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Free quiz
Test your knowledge with this week’s free quiz, which features questions about ICD-9-CM codes for hereditary and degenerative diseases of the central nervous system. (View)
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Mini-poll
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
- We are making the case for outpatient CDI and hope to implement such reviews within the year
- We conduct ED record reviews only
- We conduct outpatient record reviews
- We have not expanded into outpatient reviews
Last week’s mini-poll
Which area of coding gives you the most trouble?
- Evaluation and management: 33%
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- Orthopedics: 18%
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- Sepsis: 21%
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- Surgery: 28%
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Thank you to the 57 readers who participated in last week’s mini-poll!
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Trivia question
What is the correct ICD-9-CM code for cellulitis of the pectoral region?
a. 682.0
b. 682.1
c. 682.2
d. 682.3
Know the answer and want to be featured in the next issue of JustCoding News: Inpatient? Contact Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
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Product of the week: Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together live webinar
Coders and CDI specialists don’t always identify the same areas of concern; sometimes they don’t even agree on what documentation is necessary to support the coding of a particular condition. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, will help you bridge the communication gaps between these two complimentary departments.
Join us at 1 p.m. (Eastern) Wednesday, October 1, for the 90-minute webinar, Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together. During this program, our expert speakers will provide both the coding and CDI perspectives on common diagnoses in ICD-10-CM to help each department understand what the other is thinking. They will also explain why these differences in vantage points occur and how to incorporate both views into your organizations.
Can’t get everyone together for the live program? Don’t worry. You will also receive a complimentary on-demand version of the webinar to share with everyone in your organization.
For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.
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Q&A: Acute or chronic cor pulmonale
Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and edema?
A: You have obviously put a lot of thought into this question because it is difficult to differentiate between acute and acute-on-chronic cor pulmonale.
Cor pulmonale just means elevated right-sided circulatory pressures. Let’s take a typical patient with COPD. Because of loss of arterials and associated loss of alveoli, the patient’s pressures in the right system go up. It’s like squeezing the end of a hose. The pressure goes up on the end of the hose because you have less caliber, less diameter.
With emphysema, for instance, the pressures that the pulmonary artery has to push up against are elevated. When that happens, we call that cor pulmonale and increased right-sided heart pressures. When the right ventricle fails, we call that right-heart failure.
When the right ventricle fails, fluid backs up into the peripheral circulation, into the legs, into the head and into the liver. You see swelling or a fluid accumulation in those areas.
In a patient who comes in with an acute exacerbation of COPD and has cor pulmonale, how do you differentiate between acute cor pulmonale as the principal diagnosis, acute cor pulmonale as an additional diagnosis, or merely chronic cor pulmonale?
You’re not going to like this answer, but when my patients who have chronic cor pulmonale from COPD–in other words, they may oftentimes have a little pedal edema or a little facial swelling or extension of neck veins–come in acutely exacerbated, they indeed may have more swelling in their legs. I think of that as sort of an acute exacerbation of chronic cor pulmonale. I don’t look at it as acute primary cor pulmonale, which I associate with conditions such as pulmonary embolus, where you have suddenly elevated increased right-sided pressures and a sudden development of right-heart failure. That’s what’s classically considered acute cor pulmonale, and you would report an additional diagnosis.
Editor’s note: William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Florida, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.
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Healthcare news: CMS delays collection of sepsis data for quality reporting
CMS will delay implementation of a chart-abstracted sepsis measure included in the IPPS final rule for fiscal year 2015, the AHA informed members.
CMS was set to begin collecting data on the Severe Sepsis and Septic Shock: Management Bundle measure (National Quality Forum #0500) January 1, 2015 for the FY 2017 inpatient quality reporting program.
In comments on the 2015 IPPS proposed rule, AHA stated it was premature to finalize the bundle measure for severe sepsis and septic shock management. AHA noted that a National Quality Forum committee recommended revising it.
The delay does not affect the data collection period for any other hospital inpatient quality reporting measures.
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2015 IPPS final rule: Quality measures can cause coding concerns
Quality measures, such as the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program, form the basis of the 2015 IPPS final rule, released in early August.
Hospital administrators and their staff need to understand the changes finalized in the rule, as well as how the different quality measures interrelate.
"The 2015 IPPS rule emphasizes that hospitals, physicians, coders, and clinical documentation integrity staff must understand the risk-adjustment methodologies inherent to value-based purchasing, which are outlined on the Web," says James S. Kennedy, MD, CCS, CDIP, president of CDIMD -- Physician Champions in Smyrna, Tennessee. "These complex documentation requirements must be woven into the hospital's EMR fabric so as to not impede the physician's natural workflow or burden him or her with numerous post-discharge queries."
Some of the information and implications are less obvious, says Cheryl Ericson, MS, RN, CCDS, CDI-P, AHIMA-approved ICD-10-CM/PCS trainer, associate director of education for ACDIS and CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts.
