Coma, stroke codes I67–I68: I69: require more specific ... · Coma, stroke codes require more specific documentation A quick glance at ICD-9-CM and ICD-10-CM stroke and coma codes

ICD-10

Coma, stroke codes require more specific documentation

A quick glance at ICD-9-CM and ICD-10-CM stroke

and coma codes reveals many similarities and some

important differences.

How ICD-10 stroke codes are organized

The 2013 ICD-10-CM Table of Diseases organizes

cerebrovascular disease codes as follows:

➤ I60–I62: Non-traumatic intracranial hemorrhage

(i.e., spontaneous subarachnoid, intracerebral,

or subdural hemorrhages)

➤ I63: Cerebral infarctions (i.e., due to a vessel

thrombosis or embolus)

➤ I65–I66: Occlusion and stenosis of cerebral or

precerebral vessels without infarction

➤ I67–I68: Other cerebrovascular diseases

➤ I69: Sequelae of cerebrovascular disease (late effect)

Note that some neurologic manifestations of cerebro-

vascular disease, such as transient cerebral ischemic attacks

and related syndromes (G45), are classified elsewhere.

Greater specificity for strokes

ICD-10-CM stroke codes are more specific than their

ICD-9-CM counterparts.

First, codes

I60–I62 specify the

location or source

of a hemorrhage as

well as its laterality.

For example, ICD-

10-CM code I60.11

denotes nontraumatic subarachnoid hemorrhage from

right middle cerebral artery.

A CT scan usually indicates the specific location of

a hemorrhage, says Alice Zentner, RHIA, director of

auditing and education at TrustHCS in Springfield, Mo.

“Hopefully, the physician will bring this information

forward into his or her progress notes,” she says.

Second, code I63 specifies the following:

➤ Cause of the ischemic stroke (e.g., thrombosis,

embolus, or unspecified)

➤ Specific location and laterality of the occlusion

(i.e., specific artery)

For example, ICD-10-CM code I63.331 denotes

cerebral infarction due to thrombosis of right posterior

cerebral artery.

Zentner says that coders must be able to differentiate

the following terms when reporting a code from category

I63–I65:

This month’s tip—For better

or worse? Robert S. Gold, MD,

answers this question in his

assessment of various code

revisions on p. 6.

September 2012 Vol. 15, No. 9

IN THIS ISSUE

p. 4 ComplicationsLearn how differing interpretations of medical terminology affects coder understanding of physician documentation.

p. 6 Clinically speakingRobert S. Gold, MD, shares his thoughts about various code revisions.

p. 8 Recovery AuditorsLearn the benefits of conducting a self-audit before submitting records for review.

p. 11 PEPPERHospital feedback helps TMF Quality Institute enhance value of its reports.

p. 12 DocumentationLearn how coding managers and their staff members can help physicians understand what they need.

Inside: Coding Q&A insert

Page 2 Briefings on Coding Compliance Strategies September 2012

© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.

➤ Stenosis—narrowing of the artery

➤ Occlusion—Complete or partial obstruction

➤ Thrombus—Solid mass of platelets or fibrin that

forms and remains in a blood vessel (stationary

blood clot)

➤ Embolism—Blood clot that travels from the site

where it formed to another location in the body

Coders should also be able to distinguish cerebral and

precerebral arteries because ICD-10-CM codes make

this distinction, says James S. Kennedy, MD, CCS,

CDIP, managing director at FTI Consulting in Atlanta.

Precerebral arteries include the vertebral, basilar, and

carotid arteries and their branches. The cerebral arteries

include the anterior, middle, and posterior cerebral

arteries and their branches.

Third, code category I69 specifies the type of stroke

that caused the sequelae as well as the residual condi-

tion itself. For example, code I69.01 denotes cognitive

deficits after nontraumatic subarachnoid hemorrhage.

In ICD-9-CM, code 438.xx simply denotes the residual

condition—not the type of stroke that caused the

condition.

Coders can report code I69 in conjunction with a

condition classifiable to code category I60–I67 if the

patient has a current cerebrovascular disease and deficits

from an old cerebrovascular disease. The guidelines also

state that the neurological deficits caused by a stroke

may be present from the onset of a stroke or arise at any

time after the onset of the stroke. Note that code I69 is

exempt from POA reporting.

When a patient has a history of cerebrovascular disease

without any neurologic deficits, coders should report code

Z86.73 (personal history of transient ischemic attack,

and cerebral infarction without residual deficits) and a

code for the cerebral infarction without residual deficits

(not code I69), according to ICD-10-CM guidelines.

Reporting bilateral hemorrhages

If a patient has bilateral nontraumatic intracerebral

hemorrhages, coders should report code I61.6 (nontrau-

matic intracerebral hemorrhage, multiple localized).

Conversely, if a physician documents bilateral non-

traumatic subarachnoid hemorrhage sites, coders must

report an ICD-10-CM code for each side. ICD-10-

CM guidelines state that if the patient has a bilateral

condition—and no bilateral ICD-10-CM code exists—

coders should assign separate codes for the left and right

sides.

For example, in the rare event that a patient suffers a

nontraumatic subarachnoid hemorrhage of both anterior

communicating arteries, assign I60.21 (nontraumatic

subarachnoid hemorrhage from right anterior commu-

nicating artery) and I60.22 (nontraumatic subarachnoid

hemorrhage from left anterior communicating artery).

However, coders should note that code categories

I65–I66 include bilateral codes. Therefore, if a patient has

Editorial Advisory Board Briefings on Coding Compliance Strategies

Paul Belton, RHIA, MHA, MBA, JD, LLMVicePresidentCorporate Compliance Sharp HealthCare San Diego, Calif.

