Briefings on Coding Compliance Strategies

Your inpatient coding, billing, documentation, and regulation resource Briefings on Coding Compliance Strategies P5 P7 P11 Using data to drive physician engagement Various CDI professionals and ACDIS Advisory Board members comment on ways to drive physician engagement to ensure for better documentation and communication between departments. Clinically Speaking James S. Kennedy, MD, CCS, CDIP, writes about AHIMA s response to clinical validity and coding compliance. Coding Q&A Our experts answer questions about coding Resections, DRG assignment, and more. Volume 19 Issue No. 8 AUGUST 2016 Postoperative respiratory failure s introduction into the CMS value-based reimbursement model By Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult. The importance of data quality for post-procedural acute respiratory failure will impact quality outcomes linked to reimbursement under the Hospital-Acquired Condition Reduction Program (HACRP), as well as the Hospital Value-Based Purchasing Program (HVBP), if language in the fiscal year (FY) 2017 IPPS proposed rule is finalized. In this article we ll provide insights into how clinical documentation and reported codes may impact payments, and guidance on some common CDI challenges to strengthen data quality. Performance may impact reimbursement in FY 2018 A quality measure named Patient Safety Indicator (PSI) 11 has existed since 1998, when it was developed by the Agency for Health Care Research and Quality (AHRQ). The measure has been adopted for use by CMS and other comparative databases, such as the University HealthSystem Consortium and Healthgrades, to compare performance across hospitals. If the proposed rule is finalized as written, how well your hospital performs on this measure will begin to impact hospital reimbursement under the two hospital pay-for-performance programs noted above. Reimbursement impact will begin in: FY 2018 for the HACRP FY 2019 for the HVBP Performance for this measure will be assessed and scored, and the score will then be rolled into a weighted patient safety composite measure. Performance for the overall composite measure will then determine reimbursement impact. The name of this composite measure is the Patient Safety and Adverse

Briefings on Coding Compliance Strategies August 2016 Events Composite, previously known as the PSI 90 composite measure. The Patient Safety and Adverse Events Composite measure was reviewed in last month s column. What is important to note for PSI 11 is that performance for this measure will impact approximately 22% of the composite weight: Data quality and PSI 11 performance PSI 11 performance is determined by the diagnosis (ICD-10-CM) codes we submit on claims. This is a riskadjusted measure evaluated using an observed over an expected ratio. Discharges included in the measure: All elective surgical discharges treated at the hospital are evaluated for comorbidities which impact the complexity of the patient mix and the associated expected rate of postoperative respiratory failure events Note that some elective surgery procedures are excluded to eliminate discharges which represent potential coding errors and/or highrisk patients Examples of excluded discharges include those involving placement of a tracheostomy prior to the first operating room procedure, procedures for lung cancer, and discharges grouped to Major Diagnostic Category 5 (diseases of the circulatory system) 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 reimbursement. @HCPro_Inc 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: 1098-0571 [print]; 1937-7371 [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 37027. 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 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-785-9212, or email customerservice@hcpro. com. Visit our website at www.hcpro.com. 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 978-750-8400.

