The Coding and Counting COVID-19 Patients

There is so much information out there about COVID-19.  It can be confusing because so much of what we are told on a day-to-day basis about COVID-19 conflicts: Stay at home. We need to prevent the spread of this virus. Don’t stay at home.  We need to develop immunity. Wear a mask. Don’t wear a mask. Etc. Etc. Etc.

I cannot provide expert advice on the vast majority of this information. I do not have a medical degree and expertise regarding how to best treat COVID-19 patients. Nor do I know the best course of action regarding when the stay-at-home orders should be lifted and the economy re-opened.

But I am an expert in the arena of Health Information Management (also known as H.I.M.), and H.I.M.is important to COVID-19 because H.I.M. is the department/profession that houses medical coding.  Coding assigns diagnosis codes to the medical records of patients, which in turn generates data on the number of COVID-19 cases in the United States.  And with that data, the government, health officials and others make important decisions on our path forward. In the future, this data will be very important in research and the retrospective evaluation of COVID-19.

Because I am a Health Information Management professional, I want to clear up a few questions about how diagnosis codes are assigned to patients. I have heard conspiracy theories and questions about the counting of COVID-19 patients. Some say that the numbers are being padded. I have heard doctors are saying they are being “pressured” to add COVID-19 to the diagnosis list. These questions and concerns cannot be addressed until one understands how diagnosis coding works.  And many people – including doctors – do not understand how and when a diagnosis code is assigned to a patient’s medical chart.

First, a patient either has COVID-19 or he doesn’t. There are now COVID-19 tests that say “positive” (patient has COVID-19) or “negative” (patient does not have COVID-19). There have been questions about how accurate these laboratory tests are for COVID-19 – but that is another conversation and outside my area of expertise. If the laboratory test comes back positive, this means the patient has COVID-19 and this means that COVID-19 should be listed among the patient’s diagnoses in the medical documentation by the doctor.  And in turn, the diagnosis code of U07.1 (COVID-19) will be listed in the patient’s medical record and on the encounter. Think of “encounter” as an encounter with the health system – whether it is an inpatient stay in a hospital, a visit to the Emergency Room, appointment with family doctor, etc.

COVID-19 should never be excluded from a patient’s medical record if the patient has it.  Regardless of if the patient came to the hospital for another reason; even if he died of something else; even if the patient had other medical issues going on at that time which worsened his case of COVID-19.

Because everything that is abnormal with a patient should be listed in medical documentation. Because the medical professionals taking care of the patient need ALL the information in order to treat the patient effectively.  And should the patient return to the hospital again for the same or another reason, there needs to be continuity of care with that patient. This is how all medical documentation and coding works and has worked for a very long time. It is not different with coding for COVID-19. We will get to the how and in what order diagnosis codes are listed later on. But to wrap up my point, there is no “pressuring” to entice doctors to add COVID-19 to a patient chart. The patient either has COVID-19 or he doesn’t. Sure, if someone is pressuring doctors to add COVID-19 to a patient chart when the patient doesn’t have COVID-19, then that is a problem. But the vast majority of doctors would not deem it acceptable to enter false information into the medical chart. They could lose their medical license. Therefore, I can only assume that when a doctor says he is being “pressured” into adding COVID-19 to the diagnosis list – the patient(s) in question do actually have COVID-19 – but the doctor thinks that it is unimportant to the visit and/or he doesn’t think the patient should be “counted” as a COVID-19 patient for whatever reason. And therefore, he doesn’t want to add COVID-19 to the diagnosis list. But that isn’t his call.  That is not how medical documentation and coding works. The patient has COVID-19 or he doesn’t. It isn’t an “opinion” – unless there is some suspicion that the laboratory test is inaccurate. It is important to know how many patients do actually have COVID-19 – whether it contributes to the death rate or survival rate. Accurate data is important. And further, it is important to have the COVID-19 diagnosis in the patient’s medical record to ensure the safety of the patient’s caregivers – in the healthcare system and at home – so that they take the necessary precautions to protect themselves and others.

