Falling Case Mix Have You Confused?
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. During many of our recent reviews, our findings show a big impact when it comes to case mix.
For example, Encephalopathy. Here’s how:
Case 1: Patient admitted for subtrochanteric femur fracture. The patient had operative repair of the fracture with an ORIF. Postop the patient had some confusion the provider documented “acute encephalopathy post op. Likely due to post-anesthesia.”
The coder reported the appropriate principal diagnosis and procedure code but assigned G9340, Encephalopathy unspecified, as a secondary diagnosis. Prior to October 1, 2018 unspecified encephalopathy would have been considered an MCC. The DRG would have been 480, Hip & Femur Procedures Except Major Joint W MCC, CMS weight 3.0304. Post 10/1/2018 unspecified encephalopathy is no longer considered an MCC, but toxic encephalopathy is. Documentation in the record suggests that the encephalopathy may have been caused by the anesthesia. A query to the provider to document the cause/type of the encephalopathy could impact the DRG.
- Pre 10/1/2018 – DRG 480, Hip & Femur Procedures Except Major Joint with MCC, Wt. 3.0304
- Using $5500 as the base rate $16,667.20
- Post 10/1/2018 – DRG 481, Hip & Femur Procedures Except Major Joint with CC, Wt. 2.0623
- Using $5500 as the base rate $11,342.65
- Resulting in a decrease of 0.9681 to the case weight and a reduction of $5,324.55 to reimbursement
Better documentation for the cause/type of encephalopathy could potentially support DRG 480 post 10/1/2018.
Case 2: Patient admitted for hyponatremia and encephalopathy. Documentation on the H&P stated the encephalopathy was metabolic. The coder assigned the appropriate code for hyponatremia as the principal diagnosis. The coder assigned G9340, Encephalopathy unspecified, as a secondary diagnosis.
Documentation in the H&P did support a more specific code for Encephalopathy and code G9341, Metabolic Encephalopathy, could have been reported. The more specific code for Metabolic Encephalopathy is still considered an MCC post 10/01/2018. Unspecified encephalopathy is not.
- Pre 10/1/2018 – DRG 640, Misc Disorders of Nutrition, Metabolism with MCCC, Wt. 1.1902
- Using $5500 as the base rate $6,546.10
- Post 10/1/2018 – DRG 641, Misc Disorders of Nutrition, Metabolism Without MCC, Wt. 0.7519
- Using $5500 as the base rate $4,135.45
- Resulting in a decrease of 0.4383 to the case weight and a reduction of $2,410.65 to reimbursement
Documentation in the record supported a more specific encephalopathy code. The documentation could have been better or documented more during the encounter. However, reporting the more specific code would support DRG 640 post 10/1/2018.
Educate Your Staff with HIAlearn
HIA can provide your coding staff with a comprehensive understanding of these changes via HIAlearn.
Our learning management system provides your staff with on demand access and the flexibility you need to set a training schedule that meets individual needs.
- ICD-10-PCS New Codes FY2019: This two and one half (2.5) hour session, with accompanying aptitude quiz, focuses on the additions/deletions/revisions to ICD-10-PCS, including guideline changes. This session is approved for 2 AHIMA CEUs.
- ICD-10-CM New Codes FY2019: This two and one half (2.5) hour session, with accompanying aptitude quiz, focuses on additions/deletions/revisions for ICD-10-CM for FY2018, including guideline changes. This session is approved for 3 AHIMA CEUs and/or 2.5 AAPC CEUs.
- FY2019 IPPS Changes: This approximately one and one half (1.5) hour session focuses on changes in MS-DRG assignment, reimbursement updates and MCE edits to the IPPS for FY2018. This session is approved for 1.5 AHIMA CEUs.
Our extensive Action Plan Library provides targeted and interactive sessions in an easily digestible format, including one on “Encephalopathy, Altered Mental Status, Dementia and Delirium Coding.”
The Code Hard Truth: Every Code Counts
Complete and accurate documentation + Complete and accurate coding = Complete and accurate reimbursement.
Many of our client partners have reached out to validate that their coding staff has a good understanding of the ICD-10-CM/PCS and IPPS changes with a comprehensive review.
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.
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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.
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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.
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