HACs
HACs are a group of "preventable" conditions identified by CMS that patients do not have upon admission to a hospital, but instead develop during the hospital inpatient admission. The Affordable Care Act requires CMS to reduce payment by 1% for hospitals that rank in the lowest-performing 25% for HACs.
In the 2014 IPPS final rule, CMS finalized the scoring method for calculating a HAC score for each hospital. The score consists of two domains. The first is based on Patient Safety Indicator (PSI) 90, an administrative claims-based measure. PSI 90 is a composite of eight measures:
- PSI 03, pressure ulcer
- PSI 06, iatrogenic pneumothorax
- PSI 07, central venous catheter-related bloodstream infections (CLABSI)
- PSI 08, postoperative hip fracture
- PSI 12, postoperative pulmonary embolism or deep venous thrombosis
- PSI 13, postoperative sepsis
- PSI 14, postoperative wound dehiscence
- PSI 15, accidental puncture or laceration
The second domain is based on two healthcare-associated infection measures (plus a third measure, surgical site infections, to be added for FY 2016):
- CLABSI
- Catheter-associated urinary tract infection
A score is calculated for each domain, and the two domains are weighted to determine a total HAC score.
The old HAC penalty was not a significant penalty for most organizations because it only excluded the CC or MCC associated with the HAC, Ericson says. Small community hospitals were more at risk for HAC penalties because they usually had only one CC or MCC per record. However, when it comes to the new scoring methodology, small community hospitals may have an edge over larger academic medical centers. The small community hospitals often have more manageable revenue cycle processes, so they look better in comparative measures.
Hospital VBP
VBP is composed of elements of the Hospital Inpatient Quality Reporting (Hospital IQR) Program, which allows CMS to pay hospitals that successfully report designated quality measures a higher annual increase to their payment rates.
Hospitals need to be aware of the increased penalty if they are in the bottom quartile, says Ericson. For 2015, the penalty will increase from 1.25% to 1.5%. "Then you have a separate penalty for readmission, a component of HVBP as well as its own measure, which can be in addition to the 1.5% for value-based purchasing and a potential HAC penalty. It really starts to add up."
Hospitals may not realize that these measures are comparative to other hospitals, Ericson says. "If you maintain the status quo and everyone around you becomes very aggressive in their efforts, you're going to be on the losing end."
CMS is finalizing a total of 63 measures (47 required and 16 voluntary electronic clinical quality measures) in the Hospital IQR Program measure set for the FY 2017 payment determination and subsequent years. It reduced the number of required measures from 57 to 47 and added 11 new measures (one chart-abstracted, four claims-based, and six voluntary electronic clinical quality measures).
For FY 2017, CMS will add two new safety measures and one new clinical care-process measure. The two new safety measures are for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and C. difficile.
CMS will also readopt the current version of CLABSI and remove these six "topped-out" clinical process measures:
- Initial antibiotic selection for CAP in immunocompetent patients
- Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period
- Prophylactic antibiotic selection for surgical patients
- Prophylactic antibiotics discontinued within 24 hours after surgery end time
- Urinary catheter removed on postoperative day 1 or postoperative day 2
- Surgery patients who received appropriate venous thromboembolism prophylaxis from 24 hours prior to surgery to 24 hours after surgery
When a measure is topped out, CMS does not see enough of a deviation between hospitals to make it worth using the measure any longer. "That should let you know how competitive the process is, when CMS has to drop measures because they have topped out," Ericson says.
However, just because a measure has topped out doesn't mean hospitals have resolved all of the problems associated with the measure. For example, discharge instructions for heart failure used to be a problem for hospitals, Ericson says. The measure only required discharge instructions if the patient was admitted for heart failure, but because coding occurs after discharge, there were often discrepancies when it came to heart failure being reported as the principal diagnosis.
As a result, hospitals began identifying all patients who had heart failure anywhere in their history and would then provide all of those patients with discharge instructions for heart failure, Ericson says. Just providing discharge instructions as a blanket measure doesn't necessarily meet CMS' intent when it created the measure.
"People have figured out work-arounds on some of these metrics, and they have topped out because everyone is doing so well on them," Ericson says. That said, just providing discharge instructions as a blanket measure doesn't necessarily meet CMS' intent for creating the measure.
Because CMS is removing the topped out measures, it will revise the domain weighting for FY 2017. In addition, CMS will adopt one new hospital-level risk-standardized complication rate following elective hip and knee arthroplasty measure with a 30-month performance period for FY 2019 and a 36-month performance period for FY 2020.
These measures often require organizations to evaluate their revenue cycle processes, Ericson says. Any weak link in the chain can erroneously lead to failures on these quality measures. For example, does the registration staff know how to accurately identify when a hip or knee arthroplasty is elective compared to non-elective i.e., urgent?
