Effective Coding Under MS- · PDF fileEffective Coding Under MS-DRGs OHIMA ... Review the pathophysiology of the new ... Chronic osteomyelitis

OHIMA Convention April 2, 2008

James S. Kennedy MD, CCS - 615-324-8676 -Original Content (c) 2008 FTI Healthcare 1

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Effective Coding Under MS-DRGs

OHIMAJames S. Kennedy, M.D., C.C.S.

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Faculty

James S. Kennedy, M.D., C.C.S.Director, FTI Healthcare

Brentwood, TN & Atlanta, GAMedical School: University of Tennessee, 1979Residency: Internal Medicine

University of Tennessee, 1980-82Board Certification: Internal MedicineCoding Certification: CCS – AHIMA, 2001Publications:

Severity-Adjusted DRGs: an MS-DRG PrimerHypovolemia & Dehydration, JAHIMA, 2006Letter – Annals of Internal Medicine 2006

Contact: [email protected]



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Faculty DisclosureAll faculty participating in Continuing Education programs provided by OHIMA are expected to disclose to the audience any real or apparent commercial financial affiliations related to their presentations and materials. Dr. Kennedy discloses that he is an employee of FTI Healthcare, a consulting firm that supports physicians, hospitals, and their employees in the interpretation and implementation of ICD-9-CM and HCPCS codes in the healthcare revenue cycle process and has assisted facilities in the state of Ohio.

This presentation is designed to provide accurate and authoritative information in regard to the subject matter covered. The information includes both reporting and interpretation of materials in various publications, as well as interpretation of policies of various organizations. This information is subject to individual interpretation and to changes over time. Under no circumstances does Dr. Kennedy, his employer (FTI Healthcare), nor OHIMA endorse any scheme or process that inaccurately represents the patient’s severity of illness or the provider’s care through the use of ICD-9-CM, CPT, or HCPCS and will not take responsibility for any misapplication of the information presented. The audience is encouraged to consult with their compliance officer or legal counsel prior to changing any current policies, procedures, or practice.

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Today’s Goals

Provide an overview of MS-DRGs and its impact upon short-term and long-term acute care hospitalsReview the pathophysiology of the new CC-MCC structure as to support physician documentation and query.Outline an organized process that accurately captures and reports CCs and MCCs in administrative coded data sets



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Definition of a DRG

A Diagnosis Related Group (DRG) is a group of clinically coherent conditions with a similar pattern of resource intensity primarily determined by: • Principal diagnosis: • Significant additional diagnoses

• Present on admission status may matter:• Procedures

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Patient Condition Components (M.U.S.I.C.)

Manifestation• e.g. – Chest pain (angina, pleuritic pain, heart burn); Altered

Mental Status (Acute Delirium, Chronic Dementia); FeverUnderlying Pathology• e.g. – Coronary artery disease, GERD, pleurisy, toxic

encephalopathy from prescribed medications, pneumoniaSeverity• Angina – At rest, Accelerated – progressed to MI• Sepsis – without or with organ dysfunction (severe sepsis)

Instigating or Precipitating Cause• Recent surgery• Medication noncompliance

Consequences• Acute Systolic Heart Failure• Acute Respiratory Failure• Acute Renal Failure



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Clinical Definitions of TermsRole of ICD-9-CM/Coding Clinic

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.Clear and concise documentation is required in order to accurately report (whatever condition or procedure). The link between good provider documentation and correct coding has always been emphasized in Coding Clinic. It is critical that hospitals work with their providers to ensure that the documentation used to support (whatever) clearly describes the (procedure performed/diagnosis assigned). If the documentation is not clear or there is any question about the procedure, the provider should be queried for clarification”.

Coding Clinic, 1st Quarter, 2008, page 3Clinical information ONLY provide foundation for coder query

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Clinical Definitions of TermsRole of ICD-9-CM/Coding Clinic

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. 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.

ICD-9-CM Official Guidelines for Coding and Reporting



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Things coders cannot do

Cannot assume what the doctors meant• Dissect the word “assume” to learn of the consequences.

Cannot interpret laboratory and clinical scenarios• Physicians must explicitly declare their diagnoses in a

manner acceptable to outside authorities• Coders are responsible for querying if the circumstances

are not clear.Cannot contradict the attending physician when he conflicts with other physician’s documentation.

In other words – FOLLOW THE RULES!!!When in doubt, query.

Failure to query violates the Guidelines & Coding Clinic

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ICD-9-CMPrincipal Diagnosis

Defined by the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”• The circumstances of admission, the diagnostic

approach and the treatment rendered factor into principal diagnosis selection.



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Principal Diagnosis

“Reason patient couldn’t go home”• Pneumonia

– Specific organism – respiratory failure vs. sepsis

• Respiratory Insufficiency vs. Respiratory Failure

• Sepsis (SIRS due to infection)• Acute vs. Chronic Kidney Disease/Failure• Other Comorbidities and “Complex”

DiagnosesThis is NOT just a vague symptom such as joint pain;

an underlying etiology needs to be discussed.