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIMConsultantFremont, Calif.

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Fla.

James S. Kennedy, MD, CCSManagingDirectorFTI Healthcare Atlanta, Ga.

Laura Legg, RHIT, CCSRevenueControlCodingConsultantRevenue Cycle Management Washington/Montana Regional Services Providence Health & Services Renton, Wash.

Monica Lenahan, CCSManagerofCodingEducationandComplianceRevenue Management Centura Health Englewood, Colo.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS DirectorofCodingandHIMHCPro, Inc. Danvers, Mass.

Jean Stone, RHIT, CCSCodingManager-HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, Calif.

Managing Editor: Geri Spanek

Contributing Editor: Lisa Eramo, [email protected]

Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

September 2012 Briefings on Coding Compliance Strategies Page 3


bilateral stenosis of the vertebral arteries, coders should

assign I65.03—not I65.01 and I65.02 to denote the right

and left vertebral arteries, respectively.

Reporting intraoperative and

postprocedural strokes

Unlike ICD-9-CM, ICD-10-CM distinguishes the

following:

➤ Intraoperative stroke during cardiac surgery (I97.810)

or during other surgery (I97.811)

➤ Postprocedural stroke during cardiac surgery

(I97.820) or during other surgery (I97.821)

“If a stroke occurs in the setting of an operation, a

query is needed to determine if the stroke occurred

during or after surgery,” says Kennedy.

Coma codes

The most noticeable difference between ICD-9-CM

code 780.01 (coma) and its ICD-10-CM counterpart

(code R40.2) is that the latter incorporates the Glasgow

Coma Scale (GCS), a neurological scale that captures

a patient’s conscious state for initial and subsequent

assessment.

“It really shows the condition of the patient and

the severity of the event,” says Zentner. “If reported at

different intervals, it shows the patient’s progress and

response to treatment.”

Coders may report the GCS with any appropriate

illness. The coma scale codes should be sequenced after

the diagnosis code(s).

The GCS may be coded based on an aggregate score

(code R40.24, GCS total score), or based on its individual

components. Code R40.24 is appropriate when only the

total score—and not the individual components—are

documented. When the individual components are

documented, coders may report the GCS based on the

components. However, they must report a code from

each of the following subcategories:

➤ R40.21: Eye response (eyes never open or eyes open

to pain, sound, or spontaneously)

➤ R40.22: Best verbal response (clarity of words

incomprehensible, inappropriate, confused, oriented)

➤ R40.23: Best motor response (voluntary and

involuntary responses [extension, flexion, abnormal,

obeys commands])

If a physician doesn’t document the GCS—or docu-

ments only a portion of it—coders must report R40.244.

Codes R40.21–R40.23 require a 7th character to

denote when the scale was recorded (i.e., unspecified

time, in the field [EMT or ambulance], upon arrival at

the ED, at hospital admission, or 24 hours or more after

admission).

Coders must report codes for all three components,

and they must ensure that the 7th character matches

for all three, says Kennedy. Coders also should note that

hospitals may report the GCS at multiple intervals and

that physician and EMT documentation supports code

assignment, he says.

“Facilities that have a trauma registry will certainly

want to report these codes,” says Zentner. “If the center

wants to follow the patient and see how he or she is

progressing, they may want to report several codes.”

Educating ED physicians about documentation of coma

scale scores and the new codes is important. Hospitals

should consider revising templates so they incorporate

this information, she says.

Separate symptoms and combination codes

Coders should search the ICD-10-CM Alphabetic

Index for codes that automatically incorporate coma in

their descriptions. For example, code E11.641 denotes

Type 2 diabetes mellitus with hypoglycemia with coma.

Assigning ICD-10-CM code R40.20 (coma, unspecified)

as an additional code would be appropriate because com-

bination code E11.641 includes the coma (symptom) as

an integral component. n

Editor’s note: Access the most recent version of ICD-10-CM

at http://tinyurl.com/yd94dqr. Access the 2012 ICD-10-CM

guidelines, at http://tinyurl.com/7zkjdyu.



Complications are … well, complicated. There’s no

other way to say it. Why are they so difficult to code?

The answer is simple—coding and clinical termino logy.

Coders and physicians interpret several important terms dif-

ferently, says Audrey G. Howard, RHIA, senior inpatient

consultant at 3M Health Information Systems in Atlanta.

For coders, postoperative denotes a condition related to

a surgical procedure. For physicians, this term denotes

a condition occurring during the postoperative period—

not necessarily one that’s related to the surgery. Like-

wise, CMS (and coders) define complication as a condition

occurring after admission that increases length of stay by

at least one day in at least 75% of patients. Physicians

define this term as an additional condition caused by a

procedure, treatment, or illness. Complication generally

has a negative connotation for physicians, says Howard.

Clear documentation can help, says Howard. Physi-

cians should document postoperative only if the complica-

tion is due to the surgery or the anesthesia used during

surgery. If not, all other conditions should be document-

ed as “occurring after surgery” or “unrelated to surgery.”

Clarification is paramount, says Cheryl Manchenton,

RN, BSN, senior inpatient consultant at 3M Health Infor-

mation Systems in Atlanta. Why? Complications not only

have financial implications, but many agencies also factor

them into hospital and physician profiles, some of which

are available to the public. Many CDI programs are begin-

ning to target complications to ensure coding accuracy and

promote data quality to prevent poor quality reports for

physicians and the hospitals where they work, she says.

