P7 Discover documentation insufficiencies before ICD-10 ... · or possibly a localized infection such as a urinary tract infection? ... HIT Pro-CP “Without physician ... • Puerperal

November 2013Volume 16Issue No. 11

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Briefings on

Coding Compliance

Strategies

Your inpatient coding, billing, documentation, and regulation resource

Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.

Coders know that physicians often use the terms “bacteremia,” “sep-ticemia,” and “sepsis” interchangeably, even though those terms refer to different clinical conditions. (For definitions of the conditions, see p. 3.) ICD-9-CM contains separate codes for each of those conditions. Physicians also use the nonspecific term “urosepsis.”

Part of the difficulty is that physicians aren’t familiar with either the vari-ous ICD-9-CM or ICD-10-CM definitions for these conditions or the coding guidelines for coding sepsis, says Ann Barta, MSA, RHIA, CDIP, direc-tor of practice excellence for AHIMA in Chicago. “That really makes it a challenge for coders.”

Does the patient really have septicemia or sepsis? Is it really bacteremia or possibly a localized infection such as a urinary tract infection? “Each of those conditions result in a different code assignment whether I’m in ICD-9-CM or ICD-10-CM,” Barta says.

Another problem arises when the physician documents all of the signs and symptoms of sepsis without documenting a diagnosis of sepsis.

“If I am reading the chart as a coder, I can tell from the patient’s signs and symptoms that this patient really meets the clinical criteria for sepsis,

Specificity key to simplifying sepsis coding in ICD-10-CM

Wound care goes beyond pressure ulcersLearn what physicians consider a wound and what to look for in the documentation.

Discover documentation insufficiencies before ICD-10 implementationWith less than one year until implementation, know whether your physician documentation is sufficient.

Use PEPPER to understand coded dataKnow what your hospital’s data says about the care you provide.

Clinically SpeakingRobert S. Gold, MD, discusses contradictory guidance about systemic inflammatory response syndrome.

P5

377Number of claims from 2009 to 2011 the OIG reviewed.

96%Percentage of the 377 claims that incorrectly report ICD-9-CM procedure code 96.72.

$7.7 millionAmount CMS overpaid for those claims.

Source: OIG report, Medicare Incorrectly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Hours of Mechanical Ventilation.

Inside: Coding Q&A insert

P7

P9

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November 2013Briefings on Coding Compliance Strategies

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Contact Senior Managing Editor Michelle Leppert at [email protected] or 781-639-1872, Ext. 3737.

“ People are scared about ICD-10-PCS. ICD-10-PCS really isn’t scary. Most often the information coders need is already in the chart.”

Mark N. Dominesey, MBA, RN, CCDS,

CDIP, HIT Pro-CP

“ Without physician buy-in, all the chart analysis in the world does you no good.”

Christian Omba

from The fieldonline

Inpatient vs. Observation Facilities need to change their utilization review process to avoid payment deni-als based on the CMS IPPS final rule for 2014. The new inpatient admission criteria and rebilling provisions will impact observation use and hospital strategies for achieving accurate reimbursement.

Join HCPro and Deborah K. Hale, CCS, CCDS, at 1 p.m. (Eastern) Wednesday, November 6, for the live audio confer-ence “Inpatient Versus Observation.” You’ll learn how physicians should doc-ument to comply with the 2-midnights requirement and pick up strategies for measuring admission status accuracy.For more information, visit www.HCMarketplace.com.

ICD-10 LCD deadline setCMS released Transmittal R1293OTN setting April 10, 2014, as the deadline for all local coverage determinations (LCD) and related articles to be published in the Medicare Coverage Database.

MACs may simply translate ICD-9 codes to ICD-10 and update the LCD with that new information. MACs can also revise more than just the ICD-10 code(s)

Quick Hits

Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $269/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2013 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encour-aged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copy-right Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorse-ment. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

editorial advisory board

Lori Belanger, RN, BSN, RHITInpatient Coder/CDI SpecialistNorthern Maine Medical Center Fort Kent, Maine

Paul Belton, RHIA, MHA, MBA, JD, LLMVice PresidentCorporate ComplianceSharp HealthCare San Diego, Calif.

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM ConsultantFremont, Calif.

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Fla.

James S. Kennedy, MD, CCSManaging DirectorFTI Healthcare Atlanta, Ga.

Senior Managing EditorMichelle Leppert, [email protected]

Laura Legg, RHIT, CCSHIM and Coding ConsultantRenton, Wash.

Monica Lenahan, CCSManager of Coding Education and ComplianceRevenue Management Centura Health Englewood, Colo.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDSDirector of Coding and HIMHCPro, Inc. Danvers, Mass.

Jean Stone, RHIT, CCS, CDIPManager of Clinical Documentation Integrity Program/HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, Calif.

This document contains privileged, copyrighted informa-tion. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclo-sure, forwarding, copying, or other communication of the contents is prohibited without permission.

Briefings on Coding Compliance StrategiesNovember 2013

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• A40.3, sepsis due to streptococcus pneumoniae• A40.8, other streptococcal sepsis• A40.9, streptococcal sepsis, unspecified

ICD-10-CM category A40 instructs coders to code first other categories that identify sepsis directly re-lated to procedures or in pregnancy-related situations:• Postprocedural streptococcal sepsis (T81.4)• Streptococcal sepsis during labor (O75.3• Streptococcal sepsis following abortion or ectopic

or molar pregnancy (O03–O07, O08.0)• Streptococcal sepsis following immunization (T88.0)• Streptococcal sepsis following infusion, transfu-

sion, or therapeutic injection (T80.2-)

The A40 series of codes also has an Excludes1 note, which tells coders not to report the following condi-tions using a code from A40:

but the physician is not actually giving me the diag-nosis,” Barta says. “SWhen this situation occurs a coder currently queries the physician for clarification in ICD-9-CM and will continue to have to query with the transition to ICD-10-CM. The clinical picture of sepsis isn’t going to change.”

