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
A Review of Coding Clinic for ICD-9-CM CDI Highlights James S. Kennedy MD CCS Managing Director – FTI Healthcare Atlanta & Nashville [email protected] Speaker • James S. Kennedy, MD, CCS – Credentials • • • • • Medical school: University of Tennessee Private practice: general internal medicine, 1983–1998 AHIMA CCS certification: 2001 AHIMA ICD-10 certified trainer Publications: – 2007–current: “Minute for the Medical Staff” in Medical Records Briefings – 2008: AHIMA – Severity-Adjusted DRGs, an MS-DRG Primer – 2009: ACDIS – Physician Query Handbook – 2008–current: Coding Clinic update for the ACDIS CDI Journal – Current practice • Managing director, FTI Healthcare • CDCI practice leader Goals • Review 2010 AHA Coding Clinic on ICD-9-CM advice applicable to clinical documentation and coding integrity – Special emphasis on clarifying imprecise, incomplete, inconsistent, and conflicting documentation • Reconcile Coding Clinic advice with ICD-9-CM, the ICD9-CM Official Guidelines for Coding and Reporting, our own clinical judgment, and their applications to MSDRGs and APR-DRGs • Develop strategies that negotiate clinically congruent provider documentation and defendable ICD-9-CM code assignment Hierarchy for ICD-9-CM Diagnosis Code Assignment – Basics 1. ICD-9-CM Index to Diseases (Volume 1) – The term must be looked up here first 2. ICD-9-CM Table of Diseases (Volume 2) – The code that was noted in Volume 1 must be examined in Volume 2 for other rules, such as “excludes,” “code in addition,” “code first,” and other similar notes 3. ICD-9-CM Official Guidelines for Coding and Reporting 4. Advice from the Coding Clinic for ICD-9-CM 5. Court opinions or other payer-specific regulations Hierarchy for ICD-9-CM Procedure Code Assignment – Basics 1. ICD-9-CM Index to Procedure (Volume 3) – The term must be looked up here first. 2. ICD-9-CM Table of Procedure (Volume 3) – The code that was noted in Index to Procedure must be examined in the Table for Procedures for other rules, such as “excludes,” “code in addition,” “code first,” and other similar notes 3. Advice from the Coding Clinic for ICD-9-CM 4. Sequencing is based upon the principal diagnosis/Major Diagnostic Category assignment and CMS’ surgical hierarchy 5. Court opinions or other payer-specific regulations How the Index to Diseases Affects Code Assignment – Basics • Injury – kidney - see Injury, internal, kidney – acute (nontraumatic) 584.9 Note that acute kidney injury codes only to 584.9, whereas acute renal failure codes up to 584.5 through 584.8 • Failure – renal 586 • acute 584.9 – with lesion of • necrosis cortical (renal) 584.6 medullary (renal) (papillary) 584.7 tubular 584.5 • specified pathology NEC 584.8 How the Table of Diseases Affects Code Assignment – Basics • Pancytopenia (acquired) 284.1 – with malformations 284.09 – congenital 284.00 Note how pancytopenia due to chemotherapy is coded 284.89 Other specified aplastic anemias Aplastic anemia (due to): chronic systemic disease drugs infection radiation toxic (paralytic) • 284.1 Pancytopenia Excludes pancytopenia (due to) (with): – aplastic anemia NOS (284.9) – bone marrow infiltration (284.2) – constitutional red blood cell aplasia – – – – – – – – (284.01) drug induced (284.89) hairy cell leukemia (202.4) human immunodeficiency virus disease (042) leukoerythroblastic anemia (284.2) malformations (284.09) myelodysplastic syndromes (238.72– 238.75) myeloproliferative disease (238.79) other constitutional aplastic anemia (284.09) ICD-9-CM Official Guidelines for Coding and Reporting • A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. – The definition of CDCI/CDI – These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. • The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. • The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. The AHA Central Office (on ICD-9-CM) • Created through a written Memorandum of Understanding between the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS) in 1963 to: – Serve as the U.S. clearinghouse for issues related to the use of ICD-9CM – Work with NCHS, the Centers for Medicare & Medicaid Services (CMS), and AHIMA (American Health Information Management Association)— known as the Cooperating Parties—to maintain the integrity of the classification system – Recommend revisions and modifications to the current and future revisions of the ICD – Develop educational material and programs on ICD-9-CM • Publishes Coding Clinic for ICD-9-CM (quarterly) – Deemed by the four Cooperating Parties as the official publication for ICD-9-CM coding guidelines and advice. – Coding Clinic (CC), 1st Quarter 2007, p. 19 The guidelines and directives in the ICD-9-CM manual take precedence over advice published in Coding Clinic. CC, 1st Quarter 1997, pp. 5–6 Pancytopenia w/ Myelodysplastic Synd • Question: Is pancytopenia an integral part of the disease process of myelodysplastic syndrome? • Answer: Pancytopenia is not an integral part of myelodysplastic syndrome. – Assign code 238.7, Neoplasms of uncertain behavior, Other and unspecified sites and tissues, Other lymphatic and hematopoietic