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Get ready for JustCoding’s website redesign!

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The team at JustCoding is proud to announce a revamped and redesigned website launching soon. The new site will include great new features and make it easier than ever to browse our content, track your CEs, and more.

Before the new site launches, we ask all of our Basic and Platinum customers to print out their certificates for quizzes they’ve already taken. We will not be able to transfer quiz history to the new site. To get certificates for 2015 after the new site launches, you will have to retake the quizzes. Click here to access your current certificates.
 
Our new site will also require Free users to register to access the weekly free article, mini-poll, free quizzes, and other resources. Don’t worry—it’ll take less than a minute. Please click here and you’ll be all ready when the new site launches. If you are already a JustCoding Basic or Platinum subscriber, you don’t need to do anything—we’ll send you information when it’s time to access the new site!
 
New on JustCoding Platinum
Book excerpt in Special Reports and News: PEPPER reports
This excerpt from Hospital Billing from A to Z covers what PEPPER reports are and how facilities can use them.

Free quiz: ICD-10-CM codes for diseases of the oral cavity and salivary glands

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Test your knowledge with this week’s free quiz, which focuses on ICD-10-CM codes for diseases of the oral cavity and salivary glands. (View) 

Mini-poll: Does your hospital have an inpatient or outpatient CDI program?

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Does your hospital have an inpatient or outpatient clinical documentation improvement (CDI) program?

  • Yes, we have a CDI program that reviews inpatient records
  • Yes, we have a CDI program that reviews inpatient and outpatient records
  • No, we do not have a CDI program
  • Not applicable, I work in a physician office setting
  • I don’t know

Vote here

Last week’s mini-poll 

How do you plan to spend Black Friday this year

  • I won’t be doing any shopping: 60%
  • Shopping online: 21%
  • Shopping whenever I have time: 18%
  • Waking up early to get in line: 1%

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

Trivia question: ICD-10-CM code for sodoku

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What is the correct ICD-10-CM code for sodoku?
 
a. A25.0
b. A25.1
c. A25.8
d. A25.9

 

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

Product of the week: Clinical Documentation Improvement Tips to Identify Patient Safety Indicator Targets webcast

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Clinical documentation improvement (CDI) programs need to expand their focus beyond CC/MCC capture reviews. New reimbursement methods are punishing facilities that cannot prove they meet certain quality standards. That proof often lies within what is (or isn’t) documented in the medical record.
 
Join us at 1 p.m. (Eastern) Tuesday, January 19, for the 90-minute webcast. During this program, expert speakers Michelle McCormack, RN, BSN, CCDS, CRCR, and Mark LeBlanc, RN, MBA, CCDS, will discuss how traditional reviews can be expanded to include investigations into Patient Safety Indicators and how to work cohesively with their quality departments to improve the overall capture of these important statistics.

 

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!

Q&A: Can non-physicians answer queries after discharge?

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Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?
 
A: This is a difficult question to answer without knowing the policies within your organization related to discharge summaries, amending summaries, and the retention of queries.
 
We certainly can apply code assignments from any provider (physician, NP, or PA) that has been involved in the care of the patient. So, in general, the PA or NP answering these queries is acceptable, if, of course, they provided care to the patient during the encounter.
 
If you ask them to amend the discharge summary, examine your organization’s policies related to who is allowed to amend discharge summaries. For example, if the PA is not the one who wrote the discharge summary, should they be the one to add a change? I would suggest you speak to your HIM director if this is an issue.
 
Lastly, if you ask a query due to conflict between providers (for example, the PA states one diagnosis and the attending is stating a completely different diagnosis) the clarification must come from the attending physician.
 
As is almost always the case in the world of clinical documentation improvement, coding, and medicine, it is a bit complicated.
 
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.

Healthcare News: Majority of industry stakeholders find smooth transition to ICD-10, according to survey

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ICD-10 implementation has gone smoothly for approximately 80% of attendees who responded to a survey during a recent webcast from audit, tax, and advisory firm KPMG.
 
For 28.3% of the 298 respondents to the November survey, the ICD-10 transition has been smooth, while 51.4% reported a few technical issues, but overall success with the new code set since October 1.
 
Another 11.1% reported complete failure since implementation and 8.6% said serious work was needed but they are surviving the transition. Respondents included healthcare staff related to IT, finance, and the clinical side.
 
While the transition has been relatively smooth for the majority of industry stakeholders, providers will need to dedicate more attention to the quality and specificity of clinical documentation to reduce rejected medical insurance claims, said Catherine O’Leary, KPMG managing director, in a press release.
 
KPMG asked attendees which of the following was the largest challenge they faced with ICD-10 implementation:
  • Clinical documentation improvement and continuous physician education
  • Increase in denials or rejected claims
  • Reduced revenue due to coding delays or coding errors
  • System testing and information technology fixes
Approximately 42% of the respondents noted all of the issues remain a challenge at their facility, while 11.1% said none of the issues would be their largest challenge.

 

Respondents are tracking a variety of key performance indicators following implementation, with many focusing on denials and rejections (18%) and accounts receivable (11.1%). Facilities are also tracking discharged not final billed accounts (5.6%) and CC and MCC capture (4.9%). A majority of respondents (60.8%) are tracking all four of these key performance indicators. 

Adding venous thromboembolism to the CDI checklist at your facility

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By Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
 
The annual incidence of an initial venous thromboembolism (VTE) event, either a pulmonary embolus (PE) or a deep vein thrombosis (DVT), is approximately 0.1% in the United States, with the highest incidence among the elderly and a recurrence rate of about 7% at six months. At the same time, thrombotic stroke is the third leading cause of death in the United States. Virchow's triad theory suggests that VTE occurs due to three factors: 
  • Altered blood flow
  • Vascular endothelial injury
  • Alterations in the blood constituents, or hypercoagulable state

A patient with an abnormally increased tendency toward coagulation may be said to experience a hypercoagulable state. Hypercoagulable states can be further specified as primary or secondary. Primary hypercoagulable states are inherited thrombophilia conditions caused by deficiencies or defects of the physiologic anticoagulants or increased coagulation factors, according to the journal Cardiovascular Medicine (2007). The major causes of inherited thrombophilia include factor V Leiden mutation, antithrombin deficiency, protein S and protein C deficiency, and prothrombin gene mutation.

