get ready for icd-10-cm combination codes - · get ready for icd-10-cm combination codes coders...
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Get ready for ICD-10-CM combination codes
Coders well versed in ICD-9-CM know that a com-
bination code is a single code used to classify one of
the following:
➤ Two diagnoses
➤ A diagnosis with an associated secondary process
(manifestation)
➤ A diagnosis with an associated complication
ICD-10-CM technically defines combination codes
the same way. However, the codes take on an entirely
different flavor. Not only does ICD-10-CM include more
of them, but they often provide more specific informa-
tion. This additional specificity requires coders to place
greater emphasis on abstracting information from the
medical record.
Consider pressure ulcers. Coders using ICD-9-CM
must assign two codes—one for the site of the ulcer
and another for the stage of the ulcer. Conversely,
ICD-10-CM includes nearly six pages of pressure ulcer
combination codes (category L89) that identify the site
and stage of an ulcer and laterality—all in one code. For
example, ICD-10-CM code L89.013 denotes pressure
ulcer of the right
elbow, stage 3.
As with ICD-9-
CM, coders may
derive the stage
of an ulcer from
wound care or
nursing notes.
However, the
actual diagnosis
and site (including laterality) must be based on physician
documentation.
Upon quick glance, many ICD-10-CM combination
codes demonstrate conciseness that will facilitate re-
search, medical necessity, and denial management. For
example, a patient presents with type 2 diabetes with
mild nonproliferative retinopathy with macular edema.
Coders using ICD-9-CM must report the following three
separate codes to capture this information:
➤ 250.52 (type 2 diabetes with ophthalmic
manifestations)
➤ 362.04 (mild nonproliferative diabetic retinopathy)
➤ 362.07 (diabetic macular edema)
However, with ICD-10-CM, only one code—E11.321
(type 2 diabetes mellitus with mild nonproliferative
diabetic retinopathy with macular edema)—is necessary.
This code denotes the type of diabetes mellitus, the body
system affected, and the specific complications affecting
that body system.
Understanding the
etiology of a disease
process will be paramount
when thinking about
combination codes, says
Jean Bishop, MSPh, MBA,
RHIT, CPC, CFE, CPhT.
November 2011 Vol. 14, No. 11
IN THIS ISSUE
p. 4 Medicare publication offers valuable coding tipsKnow how inpatient RAC target areas may reveal compliance traps.
p. 7 Keep pace with regulatory changesLearn how to avoid information overload in times of rapid changes.
p. 8 Clinically SpeakingRobert S. Gold, MD, explains new codes for hypertrophic cardiomyopathy.
p. 10 Pneumonia codingEnsure documentation is clear, consistent, and thorough before assigning codes for aspiration pneumonia and pneumonia without evidence of infiltrate.
p. 12 Coders and readmissionsKnow what role coders play in monitoring readmissions for three diagnoses addressed in the FY 2012 IPPS final rule.
Inside: Coding Q&A
Page 2 Briefings on Coding Compliance Strategies November 2011
© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
These combination codes exemplify the impressive
specificity that ICD-10-CM offers.
Further, these more specific and concise codes will
require more specific physician documentation, says
Donna Smith, RHIA, senior consultant at 3M in At-
lanta. In some cases, physicians may not be accustomed
to documenting in such detail, Smith explains. For
example, a patient presents with an acute gout flare.
Coders currently assign ICD-9-CM code 274.01 to cap-
ture this information. However, assigning a complete
ICD-10-CM code will require that they know the specific
cause of gout and link it to a specific joint, she says. For
example, ICD-10-CM code M10.061 denotes idiopathic
gout of the right knee.
“Interestingly enough, ICD-10 uses the term ‘idio-
pathic’ a lot. It basically means due to an unknown
cause,” says Smith. “But unless the physician tells us
that, we’d have to query or report it as unspecified.”
Research the etiology of diseases
Understanding the etiology of a disease process will
be paramount when thinking about combination codes,
says Jean Bishop, MSPh, MBA, RHIT, CPC, CFE,
CPhT, an independent consultant in Arlington, VA. For
example, ICD-10-CM includes combination codes for
atherosclerotic heart disease with angina pectoris. The
subcategories for these codes are:
➤ I25.11 (atherosclerotic heart disease of native coro-
nary artery with angina pectoris)
➤ I25.7 (atherosclerosis of coronary artery bypass
graft[s] and coronary artery of transplanted heart
with angina pectoris)
Assigning a separate code for angina pectoris is un-
necessary because it’s included in the combination code.
ICD-10-CM guidelines state that coders can assume a
causal relationship between atherosclerosis and angina
pectoris unless documentation indicates the angina is
due to something other than atherosclerosis.
Coders should remember that although unstable an-
gina (a CC) is included in the combination code and not
separately reported, it will continue to affect MS-DRG
calculation, says Smith.
How to identify combination codes
One of the most challenging aspects of combination
codes is simply knowing they even exist, says Bishop.
For example, a patient has toxic liver disease, chronic ac-
tive hepatitis, and ascites. Coders using ICD-9-CM don’t
report a combination code. Instead, they report 573.9
(toxic liver disease), 571.49 (chronic active hepatitis),
and 789.59 (ascites).
