Download 264920.ppt

POINT-COUNTERPOINT
Discussing differences in
interpretation of clinical situations
and coding guidelines
Joel Moorhead, MD, PhD
Associate Medical Director
FairCode Associates
GOALS
• Recognize reasons for different interpretations of …
– Clinical findings
– Coding guidelines
• Explore examples of situations that can be viewed in
more than one way
• View differences as learning opportunities
• Consider ways to resolve differences
Different Physicians
Different Diagnoses
Diabetes – Manifestations - 1
Common
Less Common
• Neuropathy (250.6x + …)
• Neuropathy (250.6x + …)
– Gastroparesis (536.5)
– Polyneuropathy (357.2)
• Nephropathy (250.4x + …)
– CKD
• Other (250.8x + …)
– Ulcer, especially foot (707.xx)
– Osteomyelitis (730.xx)
• Bone involvement in diseases
classified elsewhere (731.8)
• Association assumed
– Radiculopathy /
Polyradiculoneuropathy
(723.4, 724.4)
– Neurogenic arthropathy
(713.5)
• Charcot foot
– Amyotrophy (353.1)
– Peripheral autonomic
neuropathy (337.1)
• Diabetic locomotor ataxia
Diabetes – Manifestations - 2
I have seen this one
Possible
• Other manifestations
•
(250.8x + …)
– “Hyponatremia secondary to
Cardiomyopathy
– Develops after 4-5 years of diabetes, due
to hyperglycemia
•
underlying diabetes” (276.1)
•
•
•
•
Depuytren’s contracture
– Found in 22% Type II diabetics
Hemochromatosis (primary) (275.01)
– “Bronzed diabetes” inclusion term
Non-alcoholic fatty liver
– 21-45% have diabetes
Pancreatitis
– DM → 3x risk
Musculoskeletal manifestations of
diabetes
– Carpal tunnel syndrome
– Osteopenia
– Shoulder capsulitis
•
Curr Opin Rheumatol 2004;17:64-69
What we see depends
mainly on what we look for.
John Lubbock (British archeologist)
Complications – Bariatric Surgery
Common
Are these postop conditions?
• Post-gastric surgery syndromes
•
Other postoperative functional intestinal disorders
(564.4)
– Constipation (40%)
– Diarrhea (fat malabsorption) (15%)
– Vomiting (15%)
•
Post-surgical malabsorption (579.3)
– Nutritional deficiencies (30%)
(564.2)
– Dumping syndrome
Food bypasses stomach undigested
• Early – soon after eating
•
– Cramping, bloating
Late – 1-3 hours after eating
– Weakness, sweating, dizziness
•
•
– Jejunal syndrome
– Post-gastrectomy syndrome
– Post-vagotomy syndrome
• Post-surgical malabsorption
(579.3)
– B12 deficiency
• Failure to separate protein-bound
B12 in gastric pouch
•
•
•
•
Iron-deficiency anemia (15%)
– Iron absorbed in duodenum
Vitamin deficiencies
– Fat-soluble vitamins (10%)
– Folate
Osteoporosis and metabolic bone disease
– Hypocalcemia
Hypoalbuminemia / hypoproteinemia
Gallbladder disease/gallstones (3-30%)
Abdominal pain (15%)
– Kral JG (1998). Surgical treatment of
obesity. In Kopelman PG, Stock MJ
eds. Clinical Obesity, pp. 545-563.
Dumping Syndrome +
Postop B12 deficiency?
• Post-gastric surgery syndromes (564.2)
EXCLUDES
– Malnutrition following gastrointestinal surgery (579.3)
– Other/unspecified post-surgical malabsorption (579.3)
• If 564.2 excludes 579.3,
we can’t code them together, right?
– Let’s return to this question later …
Different Coders
Different Codes
Honest disagreement is
often a good sign of
progress.
Mahatma Ghandi
Differences of Opinion - Reasons
One Best Code Assignment
Two or more Reasonable Codes
• Definitive source
• Two or more guidelines
– ICD-9-CM Official Guidelines
for Coding and Reporting
• Conventions
• Chapter-specific guidelines
• General coding guidelines
– AHA Coding Clinics
• Our brains may see patterns,
not detail
• Obscure source
• Excludes notes
•
•
•
•
•
•
apply
Chronic conditions
Underlying causes
Interpreting clinical
information
Principal diagnosis
My encoder doesn’t take
me there
Us - ourselves
One Best
Code Assignment
Well, probably one best
ONE BEST CODE ASSIGNMENT - 1
Definitive Source - 1
• Hierarchy of sources for code selection (in descending order)
– ICD-9-CM Official Guidelines for Coding and Reporting (OGCR)
(“Section …” citations in slides to follow refer to the ICD-9-CM Official Guidelines)
• Conventions (conventions considered separately from guidelines)
– Chapter-specific guidelines
• General guidelines
– AHA Coding Clinics
• ICD-9 Alphabetic Index or Tabular List take precedence over advice in Coding
Clinic
– Coding Clinic 1Q 2008, page 17
• Reasons definitive source may be missed
– Specific convention, general guideline, or Coding Clinic applies but missed
– Chapter-specific guideline applies but missed
•
•
•
•
•
•
Chapter 1: Infectious and Parasitic Diseases
Chapter 2: Neoplasms
Chapter 3: Endocrine, Nutritional, Metabolic, Immunological
Chapter 11: Complications of Pregnancy, Childbirth, Puerperium
Chapter 15: Newborn (Perinatal)
Chapter 17: Injury and Poisoning
ONE BEST CODE ASSIGNMENT - 1
Definitive Source - 2
General perinatal rules
• If the Index does not provide a specific (Chapter 15) code for a
perinatal condition …
– Assign code 779.89, Other specified conditions originating in the perinatal period
…
– Followed by the code from another chapter that specifies the condition (OGCR
Section I.C.15.a.2). BUT …
• Congenital anomalies (Chapter 14)
– 779.89 apparently not required (Section I.C.14.a.)
