Have Confidence Coding the Top 6 Diagnoses Most Audited by Payors

Presented by: Laura Legg, RHIA, RHIT, CCS, CDIP

Objectives

• Identify top 6 diagnoses that payors love to audit

• Review clinical criteria needed for assignment of the diagnoses codes

• Understand documentation needs for each diagnosis

• Answer the question: What happens when you get the denial?

What Documentation Counts?

• Any Healthcare Provider

• Attending vs. Consulting provider

• Code From the Entire Record

• Clinical Validation

Clinical Validation

• CMS does not allow providers to submit claims with codes for conditions that cannot be validated or substantiated by the clinical findings, criteria or circumstances documented in the record.

• The days of coding whatever the doctor documents without clinical validity are gone.

• Coders must have training and experience to recognize and confirm validating clinical criteria and circumstances.

Rules for Code Assignment

Conventions for ICD-10-CM:

19. Code Assignment and Clinical Criteria: The assignment of a

diagnosis code is based on the provider’s diagnostic statement

that the condition exists. The provider’s statement that the patient

has a particular condition is sufficient. Code assignment is not

based on clinical criteria used by the provider to establish the

diagnosis.

Supporting Clinical Documentation needed

• Documentation of a diagnosis by the provider in clear, concise, consistent language:

• Presenting signs and symptoms

• Documented test results

• Corroboration by consulting physicians when appropriate

• Detailed history of progression of disease or condition

Troubleshooting for Common Problems

• Abnormal findings vs. confirmed diagnoses

• Signs/symptoms routinely seen as part of a disease process

• Suspected, probable, or possible diagnoses

• Conflicting, incomplete, inconsistent documentation

Abnormal Findings

• Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance.

• If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

• The physician must indicate that the condition is clinically significant AND the condition must meet criteria for assignment as a secondary diagnosis.

Signs and Symptoms Routinely Seen

• It is common to see well established signs or symptoms as part of a disease process:

• Abdominal pain in a patient with an acute appendicitis

• Chest pain in a patient who is experiencing an acute MI

• SBO in a patient with pneumonia

Uncertain Diagnoses

• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established.

• This means in the discharge summary or final progress note.

Is the Documentation Complete, Clear and Consistent?

• Maintaining high standards for accuracy and competency:

• Unclear or inconsistent documentation: Do you need a query?

• Conflicting documentation between providers then the attending has the final say

• Know your facility’s policy on initiating queries

• Prevent unnecessary queries

Know the rules; Know the payors

• ICD-10-CM

• ICD-10-PCS

• Official guidelines for coding and reporting

• AHA coding clinics

• Payers contracts – Medicare – Medicare advantage – Private insurance companies

Maintain your clinical focus

• High-value diagnoses: if you have an unusual circumstance do a AHA Coding Clinic search

• Facility criteria-Coding policies and procedures

• Physician Advisor

• Textbook diagnostic and treatment guidelines

The Top 6 High-Risk Diagnoses Payors Audit

1. Encephalopathy

2. Acute blood loss anemia

3. Malnutrition

4. Pleural effusion

5. Atelectasis

6. Acute respiratory failure

6

Diagnosis: Encephalopathy

Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation, paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain.

#1

Encephalopathy Codes

Encephalopathy Types

• Type and acuity must be documented:

• Metabolic-toxic and drug-induced

• Alcoholic

• Hypertensive

• Septic

• Anoxic

• Caused by infection

Encephalopathy Signs and Symptoms

• Altered mental status

• Delirium

• Confusion

• Agitation

• Physical symptoms (stupor, coma, rigidity/stiffness of muscles)

Encephalopathy Treatment

• Treatment of the underlying cause

• Adjustment of medication

• Fluids

• Tests to determine underlying cause

Encephalopathy Documentation

• Insurance carriers continue to target claims where encephalopathy is assigned as a principal or secondary diagnosis.

• Documentation must be:

• Clear

• Thorough

• Consistent

• Supported by clinical indicators

Encephalopathy Documentation

• Look for documentation supporting a specified form of encephalopathy (metabolic, toxic)

• When encephalopathy is documented and the etiology is not identified or clear, query the cause based on the record

• When a cause cannot be identified use G93.40 encephalopathy unspecified

• Sequencing will depend on the index, guidelines and coding instructions

Clinical indicators to look for

• Acute encephalopathy

• Acute alteration of brain function

• Reversible and resolves when the underlying cause is corrected

• No structural changes-CT/MRI unremarkable

• Chronic encephalopathy

• Irreversible, structural

• Due to other chronic condition such as Korsakoff, Binswanger, trauma, alcohol, chronic toxic other hereditary metabolic disorders

Pitfalls for Coding Encephalopathy

• One time documentation

• Conflicting documentation

• Absent clinical indicators

• Did the physician document the baseline of the patient and what current signs and symptoms represent acute encephalopathy?

• Other etiologies for symptoms

Delirium vs. Encephalopathy

• Delirium - mental disorder or symptom

• Encephalopathy - a specific medical condition that may cause delirium (a medical condition not a mental disorder)

• Whenever a diagnosis of delirium is documented a query for the underlying cause such as encephalopathy may be warranted

Additional instruction

Review these Coding Clinics ICD-10-CM/PCS

• CC 2nd Q 2017 Encephalopathy due to sepsis

• CC 2nd Q 2018 Encephalopathy due to other conditions

• CC 2nd Q 2018 Encephalopathy due to UTI

• CC 4th Q 2018 Lacunar infarction

• CC 4th Q 2017 Clarification of severe sepsis guidelines

• CC 2nd Q 2017 Encephalopathy associated with CVA

• CC 2nd Q 2016 Hepatic encephalopathy

• Definition: Anemia due to loss of blood, decreased red blood cell mass, hemoglobin/hematocrit level below normal reference range

• Documentation:

• Anemia due to hemorrhage

• Acute blood loss

• Not on the amount of blood lost or whether a transfusion was done

Diagnosis: Acute blood loss anemia

#2

Acute Blood Loss Anemia Codes

Acute Blood Anemia Signs and Symptoms

• Faintness, dizziness, thirst, sweating, weak, rapid pulse, rapid respiration

• Orthostatic hypotension

• Syncope

• Shortness of breath

• Heart palpitations

Acute Blood Anemia Treatment

• Hemostasis-treat source of bleeding

• Restoration of blood flow: Transfusion

• Fe therapy to restore lost iron

• Absolute rest, oral fluids

• Fe therapy to restore lost iron

Acute Blood Anemia Clinical indicators

• Elevated RBC, hemoglobin, hematocrit: During and immediately after hemorrhage

• Decreased RBC, hemoglobin: Several hours after hemorrhage

• Elevated platelet count

Blood Anemia Documentation

• Transfusion given

• Development of symptoms (weakness, SOB, syncope)

• Drop in hemoglobin of 1.0-2.0 gm/dl and/or hematocrit of 3-6%

• Monitored with serial HCT/HGB

• Prescription for Iron supplements

Pitfalls for coding acute blood loss anemia

• Conflicting documentation regarding significance of anemia

• Present but not clinical significant or treated

• Expected following surgical procedure

Additional Instruction

• Coding Clinic, First Quarter 2014: Page 15 Facility-Specific Coding Guidelines

• Coding Clinic, Third Quarter 2013 Page: 9 Gastrointestinal Bleeding and Blood Loss Anemia due to Colon Malignancy

• Coding Clinic, First Quarter 2007 Page: 19 Postoperative Anemia

• Coding Clinic, Third Quarter 2004 Page: 4 Postoperative Anemia Secondary to Expected Blood Loss

• Malnutrition is defined as a chronic state of nutritional deprivation resulting in a constellation of characteristic clinical findings:

• Physical findings

• Risk factors

• Biochemical markers

• Body mass composition

Diagnosis: Malnutrition#3

Malnutrition Codes

Malnutrition Signs and Symptoms

• Physical signs and symptoms

• Cachexia, underweight, wasted

• Failure to thrive diagnosis

• Terminal malignant neoplasm diagnosis

Malnutrition Treatment

• Nutritional consult

• Oral supplementation

• Dietary changes

• Monitoring of calorie counts

• I/O

• Enteral or parenteral nutrition

• Aggressive oral supplementation

Malnutrition Clinical Indicators

Criteria Severe Moderate Mild

Albumin/prealbumin <2.0/<5.0 <2.5/<10.0 <3.0/<15.0

Ideal body weight <70% <80% <90%

Usual body weight <75% <85% <95%

BMI <16 <17 <18.5

Malnutrition Documentation

• Clear, concise documentation from the provider

• Consultation from a registered dietician

• Complications related to malnutrition

• Treatment directed at the malnutrition

• Abnormal lab values

Pitfalls For Coding Malnutrition

• Weight loss does not equal malnutrition!

• Documented only once

• Nutritional consult not available

• Type and acuity (severity) is not documented

• Medicare and other payors may not endorse assignment of malnutrition codes in common acute circumstances

• No established coding and query policies to assist coders

Additional Instruction

• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018: Page 77 Body Mass Index

• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 108 Malnutrition and Malabsorption

• Coding Clinic for ICD-10-CM/PCS, Third Quarter 2017: Page 24 Emaciation and Malnutrition

• Coding Clinic for ICD-10-CM/PCS, Third Quarter 2017: Page 25 Severe Malnutrition

• Pleural effusion is an abnormal accumulation of fluid within the pleural spaces. It occurs in association with pulmonary disease and certain cardiac conditions, such as congestive heart failure, or certain diseases involving other organs.

• Pleural effusion is almost always integral to the underlying disease, is usually addressed only by treatment of that condition, and, in these cases, should not be coded.

Diagnosis: Pleural Effusion#4

• Occasionally the effusion is addressed separately, with additional diagnostic studies such as decubitus X-ray or diagnostic thoracentesis. The effusion may be treated by therapeutic thoracentesis (chest-tube drainage).

Diagnosis: Pleural Effusion

Pleural Effusion Codes

Pleural Effusion Sings and Symptoms

• Sudden, sharp, knifelike pain exacerbated by breathing and coughing; lessens with splinting and breath-holding

• Dyspnea

• Pleural friction rub on auscultation

• Shortness of breath

• Cough

• Hiccups

• Chest pain

• Rapid breathing

Pleural Effusion Diagnosis and Treatment

• Diagnostics-Chest x-ray, Ultrasound, CT chest

• Thoracentesis

• Anti-inflammatories, antitussives, analgesics

• Bed rest

• Intercostal nerve block

• Pain control

Pleural Effusion Clinical Indicators

• Physical exam findings

• Seen on radiologic studies

• Symptoms present

• Other conditions also present CHF, malignant neoplasm lung

Pleural Effusion Documentation

• 300 ml of fluid present or more

• Significance when symptomatic requires document of work up, requires monitoring and/or treatment

• May be assigned as an additional code following the code for etiology of the effusion when know

• Integral to congestive heart failure and will typically not be reported unless additional treatment beyond CHF could include: monitoring and evaluation with additional decubitus x-rays or treatment by thoracentesis or chest tube

Pitfalls to Coding Pleural Effusion

• Is it clinical significant or an incidental findings on radiology exam?

• When CHF is also present is the PE evaluated and treated beyond the treatment directed at the CHF?

• Did the PE resolve after treatment?

• Document of presence and significance must be clear and consistent

Additional Instruction

• Coding Clinic, Second Quarter 2015: Page 15 Heart Failure with Pleural Effusion

• AHA Coding Handbook 2019: Case Summary Exercises-Neoplasms

• AHA Coding Handbook 2019 page 223, 232

• Atelectasis is an incomplete expansion of the lung segments that may result in partial or complete lung collapse. It occurs to some degree in many patients undergoing upper abdominal or thoracic surgery.

• Prognosis depends on prompt removal of any airway obstruction or hypoxia by re-expanding the lung.

Diagnosis: Atelectasis#5

Atelectasis Codes

• Atelectasis is a very common finding in chest X-rays and other radiological

studies. It is a condition where the alveoli are deflated. It may be caused by

normal exhalation or by several medical conditions.

• Atelectasis reduces the ventilatory function. Pulmonary collapse can be a

severe problem, but mild atelectasis usually has little effect on the patient's

condition or the therapy provided. Slight strands of atelectasis are often

noted on X-ray reports, but this finding is generally of little clinical importance

and is usually not further evaluated or treated.

• Code J98.11, Atelectasis, should not be assigned on the basis of an X-ray

finding alone; it should be coded only when the physician identifies it as a

clinical condition that meets the criteria for a reportable diagnosis.

Atelectasis Codes

Atelectasis Signs and Symptoms

• Shortness of breath

• Tachycardia

• Cyanosis

• Decreased lung sounds

• Cough

• Dyspnea

• Transudate pleural effusion

Atelectasis Treatment

• Incentive spirometer

• Respiratory therapy for deep breathing, coughing

• Early mobilization/ambulation

• Use of nebulized bronchodilators

• IPPB

• Bronchoscopy

• NG suction

• Paracentesis

• Antibiotics

Atelectasis Clinical indicators

• Temp > 102

• WBC > 18

• WBC > 15 & Bands >7%

• Tachycardia

• Abnormal chest x-ray

Atelectasis Documentation

• Document the clinical significance

• PO atelectasis-expected outcome following surgery

• Document additional workup due to atelectasis (repeat chest x-ray)

• Extended LOS of holds up discharge

• Document if postoperative complication

Pitfalls to Coding Atelectasis

• Similar to pleural effusion, atelectasis is often considered a minimal, self-resolving condition that does not require treatment or evaluation beyond treatment of the underlying condition.

• X-ray finding only

• Clinically significant

• Meets criteria for assignment as a secondary diagnosis

• PO atelectasis (was it an expected outcome following surgery)

Additional Instruction

• Coding Clinic, Fourth Quarter 1990 Page: 25 Postoperative atelectasis

• AHA Coding Handbook 2019 page

• Respiratory failure is a life-threatening condition that is always due to an underlying condition. It may be the final pathway of a disease process or a combination of different processes.

• Respiratory failure can result from either acute or chronic diseases that cause airway obstruction, parenchymal infiltration, or pulmonary edema. It can arise from an abnormality in any of the components of the respiratory system, central nervous system, peripheral nervous system, respiratory muscles, and chest wall muscles.

Diagnosis: Acute respiratory failure

#6

• The diagnosis is based largely on findings from arterial blood gas analysis, which vary from individual to individual, depending on several factors

• Never assume a diagnosis of respiratory failure without a documented diagnosis by the physician

Diagnosis: Acute respiratory failure

Respiratory Failure Codes

Respiratory Failure Signs and Symptoms

• Shortness of breath

• Dyspnea

• Respiratory distress

• Respiratory rate > 20

• Labored breathing

• Wheezing,

• Use of accessory muscles

Respiratory Failure Treatment

Respiratory Failure Clinical Indicators

• O2 levels

• ABGs: pH <7.35, PO 2 <60 mmHg (normal lungs),PCO2 >50 mmHg (normal lungs)

• For patients with previously abnormal lungs, such as chronic obstructive lung with a PCO 2 >50 mmHg—a change in the Po 2 <60mmHg representing a drop of 15 mmHg from the previous “normal”

• Radiologic reports

• Physical exam

• Change from patient’s baseline status

Respiratory Failure Documentation

• Current status of respiratory failure: acute, chronic, acute on chronic, hypoxic or hypercarbic (type and acuity)

• Clinical indicators documented

• Treatment provided

• Present on admission indicator

• Discharge disposition

Pitfalls for Coding Respiratory Failure

• Sequencing of condition will depend on:

• Documentation

• Present on admission status

• Does condition meet criteria for assignment as principal or secondary diagnosis after study?

Additional Instruction

• AHA Coding Handbook 2019, Chapter 19 Disease of the Respiratory System

• Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019: Page 28 Chemotherapy Induced Pneumonitis

• Coding Clinic, Fourth Quarter 2014: Page 3 Mechanical Ventilation

• Coding Clinic, Fourth Quarter 2013: Page 121 Smoke Inhalation and Acute Respiratory Failure

Lower Denial Risk for Top 6 Diagnoses

• Accurate/Compliant documentation is priority

• No time for re-work

• Query process must be compliant and transparent

• Timing critical –concurrent reviews

• Clinical Validation is pre-bill

• Clinical Validation Queries part of legal record

• Collaboration between Coding and CDI is critical to success – be proactive rather than reactive

Lower Denial Risk for Top 6 Diagnoses

• Knowledge of coding compliance and risk areas

• Official Guidelines for Coding and Reporting

• AHIMA Standards of Ethical Coding

• AHIMA Guidelines for Achieving a Compliant Query Practice (2019 update)

• AHIMA Practice Brief for Clinical Validation

• AHA Coding Clinics

Lower Denial Risk for Top 6 Diagnoses

• Ensure CDI/coding professionals understand role in revenue cycle

• Establish “hard stops” for High-Risk Dx

• Coding should refer Clinical Validation opportunities to CDI team PRIOR to final coding

• Track CV queries and responses by CDI and MD

• Be sure to track denials by type (DRG, CV, medical necessity) – By diagnosis and physician

• Focused education

Be Prepared to Appeal

• Encourage physicians to “document the clinical rationale” when atypical clinical presentation and clinical indicators and treatments do not align well

• If after CVQ, the attending MD affirms a particular condition in spite of certain clinical parameters not being met, facility should request MD document clinical rationale and be prepared to defend condition if audited and denied

• Consider developing a Peer-to-Peer or Multi-Disciplinary Committee “Escalation” process if CVQ are not answered or Dx confirmed without additional clinical support documented

Write a Successful Appeal

• Team effort

• Dedicate uninterrupted time

• Identify exactly what they are denying and why

• Review their references for accuracy and relevance

• As you review the record - Counter point-for-point – Identify what document was referenced – Look for supporting documentation

• Provider notes & Non-provider notes

• Beware of copy/paste

Write a Successful Appeal

• Go back to your documentation and review it again thoroughly

• Do you have well documented clinical indicators?

• Is the condition consistently documented throughout the record?

• Does it meet criteria for assignment as a secondary diagnosis?

Write a Successful Appeal

• Composition –Restate the reason for denial

• Indicate that you disagree

• Put each counter-point in it’s own paragraph

• Keep it direct

• Brief summary

• End with a thank you

Questions & Answers

BESLER has developed a suite of services to address common mid-revenue cycle concerns such as auditing, revenue capture, denial avoidance and compliance.

Whether you have an existing revenue integrity team that wants to recover more revenue – or no revenue integrity team at all – BESLER’s Revenue Integrity Services can help your hospital capture more revenue and stay compliant.

• Inpatient DRG Validation & Outpatient

Correct Coding and Charge Capture

• Compliance Validation

• Auditing

3 Independence Way, Suite 201

Princeton, New Jersey 08540

1.877.4BESLER

www.besler.com

Thank you

Laura Legg Director of Revenue Integrity Solutions

Phone: (732) 392-8223 Email: llegg@besler.com