Hospital Readmissions Reduction Program
CMS finalized the third increase in the Hospital Readmissions Reduction Program maximum penalty, raising it from 2% to 3%, as required by the Affordable Care Act.
The readmissions reduction program began in 2013 with a 1% maximum reduction in payments for hospitals with excessive readmissions. The maximum penalty increased to 2% for FY 2014 and will be 3% in FY 2015.
CMS will assess hospitals' readmission penalties using these five readmissions measures:
- Heart attack
- Heart failure
- Pneumonia
- Chronic obstructive pulmonary disease
- Hip/knee arthroplasty
As part of the FY 2015 IPPS final rule, CMS finalized an updated method to account for planned readmissions. CMS will add readmissions for coronary artery bypass graft (CABG) surgical procedures to the list for FY 2017.
Moving targets
CMS annually reviews and readjusts what is included in various measures. This makes the measures moving targets, and that creates difficulties for hospitals, Ericson says.
For many years hospitals followed the same practices and procedures. In the past five to 10 years things have move at a faster pace. "Things are changing so rapidly, hospitals aren't built to respond that quickly," Ericson says. "As more and more penalties apply some organizations are heavily investing in these areas, so even if they don't have quality, they are going to pull themselves out of the bottom quartile because it is comparative and they know how to look comparatively 'good' within the coded data."
IQR and EHRs
CMS is beginning to link IQR with EHR incentives, which is both good and bad, Ericson says.
Consider tobacco dependence with withdrawal. In ICD-10-CM, this condition is a CC. Recording smoking status and delivering tobacco cessation is included in EHR meaningful use stages 1 and 2. However, the way CMS is asking for information about smoking for meaningful use is different from the documentation coders need to accurately report the condition, Ericson says.
IQR includes chart-abstraction measures and chart extraction generally happens 60 days or longer after discharge. Hospitals have only recently started assessing quality measures in real-time to be able to identify potential coding and reporting discrepancies, Ericson says.
If hospitals perform a chart abstraction 60 days after discharge, the coding manager is often reluctant to rebill the claim with the additional information unless it resulted in overpayment, Ericson says. When hospitals found that the data wasn't what they wanted it to be, they started looking for ways to improve the reporting.
CMS finalizes MS-DRG changes
The 2015 IPPS final rule focuses on quality measures, such as the Hospital VBP Program, the Hospital Readmissions Reduction Program, and the HAC Reduction Program.
CMS introduced no new ICD-9-CM codes for 2015 because a code freeze is in effect until ICD-10 implementation October 1, 2015. However, it did finalize several MS-DRG changes.
CMS finalized its proposal to create the following MS-DRGs for endovascular cardiac valve replacements:
- MS-DRG 266 (endovascular cardiac valve replacement with MCC)
- MS-DRG 267 (endovascular cardiac valve replacement without MCC)
CMS also will replace MS-DRGs 490 and 491 with the following new MS-DRGs:
- MS-DRG 518 (back and neck procedures except spinal fusion with MCC or disc device/neurostimulator)
- MS-DRG 519 (back and neck procedures except spinal fusion with CC)
- MS-DRG 520 (back and neck procedures except spinal fusion without CC/MCC)
CMS also finalized removing the following additional diagnosis codes to MS-DRG 794 (neonate with significant problems):
- V17.0, family history of psychiatric condition
- V17.2, family history of other neurological diseases
- V17.49, family history of other cardiovascular diseases
- V18.0, family history of diabetes mellitus
- V18.19, family history of other endocrine and metabolic diseases
- V18.8, family history of infectious and parasitic diseases
- V50.3, ear piercing
Editor’s note: This article was originally published in the September issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
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Integrate medical necessity, documentation, and coding
Editor’s note: This article is the second in a series regarding the coder’s role in obtaining an accurate depiction of medical necessity in principal diagnosis selection. This piece illustrates how to integrate such efforts using a real-life case study. Part one, Learn why medical necessity is an integral part of the coding process, was published July 29.
By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI
Documentation and coding of principal and secondary diagnoses should be inseparable medical necessity. Together these concepts serve as the solid foundation for improving the hospital’s overall revenue cycle process and the accuracy of the medical record.
Clinically accurate, compliant code assignment complemented by effective clinical documentation improvement (CDI) programs are the hallmarks of effective “denials avoidance” programs today.
Essentially, facilities need to stop thinking about denials management on the back-end and start proactively ensuring the medical record contains all the clinical evidence needed to support the codes assigned. Why try to manage denials when the facility can effectively stop them altogether by ensuring that the medical record contains the necessary documentation to prove medical necessity and assign accurate codes for the care?
