Monday, April 29, 2019

Passion for Politics

by Clarice Warner, RHIA, CCS-P, CPC, CHC

Have you ever had a passion for something. Something totally unexpected. Well recently, I’ve had the passion for politics.  Yes, politics.  I guess it started with me becoming a delegate for OHIMA. This year, I was provided the opportunity to attend AHIMA’s Hill Day and it was a great experience.  On March 25th and 26th, delegates from all 50 states gathered in Washington D.C. to visit our respective elected officials. I had the opportunity to visit with a member of Senator Rob Portman’s staff, a member of Senator Sherrod Brown’s staff and almost everyone in representative Steve Chabot’s office.  I also got an opportunity to meet with him personally as well.  As you can see the the elected officials showcase their pride in their states and the communities that they represent.   It was great to see the mementos and keepsakes displayed in their offices.

There were several issues that we brought before the officials.  The first one is to encourage notes sharing with patients in real time.  Unfortunately, our pervasive culture in medicine has kept real-time access of notes from getting into the hands of patients despite the numerous benefits of sharing notes with patients in real time.  The vast majority of hospitals and physician offices do not engage in systematic note sharing so AHIMA’s recommendation to Congress using its oversight authority to promote efforts such as open notes, the Medicare and Medicaid payment programs including the promoting interoperability programs, the MIPS improvement activity performance category and other innovative payment models so that the practice of note sharing benefits patients nationwide.

Next is align HIPAA right of access with the ONC’s Health IT certification functionality with all of the laws that we have for access to patient information individuals ability to access and use their health information continues to be a challenge and AHIMA recommends law makers to revise the definition of the designated record set (DRS) and require certified Health IT to provide the amended DRS to patients electronically while maintaining computability.  Further, regulators should develop guidance and request regular feedback from stakeholders on continued barriers to delivering this right under HIPAA.  This revision will provide greater clarity and predictability of what constitutes the DRS to both providers and patients.

Next is patient matching.  Since 1999, Congress has prohibited the use of appropriations by the U.S. Department of Health and Human Services (HHS) to promulgate or adopt any standard for unique health identifier until legislation is enacted specifically approving the standard.  This limitation has been included in every subsequent appropriations bill since fiscal year 1999 and is often seen as a barrier to public private sector collaboration and accelerating and scaling effective patient identification and matching solutions and AHIMA’s request to Congress is to omit the 1999 language in the fiscal year 2020 appropriations legislation to empower HHS to work with industry to advance a nationwide patient matching strategy. 

And lastly, extending HIPAA’s individual right of access to non-covered entities.  With all the rules and laws the ability of individuals to access and use their health information continues to be a challenge.  This challenge has only compounded in recent years with the proliferation of mobile health and health social media applications which are typically not covered by HIPAA’s right of access.  Such technologies are examples of HIPPAs non-covered entities (NCEs).  While Congress has passed several policies with HHS and has implemented a host of programs to improve patient data access, patients find that they have little access to and control of their health information collected by most HIPAA NCEs such as Fitbit and health apps. AHIMA recommends that lawmakers develop or directs HHS to define HIPAA NCEs in law and at a minimal extend HIPAA’s right of access to NCEs.  The goal of such a policy is to create a uniform data access policy for individuals using technology developed by an entity that produces and or manages their individually identifiable health information regardless of commercial or legal status.  We presented these issues to our elected officials and had 15-20 minute conversations with them.  Most of them were really interested in the NCEs because that was relatable. Everyone could relate to that and how that could potentially affect their constituents.

Is this the kind of work that you would be interested in?  Do you also have a passion for politics?  If so, feel free to volunteer for OHIMA and/or local American Health Information Management Association organizations. 

About the Author

Clarice Warner, RHIA, CCS-P, CPC, CHC is the Corporate Director of Corporate Responsibility for the Mercy Health Corporate Office in Cincinnati, Ohio.  She is also the Founder and Education Director for the Professional Reimbursement Network.  Clarice serves as a 1st-year Director and Delegate on the OHIMA FY 2018-19 Board of Directors, overseeing the Public Good strategy and Advocacy Committee.   

