What to expect when coding CAD, MI with ICD-10-CM · What to expect when coding CAD, MI with...

What to expect when coding CAD, MI with ICD-10-CM

Let’s get to the heart of the matter.

ICD-10-CM coronary artery disease (CAD) and

myocardial infarction (MI) codes will undoubtedly differ

from their ICD-9-CM counterparts in some ways, but

some aspects will remain the same.

Native and bypass grafts

In ICD-9-CM, CAD appears in category 414. ICD-10

code I25.- denotes CAD. Both ICD-9-CM and ICD-10-

CM codes indicate whether CAD is in the native artery

or a bypass graft. The term “native artery” describes

an artery with which a patient is born and that has

not been grafted during a coronary artery bypass graft

(CABG) procedure. A “bypass graft” is a graft inserted by

a surgeon during a CABG procedure to bypass a blocked

coronary artery.

ICD-10-CM code category I25.1 denotes CAD of a

native artery. Patients can also have CAD of several types

of bypass grafts, including:

➤ Unspecified (I25.700–I25.709)

➤ Autologous vein (i.e., a vein that originates from

the patient, such

as the saphenous

vein graft in the

leg that is used to

create a bypass

in the coronary

artery) (I25.710–

I25.719)

➤ Autologous artery (i.e., an artery that originates

from the patient, such as an internal mammary

artery graft that is used to create a bypass in the coro-

nary artery) (I25.720–I25.729)

➤ Non-autologous biological (i.e., the graft-

ing material doesn’t originate from the patient)

(I25.730–I25.739)

Patients can also have CAD in a transplanted heart.

In this scenario, coders should report I25.75- for CAD of

the native artery and I25.76- for CAD of a bypass graft.

Documenting the specific type of bypass graft is impor-

tant because it affects code assignment, says Shannon

E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC,

CCDS, director of HIM and coding at HCPro, Inc., in

Danvers, Mass. Most physicians tend to only document

“patient had a CABG or history of CABG”—and not the

specific graft that was used.

CAD and angina pectoris

If a patient has both CAD and angina, coders using

ICD-9-CM must assign a code for each condition sepa-

rately. They report a code from category 414.0x for CAD

This month’s tip: Learn

what inpatient coders, who

don’t typically assign E/M

codes, should know about

documentation of history of

present illness on p. 12.

July 2012 Vol. 15, No. 7

IN THIS ISSUE

p. 5 Recovery AuditorsLearn how the three-day rule has changed and how this affects hospitals as Recovery Audits get under way.

p. 6 Three-day ruleLearn important details about the three-day rule that every inpatient coder should know.

p. 8 MalnutritionNew clinical guidelines for malnutrition, which has never had universally accepted clinical criteria, could help alleviate compliance challenges associated with coding the condition.

p. 10 Clinically SpeakingRobert S. Gold, MD, ponders the causes of mechanical and paralytic ileuses.

p. 12 E/M documentationInpatient coders don’t typically assign E/M codes, but they should be aware of documentation of the history of present illness.

Inside: Coding Q&A

Page 2 Briefings on Coding Compliance Strategies July 2012

© 2012 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978-750-8400.

and either code 411.1 (unstable angina) or code 413.9

(other and unspecified angina pectoris) for angina. How-

ever, this has always raised a question about sequencing,

particularly because code assignment order affects MS-

DRG assignment.

“What usually prompts the person to come in the

facility is the angina. Angina is basically a thoracic chest

pain when the heart muscle doesn’t get enough blood,”

says McCall. “So the question is, although the angina

is what brought them in, what’s the underlying cause

of the angina? In many cases, it’s the underlying CAD.

The person wouldn’t have likely had the angina if they

didn’t have CAD.”

Generally, CAD is the principal diagnosis even when

diagnostic tests confirming the condition are performed

before admission, she says.

However, when both conditions are POA and both are

treated equally during a hospital stay, coders often have

difficulty determining which should be reported as the

principal diagnosis, says McCall.

The good news is that coders using ICD-10-CM won’t

need to worry about sequencing these two conditions

because CAD codes are combination codes. They include

additional characters that denote the presence or absence

of angina pectoris. For example, ICD-10-CM code

I25.110 denotes CAD of the native artery with unstable

angina. ICD-10-CM code I25.721 denotes CAD of auto-

logous artery coronary artery bypass graft(s) with angina

pectoris with documented spasm. ICD-10-CM code

I25.751 denotes CAD of native artery of transplanted

heart with angina pectoris with documented spasm.

Similarly, ICD-10-CM code I25.10 denotes CAD of

native artery without angina pectoris. ICD-10-CM code

I25.81- denotes CAD of other coronary vessels without

angina pectoris.

Coders using ICD-10-CM must remember that they

may not assign unstable angina separately when a patient

also has CAD, says McCall. “Coders are so used to assign-

ing separate codes for CAD and angina, so we have to be

very careful because technically if you look up the main

term angina, unstable in the Alphabetic Index … it gives

you one option: I20.0—that is, unless you notice the

entry stating ‘angina, with atherosclerotic heart disease,’

which provides a cross-reference to the CAD entry in

the index. If you go to I20.0, it says unstable angina.”

Although patients can have unstable angina without

CAD, this is not a common occurrence, she says.

Coders should note that an Excludes1 note in ICD-

10-CM category I20 precludes coders from assigning this

code with a code from the I25.1- or I25.7- categories or

with code I23.7 (postinfarction angina), says McCall.

Code category I20 is reserved for patients with angina

not related to CAD.

Coders can—and should—make assumptions about

causal relationships between CAD and angina when both

are documented, says McCall. This liberty doesn’t often

occur in the coding world. However, the ICD-10-CM

Editorial Advisory Board Briefings on Coding Compliance Strategies

Paul Belton, RHIA, MHA, MBA, JD, LLMVice PresidentCorporate Compliance Sharp HealthCare San Diego, Calif.

