Download What to expect when coding CAD, MI with ICD-10-CM

July 2012 Vol. 15, No. 7
What to expect when coding
CAD, MI with ICD-10-CM
Let’s get to the heart of the matter.
ICD-10-CM coronary artery disease (CAD) and
myocardial infarction (MI) codes will undoubtedly differ
from their ICD-9-CM counterparts in some ways, but
some aspects will remain the same.
Native and bypass grafts
In ICD-9-CM, CAD ­appears in category 414. ICD-10
code I25.- denotes CAD. Both ICD-9-CM and ICD-10CM codes indicate whether CAD is in the native artery
or a bypass graft. The term “native artery” describes
an artery with which a patient is born and that has
not been grafted during a coronary artery bypass graft
(CABG) procedure. A “bypass graft” is a graft inserted by
a surgeon during a CABG procedure to ­bypass a blocked
coronary artery.
ICD-10-CM code category I25.1 denotes CAD of a
­native artery. Patients can also have CAD of several types
of bypass grafts, including:
➤➤ Unspecified (I25.700–I25.709)
➤➤ Autologous vein (i.e., a vein that originates from
the patient, such
as the saphenous
This month’s tip: Learn
vein graft in the
what inpatient coders, who
leg that is used to
don’t typically assign E/M
create a bypass
codes, should know about
in the coronary
documentation of history of
­artery) (I25.710–
present illness on p. 12.
I25.719)
➤➤ Autologous artery (i.e., an artery that originates
from the patient, such as an internal mammary
­artery graft that is used to create a bypass in the coronary artery) (I25.720–I25.729)
➤➤ Non-autologous biological (i.e., the grafting material doesn’t originate from the patient)
IN THIS ISSUE
(I25.730–I25.739)
p. 5 Recovery Auditors
Learn how the three-day rule has changed
and how this affects hospitals as Recovery
Audits get under way.
Patients can also have CAD in a transplanted heart.
In this scenario, coders should report I25.75- for CAD of
the native artery and I25.76- for CAD of a bypass graft.
p. 6 Three-day rule
Learn important details about the three-day rule that every inpatient
coder should know.
p. 8 Malnutrition
New clinical guidelines for malnutrition, which has never had universally
accepted clinical criteria, could help alleviate compliance challenges
associated with coding the condition.
p. 10 Clinically Speaking
Robert S. Gold, MD, ponders the causes of mechanical and paralytic ileuses.
p. 12 E/M documentation
Inpatient coders don’t typically assign E/M codes, but they should be
aware of documentation of the history of present illness.
Inside: Coding Q&A
Documenting the specific type of bypass graft is important because it affects code assignment, says ­Shannon
E. McCall, RHIA, CCS, CCS-P, CPC, ­CPC-I, CEMC,
CCDS, director of HIM and coding at HCPro, Inc., in
Danvers, Mass. Most physicians tend to only document
“patient had a CABG or history of CABG”—and not the
specific graft that was used.
CAD and angina pectoris
If a patient has both CAD and angina, coders using
ICD-9-CM must assign a code for each condition separately. They report a code from category 414.0x for CAD
Briefings on Coding Compliance Strategies
Page 2
and either code 411.1 (unstable angina) or code 413.9
July 2012
However, when both conditions are POA and both are
(other and unspecified angina pectoris) for angina. How-
treated equally during a hospital stay, coders often have
ever, this has always raised a question about sequencing,
difficulty determining which should be reported as the
particularly because code assignment order affects MS-
principal diagnosis, says McCall.
DRG assignment.
The good news is that coders using ICD-10-CM won’t
“What usually prompts the person to come in the
need to worry about sequencing these two conditions
facility is the angina. Angina is basically a thoracic chest
because CAD codes are combination codes. They include
pain when the heart muscle doesn’t get enough blood,”
additional characters that denote the presence or ­absence
says McCall. “So the question is, although the angina
of angina pectoris. For example, ICD-10-CM code
is what brought them in, what’s the underlying cause
I25.110 denotes CAD of the native artery with unstable
of the angina? In many cases, it’s the underlying CAD.
angina. ICD-10-CM code I25.721 denotes CAD of auto­
The person wouldn’t have likely had the angina if they
logous artery coronary artery bypass graft(s) with angina
didn’t have CAD.”
pectoris with documented spasm. ICD-10-CM code
Generally, CAD is the principal diagnosis even when
diagnostic tests confirming the condition are performed
before admission, she says.
I25.751 denotes CAD of native artery of ­transplanted
heart with angina pectoris with documented spasm.
Similarly, ICD-10-CM code I25.10 denotes CAD of
native artery without angina pectoris. ICD-10-CM code
Editorial Advisory Board Briefings on Coding Compliance Strategies
Associate Editorial Director: Ilene MacDonald, CPC
Managing Editor:
Geri Spanek
Contributing Editor: Lisa Eramo,
[email protected]
I25.81- denotes CAD of other coronary vessels without
angina pectoris.
Coders using ICD-10-CM must remember that they
may not assign unstable angina separately when a patient
also has CAD, says McCall. “Coders are so used to assigning separate codes for CAD and angina, so we have to be
Paul Belton, RHIA, MHA, MBA,
JD, LLM
Vice President
Corporate Compliance
Sharp HealthCare
San Diego, Calif.
Laura Legg, RHIT, CCS
Revenue Control Coding Consultant
Revenue Cycle Management
Washington/Montana Regional Services
Providence Health & Services
Renton, Wash.
very careful because technically if you look up the main
Gloryanne Bryant, RHIA, CCS,
CDIP, CCDS
HIM Consultant
Fremont, Calif.
Monica Lenahan, CCS
Manager of Coding Education
and Compliance
Revenue Management
Centura Health
Englewood, Colo.
entry stating ‘angina, with atherosclerotic heart disease,’
Shannon E. McCall, RHIA, CCS,
CCS-P, CPC, CPC-I, CEMC, CCDS
Director of Coding and HIM
HCPro, Inc.
