Q:Should physician queries be part of the legal medical record? 

A:

At MMP we have seen facilities maintain queries as part of the legal medical record and other facilities maintain the query forms within the CDI Department. Ultimately, this is a hospital specific decision.

Below are excerpts from two complimentary AHIMA Practice Briefs where they have provided guidance regarding query retention.

Query Retention

Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database.

Before this decision is made a discussion with the facility compliance and legal staff may be beneficial. Regardless, the query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query a permanent part of the health record to demonstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It also can demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documentation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

Article Citation: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010); expanded web version.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

Develop Query Retention Policies

Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated. As noted in AHIMA’s toolkit, “Amendments in the Electronic Health Record,” “the addendum should be timely, bear the current date, time, and reason for the additional information being added to the health record, and be electronically signed.”

Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.

An important consideration in query retention is the ability to collect data for trend analysis, which provides the opportunity for process improvement and identification of educational needs.

Article Citation: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018

Our next topic for the I-10 corner is the mental health chapter, Mental, Behavioral, and Neurodevelopmental Disorders. Chapter 5 is another example of the massive expansion of codes in ICD-10. I have highlighted some changes and included tips that I think are important to know for coding these conditions.

See below how the codes in this chapter are no longer grouped by psychotic, non-psychotic disorders, or mental retardation.

CODE COMPARISON

‍NOTE FROM ICD-10-CM CODER TRAINING MANUAL 2014

Many title changes for categories and subcategories were made in Chapter 5. Such as:Bipolar 1 Disorder, Single Manic Episode (296.0x) = Manic Episode (F30.xx)

Many changes were made due to outdated terminology. Examples can be seen in the accompanying table.

DID YOU KNOW?

DRG Shift

The CMS ICD-10 website contains information on the ICD-10 MS-DRG Conversion Project. An article from CMS, “Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments”, lists the top 10 MS-DRGs that shift to another DRG when re-coded with ICD-10. DRG 885, Psychoses is on that list. Currently, ICD-9 cases that have 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis will group to DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9 (also includes Depression NOS) which groups the case to DRG 881, Depressive Neuroses, a lower-weighted DRG. Interestingly, many hospitals in Alabama have DRG 885 listed in their top 10 diagnoses each year. It would be a good idea to see how this change will impact your facility.

A large classification change was made to the drug and alcohol abuse/dependence codes.

• There are codes to denote alcohol and drug “use”.
• No longer identify “Continuous” and “Episodic” in I-10
• Can code Blood Alcohol Levels as an additional code, if applicable:
  Y90.0, Evidence of alcohol involvement determined by blood alcohol level

Chapter 5 Guidelines

• Physician documentation of a history of drug or alcohol dependence is coded as “in remission”.
• For psychoactive substance use, abuse and dependence:

TIP

The codes in Chapter 5 parallel the codes in DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders-4 Text Revision) in most cases….from the ICD-10-CM Coder Training Manual, 2014 Instructor’s Edition. Psychiatrists tend to document these conditions as they are listed in the codebooks, which can make mental health coding a little easier. In addition, I hope all of the information provided to you in the I-10 Corner has helped make your job a little easier.

In this week’s article, we’re discussing a few of the changes for ICD-10-CM in the Nervous System (Chapter 6): Alzheimer’s Dementia, Epilepsy, Hemiparesis/Hemiplegia (Dominant vs. Non-Dominant), Migraine, Phantom Limb Pain and Sleep Apnea

Alzheimer’s Dementia

I-9: Alzheimer’s Dementia

• with behavioral disturbance (aggressive) (combative) (violent) (331.0 / 294.11)
• without behavioral disturbance (331.0 / 294.10)

NOTICE:

The category for Alzheimer’s disease (G30) has been expanded to reflect onset (early vs. late)

I-10: Alzheimer’s Dementia

• behavioral disturbance (G30.9 / F02.81)
• early onset (G30.0 / F02.81)
• late onset (G30.1 / F02.80)
• specified NEC (G30.8 / F02.80)

Epilepsy

Terms for Epilepsy have been updated to classify the disorder, e.g,

• Localization-related Idiopathic Epilepsy
• Generalized Idiopathic Epilepsy
• Special Epileptic Syndromes

Example:

I-9: Epilepsy, epileptic (idiopathic) (345.9)

Epilepsy, localization related (focal) (partial) and (epileptic syndromes)

• With
• Complex partial seizures (345.4)
• Simple partial seizures (345.5)

NOTICE:

Within each category, more specificity can be described to identify: Seizures of Localized Onset, Complex Partial Seizures, Intractable and Status Epilepticus.

