Coding Emaciation in Adult Patients

A physician documents emaciation for a 72-year-old female patient.  Using the ICD-10-CM index, you are led to code E41, should you assign it?  The short answer is no, and this installment of “In the kNOW” will explore the rationale for that answer. 

E41 is the code for nutritional marasmus or severe malnutrition with marasmus.  Further information provided under the code tells us that marasmus is a type of protein-calorie malnutrition in children.  Since our patient is 72-years-old, this code would not apply.  So what now?  How should we code emaciation in adult patients?

3^rd Qtr. 2017 Coding Clinic (pages 24-26) states that if the physician documents emaciation, the proper code to be assigned is R64 for cachexia or wasting.  The rationale provided for this code assignment is that emaciation means extremely thin due to wasting.  The provider should clearly document malnutrition if that is what he or she meant, but again, E41 would not be appropriate for an adult.  Rather, codes E43-E46, as appropriate, would be assigned for malnutrition status.  Remember that E40 (Kwashiokor) and E42 (Marasmic kwashiorkor) are forms of severe malnutrition usually found in underdeveloped countries and likely not applicable for our coding in the U.S.  The Index will guide coders to E43 for severe malnutrition, by finding Malnutrition, degree, severe.

The same Coding Clinic reminds coders that as a basic coding rule, if the title of the code that is suggested by the Index is not seeming to identify the condition correctly, more research will be required in order to assign the appropriate code.  This may necessitate research into the condition, use of coding resources such as Coding Clinic, or querying the physician. 

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.

Leading in HIM Education

by Nichole Russ, BS, RHIT 

Educators are some of the most vital leaders in the Health Information Management (HIM) field. They are one of the first leaders to introduce the field to students in detail. Instructors shape the picture of what HIM is and what it can be for each student. Jill Caton, RHIA, who is the Program Coordinator and an Assistant Professor for the Health Information Technology, Healthcare Administration, & Medical Coding Certificate programs at Terra State Community College is one leader in our field who has some great insight on ways to become a leader and how to improve your leadership skills.

As a previous physician educator, concentrating on documentation needs for coding purposes, Jill truly enjoyed the opportunity to educate. When an opportunity opened at Terra State Community College she took advantage of this and became a full-time faculty member. Since moving into this role in 2013 she has continued to enjoy the opportunity to educate and lead students in the HIM field. As an educator, Jill has had the opportunity to work with many students and other staff members who demonstrate leadership skills. According to Jill, these individuals stand out because, “They take initiative to work on projects or tasks and ask questions as needed. They accept leadership roles or volunteer for different events. I like to be a mentor as well in order to help them develop these skills.”

Sometimes the intuition of being a leader comes from your very own experiences and internal desires. Other times the drive to become a leader may come from a mentor or an influential person in your life who has become an inspiration. As a mentor, both personal experiences and influences from others are important. Becoming a leader can take time. Jill believes that you must look for leadership opportunities in all aspects of your life. Different chances to obtain new leadership experience may come in your personal life, your professional life, and even your social life. Jill, who is also a mother, is always trying to be a good leader for her children while trying to show them how to be leaders. She believes that her leadership skills have come from all aspects of her life.

If you have the desire to become a leader in your field, Jill encourages you to, “take initiative, solve problems, and help improve processes.” Making contributions to an organization in these ways, will make you invaluable. As a leader, showing recognition for these contributions is very important for shaping future leaders. Jill mentions that “It is extremely important to listen to or empower your employees as they are the backbone to any organization.” As an employee, do not be afraid to speak up and share your ideas with your leaders. By doing this, you are sharing your potential leadership qualities while making them stronger.

There are many mentors, or leaders, in our field that have similar views as Jill Caton. Effective leaders not only know how to lead but they also know how to listen. Leaders are found in many different positions in the HIM field and have obtained their experience from all aspects of life. These educational mentors have a very strong impact on the future of HIM as they have the power to ignite the passion and desire to succeed in this field within their students.

About the Author 

Nichole Russ, BS, RHIT is a health information management professional who specializes in the inpatient coding area. She enjoys volunteering for both the Northwest Ohio Health Information Management Association (NWOHIMA) and the Ohio Health Information Management Association (OHIMA). Currently, she holds the Past President position for NWOHIMA and is a Project Leader in Leadership for OHIMA.

Q&A: Clinical Validation of Sepsis

by Cathy Farraher, RN, BSN, MBA, CCM, CCDS & Cheryl Ericson, MS, RN, CCDS, CDIP

Following the release of the “Clinical validation and the role of the CDI professional” white paper, we received the following question from an ACDIS member.

“I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR) was less than 100 and the WBC was elevated but still less than 12. Should this be clarified with a clinical validation query?”