• Assign code only if condition affected fetus or newborn
(OGCR Section I.C.15.h.3)
• Conditions are either “community acquired” or “due to birth process.”
– Default is “due to birth process”
– If the condition occurs during the perinatal period, but is documented to be
“community-acquired,” code 779.89 is not assigned (OGCR Section
I.C.15.a.3)
• ALSO - A condition is significant if it has implications for future
healthcare needs.
ONE BEST CODE ASSIGNMENT - 1
Definitive Source - 3
• Similar clinical situations, different guidelines
– Seizure disorder related to old stroke
• Other late effects of cerebrovascular disease (438.89) is PDx
– “Since documentation specifies seizure disorder d/t old stroke”
– Epilepsy, unspecified (345.90) is additional code
• Coding Clinic 2Q 2009
• Cognitive deficits after stroke (438.0)
– Seizure disorder related to traumatic brain injury
• Post-traumatic epilepsy (345.xx)
– No mention of late effect of intracranial injury (907.0)
• Coding Clinic 4Q 2010
• Cognitive deficits after traumatic brain injury (799.5x)
– Use additional code to identify the late effect
• Coding Clinic 4Q 2010
 Consistent with Instructional note, ICD-9 Subcategory 438.89
– Why is brain injury treated differently from stroke?
ONE BEST CODE ASSIGNMENT - 1
Definitive Source - 4
•
Post-traumatic seizure disorder
– Seizure (780.3x)
•
•
Late effect of intracranial injury (907.0)
Ask the physician if post-traumatic seizures are
– Temporary (seizure - 780.3x), or
– Chronic (epilepsy - 345.9)
• Coding Clinic Nov-Dec 1987
–
Seizure disorder - Clarification
•
Epilepsy (345.xx) is appropriate code for
– Seizure disorder NOS
– Recurrent seizures
•
•
Single seizure: Other convulsions (780.39)
ICD-9 Alphabetic Index or Tabular List always takes precedence over Coding Clinic
– Coding Clinic 1Q 2008
–
Post-traumatic seizures
•
Post-traumatic seizure (780.33)
– Initial or recurrent seizure within first week post-injury
•
Post-traumatic epilepsy (345.xx)
–
Recurring seizure >1 week after injury
•
•
Coding Clinic 4Q 2010
Single seizure >1 week after injury? Ask the physician if unclear.
ONE BEST CODE ASSIGNMENT - 2
Pattern Recognition
• Subtle differences in wording
– Transient mental disorder in conditions classified elsewhere (293.9)
• “In conditions classified elsewhere” codes are never permitted to be used
as principal diagnosis (Section I.A.6.)
– Other persistent mental disorders due to conditions classified
elsewhere (294.8)
• Dementia NOS (294.8) is eligible to be used as PDx
• We may miss details in what we read
– If the fusrt and lsat ltetres are cerroct, we can unrdastend the
mneanig of the wrod.
• But process more slowly
– Rayner K, White SH, Johnson L, Psychological Science 17(3):192-193
– Do we understand, or do we just think we understand?
• Some Coding Clinics are harder to absorb than others
ONE BEST CODE ASSIGNMENT - 2
Coding Clinic Example #1
•
Mechanical complication of prosthetic joints
Coding Clinic 4th Quarter 2005
– Question
• Patient status post hip replacement, admitted with periprosthetic fracture of the prosthetic joint,
sustained after minimal activity. What is the appropriate code assignment?
– Answer
• Assign code 996.44 Periprosthetic fracture around prosthetic joint as principal diagnosis.
– BUT - Text gives examples; PDx in examples is not 996.44!
• Fracture of a prosthetic joint due to trauma
–
Traumatic fracture code with V code from subcategory V43.6 Joint replaced by other means
• Fracture of a prosthetic joint due to underlying condition, such as osteoporosis
– Pathologic fracture code, also with the appropriate V43.6 code.
•
Why could this be confusing?
– We expect complication code to be sequenced as principal diagnosis (OGCR Section II.G.)