I-10: Epilepsy, epileptic, epilepsia (attack) (cerebral) (convulsion) (fit) (seizure) (G40.909)

Epilepsy, localization-related (focal) (partial)

• Idiopathic (G40.009)
• With seizures of localized onset (G40.009)
• Intractable (G40.019)
• With status epilepticus (G40.011)
• Without status epilepticus (G40.019)
• Not intractable (G40.009)
• With status epilepticus (G40.001)
• Without status epilepticus (G40.009)

NOTE

Category G40, Epilepsy and Recurrent Seizures

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Hemiplegia and Hemiparesis  (Dominant vs. Non-Dominant Side)

This category is to be used only when the listed conditions are reported without further specification, or are stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these conditions resulting from any cause.                                      

I-9:

The following fifth-digits are for use with codes 342.0-342.9:

• 0 affecting unspecified side
• 1 affecting dominant side
• 2 affecting non-dominant side

I-10:

Per ICD-10-CM Official Coding Guidelines: Codes from category G81, Hemiplegia and hemiparesis, and subcategories, G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or non-dominant side is affected.

Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows:

• For ambidextrous patients, the default should be dominant
• If the left side is affected, the default is non-dominant
• If the right side is affected, the default is dominant

Example: G81.9 Hemiplegia, unspecified

• G81.90:  Hemiplegia, unspecified affecting unspecified side
• G81.91:  Hemiplegia, unspecified affecting right dominant side
• G81.92:  Hemiplegia, unspecified affecting left dominant side
• G81.93:  Hemiplegia, unspecified affecting right non-dominant side
• G81.94:  Hemiplegia, unspecified affecting left non-dominant side

            Excludes1: Hemiplegia and hemiparesis due to sequela of cerebrovascular disease

Migraine

I-9: Migraine, Unspecified (Idiopathic) (346.9x)

I-10: Migraine, Unspecified (Idiopathic) (G43.909)

NOTE

Category G43, Migraine

The following terms are to be considered equivalent to intractable:

• Pharmacoresistent (pharmacologically resistant)
• Treatment resistant
• Refractory (medically)
• Poorly controlled

Phantom Limb

The sensation that an amputated or missing limb is still attached to the body and is moving along with other body parts. An estimated 60% to 80% of people that have had an amputation, experience phantom sensations in the amputated limb with the majority being painful.  

I-9: Phantom limb (syndrome) (353.6)

NOTICE:

I-10 has given us the ability to identify whether pain is present or not after an amputation.

I-10: Phantom limb syndrome (G54.7)

• with pain (G54.6)
• without pain (G54.7)

Sleep Apnea

Sleep Apnea has its own subcategory with fifth character specificity identifying the type

Example:      

I-9: Sleep Apnea, Unspecified (780.57)

• with
• Hypersomnia, unspecified (780.53)
• Hyposomnia, unspecified (780.51)
• Insomnia, unspecified (780.51)
• Sleep disturbance (780.57)
• Central, in conditions classified elsewhere (327.27)
• Obstructive (adult) (pediatric) (327.23)
• Organic (327.20)
• other (327.29)
• Primary central (327.21)

I-10: Sleep Apnea, Unspecified (G47.30)

• Central (primary) (G47.31)
• in conditions classified elsewhere (G47.37)
• Obstructive (adult) (pediatric) (G47.33)
• Primary central (G47.31)
• Specified NEC (G47.39)

As you can see, there are several new terms and descriptions in the Nervous System Chapter for I-10-CM, providing more specificity and better clarity of certain conditions. If we can take just a little extra time assigning diagnosis codes for I-10, we will reflect the true severity of illness (SOI) for each and every patient.

Resources:

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Wikipedia

Have you ever questioned whether a patient actually has a UTI or not, based on the clinical signs and symptoms documented in the medical record, even if “UTI” is documented by the physician? In this week’s article, we'll be discussing UTIs in more specified detail to help with this very issue, as well as CKD.

UTI

Lab Results

We all should be aware that urine cultures growing greater than 100,000 colony forming units (CRU/mL) usually indicates that an infection is present.

Sometimes an infection, if symptoms are present, may be indicated with lower numbers (1,000 to 100,000 CFU/mL).

If a patient has a urine sample collected with a catheter, which minimizes contamination, results of 1,000 to 100,000 CFU/mL may be considered significant.

