All Entries Tagged With: "Coding"
Fall intro to ICD-9-CM offered in Boston
Gee, it seems like I’m all about the local trivia recently—from hazelnuts to evergreens, state flags to historic settlements. Well, since I’m apparently on a roll. Let’s talk about my hometown Boston.
- The first American lighthouse was built in the Boston Harbor in 1716.
- The first public school system was founded in Boston in 1635.
Boston Common is the center piece of the Olmstead designed Emerald Necklace of parks.
- When you take a stroll on the Boston Common, you are visiting the nation’s first public park, established in 1634.
- Boston Common is part of the larger Emerald Necklace parkway designed by landscape architect Frederick Law Olmstead who also designed Central Park in New York City and a little place call Moraine Farm in Beverly, MA, where yours truly married the love of her life five years ago. (By the way, according to the US Census Bureau, Massachusetts has the lowest divorce rate in the country with 2.2 divorces per 1000 people.)
- The Hyatt Harborside Hotel in Boston is the site of the next stellar program “ICD-9-CM Coding Essentials: What Every CDI Specialist Needs to Know,” on September 21.
Now I’m not saying Shannon McCall’s class is as exciting as my wedding nor as relaxing as a stroll along Boston Common, it’s definitely a day full of invaluable information. I participated in this program during the 2009 ACDIS conference in Las Vegas and was nearly overwhelmed with the depth and breadth of tools she was able to cover. And for once I’m not just playing my own tune. Many CDI specialists who attended also found it beneficial.
“I would recommend this seminar to colleagues,” said Pamela Lindsey, RN, BSN, MCRMC, Fraser, MI. “It provides a good base of information for a CDS (RN) program. It was helpful to gain information on navigating through the ICD-9 manuals along with the other materials.”
They’ve extended the early bird registration rate through August 24, which saves you $100, and if you are currently an ACDIS member be sure to ask for member discounts too. To register, visit www.hcmarketplace.com.
Query tip for principal diagnosis of fall admissions
by Joel Moorhead, MD, PhD
An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.
Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:
- Select a principal diagnosis from established conditions the physician has clearly documented.
- Query the physician to obtain a principal diagnosis when documentation is not explicit.
Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.
Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.
When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.
Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.
More on potential pitfalls of malnutrion documentation
Johns Hopkins’ Bayview Medical Center in Baltimore agreed to pay nearly $3 million to settle
Make physician documentation regarding malnutrition a matter of black and white.
allegations by two of its inpatient coders that the hospital’s physicians reported secondary diagnoses of malnutrition or acute respiratory failure not identified or treated, according to a June 30 2009 press release from the United States Attorney for the District of Maryland.
The two coders, whose primary responsibility included assisting with clinical documentation, claimed they were asked to review inpatient medical records to determine whether the hospital could increase reimbursement by changing the severity of certain patients’ secondary diagnoses. Bayview denied all allegations but agreed to pay the settlement to avoid further litigation. How can you ensure compliant documentation for these conditions and avoid becoming the target of a lawsuit?
The following ICD-9-CM codes denote malnutrition:
- 263.0, malnutrition, moderate
- 263.1, malnutrition, mild
- 263.2, arrested development following protein-calorie
- malnutrition
- 263.8, other protein-calorie malnutrition 263.9, unspecified protein-calorie malnutrition
These codes are quite specific and require the physician to document the malnutrition severity. Coding Clinic, fourth quarter 1992, reiterates this point. When coding malnutrition, look for clinical indicators such as lethargy, constipation, skin lesions, and hair loss. Potential treatment for this condition includes calorie counts, daily weigh-ins, and dietary consultations. (Note: These lists
are not comprehensive.)
“I would always look for a dietary consult,” says Kathy DeVault, RHIA, CCS, manager of professional resources at the American Health Information Management Association in Chicago. Coders may not use the dietitian’s notes when assigning codes; however, they can use them as the rationale for submitting a query to the physician.
Related reading:
Feeding the brain on malnutrition documentation
Remember the old 80’s ad for the Big Mac? “Two all beef patties, special sauce, lettuce, cheese,
Documenting malnutrition might be easier than building a Big Mac.
pickles, cheese, onions on a sesame seed bun.”
These lyrics and the associated fast food mania was a sign of what I will call food affluence, when we valued time over money, convenience over quality and taste over nutrition. And yet during that same period, the prevalence of malnutrition in hospitalized patients was investigated numerous times with results indicating the malnutrition was a major concern for elderly, hospitalized patients. The effects of malnutrition and the associated costs were also vastly studied in late 80’s and early 90’s. So why has this issue not resolved?
Of course, the issue is once again poor documentation of the severity of the diagnosis and decision making regarding care of this condition. Unfortunately, the malnutrition codes differ from the usual medical terminology. The severity of the malnutrition is indicated in the codes and while clinical severity is typically indicated in risk not actual diagnosis.
Most nutritional consult forms provide a method for the dietitian to indicate risk for malnutrition, not an actual diagnostic statement. Many forms actually ask the dietitian to specify the level of risk of malnutrition by checking the appropriate box for low, medium/moderate, or high. These indicators do not easily translate into an ICD-9-CM code forcing professional coders and CDI specialists to search for other indicators of the severity of malnutrition to clarify diagnoses with the physician.
In an attempt clarify the need to document the severity of malnutrition in adult hospitalized patients, Coding Clinic addressed the issue in the fourth quarter of 1992. It says:
Documentation tip for wound debridement
Read medical records thoroughly before assigning codes for wound debridement to determine the level and scope of work performed by the physician, said Gloryanne Bryant, BS, RHIA, RHIT, CCS, managing director for Kaiser Permanente in Oakland, CA. Bryant spoke during a March 26 HCPro audio conference titled, “ICD-9-CM Procedural Coding for Wound Care and Debridement: Confront Compliance and RAC Challenges.”
