Medical Record Guidance

We often get questions about what constitutes a complete medical record.  To date, there is no all-encompassing official definition, although CMS provides their requirements during a Risk Adjustment Data Validation.

For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available.  Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance.  This useful article will help anyone tasked with creating a coding compliance policy.  You can find a copy of this paper here.

Coding versus Interpreting

As coders, we're required to code based upon the physician's documentation, and not to read into what the physician has actually written. 

Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox. 

Original Question: 

I would like to know some opinions regarding to coding the following documentation by Physician:  “ Vascular Dementia”.   

Our Answer: 

Vascular dementia NOS is indexed to 290.40.  I don’t see any alternative code.

Then, we received a follow up:

Follow up Question: 

In my opinion I’ll use 290.40 plus 437.0.   Please see instructional notes “ Use additional code to identify cerebral atherosclerosis”.  I need your opinion.

Our Answer:

You only use an additional code if it’s documented. It’s not something you automatically do.  Based on your email, the physician only documented vascular dementia.  If he had said vascular dementia due to cerebral atherosclerosis, then you would code it.

 The instructional notes for 250.40 say:

Use additional code, to identify manifestation, as: 
        chronic kidney disease  (585.1-585.9) 
             diabetic: 
             nephropathy NOS  (583.81) 
             nephrosis  (581.81) 
             intercapillary glomerulosclerosis  (581.81) 
             Kimmelstiel-Wilson syndrome  (581.81) 
 But you don’t code all those things unless they are documented.
I hope that clarifies.

In response, the questioner indicated that they planned on coding cerebral atherosclerosis  (437.0) because:

"Vascular dementia, Arteriosclerotic Dementia, Multi-infarct Dementia and Atherosclerotic disease are synonyms.   In my opinion the documentation of Vascular Dementia is the same as  Atherosclerotic Dementia or multi-infarct Dementia.    

Please look Dementia
                                       Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"

 
I don't believe I did a good enough job explaining why you wouldn't code something not documented.  But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause.  Multi-infarct dementia (MID), due to multiple strokes or TIAs,  or mixed type due to MID and Alzheimers, or many other

 conditions that reduce blood flow to the brain, including certain autoimmune diseases (e.g., lupus eythematosus, temporal arteritis), certain inherited (genetic) diseases, infections of the heart (endocarditis), brain hemorrhage, profoundly low blood pressure can also cause vascular .   Since arteriosclerosis is not the sole cause, coding 437.0 without documentation of cerebral arteriosclerosis is not appropriate.  As coders, we must code what's documented, without inserting our knowledge of disease states or opinions into the process.

SCAN CME Course -Dementia - Depression, Acute Behavioral Change, and Decision Making Capacity

As you know, dementia prevalence increases with age.   This free CME course will help ensure that you're able to:

 •Provide structured assessments with focus on problems that are prevalent amongst patients with dementia

 •Determine decision making capacity

 •Play an important role in providing education, psychosocial support, and referrals for these identified problems, among others, for patients and caregivers

 The target audience for this free CME program is physicians; nurses; social workers; and other healthcare professionals.

 

Click here to take this free CME program today!

What's New on HCC University?

We've done a little re-arranging on HCCUniversity.com.  While all of the old ICD-9 files are still there, we've put everything prior to 2012 in an archive that you can reach from the Tools page.   This will make navigating the Tools page easier, with less scrolling.

In addition, we've put a new widget on the Tools page.  Need to find an ICD-10 code?  Need to crosswalk an ICD-10 back to the equivalent ICD-9 code?  You can do it here on the ICD-10 widget.

What new documentation or coding tools would help you?  Send us your suggestions to coding@scanhealthplan.com.

Free CMEs for Physicians

For physicians looking for CMEs, check out http://www.scancme.com/!  Not only can you receive free CMEs, but you can find content geared toward care of your senior patients.

In addition to free CMEs, you can find practice tools, such as office forms, patient education, and clinical guidelines.

Check out the newly designed SCAN CME site today!

AHIMA Posts New Paper on Coding Compliance

The American Health Information Management Association (AHIMA) has posted a new paper in its Thought Leadership series that has implications for coding compliance in Risk Adjustment.

The paper, Defining the Core Designated Clinical Documentation Set for Coding Compliance, seeks to define what core pieces of documentation are required for coding of medical records in various settings. 

While it doesn't represent official coding guidance, it may be useful to medical groups, hospitals and oters seeking to develop Policies and Procedures related coding, internal Risk Adjustment Data Validations, encounter data submissions, and encounter data corrections. 

