It’s a texting world, and more and more we use shorthand in our everyday lives. What about shorthand in a medical record? Can you code from it?
First, let’s look at what kind of shorthand you might see. Physicians may use a +, ↑, or ↓. Those symbols could mean positive (like a pregnancy test), increased level, or decreased level, respectively. The problem is, they aren’t very clear or specific.
Na↑ could mean hypernatremia (elevated sodium) or it could just mean the sodium level has increased. Maybe the patient has a low sodium level and the physician is simply indicating that treatment to raise the level is working. It could mean the sodium level is a little high or significantly elevated. Maybe the physician just documented a slight elevation so he or she remembers to have it rechecked during the patient’s next encounter.
Bottom line: you just don’t know, so you can’t code from it.
So that means it’s time to query the physician, right? Well, it depends. First, make sure you review the entire record and see if the physician documented the information anywhere else more specifically. Maybe BP↑ was just a note on a summary sheet and in the history of present illness, the physician stated, “Patient’s blood pressure elevated.” No query needed. We have the information.
Maybe the physician didn’t document it more completely elsewhere. Is the condition clinically significant?
Hypernatremia is a CC, so it could affect MS-DRG assignment and the patient’s care. You should probably query.
↓BP could also be clinically significant because a low blood pressure could cause other health problems, such as dizziness, weakness, and fainting. Again, probably worth a query.
↓low chloride is probably not worth querying, because it isn’t associated with any adverse health effects.
If you have providers who routinely seem to document using symbols, work with them to eliminate the symbols and document in clear words. (because we can’t code from symbols in any coding system). The better the physician documents, the better the story of the patient becomes.
“It’s never too early to start learning,” says Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP. “By keeping the ball rolling, staff can continue to drive home those documentation improvement aspects to providers.”
Another advantage to starting now: “We as coders and CDI specialists can become experts in ICD-10-CM coding ourselves,” Jillian says. By becoming experts, we’ll know what is needed from a documentation standpoint and we’ll also know the coding guidelines before ICD-10-CM implementation.
Diabetes coding won’t really be harder in ICD-10-CM, Jillian says, but it will be different. The codes will look different, the documentation requirements will change, and you can’t use 250.00 after October 1, 2015. (Don’t worry, though, ICD-10-CM does have an equivalent code.)
Jillian will gives coders, CDI specialists, and clinicians the inside scoop on how to code for diabetes in ICD-10-CM during the live 60-minute webinar, ICD-10-CM Diabetes: Combine Coding and Documentation for Greater Specificity.
She will reveal how the new codes better represent a patient’s clinical picture and what information coders and CDI specialists need to see in the documentation to assign the most specific code. She’ll also review what the ICD-10-CM guidelines and Coding Clinic have to say about ICD-10-CM diabetes coding and offer some tips on getting physicians to improve their documentation.
Be sure to join us at 1 p.m. Thursday, August 14, for the live webinar. Come ready with questions for Jillian! She’ll answer live questions after her presentation.
And if everyone at your organization can’t make it to the live show, don’t worry, you get a free on-demand version of the webinar!
Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are pretty good, especially considering it was first published in 1858.
Not surprisingly, anatomy hasn’t really changed since then. Our understanding of certain things–like what parts of the brain are involved in which functions—has changed, but the structures themselves have stayed the same for the last many thousands of years.
So why do you need to brush up on anatomy and physiology before ICD-10? The best reason I’ve heard so far comes from Gerri Walk, RHIA, CCS, senior manager of technical training for HRS in Baltimore.
“The vessels of the heart are like roads in Texas,” Gerri says. “Turn a corner and you’re on a different road or in a different vessel.”
ICD-10-CM and ICD-10-PCS both require specific vessels for cardiac conditions and procedures. For example, a patient suffers an acute MI. Where was the infarction? ICD-10-CM includes specific sites, such as:
- Left main coronary artery
- Left anterior descending coronary artery
- Diagonal coronary artery
- Other coronary artery of anterior wall
- Right coronary artery
- Other coronary artery of inferior wall
Some of those are easy (if the physician documents it). Some could be a little trickier. Do you know which smaller arteries are on the inferior wall and which are on the anterior wall?