Danvers, Mass.
­Although patients can have unstable angina without
William E. Haik, MD, FCCP, CDIP
Director
DRG Review, Inc.
Fort Walton Beach, Fla.
James S. Kennedy, MD, CCS
Managing Director
FTI Healthcare
Atlanta, Ga.
Jean Stone, RHIT, CCS
Coding Manager - HIMS
Lucile Packard Children’s Hospital
at Stanford
Palo Alto, Calif.
term angina, unstable in the Alphabetic Index … it gives
you one option: I20.0—that is, unless you notice the
which provides a cross-reference to the CAD entry in
the index. If you go to I20.0, it says unstable angina.”
CAD, this is not a common occurrence, she says.
Coders should note that an Excludes1 note in ICD10-CM category I20 precludes coders from assigning this
code with a code from the I25.1- or I25.7- categories or
with code I23.7 (postinfarction angina), says McCall.
Code category I20 is reserved for patients with angina
Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc.,
75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. • Briefings on Coding Compliance Strategies,
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© 2012 HCPro, Inc.
not related to CAD.
Coders can—and should—make assumptions about
causal relationships between CAD and angina when both
are documented, says McCall. This liberty doesn’t often
occur in the coding world. However, the ICD-10-CM
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Briefings on Coding Compliance Strategies
July 2012
Page 3
Official Guidelines for Coding and Reporting, Chapter 9
Consider the following scenario. A patient has
(Diseases of the Circulatory System), subsection b
CAD without angina pectoris. The patient previously
­(Atherosclerotic CAD and angina) state:
­underwent a CABG procedure. The physician didn’t
A causal relationship can be assumed in a patient with
document whether CAD is in the bypass graft or the na-
both atherosclerosis and angina pectoris, unless the documenta-
tive vessel. When documentation is unclear, coders using
tion indicates the angina is due to something other than the
ICD-10-CM should default to I25.10, which is a non-CC
atherosclerosis.
condition. If a physician had clarified that the patient
had CAD of a bypass graft without angina pectoris, cod-
“If the documentation states that the patient has both
ers could report I25.810 (atherosclerosis of CABG with-
CAD and angina pectoris, the combination code can be
out angina pectoris) or I25.812 (atherosclerosis of bypass
used,” says Melanie Endicott, MBA/HCM, RHIA,
graft of coronary artery of transplanted heart without
CCS, CCS-P, director of professional practice at AHIMA
angina pectoris) if the patient had a transplanted heart.
in Chicago. “Since the combination code for CAD and
Both of these ICD-10-CM codes are CC conditions.
angina doesn’t exist in ICD-9-CM, it may take some time
for coders to remember the rule to combine these two
conditions when coding in ICD-10-CM.”
MIs and anatomical specificity
MIs appear in ICD-10-CM code categories 410.x (acute
MI), 414.8 (chronic MI), and 412 (old MI). ICD-10-CM MI
Default code changes
Coding Clinic, Fourth Quarter 2004, instructs coders
codes include I21.- (ST elevation MIs and non-ST elevation
MIs [STEMI and NSTEMI, respectively]), I22.- (subsequent
using ICD-9-CM to default to code 414.01 (CAD of a
STEMI and NSTEMI), I25.2 (old MI), and I25.9 (chronic
native artery) for patients with CAD who have never
MI). A STEMI is due to a sudden occlusion of a coronary
undergone a CABG procedure, says McCall. Coding
artery, says McCall. The usual treatment is thrombolytic
Clinic, Fourth Quarter 2004, instructs coders to default
therapy. An NSTEMI is generally due to unstable plaque
to 414.00 (CAD of unspecified artery) for patients with
with an accumulation of platelets and is treated with anti-
CAD who have undergone a CABG when documenta-
coagulants and platelet inhibitors, she says.
tion doesn’t indicate whether the CAD is in the native
artery or the bypass graft.
“This has always raised an eyebrow because techni­
Code I21.- denotes the specific wall and specific
­coronary artery involved in an MI. Although ICD-9CM denotes the specific wall (i.e., the fourth digit), the
cally, when you perform a bypass graft, you don’t get
specificity in ICD-10-CM regarding the coronary artery
rid of the atherosclerosis that’s in the native artery,”
is new. For example, ICD-10-CM code I21.01 denotes
says McCall. “So it seemed kind of odd that Coding Clinic
left main coronary artery, and code I21.02 denotes left
would say if you’ve got a bypass graft and CAD, you
anterior descending coronary artery.
have to use the unspecified vessel even though you
This information helps capture exactly where an
know the patient still has CAD in their native artery.
infarction is occurring, says McCall. Coders typically find
That’s why the physician performed the bypass initially.”
this information in cardiac catheterization reports.
ICD-10-CM remedies this; the Alphabetic Index maps
Coders should review current MI documentation to
CAD, not otherwise specified, to the default code for
determine whether it specifies both the wall and specific
CAD of the native artery (I25.10), says McCall.
coronary artery, says Endicott. “If all necessary documen-
However, clarifying whether CAD is of the native artery
tation is not present, then this is an opportunity to work
or a bypass graft is important because this information can
together with the cardiac physicians to share with them
have financial ramifications in ICD-10-CM, she says.
what documentation is required with the new codes.”
© 2012 HCPro, Inc.
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Briefings on Coding Compliance Strategies
Page 4
Note that ICD-10-CM guidelines provide additional
July 2012
they have a fifth digit of 1 (initial episode of care), says
information about the evolution of an NSTEMI to a
McCall. In ICD-10-CM, the MS-DRG remains the same
STEMI. The ICD-10-CM Official Guidelines for Coding and
regardless of whether a patient is being treated for a first
Reporting, Chapter 9 (Diseases of the circulatory system),
MI or a subsequent one, she says. Codes I21.- and I22.-
subsection e (Acute MI) state:
are considered MCCs and will map to the same DRG
If NSTEMI evolves to STEMI, assign the STEMI code.
