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Did you know?
• Heart Disease is the #1 killer of women, claiming
almost 435,000 lives a year, or nearly 1 per
minute.
• Your circulatory system of blood vessels
(arteries, veins and capillaries) is over 60,000
miles long
• By the age of 70, the average human heart has
beaten more than 2.5 billion times and the heart
has pumped about 1 million barrels of blood.
Avoiding Errors in Documentation
Priority: High
• Over the past 5 years, CMS has audited thousands
of MA members’ charts. The results have been
both alarming and encouraging.
• Alarming because the error rate remains high
– Risk Adjustment Data Validation (RADV) studies
(audits) have increased in scope, and the potential
effect on both MA organizations and providers are
substantial.
• CMS has published a final rule on RADV, and
overpayments will be extrapolated across a health
plan’s network.
– OIG / Pacificare of Texas
What can physicians do to protect themselves?
• A small handful of errors in documentation
make up the vast majority of coding errors.
• Better yet, these errors are easily corrected,
once physicians understand the underlying
ICD-9 coding rules.
• Due Diligence
– Education and Training
– Compliane: Policies and Procedures
– Become Certified
• Physicians must understand that the ICD-9 and
clinical medicine have little in common.
• Physicians must distance themselves from their
clinical knowledge, both in general and
specifically, about the patient at hand.
• The ICD-9 doesn’t allow assumption, and relies
solely on what’s written in the progress note.
 A physician writes a note, and then chooses a code reflecting
what’s wrong with the patient, not what they’ve documented
in the medical record.
 The physician may document signs, symptoms, and historical
data, and fail to record a diagnosis. Then, knowing what’s
wrong with the patient, they may choose a diagnosis on a
superbill—without it having been recorded in the progress
note.
Most Common Mistakes
Problem: Choosing a code that looks right, without knowing the rules
for using that code.
Example: Coronary atherosclerosis of unspecified type of vessel,
native or graft (414.00).
Solution: Understand the rules for use of commonly used codes in your practice.
To use code 414.00, you must state that the patient has had a CABG, but fail to
state whether a native or non-native vessel is affected.
If your note simply says “coronary atherosclerosis” or “ASHD”, and does not
reference a previous CABG, then the correct code is 414.01.
Problem:
Trying to use ICD-9 titles to support a code selection, or simply writing the ICD-9 code in the
medical record.
Example:
Diabetes with renal manifestations (250.40).
Solution:
Document both diseases in a brief narrative. For example, if the patient has Stage 3 CKD due
to diabetes mellitus, then your note should reflect that.
Problem:
Writing only a diagnosis code in the chart.
Example:
Impression: 250.40.
Solution:
Since coding is derived from a narrative description of the disease state, writing 250.40 in the
chart cannot be coded. Documentation should clearly reflect the condition of
the patient.
ESRD secondary to DM clearly describes the condition.
Problem:
Documenting and coding CVA in the office setting. A CVA is an acute event.
Once the patient is discharged from the hospital or rehabilitation setting, the
diagnosis of acute CVA is inaccurate and leads to miscoding.
Example:
Each time a status post CVA patient is evaluated, the physician documents
“CVA” in the record and codes 434.91 (CVA, ischemic or unspecified).
Solution:
Document that the patient is status post CVA or has a history of CVA (V12.54).
What is often overlooked are the sequelae of CVA, since they have often been
present for many years. When assessing the patient, it’s important to
document and code these as well. There are ICD-9 codes for all of the common
and pertinent sequelae of CVA in the 438.XX series of ICD-9.
Problem:
Malignancy coded when the correct coding would be personal history of malignancy of
___________. In the case of malignancies, the ICD-9 again differs from current clinical
thinking. The ICD-9 allows coding of the malignancy until definitive treatment is finished
(unless there are signs of active disease).
Definitive treatment is that aimed at eradicating the cancer, such as surgery,
chemotherapy and/or radiation therapy. Patients with biopsy proven malignancies who
are not treated continue to be coded with the diagnosis of cancer.
Example:
Patient who is status post pneumonectomy for lung cancer 5 years ago. The patient is on
no therapy, but surveillance is continued for the patient’s lifetime.
Solution:
Document and code personal history of the cancer. These codes are found in the V10.XX
series of the ICD-9.
Problem: Documentation of multiple primary sites of malignancies when the
patient has metastatic disease.
Example: Patient has primary breast cancer which has metastasized to the brain.
Solution: If the patient is being assessed or treated for both, then coding for the
breast cancer would be in the 174.X (depending on area of the breast) and 198.3,
secondary neoplasm of brain or spinal cord.
Problem: “History of” means the disease is in the past. You cannot code an active disease
you have documented as a “history of.”
