ICD-10-CM Guideline I.A.15 “With”

Are you still struggling to apply the ICD-10-CM guideline I.A.15 “With”?  If so, you won’t be the only one.  You will recall this guideline was clarified in recent years to indicate that the word “with” presumes a causal relationship to exist between the terms linked by that word in the index unless the physician indicates there is no relationship or another guideline exists that states the conditions must be linked with specific documentation.  In this edition of “In the kNOW”, we will look at how this guideline should be applied to G.I. bleeds by exploring the following scenarios.

A patient presents to the ER with G.I. bleeding and is taken to the endoscopy suite for an EGD.  The final diagnosis documented from the procedure is that of an esophageal ulcer.  How should this be coded?

If your first thought is K22.10 (ulcer, esophagus) and K92.2 (bleeding, gastrointestinal), let’s review.  Applying the guideline I.A.15 “With”, we can use a combination code found under ulcer, esophagus, with bleed, K22.11.  Because the index entry under Ulcer, esophagus, is “with bleeding”, the classification is permitting the assumption of a causal relationship between these two conditions.  It is not necessary for the physician to indicate a relationship in his/her documentation.    

Now, let’s apply the guideline to this example.  Patient with hematochezia undergoes a colonoscopy with final documentation indicating diffuse diverticular disease of the large intestine.  Again, using the index, we identify diverticulosis, large intestine, with bleeding leading to combination code K57.31. 

Similar index entries can be found for gastric ulcers, angiodysplasia, gastritis, and diverticulitis with bleeding.  Again, the classification is making a coder’s job easier by permitting the assumption of the causal relationship.  It is not necessary to query the physician, as we have classification guidance on the assignment of the combination code. 

3rd Qtr. 2017 Coding Clinic (page 27) provides clarification on this topic as well.  It does warn coders to watch for any documentation that would indicate the conditions are not related though.  In those circumstances, if we revisit our first example and the physician indicated the bleeding was not from the ulcer, we would definitely assign K22.10 and K92.2.

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.

Documentation that Serves a Purpose

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

In drafting a physician open door forum presentation on the role of complete and accurate clinical documentation as an effective strategy for preparation in value based performance measurement and the Merit Based Incentive Payment System, I came across a PowerPoint slide I have referred to in the past. Dr. William Osler, a highly accomplished physician in his time, the Father of Modern Medicine, the creator of the of residency programs as they exist today as one of the founding fathers of John Hopkins Medical School, has coined many practical provocative sayings. The following really hits home as a CDI professional who continually advocates for a unique vision of CDI that incorporates methodologies and processes to affect positive sustainable change in physician practice patterns of documentation standing for communication of patient care versus primary focus upon reimbursement associated activities and physician education.

• The physician treats the disease; the great physician describes, shows, tells and treats the patient who has the disease. Sir William Osler (1849-1919)

The CDI profession can truly collaborate and partner with physicians in preparation for MIPS and other value based healthcare delivery models by acquiring the core knowledge and skill sets representing evidence based concepts of documentation improvement. We certainly can assist physicians in their quest to describe, show and tell the patient who has a disease, complemented by our proven ability to promote and achieve documentation of clinical specificity including increasingly important elements of clinical validation.

So, what is the makeup for the physician to show, describe and tell the clinical facts, information and clinical context associated with hospital level of care? The following fundamental components of documentation are essential in the scheme of patient care:

H & P

H & Ps should adhere to the following outlines

• Chief Complaint setting the stage for nature of presenting problem
• History of Present Illness with an emphasis upon “present” vs. “past”
• Clinically relevant Past Family Social History and Review of Systems
• Physical exam congruent with the nature of the presenting problem and clinical judgment of the physician
• Medical decision-making correlating with the clinical information, facts of the case and accurate reflection of assimilation of information as documented in the record including results of diagnostic workup treatment in the Emergency Department as well as the available test results and clinicals of the patient
• Clinical impression accurately reflecting and reporting provisional and definitive diagnoses that can be traced back to the physician work performed and clinical picture as described, told and shown in the HPI
• Plan of care congruent with the assessment, matching up each order to the diagnosis(es) and/or symptoms

