Accuracy in Diagnosis and Coding What Physicians Need to Know

Transcription

1 1 Accuracy in Diagnosis and Coding What Physicians Need to Know Presenter: Karl N. Hanson MD The information contained within this presentation is the Peoples Health interpretation of the ICD-9-CM Coding Guidelines. Each healthcare provider is ultimately responsible for independently reviewing, applying and meeting the guidelines. Welcome to this Peoples Health Network presentation for primary care physicians entitled Accuracy in Diagnosis and Coding What Physicians Need to Know. My name is Karl Hanson. I m a Family Medicine physician in Kenner, Louisiana and a Board member of PHN. The purpose of this presentation is to provide you with keys to help you document and code accurately, completely and efficiently. Our major focus will be on precision in documenting diagnosis. 2 Benefits Improves patient outcomes Enables quality improvement initiatives Promotes continuity of care Ensures correct and accurate reimbursement Accurate coding and documentation are important for several reasons: First, it s an issue of patient safety. An illegible, incomplete, imprecise medical record poses the risk of misinterpretation and medical error. A medical record with precise and complete documentation will promote better patient outcomes and continuity of care. It can help reduce fragmentation of care between multiple healthcare providers and across care settings. Second, accurate encounter data from claims can also be used for quality improvement purposes, to develop initiatives in patient care such as disease management programs. Third, accurate documentation and coding serves to justify the services, which are billed and reimbursed. If a condition is not reported or is not coded accurately, the Medicare reimbursement may be reduced accordingly. Likewise, coding without having a supporting diagnosis in the chart note can lead to overpayment and risk for both plan and provider. 3 Additional Benefits 1

2 Promotes good record-keeping in advance of Medicare audits (RAC, HEAT, RADV) Prepares for ICD-10 code change Accurate documentation and coding also promote appropriate record-keeping, which helps your practice build a more thorough record database for Medicare audits. These include Recovery Audit Contractor (RAC) audits, Healthcare Fraud Prevention and Enforcement Action Team (HEAT) audits and Risk Adjustment Data Validation (RADV) audits. Lastly, developing accurate documentation and coding practices now can help offices prepare for the implementation of ICD-10 codes, which are more detail-driven. 4 Basics All medical record entries and forms should: Be LEGIBLE Document conditions evaluated, diagnosis, assessment and plan of care Identify patient s name, DOB or unique identifier Identify date(s) of service Have provider s name, signature and credentials There are 5 basic points to keep in mind when documenting and coding. Each entry in the medical record should encompass the following: Be written legibly for all readers. clearly document the conditions evaluated, the diagnosis, the assessment and plan of care. identify the patient s name, date of birth or other unique identifier on each page of the documentation. identify the date of service and the provider s name, signature and credentials. If you are using an electronic medical record, the electronic signature you use must be authenticated and password-protected. 5 SOAP NOTES S O Physicians are encouraged to use a consistent format for documenting in the chart such as the Problem Oriented Medical Record (POMR) or the SOAP format. In this discussion we will follow the SOAP 2

3 A P format. SOAP is a tool that promotes sharper thinking and clearer documentation in the medical record. SOAP is an acronym for Subjective Objective Assessment Plan 6 S/SUBJECTIVE Documents the CC, HPI, ROS and History Reason for visit: follow up with a circle and a slash across it. Reason for visit: Refill meds with a circle and a slash across it. Reason for visit: diabetes management; refill medications. Let s look at these one at a time. Subjective data are what your patient perceives and tells you. It s the patient s reason for today s visit or the chief complaint. It includes history of present illness; complications or co-morbidities; review of symptoms; and past medical, family and social history. Be specific when documenting the reason for the visit or chief complaint. An example of documentation that is not sufficient would be follow-up. Follow up on what? Similarly, refill meds is not sufficient. Meds for what condition? You can make this documentation complete by writing, quite economically, Reason for visit: diabetes management; refill medications; follow up for chronic conditions. 7 O/OBJECTIVE Documents the patient s vitals, physical exam and results of diagnostic tests Cholesterol level remains mildly elevated, continue statin therapy for dyslipidemia. Objective data include your observations, measurements, test results and physical findings. When noting test results, it s important to indicate the clinical significance or impact of the results on your diagnosis or decisions based on those results. 3

