Get ready for ICD-10-CM combination codes - · Get ready for ICD-10-CM combination codes Coders well versed in ICD-9-CM know that a com-bination code is a single code used to classify

Get ready for ICD-10-CM combination codes

Coders well versed in ICD-9-CM know that a com-

bination code is a single code used to classify one of

the following:

➤ Two diagnoses

➤ A diagnosis with an associated secondary process

(manifestation)

➤ A diagnosis with an associated complication

ICD-10-CM technically defines combination codes

the same way. However, the codes take on an entirely

different flavor. Not only does ICD-10-CM include more

of them, but they often provide more specific informa-

tion. This additional specificity requires coders to place

greater emphasis on abstracting information from the

medical record.

Consider pressure ulcers. Coders using ICD-9-CM

must assign two codes—one for the site of the ulcer

and another for the stage of the ulcer. Conversely,

ICD-10-CM includes nearly six pages of pressure ulcer

combination codes (category L89) that identify the site

and stage of an ulcer and laterality—all in one code. For

example, ICD-10-CM code L89.013 denotes pressure

ulcer of the right

elbow, stage 3.

As with ICD-9-

CM, coders may

derive the stage

of an ulcer from

wound care or

nursing notes.

However, the

actual diagnosis

and site (including laterality) must be based on physician

documentation.

Upon quick glance, many ICD-10-CM combination

codes demonstrate conciseness that will facilitate re-

search, medical necessity, and denial management. For

example, a patient presents with type 2 diabetes with

mild nonproliferative retinopathy with macular edema.

Coders using ICD-9-CM must report the following three

separate codes to capture this information:

➤ 250.52 (type 2 diabetes with ophthalmic

manifestations)

➤ 362.04 (mild nonproliferative diabetic retinopathy)

➤ 362.07 (diabetic macular edema)

However, with ICD-10-CM, only one code—E11.321

(type 2 diabetes mellitus with mild nonproliferative

diabetic retinopathy with macular edema)—is necessary.

This code denotes the type of diabetes mellitus, the body

system affected, and the specific complications affecting

that body system.

Understanding the

etiology of a disease

process will be paramount

when thinking about

combination codes, says

Jean Bishop, MSPh, MBA,

RHIT, CPC, CFE, CPhT.

November 2011 Vol. 14, No. 11

IN THIS ISSUE

p. 4 Medicare publication offers valuable coding tipsKnow how inpatient RAC target areas may reveal compliance traps.

p. 7 Keep pace with regulatory changesLearn how to avoid information overload in times of rapid changes.

p. 8 Clinically SpeakingRobert S. Gold, MD, explains new codes for hypertrophic cardiomyopathy.

p. 10 Pneumonia codingEnsure documentation is clear, consistent, and thorough before assigning codes for aspiration pneumonia and pneumonia without evidence of infiltrate.

p. 12 Coders and readmissionsKnow what role coders play in monitoring readmissions for three diagnoses addressed in the FY 2012 IPPS final rule.

Inside: Coding Q&A

Page 2 Briefings on Coding Compliance Strategies November 2011

© 2011 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.

These combination codes exemplify the impressive

specificity that ICD-10-CM offers.

Further, these more specific and concise codes will

require more specific physician documentation, says

Donna Smith, RHIA, senior consultant at 3M in At-

lanta. In some cases, physicians may not be accustomed

to documenting in such detail, Smith explains. For

example, a patient presents with an acute gout flare.

Coders currently assign ICD-9-CM code 274.01 to cap-

ture this information. However, assigning a complete

ICD-10-CM code will require that they know the specific

cause of gout and link it to a specific joint, she says. For

example, ICD-10-CM code M10.061 denotes idiopathic

gout of the right knee.

“Interestingly enough, ICD-10 uses the term ‘idio-

pathic’ a lot. It basically means due to an unknown

cause,” says Smith. “But unless the physician tells us

that, we’d have to query or report it as unspecified.”

Research the etiology of diseases

Understanding the etiology of a disease process will

be paramount when thinking about combination codes,

says Jean Bishop, MSPh, MBA, RHIT, CPC, CFE,

CPhT, an independent consultant in Arlington, VA. For

example, ICD-10-CM includes combination codes for

atherosclerotic heart disease with angina pectoris. The

subcategories for these codes are:

➤ I25.11 (atherosclerotic heart disease of native coro-

nary artery with angina pectoris)

➤ I25.7 (atherosclerosis of coronary artery bypass

graft[s] and coronary artery of transplanted heart

with angina pectoris)

Assigning a separate code for angina pectoris is un-

necessary because it’s included in the combination code.

ICD-10-CM guidelines state that coders can assume a

causal relationship between atherosclerosis and angina

pectoris unless documentation indicates the angina is

due to something other than atherosclerosis.

Coders should remember that although unstable an-

gina (a CC) is included in the combination code and not

separately reported, it will continue to affect MS-DRG

calculation, says Smith.

How to identify combination codes

One of the most challenging aspects of combination

codes is simply knowing they even exist, says Bishop.

For example, a patient has toxic liver disease, chronic ac-

tive hepatitis, and ascites. Coders using ICD-9-CM don’t

report a combination code. Instead, they report 573.9

(toxic liver disease), 571.49 (chronic active hepatitis),

and 789.59 (ascites).