Although the actual codes in ICD-10-CM will look different from ICD-9-CM codes, coders will still look for the same information in the documentation, Barta says. However, coders will need to become familiar with some new codes and new guidelines in ICD-10-CM.

Septicemia ICD-9-CM contains codes for septicemia, which is

the presence of bacteria in the bloodstream causing the patient to exhibit symptoms.

Coders currently have seven series of codes for septicemia:• 038.0, streptococcal septicemia• 038.1x, staphylococcal septicemia• 038.2, pneumococcal septicemia [Streptococcus

pneumoniae septicemia]• 038.3, septicemia due to anaerobes • 038.4x, septicemia due to other Gram-negative

organisms• 038.8, other specified septicemia• 038.9, unspecified septicemia

ICD-9-CM includes a guideline that tells coders to report the underlying infection, which is usually the septicemia, first, Barta says. Coders also report the code for the sepsis, which is usually 995.91. TCoders need two codes to report sepsis in ICD-9-CM.

“In ICD-10-CM, coders will not have codes with septicemia in the code title but rather will be assigned as sepsis since it is the body’s systemic reaction to infection,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CCDS, director of coding and HIM for HCPro, Inc., in Danvers, Mass.

If a coder looks up streptococcal septicemia in ICD-10-CM, it provides a cross-reference to see—Sepsis where a specific code from category A40 (streptococcal sepsis) would be assigned. Coders then have these ad-ditional choices:• A40.0, sepsis due to streptococcus, group A• A40.1, sepsis due to streptococcus, group B

Sepsis and related conditions

Bacteremia: the presence of viable bacteria in the

blood, which may or may not be clinically significant

Sepsis: systemic inflammatory response syndrome plus

an infection

Septic shock: sepsis-induced hypotension persisting

despite adequate fluid resuscitation

Septicemia: a systemic disease associated with the

presence of pathologic microorganisms or toxins

Severe sepsis: sepsis with an acute organ failure

Systemic inflammatory response syndrome (SIRS):

a severe systemic response to a condition (as trauma,

an infection, or a burn) that provokes an acute inflamma-

tory reaction indicated by the presence of two or more of

a group of symptoms including abnormally increased or

decreased body temperature, heart rate greater than 90

beats per minute, respiratory rate greater than 20 breaths

per minute or a reduced concentration of carbon dioxide

in the arterial blood, and the white blood cell count great-

ly decreased or increased or consisting of more than 10%

immature neutrophils

Urosepsis: nonspecific term that can refer to a urinary

tract infection (UTI) or sepsis resulting from a UTI



• Neonatal (P36.0–P36.1)• Puerperal sepsis (O85)• Sepsis due to streptococcus, group D (A41.81)

““n ICD-10-CM, I am still coding the underlying infection, the streptococcal sepsis, but I don’t have an equivalent code to 995.91 because we no longer classify septicemia in ICD-10-CM,” Barta says. This change will result in coders understanding that only one code will be assigned for the diagnosis of sepsis in ICD-10-CM.

“Once coders get used to it, it should be easier be-cause it’s one less term that physicians can may docu-ment leading to confusion,,” Barta says. If a physician documents septicemia, the default code in ICD-10-CM is A41.9, (sepsis, NOS).

Severe sepsisAs sepsis progresses, a patient’s organs begin to

malfunction or could shut down. This could indicate the patient has severe sepsis. However, not all patients with sepsis will progress to severe sepsis, McCall says.

In order to code severe sepsis, coders must see documentation that supports the diagnosis in the medi-cal record—or query the provider if necessary—when clinical indicators support the more specific diagnosis. Coders need to make sure the physician ties the organ failure/dysfunction directly to the sepsis, says McCall. When other conditions cause organ failure, it would not be appropriate to assign a code for severe sepsis.

If the physician appropriately documents severe sepsis, report either ICD-10-CM code R65.21 (severe sepsis without septic shock) or R65.22 (severe sepsis with septic shock) in addition to the sepsis code (A40 or A41). Do not report a code from series R65.2- alone, McCall says.

The ICD-10-CM coding guideline for severe sepsis basically provides the same guidance as the current ICD-9-CM severe sepsis guideline, Barta says. ICD-10-CM, like ICD-9-CM, instructs coders to first report the underlying systemic infection, which is quite often sepsis, along with the code for severe sepsis and any acute organ dysfunction resulting from the severe sepsis.“That’s the same whether you are in the ICD-9 world or the ICD-10 world,” Barta says. “Coders won’t have to learn anything new for coding severe sepsis.”

The only real difference, Barta says, is that ICD-10-CM

includes a combination code for severe sepsis with septic shock. In ICD-9-CM, coders report two codes for severe sepsis and septic shock.

The combination code in ICD-10-CM is able to link severe sepsis to septic shock since a patient cannot clinically have septic shock without severe sepsis. This concept was addressed in the ICD-9-CM Official Guide-lines, which was likely the reasoning behind creating the combination code.

UrosepsisAnother common problem area in ICD-9-CM is

urosepsis. Physicians frequently use this term to refer to a systemic inflammatory response initiating from a urinary source, but without further detail in ICD-9-CM this diagnosis defaults to a urinary tract infection (UTI) (599.0), McCall says.