Clarifying whether a physician truly intended to

link a complication to the surgery is important, says

Manchenton. Querying physicians is completely appro-

priate when documentation is unclear, particularly when

postoperative appears to be a time stamp rather than an

actual indication of a complication due to the surgery.

Surgeons and medical consultants must document

consistently for conditions following surgery, she says.

ICD-10-CM also includes codes for complications,

some of which specifically reference intraoperative and

postoperative. Code category T80–T88 generally includes

complications of surgical and medical care, not elsewhere

classified. Some of the codes in this category require a 7th

character to denote whether it’s an initial, subsequent, or

sequela encounter. For example, code T85.01xA denotes a

mechanical breakdown of ventricular intracranial (com-

municating) shunt, initial encounter. However, compli-

cation codes aren’t limited to this section—they appear

throughout the entire ICD-10-CM classification according

to body system. For example, postoperative aspiration

pneumonia is reported with J95.89 (other postprocedural

complications and disorders of respiratory system, not else-

where classified) and J69.0 (pneumonitis due to inhalation

of food and vomit). Both of these codes are included in the

section for diseases of the respiratory system.

Consider these questions

Not all conditions during or following medical care or

surgery are considered complications, says Howard. Ask

these questions before reporting a complication code.

➤ Is the condition expected routinely dur-

ing or after a particular procedure? Reporting a

complication requires that a condition exceed what a

particular patient would likely experience during or after

a particular surgery as part of routine intraoperative or

postoperative care, says Howard. Physicians are respon-

sible for determining whether something that occurred

during or after surgery is a complication or an expected

outcome, she says. Refer to Coding Clinic, First Quarter

2011, pp. 13–14 for more information.

Coders and CDI specialists should determine whether

the patient received any treatment for the condition or

whether the condition extended the patient’s length

of stay. Only a physician can document this information,

she says. For example, an unexpected resection of the

intestine required to repair a laceration might indicate

an intraoperative accidental laceration. Another example

might be documentation that a surgeon called another

Ask questions before reporting complications



physician to the OR for an opinion.

➤ Did the physician document a cause-and-

effect relationship between the procedure and

the condition? This relationship is crucial to reporting

complications, says Howard. Physicians must link the

condition with the procedure before coders can report it

as a complication. The ICD-9-CM Official Guidelines for Cod-

ing and Reporting states the following:

Code assignment is based on the provider’s documenta-

tion of the relationship between the condition and the care

or procedure. The guideline extends to any complications of

care, regardless of the chapter the code is located in.

➤ Did the physician document that the condi-

tion is a complication? If a physician doesn’t explicitly

document that a condition is a complication of the pro-

cedure, coders should query, says Howard. Refer to Cod-

ing Clinic, Third Quarter 2009, p. 5 for more information.

Intraoperative accidental lacerations

Generally, when a laceration/tear/enterotomy occurs

during a procedure, the physician must document that it

was clinically significant or that it is a complication of the

procedure before coders can report it as such, says Howard.

If a physician documents a tear in the operative

report—but doesn’t indicate whether it’s clinically

significant—query for more information, she says. If a

physician states that a tear isn’t clinically significant,

omit codes for the diagnosis and procedure performed

to repair the tear. Don’t assign a traumatic injury code

(800–959) to identify complications resulting from surgi-

cal or medical care, says Howard. Refer to Coding Clinic,

First Quarter 2009, pp. 15–16 for more information.

If a physician specifically documents a tear is a compli-

cation of surgery, report code 998.2. Refer to Coding Clinic,

Second Quarter 2007, pp. 11–12 for more information.

In some cases, clinical significance may be obvious.

Consider a patient admitted for a bowel obstruction with

a history of previous bowel surgery. When the physician

begins surgery, he finds massive adhesions. While lysing the

adhesions, the physician nicks the bowel in numerous places

and must repair the nicks. The physician documents that the

surgery lasts eight hours because of the extra work involved.

Postoperatively, the patient requires TPN and remains

hospitalized for 26 days before being discharged home with

a wound vacuum-assisted closure (VAC). In this case, the

enterotomies (nicks) are clinically significant because of the

increased surgery time, the increased length of stay, and the

need for wound VAC. Coders should report them with code

998.2 and a procedure for the suture repair of the site.

Exercise care when reporting coronary artery

dissection as a complication of percutaneous translumi-

nal coronary angioplasty (PTCA), says Manchenton. If a

physician documents the dissection as a complication

of the PTCA, report 997.1 (cardiac complications) and

414.12 (dissection of coronary artery). Coding Clinic, First

Quarter 2011, pp. 3–4, tells coders not to report 998.2

(accidental puncture or laceration). However, a PTCA

usually involves dissection of the lumen, says Manchen-

ton. “There is a bit of dissection inherent in the [PTCA]

procedure,” she says, adding that further dissection alone

doesn’t make it a clinically significant complication.

Likewise, insertion of a stent because of a dissection

doesn’t automatically indicate that the dissection is clini-

cally significant. Other indicators must be present in the

record to indicate the clinical significance, she says.

Conversely, dural tears are always coded as complica-

tions because they’re always clinically significant due to

the potential for cerebrospinal fluid (CSF) leakage, says

Howard. This leakage can cause CSF headache, caudal dis-

placement of the brain, subdural hematoma, spinal men-

ingitis, pseudomeningocele, or a dural cutaneous fistula.

Coders should report code 349.31 ( accidental puncture

or laceration of dura during a procedure) to denote this

condition. Refer to Coding Clinic, Fourth Quarter 2008, pp.

