nchima webinar 10.24.12 donna wilson handoutappealacademy.com/wp-content/uploads/2012/10/... ·...

10/22/2012

1

Wednesday, October 24, 2012 1

Donna D. Wilson, RHIA, CCS, CCDS

AHIMA Approved ICD-10-CM/PCS Trainer

Compliance Concepts, Inc./Senior Director


This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner.

The author is not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding.

Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.

The views and opinions of the speaker may not reflect the opinion of their employer.

Based on AHIMA presentation during the 2012 Coding Community – “Inpatient Coding Challenges vs. Clinical Indicators.” Gloryanne Bryant, RHIA, CCS, CDIP, CCDS/AHIMA Approved ICD-10-CM/PCS Trainer, Donna D. Wilson, RHIA, CCS, CCDS/AHIMA approved ICD-10-CM/PCS Trainer, and Sharon Easterling, MHA, RHIA, CCS, CDIP


10/22/2012

2

Background Refresh your mind on basic coding guidelines Identify clinical indications for the following tests:

Complete blood count (CBC); Complete metabolic profile (CMP); Troponins, Urinalysis; and Vital signs

Review real case studies Implement improvement methods and Decrease denials Summary Questions/Answers


The number of coding/DRG denials from government and non-government payers due to lack of clinical indications to support the ICD-9-CM diagnosis code is increasing.---------------------------------------------------------------------With regulatory scrutiny over coding, we are challenged with keeping current on: AHA coding guidance/Official Coding Guidelines Clinical indications Governmental targets


All diagnoses should be supported by physician documentation.

If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement.


10/22/2012

3



Quarterly subscription, published by the AHA Office on ICD-9-CM

Contents are approved by the four cooperating parties.


10/22/2012

4

Uniform Hospital Discharge Data Set (UHDDS)

Principal diagnosis (inpatient):

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.


What does “the condition found after study” mean? The words "after study" are not referencing the

admitting diagnosis but rather the diagnosis found after workup or even after surgery that proves to be the reason for admission.

Therefore “the coder must always review the entire medical record to determine the condition that should be designated as the principal diagnosis.”

Source: Faye Brown’s ICD-9-CM Coding Handbook


The definition for “other diagnoses” includes additional conditions that affect patient care in terms of requiring:

Clinical evaluation; orTherapeutic treatment; orDiagnostic procedures: orExtended length of hospital stay; or Increased nursing care and/or monitoring


10/22/2012

5

Signs and symptoms integral to the disease process should not be assigned as additional codes unless otherwise instructed by the classification.

Do not over code◦ Redundant coding is inappropriate

Abdominal pain due to gastric ulcer: No symptom code is assigned to the abdominal pain because it is integral to the ulcer.


Inpatients diagnosed with a possible, probable, etc. at the time of discharge is considered to be an established diagnosis and should be coded and reported as though the diagnosis were established.

Other terms that fit the definition of a probable or suspected condition are: "consistent with," "compatible with," "indicative of," "suggestive of," "appears to be," and "comparable with."

Caution with epilepsy, HIV, multiple sclerosis



10/22/2012

6

When a CC/MCC is present as secondary, it may affect DRG assignment.

Cases w/ a single CC/MCC are a governmental/commercial payer coding/DRG target.

Denials are due to the secondary diagnosis being billed and not substantiated clinically in the medical record.

Let’s take a quick review of some common laboratory testing/documentation tips.


1. Complete Blood Count (CBC)

2. Complete Metabolic Panel (CMP)

3. Troponin levels4. Urinalysis5. Vital signs


Five major measurements:

a) White Blood Cell (WBC)b) Red Blood Cell (RBC) c) Hemoglobin (HgB) d) Hematocrit (HcT)e) Platelet count (Plt)


10/22/2012

7

3.3 – 8.7

3.93 – 5.69

12.06 – 16.1

38 – 47.7%

147 - 347


Even though labs may reveal abnormal hemoglobin and hematocrit levels, the physician needs to provide an interpretation or document the significance of the abnormal finding.

Patient s/p elective Total Knee Replacement donates 2 units of his/her own blood prior to the procedure to compensate for the expected blood loss during this joint replacement.


AHA CC Third Quarter 2004- Postoperative Anemia Secondary to Expected Blood Loss.

Review physician documentation. “If in the physician’s clinical judgment,

surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss.


10/22/2012

8

a) Blood sugarb) Calcium levelc) Cholesterol d) Kidney functione) Liver functionf) Protein levelsg) Sodium,

potassium, and chloride levels (electrolytes).


