coma, stroke codes i67–i68: i69: require more specific ... · coma, stroke codes require more...
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ICD-10
Coma, stroke codes require more specific documentation
A quick glance at ICD-9-CM and ICD-10-CM stroke
and coma codes reveals many similarities and some
important differences.
How ICD-10 stroke codes are organized
The 2013 ICD-10-CM Table of Diseases organizes
cerebrovascular disease codes as follows:
➤ I60–I62: Non-traumatic intracranial hemorrhage
(i.e., spontaneous subarachnoid, intracerebral,
or subdural hemorrhages)
➤ I63: Cerebral infarctions (i.e., due to a vessel
thrombosis or embolus)
➤ I65–I66: Occlusion and stenosis of cerebral or
precerebral vessels without infarction
➤ I67–I68: Other cerebrovascular diseases
➤ I69: Sequelae of cerebrovascular disease (late effect)
Note that some neurologic manifestations of cerebro-
vascular disease, such as transient cerebral ischemic attacks
and related syndromes (G45), are classified elsewhere.
Greater specificity for strokes
ICD-10-CM stroke codes are more specific than their
ICD-9-CM counterparts.
First, codes
I60–I62 specify the
location or source
of a hemorrhage as
well as its laterality.
For example, ICD-
10-CM code I60.11
denotes nontraumatic subarachnoid hemorrhage from
right middle cerebral artery.
A CT scan usually indicates the specific location of
a hemorrhage, says Alice Zentner, RHIA, director of
auditing and education at TrustHCS in Springfield, Mo.
“Hopefully, the physician will bring this information
forward into his or her progress notes,” she says.
Second, code I63 specifies the following:
➤ Cause of the ischemic stroke (e.g., thrombosis,
embolus, or unspecified)
➤ Specific location and laterality of the occlusion
(i.e., specific artery)
For example, ICD-10-CM code I63.331 denotes
cerebral infarction due to thrombosis of right posterior
cerebral artery.
Zentner says that coders must be able to differentiate
the following terms when reporting a code from category
I63–I65:
This month’s tip—For better
or worse? Robert S. Gold, MD,
answers this question in his
assessment of various code
revisions on p. 6.
September 2012 Vol. 15, No. 9
IN THIS ISSUE
p. 4 ComplicationsLearn how differing interpretations of medical terminology affects coder understanding of physician documentation.
p. 6 Clinically speakingRobert S. Gold, MD, shares his thoughts about various code revisions.
p. 8 Recovery AuditorsLearn the benefits of conducting a self-audit before submitting records for review.
p. 11 PEPPERHospital feedback helps TMF Quality Institute enhance value of its reports.
p. 12 DocumentationLearn how coding managers and their staff members can help physicians understand what they need.
Inside: Coding Q&A insert
Page 2 Briefings on Coding Compliance Strategies September 2012
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➤ Stenosis—narrowing of the artery
➤ Occlusion—Complete or partial obstruction
➤ Thrombus—Solid mass of platelets or fibrin that
forms and remains in a blood vessel (stationary
blood clot)
➤ Embolism—Blood clot that travels from the site
where it formed to another location in the body
Coders should also be able to distinguish cerebral and
precerebral arteries because ICD-10-CM codes make
this distinction, says James S. Kennedy, MD, CCS,
CDIP, managing director at FTI Consulting in Atlanta.
Precerebral arteries include the vertebral, basilar, and
carotid arteries and their branches. The cerebral arteries
include the anterior, middle, and posterior cerebral
arteries and their branches.
Third, code category I69 specifies the type of stroke
that caused the sequelae as well as the residual condi-
tion itself. For example, code I69.01 denotes cognitive
deficits after nontraumatic subarachnoid hemorrhage.
In ICD-9-CM, code 438.xx simply denotes the residual
condition—not the type of stroke that caused the
condition.
Coders can report code I69 in conjunction with a
condition classifiable to code category I60–I67 if the
patient has a current cerebrovascular disease and deficits
from an old cerebrovascular disease. The guidelines also
state that the neurological deficits caused by a stroke
may be present from the onset of a stroke or arise at any
time after the onset of the stroke. Note that code I69 is
exempt from POA reporting.
When a patient has a history of cerebrovascular disease
without any neurologic deficits, coders should report code
Z86.73 (personal history of transient ischemic attack,
and cerebral infarction without residual deficits) and a
code for the cerebral infarction without residual deficits
(not code I69), according to ICD-10-CM guidelines.
Reporting bilateral hemorrhages
If a patient has bilateral nontraumatic intracerebral
hemorrhages, coders should report code I61.6 (nontrau-
matic intracerebral hemorrhage, multiple localized).
Conversely, if a physician documents bilateral non-
traumatic subarachnoid hemorrhage sites, coders must
report an ICD-10-CM code for each side. ICD-10-
CM guidelines state that if the patient has a bilateral
condition—and no bilateral ICD-10-CM code exists—
coders should assign separate codes for the left and right
sides.
For example, in the rare event that a patient suffers a
nontraumatic subarachnoid hemorrhage of both anterior
communicating arteries, assign I60.21 (nontraumatic
subarachnoid hemorrhage from right anterior commu-
nicating artery) and I60.22 (nontraumatic subarachnoid
hemorrhage from left anterior communicating artery).
However, coders should note that code categories
I65–I66 include bilateral codes. Therefore, if a patient has
Editorial Advisory Board Briefings on Coding Compliance Strategies
Paul Belton, RHIA, MHA, MBA, JD, LLMVicePresidentCorporate Compliance Sharp HealthCare San Diego, Calif.
Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIMConsultantFremont, Calif.
