D1 PPT 7 2019 OPCDI Symp Pitfalls Self Coding Prescott ... 7... · to rule out osteomyelitis. Prescription for antibiotics and home health to assist with foot care. E10.9 Type 1 DM

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“Eeeny‐Meeny‐Miney‐Mo—Picking the First One Is a NO!”The Pitfalls of Provider Self‐Coding

Shannon McCall RHIA, CCS, CCS‐P, CPC, CEMC, CRC, CCDS, CCDS‐O

Director, HIM & CodingHCProMiddleton, MA

Laurie Prescott RN, MSN, CCDS, CCDS‐O, CDIP, CRC

Director, CDI EducationHCProMiddleton, MA

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Learning Objectives

After attending this presentation, the attendee will be able to:

• Identify common errors related to provider self‐coding

• Discuss methods to monitor and identify trends in coding errors

• Formulate a provider educational plan to address coding errors

2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Diagnosis Coding – Is It REALLY That Simple?

Does ICD‐10‐CM diagnosis coding

sometimes feel like this for your providers?

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Accurate Provider Coding: BarriersIt Is Almost Easier to Catch a Tiger by the Toe …

• Providers are not taught to assign codes

• Providers are likely not aware of what is stated in the coding guidelines

• Providers tend to focus more on CPT® codes than ICD‐10‐CM diagnosis codes

• Providers have little time to perform this function due to increased patient demands

• Large volumes of outpatient encounters do not support a complete auditing process

• ICD‐10‐CM is complicated to learn and apply

• ICD‐10‐CM classification does not always match the clinical language

• ICD‐10‐CM/AHA Coding Clinic® guidance is constantly updated


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Example of the Disconnect“Eeeny‐Meeny‐Miney‐Mo”

• Patient encounter for management of right great toe diabetic ulcer. Complaints of persistent numbness of lower extremities with intermittent episodes of burning pain in the feet and toes.

• HbA1c improving from 11 to at present 8. She states she is adjusting well to use of new insulin pump.

• Wound right great toe, Wagner grade 3, will require debridement. Abscess draining purulent fluid, specimen for culture obtained.

• Assessment: Diabetes, ulcer of right toe, abscess of right foot.

• Plan: Neurology and wound clinic consults, x‐ray to rule out osteomyelitis. Prescription for antibiotics and home health to assist with foot care.

□ E10.9 Type 1 DM w/o Complications

□ E11.9 Type 2 DM w/o Complications

□ E13.9 Other Specified DM w/o Complications

□ E10.622 Type 1 DM w/skin ulcer

□ E10.40 Type 1 DM w/neuropathy

E10.69 Type 1 DM with osteomyelitis

Documentation:

The provider thinks:“Diabetes… what do I choose?”

The provider thinks:“Oh wait, I have complications…” and chooses:

This Photo by Unknown Author is licensed under CC BY‐SA

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What Was Wrong?“If He Hollers, Let Him Go”

1. Chosen code: E10.622 Type 1 DM w/skin ulcer

Didn’t the documentation state diabetic ulcer of the right toe?

Did the provider ever document Diabetes, type 1?

Isn’t there an instructional note to assign an additional code for the toe ulcer based on location and depth?


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What Was Wrong? (cont.)“If He Hollers, Let Him Go”

2. Chosen code: E10.40 Type 1 DM w/neuropathy

Did the provider ever state diabetic neuropathy?

Or only symptoms of persistent numbness?

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3. Chosen code: E10.69 Type 1 DM with osteomyelitis

Was osteomyelitis confirmed in the documentation?

If it is present, don’t we need another code to identify the specific anatomical location and

type of osteomyelitis?


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What should have been coded based on the current documentation?

What was missing?

• E11.621

• Type 2 diabetes with foot ulcer

• L97.519

• Non‐pressure chronic ulcer of other part of the right foot w/unspecified severity

• R20.0

• Disturbances of skin sensation

• L02.611

• Cutaneous abscess of right foot

• Z96.41

• Presence of insulin pump

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What Documentation Would Provide Further Clarification?

• Specificity of type of diabetes

• Specificity of the severity/depth of the ulcer

• Etiology of the lower extremity numbness and burning sensation

• Confirmation of location and type of osteomyelitis


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Example of the Disconnect“My Mother Told Me to Pick the Very Best One”

• Patient encounter for management of COPD exacerbation with asthma, well controlled. History of colon cancer, s/p sigmoid resection and chemotherapy 6 months ago. Symptoms include DOE, increased, thick mucous production.

• Albuterol nebulizer and home health ordered. Gemifloxacin and Mucinex prescribed. Return in one week for chest CT if symptoms have not demonstrated improvement.

• Megace ordered due to decreased appetite and unplanned weight loss of 31 pounds in last year. BMI 18.5.