4 8 A/ASSESSMENT S+O=A COPD is the diagnosis; stable on fluticasone/salmeterol inhaler is the assessment. The assessment portion of your documentation should include your determination of the patient s condition based on the information you collected from your subjective and objective observations. For example, if you determine the patient has a diagnosis of COPD, your assessment may be that the patient is stable on their fluticasone inhaler regimen for managing their COPD. An important point to remember is that the assessment must include your diagnosis. You might ask, isn t it sufficient that COPD is documented previously in the record? The answer is no. The diagnosis must be noted at each encounter or visit where it is assessed or treated. It explains the reason for the treatment. You might ask, must I code for every diagnosis at every visit? The answer is no, code only for those diagnoses that you are addressing on that particular visit, or those that affect patient care, treatment or management. You may only code the diagnoses for an encounters that are explicitly documented in the chart notes for that encounter. Be sure to spell out the diagnosis in your assessment. Using ICD-9-CM codes in lieu of a diagnosis is not acceptable for documentation purposes. 9 P/PLAN Documents the plan of care Treatment plan may include referrals, testing ordered, medications, patient education, expected outcomes, next scheduled appointment or conditions for return visit A/P: HTN, worsened, increase Now that you have assessed the patient, the next step is to clearly document your plan of care for the patient. This may include information on referrals, testing ordered, medications, patient education, and expected outcomes. It should include the patient s next scheduled appointment or conditions for which the patient should come in for a follow-up appointment. Your documentation of the plan need not be lengthy. 4

5 metoprolol. For example, for a patient with worsening hypertension, you would indicate as part of their plan, hypertension, worsened, increase metoprolol. 10 Assess Chronic Conditions Assessment Stable Improved Tolerating meds Deteriorating Plan Monitor D/C med Continue current meds Refer Your patient s chronic conditions should be assessed at least annually. You may find it helpful to review the patient s medication list and the corresponding diagnosis for each of their medications to ensure you reassess all chronic conditions. This reassessment need not be lengthy. You may use descriptors like stable, improved, tolerating meds or deteriorating. For documentation of the plan of care, you may use action verbs such as monitor, discontinue medications, continue current medications or refer. Please note, every time you order or refill medications or durable medical equipment for a chronic condition, the condition can be assessed and documented. 11 Diagnostic Precision in Coding After documenting the status of the patient s condition, the main point to remember is to diagnose and code to the highest level of specificity. Centers for Medicare & Medicaid Services coding changes website link: viderdiagnosticcodes/index.html This should be done for all presently known or managed conditions that will affect the patient s care coordination or treatment at the time of the visit. Let s look at some general practices that will improve the specificity, completeness and accuracy of your diagnosis. Coding changes, based on mandates from the government, are effective each year on October first. Code changes are available at the CMS website. 5 If you use electronic medical record (EMR) software, make sure your software is updated to ensure you

6 are not using deleted codes and that any new or revised codes are reflected. 12 Incorrect Coding Diabetes mellitus Ulcer, Foot or Correct Coding Diabetes w/ Unspecified Manifestation Ulcer, Foot Here is an example of coding the diagnosis more specifically. Your patient presents for follow-up to manage a diabetic foot ulcer. If you use the code for uncomplicated diabetes and the foot ulcer, they appear to be unrelated. Accuracy of the diagnosis is lost. The most accurate diagnosis and the best code relates the foot ulcer to its underlying cause, diabetes. Therefore, diabetes with Unspecified manifestation and the foot ulcer is the more accurate code for the diagnosis. 13 CC: 75-year-old female for follow-up of CAD and CHF, morbid obesity, past MI. A/P: CAD controlled, monitor; CHF, continue furosemide, order chest X-ray; NSTEMI, November 2010, patient encouraged to exercise, avoid tobacco and rest as needed; morbid obesity, diet and exercise as discussed. Find the Incorrect Code Correct Codes Here is another example. Your patient presents for follow-up to manage coronary artery disease and congestive heart failure, with a previous myocardial infarction in The patient is also morbidly obese. She reports that she is feeling OK at the present time. Your assessment is that her CAD and CHF are under control. You order a chest radiograph and continue her diuretic. You advise her to increase her activity, avoid tobacco, and you discuss dieting strategies. CAD CHF Morbid Obesity- 278 NSTEMI CAD CHF Morbid Obesity Old MI-412 You diagnose and code for the Coronary Artery Disease, the Congestive Heart Failure, and the morbid obesity. So far so good. What about the old Non-ST Elevation Myocardial Infarction. Is there a problem? Yes. When you diagnose and code for NSTEMI, it appears to be a current MI, which is not true. The more precise ICD-9 code is old MI (412). The right code takes up no more space than the wrong one. Note: the diagnosis was correct, the coding was not. 6