Now, onto how and in what order the diagnosis codes are listed. The “principal diagnosis” is always the reason that the patient was being seen or was admitted into the hospital. And the principal diagnosis does not change – regardless of what happens after the patient is admitted. For example, if a patient goes to the hospital because of a hip fracture, but then develops COVID-19 symptoms while at the hospital and a test confirms the he does have COVID-19 – the hip fracture is the principal diagnosis and COVID-19 will be among the other diagnoses listed (even if the COVID-19 actually causes the death of that patient or lengthens the hospital stay of the patient). Another example, a patient goes to Emergency Room with shortness of breath and cough, tests are run and confirm that these symptoms are because of COVID-19. The principal diagnosis will be listed as COVID-19 even if the patient falls off the hospital bed and breaks his hip while in the Emergency Room.

The reason for death is another matter. In order to determine the reason a patient actually died, one would need to look at the death certificate. The death certificate will list the “cause of death” (i.e. what diagnosis actually killed the patient) – regardless of the principal diagnosis or other diagnoses the patient may have had at the time of death. Now, there may be some room for discussion regarding how the “reason for death” is evaluated and determined, but that is not within the realm of Health Information Management nor coding.  A medical examiner who does autopsies for a living would have to chime in how the “reason for death” is assigned when there might be “co-morbidities.” A patient has co-morbidities when he has more than one chronic disease or conditions at the same time. And from current data, we know that co-morbidities can worsen or complicate a case of COVID-19.

Now, do we need to look at data from different directions? For example, how many patients died with a diagnosis of COVID-19 and had no other diagnoses? How many patients died with a diagnosis of COVID-19 and had other diagnoses (co-morbidities)?  How many patients have a principal diagnosis of COVID-19 (i.e. they entered the hospital because of COVID-19)? Yes, absolutely. But hopefully, I can at least clear up any questions on how and when a diagnosis of COVID-19 is assigned to a patient’s medical record.

About the Author

Since 2011, Lauren Manson, RHIA has been the Executive Director of the Ohio Health Information Management Association (OHIMA). Before taking on her role with OHIMA, Lauren worked in the H.I.M. department at The Ohio State University Medical Center and then spent several years implementing Electronic Medical Records throughout the United States. She graduated with honors from The Ohio State University in 2008 with a major in Health Information Management and Systems and a minor in Business. 
 

Our Journey Down the Yellow Brick Road to the OHIMA 2020 Virtual Conference: COVID-19, Virtual Events, Cancellation Costs, Oh My!

by Lauren Manson, RHIA

Envision. You are the Executive Director and only full-time employee of the Ohio Health Information Management Association. You are rapidly going down the Yellow Brick Road towards the “Wizard of Oz” themed OHIMA 40th Annual Meeting & Trade Show. There is an expected attendance of over 900 attendees and 75 exhibiting companies at the conference in Columbus, Ohio. You have donned your ruby red slippers and are fighting off the flying monkeys that always seem to swoop around during this time. Things are moving along well. You’ve made this journey many times before.

A munchkin tells you that the Wicked Witch of the West Coast (whose name is COVID-19 in this story) is hanging out in California. But she seems to be keeping her distance. The Good Witch of the Midwest – Glinda, uh, I mean Dr. Acton – has been giving daily updates that the Wicked Witch may be in Ohio already but has not been sighted flying on her broom just yet. The Wicked Witch really wants those ruby red slippers that you are wearing so they expect her to make an appearance at some point, but no one knows when and where that might be.

You have taken all the necessary precautions.  Setting up hand sanitizer stations along the Yellow Brick Road; declaring the Annual Meeting & Trade Show to be a “handshake free” conference; keeping updated on the Good Witch’s press conferences. One week prior to the conference, things are moving forward with caution. You are getting closer and closer to Oz. But THEN … the Wicked Witch of the West Coast shows up in Ohio. The Wizard of Oz – er, Governor Mike DeWine – declares a state of emergency for the state of Ohio. Events are being cancelled. There are all kinds of data and recommendations flying about – kind of like those flying monkeys. Employers are not allowing their employees to travel – even within Ohio and even to Oz. There are concerns about mass gatherings. Glinda and the Wizard – uh, Dr. Acton and Governor DeWine – are making recommendations to stay home. It seems like we aren’t in Kansas, er Ohio, anymore!

The OHIMA Board of Directors has an emergency Board Meeting via conference call 5 days before the Annual Meeting & Trade Show is supposed to take place and makes the very, very difficult decision to cancel the in-person portion of the conference.  But members still need CEUs - oh my!  It is decided that the educational sessions will be offered as a Virtual Conference instead. OHIMA has never done a virtual conference before – it’s a horse of a different color – but it’s still a horse!  Making a horse change colors is no easy feat in this story.