However, coders using ICD-10-CM must recognize
that they should report only one code—combination
code K71.51 (toxic liver disease with chronic active
hepatitis with ascites). The key is understanding that the
toxic liver disease is associated with the hepatitis and
Editorial Advisory Board Briefings on Coding Compliance Strategies
Paul Belton, RHIA, MHA, MBA, JD, LLMVice PresidentCorporate Compliance Sharp HealthCare San Diego, CA
Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS Regional Managing Director of HIMNCAL Revenue Cycle Kaiser Foundation Health Plan, Inc. & Hospitals Oakland, CA
Darren Carter, MDPresident/CEOProvistas New York, NY
William E. Haik, MD, FCCPDirectorDRG Review, Inc. Fort Walton Beach, FL
James S. Kennedy, MD, CCSManaging DirectorFTI Healthcare Atlanta, GA
Laura Legg, RHIT, CCSRevenue Control Coding ConsultantRevenue Cycle Management Washington/Montana Regional Services Providence Health & Services Renton, WA
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director, Coding and HIM HCPro, Inc. Danvers, MA
Sandra L. Sillman, RHIT, PAHMDRG CoordinatorHenry Ford Hospital and Health Network Detroit
Jean Stone, RHIT, CCSCoding Manager - HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, CA
Editorial Director: Lauren McLeod
Associate Editorial Director: Ilene MacDonald, CPC
Managing Editor: Geri Spanek
Contributing Editor: Lisa Eramo, [email protected]
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: $249/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2011 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright 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 subscrip-tion information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [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 endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
November 2011 Briefings on Coding Compliance Strategies Page 3
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that the two disease processes occur together along with
a manifestation (ascites), says Bishop. The best way to
locate this code is to start with the term “disease,” then
the subterm “liver” followed by “toxic, with hepatitis,
chronic, active, with ascites,” she explains.
When determining whether a combination code might
exist, Smith says coders should ask these two questions:
➤ Are the disease processes linked?
➤ What is the root cause of a particular disease?
Coders must use combination codes when they are
available, says Bishop. “The guidelines state that mul-
tiple codes should not be used when you clearly have a
combination code that identifies all of the elements in
the diagnosis,” she says.
What you can do now
Hospitals can begin preparing for ICD-10-CM combi-
nation codes now.
Streamline the query process and obtain physician
buy-in so that the process works for both coders and
physicians, says Bishop. Establishing a robust query pro-
cess now will improve documentation and likely lead to
fewer queries in the future, she says.
Beware of unspecified codes. Even though unspecified
codes exist in ICD-10-CM, Bishop fears that coders may
default to these codes based on insufficient documenta-
tion. She sees this as a potential problem generally and
especially with combination codes. Defaulting to unspec-
ified ICD-10-CM codes could lead to noncoverage when
insurers stop paying for services that could reasonably be
better defined, Bishop says.
“There are concerns that claims will be rejected and
need to be appealed,” she says.
A high volume of unspecified codes could also lead to
poor data collection for health plan analyses and public
health purposes. Hospitals may also be more vulnerable
to RAC audits if they default to unspecified codes rather
than take advantage of ICD-10’s inherent granularity
and specificity, Bishop says. RACs may question why the
details could not be obtained, she explains.
Coders also need ample training with respect to anat-
omy, physiology, and the etiology of diseases, says Smith.
This knowledge will help coders ask more intelligent and
clinically sound queries, she says. For example, coders
may be able to more easily distinguish between condi-
tions that typically are related and scenarios in which
one condition typically causes another.
Even if a physician doesn’t link two conditions, a
coder would recognize the need to query and correctly
assign the combination code.
Coders should include physicians in the educational
process when possible, says Smith. For example, ask an
orthopedic physician to share information about muscu-
loskeletal procedures and diagnoses (e.g., the anatomy
of a joint). Coders can then explain how codes related to
this specialty will change in ICD-10-CM. Together, physi-
cians and coders can brainstorm ways to best capture the
information, she says.
Also remember that practice makes perfect, Bishop
says. Review records that would require combination
codes under ICD-10 (e.g., diabetes, coronary artery
disease, pressure ulcers, and poisonings and adverse ef-
fects), she says.
Training and preparation for ICD-10 should include
coding records with both ICD-9-CM and ICD-10-CM.
Coders also should note opportunities for CDI. n
Combination codes to ponder
Some ICD-10-CM combination codes that may sur-
prise coders include the following:
➤ Codes in categories T36–T65, which are combination
codes that include substances related to adverse ef-
fects, poisonings, toxic effects and underdosing, and
external causes (e.g., T39.011A, poisoning by aspirin,
accidental [unintentional], initial encounter)
➤ Combination external cause codes that identify se-
quential events that result in an injury, such as a fall
which results in striking an object (e.g., W01.111A,
fall on same level from slipping, tripping, and stum-
bling with subsequent striking against power tool or
machine, initial encounter)
Page 4 Briefings on Coding Compliance Strategies November 2011
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Medicare publication offers valuable coding tipsA recent Medicare Quarterly Provider Compliance News-
letter calls attention to several specific areas of inpatient
coding compliance risk, says Christina Benjamin, MA,
RHIA, CCS, CCS-P, an inpatient auditor at Anthelio
(previously PHNS) in Dallas.
Many of these topics surface during audits—includ-
ing individual coder audits—for various clients Benjamin
serves nationwide.
Some of these issues are pervasive, and experts say
they are indicative of larger and more widespread compli-
ance trends. Seeing the big picture when reviewing this
information is important, so consider the following tips.
Review the definition of principal diagnosis
The ICD-9-CM Official Coding Guidelines and Coding Clinic,
Second Quarter 2001, state that the principal diagnosis is
the condition after study that is chiefly responsible for a
patient’s admission. Coders should remember this at all
times when coding and sequencing conditions.
The July issue of the Medicare newsletter (pp. 5–6)
describes a patient who presents with an acute myo-
cardial infarction (AMI) and undergoes an emergent
left heart catheterization and angioplasty. During the
procedure, the physician documents that the patient
also has severe coronary artery disease (CAD). A coder
incorrectly sequences the CAD as the principal diagnosis,
yielding MS-DRG 237 (major cardiovascular procedures
with MCC). Instead, the coder should have sequenced
the AMI as principal; this would have yielded MS-DRG
238 (major cardiovascular procedures without MCC).