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM ConsultantFremont, Calif.

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Fla.

James S. Kennedy, MD, CCSManaging DirectorFTI Healthcare Atlanta, Ga.

Laura Legg, RHIT, CCSRevenue Control Coding ConsultantRevenue Cycle Management Washington/Montana Regional Services Providence Health & Services Renton, Wash.

Monica Lenahan, CCSManager of Coding Education and ComplianceRevenue Management Centura Health Englewood, Colo.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of Coding and HIM HCPro, Inc. Danvers, Mass.

Jean Stone, RHIT, CCSCoding Manager - HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, Calif.

Associate Editorial Director: Ilene MacDonald, CPC

Managing Editor: Geri Spanek

Contributing Editor: Lisa Eramo, [email protected]

Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $249/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

July 2012 Briefings on Coding Compliance Strategies Page 3


Official Guidelines for Coding and Reporting, Chapter 9

(Diseases of the Circulatory System), subsection b

(Atherosclerotic CAD and angina) state:

A causal relationship can be assumed in a patient with

both atherosclerosis and angina pectoris, unless the documenta-

tion indicates the angina is due to something other than the

atherosclerosis.

“If the documentation states that the patient has both

CAD and angina pectoris, the combination code can be

used,” says Melanie Endicott, MBA/HCM, RHIA,

CCS, CCS-P, director of professional practice at AHIMA

in Chicago. “Since the combination code for CAD and

angina doesn’t exist in ICD-9-CM, it may take some time

for coders to remember the rule to combine these two

conditions when coding in ICD-10-CM.”

Default code changes

Coding Clinic, Fourth Quarter 2004, instructs coders

using ICD-9-CM to default to code 414.01 (CAD of a

native artery) for patients with CAD who have never

undergone a CABG procedure, says McCall. Coding

Clinic, Fourth Quarter 2004, instructs coders to default

to 414.00 (CAD of unspecified artery) for patients with

CAD who have undergone a CABG when documenta-

tion doesn’t indicate whether the CAD is in the native

artery or the bypass graft.

“This has always raised an eyebrow because techni-

cally, when you perform a bypass graft, you don’t get

rid of the atherosclerosis that’s in the native artery,”

says McCall. “So it seemed kind of odd that Coding Clinic

would say if you’ve got a bypass graft and CAD, you

have to use the unspecified vessel even though you

know the patient still has CAD in their native artery.

That’s why the physician performed the bypass initially.”

ICD-10-CM remedies this; the Alphabetic Index maps

CAD, not otherwise specified, to the default code for

CAD of the native artery (I25.10), says McCall.

However, clarifying whether CAD is of the native artery

or a bypass graft is important because this information can

have financial ramifications in ICD-10-CM, she says.

Consider the following scenario. A patient has

CAD without angina pectoris. The patient previously

underwent a CABG procedure. The physician didn’t

document whether CAD is in the bypass graft or the na-

tive vessel. When documentation is unclear, coders using

ICD-10-CM should default to I25.10, which is a non-CC

condition. If a physician had clarified that the patient

had CAD of a bypass graft without angina pectoris, cod-

ers could report I25.810 (atherosclerosis of CABG with-

out angina pectoris) or I25.812 (atherosclerosis of bypass

graft of coronary artery of transplanted heart without

angina pectoris) if the patient had a transplanted heart.

Both of these ICD-10-CM codes are CC conditions.

MIs and anatomical specificity

MIs appear in ICD-10-CM code categories 410.x (acute

MI), 414.8 (chronic MI), and 412 (old MI). ICD-10-CM MI

codes include I21.- (ST elevation MIs and non-ST elevation

MIs [STEMI and NSTEMI, respectively]), I22.- (subsequent

STEMI and NSTEMI), I25.2 (old MI), and I25.9 (chronic

MI). A STEMI is due to a sudden occlusion of a coronary

artery, says McCall. The usual treatment is thrombolytic

therapy. An NSTEMI is generally due to unstable plaque

with an accumulation of platelets and is treated with anti-

coagulants and platelet inhibitors, she says.

Code I21.- denotes the specific wall and specific

coronary artery involved in an MI. Although ICD-9-

CM denotes the specific wall (i.e., the fourth digit), the

specificity in ICD-10-CM regarding the coronary artery

is new. For example, ICD-10-CM code I21.01 denotes

left main coronary artery, and code I21.02 denotes left

anterior descending coronary artery.

This information helps capture exactly where an

infarction is occurring, says McCall. Coders typically find

this information in cardiac catheterization reports.

Coders should review current MI documentation to

determine whether it specifies both the wall and specific

coronary artery, says Endicott. “If all necessary documen-

tation is not present, then this is an opportunity to work

together with the cardiac physicians to share with them

what documentation is required with the new codes.”



Note that ICD-10-CM guidelines provide additional

information about the evolution of an NSTEMI to a

STEMI. The ICD-10-CM Official Guidelines for Coding and

Reporting, Chapter 9 (Diseases of the circulatory system),

subsection e (Acute MI) state:

If NSTEMI evolves to STEMI, assign the STEMI code.

If STEMI converts to NSTEMI due to thrombolytic therapy, it

is still coded as STEMI.

Acute and subsequent MIs

Among the most noticeable differences between ICD-

9-CM and ICD-10-CM is that the latter defines an acute

MI as one in which the patient’s symptoms last for fewer

than four weeks, says McCall. This differs from ICD-9-

CM, which classifies an acute MI as one with a stated

duration of eight weeks or fewer.