If STEMI converts to NSTEMI due to thrombolytic therapy, it
is still coded as STEMI.
when reported as the principal diagnosis.
Remember that coders may need to clarify documentation that doesn’t specify the date of the first MI, says
McCall. This date is important because it determines
Acute and subsequent MIs
Among the most noticeable differences between ICD9-CM and ICD-10-CM is that the latter defines an acute
MI as one in which the patient’s symptoms last for fewer
whether the subsequent MI is truly subsequent to the
first MI or whether it is considered a new MI, which
should be reported with I21.-, she says.
Sequencing acute and subsequent MIs will depend
than four weeks, says McCall. This differs from ICD-9-
on the circumstances of an admission, says McCall. For
CM, which classifies an acute MI as one with a stated
example, a patient suffered a STEMI involving the left
duration of eight weeks or fewer.
circumflex coronary artery two weeks earlier and is dis-
If patients have a second, subsequent MI during the
charged. The same patient is admitted today for a STEMI of
acute phase (i.e., during the four-week period after the
the anterior wall. Coders should assign I22.0 (subsequent
first MI), coders must assign a code for the subsequent
STEMI of anterior wall) followed by I21.21 (STEMI left
MI (I22.-) as well as a code for the first MI (I21.-), says
circumflex). Report I22.0 as the principal ­diagnosis because
Endicott. The ICD-10-CM Official Guidelines for Coding and
the subsequent MI (i.e., the one that occurred within four
Reporting, Chapter 9 (Diseases of the Circulatory System),
weeks of the initial MI) is the ­reason for the admission.
subsection e(4) (Subsequent acute MI) reiterate this.
Also consider this example. A patient is admitted for
Before assigning a code from category I22, coders
an acute MI and suffers a subsequent MI two days later
must confirm that the patient suffered two MIs within
while still hospitalized. Coders should report a code from
four weeks, says McCall. ICD-10-CM specifies that a
the I21.- category as the principal diagnosis and a code
subsequent MI is one that occurs within four weeks
from the I22 category as secondary.
(28 days) of a previous MI, regardless of site.
“It’s very different from ICD-9. In ICD-10, it’s really
Old MI
showing the true picture,” says McCall. “When patients
Coders should report I25.2 for an old MI (i.e., a personal
have MIs, it’s not uncommon for them to have another
history of MI), says Endicott. This code would apply to any
one a short time after having the first one. In ICD-9, we
MI that occurred more than four weeks before admission.
don’t have a way to address this. We may end up coding it
As in ICD-9-CM, this code remains in the disease-specific
as two separate episodes of care—initial and subsequent.”
chapter rather that with other codes that denote personal
Coders are not familiar with assignment of a separate
code for a subsequent MI, says McCall. In ICD-9-CM, the
history (i.e., ICD-10-CM Z codes), says McCall.
Coders must exercise caution when documentation
term “subsequent” refers to a subsequent episode of care
states “history of MI,” particularly if it doesn’t specify
and is included as a part of the fifth digit for the MI code.
when the MI occurred, says McCall. “Technically, coders
In ICD-10-CM, it refers to a second MI rather than an
should be coding that with I22 and I21, but I could see
episode of care.
how someone could [incorrectly assign] that and code
ICD-9-CM MI codes are considered MCCs only if
© 2012 HCPro, Inc.
I21 and I25.2 instead,” she says. n
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Briefings on Coding Compliance Strategies
July 2012
Page 5
Recovery Auditors focus on three-day rule
The inevitable audits of the three-day payment rule
have begun.
match between the ICD-9-CM diagnosis codes for the
outpatient service and the inpatient admission.
Connolly, Inc., the Recovery Auditor for Region C,
“Often, we would have no exact match between the
announced it would use automated reviews to begin
symptom code that would be used on the outpatient
­auditing to assess compliance with the rule that con-
basis and the final diagnosis code that would be used on
tinues to challenge providers. CMS approved the issue
the inpatient basis,” says Hoy. “The old rule was purely
effective March 20.
based on the relationship of the codes. It was not based
Specifically, Connolly is auditing outpatient hospital
claims based on whether the associated inpatient discharge occurred before or after June 25, 2010.
on any clinical relationship.”
For example, a patient presents to the ED with a broken toe and undergoes an x-ray of the toe. The patient
Why?
sustains trauma as a result of a motor vehicle accident
June 25 marks the enactment of section 102 of the
and is admitted due to the trauma the same day.
Preservation of Access to Care for Medicare Beneficiaries
and Pension Relief Act of 2010.
Pursuant to the old rule (i.e., before June 25, 2010),
the ED visit would have been billed separately because
This law includes important changes pertaining to the
three-day payment rule, and hospitals should be aware
of them, says Kimberly Anderwood Hoy, JD, CPC,
it’s nondiagnostic and unrelated to the admission,
says Hoy.
However, the x-ray for the broken toe would have
director of Medicare and compliance at HCPro, Inc., in
been bundled into the inpatient admission because it’s
Danvers, Mass.
diagnostic, and all diagnostic services were bundled,
regardless of whether they were related, she says.
Out with the old
The result would be the same if these services
Before June 25, 2010, all diagnostic and related nondiagnostic services were subject to the payment rule on
the date of admission and during the three calendar days
before the date of admission.
only on the date of admission.
The old rule didn’t differentiate between the date of
admission and the three days prior to admission, Hoy
CMS defined related services as those having an exact
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Briefings on Coding Compliance Strategies
Page 6
In with the new
After June 25, 2010, however, the rule changed and
became somewhat more complex in the process. From
this date forward, all diagnostic and nondiagnostic
services—regardless of whether they are related to an
admission—are subject to the rule when they occur on
July 2012
­(attestation of unrelated outpatient nondiagnostic
­services) in the following situation:
➤➤ The service is clinically distinct or independent from
the reason for the inpatient admission
➤➤ Documentation in the medical record supports the
belief that the service is unrelated
the date of admission.