William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Fla.
James S. Kennedy, MD, CCSManagingDirectorFTI Healthcare Atlanta, Ga.
Laura Legg, RHIT, CCSRevenueControlCodingConsultantRevenue Cycle Management Washington/Montana Regional Services Providence Health & Services Renton, Wash.
Monica Lenahan, CCSManagerofCodingEducationandComplianceRevenue Management Centura Health Englewood, Colo.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS DirectorofCodingandHIMHCPro, Inc. Danvers, Mass.
Jean Stone, RHIT, CCSCodingManager-HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, Calif.
Managing Editor: Geri Spanek
Contributing Editor: Lisa Eramo, [email protected]
Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
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bilateral stenosis of the vertebral arteries, coders should
assign I65.03—not I65.01 and I65.02 to denote the right
and left vertebral arteries, respectively.
Reporting intraoperative and
postprocedural strokes
Unlike ICD-9-CM, ICD-10-CM distinguishes the
following:
➤ Intraoperative stroke during cardiac surgery (I97.810)
or during other surgery (I97.811)
➤ Postprocedural stroke during cardiac surgery
(I97.820) or during other surgery (I97.821)
“If a stroke occurs in the setting of an operation, a
query is needed to determine if the stroke occurred
during or after surgery,” says Kennedy.
Coma codes
The most noticeable difference between ICD-9-CM
code 780.01 (coma) and its ICD-10-CM counterpart
(code R40.2) is that the latter incorporates the Glasgow
Coma Scale (GCS), a neurological scale that captures
a patient’s conscious state for initial and subsequent
assessment.
“It really shows the condition of the patient and
the severity of the event,” says Zentner. “If reported at
different intervals, it shows the patient’s progress and
response to treatment.”
Coders may report the GCS with any appropriate
illness. The coma scale codes should be sequenced after
the diagnosis code(s).
The GCS may be coded based on an aggregate score
(code R40.24, GCS total score), or based on its individual
components. Code R40.24 is appropriate when only the
total score—and not the individual components—are
documented. When the individual components are
documented, coders may report the GCS based on the
components. However, they must report a code from
each of the following subcategories:
➤ R40.21: Eye response (eyes never open or eyes open
to pain, sound, or spontaneously)
➤ R40.22: Best verbal response (clarity of words
incomprehensible, inappropriate, confused, oriented)
➤ R40.23: Best motor response (voluntary and
involuntary responses [extension, flexion, abnormal,
obeys commands])
If a physician doesn’t document the GCS—or docu-
ments only a portion of it—coders must report R40.244.
Codes R40.21–R40.23 require a 7th character to
denote when the scale was recorded (i.e., unspecified
time, in the field [EMT or ambulance], upon arrival at
the ED, at hospital admission, or 24 hours or more after
admission).
Coders must report codes for all three components,
and they must ensure that the 7th character matches
for all three, says Kennedy. Coders also should note that
hospitals may report the GCS at multiple intervals and
that physician and EMT documentation supports code
assignment, he says.
“Facilities that have a trauma registry will certainly
want to report these codes,” says Zentner. “If the center
wants to follow the patient and see how he or she is
progressing, they may want to report several codes.”
Educating ED physicians about documentation of coma
scale scores and the new codes is important. Hospitals
should consider revising templates so they incorporate
this information, she says.
Separate symptoms and combination codes
Coders should search the ICD-10-CM Alphabetic
Index for codes that automatically incorporate coma in
their descriptions. For example, code E11.641 denotes
Type 2 diabetes mellitus with hypoglycemia with coma.
Assigning ICD-10-CM code R40.20 (coma, unspecified)
as an additional code would be appropriate because com-
bination code E11.641 includes the coma (symptom) as
an integral component. n
Editor’s note: Access the most recent version of ICD-10-CM
at http://tinyurl.com/yd94dqr. Access the 2012 ICD-10-CM
guidelines, at http://tinyurl.com/7zkjdyu.
Page 4 Briefings on Coding Compliance Strategies September 2012
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Complications are … well, complicated. There’s no
other way to say it. Why are they so difficult to code?
The answer is simple—coding and clinical termino logy.
Coders and physicians interpret several important terms dif-
ferently, says Audrey G. Howard, RHIA, senior inpatient
consultant at 3M Health Information Systems in Atlanta.
For coders, postoperative denotes a condition related to
a surgical procedure. For physicians, this term denotes
a condition occurring during the postoperative period—
not necessarily one that’s related to the surgery. Like-
wise, CMS (and coders) define complication as a condition
occurring after admission that increases length of stay by
at least one day in at least 75% of patients. Physicians
define this term as an additional condition caused by a
procedure, treatment, or illness. Complication generally
has a negative connotation for physicians, says Howard.
Clear documentation can help, says Howard. Physi-
cians should document postoperative only if the complica-
tion is due to the surgery or the anesthesia used during
surgery. If not, all other conditions should be document-
ed as “occurring after surgery” or “unrelated to surgery.”
Clarification is paramount, says Cheryl Manchenton,
RN, BSN, senior inpatient consultant at 3M Health Infor-
mation Systems in Atlanta. Why? Complications not only
have financial implications, but many agencies also factor
them into hospital and physician profiles, some of which
are available to the public. Many CDI programs are begin-
ning to target complications to ensure coding accuracy and
promote data quality to prevent poor quality reports for
physicians and the hospitals where they work, she says.
Clarifying whether a physician truly intended to
link a complication to the surgery is important, says
Manchenton. Querying physicians is completely appro-
priate when documentation is unclear, particularly when
postoperative appears to be a time stamp rather than an
actual indication of a complication due to the surgery.