You, Dorothy, calls upon her trusty friends – the Scarecrow, Tin Man and the Lion i.e. OHIMA part-time staff, Board of Directors and speakers – to help record the Annual Meeting presentations in a three-day period.  The only way to get 30+ hours of presentations coordinated and recorded is to host them on the date/time that they were supposed to take place during the in-person conference. After many long nights and the support of many munchkins, the OHIMA Virtual Conference is up and running!  One week after the in-person conference was supposed to take place. Dorothy is quite tired.  And her ruby red slippers are a bit scuffed. But she couldn’t have done with without her trusty travel companions – the Lion, Scarecrow, and Tin Man. 

Oz has been saved!  And the journey down the Yellow Brick Road will have to wait until next year… Mark your calendars for February 22-24, 2021 for the OHIMA 2021 Annual Meeting & Trade Show!  There’s No Place Like H.I.M.

Type 2 Myocardial Infarctions

Last year, in an edition of “In the kNOW” was devoted to discussion of the various types of MIs.  With changes to the ICD-10-CM guidelines this year, I felt it important to review type 2 MIs.

First a word regarding type 2 MIs; this type of MI results from another condition which is placing the supply/demand of myocardial oxygenation into an imbalance.  These conditions may include: heart failure, shock, renal failure, anemia, or chronic obstructive pulmonary disease (COPD) to name a few. 

The guideline change for type 2 MIs that occurred in October had three components as you can see highlighted below. 

Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with the underlying cause coded first. Do not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia. If a type 2 AMI is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

The first, rather insignificant change was the correction of a typographical error.  The word “balance” which was describing ischemia was amended from “balance” to “imbalance”.  This just makes sense as ischemic imbalance would be indicative of a problem.

It is the next change that is very significant in this guideline change.  Here we see that there has been a change regarding how coding professionals are to sequence type 2 MIs.  The guideline specifies that the underlying cause is to be coded first.  Until the update in October, coders were able to sequence these conditions based on the circumstance of the admission, but not any longer.

Let’s look closer at the impact this could have for our facilities.

If a type 2 MI occurs as a result of COPD, we may have previously assigned the type 2 MI as principal diagnosis giving us a DRG of 282 and reimbursement of about $4,252.  Under the guideline change the COPD will have to be sequenced first, changing the DRG assignment to 190, with estimated reimbursement of about $6,696 or an increase of about $2,400.

However, if supraventricular tachycardia was the underlying cause of the type 2 MI, our DRG will shift from 281 and about $5,528 (when the type 2 MI was sequenced first) to 282 for the SVT now principal diagnosis and drop in reimbursement to $4,252.

It is obvious that while there is definitely going to be a financial impact associated with this new guideline change, that impact has the potential to be positive or negative.  Coding and CDI professionals must be diligent when coding for this condition and examining all documentation in order to identify the underlying cause for principal diagnosis selection.

The change is further reflected in the Tabular Index where a NOTE change occurred as shown below:

Delete  Code also the underlying cause, if known and applicable, such as:
Add      Code first the underlying cause, such as:

                        anemia (D50.0-D64.9)

                        chronic obstructive pulmonary disease (J44.-)

                        paroxysmal tachycardia (I47.0-I47.9)

                        shock (R57.0-R57.9)

Once again, a reminder that the changes that come in October are not just codes, but guidelines and notes, which we must be aware of as well.

Just a quick word about the final guideline change for type 2 MIs.  There was the addition of the word “If” in the final sentence.  This just clarifies that should a type 2 MI be described by the provider as a STEMI or NSTEMI, coding professionals are still to assign the type 2 MI code at I21.A1 only.  Acute MI codes are not to be coded for type 2 MIs.

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.

Gardening Gaffes

by Dianna Foley, RHIA, CHPS, CCS 


Test your ICD-10-CM coding skills with this Klutz family experience.

Each spring, the Klutz children and their parents plant a vegetable garden behind their single-family home.  While planting over the weekend, each child sustained a bite injury.  Read on to see what happened and practice assigning ICD-10-CM diagnosis and external cause codes for the injuries.

Janine incurred the first bite injury when an aggressive squirrel bit her on the index finger of her left hand while she holding seeds to plant.  Raymond, who was barefoot, was standing nearby using the hoe when a tiny mouse bit his great toe.  Luckily, the bite was just superficial on his right foot.  A spider bit Peter on the back of his right hand as he was planting lettuce.  It was good fortune that the spider was of the nonvenomous variety.  Egon was bitten on his right ankle as he walked through some overgrowth to pull out dead plants from last year.  He was able to catch a glimpse of a Northern black racer snake slithering away.  He recalled from Boy Scouts that this snake was nonvenomous, thank goodness.  It appeared that little Dana might be spared a bite injury, but no such luck.  She developed a particularly itchy rash that was the result of being bitten by chiggers.  Mr. and Mrs. Klutz made sure that each child’s bite was tended to appropriately, and were happy the injuries hadn’t been more severe…this time!    

Click HERE for the answers.

Anesthesia Coding

Anesthesia coding will be the focus of this “Spotlight on CPT” article.  Correct assignment of the appropriate anesthesia code for the service that was provided will require that coding professionals utilize information found in the CPT manual.  Additionally, there are specific modifiers and add-on codes applicable to anesthesia codes, which we will review.

Let’s begin with the anesthesia codes themselves.  These can be found by using the Index in the CPT Manual under the term “anesthesia”.  In most circumstances, there is not a direct one-to-one match between a surgical procedure and its corresponding anesthesia code.  Instead, the anesthesia codes are more generic in nature.  For example, any procedure done on the lower anterior wall of the abdomen falls under anesthesia code 00800.  However, there are some instances where the correlation is very specific with a one-to-one match as in the case of a panniculectomy procedure, which would be coded to 00802.

As illustrated above, coding professionals will need to use appropriate procedural terminology in order to arrive at the correct anesthesia CPT code.  It will be equally important to employ their knowledge of anatomy to arrive at the correct code(s).  For example, if a patient was having an inguinal hernia repair, a coder will need to recognize that this is a hernia repair of the lower abdomen coded to 00830 and not the upper abdomen, which would code to 00750. 

Four add-on codes can be assigned under certain circumstances along with an anesthesia code.  These codes are “Qualifying Circumstance” codes and indicate that the anesthesia service was provided in a particularly difficult situation.  This could be due to the patient’s age (either very young or old), hypothermia, hypotension, or an emergency.  An emergency is deemed to exist if treatment delay would result in increased the risk to patient.  More than one of these codes could apply to the encounter and all that apply should be coded. These codes are:

    +99100     Anesthesia for patient of extreme age, younger than 1 year and older than 70
    +99116     Anesthesia complicated by utilization of total body hypothermia
    +99135     Anesthesia complicated by utilization of controlled hypotension
    +99140     Anesthesia complication by emergency conditions

Again, the aforementioned codes are to be assigned in addition to the base anesthesia code for the procedure performed.  For example, if an 82 year-old male was involved in an automobile accident and was diagnosed with a liver hemorrhage for which he underwent an emergency partial hepatectomy, the anesthesia codes would be 00792 with qualifying circumstance add-on codes +99100 (for his age) and +99140 (for the emergency).

Anesthesia codes also have their special modifiers.  These are physical status modifiers and are assigned along with the anesthesia codes.  These physical status modifiers are a way to identify the level of complexity associated with the anesthesia service that was provided.  There are six physical status modifiers as noted below:

    P1-normal healthy patient
    P2-patient with mild systemic disease
    P3-patient with severe systemic disease
    P4-patient with severe systemic disease which is a constant threat to life
    P5-moribund patient who is not expected to survive without the operation
    P6-declared brain-dead patient whose organs are being removed for donor purposes

Keeping these concepts in mind will help coding professionals accurately report anesthesia services.

Now, light has been shed on anesthesia coding.


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.

Discovering How to Teach Medical Terminology as a New HIT Instructor

by Anissa McBreen, RHIT

Who Doesn’t Love a Good Game!

I like to share with you how I discovered using games in the classroom as a new HIT Instructor.  