Services provided during the three days before admis-
In the previously described scenario, both the ED visit
sion are handled differently, however. All diagnostic
and the x-ray are bundled in the inpatient admission be-
services provided during the three days before admission
cause the new rule (i.e., effective June 25, 2010) bundles
are subject to the rule and must be bundled. Nondiag-
all diagnostic and nondiagnostic services provided on the
nostic services provided during the three days before
date of admission, says Hoy.
admission are bundled only if they are clinically related
to the admission.
However, coders must remember the new definition
of related because it determines whether a hospital will
Unlike in the past, when CMS based the relation
bundle into an inpatient claim any outpatient nondiag-
on an exact match of ICD-9-CM diagnosis codes, CMS
nostic services subject to the rule that occur during the
now defines related as being clinically associated with
three days before the admission, says Hoy.
the reason for a patient’s inpatient admission. CMS also
For example, a patient presents with shortness of
presumes that preadmission services are related to the
breath (786.05) and chest pain (786.50) for an office
admission. Hospitals must affirmatively attest if the ser-
visit at a physician practice wholly owned or operated
vices are not related.
by a hospital. The patient is admitted to the hospital that
CMS has instructed hospitals to bill unrelated nondiagnostic services to Part B with condition code 51
owns the physician practice the next day and is diagnosed with myocardial infarction (410.xx).
Three-day rule
Important facts every inpatient coder should know
The three-day payment rule, which defines certain pread-
same day as a prior admission, hospitals should combine the
mission services as inpatient operating costs, has implications
admissions or report condition code B4 if the readmission is
for inpatient coders.
unrelated to the prior one.
Inpatient coders should remember the following details
pertaining to this rule:
➤ Inpatient-only services provided on an outpatient basis during the three-day window are ex-
➤ Outpatient services subject to the window
cluded from the rule. “When there is an inpatient-only
are paid as part of the inpatient DRG. These servic-
procedure prior to an inpatient order, CMS has said it con-
es are billed on the inpatient claim to report costs, explains
siders the procedure non-covered when it was rendered,”
­Kimberly Anderwood Hoy, JD, CPC, director of Medicare
says Hoy. “Because it was noncovered when it was rendered,
and compliance at HCPro, Inc., in Danvers, Mass.
it cannot be moved over and turned into a covered service
➤ Part A (inpatient) services are excluded from
the rule. This is true even when Part A services are per-
under the three-day payment window.”
Hospitals should bill the inpatient-only procedure on a
formed within the three-day window at the same hospital,
TOB 110 (inpatient non-covered) solely for internal processing
says Hoy. If a patient is readmitted to the hospital on the
­purposes at CMS, says Hoy.
© 2012 HCPro, Inc.
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Briefings on Coding Compliance Strategies
July 2012
Page 7
Under the old rule, hospitals would have billed
➤➤ Diagnostic revenue codes are never billed on an out-
the office visit separately from the admission because
patient claim up to three days before an inpatient
the ICD-9-CM diagnosis codes didn’t match exactly
admission
(i.e., the services weren’t related). Under the new rule,
hospitals should bundle the outpatient services into
Hospitals should beware of the audit item related to
the inpatient claim because they are clinically related,
services billed before June 25, 2010, because Connolly’s
says Hoy.
description of the issue may be erroneous, says Hoy. The
audit appears to include all nondiagnostic revenue codes.
Beware of Recovery Auditors
Acknowledging the importance of this change,
­Connolly will audit to ensure the following:
Before June 25, 2010
➤➤ Certain outpatient diagnostic revenue codes and non-
However, bundling depends on the ICD-9-CM codes for
each case. Nondiagnostic revenue codes can and should
be separately billed before admission if diagnosis codes
for the service and the inpatient admission don’t match,
she says. n
diagnostic revenue codes are not billed within three
days of an inpatient admission
Editor’s note: The information in this article was originally
presented during HCPro’s audio conference “Mastering the
June 25, 2010, and thereafter
➤➤ No outpatient claim exists on the date of inpatient
admission, regardless of diagnosis codes or revenue
codes
Three-Day Payment Window.” To learn more or to purchase
an on-demand version of this audio conference, visit www.
hcmarketplace.com/prod-10185.
For more information about compliance with the
➤➤ All nondiagnostic outpatient charges subject to the
three-day payment rule, download HCPro’s white paper
rule are not billed separately unless they are accom-
at http://blogs.hcpro.com/revenuecycleinstitute/
panied by condition code 51
wp-­content/uploads/2012/04/2012-Three-day-rule.pdf.
➤ Conditions related to services subject to the
An ICD-9-CM procedure code added to the inpatient claim
three-day payment window are considered POA.
that is ­surgical in nature could also change the DRG from
Coders should code diagnoses for bundled services as POA
medical to surgical. DRGs frequently shift when patients
when they are present at the time of the admission order
are admitted within three days of outpatient surgery due
even if they are not present at the time of outpatient regis-
to complications of the surgery. When converted to ICD-9-
tration, says Hoy. Refer to CMS’ August 9, 2012, Joint Signa-
CM codes, the claim includes inpatient surgical codes that
ture Memo for more information.
­commonly shift the DRG from a medical DRG for the com-
➤ Abiding by the three-day payment rule can
shift a DRG. CMS has instructed providers to include
plications, she says.
➤ Not all CPT codes have a corresponding ICD-
charges for all services identified as subject to the payment
9-CM Volume 3 code. “There’s a very small number of
window on the Part A inpatient claim for the admission,
ICD-9 Volume 3 codes compared to CPT. That will not be
says Hoy. This includes all charges, revenue codes, and
true when it comes to ICD-10,” says Hoy. Most CPT codes
ICD-9-CM diagnosis and procedure codes. This requires
will have an ICD-10-PCS equivalent, she says. “It will be
that coders convert CPT codes to ICD-9-CM codes when
­interesting to see what the direction will be in terms of con-
possible, she says. An ICD-9-CM code added to an inpa-
verting if we’ll only have to convert those codes that affect
tient claim that is a CC or MCC could increase the DRG.
the DRG.”