Surgeons and medical consultants must document
consistently for conditions following surgery, she says.
ICD-10-CM also includes codes for complications,
some of which specifically reference intraoperative and
postoperative. Code category T80–T88 generally includes
complications of surgical and medical care, not elsewhere
classified. Some of the codes in this category require a 7th
character to denote whether it’s an initial, subsequent, or
sequela encounter. For example, code T85.01xA denotes a
mechanical breakdown of ventricular intracranial (com-
municating) shunt, initial encounter. However, compli-
cation codes aren’t limited to this section—they appear
throughout the entire ICD-10-CM classification according
to body system. For example, postoperative aspiration
pneumonia is reported with J95.89 (other postprocedural
complications and disorders of respiratory system, not else-
where classified) and J69.0 (pneumonitis due to inhalation
of food and vomit). Both of these codes are included in the
section for diseases of the respiratory system.
Consider these questions
Not all conditions during or following medical care or
surgery are considered complications, says Howard. Ask
these questions before reporting a complication code.
➤ Is the condition expected routinely dur-
ing or after a particular procedure? Reporting a
complication requires that a condition exceed what a
particular patient would likely experience during or after
a particular surgery as part of routine intraoperative or
postoperative care, says Howard. Physicians are respon-
sible for determining whether something that occurred
during or after surgery is a complication or an expected
outcome, she says. Refer to Coding Clinic, First Quarter
2011, pp. 13–14 for more information.
Coders and CDI specialists should determine whether
the patient received any treatment for the condition or
whether the condition extended the patient’s length
of stay. Only a physician can document this information,
she says. For example, an unexpected resection of the
intestine required to repair a laceration might indicate
an intraoperative accidental laceration. Another example
might be documentation that a surgeon called another
Ask questions before reporting complications
September 2012 Briefings on Coding Compliance Strategies Page 5
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physician to the OR for an opinion.
➤ Did the physician document a cause-and-
effect relationship between the procedure and
the condition? This relationship is crucial to reporting
complications, says Howard. Physicians must link the
condition with the procedure before coders can report it
as a complication. The ICD-9-CM Official Guidelines for Cod-
ing and Reporting states the following:
Code assignment is based on the provider’s documenta-
tion of the relationship between the condition and the care
or procedure. The guideline extends to any complications of
care, regardless of the chapter the code is located in.
➤ Did the physician document that the condi-
tion is a complication? If a physician doesn’t explicitly
document that a condition is a complication of the pro-
cedure, coders should query, says Howard. Refer to Cod-
ing Clinic, Third Quarter 2009, p. 5 for more information.
Intraoperative accidental lacerations
Generally, when a laceration/tear/enterotomy occurs
during a procedure, the physician must document that it
was clinically significant or that it is a complication of the
procedure before coders can report it as such, says Howard.
If a physician documents a tear in the operative
report—but doesn’t indicate whether it’s clinically
significant—query for more information, she says. If a
physician states that a tear isn’t clinically significant,
omit codes for the diagnosis and procedure performed
to repair the tear. Don’t assign a traumatic injury code
(800–959) to identify complications resulting from surgi-
cal or medical care, says Howard. Refer to Coding Clinic,
First Quarter 2009, pp. 15–16 for more information.
If a physician specifically documents a tear is a compli-
cation of surgery, report code 998.2. Refer to Coding Clinic,
Second Quarter 2007, pp. 11–12 for more information.
In some cases, clinical significance may be obvious.
Consider a patient admitted for a bowel obstruction with
a history of previous bowel surgery. When the physician
begins surgery, he finds massive adhesions. While lysing the
adhesions, the physician nicks the bowel in numerous places
and must repair the nicks. The physician documents that the
surgery lasts eight hours because of the extra work involved.
Postoperatively, the patient requires TPN and remains
hospitalized for 26 days before being discharged home with
a wound vacuum-assisted closure (VAC). In this case, the
enterotomies (nicks) are clinically significant because of the
increased surgery time, the increased length of stay, and the
need for wound VAC. Coders should report them with code
998.2 and a procedure for the suture repair of the site.
Exercise care when reporting coronary artery
dissection as a complication of percutaneous translumi-
nal coronary angioplasty (PTCA), says Manchenton. If a
physician documents the dissection as a complication
of the PTCA, report 997.1 (cardiac complications) and
414.12 (dissection of coronary artery). Coding Clinic, First
Quarter 2011, pp. 3–4, tells coders not to report 998.2
(accidental puncture or laceration). However, a PTCA
usually involves dissection of the lumen, says Manchen-
ton. “There is a bit of dissection inherent in the [PTCA]
procedure,” she says, adding that further dissection alone
doesn’t make it a clinically significant complication.
Likewise, insertion of a stent because of a dissection
doesn’t automatically indicate that the dissection is clini-
cally significant. Other indicators must be present in the
record to indicate the clinical significance, she says.
Conversely, dural tears are always coded as complica-
tions because they’re always clinically significant due to
the potential for cerebrospinal fluid (CSF) leakage, says
Howard. This leakage can cause CSF headache, caudal dis-
placement of the brain, subdural hematoma, spinal men-
ingitis, pseudomeningocele, or a dural cutaneous fistula.
Coders should report code 349.31 ( accidental puncture
or laceration of dura during a procedure) to denote this
condition. Refer to Coding Clinic, Fourth Quarter 2008, pp.
109–110 for more information. n
Editor’s note: Howard and Manchenton presented the
information in this article during HCPro’s audio conference
“Inpatient Postoperative Complications: Resolve Your Facility’s
Documentation and Coding Concerns.” For more information,
visit http://tinyurl.com/c2xzqkj.
