Healthcare – Technology – HIM

So, on my lunch breaks, I pull up You Tube videos on topics such as the future of healthcare and healthcare technology. (Feel free to insert nerd face emoji here – I take no offense.)  I find it both fascinating and encouraging that we WILL be in control of our own health and wellness.  It’s just a matter of time.

How is this possible you ask?  Through technology such as wearables, smart devices, and geo-typing,

Wearables which are currently in the form of wrist bands collecting our heart rate, calories burned and steps taken that day will advance towards smart clothing and adhesive bandages. The more data that can be obtained the better predictions can be made and preventative actions taken.  This data will be obtained through monitoring our excretions (yes, I am going there) – by analyzing data gathered from our number 1’s, number 2’s, sweat, and saliva, physicians will be able to see what we’ve been up to the other 99% of the time we are not in front of them.  This data will then be synced to our EHR. Epic (of course!) and Apple (of course!) have already partnered up to develop a tool for just this topic.

Some of this future awesomeness is already here with devices such as smart infusion machines monitoring the rate fluids are being delivered, programmable insulin and pain pumps, and robotic pharmacy dispensaries. The future tech on the horizon is bandages with sensors monitoring the moisture of the wound thereby alerting the healthcare professional it’s time for a change. Breath sensors that can detect illness, even certain types of cancer, before it occurs.  Hand-held breast exam devices will allow women all over the world access to early breast cancer detection.  There are devices that are being developed to track the rate of impact on the head in sports to assist with early detection of concussions.

Geo-typing or geonomics are being used to analyze why each of us respond differently to diet plans and fitness routines; thereby, in a sense, allowing a prescription of exactly what we need to eat and do to achieve optimal health.  As the saying goes – your genes load the gun and your lifestyle pulls the trigger.

So let’s stop here a moment and consider what we’ve just read.  With all of this data being collected when we are healthy; a personalized baseline can be achieved. Then when things go awry we can proactively take action to correct the situation.  Thereby, making it less likely for us to grace the doors of a healthcare facility.  This will save time and money – a win, win for everyone! I like knowing I’ll be the one driving the bus when it comes to my health and wellness.

So here’s where the plug for HIMer’s comes in because among all this amazingness are HIMer’s!  This is BIG DATA!  We have a seat at the table through data analytics and informatics, we just have to pull the chair out and sit down.

I can honestly say at this point in my career, I have seen our profession move up from the basement dungeons of hospitals with no sunlight to the beauty of the home office.  The future is so exciting and we’ve come a long way, baby!!

 

About the Author

Dee Mandley, RHIT, CDIP, CCS, CCS-P is the president and owner of D.Mandley and Associates, LLC.  She currently serves as as the OHIMA 2017-18 Board President.   

Hysterectomy Coding in ICD-10-PCS

Hysterectomy coding in ICD-10-PCS will be the focus of this “In the kNOW” segment.  When ICD-10-PCS codes were first adopted, we were trained that to code a total hysterectomy appropriately would require two codes: one for the resection of the uterus, and one for the resection of the cervix.  This followed the PCS guideline B3.2a which tells us that when the same root operation is performed on different body parts that have their own body part character we would code multiple procedures, thereby capturing each body part. 

Index:
Hysterectomy
    Total
       See Resection, Cervix 0UTC
       See Resection, Uterus 0UT9

So a laparoscopic total hysterectomy would have been coded as:

0 Medical and Surgical
U Female Reproductive
T Resection
9 Uterus
4 Percutaneous Endoscopic
Z No Device
Z No Qualifier

0 Medical and Surgical
U Female Reproductive
T Resection
C Cervix
4 Percutaneous Endoscopic
Z No Device
Z No Qualifier


Now fast-forward to the 2018 PCS updates and we see that there has been a change to this advice.  A new qualifier was added to the female reproductive table for resection.  This is the character “L” for supracervical.  This allows us to capture those hysterectomies when the physician has left the patient’s cervix in place, and only removes the uterus.  For example, if we were to code a laparoscopic supracervical hysterectomy our code assignment would be 0UT94ZL.

Index:
Hysterectomy
       Supracervical, see Resection, Uterus 0UT9
       Total, see Resection, Uterus 0UT9

0 Medical and Surgical
U Female Reproductive
T Resection
9 Uterus
4 Percutaneous Endoscopic
Z No Device
L Supracervical

If the procedure was a total hysterectomy performed laparoscopically, then the code would be 0UT94ZZ only.

0 Medical and Surgical
U Female Reproductive
T Resection
9 Uterus
4 Percutaneous Endoscopic
Z No Device
Z No Qualifier

Notice the Index change listing Total hysterectomy and only indicating Resection, Uterus as opposed to the previous index entry which referenced both uterus and cervix.  This change was addressed in the 4th Quarter 2017 Coding Clinic as well.

So, when coding total hysterectomy procedures for 2018 discharges, be sure to use only one ICD-10-PCS code.

