1 5 Coding and Documentation Challenges A coder-physician dialoguean HCPro audio conference presented on October 20, 2010 James S. Kennedy, MD, CCS and Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS
2 Topics For Discussion Acute Kidney Injury Altered Mental StatusComplications Cardiac Cath Lab Indications and Procedures Pulmonary Conditions and Procedures HA
3 Complications (Of Procedures)
4 Clinical Scenario A 55 year old female is admitted for an elective colon resection for colon cancer Day 1 Dx: Attending: Colon Cancer Day 2 Dx: Attending: s/p Colon Resection with postoperative ileus Day of Discharge Dx: Attending: Colon Resection with expected postoperative ileus, resolved.
5 What is a complication of a procedureA condition that is: Related to the procedure As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Source: ICD-9-CM Guidelines Not a known risk or inherent/integral to the procedure Example: Since pneumothorax is a known risk associated with most thoracic surgeries, it would be inappropriate to assign an additional code for the iatrogenic pneumothorax, based on an x-ray finding alone, without physician concurrence. CC, 3rd Quarter, 2003, page 19. Example: Requirement to query surgeons to determine if incidental serosal tears are inherent to the procedure. CC, 2nd Quarter, 2007, pages
6 ICD-9-CM Guidelines Reportable conditions must meet at least one of the following criteria: Clinically evaluated Diagnostically tested Therapeutically treated Results in increased length of stay Results in increased in nursing care/monitoring Signs and symptoms integral to a disease process are not reportable unless otherwise required by coding guidelines. The coding guideline for “integral” is carried through for conditions which are expected and that the physician considers integral to a procedure.
7 Nuances of Postoperative ConditionsRelationship to: Procedure – already discussed Relationship to a known disease If a patient has known atrial fibrillation and develops atrial fibrillation in the postoperative period, it may not be directly related to the procedure Relationship to a medication If a patient receives morphine after surgery or had epidural anesthesia, these can result in prolonged ileus.
8 Requirement for Physician Query CC, 3rd Quarter, 2009, page 5It is important to note that not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. Only a physician can diagnose a condition and the physician must explicitly document whether the condition is a complication. If it is not clearly documented, the coder should query the physician for clarification.
9 ICD-9-CM Defaults Ileus (adynamic) (bowel) (colon) (inhibitory) (intestine) (neurogenic) (paralytic) arteriomesenteric duodenal due to gallstone (in intestine) duodenal, chronic following gastrointestinal surgery gallstone mechanical (see also Obstruction, intestine) meconium due to cystic fibrosis myxedema postoperative transitory, newborn Digestive system complications Complications of: Intestinal (internal) anastomosis and bypass, not elsewhere classified, except that involving urinary tract Hepatic failure specified as due to a procedure Hepatorenal syndrome specified as due to a procedure Intestinal obstruction NOS specified as due to a procedure = CC, “intestinal obstruction NOS specified as due to a procedure” Because the physician documented “expected postoperative ileus”, do we still code 997.4? A query is necessary
10 POA Indicator Y – Yes N – No W – Cannot Be Clinically DeterminedU – Uncertain Interpreted as a “N” The POA Indicator is a powerful determinant of complications under some protocols.
11 3M Potentially Preventable ComplicationsThe State of Maryland is investigating the utilization of 3M’s Potentially Preventable Complications methodology in its Pay-for-Performance methodologies 3M has developed a methodology of conditions that are not POA that it considers to be “preventable” complications outside of the codes. e.g. 428.xx (CHF) is a PPC if not POA – Group 2 – Level 2 (Major) e.g (Acute Respiratory Failure) – Group 2 – Level 1 (Other) The expected number and severity of PPCs rises in proportion to the APR-DRG Severity of Illness If the PPC rate is inordinately high for the APR-DRG SOI level, financial consequences are assessed. Learn more of these using the website recommended by the Maryland HSCRC: User name: MDHosp Password: aprdrg401
12 Potentially Preventable ComplicationsDr. Jim Kennedy Potentially Preventable Complications Extreme Complications Extreme CNS Complications * Acute Pulmonary Edema & Respiratory Failure w Ventilation * Shock * Ventricular Fibrillation, Cardiac Arrest * Renal Failure with Dialysis * Post-Operative Respiratory Failure with Tracheostomy * Gastrointestinal Complications Major GI Complications w Transfusion or Significant Bleeding * Major Liver Complications * Major Gastrointestinal Complications without Transfusion or Significant Bleeding Other Gastrointestinal Complications without Transfusion or Significant Bleeding Present on Admission Indicator Matters FTI Healthcare 12
13 Present on Admission Indicator MattersCardiovascular-Respiratory Stroke & Intracranial Hemorrhage Pneumonia, Lung Infection * Aspiration Pneumonia * Pulmonary Embolism * Congestive Heart Failure * Acute Myocardial Infarct * Peripheral Vascular Complications Except Venous Thrombosis * Venous Thrombosis * Acute Pulmonary Edema and Respiratory Failure without Ventilation Other Pulmonary Complications Cardiac Arrhythmias & Conduction Disturbances Other Cardiac Complications Perioperative Complications Post-Op Wound Infection & Deep Wound Disruption w Procedure * Reopening of Surgical Site * Post-Op Hemorrhage & Hematoma w Hemorrhage Control Proc or I&D Proc * Accidental Puncture/Laceration During Invasive Proc * Post-Op Foreign Body * Post-Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure or I&D Procedure Post-Operative Infection & Deep Wound Disruption Without Procedure Post-Operative Substance Reaction & Non-O.R. Procedure for Foreign Body Present on Admission Indicator Matters
14 Present on Admission Indicator MattersDr. Jim Kennedy Infectious Complications Clostridium Difficile Colitis Urinary Tract Infection Septicemia & Severe Infection Cellulitis Moderate Infectious Obstetrical Complications Obstetrical Hemorrhage w Transfusion * Obstetrical Laceration & Other Trauma without Instrumentation * Obstetrical Laceration & Other Trauma with Instrumentation * Major Puerperal Infection and Other Major Obstetrical Complications * Obstetrical Hemorrhage without Transfusion Medical & Anesthesia Obstetric Complications Other Complications of Obstetrical Surgical & Perineal Wounds Delivery with Placental Complications Present on Admission Indicator Matters James S. Kennedy MD - (615) FTI Healthcare
15 Present on Admission Indicator MattersDr. Jim Kennedy Other Medical and Surgical Complications Post-Hemorrhagic & Other Acute Anemia w Transfusion * Decubitus Ulcer * Encephalopathy * Renal Failure without Dialysis GU Complications Except UTI Diabetic Ketoacidosis & Coma In-Hospital Trauma and Fractures Acute Mental Health Changes Accidental Cut or Hemorrhage During Other Medical Care Other Complications of Medical Care Other Surgical Complication – Moderate Other In-Hospital Adverse Events Malfunctions, Reactions Etc. Iatrogenic Pneumothrax * Mechanical Complication of Device, Implant & Graft * Inflammation, & Other Complications of Devices, Implants or Grafts Except Vascular Infection * Infections due to Central Venous Catheters* Infection, Inflammation and Clotting complications of Peripheral Vascular Catheters and Infusions Poisonings Except from Anesthesia Poisonings due to Anesthesia Transfusion Incompatibility Reaction Gastrointestinal Ostomy Complications Present on Admission Indicator Matters FTI Healthcare 15
16 Postoperative (Acute) Respiratory Failure 518.81 or 518.5??INDEX Failure respiration, respiratory acute acute and chronic center newborn chronic due to trauma, surgery or shock Insufficiency respiratory acute following shock, surgery, or trauma newborn TABLE Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome Pulmonary insufficiency following: shock surgery trauma Shock lung EXCLUDES adult respiratory distress syndrome associated with other conditions (518.82) respiratory failure in other conditions (518.81, ) MB added this note Other pertinent coding clinics – 1Q2010, 3Q1988 Coding Clinic, September-October 1987 Code is assigned when respiratory failure occurs following surgery or trauma.
17 PSI 11 Postoperative Respiratory FailureICD-9-CM Acute Respiratory Failure diagnosis codes that is not present on admission: ACUTE RESPIRATRY FAILURE ACUTE & CHRONC RESP FAILURE NOTE THAT is NOT INCLUDED ICD-9-CM Mechanical Ventilation for 96 consecutive hours or more procedure code: 96.72 CONTINUOUS MECHANICAL VENTILATION FOR 96 CONSECUTIVE HRS OR MORE ICD-9-CM Mechanical Ventilation procedure codes 2 or more days after the procedure: 96.70 CONTINUOUS MECHANICAL VENTILATION OF UNSPEC DURATION 96.71 CONTINUOUS MECHANICAL VENTILATION FOR LESS THAN 96CONSECUTIVE HRS ICD-9-CM Reintubation procedure code 1 or more days after the procedure: 96.04 INSERT OF ENDOTRACHEAL TUBE MB added decimals codes 2nd columns Also, note CC1Q2010 – respiratory distress progressing to acute respiratory failure
18 PSI 21 Iatrogenic PneumothoraxAll cases of code – Iatrogenic pneumothorax. Coding Clinic, 3rd Quarter, 2003, page 19: Question: A 19-year-old patient with a history of progressive adolescent idiopathic scoliosis was admitted for anterior spinal fusion. Following surgery, the chest x-ray showed a small apical pneumothorax. The patient was placed on suction and later the chest tube was removed. A follow-up chest x-ray showed the pneumothorax was still present. No active measure was taken. The physician at our facility believes the iatrogenic pneumothorax is integral to this procedure and should not be reported. Is it appropriate to assign code 512.1, Iatrogenic pneumothorax, as an additional diagnosis? Answer: Since pneumothorax is a known risk associated with most thoracic surgeries, it would be inappropriate to assign an additional code for the iatrogenic pneumothorax, based on an x-ray finding alone, without physician concurrence.
19 Bottom Line Establish the relationship Query Query QueryRule out medical conditions or adverse effects of medicine. Query Query Query To determine whether the physician believes that it is a complication or not
20 Thank You Questions? CC