If patients have a second, subsequent MI during the

acute phase (i.e., during the four-week period after the

first MI), coders must assign a code for the subsequent

MI (I22.-) as well as a code for the first MI (I21.-), says

Endicott. The ICD-10-CM Official Guidelines for Coding and

Reporting, Chapter 9 (Diseases of the Circulatory System),

subsection e(4) (Subsequent acute MI) reiterate this.

Before assigning a code from category I22, coders

must confirm that the patient suffered two MIs within

four weeks, says McCall. ICD-10-CM specifies that a

subsequent MI is one that occurs within four weeks

(28 days) of a previous MI, regardless of site.

“It’s very different from ICD-9. In ICD-10, it’s really

showing the true picture,” says McCall. “When patients

have MIs, it’s not uncommon for them to have another

one a short time after having the first one. In ICD-9, we

don’t have a way to address this. We may end up coding it

as two separate episodes of care—initial and subsequent.”

Coders are not familiar with assignment of a separate

code for a subsequent MI, says McCall. In ICD-9-CM, the

term “subsequent” refers to a subsequent episode of care

and is included as a part of the fifth digit for the MI code.

In ICD-10-CM, it refers to a second MI rather than an

episode of care.

ICD-9-CM MI codes are considered MCCs only if

they have a fifth digit of 1 (initial episode of care), says

McCall. In ICD-10-CM, the MS-DRG remains the same

regardless of whether a patient is being treated for a first

MI or a subsequent one, she says. Codes I21.- and I22.-

are considered MCCs and will map to the same DRG

when reported as the principal diagnosis.

Remember that coders may need to clarify documen-

tation that doesn’t specify the date of the first MI, says

McCall. This date is important because it determines

whether the subsequent MI is truly subsequent to the

first MI or whether it is considered a new MI, which

should be reported with I21.-, she says.

Sequencing acute and subsequent MIs will depend

on the circumstances of an admission, says McCall. For

example, a patient suffered a STEMI involving the left

circumflex coronary artery two weeks earlier and is dis-

charged. The same patient is admitted today for a STEMI of

the anterior wall. Coders should assign I22.0 (subsequent

STEMI of anterior wall) followed by I21.21 (STEMI left

circumflex). Report I22.0 as the principal diagnosis because

the subsequent MI (i.e., the one that occurred within four

weeks of the initial MI) is the reason for the admission.

Also consider this example. A patient is admitted for

an acute MI and suffers a subsequent MI two days later

while still hospitalized. Coders should report a code from

the I21.- category as the principal diagnosis and a code

from the I22 category as secondary.

Old MI

Coders should report I25.2 for an old MI (i.e., a personal

history of MI), says Endicott. This code would apply to any

MI that occurred more than four weeks before admission.

As in ICD-9-CM, this code remains in the disease-specific

chapter rather that with other codes that denote personal

history (i.e., ICD-10-CM Z codes), says McCall.

Coders must exercise caution when documentation

states “history of MI,” particularly if it doesn’t specify

when the MI occurred, says McCall. “Technically, coders

should be coding that with I22 and I21, but I could see

how someone could [incorrectly assign] that and code

I21 and I25.2 instead,” she says. n



The inevitable audits of the three-day payment rule

have begun.

Connolly, Inc., the Recovery Auditor for Region C,

announced it would use automated reviews to begin

auditing to assess compliance with the rule that con-

tinues to challenge providers. CMS approved the issue

effective March 20.

Specifically, Connolly is auditing outpatient hospital

claims based on whether the associated inpatient dis-

charge occurred before or after June 25, 2010.

Why?

June 25 marks the enactment of section 102 of the

Preservation of Access to Care for Medicare Beneficiaries

and Pension Relief Act of 2010.

This law includes important changes pertaining to the

three-day payment rule, and hospitals should be aware

of them, says Kimberly Anderwood Hoy, JD, CPC,

director of Medicare and compliance at HCPro, Inc., in

Danvers, Mass.

Out with the old

Before June 25, 2010, all diagnostic and related non-

diagnostic services were subject to the payment rule on

the date of admission and during the three calendar days

before the date of admission.

CMS defined related services as those having an exact

match between the ICD-9-CM diagnosis codes for the

outpatient service and the inpatient admission.

“Often, we would have no exact match between the

symptom code that would be used on the outpatient

basis and the final diagnosis code that would be used on

the inpatient basis,” says Hoy. “The old rule was purely

based on the relationship of the codes. It was not based

on any clinical relationship.”

For example, a patient presents to the ED with a bro-

ken toe and undergoes an x-ray of the toe. The patient

sustains trauma as a result of a motor vehicle accident

and is admitted due to the trauma the same day.

Pursuant to the old rule (i.e., before June 25, 2010),

the ED visit would have been billed separately because

it’s nondiagnostic and unrelated to the admission,

says Hoy.

However, the x-ray for the broken toe would have

been bundled into the inpatient admission because it’s

diagnostic, and all diagnostic services were bundled,

regardless of whether they were related, she says.

The result would be the same if these services

occurred any time within the three-day window—not

only on the date of admission.

The old rule didn’t differentiate between the date of

admission and the three days prior to admission, Hoy

explains.

Recovery Auditors focus on three-day rule

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In with the new

After June 25, 2010, however, the rule changed and

became somewhat more complex in the process. From

this date forward, all diagnostic and nondiagnostic

services—regardless of whether they are related to an

admission—are subject to the rule when they occur on

the date of admission.

Services provided during the three days before admis-

sion are handled differently, however. All diagnostic

services provided during the three days before admission

are subject to the rule and must be bundled. Nondiag-

nostic services provided during the three days before

admission are bundled only if they are clinically related

to the admission.