However, coders using ICD-10-CM must recognize

that they should report only one code—combination

code K71.51 (toxic liver disease with chronic active

hepatitis with ascites). The key is understanding that the

toxic liver disease is associated with the hepatitis and

Editorial Advisory Board Briefings on Coding Compliance Strategies

Paul Belton, RHIA, MHA, MBA, JD, LLMVice PresidentCorporate Compliance Sharp HealthCare San Diego, CA

Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS Regional Managing Director of HIMNCAL Revenue Cycle Kaiser Foundation Health Plan, Inc. & Hospitals Oakland, CA

Darren Carter, MDPresident/CEOProvistas New York, NY

William E. Haik, MD, FCCPDirectorDRG Review, Inc. Fort Walton Beach, FL

James S. Kennedy, MD, CCSManaging DirectorFTI Healthcare Atlanta, GA

Laura Legg, RHIT, CCSRevenue Control Coding ConsultantRevenue Cycle Management Washington/Montana Regional Services Providence Health & Services Renton, WA

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director, Coding and HIM HCPro, Inc. Danvers, MA

Sandra L. Sillman, RHIT, PAHMDRG CoordinatorHenry Ford Hospital and Health Network Detroit

Jean Stone, RHIT, CCSCoding Manager - HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, CA

Editorial Director: Lauren McLeod

Associate Editorial Director: Ilene MacDonald, CPC

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 © 2011 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 subscrip-tion information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [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.

November 2011 Briefings on Coding Compliance Strategies Page 3


that the two disease processes occur together along with

a manifestation (ascites), says Bishop. The best way to

locate this code is to start with the term “disease,” then

the subterm “liver” followed by “toxic, with hepatitis,

chronic, active, with ascites,” she explains.

When determining whether a combination code might

exist, Smith says coders should ask these two questions:

➤ Are the disease processes linked?

➤ What is the root cause of a particular disease?

Coders must use combination codes when they are

available, says Bishop. “The guidelines state that mul-

tiple codes should not be used when you clearly have a

combination code that identifies all of the elements in

the diagnosis,” she says.

What you can do now

Hospitals can begin preparing for ICD-10-CM combi-

nation codes now.

Streamline the query process and obtain physician

buy-in so that the process works for both coders and

physicians, says Bishop. Establishing a robust query pro-

cess now will improve documentation and likely lead to

fewer queries in the future, she says.

Beware of unspecified codes. Even though unspecified

codes exist in ICD-10-CM, Bishop fears that coders may

default to these codes based on insufficient documenta-

tion. She sees this as a potential problem generally and

especially with combination codes. Defaulting to unspec-

ified ICD-10-CM codes could lead to noncoverage when

insurers stop paying for services that could reasonably be

better defined, Bishop says.

“There are concerns that claims will be rejected and

need to be appealed,” she says.

A high volume of unspecified codes could also lead to

poor data collection for health plan analyses and public

health purposes. Hospitals may also be more vulnerable

to RAC audits if they default to unspecified codes rather

than take advantage of ICD-10’s inherent granularity

and specificity, Bishop says. RACs may question why the

details could not be obtained, she explains.

Coders also need ample training with respect to anat-

omy, physiology, and the etiology of diseases, says Smith.

This knowledge will help coders ask more intelligent and

clinically sound queries, she says. For example, coders

may be able to more easily distinguish between condi-

tions that typically are related and scenarios in which

one condition typically causes another.

Even if a physician doesn’t link two conditions, a

coder would recognize the need to query and correctly

assign the combination code.

Coders should include physicians in the educational

process when possible, says Smith. For example, ask an

orthopedic physician to share information about muscu-

loskeletal procedures and diagnoses (e.g., the anatomy

of a joint). Coders can then explain how codes related to

this specialty will change in ICD-10-CM. Together, physi-

cians and coders can brainstorm ways to best capture the

information, she says.

Also remember that practice makes perfect, Bishop

says. Review records that would require combination

codes under ICD-10 (e.g., diabetes, coronary artery

disease, pressure ulcers, and poisonings and adverse ef-

fects), she says.

Training and preparation for ICD-10 should include

coding records with both ICD-9-CM and ICD-10-CM.

Coders also should note opportunities for CDI. n

Combination codes to ponder

Some ICD-10-CM combination codes that may sur-

prise coders include the following:

➤ Codes in categories T36–T65, which are combination

codes that include substances related to adverse ef-

fects, poisonings, toxic effects and underdosing, and

external causes (e.g., T39.011A, poisoning by aspirin,

accidental [unintentional], initial encounter)

➤ Combination external cause codes that identify se-

quential events that result in an injury, such as a fall

which results in striking an object (e.g., W01.111A,

fall on same level from slipping, tripping, and stum-

bling with subsequent striking against power tool or

machine, initial encounter)



Medicare publication offers valuable coding tipsA recent Medicare Quarterly Provider Compliance News-

letter calls attention to several specific areas of inpatient

coding compliance risk, says Christina Benjamin, MA,

RHIA, CCS, CCS-P, an inpatient auditor at Anthelio

(previously PHNS) in Dallas.

Many of these topics surface during audits—includ-

ing individual coder audits—for various clients Benjamin

serves nationwide.

Some of these issues are pervasive, and experts say

they are indicative of larger and more widespread compli-

ance trends. Seeing the big picture when reviewing this

information is important, so consider the following tips.

Review the definition of principal diagnosis

The ICD-9-CM Official Coding Guidelines and Coding Clinic,

Second Quarter 2001, state that the principal diagnosis is

the condition after study that is chiefly responsible for a

patient’s admission. Coders should remember this at all

times when coding and sequencing conditions.

The July issue of the Medicare newsletter (pp. 5–6)

describes a patient who presents with an acute myo-

cardial infarction (AMI) and undergoes an emergent

left heart catheterization and angioplasty. During the

procedure, the physician documents that the patient

also has severe coronary artery disease (CAD). A coder

incorrectly sequences the CAD as the principal diagnosis,

yielding MS-DRG 237 (major cardiovascular procedures

with MCC). Instead, the coder should have sequenced

the AMI as principal; this would have yielded MS-DRG

238 (major cardiovascular procedures without MCC).