• Answer was complication code as PDx, but in text examples 996.64 was not PDx
• Seems 996.64 would be best for trauma + prosthesis or osteoporosis + prosthesis
– This is a long coding clinic. A busy coder might read the answer and not study the
examples.
•
Complete understanding may require multiple readings.
ONE BEST CODE ASSIGNMENT - 2
Coding Clinic Example #2
• Septicemia, SIRS, sepsis, severe sepsis, and septic shock
Coding Clinic 4th Quarter 2003
– Sepsis is defined as SIRS due to infection
– Use of term “septicemia” is in keeping with the international version
of ICD-9
• So as not to confuse existing statistics, the term “septicemia” will continue
to be used in the ICD-9-CM
– For this reason, inclusion term “sepsis” was added under code 995.91
– Default first code should be 038.9 Septicemia
• Because terms “sepsis” and “SIRS” indicate systemic infection
• What is so special about this Coding Clinic?
– SIRS due to infection on admission → 038.9 Septicemia PDx
• Documentation of the term “Sepsis” not required by ICD-CM
– Excellent discussion of REASONS underlying coding direction.
ONE BEST CODE ASSIGNMENT - 3
Obscure Source
• Left ventricular outflow tract obstruction
– Not indexed in ICD-9
– Not a specified inclusion term under any listing
• Coding Clinic 3rd Quarter 2007
Shone’s Syndrome
– “Left ventricular outflow tract obstruction
(subaortic stenosis)”
• Subaortic stenosis (746.81)
ONE BEST CODE ASSIGNMENT - 4
Excludes Notes - 1
• Terms excluded from the code are to be coded
elsewhere (OGCR Section I.A.4.)
– Codes may not be used together (let’s call this “Type 1”)
• Congenital and acquired forms of a condition
– Codes may be used together (let’s call this “Type 2”)
• Fractures of different bones coded to different codes
• Problem
“Type 1” and “Type 2” Excludes notes
look exactly alike in ICD-9.
– ICD-10 Excludes1 and Excludes2 notes will correspond to ICD9 “Type 1” and “Type 2” notes
ONE BEST CODE ASSIGNMENT - 4
Excludes Notes - 2 - COPD /Asthma
• ICD-9 Tabular List
– Asthma, acute exacerbation, with COPD (493.22)
• Excludes COPD with acute bronchitis (491.22)
• Coding Clinic 3rd Quarter 2006
– Acute exacerbation COPD + acute bronchitis +
acute exacerbation of asthma
• Assign code 491.22 and code 493.22
• Reconciling these statements
– The Excludes note under listing 493.22 indicates that
• COPD with acute bronchitis (493.22)
– Is listed elsewhere and …
– Is required for full description of the condition
• “Type 2” Excludes note
ONE BEST CODE ASSIGNMENT - 4
Excludes Notes - 3 - Hypertension
• Hypertension (401)
– Excludes
• Elevated BP without diagnosis of Hypertension (796.2)
– Elevated BP in patient with no formal diagnosis of HTN
– “Type 1” Excludes note
• Involving vessels of the brain (430-438)
– Use additional code to identify presence of Hypertension
– “Type 2” Excludes note
• Pulmonary hypertension (416.0-416.9)
– (no instructional note)
– We need to decide what kind of excludes note this is.
• The Excludes note at Category 401 indicates that essential and
pulmonary hypertension are coded in separate categories.
• When the physician documents both conditions, the two categories
can be reported together.
 Coding Clinic 3rd Quarter 2010, pages 12-13
Dumping Syndrome +
Postop B12 deficiency?
• Post-gastric surgery syndromes (564.2)
EXCLUDES
– Malnutrition following gastrointestinal surgery (579.3)
– Other/unspecified post-surgical malabsorption (579.3)
• If 564.2 excludes 579.3, we can’t code them together, right?
Hmmm
– No instructional notes under either 564.2 or 579.3
– Post-gastric surgery syndromes (564.2) do not include either
“malnutrition” or “malabsorption”
– What kind of Excludes note is this?
• “Type 2” excludes note?
• OK to add 579.3?
– Requires judgment to decide
– Legitimate differences of opinion possible
Two or More
Reasonable
Code Assignments
TWO (+) CODES REASONABLE - 1
Two (+) Guidelines Apply
Diabetic patient admitted with sepsis due to
acute osteomyelitis
•
Coding Approach #1: Septicemia (038.9) is PDx
– Generalized infection (038.9) is sequenced ahead of localized infection (Osteomyelitis 730.0x)
–
–
•
• Chapter-specific guideline (OGCR Section I.C.1.b.1.3)
No encoder warning appears when 038.9 is PDx
Sepsis is only indirectly related to diabetes (through osteomyelitis).
• Sepsis Chapter–specific guideline takes precedence?
Coding Approach #2: Diabetes (250.8x) is PDx
– Localized infection, Osteomyelitis (730.0x), was due to Diabetes
– ICD-9 assumes relationship between Diabetes and Osteomyelitis
–
–
• Coding Clinic 1Q 2004
Generalized infection (038.9) was due to diabetic condition (730.0x + 731.08 Bone involvement
in diseases classified elsewhere)
• Antibiotic treatment was for both osteomyelitis and sepsis
Diabetic code (250.xx) sequenced ahead of codes for associated conditions
• Chapter-specific guideline (OGCR Section I.C.3.a.4.)
• Also supported by ICD-9 conventions, OGCR Section I.A.6, Etiology/Manifestation convention
•
– Conventions are independent of guidelines
Since Diabetes code is supported by ICD-9 convention, Diabetes Chapter–specific guideline takes precedence?
TWO (+) CODES REASONABLE - 2
Chronic Conditions
• Chronic conditions such as but not limited to …
– CHF, asthma, emphysema, COPD, diabetes, hypertension, Parkinson’s disease
• Inclusion terms are not necessarily exhaustive (∴ coding not limited to inclusion terms
under listing)
– OGCR Section I.A.4.
– Affect the patient for the rest of his or her life
• Almost always require clinical evaluation or monitoring
• … can be coded without proving significance
– Coding Clinic 3Q 2007 / 2Q 1992 / Jul-Aug 1985
– Coding Clinics may specify additional chronic conditions
• Patient admitted for unrelated condition, taking phenytoin for seizure disorder due to old
stroke
– Seizure being treated and meets criteria for coding as an additional diagnosis
• Coding Clinic 2Q 2009
– Others?
•
•
•
•
•
•
Lupus?
Pulmonary hypertension?
Rheumatoid arthritis?
Cardiomyopathy?
Ulcerative colitis?
Crohn’s disease / regional enteritis?
TWO (+) CODES REASONABLE - 3
Underlying Causes - 1
• Rectal abscess due to Crohn’s disease
– Regional enteritis (555.9) is principal diagnosis (PDx)
• Crohn’s disease is the underlying cause of the rectal abscess and is
therefore sequenced first.
– Coding Clinic 3Q 1999; consistent with
• Coding Clinic 3Q 1999 (Colonic fistula due to Crohn’s)
• Coding Clinic 4Q 1997 (Pyoderma gangrenosum)
• Coding Clinic 2Q 1997 (Bowel obstruction due to Crohn’s)
– No ICD-9 instructional notes
• GI bleed (578.9) due to Crohn’s disease?
– Crohn’s disease is underlying cause; ∴ PDx 555.9?
– No specific Coding Clinic; ∴ PDx 578.9?
TWO (+) CODES REASONABLE - 3
Underlying Causes - 2
• Bowel obstruction due to ulcerative colitis?
– Ulcerative colitis (556.9) PDx?
• Inflammatory bowel disease very similar to Crohn’s disease
– No guideline specific to ulcerative colitis
– Ulcerative colitis is underlying cause of bowel obstruction
– Coding Clinic 2Q 1997 advises Crohn’s PDx, obstruction 2°
• Other conditions considered underlying causes
– Acute Coronary Syndrome and CAD
• Coronary atherosclerosis (414.01) is principal diagnosis
• Acute coronary syndrome (411.1) is a secondary diagnosis
• Coronary artery disease (CAD) is the underlying cause of the acute
coronary syndrome and is therefore sequenced first
• Coding Clinic 2Q 2004
TWO (+) CODES REASONABLE - 4
Interpreting Clinical Information
• Aspiration pneumonia (507.0) + SIRS
– SIRS due to non-infectious process (995.93)?
• Aspiration pneumonitis (507.0) would be PDx
SIRS due to non-infectious process (995.93) would be 2°
– Category 507.x is Pneumonitis due to solids and liquids
• No infectious disease examples among inclusion terms
• Physicians often document only aspiration, not infection
– SIRS due to infectious process (995.91)?
• Septicemia (038.9) would be PDx
Aspiration pneumonitis (507.0) would be secondary
– Antibiotics given
• Assume infection?
• Sequencing of the Principal Diagnosis
– Two or more sequencing guidelines may apply to PDx
– Which sequencing guideline takes precedence?
TWO (+) CODES REASONABLE - 5
Principal Diagnosis - 1 - Guidelines
Ensure that your principal diagnosis code is …
• Present on admission
• Consistent with circumstances of admission
• Not contradicted elsewhere in the medical records
• The most acute condition
– If choice is between an acute (subacute) or chronic condition
• Coding Clinic 4Q 2007
• The most serious condition
– Sequence the code for the most serious condition first
• OGCR Section I.C.17.a.
TWO (+) CODES REASONABLE - 5
Principal Diagnosis - 2 - Guidelines
cont.
• The most specific code supported by documentation
– Measures of coding accuracy include “attention to specificity in
code selection”
• Coding Clinic May-June 1984
– Report diagnosis codes at highest number of digits available
• OGCR Section I.B.3.
– Report “unspecified” when information insufficient to
assign more specific code
• OGCR Section I.A.5.
