Today’s Tip: Lupus

Today’s Tip: Lupus

Lupus Coding TipWhen Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible.

For instance, document SLE (systemic lupus erythematosus) instead and add any complications that accompany this diagnosis.  It is often accompanied by Sjogren’s syndrome or Sicca syndrome, which have very specific codes.  Another solution is to develop facility or provider-specific guidelines to report M32.9 (SLE, unspecified) as a default for Lupus, unspecified.

Today’s Tip: Drug-induced Neuropathy

Drug-induced neuropathy (D62.0) is a diagnosis often missed by even the savviest and seasoned coders. It is sometimes seen in documentation as ‘CIPN’ (chemotherapy-induced peripheral neuropathy) and is a common side effect caused by antineoplastic agents.  Treatment includes steroids and nerve pain medication such as Gabapentin.

Drugs related to neuropathy

The most likely chemotherapy drugs related to neuropathy include platinum drugs, such as oxaliplatin; taxanes, such as docetaxel; vinca alkaloids, such as vincristine; and myeloma treatments, such as bortezomib.  This code can also be accompanied by another code for the adverse effect (T36-T50) to identify the drug. 

Today’s Tip: Cachexia (R64)

Cachexia (R64) is also known as ‘wasting’ or ‘wasting syndrome’. It is a general state of weakness involving marked weight and muscle loss. Emaciated is another term that may be found in the documentation that also maps to code R64.

These diagnoses are often missed since they are commonly only seen in the Physical Exam or Review of Systems portion of a record. There are often ‘knee-jerk’ reactions that can lead a coder to investigate further if a patient may have these diagnoses. 

What to look for

Cachexia is commonly seen in patients who have AIDS, cancer, or other advanced heart or lung disease. You will often see a lack of appetite, fatigue, low BMI, and malnutrition. Look for nutritional consults and a PEG tube in the documentation to trigger the search for cachexia in the documentation. 

Why is this so important? 

Cachexia is a diagnosis that can affect reimbursement for both Inpatient and Risk Adjustment. Don’t miss it!

 

E/M Hot Topic: Telemedicine Update

Jeanie Heck, our Director of Education, begins our 2022 series of E/M Hot Topics with a discussion on Telemedicine. January’s Hot Topic provides an update from the CMS Final Rule​ as well as some reliable and reputable sources of information regarding telehealth.

For additional information about E/M Guideline Updates education, contact us.

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E/M Hot Topic: Social Determinants of Health (SDOH2)

In our E/M Hot Topic discussions, we previously addressed the proper capture of Social Determinant of Health (SDOH) codes that can make a difference when determining the level of service for office visit codes. When used properly, they can impact the final MDM selection and subsequent reimbursement. In the November E/M Hot Topic, Jeanie Heck, our Director of Education, re-addresses this topic and reviews the new 2022 Chapter Specific Coding Guidelines for SDOH.

For additional information about E/M Guideline Updates education, contact us.

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E/M Hot Topic: Telehealth

In September’s E/M Hot Topic, Jeanie Heck, our Director of Education at Intellis, discusses telehealth. The 2022 Medicare Physician Fee Schedule Proposed Rule proposes that CMS allow some telehealth services to remain on the list until the end of 2023. This is intended to help determine if some of the services should be permanently added to the telehealth list following the COVID-19 PHE. During this presentation, Jeanie reviews some trustworthy and reliable sites to reference regarding telehealth.

For additional information about E/M Guideline Updates education, contact us.

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E/M Hot Topic: Drug Therapy Requiring Intensive Monitoring for Toxicity

August 2021

In this month’s E/M Hot Topic, Jeanie Heck, our Director of Education, discusses “Drug Therapy Requiring Intensive Monitoring for Toxicity”. This falls under the HIGH level in our Risk element or level 5 (99205/99215). We now have a published definition for this in our 2021 CPT manual.  This definition was further clarified by the CPT editorial panel in the Errata & Technical corrections document.


For additional information about E/M Guideline Updates education, contact us.

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E/M Hot Topic: Time

July 2021

In July’s E/M Hot Topic, Jeanie Heck, our Director of Education, discusses the new guidelines for Time and the Prolonged Time codes. The new 2021 E/M guidelines are significantly different from the way we previously used to account for Time. She also addresses the latest technical corrections regarding Time from the AMA’s webinar at the end of May and gives some documentation template examples to help educate your providers.


For additional information about E/M Guideline Updates education, contact us.

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E/M Hot Topic: Takeaways from AMA’s 5/25 Webinar on E/M Office Visit Technical Corrections

June 2021

In this month’s E/M Hot Topic, Jeanie Heck, our Director of Education, addresses some of the items from the AMA webinar on May 25th regarding the Technical Corrections published on March 9th. Many of the gray areas from the technical corrections were addressed in the AMA webinar, and she discusses some of them in her presentation.


For additional information about E/M Guideline Updates education, contact us.