When my boys were little, we had a Friday night ritual; we called Family Fun Night. (pretty creative, right?)  This ritual consisted of board games and snacks, lots of salty and sugary snacks! As my boys grew, this ritual became something of a memory. As time advanced, I reintroduced the Family Fun Night into family celebrations. Now, every family gathering we have games and snacks, lots of salty and sugary snacks! What a blast we have when we come together for some games and food.

When I became a new Instructor in August 2019, I was searching for ways to incorporate fun and learning into my medical terminology lecture. One day while writing my lecture, it hit me; why not add fun into my classroom by ways of Family Fun Night. I’d like to share with you what I observed the games added for my students-enrichment, encouragement, and excitement.

Enrichment

Being a new Instructor teaching Medical Terminology, I felt that not only did I need to make a first good impression, but I knew I needed to gain the trust of my students. I also knew I needed to present topics and discussions that were fresh, high quality, and included some fun. So, I moved slowly with the fun part. I certainly did not want my students to think they signed up for all fun and no lecture! I started by incorporating funny slides and jumbles into my PowerPoint lecture, while making sure I was meeting my learning objectives. My goal was not to “talk” at my students the whole class time. I wanted them to feel the value of the lecture. Implementing a simple activity, such as a jumble during my first week of class, was a success as a new instructor. It helped the students relax and become engaged with learning and each other. I genuinely believe this has provided an enriched learning experience.

Encouragement

Students, whether 19 or 99, need encouragement to succeed in the classroom. Since memorizing medical terminology words and pronunciation can be a daunting task for some, I realized they would need a lot of encouragement. Heck, sometimes, I find myself needing encouragement when pronouncing terms during my lectures. How could I provide this in my classroom? Games? Maybe? I tried and guess what, it worked! One of my favorite games to do with students is Kahoot. Kahoot is a game-based learning platform that allows me to create quizzes based on medical terms. Students loved it and were encouraged to learn more. Plus, it appealed to their competitiveness and they liked showing off what they had learned. I felt it helped them realize they were learning the language and were motivated to learn more. Plus, winners came away with a snack! What a great way to have fun while learning.

Excitement

Who doesn’t love a good game? When I watch my students play a game, I see their excitement to play and an eagerness to learn. It fills me with satisfaction to know that I am doing my job as an Instructor. What a great feeling! Even incorporating a simple game of matching medical terms can bring enthusiasm and eagerness. More words that start with E-I think I’m on to something.

As I continue to bring Family Fun Night into my class, I have come across some great tools and resources that I like to share with you. Please think about incorporating them into your classroom. I am confident that your students will become enriched, be encouraged to learn, and feel excited about learning. And, it doesn’t hurt if you provide snacks too!

• Jeopardy Game -can find templates online. I like to give the winning team $100,000 Grand candy bars.
• Kahoot (http://www.kahoot.com)
• Proof of reading or exit slip games
• Write the wrong spelling for terms on the board. Students get into teams and race to figure out the correct words
• Flashcards/matching game-I recently purchased the book Exploring Medical Language. This book has been an excellent resource as a new Instructor. I use the matching cards that come with the text for each lesson I give.
• Jumbles- I like to incorporate jumbles into the middle of my lectures to give students a break. I have found that the jumbles on http://medicalterminologyblog.com are the best for this active learning activity.
• Crosswords-I use a crossword when I have finished a lecture early and need a good
• 20-minute activity. Sometimes, I turn it into a race.  I have found the crossword puzzles on http://medicalterminologyblog.com to be the best for this activity.
• Scramble-using medical terminology terms is a great way to use this game!
• Family Feud-student favorite!
• -ectomy game -students must race against the clock to come up with terms ending in -ectomy.
• Not sure what to do? You can make anything into a game

Now, I am getting hungry. Anyone for a snack?

 
Resources:

LaFleur Brooks, M., LaFleur Brooks, D., Exploring Medical Language, 10^th edition. Elsevier

Anissa McBreen has been providing consulting services and educational workshops to Long Term Care/Post-Acute organizations for over 27 years. Under her leadership, HIM departments have developed and maintained compliance with state and federal regulations. She has also developed HIM programs for HIPAA and QAPI and provided policy and procedure manuals. She is an RHIT working towards her RHIA. Anissa is a highly driven professional and has a passion to educate those working in non-traditional settings to be successful HIM professionals. She can be reached at mjmcbreen@aol.com for questions, networking information or just table conversation between HIM professionals.