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ICD-9-CMAdditional Diagnosis

ICD-9-CM states that for reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: • clinical evaluation; • or therapeutic treatment; • or diagnostic procedures; • or extended length of hospital stay; • or increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”



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Coding Clinic, 3rd Quarter, 2007Chronic Conditions

One of the QIOs will not allow the inclusion of COPD as a secondary diagnosis when it is only mentioned as a history of COPD and no active treatment is documented. Am I correct in stating the presence of a documented history of COPD in the physicians history and physical on an inpatient record is enough to code COPD as a secondary diagnosis, since this is a chronic condition that always affects the patients care and treatment to some extent?If there is documentation in the medical record to indicate that the patient has COPD, it should be coded. Even if this condition is listed only in the history section with no contradictory information, the condition should be coded. 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,

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Historical CMS-DRG System Structure

Did not account for patients with greater severity of illness• CCs had the same weight no matter how severe• Designated a CC by an increase in LOS by

at least one day in 75% of the patients

Paired DRG system only required one secondary diagnosis to as a CC• Patients with multiple CCs given same

resource weight as those with one.



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MS-DRGs

Implemented October 1, 2007Still have 25 MDCs• Pre-MDC and DRGs with all MDCs remain

745 total MS-DRGs • Increase from 538 CMS-DRGs• Base DRG structure basically the same• Complete overhaul of the CC structure

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MS-DRGsBase DRGs

For the most part, base DRG structure remains except for:• Creation of 1 new DRG• Elimination of 43 age

differentiations (e.g. 0-17, Diabetes age <35)

• Usual and customary minor changes in base DRGs (see subsequent slides)

• Consolidations of 34 low-volume DRGs into other DRGs

335 Base DRGs remain• Pre-MDC (e.g. trachs)• Surgical Procedure unrelated

to Principal Diagnosis• Simple/Complex Pneumonia• Excisional Debridement as

major O.R. Procedure• HIV w and w/o Major Dx• Major GI Dx• Major Esophageal Dx • Major Hematological Dx• Major Bladder Procedures• and others all remain



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MS-DRGsCC Changes

Major revision of CC structure• CCs based on resource utilization rather

than length of stay• Removal of many CCs that do not impact utilization.

• Creation of Major CC (MCC)• Expansion of CC/MCC through most of the base DRGs• Still only need one CC or MCC to change weight

Elimination of • Major Cardiovascular Diagnoses

• Problematic since acute MI or acute systolic heart failure as a principal diagnosis no longer changes the DRG

• Complex Diagnoses for Cardiac Catheterization, and • Complicating Diagnoses for Acute Myocardial Infarction.

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MS-DRGsImpact of Prev. MD Documentation

Congestive Heart Failure (428.0)• CMS noted that resource utilization did not change significantly

when physicians documented (and coders coded) CHF• Unfortunately, decompensated CHF codes to 428.0

• The presence of more specific codes led to elimination of CHF asa CC

Malnutrition• Most physicians do not specify mild or moderate malnutrition• CMS found that malnutrition changed resource utilization

whereas mild or moderate did not. As a consequence, malnutrition is a CC whereas mild/moderate malnutrition is not

• CMS Medical Officers did not accept feedback on this issue and change the methodology.



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Most Common “Single Deleted CC”Coders need a strategy to find alternatives

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New MS-DRG CCs/MCCsCCs

Many SPECIFIEDunderlying infections, obstetrical/neonatal conditions, and malignanciesCrohn’s Disease and Ulcerative ColitisTransient Ischemic AttackThiamine DeficiencyChronic osteomyelitisCABG Graft StenosisPrecipitous Drop in Hematocrit

MCCsMany SERIOUS open fractures, underlying infections and OB/neonatal conditions (e.g. encephalitis, abortion with shock)Bile duct obstructionEncephalopathy



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V-Codes in MS-DRGs - CCs

HEART ASSIST DEV REPLACEV4321

TRNSPL STATUS-INTESTINESV4284

TRNSPL STATUS-PANCREASV4283

TRSPL STS-PERIP STM CELLV4282

TRNSPL STATUS-BNE MARROWV4281

LIVER TRANSPLANT STATUSV427

LUNG TRANSPLANT STATUSV426

HEART TRANSPLANT STATUSV421

KIDNEY TRANSPLANT STATUSV420

BMI 40 AND OVER,ADULTV854*

BMI LESS THAN 19,ADULTV850*

SUICIDAL IDEATIONV6284

ATTEN TO GASTROSTOMYV551

MECH COMP RESPIRATORV4614

WEANING FROM RESPIRATORV4613

RESP DEPEND-POWR FAILUREV4612

RESPIRATOR DEPEND STATUSV4611

ARTFICIAL HEART REPLACEV4322

*Coding Clinic – 4th Quarter, 2005 – pages 96-98

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MS-DRGsDocumentation and Coding Adjustment

“Coding and Documentation Adjustment”• 0.6% reduction – FY2008• 0.9% reduction – FY2009

• Can be more or less based on CMI changes experienced during the first few months of MS-DRGs

• 1.8% reduction – FY2010

Applies only to short-term acute care hospitals; LTACHs exempt from this



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CMS’s SolutionClinical Documentation Integrity

“We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”• Direct Quote, CMS 2008 IPPS Final Rule,

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf, page 208

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Assessing our Circumstances



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MS-DRG StatisticsCMI Statistics• Total CMI• Total CMI w/o

Trachs/Transplants• Medicine CMI w/o OB-Peds• Medicine CMI w/o OB-Peds, IP

Psychiatry, Ventilators, and Rehabilitation

• Surgery CMI w/o OB-Peds• Surgery CMI w/o OB-Peds,

Trachs, Transplants• OB-Neonatal CMI

Medicine RW analysis –compared to all Medicine DRG (OB-Peds-Vents Excluded)• Medicine DRG w/RW > 0.9 • Medicine DRG w/RW > 0.6 but