tissues, as the principal diagnosis for the myelodysplastic syndrome. – Assign code 284.8, Other specified aplastic anemias for the pancytopenia, as an additional diagnosis. • Note, however, the pancytopenia code was introduced in 2006 which states that pancytopenia IS integral to myelodysplastic syndrome, thus a code from 284.8 would NOT be assigned. The guidelines and directives in the ICD-9-CM manual take precedence over advice published in Coding Clinic. How the Table of Diseases Affects Code Assignment • Pancytopenia (acquired) 284.1 – with malformations 284.09 – congenital 284.00 Note how pancytopenia due to myelodysplastic syndrome is coded 284.89 Other specified aplastic anemias Aplastic anemia (due to): chronic systemic disease drugs infection radiation toxic (paralytic) X THIS IS NOT CODED WITH PANCYTOPENIA due to MYELODYSPLASIA • 284.1 Pancytopenia Excludes pancytopenia (due to) (with): – aplastic anemia NOS (284.9) – bone marrow infiltration (284.2) – constitutional red blood cell aplasia – – – – – – – – (284.01) drug induced (284.89) hairy cell leukemia (202.4) human immunodeficiency virus disease (042) leukoerythroblastic anemia (284.2) malformations (284.09) myelodysplastic syndromes (238.72– 238.75) myeloproliferative disease (238.79) other constitutional aplastic anemia (284.09) Coding Clinic Definitions Are Educational in Nature Only! • CC, 3rd Quarter 2008, p. 15 – Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition. • CC, 1st Quarter 2008, p. 3 – The establishment of clinical parameters for code assignment is beyond the scope of authority of the Editorial Advisory Board for Coding Clinic for ICD-9-CM. All code assignment is based on provider documentation. Stroke CC, 1st Quarter 2010, p. 5 Stroke (Temporary) Manifestations • Question: According to Coding Clinic, 2nd Quarter 1989, p. 8, hospitals are not to report hemiplegia as an additional diagnosis for patients who present with acute CVA if the hemiplegia resolves prior to hospital discharge. Therefore, hemiplegia is not being reported even though these patients receive physical therapy or other treatment, which would ordinarily signify reporting the hemiplegia based on the General Rule for Reporting additional diagnoses. Could consideration be given to allow coding this clinically significant diagnosis? • Answer: Hemiplegia is not inherent to an acute cerebrovascular accident (CVA). Therefore, it should be coded even if the hemiplegia resolves, with or without treatment. The hemiplegia affects the care that the patient receives. Report any neurological deficits caused by a CVA even when they have been resolved at the time of discharge from the hospital. This current advice supersedes information previously published in Coding Clinic. Risk-Adjustment in MS-DRGs and APR-DRGs MS-DRGs • Comorbidity/complication • Major APR-DRGs • Severity of illness & risk of mortality on 1–4 scale – SOI scale influences comorbidity/complication reimbursement – ROM scale predicts mortality Simple Pneumonia • MS-DRG 195 – w/o CC – RW 0.7096 • MS-DRG 194 – w/CC – RW 1.0152 • MS-DRG 193 – w/MCC – RW 1.4796 Simple Pneumonia Base DRG -139 Other Pneumonia • • • • SOI 1 – 0.4022 SOI 2 – 0.6128 (Baby CC) SOI 3 – 0.9452 (CC) SOI 4 – 1.8787 (MCC) Effect on MS-DRGs and APR-DRGs • 431 – Intracerebral Hemorrhage – MCC – APR-DRG SOI – 4 • 784.3 – Aphasia – A CC with hemorrhage – Not a CC with other strokes – APR-DRG SOI – 2 • 342.90 – Hemiparesis – A CC – APR-DRG SOI – 2 • 253.6 – Syndrome of Inappropriate Antidiuretic Hormone – A CC – APR-DRG SOI – 3 • 518.81 – Acute Respiratory Failure – An MCC – APR-DRG SOI – 4 • 786.04 – Cheyne-Stokes Respiration Progressively faster breathing alternating with apnea – A CC – APR-DRG SOI 2 • 348.4 – Cerebral herniation • • An MCC APR-DRG SOI 4 • 780.01 – Coma • • An MCC APR-DRG SOI 4 NOTE: There’s some controversy in the coding of coma due to stroke – The listing of “apopletic coma” in the ICD-9-CM Index to Diseases states that coma is integral to acute stroke. – In this case, code 780.01 would NOT be added. CC, 1st Quarter 2010, p. 8 Cerebral Edema Due to Stroke • Question: A patient is admitted and diagnosed with intracerebral hemorrhage (ICH). The provider also documented "vasogenic edema." Is it appropriate to code the vasogenic edema? • Answer: Assign code 431, Intracerebral hemorrhage, as the principal diagnosis. Assign code 348.5, Cerebral edema, as an additional diagnosis. It is appropriate to code the cerebral edema separately since it is not inherent in cerebral hemorrhage. – Serves as a MCC in MS-DRG • Clinical – The most common cause • of neurological decline in stroke – Can be seen on CT or MRI Treatment – Mannitol – Glycerol – Diuretics – High-dose steroids (e.g., Decadron) – Hyperventilation CC, 2nd Quarter 2010, p. 17 POA Indicator with SAH w/LOC • Question: A patient is admitted with a subarachnoid hemorrhage following an injury. At the time of admission there was no mention of loss of consciousness. However, after admission the patient lost consciousness for several hours. We assigned code 852.03, Subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1–24 hours] loss of