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Q&A: Denial management teams

Have CDI questions?

Have CDI questions?

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups: [more]

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

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Q&A: Electronic query formatting

Have CDI questions?

Have CDI questions?

Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?

A: This is going to be contingent on the system your facility uses.

Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.

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Q&A: Documenting excisions in dermatologic settings

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Have CDI questions?

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

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Q&A: Missing documentation for acute kidney injury

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Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

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Q&A: Rejections for claims for removing impacted cerumen

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Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

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Note from CCDS Coordinator: Do you really need the CCDS certification?

CCDS certification

I received an interesting question recently from someone contemplating Certified Clinical Documentation Specialist (CCDS) certification. She asked:

“I am wondering whether obtaining the certification gives the CCDS holders any special privileges? Are they able to perform duties that they otherwise would not be able to if they did not hold the certification (not by knowledge, but by law)?”

In my five-plus years with ACDIS no one has ever asked this question. Obtaining the CCDS credential does not give the holder any additional rights, privileges, or responsibilities. It does not legally empower the holder to perform any duties.

What the CCDS credential does, however, is recognize individuals who have an advanced level of CDI knowledge and who have the proven ability to work as clinical documentation specialists. Candidates for the CCDS designation are required to have at least two years of experience in the profession.

The CCDS demonstrates an accomplishment that captures both experience and knowledge in the field, and many facilities suggest or require their CDI staff hold the CCDS or earn it following the two-year minimum requirement to sit for the exam, after hire. Facilities often hire individuals with nursing (clinical) or coding experience for the clinical documentation team and train them to become proficient. It is the decision of the individual facility to determine who to employ as a CDI specialist and what responsibilities are given to individuals who perform the CDI role, which may differ depending on whether or not they hold the certification.

What I didn’t tell the writer is that, for a lot of people, CCDS certification is a matter of pride. In the fall of 2016, ACDIS conducted a survey of CCDS holders and asked them what they see as the value of their credential. Their responses included:

  • The credential differentiates me as a leader
  • I am set apart as the CDI who went the extra mile to prepare for and achieve the certification for my very specialized profession
  • I am the go-to-person for others to come to with questions for assistance
  • The credential demonstrates that I put forth the effort to be knowledgeable about the work I perform
  • Professional certification is about promoting the highest standards in our industry
  • Personal satisfaction
  • It shows I take my job seriously and intend to stay on top of the knowledge I need to do the job well
  • It shows I have the experience of clinical chart review for appropriate diagnoses and the clarification/query process to physicians
  • The credential sets me apart—I have skills and knowledge
  • It’s proof that I value this job, want to continue to do it, and want to improve myself; I feel it’s a definite plus and shows that I take pride in what I do.
  • It adds much credibility with the physicians in my institution—I think I am perceived as being more professional and more knowledgeable in my role

From the same survey, several managers told us:

  • Certified individuals are viewed as more knowledgeable about coding guidelines and best practices. They are more committed to their work, better trained, and have better understanding of the role and what is required to do the job well. And because of recertification requirements, they stay current with changes in the industry.
  • Certification holders often serve as team leads, help with new staff orientation, and staff education.
  • It communicates a commitment to their craft. Requirements are such that they have to stay current with on-going changes that are occurring. It helps when interacting with their “customers,” as they really are trained and understand what they are doing.
  • Identifies that you have attained increased knowledge related to your daily practice.

What will drive you to seek CCDS certification? Whether personal pride, or a suggestion or requirement from your employer, we are here to encourage your efforts and cheer your accomplishment.

Visit the ACDIS website and download the Exam Candidate’s Handbook for more information about certification.

Editor’s note: Penny Richards is the CCDS Coordinator for ACDIS. If you have any questions regarding the CCDS credential or exam process, contact her at prichards@hcpro.com.

Q&A: Finding focus for CC/MCC reviews

haik

William Haik, MD, FCCP, CDIP

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version of the webinar, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q: I’m having trouble with querying physicians for complication codes. Could you please provide guidance?

A: This is difficult. Unless there is an (coding) index directive, query the attending physician to determine if a condition occurring after surgery is due to, or caused by, the surgical procedure (such as atelectasis following surgery). From a medical perspective, the conditions which occur after surgery are not typically due to the surgery, but are due to other factors such as in atelectasis, operative pain, sedation, supine position, etc. Therefore, when I ask, it is when there is a high probability of being related to the surgical procedure (hematoma, excess hemorrhage which is addressed intraoperatively or immediately post-operatively). 

Q: Does systemic inflammatory response syndrome (SIRS) with pneumonia qualify for sepsis or should this be queried?

A: Unfortunately, in ICD-10-CM, there is no coding index entry for SIRS, and the previous index entry in ICD-9-CM for SIRS with infection no longer leads to sepsis. Therefore, the physician must be queried to clarify the documentation and assign an appropriate code.

Q: Should we query when the physicians use accelerated or malignant hypertension (HTN) in regards to hypertensive emergency/urgency?

A: Yes, as the former terms now are considered unspecified, a more specific condition should be sought.

Q: Would a physician query be necessary if the physician documentation indicates malnutrition (CC) and the dietician’s assessment documents mild to moderate malnutrition (CC)?

