So, I recently read a funny blog....

About Coding of all things.  It's called Coder Coach.  And the author does a code for the day, with a focus on humor.  I'm not as funny as she is, so I'm not even going to try.  But I think that I will try to be more diligent about posting--and I think I'll try to do a code a day (or week...or something).

Let's face it--ICD-10 has been a royal pain of an implementation.  So, by focusing on a new code with some regularity, I might be able to lend a hand.  No time like the present!

We'll start off, not with a code, but with at category.  This category may be the most misused category of codes I've ever seen.

I've been coding for more years than I like to admit.  Let's say north of 30.  While I've seen instances where these codes (and their predecessors in ICD-9) could have been used correctly, I've never actually seen them used correctly.  They are: Neoplasms of  Uncertain Behavior.  In ICD-10 they are found in the section Neoplasms of Uncertain Behavior, Polycythemia Vera and Myelodysplastic Disorders (D37-D48).

When I see a code for neoplasm of uncertain behavior submitted, no matter the body area, it's always because:

1. The physician hasn't biopsied the lesion yet, and so he/she is uncertain of the histology; or
2. The physician has biopsied the lesion, but hasn't yet received the pathology report

Neither of these is the correct usage of the code.  The beginning of the code section explains the correct use of the codes, but unfortunately, one of the downsides of Electronic Health Records (EHRs) is that none of these instructions are visible to most users.  Here's the instruction, straight from the ICD-10:

Note: Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.

As you might guess, the instances where you can correctly use these codes are relatively rare.  So, unless the pathologist cannot tell you whether to neoplasm is benign or malignant, these codes should not be used. 

This code category points out the importance of the coding instructions and guidelines.  As noted, these are generally lost in an EHR--that's not to say EHRs are bad, simply that they have their limitations.   So, what's a coder (or the physician who is coding) to do?  I strongly recommend that coders AND physicians read the sections of the Coding Guidelines that apply to them.  That means any specialty specific guidelines, and the entire Outpatient coding section.  You should also review the section of the code book that includes common codes you use.  And, when faced with the new and unusual (like these), take a quick glance at the book to see if there are special instructions like we found here. 

Now, if you have an EHR, you don't have to buy the code book to do that.  Every year, we post a full text copy of the ICD-10 on HCC University.

I'm going to do my best to keep posting these coding tips.  If I fall behind, feel free to email me at Coding@scanhealthplan.com to remind me.  I sometimes suffer from mild memory loss, NOS (R41.3)

Confessions of a Vegetarian Coder—or, why I hate M.E.A.T.!!

First-- I hope I’m not offending anyone.   The spirit of this post is lighthearted, and I’m having a little bit of fun. BUT, I’m also serious about proper coding, and that’s my only intent.  Better documentation and coding helps us all in many ways, and should lead to better and more efficient medical care for the members of our medical groups and health plans. It also affects our reimbursement. Done correctly, though—a wealth of important information is obtained, to help our members to obtain access to excellent treatment programs, that enhance their lives and living.

So, there is NOTHING official about “MEAT”, it’s just a handy acronym that someone thought up one day.   It’s cute.   It sort of addresses what’s needed for ANY diagnosis, not just risk adjustment or so-called “HCC Coding” (which also doesn’t exist).  By law, under HIPAA, what is required for any ICD-9 code is defined by what is in the ICD-9-CM Official Guidelines for Coding and Reporting,  found here ,  and Coding Clinic (see the 2nd paragraph of the guidelines).  You can’t replace 107 pages with 4 letters, two of which mean the same thing!

If you look at MEAT for just a minute, you can see it’s not official, and pretty meaningless:

Monitoring (or Medication)

Evaluation

Assessment;  or

Treatment

Evaluation and Assessment mean exactly the same thing!  And no “Official Guideline”  for anything, much less something that leads to Federal Government payment, would be complete at 4 letters, 6 if you include the “or”.   