For Dilation procedures (balloon angioplasty and stents) in ICD-10-PCS, you only need to know the number of coronary sites treated. For Bypass procedures, you need to know the number of sites bypassed from and where the bypass is going:
- 3, coronary artery
- 8, internal mammary, right
- 9, internal mammary, left
- C, thoracic artery
- F, abdominal artery
- W, aorta
Don’t code cardiac cases? You still need to know arteries. For a procedure involving an artery, for example, you will need to know which artery is involved, where it is located in the body, what approach the physician used, what type of repair he or she performed, and whether the physician used a device.
Consider a patient with septic thrombosis of the choroid vein. If you know that the choroid vein is an intracranial vein, you’re all set. You can report ICD-10-CM code G08 (intracranial and intraspinal phlebitis and thrombophlebitis). You’ll notice all of the intracranial veins and sinuses are lumped into this one code. If you don’t know where the vein belongs and your physician simply documents septic thrombosis of the choroid vein, you’ll need to research the vein. This decreases productivity, which slows down cash flow and so on and so forth.
If you code for the ED or orthopedics, you definitely need to know your bones (not just where they are, but what kind of sections they have) and muscles.
For example, where would you find the navicular bone? It’s kind of a trick question because humans have a navicular bone in the foot as well as the wrist. The one in the wrist is also called the scaphoid bone. ICD-10-CM lists it as the navicular (scaphoid).
The navicular bone in the wrist can be fractured in the distal pole, middle third, or proximal third. Each has a separate subcategory in ICD-10-CM that includes options for laterality and displaced vs. nondisplaced.
The navicular of the foot doesn’t have those location differences. Your choices are displaced or nondisplaced, left or right.
If you only code one type of record all the time—for example, if you work for a pulmonologist—you probably only really need to brush up on the anatomy for that body system or area. If you work at a hospital or are part of a pool of coders, you might see a wide range of cases. Then you’re going to need to understand a wider range of anatomy.
You don’t need to take a full-blown anatomy course. Figure out what anatomy you already know well. Odds are you know some of it very well. Identify areas where you aren’t as strong and do some focused training. It can be as simple as looking at Gray’s Anatomy (again, the book, not the TV show).
Find ways to make it fun. An anatomy version of Jeopardy! could be interesting. You can find a lot of free resources online, just make sure you choose ones from a reputable source.
We all know that ICD-10 codes will require more complete documentation. We’ve been telling physicians that, but maybe we’re not explaining it well or correctly.
For example, Eric is a diabetic patient with peripheral neuropathy. Dr. Jones documents “diabetes” in Eric’s medical record. In ICD-10-CM, we would default to E11.9 (Type 2 diabetes mellitus without complications).
Unfortunately, that code doesn’t really reflect Eric’s severity of illness. The code description states “without complications,” but Eric in fact does suffer from a diabetic complication. The physician didn’t document it, so we can’t code it.
If you work in an outpatient setting, E11.9 alone probably won’t support a high-level visit CPT code. And it’s definitely not going to support medical necessity for an inpatient admission.
However, if the physician documents “Type 2 diabetic with peripheral neuropathy,” we can report E11.43 (Type 2 diabetes mellitus with diabetic autonomic [poly[neuropathy). The physician added five words, but we coded a much more specific diagnosis.
If you have an EHR, find out whether you can add prompts to the system to require additional information. If the physician chooses “diabetes” from a drop-down menu, can you add a submenu that requires the physician to specify Type 1 or Type 2? Can you add a prompt asking if the patient has any associated conditions (such as renal failure) or other complications?
Maybe you can, maybe you can’t. It doesn’t hurt to ask.
We’re not asking physicians to write War and Peace for every patient (although some patients may require extensive documentation). The content of the documentation, the actual clinical information the physician uses, is much more important than volume of the documentation. If the physician writes an 18-page progress note for an inpatient with a diabetic foot ulcer, but doesn’t connect the diabetes to the ulcer or provide any information about the stage and site, you’re stuck reporting less specific codes.
