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!

ICD-10-CM Guideline I.A.15 “With”

Are you still struggling to apply the ICD-10-CM guideline I.A.15 “With”?  If so, you won’t be the only one.  You will recall this guideline was clarified in recent years to indicate that the word “with” presumes a causal relationship to exist between the terms linked by that word in the index unless the physician indicates there is no relationship or another guideline exists that states the conditions must be linked with specific documentation.  In this edition of “In the kNOW”, we will look at how this guideline should be applied to G.I. bleeds by exploring the following scenarios.

A patient presents to the ER with G.I. bleeding and is taken to the endoscopy suite for an EGD.  The final diagnosis documented from the procedure is that of an esophageal ulcer.  How should this be coded?

If your first thought is K22.10 (ulcer, esophagus) and K92.2 (bleeding, gastrointestinal), let’s review.  Applying the guideline I.A.15 “With”, we can use a combination code found under ulcer, esophagus, with bleed, K22.11.  Because the index entry under Ulcer, esophagus, is “with bleeding”, the classification is permitting the assumption of a causal relationship between these two conditions.  It is not necessary for the physician to indicate a relationship in his/her documentation.    

Now, let’s apply the guideline to this example.  Patient with hematochezia undergoes a colonoscopy with final documentation indicating diffuse diverticular disease of the large intestine.  Again, using the index, we identify diverticulosis, large intestine, with bleeding leading to combination code K57.31. 

Similar index entries can be found for gastric ulcers, angiodysplasia, gastritis, and diverticulitis with bleeding.  Again, the classification is making a coder’s job easier by permitting the assumption of the causal relationship.  It is not necessary to query the physician, as we have classification guidance on the assignment of the combination code. 

3rd Qtr. 2017 Coding Clinic (page 27) provides clarification on this topic as well.  It does warn coders to watch for any documentation that would indicate the conditions are not related though.  In those circumstances, if we revisit our first example and the physician indicated the bleeding was not from the ulcer, we would definitely assign K22.10 and K92.2.

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.

Documentation that Serves a Purpose

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

In drafting a physician open door forum presentation on the role of complete and accurate clinical documentation as an effective strategy for preparation in value based performance measurement and the Merit Based Incentive Payment System, I came across a PowerPoint slide I have referred to in the past. Dr. William Osler, a highly accomplished physician in his time, the Father of Modern Medicine, the creator of the of residency programs as they exist today as one of the founding fathers of John Hopkins Medical School, has coined many practical provocative sayings. The following really hits home as a CDI professional who continually advocates for a unique vision of CDI that incorporates methodologies and processes to affect positive sustainable change in physician practice patterns of documentation standing for communication of patient care versus primary focus upon reimbursement associated activities and physician education.

• The physician treats the disease; the great physician describes, shows, tells and treats the patient who has the disease. Sir William Osler (1849-1919)

The CDI profession can truly collaborate and partner with physicians in preparation for MIPS and other value based healthcare delivery models by acquiring the core knowledge and skill sets representing evidence based concepts of documentation improvement. We certainly can assist physicians in their quest to describe, show and tell the patient who has a disease, complemented by our proven ability to promote and achieve documentation of clinical specificity including increasingly important elements of clinical validation.

So, what is the makeup for the physician to show, describe and tell the clinical facts, information and clinical context associated with hospital level of care? The following fundamental components of documentation are essential in the scheme of patient care:

H & P

H & Ps should adhere to the following outlines

• Chief Complaint setting the stage for nature of presenting problem
• History of Present Illness with an emphasis upon “present” vs. “past”
• Clinically relevant Past Family Social History and Review of Systems
• Physical exam congruent with the nature of the presenting problem and clinical judgment of the physician
• Medical decision-making correlating with the clinical information, facts of the case and accurate reflection of assimilation of information as documented in the record including results of diagnostic workup treatment in the Emergency Department as well as the available test results and clinicals of the patient
• Clinical impression accurately reflecting and reporting provisional and definitive diagnoses that can be traced back to the physician work performed and clinical picture as described, told and shown in the HPI
• Plan of care congruent with the assessment, matching up each order to the diagnosis(es) and/or symptoms