The paper may be downloaded from the AHIMA website, at: http://www.ahima.org/downloads/pdfs/advocacy/DefiningCoreClinicalDocumentation_TL.pdf

Inpatient Coding Guidelines

We often get questions about when to use the Inpatient Coding Guidleines--can they be used for a discharge summary alone, or a consultation that took place during an inpatient stay?  According to CMS' RADV Q&A from 2009, the answer is NO:

Q15: Are practitioner visits during a hospital admission acceptable as "PHYSICIAN" records? If yes, what coding rules will apply to these records?

A15: If a member has an inpatient hospital discharge that supports the HCC, it is usually best to select the inpatient discharge and submit the entire inpatient medical record for coding. However, if the entire inpatient medical record cannot be obtained, the organization can submit medical record documentation from an inpatient physician visit for review and it would be reviewed in accordance with the Diagnostic Coding and Reporting Guidelines for Outpatient Services. When submitting these forms of documentation please note the following:

In the outpatient setting, coders do not code diagnoses documented as "probable" "suspected," questionable," or "rule out" but rather coders code the condition to the highest degree of certainty for that encounter/visit (i.e., symptoms, signs, abnormal rest results.) This limited documentation may not support the HCC. Acceptable inpatient physician visit medical records are: inpatient history and physical examinations, progress notes, consultation reports, and discharge summaries. When submitting medical record documentation from an inpatient physician visit, the organization has two options:

1. Select a service date from the stored risk adjustment data listed in Section 3A of the coversheet (i.e., RAPS data) for a PHYSICIAN visit. The RAPS record most likely was for the physician claim for inpatient visit services. Be sure that the record you are submitting exactly matches the date of the selected service date. For example, the coversheet is

checked with a service date of 9/5/2003 through 9/5/2003 and a signed inpatient physician consultation report dated 9/5/2003 is attached for review.

2. Submit an "in lieu of" medical record by completing Section 3B of the coversheet for a PHYSICIAN visit. Be sure that the record you are submitting exactly matches the date of the selected service date. For example, Section 3B of the coversheet has a service date of 10/3/2003 through 10/3/2003 and a signed inpatient physician admission history and physical examination report dated 10/3/2003 is attached for review.

The reason for this is the nature of the Inpatient Coding Guidelines for coding uncertain diagnoses: 

H. Uncertain Diagnosis
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. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note:

This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals

As you can see, this guideline requires that the diagnostic workup and initial therapeutic approach correspond to that uncertain diagnosis.  Simply saying "rule out MI" in a consultation note, or even a discharge summary, does not show that diagnostic workup or therapeutic approach.  You need the entire chart (or the majority of it) to support this.  So, standalone documents from an inpatient stay are always coded as if they are outpatient documents.

Have a coding question related to risk adjustment, or risk adjustment data validation (RADV)?  Send it to us at Coding@scanhealthplan.com

OIG Posts Video-- Outlook 2013

This morning, the Office of the Inspector General posted this video on their Outlook 2013 page. 

OIG senior executives discuss emerging trends in combating fraud, waste, and abuse in Federal health care programs, and the OIG's top priorities for 2013.   In addition, they discuss new and ongoing projects from the OIG's Work Plan.

 

We'll be posting about the OIG Work Plan in the next few days.

Where are the New ICD-9 Codes?

Since we're already halfway through October, some people are starting to wonder where the new  ICD-9 codes are.   By this time, they're usually up on the HCCUniversity.com website for people to download.

Because of the transition to ICD-10 in October 2014, there is a moratorium on creation of new codes, except in very limited circumstances.  So, there are no new ICD-9-CM diagnosis codes for 2013.  There is also no change to instructions or the Official Coding guidelines, which were effective October 1, 2011.

There is one change-a single ICD-9 procedure code (used only by inpatient hospitals), 00.95, Injection or infusion of glucarpidase, was added.   This drug is used to treat a common side effect of methotrexate administration.

If there are any future changes to the ICD-9, we'll post it here and on HCC University.

HHS and DOJ Issue Joint Letter on Cloning of Medical Records

On September 24, 2012, Secretary Katherine Sebelius of the Dept. of Health and Human Services, and Eric Holder, Attorney General, of the Department of Justice, issued a joint letter to several health care associations, including the American Hospital Association and Federation of American Hospitals. You can view a copy of the letter on HCC University, on our Tools page.

Although the letter applauds the widespread adoption of EHRs, it notes that there are indications that some providers are using them to clone records and to game the system.  The letter points out that this type of false is not only dangerous to the patient, but also illegal. 