Unlike in the past, when CMS based the relation

on an exact match of ICD-9-CM diagnosis codes, CMS

now defines related as being clinically associated with

the reason for a patient’s inpatient admission. CMS also

presumes that preadmission services are related to the

admission. Hospitals must affirmatively attest if the ser-

vices are not related.

CMS has instructed hospitals to bill unrelated non-

diagnostic services to Part B with condition code 51

(attestation of unrelated outpatient nondiagnostic

services) in the following situation:

➤ The service is clinically distinct or independent from

the reason for the inpatient admission

➤ Documentation in the medical record supports the

belief that the service is unrelated

In the previously described scenario, both the ED visit

and the x-ray are bundled in the inpatient admission be-

cause the new rule (i.e., effective June 25, 2010) bundles

all diagnostic and nondiagnostic services provided on the

date of admission, says Hoy.

However, coders must remember the new definition

of related because it determines whether a hospital will

bundle into an inpatient claim any outpatient nondiag-

nostic services subject to the rule that occur during the

three days before the admission, says Hoy.

For example, a patient presents with shortness of

breath (786.05) and chest pain (786.50) for an office

visit at a physician practice wholly owned or operated

by a hospital. The patient is admitted to the hospital that

owns the physician practice the next day and is diag-

nosed with myocardial infarction (410.xx).

Three-day ruleImportant facts every inpatient coder should know

The three-day payment rule, which defines certain pread-

mission services as inpatient operating costs, has implications

for inpatient coders.

Inpatient coders should remember the following details

pertaining to this rule:

➤ Outpatient services subject to the window

are paid as part of the inpatient DRG. These servic-

es are billed on the inpatient claim to report costs, explains

Kimberly Anderwood Hoy, JD, CPC, director of Medicare

and compliance at HCPro, Inc., in Danvers, Mass.

➤ Part A (inpatient) services are excluded from

the rule. This is true even when Part A services are per-

formed within the three-day window at the same hospital,

says Hoy. If a patient is readmitted to the hospital on the

same day as a prior admission, hospitals should combine the

admissions or report condition code B4 if the readmission is

unrelated to the prior one.

➤ Inpatient-only services provided on an out-

patient basis during the three-day window are ex-

cluded from the rule. “When there is an inpatient-only

procedure prior to an inpatient order, CMS has said it con-

siders the procedure non-covered when it was rendered,”

says Hoy. “Because it was noncovered when it was rendered,

it cannot be moved over and turned into a covered service

under the three-day payment window.”

Hospitals should bill the inpatient-only procedure on a

TOB 110 (inpatient non-covered) solely for internal processing

purposes at CMS, says Hoy.



Under the old rule, hospitals would have billed

the office visit separately from the admission because

the ICD-9-CM diagnosis codes didn’t match exactly

(i.e., the services weren’t related). Under the new rule,

hospitals should bundle the outpatient services into

the inpatient claim because they are clinically related,

says Hoy.

Beware of Recovery Auditors

Acknowledging the importance of this change,

Connolly will audit to ensure the following:

Before June 25, 2010

➤ Certain outpatient diagnostic revenue codes and non-

diagnostic revenue codes are not billed within three

days of an inpatient admission

June 25, 2010, and thereafter

➤ No outpatient claim exists on the date of inpatient

admission, regardless of diagnosis codes or revenue

codes

➤ All nondiagnostic outpatient charges subject to the

rule are not billed separately unless they are accom-

panied by condition code 51

➤ Diagnostic revenue codes are never billed on an out-

patient claim up to three days before an inpatient

admission

Hospitals should beware of the audit item related to

services billed before June 25, 2010, because Connolly’s

description of the issue may be erroneous, says Hoy. The

audit appears to include all nondiagnostic revenue codes.

However, bundling depends on the ICD-9-CM codes for

each case. Nondiagnostic revenue codes can and should

be separately billed before admission if diagnosis codes

for the service and the inpatient admission don’t match,

she says. n

Editor’s note: The information in this article was originally

presented during HCPro’s audio conference “Mastering the

Three-Day Payment Window.” To learn more or to purchase

an on-demand version of this audio conference, visit www.

hcmarketplace.com/prod-10185.

For more information about compliance with the

three-day payment rule, download HCPro’s white paper

at http://blogs.hcpro.com/revenuecycleinstitute/

wp- content/uploads/2012/04/2012-Three-day-rule.pdf.

➤ Conditions related to services subject to the

three-day payment window are considered POA.

Coders should code diagnoses for bundled services as POA

when they are present at the time of the admission order

even if they are not present at the time of outpatient regis-

tration, says Hoy. Refer to CMS’ August 9, 2012, Joint Signa-

ture Memo for more information.

➤ Abiding by the three-day payment rule can

shift a DRG. CMS has instructed providers to include

charges for all services identified as subject to the payment

window on the Part A inpatient claim for the admission,

says Hoy. This includes all charges, revenue codes, and

ICD-9-CM diagnosis and procedure codes. This requires

that coders convert CPT® codes to ICD-9-CM codes when

possible, she says. An ICD-9-CM code added to an inpa-

tient claim that is a CC or MCC could increase the DRG.

An ICD-9-CM procedure code added to the inpatient claim

that is surgical in nature could also change the DRG from

medical to surgical. DRGs frequently shift when patients

are admitted within three days of outpatient surgery due

to complications of the surgery. When converted to ICD-9-

CM codes, the claim includes inpatient surgical codes that

commonly shift the DRG from a medical DRG for the com-

plications, she says.

➤ Not all CPT codes have a corresponding ICD-

9-CM Volume 3 code. “There’s a very small number of

ICD-9 Volume 3 codes compared to CPT. That will not be

true when it comes to ICD-10,” says Hoy. Most CPT codes

will have an ICD-10-PCS equivalent, she says. “It will be

interesting to see what the direction will be in terms of con-

verting if we’ll only have to convert those codes that affect

the DRG.”



