Release of Information

 

 

 

 

For more detailed information on Release of Information, click HERE for full presentation slides.

 

 

 

 

When is it appropriate to use other clinicians' documentation to record a diagnosis?

A 2019 Official Coding Guideline update addressed using other providers’ documentation for assignment of specific diagnosis codes.  This installment of “In the kNOW” explores when it is appropriate to use the documentation of clinicians in a patient’s record to record a diagnosis.

Previously, the Official Coding Guidelines outlined several “qualifiers” of conditions where it was acceptable for coding professionals to use documentation by a clinician to capture the code.  These “qualifiers” include:

• BMI
• NIHSS
• Coma scale
• Depth of non-pressure chronic ulcers
• Stage of pressure ulcers

The same guideline (I.B.14) shared that the patient’s provider, who is considered their physician, or other healthcare practitioner legally accountable for establishing the patient’s diagnosis, must be the one who documents the associated diagnosis, such as obesity, stroke, or pressure ulcer.  Since the “qualifiers” listed above provide more detail regarding the diagnosis established by the provider, it is acceptable to utilize the documentation of a clinician such as a dietitian for the BMI, a nurse for pressure ulcer stage, or even an emergency medical technician for the coma scale.

With the 2019 Official Coding Guideline update, we see that the previous title of this applicable guideline changes from “Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale” to “Documentation by Clinicians Other than the Patient's Provider”.  While all the above information remains under this guideline, a new section has been added which addresses code assignment for social determinants of health. 

Codes for social determinants of health are found in categories Z55-Z65.  This section is entitled “Persons with potential health hazards related to socioeconomic and psychosocial circumstances”.  Within this section, coding professionals find codes that identify the following:

• Problems related to education/literacy
• Z55.3 Underachievement in school
• Problems related to employment/unemployment
• Z56.2 Threat of job loss
• Problems related to housing and economic circumstances
• Z59.0 Homelessness
• Problems related to upbringing
• Z62.1 Parental overprotection
• Problems related to other psychosocial circumstances
• Z65.2 Problems related to release from prison

These are just a few of the areas and codes represented in this section. 

The rationale for being able to use the clinician documentation to assign these codes is that they are not medical diagnoses but rather they reflect social information.  Additionally, this point is echoed in ICD-10-CM/PCS Coding Clinic, First Quarter 2018 pg: 18.    

A further Official Coding Guideline update involves the coding of BMI at I.C.21.c.3.  Coding professionals are instructed not to code the BMI unless a related diagnosis of overweight or obesity is documented by the provider and meets the definition of reportable diagnosis.  The same update states that BMI is not to be coded for pregnant patients. 

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.

OHIMA 2019 Annual Meeting & Trade Show

Submit your registration for the OHIMA 2019 Annual Meeting & Trade Show by Tuesday, February 26th to take advantage of the Early Bird discounted rates.  Registration rates will increase after this date!  Receive a $60 discount for OHIMA members and 17 AHIMA & AAPC CEUs if you attend all three days.  If you haven't done so already, send your registration and payment today!

Functional Endoscopic Sinus Surgery

FESS.  Functional Endoscopic Sinus Surgery are procedures performed to open sinus cavities in order to promote airflow and drainage.  This inaugural installment of “Spotlight on CPT” looks at appropriate coding for FESS from a CPT perspective.

Properly coding outpatient endoscopic sinus surgery procedures begins with understanding the notes that pertain to those codes.   Some notes pertain to the entire sinus endoscopy section, while others are parenthetical notes that pertain to the specific code that they follow.  Many of the parenthetical notes dictate which, if any, other codes from the sinus endoscopy section can be coded in conjunction with the code the note follows.  As seen with all endoscopic type procedures, the initial section note instructs coders that a diagnostic endoscopy is included with a surgical sinus endoscopy and specific to surgical sinus procedures, sinusotomy is also included.  It is, however, permissible to assign a separate code for stereotactic computer-assisted navigation (61782) if it is performed in conjunction with an FESS procedure. 