Medical necessity
The previous article, “Learn why medical necessity is an integral part of the coding process,” argued for incorporating medical necessity into the general principles of ICD-9 coding. To assign an accurate ICD-9 code, coders must adhere to the Official Guidelines for Coding and Reporting, advice from the AHA’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS), and finally the rules regarding medical necessity.
Let’s take a closer look at the concept of medical necessity. The AMA’s Model Managed Care Contract, (cited in“A Refresher on Medical Necessity,” Family Practice Management, July-August 2006http://www.aafp.org/fpm/2006/0700/p28.html) defines medically necessary services as:
Health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:
a) in accordance with generally accepted standards of medical practice;
b) clinically appropriate in terms of type, frequency, extent, site and duration; and
c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician or other health care provider.
CMS introduced the concept of medically necessary services for inpatient admission as care that the physician deems will require the patient to remain in the hospital over a period of two midnights—dubbed the “2-midnight rule.” Basically, if the physician expects the patient care (i.e., workup and management supported documentation of the physician’s clinical judgment, thoughts, and medical decision-making) then all is right with the world and the inpatient admission stands as medically necessary. CMS repeatedly stated the following in clarifying this benchmark from a documentation point of view:
Medicare review contractors should consider complex medical factors that support a reasonable expectation of the needed duration of the stay relative to the 2-midnight benchmark. Both the decision to keep the beneficiary at the hospital and the expectation of needed duration of the stay are based on such complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered. In other words, if reviewer determines that it was reasonable for the physician to expect the beneficiary to require medically necessary hospital care lasting 2 midnights, and that expectation is documented in the medical record, inpatient admission is generally appropriate, and payment may be made under Medicare Part A; this is regardless of whether the anticipated length of stay did not transpire due to unforeseen circumstances
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Documentation, coding, and integration of medical necessity
How does the 2-midnight rule affect ICD-9 principal and secondary diagnoses code assignment? A coder’s primary responsibility is to determine the most clinical relevant principal diagnosis—that is, according to the UHDDS definition, the chief reason after study that occasioned the admission to the hospital.
However, coders often must choose the principal diagnosis despite insufficient or incomplete documentation. In assigning a code for the principal diagnosis, the coder must also take into account the following clinical factors cited by CMS in its 2-midnight rule:
Medicare review contractors will continue to follow longstanding guidance to review the reasonableness of the inpatient admission decision based on the information known to the physician at the time of admission. The expectation for sufficient documentation is well rooted in good medical practice. Physicians need not include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. …The entire medical record may be reviewed to support or refute the reasonableness of the decision, but entries after the point of the admission order are only used in the context of interpreting what the physician knew and expected at the time of admission. (CMS, Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013)
When reviewing the chart, the coder must by definition and intent of the 2-midnight rule take into account the clinical conditions of the patient, as documented, that clearly support the physician’s reasonable expectations of at least a two midnight stay in the hospital.
Coders look to the patient’s:
- Presenting clinical signs and symptoms
- Severity of the same
- Intensity of service
- Plan of care
- History of present illness
When two potential diagnoses equally meet the definition of principal diagnosis assignment, coders should consider the above factors and include medical necessity as the third element considered for principal diagnosis code selection.
Case study
Let’s take a look at the following real life case study.
A patient with long standing, worsening ascites secondary to advanced cirrhosis presented to the ED with a sudden onset of inability to catch his breath. The patient’s abdomen was extended which is attributable to the ascites and as part of the advanced cirrhosis. The patient also complained of diarrhea, nausea and vomiting, abdominal pain, fatigue, bloating, general loss of appetite, and was feeling hot and sweaty. The infectious disease specialist was consulted in the ED by telephone, and in light of the temperature of 101 F, white count of 13 and above signs and symptoms, recommended a paracentesis with culture which was carried out in the ED as well as inpatient admission. The hospitalist wrote orders for inpatient admission with a reasonable expectation of a two midnight stay outlining in his clinical assessment the possibility of infectious process in the face of advanced cirrhosis. The physician specifically documented sepsis and spontaneous bacterial peritonitis. The next morning a new hospitalist assumed clinical management of the patient and overlooked the potential infectious processes associated with the patient’s presentation to the ED with ascites secondary to advanced cirrhosis.
In his follow-up note, the infectious disease specialist on the case expressed frustration that the culture from the earlier paracentesis of abdominal fluid was not performed by the lab as ordered. He reordered another paracentesis with culture cytology, noting “must rule out spontaneous bacterial peritonitis.” Cytology of ascites came back positive for bacteria and the patient’s antibiotics were continued upon discharge from the hospital.
Discharge summary listed final diagnoses of ascites, spontaneous bacterial peritonitis, advanced cirrhosis secondary to long standing and continued alcoholism, diabetes, hypertension and hyperlipidemia. Code assignment included:
Principal diagnosis: ascites
Secondary diagnoses:
- Spontaneous bacterial peritonitis
- Hypertension
- Diabetes
- Hyperlipidemia
- Alcoholic cirrhosis
This leads to MS-DRG assignment 947 (signs and symptoms with MCC).