Symptoms of a UTI

• Painful urination
• Frequent urination
• Urine that is cloudy, bloody, or has an odor
• Pain and pressure in the pubic bone area (women) and rectal pressure (men)
• Feeling of a full bladder but only have drops of urine on urination
• Tiredness
• Weakness
• Fever if the UTI has spread to the kidneys or blood
• Fever is not common with a UTI of the lower urinary tract (urethra or bladder)

NOTE FROM 2Q Coding Clinic, page 20

The provider must clearly document the causal relationship between the UTI and catheter. A coder cannot automatically assign a Catheter-Associated Urinary Tract Infection (CAUTI) when the patient has an indwelling catheter and then develops a UTI.

However, preventing and tracking CAUTIs is very important so if a patient has an indwelling catheter and a UTI, the coder should query the provider as to the cause of the UTI. This information should be documented in the record, as well.

UTI’s in the Elderly

TIP

Look for catheter use in the elderly.

Symptoms can appear non-specific and a diagnosis may be more difficult to determine in the elderly population and/or for those patients in healthcare settings requiring long-term catheter use.

UTI Due to a Catheter--See Complication, catheter, urethral, indwelling, infection and inflammation in the alphabetic index.

• ICD-9--(996.64)
• ICD-10—(T83.51X_) (seven characters)
• initial encounter
• subsequent encounter
• sequela

Contaminant

Remember, if a UTI is documented and the urine sample grows >100,000 colonies, but is labeled as contaminated, no UTI code is reported.

Something You May Not Know

• Females get UTIs more frequently than males.
• For patients that have frequent UTIs, their bacteria may become resistant to antibiotics over time.
• Patients may be more prone to recurring UTIs if the following are present:
• Kidney disease
• Diseases that affect the kidneys, i.e. Diabetes, Hypertension, etc.
• Compromised immune systems

Chronic Kidney Disease

Chapter 14: Disease of Genitourinary System (I-10)-Coding Guidelines

(Unless otherwise indicated, these guidelines apply to all health care settings)

1. Stages of chronic kidney disease (CKD)
   
   The ICD-10-CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).
   
   If both a stage of CKD and ESRD are documented, assign code N18.6 only.
   
   
2. Chronic kidney disease and kidney transplant status
   
   Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
   
   
3. Chronic kidney disease with other conditions
   
   Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

See I.C.9. Hypertensive chronic kidney disease

See I.C.19. Chronic kidney disease and kidney transplant complications

NOTE FROM 3Q Coding Clinic, page 3

Complications of a transplanted organ are assigned when the transplanted organ is being rejected by the recipient or there are other complications or diseases of the transplanted organ. Ex: A patient develops Acute Renal Failure after a transplant. If the post-transplant condition affects the function of the transplanted organ, two codes are required. One for the Complication of the Transplanted Organ (996.81) (T86.12), which is sequenced as the principal diagnosis, and a second code describing the Acute Renal Failure (584.9) (N17.9).

Pre-existing conditions or medical conditions that develop after a transplant are coded as Complications of the Transplanted Organ only when they affect the function of that organ.

Status code V42.0 should only be used if there is no complication of the organ replaced. A V42.x status code is never used in conjunction with a (996.8x) code if there is no complication of the same transplanted organ.

Sometimes there are no easy solutions when it comes to coding. After all record documentation has been thoroughly reviewed and analyzed there may be only one solution left. When in doubt, query the physician. The worst that can happen is the physician says ‘no’, right?

Resources:

American Association for Clinical Chemistry

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Medicine.Net

Our next chapter to address in the I-10 Corner is the Digestive System. Please review the table below so that you can see what areas of the chapter have either been expanded or restructured.

EXAMPLE

For this edition of the I-10 Corner, we have included some helpful hints that will make coding procedures in the Endocrine System a little easier.   To gain familiarity, practice looking up procedures in the ICD-10-PCS coding book that are performed at your facility on a routine basis.

