Thursday, June 30, 2016

Really Common Coding Errors--and how to fix them!

Sometimes, it seems like we see the same list of "common coding errors" over and over.  Mine probably won't be that different, except that I thought something was missing from those lists--the SOLUTION!  So here's my list of common coding and documentation errors--and how to fix them.

Problem: The record doesn't contain a legible signature and/or credential
Solution: If you hand write your charts, make sure your name and credential are on your progress note letterhead.  If there's more than one person in the practice, have a check box (be sure to check it!) next to each name/credential.

Problem:  The status of a disease is unclear, due to use of "history of"
Solution:   Be sure to re-state any disease being assessed/treated on this date of service in the present tense, in your assessment.  Be sure to include the patient's current status.  For example, you might note "diabetes well controlled on diet, ck HbA1C 1 week prior to next visit.  f/u 3 mos.

Problem: The documentation doesn't match the ICD-10-CM diagnosis code chosen.
Solution:  This one comes in many flavors.  Some of the most common are things like "h/o CVA 2-20-13, no neurologic deficits" and the diagnosis code is for an acute CVA.  Another common issue is with amputations--the patient lost an arm in an accident 10 years ago, and the ICD10 code chosen is for a traumatic amputation.   The last section of the ICD-10 is Factors influencing health status and contact with health services (Z00-Z99), and this section contains codes representing statuses like amputations and history of many illnesses.

Problem:  The status of a patient's cancer isn't clear.
Solution:    If the patient is still undergoing treatment, then it is considered an active malignancy.  The ICD-10-CM, Chapter 2 m. "When a primary malignancy has been excised but further treatment,
such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to
that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no
further treatment (of the malignancy) directed to that site, and there is no evidence of any
existing primary malignancy, a code from category Z85, Personal history of malignant
neoplasm, should be used to indicate the former site of the malignancy."

So, if  the patient is undergoing routine surveillance only, it should be documented and coded as a "history of" the cancer.

Problem:  The documentation is not sufficient to support a diabetic complication.
Solution:  Be sure to document the history, physical exam and treatment directed at the complication.
Problem: Chronic conditions are not documented in the medical record at least annually.
Solution:  This one happens a lot--and we often see signs (for example, medications ordered) that the disease exists.  But unless you're documenting the disease, it's current status, and anything you've advised the patient, it can't be coded.

Problem: Electronic medical record is not signed.
Solution:  Assign someone the task of following up on all records that have not been properly closed by authentication every week. Be sure that all staff are aware that they must close records by authentication immediately following the visit.

Problem: Diseases are coded without proper supporting documentation.
Solution:  According to the Official Guidelines for Coding and Reporting, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, J.: "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management."   If there's no documentation that they required (and received) treatment or management, or had an impact on your treatment of another condition, they should not be reported.

Problem:  The diagnosis code chosen was more specific than the documentation.
Solution:   Be sure you thoroughly document all illnesses, including their complications.  Always document the patient's  response (or lack of response) to treatment.

Problem:  The diagnosis code chosen was not at the highest level of specificity documented.
Solution:  This is the opposite of the problem above--you've documented the patient's condition and complications well--but chosen a code that doesn't reflect those complications.  If the patient has multiple complications of a disease, each one should be coded separately.

Friday, June 10, 2016

Coding Clinic Q1 2016 Addresses Diabetic Complications

In the Q1 2016,  AHA Coding Clinic addresses a number of issues--two of which are hot topics for coders in risk adjustment.

Most of the questions we get in the Coding Inbox ( deal with "Diabetes and ______________", and whether or not the ICD-10CM assumes a causal relationship.  Usually, this is because the physician has not made a link in the medical record, and the coder is unsure whether or not they can code the diabetic complication.

In ICD-9, the question also came up a lot--and most often, the answer was NO.