The letter notes that CMS is stepping up its medical record review activities to identify these issues, and that the DOJ, FBI and other law enforcement are monitoring these issues and will take action when warranted.

So--how do CMS, the DOJ and others identify cloned medical records?   Cloned records are often very obvious.  Although they may occur in handwritten records, it is most often found in EMRs with cut and paste and template functionality. 

Although templates are not inherently bad, auto-populating them indiscriminately with information can lead to obviously cloned records. While some things may not change significantly from visit to visit (for example, the bulk of the patient's history may remain the same), a patient's condition is rarely, if ever, static.  A patient's interim history, vital signs, symptoms and treatment are almost never exactly the same. Copying and pasting these components leads to inaccurate medical records.

Another area where cloning becomes obvious is in the assessment.  Often, previously treated or self-limiting diseases remain in the assessment for months or even years.  We've seen charts where a diagnosis of "acute sinusitis" continued on for over a year, with no treatment after the initial date of service where it appeared.

It's important to remember that once one part of the medical record is obviously wrong, and auditor is likely to discount the record in its entirety, since it's impossible to tell what is and isn't accurate.

Clinicians using EMR should use templates wisely, and cut and paste functionality very sparingly.  All information in the chart should accurately reflect the patient's complaints, conditions, and treatments on the current date of service.

Coding Borderline Diagnoses

A recent Coding Clinic (Q 1 2012) answered the following question:


Coders are confused as to the correct coding of “borderline” diagnosis. The advice published in Coding Clinic, First Quarter 2011, pages 9-10, appears to be contradictory. The advice instructs coders to assign code 416.8, Other chronic pulmonary heart diseases, for borderline pulmonary hypertension as if it were confirmed; however, a diagnosis of borderline diabetes without further confirmation of the disease is assigned to code 790.20, Abnormal glucose.
Should code 793.2, Nonspecific (Abnormal) findings on radiological and other examination of body structure, Other intrathoracic organ, be assigned for a diagnosis of “borderline pulmonary hypertension” or should all borderline diagnoses require clarification from the attending physician so that the appropriate code may be reported?

Coding Clinic's Advice:

"Borderline diagnoses" are coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-9-CM, it should be coded as such.

They went on to indicate that  borderline conditions are not uncertain diagnoses, and no distinction is made between the care setting (inpatient versus outpatient). 


However, when documentation is unclear regarding a borderline condition, coders should query for clarification.

Need Free CMEs?

Check out the newly re-designed SCAN Health Plan® Continuing Medical Education /Performance Improvement Education (CME/PIE)  website, at http://www.scancme.com/. 

The mission of the SCAN Health Plan® Continuing Medical Education / Performance Improvement Education (CME/PIE) Program is to provide high-quality, evidence-based activities designed to narrow the professional practice gaps of providers caring for geriatric patients.

In addition to earning free CMEs, you'll find practice tools to help make your practice run more smoothly.

Stop by and check out the new SCAN CME/PIE site today!

OIG Posts Podcast on the Importance of Documentation

The OIG has posted a podcast on the importance of medical record documentation.  You can listen to the podcast or view the video by going to the podcast page.

If you can't listen to the podcast, you can review the transcript, here.

California Physician Adoption of EHRs

A recent report by the California HealthCare Foundation, showed that 71% of physicians responding have an EHR in their main practice location.   That's great news, right?  Now for the bad news--only 30% of those physicians can meet 12 Stage 1 Meaningful Use objectives.

The study found that only 37% of the physicians plan to apply for either the Medi-Cal or Medicare incentives.

While the physicians may not meet the requirements (or choose to apply) to receive the $44,000 in incentive money, most physicians are happy with their EHRs --35% of respondents said they were very satisified with their EHR, 38% were somewhat satisfied.  The study found a link between the functionality available in the EHR and physician satisfaction.

The study provides recommendations for outreach to physicians by DHCS to help physicians meet the requirements for the Medi-Cal incentives.

What's New on HCC U?

We've updated the Risk Score Calculator on the Tools page, so you can display 2013 risk scores.   You can view the calculator here.

In addition, we've updated the presentation explaining the new requirements for the Annual Wellness Visit.  There's also a form, and the ICE Health Risk Assessment form, to help you document the patients' Annual Wellness Visit.

That's it for now.  If there are new tools you'd like to see on HCC University, you can contact us at coding@scanhealthplan.com.

What's New On HCC University

We've posted an updated list of Payment Year 2013 (2012 DOS) diagnoses in the CMS HCC model on the Tools Page.  You can download the Excel file here.

