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.
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.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
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?
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 Kerry Atkins, CDIP, CCS‑P, COC, CPC, CPCO, CPMA, CEMC, COBGC, RMB, Physician Services Consultant at HIA, about the steps she takes to find her routine.
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.
There may be instances where a coder will suspect the patient has acute kidney injury (AKI), but the physician has failed to document the diagnosis. In another scenario, the physician may have made the diagnosis, but there is a question of clinical validity. In either case, a query would be justified.
Changes to CC/MCC designations included in the proposal could have a potentially dramatic effect on casemix. The presence of a major complication or comorbidity (MCC) or complication or comorbidity (CC) generally is representative of a patient that requires more resources.
How many times have you heard “it only takes one code to get the claim paid”? With the emphasis on the severity of illness and the move toward value-based reimbursement in today’s healthcare climate, it is more important than ever for coders to report all applicable diagnoses. There are three important pieces: what the provider documents, how to the coder interprets that documentation and codes it, and then how it is extrapolated.
The reimbursement landscape is already a complicated one – and the highly-complex claims denials process only adds fuel to the fire. A denied claim is one that has been determined by a payor to be in appropriate. Once a coding specialist amends the errors on a rejected claim, they can resubmit it for consideration. The time-intensive process has a significant impact on the cash flow for any setting in the healthcare environment. They are also very costly to appeal.
When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a coder has four choices: (1) Code the diagnosis; (2) Ignore the diagnosis; (3) Generate a query to confirm clinical validation of a diagnosis; (4) Follow the facility’s escalation policy for clinical validation.
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.
Happy National Volunteer Week! This week we celebrate the impact volunteer work has on building stronger communities. We know that our staff have a positive impact while they’re on the job, and we are proud to share a few ways our #PeopleBehindTheNumbers are taking time to volunteer in their own local communities.
Scrutiny of coding compliance in the growing ambulatory surgical center (ASC) market has increased in recent years from both Medicare and private payers. This will only increase as the Centers for Medicare and Medicaid Services (CMS) moves towards value-based care.
Patients being admitted for acute renal failure due to dehydration have been happening for many, many years now. Typically what happens is a patient gets dehydrated for one reason or another. Once dehydration sets in, it can quickly start to affect many body organs. This can lead to acute renal/kidney failure/injury.
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 Zahra Ghahremani, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
All queries require at least two elements – clinical indicators and a query question. Coders can also include multiple choice options for response or leave the query open-ended for a free text response. The order in which these elements are listed in a query is open to coder or facility preference.
Giving back is an important part of the HIA mission. Each year, HIA employees take a consensus and choose three National charities to support. Individuals can volunteer a portion of their wages to one of the three organizations. HIA Corporate will match each individual donation up to five dollars. We are proud to share with you our 2018 contribution totals combined with HIA matching funds.
One area that coders struggle with is when to report a separate condition code when an already assigned combination code includes the condition. For example, if an obstetric patient is admitted and delivers, and the physician documents “obstetric patient delivered with anemia,” should both code O99.02 Anemia complicating childbirth and D64.9, Anemia, unspecified be coded or should only O99.02 be assigned?
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 Donna Cowan, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
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. In this week’s Query Tip, we provide examples of two queries in which the options for response are not reasonable based on clinical indicators used by coder.