– Assign codes for Symptoms, Signs, and Ill-defined
Conditions when no more specific diagnosis can be made
• ICD-9 Chapter 16 - Instructional Note
TWO (+) CODES REASONABLE - 5
Principal Diagnosis - 3 - Guidelines
cont.
• The most specific code supported by documentation
(cont.)
– Example: Leaking abdominal aortic aneurysm resulting in
fluid collection adjacent to abdominal aorta
• “Leak” - no listing
• “Hemorrhage - artery” → Hemorrhage, unspecified (459.0)
• “Hemorrhage - retroperitoneal” → Hemorrhage, unspecified (459.0)
– ICD-9 Alphabetic Index
• “Hematoma - retroperitoneum” → Hemoperitoneum (568.81)
– ICD-9 Alphabetic Index
• Fluid collection likely a hematoma
 Query for medical term corresponding to “fluid collection”
TWO (+) CODES REASONABLE - 5
Principal Diagnosis - 4 - Guidelines
cont.
Ensure that your principal diagnosis code is …
• Consistent with the desired classification of the diagnosis
– “Refer to the Tabular List to verify that the code number is in accord with
the desired classification of the diagnosis.”
• Coding Clinic Jan-Feb 1985
– “Further research is done if title of code clearly does not identify the
condition correctly.”
• Coding Clinic 2Q 1991
• Examples
– “Weakness”
• General paresis → Neurosyphilis (094.1)
• Generalized weakness → Other malaise and fatigue (780.79)
• Left-sided weakness after stroke
 Paresis → See Paralysis, brain
– “Inflammatory bowel disease”
• “Disease - bowel” → Unspecified disorder of intestine (569.9)
• “Inflammation - bowel” → Other noninfectious colitis (558.9)
• Physicians documenting “inflammatory bowel disease” often INTEND
Crohn’s disease (555.x) or Ulcerative Colitis (556.x)
 Treatment with Asacol® or similar medication
 Query if “desired classification of the diagnosis” is uncertain
TWO (+) CODES REASONABLE – 5
Principal Diagnosis - 5 - Guidelines cont.
• Right code but for questionable reason?
– “ ‘Hemorrhage’ or ‘Bleeding’ - retroperitoneal - non-traumatic” →
Hemoperitoneum (568.81)
• No Alphabetic Index pathway for this
• Encoder may take you here - is this code supported?
– Coding Clinics “hemoperitoneum” address intraperitoneal bleeding (not
retroperitoneal)
– Listing 568.81 does not include “retroperitoneal hemorrhage”
• Encoder is a software program to help us to use ICD-9
• Encoder is not a primary reference for code selection, versus …
– ICD-9-CM Official Guidelines for Coding and Reporting
• Conventions
• Chapter-specific guidelines
• General coding guidelines
– AHA Coding Clinics
TWO (+) CODES REASONABLE – 6
Encoder doesn’t take me there - 1
• Physicians don’t commonly use the term
– Functional quadriplegia (780.72)
• Coding Clinic 4Q 2008 description
– Inability to move due to another condition
• Most often dementia; also severe contractures, arthritis, etc.
– Immobile due to severe disability or frailty
– Lacks mental ability to ambulate
• Rarely documented
• Find documentation of functional mobility in
– Nurses notes
– Braden Scores for “Activity” and “Mobility”
– History of Present Illness and Physical Examination
• Attending physician
• Consultants
– Leukoaraiosis
• Age-related degenerative changes in white matter of brain
– Periventricular leukoaraiosis
– Leukoaraiosis in area of centrum semiovale
• Coding Clinic 1Q 2009
TWO (+) CODES REASONABLE – 6
Encoder doesn’t take me there - 2
• Different search terms → Different Codes
– Sequence of search terms affects encoder output
– Example: Ataxia after cerebellar stroke
• Ataxia - acute (or unspecified): Lack of coordination (781.3)
• Ataxia - brain (or cerebral): Cerebral degeneration (331.89)
• Ataxia - cerebellar: Cerebellar ataxia (334.3)
– Changing sequence of search terms may be needed for encoder to
output most specific code supported by documentation.
TWO (+) CODES REASONABLE – 6
Encoder doesn’t take me there - 3
• Patient brought to the hospital by family d/t altered
mental status
• Final diagnoses:
Hyponatremia, pleural effusions, and altered mental
status due to psychogenic polydipsia and water
intoxication
• Treatment
– Psych consult done, patient to be followed by psychiatry after
discharge
– Water restriction and salt tablets resulted in resolution of
hyponatremia, altered mental status, and pleural effusions
TWO (+) CODES REASONABLE – 6
Encoder doesn’t take me there - 4
•
•
•
•
Coding Approach #1: Hyponatremia (276.1) is PDx
– Hyponatremia was the cause of the patient’s altered mental status
Coding Approach #2: Fluid overload (276.69) is PDx
– “Water Intoxication” codes to Fluid overload (276.69)
– Fluid overload was the underlying cause of the patient’s pleural effusions
Coding Approach #3: Polydipsia (783.5) is PDx
– Polydipsia was the underlying condition of the patient’s fluid overload
– Both the psychogenic polydipsia and the physical conditions were treated
– Psychophysiologic disorder NOS (306.9) is secondary diagnosis
Coding Approach #4: Psychogenic factors associated with physical conditions (316) is
PDx
– Excludes Physical symptoms / psych malfunctions not involving tissue damage (306.x)
–
–
–
• Hyponatremia and pleural effusions would reasonably fall under “tissue damage”
Psychogenic factors associated with physical conditions: 316
Use additional code to identify the associated physical condition, as psychogenic … asthma (493.9), etc.
