Query Tip: Choosing Reasonable Options for Response
“Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record…” Guidelines for Achieving a Compliant Query Practice (2019)
The key to choosing reasonable options for a query response is to remember that the query must stand alone. Any clinical indicators supporting the options must be included in the query itself. Below are examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.
Example of Unreasonable Query Options:
|*SOB on admission with BNP 1100 and CXR showing CHF (H&P)|
*IV Lasix given x 2 days with improvement, continued home dose at discharge (DS)
*Final diagnosis CHF exacerbation (DS)
Can you clarify the type of CHF being treated?
The type of CHF is based on evaluation of the right and left ventricular function. Tests that can show this include echocardiogram, MUGA scan, or cardiac catheterization. The measure of the left ventricle’s ability to pump (ejection fraction or EF) can be obtained from these tests. Therefore, a query for the specific type of CHF must include clinical indicators related to ventricular function, otherwise the options would not be reasonable. The coder could add the EF value, or any ventricular dysfunction as part of the clinical indicators. That would make these options for response reasonable and clinically supported.
Example of Unreasonable Query Options:
|*SOB and tachycardia on admission with H&H 5.6/20.4 (H&P)|
*PRBC x 2 with improvement (DS)
Can you specify the type of anemia being treated?
A reasonable option must be supported by whatever the coder uses as clinical indicators. There is nothing in this query to show that the patient had a history of blood loss. In fact, there is nothing in the clinical indicators to support any specific type of anemia. The coder should add documentation that refers to blood loss, either acute or chronic. If the coder feels the anemia may be related to something else, entries such as recent chemotherapy or malignancy, or use of iron supplementation may also be added. It is vital that any options for response are reasonable and clinically supported by documentation contained in the query itself.
The information contained in this query advice 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.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
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 reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.