Round Table 142: Navigating ICD-10-CM Diagnosis Coding Hot Spots

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0:04	Everyone, and welcome to Roundtable 142. This is our first roundtable on the Year 20 22, So thanks for joining us today.
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0:24	My name is Scott …, I’m the vice president of Coding education and continuous improvement for sciences.
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3:47	Yeah, great. All right, thanks, everyone. Welcome to today’s webinar. Thank you, Scott. So as Scott mentioned, today’s webinar is going to be Navigating ICD 10 CM Diagnosis, coding hotspots. And then the next webinar, we’ll dive into some PCS coding hotspots. So, I do, first, I guess, first up, we have our agenda for today.
4:11	And I only have an hour, so I picked a couple of things. Principal Diagnosis selection, I think that’s always a good topic to discuss, and we’re gonna go over some case studies there. And then we’re gonna kind of take a brief kind of intermission break.
4:26	An ad break, I guess, to talk about examples of breaking the with guideline because that’s going to come into play when we’re going over our principal diagnosis selection. And I think all of you can probably relate to some of these. You know, if you’re a coding manager or coding, call it. you’re probably seeing some of these things on your, your findings.
4:42	So, for any of coders on the call, or any other other people that are actively coding, just, we want to provide some examples of breaking the width guideline. I think there’s still some confusion. Of course, it makes sense.
4:56	I mean, the guideline has changed so many times over the last couple of years. It’s, to me, it’s also open to interpretation.
5:05	And when we do have coding clinic that has been supplying us with some interpretation as well, via published coding connects and non publish coding clinics, I wish they would publish, publish them all. Sadly, they don’t.
5:19	I think they give, you know, the ones that we’ve written to them about, I feel like they’ve given us a very clear picture of what we’re looking at with the, With the, with the, with the width guideline. So, anyway, kind of the next thing I want to talk about is the updated guidelines regarding ladder reality. It was They updated that for 2022. And I kind of put in parentheses with specificity because it goes along with our Specificity of Codes, which is always an issue on our quality reviews Right, Getting to the most specific code available.
5:49	So, we will spend some time on not as well, at the end. So, let’s get started. Interestingly, I know, before I get started, I heard some some interesting news. I think it was, within the last week or so, about the they did a, they did the pig heart transplant.
6:05	So I just looked that up and there is actually an option, an option for zoo, plastic tissue for the heart transplant. I don’t know if anyone else has heard about that in the news. Let me know in the comments if you have.
6:19	Yes.
6:21	OK, Scott, can you still hear me? Are you still here? I have 1 or 2 people talking about the sound.
6:32	And just before I officially get started just to kind of this is only approved for rahima. This is not approved for APC.
6:42	So, if you’ve had trouble with a PC in the past, that’s why these are not approved by a PC.
6:49	If you are six employees, please refer to our Yammer group for more information.
6:58	Oh, good. Some of you have heard about the pig transplant. I thought it was interesting. If anyone hasn’t heard about that, I think there’s a couple of interesting points about that not, you know, ethically, morally, you know, I’m not gonna get into that, but I did verify. We do have an option for heart transplant. We have an option for Z Z plastic.
7:15	So if there was coming to fruition, anytime soon we do already have a code for heart transplants involving … plastic tissue, so I just thought I’d mentioned that. It was on the top of my mind.
7:31	Yeah, very exciting. Indeed.
7:34	OK, so let’s get started with our case one Principal Diagnosis Selection. So obviously this isn’t the full the full chart, right? So I took, you know, we took some liberties here just to kind of give us an idea of what’s going on with this patient.
7:47	So what I want everyone to think about, as we go through this case study, is, what are possible Principal Diagnosis? I want everyone to think about this. You know, as you read through a chart, you should be considering, You know, this is our principle, this is not our principle, what are the guidelines that we’re applying in the situation? So we have an elderly met female. She has a past medical history of a-fib, heart failure with preserved ejection fraction. So if we do see heart failure with preserved ejection fraction, what are we going to code that out? I’m throwing that out as like a little quiz there. We also have chronic kidney disease, hypertension.
8:21	So, if we’re thinking about our coding guidelines there, we’re going to assume the relationship there with the heart failure, chronic kidney disease and the hypertension.