Malnutrition

New criteria could help ensure consistent codingNew clinical guidelines for malnutrition could help

alleviate compliance challenges associated with coding

the condition, which has never had universally accepted

clinical criteria.

New guidelines published in the May 2012 Journal

of the Academy of Nutrition and Dietetics, represent a con-

sensus statement of the American Academy of Nutrition

and Dietetics (the Academy) and the American Society

for Parental and Enteral Nutrition (ASPEN). The Acad-

emy and ASPEN both advocate for provider use of a

standardized set of diagnostic characteristics to identify

and document adult malnutrition, says Jane White,

professor emeritus in the department of family medi-

cine at the University of Tennessee in Knoxville. White

also serves as chair of the Academy’s adult malnutrition

work group. The Academy and ASPEN say malnutrition

should be diagnosed when at least two or more of the

following six characteristics are identified:

➤ Insufficient energy intake

➤ Weight loss

➤ Loss of muscle mass

➤ Loss of subcutaneous fat

➤ Localized or generalized fluid accumulation that may

sometimes mask weight loss

➤ Diminished functional status as measured by hand

grip strength

Providers must assess these six characteristics in the

context of an acute illness or injury, a chronic illness, or

social or environmental circumstances to determine if

malnutrition is present and whether it’s severe or non-

severe (moderate). The article, available at http://tinyurl.

com/ckbclxa, provides a table with more detailed clinical

criteria to which providers can refer when documenting

severity levels for malnutrition.

The Academy and ASPEN have asked the NCHS to

adopt ICD-9-CM malnutrition codes that use etiological-

based nomenclature, says White. If adopted, the ICD-9-CM

codes will better reflect the clinical presentations that pro-

viders encounter when assessing malnutrition, she says.

Don’t fall into a compliance trap

This all comes as good news for coders and providers

who continue to struggle with third-party audits of

CC and MCC conditions, including malnutrition, says

James S. Kennedy, MD, CCS, CDIP, managing

director at FTI Consulting in Atlanta.

One need not look far to discover the case involving

a Maryland hospital whose employees allegedly used

leading queries to add malnutrition as a secondary diag-

nosis. Good Samaritan Hospital in Baltimore denied the

accusations, but agreed to pay nearly $800,000 to resolve

the False Claims Act violation allegations, according to

a March 28 press release from the U.S. Department of

Justice, available at http://tinyurl.com/d4j6hqy.

“If patients had truly had malnutrition, it wouldn’t

have been as much of an issue,” says Kennedy. He attri-

butes incorrect malnutrition coding to a lack of consis-

tent clinical criteria and says that many CDI programs

also incorrectly define malnutrition solely on low albu-

min or prealbumin levels.

Another case involved Shasta Regional Medical

Center in Redding, Calif., which allegedly billed

Medicare for treatment of more than 1,000 cases

of kwashiorkor over a two-year period, according

to a California Watch analysis of state health data.

California Watch describes itself as “the largest group

of journalists dedicated to investigative reporting in the

state” on its website.

Kwashiorkor, a form of malnutrition that occurs

when a diet lacks sufficient protein, is very rare in the

United States, and is not something that coders encoun-

ter frequently, says Alice Zentner, RHIA, director of

auditing and education at TrustHCS in Springfield, Mo.

Physicians must specifically document the term “kwashior-

kor” for coders to report it, she says.



Although the ICD-9-CM index instructs coders to

report code 260 (kwashiorkor) for unspecified protein

malnutrition, Coding Clinic, Third Quarter 2009, p. 6

discourages assignment of this code when physicians

document moderate or mild protein malnutrition, says

Kennedy.

Rely on helpful strategies

Coders should remember and use the following

strategies:

➤ Don’t always assume documentation is correct.

It may seem counterintuitive, but coders should ques-

tion a diagnosis when it appears that no clinical evidence

supports it, says Kennedy. For example, physicians often

incorrectly diagnose malnutrition based solely on a low

albumin or prealbumin, he says. Third-party auditors will

challenge this diagnosis, and coders should also question

it, he says.

Coders must ensure that severe protein-calorie

malnutrition—an MCC—is documented consistently

and treated, says Zentner. “If that code is on a record, it’s

certainly a red flag for a RAC to audit,” she says.

Malnutrition must also meet the definition of a

reportable secondary diagnosis, says Zentner. Coders

should also remember not to report cachexia, a wasting

syndrome, as malnutrition—instead, cachexia is denoted

by a symptom code (799.4), she says.

Hospitals should develop policies that explain how

coders should address inconsistent and unreliable diag-

noses, says Kennedy. Unreliable diagnoses are those that

don’t meet reasonable criteria established by the medical

staff. Once identified, these diagnoses should be vetted

by a coding supervisor, physician advisor, or CDI special-

ist, he says.