Measurement/Normal Values

a) Blood sugar (Glucose test) / 100 mg/dL

b) Calcium level/ 8.5 – 10.9 mg/dL

c) Cholesterol/ 120-200 mg/dl

d) Kidney function :

BUN = 7-20 mg/dL

Creatinine = 0.8 – 1.4 mg/dL.


Measurement/Normal ValuesALT/ 7 to 55 units per liter (U/L)

AST/ 8 to 48 U/LALP/ 45 to 115 U/LAlbumin/ 3.5 to 5.0 grams per deciliter (g/dL)Total protein/ 6.3 to 7.9 g/dLBilirubin/ 0.1 to 1.0 mg/dLGGT/ 9 to 48 U/LLDH/ 122 to 222 micromoles per liter (mcmol/L)PT/ 8.3 to 10.8 seconds


10/22/2012

9

Measurement/Normal Valuesf) Protein levels/ 6.3 – 7.09 g/dLg) Sodium/ 136-144 mEq/Lh) Potassium/ 3.07 – 5.2 mEq/Li) Chloride levels / 96 – 106 mmol/Lj) CO2 (carbon dioxide)/ 20 – 29 k) Total bilirubin / 0.2 – 1.9 mg/dL


Measurement/Normal Valuesf) Protein levels/ 6.3 – 7.09 g/dLg) Sodium/ 136-144 mEq/Lh) Potassium/ 3.07 – 5.2 mEq/Li) Chloride levels / 96 – 106 mmol/Lj) CO2 (carbon dioxide)/ 20 – 29

mmol/Lk) Total bilirubin / 0.2 – 1.9 mg/dL


Protein malnutrition codes to code ICD-9-CM code 260 –Kwashiorkor.

Kwashiorkor is an EXTREMELY RARE form of malnutrition seen in third world countries.

If a physician writes “protein malnutrition,” validate documentation and clinical indicators/query.

See Sample query next slide.


10/22/2012

10

Dear Dr.__________________:You have documented “protein

malnutrition” which ICD-9-CM classification indexes to “Kwashiorkor” a rare syndrome occurring mostly in starving children. Please clarify whether your patient had Kwashiorkor, or whether he/she had “protein malnutrition,” “malnutrition unspecified,” or some other nutritional diagnosis.Thank you – Susie coder or Sandy CDI


Coded as Acute Renal Failure (CC) based solely on physician documentation of ARF in Progress Notes.

No elevated BUN or Creatinine Levels. Denied my Commercial payer based on

secondary diagnosis code not supported clinically.

Best Practice-when in doubt QUERY, especially if this is your only CC or MCC!


Review the medical record for specific signs and symptoms relating to an MI

i.e. elevated troponin-cardiac enzymes- when the patient presents with chest pains.


10/22/2012

11

Have become the cardiac markers of choice for patients with ACS (acute coronary syndrome).

Elevated troponin levels, but negative CK-MB values, who were formerly diagnosed with unstable angina are now reclassified as non–ST-segment elevation MI (NSTEMI), even in the absence of diagnostic electrocardiogram (ECG) changes.

Similarly, only 1 elevated troponin level above the established cutoff is required to establish the diagnosis of acute MI, according to the ACC guidelines for NSTEMI.


Normal Troponin T < 0.4 ng/ml

Cardiac enzymesCK-index = 0-3CK-MB = 0-3

Total CK= 38 – 120


DOJ – ICD medical necessity

criteria includes –patients who were coded with a principal or secondary dx of MI within 30-40 days of the ICD placement.

Possible, probable MIs are included.

• Cases with positive troponin levels but the MI was ruled out.

• Cases coded as MI and now claim is part of DOJ review.

• * Acute MI is also a core measure.*


10/22/2012

12

Ten measurements• Urine Bilirubin• Urine Blood• Urine Ketone• Urine Leukocytes• Urine Micro• Urine Nitrate• Urine Protein• Specific gravity• Urine pH• Urobilogen


Measurement Normal Values

Urine Bilirubin Negative

Urine Blood Negative

Urine Ketone Negative

Urine Leukocytes Negative


Measurement Normal ValuesUrine Nitro RBCs: 0-2/HPF

WBCs: 0-2/HPFRBC Cases: 0/HPF

Urine Nitrate NegativeUrine Protein Negative-TraceUrine Specific Gravity 1.002-1.030

Urine pH 5-7

Urobilogen 0.2-1.0 Her U/dl


10/22/2012

13

Measurements of the body's most basic functions-vital signs:

body temperature pulse rate respiration rate (rate of breathing) blood pressure (Blood pressure is not

considered a vital sign, but is often measured along with the vital signs.)