Page 6 Briefings on Coding Compliance Strategies September 2012
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Contact Contributing Editor Lisa Eramo
Telephone 401-780-6789
Email [email protected]
Questions? Comments? Ideas?
by Robert S. Gold, MD
ICD-9-CM codes invariably change over
time. Some changes are for the better, and
some are for the worse. Some evolutions
occur more rapidly while other codes lag behind. As the
industry moves toward ICD-10-CM, code changes will con-
tinue, hopefully moving toward more accurate data capture.
Renal disease
Coding classifications of renal disease have evolved over
time. Currently, renal disease codes incorporate clinical
definitions of renal function or dysfunction. This includes a
stratification of the stages of chronic kidney diseases (CKD).
In the future, it will include the stages of acute renal disease.
But how did the medical community get to this point?
Coder and physician dissatisfaction with the term
renal insufficiency largely drove these changes. One need
not look far to find documented frustration with the
term. Coding Clinic, the National Kidney Foundation,
and Kidney Disease Improved Global Outcomes all have
published information about the difficulties associated
with use of this terminology.
What’s wrong with renal insufficiency? The term
doesn’t provide any indication as to whether the patient
has an acute or chronic problem. It also doesn’t indicate
whether it’s a progressive problem with renal function,
and it doesn’t reveal the severity of the problem.
The ICD-9-CM Coordination and Maintenance Com-
mittee divided the codes for CKD—alternatively known
as chronic renal failure—into five stages. The stages are
based on a patient’s glomerular filtration rate, which is
calculated with a patient’s creatinine level, age, gender,
and race. Stage I denotes normal renal function with a
glomerular filtration rate of more than 90 ml per minute.
Stage V denotes kidney failure with a glomerular filtration
rate of less than 15 ml per minute. The ICD-9-CM Coordi-
nation and Maintenance Committee added a classification
of ESRD in the code set to denote permanent dialysis.
As a result of these changes, chronic renal insuffi ciency
became measurable. The changes also allowed the medical
community to further research whether organ function
(other than the kidneys) suffered when the glomerular fil-
tration rate dropped to less than 45 ml per minute. Coded
data could also help track whether hyperparathyroidism or
anemia is associated with CKD and whether other homeo-
static problems might be related to the renal dysfunction.
The RIFLE criteria helped to stage acute renal failure. R
(risk), I (injury), and F (failure) denote progressively worse
levels of acute renal failure. These levels are measured by
changes in a patient’s serum creatinine, decrease in urine
output, or changes in the calculated glomerular filtration
rate. L (loss) denotes loss of renal function for at least four
weeks. E (ESRD) denotes permanent loss of renal function.
The Acute Kidney Injury Network (AKIN) eventually
determined that using the glomerular filtration rate to
measure the acute stages of renal damage is inappropriate.
This rate should be reserved for a patient’s chronic state
of kidney function. As a result, AKIN published Stages 1,
2, and 3 of acute renal failure, which is also referred to
as acute kidney injury.
Nephrologists argue that the cause of a patient’s CKD
is almost never the same as the cause of a patient’s acute
renal failure. They insist that “acute on chronic” shouldn’t
be used as a descriptor when referring to renal disease. A
patient with Stage 3 CKD due to hypertensive nephroscler-
osis can develop acute renal failure due to septic shock. A
patient with Stage 2 CKD from diabetic nephropathy can
Some codes evolve more slowly than others
September 2012 Briefings on Coding Compliance Strategies Page 7
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develop acute kidney injury from acute lupus nephritis.
Distinguishing between acute and chronic is helpful,
as is understanding severity and being able to identify
the cause of a patient’s renal problem. Coders can use
this information to assign ICD-9-CM codes for all of the
possible permutations.
Respiratory disease
Unfortunately, respiratory disease codes haven’t evolved
as quickly. ICD-9-CM currently includes codes for acute re-
spiratory failure, chronic respiratory failure, and acute-on-
chronic respiratory failure. However, aside from listing a
myriad of codes that simply aren’t specific enough, coders
cannot denote the cause or severity of respiratory failure.
ICD-9-CM also currently includes codes for respira-
tory insufficiency and respiratory distress. The codes only
denote that the insufficiency or distress is due to trauma,
surgery, or a disease. However, the codes don’t denote
whether the trauma or the surgery performed to treat the
traumatized patient caused the respiratory insufficiency or
distress. Making matters worse is the lack of a definition of
respiratory insufficiency or acute respiratory distress.
ICD-9-CM groups acute respiratory distress syndrome
(ARDS) and acute respiratory distress as inclusion terms
under respiratory insufficiency (ICD-9-CM code 518.82).
This means that the same codes are used for patients with
ARDS, who have a 10%–90% mortality rate, and patients
who are mildly short of breath for no particular reason.
In 1987, ICD-9-CM code 799.1 denoted cardiorespira-
tory arrest. This code still exists today. However, cases
of respiratory failure were removed from this code due
to new medical information that included development
of formal definitions of hypoxemic and hypercapnic
respiratory failure and acute and chronic respiratory
failure. As a result, ICD-9-CM code 518.81 was assigned
for acute respiratory failure. ICD-9-CM code 518.83 was
assigned for chronic respiratory failure. ICD-9-CM code
518.84 was assigned for acute and chronic respiratory
failure. ARDS—a specific type of acute inadequacy in
lung function that is a specified cause of acute respira-
tory failure—was included in ICD-9-CM code 518.82.