<0.9• Medicine DRG w/RW < 0.6

CC/MCC Capture Rate• Total• Medicine Cases• Surgery Cases

Service Line CC/MCC Capture• Cardiothoracic surgery

• CV Surgery MCC rate• Valve/Chest surgery

CC/MCC rate• Cardiology CC/MCC rate• General Surgery CC/MCC• Orthopedics CC/MCC• Neurosurgical CC/MCC• Urological CC/MCC• OB CC capture

Metrics in red worth following on a monthly basis

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CC and MCC CaptureRegular Rate

DRGs with MCCs• Speak for themselves

DRGs with CCs• Those with CCs• Those with CC/MCC

• CC and MCC have equal weight in changing the DRG

DRGs without CC/MCCs or MCCs• Speak for themselves

Overall DRG statistics• Without CC -41.1%• With CC – 36.6%• With MCC – 22.2%

Code differentiation• MCC – 1,096 • CC – 4,221• Non-CC – 8,232



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CC and MCC Capture Impact Rate

CC Capture Rate• Numerator:

• DRGs with CCs• DRGs whereby CCs and

MCCs equally affect the DRG

• Denominator• DRGs without CC/MCC

whereby a CC can change the DRG

• DRGs without MCC excluded since a CC does not change the DRG

MCC Capture Rate• Numerator

• DRGs with MCCs• DRGs whereby CCs and MCCs

equally affect the DRG are excluded.

• Denominator• DRGs without MCC• DRGs without CC/MCC where a

MCC changes the DRG to a higher relative weight than a CC

• DRGs w/o CC/MCC where CC or MCC have equal effect in changing it are excluded

No standard method available. These are suggested as a way to measure Clinical Documentation and Coding improvement efforts

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Other MS-DRG MetricsComplex to Simple PneumoniaPneumonia to COPDAcute Resp. Fail. to COPD/CHFCOPD to AsthmaSepsis to UTI/PneumoniaStroke to TIASepsis to Other Resp. Dx w/ventilator over 96 hoursPathological Fracture to Medical Back

Appendectomy w/Complicating Dx to w/oMI with CC or MCC to MI without CCCardiac Cath with MCC to Cardiac Cath w/oDVT with CC to DVT w/o CCGI bleed with CC to GI bleed without CCOB with complicating diagnosis

Example: Complex to Simple Pneumonia RatioVolume of 177, 178, 179

Volume of 177, 178, 179, 193, 194, 195National Medicare volumes available at:

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/FY2008Table7A.zipin the final rule or can be calculated from the MedPAR



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Example:CC Capture rate in UGI Hemorrhage

MS-DRG Medicare StatisticsGI Hemorrhage

36.0%GI Hem w/o CC37944.8%GI Hem w/CC37819.2%GI Hem w/MCC377

285.1 – Acute Blood Loss Anemia is a CCMost patients admitted with an Upper GI bleed have

acute blood loss anemia An obvious query opportunity

Others include DVT (hypercoagulable disorder) and neurodegenerative disorders

(dementia with behavioral manifestations)

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Other Metrics

CAP utilizing any antibiotic but ceftriaxone, azithromycin, or levofloxacin – option for DRG 177-179 00.51 (CRT) without 88.52 – radiology of right heart structureTransient ischemic attack receiving tPAUse of Xigris without code 995.92Blood transfusions in surgery without a CC (Acute Blood Loss Anemia – 285.1)Drug eluting stents vs. non-drug eluting stentsPacemakers vs. AICDsUse of BiPAP without sleep apnea or acute (on chronic) respiratory failure codeUse of mechanical ventilation without acute (on chronic) respiratory failure code



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Specific Issues in CC and MCC Capture

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Principal DiagnosisPrincipal Procedure

Simple vs. Complex PneumoniaSepsis vs. Underlying Cause

• “Febrile Neutropenia”Stroke or cerebral embolus vs. TIACAD in setting of angina pectorisComplications of carePathological vs. regular fracturesAcute Respiratory Failure vs. COPD or asthma exacerbationAcute Renal Failure vs. dehydrationNoncardiogenic pulmonary edemaAlternatives to PancytopeniaEncephalopathy or Neurodegenerative d/o vs their psychiatric manifestationsComplications when admitted for “uncontrolled diabetes”

Ascertaining the relationship between the principal diagnosis and the any procedures that are done.Capturing significant procedures not done in the operating room• tPA administration with stroke• Angioplasties done in radiology• Excisional debridement done on

the floor• Procedures in the ER or within

72 hours of admissionLysis of Adhesions in surgeryExcisional vs. nonexcisional debridementCoronary vein angiography during lead placement of a cardiac resynchronization pacemaker implantation

Diagnoses Procedures



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Excisional DebridementCovered in CC 1st Q, 2008, p 3-4

“Documentation of excisional debridement should be very specific regarding the type of debridement”• If the physician documents that an excisional

debridement was carried out, code 86.22• No requirement that the physician document that he used a

scalpel to go beyond the border of the wound.• No requirement that tissue be submitted to pathology

• If the physician documents that the debrided a wound with sharp excision, code to the deepest layer of excision

• If the physician documents that the debridement was “sharp”, the provider must be queried.

• Failure to query violates Coding Clinic advice and may be construed as reckless disregard or willful ignorance of HIPAA.

Very important to consider this with RACs

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Coronary Venography with Cardiac Resynchronization Rx

Coding Clinic, 1st

Quarter, 2007• CRT placed – a left

coronary venogram is performed during placement.

• Coding Clinic recommended coding procedure code 88.52 along with 00.51.