Body temperature/ 97.8°- 99°F Pulse rate / 60 to 100 beats per minuteRespiration rate / 15 to 20 breaths per minuteBlood pressure / less than 120 mm Hg systolic

pressure over less than 80 mm Hg diastolic pressure


SEPSIS CLINICAL INDICATIONS: (TWO OR MORE REQUIRED FROM # 1-4):1) Fever= temp > 100.4 or < 96.8.2) Respir. > 20 bpm or arterial blood PCO2 < 32mm.3) Heart rate > 90 beats per minute.4) Leukocytosis WBC >12,000 or <4,000 or w/10% immature band forms.

AND-next slide


10/22/2012

14

ALTERED ORGAN PERFUSION (ONE FROM # 5-12):

5) Hypotension.

6) Metabolic acidosis.

7) Oliguria.

8) Acute altered mental status.

9) Shock.

10) Positive blood cultures and/or positive urine cultures (the absence of + B/C does not preclude the dx of Sepsis).

11) Patient is receiving ATB prior to admission.

12) Sepsis is documented as due to internal device, implant or graft.



#1. 68 yo male Background:

History - admitted in atrial fibrillation, recently treated for bronchitis during a previous admission but lungs are clear.

CXR- clear lungs Cardiology consult – ? Pneumonia (MCC) Zithromax continued @ 250 MG/DAY. DRG 308 (Cardiac arrhythmia w/ MCC) to

DRG 310 (Cardiac arrhythmia w/out CC/MCC).


10/22/2012

15

#1. 68 yo male Appealed with UHDDS guidelines:

Clinical evaluation; or Therapeutic treatment; orDiagnostic procedures; or Extended length of hospital stay; or Increased nursing care/or monitoring.


#1. 68 yo male –Case denied after appeal:

Quoted AHA CC 2nd Qtr. 2000 pgs. 17-18: “If there is evidence of a diagnosis within the medical

record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder’s responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement.”


#2. 92 yo female

History-admitted with acute pancreatitis. Treatment toward pancreatitis. Renal U/S & Abdominal CT – Hydronephrosis (CC)No treatment toward hydronephrosis.

DRG 439 (Disorders of Pancreas w/ CC) to DRG 440 (Disorders of Pancreas w/out CC/MCC).


10/22/2012

16

#2. 92 yo female Appealed with UHDDS guidelines:




Quoted AHA CC 2nd Qtr. 2002: “When the attending physician does not confirm the

results of the radiology report for inpatient coding, query the attending physician regarding the clinical significance of the findings and request appropriate documentation be provided.”


#3. 74 yo male History-admitted with chronic abdominal pain. EGD – Ulcer in the atrium & fistula into duodenal wall

with no perforation PN- AKI (acute kidney injury). BUN=22/Creat 1.73.

DRG 381 (Complicated Peptic Ulcer w/ CC) to DRG 382 (Complicated Peptic Ulcer/out CC/MCC).


10/22/2012

17

#3. 74 yo maleAppealed with UHDDS guidelines:




Quoted AHA CC 2nd Qtr. 2000 pgs. 17-18: “If there is evidence of a diagnosis within the medical

record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder’s responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement.”



10/22/2012

18

Perform reviews on areas with increased scrutiny or known to be problematic

Documentation Success

Review

Analyze

Educate


Utilize a team approach Select problematic areas Perform Review (new review or current audit

findings) Select timeframe for cases Perform drill-down◦ Physician, coder, CDI, service line, query occurrence

Report findings Develop next steps


Areas identified on internal or external audits Industry trends OIG workplan/audit reports Contractor audits – RAC, ZPICS, Commercial, etc… CERT, PEPPER, MAC reviews New DRGs or codes introduced New technology/diagnoses New systems/processes/coders/CDI staff


10/22/2012

19

For DRG Validations, certified coders shall ensure they are not looking beyond what is documented by the physician, and are not making determinations that are not consistent with the guidance in Coding Clinic.

RAC Final Statement of Work 9/2011


Set goals on what is identified from review… Is there additional coding or clinical knowledge

needed? To whom – coding, CDI, physician advisor? Who will educate? How? (Webinar, workshop, clinical training needed

such as disease process) Set date for re-evaluation…


Ensure providers understand the quality, severity and mortality rates impacted by coding

Coding competencies – improve and enhance Anatomy and physiology (AHIMA proficiency tests) Disease process Coding guidelines/changes such as Coding Clinics Share findings from reviews Share denials such as with contractor reviews Clinical information related to problematic body

systems, diagnoses and procedures (AHIMA 2005)


10/22/2012

20

Coder/CDI◦ Take back to coder/CDI◦ Determine their understanding and educational needs – will

reaudit◦ Perform regular departmental coding education◦ Ensure CDI is also kept in the loop and educated◦ Bring in those individuals with strong clinical knowledge in

identified area – good educator


One effective method to achieve a greater level of training is to use clinicians from your facility to present classes on new surgical or diagnostic procedures, various clinical disease processes and/or how certain surgical instruments are utilized (Bowman 2007). This type of training can serve to educate both the coders and the clinicians. You should ask the coders to list prior to the training their clinical questions that impact coding on the topic to be presented. This helps the presenter know what to cover and increases his or her understanding of the relationship of clinical documentation to coding. The questions can also point out areas where improved physician documentation is needed.