®
© 2012 HCPro, Inc.
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Briefings on Coding Compliance Strategies
Page 8
July 2012
Malnutrition
New criteria could help ensure consistent coding
New clinical guidelines for malnutrition could help
alleviate compliance challenges associated with coding
codes will better reflect the clinical presentations that providers encounter when assessing malnutrition, she says.
the condition, which has never had universally accepted
Don’t fall into a compliance trap
clinical criteria.
New guidelines published in the May 2012 Journal
This all comes as good news for coders and ­providers
of the Academy of Nutrition and Dietetics, represent a con-
who continue to struggle with third-party audits of
sensus statement of the American Academy of Nutrition
CC and MCC conditions, including malnutrition, says
and Dietetics (the Academy) and the American Society
James S. Kennedy, MD, CCS, CDIP, managing
for Parental and Enteral Nutrition (ASPEN). The Acad-
­director at FTI Consulting in Atlanta.
emy and ASPEN both advocate for provider use of a
One need not look far to discover the case involving
standardized set of diagnostic characteristics to identify
a Maryland hospital whose employees allegedly used
and document adult malnutrition, says Jane White,
leading queries to add malnutrition as a secondary diag-
professor emeritus in the department of family medi-
nosis. Good Samaritan Hospital in Baltimore denied the
cine at the University of Tennessee in Knoxville. White
accusations, but agreed to pay nearly $800,000 to resolve
also serves as chair of the Academy’s adult malnutrition
the False Claims Act violation allegations, according to
work group. The Academy and ASPEN say malnutrition
a March 28 press release from the U.S. Department of
should be diagnosed when at least two or more of the
Justice, available at http://tinyurl.com/d4j6hqy.
following six characteristics are identified:
“If patients had truly had malnutrition, it wouldn’t
➤➤ Insufficient energy intake
have been as much of an issue,” says Kennedy. He attri-
➤➤ Weight loss
butes incorrect malnutrition coding to a lack of consis-
➤➤ Loss of muscle mass
tent clinical criteria and says that many CDI programs
➤➤ Loss of subcutaneous fat
also incorrectly define malnutrition solely on low albu-
➤➤ Localized or generalized fluid accumulation that may
min or prealbumin levels.
sometimes mask weight loss
➤➤ Diminished functional status as measured by hand
grip strength
Another case involved Shasta Regional ­Medical
­Center in Redding, Calif., which allegedly billed
­Medicare for treatment of more than 1,000 cases
of kwashiorkor over a two-year period, according
Providers must assess these six characteristics in the
to a California Watch analysis of state health data.
context of an acute illness or injury, a chronic illness, or
­California Watch describes itself as “the largest group
social or environmental circumstances to determine if
of journalists dedicated to investigative reporting in the
malnutrition is present and whether it’s severe or non-
state” on its website.
severe (moderate). The article, available at http://tinyurl.
Kwashiorkor, a form of malnutrition that occurs
com/ckbclxa, provides a table with more detailed clinical
when a diet lacks sufficient protein, is very rare in the
criteria to which providers can refer when documenting
United States, and is not something that coders encoun-
severity levels for malnutrition.
ter ­frequently, says Alice Zentner, RHIA, director of
The Academy and ASPEN have asked the NCHS to
­auditing and education at TrustHCS in Springfield, Mo.
adopt ICD-9-CM malnutrition codes that use etiological-
Physicians must specifically document the term “kwashior-
based nomenclature, says White. If adopted, the ­ICD-9-CM
kor” for coders to report it, she says.
© 2012 HCPro, Inc.
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Briefings on Coding Compliance Strategies
July 2012
Although the ICD-9-CM index instructs coders to
Page 9
labs or clinical findings,” he says. Consider the ­following
report code 260 (kwashiorkor) for unspecified protein
query based on the new criteria from the Academy
malnutrition, Coding Clinic, Third Quarter 2009, p. 6
and ASPEN:
discourages assignment of this code when physicians
The following clinical indicators are in the medical record:
document moderate or mild protein malnutrition, says
➤➤ Current BMI _____
Kennedy.
➤➤ Stress indicator – Acute illness – Chronic illness – Social
➤➤ Energy intake over the previous ___ days ___%
Rely on helpful strategies
Coders should remember and use the following
strategies:
➤➤ Amount of weight loss over ___ days ____%
➤➤ Loss of subcutaneous fat (circled)
–– None – Mild – Moderate – Severe
➤➤ Don’t always assume documentation is ­correct.
It may seem counterintuitive, but coders should question a diagnosis when it appears that no clinical evidence
supports it, says Kennedy. For example, physicians often
incorrectly diagnose malnutrition based solely on a low
➤➤ Loss of muscle mass (circled)
–– None – Mild – Moderate – Severe
➤➤ Fluid accumulation (circled)
–– None – Mild – Moderate – Severe
➤➤ Measurably reduced grip strength present – Yes – No
albumin or prealbumin, he says. Third-party auditors will
challenge this diagnosis, and coders should also question
it, he says.
Please indicate what diagnosis best correlates with these
findings:
Coders must ensure that severe protein-calorie
➤➤ Cachexia without malnutrition
­malnutrition—an MCC—is documented consistently
➤➤ Nutritional risk without malnutrition
and treated, says Zentner. “If that code is on a record, it’s
➤➤ Malnutrition, severity unknown
certainly a red flag for a RAC to audit,” she says.
➤➤ Malnutrition, non-severe (moderate)
Malnutrition must also meet the definition of a
➤➤ Malnutrition, severe, not otherwise specified
reportable secondary diagnosis, says Zentner. Coders
➤➤ Marasmus – A specified severe protein-calorie malnutrition
should also remember not to report cachexia, a wasting
➤➤ Kwashiorkor – A specified severe protein malnutrition
syndrome, as malnutrition—instead, cachexia is denoted
➤➤ Another medical diagnosis
by a symptom code (799.4), she says.