8:29	However, we want to kind of keep in mind there, you know, we do have some guideline that says, if it’s not related to the hypertension, that we’re not going to link it, right? So, we want to keep that in mind, as we’re reading through our cases, as well, because we do see a lot of errors where these have been linked or not linked. And we have to take into consideration the with guideline. And also, the interpretation of that guideline that’s presented to us in Coding Clinic and Coding Clinic, I would say, is an official source. They’re one of the co-operating parties. They even mentioned them in the final rule as the person, as the organization or the one of the co-operating parties that’s responsible for providing us with education and interpretation of the guidelines.
9:07	When they’re not, You know, 100% clear are applying the guidelines to certain situations. So this patient also has dementia, and they also, they present with acute hypoxic respiratory failure. We also want to keep in mind perhaps our respiratory failure guideline as we go through this. So Day one, they’re going to do a cat scan to get better images of the lungs and rot, pleural effusion, and pneumonia. So they’re working up the cause of their respiratory failure. Why do they have respiratory failure? Day two, they said they are likely they likely volume overload secondary to CHF exacerbation as her BNP was elevated and she also has …. However, she hasn’t We haven’t seen much improvement with IV Lasix. And unfortunately Cretan is getting worse. CT chest findings are concerning for multifocal pneumonia starting on antibiotics, Vancomycin.
9:54	And as tree, own him.
9:59	And then, also, on day four, they confirm the speech therapy. They did an evaluation to confirm that the patient is silent silently aspirated to thin in mild liquids and they just, because they notice this on their speed, Their video swallow study day six, they say, acute, hypoxic, respiratory failure, Acute suspect primarily second year to aspiration pneumonia. In the setting of dysphagia, we also have to think about our suspect possible, probable, right, in this setting, continue.
10:28	…, I lost my spot, and fragile for seven days, strict n.p.o. for now until transitioning to comfort care. Dysphagia n.p.o.. Aspiration, precaution support with IV fluids now. They’re saying they have chronic systolic heart failure with depressed ejection fraction.
10:45	So initially, they say preserved ejection fraction, right, But then they did an echo and they see they have a depressed ejection fraction and they also have diastolic heart failure, secondary, to valvular heart disease, severe, and severe mitral regurgitation suspect, D compensation on admission. However, good urine output continue. Lasix and I am not suspecting CHS as the primary etiology As even with significant diaries. This no change in our oxygen requirement and in fact got worse day 7 and 8, they pretty much say the same thing. They suspect the primary issue is the aspiration pneumonia in the setting of dysphagia continue, the antibiotics. We have chronic systolic heart failure with depressed ejection fraction, diastolic heart failure, secondary, to value the heart disease, severe mitral regurgitation ILD, compensation, having good urine output. I’m continually success, tolerate it, but I’m not suspecting the CHF as the primary etiology.
11:36	OK, so possible, PDF options. For this case, I’m going to read some of the comments. So good, so for my first question about the preserved ejection fraction that is going to be diastolic heart failure. It’s a history of so that would be chronic diastolic heart failure. And then after study, we want to think about after study, right? So it’s still confirms, they have diastolic heart failure, They have a depressed ejection fraction would indicate which would indicate systolic So it would be acute on diastolic.
12:03	And they have D compensation, exacerbation, etcetera, So it would be acute on chronic, diastolic and systolic heart failure in this scenario.
12:12	OK, so let’s get back to our possible Principal Diagnosis.
12:19	So the main the acute condition POA. That is the main reason for the admission, the condition after study that was the reason for the admission. So, taking that into consideration, what would be are possible PDFs in this case?
12:32	So, we have someone, someone commented aspiration. Pneumonia is the PBX and acute respiratory failure is the MCC. And I think you could also flip them. But why would you? So, that’s what we want to think about, Right. Coders don’t think about optimization, but we want to first get this. We’re thinking through all of the thought processes here between guidelines, and also, then, we’ll think about optimization. I think that’s where you were going with rows. So, rosemarie, so, next, I’d let me read another comment. Acute respiratory failure versus aspiration pneumonia, How was the respiratory failure treated? We’re leaning more.
13:07	I’m leaning more toward the Aspiration pneumonia, Max DRG, and got the majority of the, the thrust of care.