7 14 Coding Example CC: Patient c/o increased SOB and coughing, presents with poorly controlled DMII, and erectile dysfunction due to diabetes. Chronic asthma with COPD with occasional flareups. A/P: Asthma with COPD, refill albuterol; S/P CVA with residual hemiparesis, continue warfarin; diabetes w/neurologic manifestation, ED due to diabetes, continue tadalafil as needed. Side effects reviewed. Find the Incorrect Code Correct Codes In the next example, the patient is experiencing shortness of breath and poorly controlled type 2 diabetes, as well as erectile dysfunction as a complication of diabetes. Your Assessment and Plan is asthma with COPD, refill albuterol; past CVA with hemiparesis, continue warfarin. Erectile dysfunction due to diabetes, continue tadalafil as needed. If testing has been done and you can be more specific as to ED due to vascular or neurological manifestations, you should use the correct diabetes with manifestation code. Notice that coding and diagnosing Asthma and COPD separately is not as accurate as the correct diagnosis, asthma with COPD, accurately reflecting a greater severity. Asthma COPD 496 CVA Hemiparesis Erectile Dysfunction Asthma w/copd Hemiparesis (Dominant Side) Due to Old CVA Erectile Dysfunction Likewise, the code for plain CVA is incorrect because it would mean the CVA is acute. The plain hemiparesis code does not indicate that it is due to the stroke. So the correct code is the one that links the two: hemiparesis due to old CVA. The code for plain erectile dysfunction means erectile dysfunction of organic origin. If you add diabetes, you have now indicated the cause. Diabetes w/other specified manifestation Link Test Results to the Diagnosis Now that we ve had an overview of coding and 7

8 Example: Spinal x-rays confirm osteoarthritis and osteoporosis. Initiate bisphosphonate therapy. Document also: Significance of test results Diagnosis as result of tests How results affected plan of care documentation, let s look at some general practices that will improve the accuracy of your documentation. Results from lab or radiology testing should be documented in the patient s medical record and linked explicitly to the diagnosis. It is not sufficient to date and initial the test results. It is not sufficient to place a copy of the results in the chart. You must also document the clinical significance of the test results, state the diagnosis you have identified from the results, and how the results affected the plan of care. Once again this may be brief and to the point. An example is Spinal x-rays confirm osteoarthritis and osteoporosis. Initiate bisphosphonate therapy. 16 Abbreviations: Use Only Standard Abbreviations and Use Sparingly Use only standard abbreviations based on ICD-9 guidelines Examples of abbreviations that cloud intent: LBP, continue treatment OP, continue treatment 17 Symbols are Not Diagnoses The diagnosis must be written out. BP cannot be coded as hypertension lipids cannot be coded as hyperlipidemia A basic rule of documentation is to use only standard abbreviations, as defined in ICD-9 guidelines. Nonstandard abbreviations create confusion and possible error. For example, if the chart note lists LBP, continue treatment, is it lower back pain or low blood pressure? If a note reads, OP, continue treatment does it mean osteoporosis or osteopenia? As a general rule, it s a good idea to keep even standard abbreviations to a minimum. Symbols are convenient as shorthand, but they should not be used in place of a diagnosis when you document. In these examples, the arrow symbol cannot be used to support coding for hypertension or hyperlipidemia. Increased BP with an arrow would indicate only a transient increase in blood pressure. Increased lipids with an arrow can only be coded as abnormal lab result. Diagnoses must be written out. 8

