Learning Objectives. Denver Health Medical Center. Complex Coding Scenarios and Resolution

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1 Complex Coding Scenarios and Resolution Eric Ryland, MS, RHIA, CCDS, CHDA, CCS, CPC Manager of Coding Denver Health Medical Center Denver, Colo. 2 Learning Objectives Denver Health Medical Center Evaluate difficult coding scenarios Describe the complexity of each scenario and how to resolve the documentation/coding issues Identify relevant ICD-10 documentation issues for each scenario Implement lessons learned from case study review DHMC is a 477-bed Level One Trauma Center CDI & coding are in the HIM department CDI team CDI nurse manager 4 CDI nurses Medicare charts reviewed expanding to other areas Coding team Coding manager 30 coders 3 4 For questions please contact HCPro customer service at

2 Today s Objectives Present coding scenarios These are actual cases we encountered involving much discussion and review Present the complexity of each scenario Present relevant ICD-10 information to each issue Summarize lessons learned & opportunities Scenario One Core measures vs. reimbursement Presentation Shortness of breath Pulmonary edema Diagnosis CHF POA Y Pneumonia POA Y Both the CHF & pneumonia treated 5 6 Initial Coding Core Measures Component DRG 291 Heart Failure & Shock w/ MCC Weight Principal diagnosis CHF Secondary diagnoses Pneumonia 486 Acute Renal Failure Diabetes After coding and billing it was determined that this account was failing core measures The final medicine reconciliation was performed by a pharmacist rather than a physician Coding was asked, If, since both CHF and pneumonia were present on admission, couldn t the pneumonia be made the principal diagnosis? 7 8 For questions please contact HCPro customer service at

3 DRG Comparison DRG 291 Heart Failure & Shock w/ MCC Weight In this scenario the account would fail core measures DRG 194 Simple Pneumonia & Pleurisy w/ CC Weight In this scenario the account would pass core measures How would you address this situation? Scenario Two Coder interpretation of documentation Admitting diagnoses Chest pain Hypoxia Volume overload 9 10 Progress Notes Progress Notes Day one SOB: O 2 up 2L from 1L NSTEMI: ASA 81, check TTE N/V/D Day two SOB: pleural effusion transudative NSTEMI: Trop peaked at 0.63, ASA 81, BB GERD: continue PPI Severe malnutrition: Nutrition consult Day three Recurrent transudative pleural effusion NSTEMI: on ASA & B Blocker Severe malnutrition GERD Day four Hypoxia 2/2 pleural effusions, S/P thoracentesis CAD/NSTEMI: continue ASA/metoprolol GERD For questions please contact HCPro customer service at

4 Discharge Summary Discharge Summary Detail Discharge diagnoses 1. Pleural effusion 2. NSTEMI 3. Lower extremity edema 4. GERD 5. Anemia 6 Depression 7 Insomnia 8 Chronic pain Diagnosis 1: Pleural effusion Patient presented shortness of breath. A chest x-ray showed persistent bilateral pleural effusions. Thoracentesis was performed; 1.4 L of straw-colored fluid removed. Patient s pleural effusion was consistent with a transudative effusion Discharge Summary Detail Diagnosis 2: NSTEMI Patient had a troponin of 0.40 in the emergency department. It peaked at 0.64 before trending down. Her troponin leak was attributed to likely demand ischemia from a fixed coronary defect. Transthoracic echo was done, which showed no wall motion abnormalities and no evidence of decreased left ventricular function. Patient was started on aspirin 81 mg p.o. daily and metoprolol 12.5 mg p.o. b.i.d. EKG was significant for normal sinus rhythm and Q-waves in the leads 3, avf, and V1 through V4. Why Is This Complex for the Coder??? What would be the principal diagnosis? Is this clear from the documentation? Is this a query opportunity? How does the phrase you don t know what you don t know apply? What is the CDI opportunity from this scenario? For questions please contact HCPro customer service at

5 Scenario Three Final Codes Multiple fractures & procedures Patient is a restrained passenger in a motor vehicle crash with another car at an intersection Patient sustained multiple fractures Procedures performed: ORIF of humerus Closed reduction of dislocation of shoulder Suture of tendon Closed FX of upper end of humerus Other pulmonary insufficiency Closed FX, eight or more ribs Pneumothorax, without open wound Closed FX of sternum Contusion of heart w/o open wound Intrathoracic organ injury w/o wound Pulmonary collapse Sprain of unspecified site of shoulder What s the Principal Diagnosis? How Do We Code This? DRG 493 Lower Extremity & Humerus Procedure Closed FX of upper end of humerus Sprain of unspecified site of shoulder DRG 982 Extensive OR Procedure Unrelated to Principal Diagnosis Other pulmonary insufficiency Closed FX, eight or more ribs Pneumothorax, without open wound Closed FX of sternum Contusion of heart w/o open wound Intrathoracic organ injury w/o wound Pulmonary collapse Is the choice of principal diagnosis clear? Do you query? Is so, what would you query? DRG 982 has been a target of RAC audits Procedures unrelated to principal diagnosis DRGs 981, 982, 983, 987, 988, For questions please contact HCPro customer service at

