AHIMA House of Delegates 2020 Meeting, Synopsis on Strategic Pathfinder Session Telehealth

by Kristin Nelson, MS, RHIA

AHIMA held its 74^th and first ever virtual House of Delegates (HoD) meeting on Saturday October 17^th, 2020.  As part of this all day event, Delegates were broken out into six pre-selected strategic pathfinder groups (Taking the Lead in Data Governance, The Future of Patient Matching and Identification, The Role of the HI Professional in Shaping Health Equity, Public Health, Ethics and Health Information, Revenue Cycle Challenges for Health Information, and Telehealth in the Future).

Using AHIMA Strategy as a baseline, Delegates were asked to react to assumptions on the future of these health information topics and help inform AHIMA’s future through management of health information. The purpose of the sessions are to:

•       Expand field awareness and understanding of the operational realities faced by health information professionals as they seek to address each topic

•       Apply newly learned material to a new situation

•       Analyze data to build connections among ideas

•       Support content which furthers AHIMA’s mission, vision, and core purpose.

I attended the strategic pathfinder session, Telehealth in the Future.  The two hypothesis presented to this group were:

1.       If the COVID pandemic is eradicated in 2021, telehealth will continue to accelerate.

2.       If the COVID pandemic is eradicated or not eradicated in 2021, the adoption rate of telehealth will remain consistent with the rate seen at the end of 2020.

 

Based off feedback from colleagues in the profession the group initially felt the first hypothesis to be the most true because of the convenience and ease of access. Participants mentioned there is now access to specialists and providers that patients may not have had previously.  One attendee told a personal story of how Telehealth saved her mom’s life by allowing her to have access to the specialist she needed to effectively treat her condition. Some even pointed out the potential for documentation to be richer due to recorded visits. However, after further discussion, the second hypothesis became the most popular choice. The shift in numbers was a direct result of items such as lack of access in rural areas, trust in technology, reimbursement concerns, and the fact that not all conditions can be adequately treated through telehealth. The group agreed that in order to advance Telehealth in the future, HIM professionals must have a seat at the table to assist with creating standards for documentation, patient identity, and patient privacy.

About the Author 

Kristin Nelson, MS, RHIA is the currently Board President on the OHIMA FY 2020-21 Board of Directors. Kristin is a Clinical Instructor at The Ohio State University School of Health and Rehabilitation Sciences HIMS Division.

Using Coding Denials to your Advantage – Coder Education

by Theresa Andrews, RHIT

Most of the time, coding denials would not be thought of as being beneficial to a facility. It can seem that insurance companies are just trying to manipulate coding guidelines to their advantage to reduce the amount of reimbursement a facility should be receiving. However, there are times when the audits do catch what I would consider to be a legitimate coding error. Still not sounding beneficial? Well, the silver lining of this is that it provides a great opportunity for coder education. Rather than ignoring these legitimate denials and hoping they don’t happen again, our facility finds that the best practice is to face the issue head on and provide education to coders, CDI, and anyone else that may benefit from the learning opportunity presented by these denials.

At our facility, the denials team will send out a simple yet detailed educational e-mail after receiving a denial that we believe to be a true coding error, especially if we have received multiple audits regarding the same diagnosis or coding guideline. These e-mails usually express one or both of the following:

1. Situations when a query could have been helpful to secure a denied diagnosis
2. Coding Clinics/Coding Guidelines that coders/CDI may be unaware of, or need refreshed on

For example, we have received several denials referencing Section III.C of the ICD-10-CM Official Coding Guidelines regarding uncertain diagnoses, which states the following: “If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” code the condition as if it existed or was established.” Coders are already aware that a diagnosis can be coded in the inpatient setting if it is documented with uncertainty; however, it can sometimes be overlooked whether the uncertain diagnosis was still documented at the time of discharge, and if it was not, there’s a good chance it will be denied. When this happens, sending out a quick refresher e-mail on this coding guideline can be a helpful reminder that coders should be querying in cases where an uncertain diagnosis is documented but is not mentioned at all at the time of discharge, to see whether this condition is still being considered as a possible diagnosis, or has been ruled out. Including CDI is also beneficial, since they are in direct communication with the doctors during the patient’s admission, and can remind the physicians to either continuously state the diagnoses or rule them out if they are no longer being considered.

We have also received multiple denials regarding serosal tears during surgery. These denials have referenced the same 2007 Coding Clinic titled “Intraoperative serosal tears” which states, “When a tear is documented in the operative report, such as a small serosal tear of the stomach, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure.” This is another example of a great education opportunity.

There could be a number of reasons that the coding staff need refreshed on this guidance.  Among them are: there is a brand-new coder with little experience; an outpatient coder who transitioned to inpatient coding, infrequent documentation of these serosal tears, lack of training for coding staff on accessing Coding Clinic material, or insufficient coding education on Coding Clinic guidance.  Regardless, with this Coding Clinic from 2007, a review is definitely in order. After sending out a quick e-mail stating that we had been receiving denials for this, with the above-referenced Coding Clinic attached, the coders now know to query the physician asking whether a small serosal tear during surgery was an incidental occurrence, or was a clinically significant complication of the procedure.

Continuing education is crucial in the coding world, and there is an opportunity for some of this education to come from the Denials Team. In my experience, this can help your facility to ensure more accurate coding in the future as well as proactively prevent these coding denials – and that is definitely an advantage!

About the Author 

Theresa Andrews, RHIT is currently working as the Revenue Integrity Analyst at Weirton Medical Center. Theresa graduated from the HIM Associate's Degree program at Eastern Gateway Community College in 2016. Since then, she has worked at WMC as a Scan Technician, Coder, Coding Team Lead, Denials Coordinator, and now the Revenue Integrity Analyst. .

Common Inpatient DRG Validation Coding Denials in 2020

by Theresa Andrews, RHIT

In Denials Management, it can be very useful to keep track of trends, including which denials you see the most often, and which are the most difficult to get overturned. Here are 2 of the most common coding denials that I have seen at our facility in 2020 (fellow Denials Coordinators, these may look familiar):

Use of J44.0 (COPD w/ lower respiratory infection) as principal diagnosis, with pneumonia as secondary diagnosis.

As I’m sure you all remember very well, the instructional note regarding the sequencing of these diagnoses has changed a few times in the recent past. At this point in time, code J44.0 has an instructional note to “Code also to identify the infection.” This “code also” note can be interpreted to mean that either code J44.0 or the code for the infection may be used as principal diagnosis depending on the circumstances of admission; however, auditors have really been targeting the use of J44.0 as PDX. We have received multiple audits where our facility had used code J44.0 as PDX, with the code for pneumonia as a secondary diagnosis. These audits always seem to state that the pneumonia should have been PDX because IV antibiotics were given for pneumonia, while no IV steroids were given for the COPD. There was one instance where IV steroids actually were given in the ER, but the audit still argued that the pneumonia was the main focus of treatment and therefore should have been PDX. We did attempt to appeal some of these denials, but they have proven very difficult to get overturned. Coder education was done at our facility explaining that coders should really be taking the specific treatment into account before choosing which diagnosis to assign as PDX in these cases. Regardless, this has definitely been a source of confusion for coders due to the recent changes in the instructional note, and auditors have definitely taken notice.

One additional point, make sure when you are reviewing denials that you are using the information that was in effect during the timeframe of the claim.  As noted above, guidance can change and your basis for overturning a denial for a current claim may well be different than what was applicable for claims from two or three years ago.

PCS Code for Excisional Debridement

Denials for excisional debridement have also proven to be very difficult to get overturned, although this can be done. As a refresher, Coding Clinic states that in order for a debridement to be considered excisional, the provider must blatantly state that the debridement was excisional, and/or the procedure must meet the root operation of excision, which is “cutting out or off, without replacement, a portion of a body part.” At least at our facility, it is very rare for a physician to specifically state that he or she is performing an “excisional debridement,” and so, more often than not, coders are looking for documentation to support that the physician truly excised a portion of a body part (usually subcutaneous tissue). We have gotten some of these denials overturned, but we have also sent out coder education regarding this topic so that the coders are able to recognize when a query is necessary regarding which type of debridement has actually been performed.

These are just a few of the more common coding denials I have seen lately. Your experience may be similar but regardless, it is up to the denial management team in collaboration with coding professionals and CDI specialists to challenge denials when appropriate and educate appropriate staff when a legitimate issue is identified to prevent future recurrences.

About the Author 

Theresa Andrews, RHIT is currently working as the Revenue Integrity Analyst at Weirton Medical Center. Theresa graduated from the HIM Associate's Degree program at Eastern Gateway Community College in 2016. Since then, she has worked at WMC as a Scan Technician, Coder, Coding Team Lead, Denials Coordinator, and now the Revenue Integrity Analyst. .