RSSAll Entries Tagged With: "Guest post"

Guest Post: Communication eases challenges of fiscal year 2018 code changes

coding changes

On October 1, over 800 code changes take effect!

by Crystal Stalter, CDIP, CCS-P, CPC

It’s that time of year again—time to wonder just how the 2018 IPPS final rule will affect CDI and coding efforts.

The 2018 IPPS final rule includes more than 800 ICD-10-PCS changes. Previously recognized operating room codes have become non-operating room codes, affecting DRG assignment, changing surgical DRGs to medical DRGs, and thus affecting reimbursement. Some diagnoses are gaining new definitions and explanations that will result in new ICD-10-CM code assignments and shift DRGs as well.

[more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.

[more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]

Guest Post: Minute for the medical staff, part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Definitions matter

Many clinical documentation improvement (CDI) programs now look to capture risk-adjusted conditions which help improve the capture of a patient’s severity of illness and risk of mortality regardless of setting. Since risk-adjusted outcomes depends on the definitions of coded diagnoses, let’s discuss current literature which supports specific clinical terms:

Shock: a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen use by the cells. In assessing the potential presence of shock, abnormalities of the skin (degree of cutaneous perfusion); kidneys (urine output); brain (mental status) are examined. While arterial hypotension (defined as systolic blood pressure of less than 90 mmHg, or mean arterial pressure of less than 65 mmHg, or a decrease of greater than or equal to 40 mmHg from baseline), is commonly present, it should not be required to define shock. As such, lactate levels in shock states are typically less than 2 mEq/L (or mmol/L) in shock states. In neonates, significant shock stigmata, such as decreased capillary refill, mottling, cool extremities, and tachycardia, can define shock in the right clinical circumstance.

[more]

Guest Post: Minute for the medical staff, part 1

James Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Those of us who care for critically ill patients intuitively know who will have a long hospital stay and who will die. As such, intensive care unit (ICU) scoring systems based on clinical indicators such as Acute Physiology and Chronic Health Evaluation Three (APACHE-3) or Simplified Acute Physiology Score Three (SAPS III) in adults or Pediatric Index of Mortality Two (PIM2) in children have been developed, though validity in an individual patient varies.

Medicare, state governments, and private enterprise, such as Vizient, Truven, Quantros, and 3M, also have scoring systems based on the ICD-10-CM codes derived from explicit, clear, and consistent provider documentation. As such, how we define and document diagnoses that predict morbidity and mortality is essential if we want our patient’s risk to be accurately portrayed.

Physician definitions and documentation are crucial

In navigating the ICD-10-CM maze, we must remember the following as written in the Coding Clinic for ICD-10-CM, Fourth Quarter, 2016: [more]

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.

[more]

Guest Post: Improving the selection of a principal diagnosis

Commeree_Adrienne_web_106x121

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.

Guest Post: Postoperative complication coding and value-based purchasing

by Ghazal Irfan, RHIA

Achieving compliant coding

Postoperative complication coding guidelines continue to cause difficulties for coders and CDI professionals. So, let’s analyze the steps needed to ensure complete, accurate, and compliant coding.

The first step in compliance is defining a postoperative complication. In general, a postoperative complication is an unanticipated outcome (in the form of a condition or a disease) that develops following an illness, treatment, or procedure.

For example, a 60-year-old female comes in for a herniorrhaphy (hernia repair). She has a past medical history of hypertension and morbid obesity with body mass index greater than 40. She smokes and has chronic obstructive pulmonary disease (COPD). Surgery goes well; however, post-surgery, the patient has a hard time weaning off of the ventilator and is immediately given inhaler treatments and placed on BiPAP. After a couple of incentive spirometry sessions and inhaler treatments, the patient feels better, and she is discharged home the following day.

The body of the operative report documents the patient’s inability to breathe on her own due to “acute respiratory insufficiency following extubation.” The header of the operative report, however, documents no complications. How should acute respiratory insufficiency following extubation be coded? Should it be coded as a “postoperative complication,” or as an “acute respiratory insufficiency?”

The ICD-10-CM Official Guidelines for Coding and Reporting states that “code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in.”

The Guidelines go on to explain that “it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.”

Keeping these rules in mind, a coder cannot report the diagnosis as a postoperative complication due to the legal ramifications of these codes, and due to the conflicting documentation: acute respiratory insufficiency following extubation versus no complication.

When to query

While deciding on a secondary diagnosis, coders and CDI specialists need to ask questions like:

  • “Was the condition clinically evaluated, tested, and treated?”
  • “Did the condition result in extended length of stay?”
  • “Did the condition require increased nursing care?”

Patients who are smokers with COPD and morbid obesity have a hard time clearing their lungs of carbon dioxide and need a little help to get the gas exchange going. Since a coder/CDI specialist is not a doctor and cannot assume a cause-and-effect relationship, the coding guidelines will direct them to query the physician regarding postoperative complication.

The following query form can be used for any postoperative complication clarification and should be made part of the legal medical record.

query

Chances are, an inexperienced coder will look at the operative report, assign the postoperative complication code as not present on admission (POA-N), and drop the chart. Such an assignment negatively affects the facility’s quality outcomes report since postoperative complication codes with POA N are counted as the Agency for Healthcare Research and Quality’s patient safety indicators. A seasoned coder/CDI specialist, however, would submit a query and ask for clarification. Accurate, complete, and compliant coding can only be achieved when coders and CDI specialists have leadership support and physician buy-in. Coders need education on the significance of reaching out to physicians when coding postoperative complications, and when documentation is conflicting or inconsistent, even though the DRG stays the same.

Also, managers should not penalize coders for holding charts or failing to meet productivity benchmarks when pursuing a clarification. Code assignment affects reimbursement, quality outcome reporting under the VBP program, and academic research programs. Working collaboratively—coders, CDI professionals, and physicians—can assist facilities in gathering the most complete and accurate data sets, which will result in valid, ethical, and reliable quality outcomes reporting.

Editor’s note: This article originally appeared in JustCoding. Irfan is the coding compliance manager of hospital services for RevWorks AH-Corp and works with her team to ensure revenue cycle compliance. She holds a degree in health information management and is pursuing a master’s degree in biomedical informatics at Oregon Health and Science University. Opinions expressed are that of the author and do not represent HCPro or ACDIS.