Briefings on Coding Compliance Strategies

Transcription

1 Your inpatient coding, billing, documentation, and regulation resource Briefings on Coding Compliance Strategies P4 P5 P7 P9 Coding Clinic for CDI Laurie L. Prescott, MSN, RN, CCDS, CDIP, writes about the latest guidance in Coding Clinic on heart failure, obstetrics, and linking language. In memory Saying goodbye to Robert S. Gold, MD. Clinically Speaking Dr. James S. Kennedy introduces himself as BCCS new Clinically Speaking columnist. Tips for reporting bronchoscopy procedures Paul Evans, RHIA, CCS, CCS-P, CCDS, gives readers ICD-10-PCS documentation and coding tips for three of the most common bronchoscopy procedures. Volume 19 Issue No. 7 JULY 2016 P10 Coding Q&A Our experts answer questions about medical record review, respiratory failure documentation, and more. PSI 90 s transformation into the Patient Safety and Adverse Events Composite by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer The fiscal year (FY) 2017 IPPS proposed rule alerted us to some significant changes to Patient Safety Indicator (PSI) 90, one of which is a new name: the Patient Safety and Adverse Events Composite. A fact sheet released by the measure s owner, the Agency for Healthcare Research and Quality (AHRQ), provides insights into what may lie ahead if the proposed rule s content is finalized. Nothing new here The underlying objective of this modified claimsbased quality measure remains the same. The Patient Safety and Adverse Events Composite provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients. The measure will also continue to be included in CMS hospital pay-for-performance programs: The Hospital-Acquired Condition Reduction Program (HACRP) will adopt the measure in FY 2018 The Hospital Value-Based Purchasing Program will adopt the measure in FY 2019 after the statutorily required one-year public posting of performance on CMS Hospital Compare under the Inpatient Quality Reporting Program PSI performance will still be assessed using an observed over expected ratio, and the risk adjustment methodology will remain the same, although comorbidity variables and coefficient weights will likely be refined PSIs in the CMS composite will change CMS has included eight PSIs in the composite used in hospital pay-for-performance programs: 3, pressure ulcer 6, iatrogenic pneumothorax 7, central line associated bloodstream infection 8, postop hip fracture 12, preop pulmonary embolism or deep vein thrombosis

2 Briefings on Coding Compliance Strategies July , postop sepsis 14, postop wound dehiscence 15, accidental puncture/laceration The modified measure will delete PSI 7 from the composite, citing duplication with other similar measures. Three of the PSIs (8, 12, and 15) will be re-specified, which means that the types of patients included in the PSIs will be revised (see Revised PSIs on p. 3). Composite weights are revised A new algorithm that considers both the volume of events and their probability of harm will be used. The graph on p. 3 illustrates the proposed impact of each PSI s performance on the overall composite weight. PSI 15, which at present comprises half of the composite weight, is reduced to 0.82%! Preparation challenges Although the HACRP will adopt this modified measure in FY 2018, performance will be based on today s discharges. Therefore, a review of the revised measure specifications and risk adjustment variables is encouraged. The challenge: The ICD-10-ready specifications for this modified version will not be ready until sometime this summer, and the risk adjustment variables are not anticipated to be ready until next year. AHRQ is evaluating ICD-10 data in its databases to finalize this information. What to do in the interim? In the meantime, we recommend the following: Continue to use the most recent measure specifications and risk adjustment variables used by CMS for the current PSI 90 cohorts A close review of the ICD-10 drafts by your CDI program experts will likely identify ICD-9 to ICD-10 mappings that do not appear to support the intention of the measure The current ICD-10-ready drafts are just that drafts and AHRQ acknowledges that they will likely be refined Review the most recent measure specifications for the proposed new cohorts (PSI 9, 10, and 11) to identify CDI risk areas This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Amanda Tyler Associate Editor atyler@hcpro.com Follow Us Follow and chat with us about all things healthcare compliance, management, and Lori Belanger, RN, BSN, RHIT Inpatient Coder/CDI Specialist Northern Maine Medical Center Fort Kent, Maine Paul Belton, RHIA, MHA, MBA, JD, LLM Vice President Corporate Compliance Sharp HealthCare San Diego, California Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM Consultant Fremont, California William E. Haik, MD, FCCP, CDIP Director DRG Review, Inc. Fort Walton Beach, Florida James S. Kennedy, MD, CCS President CDIMD Smyrna, Tennessee Laura Legg, RHIT, CCS HIM and Coding Consultant Renton, Washington Monica Lenahan, CCS Manager of Coding Education and Compliance Revenue Management Centura Health Englewood, Colorado Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of Coding and HIM HCPro Danvers, Massachusetts Briefings on Coding Compliance Strategies (ISSN: [print]; [online]) is published monthly by HCPro, a division of BLR. Subscription rate: $269/year. Briefings on Coding Compliance Strategies, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro. com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 July 2016 Briefings on Coding Compliance Strategies Revised PSIs PSI Current name New name Key change 8 Post-Operative Hip Fracture In-Hospital Fall with Hip Fracture Targets all hip fractures from inpatient falls, not just Rate postop hip fractures. 