EVERY condition that is submitted as an ICD-9 code has to meet the Official Guidelines.  There’s no exception because something doesn’t risk adjust.  Just writing the word “Stable” does not magically mean you can code something.  Or just because the diagnosis listed under the “Assessment” heading in a chart note doesn’t mean someone assessed it.  What is under that word are conclusions, 90 times out of 100, not an evaluation of the patient or an assessment.   If you look at the word “evaluation” in dictionary.com, it says this:

evaluation

e•val•u•a•tion

[ih-val-yoo-ey-shuhn]

noun

1 an act or instance of evaluating or appraising.

2. (especially in medicine) a diagnosis or diagnostic study of a physical or mental condition.  (emphasis added)

Here’s where the word “meat” or “substance” comes into play. There really has to be some substance to an evaluation.   Just writing:

Diabetes with neurological manifestations

in a chart note does not mean the doctor evaluated ANYTHING or can code 250.60

First of all ________manifestations isn’t a diagnosis at all. By itself, it means nothing.  No matter what someone from somewhere told you, you cannot just write “stable” or “continue on meds” next to a couple of words and you now have something you can code.  I have seen it fail in CMS RADVs more than once.  And I think that failing something like that is proper.  It never should have been coded in the first place! 

On the other hand, if you can see in that chart note that the  physician did a foot exam, and documented the patients symptoms of burning or tingling in their feet, did a monofilament exam—NOW YOU HAVE SOMETHING!!!!!!!!!

Now he or she can say in the “Assessment” section:

Diabetes with diabetic polyneuropathy.  Patient started on Neurontin, 300 mg, TID

TA DA!! We have something that we can code!!!  YAY!!!!!!!!!!!!!  There is the "meat" that's needed.  An evaluation and/or some indication that the condition was either assessed, being treated (actively) or it has an impact on the treatment of other diseases as the ICD-9 requires.

When people talk about “HCC Coding” being somehow different, there isn’t really a citation they can point to, or an example.   On the other hand, CMS DOES have specific signature requirements for a medical record, but that isn’t a coding issue per se. It is a Medical Record issue.  So, in my diet, I’m a happy omnivore, savoring a juicy steak when I can.  But when it comes to “M.E.A.T.” and coding, I’m a vegetarian coder all the way.

Stacey Hernandez, CCS-P

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

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.

2012 ICD-9-CM Guidelines Posted

The Official ICD-9-CM coding guidelines, effective 10-1-2011, were posted on the National Center For Health Statistics website.  A copy of the new guidelines will be posted on the Tools page at hccuniversity.com shortly.

Few changes are included, but there are some of note.  There are new sections added to describe:

• Appropriate coding of post-procedural infection and post-procedural septic shock (I.C.1.b.10.c.)
• Appropriate coding of types and stages of glaucoma (I.C.6.b.) and
• Guidelines for complications of care (I.C.17.f.1.)

Coding Symptoms Inherent in a Disease

In the first quarter of 2010, the following question was submitted to Coding Clinic:

What is the correct code assignment for a diagnosis of “compensated respiratory acidosis” in a patient with chronic obstructive pulmonary disease (COPD)?

Coding Clinic advised that only one code should be assigned--496 for the COPD.  This answer illustrates a coding principle that sometimes is problematic--symptoms of a disease are not coded when they are inherent to the disease.  Often, physicians will list these symptoms or signs when they are causing a specific problem for the patient.  For example, tremor is a hallmark of Parkinson's disease, and a physician may note that the tremor exists, is increasing or is decreasing.  Coders may be tempted to code the tremor because the physician has evaluated it--but it's a part of the disease. In that case, only the Parkinson's disease should be coded.

Sometimes, it's not so clear that a problem is a usual part of the disease.  For example, in the second quarter of 2010, a patient presented with gross hematuria due to a prostate malignancy.  While the prostate malignancy caused the hematuria, it isn't a usual part of the disease, and the questioner was instructed to code the hematuria, and the prostate cancer as a secondary diagnosis. In that case, the hematuria was a complication, and complications are coded separately.

When in doubt, coders should query the physician as to whether a listed symptom or sign is a usual part of the disease process, or a complication.  This affords coders a great opportunity to work collaboratively with the physician--it allows the coder the opportunity to both gain information from the physician, and provide the physician with information regarding coding rules.