Better documentation will benefit physicians and coders now and after the ICD-10 transition. Look for ways to help your physicians document better to make your own transition easier. Ambiguous, incomplete, or unclear documentation makes the coder’s job harder. The better the physician documentation, the easier it is to assign the correct code.
Use the extra time between now and ICD-10 implementation to convince your physicians of the value of better, clearer, concise documentation.
Greetings from Atlanta! I spent the weekend collecting all kinds of tips and information about ICD-10 during the AHIMA Conference pre-conference sessions. These are just a few of the best tidbits from the weekend.
I found the absolute best reason to transition to ICD-10, courtesy of Gerri Walk, RHIA, CCS-P, from HRS in Baltimore: We’re staving off dementia! Use your brain or lose it and ICD-10 is going to let us exercise our brains. A lot.
Donna L. Rudolph, RHIT, CCS, and Joanne Schade-Boyce, BSHD, MS, COC, ACS, PCS, from Health Revenue Assurance Associates talked about the hidden impact of ICD-10. For example, the timeframe for an acute MI in ICD-10-CM goes from eight weeks to four weeks. Not only is that going to be a struggle for coders to remember, it can also affect your MS-DRG, Donna says.
Have you thought about how you current coding policies and procedures will have to change under ICD-10? We’re so focused on education right now, we may not be assessing policies and procedures, Joanne says.
You’ll hear lots more from Joanne and Donna’s presentation in an upcoming issue of JustCoding.
When are you planning to start dual coding and which method are you going to use? Are you going to code concurrently or retrospectively? How many records are you going to code in ICD-10 and how will you check the accuracy? Kimberly Carr, RHIT, CCS, CDIP, manager of clinical documentation for HRS, raised all of those questions during her session on justifying the cost of dual coding. One of the biggest advantages to dual coding: reducing your risk for inaccurate coding because coders will be more comfortable in ICD-10. And, oh, by the way, that will reduce your productivity loss as well.
How do you get to the Carnegie Hall of ICD-10? Practice, practice, practice. That’s Donna’s line, but it was a consistent theme across multiple presentations. The best way for coders to learn ICD-10 and get comfortable is to practice coding actual records in ICD-10. The challenge is to find the time.
More on these presentations and other ICD-10 sessions from AHIMA later.
People are creatures of habit. Some of them are good, some not so good.
Coders, too, are creatures of habit. We know certain codes without having to look them up. (Anyone know the code for unspecified diabetes?) We know where to look in the record for certain information.
One reason coders are worried about the transition to ICD-10-CM is we’re losing all of those codes we know so well. Now we’ll have to look up diabetes unspecified instead of entering 250.00. In case you’re interested, the ICD-10-CM code is E11.9. Yes, we still have unspecified codes in ICD-10-CM.
I had an interesting conversation with AHIMA’s Ann Barta, MSA, RHIA, CDIP, earlier this week. We were talking about how sepsis coding will change in ICD-10-CM and she made an interesting observation.
Ann commented that all coders have a group of ICD-9-CM codes that they know by heart. We didn’t learn those codes overnight. I doubt anyone sat down with an ICD-9-CM manual and decided to memorize certain codes. You learn them by using them over and over again.
The same thing will happen with ICD-10-CM, Ann says. She has been working with ICD-10-CM for seven years now (she’s way ahead of the rest of us). And at this point, she already has some ICD-10-CM codes memorized.
So if you’re worried about ICD-10-CM because you’re losing your comfortable codes, don’t be. You didn’t have the ICD-9-CM codes memorized when you started coding. You learned them as you went. The same thing will happen in ICD-10-CM.
One caveat though. Don’t expect to memorize ICD-10-PCS codes. Ann by now knows the first three characters (section, body system, root operation), so she can go right to the tables. However, she still looks up the last four in part because the fourth character—body part—changes with each body section. The ICD-10-PCS codes are a little too complex to memorize completely, but if you know the first three, you can get to the correct table, and that’s the important thing for PCS.
In ICD-9-CM, we know not to code solely from the Alphabetic Index. After all, the code could have additional digits or excludes notes or other coding directions (such as “code first” or “use an additional code”).
ICD-10-CM codes can be up to seven characters in length. The Alphabetic Index rarely lists all seven.
Sometimes ICD-10-CM is nice enough to let us know we need additional characters by putting a dash at the end of the code in the Alphabetic Index. For example, if you look up unilateral conductive deafness, the Alphabetic Index gives you code H90.1-.
When you look up H90.1- in the Tabular List, you find two choices:
- H90.11, conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side
- H90.12, conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
Coding life would be easy (well, easier) if ICD-10-CM did that for all of the codes that require additional characters. Alas, it does not.
Look up gout, chronic, idiopathic, multiple sites in the Alphabetic Index. You see code M1A.09. That’s all. However, when you flip back to the Tabular List, you find out that you need a seventh character. Actually you need a sixth character placeholder and a seventh character to denote:
- 0, without tophus (tophi)
- 1, with tophus (tophi)
For chronic idiopathic gout of multiple sites without tophus, you would report code M1A09X0.
Most of the codes without the dash actually require placeholders. You can have up to three X placeholders in a single code. You’ll usually find those in the External Causes section, such as:
- W64.XXXA, exposure to other animate mechanical forces, initial encounter
- W73.XXXD, other specified cause of accidental non-transport drowning and submersion, subsequent encounter
- W85.XXXS, exposure to electric transmission lines, sequela
Don’t be fooled by the lack of a dash. Make sure you check the Tabular List to get the complete code.
First we saw the new ICD-10-PCS codes and guidelines in May, followed by the new ICD-10-CM codes in June and the ICD-10-CM guidelines in July. Now we have updated general equivalence mappings (GEMs) from CMS for both ICD-10-CM and ICD-10-PCS.
GEMs are a way to translate ICD-9 codes into ICD-10 codes and vice versa. The maps are a great tool and will get you to the correct code neighborhood, but they won’t always take you to the correct house. If you always had a one-to-one translation, moving to ICD-10 would be pointless.
More commonly, you’ll get a one-to-many match when you go from ICD-9-CM to ICD-10-CM. For example, in ICD-9-CM, simple chronic conjunctivitis goes from one code (372.11) to four codes:
- H10.421, simple chronic conjunctivitis, right eye
- H10.422, simple chronic conjunctivitis, left eye
- H10.423, simple chronic conjunctivitis, bilateral
- H10.429, simple chronic conjunctivitis, unspecified eye
You cannot code directly from the GEMs, but they will point you in the right direction. Look at your common diagnoses by ICD-9-CM code, then plug those codes into the GEMs and see where the GEMs take you. You can use the GEMs to familiarize yourself with the ICD-10-CM codes (and the ICD-10-PCS codes for inpatient procedures). You can also see what the ICD-10-CM options are for diagnoses you commonly report. That can help you educate your physicians about any additional documentation they will need to provide for ICD-10.
Anytown’s baseball team just completed its home opener and while the team came away with a win, not all of the players made it through the game.
Eddie the outfielder suffered a painful run-in with the left-field fence in the second inning. Eddie raced back to catch a fly ball and jumped up. Unfortunately, he was too close to the fence and ripped his right ear open on the top of the fence. He cut through the cartilage in his ear and now sports a spiffy row of stitches. Fence 1, Eddie 0.
Dr. Selig documented no foreign body in the laceration and also noted this was Eddie’s first visit. That gives us ICD-10-CM code S01.311A, laceration without foreign body of right ear, initial visit.
We can also add some codes for external causes:
- W18.01xA, striking against sports equipment with subsequent fall, initial encounter (if you consider the fence a piece of baseball equipment)
- Y92.320, baseball field as the place of occurrence of the external cause
- Y93.64, activity, baseball
Eddie’s teammate Ken also suffered a setback in the first game of the season. Ken failed to move out of the path of an oncoming fastball and earned a free base—and a massive bruise to his hip. Fortunately, the pitch wasn’t that fast, so Ken didn’t suffer any breaks, but he’s going to be sore for a while.
When we review Dr. Selig’s note, we find that he did not document laterality or encounter. That means we need to query.
ICD-10-CM does contain a code for contusion to unspecified hip, but in order for any contusion code to be valid, we need a seventh character to denote the encounter. Since we’re asking for one piece of information, we may as well ask for both. That way the record will be more complete and we don’t need to worry about a possible denial for an unspecified code.