12 Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate 15 Accidental Puncture or Laceration Rate Source: Shannon Newell, RHIA, CCS. Same Unrecognized Abdominopelvic Accidental/Puncture Laceration Removes isolated calf vein DVT from the numerator as these are more likely identified in clinical screening and typically clinically insignificant. Revises eligible discharges for inclusion in measure from medical and surgical discharges to surgical discharges with abdominopelvic procedures only. In addition, only counts these reported events as an outcome of interest if the patient was returned to the OR one or more days after the index procedure. Modified PSI-90 composite weighting 30% 25% 24.13% 21.54% 20% 18.43% 15% 15.03% 10% 9.74% 5% 3.63% 4.92% 0% 0.88% 0.89% 0.82% PSI weight as % of composite Source: Shannon Newell, RHIA, CCS HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 Briefings on Coding Compliance Strategies July 2016 PSI 11, postoperative respiratory failure, has traditionally been a known CDI vulnerability Study the proposed re-specified measures to identify CDI opportunities Meet with the quality team and determine what version of measures they currently use to assess organizational performance and to get in sync on the versions impactful to CMS value-based outcomes Educate your CDI team and providers on PSI documentation needs, and tighten up operational processes to flag discharges that trigger the PSIs Don t forget that PSI 90 is a risk-adjusted measure; the capture of comorbidities for all discharges in the measure denominators is essential to reflect accurate performance Summary Strong performance in patient safety events has broad implications. Patient safety events have downstream cost and quality ramifications ranging from the cost to treat the safety event to readmissions and mortality. Data quality is an essential component to appropriate focus and measurement of patient care improvement efforts. CDI programs that have already established the infrastructure to monitor and effectively impact claims-based quality measures are likely positioned well to navigate these changing waters. Additional information can be located at ahrq.gov/news/psi90_factsheet_faq.pdf as well as aspx. H EDITOR S NOTE Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under valuebased payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at or shannon.newell@enjoincdi.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. Coding Clinic gives direction on heart failure, obstetrics, and linking language by Laurie L. Prescott, MSN, RN, CCDS, CDIP We are more than six months into the transition to ICD-10-CM/PCS, and at times it appears there are more questions than answers. The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for (The list can be found on CMS website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for (This is also available on CMS site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer. The transition to ICD-10 was not a one-time process that ended on October 1, 2015 it will continue for quite some time. As CDI specialists, we must keep informed of the new information, including the latest guidance offered by AHA Coding Clinic for ICD-10-CM/PCS. The latest release, First Quarter 2016, focused on ICD- 10-CM diagnosis codes, in comparison to 2015, which focused more on the procedure side. One thing remains constant, though: It seems like every Coding Clinic offers some guidance that makes me think, Finally, it s about time! yet also contains other pieces of advice that simply prompt more questions. Heart failure differentiation Let s start with the long-awaited direction related to differentiation of heart failure. Coding Clinic heeded the American College of Cardiology and will now allow the more current descriptions of heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) to be coded as systolic and diastolic heart failure, respectively. This guidance is highly welcomed. Obstetrics admission For those who review obstetrical cases, there is guidance related to selection of principal diagnoses related to an obstetrics admission. The condition prompting 4 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 July 2016 Briefings on Coding Compliance Strategies the admission should be sequenced as the principal diagnosis for an obstetrical patient. If there is a complication of the delivery, the appropriate code would be assigned as a secondary diagnosis. Coding Clinic provides the example of an admission for premature rupture of membranes with a laceration complicating a delivery. In such a