109–110 for more information. n

Editor’s note: Howard and Manchenton presented the

information in this article during HCPro’s audio conference

“Inpatient Postoperative Complications: Resolve Your Facility’s

Documentation and Coding Concerns.” For more information,

visit http://tinyurl.com/c2xzqkj.



Contact Contributing Editor Lisa Eramo

Telephone 401-780-6789

Email [email protected]

Questions? Comments? Ideas?

by Robert S. Gold, MD

ICD-9-CM codes invariably change over

time. Some changes are for the better, and

some are for the worse. Some evolutions

occur more rapidly while other codes lag behind. As the

industry moves toward ICD-10-CM, code changes will con-

tinue, hopefully moving toward more accurate data capture.

Renal disease

Coding classifications of renal disease have evolved over

time. Currently, renal disease codes incorporate clinical

definitions of renal function or dysfunction. This includes a

stratification of the stages of chronic kidney diseases (CKD).

In the future, it will include the stages of acute renal disease.

But how did the medical community get to this point?

Coder and physician dissatisfaction with the term

renal insufficiency largely drove these changes. One need

not look far to find documented frustration with the

term. Coding Clinic, the National Kidney Foundation,

and Kidney Disease Improved Global Outcomes all have

published information about the difficulties associated

with use of this terminology.

What’s wrong with renal insufficiency? The term

doesn’t provide any indication as to whether the patient

has an acute or chronic problem. It also doesn’t indicate

whether it’s a progressive problem with renal function,

and it doesn’t reveal the severity of the problem.

The ICD-9-CM Coordination and Maintenance Com-

mittee divided the codes for CKD—alternatively known

as chronic renal failure—into five stages. The stages are

based on a patient’s glomerular filtration rate, which is

calculated with a patient’s creatinine level, age, gender,

and race. Stage I denotes normal renal function with a

glomerular filtration rate of more than 90 ml per minute.

Stage V denotes kidney failure with a glomerular filtration

rate of less than 15 ml per minute. The ICD-9-CM Coordi-

nation and Maintenance Committee added a classification

of ESRD in the code set to denote permanent dialysis.

As a result of these changes, chronic renal insuffi ciency

became measurable. The changes also allowed the medical

community to further research whether organ function

(other than the kidneys) suffered when the glomerular fil-

tration rate dropped to less than 45 ml per minute. Coded

data could also help track whether hyperparathyroidism or

anemia is associated with CKD and whether other homeo-

static problems might be related to the renal dysfunction.

The RIFLE criteria helped to stage acute renal failure. R

(risk), I (injury), and F (failure) denote progressively worse

levels of acute renal failure. These levels are measured by

changes in a patient’s serum creatinine, decrease in urine

output, or changes in the calculated glomerular filtration

rate. L (loss) denotes loss of renal function for at least four

weeks. E (ESRD) denotes permanent loss of renal function.

The Acute Kidney Injury Network (AKIN) eventually

determined that using the glomerular filtration rate to

measure the acute stages of renal damage is inappropriate.

This rate should be reserved for a patient’s chronic state

of kidney function. As a result, AKIN published Stages 1,

2, and 3 of acute renal failure, which is also referred to

as acute kidney injury.

Nephrologists argue that the cause of a patient’s CKD

is almost never the same as the cause of a patient’s acute

renal failure. They insist that “acute on chronic” shouldn’t

be used as a descriptor when referring to renal disease. A

patient with Stage 3 CKD due to hypertensive nephroscler-

osis can develop acute renal failure due to septic shock. A

patient with Stage 2 CKD from diabetic nephropathy can

Some codes evolve more slowly than others



develop acute kidney injury from acute lupus nephritis.

Distinguishing between acute and chronic is helpful,

as is understanding severity and being able to identify

the cause of a patient’s renal problem. Coders can use

this information to assign ICD-9-CM codes for all of the

possible permutations.

Respiratory disease

Unfortunately, respiratory disease codes haven’t evolved

as quickly. ICD-9-CM currently includes codes for acute re-

spiratory failure, chronic respiratory failure, and acute-on-

chronic respiratory failure. However, aside from listing a

myriad of codes that simply aren’t specific enough, coders

cannot denote the cause or severity of respiratory failure.

ICD-9-CM also currently includes codes for respira-

tory insufficiency and respiratory distress. The codes only

denote that the insufficiency or distress is due to trauma,

surgery, or a disease. However, the codes don’t denote

whether the trauma or the surgery performed to treat the

traumatized patient caused the respiratory insufficiency or

distress. Making matters worse is the lack of a definition of

respiratory insufficiency or acute respiratory distress.

ICD-9-CM groups acute respiratory distress syndrome

(ARDS) and acute respiratory distress as inclusion terms

under respiratory insufficiency (ICD-9-CM code 518.82).

This means that the same codes are used for patients with

ARDS, who have a 10%–90% mortality rate, and patients

who are mildly short of breath for no particular reason.

In 1987, ICD-9-CM code 799.1 denoted cardiorespira-

tory arrest. This code still exists today. However, cases

of respiratory failure were removed from this code due

to new medical information that included development

of formal definitions of hypoxemic and hypercapnic

respiratory failure and acute and chronic respiratory

failure. As a result, ICD-9-CM code 518.81 was assigned

for acute respiratory failure. ICD-9-CM code 518.83 was

assigned for chronic respiratory failure. ICD-9-CM code

518.84 was assigned for acute and chronic respiratory

failure. ARDS—a specific type of acute inadequacy in

lung function that is a specified cause of acute respira-

tory failure—was included in ICD-9-CM code 518.82.