Dr. Selig responds (three days later) with a notation of left hip, initial encounter, so we would report:
- S70.02xA, contusion of left hip
- W21.03xA, struck by baseball
- Y92.320, baseball field as the place of occurrence of the external cause
- Y93.64, activity, baseball
Note that we need placeholders for codes for the contusion and the struck by baseball. Without the X placeholder, the seventh character ends up in the sixth position, making the code invalid.
Eddie and Ken will both be back on the field tomorrow, but their teammate Keith is headed for the injured reserve. Keith slid into second and dislocated his right ankle when he hit the bag awkwardly. To add insult to injury, he was out. He had larceny in his heart, but lead in his feet. And now a cast to go with it.
What do we need in Dr. Selig’s documentation to code Keith’s dislocated ankle?
- Laterality (right)
- Encounter (initial)
- Dislocation or subluxation (dislocation)
That gives us:
- S93.04xA, dislocation of right ankle joint, initial encounter
- Y92.320, baseball field as the place of occurrence of the external cause
- Y93.64, activity, baseball
We would not report W18.01xA because Keith didn’t fall. ICD-10-CM does not contain a code for sliding into a base. At least not yet.
So how would you like to explain this accident to your physician? Doctor, I was crossing the street wearing ice skates and was hit by a bicycle.
- V06.19, pedestrian with other conveyance injured in collision with other nonmotor vehicle in traffic accident
That code includes a long list of specific circumstances, such as:
- Pedestrian on ice-skates injured in collision with other nonmotor vehicle in traffic accident
- Pedestrian on sled injured in collision with other nonmotor vehicle in traffic accident
- Pedestrian on snowboard injured in collision with other nonmotor vehicle in traffic accident
- Pedestrian on snow-skis injured in collision with other nonmotor vehicle in traffic accident
Odds are, you won’t use code V06.19 often, but it’s there if you need it.
ICD-10-CM contains a wide range of codes for external causes, so let’s look at some of the others you may need during the winter.
New England is bracing for a major snow storm this weekend, so we may see people come in with various injuries caused by activities involving ice and snow (Y93.2). Note that the Y93.2 series excludes injuries related to shoveling ice and snow. They have their own external causes code—Y93.H1.
We’ll also report X37.2 (blizzard [snow][ice]). Don’t forget the seventh character to denote the encounter.
Perhaps your patient is Lindsey Vonn, the Olympic skier who recently suffered torn knee ligaments in a horrible crash during a race. If we code the activity of skiing, we need to know what type of skiing:
- Y93.23, activity, snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing, and snowtubing
- Y93.24, activity, cross country skiing
In Lindsey’s case, it’s downhill skiing, so we would code Y93.23 in addition to her injury codes.
What other trouble can we get into in the snow? We could fall because of the snow and ice (it’s not fun, I don’t recommend it). In that case, we would report a code from the W00.- series (fall due to ice and snow):
- W00.0, fall on same level due to ice and snow
- W00.1, fall from stairs and steps due to ice and snow
- W00.2, other fall from one level to another due to ice and snow
- W00.9, unspecified fall due to ice and snow
These codes require a seventh character to denote the encounter, so we’ll need to add two X placeholders so our seventh character ends up in the seventh place.
W00.0 also includes collusions with another person, so when you go sliding across the icy sidewalk straight into an innocent bystander, you get W00.0XXA (for the initial encounter).
If a patient comes in suffering from hypothermia (T68-), we need use additional code to identify source of exposure:
- Exposure to excessive cold of man-made origin (W93)
- Exposure to excessive cold of natural origin (X31)
W93 requires a seventh character to denote the encounter type and includes:
- Excessive cold as the cause of chilblains NOS
- Excessive cold as the cause of immersion foot or hand
- Exposure to cold NOS
- Exposure to weather conditions
W93 specifically excludes:
- cold of man-made origin (W93.-)
- contact with or inhalation of:
- dry ice (W93.-)
- liquefied gas (W93.-)
All of these winter codes are making me cold. Pass the hot chocolate.