In the ACDIS white paper, “Coding Clinic for CDI: Addressing and clarifying 2017 Guideline recommendations,” Sharme Brodie, RN, CCDS, CDI Boot Camp instructor based in Middleton, Massachusetts states that,

“Coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) […] Coding Clinic points readers to the 2017 Official Guidelines for Coding and Reporting when assigning codes for sepsis, severe sepsis, and septic shock, and states that coders must use the most current version of the ICD-10-CM classification along with the Guidelines, and not clinical criteria. Physicians can use whatever criteria they wish to diagnose the patient, but remember, those criteria do not change how the condition will be coded.”

Regardless of whether the practitioner chooses to use Systemic Inflammatory Response Syndrome (SIRS) criteria, sequential organ failure assessment (SOFA) criteria, or some other set of criteria, if the condition is documented and appears to be supported in the record, it can and should be coded without a query.

In the above question, with the limited information we have available to review, perhaps the WBC was trending up quickly, or was already being treated with antibiotics and was trending down. The HR was less than 100, but still met the SIRS guideline of greater than 90. Perhaps the patient also had mental status changes and that had already been documented elsewhere. Without the luxury of a complete review of the record, it is difficult to make a definitive case either for, or against, sending a validation query.

Best practice is for organizations to create a consensus statement defining sepsis. Such a statement would help coders know when to forward the case to CDI for clinical validation as well as help the CDI specialist determine whether the organizational criteria for a diagnosis of sepsis is met.

The consensus statement should not only define sepsis and severe sepsis, but also provide guidance regarding documentation of “early” sepsis or “meets sepsis criteria.” Specifically, it is not always clear if this type of documentation is making a diagnosis or merely an observation. It is also important to remember that both CDI and coding should not only look for clinical indicators supporting the diagnosis of sepsis, but also consider what treatment was rendered.

Not only should sepsis meet criteria as a reportable diagnosis, but it would also be helpful for CDI specialists to understand the Hospital Inpatient Quality Measure requirements of the early management bundle for severe sepsis/septic shock, as such these measures are driving many hospital’s efforts to quickly identify and treat severe sepsis cases. Verifying these criteria are met with the diagnosis of severe sepsis can help the CDI specialist determine if the diagnosis requires additional clinical validation or not.

Editor’s note: Cathy Farraher, RN, BSN, MBA, CCM, CCDS, a CDI specialist at Newton-Wellesley Hospital in Newton, Massachusetts, and Cheryl Ericson, MS, RN, CCDS, CDIP, is manager of clinical documentation services at DHG Healthcare in the Charleston, South Carolina area. Both Ericson and Farraher are members of the CDI Practice Guidelines Committee, and serve as committee chair and chair-elect, respectively. If you have a question for the committee, email ACDIS Editor Linnea Archibald (larchibald@acdis.org). 

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

The Coder as the Last, Best Hope for the Right DRG

by Erica Remer, MD, FACEP, CCDS

If the story doesn’t make sense, there is probably something missing. There are a variety of reasons why the DRG might not tell the story of the patient encounter. Some of these include:

• Suboptimal medical care
• Confusing story because the provider wasn’t clear on what was going on
• No clear answer because the signs/symptoms resolved without a satisfying ultimate diagnosis
• Whack-a-mole medicine – the provider chases each abnormal test result and symptom without stepping back to see the big picture
• Clinician practicing bad medicine, often disregarding medical necessity

• Suboptimal documentation
• Provider practice of describing, instead of ascribing
• Providers being taught CDI “buzz words,” without understanding the goal is to accurately depict the encounter including conditions which make the course more complex or complicated
• Coding-clinical disconnects

• Missed CDI opportunities (CDIS is used for whoever is performing the CDI role)
• CDIS with limited repertoire of commonly missed CCs and MCCs without picking up on uncommon conditions which increase severity and complexity
• Auditor aversion where CDIS declines to query because she/he has been burned by denials
• Provider aversion where CDIS declines to query because she/he is intimidated by the provider, and has low expectations of getting the correct response
• Unrealistic productivity goals
• Over-reliance on Computer-Assisted CDI

• Suboptimal coding
• ICD-10-CM has A LOT of codes. Every day I find a new code that I never saw before! Can’t code it if you don’t know it exists and are not looking for it in the encoder or book.
• Only coding from limited parts of the record, like, “It has to be in the discharge summary” or just looking at the assessment or impression without reading the narrative
• Not reading the story to understand the big picture, especially if utilizing Computer-Assisted Coding
• Unrealistic productivity goals 

I just finished putting together the slide deck for my talk, CDI: The Coder as the Last, Best Hope for the Right DRG and I can’t wait for March 21st! I have some fascinating cases to go over with you, and some conditions which you might not always see. I can’t fix ALL of the reasons why the DRG goes awry, but let’s explore some together. Join me at the OHIMA 2018 Annual Meeting & Trade Show in Columbus in March.  Hope to see you there!

Dr. Erica Remer is scheduled to speak at the OHIMA 2018 Annual Meeting's Coding Day on Wednesday, March 21st at 12:45 PM.  If you are interested in hearing her presentation as well as many other fantastic speakers, register for the OHIMA Annual Meeting today!