9 18 History Of Under ICD-9 guidelines, history of means the patient no longer has the condition. Do not use h/o CHF to indicate compensated CHF Or h/o A Fib to mean A Fib controlled with meds Or h/o COPD to mean COPD controlled with fluticasone Another documentation issue is the use of the phrase history of. According to ICD-9 guidelines, history of means the patient no longer has the condition. Physicians should never use this term to describe an active or chronic disease. It s inaccurate and it contradicts coding guidelines. Examples of inappropriate use include: history of congestive heart failure when it is actually compensated CHF, or history of atrial fibrillation when it is really A Fib controlled with medications. These conditions didn t go away, they are under control with appropriate therapy. So you can test yourself by asking If I took the meds away, would the condition come back? If the answer is yes, then don t use history of. 19 Qualifying Language If documentation indicates any of the following, the condition cannot be coded, as it does not confirm a diagnosis. Code the symptom. Rule out Probable Suggestive of Consistent with 20 Provide an Explicit Diagnosis If you don t document the disease or diagnosis by name, you can t code for it Note that qualifying language does not provide confirmation of a diagnosis. Qualifiers include phrases such as rule out, probable, suggestive of or consistent with. When qualifying language is used in documentation, you may only code for the symptoms until the diagnosis is confirmed. For example, if a patient comes in with chest pain but you want to conduct testing to confirm the diagnosis for the pain, for that visit you can code for chest pain and document what you believe the chest pain is suggestive of. However, you may not code for the diagnosis you believe the pain is suggestive of until you receive the results from the testing. Provide an explicit diagnosis in your documentation. There are 2 reasons for doing this: 1) for accurate diagnosis and 2) because an explicit diagnosis is needed to support the codes you submit on your 9

10 on the claim. Example: Claim encounter code: (HTN) Sole supporting documentation: BP 155/87. ICD-9-CM code could not be validated because diagnosis is not stated and there is no assessment. claims. If your documentation includes notes about signs, symptoms or findings related to the patient s disease but does not include a note that defines the actual disease or diagnosis the code for that diagnosis cannot be validated during an audit. It is not enough that the diagnosis may be inferred by the reader; the documentation must spell out the diagnosis and indicate that it was assessed on that date of service. 21 Document Causal Relationships Which one accomplishes this? Example 1-1. DM Peripheral neuropathy CKD stage lll Example 2-1. Diabetic peripheral neuropathy ( and 357.2) 2. CKD stage lll due to DM ( and 585.3) For greater accuracy in diagnosis and coding, it s essential to capture causal relationships. If you document the diabetes, peripheral neuropathy and stage III chronic kidney disease as separate items, as shown in example 1, each code will be assigned separately and it will appear that these diagnoses are not related. If they are in fact related, then the documentation and coding in example 1 is not a complete picture. The revised documentation in example 2 reflects the relationships among the conditions and provides a more complete description of the patient s health. 22 Abnormal Findings Chart note states BMI = 41 Next let s explore a few specific evaluation scenarios of abnormal findings and how to document them appropriately. Incorrect Coding Morbid obesity Correct Coding Morbid obesity V BMI First consider documentation for results considered higher than the norm, such as someone with a BMI that places them in the morbidly obese range. In this example, the chart note states only BMI = 41. This documentation is only sufficient to support a code for that BMI measurement range. It is not sufficient to support a code of for morbid 10