In addition, we've updated our Risk Adjustment 101 presentation.  You may want to use it in training new staff.  It's on our Training and Presentations page.

New Specialties Approved for Risk Adjustment

Effective January 2012, the following CMS Physician Specialties are approved for risk adjustment submission:

• 21   Electrophysiology
• 23   Sports Medicine
• C0  Sleep Medicine

CMS has indicated that they will publish a complete specialty listing soon. When the listing is published, we'll post it to the Tools section of HCCUniversity.com

Coding BMI

We often receive questions about when certain conditions can be coded.  Most often, the questions are about whether or not anything (everything) a physician or physician extender writes down can be coded. Almost always, the answer is that the condition must be:

• Documented
• Supported by the history, physical examination or clinical condition of the patient

When it comes to secondary diagnoses, they must meet the definition of a reportable additional diagnosis per coding guidelines.  From the Coding Guidelines: "As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses)."

According to Coding Clinic, 2Q 2010 the associated diagnosis (such as overweight, obesity, or underweight) must be documented by the provider.  If no associated diagnosis is documented, then the recorded BMI cannot be coded.

Free CME for Physicians

Did you know that your can earn free category 1 Continuing Medical Education from Medicare?   The Medicare Learning Network (MLN) offers free CME for an online course in conjunction with the Office of the Inspector General  (OIG).   You can get more information on their course, Avoiding Medicare Fraud and Abuse: A Roadmap for Physicians.  Learn more about it here.

Update on Diagnosis Codes Instead of a Diagnosis

A couple of weeks ago, we published information on a Q 1 2012 Coding Clinic ruling on physicians using a diagnosis code in lieu of a written diagnosis.  This has led to some questions, so we wanted to provide additional information.

Coding Clinic was asked about physicians choosing a diagnosis code in an EMR vs. using a written diagnosis--but this advice applies to handwritten or dictated notes as well.  One important point that Coding Clinic made relates to something we see frequently--physicians just picking the diagnosis code and short descriptor of the code and using it as an assessment.  Coding Clinic said:

"...it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-9-CM is a statistical classification, per se, it is not a diagnosis. "  (emphasis added).

Here's an example that we see frequently as an assessment:

250.40--Diabetes with renal manifestations

As you can see, this is not a diagnosis, but a category of diseases, or in ICD-9 terms, a statistical classification.

The clinician is responsible for providing a diagnosis, so they may need to add to the short descriptor of a diagnosis code in the EMR.  For example:

250.40--Diabetes with renal manifestations - CKD 4 due to DM

This provides an actual assessment (diagnosis) of the patient's condition, that allows correct coding.

EMRs can be tremendous time savers, but physicians and clinicians must ensure that they meet coding and documentation requirements.

Proposed 1 Year Delay in ICD-10 Implementation

On Tuesday, April 17, 2012, the Department of Health and Human Services published a proposed rule, entitled " Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD–10–CM and ICD–10–PCS Medical Data Code Sets"

The proposed rule can be downloaded at: http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf

In addition to a proposed delay in the compliance date for ICD-10 (to October 1, 2014), there are proposals for a Unique Health Plan Identifier, and an identifier for entities that currently cannot obtain an NPI.

Comments on the proposed rule are being accepted until May 17, 2012 at 5:00pm EST.

Code Numbers Instead of a Narrative Diagnosis

All too often, we see a diagnosis code written in the medical record, in lieu of a narrative diagnosis.  In those instances, we cannot code what has been written for two important reasons:

• Coding is done based on the narrative documentation in the medical record--with no narrative, no coding can take place
• There's no way of telling if the diagnosis code in the chart is correct (i.e., what the provider meant to code)

We get this question at least once a year--and sometimes it leads to lively exchanges.  Thankfully, Coding Clinic, Q1 2012, has decided to address it.  Their answer, in part reads:

"There are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition, and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnosis."

So--the next time you're asked if a provider can just write the code in the chart--you'll know where to point them for clear guidance.

Keeping Up with What's New in Medicare

The Medicare program is massive, and ever changing.  Changes come out several times a year--Part A changes around September, Part B changes in January.  Add that to changes in ICD-9 and CPT, changes in your commercial business--it's all a bit much.

How can you keep up with all these changes? The CMS website is difficult to navigate--and finding things is complicated. 