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Immunodeficiency Status Codes

New codes were created in October 2020 to report specific causes for a patient’s immunocompromised state. Previously, there was no way to capture a patient who was immunocompromised or immunodeficient. The only way was to use the “long-term use of drugs” and/or the conditions related to the immunocompromised state.

 

So what does it mean when a patient is immunocompromised or immunodeficient?

 

An immunocompromised state refers to the weakened condition of an individual’s immune system that makes it less able to fight infections and other diseases. When the immune system fails to respond adequately to infection, it’s called an immunodeficiency, and the patient may become immunocompromised.

Treating a patient who is immunocompromised poses more risks and challenges; therefore, it is important to identify a patient with this status whether coding hospital Inpatient/Outpatient or Physician Office records.

Why is this important for coding? 

The new D codes below are all Complications/Comorbidities (CCs) that will impact the MS-DRG for inpatient reimbursement. And they also have an effect on Risk Adjustment Scores for Medicare Advantage patients since these codes are CMS-HCCs (Hierarchical Condition Categories).

Multiple codes may be assigned to show immunodeficiency due to multiple causes (e.g., cancer and antineoplastic medication). In cases where the cause of the immunosuppression is not clearly documented, query the provider.

D84.821 Immunodeficiency due to drugs

Immunodeficiency due to medications that interfere with the immune system. These medications include but are not limited to immunosuppressants, corticosteroids and chemotherapy.

D84.822  Immunodeficiency due to external causes

Immunodeficiency caused by external factors such as exposure to radiation therapy or due to bone marrow transplant.

D84.81 Immunodeficiency due to conditions classified elsewhere

Created for an immunocompromised state due to a specific medical condition such as HIV, AIDS*,(See explanation below) certain cancers and genetic disorders that are classified elsewhere in ICD-10-CM.

D84.89 Other immunodeficiencies

*There was an update in the First Quarter 2021 Coding Clinic that clarified the use of D84.81.  “It is not appropriate to assign code D84.81, Immunodeficiency due to conditions classified elsewhere, together with code B20, human immunodeficiency virus (HIV) disease. Immunocompromise/immunodeficiency is part of the clinical picture in HIV disease, and code B20 captures fully the immunocompromised state.” Fortunately, there is an Excludes1 note under code D84.81, excluding B20, confirming that HIV/AIDS is not coded here.

Here are some examples of the new Immunodeficiency Status codes in practical use directly from Coding Clinic:

Question:

A patient was seen in the emergency department for cellulitis of two fingers on her right hand. She was admitted to start intravenous antibiotics due to having an immunocompromised state caused by immunosuppressant medication that she takes for systemic lupus erythematosus (SLE). What are the appropriate code assignments for the admission?

Answer:

Assign code L03.011, Cellulitis of the right finger, as the principal diagnosis. Assign codes M32.9, Systemic lupus erythematosus, unspecified, for SLE, D84.821, Immunodeficiency due to drugs, and Z79.899, Other long-term (current) drug therapy, for the patient’s immunosuppressed state due to long-term use of immunosuppressants.

In this case, the immunosuppressant medication was prescribed by the provider to suppress the patient’s immune system. An adverse effect code is not assigned when the medication has achieved its intended result in lowering the patient’s immune response to systemic lupus erythematosus.

 

Question:

A patient with multiple myeloma was seen for ear pain and cold symptoms due to acute otitis media of the left ear and acute viral bronchitis. The provider documented that the patient is immunosuppressed due to current long-term chemotherapy. What are the appropriate code assignments for this encounter?

Answer:

Sequence either code J20.8, Acute bronchitis due to other specified organisms, or code H66.92, Otitis media, unspecified, left ear, as the first-listed diagnosis. Assign codes D84.821, Immunodeficiency due to drugs, for the patient’s immunosuppressed state as a result of chemotherapy, and T45.1X5A, Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter. In this case, immune suppression is not part of the intended effect of the antineoplastic drugs and is coded as an adverse effect. Additionally, assign codes C90.00, Multiple myeloma not having achieved remission, for the multiple myeloma and Z79.899, Other long term (current) drug therapy, for the chemotherapy.

 

BMI and the Query Conundrum

Measuring body mass index (BMI)requires the following equation:
BMI = (weight (lb) ÷ height2 (in)) x 703

The Result?

BMI = A physiologically misleading indicator used to classify health status. Misleading because weight divided by height squared (x 703 to make up for the metric system) tells us nothing about a patient’s bone density or muscle mass, both of which tell us a great deal about a person’s physical health. This misleading indicator is then broken into categories that patients are often bucketed into: underweight (below 18.5), normal (18.5-24.9), overweight (25.0-29.9), obese (30.0-39.9), morbidly obese (over 40) without consideration of gender, ethnicity, age, or athleticism variances. Well-conditioned athletes and weightlifters often have notoriously high BMI’s due to exceptional bone health and increased muscle mass.

