Book Excerpt: Outpatient CDI Reporting Structure

By Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC

If your organization has an inpatient CDI team, decide if outpatient CDI will share the same reporting structure or if the teams should be separate. A shared reporting structure can allow the new outpatient CDI specialists to benefit from the knowledge and expertise of the inpatient team, and common leadership can promote continuity within the organization.

On the other hand, since the focus of outpatient CDI is distinct from inpatient CDI, some organizations determine that the inpatient and outpatient teams are better served by separate reporting structures. Such decisions can be influenced by several factors, such as clinic size, whether the physician practice is part of a larger health system, and differences in the operational structure of the physician clinics, which could be deciding factors on where the outpatient CDI team reports.

Regardless of your CDI program’s structure, outpatient CDI professionals should have clearly established duties as differentiated from the roles of others. Dual roles, mixed goals, and overwhelming task assignments can dilute the program mission and make it difficult for new CDI to acclimate to the basic duties assigned and the overarching mission of the program.

Similarly, as a new CDI professional you must bring with you past skill sets but remember that once you take on the CDI mantle, that is the role that must take precedence. Many new staff defer to their comfort level. For example, those experienced in case management or utilization review may lean on their skills in that area, focusing their record review toward their area of expertise at the expense of the CDI program’s actual mission (typically record accuracy and reimbursement).

Those with nursing or physician backgrounds may find it difficult to move from hands-on caretaking to a supportive role influencing documentation. The CDI specialist, even if he or she is a physician, is not considered part of the treating healthcare team. CDI specialists, just like coders, cannot freely interpret or add to existing documentation with assessments or evaluations of their own. Only the treating physician can diagnose the patient, since it is his or her clinical opinion that guides the treatment and care of the patient.

In short, all program reporting structures can prove effective, provided they have clearly defined roles within them. The best fit for your facility depends on the overall goals of the program, support of the facility leadership, and the ongoing evaluation, support, and effort of the CDI team, according to a July 2010 CDI Journal article, “Survey Shows Structure of Healthcare Documentation Improvement Programs.”

By 2017, the majority of inpatient programs reported to the HIM department, followed by those with their own CDI program reporting structure, according to the ACDIS CDI Salary Survey that year. As outpatient programs continue to expand, additional data will provide better illumination as to national trends for its specific reporting structure; anecdotally thus far, however, trends seem to be following the patterns of their inpatient counterparts.

Editor’s note: This is an excerpt from The Outpatient CDI Specialist’s Complete Training Guide.

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

Cataract Extraction Procedures

Today, in “Spotlight on CPT” the conversation will be on cataract extraction procedures.  It may seem that this should be a very straightforward procedure to code.  However, there are some variables that impact the correct CPT code assignment which we will examine today.

Most cataract removals are referred to ECCEs or extracapsular cataract extractions and are performed with the concomitant insertion of an IOL or intraocular lens.  When this procedure is performed, the CPT code assigned is 66984.  Modifiers should be appended as well to indicate the laterality of the procedure that was performed; RT, LT, or 50.  If the same procedure was performed via an intracapsular extraction, the code would be 66983.  The difference between extracapsular and intracapsular extraction is that when an extracapsular extraction is performed, only the lens material is removed with the posterior capsule remaining intact; whereas for intracapsular extraction, which is rarely performed, the entire capsule as well as the lens material is removed.      

As noted, the codes above will include the IOL insertion performed during the same encounter.  If the patient has to have the cataract removed and the IOL inserted at a separate encounter, the coding will change.  The appropriate cataract removal code will be found in the CPT range of 66840-66940 and should be assigned based on the method of extraction: aspiration, phacofragmentation, etc.  When the patient returns at a subsequent encounter for the IOL insertion, 66985 is the CPT code to assign.

Coding professional should be aware that there are a number of components that may be a part of a cataract surgery which can include lateral canthotomy, iridectomy, iridotomy, anterior capsulotomy, posterior capsulotomy, the use of viscoelastic agents, enzymatic zonulysis, use of other pharmacologic agents, and subconjunctival or sub-Tenon injections. The performance of any of these services is considered part of the overall cataract extraction procedure and should not be separately reported.  However, if a vitrectomy is performed at the same time as the cataract extraction, it is not considered part of the bundled services and an additional code for the vitrectomy should be added.

There are some occasions when cataract extractions become more complicated.  For example, the patient’s pupil may not dilate well or zonular dehiscence may occur during the procedure.  In either circumstance, either before the procedure actually begins or after the IOL has been inserted, if such a condition occurs, the surgeon may place a Malyugin ring  or a capsular tension ring, respectively.  The use of these devices will impact the CPT code choice, which will change to 66982.  This code is to be used when devices are used to expand the iris, sutures are used to support the lens, or in the event that a posterior capsulorrhexis must be performed.  The same code should be used if the cataract surgery is performed on a patient in the amblyogenic developmental stage. 