During the 1960s, ARDS was referred to as acute

respiratory distress syndrome. The term eventually became

known as adult respiratory distress syndrome to differenti-

ate it from infantile respiratory distress syndrome. How-

ever, acute respiratory distress syndrome was readopted

in 1993 because children other than newborns could also

experience the condition, and calling it adult respiratory

distress syndrome is inappropriate in the case of a child.

Thus, the description for ICD-9-CM code 518.82 was re-

vised to include the term acute rather than adult. However,

the revision stated acute respiratory distress—not acute re-

spiratory distress syndrome. This change has subsequently

continued to cause coding and documentation problems.

Respiratory insufficiency and acute respiratory distress

aren’t definable conditions. These are symptoms—not

diseases—and considering either term worthy of finan-

cial impact for a hospital or outpatient case is ludicrous.

The good news is that the crosswalk from ICD-9-CM

to ICD-10-CM demonstrates that ICD-9-CM code 518.82

maps to ICD-10-CM code J80 (acute respiratory distress

syndrome), which specifically excludes P22.0 (respira-

tory distress syndrome of the premature). The 518.5

series of codes don’t yet crosswalk appropriately to ICD-

10-CM. However, I hope that the codes will eventually

follow in the footsteps of code 518.82.

Meanwhile, coders have little choice but to assign ICD-

9-CM codes 518.82 and 518.52 when there is documenta-

tion of some of the unintended meanings of the codes. Do-

ing so means that although hospitals will reap additional

funds now, providers who treat patients with ARDS will

eventually receive less money in the future. Furthermore,

reporting these codes will probably cost Medicare and

Medicaid somewhere in the range of $500 million annu-

ally due to overbilling that technically follows the rules.

For now, if it looks like a symptom, don’t code it in

addition to the diagnosis. This practice follows the official

rule of coding symptoms that are integral to a diagnosis. n

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm

in Atlanta that provides physician-to-physician CDI programs.

Contact him at 770-216-9691 or [email protected].



Do you audit records before sending them to your

Recovery Auditor? If not, your hospital may be one of

many that simply don’t have the resources to do so.

Lori Brocato, product manager at HealthPort in

Atlanta, provides some of the many reasons hospitals

should consider self-audits. These include:

➤ Quality assurance (ensuring that all necessary

documents are included and that you don’t inadver-

tently mix dates of service or include documents that

the Recovery Auditor didn’t request)

➤ Advance notice of potential denials (knowing

beforehand whether a denial is likely as well as the

potential financial impact)

➤ Extra time for appeals (additional time to gather

data to include in a formal Recovery Auditor appeal)

“Another reason to perform the self-audit is to see the

potential for any secondary or tertiary payer trying to

come back and recover funds as well,” says Brocato.

When Recovery Auditors first began requesting records,

many hospitals performed self-audits mainly because of

anxiety and a desire to understand their own potential for

denials, says Brocato. Over time—and as Recovery Auditor

targets and denial patterns have become more apparent—

fewer hospitals seem to undertake the task. Some hospitals

choose to perform self-audits only when Recovery Audi-

tors announce new issues or targets, she says.

“I think most hospitals are trying to at least audit a

certain percentage whereas I think they used to try and

audit 100%,” says Brocato. Hospitals should self-audit at

least 10% of the records requested before sending them

to the Recovery Auditor so that they can keep a constant

barometer on their performance, she says.

Providence Health & Services

Providence Health & Services, a large hospital system

that spans Alaska, California, Montana, Oregon, and

Washington, initially performed self-audits of all records

before sending them to a Recovery Auditor. However,

when the Recovery Auditors started doubling their re-

quests, staff members couldn’t maintain the pace.

“With the increase in the number of records requested,

we have centered our resources around satisfying the

medical record requests and reviewing and responding to

denials,” says Laura Legg, RHIT, CCS, revenue control

coding consultant at Providence Health & Services.

Legg spends approximately 80% of her time reviewing

and appealing coding-related RAC denials for eight of the

health system’s 27 hospitals. She spends the remaining

20% of her time reviewing and appealing denials from

other auditors, performing internal audits, and educat-

ing coders about audit results. “The information has to

be passed on to the people who are actually doing the

work,” she says.

Recovery Auditor denials, in particular, have become

more complex and time-consuming to process as the

program has evolved, says Legg. “RACs are getting

smarter. At first, it was sepsis, excisional debridement,

and other things that we’ve known to be problems for a

very long time,” she says. “Now, they’re starting to deny

additional diagnoses for clinical validation. I’ve also seen

more principal diagnosis changes.”

Performing self-audits prior to sending records to a

Recovery Auditor has value, but many hospitals, like

Providence Health & Services, must instead focus on

reviewing actual denials, says Legg.

Phelps County Regional Medical Center

Phelps County Regional Medical Center, a 240-bed

rural facility in Rolla, Mo., has a different approach.

Cathie Eikermann, MSN, RN, CNL, CHC, interim

compliance and privacy officer and RAC manager, current-

ly reviews records before sending them to a Recovery Au-

ditor. When the Recovery Audit program began, the hospi-

tal received 50–70 requests every 48 days, and Eikermann

spent most of her time performing self- audits. The job was

Recovery Auditors

Consider self-audit before responding to request



demanding, yet manageable. However, when the requests

spiked to 200, Eikermann, a full-time employee, could no

longer review every record herself. “Our physician re-

viewer is still looking at each one, fortunately,” she says.

The physician reviewer helps identify records at risk for

potential denial based on lack of documentation or lack of

substantiating clinical evidence, she says.