11 Code Morbid Obesity alone Incorrect! Not supported in documentation. Must document both the clinical significance of the BMI score and the care rendered. A/P: BMI = 41, morbidly obese, discussed risk and need for diet and exercise obesity. Accurate documentation requires chart notes that explain the clinical significance of the BMI score (that is, morbid obesity); and the plan of care developed in this case, that risk and the need for diet or exercise were discussed with the patient. 23 Is the Condition Acute or Chronic? These examples have 3 different coding choices: Bronchitis 490 Unspecified Acute Chronic Hepatitis C Unspecified Acute Chronic Respiratory Insufficiency Acute Chronic Acute or chronic presentations of a condition represent 2 different diagnoses which may require different treatments, and different ICD-9 codes. Select the code that accurately reflects acute or chronic. To ensure accurate diagnosis and coding for these conditions, document to the highest level of specificity. In these examples, the unspecified code should only be used if the condition cannot be specified as acute or chronic. 24 Commonly Overlooked Diagnoses: Amputation Status BKA V49.75 AKA V49.76 Foot V49.73 Toe V49.71 or V49.72 Reason for visit should include management of chronic conditions Example: A/P: R BKA, well-healed, review fall risk, monitor There are also some diagnoses that may be overlooked when documenting a patient visit, such as amputation status. Although these conditions may come to be viewed as the norm for the patient, they are often high risk and require ongoing care management. They should continue to be evaluated, documented and coded at least annually. The assessment of these conditions and the plan of care should be documented in the notes and coded for the visit, as well as the reason for the visit. The reason for visit should include management of chronic conditions. An example would be 11

12 Assessment/Plan: Right Below the Knee amputation, well-healed, discuss fall risk, monitor. 25 Commonly Overlooked Diagnoses: Artificial Openings Gastrostomy V44.1 Colostomy V44.3 Tracheostomy V44.0 Ileostomy V44.2 CC: F/U Diabetes mellitus type 2 and HTN. History of colon cancer and a colostomy. Exam: Ostomy site looks good, no sign of infection. A1c = 7.0. Pt in need of ostomy supplies. A/P: Diabetes, continue metformin, pt encouraged to follow diet; HTN, stable on amlodipine; History of colon CA, no signs of recurrence; Colostomy, continue to clean site regularly, submit auth for ostomy supplies. Another commonly overlooked diagnosis is the presence of artificial openings. This example describes a patient who has an appointment to manage his chronic conditions of diabetes and hypertension, but who also has a history of colon cancer with a colostomy. Note how the assessment documents the presence of the ostomy site and the ongoing plan of care for the ostomy site. TIP: Conditions noted on authorization requests for services, such as ostomy supplies, should be corroborated within the patient s medical record. 26 ICD-9 Coding Guidelines for Common Conditions Myocardial infarction Cancer Metastatic cancer Malnutrition Deep vein thrombosis Chronic kidney disease ESRD Congestive heart failure and hypertension Diabetes Ulcers and wounds Now we will cover information about coding and documentation based on ICD-9 coding guidelines for the following conditions: Myocardial infarction Cancer Metastatic cancer Malnutrition Deep vein thrombosis Chronic kidney disease ESRD Congestive heart failure and hypertension Diabetes Ulcers and wounds 12

13 27 Myocardial Infarction: Acute or Old? MI acute condition that can only be documented and coded as acute for a duration of eight weeks or less ( If patient has an MI over eight weeks old, then document and code old MI, S/P MI or h/o MI (412) Coding for myocardial infarction, or MI, will vary based on when the infarction occurred. MI may only be documented and coded as acute for a duration of 8 weeks or less after the infarction occurred. If the patient presents for a visit and has had an infarction 8 weeks ago or longer, you may document for a history of MI or an old MI. Specific codes are provided for both of these scenarios. 28 Cancer: Current or History Of? When malignancy is excised or eradicated and there is no further treatment or evidence of the malignancy, a code from category V10 (Personal History of Malignant Neoplasm) should be used. Example: h/o breast cancer V10.3 Similarly, the coding and documentation used for cancer will vary based on the status of the cancer. If a malignancy is removed, has no further presence in the body and requires no further treatment, code from the V10 category codes to verify a history of a malignancy. In this example, code V10.3 is used to denote history of breast cancer. 29 Cancer: Active? Under Treatment? Document and code cancer as active in all cases where a malignancy is present, regardless of whether the patient accepts treatment for it. Treatment: Chemotherapy Radiation Adjunct therapy Documentation: Breast CA on tamoxifen Code: If the patient is currently receiving treatment for cancer, document and code the cancer as active, and also document the treatment. Even if the patient has not elected to receive treatment, code the cancer as active. In these instances, it is also best to include the cancer onset date and documentation of non-compliance with recommended treatment. Treatment includes chemotherapy, radiation and adjunct therapy. In this example, code is used for a patient with breast cancer who is on tamoxifen, and the documentation should explicitly states breast cancer on tamoxifen. 13