Knowing the Root Operations is the key to making all of this work!                                              

FROM THE ICD-10-PCS REFERENCE MANUAL

Examples of Root Operations

Excision—Root operation B

Definition: Cutting out or off, without replacement, a portion of a body part

Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies

Examples: Partial thyroidectomy, ovarian biopsy

Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to

• Scalpel
• Wire
• Scissors
• Bone saw
• Electrocautery tip

Resection—Root operation T

Definition: Cutting out or off, without replacement, all of a body part

Explanation: N/A

Examples: Total nephrectomy, total lobectomy of lung

Resection is similar to Excision, except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

Release—Root operation N

Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out

Examples: Adhesiolysis of right ovary

The objective of procedures represented in the root operation Release is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Reposition—Root operation S

Definition: Moving to its normal location or other suitable location all or a portion of a body part

Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Examples: Reposition of undescended testicle

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

Laterality is necessary in code assignment for the following organs:

• Thyroid
• Ovaries
• Testicles
• Adrenals

EXAMPLE

‍

Don’t Forget: 0 vs O:

FROM THE ICD-10-PCS REFERENCE MANUAL

Values

One of 34 possible values can be assigned to each character in a code: the numbers 0 through 9 and the [whole] alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014
B4. Body Part

B4.3 Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.

For the I-10 Corner this week, we are discussing a few of the specific coding differences for cardiac diagnoses and conditions in ICD-9-CM and ICD-10-CM.

Angina Pectoris with Atherosclerotic Heart Disease (ASHD):

I-9

Angina, Unspecified (413.9)

ASHD, Unspecified (414.00)

I-10

Angina with ASHD, Unspecified—see Arteriosclerosis, Coronary (artery), Unspecified (I20.9)

NOTE FROM AUTHOR
Attention: Two codes in I-9 vs. one code in I-10

Atrial Fibrillation:

I-9

Atrial Fibrillation (established) (paroxysmal) (427.31)

I-10

Atrial Fibrillation or Auricular (established) (I48.91)

Chronic (I48.2)

Paroxysmal (I48.0)

Permanent (I48.2)

Persistent (I48.1)

Atrial Flutter:

I-9

Atrial Flutter or Auricular (427.32)

I-10

Atrial Flutter or Auricular (I48.92)

Atypical (I48.4)

Type I (I48.3)

Type II(48.4)

Typical (I48.3)

NOTE FROM AUTHOR
Attention: There are specific descriptions for Atrial Fibrillation and Atrial Flutter in I-10. In addition, there are no specific codes for Postoperative Fibrillation or Postoperative Flutter in the alpha index.

Heart Failure:

I-9

Congestive Heart Failure (compensated) (decompensated) (428.0)

Diastolic (428.30)

Acute (428.31)

Acute on Chronic (428.33)

Chronic (428.32)

Systolic (428.20)

Acute (428.21)

Acute on Chronic (428.23)

Chronic (428.22)

I-10

Congestive Heart Failure (compensated) (decompensated) (I50.9)

Diastolic (congestive) (I50.30)

Acute (congestive) (I50.31)

            and (on) chronic (congestive) (I50.33)

Chronic (congestive) (I50.32)

            and (on) acute (congestive) (I50.33)

Combined with Systolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Systolic (congestive) (I50.20)

Acute (congestive) (I50.21)

            and (on) chronic (congestive) (I50.23)

Chronic (congestive) (I50.22)

            and (on) acute (congestive) (I50.23)

Combined with Diastolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Myocardial Infarction (MI):

I-9

Infarct, Myocardial (acute or with a stated duration of 8 weeks or less) (with Hypertension) (410.9x)

NOTE FROM MANUAL
Note—Use the following fifth-digit subclassification with category 410:

0 - episode unspecified

1 - initial episode

2 - subsequent episode without recurrence

I-10

Infarct, Myocardial (acute) (with stated duration of 4 weeks or less) (I21.3)

NOTE FROM AUTHOR
Attention:

• For the episode of care in I-10, MIs are identified as either Acute (I21.xx) or Subsequent (I22.xx).
• The timeframe (stated duration of the MI) has decreased in I-10 to 4 weeks from 8 weeks in I-9.

Most MIs are considered to be ST-Elevation (STEMI) unless stated as Non-ST Elevation (NSTEMI) or Subendocardial.

STEMI

Anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) (I21.09)

Inferior (I21.09) (diaphragmatic) (inferolateral) (inferoposterior) (wall) NEC (I21.19)

Inferoposterior Transmural (Q wave) (I21.11)

Lateral (I21.29) (apical-lateral) (basal-lateral) (high) (I21.29)

Posterior (I21.29) (posterobasal) (posterolateral) (posteroseptal) (true) I21.29)

Septal (I21.29)

Specified NEC (I21.29)

NSTEMI

Subendocardial (I21.4)

Non-Q wave NOS (I21.4)

Nontransmural NOS (I21.4)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

NOTE FROM AUTHOR
For Acute MIs, we can now identify the specific coronary artery impacted. For example, per the alpha index:

Infarct, Myocardial, Involving

Coronary artery of anterior wall NEC (I21.09)

Coronary artery of inferior wall NEC (I21.19)

Diagonal coronary artery (I21.02)

Left anterior descending coronary artery (I21.02)

Left circumflex coronary artery (I21.21)

Left main coronary artery (I21.01)

Oblique marginal coronary artery (I21.21)

Right coronary artery (I21.11)

Please refer to the our article, ICD-10-CM Diseases of the Circulatory System, describing specific coding guidelines for cardiac diagnoses and conditions.

