what to expect when coding cad, mi with icd-10-cm · what to expect when coding cad, mi with...
TRANSCRIPT
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
© 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.
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.”
Page 4 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.
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
July 2012 Briefings on Coding Compliance Strategies Page 5
© 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.
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
❑ Start my subscription to BCCS immediately.
Options No.ofissues Cost Shipping Total
❑ Electronic 12 issues $249 (CCSE) N/A
❑ Print & Electronic 12 issues of each $249 (CCSPE) $24.00
Salestax (see tax information below)*
Grandtotal
BCCS SubscriberServicesCoupon Yoursourcecode:N0001
Name
Title
Organization
Address
City State ZIP
Phone Fax
Emailaddress(Requiredforelectronicsubscriptions)
❑ Payment enclosed. ❑ Please bill me.❑ Please bill my organization using PO # ❑ Charge my: ❑ AmEx ❑ MasterCard ❑ VISA ❑ Discover
Signature(Required for authorization)
Card # Expires(Your credit card bill will reflect a charge from HCPro, the publisher of BCCS.)
Orderonlineatwww.hcmarketplace.com.
BesuretoentersourcecodeN0001atcheckout!
Mail to: HCPro,P.O. Box 3049, Peabody, MA 01961-3049 Tel: 800-650-6787 Fax: 800-639-8511 Email: [email protected] Web: www.hcmarketplace.com
Fordiscountbulkrates,calltoll-freeat888-209-6554.
*TaxInformationPlease include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR.
Page 6 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.
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.
July 2012 Briefings on Coding Compliance Strategies Page 7
© 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.
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.”
Page 8 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.
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.
July 2012 Briefings on Coding Compliance Strategies Page 9
© 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.
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)
– None – Mild – Moderate – Severe
➤ Fluid accumulation (circled)
– None – Mild – Moderate – Severe
➤ 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
Page 10 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.
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
July 2012 Briefings on Coding Compliance Strategies Page 11
© 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.
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?
Page 12 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.
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].