consciousness, as the principal diagnosis. What is the appropriate POA indicator since the patient lost consciousness after admission? • Answer: Assign POA indicator "Y" since the injury occurred prior to admission. Loss of consciousness is part of the natural history of the disease process. In addition, the POA guideline governing combination codes does not apply here, since this is not a combination of diagnoses. The skull fracture (800–804) and intracranial injury (850–854) categories are unique, so this advice only applies to these categories. Effect on MS-DRGs • 55-year-old admitted for head trauma and cervical spine fracture. Found to have a subarachnoid hemorrhage on admission, but had a brief loss of consciousness after the inpatient admission. • If the cervical spine fracture is listed as the principal diagnosis, the impact of code 852.02 – SAH after injury, no open intracranial wound, brief unconsciousness, as a secondary is: – POA – N – MS-DRG 965 – Other Multiple Significant Trauma without CC/MCC – 0.9386 (deemed a HAC) – POA – Y – MS-DRG 965 – Other Multiple Significant Trauma without CC/MCC – 0.9386 CC, 3rd Quarter 2010, p. 5 Hemorrhagic Conversion of Stroke • Question: A 77-year-old patient was admitted with expressive aphasia secondary to acute cerebral infarction. The patient was given intravenous (IV) tissue plasminogen activator (tPA) within 4.5 hours of the onset of symptoms with significant improvement of aphasia. Brain MRI showed acute left temporoparietal infarct with asymptomatic hemorrhagic conversion. The provider stated that the hemorrhagic conversion was caused by the tPA therapy. What are the code assignments for hemorrhagic conversion of the temporoparietal infarction due to tPA? • Answer: Assign codes – 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction, as the principal diagnosis. – Code 997.02, Iatrogenic cerebrovascular infarction or hemorrhage. – Code 431, Intracerebral hemorrhage, for the cerebral hemorrhagic conversion due to the thrombolytic therapy. – Code 784.3, Aphasia. – Code E934.4, Drugs, medicinal and biological substances causing adverse effects in therapeutic use, Fibrinolysis-affecting drugs, as additional diagnoses. • The additional code of 431 is an MCC. 997.02 is a complication. Coding of Adverse Events from Drugs That Are Properly Administered • ICD-9-CM Guidelines • Adverse Effect When the drug was correctly prescribed and properly administered, code the reaction plus the appropriate code from the E930–E949 series. – The effect, such as tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure, is coded and followed by the appropriate code from the E930– E949 series. tPA Administration Must Be a ‘Medical Intervention’ • ICD-9-CM Guidelines • A cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded to 997.02, Iatrogenic cerebrovascular infarction or hemorrhage. – Medical record documentation should clearly specify the causeand-effect relationship between the medical intervention and the cerebrovascular accident in order to assign this code. A secondary code from the code range 430–432 or from a code from subcategories 433 or 434 with a fifth digit of “1” should also be used to identify the type of hemorrhage or infarct. • This guideline conforms to the use additional code note instruction at category 997. Code 436, Acute, but illdefined, cerebrovascular disease, should not be used as a secondary code with code 997.02. What about heparin, warfarin, aspirin, Plavix, or other medications affecting the coagulation system? CC, 3rd Quarter 2010, pp. 5–6 Hemorrhagic Conversion of Stroke • Question: A patient sustained a left frontal cerebral infarction with hemorrhagic conversion. The provider documented that the patient had presented with expressive aphasia due to an acute cerebral infarct and later developed hemorrhagic conversion of the infarct. When queried, the provider stated that the hemorrhagic conversion had occurred spontaneously. What are the correct code assignments for spontaneous hemorrhagic conversion of a cerebral infarction? • Answer: Assign both code 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction, and code 431, Intracerebral hemorrhage. Hemorrhage can spontaneously occur after the original infarct. Conclusion • Physician must define and document all consequences of stroke – Cerebral edema, cerebral herniation, acute respiratory failure, hemiparesis, aphasia, and others are commonly left out – Be careful with “coma due to stroke” • Consider reasons why stroke patients decompensate and/or die • Determine whether any hemorrhagic conversion of stroke is a consequence of a pharmaceutical interaction, warranting code 997.02 Pulmonary Conditions CC, 1st Quarter 2010, pp. 5–6 Compensated Respiratory Acidosis with COPD • Question: What is the correct code assignment for a diagnosis of "compensated respiratory acidosis" in a patient with chronic obstructive pulmonary disease (COPD)? • Answer: Assign only code 496, Chronic airway obstruction, not elsewhere classified, for the COPD. It would be inappropriate to separately report a code for compensated respiratory acidosis. – Note that it didn’t prohibit the