Eikermann’s own process for reviewing records is highly

organized and efficient. During her 10- or 15-minute re-

view of each record, she performs these tasks:

➤ Review the record to ensure that it includes all items

on a checklist that she developed (see p. 10). Giving re-

viewers the big picture is important, she says. Provid-

ing all necessary information up front so that reviewers

don’t deny a claim due to an apparent lack of support-

ing documentation, particularly when the documenta-

tion exists but simply wasn’t sent, is more cost-effective.

➤ Identify any documents that may be missing from the

record.

➤ Remove non-pertinent information (e.g., duplicate

copies, insurance information, and hospital-specific

forms such as room changes or home medication lists)

from the record.

➤ Assess the potential risk for a medical necessity

denial. This includes validating admission orders as

well as reviewing ED documentation, the physician’s

history and physical exam, and any other informa-

tion available at the time of admission to determine

whether the correct admission status was assigned.

➤ Determine whether documentation is present to sup-

port an appeal if the record is denied. This includes pre-

liminary research of updated evidence-based practice

standards that can be used during the appeal process.

Questions to consider

When deciding whether to perform a self-audit before

submitting records, consider the following questions:

➤ How many Recovery Auditor requests does

your hospital receive? In reviewing this number,

hospitals must consider whether reviewing all or a por-

tion of the requests is realistic, says Legg. “The number

of requests a facility receives really determines the ad-

ministrative burden placed on the facility,” she says.

Hospitals with a larger volume of requests may find

it difficult—or virtually impossible—to review records

beforehand, says Brocato.

➤ Are staff members available to complete a self-

audit? Ideally, a coding professional with a strong clinical

background, a CDI specialist, and a physician should all

participate in the self-audit, says Legg. Each must have a

clear understanding of how data gleaned from Recovery

Auditor requests, reviews, and denials can provide crucial

information for future process improvement.

➤ Do you have a defined process for performing

self-audits? Hospitals have 45 days to respond to Re-

covery Auditor requests, which is why it’s paramount to

develop an efficient self-audit process prior to sending the

record, says Brocato. “It’s a very time-consuming process.

It’s basically like re-coding that record again,” she says.

➤ How will staff members report errors discov-

ered during a self-audit? Each facility must determine

what will trigger self-disclosure to CMS, says Brocato.

“We do self-report, sending in the overpayment and re-

billing if within the timely filing period,” says Eikermann.

Note that isolated errors don’t necessarily require self-

disclosure to CMS. However, if self-audits reveal a larger

pattern or trend of errors, hospitals should consult with

legal counsel to determine whether disclosure is necessary.

For more information, access Transmittal 425, published

June 15, at http://tinyurl.com/clapker. CMS also has proposed

revisions to its Provider Self-Disclosure Protocol, which

establishes a process for providers to disclose potential fraud

as well as investigate and report fraud. Access the current

protocol, first published in 1998, at http://tinyurl.com/ccdeusk

as well as the proposed revisions published in the June 18

Federal Register at http://tinyurl.com/7mn5ozr.

“If you do find something that could be considered

fraudulent, you’re obligated to self-disclose that,” says

Brocato. “So if you’re going to self-audit, you’d better

have a plan in place for how you’re going to handle [any

errors that you find].” This plan should also include how

you’ll provide education for those who need it, she says. n



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Self-audit checklist

Recovery Auditor document checklist

Patient: ❒ Copy of HDI retrieval list DOS:❒ Attestation statement MR#:❒ UB 04 DRG:❒ Face sheet❒ Permits and authorizations❒ ED records❒ Order sets (if applicable) written and electronic orders❒ Laboratory reports❒ Radiology reports❒ All other clinical results such as echocardiograms, Doppler studies, TTE❒ History and physical ❒ Consultation notes❒ Progress notes (including pre/postoperative reports)❒ Physician discharge summary❒ Medication administration records❒ Dialysis/hemodialysis (if applicable)❒ Blood transfusion records (if applicable)❒ OR records❒ Telemetry recordings (if applicable)❒ Nursing clinical documentation❒ Nursing notes❒ Interdisciplinary team meeting notes❒ Discharge medication orders/instructions❒ Other forms: (list)

Source:CathieEikermann,MSN,RN,CNL,CHC,interimcomplianceandprivacyofficerandRACmanageratPhelpsCountyRegionalMedicalCenterinRolla,Mo.Adaptedwithpermission.



Add PEPPER data to your audit programInformation received by TMF Quality Institute during

the past year indicates that 61% of hospitals use PEPPER

data to guide their auditing process and help them focus

on areas of potential vulnerability.

TMF is the nonprofit organization under contract with

CMS to provide comparative data reports to hospitals,

MACs, and FIs.

The feedback is based on a form that hospitals can

populate with data about their PEPPER use and sugges-

tions for improving the report. More than 70 respondents

have completed the survey. Data available at the time of

publication indicates that respondents use PEPPER to do

the following:

➤ Assess previous efforts to change billing patterns (39%)

➤ Review the diagnosis and procedure coding

process (50%)

➤ Educate staff about coding guidelines (43%)

➤ Assess case management procedures (44%)

➤ Improve the quality of clinical documentation (53%)

➤ Educate medical staff (43%)

“We review this information every quarter and share it

with CMS as a CMS contractor,” says Kimberly Hrehor,

MHA, RHIA, CHC, project director at TMF Health

Quality Institute in Austin, Texas. “We always review the

suggestions and recommendations for improvements to

see if they are items we can act upon and implement.”