scenario, the principal diagnosis is pregnancy complicated by premature rupture of the membranes, and a secondary diagnosis of laceration would be assigned. There is also guidance related to ICD-10-PCS code assignment for the repair of obstetrical lacerations; it instructs us to code the body part as related to the degree of the laceration or the deepest level of the repair as described (perineum, perineal muscle, rectal mucosa, and anal sphincter, for example). Linking language ICD-10-CM provides many opportunities to assign combination codes, especially those related to diabetes and the many complications associated with this condition. CDI specialists at your facility no doubt have worked diligently with providers to document the relationship using linking language. The question posed in this latest Coding Clinic asks if the provider must document the relationship between the two diagnoses or whether the coder can assume the relationship and assign the appropriate combination code. The answer provided (on p. 11 of Coding Clinic) actually left me more perplexed. It states: The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves and circulatory system. Assumed cause and effect relationships in the classification are not necessarily the same in ICD-9-CM as ICD-10-CM. Several examples provided seem to infer that the relationship between diabetes and conditions such as polyneuropathy and ESRD can be assumed, unless of course there is documentation that indicates another identified cause. Coding Clinic also reinforced the existing understanding that there is no assumed relationship between osteomyelitis and diabetes, as previously stated in Coding Clinic, Fourth Quarter 2013, p So, although the direction related to osteomyelitis reinforces previous instruction, the direction related to diabetes and other conditions of the kidneys and nervous/ circulatory systems is brand-new and not particularly clear. What conditions are assumed and what are not? Where is linking required in documentation? I hope to receive further guidance related to these examples. Review the latest Coding Clinic guidance related to diabetes and its manifestations to make sure that your CDI specialist team interprets these pieces of advice consistently. When you discover one of these shades of gray areas within the guidance, submit your questions to the Coding Clinic editorial board for clarification (they can be submitted at The only way to learn is to ask questions. H EDITOR S NOTE Prescott is the CDI education director at HCPro in Middleton, Massachusetts, and a lead instructor for its CDI-related Boot Camps. Contact her at lprescott@hcpro.com. The article originally appeared in CDI Journal. Robert S. Gold, The passing of an industry great If you ve ever read an issue of HCPro s flagship newsletter HIM Briefings, if you ve ever picked up an issue of Briefings on Coding Compliance Strategies and turned to the column Clinically Speaking, if you ve been a regular listener of HCPro s HIM or CDI audio conferences or webinars, if you re a member of the Association of Clinical Documentation Improvement Specialists (ACDIS) and subscribe to the CDI Talk newsgroup or listen to the ACDIS quarterly conference calls, chances are you ve encountered the phenomenon known as Robert Gold, MD. For the better part of 20 years, Dr. Gold has been a fixture in the HCPro and ACDIS community, authoring countless articles and several handbooks, and speaking on numerous webcasts and audio conferences. He served two terms on the ACDIS Advisory Board, helping 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 5

6 Briefings on Coding Compliance Strategies July 2016 ACDIS get off the ground by serving as an inaugural board member from 2007 to On May 11, his one-of-a-kind voice was silenced. Dr. Gold lost a battle with cancer that began last year, passing away at the age of 74. We re all saddened by his loss, and the coding and CDI communities are greatly diminished by it. A graduate of Hahnemann Medical College, Dr. Gold trained in general surgery in the U.S. Navy, where he spent his professional career as a practicing surgeon. After leaving the service, he worked as a consultant in the fields of managed care medicine, locum tenens, home health, hospital accreditation, and licensure. Later Dr. Gold co-founded DCBA, Inc. (short for Documentation Coding and Billing Accuracy). There, he quickly gained a reputation as a consultant who married clinical knowledge with coding expertise. His clinical acumen, knowledge of medical coding and billing, and easy, engaging manner allowed him to bridge the gap between healthcare delivery and the business of medicine and he did it with his own unique, caring, personal, and inimitable style. I had a chance to watch Dr. Gold at work a couple years ago. He was in town near our home office, on assignment at Beverly Hospital, and invited me to pay him a visit. There I got to see him work with a small CDI team as they reviewed patient charts together on the floor. He was a patient, engaging teacher, asking questions of the CDI nurses about the nature of the patients they were seeing and encouraging them to use their critical thinking skills through