Another note clarifies that all the codes in the range of 31233-31298 are considered unilateral unless noted otherwise.  Code 31231, which begins the FESS section, is unilateral or bilateral, which is important to note.  Additionally, the three diagnostic codes (31231-31235) include the inspection of all the following areas: 

• Interior of the nasal cavity 
• Middle and superior meatus 
• Turbinates 
• Spheno-ethmoid recess

When one or more of the areas is not examined either because it is deemed not clinically necessary, altered anatomy precludes the inspection, or it is not technically feasible to perform the inspection, then a modifier should be added to indicate the reduction in service.  Modifier 52 is used if a repeat examination is not planned, or if a repeat examination will be done, then modifier 53 should be used.

In the 2018 CPT code updates, several combinations codes were introduced that combined a total ethmoidectomy procedure with frontal and sphenoid sinus procedures.  The key piece to assigning these codes correctly is that the ethmoidectomy must be a total procedure, meaning both anterior and posterior; otherwise, if only a partial ethmoidectomy is performed, two separate codes will be assigned; 31254 for the partial ethmoidectomy, and either 31276, 31287, or 31288 as appropriate for the other sinus procedures.

Another new combination code bundled frontal and sphenoid sinus ostial dilation (31298) when performed ipsilaterally.  Coders should take note that this code does not include maxillary sinus dilation (31295) thereby making it appropriate to assign the 31295 in addition to the 31298 if all three sinus ostia are dilated.

CPT Assistant clarification from February of 2016 indicates that packing used at the conclusion of an FESS procedure and any stent or implant placement is all considered part of the work incorporated with the FESS codes.  However, there are two drug-eluting implant codes specifically for the ethmoid sinus:

0406T Nasal endoscopy, surgical, ethmoid sinus, placement of drug-eluting implant
 
0407T Nasal endoscopy, surgical, ethmoid sinus, placement of drug-eluting implant with biopsy, polypectomy, or debridement

These are category III CPT codes which are temporary CPT codes and must be reported in lieu of an unlisted category I CPT code.   Unlisted code 31299 is to be used for placement of a drug-eluting implant in any sinus except the ethmoid.  The two temporary codes above may be assigned when the placement of the drug-eluting implant is a stand-alone procedure only.  Information provided in the notes precludes assignment of the implants with any other ipsilateral ethmoid procedure.

Now, light has been shed on FESS coding in CPT.

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.

How I Manage

by Marie Janes, RHIA, FAHIMA

At the upcoming OHIMA 2019 Annual Meeting and Trade Show, I will be presenting on a topic that is paramount to HIM professionals, whether or not they hold a title of manager, supervisor or director. H.I.M.: How I Manage will examine management types, identify management myths, and introduce the audience to the 10 Laws of Management. During the presentation, the audience will participate in “reflection” activities, along with “self-assessment.”

My goal is to explore on-the-job or off-the-job circumstances that impact individuals’ leadership and management knowhow. Is your style demonstrating practical use—or is it practically useless? There is a myriad of exceptional resources available, although many of us simply do not have the time to delve into them. Please join me as I offer ideas, concepts, and techniques to validate the fundamental meaning of stating, this is How I Manage!

Marie Janes has worked in the HIM profession since graduating with her Associate’s degree in Applied Science in HIT from BGSU Firelands College in 1984. In 1986 she was hired by Firelands College as the Instructional/Technical Assistant in the HIT program. She completed her baccalaureate degree through the Medical College of Ohio (now UTMC) and the University of Toledo consortium for Health Care Supervision and Management, graduating cum laude in 1994. With the advent of the Internet and its impact on technology in health care, Marie entered graduate studies, earning a Master’s in Education from the Technical College at Bowling Green State University in 2000. In 2002, she began a doctoral program at the University of Toledo; however, she withdrew a year later in order to create the first online HIM program in Ohio, which earned CAHIIM accreditation in 2005 and is still going strong. Throughout her career she has experience "the joy of victory and the agony of defeat." Teaching is her passion, but helping others “manage” is her calling. She has been promoted, demoted, downsized and discharged; however, each experience has provided insight to help others as they achieve their dreams or deal with their disappointments.