For example, TMF recently received a request to

separate out the number of claims with only one CC or

MCC for a particular DRG, she says. Currently, PEPPER

identifies medical and surgical DRGs with one or more CCs

or MCCs coded on a claim. “We’re working on assessing

claims data to see if we can refine those target areas,”

she says. “And if so, with CMS’ approval, we could

implement revisions in a future report.”

Dig deeply into PEPPER

PEPPER awareness is increasing, says Hrehor. “There

has been more press about it, and I think there has been

more of an interest in it as a result,” she says. Reports are

currently available for short-term acute care hospitals,

long-term acute care hospitals, CAHs, IPFs, and IRFs.

They’ll also soon be available for hospices and partial

hospitalization programs, she says.

Why should hospitals review PEPPER? The answer is

simple, says Glenn Krauss, BBA, RHIA, CCS, CCS-P,

CPUR, C-CDI, CCDS, an independent HIM consultant

in Madison, Wis. “Why wait for denials when you can

prevent them?” he says.

For example, Trailblazer Health Enterprises, LLC, the

MAC for Jurisdiction 4, published a resource for hospitals

that reminds them to review PEPPER data. The resource

also acknowledges the MAC’s awareness that these targets

may be at risk for improper payments, says Krauss.

Recovery Auditors may also be reviewing PEPPER,

says Hrehor. “We don’t send PEPPER to the RACs, but

we do provide them with the database that includes

all of the statistics that are included in a PEPPER. Each

hospital’s information is in the database,” she says.

Who should review PEPPER? Coders, the compliance

officer, business office staff, the CFO, the HIM direc-

tor, CDI specialists, physician advisors, and utilization

review/management should all participate, says Krauss.

“They all have a vested interest in the PEPPER data,” he

explains.

Coders, in particular, need access to PEPPER because

code assignment can influence the data, says Krauss,

adding that hospitals can’t afford to perpetuate inac-

curate information on which auditors can prey. “I think

coders are very integral to the whole process, and they

rarely get feedback,” he says. “The focus is on getting

claims out the door.”

Coding managers can analyze PEPPER data to initiate

various process improvement techniques, says Krauss. For

example, identify areas in which a hospital ranks above

the 80th percentile. Then consider the following measures:

➤ Develop screens and coding protocols for certain

high-risk cases



➤ Tailor coder education that addresses the importance

of sequencing diagnoses and the effect on DRG

assignment and PEPPER data

Direct questions about PEPPER, including questions

about hospital-specific data, to TMF’s help desk at

www.pepperresources.org/HelpContactUs.aspx. “If hospitals

have questions, we want them to contact us,” says

Hrehor. “We are the authoritative source on PEPPER

information.” n

Editor’s note: Access the PEPPER feedback form at

http://tinyurl.com/775r2op.

Access the Trailblazer PEPPER resource at

www. trailblazerhealth.com/Publications/Job%20Aid/

PEPPERResources.pdf.

Documentation

Help physicians understand what coders need Coding managers and their team members some-

times must approach physicians in person regarding

documentation. Clarification may be necessary, or

perhaps you will need to coax the physician to complete

certain records without further delay. Physicians don’t

have much time, and they are inundated with documen-

tation requirements. Anything that coding managers can

do to help physicians understand coders’ documentation

needs and reduce queries should be welcome advice.

Physicians thrive on helping others, so asking them if

they can help is a good approach. Then quickly and con-

cisely explain what is needed and ask whether the physi-

cian can be of assistance. Rarely will a physician say no.

Coding managers can increase awareness of their role

and the challenges coders face by contributing a column

to the medical staff’s monthly newsletter. Be brief.

Consider topics such as those addressed in newsletters

or issues that have been discussed at the CDI committee

meeting. Examples from articles and columns in Medical

Records Briefing include “Why accuracy and specific-

ity matter” (January 2010), “Know ICD-9-CM, CDC, and

MS-DRG classifications for HIV” (August 2009), “Use

medical literature to defend patients’ severity of illness in

pay-for-performance risk adjustment” (June 2009), “ICU

documentation is critical: Reflect patient severity to get

credit where credit is due” (May 2009), and “What’s in it

for us? Documentation and physician reimbursement go

hand in hand” (November 2009).

Finally, consider meeting with the medical staff office

managers quarterly. These meetings have been successful

in developing rapport between the office managers and

key individuals in organizations. The administration often

hosts these meetings, and representatives of multiple

departments may be in attendance. Building rapport with

office managers is a common goal because they often are

the gateway to obtaining information from physicians.

Office managers usually have the physicians’ trust and

their ear. They usually can move something from the bot-

tom of the physician’s pile to the top. Developing positive

relationships with office managers will have paybacks.

Coding managers are in an ideal position because physi-

cian office managers often need coding guidance. Devel-

oping a quid pro quo arrangement benefits both parties. n

Editor’s note: This article is adapted from The Coding

Manager’s Handbook, published by HCPro, Inc.

2013 IPPS Final Rule

Editor’snote:CMSreleasedthe2013IIPSFinalRuleas

Briefings on Coding Compliance Strategieswentto

press.TheOctoberissuewillexaminetheruleindetail.

WanttolearnmoreaboutthechangesCMSfinalizedas

partoftheIPPSfinalrule?JoinHCProandourexpertspeak-

ersat1p.m.EDT,September20,foraliveaudioconference,

2013 IPPS Final Rule Highlights and New Initiatives.

A monthly service of Briefings on Coding Compliance Strategies

September 2012

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Contributing Editor Lisa Eramo at [email protected].

Editor’s note: Answers to the following questions are

based on limited information submitted to Briefings on

Coding Compliance Strategies. Review all documen-

tation specific to your scenario before determining appropri-

ate code assignment.