When patients have both AMI and CAD, coders
should first determine which one (or both) was POA,
says Benjamin.
“If the AMI was POA or determined to be POA after
study, then that’s going to be your principal diagnosis,”
she says.
However, even if both AMI and CAD are POA, AMI
will likely be the principal diagnosis because it’s most
likely the acute event that prompted the admission, says
Benjamin. The CAD is probably a chronic condition that
doesn’t warrant the admission, she says.
Think twice before reporting excisional
debridement
Coding excisional debridement requires that the pro-
cedure involves the skin and subcutaneous tissues only,
says Benjamin. If physicians mention that they identified
the nerves or minor vessels or that they extended the
excision into the fascia, it’s probably not an excisional
debridement to the skin alone, she says. “If the docu-
mentation is really not adequate, the coder needs to find
out what’s going on,” Benjamin says.
In some cases, the documentation may be adequate;
however, the coder might not take the time to fully read
through it, says Glenn Krauss, BBA, RHIA, CCS,
CCS-P, CPUR, C-CDI, CCDS. Krauss is an independent
HIM consultant in Madison, WI.
For example, the newsletter (pp. 12–13) describes a
patient who is admitted with acute cerebrovascular ac-
cident, acute renal failure, hypertension, and sacral and
heel ulcers. While in the hospital, the patient receives
wound debridement documented as debridement down
to the fascia. A coder reports 86.22 (excisional debride-
ment of wound, infection, or burn) as the principal
diagnosis, which yields MS-DRG 040 (peripheral/cranial
nerve and other nervous system procedures with MCC).
Instead, the coder should have reported 83.39 (excision
of lesion of other soft tissue) as principal, which would
have yielded MS-DRG 987 (non-extensive OR procedure
unrelated to principal diagnosis with CC).
Many coders are leery of reporting MS-DRG 987, but
in some cases—such as the one previously described—
the documentation warrants it, says Benjamin.
Coders should remember that they may see documen-
tation of both “excisional debridement” and “debride-
ment down to the fascia.” This could indicate multiple
ulcers, some of which require excisional debridement
and some of which require debridement further into the
November 2011 Briefings on Coding Compliance Strategies Page 5
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body tissues, says Benjamin. Coding Clinic, First Quarter
1999, p. 8, reminds coders that although multiple ulcers
may be present, each ulcer requires its own code for the
specific type of debridement the physician performs.
Documentation of excisional debridement and de-
bridement down to the fascia could also indicate mul-
tiple-layer debridement of the same site, in which case
coders should only report the deepest layer of debride-
ment. See Coding Clinic, Second Quarter 2005, p. 3.
Coders can’t assume that documentation of the word
“excisional” necessarily means the physician performed
excisional debridement of the skin and subcutaneous tis-
sue, says Krauss.
“If you don’t have the descriptive terminology of ex-
actly what the physician did when he or she performed
the excisional debridement, then you need to ask,” he
says. Documentation should include a description of the
wound, a description of the instruments used, the depth
and type of the debridement performed, and the type of
tissue debrided, he explains.
Don’t code conditions that are no
longer present
“Look for current treatment,” says Benjamin. “If
there is no evidence of current treatment, don’t code
it. If you do, you may end up accidentally capturing a
CC or MCC.” If a physician documents a condition in a
patient’s history, that might be one clue that it shouldn’t
be coded as part of the current encounter, she says.
For example, the newsletter (pp. 3–4) describes a pa-
tient undergoing dialysis in the dialysis unit who is sent
to the ED for evaluation of anemia. Results of a prior
workup for a gastrointestinal (GI) bleed were inconclu-
sive; however, the admitting diagnosis is documented
as anemia. The ED physician documentation states the
patient has not noticed any melena or hematochezia.
A GI consultation states the patient is admitted with
anemia and denies any GI complaints and any recent
GI bleeds. The discharge summary states the patient has
anemia with end-stage renal disease. A coder reports
blood in the stool as the principal diagnosis, which yields
MS-DRG 377 (GI hemorrhage with MCC). Instead, the
coder should have reported the iron deficiency anemia
as principal, which would have yielded MS-DRG 811
(red blood cell disorders with MCC).
Coders must evaluate each scenario individually
when thinking about whether conditions have resolved
prior to admission, particularly those involving chronic
systemic conditions, says Benjamin.
For example, if a patient has a history of chronic
obstructive pulmonary disease (COPD) and is no longer
receiving any medication or treatment for the condition,
coders should still report it because it’s controlled but not
cured, and it meets the Uniform Hospital Discharge Data
Set definition of a secondary diagnosis, says Benjamin.
Coding Clinic, Third Quarter 2007, states that chronic
conditions (e.g., hypertension, Parkinson’s disease, COPD,
and diabetes mellitus) are chronic systemic diseases that
ordinarily should be coded even in the absence of docu-
mented intervention or further evaluation. Multiple
sclerosis and rheumatoid arthritis are mentioned under
this same class in Coding Clinic, March–April 1985. Con-
gestive heart failure is mentioned in Coding Clinic, Second
Quarter 2000, pp. 20–21.