Urosepsis is very ambiguous, Barta says. Coders often query physicians to clarify whether they are docu-menting a UTI or sepsis. “If I don’t get that clarification from the physician or if as I am clinically reading the chart, I don’t think that patient has the symptoms that go with sepsis, I can code it to 599.0,” Barta says.

ICD-10-CM does not include a default code for uro-sepsis. “I think coders will be very glad because urosep-sis has always been very confusing,” Barta says.

The ICD-10-CM Official Guidelines for Coding and Reporting state:

The term urosepsis is a nonspecific term. It is not to be considered synonymous with sep-sis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

“ICD-10-CM forces physicians to specify whether the patient has a UTI or a systemic inflammatory response from a urinary source,” McCall says. “If the physician doesn’t specify, it will result in a query 100% of the time.”

The change is great for coders, Barta says, because it eliminates the term urosepsis. FFor those physicians who still document urosepsis without further clarifica-tion, it will mean more queries for clarification. Hope-fully those physicians will get on track,” Barta says. “For years we have been trying to get physicians to stop documenting urosepsis because it really is not a recog-nized diagnosis in the coding classification system.” H



Wound care goes beyond pressure ulcers All pressure ulcers are wounds, but not all wounds

are pressure ulcers. A wound is an injury to living tis-sue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.

Inpatient coders may be very familiar with pressure ulcers and their stages, but they also need to under-stand other types of wounds. “People are sometimes so focused on one area that they forget wounds consist of a lot of different types,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

Define a woundTo a physician, a wound can be any of the following:

• Surgical incisions, whether closed and intact, pur-posely left open, dehisced, or infected

• Lacerations and abrasions, such as road burns or any traumatic damage to the skin, including open fractures

• First- to third-degree burns, regardless of the cause• Draining infections, such as osteomyelitis, pilonidal

abscess, perianal abscess, cellulitis with ulceration, and even infected insect bites

• Open areas of skin necrosis from any cause, includ-ing open gangrene, venous ulcers, pressure ulcers, diabetic vascular ulcers, and neuropathic ulcers

“Generally when you talk about ICD-9-CM procedure code 86.22 [excisional debridement of skin and subcu-taneous tissue], you talk about necrotic tissue, infec-tions, or burns,” Gold says. “But there are some many different types of wounds. We need to be aware of all of the different types of wounds.”

Review the anatomyWounds generally start at the skin and work deeper,

Gold says. “On occasion, you can have a contusion of the brain and you are not going to see anything on the outside,” he adds. • The skin is divided into three layers:• Epidermis: the outermost layer of skin• Dermis: beneath the epidermis; contains tough

basilar tissue, hair follicles, and sweat glands• Subcutaneous tissue: also known as the hypoder-

mis; made of fat and connective tissue

Wounds that involve only the epidermis are generally stage 1. As the wound progresses toward the dermis, it becomes stage 2. When the subcutaneous tissue is in-volved, the wound is at stage 3. If the wound goes into deeper tissue, it becomes stage 4, Gold says.

Most of the body also has two layers of fascia. The superficial layer of fascia is within the subcutaneous tissue, Gold says. The deep fascia lies underneath and surrounds the muscles.

A wound that extends to the superficial fascia is still in the skin layer, Gold says. In fact, there is a muscle in this subcutaneous layer in the face called the platysma muscle. This is still skin and subcutaneous tissue. “It’s not until we get to the deep fascia which overlays the rest of the muscles that you are going to get a stage 4 wound.”

Documentation for woundsWhen talking about a care plan for a patient with a

wound, clinicians need to consider both the ultimate goal of treatment and the etiology of the wound, says Gloria Miller, CPC, CPMA, vice president of re-imbursement services for Comprehensive Healthcare Solutions, Inc., in Tacoma, Wash.

Ulcers are generally chronic wounds, while other types of wounds can be acute or chronic, she says.

Ulcers often have comorbidities, such as diabetes, Miller says. Those comorbidities can influence treat-ment choices.

Coders also need to look for an appropriate diagnosis and appropriate staging for hospital-acquired pres-sure ulcers. These are ulcers that were not present on admission.

If a clinician cannot stage an ulcer at a given time because the bottom cannot be visualized, coders can report the ulcer as unstageable, Miller says. However, once the clinician is able to document the stage after cleaning or debridement of the ulcer, coders should use that stage going forward. “For example, if it’s a stage 3, then it is considered a healing stage 3 throughout the course of treatment,” Miller says.

In order to document a wound, the physician needs to name the wound and provide a diagnosis; for example, a diabetic foot ulcer of the left foot. The physician also needs to document the:



• Cause of the wound (e.g., diabetes, arterial ulcer, venous stasis ulcer, etc.).

• Length, width, and depth of the wound.• Plan of care to get to the healing process. This can

include surgical intervention, resection of dead tis-sue (also known as debridement), dressings, pa-tient education, and possibly further testing.

• Order for any procedure(s).• Plan of care.

Wound care goes far beyond just excisional debride-ment, Miller says. Part of the reason is because of the variety of surgical procedures that are available.

Treatment options for surgical incisions include pri-mary closure, delayed primary closure, and closure by secondary intention.

Physicians can suture lacerations by preparing the skin edges and debriding necrotic or damaged tissue, then suturing it closed. They can also use primary or sec-ondary grafts, apply dressings, or leave the wound open if it is too dirty to close. The preparation of the wound for closure is integral to the closure, and debridement is not ordinarily codable as excisional debridement.

