Q&A: Dealing with unanswered queries

September 8, 2015, 9:00 pm

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Q: In my facility, we are supposed to send an email to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?

A: We do suggest every clinical documentation improvement (CDI) program have well-developed query policies. These should be consistent with those policies followed by the coding department. Look at how unanswered queries are addressed on the retrospective side.

Your query policies should include clear guidance on:

What instances queries are to be asked
Where they are placed within the record
Who is responsible for following through
How queries are to be prioritized

Query policies should also include an escalation policy that describes how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the PA, your department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for your organization.

In my experience, if a query was unanswered, the CDI specialist and inpatient coder would discuss the need to follow up. If it was determined that the answer would provide little impact, we would close it, leaving the query unanswered. But if we concluded an answer was required, the CDI specialist would address it with the provider. There was a process of escalation in those instances when no response was received.

Ultimately, your policies should indicate what instances a query can go unanswered, and when it should be followed through. There may be instances when a query does not impact the reimbursement or quality measures and can be left unanswered. These are conversations that must be discussed within your organization.

Few organizations can boast a query response rate of 100%, but there are some things you can do to boost response rates. Take a look at your query templates or perform a query audit. There should always be choices that allow the physician to offer his or her own interpretation, or to state that there is no significance, or the answer is unknown. Often, physicians do not answer queries because they either do not like the choices offered or they are unsure exactly what is being asked.

It might be helpful to monitor physician query response rate based on the CDI specialist responsible for the account. You may find a specific CDI specialist is having difficulty writing effective queries or lacks assertiveness in following up on unanswered queries. Most programs have a time limit or goal for queries to be answered that tied to individual CDI productivity or effectiveness in the role. For example, an expectation that 80% of all queries asked will be answered within 48 hours.

Administrative support is invaluable in encouraging physician involvement in your program. Many organizations track physician response rates to queries in their physician profiling, or “quality report card” efforts. Instead of forwarding administration every unanswered query, set an acceptable response rate. When a physician falls below the suggested benchmark, the matter should be addressed by a department director, PA, or senior administration.

I also like to give positive reinforcement where it is due. Recognize those physicians who are working with you and are demonstrating a high response rate. It creates a sense of competition and, often, we catch more flies with honey.

Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and CDI education specialist at HCPro, a division of BLR, in Danvers, Massachusetts, answered this question on the ACDIS website. 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 individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to editor Steven Andrews at sandrews@hcpro.com and we’ll do our best to get an answer for you.

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Healthcare News: CMS discusses ICD-10 end-to-end testing results, coding guidance

September 8, 2015, 9:00 pm

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CMS has released a transcript and recording of its August 27 MLN Connects Call featuring ICD-10 coding guidance and the results of CMS’ final round of end-to-end testing.

CMS Acting Administrator Andy Slavitt provides a national implementation update and how CMS has prepared its systems for the transition.

Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in Chicago, and Nelly Leon-Chisen, RHIA, director of coding and classification for the American Hospital Association in Chicago, follow with some of the latest coding advice and guidance available.

The call also includes the results of CMS’ third and final round of end-to-end testing in July. The round of testing resulted in a similar acceptance rate to January and April testing weeks—but with the largest group of volunteers yet. Approximately 1,200 volunteers, from a broad range of provider, claim, and submitter types participated, including 493 who participated in previous testing weeks.

Testers submitted a record 29,286 claims and CMS accepted 25,646 of them, resulting in an 87% acceptance rate. This is a similar rate to previous testing weeks, and most rejections were the result of provider submission errors that would not occur with actual claims, according to CMS. Errors include incorrect NPIs or submitter IDs, invalid HCPCS codes, and dates of service outside of the range of testing.

Coding errors also led to rejections, with 1.8% of claims rejected due to an invalid ICD-10 code and 2.6% rejected due to an invalid ICD-9-CM code. Some of these errors may be due to providers intentionally submitting invalid codes to make sure the claim would be rejected.

Additionally, CMS rejected no claims due to front-end system issues and identified no new ICD-10-related issues in the Medicare fee-for-service claims processing systems.

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CMS focuses on value over volume in IPPS rule

September 8, 2015, 9:00 pm

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CMS continued its focus on improving the quality of patient care in the fiscal year (FY) 2016 IPPS final rule, released July 31.

"The final rule includes policies that advance the vision and commitment to increasingly shift Medicare payments from volume to value," says Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM trainer, director of CDI Quality Initiative for Huff DRG Review in Eads, Tennessee.

Most of the changes included in the final rule fall under CMS' various quality improvement measures. The agency did finalize some coding and MS-DRG changes for 2016. However, the changes are minor because of the ongoing code freeze prior to ICD-10 implementation.

CMS finalized the addition of seven new measures to the Hospital Inpatient Quality Reporting (IQR) Program. In addition, the agency finalized changes to the pneumonia readmission measure as part of the Hospital Value-Based Purchasing (HVBP) Program and the Hospital Readmissions Reduction Program (HRRP).

CMS is not adding or removing any Hospital-Acquired Condition (HAC) categories for FY 2016. It estimates that 19.4% of all hospitals will be penalized with a 1% reduction in MS-DRG payments for all traditional Medicare discharges in FY 2016 due to HAC Reduction Program (HACRP) performance.

CMS also addressed provider comments on its plan to expand the Bundled Payments for Care Improvement (BPCI) Initiative.

The BPCI Initiative is composed of four related payment models that link payments for multiple services received by Medicare beneficiaries during an episode of care into a bundled payment.

More than 75 stakeholders responded to CMS' request for comments on the BPCI Initiative. While CMS stated it would consider these comments if it does expand the initiative, it provided only general topics addressed by the commenters.

CMS included a small discussion on short stays and the 2-midnight rule. CMS did not propose any changes to the 2-midnight rule in the 2016 IPPS proposed rule, but reminded stakeholders that it did address short stays in the 2016 OPPS proposed rule. Stakeholders have until August 31 to submit comments on the short-stay proposals.

In the CY 2016 OPPS proposed rule, CMS states that it will look at short inpatient stays that do not cross two midnights. CMS will approve these short admissions on a case-by-case basis, based on the physician's judgment and the documentation justifying the stay.

CMS expects short stays for minor surgical procedures or hospital care to be rare and will monitor these types of admissions to prioritize them for medical review.

Beginning October 1, Quality Improvement Organizations (QIO) will conduct initial patient status reviews to determine the appropriateness of Part A payment for short-stay inpatient hospital claims. Recovery Auditors had been scheduled to conduct these reviews.

QIOs will base their reviews from October 1 through December 31, 2015, on Medicare's current 2-midnight policy. Beginning January 1, 2016, QIOs will incorporate any changes to the 2-midnight rule finalized in the OPPS rule to conduct the patient status reviews.

The IPPS final rule did not include an extension of the partial enforcement delay of the 2-midnight policy. However, CMS did extend the delay until December 31 after the rule was released.