HPMP Compliance Workbook 2006 rev.2008


Utilize the AHIMA query guidance (Practice Brief) Perform random reviews on queries Follow-up on those needing additional structure on

formation and language Follow query response rates Utilize physician advisor or coding/CDI leader for

problems Monitor number of queries related to certain diagnoses

and reductions in initiation of queries Use queries to educate regarding documentation

shortcomings


10/22/2012

21

Know your coding rules, guidelines◦ Coding diagnoses/procedures “because it was documented is not the

defense to WIN”

Challenge clinical denials that you have confidence in Utilize clinical resources for justification of your denial

when clinical Address chronicity of symptoms (Coding Clinic and

guidelines) Utilize medical staff/physician advisor Need to understand rules of coding and clinical disease

process


Pneumonia◦ Fever, labs, cultures, chest x-ray, IV antibiotics, vent

Acute Renal Failure◦ Labs, IV Fluids impact (receiving fluid and possibly halting

fluid), dialysis

Sepsis Fever, labs, cultures, blood pressure - hypotension, IV antibiotics

(more than 1), confusion


Respiratory Failure◦ Signs/Symptoms; ABGs; Respiratory treatment; nonbreather;

O2; medications

GI Bleed◦ Labs, endoscopy, bowel procedures, meds, mental status,

blood

COPD◦ Oxygen levels including dependence on O2, ABGs, Steroids,

bronchodilators, smoker, h/o asthma, environmental, color –blue, difficulty breathing, chest x-ray


10/22/2012

22

Coding Resources◦ Alphabetic Index◦ Tabular Index◦ CPT Manual◦ HCPCS Manual

Coding Clinic LCDs/NCDs Regulatory Guidance


Coders need to review carefully the final code that the encoder software is providing

Use your ICD-9-CM code book◦ Alpha and Tabular

Documentation must be supported for the assignment of the code.◦ Coding from memory is risky

Coding guidelines change


Audit and Assess coding competencies Communicate Educate Utilize physician advisor or coding/CDI leader Enhance clinical knowledge for the coding

professional Engage HIM Coding in RAC appeals process


10/22/2012

23


ICD-9-CM Official Coding Guidelines FY2012 National Institute of Health Patient Education -

www.cc.nih.gov/ccc/patient_education/pepubs/cbc97.pdf

U.S. National Library of Medicine-http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003939/

Mayo clinic-Liver function tests -http://www.mayoclinic.com/health/liver-function-tests/MY00093/DSECTION=results


Use of cardiac markers in the Emergency Department, MEDSCAPE Reference -http://emedicine.medscape.com/article/811905-overview

University of Minnesota-Medical Student-http://www.student.med.umn.edu/wardmanual/normallabs.php#Cardiac_Enzymes

Ohio State University Wexner Medical Center -http://medicalcenter.osu.edu/patientcare/healthcare_services/emergency_services/non_traumatic_emergencies/vital_signs/Pages/index.aspx


10/22/2012

24

www.nlm.nih.gov/medlineplus HcPRO, 2011, “Coding & Physician Language 2nd

Edition.” Gloryanne Bryant,RHIA,CCS,CDIP,CCDS. Bryant, Gloryanne RHIA,CCS,CDIP,CCDS and

Donna D. Wilson, RHIA,CCS,CCDS. “Data Mining result raises coding concerns.” Health Care Compliance Association. July 2011.

Sharon Easterling, MHA, RHIA, CCS, CDIP◦ Carolinas Healthcare System/Consultant ◦ President/CEO Recovery Analytics, Inc.


Must Have: Current ICD-9-CM book Current CPT™ book Official Coding Guidelines AHA Coding Clinic on ICD-9-CM AMA CPT Assistant Other Coding References: Faye Brown's ICD-9-CM Coding Handbook Medical dictionary Anatomy & physiology book Coder's Desk Reference for Procedures (Ingenix) Medical abbreviations book Merck Manual (diseases)


Donna D. Wilson, RHIA,CCS,CCDS Senior Director/Compliance Concepts, Inc. 103 Bradford Road, Suite 320 Wexford, PA 15090 843-345-4653 [email protected] www.complianceconcepts.com


nchima webinar 10.24.12 donna wilson handoutappealacademy.com/wp-content/uploads/2012/10/... ·...

Documents