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Oregon Health Information Management AssociationMay 2016
Annual ConferencePortland, Oregon
SpeakerGloryanne Bryant, RHIA, CDIP, CCS, CCDS AHIMA‐Approved ICD‐10‐CM/PCS Trainer CHIA Past President 35+ Year Coding HIM Professional
National Director Coding Quality, Education, Systems and Support
Kaiser Permanente – National Rev Cycle Oakland, CA
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Disclaimer 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.
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NOTE: The content of this presentation, the comments and opinions of the presenter do not reflect those of ORHIMA or
Kaiser Permanente.
Goals/Objectives Review key documentation aspects for ICD‐10 coding
Understand challenges and steps to take to close gaps
Improve ICD‐10‐CM and PCS coding knowledge and skills
Question/Answers
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Some things are not NEW, as History Does Repeat Itself!
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Coding Classification System: Historical Timeline 1893: The first International List of Causes of Death (at that time called the Bertillon
Classification of Causes of Death) was adopted by the International Statistical Institute at a meeting in Chicago
1898: At a meeting of the American Public Health Association in Ottawa, the International List of Causes of Death (Bertillon Classification) was recommended for use by registrars of Canada, Mexico, and the United States of America.
1900–1929: The Government of France convened the first International Conference for the Revision of the Bertillon or International List of Causes of Death in 1900.
1938: the first International Conference for the Revision of the International List of Causes of Death
1948 The International Conference for the Sixth Revision of the International Lists of Diseases and Causes of Death was convened in Paris
1955–1983: Succeeding decennial revision conferences (in 1955, 1965 and 1975) recognized the increasing use of ICD for the indexing of hospital medical records
1977: ICD 9th revision was published 1983‐84: Diagnostic Related Groups (DRGs_ were implemented in the US, increasing
greater the importance of ICD‐9‐CM coding for the Inpatient Prospective Payment System, called “IPPS”.
1996‐2006: ICD‐10 implementation starts in many other countries 2007: IPPS is changes to a Medicare Severity DRG system, increasing once again the
importance and need for accurate coding…. And documentation 2013: ICD‐10 Delay 2014: ICD‐10 Delay 2015: ICD‐10 was implemented in the US
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ICD‐10 Experience 1/19/2016
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Clinical Documentation
Justifies treatment, supports the diagnosis
Advances Regulatory Compliance
Patient safety
Increases accuracy of publicly reported Patient Care Outcomes
Captures patient severity and acuity
Kicks off the revenue cycle and improves Reimbursement
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Clinical Documentation (con’t)
Accurate documentation is critical to Tell the patient’s story
Details the patient’s diagnoses and describes how they were determined and treated
Enable proper reimbursement of care Correct MS‐DRG and SOI and ROM assignments result in case
weight that reflects resources used Medical Necessity
Ensure hospital and physicians correctly rated Public reporting Scorecards Outcomes
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Clinical Documentation (con’t) Clinical documentation is the cornerstone of patient care monitoring, determining quality, research and reimbursement.
Quality/Core measure adherence
Potentially Preventable Complication (PPC) performance
Tumor Registry data
Physician and hospital profiling
Including mortality data
Compliance for reimbursement/denial prevention
Commercial payers
RAC audits
Protection in the event of litigation9
Clinical Documentation… is so Important
Legal Ramifications
Disciplinary action by licensing body for unprofessional conduct
Criminal prosecution by the DA or AG
Altering medical records or creating false medical data is a misdemeanor
Loss of accreditation from various agencies
Loss of funding/reimbursement for the care provided
Patient/client loses benefits they are otherwise entitled to
Adverse impact on defense in malpractice case
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Clinical Documentation into Clinical Data Core Measures
Ever expanding—including CVA, VTE
CMS Hospital Compare
PPCs: Potentially Preventable Complications
Publically accessible websites rating physicians
CMS Physician Compare
Outcomes based data for inpatient care
www.HealthGrades.com – Independent source of physician information and hospital quality outcomes
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Why Coded Data Matter? (Hospital and Physician profiling data is available to the public)
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BAA Requirement As specified in §4317(b) of the Balanced Budget Act (BBA), referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered. As further indicated in 42 CFR 410.32 all diagnostic tests “must be ordered by the physician who is treating the beneficiary.”