During the 1960s, ARDS was referred to as acute
respiratory distress syndrome. The term eventually became
known as adult respiratory distress syndrome to differenti-
ate it from infantile respiratory distress syndrome. How-
ever, acute respiratory distress syndrome was readopted
in 1993 because children other than newborns could also
experience the condition, and calling it adult respiratory
distress syndrome is inappropriate in the case of a child.
Thus, the description for ICD-9-CM code 518.82 was re-
vised to include the term acute rather than adult. However,
the revision stated acute respiratory distress—not acute re-
spiratory distress syndrome. This change has subsequently
continued to cause coding and documentation problems.
Respiratory insufficiency and acute respiratory distress
aren’t definable conditions. These are symptoms—not
diseases—and considering either term worthy of finan-
cial impact for a hospital or outpatient case is ludicrous.
The good news is that the crosswalk from ICD-9-CM
to ICD-10-CM demonstrates that ICD-9-CM code 518.82
maps to ICD-10-CM code J80 (acute respiratory distress
syndrome), which specifically excludes P22.0 (respira-
tory distress syndrome of the premature). The 518.5
series of codes don’t yet crosswalk appropriately to ICD-
10-CM. However, I hope that the codes will eventually
follow in the footsteps of code 518.82.
Meanwhile, coders have little choice but to assign ICD-
9-CM codes 518.82 and 518.52 when there is documenta-
tion of some of the unintended meanings of the codes. Do-
ing so means that although hospitals will reap additional
funds now, providers who treat patients with ARDS will
eventually receive less money in the future. Furthermore,
reporting these codes will probably cost Medicare and
Medicaid somewhere in the range of $500 million annu-
ally due to overbilling that technically follows the rules.
For now, if it looks like a symptom, don’t code it in
addition to the diagnosis. This practice follows the official
rule of coding symptoms that are integral to a diagnosis. n
Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm
in Atlanta that provides physician-to-physician CDI programs.
Contact him at 770-216-9691 or [email protected].
Page 8 Briefings on Coding Compliance Strategies September 2012
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Do you audit records before sending them to your
Recovery Auditor? If not, your hospital may be one of
many that simply don’t have the resources to do so.
Lori Brocato, product manager at HealthPort in
Atlanta, provides some of the many reasons hospitals
should consider self-audits. These include:
➤ Quality assurance (ensuring that all necessary
documents are included and that you don’t inadver-
tently mix dates of service or include documents that
the Recovery Auditor didn’t request)
➤ Advance notice of potential denials (knowing
beforehand whether a denial is likely as well as the
potential financial impact)
➤ Extra time for appeals (additional time to gather
data to include in a formal Recovery Auditor appeal)
“Another reason to perform the self-audit is to see the
potential for any secondary or tertiary payer trying to
come back and recover funds as well,” says Brocato.
When Recovery Auditors first began requesting records,
many hospitals performed self-audits mainly because of
anxiety and a desire to understand their own potential for
denials, says Brocato. Over time—and as Recovery Auditor
targets and denial patterns have become more apparent—
fewer hospitals seem to undertake the task. Some hospitals
choose to perform self-audits only when Recovery Audi-
tors announce new issues or targets, she says.
“I think most hospitals are trying to at least audit a
certain percentage whereas I think they used to try and
audit 100%,” says Brocato. Hospitals should self-audit at
least 10% of the records requested before sending them
to the Recovery Auditor so that they can keep a constant
barometer on their performance, she says.
Providence Health & Services
Providence Health & Services, a large hospital system
that spans Alaska, California, Montana, Oregon, and
Washington, initially performed self-audits of all records
before sending them to a Recovery Auditor. However,
when the Recovery Auditors started doubling their re-
quests, staff members couldn’t maintain the pace.
“With the increase in the number of records requested,
we have centered our resources around satisfying the
medical record requests and reviewing and responding to
denials,” says Laura Legg, RHIT, CCS, revenue control
coding consultant at Providence Health & Services.
Legg spends approximately 80% of her time reviewing
and appealing coding-related RAC denials for eight of the
health system’s 27 hospitals. She spends the remaining
20% of her time reviewing and appealing denials from
other auditors, performing internal audits, and educat-
ing coders about audit results. “The information has to
be passed on to the people who are actually doing the
work,” she says.
Recovery Auditor denials, in particular, have become
more complex and time-consuming to process as the
program has evolved, says Legg. “RACs are getting
smarter. At first, it was sepsis, excisional debridement,
and other things that we’ve known to be problems for a
very long time,” she says. “Now, they’re starting to deny
additional diagnoses for clinical validation. I’ve also seen
more principal diagnosis changes.”
Performing self-audits prior to sending records to a
Recovery Auditor has value, but many hospitals, like
Providence Health & Services, must instead focus on
reviewing actual denials, says Legg.
Phelps County Regional Medical Center
Phelps County Regional Medical Center, a 240-bed
rural facility in Rolla, Mo., has a different approach.
Cathie Eikermann, MSN, RN, CNL, CHC, interim
compliance and privacy officer and RAC manager, current-
ly reviews records before sending them to a Recovery Au-
ditor. When the Recovery Audit program began, the hospi-
tal received 50–70 requests every 48 days, and Eikermann
spent most of her time performing self- audits. The job was
Recovery Auditors
Consider self-audit before responding to request
September 2012 Briefings on Coding Compliance Strategies Page 9
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demanding, yet manageable. However, when the requests
spiked to 200, Eikermann, a full-time employee, could no
longer review every record herself. “Our physician re-
viewer is still looking at each one, fortunately,” she says.
The physician reviewer helps identify records at risk for
potential denial based on lack of documentation or lack of
substantiating clinical evidence, she says.