Analysis and conclusion
Although the discharge summary lists ascites first, the most clinically accurate principal diagnosis and MS-DRG assignment is spontaneous bacterial peritonitis, which leads to MS-DRG 372 (major gastrointestinal disorder and peritoneal infection with CC). Given the facts of this case, the physician’s reasonable expectation of a 2-midnight stay in the hospital and the patient’s need for hospital level of care that was reasonable and necessary for work up and of an illness or injury and management of the patient was based upon the potential infection that culminated in a diagnosis of spontaneous bacterial peritonitis.
The coder’s selection of principal diagnosis must be based on a multitude of factors including:
- adherence to the official definition of principal diagnosis
- explicit clinical documentation
- establishment and substantiation of medical necessity
- provisions of the CMS 2-midnight rule
Coders must remain cognizant of and consider multiple factors in the principal diagnosis code selection to achieve clinical accuracy and excellence in ICD-9 code assignment.
Editor’s note: Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI,is a manager with Accretive Health in Chicago. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
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Check out ICD-10-PCS root operations Control and Repair
The 31 root operations in the ICD-10-PCS Medical and Surgical section are often divided into nine categories of related root operations. For example, root operations Restriction, Occlusion, Bypass, and Dilation are all used for procedures that change the size or route of a tubular body part.
Some root operations fall into less specific categories. Control and Repair, for example, are used when a procedure doesn’t really fit into a different root operation.
Control
Consider this scenario: A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.
In ICD-10-PCS, coders will use root operation Control (third character 3) to report the cauterization.
Control (stopping, or attempting to stop, post-procedural bleeding) in ICD-10-PCS represents a very limited set of procedures. Coders will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.
Procedures that fall under Control include:
- Irrigating or evacuating a hematoma at the operative site=
- Ligation of arterial bleeders
- Cautery with blood clot evacuation
- Drainage at previous operative site to stop bleeding
The site of the bleeding is coded as an anatomical region and not to a specific body part. For the patient with the post-hysterectomy bleed, report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).
Other Control procedures include:
- 0X3F0ZZ, open exploration and ligation of postop arterial bleeder, left forearm
- 0W3H0ZZ, control of postoperative retroperitoneal bleeding via laparotomy
- 0W3C0ZZ, reopening of thoracotomy site with drainage and control of postop hemopericardium
- 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee
In some cases, the physician needs to perform a more involved procedure to stop the bleeding. For example, a physician needs to remove the spleen in order to control post-procedural bleeding. That raises the question of whether to report a Control procedure, a Resection (removal of the spleen) procedure, or both.
According to ICD-10-PCS guideline B3.7:
If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
“The root operation Control is defined as stopping or attempting to stop post-procedural bleeding,” says Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, director of education at TrustHCS in Springfield, Missouri. If the physician is unable to stop the bleeding and must perform a more involved procedure, report the root operation for the more significant procedure.
In the case of the spleen removal, coders would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).
Consider another case. A physician performs an open transverse colectomy to stop post-procedural hemorrhage following a biopsy for diverticulitis. Coders need to carefully read the operative report to determine how much of the colon the physician removed, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM for HCPro, in Danvers, Massachusetts.
“It needs to be clear from the documentation whether the physician removed the whole segment or only part of it,” McCall says. “That detail can change the root operation.”
If the physician removed the entire transverse colon, report a Resection (cutting out or off, without replacement, all of a body part). However, if the physician removed only part of the transverse colon, report an Excision (cutting out or off, without replacement, a portion of a body part), McCall says.
Repair
In ICD-10-PCS, Repair is almost a not-elsewhere-classified kind of root operation. Even the official definition is somewhat vague: restoring, to the extent possible, a body part to its normal anatomic structure and function.
The root operation Repair represents a broad range of procedures for restoring the anatomic structure of a body part, such as suture of lacerations.
Coders will only use Repair when the method used to accomplish the repair is not one of the other root operations. For example, if the physician performs a herniorrhaphy, coders would code Repair. However, if the physician used mesh to perform the herniorrhaphy, coders would go to the root operation Supplement (putting in device that reinforces or augments a body part). The physician implanted mesh (a device) to shore up the weak spot, so the procedure is no longer a simple repair.
Other Repair procedures include :
- 0LQ30ZZ, suture repair of right biceps tendon laceration, open
- 0WQF0ZZ, closure of abdominal wall stab wound
Closure of an operative incision does not qualify as a Repair. Closing the patient is an integral part of the surgical procedure.
Consider a patient who has a left indirect inguinal hernia. The physician performs a laparoscopic repair without graft or prosthesis.
