Coders want everything to be very clear-cut, without ambiguity. That way, they can easily assign the correct code and their coding is audit proof. In the real world, coding, documentation, and diagnoses are often filled with shades of gray, which can challenge even experienced codes.
Let’s review three of the more challenging diagnoses: encephalopathy, stroke, and anemia.
Encephalopathy
“Encephalopathy is a great big monster,” says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida. Coders and clinical documentation improvement (CDI) specialists want physicians to document encephalopathy, when appropriate, because it is an MCC.
By definition, encephalopathy is a global cerebral dysfunction in the absence of structural brain disease, Brundage says. “That definition is very nebulous.”
Unfortunately, providers often describe encephalopathy instead of diagnosing it, says Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, associate director for education at ACDIS and CDI education director at HCPro, a division of BLR, in Danvers, Massachusetts.
To make the diagnosis and coding audit proof, the physician needs to document the etiology of the encephalopathy, not just document “altered mental status,” “mental status change,” or “confusion,” Brundage says.
The underlying etiologies of encephalopathy include:
- Anoxic (348.1)
- Hepatic (572.2)
- Hypertensive (437.2)
- Toxic/metabolic (ICD-9-CM code 349.82)
- UTI or sepsis (septic encephalopathy (348.31)
Encephalopathy can also be a late effect of a stroke (i.e., multi?infarct dementia), Brundage says.
In many cases, auditors want physicians to perform a mini-mental status examination, but physicians rarely use it, Brundage says.
“A mental function test is not necessary if the progress of the encephalopathy is described by the physician and nursing staff,” adds Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, executive director of the Foundation for Physician Documentation Integrity in Burlington, Vermont.
Stroke and transient ischemic attack
A cerebrovascular accident (CVA), also called a stroke, occurs when the blood supply to part of the brain is slowed or cut off, resulting in the sudden death of some brain cells due to lack of oxygen. A CVA can be caused by a blockage (ischemic) or rupture of an artery to the brain (hemorrhagic).
Common ischemic strokes include thrombotic stroke (434.01), or the formation of a blood clot in an artery that supplies blood to the brain, and embolic stroke (434.11), which occurs when the blood clot breaks off and travels through the bloodstream to a vessel that feeds the brain.
Coders will assign a code from category 433 if the CVA is caused by an occlusion or stenosis of a precerebral artery, such as the basilar, carotid, and vertebral. Coders will use the fifth digit to show that the occlusion/stenosis caused the CVA. The physician must document that the stroke occurred as a result of the occlusion or stenosis before the fifth digit of 1 can be assigned. If the physician does not document an infarction, coders will use 0 as the fifth digit.
Modern imaging findings obtained by diffusion?weighted MRI highlight tissue changes several minutes after transient or permanent ischemic events. Stroke can be diagnosed with MRI findings regardless of symptoms and in less than 24 hours, Brundage says.
A physician can still diagnose a stroke without an MRI if the patient shows clinical evidence of a permanent injury, Brundage says.
However, this has muddied the waters somewhat when it comes to transient ischemic attacks (TIA). A TIA is a temporary interruption of the blood flow to the brain. The signs and symptoms are the same as a stroke but last for a shorter period of time and leave no residual effects.
A time definition for symptoms (less than 24 hours) should not be the only diagnostic criteria for TIA, Brundage says. In fact, “if the physician is using the 24-hour rule, he or she is practicing outdated medicine.” Instead, physicians should use an MRI if available and look for evidence of permanent injury.
Hemiplegia and aphasia are comorbidities/complications in CVA patients, and physicians need to document their relationship to the stroke clearly. Patient may also experience ataxia, dementia, or contracture of a joint as a result of a stroke.
“Tell the physician, ‘don’t tell me the patient has a history of stroke,’” Brundage says. “Tell me this is a sequela, late effect, or manifestation of the stroke.”
Anemia
Anemia is another tricky condition from a diagnostic standpoint because as many as one-third of patients in the U.S. could have some type of anemia, says Cesar M. Limjoco, MD, vice president of clinical services for DCBA, Inc. in Indianapolis, Indiana.
If a patient with acute bleeding loses enough blood to become anemic, the diagnosis of acute blood loss anemia is appropriate, says Richard D. Pinson, MD, FACP, CCS, of HCQ Consulting in Chattanooga, Tennessee. This definition also encompasses patients who have preexisting anemia and become more anemic due to bleeding.
If the physician just documents “anemia,” he or she is not capturing the patient’s severity of illness, Limjoco says. Coders will report ICD-9-CM code 285.9 when the physician does not specify the type of anemia.
Physicians can be much more specific when documenting anemia, Limjoco says. For example, the physician can document:
- Acute blood loss anemia (285.1)
- Chronic anemia secondary to chronic kidney disease stage IV or V (ICD-9-CM code 285.21)
- Chronic blood loss anemia (280.0)
- Iron deficiency anemia (280.9)
Physicians don’t document acute blood loss anemia well, Brundage says.
Acute blood loss anemia can be linked to a hemorrhagic process, such as:
- Any procedure or surgery
- Fracture
- GI bleed
“This should be documented separately from its cause,” Brundage says.
If a patient experiences post-procedural bleeding, the physician should document whether it is expected, Brundage adds.
For example, an elderly patient fractures her hip and blood flows into the hip joint. As a result, the patient experiences acute blood loss anemia. Depending on the type of fracture, that could be an expected occurrence, Brundage says.
Even if the amount of blood lost following surgery is expected and routinely associated with the procedure, acute blood loss anemia is still present if anemia occurs, Pinson says. A common example of this is substantial bleeding and consequent anemia associated with joint replacement surgery.
Remind physicians not to document “bright red blood per rectum” because it can’t be coded, Brundage says. Consider documenting “lower GI bleed due to diverticulosis.”
Email your questions to associate product manager Michelle A. Leppert, CPC, at mleppert@hcpro.com.