Transcript 264930

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.
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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