Just a quick word on zonular dehiscence or zonular dialysis.  This is a condition of the zonules of the eye (zonule of Zinn), which are fibrous bands that connect the lens with the ciliary body (see picture below).  This collection of bands, approximately 140, provides support to the lens.  If the zonules are damaged or weakened, subluxation of the lens can result.      

Source: https://www.anatomynote.com/human-anatomy/ophthalmology-eye-anatomy/zonules-in-the-eye/

Postprocedurally, if the intraocular lens becomes subluxated, repositioning may be needed.  For those procedures, CPT code 66825 should be assigned. 

Coding professionals should take care not to confuse initial cataract extractions with removal of secondary cataracts, which can also be termed after-cataracts or opacified posterior capsules.  Procedures for treatment of secondary cataracts depends on the method of removal; either via a stab incision (66820) or YAG laser (66821). 

One final tidbit of information.  In a 1st Qtr. 2007 Coding Clinic for HCPCS, a question about coding for limbal relaxing incisions performed during cataract surgery was posed.  The advice given was that limbal relaxing incisions are incidental to cataract extractions and therefore, not reported separately.  This procedure may be performed in patients who present with astigmatism.  If the procedure is performed independently, coding professionals are directed to use the unlisted code 66999 for reporting.

Now, light has been shed on coding for cataract extraction procedures.

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.

Atrial Fibrillation

This “In the kNOW” discussion will focus on the condition often shortened in medicine as a-fib or AF, but in actuality termed atrial fibrillation.  This condition is a type of cardiac arrhythmia affecting the atria or upper chambers of the heart.  Rather than pumping effectively, in patients with a-fib, the atria quiver and the heart is ineffective in moving blood out to the body.  When blood pools or collects in the heart, clots may form and therefore, patients with atrial fibrillation are at a high risk for strokes.

 
The symptomatology for atrial fibrillation is quite variable. Patients may experience dizziness, shortness of breath, rapid heartbeat, a fluttering sensation in the chest, overall fatigue, and even chest pain.  However, there are individuals with a-fib who do not exhibit any symptoms with the condition discovered on a routine physical exam.         

Risk factors for atrial fibrillation include underlying heart problems such as cardiomyopathy or valve issues.  Other chronic conditions such as hypertension, diabetes, hyperthyroidism, and asthma can all increase the risk of atrial fibrillation as does age, as an individual’s risk increases with age. Surprisingly, athletes, who we tend to think of as being in good physical condition, are at risk as they may have a type of rapid heartbeat known as supraventricular tachycardia, which can trigger a-fib.  Excessive alcohol consumption can also precipitate a-fib.  Finally, atrial fibrillation is a very common postoperative complication.

The treatments available for a-fib range from medication and lifestyle changes, to a variety of procedures, such as cardioversion, insertion of pacemakers, or electrophysiological ablation.

There are several different types of atrial fibrillation, and this year, the ICD-10-CM update makes some changes to the coding of this condition.  Let’s look at the different types of atrial fibrillation before exploring the coding changes.

Paroxysmal atrial fibrillation – generally lasts less than a week, may resolve on its own

Persistent atrial fibrillation – lasts longer than a week, may require medication or cardioversion treatment
 
Long-Standing Persistent atrial fibrillation – lasts more than a year, treatment with ablation may be necessary
 
Permanent (Chronic) atrial fibrillation – this type of atrial fibrillation is generally not correctable
 
Postoperative atrial fibrillation – occurs after a surgical procedure, medication is likely treatment
 
Acute Onset atrial fibrillation – occurs suddenly and generally resolves within a day or two

Coding professionals may often see the term “rapid ventricular response” or RVR noted alongside a diagnosis of atrial fibrillation.  This term indicates that the irregularity of the atria have affected the ventricles or lower heart chambers.  This results in the ventricles beating too fast.  RVR does not impact the assignment of the atrial fibrillation code as clarified in a Coding Clinic from 3rd Qtr. 2018.  Coders should assign the code for the type of atrial fibrillation documented by the physician.
Here is a comparison of the Alphabetic Index for atrial fibrillation from 2019 to 2020.  Coders can identify the changes at a glance.  While unspecified and paroxysmal atrial fibrillation codes remain the same, the codes for chronic, persistent, and permanent underwent changes with the additions of fifth digits.  
 
 

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.