For burns, physicians can apply dressings, debride necrotic tissue, use a skin graft or flap, and use hyper-baric oxygen therapy.

For an abscess, the physician can open the abscess, debride the necrotic tissue, then drain the abscess or close it over a drain.

Various conditions can result in open areas of skin necrosis. For arterial ulcers or open gangrene, physi-cians can perform debridement, increase arterial flow if possible, apply a graft, administer topical wound care, or possibly amputate the limb.

Venous ulcers typically require topical wound care, Miller says.

For pressure ulcers, physician can perform excisional or non-excisional debridements, administer topical wound care, and/or create a flap closure.

Physicians can debride diabetic vascular or neu-ropathic ulcers, or perform topical or non-excisional wound care.

DebridementBefore a coder can report 86.22, they need to know

whether the physician actually performed a true

excisional debridement of skin and subcutaneous tis-sue, Miller says.

A true debridement is defined as an excisional procedure. Cleaning and irrigation are not considered true debridement, Miller says. Physicians use a rec-ognized sharp instrument, such as a cutting curette, laser, scissors, or scalpel, to perform the excisional debridement.

“The excisional debridement itself is not related to the depth of the wound, but to the type of tissue re-moved from it,” Miller says.

Excisional debridement is always considered surgi-cal, Miller says. It involves removing or cutting away devitalized tissue, necrosis, or slough. Physicians can perform excisional debridement on burns, wounds, or infections, as well as ulcers.

Depending on the circumstances, the physician may perform the debridement in a surgical suite, at the bedside, in the ED, or in an outpatient wound clinic, Miller says.

Documentation for the debridement for proper cod-ing by ICD or by CPT must include:• Medical justification for the debridement• Specific procedure performed and the outcome• Type of surgical instrument used• Type of tissue removed, including depth of the

procedure• Pain control used and how tolerated• Amount of bleeding and how controlled• Follow-up treatment plan

ICD-9-CM coding for debridementICD-9-CM includes several procedure codes for

debridement. Report code 86.22 for excisional debride-ments. Do not report 86.22 for:• Bone (77.60–77.69)• Muscle (83.45)• Hand (72.36)• Nail bed (86.27)• Non-excisional debridement (86.28)• Open fracture site (79.60–79.69)• Pedicle or flap grafts (86.75)

If the physician uses a VersaJet, coders will report 86.28, because the jet is not a sharp instrument. Non-excisional debridement also includes maggot



therapy, brushing, irrigation, washing, and ultrasonic debridement.

For an abdominal wall debridement, coders need to pay careful attention to the depth of the debridement. If it is just a skin incision in the abdominal wall, such as a surgical incision that requires debridement, coders will use the code for skin, Gold says. In the past, coders were instructed to use ICD-9-CM code 54.3. If the de-bridement goes deeper than the skin and subcutaneous layers and through to the peritoneum, report 54.3.

“Only debridement down to the peritoneum justi-fies code 54.3,” Gold says. AHA’s Coding Clinic, Third Quarter 2014, will state this fact as a change to existing advice.

ICD-10-CM for woundsICD-10-CM includes additional details in codes for

wounds. Wounds are identified by specific anatomical site, including laterality and type of wound (e.g., lacera-tion, puncture, open), Gold says. Some of the codes also require coders to specify whether any foreign body re-mains in the wound. Wound codes in ICD-10-CM also

require a seventh character to denote the encounter.For the initial visit for a laceration of the right ankle

without a foreign body, coders would report ICD-10-CM code S91.011A. If a foreign body remains in the wound, the code becomes S91.021A.

Another change in ICD-10-CM is the inclusion of stages of more types of wounds. In ICD-9-CM, cod-ers are used to coding pressure ulcers by stage. But in ICD-10-CM, they will also need stages to code arterial ulcers, venous ulcers, and ulcers caused by diabetic neuropathic disease, Gold says.

For a patient with a non-pressure chronic ulcer of the right calf, coders will use different codes for the follow-ing depths of the ulcer:• Limited to breakdown of skin (L97.211)• With fat layer exposed (L97.212)• With necrosis of muscle (L97.213)• With necrosis of bone (L97.214)

If the physician fails to document the depth of the ulcer, report L97.219 (non-pressure chronic ulcer of right calf with unspecified severity). H

Discover and correct common documentation insufficiencies before ICD-10 implementation

How well could you code in ICD-10 using your cur-rent physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?

ICD-10 implementation is less than one year away, which means facilities need to make sure their docu-mentation is in order now.

Coder productivity will become a serious consid-eration after the transition to ICD-10 occurs. Canada experienced a 50% decline in coder productivity after it transitioned to ICD-10 between 2001 and 2004. Coder productivity has still not returned to pre-ICD-10 levels, according to Cynthia Grant, director of Canadian consultancy Courtyard Group.

One way to reduce that productivity decline is to im-prove physician documentation. Complete and accurate

documentation reduces the need for coder and CDI queries and allows coders to complete a chart sooner.

ICD-10-CM retains many of the coding guidelines and conventions from ICD-9-CM, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, Mass.

The major difference between the two systems is the level of detail required to correctly assign ICD-10-CM codes, McCall says. For example, many ICD-10-CM codes include laterality. Odds are physicians are docu-menting laterality now; coders just aren’t looking for it.

The transition to ICD-10-PCS for inpatient coders may be more challenging because ICD-10-PCS is a completely different system.

“People are scared about ICD-10-PCS,” says Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, director of auditing and clinical documentation



improvement services for TrustHCS in Springfield, Mo. “ICD-10-PCS really isn’t scary. Most often the informa-tion coders need is already in the chart.”