As defined in §15021 of the Medicare Carrier Manual (MCM), an “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.
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Clinical Data for Research
Cancer research has come a long way.
Forty years ago, researchers and doctors often knew nothing about many types of cancers.
Today, they have the ability to break individual cancers down on a genomic basis.
Every tumor has its own unique genetic signature. No tumor is like any other.
Big Data is Key . . . Clinical Data is the Linkage!
Documentation and Coding are the core
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CODED DATA
Healthcare circle of life……..
Patient seen
Coding Analysis and translation of clinical statements, clinical results, clinical documentation and information in the medical record to assign codes from a clinical classification system whereby the coding professional (user) applies appropriate conventions, rules and guidelines.
Documentation and Coding are linked
They go together
We can’t talk about one without the other . . .
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Coding Competencies(Hospital, Physician & Other Settings) Anatomy and Physiology Disease Process and Medical Terminology Pharmacology Health Information Documentation ICD‐10‐CM Diagnosis Coding & UHDDS ICD‐10‐PCS Procedure Coding CPT/HCPCS & Modifiers Data Quality Confidentiality & Ethical Issues Healthcare Compliance
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ICD‐10‐CM Secondary Diagnosis Reporting:
clinical evaluation; ortherapeutic treatment; or
diagnostic procedures: orextended length of hospital stay; orincreased nursing care and/or monitoring
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ICD‐10‐CM (con’t) Chronic Systemic Conditions
For chronic systemic conditions identified as secondary diagnoses, the conditions must coexist at the time of admission
Chronic Systemic Conditions do NOT need to meet the other secondary diagnosis definitions, per AHA Coding Clinic. . .
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Systemic Conditions Definition: Systemic means affecting the entire body, rather than a
single organ or body part. For example:
o Systemic disorders such as high blood pressure or systemic diseases such as influenza affect the entire body.
o An infection that is in the bloodstream is called a systemic infection (Source: Medline Plus)
A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole. (Source: Wikipedia)
A condition that pertains to or affects the body as a whole. (Source: Dorland’s Medical Dictionary.)
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Documentation Key Elements Type of condition
Type I or Type II diabetes
Onset
When did it start?
Etiology / Cause
Infectious agent
Physical agent
Internal failure
Congenital
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Anatomical location Which anatomical structure
Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior…
Laterality Right side or left side
Severity Mild, moderate or severe
Environmental factors Smoking
Geographic location
Documentation Key Elements (con’t) Findings and symptoms
Fever
Hypoglycemia/hyperglycemia
Wheezing
External causes Motor vehicles, injury locations
Assault, accidental, work related, intentional self harm
Type of encounter Initial encounter, subsequent encounter, encounter for condition sequela, routine evaluation, administrative encounter
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Time parameters Intermittent/Paroxysmal Recurring Acute or chronic Post‐op, post delivery
Comorbidities or complications Diabetes with neuropathic joint Intracranial injury
Manifestations Paralysis Loss of consciousness
Healing level Routing healing, delayed healing, non‐union, malunion…
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Documentation: H&P
At a minimum the following should be documented: Chief Complaint/Initial diagnostic impression/Reason for
Admission History of Present Illness Past medical/Surgical History Immunization Record (for Pediatric Patients) Allergy Record Current Medications Family History Social History Review of Systems Physical Examination Impression Plan
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Documentation: Progress Notes At a minimum the following should be documented:
Signed, dated and timed
Problem(s) and/or diagnosis
Subjective assessment
Observations/findings; change in condition; Pertinent lab/radiology findings
Action and treatment plan
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Documentation: Operative Report At a minimum the following should be documented: Date/Time of Procedure Pre and Postoperative diagnosis Name of Procedure Performed Name of Practitioner Performing Procedure and any assistants Type of Anesthesia given Complications, if any Technique(s) used and findings Any tissue removed or altered Estimated Blood Loss Prosthetic devices, grafts, tissues, transplant or devices implanted, if any
