Is Reporting a Bad Thing? Complete Diagnosis Coding for OP ... Reporting a Bad... · 23 Diagnosis Coding –Professional E/M Levels •CDI opportunities: –Indicate the management/treatment

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Is Reporting a Bad Thing? Complete Diagnosis Coding for OP/Provider Encounters

Allen Frady, RN‐BSN, CCDS, CCS, CRCCDI Education SpecialistHCProMiddleton, MA

Shannon McCall, RHIA, CCS, CCS‐P, CPC, CEMC, CRC, CCDSDirector of HIM/CodingHCProMiddleton, MA

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Discuss significance of Section IV of the ICD‐10‐CM Official Guidelines for Coding and Reporting

– Demonstrate how diagnosis codes assist in supporting medical necessity

– Explain impact of diagnosis codes on E/M level assignment

– Learn how diagnosis codes affect risk adjusted reimbursement methodologies

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Definition of Documentation

• doc∙u∙men∙ta∙tion = material that provides official information or evidence or that serves as a record

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Two Principal Types of Coding Systems

• Diagnosis coding system

– Used to report why the patient received healthcare services

• ICD‐10‐CM (all settings, IP and OP)

• Procedure coding systems

– Used to describe what services/items the patient received

• CPT and HCPCS II (outpatient/professional services)

• ICD‐10‐PCS (inpatient services)


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Coding Systems by Service –Hospital Outpatient

Hospital Outpatient

Diagnosis Codes

(ICD‐10‐CM)

Procedure Codes

(CPT and HCPCS II)

Ambulatory Payment

Classifications

(APCs)

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Coding Systems by Service –Professional Services

Professional Services

Diagnosis Codes

(ICD‐10‐CM)

Procedure Codes

(CPT and HCPCS II) Physician Fee

Schedule


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So Who Makes the Rules? – ICD‐10‐CM

• ICD‐10‐CM Official Guidelines for Coding and Reporting

– Provides guidance and additional information regarding code assignment based on setting type:

• Section I – Applicable to all settings (inpatient, outpatient/professional)

• Sections II–III – Inpatient guidelines

• Section IV – Outpatient/professional services Guidelines

• https://www.cdc.gov/nchs/icd/data/10cmguidelines‐FY2019‐final.pdf

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Selection of a First‐Listed Code

• First‐listed code – the ICD‐10‐CM code for the diagnosis, condition, problem, or other reason for encounter/visit to be chiefly responsible for the services provided

– Examples of chief “complaint” or reason for a visit

• “2‐week history of cough”

• “Viral pneumonia follow‐up”

• “Routine physical exam”


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Selecting Additional/Coexisting Diagnoses

• Code all documented conditions that coexist at the time of the encounter/visit, and that require or affect patient care treatment or management

• Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

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• Do not code diagnoses documented as:

– Probable

– Suspected

– Questionable

– Rule out

– Consistent with

– Compatible with

• Rather, code to the highest degree of certainty possible based on documented signs and symptoms

Uncertain Diagnoses –Outpatient and Professional Services


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Managing the Problem List

• The problem list is “a compilation of clinically relevant physical and diagnostic concerns, procedures, and psychosocial and cultural issues that may affect the health status and care of patients.” <AHIMA>

– Should be updated and reviewed during each visit and not just “cut and pasted”

• Problem lists became widely used and were later required as part of the meaningful use incentive program. They should identify all past and existing diagnoses, pathophysiological states, abnormal physical signs and laboratory findings, disabilities, and unusual conditions.

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Obstacles – Clinical Versus Coding Verbiage

Healthcare providers typically document care using “clinical” terms, symptoms,

differential diagnoses, orders, and test results

Code assignment requires specific

language to allow a “match” between the documented verbiage and a diagnosis code

Good Provider Documentation


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Improving “Physician Speak”

• Be sure to clearly delineate “findings,” “differential diagnoses,” “observations,” etc. from conditions that are reportable.

– Complaint: “I have pneumonia” – not reportable

– Finding: “Patient has moderate wheezing and slight rattles with productive cough” – not reportable

– Problem list: “Long history of recurrent pneumonia” – not reportable

– Diagnosis: “COPD with lower respiratory tract infection and bronchitis” – reportable

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What Does Diagnosis Coding Impact for OP/Provider Services?

Provider documentation of diagnoses and procedures (if performed)

Assignment of ICD‐10diagnosis codes & HCPCS codes

Impacts:‐Medical necessity‐Professional E&M levels‐Risk adjustment‐Publicly reported data


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Diagnosis Coding – Medical Necessity

• Local coverage determinations (LCDs), national coverage determinations (NCDs), or commercial payer policies may limit which ICD‐10‐CM diagnosis codes are deemed medically necessary and may identify required documentation for coverage

– https://www.cms.gov/medicare‐coverage‐database/details/lcd‐details.aspx

• LCDs are published by the various different Medicare Administrative Contractors (MACs)

– Examples: Wisconsin Physician Services, Palmetto GBA, etc.