a series of probing questions. I learned a lot that day about what CDI specialists do about the difficult detective work it takes to ferret out diagnoses and comorbidities from physicians clinical decision-making and from documentation that s often incomplete and imprecise. But I also learned a lot about Dr. Gold. With the news of his passing, several tributes and remembrances made their way into our inboxes. Here is just a sampling: Dr. Gold challenged us to look through another lens, and with that, he helped us grow. He will forever be remembered, said Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, director of education at MedPartners. Certainly a legacy! A man that has challenged, inspired, and directed CDI to capturing the nature of clinical care. Always motivating change! He will be missed, but remembered, said James Fee, MD, CCS, CCDS, vice president of Enjoin. Dr. Gold was excellent with people. He never talked down to anyone. He helped doctors think outside the box, said Lamar Blount, president of American Benefit Advisors and Health Law Network. Dr. Gold has been a legend in the industry, always deeply concerned about getting the correct diagnosis reported, and calling it like he saw it. I did not always agree with his final views, but I always knew where he stood, and for that, I admired his convictions, dedication, and passion. Few were as passionate or dedicated as he. Several times he called me in order to discuss various issues. I have to say I was impressed that he would care so much to reach out to a me, a person he did not really know. May he rest in peace, said Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation at Sutter West Bay. Right up to the end, Dr. Gold was deeply involved in the healthcare industry. He was due to present at the recent ACDIS Conference. He had been working with the ICD-10 Coordination and Maintenance Committee to fix some ongoing cardiology issues in ICD-10, including proposals he had put forth to break down heart failure into right, left, and biventricular; add HFrEF and HFpEF as alternate phrases for systolic and diastolic (now passed); stratify New York Heart Association heart failure classes; add end-stage heart failure; and reclassify atrial fibrillation. He had irons in the fire at AHA Coding Clinic, seeking clarification on what he saw as imperfections in the marriage of medical codes with clinical practice. He was writing to me, and to current ACDIS Advisory Board members, regarding suggestions for reconciling current ICD-10 limitations with the newly released definitions of sepsis and septic shock. For those that got to know Dr. Gold, he revealed himself as a caring, compassionate, big-hearted man underneath his occasionally gruff exterior. On a couple occasions, he invited our CDI Boot Camp instructors out to his home in Atlanta to see his gardens and his extensive baseball card collection. 6 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 July 2016 Briefings on Coding Compliance Strategies He loved Halloween and each year decorated his home with an awesome, sprawling display of ghosts, goblins, and ghouls, delighting thousands of neighborhood children. Dr. Gold cared about the clinical truth. He cared about medical codes and the powerful truths they can convey when reported with accuracy. But most of all, he cared about people. And for that, we ll miss him. Farewell, Dr. G. H EDITOR S NOTE This letter was written by Brian Murphy, director of ACDIS, and it originally appeared on the ACDIS website. You can read Dr. Gold s obituary online at obituaries/atlanta/obituary.aspx?n=robert-stanley-gold&pid= &fhid=4904. BCCS welcomes Dr. James S. Kennedy to Clinically Speaking Allow me to introduce myself as the new columnist for the Clinically Speaking section of Briefings on Coding Compliance Strategies after the recent passing of Dr. Bob Gold. My hope is that this column will continue his legacy of helping you promote complete, precise, and clinically congruent ICD-10-CM/ PCS code assignments resulting in defendable DRG assignment and applicable severity and risk adjustment. Thank you for this privilege of writing to you; I solicit your feedback and advice. I m James S. Kennedy, MD, CCS, CDIP, CCDS, a general internist who trained at the University of Tennessee in Memphis in public and VA hospital environments from 1976 to 1983 and who practiced general medicine in Williamson County Tennessee from 1983 to My clinical experience revolved around inpatient, outpatient, and nursing home adult medicine; however, at times I would work at a walk-in clinic and evaluate urgent cases in pediatrics, gynecology, and psychiatry. While most of my work was in a suburban environment, I maintained privileges in downtown Nashville hospitals and took call in their emergency department rotations. I served as the medical examiner for my county for 14 years, witnessing accidents, suicides, homicides, and other cases of forensic interest. I also chaired our county s enhanced 911 committee that advanced emergency dispatch during the 1990s. Hospital committee assignments included medical record and utilization review, pharmacy and therapeutics, and medical executive