14 30 Metastatic Cancer Document and code the site of the metastases Example: Breast CA on tamoxifen w/mets to the liver (codes and 197.7) Example: Prostate CA w/bone mets (codes 185 and 198.5) 31 Malnutrition, Underdiagnosed Malnutrition 263.x Commonly used indicators: Albumin < % unintentional loss in 6 12 months 5% unintentional loss in 3 6 months BMI < 18.5 Marked reduction in physical capacity Wasting appearance/muscle wasting Poor nutrition or loss of appetite Cachexia (799.4) protein-wasting syndrome 32 Deep Vein Thrombosis Document and code: o Acute DVT (initial episode of care) o Chronic DVT (on anticoagulant therapy for treatment) o H/O DVT o Personal history of DVT with no anticoagulants V12.51 o Use of anticoagulant for prophylaxis or prevention V58.61 If cancer has metastasized, document and code the site or sites of the metastases. These examples include appropriate documentation for breast cancer and prostate cancer that have metastasized, by stating the site where it has metastasized. Malnutrition is under-diagnosed and under-coded in the elderly. Here is a list of the common indicators that may be used to diagnose and support the 263 category codes for malnutrition, and for cachexia. These indicators include an albumin level of less than 3.4, an unintentional loss of 10 percent of body weight in 6-12 months, muscle wasting and loss of appetite. For deep vein thrombosis, or DVT, coding and documentation are based on the treatment plan being provided to the patient. If a patient is on anticoagulant therapy, please note that documentation should indicate chronic DVT and the corresponding code, , should be used. As shown, there are also specific codes for chronic DVT on anticoagulant therapy and history of DVT. In general, please note that coding for pulmonary embolism follows the same guidelines as coding for deep vein thrombosis. 14

15 NOTE: Same guidelines apply for pulmonary embolism 33 Chronic Kidney Disease (CKD) Code 585 = chronic kidney disease The 4th digit indicates the stage CKD Stage I (GFR > 90 + evidence of kidney damage) CKD Stage II (mild - GFR evidence of kidney damage) CKD Stage III (moderate - GFR 30-59) CKD Stage IV (severe - GFR 15-29) CKD Stage V (end-stage/not on dialysis - GFR <15) ESRD (on dialysis) CKD unspecified Diagnosis and coding of chronic kidney disease is determined by the staging of the disease. The code for CKD begins with the three digits 585; the fourth digit represents the stage of the CKD. Here is a list of the 7 codes that may be used for coding CKD, along with their descriptions. The first 5 correspond to the 5 Stages of advancement of the disease, followed by the codes for on dialysis and unspecified. Note that when coding for CKD stage 1 or stage 2, documentation must include evidence of kidney damage, including evidence based on urine abnormality, ultrasound results or biopsy results. 34 ESRD For a patient with ESRD on dialysis, use 2 codes: ESRD Renal dialysis status V45.11 For a patient with ESRD on dialysis due to diabetes, use 3 codes: When coding for patients with ESRD who are on dialysis, use 2 codes the ESRD code and the renal dialysis status code. If the patient is on dialysis as a result of ESRD caused by diabetes, document ESRD on dialysis due to DM, and use 3 codes one for diabetes with renal manifestations; one for ESRD; and one for renal dialysis status. DM w/renal manifestations ESRD Renal dialysis status V