August 2016 Briefings on Coding Compliance Strategies Identification of postoperative respiratory events: Any discharge included in the measure which has one of the following ICD-10-CM codes on the claim triggers a reportable actual or observed postoperative respiratory failure event: A secondary diagnosis which is not present on admission: Acute post-procedural respiratory failure (J95.821) Acute and chronic post-procedural respiratory failure (J95.822) One of the following procedure codes: Mechanical ventilation greater than 96 consecutive hours (5A1955Z) Note the date of the procedure must be 0 or more days after the first major operating room procedure Respiratory ventilation, 24 96 consecutive hours (5A1945Z) Note the date of the procedure must be two or more days after the first major operating room procedure Reintubation procedure codes (0BH13EZ, 0BH17EZ, 0BH18EZ) Note the date of the procedure must be one or more days after the first operating room procedure Additional details for key measure drivers can be found on review of PSI 11 specifications located on the AHRQ website at www.qualityindicators.ahrq.gov/modules/psi_resources.aspx. PSI 11 CDI vulnerabilities In our review of thousands of medical records for hospitals across the country, we see common challenges which impact PSI 11 data quality. We discuss a few of the common questions we encounter below to assist your internal data quality efforts. How do I recognize acute respiratory failure? Acute respiratory failure is at the end of a continuum initiated by respiratory dysfunction resulting in abnormalities of oxygenation and/or carbon dioxide elimination Acute on chronic respiratory failure is an exacerbation or decompensation of chronic respiratory failure Clinical criteria to identify if not documented and/or to validate a documented diagnosis include: The use of supplemental oxygen or non-invasive/invasive mechanical ventilation Signs and symptoms indicative of increased work of breathing (e.g., dyspnea, tachypnea [respiratory rate greater than 28], respiratory distress, labored breathing, use of accessory muscles) Impaired gas exchange, which may be identified by the following clinical indicators: Patient with previously normal lungs Abnormal gas exchange -Acute hypoxemic respiratory failure (low oxygen) Abnormal gas exchange -Acute hypercapnic respiratory failure (CO2 elevation) -po2 <60mmHG (Spo2<90%) on room air, or -po2/fio2 (P/F) ration <300 -pco2 > 50 mmhg with ph <7.35. (Normal is 7.35 7.45) Patient with previously abnormal lungs (i.e., COPD) Abnormal gas exchange -Acute hypoxemic respiratory failure (low oxygen) Abnormal gas exchange -Acute hypercapnic respiratory failure (pco2 retention) Same criteria as above for patients with previously normal lungs except: The baseline represents what is normal for the patient 10 mmhg decrease in baseline po2 (if known) Same criteria as above for patients with previously normal lungs; however, the baseline represents what is normal for the patient. Generally the arterial blood ph is a more useful criteria than simply following the pco2. What is the definition of prolonged postoperative mechanical ventilation? A code for mechanical ventilation (and intubation) should not be assigned postoperatively for mechanical ventilation when it is considered a normal part of surgery. Prolonged mechanical ventilation should be reported for an extended period postoperatively. A general rule of thumb for extended is 48 hours with the start time as the time of intubation for the procedure. Provider documentation should support what appears to be an extended time, but is in fact unexpected given the procedure and/or patient complexity. 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 978-750-8400. HCPRO.COM 3

Briefings on Coding Compliance Strategies August 2016 In addition, if the duration of mechanical ventilation is less than 48 hours, but the physician documents this as prolonged and/or unexpected due to a specific problem, a code for mechanical ventilation may be assigned. When the clinical picture and/or documentation do not appear congruent, the CDI team should generate a documentation query or clarification. If the patient is extubated postoperatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate? To determine if this represents acute respiratory failure the values for impaired oxygen exchange can be utilized, along with the amount of oxygen being administered to the patient. The P/F ratio can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen: The P/F ratio is an indicator of hypoxemia. This is a useful tool when a patient is on supplemental oxygen. The P/F ratio is provided on arterial blood gas (ABG) tests. A P/F ratio less than 300 suggests acute respiratory failure. If an ABG test is not available, an estimated P/F ratio can be calculated: The calculation is po2 divided by FIO2: The FIO2 is determined by the liters of oxygen the patient is receiving expressed as a decimal (e.g., 32% is.32). An example for O2 administration by nasal cannula is provided in the table below: An illustration of the calculation follows: Patient is receiving 3L oxygen by nasal cannula, and has a po2 of 40 mm Hg. That would be 40/.32, which results in 125 (acute respiratory failure). The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen. When respiratory failure exists in a post-procedural patient, how do I determine if this is, and/or is not, related to the procedure? Physician education to promote clear documentation which relates the respiratory failure to an underlying condition (e.g., COPD) and/or to a procedure, and/or to the anesthesia, is essential. When such documentation is not clear, a documentation query or clarification is required. In addition to the above, other record review findings which negatively impact PSI 11 data quality include: Accurate reporting of mechanical ventilation duration: Given that PSI 11 is tripped when mechanical ventilation greater than 24 consecutive hours is reported, a strong understanding of how to calculate hours, and clear documentation to support that calculation, is essential. Accurate selection of post-procedural respiratory failure as the principal diagnosis: Discharges with this diagnosis as the principal diagnosis are not counted in this patient safety measure. This challenge typically manifests when patients are admitted after an outpatient procedure. Liters O2 (nasal cannula) FIO2 1 L/min 24% 2 L/min 28% 3 L/min 32% 4 L/min 36% 5 L/min 40% 6 L/min 44% Note: Hemoglobin oxygen saturation conversion to po2 is only an approximation, as several factors such as ph, temperature, and s,3-diphosphoglycerate (DPG) content may impact it. Note: Applicable to adult population Summary Value-based care will increasingly utilize claims-based measures to assess quality and cost outcomes linked to payment. To strengthen organizational performance for PSI 11, the following steps are suggested: Establish synergy between the CDI program and quality department to support: Expertise on key vulnerabilities that impact data quality Approaches to strengthen and monitor performance 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 978-750-8400.