committees. While starting as a solo practitioner in 1983 during a time before DRGs, I subsequently joined with other physicians to form a multispecialty group. Our group, for which I managed the professional billing with CPT codes, was then sold to Vanderbilt University Medical Center in 1996, where I served as a clinical assistant professor in the department of medicine. My current career in coding compliance began in 1999 after I retired from direct patient care due to an illness that moved my cheese. Upon networking with Lamar Blount, one of the principals of Hyatt, Imler, Ott and Blount, an accounting firm in Atlanta that developed the DRG Assurance program before it was acquired by 3M, I worked for his company, Healthcare Management Associates, whose clinical director was none other than Dr. Gold. My first assignment was to help rewrite the AMA s text, Managing the Reimbursement Process, and to be mentored by Dr. Gold in inpatient CDI principles. We would go to rural Georgia hospitals that were financially struggling after the passage of the Balanced Budget Act of 1997 and work with their coding and clinical staff to improve documentation affecting the old CMS-DRGs. There, we confronted terms like urosepsis, bacteremia, altered mental status, and many of the issues we still struggle with today. When I asked Lamar Blount how to best grow in my CDI career, he advised that I obtain an AHIMA CCS credential, which I did in I joined AHIMA before its membership opened to other non-him-credentialed individuals, contributed to AHIMA s initial efforts to develop clinical expertise with coders, spoke frequently in audio seminars, and eventually wrote AHIMA s text on MS-DRGs in By then I had joined FTI Consulting to develop and implement CDI principles in hospital 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 7

8 Briefings on Coding Compliance Strategies July 2016 turnaround projects and to support DRG audits and testimony as the company acted as independent review officers for healthcare entities with Office of Inspector General corporate integrity agreements. Over the past eight years, I have co-written the Minute for the Medical Staff column in HCPro s HIM Briefings (along with Dr. Gold), served on the editorial advisory board for Briefings on Coding Compliance Strategies, and authored the Present-on-Admission Handbook, the CDI Physician Advisor Handbook, and other publications for HCPro. I have also served on the ICD-10 committee for the Tennessee Health Information Management Association, as well as the ACDIS Advisory Board, and have commented on any CDI-related AHIMA practice brief I can find. Additionally, I ve supported clients in their documentation and coding integrity efforts through my company, CDIMD, outside Nashville. I still read the New England Journal of Medicine, Annals of Internal Medicine, JAMA, Mayo Clinic Proceedings, and the American College of Physicians MKSAP to maintain clinical competency, and I strengthen my coding expertise through ongoing AHIMA-oriented clinical medical education, attaining the AHIMA CDIP certification and the ACDIS CCDS certification. My special interest is the application of Coding Clinic for ICD-10-CM/ PCS to tough inpatient coding questions, and I read each Coding Clinic almost immediately upon publication. I hope you will find in this column a balance of clinical and coding perspectives that will support your work in ensuring and defending ICD-10-CM/PCS coding compliance. I m a stickler for up-to-date definitions of clinical terms, recognizing that there are differences of opinion as to what indicators support some clinical terms impacting ICD-10-CM code assignment (e.g., sepsis, functional quadriplegia, acute pulmonary insufficiency following surgery, acute kidney injury) and how the ICD-10-CM/PCS Index, Table, Guidelines, and official advice are interpreted. Know that I have tremendous respect for the National Center for Health Statistics authority in maintaining ICD-10-CM, for CMS in maintaining ICD-10-PCS and the MS-DRG system, for the Central Office for ICD- 10-CM/PCS in writing Coding Clinic, for AHIMA as a member of the ICD-10-CM/PCS Cooperating Parties, and for you in developing your relationships with providers in a joint effort to obtain clear, complete, precise, consistent, and valid documentation essential to ICD-10-CM/PCS code assignment. I will work to ensure all statements of fact in this column are appropriately referenced and will declare what is my own personal opinion, given that ICD-10-CM/PCS is not always black and white. I ll be the first to admit when I ve made a mistake; thus, if you see any error in this column, please be sure to let me or an editor know so that we can correct it. All that said, I m sure you didn t subscribe to BCCS to hear my life story, so where s the clinically speaking part of this month s column? Well, we could talk about the new Coding Clinic for ICD-10-CM/PCS, Second Quarter 2016, that came out on June 3 it emphasized the proper coding of hepatic encephalopathy (p. 35); the requirement for comparative/contrasting diagnoses as secondary diagnoses to be considered as uncertain, which must be documented at the time of discharge