coding of uncompensated respiratory acidosis, nor did it prohibit the coding of documented chronic hypercapnic respiratory failure Chronic Respiratory Failure • Hypoxemic – Failure to oxygenate • 2010 Murray & Nadel Pulmonary Textbook - pO2 < 60 mm Hg – Medicare criteria - Home O2 • Resting PaO2 < 55 mm Hg or O2 saturation < 88% • Resting PaO2 of 56-59 mm Hg or O2 sat of 89% in the presence of any of the following – Dependent edema suggesting congestive heart failure – P pulmonale on the electrocardiogram • Hypercapnic – Failure to ventilate – pCO2 over 50 with pH that is • Normal or • Slightly low pH (between 7.33–7.35) – Because of the chronic respiratory acidosis, the serum HCO3 will likely be high (over 28) as part of a compensation metabolic alkalosis 518.83 – Chronic respiratory failure is a CC in MS-DRGs and a level 3 designation in APR-DRGs CC, 1st Quarter 2010, pp. 12–13 COPD & Pneumonia • Question: When a patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and an infection such as pneumonia, is pneumonia always sequenced as the principal diagnosis? • Answer: Sequence either code 486, Pneumonia, organism unspecified, or code 491.21, Obstructive chronic bronchitis, with (acute) exacerbation, as the principal diagnosis, when the patient is admitted with both conditions. The pneumonia and COPD are two separate conditions that presented simultaneously. The pneumonia is not the exacerbation of the COPD. Consequences • Pneumonia as principal – MS-DRGs • 194 – Simple Pneumonia & Pleurisy with CC – 1.0152 – APR-DRGs • 139 – Other Pneumonia – SOI of 2 – RW 0.6128 • COPD as principal – MS-DRGs • 190 – COPD w/MCC RW 1.1924 – APR-DRGs • 140 – COPD SOI of 2 – RW 0.6399 • GN pneumonia as principal • COPD as principal – MS-DRGs • 178 – Respiratory Infections & Inflammations with CC – 1.4887 – APR-DRGs • 139 – Major Respiratory Infections SOI of 1 – RW 0.6879 – MS-DRGs • 190 – COPD w/MCC RW 1.1924 – APR-DRGs • 140 – COPD SOI of 3 – RW 0.8851 CC, 1st Quarter 2010, pp. 12–13 COPD & Pneumonia • "In those rare instances when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first." The Guidelines also state • Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis. – When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise. CC, 3rd Quarter 2010, p. 19 Resp Failure & Pneumonia 2° Smoke • Question: A patient was admitted with burns to the arms, firstdegree burns to the ears, respiratory failure, and pneumonia due to smoke inhalation when a fire started in his home. What are the appropriate diagnosis code assignments? • Answer: Assign – Code 506.3, Other acute and subacute respiratory conditions due to fumes and vapors, as principal diagnosis, for respiratory problems due to smoke inhalation. – Codes 506.0, Respiratory conditions due to chemical fumes and vapors, bronchitis and pneumonitis due to fumes and vapors; 518.5, Pulmonary insufficiency following trauma and surgery; 941.11, Burn of face, head, and neck, erythema [first degree], ear [any part]; 943.00, Burn of upper limb, except wrist and hand, unspecified degree; and E890.2, Conflagration in private dwelling, other smoke and fumes from conflagration, as additional codes. Why not allow the option to code the 518.5 as the principal diagnosis, given both were POA and necessitated admission? CC, 1st Quarter 2008, pp. 18–19 Aspiration Pneumonia & ARF • Question: When acute respiratory failure is present on admission along with aspiration or bacterial pneumonia and both conditions are equally treated, can either condition be sequenced as the principal diagnosis? • Answer: In this case, sequence either code 507.0, Pneumonitis due to inhalation of food or vomitus, or code 518.81, Acute respiratory failure, as the principal diagnosis. – The Official Guidelines for Coding and Reporting regarding two or more diagnoses that equally meet the definition for principal diagnosis state, "In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first." Previous advice needs clarification in light of this Coding Clinic (which was also written as a clarification). CC, 1st Quarter 2010, p. 18 POA for Acute Respiratory Failure • Question: A 70-year-old female with chronic obstructive pulmonary disease (COPD) was admitted with an acute exacerbation of COPD. The patient presented to the hospital with acute respiratory distress and hypoxia. On day two, she was transferred to the ICU and placed on mechanical ventilation to treat acute respiratory failure. What are the appropriate POA indicators? • Answer: For coding and reporting purposes, both the COPD exacerbation and the acute respiratory failure would be separately coded. If the health record documentation is not clear regarding whether respiratory failure was present on admission, query the provider for clarification. – If the provider responds that the respiratory failure developed after admission, assign a POA indicator of "N." – If the provider cannot determine whether the respiratory failure was present on admission, assign a POA indicator of "W." Just because it quacks, waddles, has feathers, and flies south for the winter, it’s not a duck unless the physician documents that it’s a duck, hence