Learning Objectives. Guidance Hierarchy. AHA Coding Clinic Update

Transcription

1 1 AHA Coding Clinic Update Nelly Leon Chisen, RHIA Director, Coding and Classification Executive Editor, Coding Clinic American Hospital Association Chicago, IL Learning Objectives At the completion of this educational activity, the learner will be able to: Identify the hierarchy of coding guidance Reflect on the relationship between clinical criteria and code assignment Explain the ICD 10 CM guideline on the term with as it relates to linking medical conditions Discuss recent AHA Coding Clinic for ICD 10 CM and ICD 10 PCS updates on Type 2 myocardial infarction and sequencing of COPD with respiratory conditions 2 Guidance Hierarchy Classification (Index, Tabular, Instructional Notes) Guidelines are supplemental to the classification Coding Clinic provides official interpretation, clarification, application of classification and guidelines Case specific Nothing is published without the approval of CMS and CDC, federal agencies responsible for the creation and maintenance of ICD 10 CM and ICD 10 PCS codes 3 1

2 4 Code Assignment and Clinical Criteria Guideline The assignment of a diagnosis code is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. Official Guidelines for Coding and Reporting, Section I.A.19 Code Assignment and Clinical Criteria Guideline: Coding Clinic Says... Reaffirming long standing advice: Coding must be based on provider documentation Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient s diagnosis, can diagnose the patient Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider s clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient s medical condition 5 Code Assignment and Clinical Criteria Guideline: Coding Clinic Says... (cont.) Is clinical documentation improvement (CDI) going away? NO. Guideline is addressing coding, not clinical validation. This is a separate function. It is appropriate for facilities to ensure that documentation is complete and accurate, and that it appropriately reflects the patient s clinical conditions. 6 2

3 7 Code Assignment and Clinical Criteria Guideline: Coding Clinic Says... (cont.) Clinical validation is a separate function from the coding process and clinical skill CMS definition of clinical validation cited in the AHIMA Practice Brief: Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record Coding Clinic, Fourth Quarter 2016, pages Code Assignment and Clinical Criteria Guideline: Coding Clinic Says (cont.) Coding is based on provider documentation regardless of which clinical definition or set of clinical criteria he or she uses While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his or her documentation, not on a particular clinical definition or criteria set Coding Clinic, Fourth Quarter 2016, pages And Speaking of Clinical Criteria... Regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coding Clinic, Fourth Quarter 2016, pages

4 10 And Speaking of Clinical Criteria... (cont.) Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded. If the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician s diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn t be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system. Coding Clinic, Fourth Quarter 2016, pages Coding of Sepsis and New Clinical Definitions Coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis). The coding guidelines are based on the ICD 10 CM classification as it exists today. Continue to code sepsis, severe sepsis and septic shock using the most current version of the ICD 10 CM classification and the ICD 10 CM Official Guidelines for Coding and Reporting. Code assignment is based on provider documentation (regardless of the clinical criteria the provider used to arrive at that diagnosis). Coding Clinic, Third Quarter 2016, pages Clinical Criteria for Clinical Validity Whose definition or criteria? Licensed provider who has face to face contact with patient? Facility accountable for ensuring the validity of the documented diagnosis? Payer? Anyone else? Unfortunately, Coding Clinic does not have the authority to make a pronouncement. 12 4

5 13 To Link or Not Link, That Is the Question Assumed cause and effect relationships in the classification are not necessarily the same in ICD 9 CM and ICD 10 CM. Coding Clinic, First Quarter 2016, page 11 More on Linkage It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. The entire record should be reviewed to determine whether a relationship between the two conditions exists. The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, query the provider. Coding Clinic, First Quarter 2014, page 15 and First Quarter 2016, page With Guideline: To Link or Not Link, That Is the Question 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 List The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List Official Guidelines for Coding and Reporting, Section I.A

6 16 Diabetes With Associated Conditions Alphabetic Index Example Diabetes, diabetic (mellitus) (sugar) E11.9 with amyotrophy E11.44 arthropathy NEC E autonomic (poly) neuropathy E11.43 cataract E11.36 Charcot s joints E chronic kidney disease E11.22 The physician documentation does not need to provide a link between the diagnoses of diabetes and chronic kidney disease to accurately assign code E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease. This link can be assumed since the chronic kidney disease is listed under the subterm with. Coding Clinic, Second Quarter 2016, pages Diabetes and Osteomyelitis ICD 10 CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such. Is this still true? Coding Clinic, Fourth Quarter 2013, page Diabetes With Osteomyelitis Caution: Review Index Changes Effective October 1, 2016, the Alphabetic Index has been revised as follows: Diabetes, diabetic (mellitus) (sugar) E11.9 with osteomyelitis E

7 19 Diabetes With Osteomyelitis (cont.) The physician documentation does not need to provide a link between the diagnoses of diabetes and osteomyelitis to accurately assign code E11.69, Type 2 diabetes mellitus with other specified complication This link can be assumed since osteomyelitis is now listed under the subterm with These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the osteomyelitis is unrelated and due to some other underlying cause besides diabetes Diabetes With Osteomyelitis (cont.) The same linkage between diabetes and osteomyelitis applies to other types of diabetes from categories E08 E13 as noted in the following index entry: Osteomyelitis in diabetes mellitus see E08 E13 with.69 Coding Clinic, Fourth Quarter 2016, page Hypertension With Linkage The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term with in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. 21 7