However, other chronic conditions may require clari-
fication. Be on the lookout for the following conditions:
➤ Crohn’s disease, ulcerative colitis, and
pyloric stenosis
➤ Hepatitis, gastrointestinal ulcer disease, and hernia
➤ Herpes zoster with residual
➤ Bronchitis and asthma
➤ Migraines and seizures
➤ Cardiac valve and rhythm conditions
➤ Phlebitis and thrombophlebitis
➤ Thrombosis
➤ Pathological fracture
➤ Myelopathy with and without disc disorder
➤ Glaucoma
“I do feel strongly that the issue of productivity
weighs in on coders’ thought processes,” says Krauss. He
frequently sees charts for which coders report conditions
Page 6 Briefings on Coding Compliance Strategies November 2011
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that are mentioned only once or twice in a progress note
and that don’t necessarily meet the criteria for reportable
secondary diagnoses.
Krauss says coders should ask the following questions:
➤ How many times did the physician mention
the condition?
➤ What is the clinical significance of the condition?
➤ Does the condition add complexity to the case?
Look for clinical evidence that supports
documentation
“We, as coders, should be looking at the appropri-
ateness of diagnosis and not coding in a vacuum,” says
Krauss. “One of the cardinal rules of coding is to match
up the clinical treatment with the diagnoses, but I’m
seeing a tendency to get away from that and code strictly
what the doctor said. It’s time to revisit priorities and go
back to the basics.”
For example, the newsletter (p. 2) provides a scenario
in which an 81-year-old female is admitted through the
ED with complaints of a dry cough for a couple of weeks.
The patient is assessed for wheezing and coughing, and
the history and physical impression is acute respiratory
failure secondary to exacerbation of COPD.
Progress notes include a diagnosis of acute respiratory
failure secondary to exacerbation of COPD, and the final
diagnosis on the discharge summary is acute respiratory
failure secondary to COPD exacerbation. An additional
documentation sheet in the record lists the following
information:
➤ Principal diagnosis: COPD exacerbation
➤ Other diagnoses: high blood pressure, CAD, conges-
tive heart failure, diabetes mellitus, Parkinson’s, and
rheumatoid arthritis
Krauss says the coder, who likely saw acute respira-
tory failure documented repeatedly throughout the
stay, reported acute respiratory failure (518.81) as the
principal diagnosis. However, the RAC auditor changed
it to hypoxemia (799.02). This resulted in an MS-DRG
change from 189 (pulmonary edema and respiratory
failure) to 192 (COPD without CC/MCC).
“This is a case where the doctor wrote the diagnosis,
but the RAC disallowed it,” says Krauss. This can happen
when CDI programs incorrectly prompt physicians to
document conditions that patients may not have.
The coder definitely plays a role in determining the
validity of diagnoses that physicians document, says
Krauss. Consider implementing a policy to address cases
in which coders determine that clinical treatment doesn’t
match the documented diagnosis. For example, coders
can refer these cases to a lead coder who can discuss the
matter with a physician advisor, he says. n
Editor’s note: Access the July Medicare Quarterly Provider
Compliance Newsletter, which includes many of the scenarios
described in this article, at http://tinyurl.com/43qsagm.
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Becoming inundated with coding information is easy
in this fast-paced world of interconnectedness.
The sheer volume of ongoing regulatory changes only
adds to the sense of being overwhelmed. How can coders
keep pace with this data cascade without letting it com-
pletely devour their days?
Clients frequently ask Darice M. Grzybowski, MA,
RHIA, FAHIMA, president and founder of HIMentors,
LLC, in Westchester, IL, this question. As a consultant,
Grzybowski often informs hospitals of regulatory chang-
es via presentations, training, and newsletters tailored to
meet their needs. This saves hospital employees count-
less hours they would otherwise spend researching,
reading, and relaying information, she says.
Coders and their managers can help themselves
manage this information, says Grzybowski. First, make
use of the Internet by subscribing to complimentary
e-newsletters published by professional associations and
other reputable organizations, she says.
“The information is pushed out to you rather than you
having to go out and search for it,” she says. “There’s the
old-fashioned way of hunting and searching, but you’ll
be on a journey for weeks at a time, and we don’t have
that kind of time in our busy lives.”
Vendors are another potential source of free infor-
mation; many offer newsletters, webinars, and helpful
information on their websites, says Grzybowski.
Google and AOL® alerts are also an option. These
alerts rely on key terms (e.g., ICD-9, ICD-10, RAC) to
flag updates and send the information to your inbox,
says Vickie Axsom-Brown, president of Audit &
Recovery Solutions in Henderson, NV.
“I try to set it up so that I’m not doing research 10
hours out of my 12-hour day,” says Axsom-Brown, a
Don’t fall prey to coding information overload
Manage regulatory information with these essential online resources
Certain resources can make a world of difference with re-
spect to managing regulatory information. If you don’t al-
ready have the following resources in your coding arsenal,
consider adding them now.
Complimentary e-newsletters
➤ AHA News Now, a daily publication for and about AHA
members and employees of hospitals, health systems,
and healthcare facilities
(www.ahanews.com/ahanews_app/jsp/getnewnow.jsp)
➤ Medicare Weekly Update, a weekly publication that brings
readers the latest Medicare news for hospitals from CMS
and the OIG
(www.hcmarketplace.com/prod-5091/Medicare-Weekly-
Update.html)
➤ The RAC Report, a biweekly publication that offers tips
and strategies pertaining to RACs
(www.hcmarketplace.com/prod-6895/The-RAC-Report.html)
➤ Medicare Update for CAHs, a biweekly publication that
provides specialized information for critical access
hospitals (CAH), focusing on reimbursement and CMS
updates of special concern to CAHs
(www.hcmarketplace.com/prod-9659/Medicare-Update-for-
CAHs.html)
Subscription-based websites
➤ MedicareFind™, a regulatory database that allows users
to easily and intuitively access Medicare reimbursement
rules and regulations
(www.medicarefind.com/Purchase.aspx)
➤ JustCoding.com, a continuing education website for
coding professionals
(www.hcmarketplace.com/prod-3270/JustCodingcom.html)
Other sources of information
➤ CMS e-mail updates, which address various topics of in-
terest (Visit https://www.cms.gov and select Email Updates
under Featured Content. Subscribe to updates pertaining
to Hospital Open Door Forum calls, RACs, quarterly pro-
vider updates, and CMS press releases.)
