5 Coding and Documentation Challenges A coder-physician dialogue

1. 5 Coding and Documentation Challenges A coder-physician dialogue an HCPro audio conference presented on October 20, 2010 James S. Kennedy, MD, CCS and Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS

2. Topics For Discussion Acute Kidney Injury Altered Mental Status Complications Cardiac Cath Lab Indications and Procedures Pulmonary Conditions and Procedures

3. Complications(Of Procedures)

4. Clinical Scenario • A 55 year old female is admitted for an elective colon resection for colon cancer • Day 1 • Dx: Attending: Colon Cancer • Day 2 • Dx: Attending: s/p Colon Resection with postoperative ileus • Day of Discharge • Dx: Attending: Colon Resection with expected postoperative ileus, resolved.

5. What is a complication of a procedure • A condition that is: • Related to the procedure • 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. Source: ICD-9-CM Guidelines • Not a known risk or inherent/integral to the procedure • Example: Since pneumothorax is a known risk associated with most thoracic surgeries, it would be inappropriate to assign an additional code for the iatrogenic pneumothorax, based on an x-ray finding alone, without physician concurrence. CC, 3rd Quarter, 2003, page 19. • Example: Requirement to query surgeons to determine if incidental serosal tears are inherent to the procedure. CC, 2nd Quarter, 2007, pages 11-12.

6. ICD-9-CMGuidelines • Reportable conditions must meet at least one of the following criteria: • Clinically evaluated • Diagnostically tested • Therapeutically treated • Results in increased length of stay • Results in increased in nursing care/monitoring • Signs and symptoms integral to a disease process are not reportable unless otherwise required by coding guidelines. • The coding guideline for “integral” is carried through for conditions which are expected and that the physician considers integral to a procedure.

7. Nuances of Postoperative Conditions • Relationship to: • Procedure – already discussed • Relationship to a known disease • If a patient has known atrial fibrillation and develops atrial fibrillation in the postoperative period, it may not be directly related to the procedure • Relationship to a medication • If a patient receives morphine after surgery or had epidural anesthesia, these can result in prolonged ileus.

8. Requirement for Physician QueryCC, 3rd Quarter, 2009, page 5 • It is important to note 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. • 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.

9. ICD-9-CM Defaults Because the physician documented “expected postoperative ileus”, do we still code 997.4? A query is necessary • Ileus (adynamic) (bowel) (colon) (inhibitory) (intestine) (neurogenic) (paralytic) 560.1 • arteriomesenteric duodenal 537.2 • due to gallstone (in intestine) 560.31 • duodenal, chronic 537.2 • following gastrointestinal surgery 997.4 • gallstone 560.31 • mechanical (see also Obstruction, intestine) 560.9 • meconium 777.1 • due to cystic fibrosis 277.01 • myxedema 564.89 • postoperative 997.4 • transitory, newborn 777.4 • 997.4 Digestive system complications • Complications of: • Intestinal (internal) anastomosis and bypass, not elsewhere classified, except that involving urinary tract • Hepatic failure specified as due to a procedure • Hepatorenal syndrome specified as due to a procedure • Intestinal obstruction NOS specified as due to a procedure

10. POA Indicator • Y – Yes • N – No • W – Cannot Be Clinically Determined • U – Uncertain • Interpreted as a “N” The POA Indicator is a powerful determinant of complications under some protocols.

11. 3MPotentially Preventable Complications • The State of Maryland is investigating the utilization of 3M’s Potentially Preventable Complications methodology in its Pay-for-Performance methodologies • 3M has developed a methodology of conditions that are not POA that it considers to be “preventable” complications outside of the 996-999 codes. • e.g. 428.xx (CHF) is a PPC if not POA – Group 2 – Level 2 (Major) • e.g. 518.81 (Acute Respiratory Failure) – Group 2 – Level 1 (Other) • The expected number and severity of PPCs rises in proportion to the APR-DRG Severity of Illness • If the PPC rate is inordinately high for the APR-DRG SOI level, financial consequences are assessed. • Learn more of these using the website recommended by the Maryland HSCRC: • http://www.aprdrgassign.com • User name: MDHosp • Password: aprdrg401

12. Potentially Preventable Complications Extreme Complications Extreme CNS Complications * Acute Pulmonary Edema & Respiratory Failure w Ventilation * Shock * Ventricular Fibrillation, Cardiac Arrest * Renal Failure with Dialysis * Post-Operative Respiratory Failure with Tracheostomy * Gastrointestinal Complications Major GI Complications w Transfusion or Significant Bleeding * Major Liver Complications * Major Gastrointestinal Complications without Transfusion or Significant Bleeding Other Gastrointestinal Complications without Transfusion or Significant Bleeding Present on Admission Indicator Matters