Secondary, or acquired, hypercoagulable states are a varied group of disorders with an associated elevated risk for developing thromboses. Many conditions can effect changes in the coagulation system, resulting in a hypercoagulable state. Secondary hypercoagulable state, when documented in the medical record, is a comorbidity that can increase reimbursement, impact length of stay, and reflect a higher severity of illness and risk of mortality, but it is often underdocumented and underreported.
 
Many clinicians easily recognize that patients may present a higher risk of thrombosis with evidence of a previous thrombus, recent major surgery, new trauma, malignancy, pregnancy, the use of oral contraception, antiphospholipid syndrome, or the use of a central venous catheter.
 
Patients undergoing surgery who have not received VTE prophylaxis experience a rate of DVT from 15% to 30%, and fatal PEs from 0.2% to 0.9%, according to a 2007 article in the journal Circulation. Trauma patients run almost a 60% risk of VTE. Among cancer patients, at least 50% are found to have a VTE at autopsy.
Increases in blood viscosity, fibrinogen, and factor VIII during pregnancy increase the risk of VTE in pregnant women six times higher than that of nonpregnant women. The prevalence of VTE in pregnancy is 1:600, and PE causes 9% of all deaths during pregnancy. In one study, currently available oral contraceptives increased the risk of VTE to five times that of a non-user.
 
The risk increases within four months of the start of therapy and remains unchanged, regardless of duration of use, until three months after the end of therapy.
 
However, additional conditions seen among the inpatient population also may increase the risk of developing VTE. Diabetic patients are at higher risk of thrombosis; 80% of Type 2 diabetic deaths may be attributed to thrombi. The risk of stroke and myocardial infarction is significantly higher in the diabetic population. 
 
Researchers have found modifications in the coagulation pathway in diabetic patients, including abnormal coagulation screening tests and altered clotting factor levels. Enhanced platelet aggregation and activation, along with an inhibited fibrinolytic system associated with insulin resistance, can suggest a hypercoagulable prothrombotic state that increases risk of a cardiovascular event.
 
In metabolic syndrome, in which we find obesity, chronic inflammation, and insulin resistance, we also find a hypercoagulable state associated with increased clotting factors and an inhibited fibrinolytic pathway. Elevated cholesterol levels can impact platelet aggregation and clot formation. Smoking causes damage to the endothelium, adhesion of platelets, release of growth factor, and reduced tPA production that can result in a prothrombotic state. Immobility associated with travel can triple the risk of thrombosis, particularly in obese patients. Heart failure, chronic renal failure, thyroid disease, and sepsis can also result in a prothrombotic state.
 
Documentation of secondary hypercoagulable state must, as with all secondary diagnoses, meet the definition of a secondary diagnosis, to include at least one of the following: 
  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of stay
  • Increased nursing care and/or monitoring
 
In all physician documentation, the diagnosis to the correct degree of specificity, the supporting clinical indicators, and the treatment plan must always be in alignment. 
 
While encouraging physicians to capture this comorbidity when clinically warranted, we must also emphasize that documentation of secondary hypercoagulable state is incomplete without referencing the indicators that support the diagnosis, as well as how it is being evaluated, treated, or diagnosed. 
 
Documentation of anticoagulant therapy in patients at risk for VTE should not only be associated with meeting core measures requirements, but should also be linked to the secondary hypercoagulable state and the ­underlying conditions that put the patient at risk.
 
The goal of any clinical documentation program is to paint the full clinical picture, so consider adding secondary hypercoagulable state to the paintbox. 

 

Editor's note: Brown is the director of CDI for Tanner Health System, Carrollton, Georgia. She has experience in critical care, nursing education, case management, long-term care, and, of course, CDI. She thinks the only thing better than writing for the Association for Clinical Documentation Improvement Specialists is snuggling with her cat ­Thomas. Contact Brown at catladyrn@gmail.com. Email your questions to editor Steven Andrews at sandrews@hcpro.com.

Past is present: ICD-10-CM clears some ICD-9-CM issues while others persist

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By Robert S. Gold, MD
 
I have been musing recently about things I've written for this journal over the past years. Hard to believe I've been doing monthly educational articles regarding the clinical aspects of coding since about 2002.
 
I know that a lot of my pieces had relatively universal appeal. Some had been considered outrageous and seemingly destructive, depending on the view of the reader. But time has proven they were right then, and they are still right in ICD-10. Return with us now to those thrilling days of yesteryear--the Lone Ranger rides again. 
 
SIRS
Back in 2002, I objected that the codes for "sepsis" and "septicemia" were the same codes--and they were all described as "septicemia."
 
In the article, I emphasized that sepsis was a condition that resulted when the body suffered the consequences of a localized infection mediated by chemicals that were released into the bloodstream, but that the infection was a local event. I pointed out that septicemia was an infection of the bloodstream itself--and that both could exist simultaneously, but they were different animals and needed different diagnosis codes to describe them.
 
Then, in 2003, it was finally published, after adoption of the 995.9x series of codes, that septicemia and sepsis were different (AHA's Coding Clinic, Fourth Quarter 2003, pp. 79-81) and that the new codes would identify that distinction.
 
Okay, that being somewhat resolved, I pursued the issue that SIRS plus infection is NOT sepsis in 2009. Why? Because the combination of codes for SIRS plus infection, without or with organ failure, led to a massive proliferation of coding "sepsis" cases when there was no sepsis--and often when there was no SIRS. Nothing changed in the rules or definitions.
 
I brought along some of the world's most renowned specialists in infectious disease and critical care who had supported for years (since 2001, actually) that SIRS plus infection is NOT pathognomonic of sepsis. Nothing happened.
 
Finally, with the coming of ICD-10-CM, the equivalent of 995.91 (SIRS plus infection without organ failure) disappeared. "Sepsis" is now "sepsis." You need the word "sepsis" to code "sepsis." All is right with the world, right?
 
Nope. Not a chance. Now, instead of all of the codes being "septicemia" codes, they are all "sepsis" codes--and the only "septicemia" code we have is for plague. (There's actually one for meningococcemia, which is infection of the bloodstream with the meningococcal organism.)
 