Page 8 Briefings on Coding Compliance Strategies November 2011
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regular user of alerts. “I’d rather do research one hour
out of my 12-hour day than spend all day long flounder-
ing because I don’t have the information that I need.”
If you devote time to searching for updates daily or
weekly, be sure to rely on official sources (e.g., CMS,
OIG, AHA), says Gloryanne Bryant, BS, RHIA, RHIT,
CCS, CCDS, regional managing director of HIM, NCAL
Revenue Cycle, Kaiser Foundation Health Plan, Inc. &
Hospitals in Oakland, CA.
“It’s helpful to read an actual transmittal or Medlearn
Matters article,” Bryant says. “You want the official advice
rather than hearsay interpretation or opinion from lay-
people. I try to get something that has the source docu-
ment linked to it.”
CMS Open Door Forum calls, which are free and
open to the public, also provide much information
about the latest rules and regulations, says Bryant. Pro-
viders can ask questions during the Q&A portion of
the call. Learn more at www.cms.gov/OpenDoorForums/
18_ODF_Hospitals.asp.
Regularly visit your RAC’s website, but be aware
that not all issues posted directly affect coders, and some
may not affect your organization at all, says Axsom-
Brown. “As you look at your RAC’s list of issues, it’s
critically important that you identify those that specifi-
cally have a potential for an audit hit within your
organization,” she says. RAC data can overwhelm
coders and coding managers who don’t use this filter.
Thorough knowledge of your organization’s data
is the best approach for dealing with auditors, says
Axsom-Brown. Reviewing your top 25 or 50 proce-
dures with respect to volume and determining their
relevance to recent MLN Matters articles, RAC activity,
or OIG activity is more helpful than researching infor-
mation that may not even pertain to your organization,
she says.
Delegate different tasks to individual coders. For ex-
ample, coders can select a topic (e.g., RACs, EHRs, Coding
Clinic), research updates, and present findings at monthly
meetings. “You can drill down the focus, and everyone
shares in the information,” says Grzybowski.
Remember that not all information has value
throughout the department, says Bryant. “We review
[information] and try to determine what the impact will
be to our coding staff. We do filter through the informa-
tion, and we try to summarize it on a quarterly basis
as much as we can unless it’s a transmittal that’s being
implemented quickly,” she says. n
by Robert S. Gold, MD
The good news is that as of October 1,
there are new ICD-9-CM codes to denote
hypertrophic cardiomyopathy:
➤ 425.11 (hypertrophic obstructive cardiomyopathy)
➤ 425.18 (other hypertrophic cardiomyopathy)
The bad news is that some physicians, coders, and CDI
specialists have misunderstood hypertrophic cardiomy-
opathy, leading to miscoding. Let’s set the record straight.
Hypertrophic cardiomyopathy
When hypertrophic cardiomyopathy with obstruc-
tion occurs in children, physicians sometimes refer to it as
idiopathic hypertrophic subaortic stenosis. It also is known
as hypertrophic obstructive cardiomyopathy. Previously, it
mapped to ICD-9-CM code 425.1. Hypertrophic cardio-
myopathy without obstruction mapped to 425.4, which
includes other primary cardiomyopathies described with
many nonspecific adjectives.
Hypertrophic cardiomyopathy—with and without
obstruction—is one disease with different levels of
Hypertrophic cardiomyopathy and ventricular hypertrophyUnderstanding how conditions differ is essential for correct coding
November 2011 Briefings on Coding Compliance Strategies Page 9
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functional abnormality due to structural changes. As
of October 1, ICD-9-CM classifies it under one code
(425.1x) instead of two. The fifth digit extensions specify
with or without obstruction. Cool, right? Not quite.
True hypertrophic cardiomyopathy is a genetic disor-
der. Manifestations range from no findings for a patient’s
entire lifetime to sudden cardiac death from ventricular
arrhythmias. Perhaps you’ve seen news reports about
children who died suddenly on the playing field because
of hypertrophic cardiomyopathy. Efforts to ensure echo-
cardiograms for all participants to identify those at risk of
death during intramural sports often follow.
Ventricular hypertrophy
This topic becomes confusing for coders when physi-
cians use the term “hypertrophic cardiomyopathy”
when they really mean ventricular hypertrophy. What’s
the difference?
Hypertrophy of one or both ventricles may be due
to a known secondary cause. Systemic hypertension
can lead to left ventricular hypertrophy as the left ven-
tricle works harder against pressure downstream. Right
ventricular hypertrophy with or without chronic cor
pulmonale can be caused by pulmonary artery hyper-
tension or chronic lung disease. Shunts can cause hyper-
trophy. Heart valve diseases can cause hypertrophy.
All of these are hypertrophy of one or both ventricles
due to an identifiable cause. Don’t report 425.1x for
these scenarios.
Left ventricular hypertrophy caused by hypertension
is a manifestation of hypertensive heart disease. Consider
the 402 code series. If a cardiologist identifies and docu-
ments hypertensive cardiomyopathy, reporting 425.9
(secondary cardiomyopathy, unspecified) is appropriate.
A patient with hypertensive heart disease and left ven-
tricular hypertrophy who develops significant stiffness to
the left ventricle may have chronic heart failure due to
diastolic dysfunction (428.32). The large size of the ven-
tricular wall and interventricular septum interferes with
filling of the left ventricle during diastole, and the patient
develops symptoms of congestive heart failure.