6 Multiple Fractures ICD-10 Multiple fracture sequencing Multiple fractures are sequenced in accordance with the severity of the fracture. The provider should be asked to list the fracture diagnoses in order of severity. ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1, 2011 With ICD-10 due to start on October 1, 2014, it is important to consider now the documentation and coding issues surrounding it. What are the ICD-10 rules in this scenario? What are the ICD-10 documentation issues with coding this scenario? Scenario Four Progress Notes Exclude notes & POA status An 11-year-old female arrives at the hospital with RLQ abdominal pain. It is determined the patient has appendicitis and is taken to surgery. A laparoscopic appendectomy is performed, and the surgeon documents acute appendicitis with perforation of appendix. Day two Patient was febrile overnight with leukocytosis. Day three An abdominal CT is performed showing pelvic abscess formation in the pelvis at site of appendectomy. Treating physician documents perforated appendicitis with persistent fevers and abscess formation For questions please contact HCPro customer service at

7 What Is the Principal Diagnosis? Questions Acute appendicitis with generalized peritonitis Excludes Acute appendicitis with peritoneal abscess Includes generalized peritonitis Peritoneal abscess Excludes What condition was present on admission? What condition developed later in the stay? Are two codes required or just one? How does POA status apply in this situation? Coding Clinic Guidance Coding Clinic Guidance Question: In the May-June issue of Coding Clinic for ICD- 9-CM, I question the answer given on page 13 regarding the use of rather than in the case of ruptured appendicitis with abcess. Both and should be used since one code will not cover both rupture and abcess. Answer: Localized perforation (rupture) leads to formation of appendiceal abcess, Category code 540 classifies the acute appendicitis and code includes perforation leading to abcess. Coding Clinic, November-December 1984, p. 19, American Hospital Association (AHA), Chicago, IL For questions please contact HCPro customer service at

8 What About the POA Status? ICD-10 Combination codes Assign N if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission) ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1, 2011, p. 100 of 107 What are the ICD-10 implications of this scenario? How are excludes notes handled differently? What is the situation with combination codes? Is POA status handled the same? Scenario Five Documentation Review Observation vs. inpatient status Patient presents with shortness of breath Patient t is admitted d to rule out pneumonia Physician notes on H&P probable pneumonia and treats with antibiotics; chest x-ray notes lung infiltrate Physician then writes an order to change the stay to an observation and the patient is discharged later that same day 31 From the H&P we have: Probable pneumonia documented Clinical evidence of a lung infiltrate Treatment with antibiotics The physician s final note states probable pneumonia 32 For questions please contact HCPro customer service at

9 Opportunity for Improvement ICD-10 Documented as it is, how would this observation account end up being coded from just the documentation available? Are the physicians aware of how probable and rule-out diagnoses are treated differently for coding purposes on outpatient accounts? What are the CDI and the coder opportunities for improvement in this scenario? What are the ICD-10 considerations with this scenario? How are probable diagnoses handled in ICD-10 for outpatient and inpatient accounts? Are retrospective queries handled the same in ICD-10? Scenario Six Auditor denial A denial letter was received from an auditor questioning the coding of Acute Renal Failure as a secondary diagnosis Acute renal failure was documented throughout the chart and addressed specifically in the discharge summary The auditor was questioning the appropriateness of the physician s diagnosis Discharge Summary Problem #2) Acute Renal Failure: The patient was found to have acute renal failure with a creatinine of 1.3 that improved to 1.0 with normal saline. The patient s acute renal failure was secondary to her urinary tract infection and prerenal hypovolemia For questions please contact HCPro customer service at

10 Auditor s Guidance What Is a Coder to Do??? While it is not the coder s responsibility to question a physician s clinical judgment, it is the coder s responsibility to validate diagnosis and/or procedure codes submitted for reimbursement purposes. While a condition may be consistently documented, it is the responsibility of the coder to ensure that all assigned codes are supported by clinical evidence that the condition(s) exists and is supported prior to code assignment. From the denial letter To a large extent, the coder needs to rely on what the physician documents as a diagnosis Coders are advised to query in situations where the documentation is unclear, ambiguous, or contradictory, and in situations where a treatment is given without a diagnosis The coder should not be in a position of challenging the physician s clinical diagnosis with a retrospective query Is This a New Trend in Denials? What Can CDI Professionals Do? Over the past year we have received several denials from different auditors questioning the validity of a physician s documented diagnosis This seems to be a new area of focus that we have not encountered before We believe this will continue to increase as additional ways of reviewing coding and documentation are sought out Strive to ensure that all diagnoses are documented Seek to validate any diagnosis deemed to be questionable Focus on areas of documentation or diagnoses that are under frequent review by auditors Work with the coders to help them better identify weaknesses in the clinical documentation For questions please contact HCPro customer service at

11 Scenario Lessons Learned Core measures vs. reimbursement Coder interpretation of documentation Multiple fractures & procedures Excludes notes & POA status Observation vs. inpatient Auditor denial Thank you. Questions? Eric Ryland, MS, RHIA, CCDS, CHDA, CCS, CPC In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook For questions please contact HCPro customer service at