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• Example: Polysomnography (95810) ordered for “chronic insomnia” (G51.04)


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• ICD‐10‐CM covered diagnoses

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• CDI opportunities:

– Review the medical record to determine if there are other relevant diagnoses that may also support the necessity of the procedure

• E.g., “Patient’s wife states that when patient finally falls asleep, he snores very loudly and seems to have periods of not breathing then gasping”

• E.g., “Patient states that he tends to feel very sleepy during the day because of not getting sleep at night”

– Patient is morbidly obese with a BMI of 42


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Diagnosis Coding – Medical Necessity Requires COMPREHENSIVE Documentation

• ER documentation severe left foot pain:– Diagnostic tests ordered: CBC, BMP, Hgb A1c, lower extremity ultrasound, and a head CT.

– Denial: Head CT: What happened?

– Either the physician forgot to document or the coder forgot to code the severe headache and intermittent blurry vision as so much of the workup was centered around diabetes and possible manifestations.

– Upon initial review of the record, it did not appear that headache and blurry vision met reporting requirements. Were they just “findings” on a physical exam or “patient complaints” without MD corroboration? It was not clear to the coder.

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Diagnosis Coding – Professional E/M Levels

• Evaluation and management services are generally assigned based off key components in the documentation – History (chief complaint, HPI, ROS, PFSH)

– Exam

– Medical decision‐making

• Number of possible diagnoses/number of management options considered

• Amount/complexity of data to be obtained, reviewed, and analyzed

• Risk of complications, morbidity, and/or mortality as well as comorbidities


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• CDI opportunities: – Identification of all problems managed or addressed during each

encounter

• Condition status – Specificity for acute conditions; reason for encounter.

– Stable or exacerbation for chronic conditions.

– No uncertain diagnoses! If the diagnosis is uncertain, make sure a comprehensive list of symptoms is included.

• Relevant coexisting conditions that may impact plan of care– E.g., COPD or metastatic brain CA patient on long‐term steroids with DM

– E.g., chronic HTN patient with morbid obesity, alcohol use disorder, and depression

– E.g., URI with hx of alcoholism

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• CDI opportunities:

– Clear reason for the visit (i.e., annual physical vs. a problem‐oriented visit or both)

• Preventive care services only – chief complaint = “Annual physical” (no complaints)

• Problem‐oriented visit only – chief complaint = “Abnormal mole”

• Preventive care and problem‐oriented – chief complaint = Annual physical then “oh, by the way …”


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• CDI opportunities: – Indicate the management/treatment option(s) for each problem

• Prescription drug management– Note management options to be continued somewhere in note for that encounter (e.g., medication list) when documentation indicates a continuation of current management options (e.g. "continue meds")

• “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient – this may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage – Note: Simply listing current medications is not considered “prescription drug management”<https://medicare.fcso.com/faqs/answers/0324049.asp>

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• Chronic conditions that are managed “automatically” in the physician’s process are still “managed” in many cases– Diabetes: Checked circulation, Hgb A1c, and CBG. Made a clinical

decision not to change treatment: PAD reported but diabetes not reported. Did we miss a combo code?

– COPD: Listened to breath sounds and asked patient if their ACE inhibitor had been exacerbating the coughing sensation recently. HTN reported but COPD not reported. Could it have been?

– HTN: Blood pressure reviewed and Lasix dosage decreased due to patient being too dry. CKD was reported, but not HTN. Did we miss the combo code?

– Bipolar disorder: Patient asked if they had been compliant with their Coreg and atenolol as well as their activity tolerance and mood. Patient reiterates that a few doses were missed during a bipolar episode. Doctor encourages medication compliance. Heart failure reported but bipolar not reported. Could it have been?

Taking Credit for the “MDM”


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Diagnosis Coding – Risk Adjustment

• Risk adjustment using diagnoses provides more accurate payments for MA organizations

– Higher payments for enrollees at risk for being sicker

– Lower payments for enrollees predicted to be healthier

• Risk adjustment allows CMS to pay plans based on the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries

– However, the plan must submit the qualifying diagnoses, which are subject to verification

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Diagnosis Coding – Risk Adjustment

• CDI opportunity?

Healthcare providers typically document care using “clinical” terms, symptoms,

differential diagnoses, orders, and test results

Which code is most

appropriate?

Code assignment

1) Hx of breast CA?

2) Still being treated? Rad therapy, chemo,

tamoxifen?