Monday, April 22, 2019

Intestinal Polyps

A polyp, is a polyp, is a polyp.  Right? 

The short answer is no, and in this edition of “In the kNOW”, the discussion looks at the different types of intestinal polyps and the proper code assignment for each.
First, let’s define an intestinal polyp.  A growth in the lining of the intestine is a polyp.  Non-neoplastic or neoplastic are categories of colonic polyps.  Non-neoplastic polyps generally do not evolve into a cancerous condition, whereas neoplastic polyps may progress to cancer.  Non-neoplastic polyps include inflammatory, hyperplastic, and hamartomatous polyps.  Serrated and adenomatous types of polyps are considered neoplastic polyps.  Sessile serrated polyps can be precancerous.  Intestinal polyps described as sessile are flat, while those characterized as pedunculated arise from a stalk. 
If the only description a coding professional has of a polyp of the colon is the term “polyp”, the ICD-10-CM code assigned should be K63.5, which according to a 1st Qtr. 2017 Coding Clinic is the also the code to be assigned when the polyp is described as hyperplastic.  Remember, that an outpatient coder can use the pathology report to determine if the polyp is further specified as adenomatous or inflammatory.  This would permit the assignment of a different code.  However, an inpatient coder may find that same information on a pathology report but would need to query the physician for agreement before assigning the more specific code. 
A diagnosis of an inflammatory polyp of the colon is correctly coded to K51.40 with further specificity if various other complications co-exist such as an abscess, a fistula, rectal bleeding, intestinal obstruction, or other complication.  

Colon polyps described as adenomatous are coded as benign neoplasms with further specification as to the location if it is known.  An adenomatous polyp of the ascending colon codes to D12.2.  The 2nd Qtr. 2018 Coding Clinic clarified that sessile serrated polyps should also be considered to be adenomatous in nature, thereby classifying them as benign neoplasms in the D12 category as well. 
An important point to note is that hyperplastic polyps that are specified by location (i.e. transverse colon) are not to be coded to the D12 benign neoplasm category.  A 2nd Qtr. 2015 Coding Clinic states that hyperplastic and adenomatous polyps are not the same, and that all hyperplastic polyps, regardless of location within the colon, are to be coded to K63.5.

Adenomatous colon polyps may be designated as tubular or tubulovillous and both types are coded to the benign neoplasm D12 category.  However, if the description of the polyp is that of villous adenoma, the complexion changes, and now a coding professional will assign a code from Neoplasm, uncertain behavior, by site - category D37.4.  A Coding Clinic from 2nd Qtr. 2005 made coders aware that when high-grade dysplasia is noted in an adenomatous polyp it does not alter the code assignment.  The code will still be in the D12 category.

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.

Wednesday, April 17, 2019

Book Excerpt: Creating a Career Ladder

By Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

Historically, CDI specialists transition to CDI from case management or HIM/coding due to the lack of experienced CDI specialists in the world. Today, those who do hold multiple years’ worth of CDI experience often earn top-dollar when changing careers and/or have moved up to management or director positions. Those coming into the role now, are often home-grown, mentored, and educated by existing staff.

As a result, CDI departments need to develop (or at least begin thinking about establishing) a career ladder for their programs. Career ladders help provide mobility to those who’ve served multiple years in the role and who’ve now been tasked with additional responsibilities such as mentoring new hires, educating physicians, and expanding review focus areas. The objective of a career ladder is to motivate existing staff, specifically the younger generation, to stay in the field of CDI. Many individuals will seek other opportunities when they no longer feel that there are career advancement opportunities or compensation growth. Currently, most CDI departments consist of either a CDI director or CDI manager and CDI specialists. These CDI specialist positions typically do not indicate levels of experience, which may pose some salary negotiation issues for the hiring CDI manager and the human resources department.

Typically, an entry level CDI specialist has 0–2 years of experience; a midlevel CDI specialist has 2–4 years of CDI experience, and may have obtained appropriate credentials. There is frequently a misconception that a CDI specialist position is a lateral move from a compensation perspective for a nurse coming from the clinical world, but in truth it really is not a lateral move, because a new skill set will be acquired on the job as a CDI specialist. Additionally, a CDI specialist role includes other perks, like not needing to work weekends, nights, or holidays, which may not be always true in the clinical setting. Therefore, as the CDI industry continues to expand, we may see additional benchmarks and guidance on how to appropriately pay CDI professionals based on their level of experience and expertise. Those interested in learning more about current trends in CDI compensation and salary should look to the annual salary survey reports published by ACDIS.
The career ladder structure and associated compensation increments will hopefully establish a common industry standard in terms of staffing and department structure.

Example of a CDI career ladder

CDI manager
• 5+ years of experience in CDI
• CCDS or CDIP credential
• Support effective CDI department staff activities and manage performance of CDI department and staff
• Provide staff with continuing CDI education and training
• Reconcile fellow CDI specialists’ entries in CDI tracking tool to ensure accuracy of provider clarification, abstraction of clinical indicators, and the assignment of initial DRG and working DRG
• Generate CMI report and CDI dashboard for metrics analysis
• Provide educational presentations to various physician groups on specific documentation improvement topics
• Active participation in team meetings, physician education, and leadership meetings

CDI Specialist Level 3
• 3+ years of experience in CDI
• CCDS or CDIP credential
• Assist CDI manager with reconciliation of data
• Assist CDI manager with educational presentations
• Assist CDI manager with team training
• Maintains productivity standards

CDI Specialist Level 2
• 2–4 years of experience in CDI
• CCDS or CDIP credential
• Maintain productivity standards

CDI Specialist Level 1
• 0–2 year of experience in CDI
• Maintain productivity standards

Editor’s note: This article is an excerpt from the Complete Guide to CDI Management

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

Wednesday, April 10, 2019

Coding the Excision of Lesions

This edition of “Spotlight on CPT” is going to explore the proper coding for excision of lesions.  First, coding professionals must be aware of the basic notes associated with the excision of lesions.  These include:
  • Excisions are considered full-thickness
  • Margins are included when calculating the size of the lesion
  • Simple closure of excisions is included in the code for the removal
  • Repairs which are intermediate or complex are coded separately

There are several variables to take into consideration when coding for the excision of lesions in CPT.  The first variable that must be determined is whether the lesion is benign or malignant.  Benign lesion excisions are in the code range 11400-11446, while the code range for removal of malignant lesions is 11600-11646.

Consideration of another variable is the body part where the lesions are removed.  The body part selection is broken down into three categories.  These include:
  • Trunk, arms, and legs
  • Scalp, neck, hands, feet, genitalia
  • Face, ears, eyelids, nose, lips, mucous membrane

The final variable, which can be difficult to obtain, is the size of the lesion.  There are six different subdivisions of lesion size as follows:

  • 0.5 cm or less
  • 0.6-1.0 cm
  • 1.1-2.0 cm
  • 2.1-3.0 cm
  • 3.1-4.0 cm
  • Over 4.0 cm

Coders will recall that when determining the size of the lesion, the most narrow margins taken will be included in the calculation of the size.  For example, a lesion of the cheek with a size given as 0.5 cm removed with a 0.2 cm margin all around would have a final size of 0.9 cm.  See the illustration below.

This is very important, as using the margin can possibly impact the CPT assignment as the example above illustrates.  Even though the actual size of the lesion is 0.5 cm, the total area removed is 0.9 cm with the margins and thus moves the CPT code up one level. 

Therefore, if we apply the information provided above, and a physician removes a 0.5 cm benign lesion of the cheek, taking 0.2 cm margins all around, the correct CPT code assignment is 11441.  The full definition of this code is “Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm”.  Because we added the margins to the size of the lesion to arrive at the full excisional area, the correct CPT code is 11441 for the 0.9 cm removal, rather than 11440 for a 0.5 cm removal.

Determining the correct size of the lesion removal can not only result in the assignment of a different CPT code, but may also impact reimbursement as evidenced in the table below which depicts the ambulatory payment classification (APC) rate for the various excision codes.

               CPT Code                                   APC       Total Reimbursement            
Benign lesions    Malignant lesions
11440                  11640                            5071        $511.53               
11441                  11641                            5071        $511.53               
11442                  11642                            5071        $511.53               
11443                  11643                            5072        $1,203.74               
11444                  11644                            5072        $1,203.74               
11446                  11646                            5073        $2,076.01

Notice in our original example, there was no APC change, even though by coding the margin in addition to the lesion size the CPT code changed.  If, however, we looked at the same benign lesion of the cheek, but this time it was 3.7 cm with 0.2 cm margins, notice the difference.  The size of the lesion is 3.7 cm + 0.4 cm for the margins for 4.1 cm total size.  Not only does the inclusion of the margins change the CPT code from 11444 to 11446, but also our reimbursement is almost going to double from $1,203.74 to $2.076.01.     
It bears reminding that the codes for excision of lesions in the Integumentary System of CPT are for lesions of the skin, which include the epidermis and dermis layers.  For removal of lesions occurring below the skin (subcutaneous tissue, fascia, subfascial, intramuscular, or submuscular), coders should consult the Musculoskeletal System section of the CPT manual. 

One final point about the excision of lesions is that coders should assign a separate code for each lesion removed.  As long as removal of each lesion is separate, assign a code for each individual lesion.  Obviously, if removal of two lesions occurs with one excision (en bloc) then code only one excisional code for the entire size of the area removed.

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.

Wednesday, April 3, 2019

March Misery

by Dianna Foley, RHIA, CHPS, CCS 

Test your ICD-10-CM external cause coding skills with this short scenario.

March brought a new set of health problems to the children of the Klutz family.  Each child had a condition that required something be removed beginning with Peter.  He awoke early on the 1st of March with a throbbing pain in his jaw.  His mother made an emergency appointment with the dentist who diagnosed a very carious tooth, which was going to necessitate pulling.  Fortunately, there did not appear to be an infection, so the dentist was able to use forceps to pull the lower molar that day.  Antibiotics were prescribed as a precaution. 

By the weekend, Peter was feeling much better, but his older sister, Janine, was now complaining of a dull abdominal pain.  When Mr. Klutz asked her where it was hurting, she pointed to the right lower quadrant.  When there was no relief, he took her to the emergency room, and after testing, the diagnosis was acute appendicitis.  Janine was placed in observation with laparoscopic surgery scheduled for later that evening.  Her appendix was removed, and after some antibiotics, she was discharged home the next day.  

Janine’s recovery was going well, when mid-month the next Klutz child started to complain of a sore throat.  Raymond was feverish and refusing to eat which was highly irregular for him, so his mother took him to the Minute Clinic.  There they found twelve-year-old Raymond’s tonsils were very enlarged and acutely inflamed and directed him to the emergency department.  From the ER, a second Klutz child was placed in observation, and scheduled for surgery, this time for a tonsillectomy.  Raymond did very well after surgery and went home the next day.

Egon started limping during the last week of the month and when he was seen by his family doctor, it was discovered that he had an ingrown toenail on his great left toe.  The doctor was able to perform a wedge excision of the skin around the nail during the office visit.  He gave Mrs. Klutz a prescription for an antibiotic as the area had seemed highly inflamed.

All the children were recovering nicely, and by the last day of the month, Mr. and Mrs. Klutz thought that perhaps little Dana was going to be the only one without a problem.  Of course, they were wrong once again, as that evening, Dana started to complain of a severe pain in her nose.  There was a bit of epistaxis as well, so her mother took her to the ER.  There a bean was found to be lodged up in the nose.  The children had been helping Mrs. Klutz plant some seeds to begin getting ready for spring planting and little Dana had put one up her nose.  An ENT was called and performed an endoscopic removal of the bean there in the ER.  After a period of observation, the doctors determined little Dana could go home.

With all the children home and safe, Mr. and Mrs. Klutz were relieved that their children’s miseries were over…at least for the time being!

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