Documentation reviewReview current documentation to determine whether

physicians are including all the information coders need. Start looking for gaps in current documentation by

performing a chart analysis, says Donielle Bailey, ICD-10 program coordinator for the University of North Carolina (UNC) Rex Health in Raleigh.

Remind physicians that they need to document each patient’s entire clinical picture, Bailey adds.

At UNC Rex, the transition team spent six months analyzing charts and uncovered a significant amount of missing information for inpatient procedures. Consider analyzing 100 charts for your most common diagnoses and procedures, Dominesey says. Code them using both ICD-9-CM and ICD-10-CM for diagnoses and ICD-10-PCS for procedures.

Make a list of missing or incomplete information. Look for patterns and trends. Are physicians consis-tently omitting a specific piece of information? If so, create staffwide education to address the deficiency. If a problem is limited to one or two physicians, consider individual education, Dominesey says.

The most important thing is to secure physician buy-in. “Without physician buy-in, all the chart analysis in the world does you no good,” says Christian Omba, ICD-10 program manager for UNC Rex Health.

Revamp queriesThe UNC Rex team also performed a CDI query as-

sessment and changed many of their query forms to ask for information coders will need in ICD-10.

Facilities don’t need to wait for the transition to ICD-10 to begin using new query forms, Omba says. “If you can get physicians to document better today, take advantage of it now.”

Consider rolling out one revamped query per month, Dominesey suggests. That way, physicians aren’t over-whelmed by the number of changes.

Make queries as easy to use as possible and stream-line the query process as much as you can, he adds. Also, make sure coders and CDI professionals are using the same language when querying physicians.

Look at the top 25 MS-DRGs that are going to change, Dominesey says. Then create a plan on how to roll out the new queries. Note, though, that not every MS-DRG will need a new query form. In some instanc-es, coders just need to start looking for information physicians are already documenting.

Look at root operationsThe third character in an ICD-10-PCS code, root

operation, will likely be the most difficult for coders, at least initially. Root operations identify the intent of the procedure. Each root operation has a precise definition, which is included in the ICD-10-PCS tables as well as Appendix A of the ICD-10-PCS Manual, McCall says.

ICD-10-PCS Draft Coding Guideline A.11 states that the coder is responsible for determining the root opera-tion. The physician does not need to use the ICD-10-PCS root operation terms in his or her documentation. The coder is responsible for reading the documentation and determining which root operation the physician is performing.

In some cases, that will be very easy. The root opera-tion creation, for example, is only used for sex change operations; detachment, meanwhile, involves cutting off all or part of the upper or lower extremities. Howev-er, some root operations have distinct but very similar meanings. For example, the ICD-10-PCS root operation excision involves cutting some of a body part out or off without replacing it, whereas resection involves cutting all of a body part out or off.

Look at your current documentation. Does the physi-cian clearly state whether he or she is removing all or only a section of a body part? This is a common place where documentation can be improved, McCall says.

One area where this will become complicated is when a physician is removing lymph nodes. Lymph nodes come in chains, and the surgeon may plan to remove the entire chain or only part of the chain. Additionally, surgeons cannot always verify whether they removed the entire chain of nodes.

“Look at the objective of the procedure,” says Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, director of HIM practice excellence at AHIMA in Chicago. If the physician’s goal is to remove the complete body part, report resection. If the object is to remove part of the body part, use excision. H



Use PEPPER to understand coded dataIf you’re not already actively using your hospital’s

PEPPER (Program for Evaluating Payment Patterns Electronic Report), you’re missing out on a lot of valu-able data.

As healthcare data continues to become the indus-try’s newest hot commodity, coding managers are remiss if they don’t review any and all information that comes their way. Data—including coded data—drives pay-for-performance, meaningful use, auditing targets, and more. Being “in the know” about what your hospi-tal’s data says in terms of the care provided is essential.

Seize your PEPPERPEPPER provides Medicare claims data statistics for

areas that the OIG, Quality Improvement Organiza-tions, MACs, and Recovery Auditors (RA) identify as being at risk for improper payments. It uses aggregated data to allow hospitals to see how they stack up against others in the state, jurisdiction, and nation.

The report, published by TMF Health Quality In-stitute, identifies potential over- and underpayments that hospitals can focus on internally. It also prioritizes specific target areas and provides guidance in terms of auditing and monitoring those targets.

Coding target areas include the following:• Stroke and intracranial hemorrhage• Respiratory infections• Simple pneumonia• Septicemia• Unrelated operating room procedures• Medical DRGs with CC or MCC• Surgical DRGs with CC or MCC• Excisional debridement• Ventilator support• Single CC or MCC

PEPPER also targets the medical necessity of various conditions. In addition, it includes 30-day readmis-sions to the same hospital or elsewhere and short stays (i.e., one- and two-day stays).

A hospital has an outlier if its percent in a particular target area is at or above the 80th percentile or at or below the 20th percentile.

“Use the PEPPER if you haven’t already done so as your starting point and launching point,” says Ralph Wuebker, MD, MBA, chief medical officer at Execu-tive Health Resources in Newtown Square, Pa.

Coding managers are encouraged to access their own PEPPER when it’s released each quarter, says Yvonne Focke, RN, BSN, MBA, consultant at Advanced Patient Solutions, LLC, in Loveland, Ohio. “Multiple departments, such as HIM and care man-agement, should be able to see these and assess any outlier status,” she adds.