Example: History of CHF
Solution: Remember to use the term “history of” only for diseases which have resolved. In
the case of chronic conditions like CHF and atrial fibrillation, use terms like compensated or
controlled to reflect their ongoing status.
Problem:
Not restating and coding long standing disease. The ICD-9 and the CMS HCC
risk adjustment model have no inherent memory.
– A disease only exists at the time it is assessed, documented and coded. All
chronic diseases disappear from the risk adjustment model each year, and must
be resubmitted.
Example:
A patient who is 10 years status post colon resection for carcinoma, with
colostomy.
Solution:
When your attention is directed to the illness, or in this case the site (assessing
skin integrity or signs and symptoms of a recurrence of the cancer) it is
appropriate and important to document and code these conditions. There are
codes for artificial openings (tracheostomy, colostomy, ileostomy, etc.) in the
V44.X series.
• Coding rules don’t allow choosing a code based on
lab or radiology reports, unless the physician
references them in the body of the progress note.
• Further, such references must be specific—noting
that the result is abnormal or writing a lab value
doesn’t support ICD-9 selection.
Document, Document, Document
No Documentation = No Justification For Claims Submitted
Fact:
• A Patient’s chronic conditions affect the management of the Patient, even when the Patient is
presenting with a straightforward illness that would appear unrelated to the chronic condition.
Fact:
• If the chronic condition isn’t documented
• To have affected the patient’s care (and how so)
• It is not to be coded or reported on the claim as an active condition.
• (“History Of” codes may be used, but are informational unless it’s documented how the patient’s
care was impacted by that history.)
Fact:
• Coding and reporting chronic conditions that aren’t documented to have affected the patient’s
treatment and management on that particular encounter constitutes billing for conditions that are
not supported by the documentation.
How to Proceed:
• Deliver timely comprehensive care
• Document the care you deliver
• Code the care you document
• Capture the codes you document
Medicare B News Issue 236 April 17 2007, Heading: Reminder, Title: Documentation Guidelines for Amended Records - Revised
Cardiology
Be specific
• If the patient has stable angina or a history of
myocardial infarction (MI), document this condition
as opposed to a less specific diagnosis such as
coronary artery disease (CAD) or atherosclerotic
heart disease (ASHD).
Documenting MI
• For coding purposes, an MI is considered acute
within the first 8 weeks of the event—after that,
you should document an old MI.
• For an acute MI, the coding is defined by
“episodes of care”, so from initial hospitalization
through the 8 weeks is the initial episode.
• If the patient is re-hospitalized for care related to
the MI, a subsequent episode of care begins
which has a different diagnosis code.
Documenting Arrhythmias
• Do not forget to document and code ongoing
chronic conditions such as atrial fibrillation or
arrhythmias, whether symptomatic or
asymptomatic due to pharmacological
treatment.
• Arrhythmias that no longer exist due to
ablation should not be coded.
Document Heart Failure
• Codes exist in category 428 for systolic,
diastolic and congestive heart failure. More
than one code from category 428 may be
assigned if the patient has systolic or diastolic
failure and congestive heart failure.
• Codes also exist for acute on chronic heart
failure.
Documenting and Coding a Stroke
• Patients with acute cerebrovascular accident
(CVA) usually present in an ER or hospital setting.
• Patients who recover from CVA without sequelae
should be documented as “history of CVA” and
assigned code V12.54 as an additional code for
history of cerebrovascular disease when no
neurologic deficits are present.
• Unless the patient is still hospitalized for the CVA,
you should not be using codes in the 434.XX
series.
Late Effects Of a Stroke
• Assess and document all late effects of CVA. Late
effects such as aphasia, aphagia, hemiparesis,
etc., should be documented and coded using
codes from the 438.XX series.
• Epilepsy should be fully described(convulsive,
non-convulsive, petit mal status, grand mal status)
and should describe intractable epilepsy
(pharmacology resistant, medically refractive) if
present.
• Dementia should be described fully and include a
description of causative factors if they exist.
Atherosclerosis
• Aortic atherosclerosis and peripheral atherosclerosis are chronic
conditions that should be assessed, documented and coded each
year.
• These conditions may have been identified through findings on a
radiology procedure, but must be assessed by the treating
physician.
• To code these conditions, the diagnosis must be stated in the
progress note. They cannot be coded from the radiology report.
According to Coding Clinic, the term “aortic atherosclerosis” is
inadequate for coding because it isn’t clear if it is the vessel or the
valve. Your wording should make it clear which is involved.
Renal Documentation and Coding
• CKD coding (585.X) has been changed to conform with the stages of
CKD.
• These changes include stages I-V based on a patient’s glomerular
filtration rate (GFR), which is estimated from a urinalysis and/or
serum creatinine and basic patient demographics.
• Remember that some Medicare patients with “normal” creatinine
levels may still have significantly impaired renal function.
• For people at risk, creatinine clearance or GFR should be estimated
at least twice per year.
Note that stages I and II of CKD must have 3 months of reduced GFR or
evidence of kidney damage documented.
Kidney Disease
• 581
Nephrotic syndrome
• 583
Nephritis and nephropathy, not specified as acute or chronic
• 593.9 Unspecified disorder of kidney and ureter
–
–
–
–
Acute renal disease
Acute renal insufficiency
Renal disease NOS
Salt-losing nephritis or syndrome
» Excludes:
• chronic renal insufficiency (585.9)
• cystic kidney disease (753.1)
• nephropathy, so stated (583.0-583.9)
• renal disease not specified as acute or chronic, but with
stated pathology or cause (583.0-583.9)
Chronic Kidney Disease: Staging
Severity
GFR Value
ICD-9
Codes
Stage I
Some kidney damage with
normal or slightly ↑ GFR
GFR ≥ 90 ml/min
With kidney damage *
585.1
Stage II
Mild
Kidney Damage
GFR 60-89 ml/min
With kidney damage *
585.2
Stage III
Moderate
Kidney Damage
GFR 30-59 ml/min
585.3
Stage IV
Severe
Kidney Damage
GFR 15-29 ml/min
585.4
ICD-9
Stage V
Kidney Failure
GFR < 15 ml/min
585.5
ICD-9
ESRD
ESRD
Requiring chronic dialysis or transplantation
585.6
CKD NOS, Chronic Renal
Failure, or Chronic Renal
Insufficiency.
Chronic Kidney Disease, Unspecified
585.9
Stage
Stage V
CKD Unsp.
▪ Assign V-code (V45.11) for “dialysis status,” or (V45.12) for “noncompliance to
renal dialysis” for all 585.6 and some 585.5
▪ Assign V-code (V42.0) for kidney transplant status
▪ CKD is defined as either kidney damage or GFR < 60ml/min/1.73 m² for ≥ 3 months.
*Kidney damage is defined as pathologic abnormalities or markers of damage,
including abnormalities in blood or urine tests or imaging studies.
It May Be Necessary to Calculate GFR
• Some laboratories offer an estimated GFR (eGFR).
• A manual calculation is necessary if the eGFR
is >60 ml/min.
• Typically many lab reports print out the following:
“GFR: greater than 60 ml/min”
– This does not give enough detail to stage CKD Stage I
and CKD Stage II
– Therefore, manual calculations of GFR may still be necessary
DOCUMENTATION TIPS
CKD: The stage of CKD should be stated in the medical record
based on the documented clinical findings, including the
Glomerular Filtration Rate (GFR).
CKD and Diabetes: There is no presumed linkage between
diabetes and CKD. It must be implied (diabetic) or a causal
relationship stated (due to diabetes).
CKD and Hypertension: ICD-9 assumes a relationship when a
patient has both renal disease and hypertension (cause and
effect link). Both conditions, chronic kidney disease (staged)
and hypertension, must be documented.
1
World Health Organization, Professional: ICD-9-CM for Physicians-Volumes 1&2. 2011. Alexandria, VA: Ingenix, 2010.
DOCUMENTATION TIPS
continued
CKD, Hypertension and Heart Disease: There is no
presumed linkage between hypertension and heart
disease. It must be implied (hypertensive) or a causal
relationship stated (due to hypertension).
Kidney Failure: It is important to specify the type of
kidney failure — acute or chronic — and the cause of
the kidney failure, if known. If kidney failure is chronic,
document the stage of the CKD.
Acute Renal Failure: If patient has temporary dialysis,
document it and code V45.11.
1
World Health Organization, Professional: ICD-9-CM for Physicians-Volumes 1&2. 2011. Alexandria, VA: Ingenix, 2010.
Diabetes, CKD and Hypertension – Putting it All Together
Example:
The patient has nephropathy due to
diabetes with hypertension, and CKD Stage
IV.
250.40
403.90
585.4
Assigning the 5th Digit Subclassifications for
All DM 250.x Codes:
0 Type II or Unspecified Type, Not Stated as
Uncontrolled*
1 Type I [Juvenile Type], Not States as
Uncontrolled*
*When a Provider documents “poorly controlled”
the Index instructs “code to Diabetes, by type,
with 5th digit for not stated as uncontrolled.”
2 Type II or Unspecified Type, Uncontrolled
3 Type I [Juvenile Type], Uncontrolled
Reminder: Fifth-digits 0 and 2 are for use with
Type II patients, even if the patient requires
insulin, depending on the documented control
status.