In ICD-9-CM, coders would report procedure code 53.02 (other and open repair of indirect inguinal hernia). This procedure description includes diagnostic information (i.e., indirect inguinal hernia), which does not appear in ICD-10-PCS codes.
In ICD-10-PCS, coders will look up Repair in the Alphabetic Index, then locate the subterms inguinal region, left. That gives coders the first four characters of the code: 0YQ6. In Table 0YQ, coders will find four possible approach characters (fifth character of an ICD-10-PCS code):
- 0, open
- 3, percutaneous
- 4, percutaneous endoscopic
- X, external
For the hernia repair, coders can eliminate open and external approaches based on the documentation. To differential between percutaneous and percutaneous endoscopic approaches, coders will need to carefully read the operative report.
ICD-10-PCS defines a percutaneous approach as “entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.” The only difference with a percutaneous endoscopic approach is that the physician visualizes the site of the procedure.
Table 0YQ includes only one choice for the device (Z, no device) and one choice for qualifier (Z, no qualifier). If the physician used mesh to repair the hernia, coders will not be able to build a code from the Repair table.
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New on JustCoding Platinum!
Two new terms in our Clinical Conditions Encyclopedia:
- Leprosy
- Typhus
Also on JustCoding Platinum:
Did you see this in our E-learning Library?
- Inpatient Coding: Physician Queries
Be sure to check out these other great Platinum benefits:
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Help us understand your challenges
JustCoding wants to learn more about you, our subscribers, and the daily challenges you face in the workplace. We’re looking to shadow or interview CDI and coding professionals in the New England area to better understand how you perform your duties in the ever-changing healthcare landscape. If you are willing to let us visit, please contact senior managing editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
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ICD-10 Trainer
Access the latest blog posts on ICD–10 Trainer, a free online forum for all matters related to ICD-10:
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Free quiz
Test your knowledge with this week’s free quiz, which features questions about ICD-9-CM codes for procedures on the female genital organs. (View)
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Mini-poll
How interested would you be in subscribing to a higher level of JustCoding membership that includes a code lookup tool?
- Extremely interested
- Interested
- Not interested
- I already use another code lookup tool
Last week’s mini-poll
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
- We are making the case for outpatient CDI and hope to implement such reviews within the year: 13%
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- We conduct ED record reviews only: 6%
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- We conduct outpatient record reviews: 6%
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- We have not expanded into outpatient reviews, but we do perform inpatient reviews: 75%
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Thank you to the 16 readers who participated in last week’s mini-poll!
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Trivia answer
Congratulations to this week’s winner, Sharon Moss, CCS, coder ll at Salem Hospital in Oregon. Sharon correctly answered this question:
What is the correct ICD-9-CM code for cellulitis of the pectoral region?
a. 682.0
b. 682.1
c. 682.2
d. 682.3
The correct answer is C.
Here’s a little bit about Sharon:
What are your current job responsibilities?
My main focus is acute care inpatient coding, but my position is as a float coder, which means that I also code outpatients and ED accounts.
Why did you decide to pursue a career in health information management?
The entire medical field has always fascinated me! I enjoy working with the staff, nurses, and physicians. I started out in a clerical position in the hospital and advanced into coding. Then, I wanted a little hands-on experience, so I went into EMT training. I decided that was a little too “hands on,” so I stayed with coding.
What do you like most about your job?
What I enjoy most about coding is that it is always changing. You have to keep up with constant changes and stay on your toes. There is something new around every corner.
What is your favorite area of coding?
My favorite area of coding is the acute care inpatient coding…any area!
What is your least favorite area of coding?
My absolute least favorite area to be specific is outpatient eye surgeries. I have known coders who code eye procedures specifically and it absolutely fascinates them. I have watched eye surgeries first hand and there is something about it that I just cannot wrap my brain around.
What are some of your hobbies?
I love to be outdoors as much as possible. I love gardening, walking, hiking, bike riding, and anything I can do on the water or beach
Do you have a personal motto that you live by?
My motto was passed down to me by my father and I have always tried to stick to it: “Treat others as you would want to be treated.”
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Product of the week: Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together live webinar
Coders and CDI specialists don’t always identify the same areas of concern; sometimes they don’t even agree on what documentation is necessary to support the coding of a particular condition. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, will help you bridge the communication gaps between these two complimentary departments.
Join us at 1 p.m. (Eastern) Wednesday, October 1, for the 90-minute webinar, Common Diagnoses in ICD-10-CM: Bring CDI and Coding Together. During this program, our expert speakers will provide both the coding and CDI perspectives on common diagnoses in ICD-10-CM to help each department understand what the other is thinking. They will also explain why these differences in vantage points occur and how to incorporate both views into your organizations.
Can’t get everyone together for the live program? Don’t worry. You will also receive a complimentary on-demand version of the webinar to share with everyone in your organization.