Progress Notes

• Progress notes should meet the following characteristics
• Factually correct
• Temporally relevant (no future tense references to procedures already done)
• Concise (no fluff; just a concise statement of the facts)
• Devoid of plagiarism
• Analytic- (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
• Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)

Discharge Summaries
Discharge Summaries should meet the following component parameter as required by the Joint Commission:

• Reason for hospitalization.
• Significant findings.
• Procedures and treatment provided.
• Patient’s discharge condition.
• Patient and family instructions (as appropriate).
• Attending physician’s signature.

Other recognized guidelines for discharge summaries as advocated by the Society of Hospital Medicine include the following:

• Reason for hospitalization including presenting problems that precipitated hospitalization
• Concise summary of diagnoses, primary and secondary, including any complications or co-morbidity factors
• Key findings and test results
• Hospital course, including significant findings
• Procedures performed, and treatment rendered
• Conditions at discharge including functional status and condition status as well as limitations
• Discharge destination and rationale if not obvious
• Patients/Family instructions for continued care and/or follow-up

Closing Remarks

I encourage and challenge all CDI specialists to begin the journey in transitioning away from repetitive chart reviews in search of diagnoses and clinical validation only to bringing into the fold the quality and completeness of clinical documentation as outlined above. We must recognize the need and capitalize upon the opportunity to work collaboratively with our physician constituents to clearly, concisely, consistently and explicitly describe, show and tell the patient story in a manner that best communicates the quality focused cost effective patient centric efficiently guided patient care provided and achieved.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com. 

Compliance: What is it and Why is it Important

Compliance.  It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important? 

Dictionary.com defines compliance as

1. the act of conforming, acquiescing, or yielding.
2. a tendency to yield readily to others, especially in a weak and subservient way.
3. conformity; accordance: in compliance with orders.
4. cooperation or obedience: Compliance with the law is expected of all.

Quite simply put, it is following the rules.  In healthcare, patients are expected to be “in compliance with orders” from their physicians and “compliance with the law is expected of all” healthcare workers and healthcare facilities.  There are rules and regulations from insurance companies, government agencies, and regulatory agencies that must be followed.  There are numerous regulatory bodies that a healthcare organizations and workers must be compliant with: OSHA, FDA, CDC, ODH, TJC, HFAP, CMS, and the list goes on and on.  CMS and TJC are regulatory bodies that HIM professionals deal with extensively.

Why is it important that the rules are followed?  Reimbursement is a major reason to remain compliant but staying out of jail and keeping one’s job is pretty important too.  All too often there is someone or some facility in the headlines for not following the rules.

Just last month the OIG published a report that says $4.4 billion returned plus billions more are anticipated in estimated saving.  The report goes on to say for a 6 month time period in FY2017, around $296.4 million would be returned to the department of Health and Human Services based on OIG program audits.  There is not just a monetary impact.  According to the OIG report 3,244 individuals and entities have been excluded from Federal health care programs.  Excluded individuals are not just physicians or clinical professionals, but coders, office administrators/managers, and office staff are included.

It is reported in July 2017 the OIG and its law enforcement partners executed the largest health care fraud takedown in history.  The takedown covered 41 Federal districts, more than 400 defendants, and about $1.3 billion in false billings to Medicare and Medicaid.

With findings like these, we can only expect to see more investigations, more audits.  To find out what’s new with the OIG visit https://oig.hhs.gov/newsroom/whats-new/index.asp

As HIM professionals our roles in compliance will only grow.  As an individual it is more important than ever that you are diligent in everything you do. Now might be a good time to refresh yourself on your organization’s compliance policy and reporting method.  And if you are looking at making a transition to a new role, consider a role in compliance.

About the Author

Joan S. Hartman, RHIT is a Sr. Analyst of Ethics and Compliance at Ohio Health.  She also serves on the 2017-18 OHIMA Newsletter Committee.