So we have no other codes for septicemia when all of the codes had been for reporting septicemia up until now. If you look up "septicemia," you get A41.9 (sepsis, unspecified organism), equivalent to the 038.9 (unspecified septicemia) of ICD-9-CM.
 
So sepsis is septicemia again--after all of our work to distinguish that the two are different. And though septicemia is defined as infection of the bloodstream, we have no codes for bloodstream infection in ICD-10-CM except catheter-related bloodstream infection (T80.211-). And infectious disease physicians are calling these "bacteremia," so there's no chance of determining what the patient has through analysis of diagnosis codes.
 
One step forward, two steps back.
 
Syncope
In November 2002, I wrote an article on syncope. Here I spoke of the myriad of conditions that could led to the symptom of passing out. (Remember, syncope means that the patient actually passed out. When we see "near syncope" written and try to code it, the encoder sees the word "syncope" and assigns that code, recognizing that "near" and "pre-" are nonessential modifiers, so the patient didn't actually have to pass out.)
 
I talked about neurogenic syncope causes and cardiogenic causes. I spoke of volume changes (hypovolemia) and autonomic nerve dysfunction and arrhythmias such as bradycardia. In ICD-9-CM, everything went to 780.2 (syncope and collapse) without additional specifics being provided by the physician and the "due to" cause of the syncope if a cause could be found.
 
Yes, there were syncopes due to lumbar puncture and complicating delivery and such. The arrhythmia codes were arrhythmia codes, and the syncope part disappeared.
 
Well, in ICD-10-CM, all of the syncopes are now R55 (syncope and collapse). Whether it was a cardiogenic or neurogenic cause or it was attributed specifically to an arrhythmia or to heat or a coughing episode (which is really neurogenic, but it has a code of its own at R05 [cough]), there's no improvement without the physician getting involved. And the doctor must identify the cause of the syncope and make the link so that the other diagnosis would be the principal diagnosis, not the syncope.
 
In this article, I noted that the term "orthostatic hypotension" was usually a symptom when provided by the physician and not a diagnosis, but was assigned 458.0 (orthostatic hypotension). That's when the patient's blood pressure drops with change in opposition from lying to sitting or standing and causes decreased blood supply to the brain, leading to the patient becoming dizzy or passing out.
 
It should be called orthostatic changes in vital signs, but the docs and nurses call it orthostatic hypotension. It's a symptom, and it's always due to something or other. In ICD-10-CM, we again have a breakdown of codes with I95.0 (idiopathic hypotension) and I95.1 (orthostatic hypotension), which is the equivalent of 458.0 and the code for the symptom complex of orthostatic changes in vital signs.
 
We also have I95.2 (orthostatic hypotension due to drugs), as often happens with patients on beta blockers; I95.3 (hypotension of hemodialysis); and I95.89 (other specified cause of orthostatic blood pressure changes).
 
But it's still not a diagnosis. We still have no better idea about the pathophysiology of the patient's syncopal episode, with or without measured hypotension. We need this from the doc. That's the conclusion I wrote in 2002:
 
Interactions between or among drugs can cause instability of the arteries and veins. The physician might have to change the patient's beta blocker dosage or switch to a non-beta-blocker drug for treatment of the patient's hypertension. A patient might have intrinsic autonomic nerve dysfunction, where the arteries and veins cannot maintain the pressures that they normally exert on the column of blood in them, or they can't respond quickly enough to changes in position. In all of these, the patient stands up and falls down. Immediate testing of pulse rate and blood pressure on position change demonstrates "orthostatic" changes.
 
Whether it's dehydration, autonomic dysfunction of diabetes, sick sinus syndrome, or aortic stenosis, the coder must recognize that most of the time the physician knows the cause of the syncope and makes some effort to document that cause. Most of the time, however, the cause of the syncope is not clear. Keep this column nearby and refer to it when you see syncope or orthostatic hypotension documented. If you see one of these causes, a clinically oriented query couldn't hurt.
 
Hypertension
I10 is the ICD-10-CM code for hypertension, whether benign or malignant. Too easy, right? I objected, as I seem to do a lot, and wrote my objections and got together with some of the premier physicians in nephrology and hypertension.
 
We agreed that malignant hypertension kills patients and we must have a code set to demonstrate this potentially lethal condition. Word got to the code gurus in the Coordination and Maintenance Committee, and we all must be ready for this change, though it doesn't exist--yet.
 
I'm sure you have all seen documentation of such things as hypertensive emergency, hypertensive urgency, and hypertensive crisis, right? Well, this is a situation where acute onset of exceptionally high blood pressure levels can cause target organ damage, such as hypertensive encephalopathy or hypertensive stroke or seizure, acute renal failure, or acute pulmonary edema.
 
Blood pressures in the range of 220/110 or higher (it can be lower in children) must be treated quickly to avoid death of the patient. Existence of this situation is called a hypertensive crisis. It's not slight elevations in blood pressure that happen when you run a half block--it's real, serious stuff.
 
If there is target organ damage, as above, it should be referred to as hypertensive emergency. If it is identified that no target organ damage has occurred, the incident was a situation of hypertensive urgency. In future updates, there will be an I16 code for hypertensive crisis that requires specificity with the fifth character to distinguish between hypertensive emergency and hypertensive urgency. They got this almost right.
 
Instructions will be there to determine if the patient's hypertensive crisis was associated with endocrine-induced hypertension or renal artery stenosis or other secondary cause of hypertension, or if it was essential hypertension. But the instructions are not there (yet) to "code also" the target organ damage that justifies coding the hypertensive emergency. Maybe one day they will be. 
 
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 orrgold@DCBAInc.com. If you have a specific procedure or condition you would like Dr. Gold to address in his column, contact Editor Steven Andrews at ­sandrews@hcpro.com. This article was originally published in the November issue of Briefings on Coding Compliance Strategies.

A holiday checklist for HIM managers

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By Dom Nicastro
 
Some say the holidays are a time for joy. Others find stress and chaos in the last six weeks of the year.
What do your coders feel as we wind down the year? It’s a good time to check their pulse if you’re an HIM manager or director—especially in light of ICD-10 implementation.
 
“Change is stressful on staffing,” says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIM best practice consultancy HIMentors, based in Westchester, Illinois. “Many organizations lost key HIM coding staff prior to the ICD-10 go-live. Recruitment and retention strategies are key to maintaining a healthy revenue cycle process.”
 
Ask yourself if you have put in place specialized retention, recruitment, or incentive plans to keep coding and CDI staff happy and productive, Grzybowski adds.
 
HIM managers and directors can add these to-do items to their closing-out-2015 laundry list. How else can you tidy up the HIM ship as the end of the year nears? Coding experts told JustCoding that HIM directors and managers should also run a gap analysis of the ICD-10 early stages.
 
Are your coders happy?
This year is as good as any to recognize your coders’ hard work. They just underwent perhaps the most significant transition in their professional careers, ending a long journey of training, preparation, uncertainty, fear, and doubt. And that’s on top of their regular workload.
 
They want to feel appreciated more than ever, says Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, vice president of training and education for Salt Lake City-based AAPC.
 
“You’ll want to reward your employees for the good work they’ve done throughout the year,” Jimenez says, “whether it’s a bonus or a personal gift from their manager. It’s good for them to know their manager took time to think of them, especially with the year they’ve had with ICD-10.”
 
Tell them you recognize the work it took on their part—the coordination, the training—to transition to ICD-10.
 
“Some people respond well to a handwritten thank-you note specific to them,” says Jimenez. “If everyone gets the same message, they may think this is one of those canned things. But if you do something unique for that individual, it goes a long way saying specifically what they did that year that you appreciated.”
 
ICD-10 has upped the stress levels significantly, Grzybowski says. Allow adequate time off—versus months of continuously mandated “overtime”—to reduce burnout. 
 
“Salaries aren’t the only reason for change,” she says, “but not having regular feedback meetings, not having good equipment/resources, and not feeling involved in decisions plays a part. Of course, money and benefits and a flexible work schedule is important.”
 
Grzybowski works with hospitals to set up incentive coding plans and tiered coding career ladders to ensure diversity of work and bonuses for not only productivity, but also quality of work. 
 
“Coders are the heart of hospital reimbursement,” she says, “and it’s critical to keep coders happy, educated, and productive members of the HIM team.”
 
ICD-10 checkpoint
Now is a good time to run an ICD-10 gap analysis, says Jimenez. Coding staffs went through a good amount of preparation for ICD-10. Revisit budgetary items. Did all your requests and expectations come to fruition?
 
“Now that we have implemented ICD-10, see if those plans are really meeting your business needs at this time,” Jimenez says.
 
Did you bring in additional staff? If not, will you need more now that you’ve got a good idea what it takes to get codes out in a typical week under ICD-10? If you’re managing an outpatient coding team, HCPCS and CPT® code changes will be important.
 
“Some HIM managers will be involved in reimbursement and billing,” Jimenez says. “They’ll have a general understanding and accounting of how codes impact revenue. Or it may be something that only the revenue cycle management team deals with. Depending on how involved with that you are, it’s important for managers to understand the (OPPS and IPPS) final rules and how it impacts facilities.”
 
HIM directors and managers can now see payments coming in from ICD-10 and recognize where the problem areas are.
 
“Everyone was preparing for doomsday,” Jimenez says, “and we’ve seen ICD-10’s not been as problematic as we were all led to believe. It didn’t live up to its hype. But it’s good to evaluate your wins and misses and quickly make up your misses.”
 
Something missing?
Grzybowski already does see some issues with ICD-10 coding in terms of data integrity, especially in physician or clinic billing.
 
Although ICD-10 codes were just implemented October 1, she agrees it’s not too early to audit and see how accurately you are assigning and capturing the correct codes.
 
Grzybowski says she’s seen a lot of missed opportunities—though they may be invisible because the codes still get paid and processed without error. However, they’re highly inaccurate due to omissions and lack of specificity in coding. This is especially true, she says, in the physician clinic area. 
 
“Ask yourself if you have a trusted coding/[clinical documentation improvement] audit partner in place who can work with you to help educate staff and physicians and get to the root cause of problems in coding workflow,” Grzybowski says.
 
Were these problems already evident in ICD-9-CM?
 
Not really, Grzybowski says, because “the specificity wasn’t there.”
 
“Now,” she adds, “you can identify, for instance, whether this was an initial treatment for a specific diagnosis, or a subsequent visit, or dealing with the sequelae by a doctor. If the physician’s office is not taking care to include the seventh character correctly, this can impact insurance coverage for injuries or rehab care, etc.”
 
Another example is using incorrect coding guidelines. A doctor orders an MRI because the patient had a dizzy spell and facial numbness. The correct diagnoses on the initial visit are the dizziness and facial numbness (symptom codes). The doctor may have ordered the MRI to rule out a stroke.
 
“However if the billing service codes ‘stroke’ as the diagnosis—as opposed to the symptoms of the dizziness and numbness—and then the MRI is negative, there could be a medical necessity denial problem,” Grzybowski says. “Symptom codes are always to be billed for outpatient care unless the diagnosis is definitive.”
 
Educate—then educate some more
It’s up to HIM directors and managers to take the lead on this through education and auditing. A doctor’s office may be the facility at the most risk compliance-wise, Grzybowski says, if they have hired a billing/coding service that is not following guidelines. 
 
“The scariest thing I hear is when coders or a billing company say, ‘We just code what the doctor tell us to or whatever is on the report that comes out of the [electronic medical record],’” Grzybowski says. “It is evident that poorly designed crosswalks are putting out inappropriate codes that do not distinguish symptoms from rule-out conditions and are using erroneous codes due to misinterpretation of coding guidelines.” 
 
She predicts we’ll see more cases audited, problematic insurance company reimbursement, or post-payment takebacks because of this issue. 
 
“So when people say it’s ‘calm’ post-ICD-10,” Grzybowski says, “I don’t think we have even started to see some of this fallout, and may not for a good number of months, or even a year from now. The important thing is to audit and then educate, and make change happen for compliance.”
 
Email your questions to editor Steven Andrews at sandrews@hcpro.com.

 

Prepare for JustCoding’s redesign by downloading quiz certificates, preregistering

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The team at JustCoding is proud to announce a revamped and redesigned website launching soon. The new site will include great new features and make it easier than ever to browse our content, track your CEs, and more.
 
Before the new site launches, we ask all of our Basic and Platinum customers to print out their certificates for quizzes they’ve already taken. We will not be able to transfer quiz history to the new site. To get past CE certificates after the new site launches, you will have to retake the quizzes. Click here to access your current certificates.
 
Our new site will also require Free users to register to access the weekly free article, mini-poll, free quizzes, and other resources. Don’t worry—it’ll take less than a minute. Please click here and you’ll be all ready when the new site launches. If you are already a JustCoding Basic or Platinum subscriber, you don’t need to do anything—we’ll send you information when it’s time to access the new site!
 
New on JustCoding Platinum!         
Survey in Special Reports and NewsHIM director and manager salary survey
This 2015 survey from HIM Briefings (formerly Medical Records Briefing) provides an overview of trends in the industry for HIM director salaries.

 

Free quiz: ICD-10-CM codes for general symptoms and signs

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Test your knowledge with this week’s free quiz, which focuses on ICD-10-CM codes for general symptoms and signs. (View) 

Mini-poll: Which option best describes the type of facility for which you primarily code?

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Which option best describes the type of facility for which you primarily code?

  • Large hospital or healthcare system (more than 300 beds)
  • Medium-sized hospital or clinic (100-300 beds)
  • Small hospital or clinic (fewer than 100 beds)
  • Critical access hospital (fewer than 25 beds)
  • Provider-based clinic
  • Physician's office

Vote here

Last week’s mini-poll 

Does your hospital have an inpatient or outpatient clinical documentation improvement (CDI) program?

  • Yes, we have a CDI program that reviews inpatient records: 66%
  • Yes, we have a CDI program that reviews inpatient and outpatient records: 10%
  • Not applicable, I work in a physician office setting: 12%
  • No, we do not have a CDI program: 13%

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

Trivia question: ICD-10-CM code for an aneurysm of the iliac artery

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What is the correct ICD-10-CM code for an aneurysm of the iliac artery?

a. I72.0
b. I72.1
c. I72.2
d. I72.3
 
Know the answer and want to be featured in the next issue of JustCoding News: Inpatient? Contact editor Steven Andrews at sandrews@hcpro.com.  

Q&A: Coding from ED documentation and test results

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Q: Can you code strictly from emergency department (ED) documentation? Can you code from test results and imaging (radiologist reports)?
 
A: Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ED physicians or other providers (nurse practitioners and physician assistants) can be used to assign a code.
 
This comes with two notes of caution, however. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ED physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.
 
As for the second piece of your question, diagnosis codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnosis codes, as such physicians do not provide direct patient care. Coders or clinical documentation improvement (CDI) specialists would need to query the attending provider to assign the appropriate diagnosis code.
 
Coding Clinic for ICD-10-CM/PCS has published guidance regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.
 
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.

Healthcare News: CMS invites comments on 2-midnight rule payment calculation

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A recent court ruling determined that CMS had to explain its calculation for a negative 0.2% reduction in inpatient payment rates as a result of implementing the 2-midnight rule. The court also said that providers should have an opportunity to comment on the calculation. 
 
In early December, CMS released a notice with comment period to meet the court’s requirement, but providers might not be pleased with forcing the agency’s hand. CMS notes that when originally estimating the number of outpatient cases that should shift to inpatient as a result of the rule, it looked at 2011 claims containing HCPCS codes G0378 (hospital observation service, per hour) and G0379 (direct admission of patient for hospital observation care). 
 
Using this data, CMS identified approximately 350,000 observation stays that lasted two or more midnights. The agency combined that with approximately 50,000 claims that contained major procedures based on APCs that resulted in stays lasting more than two midnights. CMS also analyzed data from the inpatient side by looking at inpatient claims containing surgical MS-DRGs with stays that lasted less than two midnights and found approximately 360,000. 
 
The agency used this data to determine a net increase of 40,000 inpatient discharges as a result of the rule to calculate $220 million in increased expenditures on the inpatient side, leading to the reduction.
However, CMS now says that in light of new regulations and by using different metrics to estimate the shift, as many as 570,000 cases could move to the inpatient side, resulting in an even larger payment shift. 
 
Providers can comment on the notice at regulations.gov and all submissions must be received by February 2, 2016. 

 

 

Reporting biopsies with ICD-10-PCS

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

Biopsies are performed, most often, for diagnostic purposes. These procedures are done to obtain a sampling of cells or piece of tissue from the body that can then be pathologically analyzed. In ICD-10-PCS, a biopsy is not a biopsy.
 
Actually, there is no “biopsy” term available in this code set. ICD-10-PCS uses a variety of terms to describe these procedures, determined by what is actually done by the physician as explained by the Official Guidelines for Coding and Reporting 2016 guideline B3.4a: “Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.”
 
Fine-needle aspiration biopsy is reported with the root operative termDrainage (taking or letting out fluids and/or gases from a body part) in ICD-10-PCS. When you think about it, this is actually more specific and accurate, as the physician uses a thin needle to draw out–or drain–some fluid or gas to be used for testing.
 
For example, an amniocentesis would be reported with ICD-10-PCS code 10903ZU (Drainage of amniotic fluid, diagnostic from products of conception, percutaneous approach). Each of the characters making up the code would be:
  • 1, obstetrics
  • 0, pregnancy
  • 9, Drainage
  • 0, products of conception
  • 3, percutaneous approach
  • Z, no device
  • U, amniotic fluid, diagnostic
A lumbar puncture (spinal tap) would be reported with code 009Y3ZX (Drainage of lumbar spinal cord, percutaneous approach, diagnostic). Each character would be:
  • 0, medical and surgical section
  • 0, central nervous system
  • 9, Drainage
  • Y, lumbar spinal cord
  • 3, percutaneous approach
  • Z, no device
  • X, diagnostic
 
Core needle biopsy is reported with root operation Extraction (pulling or stripping out or off all or a portion of a body part by the use of force) because the physician uses a hollow needle, a bit larger than the needle used during a fine needle biopsy, to extract a cylindrical section of tissue to be analyzed.
 
For example for a bone marrow biopsy, the correct ICD-10-PCS code could be 07DR3ZX (Extraction of iliac bone marrow, percutaneous approach, diagnostic). The individual characters would be:
  • 0, medical and surgical section
  • 7, lymphatic and hemic system
  • D, Extraction
  • R, bone marrow, iliac, but it could also be Q for bone marrow, sternum, or S for bone marrow, vertebral
  • 3, percutaneous approach, though it could also be 0 for an open approach
  • Z, no device
  • X, diagnostic 
A punch biopsy of the skin could be reported with code 0JDD3ZX (Extraction of right upper arm subcutaneous tissue and fascia, percutaneous approach). The individual characters would be:
  • 0, medical and surgical section
  • J, subcutaneous tissue and fascia
  • D, Extraction
  • D, subcutaneous tissue and fascia, upper arm or various other characters for other specific anatomical sites
  • 3, percutaneous approach or potentially reported with 0 for Open
  • Z, no device
  • Z, diagnostic
 
Excisional and incisional biopsies are reported as an Excision (cutting out or off, without replacement, a portion of a body part), whether a sampling of tissue or an entire tumor or abnormal area is taken during the procedure.
 
For example, a liver biopsy could be reported with code 0FB20ZX (Excision of left lobe liver, open approach, diagnostic). The individual characters are:
  • 0, medical and surgical section
  • F, hepatobiliary system and pancreas
  • B, Excision
  • 2, liver, left lobe
  • 0, open or 3 for percutaneous approach or 4 for percutaneous endoscopic
  • Z, no device
  • X, diagnostic
 
A scrotum biopsy would be reported with 0VB5XZX (Excision of scrotum, external approach, diagnostic). The characters are:
  • 0, medical and surgical section
  • V, male reproductive system
  • B, Excision
  • 5, scrotum
  • X, external
  • Z, no device
  • X, diagnostic
Endoscopic biopsyis reported with the same root operation, Excision, however, coders will explain this circumstance with the appropriate approach–the fifth character: percutaneous endoscopic (4) or via natural or artificial opening endoscopic (8).
 
A natural or artificial opening endoscopic is defined as entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.
 
For example, a cystoscopy with biopsy would be reported with 0TBB8ZX (Excision of bladder, via natural or artificial opening endoscopic, diagnostic), depending on approach. The individual characters are:
  • 0, medical and surgical section
  • T, urinary system
  • B, Excision
  • B, bladder
  • 8, via natural or artificial opening endoscopic
  • Z, no device
  • X, diagnostic
 
A stomach biopsy is reported with 0DB68ZX (Excision of stomach, via natural or artificial opening endoscopic, diagnostic), depending on approach. The individual characters are:
  • 0, medical and surgical section
  • D, gastrointestinal system
  • B, Excision
  • 6, stomach
  • 8, via natural or artificial opening endoscopic
  • Z, no device
  • X, diagnostic
At times, the biopsy may be done and analyzed and directly followed by a more extensive procedure during the same encounter or session. The Official Guidelines for Coding and Reporting 2016 explain in section B3.4b that both should be reported (separately).
 
For example, a physician performs a lumpectomy of the right breast followed by mastectomy during the same session. Coders should report codes 0HBT3ZX (Excision of right breast, percutaneous approach, diagnostic) and 0HTT0ZZ (Resection of right breast, open approach). The individual characters for these respective codes are:
  • 0, medical and surgical section
  • H, skin and breast
  • B, Excision
  • T, breast, right
  • 3, percutaneous
  • Z, no device
  • X, diagnostic
And:
  • 0, medical and surgical section
  • H, skin and breast
  • T, Resection
  • T, breast, right
  • 0, open
  • Z, no device
  • Z, no qualifier
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.
 

An HIM director's holiday wish list

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By Dom Nicastro
 
The last month of the year can be a bit stressful. Closing out the books on the prior year. Making sure you leave time for all the holiday get-togethers. The traffic. The lines. The people.
 
It adds up.
 
If you’re an HIM director, it can be hectic in your healthcare facility, too. Not that it’s smooth sailing the first 11 months of the year.
 
Either way, you deserve a few treats yourself this holiday season. Make a few wishes, and who knows?
In fact, we gave an HIM director just that – the platform to make a few wishes this holiday season.
 
So, the floor is yours, Marianne Durling, MHA, RHIA, CDIP, CCS, CPC, CIC, director of Health Information Management and privacy officer at Granville Health System in Oxford, North Carolina. What do you wish for?
 
I wish contract companies would quit poaching my coders.
Most contract companies allow remote work. They pay more than small, county-owned facilities like Durling’s can afford, she says.
 
“Most coders soon find out it isn’t what they expected and the work isn’t always guaranteed, but by then their job has been filled,” Durling adds. “As a manager, I feel bad when I can’t let an employee come back. Some also limit the notification time they will allow staff to give, which can make them ineligible for rehire.”
 
I wish I could implement a full CDI program.
What are the struggles here for HIM directors? What gets in the way of realizing a full program, and what can HIM directors do in light of not being able to have a full program? First, you must decide where CDI fits into your organization’s tree. Does it come under HIM and its coders or does it come under the revenue cycle and work with the utilization review/case management team?
 
“If leaders can’t agree on this aspect then they can’t agree on how to champion for the position,” Durling says. “I think CFOs don’t understand the role and the benefit to the organization and thus won’t approve the necessary funding for an experienced CDI specialist. Since this role is new, I see a lot of leaders making due with coders or clinical staff minimally trained in coding, which means you may be missing some important skills.”
 
I wish the CMS website was more user friendly.
Use professional organization websites and references relative to what you are reviewing, Durling says. When CMS releases a new regulation that will impact family practice physicians, wait a few days or a week then check the American Academy of Family Physicians website.
 
“They get their experts to review the new rulings and regulations,” Durling says, “and then they boil it down in terms that their members can understand and apply to daily practice. This usually works for any specialty. I also find that state Medicaid websites and some [Medicare Administrative Contractor] sites have more user-friendly search features to find what you need than the CMS website.”
 
I wish my staff knew how hard I champion for them with administration.
A good leader needs to spend their time educating the C-suite on what their department does and how it impacts the organization and community. Durling takes this seriously.
 
“While we all know HIM is responsible for producing the claims that brings in the money we are widely considered a non-revenue producing department,” she says. “I’ve worked to find ways to be innovative to cut costs and actually bring in some revenue. By doing this, it keeps HIM in the eye of the administration, and they can see the importance we play in all aspects of the daily operations and how we can be a valued community partner.”
 
I wish payers reimbursed more realistically so our salaries could be more competitive.
Coder salaries are often not truly competitive, and managers can be underpaid–and even overpaid at times. Some get lucky. They avoid the day-to-day operational work because they have other managers under them for each service area they supervise, while others are underpaid if they must do everything because they don’t have the same supervisors or managers.
 
“This is because smaller hospitals still have the same work requirements, but no funding to support extra staff,” Durling says. “If payers paid more realistically, I think it would greatly impact compliance and hospital care.”
 
I wish Santa would come and work for me a day!
“Since Dad is usually Santa, I think in our environment Santa would be the CEO,” Durling says. “I would have him do just what I do every day: on a day of back-to-back meetings, juggle a staff member calling out sick, and some ‘crisis’ from another hospital area, all while dealing with staff drama or conflict.” HIM can be the “forgotten department that everyone knows exists, but no one could tell you exactly what we do,” she says.
 
I wish more hiring managers thought outside the box when it comes to hiring coders instead of just focusing on the credentials.
What should hospitals focus on when hiring coders? Work experience, skills, and personality are far more important than focusing just on the credentials.
 
“I also think that some managers think one credential is better than another, when in reality you are going to train them to do things the way you want them to do it, regardless of their credentials,” Durling says. “I have been around since before coding credentials even existed and sometimes we forget that good policies, procedures, and training can allow anyone with some aptitude and a willingness to learn to be a great coder.”
 
Oftentimes, you’ll see a coder who has a long list of credentials who can’t do the day-to-day job. What does that tell Durling? Maybe they are good at taking tests or memorizing material, but not good at applying the material.
 
“I just think too many managers take the easy way out and think the credentials alone can allow them to find a successful coder, or because they had luck in the past with one type of credential they will only hire those with that same credential, which severely limits their pool of candidates,” she says. “Step outside your comfort zone and you may find a whole world of great employees you never saw before.”
 
I wish we could offer more services to help our patients be better stewards of their personal health information and healthcare in general.
Durling says she’d like to work with her marketing department to educate their community on the importance of accurate health information and why it’s important to protect that information. She would like to help educate local providers that are not fully complaint with HIPAA learn to be compliant, so everyone can provide the same protections. She’d liked to help create a database of verified patients where patients who don’t have any picture ID can be easily verified so they have alternative methods to service their needs and protect their information.
 
I wish I could pay my coders what I know they deserve.
Durling says her staff members multitask, but they are not being compensated for all those other duties.
“We lose good staff members to larger hospitals just because of the higher pay,” she says. “The other problem is location. Because we are rural, we have a smaller local pool of qualified candidates, which means that jobs are harder to fill. We also don’t have the ability to offer remote coding because the high cost of [electronic health record] integration causes us remain a hybrid record system with a lot of paper chart elements.”
 
Smaller hospitals struggle with a smaller candidate pool, broader job duties hybrid systems, and lower salaries.
 
“This is why so many small rural hospitals are merging with larger facilities or corporate healthcare agencies,” Durling says, “but if we lose that community attachment, will it truly benefit the community in the end?”
 
I wish I could win the lottery and afford to revamp and update my department like I want.
“I would do a major remodel to our work area to make it more user friendly for the way we work today, as well as upgrade equipment to reflect our changing tasks,” Durling says. “I would spend the necessary money to back scan all our old records and integrate all our service areas so we could truly be a fully electronic medical record.”
 
“I would also use some funding to create a group to champion for smaller, rural hospitals at the government level,” Durling adds.
 
I wish the hospital staff and community realized just how much HIM really does for the hospital, the community, and patients.
Often board members, like the hospital staff in general, don’t know exactly what HIM does.
 
“I would like to speak to them at each new board installation to talk about what we do and how we serve the facility, providers, and the community,” Durling says. “I would also wish to be able to talk to them about significant changes such as things like ICD-10, HIPAA, or even issues that impact our department such as identity theft. I normally don’t get asked to present to them on these types of topics, but I believe they need to know what to expect and the impact it will/could have on our facility and our community in order to make appropriate decisions moving forward.”

 

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

AHA Coding Clinic for ICD-10 covers orthopedic, cardiovascular coding

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by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS
 
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
 
I never thought I'd be so eager to read a release about coding instead of the newest James Patterson novel, but this newsletter highlighted topics such as orthopedic screw removals, revision of total knee replacements, heart failure with pleural effusions, leadless pacemakers, the Glasgow Coma Scale, and decompression of the spinal cord. 
 
Orthopedics
Typically, when we see that a device is loose or breaking, we automatically think "that shouldn't happen," so we opt to code a complication of the device. Well, when this occurs in an orthopedic screw as an expected outcome (typically when the patient begins bearing weight during the recovery/healing process), it should not be coded as a complication.
 
The correct diagnosis codes would be assigned for the specified fracture site with a seventh character identifying a subsequent encounter with routine healing, along with the external cause code (if known), also as a subsequent encounter. (Remember that place of occurrence, activity, and status codes should only be used for the initial encounter, per the ICD-10-CM Official Guidelines for Coding and Reporting.)
The ICD-10-PCS root operation would be Removal (third character P) for the removal of the screw from the specified bone.
 
On the other hand, some orthopedic devices can present real complications necessitating removal and replacement. For example, a patient may be admitted for a painful total knee replacement, initial encounter (T84.84xA). In order to remedy this situation, the previously placed components (tibial and femoral) are removed and replaced with new components. This ­scenario leads coders to ponder whether this should be considered a Revision or Replacement, or perhaps something else.
 
ICD-10-PCS defines a Revision as "correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device." In this case, the prosthesis isn't working exactly the way it should, but the ICD-10-PCS Reference Manual states that "putting in a whole new device or a complete redo is coded to the root operation(s) performed."
 
Therefore, the correct root operations would be Removal (P) for taking out the old components, then a Replacement (third character R) for putting in/on a synthetic material that takes the place of the body part. 
 
Cardiovascular
I am confident many coders noticed that the codes for heart failure (category I50) are mostly identical to their ICD-9-CM counterparts.
 
But one thing that probably raised some eyebrows for coders was the Excludes2 note at category J91 (Pleural effusion in conditions classified elsewhere), which seemed to state that a code from category J91 would be assigned as an additional code when seen "in heart failure."
 
Of course, most coders will recall that in ICD-9-CM we normally could not assign a separate code for this situation, based off information in AHA Coding Clinic for ICD-9-CM, Third Quarter 1991. The new issue provides clarification that the same rules apply in ICD-10-CM for pleural effusions seen in heart failure patients.
 
The pleural effusions would only be reported separately if therapeutic/diagnostic interventions are required. Pleural effusion is commonly seen with congestive heart failure (CHF) with or without pulmonary edema. Usually, the effusion is minimal and resolves with aggressive treatment of the underlying CHF.
 
The issue also addresses the correct coding of a newer procedure performed for heart blocks: the insertion of leadless pacemakers. You may have asked, as I did, how in the world does this device work if there are no leads to provide the electrical impulses?
 
This technology has been explored for many years and is finally here. Current pacemaker devices are susceptible to issues such as lead failure or malpositioning, as well as pulse generator pocket complications, such as scar formation or even just the visible presence of the device. In contrast, these new cylindrical devices fit directly into the right ventricle, accessed via a transcatheter approach and placed into the endocardial tissue of the right ventricular apex to provide pacing capabilities.
 
For coding purposes, the ICD-10-PCS table 02H (Insertion, heart and/or great vessels) does not provide a specific device option for a leadless pacemaker. The correct device character should be D (intraluminal device). The full ICD-10-PCS code to be assigned is 02HK3DZ (Insertion of intraluminal device into right ventricle, percutaneous) to identify a leadless pacemaker. 
 
Neurology
Revisions in ICD-10-CM allow coders not only to report a coma (R40.20-, unspecified coma) but also to report codes that incorporate a common tool to assess the depth and duration of comas or impaired consciousness, known as the Glasgow Coma Scale.
 
Per the Centers for Disease Control and Prevention, this scale helps to gauge the impact of a variety of conditions, such as acute brain damage due to traumatic and vascular injuries or infections and metabolic disorders (e.g., hepatic or renal failure, hypoglycemia, diabetic ketosis).
 
ICD-10-CM contains subcategories to report the three elements that go into calculating the coma scale:
  • R40.21-, coma scale, eyes open
  • R40.22-, coma scale, best verbal response
  • R40.23-, coma scale, best motor response 
If coders opt to use this reporting option, three codes must be assigned to identify each of the three elements.
 
Codes for the individual Glasgow Coma Scale scores from these categories can be assigned if the provider documents the numeric values, as opposed to the physical descriptions associated with those numeric values.
 
The eye opening response is scored as follows:
  • 4, spontaneous eye opening
  • 3, eyes open to speech
  • 2, eyes open to pain
  • 1, no eye opening
 
The verbal response is divided into five categories:
  • 5, alert and oriented
  • 4, confused, yet coherent, speech
  • 3, inappropriate words and jumbled phrases consisting of words
  • 2, incomprehensible sounds
  • 1, no sounds 
The motor response is divided into six different levels:
  • 6, obeys commands fully
  • 5, localizes to noxious stimuli
  • 4, withdraws from noxious stimuli
  • 3, abnormal flexion, i.e., decorticate posturing, an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest
  • 2, extensor response, i.e., decerebrate posturing, an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, and head and neck arched backwards
  • 1, no response 
For example, the documentation states "Glasgow Coma Scale score was obtained upon arrival at the ED; eyes open = 2, best verbal = 3, and best motor = 5." Coders may assign the following:
  • R40.2122, coma scale, eyes open, to pain, at arrival to ED
  • R40.2232, coma scale, best verbal response, inappropriate words, at arrival to ED
  • R40.2352, coma scale, best motor response, localizes pain, at arrival to ED 
Per the Official Guidelines, the seventh characters must match for all three codes.
Subcategory R40.24- (Glasgow Coma Scale, total score) is an additional option provided that identifies the overall score as opposed to each of the three individual elements.
Those codes are:
  • R40.241, Glasgow Coma Scale score 13-15
  • R40.242, Glasgow Coma Scale score 9-12
  • R40.243, Glasgow Coma Scale score 3-8
  • R40.244, other coma, without documented Glasgow Coma Scale score, or with partial score reported 
Codes from R40.24- would not be assigned if the individual scores are documented.
 
Procedurally, Coding Clinic provided clarification regarding decompressive laminectomies and the assignment of the appropriate body part characters. When assigning an ICD-10-PCS code for a cervical decompressive laminectomy, the body part value states "cervical spinal cord."
 
The cervical spinal cord is considered a single body part value in ICD-10-PCS and would only be assigned one time regardless of the number of cervical levels decompressed to release the spinal cord.
The vertebral level designations of the cervical spinal cord do not constitute separate and distinct body parts anatomically; therefore, ICD-10-PCS Guideline B3.2 does not apply:
 
During the same operative episode, multiple procedures are coded if: The same root operation is repeated at different body sites that are included in the same body part value. 
 
Another note of caution: The ICD-10-PCS Index entry "Laminectomy" instructs coders to see Excision (B), but the objective of a decompressive laminectomy is to release pressure and free up the spinal nerve root. Therefore, the appropriate root operation is Release (N). 

 

Editor's note: McCall is the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see www.hcprobootcamps.com.This article was originally published in Briefings on Coding Compliance Strategies.

Prepare for JustCoding's redesign by downloading quiz certificates, preregistering

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The team at JustCoding is proud to announce a revamped and redesigned website launching soon. The new site will include great new features and make it easier than ever to browse our content, track your CEs, and more.

Before the new site launches, we ask all of our Basic and Platinum customers to print out their certificates for quizzes they’ve already taken. We will not be able to transfer quiz history to the new site. To get past CE certificates after the new site launches, you will have to retake the quizzes. Click here to access your current certificates.
 
Our new site will also require Free users to register to access the weekly free article, mini-poll, free quizzes, and other resources. Don’t worry—it’ll take less than a minute. Please click here and you’ll be all ready when the new site launches. If you are already a JustCoding Basic or Platinum subscriber, you don’t need to do anything—we’ll send you information when it’s time to access the new site!
 
New on JustCoding Platinum!      
2016 outlook in Special Reports and NewsHIM department focuses for next year
This report from HIM Briefings (formerly Medical Records Briefing) looks at trends that may emerge in 2016 and what your organization may want to focus on. 


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