For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.
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Q&A: Selecting principal diagnosis when physician uses "versus"
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”
When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.
The first guideline states:
In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.
However, let's review another guideline from the same section, which states:
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.
In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS, in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.
If there is no symptom diagnosis documented--for example the physician documents NSTEMI versus GERD--the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes and other testing.
Consider flagging a record such as this for follow-up review the next day. While the physician may not have decided a given diagnosis at the time of an initial review, you should have enough information to warrant a query to the physician for a more definitive diagnosis once lab results return and treatment is provided.. Such a query might read:
Dr. X,
Mrs. Y was admitted with complaints of chest pain. The history of present illness states NSTEMI vs. GERD. Oxygen, nitroglycerine, and morphine were administered in the ED but provided no relief. The patient received a GI cocktail and the pain decreased. Cardiac enzymes lab results were negative. EKG shows normal sinus rhythm and an EGD scheduled as outpatient. Can you please clarify the etiology of the chest pain?
__Chest pain secondary to GERD, NSTEMI ruled out
__Chest pain secondary to NSTEMI
__Other
__Unable to determine
Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI boot camp instructor for the Association of Clinical Documentation Improvement Specialists, answered this question. Contact her at lprescott@hcpro.com.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own inpidual scenario before determining appropriate code assignment.
Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.
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Healthcare News: Audits find errors with DRGs for amputations
Recovery Auditors have uncovered incorrect secondary diagnoses in patients who underwent amputations for musculoskeletal and circulatory system disorders. CMS revealed the findings in its Quarterly Compliance Newsletter.
Reviewers validated the following MS-DRGs for principal and secondary diagnoses and procedures affecting or potentially affecting the MS-DRG assignment:
- MS-DRG 239, amputation for circulatory system disorders except upper limb and toe with MCC
- MS-DRG 240, amputation for circulatory system disorders except upper limb and toe with CC
- MS-DRG 241, amputation for circulatory system disorders except upper limb and toe Without CC/MCC
- MS-DRG 474, amputation for musculoskeletal system and connective tissue disorders with MCC
- MS-DRG 475, amputation for musculoskeletal system and connective tissue disorders with CC
- MS-DRG 476, amputation for musculoskeletal system and connective tissue disorders without CC/MC
Auditors found that the physician documentation did not always support the assignment of a secondary diagnosis. CMS provided two specific case examples for coders to review.
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Seven ICD-10 misconceptions and myths busted
ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Plenty of myths are also floating around and some of them fairly prevalent. One way to make sure the most recent ICD-10 implementation delay is the last ICD-10 implementation delay is to bust some of these myths.
Myth 1: ICD-10 includes too many codes
Plenty of talk about ICD-10 has focused on the number of codes it contains. Coders will go from 17,849 ICD-9-CM codes to 69,823 ICD-10-CM codes. While the numbers may sound frightening at first glance, the change isn't really that scary, says Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in Chicago.
In fact, Bowman says she is not sure how the idea of "too many codes" took hold in the first place. Think of the code book like a phone book. The Chicago phone book includes considerably more phone numbers than the phone book for Williamsburg, Virginia, but you'd still look up a number the same way in both of them. Similarly, ICD-10-CM contains considerably more codes, but you'll still look them up the same way you did in ICD-9-CM, Bowman says. It's not harder to find the code you want just because one book contains more of them.
In fact, the increased number of codes is actually a positive thing. "The increased specificity makes it easier to know if you are at the right code," Bowman says. "If the code is too ambiguous or vague, you aren't sure."
Many ICD-9-CM codes are open to interpretation. As a result, coders may spend more time trying to choose the most accurate code because they don't have a clear-cut choice. That's particularly true when it comes to reporting inpatient procedures. One ICD-9-CM Volume 3 code can represent more than 100 very different procedures that require different levels of care. That ambiguity can leave coders confused and guessing about correct code selection. ICD-10-PCS contains 71,924 possible codes that provide detailed information about the procedure the physician performed.
ICD-10 codes are also more clinically relevant, says Donna Smith, RHIA, project manager and senior consultant with 3M Health Information Systems in Salt Lake City. "That makes it easier to select the correct code."
Consider asthma. ICD-9-CM lists asthma as intrinsic or extrinsic, which is not terminology physicians use, Smith says. ICD-10-CM classifies asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
- Other and unspecified
"That makes sense to people," Smith says. If the physician is describing the patient's condition, coders should be able to pick the correct code.
Myth 2: Coders can't report unspecified codes
It's true that ICD-10-PCS doesn't include unspecified codes, but ICD-10-CM is full of them. Codes that require laterality include options for right, left, and unspecified.
