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Regulatory MonitoringArchive for Coding
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Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
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Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
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Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
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Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
Q: A patient came into the ER with complaints of a headache and facial pain. The ER physician gave a final diagnosis of sinusitis. This patient had no history of sinusitis. After a coding review, the reviewer said we were wrong to use “acute” and told us to use “chronic.” She told us never to use “acute” unless the physician documents the condition as “acute.” We were previously under the impression that when coding ER accounts, coders should always report conditions as “acute.” Do you know of any ER coding guidelines or publications that would clear this up?
Follow these steps when researching an ICD-9-CM coding question:
- Start with the ICD-9-CM Manual. You can resolve many ICD-9-CM coding questions by carefully studying the ICD-9-CM Manual itself, paying particular attention to typographical conventions and the various notes included throughout the Manual.
- Review the official guidelines. The Public Health Service and CMS jointly publish the Official ICD-9-CM Guidelines for Coding and Reporting. The following organizations helped develop and approve these guidelines:
- American Hospital Association (AHA)
- AHIMA
- CMS
- National Center for Health Statistics
- Review Coding Clinic. Coding Clinic is a newsletter published by the AHA. Representatives from the four organizations listed above review and approve each issue of Coding Clinic. You can order a subscription or back issues of Coding Clinic from the AHA by calling 800/AHA-2626.
This tip was adapted from the handbook, Coding and You: What Every Healthcare Professional Should Know. For ordering information, visit the HCMarketplace.
Q: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood loss anemia with hemorrhage and low hematocrit and hemoglobin caused by Plavix®. A physician had instructed the patient to discontinue this medication 10 days before surgery. However, the patient admits after surgery that he or she stopped taking the drug only two days before surgery.
What ICD-9 code(s) should I report for this scenario? Read More→
The following ICD-9-CM codes denote acute respiratory failure (ARF):
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518.81, ARF
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518.82, other pulmonary insufficiency, not elsewhere classified (includes acute respiratory distress, acute respiratory insufficiency, and adult respiratory distress syndrome NEC)
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518.84, acute and chronic respiratory failure
Check out Coding Clinic, fourth quarter 1998 and first quarter 2005, for more information about when ARF should be the principal diagnosis, as well as documentation requirements.
The sequencing of respiratory failure depends on the reason for admission. When respiratory failure from an underlying condition causes the inpatient admission, the failure becomes the principal diagnosis; when the patient develops respiratory failure after admission, it is the secondary diagnosis and should be coded as such.
Q: What does an incidental pregnancy (code V22.2) mean? Is it related at all to an ectopic pregnancy (code 633.11)? Should I report the two together?
A: Coding Clinic, fourth quarter 1996, p. 50–51, states that code V22.2 is a secondary code only for use when the pregnancy is in no way complicating the reason for the visit. Otherwise, coders should report a code from the obstetric chapter.
For routine outpatient prenatal visits when no complications are present, report codes V22.0 (supervision of normal first pregnancy) and V22.1 (supervision of other normal pregnancy) as the first-listed diagnoses. Do not report these codes in conjunction with Chapter 11 codes. For more information, see Chapter 11 (Pregnancy/Childbirth) of the ICD-9-CM Official Guidelines for Coding and Reporting that took effect October 1, 2008.
Editor’s note: Alison Stangeby, RHIA, CCS, CPC, senior consultant at BKD, LLP in Little Rock, AR, answered this question that originally appeared in the August 2009 issue of Briefings on Coding Compliance Strategies.
Though many hospitals had feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31.
CMS had originally proposed a documentation and coding adjustment to account for the "effect of increases in aggregate payments due to changes in hospital coding practices that do not reflect increases in patient’s severity of illness," according to CMS.
However, CMS states it will continue to research the effects of the MS-DRG transition, including performing a complete analysis of FY 2008 and FY 2009 data. The agency may consider phasing in future adjustments over an extended period beginning in FY 2011, according to a CMS press release.
In addition, CMS expands the number of quality measures hospitals must report to be eligible for a full market basket update in FY 2011. New measures include Surgical Care Improvement Project (SCIP) Infection 9 (Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2) and SCIP INF 10 (Surgery Patients with Perioperative Temperature Management).
The agency will not make any changes to the list of hospital-acquired conditions. It will, however, evaluate the impact of the existing policy on hospital practices and care.
To view the final rule, visit www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp.
Editor's note: Visit the Revenue Cycle Institute later today for additional analysis of the IPPS final rule.
- Reviewing all Coding Clinic guidance dating back to the 1980s. Guidance regarding wound care coding has changed many times since Coding Clinic offered initial advice in 1988. Since then, it has published nine more clarifications. The most recent guidance came in Coding Clinic, in the third and fourth quarters of 2008.
- Implement standardized processes for documenting debridement. Pay particular attention to excisional debridement, as it typically falls under a higher-paying MS-DRG. During the demonstration project, the RACs focused on insufficient terminology in documentation.
- Track debridement cases at your facility. Especially focus on cases for which coders assign ICD-9 procedure code 86.22. Bryant said she started doing this in a homegrown spreadsheet within her system and continues to use coding compliance software to track this procedure information.
- Audit a random sample of patients coded with 86.22. Look for coding errors and fix any inaccurate claims. However, don’t change documentation in a medical record to prove excisional debridement, Bryant said. During a CMS RAC Open Door Forum in 2008, Bryant asked for clarification about how far back hospitals can change medical records. CMS responded that hospitals may amend documentation “in a timely manner,” but did not provide more information. Bryant urged caution here.
- Suggest the need for a standardized appeal letter. If the RAC claims that documentation in a medical record does not support ICD-9-CM procedure code 86.22, but you believe it does, “go back, look at the policy, look at the documentation, and appeal that case,” Bryant said.
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