When patients have both AMI and CAD, coders

should first determine which one (or both) was POA,

says Benjamin.

“If the AMI was POA or determined to be POA after

study, then that’s going to be your principal diagnosis,”

she says.

However, even if both AMI and CAD are POA, AMI

will likely be the principal diagnosis because it’s most

likely the acute event that prompted the admission, says

Benjamin. The CAD is probably a chronic condition that

doesn’t warrant the admission, she says.

Think twice before reporting excisional

debridement

Coding excisional debridement requires that the pro-

cedure involves the skin and subcutaneous tissues only,

says Benjamin. If physicians mention that they identified

the nerves or minor vessels or that they extended the

excision into the fascia, it’s probably not an excisional

debridement to the skin alone, she says. “If the docu-

mentation is really not adequate, the coder needs to find

out what’s going on,” Benjamin says.

In some cases, the documentation may be adequate;

however, the coder might not take the time to fully read

through it, says Glenn Krauss, BBA, RHIA, CCS,

CCS-P, CPUR, C-CDI, CCDS. Krauss is an independent

HIM consultant in Madison, WI.

For example, the newsletter (pp. 12–13) describes a

patient who is admitted with acute cerebrovascular ac-

cident, acute renal failure, hypertension, and sacral and

heel ulcers. While in the hospital, the patient receives

wound debridement documented as debridement down

to the fascia. A coder reports 86.22 (excisional debride-

ment of wound, infection, or burn) as the principal

diagnosis, which yields MS-DRG 040 (peripheral/cranial

nerve and other nervous system procedures with MCC).

Instead, the coder should have reported 83.39 (excision

of lesion of other soft tissue) as principal, which would

have yielded MS-DRG 987 (non-extensive OR procedure

unrelated to principal diagnosis with CC).

Many coders are leery of reporting MS-DRG 987, but

in some cases—such as the one previously described—

the documentation warrants it, says Benjamin.

Coders should remember that they may see documen-

tation of both “excisional debridement” and “debride-

ment down to the fascia.” This could indicate multiple

ulcers, some of which require excisional debridement

and some of which require debridement further into the



body tissues, says Benjamin. Coding Clinic, First Quarter

1999, p. 8, reminds coders that although multiple ulcers

may be present, each ulcer requires its own code for the

specific type of debridement the physician performs.

Documentation of excisional debridement and de-

bridement down to the fascia could also indicate mul-

tiple-layer debridement of the same site, in which case

coders should only report the deepest layer of debride-

ment. See Coding Clinic, Second Quarter 2005, p. 3.

Coders can’t assume that documentation of the word

“excisional” necessarily means the physician performed

excisional debridement of the skin and subcutaneous tis-

sue, says Krauss.

“If you don’t have the descriptive terminology of ex-

actly what the physician did when he or she performed

the excisional debridement, then you need to ask,” he

says. Documentation should include a description of the

wound, a description of the instruments used, the depth

and type of the debridement performed, and the type of

tissue debrided, he explains.

Don’t code conditions that are no

longer present

“Look for current treatment,” says Benjamin. “If

there is no evidence of current treatment, don’t code

it. If you do, you may end up accidentally capturing a

CC or MCC.” If a physician documents a condition in a

patient’s history, that might be one clue that it shouldn’t

be coded as part of the current encounter, she says.

For example, the newsletter (pp. 3–4) describes a pa-

tient undergoing dialysis in the dialysis unit who is sent

to the ED for evaluation of anemia. Results of a prior

workup for a gastrointestinal (GI) bleed were inconclu-

sive; however, the admitting diagnosis is documented

as anemia. The ED physician documentation states the

patient has not noticed any melena or hematochezia.

A GI consultation states the patient is admitted with

anemia and denies any GI complaints and any recent

GI bleeds. The discharge summary states the patient has

anemia with end-stage renal disease. A coder reports

blood in the stool as the principal diagnosis, which yields

MS-DRG 377 (GI hemorrhage with MCC). Instead, the

coder should have reported the iron deficiency anemia

as principal, which would have yielded MS-DRG 811

(red blood cell disorders with MCC).

Coders must evaluate each scenario individually

when thinking about whether conditions have resolved

prior to admission, particularly those involving chronic

systemic conditions, says Benjamin.

For example, if a patient has a history of chronic

obstructive pulmonary disease (COPD) and is no longer

receiving any medication or treatment for the condition,

coders should still report it because it’s controlled but not

cured, and it meets the Uniform Hospital Discharge Data

Set definition of a secondary diagnosis, says Benjamin.

Coding Clinic, Third Quarter 2007, states that chronic

conditions (e.g., hypertension, Parkinson’s disease, COPD,

and diabetes mellitus) are chronic systemic diseases that

ordinarily should be coded even in the absence of docu-

mented intervention or further evaluation. Multiple

sclerosis and rheumatoid arthritis are mentioned under

this same class in Coding Clinic, March–April 1985. Con-

gestive heart failure is mentioned in Coding Clinic, Second

Quarter 2000, pp. 20–21.

However, other chronic conditions may require clari-

fication. Be on the lookout for the following conditions:

➤ Crohn’s disease, ulcerative colitis, and

pyloric stenosis

➤ Hepatitis, gastrointestinal ulcer disease, and hernia

➤ Herpes zoster with residual

➤ Bronchitis and asthma

➤ Migraines and seizures

➤ Cardiac valve and rhythm conditions

➤ Phlebitis and thrombophlebitis

➤ Thrombosis

➤ Pathological fracture

➤ Myelopathy with and without disc disorder

➤ Glaucoma

“I do feel strongly that the issue of productivity

weighs in on coders’ thought processes,” says Krauss. He

frequently sees charts for which coders report conditions



that are mentioned only once or twice in a progress note

and that don’t necessarily meet the criteria for reportable

secondary diagnoses.

Krauss says coders should ask the following questions:

➤ How many times did the physician mention

the condition?

➤ What is the clinical significance of the condition?

➤ Does the condition add complexity to the case?

Look for clinical evidence that supports

documentation

“We, as coders, should be looking at the appropri-

ateness of diagnosis and not coding in a vacuum,” says

Krauss. “One of the cardinal rules of coding is to match

up the clinical treatment with the diagnoses, but I’m

seeing a tendency to get away from that and code strictly

what the doctor said. It’s time to revisit priorities and go

back to the basics.”

For example, the newsletter (p. 2) provides a scenario

in which an 81-year-old female is admitted through the

ED with complaints of a dry cough for a couple of weeks.

The patient is assessed for wheezing and coughing, and

the history and physical impression is acute respiratory

failure secondary to exacerbation of COPD.

Progress notes include a diagnosis of acute respiratory

failure secondary to exacerbation of COPD, and the final

diagnosis on the discharge summary is acute respiratory

failure secondary to COPD exacerbation. An additional

documentation sheet in the record lists the following

information:

➤ Principal diagnosis: COPD exacerbation

➤ Other diagnoses: high blood pressure, CAD, conges-

tive heart failure, diabetes mellitus, Parkinson’s, and

rheumatoid arthritis

Krauss says the coder, who likely saw acute respira-

tory failure documented repeatedly throughout the

stay, reported acute respiratory failure (518.81) as the

principal diagnosis. However, the RAC auditor changed

it to hypoxemia (799.02). This resulted in an MS-DRG

change from 189 (pulmonary edema and respiratory

failure) to 192 (COPD without CC/MCC).

“This is a case where the doctor wrote the diagnosis,

but the RAC disallowed it,” says Krauss. This can happen

when CDI programs incorrectly prompt physicians to

document conditions that patients may not have.

The coder definitely plays a role in determining the

validity of diagnoses that physicians document, says

Krauss. Consider implementing a policy to address cases

in which coders determine that clinical treatment doesn’t

match the documented diagnosis. For example, coders

can refer these cases to a lead coder who can discuss the

matter with a physician advisor, he says. n

Editor’s note: Access the July Medicare Quarterly Provider

Compliance Newsletter, which includes many of the scenarios

described in this article, at http://tinyurl.com/43qsagm.

❑ Start my subscription to BCCS immediately.

Options No.ofissues Cost Shipping Total

❑ Electronic 12 issues $249 (CCSE) N/A

❑ Print & Electronic 12 issues of each $249 (CCSPE) $24.00

Salestax (see tax information below)*

Grandtotal

BCCS SubscriberServicesCoupon Yoursourcecode:N0001

Name

Title

Organization

Address

City State ZIP

Phone Fax

E-mailaddress(Requiredforelectronicsubscriptions)

❑ Payment enclosed. ❑ Please bill me.❑ Please bill my organization using PO # ❑ Charge my: ❑ AmEx ❑ MasterCard ❑ VISA ❑ Discover

Signature(Required for authorization)

Card # Expires(Your credit card bill will reflect a charge from HCPro, the publisher of BCCS.)

Orderonlineatwww.hcmarketplace.com.

BesuretoentersourcecodeN0001atcheckout!

Mail to: HCPro,P.O. Box 3049, Peabody, MA 01961-3049 Tel: 800/650-6787 Fax: 800/639-8511 E-mail: [email protected] Web: www.hcmarketplace.com

Fordiscountbulkrates,calltoll-freeat888/209-6554.

*TaxInformationPlease include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR.



Becoming inundated with coding information is easy

in this fast-paced world of interconnectedness.

The sheer volume of ongoing regulatory changes only

adds to the sense of being overwhelmed. How can coders

keep pace with this data cascade without letting it com-

pletely devour their days?

Clients frequently ask Darice M. Grzybowski, MA,

RHIA, FAHIMA, president and founder of HIMentors,

LLC, in Westchester, IL, this question. As a consultant,

Grzybowski often informs hospitals of regulatory chang-

es via presentations, training, and newsletters tailored to

meet their needs. This saves hospital employees count-

less hours they would otherwise spend researching,

reading, and relaying information, she says.

Coders and their managers can help themselves

manage this information, says Grzybowski. First, make

use of the Internet by subscribing to complimentary

e-newsletters published by professional associations and

other reputable organizations, she says.

“The information is pushed out to you rather than you

having to go out and search for it,” she says. “There’s the

old-fashioned way of hunting and searching, but you’ll

be on a journey for weeks at a time, and we don’t have

that kind of time in our busy lives.”

Vendors are another potential source of free infor-

mation; many offer newsletters, webinars, and helpful

information on their websites, says Grzybowski.

Google and AOL® alerts are also an option. These

alerts rely on key terms (e.g., ICD-9, ICD-10, RAC) to

flag updates and send the information to your inbox,

says Vickie Axsom-Brown, president of Audit &

Recovery Solutions in Henderson, NV.

“I try to set it up so that I’m not doing research 10

hours out of my 12-hour day,” says Axsom-Brown, a

Don’t fall prey to coding information overload

Manage regulatory information with these essential online resources

Certain resources can make a world of difference with re-

spect to managing regulatory information. If you don’t al-

ready have the following resources in your coding arsenal,

consider adding them now.

Complimentary e-newsletters

➤ AHA News Now, a daily publication for and about AHA

members and employees of hospitals, health systems,

and healthcare facilities

(www.ahanews.com/ahanews_app/jsp/getnewnow.jsp)

➤ Medicare Weekly Update, a weekly publication that brings

readers the latest Medicare news for hospitals from CMS

and the OIG

(www.hcmarketplace.com/prod-5091/Medicare-Weekly-

Update.html)

➤ The RAC Report, a biweekly publication that offers tips

and strategies pertaining to RACs

(www.hcmarketplace.com/prod-6895/The-RAC-Report.html)

➤ Medicare Update for CAHs, a biweekly publication that

provides specialized information for critical access

hospitals (CAH), focusing on reimbursement and CMS

updates of special concern to CAHs

(www.hcmarketplace.com/prod-9659/Medicare-Update-for-

CAHs.html)

Subscription-based websites

➤ MedicareFind™, a regulatory database that allows users

to easily and intuitively access Medicare reimbursement

rules and regulations

(www.medicarefind.com/Purchase.aspx)

➤ JustCoding.com, a continuing education website for

coding professionals

(www.hcmarketplace.com/prod-3270/JustCodingcom.html)

Other sources of information

➤ CMS e-mail updates, which address various topics of in-

terest (Visit https://www.cms.gov and select Email Updates

under Featured Content. Subscribe to updates pertaining

to Hospital Open Door Forum calls, RACs, quarterly pro-

vider updates, and CMS press releases.)



regular user of alerts. “I’d rather do research one hour

out of my 12-hour day than spend all day long flounder-

ing because I don’t have the information that I need.”

If you devote time to searching for updates daily or

weekly, be sure to rely on official sources (e.g., CMS,

OIG, AHA), says Gloryanne Bryant, BS, RHIA, RHIT,

CCS, CCDS, regional managing director of HIM, NCAL

Revenue Cycle, Kaiser Foundation Health Plan, Inc. &

Hospitals in Oakland, CA.

“It’s helpful to read an actual transmittal or Medlearn

Matters article,” Bryant says. “You want the official advice

rather than hearsay interpretation or opinion from lay-

people. I try to get something that has the source docu-

ment linked to it.”

CMS Open Door Forum calls, which are free and

open to the public, also provide much information

about the latest rules and regulations, says Bryant. Pro-

viders can ask questions during the Q&A portion of

the call. Learn more at www.cms.gov/OpenDoorForums/

18_ODF_Hospitals.asp.

Regularly visit your RAC’s website, but be aware

that not all issues posted directly affect coders, and some

may not affect your organization at all, says Axsom-

Brown. “As you look at your RAC’s list of issues, it’s

critically important that you identify those that specifi-

cally have a potential for an audit hit within your

organization,” she says. RAC data can overwhelm

coders and coding managers who don’t use this filter.

Thorough knowledge of your organization’s data

is the best approach for dealing with auditors, says

Axsom-Brown. Reviewing your top 25 or 50 proce-

dures with respect to volume and determining their

relevance to recent MLN Matters articles, RAC activity,

or OIG activity is more helpful than researching infor-

mation that may not even pertain to your organization,

she says.

Delegate different tasks to individual coders. For ex-

ample, coders can select a topic (e.g., RACs, EHRs, Coding

Clinic), research updates, and present findings at monthly

meetings. “You can drill down the focus, and everyone

shares in the information,” says Grzybowski.

Remember that not all information has value

throughout the department, says Bryant. “We review

[information] and try to determine what the impact will

be to our coding staff. We do filter through the informa-

tion, and we try to summarize it on a quarterly basis

as much as we can unless it’s a transmittal that’s being

implemented quickly,” she says. n

by Robert S. Gold, MD

The good news is that as of October 1,

there are new ICD-9-CM codes to denote

hypertrophic cardiomyopathy:

➤ 425.11 (hypertrophic obstructive cardiomyopathy)

➤ 425.18 (other hypertrophic cardiomyopathy)

The bad news is that some physicians, coders, and CDI

specialists have misunderstood hypertrophic cardiomy-

opathy, leading to miscoding. Let’s set the record straight.

Hypertrophic cardiomyopathy

When hypertrophic cardiomyopathy with obstruc-

tion occurs in children, physicians sometimes refer to it as

idiopathic hypertrophic subaortic stenosis. It also is known

as hypertrophic obstructive cardiomyopathy. Previously, it

mapped to ICD-9-CM code 425.1. Hypertrophic cardio-

myopathy without obstruction mapped to 425.4, which

includes other primary cardiomyopathies described with

many nonspecific adjectives.

Hypertrophic cardiomyopathy—with and without

obstruction—is one disease with different levels of

Hypertrophic cardiomyopathy and ventricular hypertrophyUnderstanding how conditions differ is essential for correct coding



functional abnormality due to structural changes. As

of October 1, ICD-9-CM classifies it under one code

(425.1x) instead of two. The fifth digit extensions specify

with or without obstruction. Cool, right? Not quite.

True hypertrophic cardiomyopathy is a genetic disor-

der. Manifestations range from no findings for a patient’s

entire lifetime to sudden cardiac death from ventricular

arrhythmias. Perhaps you’ve seen news reports about

children who died suddenly on the playing field because

of hypertrophic cardiomyopathy. Efforts to ensure echo-

cardiograms for all participants to identify those at risk of

death during intramural sports often follow.

Ventricular hypertrophy

This topic becomes confusing for coders when physi-

cians use the term “hypertrophic cardiomyopathy”

when they really mean ventricular hypertrophy. What’s

the difference?

Hypertrophy of one or both ventricles may be due

to a known secondary cause. Systemic hypertension

can lead to left ventricular hypertrophy as the left ven-

tricle works harder against pressure downstream. Right

ventricular hypertrophy with or without chronic cor

pulmonale can be caused by pulmonary artery hyper-

tension or chronic lung disease. Shunts can cause hyper-

trophy. Heart valve diseases can cause hypertrophy.