to be captured (p. 9); and the need to query physicians if they write diabetic ketoacidosis without stating the type of diabetes involved (p. 10); it also provided a multitude of PCS advice. Or, we could talk about the new AHIMA ICD-10-PCS query practice brief that was published in the Journal of AHIMA June 1 and available to AHIMA members at or the 2017 ICD-10-PCS codes that were released by CMS June 2 and available at Perhaps we could talk about the new definition of sepsis published in JAMA in February, available at or the compliance issues surrounding the potential need for a severe sepsis (R65.20) or septic shock (R65.21) code to ensure the clinical validity of any sepsis term documented after the definition s release. Sadly, I m out of space, so we ll have to address these in future issues. Thank you again for your attention. Please let me know what topics you would like to see in this column. I m open to your electronic mail whenever you re so inclined to send one. H EDITOR S NOTE Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact Associate Editor Amanda Tyler at atyler@hcpro.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. 8 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 July 2016 Briefings on Coding Compliance Strategies Coding corner: Tips for accurately reporting bronchoscopy procedures in ICD-10-PCS by Paul Evans, RHIA, CCS, CCS-P, CCDS Following are some ICD-10-PCS documentation and coding tips for three of the most common (and commonly misunderstood/miscoded) procedures performed via bronchoscopy. Bronchoalveolar lavage (BAL) Do not confuse this with the therapeutic procedure whole lung lavage, which is performed to treat pulmonary alveolar proteinosis under general anesthesia. A BAL is performed via a bronchoscope within the lumen of the bronchus, and involves washing within the bronchus in order to obtain a sample of fluids. It is coded to the root operation drainage because fluids are removed. Lung tissue is not obtained. According to AHA s Coding Clinic for ICD-9- CM, Third Quarter 2002, the BAL is usually performed under local anesthesia via bronchoscope and consists of washing out the peripheral airways and alveoli tissue with a rinsing (sampling) solution. About cc of saline may be introduced into a subsegment of a lobe and then with gentle suction, retrieved. The BAL specimen retrieved is sent to the laboratory for various analyses. Supernatant fluid and cell pellets from BAL are useful in the diagnosis of neoplastic diseases, infections, and interstitial lung diseases. Bronchoalveolar lavage allows the recovery of cells as well as noncellular components from the epithelial surface of the lower respiratory tract. BAL is sometimes referred to as a liquid biopsy. This is not the same as whole lung lavage therapy normally done for pulmonary alveolar proteinosis. Correct coding: BAL, RLL of bronchus = 0B968ZX. (Note: This does not impact MS-DRG assignment.) Biopsy of bronchus A biopsy of the bronchus may be obtained via a bronchoscopy. This may also be referred to as brush biopsy of lung ; however, this is a misnomer, as this lung tissue is not obtained. According to Coding Clinic, Fourth Quarter 1992, p. 27, [t]he brush biopsy is of the bronchus, not the lung. The procedure is performed intrabronchially and samples are taken from within the bronchus and not the alveolar or lung tissue. Bronchial and/or lung brushings are not performed as an open procedure(s). This is different from a transbronchial biopsy where the bronchoscope biopsy forceps actually punctures the terminal bronchus and samples of the peribronchial alveoli (lung tissue) are taken. Correct coding: Biopsy, RLL of bronchus = 0BB68ZX. (Note: This does not impact MS-DRG assignment.) Biopsy of lung A biopsy of the lung tissue may be obtained via a bronchoscopy. The physician should provide documentation in the record of a transbronchial biopsy of lung parenchyma rather than bronchial material. The wall of the bronchus is perforated. Correct coding: Excision of right middle lobe-lung = 0BBD8ZX. (Note: This does impact MS-DRG assignment.) Consider the following key points when querying for accurate documentation for bronchoscopies and/or assigning the correct ICD-10-PCS code for these procedures: Was the procedure confined within the lumen of the bronchus, or was lung tissue obtained in a transbronchial approach? Remember, the bronchi have lobes, too, so ensure the correct anatomical location for coding purposes lung versus bronchus. If the intent and scope of the procedure and type of any tissue obtained is unclear, query the physician. H EDITOR S NOTE Evans is manager of regional CDI for Sutter West Bay in San Francisco. He is also a member of the ACDIS Advisory Board and the ACDIS Forms & Tools Library Committee. The article originally appeared in CDI Journal HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 9

