Coding & Quality Measures: The Code Hard Truth
In this current, ever-changing healthcare climate, health systems face many challenges. Facilities large and small must be dedicated to improving documentation and reducing complications, HACs, infection rates, and readmissions as they endeavor towards value-based care.
Coding inaccuracies can really undermine progress.
Here’s some examples:
- There’s no “one size fits all” code for HACs. In the case of UTI, coders must first explore the medical record to determine if the infection was present on admission. Next, they must ask was the infection related to a catheter inserted in the hospital? Or was it unrelated to the catheter insertion? Ultimately, if the documentation is unclear and the physician is not properly queried, the probability for an inaccurately coded UTI increases dramatically.
- When a postoperative complication such as acute respiratory failure is assigned incorrectly, it can really put a chokehold on your facility’s quality measures. Some patients take longer than others to postoperatively wean from a vent depending on several factors. Experienced coders know to examine the record for documented clinical indicators supporting acute postprocedural respiratory failure before assigning that code to a patient who is simply taking more time to wean from the vent. To do so would be indicating that PSI11 was met.
- In cases of an intraoperative laceration of a digestive system organ, for example, coders must first be able to determine whether a rent or laceration was an expected result of a procedure or if it was unintended or an accident. Also, did the physician document the rent or laceration as a complication? It’s imperative that the coder read, understand and interpret the entire operative note for the codes to reflect the whole story.
- Imagine the following 30-day Mortality scenario: a Medicare patient is admitted to ICU with severe shortness of breath. The physician has documented “probable pneumonia, rule out PE” on the admission note. The history and physical reveals the patient had just finished oral antibiotics from outpatient treatment. However, the patient was admitted at this time for pulmonary embolism. At the end of the second day, the patient expires from the pulmonary embolism during his/her stay in the hospital. There is no further documentation of pneumonia in the record. In this case the difference between assigning J18.9, Pneumonia NOS or I26.99, Pulmonary Embolus as the principal diagnosis can trigger the 30-day mortality measure for patients admitted for pneumonia. An experienced coder knows to assign the PE code as the principal diagnosis and omit the code for Pneumonia NOS since the record states the patient was admitted for PE and there was no further documentation of Pneumonia.
- When a postoperative complication such as blood loss following joint replacement is assigned incorrectly, it can really drain your facility’s quality measures. A good example is a case where a patient requires a transfusion during a routine hip replacement and subsequently presents with symptoms of post hemorrhagic anemia. The experienced coder knows a certain amount of blood loss is expected during a routine arthroplasty. Incorrectly assigning code M96.830, Postprocedural hemorrhage of a musculoskeletal structure, without supporting documentation from the surgeon, could trigger Medicare’s Hospital Compare quality measure “Complication rate for hip/knee replacement patients”, as well as, AHRQ PSI 09, “Perioperative Hemorrhage or Hematoma Rate.” Proper assignment would be one code, D62 “Acute post hemorrhagic anemia” if the surgeon did not note problematic post-surgical bleeding in the medical record.
The Code Hard Truth
Coding inaccuracies like these can not only directly impact a healthcare facility’s quality measures, but also its bottom line.
HIA’s mantra is every code counts. Our comprehensive review service validates each and every code, all DRG/APC assignments and identifies educational opportunities for coders, CDI specialists and providers alike.
Don’t let imprecise coding infect your progress.
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but there are helpful treatments and resources for quitting.
This is Part 5 of a five part series on the new 2019 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY 2019 and include examples to help the coder understand the new codes. There is 1 new lymphatic code, 2 new digestive system codes with 3 deletions, 3 new urinary system codes with one deletion and 7 deleted nervous system codes with 2 revisions.
This is Part 3 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 9 new cardiovascular CPT codes added with 2 deletions and 3 revisions.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Tilina Sablan, RHIT, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
This is Part 2 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 4 new musculoskeletal CPT codes added with 2 deletions and 0 revisions.
This is Part 1 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There were 15 new integumentary CPT codes added with 3 deletions and 1 revision.
In part 5 of our series, we look at DRG 64—Intracranial hemorrhage or cerebral infarction with MCC. For this DRG recommendation the majority (almost all) were recommended to DRG 65 (Intracranial hemorrhage or cerebral infarction with CC) with deletion of the reported MCC.
The majority of the recommendations from DRG 190 (Chronic obstructive pulmonary disease w/MCC) was to DRG 189 (Pulmonary edema and respiratory failure) with re-sequencing of respiratory failure as the PDX or adding as a new code and sequenced as PDX.
The majority of the recommendations from DRG 853 (Infectious & parasitic disease with O.R. procedure with MCC) were to DRG 871 (Septicemia w/o MV 96+ hours with MCC) with deletion or revision of the PCS code. Some of these required physician query.
The majority of the recommendations from DRG 872 (Septicemia w/o mechanical ventilation 96+ hours w/o MCC) were to DRG 871 (Septicemia w/o mechanical ventilation 96+ hours with MCC) with the addition of an MCC to the account. Not all of these required a physician query and were present in the medical record documentation without any clarification needed prior to coding.
The majority of the recommendations from DRG 871 (Septicemia w/o MV 96+ hours with MCC) were to DRG 872 (Septicemia w/o MV 96+ hours w/o MCC) with the recommendation to delete the reported MCC or query for clarification to support the MCC that had been reported.
Every year, we make plans to live a healthier, more organized, and balanced life. For some of us, we end up falling short of those expectations. This year, to keep us on track with our New Year’s goals, we have put together a few of the most common New Year’s resolutions along with their ICD-10 diagnoses codes. Check out our tips and tricks for a healthy 2019!
Top 5 ProFee diagnosis changes found in recent HIA reviews: 1. I10 – Essential (Primary) Hypertension; 2. E11.9 – Type 2 Diabetes Mellitus Without Complications; 3. K29.60 – Other Gastritis Without Bleeding; 4. R13.19 – Other Dysphagia; 5. I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris.
What is the principal procedure? The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. Procedures for diagnostic or exploratory purposes that are performed in addition to a procedure being performed for definitive treatment, would be reported in addition to the principal procedure.
A query question that is directive in nature, indicating what the provider should document, rather than asking for his/her professional determination of clinical facts, constitutes a leading query. The provider should not be made to feel obligated to document anything.
When I start coding a chart, I enter all account information in log and do any abstracting—disposition, admitting, and attending—take care of all of that first. ED, H&P, consult, progress reports, and discharge summary.
Some Speed Reading Tips: Once you start reading, don’t stop! Read the text straight through. If you have any question after you have completed reading the material, go back and reread the relevant sections. Reread the marked sections of the text (the items you indicated that you didn’t quite understand). Write a small summary at the beginning of the chapter – consisting about 3-4 sentences.
A burr hole is a small hole that is made in the skull with a drill by the surgeon. First, (after prepping the site) the scalp is cut (incised) at the desired location by the surgeon. The surgeon will then drill 1 or 2 small holes in the skull at this area to reach the dura.
In HIA quality reviews we are finding that some coders are reporting Z41.2—Encounter for routine and ritual circumcision, during the male newborn birth admission, when circumcision is performed prior to discharge.
The cause/etiology of GI bleeding is not always easily determined. During procedures, to work the bleeding up, there are often multiple potential sources of bleeding found but not identified as the culprit. Many of these findings have “with” or “in” in the main or subterms.
On December 1, 2018, the HIA team based at our headquarters in Pawleys Island, South Carolina received a visit from a surprise guest – meet Otis, HIA’s very own Elf on a Shelf. Otis will be sticking around until Christmas to keep an eye on all of us. We have a feeling he may get into some trouble! Check back daily to see what Otis is up to. #OtisOnOtisDrive
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Crystal Junkins, CCS, CPC, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
Tissue findings interpreted by a pathologist are not equivalent to the attending physician’s medical diagnosis based on the patient’s clinical condition. If the attending physician has not indicated the significance of an abnormal finding within a pathology report…
It’s that time of the year where HIM professionals take a peek at what changes are coming for CPT in the new year, 2019. Did you know that CPT started in 1966 with about 3,500 codes? For 2019, there are a total of 10,294 CPT codes.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Amy Pang, RHIA, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
For FY 2019, ICD-10-CM has added a new code for reporting of lacunar cerebral infarction. This is good news for coders since we see this specific type of cerebral infarction documented often. The new code that is reported for lacunar infarction is I63.81 —Other cerebral infarction due to occlusion or stenosis of small artery.
In 2003, the Centers for Medicare and Medicaid Services (CMS) implemented Risk Adjustment Factors (RAF) and Hierarchical Condition Category (HCC) coding to identify individuals with serious and/or chronic illnesses and assign them a risk factor score that is based on a combination of demographic information and reported diagnoses.
The ICD-10-CM/PCS code changes – effective October 1, 2018 to September 31, 2019 – could be the culprit. Comparatively speaking, there are far less changes this year than in years past. The release includes: 279 new codes, 51 deleted codes,143 revised codes. But don’t let the smaller amount of changes fool you…