➤➤ Other (please specify)
Hospitals should develop policies that explain how
➤➤ Cannot be determined
coders should address inconsistent and unreliable diagnoses, says Kennedy. Unreliable diagnoses are those that
Other clinical evidence in the record that might sug-
don’t meet reasonable criteria established by the medical
gest malnutrition includes chronic disease, insufficient
staff. Once identified, these diagnoses should be vetted
intake pre- or postoperatively, infection, malabsorption,
by a coding supervisor, physician advisor, or CDI special-
muscle wasting, poor wound healing, or lethargy, says
ist, he says.
Zentner.
➤➤ Beware of leading queries. A malnutrition
➤➤ Work with CDI specialists. Ask CDI special-
diagnosis often may not be documented when a patient
ists to educate physicians about malnutrition clinical
does, ­indeed, have the condition. However, as the Good
indicators, advises Kennedy. Also advocate for pre-
Samaritan Hospital case demonstrates, coders must be
discharge queries. “The query for malnutrition is really
certain that they don’t lead physicians when requesting
best done in a pre-discharge environment in collabo-
clarification, says Kennedy. “We are allowed, as coders,
ration with dietitians, nutritional teams, and the CDI
to ask providers for the clinical significance of abnormal
team,” he says. n
© 2012 HCPro, Inc.
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Briefings on Coding Compliance Strategies
Page 10
July 2012
Pondering causes of mechanical, paralytic ileuses
by Robert S. Gold, MD
Let me explain the digestion process.
People intake foods, solids, and liquids that occasionally mix with gases. The
contents traverse the esophagus and enter the stomach
where they encounter acid. The stomach churns the food
and liquid with acid and peptic juices and prepares it for
the duodenum. There, bile juices and pancreatic chemicals emulsify the fat. They also break down proteins into
amino acids and complex sugars into simple sugars for
subsequent absorption in the jejunum and ileum. The
residue moves through a 24-foot tunnel before it arrives in
the large intestine where bacteria breaks it down and dries
it out by absorption. Finally, the body excretes the waste.
This entire process of transit is called peristalsis.
­During normal peristalsis, the intestinal wall muscles
narrow and lengthen periodically. However, the intestinal tract may suffer from many diseases that can interrupt this process.
This column addresses the topic of ileus, which is derived from the Greek term for “twisted.” An ileus caused
by a length of bowel that is twisted on its mesentery can
cause twisting of the veins that drain the length of bowel
as well as the arteries that supply that bowel. The length
of bowel supplied by that artery and vein can die, and
the twisting causes an obstruction that stops the progression of food through the gastrointestinal tract.
Mechanical ileus
A mechanical ileus (i.e., mechanical obstruction)
­occurs when a physical blockage impedes flow. A nickel
swallowed by a patient could become stuck in a portion
malignant neoplasm that grows large enough, can also
block intestinal flow. Herniation of a length of intestine
through a defect in the abdominal wall (e.g., umbilical
hernia, inguinal hernia, or paraesophageal hiatal ­hernia)
also can block intestinal flow. Herniation through a
­defect in the fastening of the mesentery inside the
abdomen (e.g., paraduodenal fossa hernia or Ladd’s
bands) can also lead to intestinal blockage.
Blockage can occur when a length of intestine becomes twisted. This occurs with volvulus of the sigmoid,
volvulus of the cecum, and adhesions between loops
of intestine. Intussusception, which occurs when one
portion of the bowel slides into the next, can also cause
obstruction. Cystic fibrosis may lead to mechanical obstruction with excessively thick meconium in the bowel
of the newborn.
Intestinal content above the area of blockage continues to become backed up to the point at which the
patient begins vomiting. The vomitus is usually foul
smelling in nature. Mechanical ileuses are treated surgically, which usually leads to a total resolution of the
problem. This is true even if a portion of the bowel has
become gangrenous.
Coders should identify each cause of intestinal
obstruction with the most precise code possible.
­Occasionally, physicians identify a partial small bowel
obstruction due to adhesions from prior surgery. Many
of these cases resolve spontaneously with bowel rest.
If they don’t resolve, physicians must explore the
bowel and cut or cauterize adhesions to restore normal
anatomy.
Paralytic ileus
of the intestinal tract that is smaller in diameter than the
A paralytic ileus occurs when a lack of synchronized
coin (e.g., the pylorus, a passage from the stomach to the
peristalsis occurs in the absence of a physical blockage.
duodenum, or the ileocecal valve).
Viral or bacterial infections in the gastrointestinal tract
A foreign body of sufficient size can cause a mechanical obstruction. A tumor, whether a benign polyp or
© 2012 HCPro, Inc.
usually lead to hypermotility, which often results in diarrhea. However, infection in the abdominal cavity around
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Briefings on Coding Compliance Strategies
July 2012
Page 11
the intestines can also lead to cessation of neuromuscu-
However, if the surgery led to further problems with
lar coordinated activity and no movement of intestinal
the intestines (e.g., anastomotic leak or spillage and con-
content. For example, paralysis can occur when patients
tamination of the peritoneal cavity that didn’t exist prior
undergoing peritoneal dialysis have infected ascites.
to surgery), then a prolonged ileus could be a complica-
It can also occur in patients with pelvic or abdominal
tion of the operation itself.
abscesses from a perforated bowel. Those with pelvic
Not every ileus warrants assignment of a code. For
inflammatory disease or benign spontaneous peritonitis
example, an ileus that doesn’t prolong a patient’s hospi-
can experience the same problem.
tal stay beyond the average length of stay isn’t codeable,
If an area of the intestine loses some of its blood sup-
even when documented as a postoperative ileus. This
ply or venous drainage due to atherosclerosis or portal
­reflects the physiologic ileus that follows every abdomi-
venous hypertension, peristaltic activity in that area of
nal surgery and is part of the recovery. It’s not codeable.
the bowel may cease. Irritation of the outer peritoneal
However, if the postoperative ileus causes vomit-
lining of the intestine due to any cause often results in
ing, or the patient required insertion of a nasogastric
paralysis of that segment of bowel. This can happen in
tube, coders may be able to report it. Coders can also
patients with pancreatitis when digestive enzymes are
assign a code for an ileus that is prolonged due to a
released into the abdomen. It can also occur in conjunc-
disease or due to surgery for the condition that caused
tion with abdominal surgery. Each of these scenarios
the ileus. However, this code should not be a compli-
causes cessation of intestinal motility in the area of neu-
cation code because the ileus is not a complication of
romuscular function disturbance, and the entire bowel
the surgery.