➤ Beware of leading queries. A malnutrition

diagnosis often may not be documented when a patient

does, indeed, have the condition. However, as the Good

Samaritan Hospital case demonstrates, coders must be

certain that they don’t lead physicians when requesting

clarification, says Kennedy. “We are allowed, as coders,

to ask providers for the clinical significance of abnormal

labs or clinical findings,” he says. Consider the following

query based on the new criteria from the Academy

and ASPEN:

The following clinical indicators are in the medical record:

➤ Current BMI _____

➤ Stress indicator – Acute illness – Chronic illness – Social

➤ Energy intake over the previous ___ days ___%

➤ Amount of weight loss over ___ days ____%

➤ Loss of subcutaneous fat (circled)

– None – Mild – Moderate – Severe

➤ Loss of muscle mass (circled)


➤ Fluid accumulation (circled)


➤ Measurably reduced grip strength present – Yes – No

Please indicate what diagnosis best correlates with these

findings:

➤ Cachexia without malnutrition

➤ Nutritional risk without malnutrition

➤ Malnutrition, severity unknown

➤ Malnutrition, non-severe (moderate)

➤ Malnutrition, severe, not otherwise specified

➤ Marasmus – A specified severe protein-calorie malnutrition

➤ Kwashiorkor – A specified severe protein malnutrition

➤ Another medical diagnosis

➤ Other (please specify)

➤ Cannot be determined

Other clinical evidence in the record that might sug-

gest malnutrition includes chronic disease, insufficient

intake pre- or postoperatively, infection, malabsorption,

muscle wasting, poor wound healing, or lethargy, says

Zentner.

➤ Work with CDI specialists. Ask CDI special-

ists to educate physicians about malnutrition clinical

indicators, advises Kennedy. Also advocate for pre-

discharge queries. “The query for malnutrition is really

best done in a pre-discharge environment in collabo-

ration with dietitians, nutritional teams, and the CDI

team,” he says. n



by Robert S. Gold, MD

Let me explain the digestion process.

People intake foods, solids, and liq-

uids that occasionally mix with gases. The

contents traverse the esophagus and enter the stomach

where they encounter acid. The stomach churns the food

and liquid with acid and peptic juices and prepares it for

the duodenum. There, bile juices and pancreatic chemi-

cals emulsify the fat. They also break down proteins into

amino acids and complex sugars into simple sugars for

subsequent absorption in the jejunum and ileum. The

residue moves through a 24-foot tunnel before it arrives in

the large intestine where bacteria breaks it down and dries

it out by absorption. Finally, the body excretes the waste.

This entire process of transit is called peristalsis.

During normal peristalsis, the intestinal wall muscles

narrow and lengthen periodically. However, the intesti-

nal tract may suffer from many diseases that can inter-

rupt this process.

This column addresses the topic of ileus, which is de-

rived from the Greek term for “twisted.” An ileus caused

by a length of bowel that is twisted on its mesentery can

cause twisting of the veins that drain the length of bowel

as well as the arteries that supply that bowel. The length

of bowel supplied by that artery and vein can die, and

the twisting causes an obstruction that stops the progres-

sion of food through the gastrointestinal tract.

Mechanical ileus

A mechanical ileus (i.e., mechanical obstruction)

occurs when a physical blockage impedes flow. A nickel

swallowed by a patient could become stuck in a portion

of the intestinal tract that is smaller in diameter than the

coin (e.g., the pylorus, a passage from the stomach to the

duodenum, or the ileocecal valve).

A foreign body of sufficient size can cause a mechani-

cal obstruction. A tumor, whether a benign polyp or

malignant neoplasm that grows large enough, can also

block intestinal flow. Herniation of a length of intestine

through a defect in the abdominal wall (e.g., umbilical

hernia, inguinal hernia, or paraesophageal hiatal hernia)

also can block intestinal flow. Herniation through a

defect in the fastening of the mesentery inside the

abdomen (e.g., paraduodenal fossa hernia or Ladd’s

bands) can also lead to intestinal blockage.

Blockage can occur when a length of intestine be-

comes twisted. This occurs with volvulus of the sigmoid,

volvulus of the cecum, and adhesions between loops

of intestine. Intussusception, which occurs when one

portion of the bowel slides into the next, can also cause

obstruction. Cystic fibrosis may lead to mechanical ob-

struction with excessively thick meconium in the bowel

of the newborn.

Intestinal content above the area of blockage con-

tinues to become backed up to the point at which the

patient begins vomiting. The vomitus is usually foul

smelling in nature. Mechanical ileuses are treated surgi-

cally, which usually leads to a total resolution of the

problem. This is true even if a portion of the bowel has

become gangrenous.

Coders should identify each cause of intestinal

obstruction with the most precise code possible.

Occasionally, physicians identify a partial small bowel

obstruction due to adhesions from prior surgery. Many

of these cases resolve spontaneously with bowel rest.

If they don’t resolve, physicians must explore the

bowel and cut or cauterize adhesions to restore normal

anatomy.

Paralytic ileus

A paralytic ileus occurs when a lack of synchronized

peristalsis occurs in the absence of a physical blockage.

Viral or bacterial infections in the gastrointestinal tract

usually lead to hypermotility, which often results in diar-

rhea. However, infection in the abdominal cavity around

Pondering causes of mechanical, paralytic ileuses



the intestines can also lead to cessation of neuromuscu-

lar coordinated activity and no movement of intestinal

content. For example, paralysis can occur when patients

undergoing peritoneal dialysis have infected ascites.

It can also occur in patients with pelvic or abdominal

abscesses from a perforated bowel. Those with pelvic

inflammatory disease or benign spontaneous peritonitis

can experience the same problem.

If an area of the intestine loses some of its blood sup-

ply or venous drainage due to atherosclerosis or portal

venous hypertension, peristaltic activity in that area of

the bowel may cease. Irritation of the outer peritoneal

lining of the intestine due to any cause often results in

paralysis of that segment of bowel. This can happen in

patients with pancreatitis when digestive enzymes are

released into the abdomen. It can also occur in conjunc-

tion with abdominal surgery. Each of these scenarios

causes cessation of intestinal motility in the area of neu-

romuscular function disturbance, and the entire bowel

swells in size.

Some localized paralyses may occur. For example,

this can occur in newborns with Hirschsprung’s disease

(in which parts of the nervous system in the wall of the

large intestine are missing). It may also occur in bed-

bound patients with chronic constipation that can lead to

Ogilvie syndrome (pseudo obstruction).