Clinical Significance

Coding Clinic addresses in Fourth Quarter 2018 that “obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented, the body mass index (BMI) code may be coded in addition to the obesity or morbid obesity code.” But what happens when the provider has not documented a diagnosis? One cannot assume the clinical significance of a number without an associated diagnosis. Without more information about a patient, we cannot be sure that the elevated BMI requires a diagnosis or is simply a numerical finding without clinical relevance because the patient is a world-renowned bodybuilder.

An Inherent Issue

Clinical documentation integrity (CDI) specialists and coders are often trained to look for the BMI and the accompanying appearance of an associated diagnosis when a high or low value is noted. There is an inherent issue in this practice. Recall the inpatient guidelines for reporting additional diagnoses (Section III. Reporting Additional Diagnoses: General Rules for Other (Additional) Diagnoses):

“For reporting purposes, the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or treatment.”

The burden of proof rests on the CDI specialist or coder to demonstrate that a condition met “other” diagnosis criteria yet was not documented when initiating a query. Aside from being a questionable result to a math equation, how did the patient’s elevated or low BMI impact their hospital stay?

Many CDI specialists default back to “weight-based medications.” Can you identify the weight-based medications in a patient who did not receive anesthesia? Every nurse took a course in medication math to get through nursing school. If your patient received a heparin infusion at a weight-based dose, did a weight of 285 pounds in a 5’5” patient impact nursing care more than a weight of 285 pounds in a 6’5” patient would have when calculating a dose? There is an argument for therapeutic treatment varying but before you ask the question, be sure your argument is sound.

Indicators

There are indicators to look for that justify that some BMI-related diagnoses may be clinically significant. Read the nurse’s notes. Fully dependent or even partially dependent patients requiring “max assist” or “OOB w/ assist x2” demonstrates that additional nursing care was required. Specialty beds come at a premium and provide support to patients above and beyond that of a traditional inpatient bed. Nutrition consults to help a patient with a BMI of 17.0 gain weight are obviously targeted treatment.

Be on the lookout for “other” reasons for inaccurate BMI and avoid falling into the traps. Patients and clinicians are usually not accurate when guessing a patient’s weight. If you see a solid even number (say 300 pounds) entered into the electronic medical record, do some digging to see “how” the patient was weighed. Standing scales and bed scales are far more accurate than “self-report.” While it seems very specific, be mindful of bilateral amputees. Most electronic records automatically calculate BMI based on the input height and weight. Any amputee requires special consideration for the percentage of body surface lost.

Performing the CDI role is to assess a patient without the use of your senses. For those with a clinical background that required patient assessment, the CDI role requires that you do the same assessment without ever seeing, touching, or hearing the patient. Querying for accuracy in the patient record takes unique skills and it is important to exercise those skills prudently when attempting to assess a patient with a potentially misleading number.

Need help keeping your Coding and CDI teams up-to-date? Contact us to find out how we can help. Intellis offers in-depth education and training services led by our IQ Team of subject matter experts.

A Deeper Dive into the Code Changes for CKD Stage 3

The ICD-10-CM code for Chronic Kidney Disease (CKD) Stage 3 (N18.3) has been revised for Fiscal Year 2021. The most recent update to the CMS-HCC Risk Adjustment Model has CKD Stage 3 making an impact on Risk Adjustment Factor scores. On the other hand, CKD Stage 3 is not recognized as a complication or comorbidity (CC) in the DRG world of coding.

Not only do the new codes for CKD Stage 3 give more specificity and capture more detail, but they also help to define more precisely the edge within Stage 3 at which mortality becomes the main concern.

The new codes are as follows:

  • N18.30  CKD, Stage 3 unspecified
  • N18.31  CKD, Stage 3a (GFR = 45-59)
  • N18.32  CKD, Stage 3b (GFR= 30-44)

Kidney disease is often asymptomatic and occurs just before kidney failure. About one-third of the population of older adults have CKD Stage 3. When someone is experiencing Stage 3, it means their kidneys are filtering about half of what they should be, allowing for some fluids, electrolytes, and waste to build up in the body.

CKD often starts to develop without notice. However, symptoms may appear in Stage 3. For those that do experience symptoms, these may include fatigue, swelling around the ankles or eyes, unusually light-colored urine, urinating more frequently, and loss of appetite.

Once an individual has Stage 3 CKD, it’s generally considered to be irreversible. Fortunately, the majority of Stage 3 patients do not progress to the more severe stages. Still, it is important to work with a doctor to manage the condition and gain a clear picture in regard to the GFR and kidneys. This helps to identify the need for kidney replacement therapy sooner and essentially helps to keep the patient healthier longer.

References:

https://www.fairview.org/blog/A-Third-of-Older-Adults-have-Stage-3-Chronic-Kidney-Disease

https://academic.oup.com/ndt/article/22/9/2728/1842891