Coding Clinic took this subject on once again, for ICD-10CM..  In Section I. Conventions, general coding guidelines and chapter specific guidelines of the Official Guidelines for Coding and Reporting, the ICD-10 describes how the word "with" is to be interpreted:

15.     “With”

The word “with” should be interpreted to mean “associated with” or “due to”
when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular 

In a code title, the association might look like this:

E11.31  Type 2 diabetes mellitus with unspecified diabetic retinopathy

This tells you that there is an association between the two diseases.

The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in
alphabetical order.
In part, the Alphabetic Index under "Diabetes" looks like this:

Diabetes, diabetic (mellitus) (sugar) E11.9
- with
- - amyotrophy E11.44,- - arthropathy NEC E11.618
- - autonomic (poly)neuropathy E11.43
- - cataract E11.36
- - Charcot's joints E11.610
- - chronic kidney disease E11.22
- - circulatory complication NEC E11.59
- - complication E11.8
- - - specified NEC E11.69
- - dermatitis E11.620
- - foot ulcer E11.621
- - gangrene E11.52
- - gastroparesis E11.43
- - glomerulonephrosis, intracapillary E11.21
- - glomerulosclerosis, intercapillary E11.21
- - hyperglycemia E11.65
- - hyperosmolarity E11.00
- - - with coma E11.01
- - hypoglycemia E11.649
- - - with coma E11.641
- - kidney complications NEC E11.29
- - Kimmelsteil-Wilson disease E11.21
- - loss of protective sensation (LOPS) —see Diabetes, by type, with neuropathy
- - mononeuropathy E11.41
- - myasthenia E11.44
- - necrobiosis lipoidica E11.620
- - nephropathy E11.21
- - neuralgia E11.42
- - neurologic complication NEC E11.49
- - neuropathic arthropathy E11.610
- - neuropathy E11.40
- - ophthalmic complication NEC E11.39
- - oral complication NEC E11.638
- - periodontal disease E11.630
- - peripheral angiopathy E11.51

With this new Coding Clinic clarification, when the physician documents and another disease, you need to check the Alphabetic Index first, to see if the problem/complication is listed there, and then as always, go to the code itself.  If the condition is qualified by the term diabetes with ____, the you can code the complication.  The doctor does not have to state the complication--it is assumed.   If you don't find that causal relationship is supported, then the two diseases are coded as unrelated.

This clarification should help make coding more accurately reflect what the physician is trying to convey to the coder.  As always, we as coders have to be careful to ensure that we double check the ICD-10CM to be sure we're coding it right.

Thursday, June 9, 2016

Coding Clinic Q1 2016 Addresses Heart Failure Coding

Hi everyone!  It's been a while since I've posted anything--I had an unexpected "vacation" from work.

While I was away, the AHA's Coding Clinic was busy clarifying ICD-10 coding for us.  There were many situations clarified in Q1 of 2016, but a couple of them warrant blog posts.

Heart failure coding has been a challenge for quite some time--with coders and physicians going bck and forth.  The physicians telling us that the patient has heart failure, the coders telling the physcians that it doesn't say that in the chart!

Earlier Coding Clinic guidance (Q1 2014) indicated that the coder could not assume diastolic heart failure, systolic heart failure or combined diastolic/systolic heart failure when the physician documented heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF).  Thanks to input from the American College of Cardiology,  these contemporary terms for heart failure have been now been accepted by Coding Clinic.

Going forward, when the provider has documented HFpEF, HFrEF, or other similar terms noted above, the coder may interpret these as "diastolic heart failure" or "systolic heart failure," respectively, or a combination of both if the provider has documented it,  and assign the appropriate ICD-10-CM codes based on these definitions.

Just as an FYI--we've posted new information to HCC University.  The 2016 Risk Score Calculator is online, there's an updated document with all of the ICD-10 codes by HCC and the updated Companion Guides for encounter data submission.  Stay tuned for exciting HCC U news in the very near future!

Finally, remember, when you have coding questions, you can contact us at