A: It is unnecessary to query a physician regarding the non-specific documentation of malnutrition. If the physician documents mild or moderate malnutrition, one would assign malnutrition, not otherwise specified, unless the physician specifies further.

Q: Do you have any suggestions for what CDI professionals should do if the physician documents a diagnosis but it is not supported by documentation in the chart or by clinical indicators?

A: I would ask the physician to review the record along with enclosed medical criteria regarding the condition in question. I have developed a handbook which provides evidence-based clinical indicators for common medical conditions. (For a copy, email Behaik@aol.com.)

Q: Should we query for electrolyte abnormalities on gastric bypass patients. We are told imbalances are normal due to diet restrictions.

A: Although electrolyte disturbances are common in gastric bypass patients, they are not normal and not integral to the procedure. The physician would typically would treated the patient if the levels were significantly clinically deranged. In this setting, I would query the attending physician to determine if the levels are merely lab abnormalities or if they should be clinically significant and reportable.

Q: When acute respiratory failure is reported in the postop period and is integral to the procedure (for example, the patient remains on mechanical ventilation for less than two days following post op), do we have to query to see if it is significant or should we code without a query?

A: From a clinical perspective, I assume major surgery (cardiopulmonary, esophageal, gastrointestinal resection surgery) often require prolonged ventilation. In minor surgeries, such as prostate biopsies, extremity surgeries, etc., if the patient is on mechanical ventilation longer than 24-hours and assuming the patient is awake, then I would tend to query regarding post-operative respiratory failure, particularly if there is a medical complication such as aspiration pneumonia, pulmonary edema, etc.

Q: What’s the difference between acute respiratory failure and acute pulmonary insufficiency? Would oxygen dependent Chronic Obstructive Pulmonary Disease (COPD) be insufficiency instead of failure?

A: Acute respiratory failure is a life-threatening condition which is typified by a pO2 of less than 60 on room air (in patients with previously normal lungs) in the clinical situation of a patient with rapid respirations and increased work of breathing in the acute setting. Acute pulmonary/respiratory insufficiency is a poorly defined term merely meaning non-life-threatening impairment of gas exchange. Therefore, it does not represent a pO2 of less than 60 (in patients with previously normal lungs), but not a completely normal pO2. Oxygen-dependent COPD is consistent with chronic respiratory failure as to obtain oxygen (via Medicare) one must have a pO2 of less than 60.

Q: Post-operative pulmonary insufficiency is an MCC, but post-operative respiratory insufficiency is neither a CC/MCC. Is there a way to differentiate these two diagnoses?

A: There is no medical differentiation between pulmonary and respiratory insufficiency. This is merely an idiosyncrasy of ICD-10-CM.

Q: According to resources, a lactate less than 1.0mmol/L, which is normal, is considered a sepsis indicator. Why is this an appropriate indicator if it is within normal limits rather than greater than 2 which is abnormal?

A: Despite the “normal” limits of lactate up to 2.2 in most hospitals, it has been determined, retroactively, a lactic acid level of greater than 1 is a finding seen in sepsis. It is not specific as there are other hypoperfusion states and/or chronic liver disease which may result in an elevated lactic acid level. Therefore, it must only be interpreted in the appropriate clinical circumstances.

Q: Is healthcare associated pneumonia (HCAP) synonymous with hospital acquired pneumonia?

A: They are similar, but not synonymous. HCAP includes nursing homes, long-term acute care facilities, chemotherapy, and dialysis centers. Hospital-acquired pneumonia requires a hospitalization of at least a three-day stay. The pathogenic organisms are similar as is the treatment.

Conference Conversations: Fox helps make CDI programs “physician-friendly”

Fox, Nicole

Nicole Fox, MD, MPH, FACS, CPE

Editor’s Note: The ACDIS Conference is only a little over two months away. Over the coming weeks, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked to Nicole Fox, MD, MPH, FACS, CPE, the medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey, who will be presenting “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement.” Currently, Fox leads a team of 13 CDI specialists and achieved a 100% physician response rate to queries.

Q: What has been the biggest challenge you faced with physician engagement at your facility?

A: Actually one of the strengths of our program is physician engagement. We have a 100% response rate to our CDI queries. I think one of the general challenges with physician engagement is not recognizing that the best way for physicians to receive information is peer-to-peer. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise. Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help. But, they respond most effectively to one of their peers.

Q:  What are three things attendees can expect from your session?

A: Attendees can expect an interactive, dynamic presentation. They will have tangible “take-aways” to help make their CDI program physician friendly. They also will have tools to handle difficult physicians.

Q:  What one tool can CDI professionals not live without?

A: An engaged medical director for their program.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: This session challenges non-physicians to see CDI from a physician’s perspective and really evaluate their own program to determine whether or not they are set up for success in terms of physician engagement.

Q: What are you most looking forward to about this year’s conference?

A: I cannot wait to hear about other program’s successes, particularly with ambulatory CDI which is our next area of growth and expansion.

Q: Fun question: what’s your favorite breakfast food?

A: An egg white burrito with quinoa and black beans. It’s awesome with tomatillo sauce. They make a great one at the Wynn Hotel café in Vegas, so try one while you are out at the ACDIS conference.