10 Briefings on Coding Compliance Strategies July 2016 Coding Q&A We want your coding and compliance questions! The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions. To submit your questions, contact Briefings on Coding Compliance Strategies Associate Editor Amanda Tyler at Q We have a teenager with systemic lupus erythematosus and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy. What should we choose as the principal diagnosis? Would it be the hypertensive encephalopathy and not the seizures (are seizures integral to hypertensive encephalopathy)? The patient also definitely has chronic kidney disease (CKD), but sees a nephrologist at another university hospital four hours away. The patient s glomerular filtration rate (GFR) falls into Stage 3 CKD. We are considering querying for that to link it to the hypertension. A Chronic kidney disease in children is the highest cause of hypertension, whereas in adults hypertension causes CKD, said the late Robert S. Gold, MD, CEO of DCBA, Inc., of Atlanta. Hypertensive crisis takes two possible forms (and the blood pressure is usually in the less-than-180 systolic to less-than-100 diastolic range): 1. Hypertensive urgency: Patient exhibits extremely high blood pressure without organ damage 2. Hypertensive emergency: Patient exhibits extremely high blood pressure with organ damage According to Gold, the target organs for hypertensive crises include: The central nervous system with hypertensive encephalopathy, hypertensive seizures, or hypertensive stroke The heart with acute pulmonary edema, unstable angina, or non-st-segment-elevation myocardial infarction The kidneys with CKD The patient described in this scenario was admitted and treated for hypertensive seizure (R56.9), a specific manifestation of hypertensive encephalopathy (I67.4), but code both. We will have ICD code I16.0 for hypertensive emergency in the near future. The patient has hypertension due to CKD (I15.1) coming from lupus glomerulitis (M32.14), Gold said. Hypertensive encephalopathy refers to the transient migratory neurologic symptoms that are associated with the malignant hypertensive state in a hypertensive emergency, offers Kathy (Allen) Wilson, RN, CDI specialist at All Children s Hospital in St. Petersburg, Florida. The clinical symptoms are usually reversible with prompt initiation of therapy. Encephalopathy in general means any disorder of the brain, so the use of the word hypertensive provides the etiology. For coding purposes, it is important to distinguish that this is an acute encephalopathy. In this scenario, there may be three different query opportunities, Wilson says: 1. Is this an acute metabolic encephalopathy due to hypertensive crisis? 2. Is the seizure activity due to the hypertensive encephalopathy? 3. Is the hypertension related to CKD, and what stage is the CKD? Once those questions are answered, says Wilson, you can better choose your principal diagnosis between seizures, acute encephalopathy, or renal failure depending on the answers to your queries. Editor s note: This Q&A was adapted from the Pediatric CDI Talk networking group and originally appeared in the March CDI Journal. Q Is it appropriate to assign code Y95, nosocomial condition, based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAC)? It is appropriate to assign code Y95, nosocomial condition, for documented healthcare-associated conditions. Should this still be queried for specificity, 10 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 July 2016 Briefings on Coding Compliance Strategies and should the HAC condition (i.e. pneumonia) be coded as bacterial, viral, or something else? A When the provider uses terms such as CAP, HAP, or HCAP, these would default to code J18.9, pneumonia, unspecified organism, which maps to simple pneumonia MS-DRG 193/194/195. Community-acquired pneumonia (CAP) is typically a simple pneumonia, but could also be atypical pneumonia. Both hospital-acquired pneumonia (HAP) and healthcare-associated pneumonia (HCAP) can be considered nosocomial infections, and are most commonly caused by a Gram-negative organism. Identification of the organism could move any of these from a simple pneumonia MS-DRG 193, 194, or 195 to a complex pneumonia MS-DRG 177, 178, or 179. ICD-10-CM has numerous codes that link the causative organism and the pneumonia. Use of these codes is based on physician documentation linking the pneumonia and the causative organism. Per AHA s Coding Clinic, Third Quarter 1994, we do not assign a code for bacterial pneumonia unless documentation in the medical record supports the presence of a bacteria. If the physician identifies the pneumonia as a Grampositive, mixed bacterial, or bacterial pneumonia without further specification, it would be coded to J15.9, unspecified bacterial pneumonia. We always want to obtain the etiology of the pneumonia. As the MS-DRG assignment will vary based on etiology, this may require a query. The physician s clinical opinion is sufficient to diagnose the type of infection. Diagnostic data, such as a positive sputum culture or chest x-ray, is not necessary for the diagnosis. Editor s note: Sharme Brodie, RN, CCDS, AHIMAapproved ICD-10-CM/PCS trainer and CDI educational instructor at HCPro, a division of BLR, in Middleton, Massachusetts, answered this question. Q I have a patient with stage IV lung cancer who presented with fatigue, cough, and loss of appetite. Initially, the clinicians thought he had pulmonary nodular amyloidosis, but