16 35 Diabetes with Manifestations Diabetic Document the DM with the complications throughout your SOAP notes and in your assessment using one of the 3 acceptable ways: Due to diabetes Secondary to diabetes Diabetic Examples If a patient is experiencing any manifestations due to their diabetes, document the diabetes and complications in your SOAP notes. There are 3 ways that you can document the complications resulting from the diabetes: 1. Due to diabetes 2. Secondary to diabetes 3. Diabetic as adjective or modifier These 3 examples reference different diabetic complications to highlight all 3 documentation methods for manifestations. betic ulcer Peripheral neuropathy due to diabetes CKD stage lll secondary to DM 36 Diabetes: Code and Document Any Manifestations Identified Example: Document Peripheral neuropathy due to DM. Use 2 codes: DM w/neurological manifestation and peripheral neuropathy in DM. Example: It is necessary to document and code any manifestations that you have identified as being associated with a patient s diabetes. The coding examples for both peripheral neuropathy due to diabetes and peripheral vascular disease due to diabetes specify the 2 separate codes that must be used when coding each condition. For each example, one code indicates the diabetes has caused the manifestation of the other condition; and the other code describes the specific manifestation. Document PVD due to DM. Use 2 codes: DM w/peripheral circulatory disorders and PVD. 37 Differentiate Ulcers and Wounds Wound and ulcer are not interchangeable terms. Distinguish between them in documentation and 16

17 Ulcer refers to an area of breakdown in the skin (diabetic ulceration, venous stasis ulcer) Ulcer codes 707.xx Wound refers to traumatic conditions such as an avulsion, cut or laceration Wound codes 870.x 897.x 38 Differentiate Pressure and Non-Pressure Ulcers 2 types of ulcers: Non-pressure or chronic ulcer 707.1x Decubitus or pressure ulcer 707.0x Stage Pressure Ulcers l through lv Use 2 codes, one for the ulcer and one for the stage Example: Stage l pressure ulcer of sacrum ( and ) Example: diabetic ulcer of the calf ( and ) 39 CVA: Is It New or Old? CVA (434.91) is an acute event, can only be coded during initial episode of care (inpatient) Once discharged, document and code for past history of CVA (h/o CVA, old CVA, S/P CVA) unless the patient has late effects coding. Ulcer should be used to document an area of breakdown in the skin, such as a diabetic ulceration or a venous stasis ulcer. Ulcers are associated with codes from 707.xx through Wound should be used to document traumatic conditions, such as an avulsion, cut or laceration. Wounds are associated with codes from categories 870 through 897. Distinguish between chronic (non-pressure) ulcers and decubitus (pressure) ulcers in your documentation. Non-pressure ulcers are coded with codes in the 707.1x subset, using the appropriate fifth digit; pressure ulcers are coded with codes in the 707.0x subset, using the appropriate fifth digit. Pressure ulcers require staging I through IV. They also require 2 codes one for the ulcer itself, and one for the stage. For example: Stage I pressure ulcer of the sacrum, or diabetic ulcer of the calf. Cerebrovascular accidents (CVAs) are commonly miscoded. CVA is an acute event that can only be coded during the initial episode of care, such as when the patient is hospitalized, using code Documentation during any patient visits postdischarge may only reflect that there is a past history of CVA, unless the patient is experiencing late effects from the CVA. 40 Document & Code Late Effects of CVA If the patient is experiencing late effects from CVA, then your documentation and coding should reflect it. Simply coding for the CVA does not accurately 17

18 Which example is correct? Example 1: 436 CVA w/r-sided weakness Or Example 2: CVA w/hemiplegia or w/hemiparesis convey any specific late effects such as hemiparesis. The 1 st example documents a symptom, right sided weakness. Code 436 is for acute ill-defined CVA which is not explicitly documented and should not be used to code for late effects associated with a past CVA. Also be cautious that weakness has its own code. If the patient has hemiparesis due to past CVA it needs to be documented as such. Example 2 specifies that it is a past CVA with specific late effects. 41 EMR Pitfalls 42 EMR PITFALLS Copying and pasting from active problem list, chronic conditions or PMH to assessment, with no supporting documentation to indicate condition assessed during visit Canned statements Some exam notes auto-populate when not addressed or amended (e.g., no problems, WNL). It can contradict a diagnosis later documented. Selecting ICD-9 code from a dropdown menu may create issues if the supporting documentation is contradictory or if code selected is not correct (up or down coding). Special mention must be made about the use of electronic medical records (EMR) for documentation. There are a few areas to pay attention to when using EMR, to ensure you maintain the integrity of your documentation: In the EMR, when copying and pasting information from the patient s active problem list, chronic conditions or past medical history to the patient s assessment section, be sure to include notes in the documentation section that indicate the condition was assessed during the visit. The record should not reflect information in the assessment for which there is no supporting documentation for that encounter. Additionally, when completing the EMR for the patient s visit, review all sections of the EMR. Some EMR software will auto-populate sections of the EMR with placeholder exam notes that may not correspond with the diagnosis you document or your assessment. Look at all sections to verify if autopopulation occurs and make any needed adjustments. Lastly, if your EMR software offers a drop-down list of commonly used, or favorite, codes for convenience, always make sure that any code you choose is supported by your documentation. Use the most accurate code for the diagnosis. 18