the need for CDI/CDCI. CC, 3rd Quarter 2010, p. 9 AVM of the Lung • Question: What is the code assignment for arteriovenous malformation (AVM) of the middle lobe of the right lung? Is code 747.69, Anomalies of other specified sites of peripheral vascular system, correct? • Answer: Assign code 747.3, Anomalies of pulmonary artery, for AVM of the lung. Code 747.69 is not appropriate since it describes an AVM of the peripheral circulation and the pulmonary circulation is distinct from the peripheral. – 747.3 is an MCC in MS-DRGs – 747.3 has an SOI of 1 in APR-DRGs Pulmonary Arteriovenous Malformations • Abnormal communications between pulmonary arteries and pulmonary veins, which are most commonly congenital in nature • Very uncommon – Mayo Clinic only saw 8.5 cases per year in the 1980s – 70% of pulmonary AVMs are associated with hereditary hemorrhagic telangiectasia (HHT), whereas only 15%–35% of patients with HHTs have pulmonary AVMs • Common differential diagnosis in the workup of hypoxemia, pulmonary nodules, and stroke http://ajrccm.atsjournals.org/cgi/content/full/158/2/643 Pulmonary AVMs Should They Be Coded? ICD-9-CM Guidelines for Additional Diagnoses • • • • clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or • increased nursing care and/or monitoring. • In newborns, conditions that have been specified by the provider as having implications for future healthcare needs. Coding Clinic, 3rd Q2007 pp. 13–14 • Chronic conditions such as, but not limited to, hypertension, Parkinson's disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation. • Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization, and therefore should be coded. • This advice applies to inpatient coding. Repaired Congenital Anomaly CC, 4th Quarter 2010, p. 136 • Question: If a patient has a history of a congenital condition that has been repaired, is it still a reportable condition? • Answer: Query the provider as to whether the congenital anomaly has been partially or completely repaired. – If the anomaly is still present and has not been completely repaired, it is appropriate to code even in an adult patient. – If, however, the anomaly has been completely repaired, assign code V13.65, Personal history of (corrected) congenital malformations of heart and • Many congenital anomalies, although present at birth, may not manifest until later in life. In addition, some conditions may not be correctible and can persist. • The official coding guidelines state in section I.C.14.a: "Codes from Chapter 14 may be used throughout the life of the patient." Therefore, it is acceptable to code these conditions, using codes from categories 740–759, Congenital anomalies, in an adult patient. CC, 3rd Quarter 2010, p. 4 Mech Vent Reporting During Weaning • Question: Our question relates to patients admitted to a long-term care hospital on a T-piece or tracheostomy collar the day of the transfer, but placed on mechanical ventilation that evening. How are the hours of mechanical ventilation counted? Should we begin counting hours at the start of the admission even though the patient is breathing through the T-piece without mechanical ventilation, or are the hours counted from the time the patient is on the vent? • Answer: Yes, you should begin counting hours at the start of the admission. All of the period of weaning is counted during the process of withdrawing the patient from ventilatory support. The duration includes the time the patient is on the ventilator, the weaning period, and ends when the mechanical ventilation is turned off (after the weaning period). The fact that a T-piece is being used during the day does not affect code assignment. A T-piece (trach collar) trial involves the patient breathing through a T-piece without ventilatory assistance for a set period of time. Renal Conditions CC, 3rd Quarter 2010, p. 15 Acute Renal Failure with ESRD • Question: What is the appropriate code assignment for a patient with documented acute kidney failure and end-stage renal disease (ESRD) during the same admission? Is acute kidney failure an acute exacerbation of chronic kidney failure? • Answer: No, acute kidney failure is not an acute exacerbation of chronic kidney failure. Acute kidney failure and chronic kidney failure are two separate and distinct conditions. – Acute renal failure has an abrupt onset and is potentially reversible. – Chronic kidney failure progresses slowly over time and can lead to permanent kidney failure. The causes, symptoms, treatments, and outcomes of acute and chronic are different. – End-stage renal disease is when the kidneys permanently fail to work. If both acute and chronic kidney failure are clearly documented, code both. Acute Renal Failure • Coding Clinic and the National Center for Health Statistics, in concert with the Cooperating Parties, are working to refine the acute renal failure (acute kidney injury) codes to better reflect their resource requirements. – Triggered in some part by CMS’ designation of code 584.9 as a CC and the evolving definitions of acute renal failure/acute kidney injury • Read Coding Clinic very carefully to learn of these changes and to coordinate