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Important CDI and Coding Updates

by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

COPD and Pneumonia The requirement for code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) to be coded first when a patient has pneumonia and COPD has been eliminated as of October 1.

The 2018 version of ICD-10-CM replaced the “use additional code” with “code also.” According to OCG Section I.A.17, the Code Also note “does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

We are now back to where the selection of principal diagnosis between COPD and Pneumonia will be “determined by the circumstances of admission, diagnostic workup and/or therapy provided” pursuant to OCG Section II (Selection of Principal Diagnosis).

Type 2 MI
With the 2018 ICD-10-CM, we finally have codes to identify Type 2 MI (primarily due to supply/demand mismatch) and make the important distinction between it and Type 1 (primarily due to coronary artery disease). In the past, Type 2 was coded as NSTEMI creating many practical problems especially since these two types of MI have completely different causes, pathophysiology, implications, outcomes and management.

Furthermore, this situation improperly labeled patients with supply/demand mismatch (Type 2) as having acute coronary thrombosis primarily due to coronary artery disease causing significant inaccuracy with consequences for patients, clinicians, and the healthcare data base statistics and analysis.

Type 2 MI (whether new initial or subsequent) is assigned to one code (I21.A1). The code also includes any description of MI being due to “demand ischemia” or “ischemic imbalance”. As an MCC, the diagnosis of Type 2 MI has major severity impact affecting DRG assignment and quality reporting, just like Type 1 MI.

Now that a specific code exists for Type 2 MI, a supply/demand infarction should not be documented as NSTEMI since that term is reserved for MI due to coronary artery disease requiring aggressive intervention directed at thrombosis and occlusion of a coronary artery. Type 2 is managed by treating the underlying cause.

A diagnosis of “demand ischemia” has always been problematic. It is still assigned to code I24.8, Other forms of acute ischemic heart disease (a CC). Demand ischemia is supposed to be reserved for supply/demand mismatch causing ischemia without necrosis where biomarkers remain below the 99th percentile of the upper limit of reference range, but is often used by clinicians to describe what technically Type 2 MI is with biomarkers above the 99th percentile. A clinically correct distinction between demand ischemia and Type 2 MI is an important diagnostic and coding concern.

Encephalopathy due to Stroke
Coding Clinic Second Quarter 2017 responded to a question regarding whether or encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct.

Coding Clinic instructions were to “Assign code G93.49, other encephalopathy, for encephalopathy that occurs secondary to an acute cerebrovascular accident/stroke. Although the encephalopathy is associated with an acute lacunar infarct, it is not inherent, and therefore is coded when it occurs.

There are two distinct categories of encephalopathy: acute and chronic. Many sources confuse and confound these categories, lumping them together as one. However, the chronic encephalopathies are characterized by a chronic mental status alteration that, in most cases, is slowly progressive. They result from permanent, usually irreversible, diffuse structural changes in the brain.

The vast majority of encephalopathy cases encountered in the inpatient setting are acute. Acute encephalopathy is characterized by an acute, diffuse, functional alteration of mental status due to underlying systemic factors rather than local intracranial processes. It is reversible when these abnormalities are corrected, with a return to baseline mental status. Acute encephalopathy may be further identified as toxic, metabolic, or toxic-metabolic depending on its systemic cause.

Ordinarily, from a clinical standpoint, a mental status change associated with focal intracranial processes (like CVA) is more an alteration of consciousness and responsiveness in the spectrum of coma, obtundation, and lethargy – objectively measured using the Glasgow Coma Scale (GCS) scoring – and not an encephalopathic process.

The unsettled question remains whether “encephalopathy due to CVA” is a clinically valid diagnosis that can be compliantly coded on claims, since Coding Clinic disclaims any authority to assert or establish clinical diagnostic definitions or standards. Based on the definitions and descriptions above of what encephalopathy is and is not, the diagnosis of encephalopathy due to CVA could be challenged. On the other hand, obtaining a GCS may reveal one of the component scores severe enough to qualify as an MCC.

Functional Quadriplegia
Although the FY 2018 Official Coding Guidelines no longer include a paragraph describing functional quadriplegia, it is still a valid diagnosis and ICD-10-CM code:

R53.2 Functional quadriplegia (MCC)
Complete immobility due to severe physical disability or frailty.
Excludes 1:      Frailty (R54)
                           Hysterical paralysis (F44.4)
                           Immobility syndrome (M62.3)
                           Neurologic quadriplegia (G82.5-)
                           Quadriplegia (G82.50)

Editor’s note: This article originally appeared on Pinson and Tang’s website, www.pinsonandtang.com/resources. Pinson and Tang are the authors of the 2018 CDI Pocket Guide and the new Outpatient CDI Pocket Guide: Focusing on HCCs.

This article originally appeared in the ACDIS CDI Journal on November 1, 2017 and has been reprinted with permission. 

Passionate about CDI with Glenn Krauss

Did you enjoy Glenn Krauss's CDI presentation at the OHIMA Fall Coding Seminar on November 3rd?  If so, check out his guest appearance on the "Not Elsewhere Classified" podcast!