But, one great place to bookmark and visit frequently is the Medlearn Matters webpage.  This page has educational materials about new Medicare programs and coverage. It's a great way to keep up with what's new in Medicare.  https://www.cms.gov/MLNProducts/

In addition, there's a Medlearns Product Catalog, that allows you to order certain printed matter.  You can view the catalog at https://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf

You can learn about EHR incentives, the annual wellness exam, and even take online training courses, some of which have CEUs for coders.

Although you won't find everything there--you will find a lot of information about new and changed programs on the Medlearn Home page.

Medical Records Amendments

Palmetto GBA, the Jurisdiction 1 Medicare Administrative Contractor, has published a great article on Medical Record Amendments.  We get a lot of questions about these amendments, and there's very little in writing about them.  The Palmetto article is consistent with what CMS has told Medicare Advantage plans on conference calls--that these amendments should be rare, and should be done within a few days of the original medical record entry.

You can read the article here.
Do you have coding or medical records questions? You can always submit them to us at coding@scanhealthplan.com.

Upcoming CMS Conference Call

On March 28, 2012, from 2:30-4:00 pm EST, CMS will host a conference call on the Initial Preventive Physical Examination (IPPE, also called the "Welcome to Medicare Physical") and the Annual Wellness Visit.

If you are interested, you can register here.

Question of the Month

In the past two weeks, I've received or been asked some variation of the following question:

"Now that CMS is postponing ICD-10 implementation, can I stop or slow down my work on ICD-10?"

First, CMS has not postponed ICD-10, they are considering "postponing compliance for some entities"--postponing compliance (i.e., they won't penalize you for a given period of time) is different than postponing implementation.  At this point, we don't know who is affected, or for how long.

ICD-10 is coming. Although the compliance period may stretch past October 1, 2013, the Department of Health and Human Services (HHS) and CMS have not indicated a cancellation.  Understanding the impact of ICD-10 on your organization is still critical.  There is much to be done, and physicians, their staff, and hospitals must begin (continue) to assess how their current documentation and systems must change and improve in order to meet the realities of ICD-10.

I was reading an ICD-10 article the other day, and I was struck by something.  The ICD-9 was implemented in 1979.  That year, the Nobel Prize in Physiology or Medicine was given to Allan M. Cormack and Godfrey N. Hounsfield for their development of CT Scanning!  Although CT scanners are still a useful tool today--the state of medical knowledge and technology has grown by leaps and bounds in those 33 years.  ICD-9 as a coding system is too limited to have grown with it.   In order to keep pace with the science of medicine, we must move to ICD-10.

Don't stop now---don't even slow down.  There's too much work to be done.   We know it can be overwhelming.  Start with your top 10 diagnosis codes in ICD-9--and look at the possible equivalent codes in ICD-10, using a tool like the 2012 General Equivalence Mappings.  Will your current documentation support an appropriate code in ICD-10? If not, what changes are needed? Simply defaulting to a "not otherwise specified" code may not be enough.

In an Internal Medicine practice, there are large areas with a lot of impact--Diabetes, CVAs, acute MIs--all of these have many increased codes, and complexity.  Taking a look at your documentation now will help you understand where you need to make changes to support the codes that best describe your patient's illnesses.

As to the compliance postponement---we'll be monitoring HHS and CMS websites daily.  When more information becomes available, we'll be sure to post it here.

Recent Coding Clinic Decisions

Coding Clinic has been very busy the last few months.  A number of questions addressed have implications for everyday coding:

Coding Clinic (Q3 2011) was asked what the correct coding for a diagnostic statement of depression and anxiety.  Coding Clinic advised that the correct coding was 311 and 300.00, NOT 300.4, because the physician had not established a linkage between the two conditions.

Coding Clinic (Q3 2011) was also asked about the clinical significance of obesity or morbid obesity, when the physician does not do any further assessment, monitoring or care for the condition.   Coding Clinic indicated that these patients are at increased risk of certain medical conditions, and that they should be coded when documented by the physician.

The question of a diagnostic statement of "pneumonia with hemoptysis" was raised. Coding Clinic (Q3 2011) pointed out that hemoptysis is a Chapter 16 code, and as such should not be coded if it was integral to a disease process.
Finally, in Q4 2011, Coding Clinic was asked how a diagnosis of chemotherapy induced pancytopenia was coded.  The questioner was advised to code 284.11, Antineoplastic chemotherapy induced pancytopenia.  Further, the questioner was told that it was unnecessary to code E933.1, Antineoplastic and immunosuppressive drugs, since it was inherent in the title of 284.11.  However, providers could choose to capture this information if they wished.

We'll continue to monitor Coding Clinic rulings, and provide you information here.