Common ICD-10 Coding Errors Found in Audits: Part 3
The following is the third installment in a six-part coding education series from our Executive Director of Education, Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC. In this series, Patricia reviews common ICD-10 CM and PCS coding errors discovered in audits and how they may impact reimbursement. Part three in our series takes a closer look at Accidental Intraoperative Laceration, SIRS due to Infection vs. Sepsis, and Observation to Inpatient Admission.
7. Accidental Intraoperative Laceration
Example: K91.71, Accidental intraoperative laceration of digestive system organ during procedure on digestive system
Coders are often over coding/reporting when physician documents that the laceration was expected/incidental/anticipated during difficult lysis of adhesions.
Coders are not always reporting or querying MD for intraoperative lacerations due to CDI or other directive at facility when apparently significant. At the very least a query should be done on any questionable intraoperative lacerations as to whether or not they are truly complications or expected/incidental/anticipated lacerations
8. SIRS due to Infection vs. Sepsis
There is no index entry for systemic inflammatory response syndrome (SIRS) due to infection. (do not automatically translate to sepsis).
Coders must not assume SIRS due to infection is coded to sepsis without query.
- Clinical indicators must be met to query
- Coding Clinic 3Q 2014 page 4
Severe sepsis and septic shock must be documented in order to assign these codes.
SIRS of non-infectious origin is coded R65.10 or R65.11. Assign underlying cause as PDX!
There is also new Sepsis criteria:
Note that this is CLINICAL criteria. No directives for coding have been released by the cooperating parties and CMS Quality Measures are still tied to older Sepsis criteria.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
- In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.
- Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with signs including alteration in mental status, systolic blood pressure ≤100 mm Hg, or respiratory rate ≥22/min.
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
- Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors and having a high serum lactate level despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.
- A SOFA score ≥2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.
- However SOFA criteria (Sequential Organ Failure Assessment) is clinical, and CMS criteria is quality oriented.
9. Observation to Inpatient Admission
Coders are not looking closely at orders for inpatient admission coming from observation.
ED admit, Creatinine 1/15 “2.46, 1/16 “2.03”, 1/20 “1.59” acute renal failure resolved with IV fluids 500 m
1,0000 hr. rate x 2. (N17.9, acute renal failure coded as PDX)
1/18 admission note: “LOS > 2MN Pt admit for, n/v, cough. Flu +. Tamiflu, nebs, prednisone PO, sputum cx. Pt not back to baseline, green phlegm and cough continues…“
PN 1/21 “..Plan: Viral bronchitis with positive influenza.”
In the above scenario, the auditor changed PDX from N17.9 to J11.1, influenza with other respiratory manifestatons
The information contained in this coding advice is valid at the time of posting. Readers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Last week, we looked at tidbits for reporting the ICD-10-CM codes for pregnancy/obstetric records. Now we will look at some for the ICD-10-PCS reporting of these records. In reporting the appropriate ICD-10-PCS codes a coder must know what is included in the terminology of products of conception (POC).
Chances are, we all know someone affected by heart disease and stroke, because about 2,300 Americans die of cardiovascular disease each day, an average of 1 death every 38 seconds. But together we can change that.
There was a time when coding delivery records was considered simple. Many times, these types of records were given to the newer coders. However, as coding becomes more complex, this is no longer the case. With the implementation of ICD-10-CM came more codes for very detailed and specific issues that occur during pregnancy, childbirth and the puerperium.
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 Allison Curry, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
One way to shorten a lengthy query is by avoiding repetition in the supporting documentation. Does the same diagnosis really need to be mentioned multiple times in the clinical indicators? Is it necessary to list the results of a chest x-ray twice? Does listing the same documentation multiple times give further specification or explanation to the query?
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.
What is the principal procedure? The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. Procedures for diagnostic or exploratory purposes that are performed in addition to a procedure being performed for definitive treatment, would be reported in addition to the principal procedure.
A query question that is directive in nature, indicating what the provider should document, rather than asking for his/her professional determination of clinical facts, constitutes a leading query. The provider should not be made to feel obligated to document anything.
When I start coding a chart, I enter all account information in log and do any abstracting—disposition, admitting, and attending—take care of all of that first. ED, H&P, consult, progress reports, and discharge summary.
Some Speed Reading Tips: Once you start reading, don’t stop! Read the text straight through. If you have any question after you have completed reading the material, go back and reread the relevant sections. Reread the marked sections of the text (the items you indicated that you didn’t quite understand). Write a small summary at the beginning of the chapter – consisting about 3-4 sentences.
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.
The cause/etiology of GI bleeding is not always easily determined. During procedures, to work the bleeding up, there are often multiple potential sources of bleeding found but not identified as the culprit. Many of these findings have “with” or “in” in the main or subterms.
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.
COPD is a respiratory condition where there is chronic obstruction to airflow in the lungs. Air is breathed into the lungs but a patient with COPD has trouble emptying air out of the lungs. This can also cause patients with COPD to have CO2 retention. COPD is an irreversible and progressive disease in which the lung function worsens as time goes on.
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…