Coders must always look for the cause of a paralytic

ileus prior to coding. A physiologic paralytic ileus can

occur after abdominal surgery when a patient has

no other bowel-related problems. Patients receive no

sustenance by mouth until bowel sounds are heard or

the patient passes flatus.

However, when an abnormal process in the abdomi-

nal cavity leads to surgery (e.g., appendicitis, diverticu-

litis, or cholecystitis), the patient invariably had an ileus

going into surgery. Thus, the patient would naturally

have one after the surgery as well. Depending on the

severity of the inflammatory response, it could conceiv-

ably take as long as one week for the bowel to resume

function. When this occurs, the ileus is caused by the

disease—not by the surgery.

However, if the surgery led to further problems with

the intestines (e.g., anastomotic leak or spillage and con-

tamination of the peritoneal cavity that didn’t exist prior

to surgery), then a prolonged ileus could be a complica-

tion of the operation itself.

Not every ileus warrants assignment of a code. For

example, an ileus that doesn’t prolong a patient’s hospi-

tal stay beyond the average length of stay isn’t codeable,

even when documented as a postoperative ileus. This

reflects the physiologic ileus that follows every abdomi-

nal surgery and is part of the recovery. It’s not codeable.

However, if the postoperative ileus causes vomit-

ing, or the patient required insertion of a nasogastric

tube, coders may be able to report it. Coders can also

assign a code for an ileus that is prolonged due to a

disease or due to surgery for the condition that caused

the ileus. However, this code should not be a compli-

cation code because the ileus is not a complication of

the surgery.

If the late resumption in bowel activity is due to

overuse of pain medication, report a code for the ileus as

well as an E code for the adverse effect of the opiates or

whatever pain medication led to the ileus.

Finally, if the prolonged ileus occurs due to a complica-

tion of surgery (e.g., a leak), assign a complication code.

When the physician cannot determine the cause of

the ileus, also consider a complication code if the patient

starts vomiting, has had a nasogastric tube inserted, or

can’t resume eating for five or more days after surgery

when all other causes for these symptoms have been

ruled out. n

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting

firm in Atlanta that provides physician-to-physician CDI pro-

grams. Contact him at 770-216-9691 or [email protected].

Contact Contributing Editor Lisa Eramo

Telephone 401-780-6789

Email [email protected]

Questions? Comments? Ideas?



Emphasize importance of history of present illnessInpatient coders don’t typically assign E/M codes, but

they should be aware of documentation of the history of

present illness (HPI).

Why? The same documentation that affects the E/M

level generally also potentially affects clinical valida-

tion of ICD-9-CM code assignment, says Glenn Krauss,

BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an in-

dependent HIM consultant in Madison, Wis. The HPI, in

particular, helps justify a patient’s acuity and reason for

admission to the hospital, he explains.

The HPI should always include a detailed descrip-

tion of the nature of a patient’s presenting problem and

any of the eight elements of the HPI, including location,

quality, severity, duration, timing, context, modifying

factors, and associated signs and symptoms, says Krauss.

Without this information, hospitals will inevitably face

denials from third-party auditors who typically review

the ED note, history and physical, and discharge summa-

ry—and not the entire record—when auditing, he says.

“RAC contractors are making up their minds before they

even go any further. They have a tendency to prejudge the

case based on what they read right away,” he says.

Emphasize the importance of the HPI

CDI specialists and coders who discuss the importance

of the HPI with physicians should address its true mean-

ing. Ensure physicians understand that the HPI repre-

sents present illness with an emphasis on the severity

of signs and symptoms obtained from an interview and

historical inventory of a patient. Historical inventory is a

patient’s account of the presenting problem obtained via

the physician-patient interview process. Physicians often

include an extensive discussion of past history but fail to

provide sufficient emphasis on the current situation. This

detracts from the more relevant reporting of a patient’s

presenting severity of illness, signs, and symptoms, and

the physician effort required to help the patient.

The HPI should provide a clear and concise descrip-

tion of the nature of the presenting problem. A deficient

HPI frequently leads to an E/M assignment that denotes

a lower level than that which was provided. The physi-

cian simply failed to adequately demonstrate the current

acuity of the patient and the different body areas/organ

systems potentially affected by the current complaint.

Failure to provide an adequate, clinically relevant, and

appropriate HPI can affect coding for subsequent hospital

visits. Initial hospitalization E/M code sets require that

documentation meets all three E/M components—

history, physical, and medical decision-making. Subse-

quent hospitalization codes require only two of these

three components. An HPI that is insufficient to the

extent that documentation doesn’t support even the

lowest-level history component precludes using history

as one of the two key components required for E/M

assignment under subsequent hospitalization code sets.

Failure to provide an adequate HPI as part of history

calls into question the medical necessity for ordering

related diagnostic testing and therapeutic interventions

and the medical necessity for the physician service. Lack

of an adequate HPI limits the usefulness of the record.

Coders must remember that physician E/M services are

subject to medical necessity provisions similar to all other

Medicare beneficiary services ordered and provided. n

Editor’s note: This article was adapted from The Documen-

tation Improvement Guide to Physician E/M, published

by HCPro, Inc., and authored by Krauss. For more information,

visit http://tinyurl.com/crjq6by.

Upcoming eventJuly 10—Observation Services 2012: Build an Audit

Defense, Obtain Appropriate Reimbursement, featuring

Deborah K. Hale, CCS, CCDS, president of Administra-

tive Consultant Service, LLC, in Shawnee, Okla.

To register or for more information, call 800-650-6787

or visit www.hcmarketplace.com and mention source

code NEWSAD.