If the late resumption in bowel activity is due to
swells in size.
Some localized paralyses may occur. For example,
overuse of pain medication, report a code for the ileus as
this can occur in newborns with Hirschsprung’s disease
well as an E code for the adverse effect of the opiates or
(in which parts of the nervous system in the wall of the
whatever pain medication led to the ileus.
large intestine are missing). It may also occur in bedbound patients with chronic constipation that can lead to
Ogilvie syndrome (pseudo obstruction).
Coders must always look for the cause of a ­paralytic
Finally, if the prolonged ileus occurs due to a complication of surgery (e.g., a leak), assign a complication code.
When the physician cannot determine the cause of
the ileus, also consider a complication code if the patient
ileus prior to coding. A physiologic paralytic ileus can
starts vomiting, has had a nasogastric tube inserted, or
­occur after abdominal surgery when a patient has
can’t resume eating for five or more days after surgery
no other bowel-related problems. Patients receive no
when all other causes for these symptoms have been
­sustenance by mouth until bowel sounds are heard or
ruled out. n
the patient passes flatus.
However, when an abnormal process in the abdomi-
Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting
nal cavity leads to surgery (e.g., appendicitis, diverticu-
firm in Atlanta that provides physician-to-physician CDI pro-
litis, or cholecystitis), the patient invariably had an ileus
grams. Contact him at 770-216-9691 or [email protected].
­going into surgery. Thus, the patient would naturally
have one after the surgery as well. Depending on the
severity of the inflammatory response, it could conceivably take as long as one week for the bowel to resume
function. When this occurs, the ileus is caused by the
disease—not by the surgery.
© 2012 HCPro, Inc.
Questions? Comments? Ideas?
Contact Contributing Editor Lisa Eramo
Telephone 401-780-6789
Email [email protected]
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Briefings on Coding Compliance Strategies
Page 12
July 2012
Emphasize importance of history of present illness
Inpatient coders don’t typically assign E/M codes, but
historical inventory of a patient. Historical inventory is a
they should be aware of documentation of the history of
patient’s account of the presenting problem obtained via
present illness (HPI).
the physician-patient interview process. Physicians often
Why? The same documentation that affects the E/M
include an extensive discussion of past history but fail to
level generally also potentially affects clinical valida-
provide sufficient emphasis on the current situation. This
tion of ICD-9-CM code assignment, says Glenn Krauss,
detracts from the more relevant reporting of a patient’s
BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an in-
presenting severity of illness, signs, and symptoms, and
dependent HIM consultant in Madison, Wis. The HPI, in
the physician effort required to help the patient.
particular, helps justify a patient’s acuity and reason for
admission to the hospital, he explains.
The HPI should provide a clear and concise description of the nature of the presenting problem. A deficient
The HPI should always include a detailed descrip-
HPI frequently leads to an E/M assignment that denotes
tion of the nature of a patient’s presenting problem and
a lower level than that which was provided. The physi-
any of the eight elements of the HPI, including location,
cian simply failed to adequately demonstrate the current
­quality, severity, duration, timing, context, modifying
acuity of the patient and the different body areas/organ
factors, and associated signs and symptoms, says Krauss.
systems potentially affected by the current complaint.
­Without this information, hospitals will inevitably face
Failure to provide an adequate, clinically relevant, and
denials from third-party auditors who typically review
appropriate HPI can affect coding for subsequent ­hospital
the ED note, history and physical, and discharge summa-
visits. Initial hospitalization E/M code sets require that
ry—and not the entire record—when auditing, he says.
documentation meets all three E/M components—­
“RAC contractors are making up their minds before they
history, physical, and medical decision-making. Subse-
even go any further. They have a tendency to prejudge the
quent hospitalization codes require only two of these
case based on what they read right away,” he says.
three components. An HPI that is insufficient to the
extent that documentation doesn’t support even the
Emphasize the importance of the HPI
CDI specialists and coders who discuss the importance
of the HPI with physicians should address its true meaning. Ensure physicians understand that the HPI repre-
lowest-level history component precludes using history
as one of the two key components required for E/M
­assignment under subsequent hospitalization code sets.
Failure to provide an adequate HPI as part of history
sents present illness with an emphasis on the severity
calls into question the medical necessity for ordering
of signs and symptoms obtained from an interview and
related diagnostic testing and therapeutic interventions
and the medical necessity for the physician service. Lack
Upcoming event
July 10—Observation Services 2012: Build an Audit
­Defense, Obtain Appropriate Reimbursement, featuring
Deborah K. Hale, CCS, CCDS, president of Administra-
of an adequate HPI limits the usefulness of the record.
Coders must remember that physician E/M services are
subject to medical necessity provisions similar to all other
Medicare beneficiary services ordered and ­provided. n
tive Consultant Service, LLC, in Shawnee, Okla.
To register or for more information, call 800-650-6787
or visit www.hcmarketplace.com and mention source
code NEWSAD.
© 2012 HCPro, Inc.
Editor’s note: This article was adapted from The Documentation Improvement Guide to Physician E/M, published
by HCPro, Inc., and authored by Krauss. For more information,
visit http://tinyurl.com/crjq6by.
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July 2012
A monthly service of Briefings on Coding Compliance Strategies
We want your coding and compliance questions!