query efforts with your medical staff. KDOQI Definition of ESRD • End-stage renal disease (R). End-stage renal disease (ESRD) is an administrative term in the United States, based on the conditions for payment for healthcare by the Medicare ESRD Program, specifically the level of GFR and the occurrence of signs and symptoms of kidney failure necessitating initiation of treatment by replacement therapy. ESRD includes patients treated by dialysis or transplantation, irrespective of the level of GFR. • The KDOQI definition of kidney failure differs in two important ways from the definition of ESRD. – First, not all individuals with GFR <15 mL/min/1.73 m2 or with signs and symptoms of kidney failure are treated by dialysis and transplantation. Nonetheless, such individuals should be considered as having kidney failure. – Second, among treated patients, kidney transplant recipients have a higher mean level of GFR (usually 30 to 60 mL/min/1.73 m2) and better average health outcomes than dialysis patients. Kidney transplant recipients should not be included in the definition of kidney failure, unless they have GFR <15 mL/min/1.73 m2 or have resumed dialysis. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm Medicare Definition of ESRD • End-stage renal disease (ESRD) is a kidney impairment that is irreversible and permanent and requires either a regular course of dialysis or kidney transplantation to maintain life. • If the beneficiary has Medicare only because of ESRD, Medicare coverage will end when one of the following conditions is met: – 12 months after the month the beneficiary stops dialysis treatments, or – 36 months after the month the beneficiary had a kidney transplant Federal Register / Vol. 73, No. 73, p. 20371; https://www.cms.gov/employerservices/04_endstagerenaldisease.asp CC, 4th Quarter 2010, p. 135 Hypertensive Urgency (Emergency) • Question: What is the appropriate code assignment for hypertensive urgency? • Answer: Query the physician for the specific type of hypertension when only hypertensive urgency is documented. – As of October 1, 2010, revisions to the index have been made and the coder is directed to "See hypertension," when "urgency, hypertensive" is referenced. – Options: Benign, Malignant, or Unspecified. • However, if upon clarification by the physician the hypertension is still not further specified, code 401.9, Essential hypertension, unspecified, should be assigned. Other Conditions CC, 1st Quarter 2010, p. 10 SIRS Due to ‘Noninfectious’ Causes • Question: The guideline states that systemic inflammatory response syndrome (SIRS) can develop as a result of certain noninfectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. A physician at our hospital stated that acute pancreatitis is an inflammation of the pancreas that can occur with infection. Acute pancreatitis is usually caused by gallstones or by drinking too much alcohol, but these aren’t the only causes. If the guideline is accurate, could it be applied to other inflammatory conditions, such as diverticulitis, cholangitis, orchitis, etc.? • Answer: Yes, the guideline for noninfectious SIRS can be applied to other types of inflammatory conditions as well as pancreatitis. Therefore, it would be appropriate to report code 995.93, Systemic inflammatory response syndrome due noninfectious process without acute organ dysfunction, or code 995.94, Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction, for SIRS due to any noninfectious condition. One cannot assume that every “-itis” is an infection. CC, 1st Quarter 2010, pp. 10–11 SIRS Due to Medications • Question: What is the appropriate code assignment for SIRS secondary to a possible drug reaction? • Answer: – Code the presenting symptoms (e.g., tachycardia, tachypnea, fever, etc.). – Code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction, should be assigned as an additional diagnosis. DRG Options for SIRS Due to Medications • If one codes the symptoms as the principal diagnosis, the following DRG options are allowed: ICD-9-CM Code ICD-9-CM Description MS-DRG MS-DRG Description FY 2010 Relative Weight 780.60 Fever, unspecified 864 Fever 0.8276 288.50 Leukopenia, unspecified Leukocytosis, unspecified 816 Reticuloendothelial and Immunity Disorders w/o CC 0.6818 785.0 Tachycardia, unspecified 310 Cardiac Arrhythmia & Conduction Disorders w/o CC 0.5709 786.06 Tachypnea, unspecified 204 Respiratory Signs and Symptoms 0.6714 CC, 3rd Quarter 2010, pp. 15–16 Arteriosclerotic leukoencephalopathy • Question: The patient is a 68-year-old male who has been diagnosed with arteriosclerotic leukoencephalopathy. What is the appropriate code assignment for arteriosclerotic leukoencephalopathy? – Indexing of leukoencephalopathy leads to code 323.9, Unspecified causes of encephalitis, myelitis, and encephalomyelitis. – Indexing of encephalopathy, arteriosclerotic directs to code 437.0, Cerebral atherosclerosis. – Binswanger’s disease is classified to code 290.12, Presenile dementia. – However, none of these codes seem appropriate. • Answer: Assign code 437.0, Cerebral atherosclerosis, and code 323.81, Other causes of encephalitis and encephalomyelitis, for arteriosclerotic leukoencephalopathy. Assign also codes for any other manifestations present. 