read the documentation, see that there is a cause-and-effect relationship documented.” For example, coders can’t assume that postoperative bleeding and a blood transfusion are postoperative complications of hip surgery, she explains.
”If it’s anticipated, expected, and routine for certain types of procedures, you certainly don’t want someone being labeled as having had a complication when there really wasn’t one,” says Leon-Chisen. Physicians, medical directors, or physician advisors can-and should-explain to coders what are typically considered expected outcomes for certain procedures and what might constitute complications, she says.
The clarification paves the way for ICD-10-CM, says Leon-Chisen. “In ICD-10-CM, we have a lot of complications that are in the body system chapters. This gets coders in the mode of thinking that a complication doesn’t always reside within a specific range of codes,” she says.
Some ICD-10-CM combination codes denote the complication and body system affected and indicate whether the complication is postoperative, says McCall. For example, ICD-10-CM code I97.110 denotes post-procedural cardiac arrest following cardiac surgery.
Reviewing instructional notes is always important because some ICD-10-CM codes require an additional code to denote the specific condition (e.g, post-procedural heart failure requires an additional code to identify the specific type of heart failure). However, coders using ICD-9-CM always report a complication code (e.g., 997.1 for cardiac complications) and a code from the specific chapter to identify the actual complication (e.g., 427.5 for cardiac arrest).
Editor’s Note: The following case study and related questions comes from the CDI Boot Camp. If you can provide the correct answers to the three questions below by Monday, July 30, at 5 p.m., you will receive a copy of Gloryanne Bryant’s Coding and Physician Language: Strategies for Obtaining Complete Documentation.
Mrs. X is admitted from home with a TIA with aphasia and hemiparesis. The aphasia resolves and she is discharged home two days after admission with a follow-up appointment scheduled for the hemiparesis, which persists.
- What is the principal diagnosis?
- Is there an opportunity for clarification?
- If yes, what is the opportunity for clarification?
Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.
A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.
Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”
For a condition to be considered a postoperative complication all of the following must be true:
- It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
- There must be a cause and effect relationship between the care provided and the condition
- Physician documentation must indicate that the condition is a complication
According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”
Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”
For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.
“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.
Editor’s Note: This article first published on JustCoding.com.
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.
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.
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.