13:14	So, aspiration pneumonia. The respiratory failure or someone else is saying, aspiration, pneumonia, acute respiratory failure, aspiration, pneumonia. OK, good. So I think we’re on the same page here. We also have Acute Respite, or someone else is saying, also, that the heart failure is also a queue. And one of the reasons for the admission. I agree with that, as a possible Principal Diagnosis. We wanna think about what’s possible, and then we can kind of eliminate from there, right?
13:40	So this is the last day of admission, right, I’m including the last day of admission again. You guys keep in mind these are just synopsys’s of the chart. And I’m basing. We’re basing our decisions based on what we have, OK, so whether you want to suggest a query that you can do also do that, if you don’t think there’s enough information to make a decision.
13:57	So if someone else is saying, the respiratory failure should be first, um, OK, so if someone else is saying, We would need to query, if the aspiration pneumonia is POA.
14:09	So, we want to keep in mind here after study, they say if we if we’re reading after study they’re linking, they’re saying that the patient patient’s symptoms were contributed to the aspiration pneumonia. So, we do not have to query for the aspiration pneumonia. If it was present on admission. On day one, they say they want to rule out pneumonia.
14:26	After that, they do start the patient on pneumonia. They see they have concern for pneumonia on their cat scan.
14:32	And then after study, it’s ruled in that they have aspiration pneumonia and they can they say, most of their symptoms are due to the aspiration pneumonia. So I don’t think this is needed. Again, we want to think a lot of coders also forget that. It’s after study right there, suspecting that, this pneumonia was the main etiology of their presenting symptoms.
14:52	OK, we’re gonna take a look at Good. So these are all good questions, Seip. Did they have a CPAP? They have event, I don’t think they had event.
15:00	Off the top of my head. But let’s keep keep going here and take a look at.
15:05	First, let’s take a look at our possible DRG options. I just plugged all the possible DRG options and we have respiratory failure acute on chronic systolic heart failure. And I’ve plugged in some CCS and stuff to acute. And this is based on how it was originally coded. I’m not saying these codes are right or wrong. These are this is what was originally coded by the coder. And you can actually comment, make comments about what you see is wrong about any of these codes, If you will. I do see some errors, But these are the codes that were originally code it. We have acute respiratory failure. And I’m not saying they were in this order either. So acute respiratory failure. We have acute on chronic systolic. Heart failure pneumonia, itis. We have hypertensive heart and chronic kidney disease, and we have acute kidney failure. That was another CC. On the case, and you can see here are relative weights or someone said that acute respiratory failure was possibly our Principal Diagnosis.
15:50	We have that’s 1.22. We have the CHF is 1.26 relative weight. 1.849 for us for the aspiration pneumonia.
16:02	We have a nice this, I don’t think this would meet the definition of Principal Diagnosis, and we can consider this, but I think this is going to be a new point here, but that’s my opinion.
16:13	So, are possible Principal diagnosis, as we think through this thought process, are listed here as possible … options, right? We want to think about acute respiratory failure guideline. We wanna think about the thrust of treatment. So, if I’m taking a look at this, they say, after study, the debate patients majority of symptoms were attributed to this aspiration pneumonia. And I see that’s the highest relative weight.
16:36	So am I going to waste my time thinking about this and dwelling on this too much further? When I know that that was like required, that was after study, that required the majority of the treatment.
16:53	So, let’s take a look. This is the initial coding.
16:57	You can see, I can see some additional things that were not suggested by that we’re not suggested that this, I believe this was an outside reviewer, So, we have 291, the relative weight is 1.2, 6, 8, 3, the rework to your Georgi, which I agree with, 1.771 point 84912. I agree with some of these other suggestions. No, but we can take a look at that. Next.
17:23	It would, they’ve rolled out the primary etiology or CHF, right. But it’s still possible, Principal Diagnosis that we want to consider in our thought process, right?
17:36	Um, Guys, if you’re having problem with sound, I only have a couple of maybe 2 or 3 people that are saying they were having sound issues, it could be that the streaming.
17:45	So, you might want to reload your page if you can hear me, OK. So, you can see they also put them on I believe that’s the CPAP code.
17:59	So, It’s streaming guys, there is no call in number.