□ J44.0 COPD w/ Acute Lower Resp. Infection

□ J44.1 COPD w/ Exacerbation

□ J44.9 COPD, unspecified

□ J45.909 Unspecified asthma, uncomplicated

□ C18.9 Malignant neoplasm of the colon, unspecified

□ E43 Unspecified, severe protein calorie malnutrition

Documentation: The provider thinks:“COPD… what do I choose? The first one looks good!”

The provider thinks:“Oh wait, secondary diagnoses…” and chooses…

This Photo by Unknown Author is licensed under CC BY‐SA

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What Was Wrong?“If He Hollers, Let Him Go”

1. Chosen code: J44.0 COPD with acute lower respiratory infection

Did the provider ever document a lower respiratory infection

(e.g., chronic bronchitis, pneumonia)?


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AHA Coding Clinic® for ICD‐10‐CM and ICD‐10‐PCSFirst Quarter 2017 Pages: 25–26

If asthma is documented, without any further specificity of the type of asthma, only COPD would be reported.

2. Chosen code: J45.909 Unspecified asthma, uncomplicated

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3. Chosen code: C18.9 Malignant neoplasm of the colon, unspecified

Is there documentation describing the status of the colon cancer (i.e., history, current/active)?


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4. Chosen code: E43‐ Unspecified severe protein‐calorie malnutrition

Did the provider malnutrition at all?

Or were only symptoms of unplanned weight loss, BMI, and decreased appetite?

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What should have been coded based off the current documentation?

What was missing?

What should have been coded?

• J44.1 COPD with exacerbation

• Z85.038 Personal history of other malignant neoplasm of large intestine

• Z92.21 Personal history of antineoplastic chemotherapy

• R63.4 Abnormal weight loss

• R63.0 Anorexia

• Z68.1 Body mass index (BMI) 19.9 or less, adult


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What Documentation Would Provide Further Clarification?

• Further specification of the type/severity of asthma

• Identification of lower respiratory infection (e.g., acute bronchitis, pneumonia)

• Clarify status of the colon cancer

• Clarify presence & severity of malnutrition

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Polling Question #1

• What is your most commonly encountered error in provider self‐coding?

– Assigning more specific codes than are supported in documentation

– Assigning less specific codes than are supported in documentation

– Assigning codes for undocumented conditions

– Missing code(s) for clearly documented condition(s) including required additional codes

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Common Issues: Failure to Capture

Appropriate Diagnosis Codes

• Missing status codes

– Personal history

– Allergies

– Acquired absence of limb

– Acquired absence of organ

– Transplant status

– Noncompliance

– Presence of implants or devices

– Dependence upon device or machine


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• Failure to provide additional codes based on conventions such as “code first,” “code also,” and “use additional code” instructional notes

– Identification of the contributing organism

– Underlying etiology/disorder

– Associated complications

– Associated injury or wound

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Confusion as to what is considered reportable

Documentation states:

• Renal dosing for antibiotics due to decreased renal function – CKD

Missing code:

• N18.9‐ Chronic kidney disease, unspecified stage


• Continue Bumex, to see cardiologist next month for management of heart failure

Missing code:

• I50.9‐ Heart failure


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Common Issues:Documentation Does Not Match Code Specificity

• The unspecified code is assigned when documentation supports a more specific code

• A more specific code is assigned without supportive documentation


• Acute monoblastic leukemia

Code assigned:

• C95.90 Leukemia, unspecified


• Depression

Code assigned:

• F33.9 Major depressive disorder, recurrent, unspecified

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Common Issues:Codes Are Assigned w/o Supportive Documentation

• Providers often describe a condition, referring to lab values or diagnostic interpretations, but don’t actually state the diagnosis in their documentation

• The provider believes that the documentation clearly supports the code describing the condition


• Sodium level 158 mmol/L

Code assigned:

• E87.0 Hypernatremia


• Pneumonia, cultures positive for MSSA

Code assigned:

• J15.211 Pneumonia due to methicillin susceptible staphylococcus aureus


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Common Issues:Provider With a Lack of Understanding of the Guidelines

The provider assigns a code for a diagnosis documented as being

uncertain

The provider does not sequence correctly for

capture of the first‐listed diagnosis

The provider assigns a secondary diagnosis that cannot be reported with another diagnosis (Excludes1)

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Identifying and Preventing Provider Self‐Coding Errors


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Formulating a Solution:CDI & Coding Professionals Should Be the Leaders

• Your coding compliance plan should require regular auditing of provider coded accounts

• A system should be in place to identify and prioritize vulnerable diagnoses or encounters for audit (patterns of denials, audit results, tracking & trending)

– Random audits to identify concerning trends

– Focused audits of identified problems

• Specific providers

• Specific diagnoses

• Specific encounter types

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Providers should receive targeted education based on

audit results

Providers should receive ongoing education on ICD‐10‐CM coding conventions, Official

Guidelines for Coding and Reporting, and Coding Clinic

related to common diagnoses/conditions


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• Drop‐down boxes and code choices should be continually reviewed and changed to support/encourage proper code assignment versus reimbursement concerns

– What choices are listed

– Sequencing of those choices

– Quality control

• Are the codes offered correct?