The mission of Coding Q&A is to help you find an­swers to your urgent coding/compliance questions.
To submit your questions, contact Briefings on Coding Compliance Strategies
Contributing Editor Lisa Eramo at [email protected].
Editor’s note: Answers to the following questions are
Others have described scenarios similar to the one
based on ­limited information submitted to Briefings on
posed in your question (e.g., a payer deems a single CC
Coding Compliance Strategies. Review all documenta-
or MCC not supported clinically despite clear documen-
tion specific to your scenario before determining appropriate
tation in the medical record). This can be frustrating for
code assignment.
hospitals. Payers that do this negate the MS-DRG logic
that a patient only needs one diagnosis designated as a
Recently, reviewers have denied diagnostic code
584.9 (acute renal failure [ARF]) based on ­laboratory
CC/MCC for assignment to that MS-DRG.
Exploring cases that involve patients with single CCs or
values. The diagnosis is well documented and treated by
MCCs makes financial sense for payers because it affects
the attending physician, but reviewers say the
overall reimbursement. As such, documentation and clini-
laboratory values do not support the ­diagnosis of ARF.
cal indicators in the medical record should clearly support
The laboratory values (creatinine/BUN) progressed
the reported ­diagnoses to justify code assignment. I do
from normal to abnormal, and we found no defini-
not know whether your organization has a documentation
tive standards for laboratory parameters to meet the
improvement program, but I see an opportunity for poten-
definition of ARF.
tial documentation improvement efforts to assist in these
In accordance with coding guidelines for reporting
secondary diagnoses, ARF was clinically evaluated,
situations.
RIFLE criteria are helpful with respect to understand-
the patient underwent therapeutic and diagnostic
ing clinical definitions of acute renal failure:
procedures, and there was an extended length of
➤➤ Risk—Increase in serum creatinine level X 1.5 or
stay/increased nursing care. As coders, we think
decrease in GFR by 25%, or UO < 0.5 mL/kg/h
that questioning the physician’s clinical judgment is
for six hours; Cr rise of 0.3 mg in appropriate
inappropriate and that reporting ARF as a secondary
­circumstance
diagnosis is correct. Based on documentation in the
record, is coding ARF appropriate?
➤➤ Injury—Increase in serum creatinine level X 2.0 or
decrease in GFR by 50%, or UO < 0.5 mL/kg/h for
12 hours
From a coding perspective, I agree that you should
assign the code if the treating physician clearly
➤➤ Failure—Increase in serum creatinine level X 3.0,
decrease in GFR by 75%, or serum creatinine
­documented ARF and met the criteria of clinically
level > 4 mg/dL; UO < 0.3 mL/kg/h for 24 hours, or
­evaluating and/or treating this condition during an
anuria for 12 hours
admission in accordance with the UHDDS definition of
“other/additional diagnosis.” Coders should not debate
clinical scenarios with physicians (e.g., whether a patient
had a condition).
➤➤ Loss—Persistent ARF, complete loss of function >
four weeks
➤➤ End-stage kidney disease—Loss of function >
three months
A supplement to Briefings on Coding Compliance Strategies
The criteria do not merely progress from normal to abnormal; other factors in the laboratory values also play a role.
Jean Stone, RHIT, CCS, coding manager at Lucile
Packard Children’s Hospital at Stanford in Palo Alto, Calif.,
answered the previous question.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I,
CEMC, CCDS, director of HIM and coding at HCPro, Inc.,
A patient is admitted January 3 and undergoes spi-
in Danvers, Mass., answered this question, which originally
nal surgery that day. No laboratory specimens were
appeared on JustCoding.com.
drawn until January 4. At that time, the BUN was 24
(normal range is 8–20), and creatinine was 2.09 (normal
Which code should I report for atypical small
range is 0.64–1.27). A consultation was ­performed
­acinar proliferation of the prostate? Is ICD-9-CM
January 4, and the physician documented acute renal
code 602.3 (dysplasia of prostate) appropriate?
failure. What is the correct POA ­assignment?
The ICD-9-CM index does not include a reference for
Query the physician to determine whether acute
this diagnostic statement. Submit a query regarding
renal failure was POA. Appendix I of the ICD-9-CM
the clinical significance of the statement, referencing
Official Guidelines for Coding and Reporting (POA
602.3 and including its description. Provide the following
Reporting Guidelines) indicates that a query is appropri-
information in your query:
ate if documentation is unclear regarding whether a
➤➤ Clinical indicators, as advised in AHIMA’s practice
condition was POA. The provider should clarify the link-
brief, “Managing an Effective Query Process”
➤➤ The diagnosis
age of signs and symptoms to the acute renal failure,
the timing of test results, and the timing of findings.
➤➤ Request for clarification that indicates the lack of a
diagnosis code for this diagnosis
Laura Legg, RHIT, CCS, revenue control coding consultant at Providence Health & Services in Renton, Wash.,
Ask which of the following best describes the patient’s
answered the previous question.
condition:
➤➤ Dysplasia of prostate
➤➤ Neoplasm of prostate—if so, is neoplasm:
–– Malignant, primary
–– Malignant, secondary
–– Malignant, in situ
–– Benign
–– Undetermined
–– Unspecified
➤➤ Other diagnosis regarding atypical small acinar proliferation of the prostate (please specify) _______
➤➤ Unable to be determined
Are you an inpatient coding
and compliance expert?
Do you enjoy researching inpatient-related ­coding
questions? Do you stay up to date on Medicare
transmittals and publications? If you answered “yes”
to either question, you’d be a great addition to the
Briefings on Coding Compliance Strategies
editorial advisory board. Or perhaps you’d simply like
to share your insight and experiences. If you’re interested in either opportunity, contact Contributing
Editor Lisa Eramo at [email protected].
Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any
form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright
© 2012 HCPro, Inc., Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de­­scriptions, and
material only are Copyright © 2012 American Medical Association. CPT is a trademark of the American Medical
As­sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in
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restrictions apply to government use.
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