8 22 Hypertension With Linkage (cont.) For hypertension and conditions not specifically linked by relational terms such as with, associated with, or due to in the classification, provider documentation must link the conditions in order to code them as related Official Guidelines for Coding and Reporting, Section I.C.9.a Hypertension With Heart Disease Hypertension with heart conditions classified to I50. or I51.4 I51.9 are assigned to a code from category I11, Hypertensive heart disease. There is no longer a need to have a causal relationship stated The same heart conditions (I50., I51.4 I51.9) with hypertension, but without a stated causal relationship, are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter. Official Guidelines for Coding and Reporting, Section I.A.9.a.1 23 CHF With Hypertension Discrepancy between guideline and classification? No. Assign code I11.0, Hypertensive heart disease, with failure, and code from category I50, Heart failure. Classification presumes a causal relationship unless documented as unrelated. Although heart failure is not in the list of heart conditions in the inclusion note, in ICD 10 CM, there is a note instructing Use additional code to identify type of heart failure in the Tabular List. The code range under category I11, Hypertensive heart failure, is not intended to be an allinclusive list. Coding Clinic, First Quarter 2017, page

9 25 Hypertensive Chronic Kidney Disease Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present This was true before as well New for FY 2017: CKD should not be coded as hypertensive if the physician has specifically documented a different cause Official Guidelines for Coding and Reporting, Section I.A.9.a.2 Hypertensive Crisis Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. Hypertension documented as accelerated or malignant, but not as hypertensive crisis, urgency, or emergency, is assigned code I10, Essential (primary) hypertension, per the Alphabetic Index instructions. Code also any identified hypertensive disease (I10 I15). The sequencing is based on the reason for the encounter. Coding Clinic, Fourth Quarter 2016, page Sequencing of COPD and Pneumonia or Bronchitis Based on current Tabular note instructions at J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection: Use additional code to identify infection (pneumonia and acute bronchitis but not influenza) J44.0 first, followed by appropriate pneumonia code (e.g., J18.9, Pneumonia, unspecified organism) Coding Clinic, Third Quarter 2016, page 15 March 2017 ICD 10 Coordination & Maintenance Committee proposal to change to code also to identify the infection 27 9

10 28 Sequencing of COPD and Pneumonia or Bronchitis (cont.) Acute exacerbation of COPD with acute bronchitis J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation J20.9, Acute bronchitis Coding Clinic, Third Quarter 2016, page 16 Sequencing of COPD and Aspiration Pneumonia Instructional note at J44.0 to use additional code to identify infection does not apply to aspiration pneumonia Sequencing of the two conditions will depend on the circumstances of admission J69.0, Pneumonitis due to inhalation of food and vomit, is under Lung diseases due to external agents, not respiratory infection codes Coding Clinic, First Quarter 2017, page Sequencing of COPD and Aspiration Pneumonia (cont.) Instructional note at J44.0 to use additional code to identify infection does not apply to aspiration pneumonia Sequencing of the two conditions will depend on the circumstances of admission J44.9, Chronic obstructive pulmonary disease, unspecified J69.0, Pneumonitis due to inhalation of food and vomit Code is under Lung diseases due to external agents, not respiratory infection codes Coding Clinic, First Quarter 2017, page

11 31 Sequencing of COPD and Ventilator Associated Pneumonia Instructional note at J44.0 to use additional code to identify infection does not apply to ventilatorassociated pneumonia Sequencing of the two conditions will depend on the circumstances of admission J44.9, Chronic obstructive pulmonary disease, unspecified J95.851, Ventilator associated pneumonia Code is under Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified, not respiratory infection codes Coding Clinic, First Quarter 2017, page 25 COPD and Asthma If a specific type of asthma is documented, assign an additional code for the asthma If the type of asthma is not further specified, do not assign code J45.909, Unspecified asthma, uncomplicated, separately The instructional note under category J44, Other chronic obstructive pulmonary disease, states code also type of asthma, if applicable (J45 ) Unspecified isn t a type of asthma Coding Clinic, First Quarter 2017, page COPD and Asthma (cont.) Patient with asthma and acute exacerbation of COPD. Is the asthma reported as exacerbated or unspecified? If the health record documentation is not clear whether the asthma is acutely exacerbated, query the provider for clarification An exacerbation of COPD does not automatically make the asthma exacerbated Coding Clinic, First Quarter 2017, page

12 34 Type 2 Myocardial Infarction Due to Demand Ischemia Code to I21.4, Non ST elevation (NSTEMI) myocardial infarction, unless otherwise documented as STEMI Sequencing dependent on the circumstances of the admission, diagnostic workup, and/or therapy provided Follow guideline for two or more diagnoses that equally meet the definition for principal diagnosis ICD 10 Coordination and Maintenance Committee proposals for new classification of myocardial infarctions discussed March 2016, September 2016, and March 2017 Comparative/Contrasting Secondary Diagnoses in the Hospital Inpatient Setting Apply guideline for 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 Note: Guideline is applicable only to inpatient admissions to short term care, acute care, long term care, and psychiatric hospitals Coding Clinic, Second Quarter 2016, page 9 35 Uncertain Diagnoses for Physician Reporting Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Official Guidelines for Coding and Reporting, Section IV. H. Why different guidelines for physicians and hospitals? Any possible consideration for change in the future as hospitals and physicians align under initiatives like ACOs? 36 12

13 37 Addressing Questions to the Central Office Please be sure to read the FAQ section to find out what types of questions we can or cannot answer. Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide