Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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