323.81 is a MCC Leukoencephalopathy • Leukoencephalopathy is a broad term for leukodystrophy-like diseases – Leukodystrophy is a progressive degeneration of the white matter of the brain due to imperfect growth or development of the myelin sheath, the fatty covering that acts as an insulator around nerve fiber. – Leukoencephalopathy is a white matter brain disease that does not have to be related to growth and development. • Binswanger’s disease – widespread degeneration of cerebral white matter having a vascular causation and observed in the context of hypertension, atherosclerosis of the small blood vessels, and multiple strokes – Leukoaraiosis – “rarified white matter” which may occur in the periventricular or the centrum semiovale area of the brain Index to Diseases • Leukoencephalopathy (see also Encephalitis) 323.9 (a MCC) – acute necrotizing – – – – – – hemorrhagic (postinfectious) 136.9 [323.61] postimmunization or postvaccinal 323.51 Binswanger's 290.12 metachromatic 330.0 multifocal (progressive) 046.3 progressive multifocal 046.3 reversible, posterior 348.5 • Leukoaraiosis (hypertensive) 437.1 (a CC) • Binswanger’s disease or Leukoencephalopathy – 290.12 (a CC) • Alzheimer’s disease without behavioral disturbance – 331.0 + 294.10 (not a CC) CC, 4th Quarter 2010, p. 135 Gross Hematuria 2° Prostate CA • Question: A patient, who is currently under treatment for prostate cancer, was admitted for gross hematuria with a significant drop in hemoglobin. The patient had been unable to pass urine and was only passing frank blood and clots. While in the hospital, 12 units of blood were transfused, and bladder irrigation was started and continued until the urine was clear for approximately 12 hours. What is the principal diagnosis for this admission? • Answer: Assign code 599.71, Gross hematuria, as principal diagnosis. In this case, treatment was not directed at the malignancy. Assign code 185, Malignant neoplasm of prostate, as an additional diagnosis. Based on the medical documentation, the patient was admitted for gross hematuria. • What was the cause of the gross hematuria? – Was it radiation cystitis as a result of brachytherapy? • Why not code the “drop in hemoglobin”? – Is “drop in hemoglobin” requiring 12 units of blood integral to gross hematuria? • Did not the patient have an acute blood loss anemia as well? DRG & Query Options Principal Diagnosis Coding Clinic’s Advice Scenario 1 Scenario 2 Scenario 3 599.71 Gross hematuria 599.71 Gross hematuria 595.82 Radiation cystitis 285.1 - Acute Blood Loss Anemia 285.1 Acute blood loss anemia 599.71 Gross hematuria 599.71 Gross hematuria 812 Secondary #1 696 696 285.1 Acute blood loss anemia 699 Kidney & urinary tract signs and symptoms 0.6453 Kidney & urinary tract signs and symptoms 0.6453 Other kidney and urinary tract diagnoses w/CC 0.9518 Red blood cell disorders without MCC 0.7751 468 663 Other kidney/ urinary tract disorder Other anemia/blood disorder Secondary #2 MS-DRG # Description Relative Wgt APR-DRG # Description Relative Wgt. SOI 468 468 Other Other kidney/urinary kidney/urinary tract tract disorder disorder 0.4976 0.4976 0.6876 0.6257 1 1 2 2 Acetylcholine Challenge Test CC, 2nd Quarter 2010, p. 11 • Question: A patient with chest pain was referred for cardiac catheterization to rule out endothelial dysfunction. An acetylcholine (ACh) challenge test was performed. Acetylcholine was introduced into the left anterior descending artery (LAD) to rule out endothelial dysfunction. Images were taken of the diameter stenosis of the LAD. The stenosis was then reversed with intracoronary injections of nitroglycerin. What is the code assignment for this test? • Answer: Assign code 89.59, Other nonoperative cardiac and vascular measurements, for the intracoronary acetylcholine challenge test. • What is the nature of the chest pain such that it is provoked by acetylcholine and relieved with nitroglycerin? Reference: http://jama.ama-assn.org/content/293/4/477.full CC, 2nd Quarter 2010, pp. 7–8 Use of Cancer Staging Forms • Question: The patient was admitted for heminephrectomy due to bilateral renal masses. Pathologic analysis confirmed renal cell carcinoma. The provider listed "bilateral renal masses" in the final diagnostic statement since the pathological results were not available at the time. However, the cancer staging form that the provider has completed and signed is available in the health record. Our medical staff leadership has deemed this confirmation of the pathologic diagnosis of renal cancer and sufficient documentation for coding. Is the completed and signed cancer staging form appropriate documentation for coding and reporting purposes? • Answer: Yes, it is appropriate to use the completed cancer staging form for coding purposes when it is authenticated by the attending physician. • Question: What if the cancer staging form is signed by another physician other than the attending provider? CC, 2nd Quarter 2010, p. 10 Pregnancy & Genital Herpes • Question: What is the appropriate coding when a pregnant patient