Hospital Readmissions Reduction Program

CMS finalized refinements to the pneumonia readmission measure to expand the measure cohort as part of the HRRP.

Many hospitals are familiar with the Yale University mortality and readmission methodologies and cohorts that CMS uses in its HVBP Program.

In the past, CMS defined the pneumonia cohort for mortality and readmission measurement to include various pneumonia codes as a principal diagnosis, excluding cases where sepsis, aspiration pneumonia, or respiratory failure served as the principal diagnosis.

CMS amended the cohorts to include patients with a principal discharge diagnosis of:

Pneumonia
Aspiration pneumonia
Sepsis with a secondary diagnosis of pneumonia present on admission

"CMS listened to provider comments referable to their proposal to change the pneumonia readmissions measure and scaled it back significantly to a more reasonable cohort," says James S. Kennedy, MD, CCS, CDIP, president of CDIMD - Physician Champions in Smyrna, Tennessee.

CMS proposed to add patients with a principal diagnosis of sepsis, severe sepsis, or acute respiratory failure with pneumonia as a secondary diagnosis and to add all cases with aspiration pneumonia as a principal diagnosis to the cohort, Kennedy says. CMS opted not to add cases with acute respiratory failure as the principal diagnosis and excluded sepsis cases if there is a secondary diagnosis of severe sepsis.

"As such, hospitals must be diligent to identify pneumonia patients who had sepsis on admission to determine if they meet ICD-10-CM's administrative definition of severe sepsis (acute organ dysfunction, not failure, due to sepsis) which may differ from those of the Surviving Sepsis campaign," Kennedy says.

However, CMS chose not to include patients with a principal discharge diagnosis of respiratory failure or sepsis if they are coded as having severe sepsis.

"It is interesting to note that the reason CMS did not include these other populations is because, on further analysis, they found that the populations coded with respiratory failure and sepsis actually had lower risk-adjusted mortality, which was an unexpected finding attributed to 'coding patterns,' " Newell says.

The resulting change in the pneumonia cohort also impacts seven of the risk-adjustment variables used in the risk-adjustment algorithm. "These are important to capture to accurately reflect risk-adjusted mortality performance," Newell says.

The revised pneumonia cohort is expected to increase the number of discharges included in the measure by 50%, and to increase the number of hospitals (which will now meet the minimum case threshold of 25 eligible discharges). CMS expects the revised definition to impact the excess readmission rates for some hospitals.

Analyze and address performance improvement opportunities for all populations included in the HRRP, Newell says.

"The actual number of observed readmissions does not impact payment under the HRRP; it is the predicted and expected performance which determines if the hospital has excess readmissions," she adds.

The quality of documentation and coded data has a direct impact on measure performance and associated financial penalties.

Given modifications to the pneumonia cohort, revisit the definitions used to capture "severe sepsis," which disqualifies discharges from inclusion in the measure, Newell advises.

Proactive hospitals are encouraged to study and address data quality opportunities for the coronary artery bypass graft measure. Performance for today's discharges will determine the financial impact for this measure beginning in FY 2017.

Hospital Inpatient Quality Reporting Program

CMS added three new claims-based measures and one structural measure for the FY 2018 payment determination and subsequent years; it also added three new claims-based measures for the FY 2019 payment determination.

The seven new measures are:

Hospital Survey on Patient Safety Culture
Kidney/UTI Clinical Episode-Based Payment
Cellulitis Clinical Episode-Based Payment
Gastrointestinal (GI) Hemorrhage Clinical Episode-Based Payment
Hospital-Level, Risk-Standardized Payment Associated With an Episode-of-Care for Primary Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA)
Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
Excess Days in Acute Care after Hospitalization for Heart Failure

All of the new measures are claims based except for Hospital Survey on Patient Safety Culture.

Three of the new clinical episode-based measures—kidney/UTI, cellulitis, and GI hemorrhage—will impact payment in FY 2019, Newell says.

CMS finalized removal of six topped-out measures:

STK-01, Venous Thromboembolism (VTE) Prophylaxis for Patients With Ischemic or Hemorrhagic Stroke
STK-06, Discharged on Statin Medication
STK-08, Stroke Education
VTE-1, Venous Thromboembolism Prophylaxis
VTE-2, Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3, Venous Thromboembolism Patients With Anticoagulation Overlap Therapy

CMS will retain measures STK-06, STK-08, VTE-1, VTE-2, and VTE-3 as electronic clinical quality measures for the FY 2018 payment determination and subsequent years.

The agency did acknowledge that "the intent of a measure is the same whether it is reported via chart-abstraction or electronically, the submission modes are not the same and measure rates may be different."

It also removed measures:

IMM-1, Pneumococcal Immunization
SCIP-Inf-4, Cardiac Surgery Patients With Controlled Postoperative Blood Glucose

Hospital Value-Based Purchasing Program

The HVBP Program adjusts payments to hospitals for inpatient services based on their performance on an announced set of measures.

CMS finalized removal of IMM-2 (Influenza Immunization) because it determined the measure was topped out.

CMS is also removing AMI-7a (Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival) because few hospitals have the minimum number of cases necessary to report the measure.

Because CMS finalized the removal of these two measures from the Clinical Care-Process subdomain, the agency finalized its proposal to move PC-01 (Elective Delivery) from Clinical Care-Process to the Safety domain. CMS will eliminate the Critical Care-Process subdomain and rename the Clinical Care-Outcomes subdomain as simply the Clinical Care domain.

The agency also adopted a new measure for FY 2018 reporting: 3-Item Care Transition Measure (CTM-3).

The Hospital-Associated Infection measures will expand the population in FY 2019. The Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) measures will include selected ward (non-ICU) locations.

CMS defines selected ward (non-ICU) locations as adult or pediatric medical, surgical, and medical/surgical wards.

CMS also finalized the addition of Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021.

Analyze and address performance improvement opportunities for associated new and/or modified measures, Newell says.

"For claims-based measures, it is important to address documentation and coding vulnerabilities that impact the population included in the measure, referred to as the 'cohort,' as well as the risk-adjustment variables which impact the mortality, complication, and efficiency measures," she adds.

Revisit the definitions used to capture "severe sepsis," which disqualifies discharges from inclusion in the pneumonia measure, Newell says.

Hospitals and CDI departments should also analyze and address data quality opportunities to improve Patient Safety Indicator (PSI) 90 measure performance under Agency for Healthcare Research and Quality (AHRQ) QI version 4.5a, which will be used in FY 2017.

AHRQ has rolled out more updated PSI versions that have not been adopted by CMS. "These updated version measure specifications significantly impact which discharges are included in each PSI, as well as how discharges are risk adjusted," Newell says. "Hospitals interested in integrating clinical and financial performance pertinent to CMS quality programs need to make sure they are using the correct version of the measure specifications."

Hospital-Acquired Conditions Reduction Program

CMS finalized the 24-month period from July 1, 2013, through June 30, 2015, as the time frame for Domain 1 measure (AHRQ PSI-90 Composite measure).

CMS decreased the Domain 1 weight from 25% to 15% and increased the Domain 2 weight from 75% to 85% for FY 2017.

CMS also finalized an expansion of data for CLABSI and CAUTI measures. The agency will include data from pediatric and adult medical ward, surgical ward, and medical/surgical ward locations, in addition to data from adult and pediatric ICU locations for the CLABSI and CAUTI measures, beginning in FY 2018.

As part of the discussion of the HACRP, CMS acknowledged comments about quality measures included in both the HVBP Program and the HACRP.

CMS noted that the overlapping measures "cover topics of critical importance to quality improvement in the inpatient hospital setting and to patient safety."

The agency also stated that the two programs have different purposes and policy goals.

CMS noted that the National Quality Forum (NQF) has not yet completed maintenance review of the PSI 90 measure.

"CMS clarified in the final rule that PSI 90 has not lost NQF endorsement, which is in fact not required for measure adoption into the HVBP [Program]," Newell says.

The NQF is considering expanding this measure from eight PSIs to 11 PSIs. The prior version of PSI 90 remains adopted. CMS will provide notification of any future refinements to this measure upon completion of NQF maintenance review.

"CDI departments should analyze and address data quality opportunities to improve PSI 90 measure performance under AHRQ QI version 4.5a," Newell says.

Newell also encourages CDI programs to assess performance for the three PSIs targeted for potential inclusion in the CMS PSI 90 measure.

The final rule was published in the Federal Register August 17.

Editor’s note: This article was originally published in the September issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com

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Dive into root operations Revision, Replacement, and Removal

September 8, 2015, 9:00 pm

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A patient with congenital hydrocephalus with a ventriculoperitoneal shunt is admitted due to shunt failure. The surgeon removes and replaces the distal end of the shunt. Which ICD-10-PCS root operation should coders use to report the procedure?

When determining the root operation, coders first need to determine the intent of the procedure, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association (AHA) in Chicago. A ventriculoperitoneal shunt drains extra fluid form the brain into the peritoneal cavity, where the fluid is absorbed.

The shunt has three basic parts:

Ventricular catheter
Shunt valve
Distal catheter

The surgeon inserts the ventricular catheter into the fluid part of the brain. Fluid drains from the catheter into the valve. The valve controls the rate of flow into the distal catheter.

The shunt itself is not classified as a drainage device. It is initially placed to reroute the contents of the cerebral ventricle to another location. Coders will use the root operation Bypass (altering the route of passage of the contents of a tubular body part) for the initial placement of the shunt, Young-Charles says.

They will use “synthetic substance” as the device character for the initial procedure.

When the patient returns because the shunt is malfunctioning, coders will use root operation Revision (correcting, to the extent possible, a malfunctioning or displaced device). The codes for the revision would be:

0WWG4JZ, Revision of synthetic substitute in peritoneal cavity, percutaneous endoscopic approach
0JWS0JZ, Revision of synthetic substitute in head and neck subcutaneous tissue and fascia, open approach

For more information see Coding Clinic, Second Quarter 2015, pp. 9?10.

Always require a device

Six ICD-10-PCS root operations always require a device, says Anita Rapier, RHIT, CCS, senior coding consultant for AHA.

One of those is Revision (fourth character W). The others are:

Change, taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane
Insertion, putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
Removal, taking out or off a device from a body part
Replacement, putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
Supplement, putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part

ICD-10-PCS includes four basic categories of device values:

Grafts and prostheses
Implants
Simple or mechanical appliances
Electronic appliances

Devices in the Medical and Surgical section include:

Biological or synthetic material that takes the place of all or a portion of a body
Biological or synthetic material that assists or prevents a physiologic function
Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part and has the potential to be removed
Mechanical or electrical appliances used to assist, monitor, take the place of, or prevent a physiologic function

Examples of medical and surgical devices include autografts, tissue substitutes, and radioactive elements.

Revision

Revision can include correcting a malfunctioning device by taking out and/or putting in part of the device, Rapier says.

For example, a physician may need to adjust the position of a patient’s pacemaker lead. Coders would report that procedure as a Revision.

Coders will also report Revision if a portion or component of an orthopedic implant needs to be adjusted.

Revision usually involves a component of the device and the procedure can be completed without removing the entire device, Rapier says.

Coders should never assign Z (no device) as the qualifier for a Revision, Rapier says.

Other Revision procedures include:

Open revision of right hip replacement, involving recementing of a prosthesis
Revision of a vascular access device reservoir placement in the chest wall, causing patient discomfort

Coders needs to be very careful because physician documentation can be misleading, Rapier says. The physician may use the term revision for a procedure that does not meet the ICD-10-PCS definition of Revision. Coders need to select the root operation that best describes the procedure the physician actually performed, not what the physician called it. For more information, review ICD-10-PCS guideline A11.

Revision of femoropopliteal bypass graft

A patient with a femoropopliteal bypass graft comes in because the graft has become occluded. The physician performs an open thrombectomy with trimming and reanastomosis of the existing graft.

Coders would report 04WY07Z (Revision of autologous tissue substitute in lower artery, open approach).

“Because the work was done on an existing graft, you would use root operation Revision,” Rapier says.

Replacement

Coders will use ICD-10-PCS root operation Replacement when the physician removes a body part and replaces it with a device. The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure Rapier says.

When the physician removes a device from a previous surgery, coders will also report root operation Replacement.

Examples of Replacement procedures include:

Excision of abdominal aorta with GORE-TEX® graft replacement
Tendon graft to right ankle using cadaver graft
Mitral valve replacement using porcine valve

Consider a patient with an aortic aneurysm. The surgeon performs an open repair and removes the weak spot in the aorta. The surgeon then places a graft to take the place of the removed section of the aorta.

“If the aneurysm is repaired by cutting it out and putting in a graft, use root operation Replacement,” Rapier says.

Removal

In some cases a physician takes out a device and replaces it with a similar device. These procedures are coded using root operation Removal. Removal only involves removing a device.

If the physician takes out a device and puts in the new one using an external approach, use root operation Change instead of Removal, Rapier says. For example, if a physician switches out a drainage device, report Change.

Coders will report two codes for a Removal procedure. Report one code for the Removal, and a second code for putting in the new device using the root operation performed, Rapier says.

Removal encompasses a broader range of devices than those found under root operation Insertion, Rapier says.

Remember to use a general body part value when the table does not include the specific body part, she adds.

Total knee revision

A patient with painful right total knee arthroplasty presents for revision. The physician removes the old components and inserts and cements new tibial and femoral components. Coders will report two codes for this procedure: one for the removal of the old components and one for the replacement with new components, Rapier says.

According to Coding Clinic, Second Quarter 2015, pp. 18?19, coders would report:

0SRC0J9, Replacement of right knee joint with synthetic substitute, cemented, open approach
0SPC0JZ, Removal of synthetic substitute from right knee joint, open approach

Although the physician documented revision in the operative note, ICD?10?PCS defines Revision as correcting the position or function of a previously placed device without taking out and putting a whole new device in its place, Rapier says.

A complete redo of a procedure is coded to the root operation performed.

In this example, both Removal and Replacement were carried out, so coders would report those procedures, Rapier says.

Email your questions to editor Steven Andrews at sandrews@hcpro.com.

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New on JustCoding Platinum!

September 8, 2015, 9:00 pm

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Sample chapter in Special Reports and News: Root Operations Involving Cutting or Separation Only

This sample chapter from JustCoding's ICD-10-PCS Medical and Surgical Root Operations Training Handbook covers root operations involving cutting or separation only.

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Reporting ICD-10-CM seventh characters and sequelae

September 8, 2015, 9:09 pm

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By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer

You certainly have already noticed that ICD-10-CM codes are up to two characters longer than their ICD-9-CM counterparts. These extra characters give us the opportunity to provide even more specific details about the patient’s condition and communicate the medical necessity for treatments provided. The seventh characters, in particular, share different pieces of information depending on which chapter the code is from.

Seventh characters

When an ICD-10-CM code requires a seventh character, it is mandatory and may change depending upon which part of the treatment process this encounter sits. Different subsections use this position – the seventh character – to add different types of information. Most often, these choices will be listed at the top of the code category to be used for all codes within that category. With this in mind, you must always check the top of the code category for this information.

For example, within the Diseases of Musculoskeletal System and Connective Tissue chapter, the appropriate seventh character is to be added to each code:

A, initial encounter for fracture
D, subsequent encounter for fracture with routine healing
G, subsequent encounter for fracture with delayed healing
K, subsequent encounter for fracture with nonunion
P, subsequent encounter for fracture with malunion
S, sequela

Within the Pregnancy, Childbirth, and the Puerperium chapter, the appropriate seventh character is to be added to the code to specify which fetus is suffering the complication described:

0, not applicable or unspecified
1, fetus one
2, fetus two
3, fetus three
4, fetus four
5, fetus five
9, other fetus

Seventh character 0 is used to identify a single gestation or when the documentation supports that it is not possible for the physician to determine which fetus is affected by the complication.

Within the Injury, Poisoning, and Certain Other Consequences of External Causes chapter, the appropriate seventh character is to be added to each code:

A, initial encounter
D, subsequent encounter
S, sequela

The choice for this seventh character is based on the point in time of the treatment plan.

An initial encounter reports the patient is receiving active and continuing treatment. A subsequent encounter reports the provision of routine care during the healing and/or recovery phase. Remember, aftercare (Z) codes should not be used when the seventh character is providing this detail.

Sequela is for use when a complication or manifestation is being treated. When the patient has come to see this healthcare professional for the treatment of a sequela(also known as a late effect), you must code the particular problem as a sequela only when one of these situations is documented:

Scarring
Nonunion of a fracture
Malunion of a fracture
When the connection is speci?cally documented by the physician or healthcare professional confirming the new condition as a sequela of a previous condition

Coding a sequela will require at least two codes, in the following order:

The sequela condition—the condition that resulted and that is being treated
The sequela or original condition code with seventh character S

When available, the seventh character S is used to report a condition that has directly resulted from another condition. A scar that has formed as an after effect of a burn, laceration, wound, or other injury is a perfect example of a sequela.

When reporting a code with the seventh character S, you must use both the original injury code from which the sequela came, and the code for the sequela condition itself. The S is added to the injury code only, not the sequela code. This is your way, as the coder, to explain the injury that was responsible for the resulting condition (the sequela). The sequela condition code is sequenced first, followed by the injury code with the seventh character S.

A condition considered to be a late effect or sequela of an injury must be documented as such. Sequelae of external cause codes are used with a code reporting a sequela of a previous (not current) injury. This is indicated using a seventh character of S for sequela with both the injury code and the external cause code.

For example:

Rose Freeda, a 33-year-old female, comes to see Dr. Waterson for treatment of adherent scars on the back of her hand. Rose is a chef at a popular local restaurant and suffered third-degree burns on her left hand last year when she grabbed a saucepan and the gravy splashed over onto her hand. Dr. Waterson evaluates Rose’s scars and proceeds to plan out a series of plastic surgeries.

Coders should report:

L90.5, scar conditions and fibrosis of skin (adherent scar)
T23.362S, burn of third degree of back of left hand, sequela
X10.1XXS, contact with hot food, sequela
Y99.0, civilian activity done for income or pay

Sequelae of cerebrovascular disease
When the physician identi?es a condition, such as a neurologic deficit, as a late effect of cerebrovascular disease, a cardiovascular accident, or other diagnosis originally reported with a code from the I60-I67 range, report this sequela using a code from category I69, Sequelae of cerebrovascular disease, to connect the current problem (the late effect) with the original condition.

Sequelae of complications of pregnancy, childbirth, and the puerperium
Similar to the codes in category I69 for reporting the sequela of cardiovascular disease, there is a dedicated code for reporting sequela of a complication with a pregnancy, the birth of the child, and/or a complication of the puerperium.

When that complication creates a condition that requires treatment or services later on, after the postpartum period (within six weeks after delivery), and the condition is documented as a late effect of a pregnancy complication, you will use code O94 (sequelae of complication of pregnancy, childbirth, and the puerperium), sequencing it after the code to report the complication or condition.

See the following sections for references in the ICD-10-CM Manual:Section 1. A.5. 7^th Characters; Section 1. B. 10. Sequelae (Late Effects); Section 1. C. Chapter 19: Injury, poisoning, and certain other consequences of external causes, subsection a. Application of 7^th Characters in Chapter 19; Section 1. C. Chapter 20: External Causes of Morbidity, subsection i. Sequelae (Late Effects) of External Cause Guidelines; Section 1. C. Chapter 9: Diseases of Circulatory System, subsection d. Sequelae of Cerebrovascular Disease; and Section 1. C. Chapter 15: Pregnancy, Childbirth, and the Puerperium, subsection p. Code O94 Sequelae of complication of pregnancy, childbirth, and the puerperium.

Editor’s note: Safian, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.

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ICD-10 Trainer blog

September 22, 2015, 9:00 pm

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Free quiz: ICD-10-CM codes for congenital malformations and deformations of the musculoskeletal system

September 22, 2015, 9:00 pm

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Test your knowledge with this week’s free quiz, which focuses on ICD-10-CM codes for congenital malformations and deformations of the musculoskeletal system. (View)

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Mini-poll: Does your facility offer retention bonuses to coders related to ICD-10?

September 22, 2015, 9:00 pm

≫ Next: Trivia question: ICD-10-CM code for Legionnaires' disease

≪ Previous: Free quiz: ICD-10-CM codes for congenital malformations and deformations of the musculoskeletal system

Does your facility offer retention bonuses to coders related to ICD-10?

