CDI tip: Share your knowledge

March 10, 2022

CDI Strategies - Volume 16, Issue 10

by Lori Drodge, RHIT, CCS

The importance of knowledge sharing cannot be underestimated especially during this budget-infringing pandemic. Many of us struggle with finding time to keep up with new resources, network with others, or attend educational sessions needed for obtaining continuing education credits necessary to hold our certifications.

Finding the time to keep ourselves up to speed starts with looking inward and prompting ourselves with a few questions.

Are reviews of pre-billed cases and denials done by staff with both clinical and coding knowledge?

Answering “yes” to the above questions ensures “clinical truth,” as my friend and past-ACDIS Regulatory Committee member Cesar Limjoco, MD, likes to say. It also ensures the capture of appropriate MS-DRGs, and when these cases are discussed with both the CDI and coding teams, it allows for shared learning from each team.

For example, I recently reviewed a case involving alleged lack of clinical indicators for acute hypoxic respiratory failure (J96.01) in the documentation. I agreed with the assessment but before closing the case, wondered if the principal diagnosis of acute and chronic systolic congestive heart failure (I50.23) and the secondary diagnosis codes of hypertension (I10), hypertensive chronic kidney disease (CKD) (I12.9), CKD stage 2 (N18.2), and ischemic cardiomyopathy (I25.5) were correctly assigned. The workup revealed that the patient did have ischemic cardiomyopathy. The etiology of acute on chronic heart failure (the diagnosis the patient was admitted for), however, was not documented. Therefore, chapter nine of the Official Guidelines for Coding and Reporting supports assuming a link between the acute on chronic heart failure, hypertension, and CKD. Codes I10 and I12.9 were deleted, I13.0 was added as the principal diagnosis, and the DRG remained 291 without J96.01.

And don’t be tempted to assign unspecified codes without careful review. Patients who are admitted with aphasia (R47.01) and found to have an intracranial hemorrhage (I62.9) will be assigned DRG 66. A review of the CT scan, however, can reveal that the hemorrhage is located in the frontal lobe (I61.1) which changes the DRG to 65.

The same DRG impact occurs when I62.9 is assigned with a principal diagnosis of neoplasm of unspecified behavior of brain (D49.6) versus assigning I61.1 as a secondary, more specific code. See Coding Clinic, first quarter 2013, pp. 28-29 for more discussion.

Remember, there is a hierarchy of authority within code assignment instructions: The Alphabetic Index guides us to the correct code set but the tabular list provides us with additional instruction related to code assignment. The Guidelines as well as Coding Clinic provide additional advice for that code assignment.

The alphabetic index for a post-procedural air leak is J95.812: leak > air > post-procedural. The Guidelines, p. 16 state:

“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in.”

Additionally, p. 101 of the Guidelines states:

“In determining principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines.”

See also Coding Clinic, Fourth Quarter 2013 pg.98-99 and ensure that documentation is clinically valid. Recent literature defines a prolonged air leak (PAL) as an air leak lasting beyond postoperative day 5.

To “get back to the basics,” as we were reminded in the January/February CDI Journal, a simple toe amputation may seem straight-forward to code. And it is if you remember to look for resection of the metatarsal. Detachment of toe versus partial ray has DRG impact (see Coding Clinic, second quarter 2017, pp. 3-4, for the definition of a ray).

Are there free tools to use for educational purposes?

There are a few tools online that can help you make quick quizzes for your staff. One I use frequently is FlexiQuiz. With it, you can create a short quiz question, check the box for the correct answer, copy the quiz link into an email, publish the quiz, and email the group that a new quiz is ready. Quiz results are posted for the person who created the quiz. At the end of the day, email the question, correct answer, total number of respondents, total passing grades, and a resource that briefly explains the answer.

Tip: If you have a tricky case scenario and cannot find an answer after conducting your own thorough research, you can ask the American Hospital Association questions by creating a free account. The Regulatory Committee provided a detailed look at how to make comments and ask questions in this November 2021 CDI Journal article.

AHIMA and AAPC both provide free CEUs for in-house educational meetings. Contact them for details. Discussion of missed query opportunities, frequent denials, challenging operative notes, quality assurance findings, new codes, MS-DRG or Guideline changes, etc., are great topics for monthly educational meetings for CDI specialists and coders.

Need to know more about quality measures?

Check out the ACDIS Regulatory Committee’s detailed quality map on the ACDIS website.

What are other ways to gain knowledge?

Volunteer to serve on an ACDIS board or committee. Networking is one of the best ways to gain knowledge. Click here to read up on the various committee descriptions and learn more about their current members. No one knows everything. Share your strength with others.

Here are some other helpful links to useful information and insight:

Become an ACDIS member: https://acdis.org/membership/membership-benefits.
Join your local ACDIS local chapter: https://acdis.org/chapters/new. Visit websites such as projectconverge.net and brundagegroup.com/resources/
Review forums and talk groups
Review Hot Topics: https://acdis.org/resources/industry-hot-topics-insight-ambiguous-inconsistent-conflicting-advice-and-guidance
Become a member of important adjacent organizations:
Listen to podcasts:

There are many ways to share and gain knowledge. Let’s hear what works for you.

Editor’s Note: Drodge is the DRG coordinator and CDI liaison for an acute care hospital in Maine. She is also an approved ICD-10-CM trainer and member of the ACDIS Regulatory Committee. Contact her at racklodge1@gmail.com. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.

Found in Categories:

ACDIS Guidance, Clinical & Coding