If a code is incorrectly assigned or a claim is rejected, HIM and finance staff may automatically assume the coder made a mistake. But was the error truly a coding mistake—for example, the coder incorrectly sequenced the codes—or is it really a documentation problem? Did the coder have all the information he or she needed to assign the code?
If a facility’s case mix index (CMI) drops, is it because the coders aren’t coding correctly or because the physicians aren’t documenting the severity of illness (SOI) well? A lower CMI means lower reimbursement. If the reimbursement falls low enough, the facility will close.
If the physician had sufficiently and accurately documented the patients’ SOI, coders could assign more specific codes that could in turn lead to more appropriate reimbursement and better quality scores. It really does take a healthcare village to get everything right.
Documentation improvement should not be about money. It should be about patient care. “Avoid talking to physicians about reimbursement when you talk to them about documentation improvement,” says Joy Strong, PMP, ICD-10 program director for Strong9 Consulting Services in Plumas Lake, Calif. She is currently working as the contract ICD-10 program director for Adventist Health West in Roseville, Calif.
Instead, explain the benefits of good documentation. Documentation drives better:
- Picture of patient acuity
- Severity and mortality scores
- Hospital and physician quality scores
- Use of resources
“Tell physicians it’s not about the money,” says Donielle Bailey, RHIA, ICD-10 project coordinator for the University of North Carolina’s Rex Health in Raleigh. “It’s about how you look to the insurance companies. Are you really treating patients who are that sick?”
Coders can only code what is documented, Strong says. Remember, if it’s not documented, it didn’t happen. Billers bill what’s coded and payers only pay for what’s billed. It all comes back to strong documentation, Strong says.
If the physician documents the specificity coders need and clinical documentation improvement (CDI) specialists or coders perform concurrent reviews, coders can maintain productivity, Strong says.
Coders may be the best people to identify what’s missing in the documentation because they are reading the medical record and assigning codes.
“We know we have a huge problem with documentation in ICD-9-CM,” say Bailey. “It’s going to get worse in ICD-10.”
Look at the current state of your physician documentation and identify where gaps exist. For example, what do the physicians document for diabetic patients? If all the physician documents is diabetes, coders can only report ICD-9-CM code 250.00 (diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled).
Is every diabetic patient treated at the facility equally sick? Does every diabetic patient require the same treatment? Probably not, but if the physicians aren’t documenting the details, coders can’t report a more specific code and physicians can’t justify why one patient required more treatment than another.
“We can’t fix it if we don’t know where the problems are,” Strong says.
Coders need to make sure they get the additional information they need, says Jill M. Young, CPC, CEDC, CIMC, president of Young Medical Consulting in East Lansing, Mich. “We need to teach the physicians when we need more documentation,” Young says.
Physicians are used to documenting terms that don’t actually reflect the patient’s severity of illness, Young says. For example, providers commonly use sepsis and septicemia interchangeably, even though they are different conditions.
Septicemia is a systemic disease associated with the presence of pathologic microorganisms or toxins, while sepsis is systemic inflammatory response syndrome plus an infection.
They also lead to different codes. If a physician documents septicemia, coders still need to identify the cause. Coders report different codes for streptococcal septicemia (038.0) and septicemia due to anaerobes (038.3) for example. If the physician doesn’t document the causative organism, coders are left with unspecified septicemia (038.9).
If the physician documents sepsis, coders need to report at least two codes:
- One for the underlying cause (infection, trauma, etc.)
- One for the sepsis (which is usually 995.91)
Coders need to look at sepsis and septicemia on a case-by-case basis “because of the twists and turns for every patient,” she adds.
ICD-9-CM includes specific guidelines for sequencing sepsis codes. Coders report the underlying cause first, followed by the sepsis code. If they don’t follow the sequencing guidelines, payers will deny the claim.
Never assume that sepsis is present on admission (POA), adds Jennifer Avery,CCS, CPC-I, CPC-H, senior regulatory specialist for HCPro in Danvers, Mass.
Sepsis or severe sepsis may be present on admission but the physician may not confirm the diagnosis until sometime after admission. When physician documentation stating that sepsis or severe sepsis is POA is absent or unclear, coders should query the physician.
Similarly, coders should never assume that the presence of SIRS criteria on admission allows the coder to report ICD-9-CM code 038.x as the principal code without corroborating physician documentation that verifies sepsis was POA, she adds.
Coders need to know whether the sepsis was POA so they can correctly sequence the codes.
If the patient is admitted for sepsis (or severe sepsis or SIRS) and a localized infection (such as cellulitis, pyelonephritis, pneumonia, meningitis, cholangitis, or peritonitis), sequence the systemic infection (e.g., 038.X, 112.5) first, followed by code 995.91 (sepsis) or 995.92 (severe sepsis), and then the code for the localized infection.
If the reason for admission is a localized infection and the patient develops sepsis after admission, coders should list the localized infection as the principal diagnosis, followed by the code for the systemic infection, then the sepsis or severe sepsis code.
If the physician does not document whether sepsis was POA, coders would end up with the wrong sequence of codes.
When it comes to lung disease, coders need to remember that chronic obstructive pulmonary disease (COPD) is a three-digit nonspecific code in ICD-9-CM, Young says. Nonspecific codes don’t provide a good picture of what’s wrong with the patient or justify the treatment the physician provided.
The ICD-9-CM codes for acute chronic bronchitis and asthma distinguish between uncomplicated cases and those with acute exacerbation, a worsening or decompensation of a chronic condition. An acute exacerbation is not the same as an acute infection superimposed on a chronic condition, Young says. However, an acute infection may trigger an exacerbation. If the physician doesn’t document the acute and chronic conditions correctly and with enough specificity, coders will end up with the wrong code.
Because of the overlapping nature of the conditions that make up asthma and COPD, physicians can document these conditions in various ways. Coders must base their code selection on the terms the physician documented, Young says.
An acute exacerbation of asthma involves an increase in the severity of the patient’s asthma symptoms, such as wheezing and shortness of breath. Status asthmaticus refers to a patient’s failure to respond to therapy administered during an asthma attack. It can be a life-threatening complication and requires immediate emergency care.
If the provider documents status asthmaticus with any type of COPD or with acute bronchitis, code the status asthmaticus first. It supersedes any type of COPD, including that with acute exacerbation or acute bronchitis. However, the codes depend on what the physician documents in the medical record.
If the physician doesn’t document enough specificity or provides unclear or conflicting documentation, send a query, Young says.
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.