Q&A: Coding Mixed Cardiogenic and Septic Shock

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below.

But, there is more to consider. AHA Coding Clinic-for ICD-10-CM/PCS, Fourth Quarter, 2015.

“There are circumstances that have been identified where some conditions included in Excludes 1 notes should be coded, and thus might be more appropriate for an Excludes 2 note.

The new guidelines concerning Excludes 1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes 1 note.”

So, does the situation you describe allow for us to code both types of shock? To adequately answer this, we would need to delve into the record a bit deeper. To override the Excludes 1 note, the documentation would need to explicitly state there was both an infectious cause of hypoperfusion at the chemical/cellular level AND a mechanical pump failure causing reduced hemodynamic performance (but it doesn’t have to be in those exact words as long as the evidence is within the record and the doctor provided both diagnoses). You do have the statement from the provider that the shock was of multiple etiologies and this is supportive of reporting both codes. I would like to see treatment protocols that support the treatment of both etiologies documented in the record as well.

This would be a great discussion for you to investigate with your coding team to ensure you are providing them the appropriate documentation to capture the severity of the patient’s conditions.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com.

About the Author

 

Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission. 

Evacuation of Subdural Hematomas (SDH)

This installment of “In the kNOW” will address procedures for evacuation of subdural hematomas.  A subdural hematoma (SDH) is a collection of blood on the brain.  Causes of SDHs include trauma, iatrogenic, or spontaneous with most cases of SDH being trauma related.  Subdural hematomas may be characterized as chronic, subacute, or acute.  Regardless of the type of SDH, it may be necessary to evacuate the hematoma to alleviate pressure on the brain.  These procedures will often be accomplished with the use of burr holes and/or craniotomy.  These techniques may have coders questioning the appropriate approach (open vs. percutaneous) or root operation (extirpation vs. drainage vs. control).  So let’s look at a few examples for clarification.

After a fall from a 12 ft. ladder, a patient developed a right subdural hematoma.  The patient was brought to the OR, given general anesthesia, and then after a timeout, his right hemicranium was shaved and prepped, and antibiotics were administered.  Frontal and parietal burr holes were marked as well as marking for a craniotomy if necessary.  Then both frontal and parietal incisions were made and the areas retracted.  Pilot holes were initiated with bone wax applied.  There was coagulation at the dura.  Cruciate incision was made.  A large amount of blood flowed through both burr holes.  More blood was evacuated through an opening in the posterior membrane.  Placement of a drain was not necessary as I could see the brain elevate to the surface of the skull.  Likewise, there was no need for a craniotomy, since decompression was achieved.  Closure was then begun with Gelfoam in the burr holes, cranial plates secured over the burr holes, and the wounds closed in layers.  A sterile dressing was applied after Neosporin swabbed.  The patient was in satisfactory, stable condition upon discharge to PACU.

In the above procedure, the root operation will be Drainage which by definition is the taking or letting out of fluids and/or gases from a body part.  Drainage applies here because blood was evacuated rather than a clot.  Also, the 3rd Qtr. 2015 Coding Clinic has stated that Control would not be the appropriate root operation since this was a traumatic event that caused the bleed.  Using the index, we see that Drainage, subdural space, intracranial leads to table 0094.  Next we must determine the approach for the procedure.  In this case, only burr holes were made.  No craniotomy was performed, so the approach will be percutaneous.  Our final ICD-10-PCS code will be 00943ZZ since there was no drainage device.

If we change the scenario above and say the SDH was an organized hematoma (clot) that was removed after burr holes were drilled and craniotomy performed to connect the two holes allowing further irrigation and removal, then we have changed our root operation to Extirpation (taking or cutting out solid matter from a body part) and our approach to open (craniotomy).  The ICD-10-PCS code will now be 00C40ZZ.

Once you are able to determine the root operation, you can review the operative report for the information that will lead to the appropriate approach.  If you still have questions, the 3rd Qtr. 2015 Coding Clinic, pages 10-13, has other scenarios and rationale related to SDH evacuation procedures which would be helpful to review.   

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.