If dictated, then a brief operative note is required in the progress section immediately following surgery (By‐Laws Rules and Regulations). The brief operative note made in the progress note must include:
Name of Surgeon and name of any assistance Name of the procedure performed Findings of the procedure Any estimated blood loss must be documented even if no blood was lost Any specimen(s) removed (must state “none” if no specimens removed) Postoperative diagnosis Date/Time of Procedure
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Documentation: Discharge Summary At a minimum the following should be documented:
Admission Date Discharge Date Final Diagnosis (includes principal and secondary diagnoses) Reason for Hospitalization (Chief Complaint and present illness) Significant findings Hospital Course Treatment given and/or Procedures performed Any drug reactions or complications Patient’s condition and disposition at discharge Information provided to the patient and family, including provision for follow‐
up care (contained in Discharge Instructions)
Timing: written/completed: within 14 days of discharge; sooner is better Transfer Summary:
A transfer summary is to accompany the patient upon transfer to a skilled nursing or intermediate care facility or to the distinct part‐skilled nursing or intermediate care service unit of the hospital.
A copy of the transfer summary is to be given to the patient and the patient's legal representative, if any, prior to transfer to a skilled nursing or intermediate care facility 26
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Documentation: Problem List The problem list can be problematic and puts coding quality compliance at risk.
If the condition is unclear whether “active” or not that is a risk……….. you should query for clarification
Administration and maintenance of the problem list needs to be routinely performed or there is risk
The problem list needs to be updated each time there is a change in a diagnosis, medications, allergies or when a procedure is performed.
If the chronicity of a condition is unclear (chronic, acute, self‐limiting) there is a coding quality risk.
Discuss with your Medical Staff and Leadership.
Perform reviews and share findings
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Documentation: History Of
The history and physical often cites the patient as having a “history of” various conditions.
These may actually be currently active problems and, if so, must be stated as such or the coding professional cannot capture them as secondary diagnoses.
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Documentation: History Of Neoplasm Codes from category for “History of” are assigned only when the primary neoplasm has been totally eradicated and is no longer under any type of treatment.
Personal History
If still undergoing treatment then the neoplasm is current.
Document any “Family History of… neoplasm”
Physician awareness is important so the documentation reflects the correct wording.
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Documentation in ER: Chief Complaint What do we do when the documentation in the ER is only the chief complaint and the patient leaves before being seen?
Scenario: A patient comes to the emergency room and provides a chief complaint of abdominal pain, right side during the registration process. The patient is triaged (by the triage nurse) and again the chief complaint is provided as abdominal pain, right lower side, which is documented into the medical record. The patient waits in the ER until they can be seen by a physician. After waiting some time the patient leaves without being seen by a physician.
Question: Would the primary diagnosis for this ER encounter be “abdominal pain right lower side” R10.31 in ICD‐10‐CM?
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Documentation in ER: Chief Complaint (con’t)
The appropriate ICD‐10‐CM codes for this scenario are: R10.31 Right lower quadrant pain Z53.21 Procedure and treatment not carried out due to patient leaving prior to being seen by
health care provider Rationale : The Emergency Department registration staff documented “abdominal pain, right side.” The
clinical staff member, the triage nurse, documented the chief complaint with even more specificity. It is appropriate to assign to highest specificity provided. The chief complaint is subjective and not a clinical diagnosis, therefore, what is documented on the record as the patient’s specific complaint is an appropriate chief complaint, and in this case, the only symptom that can be assigned a diagnostic code (in the absence of definitive diagnosis). Z53.21 is an appropriate secondary code for supplemental and tracking information.
AHA Coding Clinic® provides clear guidance on such scenarios. Please reference AHA Coding Clinic®, 1988, 2nd Quarter, pages 4‐8 and 1999, 1st Quarter, pages 13‐14.
Also reference the 2016 Official Guidelines for Coding and Reporting, Section I.B.4 (as part of the General Coding Guidelines):
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD‐10‐CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 ‐ R99) contains many, but not all codes for symptoms.
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Documentation: Newborn Weeks of Gestation Often we code the newborn records and see the information about weeks of gestation but the documentation of “post‐term newborn” is not in the record.
Question: Can we assign “post‐term newborn” code P08.21 on the newborn record, based on the weeks of gestation if the weeks are documented by the attending/pediatrician?
Do we need the wording (documentation) of “post‐term” in the medical record?
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Documentation: Newborn Weeks of Gestation (con’t) The neonates record documents that the baby was born at 40.4 weeks of gestation. Regardless of whether the physician documented literally “post‐term” or not, the diagnostic code P08.21 describes a newborn whose birth occurred between 40 and 42 weeks of gestation.
AHA Coding Clinic® provides clear guidance on such scenarios. Please reference AHA Coding Clinic®, 2000, 1st
Quarter, pages 17‐18 and 2014, 1st Quarter, page 14. AHA Coding Clinic® 2006, 2nd Quarter, pages 12‐13 clearly states that a post‐term or prolonged gestation of an infant may be assigned based only on the gestational age of the newborn.
A specific condition or disorder does not have to be associated with the longer gestational period to use these codes.
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Documentation: BMI
The BMI may be documented in the medical record.
Often EHR will capture this through nursing assessment.
Documentation should then include a correlating condition in order to code the BMI value.
For example:
Obesity
Malnutrition
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Documentation: External Cause When a body part meets with an external object and
the result is an injury, you must explain what that external object or force was. Sequence this external cause code after the code or codes for the injury itself.
The cause may be anything from being stepped on by a cow (W55.29X‐) to falling from scaffolding (W12.XXX‐) to the forced landing of a hot air balloon, injuring the occupant (V96.02X‐).
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Documentation and CodingExternal Cause Codes There are 33 sub‐chapters used to report how the injury occurred,
the intent (unintended/accidental/intentional; suicide or assault), the activity of the patient at the time of the event, the place where the event occurred, and the patient’s status at the time of the event (civilian, military, volunteer, student, leisure etc).
An external cause code is assigned for each encounter during which an injury or condition is treated — not just for the initial treatment. To accomplish this, three new seventh‐character extensions were added to identify the episode of care for the current encounter. They include:
•A: initial encounter •D: subsequent encounter •S: sequelae
The seventh character “A” is to be used for as long as the patient continues to receive active treatment.
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External Cause Codes: ICD‐10‐CM Changes in Chapter 20
The external cause of injury codes from Chapter 20 in the ICD‐10 manual and are prefixed with the letters V, W, X, and Y.
Homicide is now termed “assault.”
Suicide is now termed “intentional self‐harm.”
Drowning: The detail is in the type of water involved (e.g., bathtub, swimming pool, natural water). In ICD‐9, the emphasis was on the activity being undertaken at the time of the event, for example, swimming, water‐skiing, and diving. Therefore, information on the activity before the incident is lost in ICD‐10. Water transportation‐related drowning codes (i.e., V90 and V92) are included in the “other transport” codes rather than with drowning codes.
Poisoning: Although ICD‐10 is generally more detailed, ICD‐10 external cause codes for unintentional and intentional poisoning are substantially less detailed than in ICD‐9. However, using multiple cause‐of‐death poisoning codes in combination with the external cause codes can regain poisoning details lost under the revision.
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Documentation for ICD‐10‐CM: Coding the Place of Occurrence
Official Guidelines
b. Place of Occurrence Guideline Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition. Generally, a place of occurrence code is assigned only once, at the initial encounter for treatment. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned. No 7th characters are used for Y92. Do not use place of occurrence code Y92.9 if the place is not stated or is not applicable.
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Documentation: It’s documented and it’s specific!. . . When it’s documented and specific be VERY sure to code it specifically.
Coding reviews have identified that coding professionals are missing the documentation.
Documentation states:
Benign hypertension and Acute gastric ulcer with hemorrhage with H Pylori
Answer: I10 and K25.0, B96.81
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Documentation & Coding Specificity
THERE IS NO PLACE FOR UNSPECIFIED CODES IF: There is sufficient information available to more accurately define the condition
For basic concepts such as: Laterality (Right, Left, Bilateral, Unilateral) Anatomical locations Trimester Type of diabetes Known complications or comorbidities Description of severity, acute or chronic or other known
parameters…
Where care is implemented that demands a more specific level of detail
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Documentation: The Words Matter . . . “88 y/o admitted from ED with c/o severe back pain and
failure to thrive. No hx of fall/trauma. PMH: osteoporosis, cardiomyopathy. New compression fx at L5.”
SOI = 2 Moderate ROM = 1 Minor VS
88 y/o admitted from ED. A/P: Pathologic fracture, L5. Continue pain meds for severe back pain. Failure thrive withmoderate malnutrition. Nutrition consult ordered. Ischemiccardiomyopathy, continue home meds as needed.”
SOI = 3 Major ROM = 2 Moderate
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Symptom
SymptomCC
Principal Diagnosis
Principal Diagnosis
Specific Dx
CC
DocumentationPoor quality documentation is bad for Payers, Providers and Patients. Billing accuracy
Quality measures
Population management
Risk management
Healthcare analytics
Research
Reimbursement
Patient Care 42
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Documentation
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• It is a best practice particularly when treating a critically ill patient that the physician document all comorbid conditions monitored, evaluated or treatment through out the patient stay.
• When undocumented, the severity of illness and the risk of mortality will be inaccurately reflected in the codes and may result in a variety of unexpected outcomes.
• Dialog with your Medical Staff• Awareness• Data sharing
Documentation: Arthritis ARTHRITIS Increased Specificity In ICD‐10‐CM, there are specific codes for primary and secondary arthritis. Within the
secondary arthritis codes there are specific codes for post‐traumatic osteoarthritis and other secondary osteoarthritis. For secondary osteoarthritis of the hip there is also a code for dysplastic osteoarthritis.
Arthritis codes in ICD‐10‐CM is both similar and different than ICD‐9‐CM. For example, currently, in ICD‐9, osteoarthritis can be described as degenerative, hypertrophic, or secondary to other factors, and the type as generalized or localized. ICD‐10 provides more options for the coding osteoarthritis related encounters, including:
Generalized forms of osteoarthritis or arthritis where multiple joints are involved. Localized forms of osteoarthritis with more specificity that includes primary versus
secondary types, subtypes, laterality, and joint involvement.
Indicate the type, location, and specific bones and joints (multiple sites if applicable) involved in the disease. In addition, describe any related underlying diseases or conditions.
M19.041 Primary osteoarthritis right hand M19.241 Secondary osteoarthritis, right hand M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
Source: CMS
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Documentation: OB/GYN ICD‐10 Code Examples ABORTION Definition Change The timeframe for a missed abortion (vs. fetal death) has changed from
22 to 20 weeks. In ICD‐10‐CM, an elective abortion is now described as an elective termination of pregnancy.
There are four spontaneous abortion definitions in ICD‐10; use the appropriate definition in your documentation:
No bleeding, os closed Bleeding, os closed Bleeding, os open, products of conception (POC) are extruding Possible bleeding or spotting, os closed, all POC expelled
O02.1 Missed abortion O36.4XX1 Maternal care for intrauterine death, fetus 1 Z33.2 Encounter for elective termination of pregnancy Source: CMS
Documentation: OB/GYN (con’t)
VOMITING
Definition Change
The time frame for differentiating early and late vomiting in pregnancy has been changed from 22 to 20 weeks.
O21.0 Mild hyperemesis gravitum
O21.2 Late vomiting of pregnancy
Source: CMS
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Documentation: OB/GYN (con’t)
COMPLICATIONS OF PREGNANCY Increased Specificity Documentation of conditions/complications of pregnancy will need to
distinguish between pre‐existing conditions, or pregnancy‐related conditions.
When documenting well child exams and screen, include the following: Was the condition pre‐existing (i.e., present before pregnancy) When did the pregnancy‐related condition develop? Establish the relationship between the pregnancy and the complication (i.e.
preeclampsia)
O99.011 Anemia complicating pregnancy, first trimester O13.2 Gestational [pregnancy‐induced] hypertension without significant
proteinuria, second trimester O24.012 Pre‐existing diabetes mellitus, type 1, in pregnancy, second trimester
Source: CMS
Documentation: Underdosing UNDERDOSING Terminology Difference Underdosing is an important new concept and term in ICD‐10. It allows
you to identify when a patient is taking less of a medication than is prescribed.
When documenting underdosing, include the following: Is the underdosing deliberate? (e.g., patient refusal) Why is the patient not taking the medication? (e.g. financial hardship,
age‐related debility)
Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship
T36.4x6A Underdosing of tetracyclines, initial encounter T45.526D Underdosing of antithrombotic drugs, subsequent encounter
Source: CMS
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Documentation: Cardiomyopathy CARDIOMYOPATHY Increased Specificity When documenting cardiomyopathy, include the following,
where appropriate: e.g. Dilated/congestive, obstructive or nonobstructive
hypertrophic, etc. e.g. Endocarditis, right ventricle, etc. e.g. Congenital, alcohol, etc.
List cardiomyopathy seen in other diseases such as gout, amyloidosis, etc.
I42.0 Dilated cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.3 Endomyocardial (eosinophilic) disease
Source: CMS
Documentation by Providers Physicians, nurse practitioners and physician’s assistants —documentation from any of them can be used to support coding and billing.
Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician.
Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment.
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Use and Refer to the ICD‐10‐CM Official Guidelines
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Lesson
Official ICD‐10‐CM/PCS Coding and Reporting Guidelines
Review and understand
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Lesson: Coding Advice
AHA Central Office Coding Clinic
Free advice – send in question
Quarterly Subscription
AHIMA Code Check
Paid subscription
24‐48 hr. turnaround with answer
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Lesson AHA Coding Clinic on ICD‐10‐CM and ICD‐10‐PCS 2012, Coding Clinic began answering ICD‐10‐CMS/PCS questions
Every effort was made to carry over the ICD‐9‐CM guidelines and concepts into ICD‐10‐CM, unless there was a specific change in ICD‐10‐CM that precluded the incorporation of the same concept into ICD‐10‐CM.
However, some of the guidelines in ICD‐9‐CM included information that may have been clinical in nature and therefore not appropriate for coding guidelines.
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Lesson: AHA Coding Clinic (con’t) Care should be exercised as ICD‐10‐CM has new combination codes as well as instructional notes that may or may not be consistent with ICD‐9‐CM.
HTN and CKD
Assumed relationship
Lesson: Documentation within an Imaging Report “It is appropriate to utilize imaging reports to provide greater specificity of the anatomic site as documented by the physician. Therefore, if a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, it would be appropriate to utilize the imaging report to determine the location of the stroke or infarction.”
See Coding Clinics 3Q 2014, page 5, First Quarter 2013, page 28, and First Quarter 1999, page 5
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Lesson: Follow the coding steps Alpha
Step 1: Find the condition in the alphabetic index.Begin the process by looking for the main term in the alphabetic index. After locating the term, review the sub terms to find the most specific code available. Instructional notes in this section will help guide the reader with information such as “see,” “see also,” “with, ”without,” “due to,” and “code by site.”
Tabular Step 2: Find the condition in the tabular index. Verify the code in the tabular
index. This is the alphanumeric listing which organizes codes by disease and injury. Additional detail is found here to create the most complete code. For example, the default code for asthma in the alphabetic index is J45.909. If is the reader selects this code without consulting the tabular index, an unspecified code would be reported.