Aortic stenosis can narrow the opening from the
left ventricle into the aorta, causing the ventricle to
work harder to eject blood. As with hypertension, the
added work can lead to hypertrophy. The left ventricular
hypertrophy can lead to inadequate filling during the
diastolic portion of the heart cycle. Once symptoms
of heart failure begin, patients may develop chronic
heart failure due to diastolic dysfunction (428.32) that
is due to valvular cardiomyopathy (425.9) of aortic ste-
nosis (424.1).
Interestingly, muscle fibers can become so over-
stressed that they essentially lose strength, and the heart
dilates. This occurs with both primary genetic hyper-
trophic cardiomyopathy and acquired left ventricular
hypertrophy due to another disease process.
A patient whose heart is hypertrophic may develop
chronic diastolic failure. Without appropriate treat-
ment, the heart will start to dilate, and the echocar-
diogram will now demonstrate a low ejection fraction.
When this occurs, a patient will also experience
systolic failure.
Patients can experience almost a total reversal of
hypertrophy or even late-stage dilation after treatment
for hypertension for several years or after repair or
replacement of the aortic valve. When patients have left
ventricular hypertrophy due to a disease process, their
cardiodynamics can virtually return to normal over time.
Surgery can relieve symptoms of the genetic form of
hypertrophic cardiomyopathy that interfere with daily
life, but only a heart transplant can cure it.
In summary, hypertrophic cardiomyopathy with or
without obstruction is considered a genetic condition.
Left (or right) ventricular hypertrophy is an acquired
condition. New ICD-9-CM codes denote hypertrophic
cardiomyopathy with or without obstruction. No codes
denote left ventricular hypertrophy. The only option is
429.3 (cardiomegaly). n
Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting
firm in Atlanta that provides physician-to-physician CDI pro-
grams. Contact him at 770/216-9691 or [email protected].
Page 10 Briefings on Coding Compliance Strategies November 2011
© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Like many diagnoses, pneumonia presents challenges
for coders when physician documentation is unclear.
Aspiration pneumonia
Clear documentation of aspiration pneumonia, in par-
ticular, continues to be problematic, says Joy J. King,
RHIA, CCS, CCDS, principal of Joy King Consulting,
LLC, in Birmingham, AL. Why? Physicians often docu-
ment “aspiration” or “pneumonia” without specifically
stating “aspiration pneumonia.” This occurs even though
clinical evidence in the record suggests a link between
the two, she says.
What should coders do? Review pathophysiology, and
then consider asking the physician for clarification, says
Lolita M. Jones, RHIA, CCS, an independent consul-
tant in Fort Washington, MD.
Aspiration pneumonia occurs when patients breathe
foreign materials (e.g., food, liquid, vomit, or fluids from
the mouth) into the lungs, causing inflammation. Risk
factors for developing aspiration pneumonia include
coma, esophageal stricture, gastroesophageal reflux,
high consumption of alcohol, general anesthesia, old age,
stroke, brain injury, and difficulty swallowing. Symp-
toms of the condition include bluish skin color, chest
pain, cough, fatigue, fever, shortness of breath, wheez-
ing, breath odor, and excessive sweating.
Several diagnostic tests help physicians determine
whether patients have aspiration pneumonia, says
Jones. These include a physical exam (to identify crack-
ling sounds in the lungs or a rapid pulse/heart rate),
arterial blood gas, blood culture, bronchoscopy, chest
x-ray, com plete blood count, CT scan of the chest,
sputum culture, or swallowing study. Therapeutic inter-
ventions include antibiotics, mechanical ventilation,
or oxygen therapy.
Coders can only code aspiration pneumonia when a
physician clearly documents a link between the aspira-
tion and the pneumonia, says King.
“It’s very important that you have both of these words
documented and linked together before you assign that
507.0 code,” she says.
When coding postoperative aspiration pneumonia,
coders must first report complication code 997.39 (other
respiratory complications) followed by code 507.0
(pneumonitis due to inhalation of food or vomitus) to
further specify the respiratory complication, says King.
Pneumonia without evidence of infiltrate
Coders shouldn’t be surprised to see more frequent
documentation of clinical pneumonia in the absence
of positive chest x-rays, says Jones. This can occur for
several reasons. For example, research has found that
radiologist interpretation of the presence of infiltrates is
somewhat subjective, she says.
Note that patients who are dehydrated must first
receive fluids before an infiltrate would even show up
on a chest x-ray, notes King.
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November 2011 Briefings on Coding Compliance Strategies Page 11
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CT scans—rather than chest x-rays—are becoming
more frequently used to detect pneumonia, says Jones.
Other types of alternative tests for diagnosing pneu-
monia include C-reactive protein (which rises and falls
with infection and is stimulated more often by bacteria),
procalcitonin (which rises when bacteria are present),
and soluble triggering receptor expressed on myeloid
cells (which rises in the presence of bacteria and fungal
infections but does not respond to viruses or noninfec-
tious disorders).
However, negative chest x-rays can raise red flags.
Hospitals continue to experience denials due to patients
diagnosed and coded as having clinical pneumonia when
the chest x-ray is negative, says King.
“An infiltrate on a chest x-ray is still considered the
gold standard by the OIG, the RACs, and the other
governmental agencies that are out there looking at our
records,” she says.
What can coders do? In the absence of infiltrates on
chest x-rays, coders can and should look for documenta-
tion of certain signs and symptoms before coding pneu-
monia, says King. These include respiratory rate greater
than 25, heart rate greater than 100, rales, crackles,
rhonchi, dullness to percussion, or decreased breath
sounds, she says.