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Present On Admission RequirementWill not serve as CCs/MCCs if not POA

1. Serious Preventable Event- Object left in surgery2. Serious Preventable Event- Air embolism3. Serious Preventable Event- Blood incompatibility4. Catheter Associated Urinary Tract Infections5. Pressure Ulcers (Decubitus Ulcers)6. Vascular Catheter Associated Infection7. Surgical Site Infection-Mediastinitis after

Coronary Artery Bypass Graft (CABG) surgery8. Injury due to Falls

36Smith, D. M. Ann Intern Med 1995;123:433-438

Classification of Pressure Ulcers



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POARadar for FY2009

Staph aureus septicemiaDeep Venous ThrombosisPulmonary EmbolusVentilator Associated Pneumonia

Other considerations?• Malnutrition• C. Difficle colitis• Other nosocomial

infections besides UTI and mediastinitis

Bottom LineIf it is POA, it is a comorbidity

If it is not POA, it is a complication

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COPD – Asthma – HypoxemiaCoexisting Conditions

518.83 – Chronic respiratory failure for patients on home oxygen (requirement of pO2 less than 55) or chronic elevation of pCO2 (over 50)428.20 – Chronic systolic right heart failure from chronic pulmonary hypertension – edema, jugular venous distension, RVH on ECGExacerbations -a sustained worsening of the patient’s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD.

• Mild - Patient has an increased need for medication, which he/she can manage in own normal environment

• Moderate - Patient has an increased need for medication and feels the need to seek additional medical assistance

• Severe - Patient/caregiver recognizes obvious and/or rapid deterioration in condition, requiring hospitalization

“Status Asthmaticus” – Asthma exacerbation that does not respond to standard treatments of bronchodilators and steroids

http://www.chestjournal.org/cgi/content/full/117/5_suppl_2/398S



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CC-MCC DifferentiationAcute Respiratory Failure

Hypoxemia• Classical definition: pO2

< 60 mm Hg• Critical Care definition

• pO2 divided by FiO2 is less than 200-250

Hypercapnia• pCO2 >50, usually with

pH less than 7.35

WITHRespiratory assistance or monitoring• Frequent monitoring,

usually in the ICU or ER• BiPAP• Mechanical Ventilation

pO2 < 60 corresponds to O2 Sat < 88%

Physician must document “Acute Respiratory Failure”

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CC-MCC DifferentiationExacerbation of COPD/Asthma

Other Causes - MCCs• Acute Pulmonary Embolus – Geneva Score

(5-8 intermediate risk; >8 high risk)• 1 point – Age >60, Pulse > 100, pCO2 36-39, pO2 73-83;

Atelectasis • 2 points – Age > 80; Previous PE or DVT; pCO2 < 36; pO2 61-

72; • 3 points – Recent surgery or malignant disease; pO2 50-60• 4 points – pO2 < 50

• Acute (systolic or diastolic) heart failure• Elevated BNP; increasing edema or hypotension

• Pneumonia• New infiltrate on CXR treated with antibiotics

http://www.annals.org/cgi/reprint/144/6/390.pdf



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Deleted CC428.0 Congestive Heart Failure

TITLEMS-DRGCMSICD9

HEART FAILURE NOSCMS CC4289

AC/CHR SYST/DIA HRT FAILMSDRG MCCCMS CC42843

CHR SYST/DIASTL HRT FAILMSDRG CCCMS CC42842

AC SYST/DIASTOL HRT FAILMSDRG MCCCMS CC42841

SYST/DIAST HRT FAIL NOSMSDRG CCCMS CC42840

AC ON CHR DIAST HRT FAILMSDRG MCCCMS CC42833

CHR DIASTOLIC HRT FAILMSDRG CCCMS CC42832

AC DIASTOLIC HRT FAILUREMSDRG MCCCMS CC42831

DIASTOLC HRT FAILURE NOSMSDRG CCCMS CC42830

AC ON CHR SYST HRT FAILMSDRG MCCCMS CC42823

CHR SYSTOLIC HRT FAILUREMSDRG CCCMS CC42822

AC SYSTOLIC HRT FAILUREMSDRG MCCCMS CC42821

SYSTOLIC HRT FAILURE NOSMSDRG CCCMS CC42820

LEFT HEART FAILUREMSDRG CCCMS CC4281

CHF NOS (decomp – R Hrt Fail)CMS CC4280

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Heart FailureManifestation - Is it heart failure?• Must differentiate from fluid overload in

normal heart• Acute, Chronic, or Acute on Chronic• Systolic vs. Diastolic vs. both

Underlying Cause• Cardiomyopathy – Pericardial Disease – COPD

– Cor Pulmonale – Accelerated HTNSeverity – Acute vs. Chronic• Acute = Flare up of HF symptoms• Decompensated doesn’t Count

Instigating – ?MI?, ?PE?Complication – Acute Respiratory Failure (MCC), Acute Renal Failure (MCC), pleural effusions (if addressed –CC)

Acute or Chronic?

