Tuesday, November 28, 2017

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. 

Monday, November 20, 2017

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!

Tuesday, November 14, 2017

Student Leadership

Most people simply accept their lives- they don’t lead them.  ~ John C. Maxwell

As an instructor, I have witnessed students who I can immediately identify as a leader and those who prefer to be led.  I often ask myself if those who prefer to be led have that thought because they don’t feel they have the skills to be a leader.  Maybe they feel as a student they are still learning and will lead “one day” on the job.  The truth is leadership skills can be demonstrated at any level, from student to CEO. 

Lora Spencer, an adjunct instructor at Scott Community College, discussed with me leadership in the classroom.  In a classroom, it can be difficult to teach leadership skills, but there are ways, as a student, you can demonstrate leadership skills.  “Leadership isn’t always about being the best student in the class, it’s about working as a whole towards a common goal and being a good colleague to your peers,” says Lora.   

So how can you be a student leader?  What can you demonstrate as a student that will ultimately help make you a better leader in the workplace? 

  • Ask questions.  It sounds too simple, right?  How do you develop leadership skills without asking those who can help provide you guidance?  You will feel more comfortable about stepping up as a leader when you are armed with knowledge. 

  • When given the opportunity, volunteer to share your knowledge or research with your classmates or outside audience.  Do you have an opportunity to present a poster at your school or state association?  Go for it! 

  • Volunteer for your local, state or national professional organizations.  This will give you an opportunity to not only learn leadership skills, but also see them demonstrated on a regular basis.  It will build your confidence to continue to volunteer or take leadership roles within the organization.  Employers like to see this on your resume!

  • When you are given a group project, step up and lead the group!  Don’t sit back and wait for others to figure it out, do your part.  The skills developed in the classroom ultimately translate into the work environment. 

  • Seek a mentor.  How can you get where you want to go?  Look at the path someone has taken and emulate it.  Lora (Spencer) knew that when she graduated from her community college she one day wanted to come back and mentor future HIM professionals.  She made her goals clear to her instructors while she was in the program and kept in touch after graduation.  When a position opened up, she applied, and was hired as an adjunct at the very school in which she graduated.

  • Work on your soft skills.  Think about how you communicate with your instructor and your classmates.  Employers need, and want, those who can communicate effectively.  Other soft skills you should demonstrate in the classroom include, time management, problem-solving, and the fine art of collaboration.

  • If you are a strong leader in your classroom, use those to influence your classmates.  Perhaps that means encouraging and supporting them to lead a group project. 

Being a student does not mean you can wait to show your leadership skills later, show them now!  Build the skills needed to get the job you desire.  Leadership is demonstrated at all levels.  You do not need to be a CEO, CFO, HIM Director or Manager to be a leader. 
Be on the lookout for more leadership blogs in the coming months.  

About the Author 

Megan Patton, MEd, RHIA has over 16 years in the Health Information Management field.  She has been in education for the last 7 years and is currently an Assistant Professor at the University of Cincinnati’s Online HIM program.  Megan currently serves as a Executive Board Director on the OHIMA Board of Directors.