“Communication with attending physicians about the
importance of documenting more about the clinical di-
agnosis of pneumonia in the absence of infiltrate is going
to be increasingly important to capture in the medical
record,” King says.
Also note these important coding guidelines regard-
ing pneumonia:
➤ When patients have hypoxemia with pneumonia, code
the hypoxemia separately. Unlike respiratory failure,
hypoxemia is not considered an inherent part of pneu-
monia. See Coding Clinic, Second Quarter 2006, p. 24.
➤ Coders cannot assume the causal organism of the
pneumonia based on sputum cultures. “Because spu-
tum cultures are often misleading or negative, the
physician must actually document a link between re-
sults on the culture and the pneumonia itself in order
for [coders] to link those,” says King. “This contin-
ues to be something coders struggle with.” See Coding
Clinic, Second Quarter 1998, pp. 3–4. n
Editor’s note: This article is based on content originally
presented during HCPro’s audio conference “Top ICD-9-CM
Trouble Spots: Master Clinical Background and Coding Guide-
lines for Accurate Coding.” For more information, visit
http://tinyurl.com/6dl5ad7.
Coding Clinic pneumonia references at a glance
Review the following Coding Clinic references for
pneumonia:
➤ Fourth Quarter 2010, p. 135
➤ First Quarter 2010, pp. 3, 12
➤ Third Quarter 2009, p. 16
➤ Fourth Quarter 2008, pp. 69, 140
➤ Second Quarter 2006, pp. 20, 24
➤ Second Quarter 2003, pp. 21–22
➤ Fourth Quarter 1999, p. 6
➤ Third Quarter 1998, p. 7
➤ Second Quarter 1998, pp. 3–5, 7
➤ First Quarter 1998, p. 8
➤ Third Quarter 1997, p. 9
➤ Fourth Quarter 1995, p. 52
➤ Third Quarter 1994, p. 10
➤ First Quarter 1994, pp. 17–18
➤ Third Quarter 1993, p. 9
➤ First Quarter 1993, p. 9
➤ First Quarter 1992, pp. 17–18
➤ First Quarter 1991, p. 13
➤ Third Quarter 1988, pp. 11, 13
Review the following Coding Clinic references for
aspiration pneumonia:
➤ First Quarter 2011, p. 16
➤ First Quarter 2008, p. 18
➤ Third Quarter 1991, pp. 16–17
➤ First Quarter 1989, p. 10
Page 12 Briefings on Coding Compliance Strategies November 2011
© 2011 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
Monitor diagnoses targeted for readmission reductionCMS is starting to crack down on readmissions, and
hospitals may soon feel the effects from a financial
perspective.
Beginning in FY 2013 (i.e., for discharges on or after
October 1, 2012), CMS will implement a program to
reduce hospital readmissions for certain hospitals with
excessive readmissions of patients with three conditions:
➤ Acute myocardial infarction (i.e., heart attack)
➤ Heart failure
➤ Pneumonia
CMS explained the program and its payment implica-
tions in greater detail in the FY 2012 IPPS final rule.
Diagnostic and other criteria
CMS based selection of the three conditions on analy-
sis of 235 diagnostic categories for hospitalization derived
from 2008 Medicare hospital claims data. Analysis re-
vealed that heart failure was the most frequent diagnos-
tic category for admissions and readmissions. Pneumonia
was second most frequent for admissions and readmis-
sions. Acute myocardial infarction ranked eighth and
ninth for readmission and admission, respectively.
In its final rule, CMS describes readmission as “oc-
curring when a patient is discharged from the applicable
hospital and then is admitted to the same or another
acute care hospital within a specified time period from
the time of discharge from the index hospitalization.”
The specified time period is 30 days.
The reductions are part of a larger Hospital Readmis-
sions Reduction Program required by the Affordable
Care Act. CMS will implement the program over two
years, addressing selection of readmission measures and
calculation of the excess readmission ratio during the
first year and using the ratio to calculate the actual read-
mission payment adjustment factor that it will apply to
each relevant base DRG during the second year.
The three applicable conditions apply only to patients
discharged with a principal diagnosis code denoting acute
myocardial infarction, heart failure, or pneumonia. Re-
admission measures don’t apply to patients who contract
infections from transplantation of infected organs.
“Recognizing that this data will start being collected
on October 1, 2011, the sooner the coding department
works with the quality department on this issue, the
better,” says James S. Kennedy, MD, CCS, managing
director at FTI Consulting in Atlanta.
Coders should understand the implications that cod-
ing and sequencing may have on readmissions data
and cohort selection. For example, if coders report
documented septicemia or acute respiratory failure as
the principal diagnosis when a patient is admitted for
pneumonia—and a readmission occurs within 30 days—
CMS will not count the second admission as a read-
mission, says Kennedy. Similarly, certain heart failure
patients won’t be included depending on how conditions
are sequenced. For example, a patient admitted with
heart failure also has symptoms and an acute troponin
rise indicative of acute myocardial infarction or clinical
circumstances supporting acute respiratory failure at the
time of admission. If acute myocardial infarction or acute
respiratory failure is sequenced as principal and the pa-
tient is readmitted within 30 days, CMS won’t consider
the second admission to be a heart failure readmission.
Visit http://tinyurl.com/b5zrph for more information.
The following measures can lower readmission rates:
➤ Ensure that patients are clinically ready for discharge
and understand their care plans
➤ Reduce the risk of infection
➤ Reconcile medications
➤ Improve communications with community providers
responsible for post-discharge patient care
➤ Improve care transitions n
Editor’s note: Access the final rule at www.gpo.gov/fdsys/
pkg/FR-2011-08-18/pdf/2011-19719.pdf. The discussion
regarding readmissions begins on p. 185.