When hospitals have outliers in a particular risk area, they should audit their medical records to determine whether a compliance problem exists, says Focke. “Some facilities may choose to review concurrently rather than retrospectively,” she says. “Auditing your own records may prevent providers from being accused of reckless disregard and/or deliberate ignorance.”

For example, if a hospital’s target area for simple pneumonia is low, and its target area for respiratory failure is high, coding managers may want to question whether coders are overcoding, says Focke.

Keep in mind that not every outlier suggests non-compliance, says Focke. One or more of the following factors can inadvertently affect risk status or outlier status:• Changes in admission practices• New physician• New coding or care management staff• Implementation of a CDI program• Change in patient population• New service lines

It’s important for hospitals to implement a quality improvement process around any outlier, says Focke. This ensures that hospitals can support their practices if an auditor ever questions them.

“It’s just not worth having all of the denials and audits on the back end. Always look for opportunities to improve,” she says. “Seize those opportunities and be proactive. Keep the money at your institution instead of having to return money. When a claim is paid, we want it to stay paid.”



Other resourcesPEPPER is one of many resources hospitals can rely

on to better understand their data, says Wuebker. CMS provides provider-specific probe letters that inform providers when they have been selected for prepayment claims reviews. These letters also provide a compara-tive billing report.

MACs may also provide educational tip letters to

providers regarding Medicare non-covered services. These letters provide education specific to each denial as well as suggestions and CMS references to help pre-vent similar denials.

The goal is to stay abreast of these and other publica-tions—as well as keeping ahead of regulatory changes—so you can ensure that your data is accurate, says Focke. H

Dear SIRS, let me introduce you

by Robert S. Gold, MD

Over and over, one gets frustrated that professional coders are told that they are smart and educated and know about

anatomy, physiology, and pharmacology, and then the same people turn around and say, “You code what the doctor documented and it’s not up to you to question the physician.”

Your professional organizations are the ones that do both of these at different times, depending on the point they want to make. They show you alternately respect and disdain. I don’t know about you, but I don’t like it.

Some citations in guidance say that the professional coder is supposed to read an orthopedist’s operative note and assign codes for the procedure the orthopedist actu-ally did, not what the orthopedist said he or she did (like closed reduction and fixation of fractured femur despite documentation of open reduction and internal fixation).

Others tell the professional coder to assign a code for acute renal failure in a patient who has total shutdown of both kidneys, has been on dialysis three times a week for three years, and missed a dialysis session, coming in with an elevated creatinine level. Someone told the physician’s assistant to document acute renal failure because the creatinine level was up and the attending physician signed the note.

Another reference says that if the physician document-ed in a progress note that he or she did excisional de-bridement, you are to assign the 86.22 code. You are to use this code even if the record contains no evidence that

the physician actually did anything, much less evidence of debridement, much less evidence that what was done meets the criteria for 86.22 and not some other code. Code 86.22 requires specific information to be in the record, not just a statement of “excisional debridement.”

Okay, let’s get to the point for today.A Coding Clinic citation regarding a physician’s docu-

mentation of systemic inflammatory response syndrome (SIRS) in relation to a patient who had probably taken an overdose of Zyprexa® because the patient presented with tachycardia, tachypnea, fever, etc. Now, we have to guess that the questioner reproduced the physician’s documen-tation accurately, right? I mean, when one doesn’t know the clinical aspects of a case, one might misrepresent what was actually documented and it comes out in writing the way one interpreted the documentation. The physician may well have identified criteria of SIRS somewhere and then found that the criteria were not caused by an inflam-matory process but attributed to the antipsychotic drug that the patient overdosed on. That’s always possible. But let’s take it as it was presented.

The guidance stated that the coding should follow the presenting symptoms along with the E code for the drug and, finally, 995.93 (SIRS due to noninfectious process). It goes on to say that “the systemic inflamma-tory response syndrome occurred as an adverse reac-tion to the medication.”

Ay! There’s the rub!SIRS has to be the response to an inflammatory

process, and we had no such thing in this case! There was no inflammation, so we cannot possibly have a



response to inflammation.To understand what I mean, let’s start from the very

beginning. The description of the relationship between SIRS and sepsis was promoted in the United States in the classic article in 1992 from a joint consensus between members of the Society of Critical Care Medi-cine and the American College of Chest Physicians. They reviewed lots of their own cases and compiled the literature on many patients in critical care units. They pronounced that they saw a common thread through most of these patients; that is, whether because of an infectious inflammatory process or a noninfectious inflammatory process, certain chemicals seemed to be released into the bloodstream by tissue macrophages (monocytes, when they’re in the bloodstream), and these chemicals produced a response by the body that consisted of four common criteria:

• Temperature either over 38o°C or under 36o°C• Heart rate about 90 beats per minute or higher• Respiratory rate about 20 or higher or PaCO2

under 32 mm Hg• White blood cell count approximately 12,000 or

higher or approximately 4,000 or lower or 10% bands

These criteria were called the criteria of SIRS. Are you ready? If an inflammatory process has caused tis-sue macrophages to gobble up the bad guys or the dead cells, and they released tumor necrotizing factor or in-terleukin-1 or certain other kinins into the bloodstream that caused the criteria of SIRS, then the patient had the systemic response syndrome to an inflammatory process.

Did you see that? Read it again. If the inflammatory process caused the changes in vital signs and white cell composition through the mechanism of macrophages and kinins, you have SIRS. Cause and effect. You have to have the cause before you can consider a relationship of the effect. Why? Because a zillion other things can cause these changes in vital signs and white blood cell component ratios other than an inflammatory pro-cess—and those are not SIRS!