Eikermann’s own process for reviewing records is highly
organized and efficient. During her 10- or 15-minute re-
view of each record, she performs these tasks:
➤ Review the record to ensure that it includes all items
on a checklist that she developed (see p. 10). Giving re-
viewers the big picture is important, she says. Provid-
ing all necessary information up front so that reviewers
don’t deny a claim due to an apparent lack of support-
ing documentation, particularly when the documenta-
tion exists but simply wasn’t sent, is more cost-effective.
➤ Identify any documents that may be missing from the
record.
➤ Remove non-pertinent information (e.g., duplicate
copies, insurance information, and hospital-specific
forms such as room changes or home medication lists)
from the record.
➤ Assess the potential risk for a medical necessity
denial. This includes validating admission orders as
well as reviewing ED documentation, the physician’s
history and physical exam, and any other informa-
tion available at the time of admission to determine
whether the correct admission status was assigned.
➤ Determine whether documentation is present to sup-
port an appeal if the record is denied. This includes pre-
liminary research of updated evidence-based practice
standards that can be used during the appeal process.
Questions to consider
When deciding whether to perform a self-audit before
submitting records, consider the following questions:
➤ How many Recovery Auditor requests does
your hospital receive? In reviewing this number,
hospitals must consider whether reviewing all or a por-
tion of the requests is realistic, says Legg. “The number
of requests a facility receives really determines the ad-
ministrative burden placed on the facility,” she says.
Hospitals with a larger volume of requests may find
it difficult—or virtually impossible—to review records
beforehand, says Brocato.
➤ Are staff members available to complete a self-
audit? Ideally, a coding professional with a strong clinical
background, a CDI specialist, and a physician should all
participate in the self-audit, says Legg. Each must have a
clear understanding of how data gleaned from Recovery
Auditor requests, reviews, and denials can provide crucial
information for future process improvement.
➤ Do you have a defined process for performing
self-audits? Hospitals have 45 days to respond to Re-
covery Auditor requests, which is why it’s paramount to
develop an efficient self-audit process prior to sending the
record, says Brocato. “It’s a very time-consuming process.
It’s basically like re-coding that record again,” she says.
➤ How will staff members report errors discov-
ered during a self-audit? Each facility must determine
what will trigger self-disclosure to CMS, says Brocato.
“We do self-report, sending in the overpayment and re-
billing if within the timely filing period,” says Eikermann.
Note that isolated errors don’t necessarily require self-
disclosure to CMS. However, if self-audits reveal a larger
pattern or trend of errors, hospitals should consult with
legal counsel to determine whether disclosure is necessary.
For more information, access Transmittal 425, published
June 15, at http://tinyurl.com/clapker. CMS also has proposed
revisions to its Provider Self-Disclosure Protocol, which
establishes a process for providers to disclose potential fraud
as well as investigate and report fraud. Access the current
protocol, first published in 1998, at http://tinyurl.com/ccdeusk
as well as the proposed revisions published in the June 18
Federal Register at http://tinyurl.com/7mn5ozr.
“If you do find something that could be considered
fraudulent, you’re obligated to self-disclose that,” says
Brocato. “So if you’re going to self-audit, you’d better
have a plan in place for how you’re going to handle [any
errors that you find].” This plan should also include how
you’ll provide education for those who need it, she says. n
Page 10 Briefings on Coding Compliance Strategies September 2012
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Self-audit checklist
Recovery Auditor document checklist
Patient: ❒ Copy of HDI retrieval list DOS:❒ Attestation statement MR#:❒ UB 04 DRG:❒ Face sheet❒ Permits and authorizations❒ ED records❒ Order sets (if applicable) written and electronic orders❒ Laboratory reports❒ Radiology reports❒ All other clinical results such as echocardiograms, Doppler studies, TTE❒ History and physical ❒ Consultation notes❒ Progress notes (including pre/postoperative reports)❒ Physician discharge summary❒ Medication administration records❒ Dialysis/hemodialysis (if applicable)❒ Blood transfusion records (if applicable)❒ OR records❒ Telemetry recordings (if applicable)❒ Nursing clinical documentation❒ Nursing notes❒ Interdisciplinary team meeting notes❒ Discharge medication orders/instructions❒ Other forms: (list)
Source:CathieEikermann,MSN,RN,CNL,CHC,interimcomplianceandprivacyofficerandRACmanageratPhelpsCountyRegionalMedicalCenterinRolla,Mo.Adaptedwithpermission.
September 2012 Briefings on Coding Compliance Strategies Page 11
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Add PEPPER data to your audit programInformation received by TMF Quality Institute during
the past year indicates that 61% of hospitals use PEPPER
data to guide their auditing process and help them focus
on areas of potential vulnerability.
TMF is the nonprofit organization under contract with
CMS to provide comparative data reports to hospitals,
MACs, and FIs.
The feedback is based on a form that hospitals can
populate with data about their PEPPER use and sugges-
tions for improving the report. More than 70 respondents
have completed the survey. Data available at the time of
publication indicates that respondents use PEPPER to do
the following:
➤ Assess previous efforts to change billing patterns (39%)
➤ Review the diagnosis and procedure coding
process (50%)
➤ Educate staff about coding guidelines (43%)
➤ Assess case management procedures (44%)
➤ Improve the quality of clinical documentation (53%)
➤ Educate medical staff (43%)
“We review this information every quarter and share it
with CMS as a CMS contractor,” says Kimberly Hrehor,
MHA, RHIA, CHC, project director at TMF Health
Quality Institute in Austin, Texas. “We always review the
suggestions and recommendations for improvements to
see if they are items we can act upon and implement.”