Systolic: EF<40%; Diastolic: EF>40% or ↑LVEDP



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Heart Failure DifferentiationWithout EF

LVH on EKGS4 gallop

Abnl relax on ECHOMore likely is hypertensive

Diastolic

Combination of bothOK to say “possible or

probable”Both

Paroxysmal nocturnal dyspnea

Neck vein distention

Rales

Acute pulmonary edema or Increased BNP

Increased CVP > 16 cm

Hepatojugular refluxPulmonary edema,

visceral congestion, or cardiomegaly at autopsy

Weight loss ≥ 4.5 kg in 5 days in response to treatment of

CHF

Cardiomegaly on CXRS3 gallop

Dilated on ECHOSystolic

Acute (MCC)Chronic (CC)

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CardiomyopathiesAll are CCs except Ischemic CM

425.0 Endomyocardial fibrosis 425.1 Hypertrophic obstructive CM425.2 Obscure cardiomyopathy of

Africa 425.3 Endocardial fibroelastosis425.4 Other primary

cardiomyopathies • Cardiomyopathy:• NOS

• congestive• constrictive• familial• hypertrophic• idiopathic• nonobstructive• obstructive• restrictive• Cardiovascular collagenosis

425.5 Alcoholic cardiomyopathy 425.7 Nutritional and metabolic

cardiomyopathy• Code first underlying disease, as:

• amyloidosis (277.30-277.39) • beriberi (265.0) • cardiac glycogenosis (271.0) • mucopolysaccharidosis (277.5) • thyrotoxicosis (242.0-242.9) • gouty tophi of heart (274.82)

425.8 Cardiomyopathy in other diseases classified elsewhere

• Code first underlying disease, as:• Friedreich's ataxia (334.0) • myotonia atrophica (359.21) • progressive muscular dystrophy

(359.1) • sarcoidosis (135) • cardiomyopathy in Chagas' disease

(086.0)

425.9 Secondary cardiomyopathy, unspecified



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Systolic/Diastolic Heart Failure due to Aortic and Mitral Valve Disease

398.91 – Rheumatic Heart Failure is a CC; • ICD-9-CM does not allow 428.xx codes serving as a MCC

Coding Clinic, 2nd Quarter, 2000, page 16-17• Stipulate that a coder is NOT to make an assumption that

congestive heart failure is rheumatic in nature when a physician documents valvular disease, including one listed in the subchapter 393-398 (397.0 – Diseases of the tricuspid valve).

• Unless ICD-9-CM directs the coder to assign the code for rheumatic congestive heart failure (which is not required under 396.x) or the physician states the condition is rheumatic, it isinappropriate to assign a code for rheumatic congestive heart failure.

Coding Clinic, 3rd Quarter, 2006, page 7 appears to support this as well.

CC 1st Quarter 2008, page 19 – “Whenever new advice is published, it ALWAYS supercedes earlier advice”

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Pericarditis

All pericarditis code are now CCs423.3 – cardiac tamponade - a CC• Consider acute

right diastolic failure (MCC) in this circumstance



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Deleted CCAngina Pectoris

Angina Pectoris (not just CAD)• 413.9 Angina NOS – Not a CC• 413.0 Angina at rest (angina decubitus) – CC

• Suspect if the patient uses nitroglycerin w/i past month

Unstable Angina - CC• Occurs at rest and lasts for over 20 minutes OR• Severe, described of flank pain, and started within past

month, OR• Cresendo pattern

Non-Q wave Myocardial Infarction - MCC• Elevations of troponin in the setting of anginal

symptoms, EKG changes, post-angioplasty, or other cardiac manifestations

http://content.onlinejacc.org/cgi/content/full/50/7/e1

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Atherosclerosis of CABG Graft“In-Stent Stenosis”

“In-stent” Stenosis NOSCABG Graft Occlusion NOSMSDRG CC99672

COR ATH BPS GRAFT TP HRTMSDRG CC41407

TitleCC DesignationCode

COR ATH NATV ART TP HRTMSDRG CC41406

COR ATH ARTRY BYPAS GRFTMSDRG CC41404

CRN ATH NONATLG BLG GRFTMSDRG CC41403

CRN ATH ATLG VN BPS GRFTMSDRG CC41402



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Elimination of Major CV Diagnoses as Principal/Secondary Diagnoses

Example:DRG 235 CABG w/MCC• R.W. 5.1381

DRG 236 CABG w/o MCC• R.W. 3.7307

MCVDs that are not MCCsBifascicular BlockTrifascicular Block Complete Heart BlockCHF NOS996.72 • Occluded graft• “In-stent stenosis”

Cerebral embolus w/o infarctionAcute Pericarditis

MCCs pertinent to CV surgerySepsis (995.91 and 995.92)SIRS due to CV surgery w/organ dysfunction (995.94)Acute Respiratory Failure (518.81)Pressure sores (Present on Admit)(Toxic-Metabolic) Encephalopathy • Instead of delirium/ICU psychosis

Acute Systolic/Diastolic heart failureIndication for amiodarone (vent. Fib)Non-Q-wave MI at referring hospital – possibly a MCC (see next slide)

Now requires MCC as athe secondary diagnosis

Principal no longer good enough

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Acute MI Present on AdmissionNot a MCC

A 69 yo was admitted with severe chest pain. A left cardiac catheterization, coronary angiography, left ventriculography, and stenting of second obtuse margin was performed. The postoperative diagnosis was non-ST segment myocardial infarction with two-vessel coronary artery disease. What are the appropriate code assignments for this admission?Answer: Assign code 410.71, Acute myocardial infarction, subendocardial infarction, initial episode of care, for the non-ST segment myocardial infarction, as the principal diagnosis.