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 Contributing Editor Lisa Eramo at [email protected].
November 2011
Coding Q&AA monthly service of Briefings on Coding Compliance Strategies
Editor’s note: Answers to the following questions are
based on limited information submitted to Briefings on
Coding Compliance Strategies. Review all documen-
tation specific to your scenario before determining appropri-
ate code assignment.
Some of our physicians are uncomfortable making
addenda to the discharge summary to include
pathological findings (e.g., malignancy). They think
an addendum to the discharge summary containing
information from a pathology report received after a
patient is discharged might be illegal. Instead, they
dictate tumor board notes that summarize the course
of treatment and final pathological diagnosis. Our
concern is that the tumor board note is usually dated
a few days after the patient is discharged.
When a condition meets reporting guidelines for
an inpatient admission, is the use of documenta-
tion dated after the inpatient admission for coding
purposes appropriate? Do specific laws or guidelines
prohibit coding from documentation dated after an
inpatient admission?
For example, a patient is discharged January 1
with a diagnosis of uterine mass. A pathology report
showing uterine cancer arrives January 3, and the
physician documents a tumor board note that states
“uterine cancer” January 5. May we assign a uterine
cancer code based on this tumor board note?
You may report an ICD-9-CM code for uterine cancer
if the tumor board note:
➤ Qualifies as a “cancer staging form” as described in
Coding Clinic, Second Quarter 2010, pp. 7–8
➤ Is part of the permanent medical record for
that encounter
➤ Is signed by the attending (not consulting) physician
for that admission
Refer to the aforementioned Coding Clinic and your
facility’s medical staff bylaws or HIM/coding policies
and procedures for further clarification. If the scenario
described in your question meets these requirements,
report ICD-9-CM code 625.8 for the uterine mass and
ICD-9-CM code 179 for the additional diagnosis of
uterine cancer.
A query is appropriate if the pathological report was
present on the chart before final coding without a cancer
staging form signed by the attending physician and there
is no documentation in the record of its findings by any
treating physician.
Consider the following query:
According to Coding Clinic, Third Quarter 2008,
pp. 11–12, and the ICD-9-CM Official Guidelines for
Coding and Reporting, we may not report and code
abnormal findings on the pathology report unless the
provider indicates their clinical significance. Now that the
pathology report is available, if appropriate, could you
please clarify the patient’s diagnoses in your documenta-
tion based on these findings?
Coders should include the findings or pathology
report for physician inspection with the query.
This may frustrate physicians because the final diag-
nosis established by the pathology report factors into the
reason for admission and follow-up care, but physicians
should be encouraged to reflect this diagnosis in their
A supplement to Briefings on Coding Compliance Strategies
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 © 2011 HCPro, Inc., Danvers, MA. Telephone: 781/639-1872; fax: 781/639-7857. CPT codes, de scriptions, and material only are Copyright © 2011 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.
medical decision-making. Coders face the same dilemma
with electrocardiograms and radiology reports, even
though competent physicians interpreted them.
Refer to Coding Clinic, Third Quarter 1992, p. 7, for
additional guidance.
James S. Kennedy, MD, CCS, managing director of FTI
Consulting in Atlanta and Association for Clinical Documen-
tation Improvement Specialists advisory board member,
and Sandra L. Sillman, RHIT, PAHM, a DRG coordina-
tor at Henry Ford Hospital & Health Network in Detroit,
answered the previous question, which first appeared on
JustCoding.com.
One of our podiatrists documents “surgical
debridement of devitalized tissue with scalpel” in
his inpatient progress notes. I explained that he must
clarify the technique, appearance and size of the
wound, and the depth of the debridement. He agreed
to document these details but resists documenting
the term “excisional.”
The podiatrist says he and his peers have omitted
this term for years and that it isn’t required. He con-
siders surgical debridement a more accurate term
because the procedure involved cutting and the
patient went to the OR.
I explained that ICD-9-CM categorizes debridement
as either excisional (ICD-9-CM procedure code 86.22)
or non-excisional (ICD-9-CM procedure code 86.28).
I explained that the procedure would default to the
lesser-weighted DRG without documentation of the
term excisional.
What should I do? I have shared relevant Coding
Clinic issues to no avail. I couldn’t find any medical or
podiatry literature that addresses documentation of
surgical/sharp and excisional debridement.
The terminology used in ICD-9-CM procedures
does not always align with clinical or surgical terms.
Explain the difference between ICD-9 codes for hospital
inpatients and the CPT® code description and language.
The hospital and clinician use the same procedure codes
and descriptions for outpatient services. However, codes
and descriptions differ on the inpatient side.
Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional
managing director of HIM, NCAL revenue cycle, Kaiser
Foundation Health Plan, Inc. & Hospitals in Oakland, CA,
answered the previous question. n
BCCS, P.O. Box 3049, Peabody, MA 01961-3049 • Telephone 781/639-1872 • Fax 781/639-7857
Contact Contributing Editor Lisa Eramo
Telephone 401/780-6789
E-mail [email protected]
Questions? Comments? Ideas?
CMS issues Medicaid RAC final rule
State Medicaid agencies must implement a RAC
program by January 1, 2012, according to a final rule
CMS released September 14.
The rule includes information about payment meth-
odology determinations, the timing of payments, the
structure of payments, and more. Access the rule at
www.ofr.gov/OFRUpload/OFRData/2011-23695_PI.pdf.
Learn more about preparing for Medicaid RACs by
reviewing the tips and strategies in the July Briefings
on Coding Compliance Strategies (pp. 1–3).