For example, TMF recently received a request to
separate out the number of claims with only one CC or
MCC for a particular DRG, she says. Currently, PEPPER
identifies medical and surgical DRGs with one or more CCs
or MCCs coded on a claim. “We’re working on assessing
claims data to see if we can refine those target areas,”
she says. “And if so, with CMS’ approval, we could
implement revisions in a future report.”
Dig deeply into PEPPER
PEPPER awareness is increasing, says Hrehor. “There
has been more press about it, and I think there has been
more of an interest in it as a result,” she says. Reports are
currently available for short-term acute care hospitals,
long-term acute care hospitals, CAHs, IPFs, and IRFs.
They’ll also soon be available for hospices and partial
hospitalization programs, she says.
Why should hospitals review PEPPER? The answer is
simple, says Glenn Krauss, BBA, RHIA, CCS, CCS-P,
CPUR, C-CDI, CCDS, an independent HIM consultant
in Madison, Wis. “Why wait for denials when you can
prevent them?” he says.
For example, Trailblazer Health Enterprises, LLC, the
MAC for Jurisdiction 4, published a resource for hospitals
that reminds them to review PEPPER data. The resource
also acknowledges the MAC’s awareness that these targets
may be at risk for improper payments, says Krauss.
Recovery Auditors may also be reviewing PEPPER,
says Hrehor. “We don’t send PEPPER to the RACs, but
we do provide them with the database that includes
all of the statistics that are included in a PEPPER. Each
hospital’s information is in the database,” she says.
Who should review PEPPER? Coders, the compliance
officer, business office staff, the CFO, the HIM direc-
tor, CDI specialists, physician advisors, and utilization
review/management should all participate, says Krauss.
“They all have a vested interest in the PEPPER data,” he
explains.
Coders, in particular, need access to PEPPER because
code assignment can influence the data, says Krauss,
adding that hospitals can’t afford to perpetuate inac-
curate information on which auditors can prey. “I think
coders are very integral to the whole process, and they
rarely get feedback,” he says. “The focus is on getting
claims out the door.”
Coding managers can analyze PEPPER data to initiate
various process improvement techniques, says Krauss. For
example, identify areas in which a hospital ranks above
the 80th percentile. Then consider the following measures:
➤ Develop screens and coding protocols for certain
high-risk cases
Page 12 Briefings on Coding Compliance Strategies September 2012
© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.
➤ Tailor coder education that addresses the importance
of sequencing diagnoses and the effect on DRG
assignment and PEPPER data
Direct questions about PEPPER, including questions
about hospital-specific data, to TMF’s help desk at
www.pepperresources.org/HelpContactUs.aspx. “If hospitals
have questions, we want them to contact us,” says
Hrehor. “We are the authoritative source on PEPPER
information.” n
Editor’s note: Access the PEPPER feedback form at
http://tinyurl.com/775r2op.
Access the Trailblazer PEPPER resource at
www. trailblazerhealth.com/Publications/Job%20Aid/
PEPPERResources.pdf.
Documentation
Help physicians understand what coders need Coding managers and their team members some-
times must approach physicians in person regarding
documentation. Clarification may be necessary, or
perhaps you will need to coax the physician to complete
certain records without further delay. Physicians don’t
have much time, and they are inundated with documen-
tation requirements. Anything that coding managers can
do to help physicians understand coders’ documentation
needs and reduce queries should be welcome advice.
Physicians thrive on helping others, so asking them if
they can help is a good approach. Then quickly and con-
cisely explain what is needed and ask whether the physi-
cian can be of assistance. Rarely will a physician say no.
Coding managers can increase awareness of their role
and the challenges coders face by contributing a column
to the medical staff’s monthly newsletter. Be brief.
Consider topics such as those addressed in newsletters
or issues that have been discussed at the CDI committee
meeting. Examples from articles and columns in Medical
Records Briefing include “Why accuracy and specific-
ity matter” (January 2010), “Know ICD-9-CM, CDC, and
MS-DRG classifications for HIV” (August 2009), “Use
medical literature to defend patients’ severity of illness in
pay-for-performance risk adjustment” (June 2009), “ICU
documentation is critical: Reflect patient severity to get
credit where credit is due” (May 2009), and “What’s in it
for us? Documentation and physician reimbursement go
hand in hand” (November 2009).
Finally, consider meeting with the medical staff office
managers quarterly. These meetings have been successful
in developing rapport between the office managers and
key individuals in organizations. The administration often
hosts these meetings, and representatives of multiple
departments may be in attendance. Building rapport with
office managers is a common goal because they often are
the gateway to obtaining information from physicians.
Office managers usually have the physicians’ trust and
their ear. They usually can move something from the bot-
tom of the physician’s pile to the top. Developing positive
relationships with office managers will have paybacks.
Coding managers are in an ideal position because physi-
cian office managers often need coding guidance. Devel-
oping a quid pro quo arrangement benefits both parties. n
Editor’s note: This article is adapted from The Coding
Manager’s Handbook, published by HCPro, Inc.
2013 IPPS Final Rule
Editor’snote:CMSreleasedthe2013IIPSFinalRuleas
Briefings on Coding Compliance Strategieswentto
press.TheOctoberissuewillexaminetheruleindetail.
WanttolearnmoreaboutthechangesCMSfinalizedas
partoftheIPPSfinalrule?JoinHCProandourexpertspeak-
ersat1p.m.EDT,September20,foraliveaudioconference,
2013 IPPS Final Rule Highlights and New Initiatives.
A monthly service of Briefings on Coding Compliance Strategies
September 2012
We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.
To submit your questions, contact Briefings on Coding Compliance Strategies Contributing Editor Lisa Eramo at [email protected].
Editor’s note: Answers to the following questions are
based on limited information submitted to Briefings on
Coding Compliance Strategies. Review all documen-
tation specific to your scenario before determining appropri-
ate code assignment.
How do a cervical/vaginal laceration complica-
tion/repair and a routine episiotomy performed
for ease during delivery differ?
A routine episiotomy is a procedure during which a
surgeon performs a surgically planned, less-than-
second-degree incision on the vulva/vagina area or region
to prevent a more serious laceration or tear at the time of
vaginal delivery. The incision is usually only 1–2 centimeters
in length. A cervical/vaginal complication occurs when
there is a l aceration of the cervix or the high vaginal area
that occurs naturally at the time of delivery.
Coders must review documentation to ascertain wheth-
er the patient had a routine episiotomy or whether a cervi-
cal or high-vaginal tear/laceration occurred at the time of
delivery. Sometimes the high-vaginal tear/ laceration occurs
in addition to an episiotomy. Many coders forget to code
the complication.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG,
a coder at St. Alphonsus Regional Medical Center in Boise,
Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer,
answered this question.
A patient was exposed to shingles, for which a
coder reported ICD-9-CM code V01.79 (exposure
to other viral diseases, including HIV). This poses a
problem for billing because code V01.79 is a confiden-
tial diagnosis that requires special release of informa-
tion from the patient, and this information would
remain in the insurance record. As an RN and certified
coder, I think code V01.71 (exposure to varicella) is the
correct code because the varicella virus causes both
chicken pox and shingles. However, the chief business
officer has overruled me. Which code is correct?
I understand where the confusion lies for both the
coder and the business office. When you look up
“Shingles” in the ICD-9-CM Manual, it directs you to
herpes zoster, which is not a modifying term under the
main term “exposure.” Therefore, code V01.79 would
seem appropriate.
Interestingly, certain viruses (e.g., smallpox and
varicella) have specific codes, but other viruses are within
the not elsewhere classified (NEC) category, again making
code V01.79 seem appropriate. Also, HIV does not have a
specific code and is grouped with viruses NEC.
Shingles are caused by herpes zoster, an infection that
results when a varicella-zoster virus reactivates from its
latent state in the posterior dorsal ganglion, according to
Merck. Both chicken pox and herpes zoster are caused by
the varicella-zoster virus (herpes virus type 3). Chicken pox
is considered an active phase of the virus, whereas shingles
(herpes zoster) is a latent phase of the virus (i.e., a reactiva-
tion of the virus). Therefore, I agree that exposure to vari-
cella, code V01.71, would be appropriate here.
However, neither the alphabetic index nor the tabular
list offer guidance, making it understandable why view-
points differ with respect to coding. Coding Clinic does not
provide any advice on the subject either.
A supplement to Briefings on Coding Compliance Strategies
Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2012 HCPro, Inc., Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2012 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
Unfortunately, a clear answer may not be possible.
Both opinions seem logical and appropriate, and I can’t
say for certain that either is truly correct because herpes
zoster does not have its own specific code and it doesn’t
cross-reference varicella.
My only advice is to educate the business office staff
and try to persuade them that you are correct. However,
I’m not 100% certain that they are incorrect.
Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory
specialist at HCPro, Inc., in Danvers, Mass., answered this
question that originally appeared on JustCoding.com.
What is the appropriate principal diagnosis for a
patient who presents repeatedly with COPD
exacerbation and chronic pulmonary fibrosis?
During one admission, the physician documented
“acute flareup of pulmonary fibrosis,” and we concurred
that pulmonary fibrosis was the principal diagnosis.
However, other admissions for which both conditions
are documented aren’t as clear. Some coders and CDI
specialists think that the COPD should be sequenced
first because it’s an acute exacerbation. Others think
that the pulmonary fibrosis should be sequenced first
because it causes the COPD.
Can the physician document any particular terms to
illustrate the severity and priority of diagnoses so that
we know which to report as the principal diagnosis?
Pulmonary fibrosis is not designated as one of the
diagnoses included in COPD, according to the
ICD-9-CM index or tabular reference. Coders and
CDI specialists should review the patient’s record to
determine whether the physician identifies COPD as a
separate disease process from pulmonary fibrosis. If the
record supports a separate disease process, coders may
report COPD exacerbation as the principal diagnosis,
depending on the circumstances of the admission and
physician documentation.
There is also no ICD-9-CM index or tabular reference
for pulmonary fibrosis exacerbation. The ICD-9-CM Official
Guidelines for Coding and Reporting (effective October 1,
2011), Chapter 8: Diseases of the Respiratory System, state:
An acute exacerbation is a worsening or a decompen-
sation of a chronic condition. An acute exacerbation is
not equivalent to an infection superimposed on a chronic
condition, though an exacerbation may be triggered by
an infection.
Again, carefully review the record for an acute infec-
tious process or other instigating event. If the record refers
only to pulmonary fibrosis, that should be the principal
diagnosis. The index includes a long list of the types of
pulmonary fibrosis. Coders should select a code based on
specific physician documentation. An infectious process
such as bacterial pneumonia may be the principal diagno-
sis, depending on the circumstances of the admission.
Your inquiry indicates the patient has frequent admis-
sions. Coders should query the physician if documentation
is unclear. It might be useful for CDI specialists to discuss
this patient’s condition(s) with the physician and provide
the available ICD-9-CM classifications for each diagnosis.
Jean Stone, RHIT, CCS, coding manager at Lucile Packard
Children’s Hospital at Stanford in Palo Alto, Calif., answered
this question.
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