What are some of the conditions that do cause in-flammatory response, you might ask? Well, I’ll tell you.

Infections can definitely cause inflammation that will mobilize the tissue macrophages to fight the invasion.

Most infections cause the systemic inflammatory response—unless the patient can’t mount a response. Patients on chemotherapy, on steroids, or with immuno-logic diseases that prevent such reactions won’t mount a response, or will only mount some pieces of a response.

People with acute pyelonephritis, acute diverticulitis, acute appendicitis, pneumonia, acute otitis media, or the flu will demonstrate fevers and tachycardias and tachy-pneas and some alteration of white cell count.

Patients with burns or hemorrhagic pancreatitis or other conditions that kill cells in the absence of infec-tion will mount the response—noninfectious sources that require tissue macrophages to help knock off the offensive tissues. Even acute myocardial infarction (MI) can have fever or elevated white blood cell count or tachycardia or tachypnea caused by the dead myo-cardial cells—and that’s SIRS—but after an MI, we call it Dressler’s syndrome.

What other things that have no inflammatory com-ponent at all can cause some of these changes in vital signs or blood cell count? Tachycardia and tachypnea are frequent byproducts of running up a flight of stairs. Is that an inflammatory process? No!

Pain can cause them, and the stress of pain can raise the temperature—and even the white blood cell count—with no inflammation going on at all. Congestive heart failure, abdominal distention (as in gaseous buildup in the intestine), morbid obesity, hyperthyroidism, hy-poxia from any cause (from drowning to being choked to aspiration of acid fumes to fracture of the fourth cervical vertebra), dehydration—all of these things can cause two or more of the four criteria of SIRS, but they don’t represent SIRS.

Then we have some chemical reactions in the body—release of certain substances integral to body function—and many cause the elements listed above through their direct chemical effects.

Or we can have ingestion of chemicals that either mimic the effects of inherent chemicals or have some manifestations of their own. Epinephrine causes tachy-cardia, changes in resistance in the bronchi, and lots of other modifications. Steroids from your own organs cause changes. Sometimes a tumor of an endocrine gland causes significant changes in respiratory rate, temperature, white blood cell count, or heart rate. Injections of these chemicals will cause the same kind



of direct chemical effects. And there’s no inflammatory process going on—it’s just chemical reaction.

Check out the word “toxidrome.” This is a word that combines “toxicity” and “syndrome.” It was invented around 1970 to demonstrate symptom complexes caused by certain chemicals based on their effects on the body. Some of them are cholinergics (mimicking the release of the chemical acetylcholine at nerve endings) and some are anticholinergics (blocking the effects of acetylcholine at nerve endings). Some are sedatives, some are hallu-cinogens, and some are sympathomimetics. As you can see in the chart below, many of them cause elements of the criteria of SIRS, but it’s not SIRS because there’s no inflammation or dead cells.

Now we come to the major point. Drugs used to treat a patient’s illnesses can have effects just like the ones already mentioned. Zyprexa, or olanzapine, is an antipsychotic drug that has chemical effects on parts of the body under normal circumstances. Some of the effects may be called side effects, some toxic effects, but they are all chemical effects like the toxidromes. A po-tentially fatal effect of overdosage is called neuroleptic malignant syndrome (NMS). The syndrome is usually associated with haloperidol, but Zyprexa can cause the chemical reaction as well.

Fever, tachycardia, and elevated white blood cell count are classic elements indicating NMS. Other symptoms include mental status changes, which may appropriately be called “toxic encephalopathy,” and au-tonomic instability, which may present as hypotension. Tremors and sweating may make it look like the patient is having a septicemic episode. Treatment includes

stopping the drug, stabilizing the elements that are unstable, and managing with drugs such as dantrolene and bromocriptine.

A physician caring for a patient who presents with such manifestations must rule out infection or other noninfectious causes of SIRS. The patient has many of the criteria of SIRS, but does not, after workup, have SIRS because there’s no inflammatory process going on. It’s all chemical reaction.

The ultimate point is this. You are being told to assign codes just because somebody said the magic words, whether or not the condition exists. You are be-ing required to do it according to the rules, whether or not the rules are right. And no matter how many times I bring it up to the rule writers, their response is, “Cod-ers should continue to assign the codes if the provider has documented the condition.”

They can’t have it both ways. Coders should be em-powered to discern the clinical differences and clinical criteria of particular diseases and injuries, and if it is identified that the documented conditions are inac-curately represented, coders should be able to clarify rather than blindly code to ensure the most accurate and specific diagnoses are presented.

Asking you to do it one way at one time and another way at another time is unfair and will lead to inaccurate coding, for which you will be blamed—both by the providers and by your professional societies—and that is a recipe for disaster. H

EDITOR’S NOTEDr. Gold is cEO of DcBA, inc., a consulting firm in Atlanta that provides physician-to-physician cDi programs. contact him at 770-216-9691 or [email protected].

Toxidrome

Symptoms BP HR RR Temp Pupil size Bowel sounds Diaphoresis

Anticholinergic ~ up ~ up up down down

Cholinergic ~ ~ ~ ~ down up up

Hallucinogenic up up up ~ up up ~

Sympathomimetic up up up up up up up

Sedative-hypnotic down down down down ~ down down

Source: Goldfrank, Flomenbaum, Lewin, Weisman, Howland, Hoffman (1998). Goldfrank’s Toxicologic Emergencies (6th ed.).

Stamford, CT: Appleton & Lange.

