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.
A California-based healthcare services provider and several of its affiliates have agreed to pay $30 million to resolve allegations they submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, according to the Department of Justice.
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