Home Hazards

by Dianna Foley, RHIA, CHPS, CCS 


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

Since the Klutz children are in so many activities once spring arrives, Mr. and Mrs. Klutz decided to take advantage of a cold, snowy weekend in February to get some spring-cleaning chores out of the way around their single-family home.  Each of the children had a task to help with as well, and true to course, each child ended up with some injury.  Let us see what transpired.

Raymond was helping his father clean out the garage by holding a large box that his father was filling with items to throw away.  Raymond had both arms under the box, which became quite heavy, but he did not want to complain, so he held the box in the same position for an hour.  By the time Raymond put the box in the dumpster, he had strained both wrists from the rather awkward position he had kept the box in. 

Little Dana suffered a strain of her big toe when she fell out of a pair of her mother’s high-heeled shoes that were going to be thrown away.  Dana could not help but want to try on the fancy shoes when she was supposed to put them in the trash.  She took them to her bedroom so she could secretly wear them.  However, she misjudged how big the shoes were and walked into a dresser in her bedroom and then fell, injuring her left toe.    

Egon carried boxes of old clothes to the attic for his mother making multiple trips up the ladder and lifting the heavy boxes overhead.  He ended up with a right shoulder strain by the end of the day.
Janine was pitching in by scrubbing and then waxing the floors in the kitchen and both bathrooms.  For several hours, she was busily scrubbing and waxing using the circular motions her mother had taught her.  By late afternoon when she was finished, it was evident that she strained both of her biceps from the day’s work.

Peter’s contribution to the spring cleaning day was vacuuming all the carpets and rugs in the house, including the bedrooms, living room, dining room, and family room.  This took several hours as he moved the furniture to sweep behind and/or under it.  The constant reaching and repetitive movement took its toll on his low back, which ended up strained by day’s end.

The Klutz children were all glad when the annual spring-cleaning was finished…for this year!


Click HERE for the answers.

Advocacy - It's in You!!

Did you know you are already an advocate?  Yes, you are.  Before I can convince you, let’s define advocacy.  "Advocacy" simply means an action taken by concerned citizens to demonstrate support for an issue. 

You as a member of both OHIMA and AHIMA advocate for our profession all the time.  Telling people about your profession and what it entails, is part of advocacy.  How many times do you have to remind someone of your role and its importance?

There are other ways that you also advocate.  I’ll briefly give you four...

First and foremost as a citizen of the United States, your most powerful advocacy tool is your vote.  Exercising your vote in presidential, congressional state and local level elections is your first step as an advocate.

Next, you advocate for the profession when you participate in petition campaigns for AHIMA. When you get the emails to reach out to your congressional leader to bring their attention to an issue that impacts our profession- that’s advocacy.

Another way you advocate is by voicing your opinion and engaging in social media.  At a bare minimum, liking a post and sharing a post that advances and/or addresses an issue for the HIM profession is advocacy.

Finally, you can take your advocacy to another level by participating in OHIMA’s Hill Day. OHIMA’s Hill Day is a biennial event that places state leader and/or members of their staff with you, their constituents. The event offers you a face-to-face opportunity to advocate for our profession just by having a conversation.  Probably that same conversation you have had with others about your role as an HIM professional.  These meetings allow you to represent the HIM profession and our professional interests by:  

• Ensuring that we are part of the decision making process,
• Building name recognition for OHIMA and HIM professionals, and lastly
• Making valuable legislative and agency contacts.

This past year, our Hill Day was held on November 20th at the Ohio Statehouse.  We had over 80 participants.  We provided 3 asks and talking points related to data collection of social determinants of health, consideration of HIM professionals expertise and advice on initiatives related to health information and financial support of current Health Information Management and Technology college programs.  We also had keynote speakers discuss health plans and HIPAA and patient-centered outcomes research institute (P-CORI). We also had a panel of advocacy professionals who gave us a glimpse into their world as advocates and tips on how to advocate.

So remember you are already and advocate.  I am certain that you have participated in at least one or more of the above that proves that advocacy is in you.

 

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.   

Coding Vaccinations

With flu season upon us, this installment of “Spotlight on CPT” presents information on coding for vaccinations.

Coding professionals who assign CPT codes for vaccinations must be aware that two codes will be needed in order to capture the entirety of the procedure; one code is for the administration of the vaccine (the actual injection itself), and the second code is for the vaccine or toxoid that is being given.  Let’s talk about the administration codes first.

CPT codes for the administration of a vaccine are broken down into two distinct groups.  The first group of codes (90460-90461) require that the physician or qualified healthcare professional provide counseling regarding the component(s) of the vaccine to the patient.  For this code group, the age of the patient is a factor with the age being through 18 years.  The second group of codes (90471-90474) are to be used when there is no counseling performed.  The breakdown of these codes is by the route of administration: either percutaneous, intradermal, subcutaneous, or intramuscular injection or via intranasal or oral route.  There is an add-on code for each of the base codes to identify any additional vaccines that may be administered.