Yes, we will receive bonuses in full after implementation
Yes, we will receive bonuses in stages after implementation
Yes, we have already started receiving bonuses
No, we will not receive any bonus for staying after implementation

Vote here

Last week’s mini-poll

What kind of testing has your organization done for ICD-10?

End-to-end testing with a group of payers: 17%
End-to-end testing with all payers: 17%
We aren't doing any testing: 11%
I don't know: 44%
Limited testing with most payers: 11%

Thank you to the readers who participated in last week’s mini-poll!

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Trivia question: ICD-10-CM code for Legionnaires' disease

September 22, 2015, 9:00 pm

≫ Next: Product of the week: How to Educate Surgeons on ICD-10-PCS Documentation Requirements live webcast

≪ Previous: Mini-poll: Does your facility offer retention bonuses to coders related to ICD-10?

What is the correct ICD-10-CM code for Legionnaires’ disease?

a. A48.0

b. A48.1

c. A48.2

d. A48.3

Know the answer and want to be featured in the next issue of JustCoding News: Inpatient? Contact editor Steven Andrews at sandrews@hcpro.com.

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Product of the week: How to Educate Surgeons on ICD-10-PCS Documentation Requirements live webcast

September 22, 2015, 9:00 pm

≫ Next: Q&A: Preparing for ICD-10-PCS

≪ Previous: Trivia question: ICD-10-CM code for Legionnaires' disease

Even though ICD-10 starts in October, it’s not too late to get your surgeons up to speed!

Join us at 1 p.m. (Eastern) Tuesday, October 6, for the live 90-minute webcast, How to Educate Surgeons on ICD-10-PCS Documentation Requirements. During the program, Cheree A. Lueck, RN, BSN, and Gwen S. Regenwether, BSN, RN, will outline their ICD-10-PCS surgical education program at Denver Health and Hospital Authority. They will help you pinpoint areas of vulnerability and educational opportunities, describe how ICD-10 affects facility cash flow, and provide tools to get you started.

For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace. JustCoding Platinum members save 20% every day! Upgrade now!

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Q&A: Preparing for ICD-10-PCS

September 22, 2015, 9:00 pm

≫ Next: Healthcare News: CMS guidance clarifies instructions for reporting services spanning October 1

≪ Previous: Product of the week: How to Educate Surgeons on ICD-10-PCS Documentation Requirements live webcast

Q: How can our team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes? Should we consider hiring additional staff or staff with a surgical background?

A: The shift to ICD-10 will affect coding and clinical documentation improvement (CDI) productivity, primarily due to the technical features of PCS. Using surgical templates for high-volume procedures can make the transition to PCS easier. These templates could ask the surgeon to identify devices, grafts, and other qualifying information [that CDI and coders need to document to the highest specificity]. For example, was the stent bare metal or drug-eluting? Or was cement used for the arthroplasty?

I do not think we need surgical experience to help us with the PCS coding, as knowledge of anatomy and physiology should suffice. I have found that the extremely granular requirements of PCS coding can make proper MS-DRG assignment challenging in certain situations. This factor will impact CDI and coding DRG-match efforts.

I think the most pertinent value and mission for CDI professionals is accurate documentation of diagnoses, but we can selectively query for some PCS procedures.

Editor’s note: Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of Regional Clinical Documentation & Coding Integrity at Sutter West Bay in San Francisco, answered this question on the ACDIS website. Contact him at evanspx@sutterhealth.org.

Need expert coding advice? Submit your question to editor Steven Andrews at sandrews@hcpro.com and we’ll do our best to get an answer for you.

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Healthcare News: CMS guidance clarifies instructions for reporting services spanning October 1

September 22, 2015, 9:00 pm

≫ Next: ICD-10-PCS queries will vary by specialty

≪ Previous: Q&A: Preparing for ICD-10-PCS

Providers need to report all services from October 1 forward with ICD-10 codes, but many will likely face scenarios with patients whose dates of service begin prior to October 1 and end after implementation. CMS has released special guidance to clarify how those instances would be billed with each bill type in MLN Matters^® SE1325.

On a Type of Bill (TOB) 12X for reporting inpatient Part B hospital services, CMS requires providers to split claims so that all ICD-9-CM codes remain on one claim with dates of service through September 30. All claims with dates of service beginning October 1 or later are required to be reported with ICD-10 codes. Providers should use the “from” date to determine the dates of service, not the “through” date.

For TOB 11X with inpatient hospital services, if the claim has a discharge and/or through date on or after October 1, the entire claim should be reported with ICD-10 codes.

CMS has included example bills for ED and observation services in MLN Matters SE1325 and recommends providers check with individual payers to determine how they will handle claims that split the implementation date.

For more information, CMS has also released MLN Matters SE1408 with additional guidance.

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ICD-10-PCS queries will vary by specialty

September 22, 2015, 9:00 pm

≫ Next: Identify opportunities from audits

≪ Previous: Healthcare News: CMS guidance clarifies instructions for reporting services spanning October 1

ICD-10-PCS queries will vary by specialty

Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.

Physicians generally don't think in-depth about their operative reports, says John C. Alexander Jr., MD, MBA, a cardiac and thoracic surgeon and member of the Huff DRG Review Services ICD-10 Physician Task Force. Before ICD-10-PCS, they didn't really need to think about who was going to read the operative report.

In fact, the majority of operative reports were not read, he says. "The referring physician wants to know that you put in an aortic valve and two bypass grafts and that's it," Alexander says.

Surgeons have developed their own way of generating operative notes that serve their purposes, he adds. Operative notes across a health system generally have some degree of consistency, but when operative notes are compared across systems, you find a large degree of variability, Alexander says.

The goal of ICD-10 PCS is to structure a code that will invariably define an operative procedure across health systems, which then becomes the center of quality and financial assessment. However, the source document from which it is constructed is anything but consistent, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, vice president of Huff DRG Review Services. Fee is also a board member of the Association of Clinical Documentation Improvement Specialists.

Coders might think that one operative report is much like another, Alexander says. "When you start to read them, you realize they aren't."

"The PCS portion of ICD-10 is going to be problematic," Alexander says. The language that surgeons use in operative notes is "local" and coders might struggle to code what is meant unless both coders and surgeons understand what needs to be done to get it right.

Coders will need to talk directly with their surgeons about what is meant by their dictations, Alexander says. Surgeons are unlikely alter their clinical descriptions to make this uniform for coders.

"I am always surprised to read op notes that the surgeons are completely satisfied with, but that make no sense to the coding community because of local customary language in the dictation," Alexander says. "I do not think that admonitions to the surgeons to be concise and complete will accomplish much unless both coders and surgeons understand the objective and the rules of coding."

The only way coders are going to be able to make sense of an operative report is to develop a relationship with the surgeons, Alexander says. "The coding community is going to have to have a relationship with the surgeons where they can say, here's what we need in that operative note and develop a strategy at the local level to get that information."