when they did an echocardiogram on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next day the patient had a cardiac arrest. Given the pericardial effusion, they did a bedside echo during resuscitation. This showed right atrial collapse, and they performed an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but deemed terminal and later died. No definitive treatment was directed at the lung cancer. We are discussing two concerns related to this case: How to code the effusion: Our coder thinks it may be appropriate to only code C79.89 (secondary malignant neoplasm of other specified sites), but I think that J91.0 (malignant pleural effusion) should be coded. Sequencing: Our coder assigned C79.89 as the principal diagnosis. If we code J91.0, would that end up being the principal? The Official Guidelines for Coding and Reporting say that complications of neoplasm should be listed as principal. A J91.0 (malignant pleural effusion) is a manifestation code and cannot be sequenced as the principal diagnosis, says Sharon Salinas, CCS, HIM manager at Barlow Respiratory Hospital in Los Angeles. The underlying condition is to be sequenced first. Per the National Institutes of Health, malignant pericardial effusion is also a manifestation, so I think the lung KEEP CURRENT ON ICD-10! Certified Coder Boot Camp ICD-10-CM and ICD-10-PCS Attend in-person, online, or bring this boot camp to your facility. For class locations and to register go to: HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11

12 Briefings on Coding Compliance Strategies July 2016 neoplasm might have to be the principal if that is the underlying cause, Salinas says. Look also at ICD-10-CM code I30.9 for acute neoplastic pericardial effusion present on admission (POA) plus the C code for secondary malignancy POA and finally, pericardial tamponade, not POA. Coding Clinic for ICD-9-CM, Second Quarter 1989, directs coders to the Alphabetic Index entry for effusion, pericardium, which has a note to see also pericarditis and leads to options of pericarditis (with effusion), neoplastic (chronic), and acute. The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas). Unfortunately, says Salinas, ICD-10-CM lost some specificity for situations like this. Code I31.3 (pericardial effusion [noninflammatory]) isn t specifically for malignant pericardial effusion, but it comes close. I would query for acuity and for underlying cause of effusion (e.g., primary, metastatic, other, undetermined). I think you need both queries to determine the principal, she says. Editor s note: This Q&A is an example of the information shared daily amongst ACDIS members on CDI Talk, and originally appeared in CDI Strategies. Q How many people should be involved in reviewing a medical record? A With the current focus on greater efficiency, hospitals should consider the number of people reviewing precisely the same documentation but for different purposes. Utilization review (UR) specialists are screening documents for evidence of medical necessity; CDI specialists are screening the documents to identify opportunities for the physician to consider greater specificity and clarification; and medical record coders are reviewing the same series of documents to assign accurate codes for the claim forms and to comply with the broad array of regulatory reporting requirements. There is some evidence that the introduction of userfriendly CDI applications has prompted the integration of the CDI and UR specialist roles, most recently in the emergency department. In the meantime, CDI programs are becoming more sophisticated as newer applications provide physician access to CDI queries via smartphones and tablets. By streamlining the query and response process, coders will be able to shorten the time between review and dropping a clean bill. Similarly, the introduction of computer-assisted coding (CAC) applications adds a new wrinkle. Some CAC applications can highlight key clinical terms in selected documents for easy recognition by reviewers and coders. CAC applications can auto-assign an ICD-10 code, which brings the value of concurrent coding into question. Developing a method for efficiently integrating some or all three primary review activities UR, CDI, and concurrent coding is a struggle for many in the healthcare industry, and there is no best practice approach; rather, facilities must examine each record review process, identify opportunities of collaboration and areas of overlap, and develop policies for effective process management. Editor s note: This answer is an excerpt from the book The Hospital Guide to Contemporary Utilization Review. H Stay connected BCCS in your inbox Sign up for any of our 17 newsletters, covering a variety of healthcare compliance, management, and reimbursement topics, at Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to Briefings on Coding Compliance Strategies, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving Briefings on Coding Compliance Strategies, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at At the time of your call, please share with us the name of your replacement. 12 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or