For example, ICD-10-CM includes four choices for chronic serous otitis media:
- H65.20, chronic serous otitis media, unspecified ear
- H65.21, chronic serous otitis media, right ear
- H65.22, chronic serous otitis media, left ear
- H65.23, chronic serous otitis media, bilateral
Physicians should be documenting laterality already, says Smith.
"The better you tell the story of the patient's condition, the better it will help you in the long run," Smith says. "It's not going to get you paid more, but it will help that payment move along faster. You won't get as many denials and you won't get as many requests for additional information."
That said, while physicians should be as specific as possible, in some cases they just don't know, Smith says. ICD-10-CM guideline B.18 states:
Sign/symptom and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
ICD-10-CM also includes more symptom codes than ICD-9-CM, so coders have additional nonspecific choices.
Myth 3: Physicians will need to perform unnecessary tests just for code specificity
This relates to the previous myth about unspecified codes. ICD-10-CM includes additional information about infectious diseases, including causative organisms (for diseases such as botulism or salmonella) or types (such as pneumonia).
If a physician diagnoses a patient with pneumonia but doesn't know the specific type, coders should assign an unspecified code (J18.9, pneumonia, unspecified organism). Physicians don't need to order an additional test to determine whether the patient has pneumonia due to Klebsiella pneumonia, Pseudomonas, or staphylococcus.
Guideline B.18 states:
It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
Myth 4: Clinicians had no input into ICD-10 codes
Another common myth cited by the physician community is that clinicians had no input into ICD-10 codes.
ICD-10 has always been an open forum, meaning anyone can submit information or requests for codes, Smith says. "ICD-10 has been updated yearly based on clinical input."
In fact, the vast majority of ICD-10 updates come from physician groups, Bowman says. Physician groups regularly attend ICD-10 Coordination and Maintenance Committee meetings to provide input into new codes.
Myth 5: ICD-9-CM works fine
In fact, ICD-9-CM does not work fine. The National Committee on Vital and Health Statistics actually sent a letter to the Secretary of Health and Human Services recommending the U.S. move to ICD-10 more than 10 years ago.
ICD-9-CM is outdated and out of room. It does not reflect current clinical knowledge, up-to-date medical terminology, or the current practice of medicine. It also hasn't been updated since 2011.
ICD-9-CM's limited structural design lacks the flexibility to keep pace with changes in medical practice and technology, Bowman adds. "The longer ICD-9-CM is in use, the more the quality of healthcare data will decline, leading to faulty decisions based on inaccurate or imprecise data."
The lack of specificity in ICD-9-CM also results in more frustrating back and forth with insurance companies and more records requests. Physicians and office staff must spend time dealing with record requests and administrative headaches.
For example, in ICD-9-CM, physicians cannot specify laterality in many cases. If a patient comes in with a closed fracture of the proximal phalanx of the right index finger, coders would report 816.01. Suppose the same patient comes in two days later with a closed fracture of the proximal phalanx of the left ring finger. Coders would still report 816.01. Payers may see this and reject the second claim thinking it is a duplicate code or an error in billing.
In ICD-10-CM, coders would report two different codes:
- S62.610A, displaced fracture of proximal phalanx of right index finger, initial encounter
- S62.615A, displaced fracture of proximal phalanx of left ring finger
Thanks to the separate codes, the payer knows that the patient clearly suffered two distinct fractures, which should speed up the reimbursement process.
Myth 6: We can use SNOMED CT instead of ICD-10
SNOMED CT and ICD-10 are complementary systems, not interchangeable ones. Neither can serve all current and future uses for coded data required in the U.S. healthcare delivery system, says Bowman.
SNOMED CT is designed for the primary documentation of clinical care. "When implemented in software applications, SNOMED CT can be used to represent clinically relevant information consistently, reliably, and comprehensively as an integral part of producing EHRs," Bowman says.
The ICD system defines the universe of diseases, disorders, injuries, and other related health conditions. It organizes content into meaningful standardized criteria that can be stored and retrieved for epidemiological and research purposes.
"SNOMED CT and ICD are designed for different purposes, and each should be used for the purpose for which it is designed," Bowman says.
Myth 7: We can just wait for ICD-11
ICD-11 is a long way off. The World Health Organization doesn't plan to release the codes for use until 2017 (two years later than it originally planned). But even then, the codes wouldn't be immediately ready to use. They would still need to be modified for use in the U.S., which would probably take another 20 years, Smith says.
Healthcare will miss out on the improvements associated with ICD-10 coding, such as laterality, greater specificity, and more room to add codes. In fact, CMS stated that one of its reasons for setting October 1, 2015, as the new implementation date was so the healthcare industry could reap the benefits of ICD-10 without an even longer wait.
In addition, healthcare providers and coders will have a more difficult time learning ICD-11 without learning ICD-10 first. Although the ICD-11 codes aren't final yet, the system builds on concepts introduced in ICD-10.
Editor’s note: This article was originally published in the September issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.
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