Specialty specific

The number and types of queries will depend largely on the specialty, as well as the individual surgeon's documentation.

For example, most orthopedic procedures are performed on an outpatient basis, says George W. Wood II, MD, professor of orthopedic surgery at the University of Tennessee Center for Health Sciences in Memphis and a member of the Huff DRG Review ICD-10 Physician Services team. Even total hip and knee replacements are now done on outpatients, although they remain primarily inpatient procedures.

Coders will continue to report those outpatient services with CPT^® codes. However, inpatient orthopedic surgeries could present a significant challenge because they are often very complex and involved, Wood says.

Orthopedic surgeons usually dictate a note so it can be checked later to determine the approach, implant, and any specific graft that was used because these implants may require revision or removal many years later. Unfortunately, this detail may or may not be enough for ICD-10-PCS coding, Wood says.

Devices may also present problems for inpatient orthopedic procedures. Surgeons often refer to a device by manufacturer name, Wood says. The coder may or may not know what type of device that is. For example, a surgeon performs a hip replacement. The ICD-10-PCS table provides the following choices for the device:

1, synthetic substitute, metal
2, synthetic substitute, metal on polyethylene
3, synthetic substitute, ceramic
4, synthetic substitute, ceramic on polyethylene
J, synthetic substitute

If the surgeon documents DePuy Elite Plus Ogee Cup, the coder may not know the surgeon used a cemented ultra-high molecular weight polyethylene implant.

"As a result, the coder may have to Google the device," Wood says. "Sometimes, that doesn't even help because a lot of the devices have multiple parts."

Coders will likely see a higher volume of cardiac procedures than orthopedic ones because many are performed on an inpatient basis. Many of these procedures, such as coronary artery bypass grafts (CABG) and Maze procedures will present coders with specific challenges, Alexander says.

Mitral valve repair procedures are going to be coded using root operation Supplement, which will not fit with the verbiage used by surgeons, he adds.

"I think each institution will have different issues once PCS coding begins because of local language habits," Alexander says.

Exchange information

The only way to make any sense of the procedures and documentation is for coders and physicians to develop a good working relationship with each other, Alexander says.

Too often the relationship is adversarial, Alexander says. "Interestingly I think this adversarial relationship is created because of the rules of the road for coders, i.e., no assumptions and if it is not expressly stated it cannot be coded."

Once the surgeons really understand the query process, they tolerate it much better, he adds. "When you are asked questions that you think are obvious, you lose trust in a coder, which breeds animosity."

The best way to get everyone on the same page is to ask the surgeons to explain the procedures to the coders. That way, coders can learn not only what the procedure itself is, but also how their surgeons perform it, Alexander says.

At the same time, coders and CDI specialists need to communicate to the surgeons why this is important. In the past, surgeons regarded coding as something that is done in the basement of the hospital by people they didn't know, and they didn't want to be bothered by coders, Alexander says.

"Unfortunately, I think that attitude is pervasive," Alexander says. "That's really got to change because coding is going to be very important. I don't know if any of the surgeons are going to take it seriously until they get hit in the face with denials and revenue shortfalls at the facility level."

Coders need to remember that surgeons want to do a good job, Alexander says. But they need to know the rules of the road. They also don't want to be viewed as being difficult, so coders needs to help them understand what they need to do differently.

Open to interpretation

ICD-10-PCS does not require coders to use the Alphabetic Index. Once you know the root operation, you can go straight to the table. However, you do need to consider the evolution of the disease process, Fee says.

Sometimes coders have to use the index because the original procedure is coded based on the original condition and not the evolution of the condition. That becomes a significant complexity.

Consider a subdural hematoma. The ICD-10-PCS Alphabetic Index instructs coders to report root operation Extirpation because the initial physiological process of a hematoma means it has particle matter in it, Fee says. The physician is removing both liquid and clot material.

If the physician doesn't drain the subdural hematoma until later in the process when it becomes chronic, the hematoma is more liquid. That raises the question of whether coders should use root operation Drainage, Fee says.

The ICD-10-PCS Official Guidelines for Coding and Reporting state that the coder must choose the root operation based on the intent of the procedure. Physicians are not required to specify the root operation in their documentation. The physician can document evacuation of a hematoma.

Pre-code common procedures

Organizations should already have identified the most common operations performed, Wood says. Make sure coders can code those operations well. Resolve any coding errors or lack of documentation in those procedures first.

"After that, you'll be left with a smaller number of less common operations," Wood says. For those procedures, coders can spend a little more time looking at the operative report and determining the code and any documentation shortcomings.

Coders and CDI specialists will likely send quite a few queries in the initial months after ICD-10-PCS implementation, Wood says. However, they can reduce the number of queries and improve the actual queries by doing some work now.

Look at standard descriptions of operations and try to pre-code them, Wood suggests. Then determine whether the coding accurately represents the procedure. "I really think when you look back at standardization, you should look back at the textbooks, which will explain some of these operations," he says.

One of the things coders won't find in standard operative reports is the implant. Hopefully physicians will realize that other physicians don't use the same implants they do, Wood says. If the patient goes elsewhere, the patient and new treating physician need to know what implant was inserted and may need to be removed.

Help the surgeons

Coders and CDI specialists can help surgeons prepare now, Wood says. Consider creating simple cards that list the information the surgeon needs to document. For a joint replacement, coders need to know exactly what part(s) the surgeon removed, what parts the surgeon repaired, and what parts were

put in.

Recruit your facility's physician advisor to help, Fee says. The physician advisor is typically a medical specialist, but he or she can branch out to talk to surgeons in various specialties. The physician advisor can work with the surgeons to compile a list of common devices and approaches used.

"Often it's going to be a case of clinical understanding," Fee says. "The more physicians are involved, the better, and the more specialty physicians involved, the better."

Larger facilities may also develop specialty-specific coders, Fee says. Those coders would be able to build relationships with the physicians and would develop a good understanding of what procedures are performed, how the surgeon performs it, and what, if any, devices are commonly used.

Consider adding templates to your electronic medical record to prompt surgeons to document specific information. Make sure the template allows surgeons to include individual information, Wood says.

How to query

Many coders and CDI specialists may be worried about how to get queries in front of surgeons. After all, surgeons aren't used to seeing queries for most procedures and often aren't providing daily care during the recovery period.

No single approach will work well for every surgeon, Wood cautions. Some physicians carry a cell phone everywhere, so sending a message to their phones might be the best way to query them. Other physicians would rather get a query by email.

Talk to the individual surgeons and learn their preferences. They'll be more likely to respond to a query communicated through their preferred method, Fee says. "Don't try to force a general approach. Find ways to customize how you send queries."

Editor’s note: This article was originally published in the August issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com.