How do a cervical/vaginal laceration complica-

tion/repair and a routine episiotomy performed

for ease during delivery differ?

A routine episiotomy is a procedure during which a

surgeon performs a surgically planned, less-than-

second-degree incision on the vulva/vagina area or region

to prevent a more serious laceration or tear at the time of

vaginal delivery. The incision is usually only 1–2 centimeters

in length. A cervical/vaginal complication occurs when

there is a l aceration of the cervix or the high vaginal area

that occurs naturally at the time of delivery.

Coders must review documentation to ascertain wheth-

er the patient had a routine episiotomy or whether a cervi-

cal or high-vaginal tear/laceration occurred at the time of

delivery. Sometimes the high-vaginal tear/ laceration occurs

in addition to an episiotomy. Many coders forget to code

the complication.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG,

a coder at St. Alphonsus Regional Medical Center in Boise,

Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer,

answered this question.

A patient was exposed to shingles, for which a

coder reported ICD-9-CM code V01.79 (exposure

to other viral diseases, including HIV). This poses a

problem for billing because code V01.79 is a confiden-

tial diagnosis that requires special release of informa-

tion from the patient, and this information would

remain in the insurance record. As an RN and certified

coder, I think code V01.71 (exposure to varicella) is the

correct code because the varicella virus causes both

chicken pox and shingles. However, the chief business

officer has overruled me. Which code is correct?

I understand where the confusion lies for both the

coder and the business office. When you look up

“Shingles” in the ICD-9-CM Manual, it directs you to

herpes zoster, which is not a modifying term under the

main term “exposure.” Therefore, code V01.79 would

seem appropriate.

Interestingly, certain viruses (e.g., smallpox and

varicella) have specific codes, but other viruses are within

the not elsewhere classified (NEC) category, again making

code V01.79 seem appropriate. Also, HIV does not have a

specific code and is grouped with viruses NEC.

Shingles are caused by herpes zoster, an infection that

results when a varicella-zoster virus reactivates from its

latent state in the posterior dorsal ganglion, according to

Merck. Both chicken pox and herpes zoster are caused by

the varicella-zoster virus (herpes virus type 3). Chicken pox

is considered an active phase of the virus, whereas shingles

(herpes zoster) is a latent phase of the virus (i.e., a reactiva-

tion of the virus). Therefore, I agree that exposure to vari-

cella, code V01.71, would be appropriate here.

However, neither the alphabetic index nor the tabular

list offer guidance, making it understandable why view-

points differ with respect to coding. Coding Clinic does not

provide any advice on the subject either.

A supplement to Briefings on Coding Compliance Strategies

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2012 HCPro, Inc., Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2012 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

Unfortunately, a clear answer may not be possible.

Both opinions seem logical and appropriate, and I can’t

say for certain that either is truly correct because herpes

zoster does not have its own specific code and it doesn’t

cross-reference varicella.

My only advice is to educate the business office staff

and try to persuade them that you are correct. However,

I’m not 100% certain that they are incorrect.

Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory

specialist at HCPro, Inc., in Danvers, Mass., answered this

question that originally appeared on JustCoding.com.

What is the appropriate principal diagnosis for a

patient who presents repeatedly with COPD

exacerbation and chronic pulmonary fibrosis?

During one admission, the physician documented

“acute flareup of pulmonary fibrosis,” and we concurred

that pulmonary fibrosis was the principal diagnosis.

However, other admissions for which both conditions

are documented aren’t as clear. Some coders and CDI

specialists think that the COPD should be sequenced

first because it’s an acute exacerbation. Others think

that the pulmonary fibrosis should be sequenced first

because it causes the COPD.

Can the physician document any particular terms to

illustrate the severity and priority of diagnoses so that

we know which to report as the principal diagnosis?

Pulmonary fibrosis is not designated as one of the

diagnoses included in COPD, according to the

ICD-9-CM index or tabular reference. Coders and

CDI specialists should review the patient’s record to

determine whether the physician identifies COPD as a

separate disease process from pulmonary fibrosis. If the

record supports a separate disease process, coders may

report COPD exacerbation as the principal diagnosis,

depending on the circumstances of the admission and

physician documentation.

There is also no ICD-9-CM index or tabular reference

for pulmonary fibrosis exacerbation. The ICD-9-CM Official

Guidelines for Coding and Reporting (effective October 1,

2011), Chapter 8: Diseases of the Respiratory System, state:

An acute exacerbation is a worsening or a decompen-

sation of a chronic condition. An acute exacerbation is

not equivalent to an infection superimposed on a chronic

condition, though an exacerbation may be triggered by

an infection.

Again, carefully review the record for an acute infec-

tious process or other instigating event. If the record refers

only to pulmonary fibrosis, that should be the principal

diagnosis. The index includes a long list of the types of

pulmonary fibrosis. Coders should select a code based on

specific physician documentation. An infectious process

such as bacterial pneumonia may be the principal diagno-

sis, depending on the circumstances of the admission.

Your inquiry indicates the patient has frequent admis-

sions. Coders should query the physician if documentation

is unclear. It might be useful for CDI specialists to discuss

this patient’s condition(s) with the physician and provide

the available ICD-9-CM classifications for each diagnosis.

Jean Stone, RHIT, CCS, coding manager at Lucile Packard

Children’s Hospital at Stanford in Palo Alto, Calif., answered

this question.

BCCS, P.O. Box 3049, Peabody, MA 01961-3049 • Telephone 781-639-1872 • Fax 781-639-7857

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