Progress Notes

• Progress notes should meet the following characteristics
• Factually correct
• Temporally relevant (no future tense references to procedures already done)
• Concise (no fluff; just a concise statement of the facts)
• Devoid of plagiarism
• Analytic- (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
• Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)

Discharge Summaries
Discharge Summaries should meet the following component parameter as required by the Joint Commission:

• Reason for hospitalization.
• Significant findings.
• Procedures and treatment provided.
• Patient’s discharge condition.
• Patient and family instructions (as appropriate).
• Attending physician’s signature.

Other recognized guidelines for discharge summaries as advocated by the Society of Hospital Medicine include the following:

• Reason for hospitalization including presenting problems that precipitated hospitalization
• Concise summary of diagnoses, primary and secondary, including any complications or co-morbidity factors
• Key findings and test results
• Hospital course, including significant findings
• Procedures performed, and treatment rendered
• Conditions at discharge including functional status and condition status as well as limitations
• Discharge destination and rationale if not obvious
• Patients/Family instructions for continued care and/or follow-up

Closing Remarks

I encourage and challenge all CDI specialists to begin the journey in transitioning away from repetitive chart reviews in search of diagnoses and clinical validation only to bringing into the fold the quality and completeness of clinical documentation as outlined above. We must recognize the need and capitalize upon the opportunity to work collaboratively with our physician constituents to clearly, concisely, consistently and explicitly describe, show and tell the patient story in a manner that best communicates the quality focused cost effective patient centric efficiently guided patient care provided and achieved.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com. 

Compliance: What is it and Why is it Important

Compliance.  It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important? 

Dictionary.com defines compliance as

1. the act of conforming, acquiescing, or yielding.
2. a tendency to yield readily to others, especially in a weak and subservient way.
3. conformity; accordance: in compliance with orders.
4. cooperation or obedience: Compliance with the law is expected of all.

Quite simply put, it is following the rules.  In healthcare, patients are expected to be “in compliance with orders” from their physicians and “compliance with the law is expected of all” healthcare workers and healthcare facilities.  There are rules and regulations from insurance companies, government agencies, and regulatory agencies that must be followed.  There are numerous regulatory bodies that a healthcare organizations and workers must be compliant with: OSHA, FDA, CDC, ODH, TJC, HFAP, CMS, and the list goes on and on.  CMS and TJC are regulatory bodies that HIM professionals deal with extensively.

Why is it important that the rules are followed?  Reimbursement is a major reason to remain compliant but staying out of jail and keeping one’s job is pretty important too.  All too often there is someone or some facility in the headlines for not following the rules.

Just last month the OIG published a report that says $4.4 billion returned plus billions more are anticipated in estimated saving.  The report goes on to say for a 6 month time period in FY2017, around $296.4 million would be returned to the department of Health and Human Services based on OIG program audits.  There is not just a monetary impact.  According to the OIG report 3,244 individuals and entities have been excluded from Federal health care programs.  Excluded individuals are not just physicians or clinical professionals, but coders, office administrators/managers, and office staff are included.

It is reported in July 2017 the OIG and its law enforcement partners executed the largest health care fraud takedown in history.  The takedown covered 41 Federal districts, more than 400 defendants, and about $1.3 billion in false billings to Medicare and Medicaid.

With findings like these, we can only expect to see more investigations, more audits.  To find out what’s new with the OIG visit https://oig.hhs.gov/newsroom/whats-new/index.asp

As HIM professionals our roles in compliance will only grow.  As an individual it is more important than ever that you are diligent in everything you do. Now might be a good time to refresh yourself on your organization’s compliance policy and reporting method.  And if you are looking at making a transition to a new role, consider a role in compliance.

About the Author

Joan S. Hartman, RHIT is a Sr. Analyst of Ethics and Compliance at Ohio Health.  She also serves on the 2017-18 OHIMA Newsletter Committee.