“Encephalopathy is a great big monster,” says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida. Coders and clinical documentation improvement (CDI) specialists want physicians to document encephalopathy, when appropriate, because it is an MCC.
By definition, encephalopathy is a global cerebral dysfunction in the absence of structural brain disease, Brundage says. “That definition is very nebulous.”
Unfortunately, providers often describe encephalopathy instead of diagnosing it, says Cheryl Ericson, MS, RN, CCDS, CDIP, [more]
Q: When I started CDI, I was told that when a complication code happens to be the reason of admission, along with another condition also contributing to the admission, the complication code takes precedence over the other condition code. Is this correct, and is there any written evidence, like a Coding Clinic that tells me to do so?
A: The code set offers us direction within the alphabetic index and tabular list related to sequencing with notes that instruct us to code first, or code also, for example. There is instruction within the Official Guidelines for Coding and Reporting as to how to interpret the directional notes, found in Section I. The coding conventions is often the first place I check.
And, of course, the AHA Coding Clinic also gives us guidance. There is a hierarchy of what piece of guidance supersedes the other. The instructions within the index and tabular list (coding conventions) is the highest, followed by the Official Guidelines of Coding and Reporting, and, last, the AHA Coding Clinic.
In the Official Guidelines of Coding and Reporting Section II: Selection of Principal Diagnosis, Section G states:
“Complications of surgery and other medical care when the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.”
Thus, your understanding of how these should be sequenced is absolutely correct and now you are able to state where you accessed this instruction.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or H&P documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
A: There are a few issues to consider here. First, can you code from EMT documentation, such as trip sheets? No. Although these documents are often included in the health record, these documents are not “owned” by the hospital. They are usually classified as external correspondence. If the claim is selected for complex review, the EMT trip sheet cannot be released. As such, it can’t be used to support code assignment.
There is one caveat to this statement. In ICD-10-CM, when implemented, the code for Glasgow coma requires a character that indicates when the assessment was made, which can include those made by an EMT. Coding Clinic from 1st Quarter 2014 states:
“. . . If the EMT documents the patient’s initial GCS core in the field, can the EMT’s documentation be used? Coders are concerned there is no official advice or guideline that allows the use of nonphysician documentation for Glasgow coma scores. . . “The response was, “It would be appropriate to use the pre-hospital report containing the EMT’s documentation and other nonphysician documentation to determine the Glasgow coma score.”
Second, there could be an issue with how the provider is reiterating the EMT findings in the health record. The provider is expected to provide a history of present illness as part of the history and physical. However, conditions not related to the current episode of care should not be reported. The documentation by the provider needs to clearly show the conditions that exist at the time of admission, rather than just listing an overall history.
Sometimes a coder’s perspective is different than a clinician’s regarding what they define as a history of a condition. Often, if a provider fails to carry a diagnosis throughout the health record, and doesn’t include it in the discharge summary, it may not be perceived as reportable by a coder. Many coders begin the coding process with the discharge summary, because it is the final word of the attending provider. However, it is important to note that Coding Clinic 1st Qtr. 2014 states “documentation is not limited to the face sheet, discharge summary, progress note, history and physical, or other report designed to capture diagnostic information. This advice only refers to inpatient coding.”
Just because the provider doesn’t mention a diagnosis more than once does not mean it isn’t reportable. Oftentimes, the provider’s focus changes daily, so they may not feel the need to summarize conditions that are no longer a focus of their efforts. If there is a disagreement between CDI and coding, it is best to clarify with the provider, assuming the totality of health record supports the condition as reportable.
If the provider only mentions the condition(s) in the history and physical, it might be helpful to query for the status of the condition to see if it should be reported. For example, if the provider, in their history and physical, documents “early clinical sepsis” and it is never documented again, be sure there are clinical indicators that support it as a reportable diagnosis. If there are clinical indicators to support it as a reportable condition than your query may be as follows:
Please clarify the status of the condition “early clinical sepsis” as documented in the H&P in this patient who presented with (give specific s/sx) and was treated with (give specifics) or had the following diagnostics (give specifics), etc. Was the “early clinical sepsis”
- Confirmed and ongoing
- Confirmed and resolved
- Ruled out
- Without clinical significance
- Unable to determine
Also note, the multiple choice format would only work well if your organization maintains the query as part of the health record so it would need to be validated by the provider. If the provider responds, by confirming the diagnosis (either ongoing or resolved), it would be reportable. If the provider responds with any other choice, it would not be reportable.
Keep in mind that you can use clinical indicators obtained from EMT documentation to query the provider if there appears to be an undocumented, reportable condition relevant to the current episode of care, if the current provider documentation doesn’t support code assignment.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass, contributed to this post.
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?