• Are the codes updated to reflect regulatory guidance?– Coding Clinic

– Annual ICD‐10‐CM updates

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• Providers should have easy access to timely assistance

– Who do they call/email?

• Selected central contact(s)

• Coding information help desk

• Easy access coding resources

• Tip sheets/documentation pointers

– Specialty specific

– Encounter specific


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Polling Question #2

• Do your providers receive coding education based on the Official Guidelines for Coding and Reporting, including coding conventions & the AHA’s Coding Clinic?

– Yes

– No

– Sometimes


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Developing a Provider Education Plan

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Develop an Education Plan:Don’t Go In Blind! Do Your Homework!

Assess

Analyze

PlanImplement

EvaluateNurses …

Does this look familiar?


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Assessment: Establish Baseline “Function”

Complete a random audit of the provider’s documentation to identify errors in code assignment. Use a check sheet to capture objective data (trend & track).

• Coding errors (type of error)

– Failure to capture an appropriate code

– Missing specificity to match assigned code

– Choosing the unspecified code when a more specific code would be correct

– Code assigned without supportive documentation

• Identify the “etiology” of the error

– Simply choosing the first offered option

– Incorrect application of coding guidance

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Analyze

• Analysis of the data should help identify areas in need of improvement

• Identify strengths and opportunities

Notice I said “opportunities,” not problems!


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Plan

• Know your audience

• Identify the best method to communicate

– One to one—face to face

– Email feedback with follow‐up

– Phone consultation

• Communicate the data/facts (motivators!)

– Peer comparison (risk scores, quality scores, E&M, denials)

– Financial impact

• Use concrete, personal documentation examples

– Before & after comparisons with rationale

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Implementation: Putting the Plan Into Action

• Review the results

• Offer education and rationale to capture opportunities

• Leave written summary of your discussion for later review—with your contact information

• Contact provider the following day to say thank you and reinforce teaching

– Email/phone/face to face

– Identify timeline for revaluation/assessment

– Provide “tip sheet” related to identified opportunities

• Include contact information for Q&A, troubleshooting


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Evaluate

• Establish when you reevaluate/audit the record for progress and ensure you return with the new assessment when complete

• Compare the results to those completed prior to the education

– Identify areas of improvement

– Identify areas of needed opportunity

Reward and provide positive feedback when behavior is modified!

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Concepts to Reinforce in Your Education Plan


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Concept 1:Complete Documentation Equals Accurate Code Assignment, Which Equals …

Provider documentation of diagnoses & plan of care

Assignment of ICD‐10diagnosis codes & CPT codes

Influence:DRG assignmentDenials‐Medical necessity‐Clinical validityProfessional E&MQuality scores‐Hospital (HVBP)‐Provider (MACRA, MIPS)‐HEDIS measuresSeverity of illness (SOI)Risk of mortality (ROM)Patient risk score (RAF)

Notice the impact reaches beyond just OP/provider services!

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Concept 2:The Rules of Code Assignment

Coding is an exact discipline where the clinical documentation must exactly match the coding terminology for a code to be assigned.

There are strict guidelines and direction related to:

• When the documentation is sufficient to assign a code

• Which code to assign with which clinical indicators

• How to sequence the codes (identification of the first‐listed diagnosis)

“Close enough” only works in horseshoes!


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Concept 3:Specificity Is Key

• Specificity is required for:

– Medical necessity (coverage determinations)

– Risk‐adjusted payment methodologies

– Completeness of code assignment based on guidelines

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Concept 4:Beware of the Dangers of Cut & Paste

It is the physician’s responsibility to determine the diagnoses applicable to the current encounter and document in the

patient’s record.<AHA Coding Clinic, First Quarter 2015>

Documentation for the current encounter should clearly reflect those diagnoses that

are current and relevant for that encounter.

<AHA Coding Clinic, First Quarter 2015>


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Eeeny‐meeny‐miney‐mo,Catch a tiger by the toe,If he hollers, let him go,My CDI told me to pick the very best one,And you ARE it!

Empower your providers with the knowledge of code assignment and the ability to confidently choose the “very best one.”

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Thank you. Questions?

[email protected]@hcpro.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


D1 PPT 7 2019 OPCDI Symp Pitfalls Self Coding Prescott ... 7... · to rule out osteomyelitis. Prescription for antibiotics and home health to assist with foot care. E10.9 Type 1 DM

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