Inclusion terms are not necessarily exhaustive (∴ coding not limited to inclusion terms under listing 316)
• OGCR Section I.A.4.
• Consider “Psychogenic” as first search term if considering a
psychogenic diagnosis
TWO (+) CODES REASONABLE – 7
Us - Ourselves
• Information processing and learning
– Natural preferences
• Hard-wired
– Acquired skills
• Develop over time in context of experience
• Ways to view differences - examples
– Myers-Briggs
– The four “selves”
Myers-Briggs Type Indicator Profiles
• Personality preferences
– Extraversion (E) versus Introversion (I)
• E: Energized by contact with people
• I: Need more time alone to keep high energy level
– Intuition (N) versus Sensation (S)
• N: Think in concepts, focus on future possibilities
• S: Want facts, focus on the present
– Thinking (T) versus Feeling (F)
• T: Analytical and objective
• F: Context of way situation affects self and others
– Judging (J) versus Perceiving (P)
• J: Like events to be fixed and settled
• P: Comfortable with lots of options
 Kiersey D, Bates M. Please Understand Me. 1984
Mental Processing Types - 1
Practical Organizers (ESTJ)
Inquisitive Analyzers (INTP)
• Concrete, present-day
• Intuitive
•
•
•
•
– Rules
– Standard procedures
Decides quickly
– Early closure
Direct, tough-minded
Protects what works
Structured learner
– Task-focused
•
•
•
•
Lawrence G. Looking at Type and Learning Styles. CAPT 1997.
– Appreciates complexity
– Reframes the obvious
Decides more slowly
– In-depth analysis
Values ideas, flexibility
Looks for possibilities
Spontaneous learner
– Follows intriguing ideas
Mental Processing Types - 2
• Practical organizers and
intuitive analyzers can
work well as a team
– Analyzers challenge
organizers to consider new
ideas
– Organizers keep analyzers
grounded in reality
The Four ‘Selves’
• Fact
–
–
–
–
Rational self
Realistic
Likes facts
Bottom line
• Form
–
–
–
–
Safekeeping self
Creates order
Establishes procedures
Detail-oriented
From Linney B. The Physician in Management II.
American College of Physician Executives, 1997
• Future
–
–
–
–
Experimental self
Intuitive
Imagines possibilities
Big picture
• Feeling
–
–
–
–
Emotional self
Senses feelings
Likes harmony
Relationship-oriented
Who Are We?
• We are
“practical organizers” and
“intuitive analyzers.”
– But natural preference for
one or the other
• We are
all four “selves.”
– But one or two more
strongly than the others
We might view these situations
differently
•
•
•
•
•
•
•
•
•
•
Diabetes + sepsis + osteomyelitis
Chronic condition?
GI bleed due to Crohn’s disease
Bowel obstruction due to ulcerative colitis
Aspiration pneumonia - infectious? Non-infectious?
Inflammatory bowel disease or nonspecific colitis?
Leaking abdominal aortic aneurysm
Functional quadriplegia
Ataxia
Psychogenic factors assoc. with physical conditions
Why such different opinions?
• We see things the way we are,
not the way they are.
Anais Nin
• Differences in:
– Training
– Experience
– Natural preferences
• How do we make decisions
when we see things so differently?
Decision-Making - 1
Are we more likely to be
eaten by a shark or killed
by falling airplane parts?
Decision-Making - 2
• Are we more likely to be
eaten by a shark or killed
by falling airplane parts?
– 30 times more likely to be
killed by falling airplane
parts
– Plous, Scott. The
Psychology of Judgment
and Decision. McGraw-Hill
Higher Education, 1993.
Decision-Making - 3
• Are we more likely to be
eaten by a shark or killed
by falling airplane parts?
– 30 times more likely to be
killed by falling airplane
parts
• Mental shortcut may lead
to “eaten by shark”
– Being eaten by a shark is:
• More familiar
• Easier to imagine
• On the news every summer
Decision-Making - 4
• Mental shortcuts (Heuristics)
– #1: Availability
• An event is judged to be more likely if it:
– Is familiar
– Is easier to imagine
– Took place recently
– #2: Anchoring and adjustment
• We are taught to “Go with your first answer” when taking a test
– Initial position may be too extreme
• Other possibilities may be ~ equally likely
– Insufficient adjustment for new information
• Reluctance to change from original (extreme) position
 Kahneman, Slovic, and Tversky, 1982
Decision-Making - 5
• Mental shortcuts (cont.)