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Identify opportunities from audits

September 22, 2015, 9:00 pm

≫ Next: Getting to the root of cardiovascular procedures in ICD-10-PCS

≪ Previous: ICD-10-PCS queries will vary by specialty

By Robert S. Gold, MD

It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or clinical documentation improvement (CDI) specialists about areas of misunderstanding by coding professionals or elements of patient experience that require specific documentation for proper code assignment.

These misunderstandings can be either in application of guidelines or clinical approach, but addressing them can lead to greater accuracy in the future. After all, the most important part of the patient record is the patient. (Unless you're the chief financial officer of a hospital.)

Here's some tidbits from recent reviews I've done. See if you've come across any of these in the past.

Volume overload in ESRD patients

A patient with end-stage renal disease (ESRD) comes into the ED with volume overload, identified by increased swelling of the legs and slight shortness of breath. Chest x-ray shows some pulmonary edema. Studies show a creatinine level of 9.8 that went down to 4.5, hemoglobin of 10.5 and BNP of 25,000. The patient is admitted for dialysis, gets rapid relief, and is discharged the next day.

Coders assigned the following, among other codes:

403.91, hypertensive renal disease with chronic kidney disease (CKD) stage 5 or ESRD
585.6, ESRD
514, pulmonary congestion and hypostasis
428.33, acute on chronic diastolic heart failure
285.29, anemia of other chronic disease
584.9, acute kidney injury (AKI)

Somewhere in the chart we had noticed history of congestive heart failure, so the CDI team member approached the PA with the evidence of a BNP of 25,000 and previous echo demonstrating ejection fraction of 65%. The CDI specialists asked whether these two pieces met the criteria needed for acute on chronic diastolic (heart failure with preserved ejection fraction) heart failure.

Other conversations included that the creatinine dropped from 9.8 to 4.5, a greater than 0.3 drop and certainly a 50% improvement in renal function, so obviously AKI must have existed.

The patient's hemoglobin was only 10.5, so it was probably anemia of the patient's chronic disease.

And the pulmonary edema documented in the ED physician's note, having been seen on the chest x-ray and copied and pasted on every progress note, must be 514.

Wrong!

You don't jump at numbers. You look at the patient and the evidence and use clinical thinking.

People with ESRD and who are on dialysis, people who don't have renal function, can't go into acute renal failure. There's nothing left to fail. The change in creatinine level was caused by dialysis removing nitrogenous products from the bloodstream. That's all. Renal function didn't change at all.

People with ESRD constantly have higher-than-normal levels of fluid in the bloodstream. Why? They can't get rid of the fluid in the urine—they're not making urine. So the venous circulation fills up with fluid.

When the right atrium gets stretched by volumes of fluid in the right side of the circulation, it stretches every day. And when the atria of the heart stretch, BNP is produced so that the body can try to urinate the extra fluid. That's the normal mechanism in everybody.

But the kidneys don't work, so the stretch stays there and it gets worse. The BNP level rises and rises. These people walk around with BNP levels in the thousands, ten thousands, hundred thousands every day, and they're not in acute congestive heart failure at all. It's their new baseline. Get over it. Check their last 20 BNP levels; it's the same high level.

Are you kidding about 514? I have ranted enough about 514. I'm tired of ranting about 514. But I'll keep on ranting about 514 until someone gets it.

Pulmonary congestion and hypostasis was invented in the early 1800s (it was called 94 at that time). It defined a finding at postmortem exam of some people who had lain without moving with minimal nutrition for extended periods of time while they died of something, whether cancer or tuberculosis or leprosy. The pathologists who performed the autopsies on these patients gave it several descriptive names, including pulmonary congestion, pulmonary edema, hypostatic pneumonia, and apoplexy of the lung. Here is an excerpt from the Manual of the International List of Causes of Death from 1909:

MANUAL OF THE INTERNATIONAL LIST OF CAUSES OF DEATH SECOND REVISION. PARIS, 1909 Cornell IV.

DISEASES OF THE RESPIRATORY SYSTEM Continued.

94. Pulmonary congestion, pulmonary apoplexy.

This title includes:

· Active congestion of lung

· Apoplexy of lung

· Collapse of lung (3m+)

· Congestion of lung

· Dropsy of lung

· Engorgement of lung

· Hyperemia of lung

· Hypostatic congestion of lung pneumonia

None of these terms were ever designed to be diagnoses. They were all ways that pathologists described the lungs in these patients. The instructions for codes, which represented signs and symptoms and findings on autopsy of patients who died, were to never assign such codes for a patient.

Here again is a quote from the instructions on coding for death certificates from that time (emphasis added):

(d) The physician may indicate the relation of the causes by words, although this is a departure from the way in which the blank was intended to be filled out. For example, "Bronchopneumonia following measles" (primary cause last) or "Measles followed by bronchopneumonia" (primary cause first). 2. If the relation of primary and secondary is not clear, prefer general diseases, and especially dangerous infective or epidemic diseases, to local diseases. 3. Prefer severe or usually fatal diseases to mild diseases. 4. Disregard ill-defined causes (Class XIY), and also indefinite and ill-defined terms (e.g., "debility," "atrophy") in Classes XI and XII that are referred, for certain ages, to Class XIY, as compared with definite causes. Neglect mere modes of death (failure of heart or respiration) and terminal symptoms or conditions (e.g., hypostatic congestion of lungs).

In our case, pulmonary edema was an x-ray finding and not a diagnosis at all. It was evidence of volume overload, which the physician diagnosed.

And finally, the anemia of chronic disease. We have no code for anemia of chronic disease. Code 285.29 is not anemia of chronic disease. We have code 285.21 for anemia of CKD (which is what the physicians were actually talking about, but somebody told them of "anemia of chronic disease"), 285.22 for anemia of neoplastic disease, and 285.29 for anemia of other chronic disease—you tell us which other chronic disease the patient has. If you can't, it's not 285.29, period.

Is it systolic or diastolic or both?

Sometimes in reviewing a medical record, we can see different physicians referring to the left ventricular status of a heart failure patient in totally different ways. Sometimes, that's the way the status is and sometimes it's a misunderstanding by the docs.

There are two basic models of left ventricular heart failure. One is referred to as heart failure with reduced ejection fraction (HFrEF) and is synonymous, according to the American College of Cardiology and the American Heart Association, with systolic heart failure. The other is referred to as heart failure with preserved ejection fraction (HFpEF) and is synonymous, for coding and continued classification purposes, with diastolic heart failure. Okay? That's it.

Now we have another conundrum. A patient can move from one to the other. Oops! Or, even more oops, a patient with one can have it resolve totally and have no chronic heart failure at all.

Here's part of the issue. Heart failure can be an acute event with no chronicity associated with it at all and heart failure can be a chronic condition with no acute decompensation ever.

A patient who has a viral myocarditis can develop dilation of the left ventricle associated with severe reduction in ejection fraction (EF) to the 12% levels with severe, debilitating symptoms and then occasionally have the dysfunction resolve totally (although most retain functional disability and do become chronic systolic failure patients).