A supplement to Briefings on Coding Compliance Strategies

A monthly service of Briefings on Coding Compliance Strategies

november 2013

Coding Q&A

Editor’s note: Answers to the following questions are based on limited information submitted to Brief-ings on Coding Compliance Strategies. Review all documentation specific to your scenario before determining appropriate code assignment.

Q Our facility has a question about how other hos-pitals address this scenario: Patient is discharged

to home (discharge status code 01). No documentation exists in the medical record to support postacute care. Several months later, our MAC notifies us that the pa-tient indeed went to postacute care after discharge. The MAC retracts our entire payment.

We need to resubmit the claim with the correct dis-charge status code. We are reluctant to do so because nothing in the medical record supports the postacute care provided. Are other hospitals amending the record? If so, what department is adding the amended note?

A To answer this question completely, I would need access to the records in question. However, I will

do my best to provide some guidance. First, call your MAC to determine the reason for the change in discharge sta-tus. Second, confirm with the transfer facility that the pa-tient did, in fact, receive postacute care. Finally, amend the health record to reflect the change in discharge status.

Patients are commonly discharged home and unex-pectedly receive home health after a physician decides after discharge that they need the services. This results in discharge status code 06—not 01.

However, sometimes the MAC is wrong. For ex-ample, this can occur when patients may have already been in an episode of home health care prior to hospi-talization. When these patients resume home health care more than three days after hospital discharge, a

MAC may incorrectly identify discharge status code 01 as erroneous.

William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, FL, an-swered this question.

Q Do all payers follow official coding guidelines?

A Unfortunately, they don’t. They’re supposed to, but they don’t. Coding Clinic guidance talks about

what to do in a situation where a payer may not follow of-ficial coding guidelines. It is a difficult situation for coders, because they’re torn. From day one they’re taught to fol-low official coding guidelines. It’s part of their duty as cod-ers, and then you have a situation where a payer says, “I don’t want to see that code. I want to see this code.”

In that situation, it is extremely important that all of that information is documented and maintained by the facility so that you can support why you are not following official guidelines. Make sure you document exactly what occurred and what you were asked to do by the payer. Make sure you’ve got the payer’s acknowledgement that it wants you to follow its instructions and that the payer is aware that it is not following official guidelines.

I’ve been involved in situations where the payer did acknowledge it and said, “Yes, I want you to code this code first,” instead of a V code, for example. As long as all the documentation is there and in writing, then following the payer’s instructions is appropriate. It’s a rare occasion, so make sure you have all your i’s dotted and t’s crossed.

Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Ind., answered this question.

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Senior Managing Editor Michelle Leppert, CPC, at [email protected].

A monthly service of Briefings on Coding Compliance Strategies

there to support our work as it relates to coding and documentation education. Coding Clinic and the coding manuals are our resources. Any time someone has asked me whether it’s okay to do something, I have the per-son check his or her coding manual to see if there’s any excludes or includes or any further information given for the code. I also tell the person to refer to Coding Clinic.

Deborah Lantz, RHIA, an AHIMA-approved ICD-10-CM/PCS trainer and director of HIM at St. Charles Hospital in Port Jefferson, N.Y., answered the previous question.

Q My question is about the 2-midnight rule in the IPPS final rule. Is CMS saying that if the patient

meets medical necessary and we’re approaching 48 hours, the physician or utilization management committee should change that patient’s status from observation to in-patient if he or she hasn’t been made inpatient yet?

A CMS addressed this during an open door forum call. If the patient has been here overnight, the

physician should write an order for inpatient if he or she plans for the patient to be there one additional night. I believe in the rule CMS states that a patient should not stay two midnights without an inpatient order.

This is the responsibility of the attending physician, though, not the utilization review committe.

Day two is when the attending physician has to decide whether to keep the patient one more midnight and admit the patient or discharge the patient home.

If at any point that decision to discharge home changes, then that’s when the physician needs to order that care. If at any point the physician believes he or she will keep the patient for a second midnight, the physician needs to order the inpatient care.

Kimberly Anderwood Hoy Baker, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, Mass., answered this question. H

Q Should a query response be part of the legal medical record?

A AHIMA, with ACDIS collaboration, released its new “Guidelines for Achieving a Compliant Query

Practice” in February. In that guidance, AHIMA is silent on this subject and leaves it up to the organization. There are a lot of different ramifications within an organiza-tion, which is why you need to have the medical execu-tive committee, the legal team, and compliance involved in determining if it’s part of the legal health record.

When we’re talking about the legal health record, I’m assuming you’re talking about the part that under HIPAA. If I requested to see my record, this is what’s presented. The business record is that other part of the record that is associated with a claim or maybe held elsewhere, but not typically released as part of the medical record—it’s something that would be ac-cessed differently or separately. AHIMA did advise us that for certain types of query construction—for ex-ample, if the physician is writing on the query form in order to answer the yes/no or the multiple choice—the query response should be part of the medical record because that is the only way the information could get into the record.

Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director at HCPro, Inc., in Danvers, Mass., answered the previous question.

Q Does the physician need to document the work as acute? What if he or she states exacerbation only?

A Coding Clinic has done a great job answering this. If the physician is only saying the patient

had exacerbation, is that equivalent to saying that this patient is in acute state? And the answer to that is yes.

When we’re doing our job as clinical documentation specialists, coders, HIM directors, CDI directors, and leads, we should be aware of the resources that are out

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2013 HCPro, Inc., Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2013 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

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P7 Discover documentation insufficiencies before ICD-10 ... · or possibly a localized infection such as a urinary tract infection? ... HIT Pro-CP “Without physician ... • Puerperal