– We may be more likely to use a code if we:
• Use that code frequently
– But we may overlook important differences in current situation
• Thought of that code first
– But further analysis might support different coding approach
– Mental shortcuts appeal to our “gut” instincts
• Uncritical use of shortcuts → overconfidence
– Factors important to good decision-making
• Intuition
• Analysis - unbiased examination of each alternative
• Kahneman, Slovic, and Tversky, 1982
All problems become solved if
talked about for long enough.
Reaching Agreement - 1
• Reaching agreement on a treatment plan
– Discussion of patient’s explanatory model
– Discussion of physician’s explanatory model
• Non-technical
• Time for response to patient questions
– Comparison of patient and physician models
– Mutually accepted explanation of illness
• Acknowledge different views
• Develop therapeutic alliance
– Mutually accepted treatment plan
• Based on Kleinman, A. (1978). "Clinical relevance of anthropological
and cross-cultural research: Concepts and strategies." Am J
Psychiatry 135: 427-431.
Reaching Agreement - 2
• Reaching agreement on a coding approach
– Meeting #1
• Discussion of person 1’s coding approach
• Discussion of person 2’s coding approach
– If no agreement
• Agree to meet again
• Research
– Meeting #2
• Organized analysis of approaches
• Comparison of Person 1’s and Person 2’s approaches
– Assess strength of support for each coding approach
– If no agreement, consider for a day or two
– Meeting #3
• Present new information
– Avoid arguing over information presented previously
• Reach agreement
– One coding approach significantly better supported
• Agree to disagree
– Both coding approaches reasonable
Reaching Agreement - 3
Organized Approach
• Does the difference of opinion focus on a:
– Coding question?
– Medical question?
– Both?
• Discuss coding questions separately from medical
questions
– Consider both together only in final analysis
• Beware of motivated reasoning
– We look harder for flaws in reasoning when we
disagree with the conclusion.
• Sharon Begley. “The Limits of Reason.” Newsweek, 8/16/2010
Researching
• Search variety of
resources
– ICD-9
– Coding Clinics
– Web-based resources
– Advisors
• Use variety of search
strategies
– Try multiple search terms
– Try different order of search
terms
Researching Coding Questions - 1
• “Re-search” and re-read definitive sources
– ICD-9-CM Official Guidelines for Coding and Reporting
– AHA Coding Clinics
• Discuss with colleagues and supervisors
• Online resources
– Google
• Try variety of search terms sequenced differently
– Coding newsletters on the Web
– Coding forums and discussion boards
• Submit a question in writing
Researching Coding Questions - 2
• Coding newsletters on the Web
– Free access
• www.maximhealthinformationservices.com/codingcorner.aspx
– Paid subscription
• www.justcoding.com
– Benefits of organization memberships
• www.ahima.org/publications/newsletters.aspx
• www.aapc.com/resources/publications/billinginsider-subscribe.aspx
• Coding forums and discussion boards
– American Association of Professional Coders (AAPC)
• www.aapc.com/memberarea/forums/index.php
– Supercoder
• www.supercoder.com/coding-community/discussion-group-coding911
– Separated by specialty.
– Categories include Gastroenterology, General Surgery, Orthopedic, OB/GYN, pulmonology, and
others
– BC Advantage
• www.billing-coding.com/forum/view_forum.cfm?ForumID=5
– Medical Billing and Coding Net
• www.medicalbillingandcoding.net/medical_billers_forum.htm
Researching Coding Questions - 3
• Submit an inquiry in writing
– 3-M
– Coding Clinics
• Submit question in detail
– Describe alternative coding approaches
• Provide support for each coding approach
– AHA phone message encourages sending supporting materials
– End your inquiry with specific question(s)
• Request specific reason(s) for preference of one coding approach
over the other(s)
Researching Coding Questions - 4
• Coding question - example of written inquiry
– Diabetic patient admitted with sepsis due to acute
osteomyelitis
• The OGCR Section I.A. states that the Conventions for the ICD-9CM are for use independent of the Guidelines
• Do the Conventions for the ICD-9-CM take precedence over the
chapter-specific guidelines?
• For example, if the "Etiology/Manifestation Convention" (Section
I.A.6.) and two or more chapter-specific guidelines apply (e.g.,
Chapter 3 + one other) …
– Would a chapter-specific guideline supported by an
etiology/manifestation convention take precedence over a chapterspecific guideline not mentioned in a convention?