I hope this article has been beneficial in helping you become more familiar with cardiac diagnoses and conditions in ICD-10-CM.           

For the I-10 Corner this week, we’re discussing a few of the procedural coding guidelines for Cardiac Bypass Procedures, including a few examples.

Remember: The letters I and O and not used in PCS since they are easily confused with numbers one (1) and zero (0).

ICD-10-PCS Coding Guidelines

Coronary Bypass Procedures

B3.6b. Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.

Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the ‘aorta’ as the body part bypassed from.

B3.6c. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

Coronary Excision for Graft

B3.9. If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Coronary bypass with excision of saphenous vein graft; excision of saphenous vein is coded separately.

Coding Example: CABG of LAD using left internal mammary artery, open; off pump (02100Z9). Root Operation: Bypass, Coronary Artery, One Site, (0210), Open (0), No Device (z), Internal Mammary, Left (9).

                Note: The Internal Mammary Artery = No Device. It is not considered graft material.

Coding Example: Open coronary artery bypass graft of three coronary arteries using left autologous greater saphenous vein (021209w). Root Operation: Bypass, Coronary Artery, Three Sites (0212), Open, (0), Autologous Venous Tissue (9), Aorta (w).

Note: For Coronary Bypass, the Body Part identifies the number of coronary artery sites bypassed to-- which is the Aorta.

Coronary Body Parts

B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number or arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site, with Intraluminal Device, and Dilation of Coronary Artery, One Site, with no device.

Coding Example: PTCA of two coronary arteries: RCA with stent (intraluminal device) (02703DZ) and LAD without stent (02703ZZ). Root Operation: Dilation, Artery, Coronary, One Site (0270)—one with an intraluminal device and one without.

Note: Coronary arteries are counted as single body parts. It doesn’t matter how many arteries were treated. The main distinguishing factor is the number of sites treated.

MMP hopes this article was beneficial in helping you become more familiar with cardiac bypass procedures in ICD-10-PCS.         

The Centers for Medicare and Medicaid Services (CMS) hosted a National Provider Call regarding the 2-Midnight Rule that went into effect on October 1, 2013 with the Fiscal Year (FY) 2014 IPPS Final Rule. For those of you that were unable to attend here is a run-down of 5 key takeaways from the session.

1. CMS is already planning future training sessions for Physician Orders/Certification and Transfers.
2. CMS has acknowledged that there could be times when an inpatient stay would still be appropriate even though an “unforeseen circumstance” occurs and the patient ultimately does not require a 2-Midnight or greater hospitalization. Specific examples from CMS have included patient death, transfer, leaving against medical advice (AMA) or the patient rapidly improving. New to this list is a patient that is admitted, documentation clearly supports a 2-Midnight expectation and the patient / family elect Hospice care and the patient is discharged home to hospice. Key to all of these “unforeseen circumstances” is that documentation in the record clearly supports the physician expectation of a 2-Midnight stay.
3. Effective December 1, 2013, the NUBC redefined Occurrence Span Code 72 to allow “Contiguous outpatient hospital services that preceded the inpatient admission” to be reported on inpatient claims. At this time this is a voluntary code but CMS encourages hospital to use this code.
4. Prior to opening the call up to questions and answers, CMS provided answers to two common questions that they had received prior to this call.
5. Q: How does level of care factor into the 2-Midnight Rule?
6. A: Under the 2014 IPPS Final Rule, the decision to admit is based on medical necessity of hospital care whether it is observation or inpatient care. If the answer is yes then the next question to ask is do you think this patient will be in the hospital for at least 2-Midnights?
7. Q: Can any elective surgeries be ok in Inpatient setting?
8. A: If there is an “unexpected circumstance” requiring 2-Midnights (i.e. a complication) then the stay would be appropriate as an Inpatient admission.
9. During the open Q&A session a question was asked regarding patients staying beyond 2-Midnights and whether or not a hospital would still be able to use InterQual® criteria. CMS responded by indicating that they believe hospitals will not use InterQual® or Milliman. They did go on to indicate that these screening tools could be used to help determine whether a patient should remain in the hospital or is safe for discharge.