Once the appropriate administration code has been chosen, the coding professional will need to determine the appropriate vaccine or toxoid code that should also be assigned.  In this coding step, it is important that the precise code for the vaccine/toxoid is assigned.  Different CPT codes exist for vaccines that have variations in chemical formulation (influenza vaccines for example), dosage (hepatitis A-adult vs. pediatric dosage for example), or route of administration (rabies-intradermal vs. intramuscular for example).

When assigning the vaccine/toxoid code, coding professionals should be aware that there are combination codes available.  Like with all other combination code guidelines, it is inappropriate to separately code for the individual components of a vaccine if a combination code exists.  For example, if an adult patient was to receive an intramuscular Hib-HepB vaccine, the appropriate code is 90478 and not 90739 and 90647.

As previously mentioned, it is important to assign the precise vaccine/toxoid code.  Should a coding professional encounter a vaccine that does not have a specific CPT code, an unlisted code (90479) should be reported instead.  Also, be aware that the coding for immune globulins does not fall into any of the previously mentioned categories of codes.  Instead, those codes are in the ranges of 90281-90399 (immune globulin) and 96365-96375 (administration).

Let’s look at a specific scenario in order to apply the concepts noted above.  A 60 year-old female goes to a local pharmacy to get a Shingrix vaccine.  The pharmacist administers the vaccine intramuscularly in the left shoulder and provides information on possible side effects.  The CPT codes to assign are 90471 for the administration and 90750 for the Zoster vaccine.

Now, light has been shed on coding for vaccinations.

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.

G. I. Bleeding

G. I. bleeding will the topic explored in this “In the kNOW” conversation.  Ever since Coding Clinic clarification of the term “with” in the Index a few years ago, questions have continued to arise about appropriate linking, and coding for G.I. bleeding has been part of that discussion.  

First, it is important to remember that as coding professionals we are always to rely on the Official Coding Guidelines as a primary source of information and assistance for code assignment.  In this circumstance, Section I.A.15 explains the term “with” to mean “associated with” or “due to” when it appears in one of three places:

- A Code title

- Alphabetic Index

- Instructional note in the Tabular List

The definition goes on to state that coding professionals are to assume a causal relationship between the linked terms, and unless the provider specifically indicates another cause, we are to assign the linked code even without provider documentation stating such a linkage exists.  So, in plain English, what does that mean?  If the provider states the patient is a Type 2 diabetic and has neuropathy, the appropriate code assignment would be E11.40.  

This same definition applies to coding for G.I. bleeding conditions.  Let’s look at diverticulosis as an example.  Here is the Alphabetic Index for diverticulosis:

Diverticulosis K57.90

- with bleeding K57.91

- large intestine K57.30

- - with

- - - bleeding K57.31

- - - small intestine K57.50

- - - - with bleeding K57.51

- small intestine K57.10

- - with

- - - bleeding K57.11

- - - large intestine K57.50

- - - - with bleeding K57.51

As you can see, the first entry is “with bleeding” meaning that if the physician documents the patient has a G. I. bleed and diverticulosis, the code K57.91 is correct to assign.  We can use the same reasoning to code for diverticulosis in the large or small intestine with bleeding at K57.91 or K57.11, respectively.  Coding Clinic, which is a secondary source for coding knowledge, supports this coding as well as documented in the 3^rd Qtr. 2017 publication.

The same rationale applies if we are coding multiple conditions, such as diverticulosis and angiodysplasia of the intestine, and there is bleeding.  Combination codes for both conditions exist for “with bleeding”, as seen below:

Angiodysplasia (cecum) (colon) K55.20

- with bleeding K55.21

- duodenum (and stomach) K31.819

- - with bleeding K31.811

- stomach (and duodenum) K31.819

- - with bleeding K31.811

In this case, both the diverticulosis and angiodysplasia with bleeding codes should be assigned (K57.91 and K55.21).  The same applies to upper G.I. conditions as well.

Remember that the bleeding does not have to be occurring during the admission in order to assign the “with bleeding” code.  Bleding does not have to be found during an endoscopic exam either in order to assign the code.  This is explained in the 3^rd Qtr. 2018 Coding Clinic.  

Keep in mind, that when providers perform procedures to address these bleeding issues, coding professionals should be assigning a “Control” procedure.  This is true even if the condition is not currently bleeding as documented in the 4^th Qtr. 2017 and 1^st Qtr. 2018 Coding Clinics.

 

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.