A patient with left ventricular hypertrophy due to chronic hypertensive disease (hypertensive cardiomyopathy) or aortic valvular stenosis (valvular cardiomyopathy) with the development of severe diastolic dysfunction and chronic diastolic heart failure can evolve in time to a dilated left ventricle situation and systolic heart failure (with ongoing significant diastolic dysfunction).

A patient who has an acute myocardial infarction with an echo demonstrating dilation and severely reduced EF (acute systolic failure), which developed due to stunning of the surrounding myocardium, can have this resolve totally and be left with no dysfunction at all and never develop chronic failure.

So one has to look at the clinical circumstances. In truth, a patient with chronic heart failure due to valvular cardiomyopathy from aortic stenosis can suffer stress cardiomyopathy (Takotsubo syndrome) and develop acute systolic heart failure, which then resolves totally and the patient is left with chronic diastolic heart failure.

If you see an old echo showing an EF of 30% and a new one showing 70%, it seems as though the episode with the 30% EF was a temporary one and there is either no chronic heart failure at all or the patient had an acute systolic heart failure on top of a chronic diastolic heart failure. Don't shoot for systolic if it's only a history and the current EF is normal.

The current EF should line up to some extent with the systolic or diastolic status.

Many cardiologists recognize that an acute heart failure event with backup of fluid into the lungs is really, physiologically, acute diastolic dysfunction, whether the patient has chronic systolic failure or chronic diastolic failure or no chronic heart failure whatsoever.

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at (770) 216-9691 or rgold@DCBAInc.com.

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Getting to the root of cardiovascular procedures in ICD-10-PCS

September 22, 2015, 9:00 pm

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By Cindy Basham, MHA, MSCCS, BSN, CCS, CPC

ICD-10-PCS is a complex system that requires a better understanding of anatomy and physiology and surgical procedure technique compared to ICD-9-CM, Volume 3. This requirement is one of the reasons why many experienced coders may shy away from learning the fundamentals of ICD-10-PCS coding.

In order to master this complex coding system, coders need to build their foundation of knowledge by having a deep understanding of root operations.

The ICD-10-PCS coding guidelines direct the coder to understand the objective of the procedure, which will assist in the selection of the correct root operation. The guidelines further state “it is not the responsibility of the physician to alter their documentation.” Thus, the lines of communication between coders and physicians must be clear, open, and direct.

Cardiovascular procedure coding is complex, requiring extensive knowledge of anatomy as well as the objective of the procedure. Let’s begin at the guidelines specific for cardiovascular procedure coding, then discuss the root operations (objective) that are common with cardiovascular procedures.

Unique to the ICD-10-PCS coding system is the development of procedure guidelines. The following are guidelines specific to cardiovascular procedure coding:

ICD-10-PCS guideline B3.6a: Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier (seventh character) specifies the body part bypassed to. This guidelines applies to all bypass procedures except the coronary arteries.

Example: Bypass from femoral artery to the popliteal artery. The femoral artery would be identified with the body part character (four) and the popliteal artery would be identified with the qualifier character (seventh).

ICD-10-PCS guideline B3.6b: Coronary arteries are classified by the number of distinct sites treated, rather than the number of coronary arteries or anatomic name of the coronary artery. Coronary artery bypass procedures are coded differently than other bypass procedures such as those mentioned in guideline B3.6a. The body part (fourth) character identifies the number of coronary artery sites bypassed to and the qualifier (seventh) character identifies the vessel bypassed from.

Example: Aortocoronary artery bypass of one site on the left anterior descending artery. The body part (fourth) character specifies one coronary artery site and the qualifier (seventh) character specifies the aorta as the vessel bypassed from.

ICD-10-PCS guideline B3.6c: If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aortocoronary artery bypass and internal mammary artery bypass are coded separately. This is due to the different qualifier seventh character.

ICD-10-PCS guideline B3.9: If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Aortocoronary artery bypass using the greater saphenous vein as the graft. The graft would be captured with an additional procedure code with the root operation of Excision.

ICD-10-PCS guideline B4.4: The coronary arteries are classified as a single body part that is further specified by the number of sites treated and not by the name of the coronary artery or number of arteries. Separate body part values (fourth character) are used to identify the number of sites are treated when the same procedure is performed on multiple sites in the coronary arteries.

Example: Angioplasty with stent placement of one site in the proximal region of the left anterior descending artery and an angioplasty without a stent placed to one site of the distal region of the left anterior descending artery. There would be two different codes assigned. Both codes would identify the root operation Dilation, but one procedure included an intraluminal device (device character) and the other procedure did not utilize a device.

ICD-10-PCS has 31 different root operations. While many root operations are applicable to cardiovascular procedure coding; the following root operations are most common to cardiovascular procedures:

Bypass: Most commonly used for coronary artery bypass surgeries (CABG).
Destruction: Used mostly for cardiac ablation procedures to treat cardiac arrhythmias.
Map: Used mostly during electrophysiology studies (EPS) of the electrical conduction pathway of the heart.
Dilation: Used to identify whether the procedure objective is to dilate or open the lumen of a vessel such as percutaneous transluminal coronary angioplasty (PTCA).
Insertion: This root operation involves the use of a device. The most common cardiovascular procedures include pacemakers, cardioverter-defibrillators, and cardiac resynchronization devices. Similar to ICD-9-CM, ICD-10-PCS requires a code for the placement of the generator as well as insertion of the electrodes (leads).
Removal: This root operation objective is to remove the device. For example, to correctly identify a pulse generator change of a pacemaker, the coder would assign a procedure code to identify the removal of the pacemaker generator and a separate code to identify the insertion of the pacemaker generator.
Measurement: This root operation is the choice when coding for cardiac catheterization procedures; right, left, or right and left. The additional procedures done during a cardiac catheterization such as coronary angiography and left ventriculography are coded separately from the Imaging section of ICD-10-PCS.
Replacement: Use of this root operation is necessary for valve replacement surgeries including aortic, mitral, and pulmonary valves. The device (sixth) character will identify the type of graft such as autologous tissue substitute and non-autologous tissue substitute.
Performance: For cardiovascular procedures such as CABGs, this root operation captures the use of the cardiopulmonary bypass.
Supplement: Often this root operation is difficult to apply but in the cardiovascular valve procedures such as a mitral valve annuloplasty, this root operation captures the objective to supplement.

This only summarizes the complexity of cardiovascular coding in ICD-10-PCS. However, a focused review of the tables will provide additional insight into this complex system and information required for correct procedure code assignment. Continue learning about the objective of the procedure as this will assist in selecting the correct root operation.

Finally, to complete the development of a strong cardiovascular coding foundation, continue to discuss and work with the cardiothoracic surgeons about documentation requirements and to learn more about cardiovascular procedures.

Email your questions to editor Steven Andrews at sandrews@hcpro.com.

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