19 43 Key Points Accurately document in the medical record all conditions evaluated and coded during the visit. Verify you have a diagnosis and plan to correspond to the patient s chief complaint or reason for visit. Document assessment of diagnosis or diagnoses evaluated or treated. Document the patient s progress and results of treatment. To summarize, here are the key points you should keep in mind to ensure successful documentation and coding: Document in the patient s medical record all conditions you evaluate at each visit and the diagnosis and plan of care that correspond to the reason for the patient s visit. Document an assessment of your observations and diagnoses for the patient s visit. Your assessment is a crucial part of creating documentation that supports the codes you submit. Indicate any progress the patient makes or the results of treatment. 44 Key Points All codes must be fully supported in the chart note for the visit Document and code to the highest level of specificity Fully assess chronic conditions at least annually 45 Peoples Health Resources Member Viewer (available through the Provider Portal) provides information about: --Pharmacy (medication lists and Prescription fill history --Labs --Diagnosis history -- Visit history Ensure the medical record contains the documentation needed to support the codes you submit. Document and code conditions to the highest level of specificity. Assess and document chronic conditions at least annually. Peoples Health offers Member Viewer, an online resource that compiles key information about each of your patients. You may find this information useful when conducting your appointments and documenting visits. Member Viewer is available through the Provider Portal. Contact your Provider Relations representative for more information about Member Viewer and Provider Portal. This concludes our presentation. We hope it is of use to you in your practice. Please help us improve our programs by providing feedback in the evaluation. Thank you. 19

20 BIBLIOGRAPHY, Accuracy in Diagnosis and Coding What Physicians Need to Know CITATIONS: This presentation was compiled using information from the ICD-9-CM Coding Guidelines and chapter 7 of the 2008 Centers for Medicare & Medicaid Services (CMS) Risk Adjustment and Training Manual. To view a complete list of 2013 ICD-9-CM revisions, additions, and deletions go to Centers for Medicare & Medicaid Services coding changes website link: FURTHER RESOURCES FOR PRIMARY CARE PHYSICIANS: 1. American College of Physicians (ACP) website. Online educational resources for internal medicine physicians, including Coding 101, Transitional Care Coding, Coding and Billing for Internists Services. Available at 2. Heidelbaugh JT, Habetler JM. Ten billing and coding tips to boost your reimbursement. Journal of Family Practice. 2008; 57(11): Accessed 1/24/13 at 3. ICD9 Coding Tools, Family Practice Management. Accessed 1/24/13 at 4. American Medical Association (AMA) Bookstore. ICD- 9 Coding resources for physicians. 5. American Medical Association (AMA). Official Coding Guidelines. Available at 6. Official ICD-9-CM Guidelines for Coding and Reporting. Available at the National Center for Health Statistics Web site, 7. AHIMA Distance Learning ICD-9-CM Diagnostic Coding Guidelines for Outpatient Services. Available at ftp://ftp.ihs.gov/pubs/ehr/him+bo/ahima%20icd9cm%20diagnostic%20coding%20gui delines%20for%20outpatient%20services% pdf 8. Prophet S. AHIMA. How to Code Symptoms and Definitive Diagnoses. Available at DocName=bok2_ Buck CJ ICD-9-CM for Hospitals, Volumes 1, 2 and 3 Professional Edition, 1e. Saunders (September 10, 2012). 20