Engaging at the Bedside
“Here come the ‘chart police.’”
Every clinical documentation specialist (CDS) has heard it. “Chart police.” For those CDSs with a nursing background, it is often heard from those nurses they have worked alongside in the following ways:
(1) when discussing their new role
(2) while explaining their current role
(3) when attempting to recruit bedside nurses into the CDS career path.
How do we educate our bedside-loving peers about the value that their documentation brings to the final coded record? Show them.
Nurses love evidence.
It has been the foundation of nursing practice since Florence Nightingale demonstrated that good hygiene improved outcomes. Pull up a stand-alone encoder and show them the difference made by inclusion of wound staging or body mass index. Clinical documentation integrity is an obscure role to most nurses so take the opportunity to translate the language. Instead of demonstrating the MS-DRG, show the difference in severity of illness (SOI) and risk of mortality (ROM) when including their documentation. Interpreting SOI and ROM is a quicker soap box discussion than CC/MCC capture and translates clinically with almost no discussion.
ICD-10-CM Guidelines for Coding and Reporting allow us “few exceptions” to the rule that “code assignment is based on the documentation by patient’s provider” but, nurses need to know that their documentation often triggers CDSs to know that a query opportunity exists. Default templates utilized by providers may repeatedly explain that the patient is oriented, but night shift nurse documentation may paint a different picture of a sundowning patient. That picture is incredibly valuable to the accuracy of the coded record, particularly when the provider is documenting in progress notes when assessing the same patient during the day.
The remote world has done wonders for production but can put a strain on those opportunities to engage our healthcare partners and demonstrate value. Other ways to engage our nursing colleagues in understanding the value of their education: round with them during an onsite day, engage nursing management to become part of the nursing skills fairs (quality documentation is inarguably a skill), or seek out the opportunity to present to new nursing hires during orientation.
Measuring body mass index (BMI)requires the following equation:
BMI = (weight (lb) ÷ height2 (in)) x 703
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.
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.
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.
Since we have passed the one-year anniversary that COVID-19 was first identified in the United States, it is important to reflect on the long-term effects of COVID-19. Throughout the pandemic, the Intellis team has worked diligently to update COVID-19 resources. Research continues to evolve as the medical community seeks to better understand the disease’s impact, and the passage of time presents the opportunity to evaluate the effects on body systems.
According to the Journal of the American Medical Association, the pandemic has been accompanied by a COVID-19 “infodemic” with more than 11,000 COVID-19 papers submitted to JAMA since the start of the pandemic! It can be overwhelming to keep up. Our White Papers serve as a guide to remind coders and clinical documentation integrity (CDI) specialists to dig deeper into the medical record to uncover overlooked diagnosis documentation. The goal is to highlight some, but not all, of the commonly seen complications in the patient population infected with COVID-19.
“1 in 2 people with very low kidney function who are not on dialysis do not know they have CKD (chronic kidney disease).” — Center for Disease Control
The implications of untreated or unmanaged kidney disease can be life-altering or lethal. CKD is a manageable co-morbid condition in its early stages with the potential for reversibility, however, once chronic kidney disease hits the later stages, management of the disease becomes significantly more resource consumptive. CMS is now in line with the clinical information by updating the most recent version of their HCC’s to reflect that even moderate CKD impacts the patient’s risk.
The intention of hierarchical condition category (HCC) coding is to utilize the patient’s medical conditions, demographics, and interactions of the patient’s diseases to calculate a risk adjustment factor (RAF) score. The RAF score conveys the severity of the patient’s conditions in a calendar year in an attempt to reflect the level of resource consumption required to manage the patient. Anyone assigning diagnosis codes, regardless of setting, should be aware and educated on this risk-based payment methodology.
Inpatient care, awareness of kidney function matters for the management of other disease processes and medications. In coding, the accuracy of appropriate staging does not just impact the care rendered. Accuracy also ensures that the patient’s RAF score accurately reflects the resource consumption of their disease process. Through code assignment and documentation, the diagnosis can be linked to those underlying conditions that most often cause degradation of the kidneys- hypertension, and diabetes.
In earlier versions of CMS-HCCs, CKD did not carry significant risk (as demonstrated through weight) until the patient’s disease had reached stages 4, 5, or end-stage renal disease. In this case, the eGFR (estimated glomerular filtration rate) has typically dropped below 30, demonstrating a serious impact on the ability to clear waste products from the bloodstream.
CKD stage 3 (eGFR typically ranging 30-59) was not recognized as a hierarchical condition category code. This changed, however, with the introduction of CMS-HCC version 24. Why the change? CKD stage 3 (N18.30) has clinically significant ramifications for comorbid disease management and medication usage. Treating and managing a patient with CKD stage 3 before progression to later stages has a significant impact on the health of the patient. CMS did not outright make this statement but it’s a clinically logical deduction from the understanding of CKD disease progression.
In the inpatient setting, CKD stage 3 is not recognized as a complication or comorbidity (CC) so clinical documentation specialists may be overlooking this important risk adjusting condition. It is important that whether functioning in the inpatient or outpatient setting, CDI specialists and coders focus on getting accurate information reflecting the patient’s health status documented in the medical record. Take a deep look at the details of the patient encounter next time “CKD, unspecified” (N18.9) appears in the record.
Wondering about those more specific CKD stage 3 codes? Look for more information regarding CKD stages 3a and 3b in future tips!
Now that we have been applying the new 2021 E/M guidelines for over a month, there’s no doubt that we have questions about some of the changes — especially the elements in MDM! Starting Feb 9th, Jeanie Heck, our Director of Education, will begin addressing “E/M Hot Topics” in monthly 10-20 minute presentations.
For additional information about E/M Updates education, contact us.
When anemia NOS is present as a current condition, and the patient has underlying chronic kidney disease (CKD) or end-stage renal disease (ESRD), it is a fast track to the usage of D63.1, Anemia in chronic kidney disease (manifestation). This is assigned unless the anemia is specified as a different form and/or attributed to another condition. Much like the diabetes category, ICD-10-CM “In/With” convention assumes “due to.”
ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I. A. 15.
The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).
For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.
Anemia refers to the reduction of the total number of circulating red blood cells. It is diagnosed when there is the detection of decreased hemoglobin concentration, hematocrit, or red blood cell count. Anemia in chronic kidney disease specifically falls under the category of decreased red blood cell production.
In CKD or ESRD, kidney function is compromised to the point that blood cannot be filtered of wastes and fluid. The kidneys also produce less erythropoietin (EPO), a hormone that signals the bone marrow to produce additional red blood cells. Furthermore, in CKD patients the red blood cells are not able to survive as long in the bloodstream and suffer a premature death. Due to associated nutrient deficiencies in underlying CKD, red blood cells are not reproduced as frequently or with the same cellular integrity as in a healthy patient.
Education Disclaimer: This coding tip is intended to serve the general community and may not account for all differences in coding routines, duties, or individual client policies. The information and opinions presented here are based on the experience, training, and interpretation of the author. Although the information has been researched and reviewed for accuracy, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This information is intended as a guide; it should not be considered a legal or consulting opinion or advice.
As healthcare continues to evolve, more procedures and care options have moved forward in the outpatient setting. This is primarily due to technological advances and value-based care incentives.
Health insurance plans and government programs have embraced the move toward offering more services in lower-cost care settings such as outpatient facilities. As the trend toward outpatient procedures continues, what is ahead for Percutaneous Coronary Intervention? Intellis Manager of Medical Coding Integrity & Education David Steinhage RHIT, CCS examines what is on the horizon in our latest IQ Point of View.
Get the IQ Point of View: White paper – Percutaneous Coronary Intervention in the OP Setting
Thousands of coding and CDI professionals from across the nation joined us for our AHIMA-Approved continuing education webinars. Following the success of our 2020 Q1 Coding Clinic Review and our COVID 19: Outpatient Coding & CDI webinars, we are adding two encore live webinars to our schedule.
Wednesday, August 26, Noon:
2020 Q1 Coding Clinic Review
Please mark your calendar and register for our 2020 Q1 Coding Clinic Review webinar. Attendees who complete the webinar can earn one AHIMA-Approved CEU. The webinar includes a 1-hour education session presented by the Intellis VP of Education & Training Kim Felix, RHIA, CCS.
This webinar includes guidance on:
- Malnutrition Q&A
- Diabetes Complications
- Spinal Tethering Procedure
- and many other important and relevant topics
Register for the LIVE webinar:
For information, please contact us: Intellis IQ Team.
Wednesday, August 19, 1:30 pm:
COVID 19: Outpatient Coding & CDI
We are focused on COVID-19 coding and CDI, and we’re quick to recognize and share critical changes as they become available. Our education and training webinar is led by Intellis IQ experts VP of Education & Training Kim Felix, RHIA, CCS and VP of Clinical and Quality Services Allison Van Doren, RN, BSN, CCDS, CDIP, CRC. Attendees who complete the webinar can earn one AHIMA-Approved CEU.
The information presented is based on trusted healthcare sources including the American Health Information Management Association (AHIMA), the American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services (CMS). The education presented is monitored to reflect the most current healthcare and industry updates.
- ICD-10-CM updates
- CPT/HCPCS/Telemedicine Procedure updates
- OP CDI updates
Register for the FREE live webinar:
For information, please contact us: Intellis IQ Team.
Our COVID-19 coding and CDI education and training webinars are AHIMA-Approved for CEUs. We are constantly focused on COVID-19 coding and CDI, and we’re quick to recognize and share critical changes as they become available. Our FREE education and training webinars are led by the Intellis IQ team of subject matter experts. The information presented is based on trusted healthcare sources including the American Health Information Management Association (AHIMA), the American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services (CMS). The education presented is monitored continuously to reflect the most current healthcare and industry updates.
Schedule your FREE live webinars today!
Email our Intellis IQ Team
For information call: 484.264.1609
Each webinar includes a 1-hour education session presented by the Intellis IQ team of industry experts. Download the webinar overview or view below.
COVID-19 has struck with stunning ferocity causing uncertainty across the healthcare landscape. Beyond patient care and staff safety demands, the crisis has evoked unprecedented health information challenges to medical coding and billing and clinical documentation integrity (CDI). Intellis’ immediate action continues to set the pace by providing three avenues for information and education from trusted healthcare sources and Intellis subject matter experts (SME). To date, nearly 1000 medical coders, HIM leaders, and CDI specialists along with 18 health organizations have benefited from Intellis’ commitment to sharing FREE COVID-19 educational resources.
One Site for Information
As the HIM industry grapples to respond and provide clear direction, ambiguity reverberated as national health organizations release evolving updates. Intellis CEO David Van Doren said, “At the outset, we recognized the huge impact of COVID-19 on health information management (HIM). With our distributed workforce, we were instantly positioned to assist providers. Further, we created our IQ Crisis Team to consolidate and share HIM information.” On the Intellis website (IntellisIQ.com), the team developed a single source where HIM professionals can obtain current COVID-19 directives and latest news from AHIMA, AMA, CDC, and CMS (intellisIQ.com/COVID-19). Each day, the website is updated as information becomes available. Also, Intellis prepared — and continually updates — Coding Tipsheets and FAQs. The Intellis IQ COVID-19 page has been visited nearly 2,500 times and the Tipsheets referenced over 1,700 times.
One Source for Online Training
To assist in disseminating timely HIM information, Intellis opened the IQ Center, the company’s education portal, to offer several FREE courses to ALL industry professionals. Intellis’ industry-recognized SMEs VP Education & Training Kim Felix, RHIA, CCS, VP of Clinical and Quality Services Allison Van Doren, RN BSN CCDS CDIP CRC, and Director of Education Jeanie Heck, BBA, CCS, CPC, CRC present coding- and CDI-related updates based on AHIMA and CMS information (education.intellisIQ.com).
One Team for COVID-19 Education
As the health crisis evolves, Intellis experts presented COVID-19 coding and CDI webinars based on AHIMA and CMS information to 18 health organizations. The one-hour sessions focused on ICD-10-CM, MS-DRG, and IP CDI updates for inpatient settings, and ICD-10-CM, CPT/HCPCS/Telemedicine, and OP CDI updates for outpatient settings. Each presentation was followed by a Q&A session. CoxHealth IP Coding Supervisor, Health Information Management Dianne Pierce, RHIT, said, “I would like to thank the Intellis educators for providing thorough, updated coding and clinical advice concerning the evolving COVID-19 pandemic. We had all of our IP and OP auditors and CDI Leadership attend at least one session and have included information we received in our policy which our coders are currently using.” Beth Israel Deaconess Medical Center (BIDMC), Director of Coding and Validation Susan B. Cohen, RHIA CDIP CCS, wrote, “Thank you so much for offering these webinars. They are so well done, and the staff really appreciate learning. Keep them coming!”
As the crisis continues, Intellis is committed to education sharing and contributing to the HIM knowledge-base. The COVID-19 online resource page, IQ Center courses, and webinars will continue to be updated as information evolves. Dates and times for updated webinars will be announced soon. Please contact info@intellisIQ.com for additional information.
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At Intellis, our team shares a deep-rooted passion for innovation, education, and a drive to solve complex HIM challenges. With experience, best practices, and agility, we combine advisory services with flexible end-to-end solutions to address revenue cycle management and data quality issues. Our expertise improves outcomes for both providers and patients. The Intellis IQ Suite includes revenue cycle management, health information management, clinical documentation integrity (CDI), health information technology, and education and training solutions. For more information, visit www.intellisiq.com.
Cassidy Communications, Inc. for Intellis
Kelly C. Vanek: 610.217.5011
Our COVID-19 resources and information page is here to keep you updated on the evolving pandemic. It includes information from public health organizations, HIM organizations, and our subject matter experts intended to share HIM best practices. For education presentations and resources regarding COVID-19, please visit the Intellis IQ Center, our HIM education portal.
Consider these questions about your team’s query compliance practices:
- Are you aware that the Office of Inspector General (OIG) is concerned with, and monitoring for, inappropriate query practice?
- Is your health system adhering to AHIMA’s Guidelines for Maintaining a Compliant
- Could use of templates be interfering with your ability to maintain an appropriate
- How can you monitor and maintain a highly compliant query process?
An Intellis Query Compliance Power Hour will help ensure your health system is on the right track. A Power Hour is an informative session taught by experienced presenters to address specific health information management concerns, provide up-to-date information for industry professionals, and promote best practices.
This Power Hour, focusing on appropriate query practice and compliance, is presented by Intellis Vice President of Clinical and Quality Services Allison Van Doren, RN BSN CCDS CDIP CRC.