is admitted to the hospital for delivery and the patient has a history of genital herpes? At the time of admission, the patient is symptom-free with no outbreaks and is usually being maintained on a drug such as Valtrex. Is this coded as a complication of the pregnancy or as a normal delivery with history of herpes since the patient is symptom-free at the time of delivery? • Answer: Assign code 647.61, Infectious and parasitic conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium, Other viral diseases, delivered, with or without mention of antepartum condition, as the principal diagnosis. Code 054.10, Genital herpes, unspecified, and code V58.69, Long-term (current) use of other medications, should be assigned. A personal history of herpes code is not appropriate because, as the Official Guidelines for Coding and Reporting state, "Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring." The herpes is still under treatment. CC, 2nd Quarter 1996, p. 7 Chronic Septra Use to Prevent UTI • Question: A patient is admitted to the hospital with atrial fibrillation. The patient is on prophylactic Septra for chronic recurrent UTIs and is continued on this medication during the current hospitalization. The patient had no urinary symptoms or problems during this short stay. Is the fact that the patient was given Septra during her admission enough to substantiate using code 599.0, Urinary tract infection, site not specified, or should V code be used for history of UTIs? • Answer: Assign code 427.31, Atrial fibrillation, as the principal diagnosis. Assign code V58.69, Long-term (current) use of other medications, and code V13.09, Personal history of disorders of urinary system, other, as additional diagnoses. Code V58.69 would be assigned to identify the fact that the patient is on long-term use of Septra. Since the patient did not have any signs or symptoms of a UTI during this admission, it would be inappropriate to assign a code for the condition. A UTI is a condition that occurs as an acute, episodic condition, which may or may not recur if the prophylactic antibiotic is discontinued. How Can I Benefit from Coding Clinic? Send Your Own Questions to Coding Clinic Obtain the required form from the AHA Coding Clinic for ICD-9-CM website AHA Coding Clinic® for ICD-9-CM A quarterly publication of the Central Office on ICD-9-CM Request for Coding Advice Get Your Own Subscription! • Subscriptions available: – Paper – Electronic AHA Coding Clinic® for ICD-9-CM A quarterly publication of the Central Office on ICD-9-CM Know that Coding Clinic will start all over again once ICD-10 is implemented on October 1, 2013. Use an Encoder • • • • • 3M Quadramed Ingenix TruCode Others CDI specialists optimally should have laptop computers with encoder software as to emulate the coding environment. Read the ACDIS CDI Journal http://www.cdiassociation.com Gratitude and Questions Questions answered to the extent they come with Fancy Feast —Sylvester A. Kennedy, master of Dr. James S. Kennedy Disclaimer • The information presented reflects Dr. Kennedy’s understanding of the ICD-9-CM and his wish that all medical conditions addressed during a clinical encounter are documented accurately in the medical record by providers and coded compliantly by the coding staff. • Dr. Kennedy, FTI Healthcare, ACDIS, HCPro, and all affiliated entities wholeheartedly support ICD-9-CM, its Guidelines, its interpretations through Coding Clinic for ICD-9-CM, and other applicable laws or practice standards. Coders, clinical documentation specialists, and physicians are expected to be familiar with applicable rules, regulations, and laws, implementing them in their daily work. It is not the intent or desire of the speaker or his affiliated entities that any physician, case manager, or coder promote diagnosis terminology that is not supported by reasonable standards of care or appropriate physician literature, nor is it their intent to encourage coding or query practices that fraudulently or abusively incur incorrect payments under government or private insurance programs. • This lecture is general in nature and reflects the opinions of a clinician discussing clinical syndromes. Nothing said in this lecture should be construed as medical advice nor an official recommendation supporting ICD-9-CM code assignment or submission of medical claims for payment. • The audience is strongly encouraged to discuss the content of this lecture with their compliance officer prior to submission of claims for payment to any healthcare insurer or government entity. Dr. Kennedy, FTI Healthcare or other entities affiliated with this lecture will not assume responsibility for any misunderstanding or misapplication of the material presented in this lecture. References/Resources • ACDIS, CDI Journal – available to members at: – http://www.hcpro.com/acdis/archive.cfm?topic=WS_ACD_JNL – http://www.cdiassociation.com • AHA Central Office – http://www.ahacentraloffice.org – http://www.ahacentraloffice.org/ahacentraloffice/shtml/links.shtml • Official ICD-9-CM Guidelines for Coding and Reporting – http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf