Retention of Medical Records

We’ve received questions about the length of time a provider has to keep medical records.  Usually the question includes a statement of how long the person asking believes they have to keep them.  Most often, we hear 7 years—although 5 years and 3 years come up.  It’s no wonder there’s confusion. 

There are likely multiple record-keeping requirements that apply to your organization, each of which your organization must comply.

For example, if your organization is a downstream contractor of a Medicare Advantage Plan, Centers for Medicare & Medicaid Services (CMS) specifically requires that your organization agree that:

·         Department of Health and Human Services, the Comptroller General, or their designees have the right to inspect, evaluate, and audit any pertinent contracts, books, documents, papers, and records involving transactions related to the Medicare Advantage contract; and

·         Department of Health and Human Services', the Comptroller General's, or their designee's right to inspect, evaluate, and audit any pertinent information for any particular contract period will exist through 10 years from the final date of the contract period [meaning the contract between CMS and the Medicare Advantage plan] or from the date of completion of any audit, whichever is later.

Source: 42 CFR 422.504 (e) (4) and Medicare Managed Care Manual, Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements, section 110.1.

Ultimately, the determination of which legal requirements apply to your organization is a complicated issue that depends on a variety of factors. As always, readers should consult qualified counsel for assistance. This article does not constitute legal advice.

More Updates from Coding Clinic

On June 3 we posted several new Coding Clinic rulings.  Today, we're posting several more updates.  Keep your eyes on this space for more posts on recent Coding Clinic rulings.

Volume:  2011

Issue:  First 

Title:  Systemic Inflammatory Response Syndrome (SIRS) due to Pancreatitis

The questioner asked for clarification of the advice published in First Quarter 2010. In that issue, coders were instructed to assign code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction for SIRS due to a noninfectious condition, such as pancreatitis. Because the etiology of pancreatitis can either be infectious or noninfectious, the questioner asked if the provider be queried.  

Coding Clinic acknowledged that pancreatitis can have various etiologies; however, the majority of cases of pancreatitis are non-infectious. In many cases, the cause is unknown.  If the provider documents specifically that the SIRS is due to infectious pancreatitis, use the infectious SIRS code rather than the noninfectious one.  The provider should be queried if the medical record documentation is not clear.

Volume:  2011

Issue:  First 

Title:  Borderline Diabetes Mellitus

The question of coding a diagnosis of borderline diabetes was posed.

Coding Clinic answered that code assignment should be based on physician documentation, and sometimes might require querying the physician.

If not, a diagnosis of “borderline diabetes” without further confirmation of the disease should be assigned the appropriate code from subcategory 790.2, Abnormal glucose.

Volume: 2011

Issue:  First 

Title:  Chronic Venous Embolism and Thrombosis

The questioner noted that there were codes for chronic venous embolism and thrombosis, and asked when  DVT becomes chronic.

Coding Clinic noted that there were no specific timelines for when DVT or any other condition becomes chronic. The assignment of chronic DVT is based on provider documentation.

 Volume:  s2011

Issue:  First 

Title:  Broken Catheter Tip Retrieved via Thrombectomy

The questioner noted that a patient was admitted for thrombosed arteriovenous graft. An aspiration of thrombus was performed. During the procedure, the catheter tip separated at the entry site of the sheath after access through scar tissue. Open thrombectomy was performed with retrieval of the catheter tip. What is the code assignment for the broken catheter tip?

Answer:

Coding Clinic advised the questioner to assign code 996.1, Mechanical complication of other vascular device, implant, and graft, for the broken catheter tip.

If the catheter tip had not been retrieved, codes 996.1, Mechanical complication of other vascular device, implant, and graft, and 998.4, Foreign body accidentally left during a procedure, would be assigned.

Note there is a previous Coding Clinic, First Quarter 1995, with  an example of a catheter tip that broke off during chemotherapy infusion.

2011

Issue:  First 

Title:  Broken Needle Left during Surgery

The questioner asked about a needle placed along the right lateral aspect of the sewing ring of the aortic valve and passed through tissue to try to cinch the valve down. The suture broke from the needle and the needle was lost within this tissue.  An x-ray was done which did not reveal the needle. The chest was closed and a second x-ray showed that the needle was to the right of the aortic valve. The chest was reopened but the needle still could not be located or palpated.

 The surgeon decided that continuing to look for the needle was likely to cause the patient more harm than good. Therefore, the chest was closed again, and the patient was transferred to ICU in stable condition.

The questioner asked what the correct diagnosis code assignment is when a provider intentionally leaves a foreign body in the patient and the documentation clearly states that removing the foreign body will cause more harm than good? Would code 998.4, Foreign body accidentally left during procedure, be appropriate?

Coding clinic advised to assign code 998.4, Foreign body accidentally left during a procedure. Although the surgeon made the decision to leave the needle because continuing to search for it might cause harm to the patient, it was not the intent of the original procedure to leave a foreign body behind.

Year:   2011

Issue:  First 

Title:  Coding for Home Health Care

The questioner asked if symptoms codes should be assigned along with the aftercare codes. As an example, they asked if it was appropriate to assign a code for gait abnormality when a patient is receiving home health aftercare following joint replacement? Does the advice change depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic answered that  symptom codes may be assigned in conjunction with V codes when they provide additional information about the specific problem being addressed. In the given example, code 781.2, Abnormality of gait, may be assigned in conjunction with code V54.81, Aftercare following joint replacement.

Year: 2011

Issue:  First 

Title:  Code Assignment Based on Up and Down Arrows

The questioner asked if it was appropriate to assign a diagnosis code for a condition listed with up and down arrows?  Examples were provided:  ↑ cholesterol, or ↑lipids, or ↓hemoglobin and hematocrit, and they wondered if a code should be assigned for hypercholesterolemia, or hyperlipidemia, or low H&H, etc.? They also wondered if the  advice changed depending on whether this is an outpatient encounter versus an inpatient admission?

Coding Clinic advised that it is not appropriate for the coder to report a diagnosis based on up and down arrows, and that diagnosing a patient’s condition is solely the responsibility of the provider.

The use of up and down arrows can have variable interpretations and do not necessarily mean “abnormal.” They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided.

Coding Clinic advised that this response was consistent with the coding guideline on abnormal findings which states: “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 same advice applies for both inpatient and outpatient admissions.

New Full Encounter Data Web-Page

In addition to the ICD-10/Full Encounter Data page on HCC University, a new web page for only Full Encounter Data Information has been launched!

Visit our new Full Encounter Data page here .

Recent Coding Clinic Decisions

The last quarter  2010 and the first quarter 2011 Coding Clinic rulings were recently released. Because there are so many decisions, we'll post them over the next week in small batches so that the posts aren't too long  We hope that this information is helpful to you!

Volume: 2011

Issue:  First 

Title:  Postoperative Aspiration Pneumonia

The question of the  correct code assignment for a diagnosis of postoperative aspiration pneumonia was made, noting that  ICD-9-CM’s Tabular List under code 997.39 provides the following inclusion terms: “Pneumonia (aspiration) resulting from a procedure.” The questioner went on to note that the instructional note under category 997 states, “Use additional code to identify complication.” Should code 997.39, Respiratory complications, Other respiratory complications, be assigned along with code 507.0, Pneumonitis due to solids and liquids, Due to inhalation of food or vomitus, to describe postsurgical aspiration pneumonia?

Coding Clinic answered that it was appropriate to assign both codes together. The questioner was instructed to assign code 997.39, Respiratory complications, Other respiratory complications, and code 507.0, Pneumonitis due to solids and liquids, due to inhalation of food or vomitus, for postsurgical aspiration pneumonia. Coding Clinic went on to indicate that the title of code 997.39 is broad  and that the  assignment of code 507.0 provides additional information about the specific respiratory complication.

Volume:  2011

Issue:  First 

Title:  Pancytopenia due to Drug

The questioner indicated confusion about coding drug-induced pancytopenia. Coding Clinic had previously advised how to code chemotherapy induced aplastic anemia but did not address pancytopenia secondary to drugs. The ICD-9-CM indexes pancytopenia to code 284.1, Pancytopenia. However, code 284.1 is excluded from pancytopenia due to or with aplastic anemia (284.9) as well as that which is drug induced (284.89). If the provider documents “pancytopenia due to chemotherapy” and there is no documentation of “aplastic anemia,” how is this coded?

Coding clinic answered that based on the instructional note under code 284.1, the correct code would be Other specified aplastic anemias 284.89, along with the appropriate E-code to identify the drug. Although there is no medical record documentation of aplastic anemia, the instructional note indicates that drug-induced pancytopenia is classified to code 284.89.

Volume: 2011

Issue:  First 

Title:  Transbronchial Biopsy of Lung  (inpatient procedure coding)

The questioner noted that a procedurewas listed as bronchoscopy due to nodular infiltrates and atelectasis and airway examination. In addition, washings, brushing and biopsy were taken from the left lower lobe and washings from the right lower lobe. Additionally, the provider has clarified that a transbronchial biopsy of the left lower lobe was performed. No lung tissue was identified on the pathology report. How should this be reported?

Coding clinic indicated that based on the provider’s documentation, they should assign procedure code 33.27, Closed endoscopic biopsy of lung, for the transbronchial biopsy. Although there was an absence of lung tissue in the pathology report, it did not preclude the assignment of the code when the procedure is performed by the provider. Tissue samples may be inadequate or inconclusive, leading to the lack of lung tissue in the path report.

 

Volume:  2011

Issue:  First 

Title:  Trichilemmal (Pilar) Cyst

The questioner indicated that a  patient presented for outpatient surgery for removal of a scalp lesion. The provider documented “skin lesion, scalp––excised.” The pathology report indicates “trichilemmal cyst (pilar cyst).” ICD-9-CM classifies a cyst of the scalp as a sebaceous cyst. There is confusion as to whether this should be coded as a trichilemmal or sebaceous cyst. What is the correct diagnosis code for this encounter?

Answer:

The questioner was told to assign code 704.8, Other specified diseases of hair and hair follicles, for the trichilemmal (pilar) cyst.

Volume:  2011

Issue:  First 

Title:  Postoperative Hemorrhage and Postoperative Hematoma

The questioner was concerned about  inconsistency in hospital coding of postoperative hemorrhage vs. postoperative hematoma.  They noted that when a surgical wound is slightly oozing blood and is treated with pressure, it is being coded as a postoperative hemorrhage. By the same token, if a small hematoma is noted after surgery, but not treated, it is still being coded as postoperative hematoma. Could you provide us with guidance so that we can consistently code these conditions?

Coding Clinic answered quite strongly, reiterating the Official Coding Guidelines on complications of  care:  “As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure” (Section I.C.17.f.1.a) Further, the Guidelines specify that “for reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation; or therapeutic treatment; or diagnostic procedures; or increased nursing care and/or monitoring.” Coding Clinic reminded the questioner that  not all conditions that occur during or following surgery are classified as complications. First, there must be more than a routinely expected condition or occurrence. In addition, there must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. Finally, they stated (emphasis added) Only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication. If it is not clearly documented, the coder should query the physician for clarification.

Volume:  2011

Issue:  First 

Title:  Superior Semicircular Canal Dehiscence Syndrome

The question was regarding a 53-year-old male who presented  with “left superior semicircular canal dehiscence syndrome (SSCDS).” What is the correct code assignment for this syndrome?

Coding Clinic answered to assign code 386.8, Other disorders of labyrinth, along with code 733.99, Other disorders of bone and cartilage, for SSCDS. In addition, codes for any other manifestations of the syndrome that are present should be coded.  Coding Clinic noted that treatment can involve reparative surgery, resurfacing the dehiscence of the semicircular canal, and that the etiology of the syndrome is unknown.

We'll post more rulings on Monday.  Have a great weekend.

OIG Posts Slides and Video from Provider Compliance Training

Update: 

The OIG has made the HEAT Provider Compliance Training Webcast Video available in 16 short modules instead of the original long video.  The content has not been changed, merely broken up for ease of viewing.

This will allow users to select a topic area to view without having to watch the entire 3 hour and 45 minute video. There is a new URL: http://go.usa.gov/Dzr

Today, the OIG  posted a video recording of the HEAT Provider Compliance Training session held on May 18, 2011 in Washington, DC. The session recording is quite long at 3 hours and 45 minutes. It is available at http://go.usa.gov/DyN

While not specifically related to Medicare Advantage, this training session is pertinent for any practice which sees Medicare and/or Medi-Cal/Medicaid patients.

 

If you can't commit to that length of time (we know you're busy!) you can find the training session's related briefing material posted at http://go.usa.gov/DyQ 

 

There are 13 files including the PowerPoint slide presentation, a number of background papers, and a link to a video recording of Inspector General Levinson's keynote speech at the HCCA 15th Annual Compliance Institute.