Radio Recap: ICD-10 documentation’s devils in the details

No one thought ICD-10 implementation was going to be easy, but after a few months of working with the new code set, 19% called their implementation process just that—easy. Another 73% said implementation was only moderately challenging, and just a handful called it “difficult,” according to an ACDIS Radio poll.

As facilities head into the second half of year one in ICD-10, CDI specialists and coding staff are noticing some anomalies within the code set. The smallest detail—or lack thereof—in the documentation can affect reimbursement dramatically, says Judy Sturgeon, CCS, CCDS, clinical coding and compliance manager at Harris Health System in Houston, who spoke on the December 23, 2015, program. Because of this, she says, coders and CDI specialists need to understand which details matter.

Skin procedures
In ICD-9, if the physician admitted a patient with an abscess and performed an incision and drainage, the procedure—incision and drainage of skin and subcutaneous tissue for an abscess—mapped to the medical DRG group for cellulitis regardless of whether it was performed in the operating room, says Sturgeon.

In ICD-10, added documentation details can shift the code out of the DRG grouping for cellulitis and into the DRG for surgical procedures for infections. If the physician documents “incision and drainage of the foot,” the DRG does not change because the procedure is focused on the general anatomic section. If the physician documents “incision and drainage of the skin,” it still remains a medical DRG. But if the physician clearly documents an incision into the subcutaneous tissue or fascia, the DRG could shift to surgical DRG.

“This is definitely an opportunity for CDI to get surgical detail that didn’t matter in ICD-9,” says Sturgeon.

Newborns and obstetrics
Under ICD-9, physicians documented common diagnoses such as hernias, hemangiomas, hydroceles, and heart murmurs—which Sturgeon refers to as the “4 H’s”— and coders simply reported them (according to AHA Coding Clinic for ICD-9-CM, First Quarter 1994, p. 13, and Second Quarter 1989, p. 14). Now, physicians must be actively treating these conditions for the coders to report them, says Laurie Prescott, MSN, RN, CCDS, CDIP, CDI education director with HCPro in Danvers, Massachusetts.

Under ICD-10, “all conditions have to meet criteria for secondary diagnoses,” says Sturgeon. “You no longer get a freebie for things documented at discharge.”

On the other hand, she says, “we’ve been given something in return.”

Take the case of a newborn who is in observation due to a mother’s suspected drug abuse. In ICD-10, whether the drug abuse is suspected or confirmed, it can be picked up and coded, says Sturgeon.

“If you have clear documentation showing extra lab tests or moving the baby up to a Level II nursery for monitoring,” she says, coders can pick that up.

For moms who have a perineal laceration at delivery, first- or second- degree lacerations do not shift the DRG out of the normal vaginal delivery DRGs, Sturgeon says. If it’s a third- or fourth-degree laceration and documentation includes surgical detail on the repair, it could map to non-extensive, or extensive, procedures unrelated to the principal diagnosis, which affects the DRG. The bottom line, she says, is that “CDI specialists need to be paying attention to the moms, not just the babies.”

Hepatic coma
In addition, there have been a number of hepatic coma changes. Persistent non-transient unconsciousness is now considered a coma and MCC, says Richard D. Pinson, MD, FACP, CCS, principal of HCQ Consulting in Houston. Hepatic coma is now classified as hepatic failure, with or without consciousness.

Previously, coders could report coma if the patient had symptoms of impending failure: now, however, hepatic encephalopathy will not apply unless the patient is comatose.

“This is a huge hit in terms of MCCs,” says Pinson. “It’s a dilemma, and I wish they’d change it.”

CDI should also be aware that metabolic encephalopathy—due to fever, dehydration, hypoxia, and organ failure—is now an Excludes1, meaning the coder should never use the excluded code with the code above the Excludes1 note (the two conditions cannot occur together), according to Allen Frady, RN, BSN, CCS, CCDS, senior consultant at Optum360 CDI, during a December 9, 2015, webcast, “CDI in Transition: Breaking Bad Habits for ICD-10 Queries.”

The condition maps to an MCC for some subset of the patient population, but only when the criteria for encephalopathy are met—meaning the patient must be comatose, says Frady.

Toxic liver has an Excludes2 note, meaning the excluded condition is not part of the condition the code represents, but a patient may have both conditions simultaneously, and may be reported with alcoholic liver disease, which could result in an MCC. This also requires the patient to be in a coma, Frady says.

Sepsis
New coding guidance may ameliorate some of the struggles facilities face regarding reporting a diagnosis for sepsis, says Pinson. Furthermore, an international task force released updated definitions for sepsis and septic shock in the Journal of the American Medical Association in February.

The new definitions state:

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Updated clinical criteria and definitions were needed, the report said, since the multiple definitions and terminologies led to discrepancies in reported incidences and observed mortalities. Despite the new criteria, coders and CDI specialists must adhere to the existing coding and documentation rules.

Under these ICD-10 coding rules, there is no longer a default code for urosepsis, and SIRS due to pneumonia no longer tracks to sepsis, says Pinson.

“I think the changes in ICD-10 are excellent,” he says. “They now put the coding classification in line, and it is comprehensible in terms of clinical practice and the standards of sepsis.”

Facilities have historically struggled with sepsis diagnoses, says Pinson. Systemic infections, like unspecified sepsis, were actually classified as septicemia, whereas sepsis was classified with SIRS codes. Septic shock also had a separate code.

“This created a lot of confusion,” he says. In ICD-10, systemic infections are now classified as sepsis, which includes septicemia. “If we have a patient with unspecified sepsis, we have that systemic infection code,” says Pinson. “Now, instead of SIRS codes, we have two simple codes that identify sepsis when it is severe and if there is sepsis shock associated with it. We add an additional code—either severe sepsis or severe sepsis with septic shock—and we eliminate the whole SIRS concept.”

Unfortunately, there’s not a code or indexing for infectious SIRS, Pinson says. This means infectious SIRS can no longer be coded when a patient has pneumonia—it would simply be coded as pneumonia.

There are still codes for non-infectious SIRS, Pinson says, including the cause of SIRS and codes for non-infectious SIRS with or without acute organ dysfunction. Urosepsis is no longer codable unless it is qualified.

For example, sepsis documented with urosepsis clarifies it. Further, bacteremia is excluded from the diagnosis of sepsis, so there’s no need to query.

“Overall, thumbs up on the sepsis changes,” says Pinson. Moving forward If there’s anything CDI specialists can take from ICD-10, it’s this: Pay attention. The smallest difference, whether a word or a sentence, can paint an entirely different clinical picture.

The industry has survived the hard part—implementation. Now, it’s time to move forward and identify ways to use documentation effectively to improve not just reimbursement, but also the quality of patient care. Doing so doesn’t have to take hours of additional work or training.

“From a practical standpoint, there are very few [changes] that require new or additional queries,” Pinson says. “The quantity of queries makes no difference.”

Editor’s note: ACDIS Radio is a free, bimonthly Web-based discussion with industry experts and stories from practicing CDI specialists. For information, visit www. acdis.org/radio.cfm.