Coding Clinic, 4th Quarter 2005, pages 69-72No MCC



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Deleted CCAtrial Fibrillation

Atrial Fibrillation –427.31 – Not a CCAtrial Flutter –427.32• A CC

“Atrial Fib-Flutter”• Probably requires

both codes –427.31/427.32

Atrial Fibrillation

Atrial Flutter May have to look on nursing notes or telemetry strips to code these

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CC-MCC DifferentiationVentricular Arrhythmias

427.1 Ventricular Tachycardia (>100/minute) - CC

• Sustained vs. Nonsustained• Not treated if <30 seconds

• Torsade de Pointes• Associated w Long QT Interval

• Amiodarone or Propafenone may be used to suppress further attack of V-tach

427.41 Ventricular Flutter - MCC427.42 Ventricular Fibrillation -

MCC• Cause of Sudden Cardiac Arrest• Look if present at referring hospital

Ventricular Flutter

Ventricular Fibrillation

Ventricular Tachycardia

Torsade de Pointes



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Sustained vs. Nonsustained Ventricular Tachycardia

Coding Clinic, 1st Quarter, 2008, p. 14• Patient demonstrates inducible ventricular tachycardia in

the EP lab. AICD placed. Is V-tach in the EP lab codeable?

• Answer: “Yes, it would be appropriate to assign a code for sustained or nonsustained ventricular tachycardia induced during an EP study”

Beware: • Coding Clinic defined nonsustained V-tach as a run of at

least six beats. Others define it as at least three beats. • Coding Clinic definitions of diagnoses are provided ONLY

FOR INFORMATIONAL PURPOSE and provide no foundation supporting or denying code application.

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Acute Renal Failure (MCC)

An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in SCr of ≥ 0.3 mg/dl, a percentage increase in SCr of ≥ to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours).

• Prerenal – due to impaired perfusion (e.g. hypovolemia, ↓ CO)• Renal – due to intrinsic disease (e.g. contrast nephropathy)• Postrenal – due to outflow obstruction (e.g. obstructive uropathy)

Mehta, et. al. the Acute Kidney Injury Network et al. Critical Care 2007 11:R31

If there is a change of the serum creatinine of ± 0.3 – 0.5 mg/dl in the hospitalization, consider acute renal failure

Biomarker: NGAL, Cystatin-C, IL-18 under consideration



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ARF Classification Harrison’s Textbook of Medicine

Obtain Access to Harrison’s 17th Edition for your Queries

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Electrolyte Imbalances

Hyponatremia (CC)• SIADH (CC)• Metabolic encephalopathy (MCC)

Hyperkalemia (Not a CC)• Hypoaldosteronism (CC)

• ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone

• CKD Stage IV-V (CC)• ESRD (MCC)

Hypercalcemia (Not a CC)• Metabolic encephalopathy (MCC)

Acidosis (CC) HCO3 < 18Alkalosis (CC) HCO3 > 28

Query –

Please describe the precise underlying etiologies/ mechanisms of this patient’s hyponatremia/ hypokalemia.

What are the consequences of this patient’s chronic illness?

Exactly how did hyponatremia or hypercalcemia cause this patient’s confusion?



57

CKD/CRI NOS

Term GFR Usual Serum Cr*585.1 – CKD Stage 1 > 90 <0.9 585.2 – CKD Stage 2 60-89 1.0-1.3585.3 – CKD Stage 3 30-59 1.4-2.5**585.4 – CKD Stage 4 15-29 2.5-4.5 - CCs**585.5 – CKD Stage 5 <15 >4.5 - CCs***585.6 – ESRD – Need for chronic dialysis - MCCs585.9 – Chronic Renal Insuff. OR Failure NOS – NOT A CC*Serum Cr. for a 170 lb white male, age 65**Red Font = CC - ***Blue Font = Major CC

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm

Laboratory should publish calculated GFR on lab reports

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Deleted CC –Chronic Blood Loss Anemia

285.1 - Acute Blood Loss Anemia• AHA Coding Clinic states that if postoperative

anemia is due to acute blood loss, assign 285.1 – Acute blood loss anemia (CC, 1st Quarter 2007)

790.01 - Drop in Hematocrit• Major Blood Loss defined as 20% blood loss

• Would correlate with drop in hematocrit of 8 if baseline is 40



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60

ICD-9-CM Official Guidelines for Coding and Reporting

Excludes Notes• An excludes note under a code indicates that the terms

excluded from the code are to be coded elsewhere. • In some cases the codes for the excluded terms should not

be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together.

• In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present.

Conditions that are an integral part of a disease process • Signs and symptoms that are associated routinely

with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

790.01 should not

be combined

with excluded

codes unless Coding Clinicallows

otherwise



61

Acquired and Nonspecific Aplastic Anemia

284.81 Red cell aplasia (acquired) (adult) (with thymoma) - MCC• Red cell aplasia NOS

284.89 Other specified aplastic anemias (all three lineages) -MCC• Aplastic anemia (due to):

• chronic systemic disease • drugs • infection • radiation • toxic (paralytic)

284.9 Aplastic anemia, unspecified – Only a CC• Anemia:

• aplastic (idiopathic) NOS• aregenerative• hypoplastic NOS• nonregenerative• Medullary hypoplasia

Classification of Red Cell Aplasia

Self Limited• Transient erythoblastopenia of

childhood• Acute B19 parvovirus infectionFetal RBC aplasia• In utero B19 parvovirus Hereditary (Diamond-Blackfan)Acquired• Thymoma or malignancy• Connective Tissue Dz (lupus)• Virus (B19 Parvovirus, hepatitis, EB

virus)PregnancyDrugs (Dilantin, INH,

azothiaprine)Unknown

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Myelodysplastic Codes238.7 Other lymphatic and hematopoietic tissues238.72 Low grade Myelodysplastic syndrome lesions• Refractory anemia (RA)• Refractory anemia with

ringed sideroblasts (RARS)• Refractory cytopenia with

multilineage dysplasia (RCMD)

• Refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS)

238.73 High grade Myelodysplastic syndrome lesions• Refractory anemia with excess

blasts-1 (RAEB-1)• Refractory anemia with excess

blasts-2 (RAEB-2) 238.74 Myelodysplastic syndrome with 5q deletion• 5q minus syndrome NOS• Excludes:• constitutional 5q deletion

(758.39)• high grade Myelodysplastic

syndrome with 5q deletion (238.73)

238.75 Myelodysplastic syndrome, unspecifiedCCs are in the box



63

Hypercoagulable Syndrome - CCAssociation with DVT

Manifestation• Phlegma cerulea dolens• Pulmonary Embolus• Deep venous Thrombosis

Underlying cause• Virchow’s Triad –

1° or 2° Hypercoagulability; Thrombophlebitis; Stasis Usually present on admission – Estrogen Use, Cancer, PregnancyStill to be ruled out - Factor V Leiden, Protein C deficiency, Protein S

deficiency – As primary hypercoagulability

Instigating Cause – recent surgery, pregnancy, underlying cancer, drug use (e.g. hormones)If patients are on chronic Coumadin®, warfarin, or heparin,

inquire if patient has hypercoaguable syndrome

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Deleted CCUncontrolled Diabetes

Still needs to be captured Dr. Kennedy defines this as:• Multiple Blood Glucoses over 250 mg/dl

requiring changes in therapeutic regime• One fasting Blood Glucose over 300

mg/dl• Recurrent hypoglycemia requiring

multiple changes in therapeutic regime• Hgb AlC over 7.0



65

Diabetic Ketoacidosis - MCC250.1x w/o Coma; 250.3x w/Coma

Results from complete deficiency of insulin AND excessive counter regulatory hormone excessHyperglycemia (300-600)Ketosis (4+ Plasma Ketones, 1:8 or greater)Diagnosis• Patient very dehydrated - Acute Renal Failure 2° Dehydration?• Kussmaul breathing, fever, possibly coma - MCC• Hyperglycemia and Ketosis• Metabolic Acidosis (pH 6.8-7.3, HCO3 < 15 meq/L, “elevated

anion gap”• Serum Potassium usually high due to acidosis; if normal, patient

very depleted.• Treatment can lead to cerebral edema

Patients with DKA invariably are Type 1 (but can be Type 2) and uncontrolled; Coding Clinic 3rd Quarter, 2006, directs DKA to be coded with a fifth digit of “3” unless MD states it is Type 2 diabetes

66

Nonketotic Hyperosmolar State – MCC Primarily in Type 2 Diabetics• Associated with absolute or relative insulin deficiency• Just enough insulin to prevent ketoacidosis, but not enough to

prevent hyperglycemia

Results in profound dehydration, hyperglycemia, and hyperosmolality (330-380)

• Blood glucose usually over 600• ?Acute Renal Failure 2° Dehydration?• pH is normal or slightly decreased due to dehydration• HCO3 usually normal• Creatinine moderately elevated due to dehydration.

Treated with rehydration with isotonic/hypotonic saline and small doses of insulin; removal of underlying cause

Patients with NKHS invariably are Type 2 and uncontrolled; but, unlike DKA, the physician must state that a patient is uncontrolled.



67

Other CC Alternativeswith Diabetes

Autonomic Neuropathy - CC• Reason for using Viagra• Florinef used to fight orthostatic hypotension

Neurogenic Bladder - CCChronic Kidney Disease - CC• Stage 4 or 5 (Creatinine over 2.0 – 2.5 mg/dl)• ESRD – MCC – on dialysis

Diabetic Nephrosis – Nephrotic Syndrome• 4+ protein (over 3 grams per day)• Hypoalbumemia• Hyperlipidemia• Associated with Chronic Kidney Disease

Insulin Coma - MCC• Not just “hypoglycemia”

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“Altered Mental Status”M & S of Music

ACUTE• Delirium (CC)• Stupor• Coma (MCC)• Mania,• Confusion,• Psychosis (CC)• Hallucinations (CC)• Delusions (CC)• Loss of consciousness

Chronic• Vegetative state• Dementia



69

Specified AMSUnderlying Cause

Diffuse Brain Disease• Encephalopathy (MCC) –

Toxic, Septic, Metabolic;

Neurodegenerative Illness• Alzheimer's Disease • Normal Pressure

Hydrocephalus – (CC) –has a shunt in place

• Multi-infarct Dementia (CC)

• Late effect of stroke (no CC)

• Lewy-Body Dementia (associated with Parkinson’s Disease);

Psychiatric Illness• Bipolar Disorder (CC)• Specified schizophrenia

(CC)• Drug withdrawal (CC)

Seizure• Postictal state is not an

encephalopathyStroke (MCC) – TIA (CC)Acute Brain Injury• Cerebral Concussion• Cerebral Contusion

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EncephalopathyA diffuse disease of the brain secondary to an otherwise nondefined neurological or a defined nonneurological illness or insultMultiple types in ICD-9-CM• Metabolic – due to metabolic

issues• Septic – due to sepsis• Toxic – due to drugs• Anoxic – due to lack of oxygen• Hypoglycemic – due to

hypoglycemia• Hypertensive – due to malignant

hypertension

Coding Clinic References:

“(Toxic) metabolic encephalopathy refers to an altered state of consciousness, usually denoting delirium.” -CC 4th Q 1993 p. 29

“Metabolic encephalopathy is always due to an underlying cause, seen in 12-33% of patients with organ failure –CC 4th Q 2003, p. 58-59