The tabular index identifies severity (intermittent, mild persistent, moderate persistent, or severe persistent) as well as complications such as an acute exacerbation or status asthmaticus. Notes provide guidance for additional conditions which would need to be reported to identify exposure to tobacco smoke or use of tobacco.
The tabular index also contains information identifying the length of a code; this is important since a code is anywhere from three to seven characters long. This index includes additional information such as “Excludes 1” and “Excludes 2” status. The exclude notes identify codes that you can never reported together (Excludes 1) and codes that you can never report at the same time (Excludes 2).
Source:: http://www.physicianspractice.com/blog/three‐steps‐selecting‐icd‐10‐codes‐accurately#sthash.pojiomGO.dpuf
Lesson: Follow the coding steps (con’t) Step 3: Review the chapter‐specific coding guidelines.The final step in locating a code is a review of the chapter‐specific coding guidelines found before the alphabetic index of the ICD‐10 manual. The index includes guidelines for specific diagnoses or conditions. Some of the more complex diagnosis codes can be found here including HIV and sepsis. Without consulting this section, important sequencing guidelines would be missed.
See more at: http://www.physicianspractice.com/blog/three‐steps‐selecting‐icd‐10‐codes‐accurately#sthash.pojiomGO.dpuf
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Lesson
Your coding Policies and Procedures for coding CANNOT go against or be contrary to Official Coding & Reporting Guidelines.
Lesson . . .
When the guidance says to query the physician you should query.
But what if you don’t have a process to query the physician, then you’re not following the guidelines that tell you to do so.
Utilize the AHIMA Query Practice Brief 2013
Compliant querying forms/templates
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Clinical Documentation Improvement (CDI)
• Clinical Documentation Improvement (CDI) programs and activities are increasing in size and setting.
• One key fact for all CDI programs is the necessary link and collaboration between coding and HIM.
• Taking a look at CDI and how it’s grown and matured can bring new insight into communication, cooperation and to being a successful collaborator.
• The past, present, and future of CDI is a hot topic that continues to grow and become more important to our healthcare
Physician Champion
• Medical Staff member
• Selecting a CDI physician advisor
• Respected in medical community, possess leadership skills.
• Can devote time each week for chart review, coder consultation, and physicians interaction
• Can serve on the UR Committee, and be involved in MS‐DRG activities
• Willing to conduct in‐house education and training programs
• Conduct interviews with those interested
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Remember . . . The role of the clinician is to document as accurately and thoroughly as possible the nature of the patient conditions and services performed.
The role of the coding professional is to assure that coding is consistent with the documentation and follows official instructions, conventions and guidelines.
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Actions to Take . . . Documentation awareness
ALSO. . . Understand the AHIMA Practice Brief on Query Process
Compliance
Develop a written Physician Query Policy
Education Coding and CDI staff: Documentation
Physician Champion
Develop ICD‐10 Physician Queries
Begin using them before go‐live
Query Retention policy
Documentation elements
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Summary
Documentation and Coding Lessons
Follow the Official ICD‐10 Guidelines
Watch Alpha and Tabular listings
Do they match what you are trying to code?
Follow Official Coding and Reporting Guidelines
Follow AHA Coding Clinic
Query process and policy
CDI & Physician engagement and involvement
Conduct reviews/audits
Questions
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Thank you
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References/Resources http://oshpd.ca.gov/HID/MIRCal/Text_pdfs/Bulletins/QuickNotesV40.pdf
AHA. Coding Clinic, Second Quarter, 2012, p. 21. AHIMA. “Amendments in the Electronic Health Record.” AHIMA Toolkit. Published August 15, 2012.
AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): 45‐50.
AHIMA. “Managing an Effective Query Process” Journal of AHIMA 79, no.10 (October 2008): 83‐88
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018
http://narhc.org/wp‐content/uploads/2013/09/ICD‐10‐Documentation‐Requirements.pdf
http://www.physicianspractice.com/blog/three‐steps‐selecting‐icd‐10‐codes‐accurately
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