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Diagnosis Coding – Critical Thinking

• Is there ever such a thing as – “History of CHF, now cured”?– “History of hypertension, now cured”? – “History of cardiomyopathy, now cured”?– “History of COPD, now cured”?– “History of diabetes type I, now cured”?

• The reality is that providers are doing more to evaluate their patient in the proper “context” of these other disease processes then even they realize

• Any adjustment in their treatment plan, evaluation, monitoring, etc. done for the context of a “background” disease process is effectively medical decision‐making and extra evaluation done for that background disease

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Diagnosis Coding – Quality Programs

• MACRA

– MIPS (Merit‐based Incentive Payment System)

• Based on 4 performance categories (Quality, Promoting Interoperability, Improvement Activities, Cost)

– APM (Alternative Payment Model systems)

• Examples: Accountable care organizations (ACOs), shared savings programs, Comprehensive Primary Care Plus (CPC+)


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Diagnosis Coding – Online Media

• Providers are being “graded” – Healthgrades

– Yelp

– Google for Business

– ZocDoc

– Facebook

– WebMD

– RateMDs

– Vitals.com

– CareDash

– Angie’s List

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Highlights of ICD‐10‐CM Official Guidelines for Coding and Reporting for FY 2019


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Official Guideline Revisions

• Link to FY 2019 ICD‐10‐CM Official Guidelines for Coding and Reporting

– https://www.cdc.gov/nchs/icd/data/10cmguidelines‐FY2019‐final.pdf

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Official Guideline Revisions – Conventions


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Official Guideline Revisions – General

• FY 2018 was previously titled “Documentation for BMI, Depth of Non‐Pressure Ulcers, Pressure Ulcer Stages, Coma Scale and NIH Stroke Scale”

NEW!

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• Assign external cause codes as additional codes to identify the cause of the injury incurred as a result of the hurricane (X37.0‐)

– The appropriate injury code should be sequenced first

– External cause codes can never be a principal/first‐listed diagnosis

• Do NOT assign for hurricane victims where there is no injury, adverse effect, or poisoning

• For all healthcare settings (i.e., any location where medical care is provided by licensed professionals)

NEW!


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• Sequencing of external cause codes for hurricane

– Codes for cataclysmic events like hurricanes take precedence over all other external cause codes (except child/adult abuse and terrorism)

• E.g., Injury sustained due to hurricane causing a building collapse

• Assign category X37.0‐ (Hurricane) then W20.1‐ (Struck by object due to collapse of building)

– With appropriate 7th character

– If it’s not clear whether an injury is related to the hurricane, assume it is related and assign (X37.0‐)

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• Use of Z codes for hurricane aftermath

– May be assigned as either principal/first‐listed or additional diagnosis if they provide additional information on reasons for presenting for care

• E.g., homelessness, inadequate housing (Z59.‐)


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Official Guideline Revisions – Sepsis

• Sepsis due to postprocedural infection

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• More on sepsis postprocedural infections

– Infections following transfusion/injection/immunization


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• More on sepsis postprocedural infections

– Infection with septic shock

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Official Guideline Revisions – Neoplasms

• History of neoplasms


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Official Guideline Revisions – Circulatory

• Removed I51.81 (Takotsubo syndrome)

What

related???

What provider would

specificallysay it’s NOT related???

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• Removed I51.81 (Takotsubo syndrome)

• Added clarification What

related???

What provider would

specificallysay it’s NOT related???


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• If different types of MIs (e.g., Type 1 and Type 2) occur within 4 weeks Use I21‐

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Official Guideline Revisions – Obstetrics

• New entry to cover other illegal/prescription drugs of abuse during pregnancy


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Official Guideline Revisions – Symptoms, Signs

• Glasgow Coma Scale – ICD‐10‐CM category R40.2‐

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Official Guideline Revisions – Injuries

• Assign burns of same anatomical site and side to highest degree

• Codes for multiple sites (e.g., T25.39‐ Burn third degree of multiple sites of ankle and foot)


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Official Guideline Revisions – Underdosing

• Added to the definition of underdosing to include Z91.14

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Official Guideline Revisions – Z Codes

• BMI codes should only be assigned with an accompanying diagnosis


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In Summary

• ICD‐10‐CM diagnosis codes do not ONLY have an impact on inpatient services

• Look for opportunities to enhance documentation to support the medical necessity of services

• Promote complete documentation of ALL diagnoses that are relevant to the encounter, not just the reason for the visit

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In Summary

• Outpatient services may not necessarily be a single‐encounter high‐dollar value, but in QUANTITY you can make a huge impact!


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Thank you. Questions?

Allen Frady ‐ [email protected]

Shannon McCall ‐ [email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Is Reporting a Bad Thing? Complete Diagnosis Coding for OP ... Reporting a Bad... · 23 Diagnosis Coding –Professional E/M Levels •CDI opportunities: –Indicate the management/treatment