August 2016 Briefings on Coding Compliance Strategies Promote point-of-care capture of risk-adjustment variables pertinent to PSI 11 performance: PSI 11 performance is risk adjusted, utilizing an observed over an expected ratio Accurate capture of acute respiratory failure and/or prolonged mechanical ventilation, which we discussed in this article, impacts the actual or observed value Capture of risk-adjustment comorbidities in all elective surgery patients is important for an accurate, optimal expected value Actively engage your CDI physician advisor with medical staff education and CDI record reviews to facilitate and promote accurate capture of documentation relevant to accurate cohort identification and risk adjustment H EDITOR S NOTE Stein is associate director of the MS-DRG Assurance program for Enjoin, providing clinical insight and education as part of the pre-bill review process. He earned his CCDS credential in June 2013 and completed AHIMA s ICD-10-CM/PCS coder workforce training in August 2013. 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 value-based 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 (704) 931-8537 or shannon.newell@enjoincdi.com. Opinions expressed are that of the authors and do not represent HCPro or ACDIS. Using data to drive physician engagement You are your own best teacher, or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers own records. With pay-for-performance and other quality initiatives underway as a part of healthcare reform, physicians need to see how they are performing in real time. Showing them this data in comparison to their peers demonstrates through real numbers how they stack up, says ACDIS Advisory Board member Robin Jones, RN, BSN, CCDS, MHA/Ed, system director for CDI at Mercy Health in Cincinnati. Query responses Until recently, most providers were not interested in seeing how unanswered clarifications or conflicting DRG assignment affected metrics, Jones says. CDI programs traditionally measure overall success by tracking items such as: Query rate (overall and by CDI specialist/physician) Physician response rate (overall and by CDI specialist/physician) Physician agreement rate (overall and by CDI specialist/physician) CC/MCC capture rates MS-DRG shifts Case-mix index changes This data isn t often shown to physicians, and yet, since queries represent the single most important tool for CDI programs, gleaning patterns of information from them often illuminates opportunities for improved physician support. For example, a lack of response from a particular physician might represent an opportunity for education or a change in approach, or the need for a new method of communication (e.g., notifying the physician of an outstanding query through a phone call rather than email). Mercy s CDI program lists physicians clarification response rates and places them in physician lounges for all to see, says Jones. To keep the information anonymous, the CDI team assigns each physician a number so they can quickly and safely gauge how they are performing in comparison to their peers. When physicians see their rate is lower than their peers, they hurriedly find our CDI supervisor, Jones says. Mercy also provides physicians with an individualized list of DRGs assigned to their patients, so they can crossreference that information to their own private billing. Case studies CDI programs can elevate the importance of data by tying it to case studies real scenarios relevant to patient care, says ACDIS Advisory Board member Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP, director of education at Med- Partners based in Tampa, Florida. 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 978-750-8400. HCPRO.COM 5

Briefings on Coding Compliance Strategies August 2016 Additional elements Show providers an example of poor documentation, then compare it to the same case with improved documentation and show how the improvement affects a variety of metrics, Newhouser says. Collectively, members of the ACDIS Advisory Board suggest sharing information regarding the following data points: Severity of illness/risk of mortality (ROM) Length of stay (LOS), average LOS, geometric mean LOS, and expected LOS Readmission rates Observed over expected mortality ratio Be transparent so physicians can see the benefits both financial and quality-related of precise documentation, Newhouser says. Physicians need to know that the money is important if they want to have a hospital to practice in, updated equipment, and a paycheck, she explains. But, it is imperative to remind them that while money is important, it is quality that must come first. For each metric, consider the data for the facility as a whole, and compare it to other facilities within the system or region, says Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford (California) Health Care. Sharing such information with the physicians illustrates how their documentation affects the larger hospital community. Then, drill down into the data to identify individual metrics, comparing physicians against one another within the facility and within a particular specialty or service line, says McCormack. External analysis Beyond simply showing physicians the data, CDI teams must teach providers how documentation and coding affects their personal profile as well as their facility s standing, says Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Phoenix. A host of consumer websites cull data and employ a variety of algorithms to rank physicians and hospitals many of these are well known, such as CMS Hospital and Physician Compare sites, Healthgrades, and Leapfrog. Understand how those practicing within your facility measure up in these reports and share important milestones as necessary, Schade says. When positive shifts occur that correlate with documentation improvement focus areas, tout those accomplishments and acknowledge the role the physicians play. Physicians will be engaged if they understand how documentation and coding impacts their personal profile, Schade says. Physicians are by nature competitive, and so they aim to be high achievers. CDI programs can use this to their advantage. Nuanced details of these reports need analysis, warns Paul Evans, RHIA, CCS, CCS-P, CCDS, manager for regional CDI at Sutter West Bay in San Francisco. For example, The San Francisco Chronicle recently published raw mortality outcomes data for the region. Since the paper did not understand how observed versus expected mortality plays a role in telling the story of a patient s care, its analysis left a tertiary care center in the Sutter family looking as though it had worse mortality rates than its competitors despite the fact that it treated extremely sick patients, Evans explains. You have to be careful to compare apples to apples, Schade agrees. With internal data in hand, Evans showed the high-level ROM of that facility s patients and demonstrated that the facility actually outperformed its competitors. Unfortunately, you can t explain statistics and ROM to the typical layperson, but you certainly can communicate it to your staff and to your physicians, Evans says. Data discretion Some data discretion may be warranted. Choose data elements that are most relevant to the CDI program s goals at the time, as well as targeted to the specific physicians in the audience. Remember to share success stories with data elements as they are reached. CDI managers should consider all data points and make sure the numbers they present to the physician accurately represents the message they need to convey and targets the needs of the physicians themselves, says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, director of CDI services at Enjoin. 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 978-750-8400.

August 2016 Briefings on Coding Compliance Strategies For example, if a service line that has not been responding to queries begins to consistently increase its response rate, include the improvements in that response rate along with the other metrics you present, McCormack says. You want to select metrics that will allow you to see progress as well as areas of opportunity, she says. It can be difficult to choose which data points to share, McCormack says, but sharing such concrete analysis leads to greater support from physicians overall. H EDITOR S NOTE This article originally appeared in the CDI Journal. For any questions, contact editor Amanda Tyler at atyler@hcpro.com. AHIMA pratice brief addresses clinical validity and coding compliance We as coders, clinical documentation specialists, and compliance officers, are actively invested in coding compliance, aren t we? AHIMA and ACDIS emphasize coding compliance in their codes of ethics. If we aren t interested in coding compliance, why are we reading newsletters named Briefings in Coding Compliance Strategies and other similar publications? Many coders I know code solely on what a doctor documents, claiming not to be physicians, nor having the authority to challenge a diagnosis or documented treatment by a provider. In fact, AHIMA s 2008 practice brief, Managing an Effective Query Process, emphasized that we should not query physicians if the clinical indicators do not support a provider s documented diagnosis. This practice brief stated: Providers often make clinical diagnoses that may not appear to be consistent with test results. Queries should not be used to question a provider s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed legibility, completeness, clarity, consistency, or precision. In June 2009, Johns Hopkins Bayview Medical Center, in Baltimore, Maryland, settled a False Claims Act case for $2.75 million. This happened after the DOJ said that the hospital s employees allegedly focused on lab test results which might indicate the presence of a complicating secondary diagnosis such as malnutrition or respiratory failure, and advised treating doctors to include such a diagnosis in the medical record, even if the condition was not actually diagnosed or treated during the hospital stay. STAY CONNECTED 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. While AHIMA told us then not to query to ascertain clinical validity of documentation, the United States Department of Justice (DOJ), or Health and Human Services, must not have gotten the memo. For class locations and to register go to: www.hcmarketplace.