“The narrative description of a procedure should be there [in the medical record] so the professional coder can review that information and assign the correct code,” she said.
Coders also need to pay attention to the instruments the provider(s) used to perform the procedure(s) because this detail may indicate what type of procedure he or she performed, and whether or not it was surgical.
However, coders shouldn’t just rely on documentation of the instrument. For example, the use of scissors may not be entirely indicative of an excisional debridement. The provider may have used scissors to cut away loose tissue fragments, an act not associated with the deeper work of excisional debridement.
Bryant says wound care documentation should always include the following:
- Who performed the procedure (e.g., nurse, physician, physical therapist, or other non-physician clinician)
- Site of the wound, burn, or infection
- Depth of the debridement
- What tissue, skin, etc. was removed/excised
JustCoding.com Platinum members can read the complete article online.
ACDIS Precon: What you need to know before you go
More than 100 people signed up for the preconference “ICD-9 Coding Essentials: What every CDI specialist needs to know.” I’m personally looking forward to learning all about how CDI fits into the coding realm from Shannon McCall, RHIA, CCS, CPC-I.
I’ve participated in her Boot Camps before and know firsthand that she is a tremendous teacher. Students from her previous courses rave about her capabilities in their evaluations so I’m sure we’ll all learn a lot and have a good time, too. Last I spoke with Shannon she was working on gathering some Las Vegas themed music to help wake us up on Wednesday.
Speaking of which, if you are among the 100+ pre-conference attendees, head down to registration around 8 a.m. Grab a muffin or bagel and some coffee and take a minute to look over the bookstore. We’ll have an hour to get 100 people registered so be patient with us. Class starts at 9 a.m.
Review the rules to master E/M coding
Even the most skilled specialists have trouble with E/M coding, says Joe Rivet, CPC, CCS-P, CICA, CEMC, a regulatory specialist at HCPro, Inc., based in Livonia, MI. The CPT Manual provides eight pages of guidelines, but this just skims the surface, he says, since the CMS requirements are even more detailed.
CDI specialists should become familiar with the CMS documentation guidelines on E/M coding, which are much lengthier and more detailed than those contained in the Manual, Rivet recommends. (Learn more about E/M guidelines on the CMS Web site.)
For example, the CPT Manual provides a definition for review of systems (ROS) and lists elements of a system review (e.g., constitutional symptoms, cardiovascular, respiratory). The 1997 Documentation Guidelines for E/M Services provides a similar definition and list of elements of a system review, too. But CMS guidelines also give detailed explanations for different levels of an ROS (e.g., problem pertinent, extended, complete) and the requirements to satisfy each level.
According to the 1997 E/M Guidelines:
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
“You really need to know them very well,” he says. “There’s a big difference between the AMA guidelines and CMS guidelines. The AMA provides a very skeletal version of the official rules [in the CPT Manual].”
Editor’s note: This article was adapted from a tip published on the HCPro site JustCoding.com. Click here to read this complete article in JustCoding.com.
Advice for coding educators: ‘Start ICD-10 plans now’
When should schools start teaching ICD-10-CM instead of 9? AHIMA recommends a three-step process that starts with academic planning this fall and transitions through a hybrid educational method in 2010 and finally full ICD-10 curriculum integration by 2011. In its practice brief “Transitioning to ICD-10-CM/PCS-An Academic Timeline” published in the April edition of the Journal of AHIMA, the association recommends:
- Preparation- Start with the August 2009 academic school year to consider the impact of the transition and begin to formulate plans.
- Hybrid-Begins in the August 2010 school year because educators will face the challenge of incorporating both coding systems into an already full academic schedule.
- Full Implementation-Starts with the August 2011 academic year for associate and baccalaureate degree programs. This is the final stage of the curriculum change with ICD-10-CM/PCS being taught as the current classification system.
Knock, knock: Picking a principal diagnosis is no joke
There was some controversy on CDI Talk this week concerning the correct way to code a case where the patient had shortness of breath, Pneumothorax, DVT, and hypoxia. The debate centered around which diagnosis was the principal: Emboli or DVT. There were many opinions, mine included, and as the talk ensued, it made me chuckle. There did not seem to be a clear-cut answer.
We all seemed to reach separate conclusions while all doing the same jobs. We all agreed with which sequence pays the most-DVT with Pneumothorax as the MCC. And we all know which diagnosis is the most resource intensive-Pneumothorax with DVT as CC. But nevertheless, we couldn’t agree about how to properly code this. It reminded me of an old knock, knock joke I heard as a kid.
It went something like this:
Anyone got this answer?
Knock.
Knock.
Who’s there?
Who’s where?
The Coding Guidelines state:
“When there are two or more interrelated conditions potentially meeting the definition of principal diagnoses, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”
When sequencing fractures in the trauma setting, the most significant should be sequenced as the principal. Does this rule only apply to bones? An emboli is certainly more life threatening than a DVT.
Knock.
Knock.
Who’s there?
Who’s where?
Who’s right?
Code sequencing is no knock knock joke. It’s a real compliance trick. CDI specialists, coders, help us out on this one. . .
CMS releases crosswalk for ICD-9 to ICD-10 translation
CMS released The General Equivalence Mappings – ICD-9-CM To and From ICD-10-CM and ICD-10-PCS Fact Sheet in March to assist in the conversion of ICD-9-CM to the anticipated October 1, 2013 implementation date for ICD-10-CM codes. The fact sheet explains how to translate 9 codes to 10 codes and vice versa.
CMS also release information from The General Equivalence Mappings information discussed in the fact sheet is also posted in the CMS Frequently Asked Questions database.