13. Cardiovascular-Respiratory Stroke & Intracranial Hemorrhage Pneumonia, Lung Infection * Aspiration Pneumonia * Pulmonary Embolism * Congestive Heart Failure * Acute Myocardial Infarct * Peripheral Vascular Complications Except Venous Thrombosis * Venous Thrombosis * Acute Pulmonary Edema and Respiratory Failure without Ventilation Other Pulmonary Complications Cardiac Arrhythmias & Conduction Disturbances Other Cardiac Complications Perioperative Complications Post-Op Wound Infection & Deep Wound Disruption w Procedure * Reopening of Surgical Site * Post-Op Hemorrhage & Hematoma w Hemorrhage Control Proc or I&D Proc * Accidental Puncture/Laceration During Invasive Proc * Post-Op Foreign Body * Post-Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure or I&D Procedure Post-Operative Infection & Deep Wound Disruption Without Procedure Post-Operative Substance Reaction & Non-O.R. Procedure for Foreign Body Present on Admission Indicator Matters

14. Infectious Complications Clostridium Difficile Colitis Urinary Tract Infection Septicemia & Severe Infection Cellulitis Moderate Infectious Obstetrical Complications Obstetrical Hemorrhage w Transfusion * Obstetrical Laceration & Other Trauma without Instrumentation * Obstetrical Laceration & Other Trauma with Instrumentation * Major Puerperal Infection and Other Major Obstetrical Complications * Obstetrical Hemorrhage without Transfusion Medical & Anesthesia Obstetric Complications Other Complications of Obstetrical Surgical & Perineal Wounds Delivery with Placental Complications Present on Admission Indicator Matters

15. Malfunctions, Reactions Etc. Iatrogenic Pneumothrax * Mechanical Complication of Device, Implant & Graft * Inflammation, & Other Complications of Devices, Implants or Grafts Except Vascular Infection * Infections due to Central Venous Catheters* Infection, Inflammation and Clotting complications of Peripheral Vascular Catheters and Infusions Poisonings Except from Anesthesia Poisonings due to Anesthesia Transfusion Incompatibility Reaction Gastrointestinal Ostomy Complications Other Medical and Surgical Complications Post-Hemorrhagic & Other Acute Anemia w Transfusion * Decubitus Ulcer * Encephalopathy * Renal Failure without Dialysis GU Complications Except UTI Diabetic Ketoacidosis & Coma In-Hospital Trauma and Fractures Acute Mental Health Changes Accidental Cut or Hemorrhage During Other Medical Care Other Complications of Medical Care Other Surgical Complication – Moderate Other In-Hospital Adverse Events Present on Admission Indicator Matters

16. Postoperative (Acute) Respiratory Failure518.81 or 518.5?? INDEX Failure respiration, respiratory 518.81 acute 518.81 acute and chronic 518.84 center 348.8 newborn 770.84 chronic 518.83 due to trauma, surgery or shock 518.5 newborn 770.84 Insufficiency respiratory 786.09 acute 518.82 followingshock, surgery, or trauma 518.5 newborn 770.89 TABLE 518.5 Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome Pulmonary insufficiency following: shock surgery trauma Shock lung EXCLUDES adult respiratory distress syndrome associated with other conditions (518.82) respiratory failure in other conditions (518.81, 518.83-518.84) Coding Clinic, September-October 1987 Code 518.5 is assigned when respiratory failure occurs following surgery or trauma.

17. PSI 11Postoperative Respiratory Failure • ICD-9-CM Acute Respiratory Failure diagnosis codes that is not present on admission: • 518.81 ACUTE RESPIRATRY FAILURE • 518.84 ACUTE & CHRONC RESP FAILURE • NOTE THAT 518.5 is NOT INCLUDED • ICD-9-CM Mechanical Ventilation for 96 consecutive hours or more procedure code: • 96.72 CONTINUOUS MECHANICAL VENTILATION FOR 96 CONSECUTIVE HRS OR MORE • ICD-9-CM Mechanical Ventilation procedure codes 2 or more days after the procedure: • 96.70 CONTINUOUS MECHANICAL VENTILATION OF UNSPEC DURATION • 96.71 CONTINUOUS MECHANICAL VENTILATION FOR LESS THAN 96CONSECUTIVE HRS • ICD-9-CM Reintubation procedure code 1 or more days after the procedure: • 96.04 INSERT OF ENDOTRACHEAL TUBE

18. PSI 21 Iatrogenic Pneumothorax • All cases of code 512.1 – Iatrogenic pneumothorax. • Coding Clinic, 3rd Quarter, 2003, page 19: • Question: A 19-year-old patient with a history of progressive adolescent idiopathic scoliosis was admitted for anterior spinal fusion. Following surgery, the chest x-ray showed a small apical pneumothorax. The patient was placed on suction and later the chest tube was removed. A follow-up chest x-ray showed the pneumothorax was still present. No active measure was taken. The physician at our facility believes the iatrogenic pneumothorax is integral to this procedure and should not be reported. Is it appropriate to assign code 512.1, Iatrogenic pneumothorax, as an additional diagnosis? • Answer: Since pneumothorax is a known risk associated with most thoracic surgeries, it would be inappropriate to assign an additional code for the iatrogenic pneumothorax, based on an x-ray finding alone, without physician concurrence.

19. Bottom Line • Establish the relationship • Rule out medical conditions or adverse effects of medicine. • Query Query Query • To determine whether the physician believes that it is a complication or not

20. Thank YouQuestions?