• Example: Diabetic patient admitted with sepsis due to acute
osteomyelitis
Researching Medical Questions - 1
• AHIMA Query Guidelines (9/29/2008)
– Clinical indicators present, but condition not identified
– Evidence for a higher degree of specificity or severity
– Clarify a cause-and-effect relationship between two
conditions or organisms
– Underlying cause when a patient is admitted with symptoms
– Present-on-admission status
• Other queries
– One PDx or 2+ co-equal PDx
– Condition considered possible at time of discharge
– Procedure documented, but significance uncertain
Researching Medical Questions - 2
• Consult medical advisor(s)
– Medical judgment of clinician with training and experience in
treating patients may be valuable
• Medical articles on the Web
• Coding articles written by clinicians
– JustCoding.com
– Search Google
Example
Headaches after Brain Surgery - 1
• 60-year-old male with worsening headaches
– H&P
• Exacerbation of chronic headaches since craniotomy for brain
metastases from lung cancer primary
• Headaches expected after surgery, “not a complication”
• Worrisome for tumor-related meningitis
• Admission to evaluate for change in postoperative appearance of brain,
assess for recurrent tumor, and manage headaches
– Discharge summary
• Workup negative - no tumor or other cause for headache exacerbation
found
• PDx: Exacerbation of chronic headaches d/t previous brain surgery
• Back to baseline - continue previous medications
• Coding Approach #1
– Headache (784.0) is PDx
• Coding Approach #2
– Other condition of brain (348.89) is PDx
Example
Headaches after Brain Surgery - 2
Approach #1:
Headache (784.0)
• Coding Question
Do coding rules provide
direct guidance for
sequencing?
– Specific code exists for
Headache (784.0)
– No specific code for
“headache due to brain
surgery”
– No encoder pathway from
“Headache” to Condition of
Brain (348.89)
Approach #2:
Other Condition of Brain (348.89)
• Coding Question
Do coding rules provide direct
guidance for sequencing?
– Headache is a symptom
• More specific code would be
preferable
– Headache caused by
condition of brain
• Sequela of brain surgery
– Encoder not 1° source
Example
Headaches after Brain Surgery - 3
Approach #1:
Headache (784.0)
Approach #2:
Other Condition of Brain (348.89)
• Medical question
• Medical question
Could another medical
condition be PDx?
– Pain?
• Probably not
– Diagnosis and
management both
– No ∆ in pain meds
– Complication?
• Probably not
– Physician states
“not a complication”
Could another medical
condition be PDx?
– Malignancy?
• Probably not
– Workup negative
– Headache not due to
malignancy
– Personal history of
malignancy (V10.85)?
• Unacceptable as PDx
– Medicare Code Editor
Example
Headaches after Brain Surgery - 4
Approach #1:
Headache (784.0)
Approach #2:
Other Condition of Brain (348.89)
• M-B Sensing (S)
• M-B Intuition (N)
– Person with sensing
– Person with intuition
preference may prefer
• Simplicity
• Tried and true
– Focus on
• Facts
– Less likely to
question authority (encoder)
• Encoder pathway direct for
preference may prefer
• Complexity
• New approaches
– Focus on
• Meaning behind facts
– More likely to
question authority (encoder)
• Support for 348.89 based
784.0, not for 348.89
Lawrence G. Looking at Type and Learning Styles. CAPT 1997.
directly on ICD-9
Example
Headaches after Brain Surgery - 5
Approach #1:
Headache (784.0)
Approach #2:
Other Condition of Brain (348.89)
• Practical organizer
• Inquisitive analyzer
– Headache legitimate PDx
– Physician didn’t document
“condition of brain”
– Simple situation
• Quick decision
– Internet posting
• Posting not authoritative
– Headache is nonspecific
– Clinical indicators present
for “condition of brain”
– Complex situation
• Needs further analysis
– Internet posting
• Consider 348.89 for brain
condition not identified with
specific ICD-9 code
• Posting reasonable
Example
Reaching Agreement - 1
• Meeting
– Discuss differences regarding CODING question
– Discuss differences regarding MEDICAL question
– View situation from perspective of other “self”
• If you are experimental-intuitive, let safekeeping-sensing selfdominate
– And vice versa
• Good exercise in empathy
• Start with open mind
– Anchor in the middle
• 50% chance that Headache will be best PDx
• 50% chance that Other Condition of Brain will be best PDx
• Educational approach
– De-personalizes the discussion
Example from ICD-10
Reaching Agreement - 2
• Meeting #2 and Meeting #3
– Agree on PDx based on either “Headache” or
“Other Condition of Brain” interpretation
• One interpretation more strongly supported
• Both interpretations supported ~ equally
– Pick one
• If your interpretation is chosen this time,
let other person’s interpretation be chosen next time
– Agree to disagree
• Mutual respect and good humor important
“If I cannot change when circumstances
demand it, how can I expect others to?”
—Morgan Freeman as Nelson Mandela
Invictus
Conclusion
• Admissions may have:
– One best code assignment, OR
– Two or more reasonable code assignments
• Differences of opinion can arise for many reasons:
– Interpretation of medical records
– Interpretation of coding guidelines
– Individual differences in information processing
• Differences in coding approaches can be based on:
– Coding questions
– Medical questions
• Analyze coding and medical questions separately first
– Then consider both together
• Differences of opinion are learning opportunities
– Encourage open discussion