18:09	OK, so, I see some couple of problems with this. But in the, in the grand scheme of things, I’m going to say, after we read all that documentation, the aspiration pneumonia to me required the thrust of treatment after study was that was the heavy hitter here. Right? That was what required the most work. They did a swallow evaluation. They gave them IV antibiotics, they did a cat scan, et cetera.
18:34	The respiratory failure, they did require a little bit of respiratory therapy There could potentially be our Principal Diagnosis, perhaps.
18:46	But again, the Aspiration pneumonias optimizing our DRG here.
18:50	And it also meets the definition Principal diagnosis. So, let’s go on to the next slide I have here. I wanted to talk about this, because it relates to what we’re talking about today. So the recommendation here is on the slide they recommend sequencing the 13 Point O as a secondary and sequencing the pneumo Notice as the principal diagnosis. based on the definition of Principal Diagnosis. Where two or more diagnosis, or two or more inter-related conditions meet. The definition of the principal diagnosis. However, what did you guys see? If we look at this documentation, chronic systolic heart, failure with depressed ejection fraction, second, narrative valvular heart, disease, severe, mitral, regurgitation …, compensation on, admission, do you even agree with the … 13 code?
19:55	So, someone is saying they don’t see the diagnosis from, it’s probably because it’s underneath here. They couldn’t fit everything here. But does every, does anyone agree with this? I 13 code, that’s kind of what I’m questioning right now.
20:15	OK, so, So does the width guidelines still apply?
20:30	OK, so heart failure with preserved ejection fraction, due to valvular disease, no heart failure, linked to value. So no. So we’re not going to link this to the hypertension, and let’s go to the next slide. So we’ll talk about this more in the upcoming slides, but because this, this heart failure is attributed to something other than hypertension, we’re not going to link the hypertension, and heart failure, so this is this, it would be incorrect. Advice.
20:56	So, we’re gonna interrupt that case study, we’re going, before we go to a case study, too, and we’re gonna go over the width guideline, because I think this is where we struggle, or some of us struggle with understanding the width guideline. So, let’s talk about the width guideline application of the width guideline.
21:15	We’re pretty much all familiar, or re unless you’re, you know, just starting out, coding. We should all be familiar with assuming the relationship between hypertension, chronic, kidney disease, and congestive heart failure because of the with guideline that states. And it’s there on the screen, right? The word with her. and they added in, I think two years ago, you know, anemia in chronic kidney disease, we can assume the relationship there. We talked about that, I think. The last roundtable. So, it’s not just with, but it’s the with. Or N should be interpreted to mean associated with or due to when it appears in the coat title the alphabetical index, either under a main term or sub term, or an instructional note in the tabular list.
21:52	The classification presumes a causal relationship between the two conditions. Linked by these terms and the Alphabetical Index or tabular list. These conditions should be coded as related in, even in the absence of provider documentation, exclusively linking them, unless the documentation clearly states the conditions are unrelated.
22:09	And I think that’s where the confusion comes in.
22:11	What does it mean when they say this conditions are unrelated?
22:13	Do they have to specifically say, hypertension not do, not due to chronic or yeah, hypertension, not causing chronic kidney disease? Do they specifically need to say that?
22:24	Or is it enough to say they have diabetic chronic kidney disease? Or is it enough to say they have CHF due to ischemic cardiomyopathy for us to unlinked those conditions from the known patient’s known hypertension? And that’s where we have to kind of use are other references, right? People may stop at this guideline, but we do have a bunch of other coding clinics that kind of give us advice. We’ve also, just to make sure, have written into coding Clinic, just to make sure that we’re interpreting that guideline correctly. And again, I wish they would publish all of them.
22:56	That way would be very clear to, to us about the width guideline.
23:02	Are actually just maybe just clarify the with, got, put, put it actually in the, with the actual guideline itself? Give an example, I think that would be very helpful. So anyway, and we know that this guideline has changed, its changed many times over the years. They’ve changed the wording, which, to me, didn’t make it clearer. And so they’ve needed to provide some clarification again, encoding clinic.
23:24	The one we specifically wrote to Coding Clinic about was CHF due to severe ischemic cardiomyopathy.
23:31	And of course we see that that presented to us quite frequently along with the CHF due to severe heart disease. Or severe mitral valve disease or a combination of valve, valvular disorders, or congenital heart disease. Whatever the case may be, we see them.
23:49	I’m linking the CHF from the hypertension and so many words right, they say CHF due to ischemic cardiomyopathy.
23:57	So we asked about this does, do they have to specifically say, you know, CHF not due to hypertension for us to on LinkedIn? And the answer is no. If they gave us a specific cause, then we’re good, so.
24:11	Know, the guidelines specifically says, These should be coded as related, even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.
24:22	So, then, if we go to Coding Clinic, they do, they do go into detail with, you know, for example, with hypertension with Diabetic nephropathy and chronic kidney Disease Coding Clinic third quarter 2019. I do have this in the slide deck. You don’t have to write it down. It’s coming, it’s upcoming. But just a reference that here, they do state that, you know, the chronic kidney disease is specifically stated to be due to diabetes then we would just code the eye 10 as an additional code. We wouldn’t automatically link that there was 1 from 20 18 that has been superseded. So, be careful which Coding Clinic you are looking at, and most make sure that you’re looking at the most recent one. So, let’s move on to our specific case study, case study, within a case study, here, we have our hypertension with example. The 60 year old male with an l-dap presented due to cough chess, congestion, shortness of breath, and fluid overload is a history of heart failure with reduced ejection fraction.
25:14	We know that systolic right, secondary to ICM or ischemic cardiomyopathy. The rejection fraction is very low at 18%. The patient is on home Miller own hypertension, CV. They also have hypertension CVA, Hyperloop edema pre-diabetes OSA. The discharge summary states that the heart failure with reduced ejection fraction is secondary to ICM and per Coding clinic. First quarter of 2017 page 47. The hypertensive link is broken. There’s obviously more than that Coding Clinic we mentioned the 2018, 1901 as well. The PX should be a 50.23 acute on chronic congestive heart failure. We recommend deleting the current … of …, 13 hypertensive heart and chronic kidney disease with hypertension heart failure in Stage 1 through 4 chronic kidney disease recommend adding I 12. So they didn’t unlinked chronic kidney disease and hypertension. So it’s still appropriate, code I 12.9, right? But they did say the CHF was specifically due to ICM.
26:09	So, in that case, they’re … the heart failure or from the hypertension.
26:14	So, we’re going to be coding … zero point two three acute on chronic systolic heart failure, and the I 12 as a secondary diagnosis. Of course, that L that, the presence of the Heart Assist device is RCC, in this case.
26:25	Um, you can see the DRG relative weight for MS DRG. It’s a change goes from DRG 291 relative Weight of one point two six eight three two two hundred ninety two with a relative weight of zero point eight six three five. Now, this, what did this did, happen to be an APR DRG. And there was no reimbursement change but it still matters based on ….
26:44	If you’re concerned with you know that, you know, so depending on the group or that you’re using or the the, the specific, excuse me, the specific refer that you’re using, it can have different impacts on your DRG assignment. I wanted to show both of them. Again, there’s no change for APR based on all the codes that we had on the account. However, if this was an MS, this happened to be an MS DRG. This would have been a DRG change.
27:12	So, this would be another example of our hypertension on linking of the hypertension. I just wanted to give these examples.
27:18	I think, everyone, most people are most coders most, um, coding professionals are pretty good at linking the hypertension with chronic kidney disease with CH chronic kidney disease. I think it’s the un linking that we struggle with a little bit. So, we want to remember to either link it or unlike it when appropriate, and make sure that we’re doing that. Again, you can see the impact here.
27:39	This is just one example, OK.
27:47	OK, so breaking the with her with the width or in link, I have some more examples. I’m not going to read these word for word, but I did reference this coding Clinic before hypertension with diabetic nephropathy and chronic kidney disease in this specific example. They say the chronic kidney disease is due to diabetes, and they also happen to have hypertension. They just tell us to code the diabetic, kidney disease, or chronic kidney disease and then the hypertension as a separate code. We’re not going to link them. We also had one back in 2018 regarding … syndrome, which is stress related, by definition. There was some instructional notes that seemed like we would be coding a combo code, like the 11.9 code. However, taking a look at that definition of … Syndrome, it’s clearly not due to die.
28:32	Hypertension is stress related stress, you know, heartbreak disease, whatever you wanna call it, stress stress on the heart that are stress related cardiomyopathy. That could potentially also lead to a myocardial infarction. But in this case, that’s another example of on linking the hypertension from heart heart disease specific example. So, you guys can read that. I just wanted to throw those in here as additional references to what we’re talking about today. We have talked about these before, so, but I am throwing them in here as a reference also, comparing that Coding Clinic, we just talked about hypertension with diabetic nephropathy and chronic kidney disease to the 2018 Coding Clinic with similar. A similar scenario.
29:14	Please note this has been superseded. This is the newer advice where they say that the provider documents, the chronic kidney diseases, due to diabetic nephropathy specifically. Now, what I’m not saying, which I know someone’s going to come back and say, that I said this when I’m not saying is, you know, if they don’t link the diabetes, or chronic kidney disease to anything specific, we can still code. We can still automatically assume the relationship between diabetes and chronic kidney disease and hypertension. It’s when they do, give us a specific cause, where we have to think about that relationship. So, we need to think about, are we going to link this, or not link this based on the documentation that’s provided?
29:50	Do we need to query? Those are all things that we have to think about. Coding can be complicated, right? But we have to kind of keep all of our guidelines in the back of our, you know, our thought processes, our secondary thought processes as we’re coding through a chart.
30:04	It’s, you know, it’s important that we understand the guidelines and how to apply them.
30:08	So, it’s, you know, this, that’s why I wanted to kind of go through these and provide different examples, OK.
30:17	OK, then, we also have another example. When we have a pressure ulcer, I still see coders doing this, so, I threw this in here. I know it’s not hypertension related, or diet diabetes related, what is diabetes related, but it’s not specifically hypertension and diabetes or chronic kidney disease? We have a pressure ulcer, The patient happens to have diabetic, peripheral vascular disease and neuropathy, but when the patient has a pressure ulcer that’s the different, that’s the specific cause. So, please feel free to read through this. You know, the primary reason here is the pressure ulcer.
30:54	This is not a diabetic ulcer. Um, you know, maybe it made it worse because the patient has diabetes, but there’s a specific underlying cause here of they’re calling it a pressure ulcer. So, we’re not going to assume the relationship here. Because they have other risk factors like peripheral neuropathy or angiography, and they also have diabetes. Pressure ulcer would not be one that we automatically assume a, A relationship with. In this scenario, we also had this, for those of us that have been coding for awhile, we also had a similar coding clinic in ICD nine, that might offer, I think it was with …. So that might offer another scenario, which is which it would still be similar, Right? Because the … was an attribute. It was attributed to the pressure ulcer, not the diabetes.
31:38	So, anyway, moving on to my GI bleeding example, and we have one example here, and I wanted to, this is another example of where we’re going to break the link, right? So, a patient, I’m gonna kinda paraphrase, feel free to read through this more, But patient has a direct transfer for GI bleed. They had a drop in hemoglobin from 11.9 to 7.8 for those of us that want to think about this clinically, what am I going to be looking for? Because I see a drop in hemoglobin?
32:05	Um, as coders, I think that’s also something that we need to keep in mind.
32:09	I know We’re not, you know, clinical, per se. But, you know, that the basic overall clinical information, we should have a basic understanding of. So if we see a drop in hemoglobin, what are we looking for? GI he was consulted. A colonoscopy yesterday was unrevealing, possibly from hemorrhage. So the thing we want to think about here is possibly this is in the progress notes after study. Was it possibly still from her hemorrhoids reporting, responding to procreate and …?
32:38	Can resume picks a ban and discharge home with outpatient follow-up? She only wants to follow up with our PCP, and she will see them that this week, the patient had a GI bleed bright red blood per ****** also, when we think about bright red blood. …. Um, typically, if they have bright red blood, correct them, what is the source of the bleeding?
32:57	Versus if we have no dark blood in the stool, what are we kind of thinking about there? OK, so next we have documented anemia. They have their Jehovah’s Witness. They can’t This is a good summary. I didn’t include every single progress note, but this this was a great a good summary here. So they have a hemoglobin of 7.8, or it dropped after numerous bowel movements.
33:19	She had bright red blood for approximately one week duration.
33:22	The cat scan showed Diverticulosis possible Khalida smile, Distention, Most likely lower GI bleed given amount of cheesier risk. Factors include AC, anticoagulation, past, GI bleed not up to date with colonoscopy and cancer screening. She’s written. She’s refusing all blood products even in life-threatening conditions due to religious reasons, Colonoscopy 12, 25, that with no evidence of active bleed, likely sources or external hemorrhoids.