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 978-750-8400. HCPRO.COM 7

Briefings on Coding Compliance Strategies August 2016 Baptist Healthcare Inc. and its affiliated hospitals near Louisville, Kentucky, paid $8.9 million in 2011 to settle a case involving the documentation, coding, and clinical validity of respiratory infections and inflammations, pulmonary edema, respiratory failure, and septicemia. These do not include the costs of attorneys, expert witnesses, and other intangibles expended in legal defense. Visit the DOJ s website to learn more of these settlements: www.justice.gov. Although it is tempting for CDI and coding professionals to define diagnoses for providers, doing so is beyond their scope. AHIMA The Medicare Provider Quarterly Compliance Newsletter then emphasized in July 2011 that providers and facilities are to determine the validity of documented acute respiratory failure, and when the clinical indicators are not present and emphasized, Recovery Audit Contractors had leeway to change a principal diagnosis based on provider documentation. This would happen if Recovery Audit Contractors believed that the clinical indictors did not support the documented diagnosis. Read the newsletter at http:// tinyurl.com/jb5aauu, page 2. AHIMA has since changed its tune. In its 2013 Query Practice Brief, AHIMA stated that a query is appropriate when the health record documentation provides a diagnosis without underlying clinical validation. The article adds the additional statement, when a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility s escalation process. Their sample escalation policy is available at http://tinyurl.com/2013ahimaescalationpolicy. AHIMA recently stepped this up a notch by publishing a clinical validation practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members at http://tinyurl.com/2016ahimaclinicalvalidation. I encourage you to get a copy from an AHIMA member or from your local medical library and to discuss this document with your compliance officer or attorney. Given that AHIMA is one of the ICD-10-CM/PCS Cooperating Parties, their practice briefs are often quoted by the DOJ, and thus must be read closely, and if agreeable, incorporated into one s compliance plan. Several points are made in this practice brief, most of which I agree with, but some of which I do not. These include: Compliance AHIMA states: Compliance, whether it s a formal compliance department that understands compliant coding or coding management performing quality audits, can support the clinical validation process. Compliance can assist in developing a standardized query policy that applies to all who perform the query process within the organization regardless of the department in which they are located. I wholeheartedly agree; however, AHIMA does not articulate under what circumstances, or how, a facility can omit an ICD-10-CM code for a documented diagnosis that is re-authenticated by an authorized provider. I personally believe that if recovery auditors can deny codes for documented diagnoses based on their clinical judgment, then facilities should be able to do the same, particularly if they believe that the code would not survive reasonable scrutiny. I wish that they had discussed this. Clinical validation AHIMA states, it appears clinical validation may be most appropriate under the purview of the CDI professional with a clinical background, emphasizing that it is the coder s role to become more clinically astute as to refer cases to a nurse or physician advisor as necessary. I disagree to some extent. The ICD-10-CM Official Guidelines state that ICD-10-CM code assignment is a joint effort between the provider and the coder, not the provider and the CDI specialist or the CDI specialist and the coder. So, I believe that a properly trained and certified coder who is well versed in clinical terminology and definitions should be able to have the conversation with the provider alone and not have to delegate this to another individual that may not be as experienced. That 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 978-750-8400.

August 2016 Briefings on Coding Compliance Strategies said, if the coder is insecure with the situation, he or she should have a lifeline for clinical support as to ensure the validity of the documented diagnosis or treatment. Referencing clinical criteria AHIMA and Coding Clinic for ICD-10-CM both say that the Coding Clinic should not be referenced as a source for clinical criteria supporting provider documentation. I wholeheartedly agree, except in cases where no definition of a clinical term is available in the physician literature, such as with functional quadriplegia or acute pulmonary insufficiency following surgery or trauma. For these two conditions, Coding Clinic and/or the ICD-10-CM Official Guidelines are the only sources for definitions as to ensure their validity. The most recent highimpact physician literature or textbooks should be referenced when defining other clinical conditions, or when defending claims of clinical invalidity. A physician advisor can point out which references are highly respected. Coders and CDI defining diagnoses AHIMA states: Although it is tempting for CDI and coding professionals to define diagnoses for providers, doing so is beyond their scope. For example, it is not appropriate for a CDI or coding professional to omit the diagnosis of malnutrition when it is based on the patient s pre-albumin level rather than American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. Many practicing physicians have not adopted ASPEN criteria and there is no federal or American Medical Association (AMA) requirement stating that ASPEN criteria must be utilized by a physician in making the diagnosis of malnutrition. While this is technically true, given that CDI and coding professionals are not licensed to practice medicine, nor are involved with direct patient care under most circumstances, they still should be their facility s representatives to encourage the medical staff, as a whole, to adopt facilitywide definitions of challenging clinical terms (e.g., sepsis, malnutrition, acute respiratory failure). They should also monitor and encourage individual providers as they adopt these definitions in their documentation and escalate noncompliance with these definitions to physician advisors, compliance officers, or medical staff leadership. While one physician may not use ASPEN, or the Academy of Nutrition and Dietetics criteria, to define and diagnose malnutrition, I challenge readers to find any support for pre-albumin or albumin as a current clinical indicator for malnutrition, or a more authoritative criteria than that of the nation s premier association of dietitians and nutritional support teams in defining, diagnosing, and documenting malnutrition in the adult and pediatric population. Multiple-choice queries AHIMA appears to have changed the language for multiple-choice queries with this practice brief, especially when clinical validity is an issue. In an example for validating documented sepsis without apparent clinical indicators, they offered the following multiple-choice options: Sepsis was confirmed Sepsis was ruled out Sepsis was without clinical significance Unable to determine Other Exciting updates for BCCS: More content, tools, and news at your fingertips! The challenges healthcare professionals tackle each day don t wait for solutions, and neither should you. That s why BCCS is transitioning to a more frequent and robust publishing model this fall. Currently, you receive print and digital issues of BCCS on a monthly basis. Under the new model, you ll get exclusive access to brand new articles weekly on the JustCoding website. You will continue to have access to a full pdf version of the complete newsletter. 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 978-750-8400. HCPRO.COM 9

Briefings on Coding Compliance Strategies August 2016 Given that this is AHIMA s query format, we re obligated to consider it; however, this does cause some difficulties. What can a coder do with sepsis was without clinical significance or unable to determine, if that s the option the provider selects? If sepsis was without clinical significance is selected, do we not code it with the belief that the documented condition doesn t qualify as an additional diagnosis as defined in the ICD-10-CM guidelines? How many of us have run into physicians who document unable to determine as a way of avoiding the question? I believe that if any of these two options are chosen, then the record should be escalated to a physician advisor or coding manager who implements the facility s policy of coding the documented diagnosis without defendable clinical indicators. Clinical validation auditing AHIMA states, auditing a small sample (e.g., 15 records per year) of coded records by each coding professional (both contract and employed) is one way to ensure that each coding professional is given some education on clinical validation. While true, I believe that these audits should include CDI specialists, given that many are not members of AHI- MA and may not read AHIMA practice briefs, much less believe that they apply to them. AHIMA does emphasize their position as one of the four Cooperating Parties for ICD-10-CM/PCS and that this brief is relevant to all clinical documentation improvement professionals and those who manage the CDI function, regardless of the healthcare setting in which they work or their credentials. Summary In conclusion, please be sure to read this practice brief and consider how this affects your organization. Given that there are no standard definitions for at-risk ICD-10- CM/PCS terminology published by any of the Cooperating Parties or payers, and given that medical terminology used in documentation should be defined by physicians and their professional organizations, I encourage all facilities to engage with their medical staff to provide indicators for the clinical terminologies most often challenged by payers. I also would encourage facilities to develop and implement policies that ensure their validity prior to any submission of HIPAA transactions sets with appropriate boundaries and limits. 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 615-479-7021 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 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. CMS releases 2017 ICD-10-CM codes CMS has released the final list of new and revised ICD-10-CM codes available for reporting beginning October 1, 2016, with more than 2,000 changes. The files include the code descriptions in tabular order, as well as an updated index and tables for neoplasms and drugs. The new files also include a list of 39 duplicate codes. CMS publishes the lists without decimals, which has led to some ICD-10-CM codes that have the same characters as certain ICD-9-CM codes; for example, ICD-10-CM code E80.21 (acute intermittent [hepatic] porphyria) and ICD-9-CM code E802.1 (railway accident involving derailment without antecedent collision injuring passenger on railway). CMS plans to release General Equivalence Mappings (GEM) for the 2017 ICD-10-CM and ICD-10-PCS codes in August. More information on the ICD-10-CM codes can be found at www.cms.gov/medicare/coding/ ICD10/2017-ICD-10-CM-and-GEMs.html The agency has already published the 2017 ICD-10- PCS codes, tables, and updated guidelines that can be found here: www.cms.gov/medicare/coding/icd10/2017- ICD-10-PCS-and-GEMs.html. Revised ICD-10-CM guidelines are still forthcoming. H 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 978-750-8400.

August 2016 Briefings on Coding Compliance Strategies 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 atyler@hcpro.com. We want your coding and compliance questions! The mission of Coding Q&A is to help you find answers to your urgent coding/compliance questions. To submit your questions, contact Briefings on Coding Compliance Strategies Editor Amanda Tyler at atyler@hcpro.com. Q When I try to code ileostomy takedown of the small bowel resection and end-to-end anastomosis I get to code 0DBB4ZZ. Is this not a repair of the ileum and coded to 0DQB3ZZ? Coding Clinic notes the prior code not the latter, but repair means restore to previous function. A Coding Clinic states: The ileostomy takedown is coded as Excision because part of the ileum is removed, and the anastomosis is considered inherent to the surgery and not coded separately. The ICD-10-PCS Official Guidelines for Coding and Reporting state Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Assign the following ICD- 10-PCS codes: 0DBB0ZZ Excision of ileum, open approach (for the ileostomy takedown); 0WQF0ZZ Repair abdominal wall, open approach (for parastomal hernia repair and stoma closure.) The definition of repair is repairing to the extent possible, a body part to its normal anatomic structure and function. I agree that the takedown does seem to fit the definition of a repair but, per the Coding Clinic, it is coded to the root operation of excision. The ICD-10 code set was designed to assist with standardization of healthcare data for use with reimbursement and statistical analysis which can be applied to quality measures, research, and demographic analysis. If we each choose to use these codes as we interpret them versus how the Cooperating Parties direct us to, the data would be useless. There are times that the coding instructions do not appear to make sense or clinically support the situation, but we are required by law to apply these rules consistently. We must do our best to follow the instructions as provided and the instruction regarding how to code a colostomy takedown within the Coding Clinic is very clear as being an excision versus a repair. We can, however, challenge this logic by submitting a Coding Clinic question to its editorial advisory board for further clarification. Questions can be submitted here. You receive a reply usually within a few weeks. And, Coding Clinic advice does change over time, as new concerns are brought to life. The most recent instruction will trump any previous advice, and any conflicting advice given in preceding years will become null. But until changes are provided, we must follow the instruction given. This can be frustrating but we must work to support the integrity of the code set. Q What exactly are DRG 067 and 068; nonspecific cerebrovascular accident (CVA) and pre-cerebral occlusion without infarct? How is it different than transient ischemic attack (TIA) or CVA? A Diagnosis-related groups (DRGs) assist us in classifying patients into one of the 751 different groups depending upon the identified principal diagnosis (reason for admission) and any secondary diagnoses identified as complications and comorbidities. The performance of a procedure can also influence the DRG assignment. The conditions grouped in each MS-DRG category are expected to require the same level of hospital resources. Thus your organization is paid a flat fee that is assigned to the specific DRG grouping. Each DRG has a list of specific diagnoses contained within that grouping. DRG 067 and 068 are two of the 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 978-750-8400. HCPRO.COM 11

Briefings on Coding Compliance Strategies August 2016 three diagnostic groupings that encompass admissions related to TIAs and occlusion or stenosis of pre-cerebral and cerebral arteries; others include: DRG 067/068: assigned for patients admitted with the diagnoses related to an occlusion and stenosis of pre-cerebral or cerebral arteries, not resulting in a cerebral infarction. DRG 69: assigned for an admission for a TIA; there are 13 different diagnoses that map to this DRG that differ related to the location of the TIA. DRGs 061, 062, 063: assigned to patients admitted with a cerebral infarction and receives administration of thrombolytics. DRGs 064, 065, 066: assigned to patients with a cerebral infarction and thrombolytics were not administered at that facility. Q The coders at my facility have stated auto linking congestive heart failure (CHF), hypertension (HTN), and chronic kidney disease (CKD) to the combination code without any documentation of CHF due to HTN. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record. I referenced the Coding Clinic, Fourth Quarter 2008, which states that unless a causal relationship exists between the heart condition and the hypertension and the physician documents this relationship in the record each condition requires its own code, and if the documentation does not make that link, an HIM/coding professional must code the two conditions separately. I understand that ICD-9 Coding Clinics may not apply in ICD-10, but I cannot find any updated guidance. Our coders are going by the Coding Clinic, First Quarter 2016, which still uses the phrase due to. A I know of no updated instruction that allows heart disease and hypertension to be an assumed relationship. We teach that the provider must clearly state the heart disease is due to (related to, secondary to, etc.) the hypertension. Of course, the relationship between CKD and hypertension is a combination that can be assumed if found to be present. For the patient that has the trifecta is hypertensive, and has heart failure and kidney disease we still need the provider to clearly state the relationship between the heart disease and the hypertension. EDITOR S NOTE Laurie L. Prescott, RN, MSN, CCDS, CDIP, is an AHIMA-approved ICD-10-CM/ PCS trainer and CDI education director at HCPro, a division of BLR, in Middleton, Massachusetts. She answered the previous three questions, portions of which were included in the CDI Journal and CDI Strategies. Q A How do you suggest we manage the need to give the MN notice after 24 hours of care? That s going to be a challenge and certainly you re going to have to be watching the clock, because you re counting for the 2-midnight rule based upon the time the patient began to receive outpatient services to determine when the patient needs to be admitted you re also counting based on when the patient first began to receive observation services to determine the number of hours to be billed. But when you re counting for the time frame to issue the MN, you re counting from the date and time the physician gave the order to provide observation services. The 2-midnight rule is talking about midnights and the MN is talking about hours, so we really have some conflicting time frames here that could be incredibly confusing. Don t get those three issues confused. You still want to count, not from the beginning of the order, but from the beginning of the service for your inpatient determinations. For the determination that a patient needs to receive a MN, you start counting toward or at the time of the order. First of all, you have to decide who is going to be responsible for issuing the notice and counting the various time requirements. Your electronic record may be able to alert you at 24 hours from the time of the observation order that the MN must be given and then perhaps it could also warn you when the 36- hour time period is about to expire and the MN must be given if it has not already been. I think you re going to need some electronic notices and if you re going to rely on the nursing, case management, or utilization review staff to issue these MNs, then I recommend doing some role-play to ensure that they understand how and when to deliver the notice. H EDITOR S NOTE Deborah Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Oklahoma, answered this question, which was submitted to the Revenue Cycle Daily Advisor. 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 978-750-8400.