The entire slide presentation from this call can be downloaded at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-01-14-Midnight-Presentation.pdf

What do Probe Reviews, the start time for when the 2 midnight benchmark begin, Physician Documentation, automatic denials and Occurrence Span Code 72 have in common? All of these issues were addressed in the CMS Frequently Asked Questions (FAQs) December 23, 2013 update. Let’s break it down be each updated FAQ.

Q1.1: “Will CMS direct the Medicare review contractors to apply the 2-midnight presumption-that is, contractors should not select Medicare Part A inpatient claims for review if the inpatient stay spanned 2 midnights from the time of formal admission?”

• Yes, when a patient has been in your hospital for two midnights AFTER the inpatient order was written review contractors are to presume that the Medicare Part A inpatient admission was reasonable and necessary.
• New to this answer is that for inpatient admissions from October 1, 2013 through March 31, 2014 “CMS will not permit Recovery Auditors to conduct patient status reviews on inpatient claims with dates of admission between October 1, 2013 and March 31, 2014. These reviews will be disallowed permanently; that is, the Recovery Auditors will never be allowed to conduct patient status reviews for claims with dates of admission during that time period.”
• Caution: These same admissions CAN be reviewed for other issues (i.e. medical necessity of a surgical procedure or coding validation).

Q2.1: “Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

• All time that a Medicare beneficiary is receiving outpatient services at the hospital will be considered in whether or not the 2-midnight benchmark was met.
• Note: “The Medicare review contractor will count only medically necessary services responsive to a beneficiary’s clinical presentation as performed by medical personnel.”
• Services to be included: observation services, treatments in the Emergency Department, and procedures provided in the operating room or other treatment area
• Services not to be included: treatment received in an outlying Emergency Department or in an ambulance en-route to your hospital.

Q4.1: “What documentation will Medicare review contractors expect physicians to provide to support that an expectation of a hospital stay spanning 2 or more midnights was reasonable?”

• Physician complex medical decision making: The expectation of a 2-midnight stay “must be supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”
• Documentation: Medicare review contractors will expect the Physician’s decision making factors to be documented in the physician assessment and plan of care. “CMS does not anticipate that physicians will include a separate attestation of the expected length of stay, but rather that this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

Q4.9: “Under the new guidance, will all inpatient stays of less than 2 midnights after formal inpatient admission be automatically denied?”

• Medicare does anticipate that most stays less than 2 midnights would be as an outpatient. However, “because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, we expect to see services payable under Part A in a number of instances for inpatient stays less than 2 total midnights after formal inpatient admission.”
• CMS has provided specific exceptions to the 2-midnight benchmark when inpatient would still be appropriate:
• Beneficiary death,
• Beneficiary transfer to another acute inpatient facility,
• Beneficiary leaving against medical advice (AMA),
• Beneficiary was admitted for a medically necessary service on the Inpatient-Only List,
• Mechanical ventilation initiated during the present visit (Note: is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment),
• Or a Beneficiary unexpectedly improves and was discharged in less than 2 midnights.
• New to this answer: “Lastly, there may be rare and unusual cases where the physician did not expect a stay lasting 2 or more midnights but nonetheless believes inpatient admission was appropriate and documents such circumstance. The MACs are being instructed to deny these claims and to submit these records to CMS Central Office for further review. If CMS believes that such a stay warrants an inpatient admission, CMS will provide additional subregulatory instruction and the Part A contractors will review any claims that are subsequently submitted for payment in accordance with the most updated list of rare and unusual situations in which an inpatient admission of less than 2 midnights may be appropriate.”

Q5.2: “Is there a way for providers to identify any time the beneficiary spent as an outpatient prior to admission on the inpatient claim so that Medicare review contractors can readily identify that the 2-midnight benchmark was met without conducting complex review of claim.”

• “Effective December 1, 2013, Occurrence Span Code 72 was refined to allow hospitals to capture ‘contiguous outpatient hospital services that preceded the inpatient admission’ on inpatient claims.”
• For now, “Occurrence Span Code 72 is a voluntary code, but may be evaluated by CMS for medical review purposes.”

The entire FAQ download can be found at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews_12232013_508Clean.pdf With the MAC Probe and Educate program just getting underway, you can expect there to be several additional updates to the FAQs.