71

TIA vs. Stroke as CC/MCC

“TIA” (a CC) – Transient Neurological Symptoms due to ischemia LASTING LESS THAN ONE HOUR and no evidence of Stroke (e.g. MRI, CT Scan)“Stroke” (a MCC) – Neurological symptoms due to ischemia with evidence of stroke on MRI or lasting over 24 hours

• If symptoms >1 hour, 85% chance of stroke• Aborted stroke coded as a stroke

Consequences• 344.1 – Paraplegia (CC)• 344.61 – Neurogenic Bladder (CC)• 348.4 – Cerebral herniation (MCC)• 348.5 - Cerebral edema (MCC)• 581.81 – Acute Respiratory Failure (MCC)• 784.1 – Transient limb paralysis (CC)• 784.3 – Aphasia (CC)• 781.8 – Neurologic Neglect Syndrome (CC)

Source: Sacco, et. al. Stroke, 37 (2): 577. (2006)

Code neurologic deficits of stroke on discharge?

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Seizures

Seizures and Seizure Disorder are not CC. Alternatives include:• Febrile Seizures (CC)• Other specified seizures disorders that are intractable (CC)

– query the physician if medications are being changed• Petit Mal (CC)• Focal (CC)

Seizures describes as being in status are MCC• Continuous clinical or electrical seizure activity or

repetitive seizures with incomplete neurologic recovery interictally for a period of at least 30 minutes



73

Schizophrenia

Schizophrenia or Schizoaffective disorder NOS is not a CCALL of the specified schizophrenic or schizoaffective disorders ARE• e.g. Chronic schizophrenia• e.g. Simple schizophrenia• e.g. Chronic schizophrenic disorders

74

Malnutrition

CC• 263.8 – Specified

Malnutrition –NEC

• 263.9 –Malnutrition NOS

MCC• 260 - Kwashiorkor • 261 – Marasmus

• Severe Malnutrition

• 262 – Other severe malnutrition

<55-910-1718-45Prealbumin (mg/dl)

<117117-133134-175

176-315Transferrin (mg/dl)

<2.12.1-2.93.0-3.43.5-5.0Albumin (g/dl)

SevereModerateMildNormalLab Values

Cooperation with

dietician, MD, and coding

essential



75

Chemical Dependency

Alcohol and Drug Use• Legal drug = Use; Illegal drug = abuse

Alcohol and Drug Abuse• Causes immediate consequences or bodily harm

Chemical dependency = Addiction• Lack of use causes withdrawal symptoms• Mental obsession to use• Continued use even though severe

consequences

Must be labeled as “CONTINUOUS or daily” to count as a CC – Alcohol and marijuana do not

count as CCs

76

Options to Consider in Chemical Dependency

Thiamine Deficiency (CC)• Most alcoholics get

thiamine 100 mg IM

Drug induced delirium (CC)Toxic Encephalopathy (MCC)• If the patient relapses

and has “altered mental status”, the drug likely caused it

Alcohol or Drug Withdrawal

• Does not necessarily have to be an illegal drugs.

• Many drugs that are legally prescribed have withdrawal symptoms if abruptly discontinued by the patient or the physician



77

Organism IdentificationLab tests or Presumptive Rx

Low-weighted “Comm. Acquired Pneumonia”• Levaquin or (Claforan/Rocephin +

Zithromax/Doxycycline combo)

Presumptive Rx for higher weighted diagnoses• Clindamycin/Flagyl = Anaerobes• Ciprofloxacin - Pseudomonas• Zosyn/Unasyn = Gram-negative rods, anaerobes• Zyvox = MRSA, other specified gram-positives• Gentamicin or Tobramycin – Gram-negative rods• Primaxin – Anaerobes, gram-negative rods• Vancomycin – Enterococci or Staph Aureus• Amphotericin or fluconazole – Fungus• INH, Rifampin, Ethambutol – Acid Fast Bacillus

Poss. GNR

Poss. MRSALook at urine for legionella and cultures.

Do NOT code from the sputum culture or antbiotic. Use these as foundation for query

78

Bacteremia vs. SepticemiaSepsis

Bacteremia (790.7 - a CC):• Bacteria in the blood without

an inflammatory response.

Septicemia (038.x - a MCC):• Pathological organisms (viruses,

bacteria, fungus, or other organisms) OR their toxins in the systemic blood.

SIRS • Due to infection (sepsis) – MCC• Due to non-infection –

Pancreatitis, Burns, Trauma• Without organ dysfunction – CC• With organ dysfunction – MCC

Systemic Inflammatory Response Syndrome (>2 of the following):

• Temperature >38 C or <36 C

• Pulse >90/min• Respirations >20/min• White Blood Cells

>12,000 or <4000 or >10% Bands formed



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Others

Hypopituitarism• On chronic steroids, thyroid

replacement, testosterone

Child and Elder AbuseInternal or vascular injuriesSecondary Myasthenia and Parkinson’s DiseaseChronic kidney stonesUTI (urosepsis) vs. sepsisSpecified locations of GI bleed Specified complications of pregnancy• Especially important if private

insurance uses MS-DRGs or APR-DRGs

Indications for Drugs• Amiodarone – atrial fibrillation,

ventricular tachycardia• Viagra – autonomic neuropathy• Neurotin – specified seizure

disorder• Coreg – chronic systolic HF• Lactulose – hepatic

encephalopathy• Methadone – continuous

chemical dependency• Sublingual nitroglycerin –

Angina at rest

80

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81

Audience Questions

82

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