All of these are hypertrophy of one or both ventricles

due to an identifiable cause. Don’t report 425.1x for

these scenarios.

Left ventricular hypertrophy caused by hypertension

is a manifestation of hypertensive heart disease. Consider

the 402 code series. If a cardiologist identifies and docu-

ments hypertensive cardiomyopathy, reporting 425.9

(secondary cardiomyopathy, unspecified) is appropriate.

A patient with hypertensive heart disease and left ven-

tricular hypertrophy who develops significant stiffness to

the left ventricle may have chronic heart failure due to

diastolic dysfunction (428.32). The large size of the ven-

tricular wall and interventricular septum interferes with

filling of the left ventricle during diastole, and the patient

develops symptoms of congestive heart failure.

Aortic stenosis can narrow the opening from the

left ventricle into the aorta, causing the ventricle to

work harder to eject blood. As with hypertension, the

added work can lead to hypertrophy. The left ventricular

hypertrophy can lead to inadequate filling during the

diastolic portion of the heart cycle. Once symptoms

of heart failure begin, patients may develop chronic

heart failure due to diastolic dysfunction (428.32) that

is due to valvular cardiomyopathy (425.9) of aortic ste-

nosis (424.1).

Interestingly, muscle fibers can become so over-

stressed that they essentially lose strength, and the heart

dilates. This occurs with both primary genetic hyper-

trophic cardiomyopathy and acquired left ventricular

hypertrophy due to another disease process.

A patient whose heart is hypertrophic may develop

chronic diastolic failure. Without appropriate treat-

ment, the heart will start to dilate, and the echocar-

diogram will now demonstrate a low ejection fraction.

When this occurs, a patient will also experience

systolic failure.

Patients can experience almost a total reversal of

hypertrophy or even late-stage dilation after treatment

for hypertension for several years or after repair or

replacement of the aortic valve. When patients have left

ventricular hypertrophy due to a disease process, their

cardiodynamics can virtually return to normal over time.

Surgery can relieve symptoms of the genetic form of

hypertrophic cardiomyopathy that interfere with daily

life, but only a heart transplant can cure it.

In summary, hypertrophic cardiomyopathy with or

without obstruction is considered a genetic condition.

Left (or right) ventricular hypertrophy is an acquired

condition. New ICD-9-CM codes denote hypertrophic

cardiomyopathy with or without obstruction. No codes

denote left ventricular hypertrophy. The only option is

429.3 (cardiomegaly). n

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

firm in Atlanta that provides physician-to-physician CDI pro-

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



Like many diagnoses, pneumonia presents challenges

for coders when physician documentation is unclear.

Aspiration pneumonia

Clear documentation of aspiration pneumonia, in par-

ticular, continues to be problematic, says Joy J. King,

RHIA, CCS, CCDS, principal of Joy King Consulting,

LLC, in Birmingham, AL. Why? Physicians often docu-

ment “aspiration” or “pneumonia” without specifically

stating “aspiration pneumonia.” This occurs even though

clinical evidence in the record suggests a link between

the two, she says.

What should coders do? Review pathophysiology, and

then consider asking the physician for clarification, says

Lolita M. Jones, RHIA, CCS, an independent consul-

tant in Fort Washington, MD.

Aspiration pneumonia occurs when patients breathe

foreign materials (e.g., food, liquid, vomit, or fluids from

the mouth) into the lungs, causing inflammation. Risk

factors for developing aspiration pneumonia include

coma, esophageal stricture, gastroesophageal reflux,

high consumption of alcohol, general anesthesia, old age,

stroke, brain injury, and difficulty swallowing. Symp-

toms of the condition include bluish skin color, chest

pain, cough, fatigue, fever, shortness of breath, wheez-

ing, breath odor, and excessive sweating.

Several diagnostic tests help physicians determine

whether patients have aspiration pneumonia, says

Jones. These include a physical exam (to identify crack-

ling sounds in the lungs or a rapid pulse/heart rate),

arterial blood gas, blood culture, bronchoscopy, chest

x-ray, com plete blood count, CT scan of the chest,

sputum culture, or swallowing study. Therapeutic inter-

ventions include antibiotics, mechanical ventilation,

or oxygen therapy.

Coders can only code aspiration pneumonia when a

physician clearly documents a link between the aspira-

tion and the pneumonia, says King.

“It’s very important that you have both of these words

documented and linked together before you assign that

507.0 code,” she says.

When coding postoperative aspiration pneumonia,

coders must first report complication code 997.39 (other

respiratory complications) followed by code 507.0

(pneumonitis due to inhalation of food or vomitus) to

further specify the respiratory complication, says King.

Pneumonia without evidence of infiltrate

Coders shouldn’t be surprised to see more frequent

documentation of clinical pneumonia in the absence

of positive chest x-rays, says Jones. This can occur for

several reasons. For example, research has found that

radiologist interpretation of the presence of infiltrates is

somewhat subjective, she says.

Note that patients who are dehydrated must first

receive fluids before an infiltrate would even show up

on a chest x-ray, notes King.

Advocate for thorough pneumonia documentation

Wear your pride as a credential with your name.

Sponsored by

The Certified Clinical Documentation Specialist (CCDS) credential recognizes your knowledge and skills in clinical documentation improvement.

It promotes documentation and medical records integrity, and supports compliance efforts.

And it’s from ACDIS, the premier professional association for clinical documentation specialists, providing education, professional growth, program recognition, and networking.

Learn more at www.cdiassociation.com

Earn your CCDS Credential

MP104106



CT scans—rather than chest x-rays—are becoming

more frequently used to detect pneumonia, says Jones.

Other types of alternative tests for diagnosing pneu-

monia include C-reactive protein (which rises and falls

with infection and is stimulated more often by bacteria),

procalcitonin (which rises when bacteria are present),

and soluble triggering receptor expressed on myeloid

cells (which rises in the presence of bacteria and fungal

infections but does not respond to viruses or noninfec-

tious disorders).

However, negative chest x-rays can raise red flags.

Hospitals continue to experience denials due to patients

diagnosed and coded as having clinical pneumonia when

the chest x-ray is negative, says King.

“An infiltrate on a chest x-ray is still considered the

gold standard by the OIG, the RACs, and the other

governmental agencies that are out there looking at our

records,” she says.

What can coders do? In the absence of infiltrates on

chest x-rays, coders can and should look for documenta-

tion of certain signs and symptoms before coding pneu-

monia, says King. These include respiratory rate greater

than 25, heart rate greater than 100, rales, crackles,

rhonchi, dullness to percussion, or decreased breath

sounds, she says.

“Communication with attending physicians about the

importance of documenting more about the clinical di-

agnosis of pneumonia in the absence of infiltrate is going

to be increasingly important to capture in the medical

record,” King says.

Also note these important coding guidelines regard-

ing pneumonia:

➤ When patients have hypoxemia with pneumonia, code

the hypoxemia separately. Unlike respiratory failure,

hypoxemia is not considered an inherent part of pneu-

monia. See Coding Clinic, Second Quarter 2006, p. 24.

➤ Coders cannot assume the causal organism of the

pneumonia based on sputum cultures. “Because spu-

tum cultures are often misleading or negative, the

physician must actually document a link between re-

sults on the culture and the pneumonia itself in order

for [coders] to link those,” says King. “This contin-

ues to be something coders struggle with.” See Coding

Clinic, Second Quarter 1998, pp. 3–4. n

Editor’s note: This article is based on content originally

presented during HCPro’s audio conference “Top ICD-9-CM

Trouble Spots: Master Clinical Background and Coding Guide-

lines for Accurate Coding.” For more information, visit

http://tinyurl.com/6dl5ad7.

Coding Clinic pneumonia references at a glance

Review the following Coding Clinic references for

pneumonia:

➤ Fourth Quarter 2010, p. 135

➤ First Quarter 2010, pp. 3, 12

➤ Third Quarter 2009, p. 16

➤ Fourth Quarter 2008, pp. 69, 140

➤ Second Quarter 2006, pp. 20, 24

➤ Second Quarter 2003, pp. 21–22



➤ Second Quarter 1998, pp. 3–5, 7

➤ First Quarter 1998, p. 8




➤ First Quarter 1994, pp. 17–18



➤ First Quarter 1992, pp. 17–18


➤ Third Quarter 1988, pp. 11, 13

Review the following Coding Clinic references for

aspiration pneumonia:



➤ Third Quarter 1991, pp. 16–17




Monitor diagnoses targeted for readmission reductionCMS is starting to crack down on readmissions, and

hospitals may soon feel the effects from a financial

perspective.

Beginning in FY 2013 (i.e., for discharges on or after

October 1, 2012), CMS will implement a program to

reduce hospital readmissions for certain hospitals with

excessive readmissions of patients with three conditions:

➤ Acute myocardial infarction (i.e., heart attack)

➤ Heart failure

➤ Pneumonia

CMS explained the program and its payment implica-

tions in greater detail in the FY 2012 IPPS final rule.

Diagnostic and other criteria

CMS based selection of the three conditions on analy-

sis of 235 diagnostic categories for hospitalization derived

from 2008 Medicare hospital claims data. Analysis re-

vealed that heart failure was the most frequent diagnos-

tic category for admissions and readmissions. Pneumonia

was second most frequent for admissions and readmis-

sions. Acute myocardial infarction ranked eighth and

ninth for readmission and admission, respectively.

In its final rule, CMS describes readmission as “oc-

curring when a patient is discharged from the applicable

hospital and then is admitted to the same or another

acute care hospital within a specified time period from

the time of discharge from the index hospitalization.”

The specified time period is 30 days.

The reductions are part of a larger Hospital Readmis-

sions Reduction Program required by the Affordable

Care Act. CMS will implement the program over two

years, addressing selection of readmission measures and

calculation of the excess readmission ratio during the

first year and using the ratio to calculate the actual read-

mission payment adjustment factor that it will apply to

each relevant base DRG during the second year.

The three applicable conditions apply only to patients

discharged with a principal diagnosis code denoting acute

myocardial infarction, heart failure, or pneumonia. Re-

admission measures don’t apply to patients who contract

infections from transplantation of infected organs.

“Recognizing that this data will start being collected

on October 1, 2011, the sooner the coding department

works with the quality department on this issue, the

better,” says James S. Kennedy, MD, CCS, managing

director at FTI Consulting in Atlanta.

Coders should understand the implications that cod-

ing and sequencing may have on readmissions data

and cohort selection. For example, if coders report

documented septicemia or acute respiratory failure as

the principal diagnosis when a patient is admitted for

pneumonia—and a readmission occurs within 30 days—

CMS will not count the second admission as a read-

mission, says Kennedy. Similarly, certain heart failure

patients won’t be included depending on how conditions

are sequenced. For example, a patient admitted with

heart failure also has symptoms and an acute troponin

rise indicative of acute myocardial infarction or clinical

circumstances supporting acute respiratory failure at the

time of admission. If acute myocardial infarction or acute

respiratory failure is sequenced as principal and the pa-

tient is readmitted within 30 days, CMS won’t consider

the second admission to be a heart failure readmission.

Visit http://tinyurl.com/b5zrph for more information.

The following measures can lower readmission rates:

➤ Ensure that patients are clinically ready for discharge

and understand their care plans

➤ Reduce the risk of infection

➤ Reconcile medications

➤ Improve communications with community providers

responsible for post-discharge patient care

➤ Improve care transitions n

Editor’s note: Access the final rule at www.gpo.gov/fdsys/

pkg/FR-2011-08-18/pdf/2011-19719.pdf. The discussion

regarding readmissions begins on p. 185.

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].

November 2011

Coding Q&AA monthly service of Briefings on Coding Compliance Strategies

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.

Some of our physicians are uncomfortable making

addenda to the discharge summary to include

pathological findings (e.g., malignancy). They think

an addendum to the discharge summary containing

information from a pathology report received after a

patient is discharged might be illegal. Instead, they

dictate tumor board notes that summarize the course

of treatment and final pathological diagnosis. Our

concern is that the tumor board note is usually dated

a few days after the patient is discharged.

When a condition meets reporting guidelines for

an inpatient admission, is the use of documenta-

tion dated after the inpatient admission for coding

purposes appropriate? Do specific laws or guidelines

prohibit coding from documentation dated after an

inpatient admission?

For example, a patient is discharged January 1

with a diagnosis of uterine mass. A pathology report

showing uterine cancer arrives January 3, and the

physician documents a tumor board note that states

“uterine cancer” January 5. May we assign a uterine

cancer code based on this tumor board note?

You may report an ICD-9-CM code for uterine cancer

if the tumor board note:

➤ Qualifies as a “cancer staging form” as described in

Coding Clinic, Second Quarter 2010, pp. 7–8

➤ Is part of the permanent medical record for

that encounter

➤ Is signed by the attending (not consulting) physician

for that admission

Refer to the aforementioned Coding Clinic and your

facility’s medical staff bylaws or HIM/coding policies

and procedures for further clarification. If the scenario

described in your question meets these requirements,

report ICD-9-CM code 625.8 for the uterine mass and

ICD-9-CM code 179 for the additional diagnosis of

uterine cancer.

A query is appropriate if the pathological report was

present on the chart before final coding without a cancer

staging form signed by the attending physician and there

is no documentation in the record of its findings by any

treating physician.

Consider the following query:

According to Coding Clinic, Third Quarter 2008,

pp. 11–12, and the ICD-9-CM Official Guidelines for

Coding and Reporting, we may not report and code

abnormal findings on the pathology report unless the

provider indicates their clinical significance. Now that the

pathology report is available, if appropriate, could you

please clarify the patient’s diagnoses in your documenta-

tion based on these findings?

Coders should include the findings or pathology

report for physician inspection with the query.

This may frustrate physicians because the final diag-

nosis established by the pathology report factors into the

reason for admission and follow-up care, but physicians

should be encouraged to reflect this diagnosis in their

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 © 2011 HCPro, Inc., Danvers, MA. Telephone: 781/639-1872; fax: 781/639-7857. CPT codes, de scriptions, and material only are Copyright © 2011 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.

medical decision-making. Coders face the same dilemma

with electrocardiograms and radiology reports, even

though competent physicians interpreted them.

Refer to Coding Clinic, Third Quarter 1992, p. 7, for

additional guidance.

James S. Kennedy, MD, CCS, managing director of FTI

Consulting in Atlanta and Association for Clinical Documen-

tation Improvement Specialists advisory board member,

and Sandra L. Sillman, RHIT, PAHM, a DRG coordina-

tor at Henry Ford Hospital & Health Network in Detroit,

answered the previous question, which first appeared on

JustCoding.com.

One of our podiatrists documents “surgical

debridement of devitalized tissue with scalpel” in

his inpatient progress notes. I explained that he must

clarify the technique, appearance and size of the

wound, and the depth of the debridement. He agreed

to document these details but resists documenting

the term “excisional.”

The podiatrist says he and his peers have omitted

this term for years and that it isn’t required. He con-

siders surgical debridement a more accurate term

because the procedure involved cutting and the

patient went to the OR.

I explained that ICD-9-CM categorizes debridement

as either excisional (ICD-9-CM procedure code 86.22)

or non-excisional (ICD-9-CM procedure code 86.28).

I explained that the procedure would default to the

lesser-weighted DRG without documentation of the

term excisional.

What should I do? I have shared relevant Coding

Clinic issues to no avail. I couldn’t find any medical or

podiatry literature that addresses documentation of

surgical/sharp and excisional debridement.

The terminology used in ICD-9-CM procedures

does not always align with clinical or surgical terms.

Explain the difference between ICD-9 codes for hospital

inpatients and the CPT® code description and language.

The hospital and clinician use the same procedure codes

and descriptions for outpatient services. However, codes

and descriptions differ on the inpatient side.

Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional

managing director of HIM, NCAL revenue cycle, Kaiser

Foundation Health Plan, Inc. & Hospitals in Oakland, CA,

answered the previous question. n

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

Contact Contributing Editor Lisa Eramo

Telephone 401/780-6789

E-mail [email protected]

Questions? Comments? Ideas?

CMS issues Medicaid RAC final rule

State Medicaid agencies must implement a RAC

program by January 1, 2012, according to a final rule

CMS released September 14.

The rule includes information about payment meth-

odology determinations, the timing of payments, the

structure of payments, and more. Access the rule at

www.ofr.gov/OFRUpload/OFRData/2011-23695_PI.pdf.

Learn more about preparing for Medicaid RACs by

reviewing the tips and strategies in the July Briefings

on Coding Compliance Strategies (pp. 1–3).

Documents

Get ready for ICD-10-CM combination codes - · Get ready for ICD-10-CM combination codes Coders well versed in ICD-9-CM know that a com-bination code is a single code used to classify