Top 5 ProFee Diagnosis Review Findings in 2018
In 2018, we conducted thousands of ProFee reviews from many different specialties for our clients. Below are the top five ProFee diagnosis changes HIA uncovered.
- I10 – Essential (Primary) Hypertension
- E11.9 – Type 2 Diabetes Mellitus Without Complications
- K29.60 – Other Gastritis Without Bleeding
- R13.19 – Other Dysphagia
- I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris
I10 – Hypertension:
Many of the changes to I10 (hypertension) were due to not following the official coding guidelines when the patient also has heart disease and/or kidney disease. ICD-10-CM assumes a relationship between hypertension when the patient has heart disease or kidney disease. The two conditions are linked by the term “with” in the Alphabetic index. These conditions should be coded as related unless the provider specifically states that they are not related or documents a different cause for the kidney or heart disease.
- ICD-10 Official Guidelines: Section I. Conventions, general coding guidelines and chapter specific guidelines, C. chapter-Specific Coding Guidelines. 9. Chapter 9: Disease of Circulatory System (I00-I99) a. Hypertension
- Hypertension, Diabetes and Chronic Kidney Disease, coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018; Page 88-89.
E11.9 – Type 2 Diabetes Without Complications:
As with hypertension changes, many of the changes to E11.9 (Type 2 Diabetes w/o complication) were related to conditions that are presumed to be related to diabetes. These fall under the “with” guidelines. Review the Alphabetic index for any condition that is presumed to be related to diabetes (chronic kidney disease, foot ulcer, gangrene, etc.).
- ICD-10 Official Guidelines: Section I. Conventions, general coding guidelines and chapter specific guidelines, C. chapter-Specific Coding Guidelines. 4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) a. Diabetes Mellitus
- A. Conventions for the ICD-10-CM – Coding Clinic, Fourth Quarter ICD-10 2018 Page: 57
K29.60 – Other Gastritis Without Bleeding:
Changes to K29.60 (Gastritis w/o Bleeding) were also related to the “with” guideline. This is a change from previous guidance given for ICD-9-CM coding. Prior to the “with” guideline for ICD-10-CM coding, it was suggested to query the provider to confirm the cause of the bleeding if the relationship was not stated in the record. Now, since the tabular index lists Gastritis “with” bleeding it would be appropriate to code gastritis with bleeding, unless the provider states the bleeding was not due to the gastritis. In addition to the “with” guideline, remember there are codes for the specific type of gastritis. Make sure to code the most specific code if appropriate.
- ICD-10 Official Guidelines: Chapter 20: Disease of the Digestive System
- Conventions for the ICD-10-CM – Coding Clinic, Fourth Quarter ICD-10 2018 Page: 57
- Gastrointestinal Bleeding due to Multiple Possible Sources – Coding Clinic, Third Quarter ICD-10 2018 Pages 21-22
- Hematemesis due to Ulcerative Esophagitis and Duodenitis – Coding Clinic Third Quarter 2018 Pages 22-23
R13.19 – Other Dysphagia:
Specificity resulted in many of the changes to R13.19 (Other Dysphagia). In reviewing the accounts, documentation supported the specific type of dysphagia (functional, hysterical, neurogenic, etc.) or that dysphagia was a result (following) another condition (CVA, intracerebral hemorrhage, etc.). Coders must always review the entire encounter to assure they are selecting the most specific code. If the dysphagia is following a specific condition, such as a CVA, make sure to select the appropriate code to reflect this condition.
- ICD-10 Official Guidelines: Cerebrovascular Accident and Disease, C. Chapter-Specific Coding Guidelines, d. Sequelae of Cerebrovascular disease
- Dysphagia – Coding Clinic, Fourth Quarter 2007, Page 92 to 94
I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery (CAD) Without Angina Pectoris:
Changes to this code were a result of documentation that the patient had angina. Under ICD-9-CM angina was coded separately from coronary artery disease (CAD). Under ICD-10-CM there is a code for CAD without angina, and codes to reflect if CAD is with angina and the type of angina. Make sure to review the index and select the codes that are appropriate to reflect if CAD is with or without angina.
- ICD-10 Official Guidelines: Diseases of the Circulatory System, Chronic Ischemic Heart Disease
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.
In June CMS released the final ICD-10-PCS codes for FY2022, which begins October 1, 2021. We are giving you a sneak peek at the changes. HIA will have a full educational module on these changes available later this summer.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits…
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES).
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 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 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
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.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.