July 2012

A monthly service of Briefings on Coding Compliance Strategies

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Contributing Editor Lisa Eramo at [email protected].

Editor’s note: Answers to the following questions are

based on limited information submitted to Briefings on

Coding Compliance Strategies. Review all documenta-

tion specific to your scenario before determining appropriate

code assignment.

Recently, reviewers have denied diagnostic code

584.9 (acute renal failure [ARF]) based on laboratory

values. The diagnosis is well documented and treated by

the attending physician, but reviewers say the

laboratory values do not support the diagnosis of ARF.

The laboratory values (creatinine/BUN) progressed

from normal to abnormal, and we found no defini-

tive standards for laboratory parameters to meet the

definition of ARF.

In accordance with coding guidelines for reporting

secondary diagnoses, ARF was clinically evaluated,

the patient underwent therapeutic and diagnostic

procedures, and there was an extended length of

stay/increased nursing care. As coders, we think

that questioning the physician’s clinical judgment is

inappropriate and that reporting ARF as a secondary

diagnosis is correct. Based on documentation in the

record, is coding ARF appropriate?

From a coding perspective, I agree that you should

assign the code if the treating physician clearly

documented ARF and met the criteria of clinically

evaluating and/or treating this condition during an

admission in accordance with the UHDDS definition of

“other/additional diagnosis.” Coders should not debate

clinical scenarios with physicians (e.g., whether a patient

had a condition).

Others have described scenarios similar to the one

posed in your question (e.g., a payer deems a single CC

or MCC not supported clinically despite clear documen-

tation in the medical record). This can be frustrating for

hospitals. Payers that do this negate the MS-DRG logic

that a patient only needs one diagnosis designated as a

CC/MCC for assignment to that MS-DRG.

Exploring cases that involve patients with single CCs or

MCCs makes financial sense for payers because it affects

overall reimbursement. As such, documentation and clini-

cal indicators in the medical record should clearly support

the reported diagnoses to justify code assignment. I do

not know whether your organization has a documentation

improvement program, but I see an opportunity for poten-

tial documentation improvement efforts to assist in these

situations.

RIFLE criteria are helpful with respect to understand-

ing clinical definitions of acute renal failure:

➤ Risk—Increase in serum creatinine level X 1.5 or

decrease in GFR by 25%, or UO < 0.5 mL/kg/h

for six hours; Cr rise of 0.3 mg in appropriate

circumstance

➤ Injury—Increase in serum creatinine level X 2.0 or

decrease in GFR by 50%, or UO < 0.5 mL/kg/h for

12 hours

➤ Failure—Increase in serum creatinine level X 3.0,

decrease in GFR by 75%, or serum creatinine

level > 4 mg/dL; UO < 0.3 mL/kg/h for 24 hours, or

anuria for 12 hours

➤ Loss—Persistent ARF, complete loss of function >

four weeks

➤ End-stage kidney disease—Loss of function >

three months

A supplement to Briefings on Coding Compliance Strategies

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2012 HCPro, Inc., Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2012 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

The criteria do not merely progress from normal to abnor-

mal; other factors in the laboratory values also play a role.

Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I,

CEMC, CCDS, director of HIM and coding at HCPro, Inc.,

in Danvers, Mass., answered this question, which originally

appeared on JustCoding.com.

Which code should I report for atypical small

acinar proliferation of the prostate? Is ICD-9-CM

code 602.3 (dysplasia of prostate) appropriate?

The ICD-9-CM index does not include a reference for

this diagnostic statement. Submit a query regarding

the clinical significance of the statement, referencing

602.3 and including its description. Provide the following

information in your query:

➤ Clinical indicators, as advised in AHIMA’s practice

brief, “Managing an Effective Query Process”

➤ The diagnosis

➤ Request for clarification that indicates the lack of a

diagnosis code for this diagnosis

Ask which of the following best describes the patient’s

condition:

➤ Dysplasia of prostate

➤ Neoplasm of prostate—if so, is neoplasm:

– Malignant, primary

– Malignant, secondary

– Malignant, in situ

– Benign

– Undetermined

– Unspecified

➤ Other diagnosis regarding atypical small acinar prolif-

eration of the prostate (please specify) _______

➤ Unable to be determined

Jean Stone, RHIT, CCS, coding manager at Lucile

Packard Children’s Hospital at Stanford in Palo Alto, Calif.,

answered the previous question.

A patient is admitted January 3 and undergoes spi-

nal surgery that day. No laboratory specimens were

drawn until January 4. At that time, the BUN was 24

(normal range is 8–20), and creatinine was 2.09 (normal

range is 0.64–1.27). A consultation was performed

January 4, and the physician documented acute renal

failure. What is the correct POA assignment?

Query the physician to determine whether acute

renal failure was POA. Appendix I of the ICD-9-CM

Official Guidelines for Coding and Reporting (POA

Reporting Guidelines) indicates that a query is appropri-

ate if documentation is unclear regarding whether a

condition was POA. The provider should clarify the link-

age of signs and symptoms to the acute renal failure,

the timing of test results, and the timing of findings.

Laura Legg, RHIT, CCS, revenue control coding con-

sultant at Providence Health & Services in Renton, Wash.,

answered the previous question.

BCCS, P.O. Box 3049, Peabody, MA 01961-3049 • Telephone 781-639-1872 • Fax 781-639-7857

Are you an inpatient codingand compliance expert?

Do you enjoy researching inpatient-related coding questions? Do you stay up to date on Medicare transmittals and publications? If you answered “yes” to either question, you’d be a great addition to the Briefings on Coding Compliance Strategies editorial advisory board. Or perhaps you’d simply like to share your insight and experiences. If you’re inter-ested in either opportunity, contact Contributing Editor Lisa Eramo at [email protected].

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