33:47	So they say that again, they’re restarting.
33:51	Her a Pixabay, an aspirin, PO, PPI daily. Her iron procrit, the discharge summary, say she was a direct transfer, she, she was transferred because of, she said, she didn’t want blood products so they wanted to transfer to a higher level of care. She also has some history of heart disease.
34:10	So, on admission, her hemoglobin was 11.9, it dropped 9.3 and then to eight, and then she had a couple more fully bowel movements. On arrival, they have our stats there, she’s a minute to him on service. So after study should have lower GI bleed anemia. It was noted to be 7.8, or baseline is typically in the 12 range. She really, she received epogen an IV iron, obviously she didn’t want any blood transfusions. She got her PPI shudder when a colonoscopy which showed no evidence of GI bleed diverticulitis and it showed external hemorrhoids.
34:42	Um, I’m the global remains stable, and she is instructed to obtain a CBC in 3 to 4 days and follow up.
34:53	And then, given significant cardiac history, she underwent a TTE with mild concentric hypertrophy, elvie, disfunction, likely, et cetera, et cetera.
35:04	So what are your thoughts on this case?
35:08	OK, me go down here with the comments, OK.
35:12	So so when we’re talking about women, that first question I asked was about there, they’re, they’re dropping hemoglobin, right? So we’re thinking about anemia. In this case, they have active bleeding. So, we’re going to think about is this acute … anemia? Is this chronic blood loss anemia? Do I need to do I have documentation of acute blood loss anemia? This is a possible query opportunity, right? So, if they have bright red blood from per ******, that usually indicates that the patient is bleeding from the lower GI tract. So, the fact that they’re saying possible hemorrhoids are possibly from hemorrhoids to me is kind of matching up with the clinical information in the chart.
35:50	So, good, great job, everyone.
35:56	OK, so good. So, hemorrhoids So someone’s making a comment here. Hemorrhoids are lower GI bleed if due to hemorrhoids cannot code the bleeding.
36:08	And then we couldn’t possibly, I’m not sure if we would curb cut, code or query for the why would you query for the CEO CHF acuity here. Is there any evidence that she had? It was acute.
36:21	Well, what would indicate that to you that it would be acute?
36:25	She had acute exacerbation of or CHF.
36:35	OK, great, another commun as it could possibly be due to her anticoagulant. So that might be another option for a query.
36:43	If needed, Great. Great. Thank you.
36:47	OK. So obviously I didn’t include the full chart, acute but loss anemia.
36:57	Hmm.
36:58	A keyboard loss anemia was actually documented in the chart.
37:02	But I wanted to kind of, you know, kind of think through that process and say, Let me be on the lookout for that acute blood loss anemia.
37:09	So this was coded to and this was coded to hemorrhage of ** and ****. And acute post haemorrhagic anemia was coded.
37:21	Recommend deleting the current PDFs of 660 K 60 to 5 hemorrhage of ** and **** and adding new PD X of K 44 for residual Hemorrhoid Oilskin Tags. Now, remember, guys, reached last roundtable. We talked about non central modifiers. So if the possible, you know, the pot, the working differential diagnosis was ischemic colitis, and hemorrhoids. And after study for the last progress note, the date of discharge, they felt the bleeding was likely due to hemorrhoids.
37:47	Um.
37:48	So we have on discharge them saying the likely source was the hemorrhoids. If we look up hemorrhoids, hemorrhage is a non essential modifier.
37:56	So that’s included in the hemorrhoid codes. We don’t have to report and a different a different code. First. We don’t have to report it as It’s not gonna be reported as our Principal diagnosis. And it’s also included in the hemorrhoids codes hemorrhoid code because it’s a non central modifier. If you need more help on my non essential modifiers, please refer back to our last presentation. I’m kind of building upon that last presentation here. The Diverticulosis was also confirmed It was noted on her colonoscopy. It was also noted on the cat scan. However, in this case, they felt like the most likely source was the hemorrhoids, right? So, if they’re linking it to specifically or possibly to the hemorrhoids, would we link this to the Diverticulosis?
38:38	If they say the specific source was document as being the external hemorrhoids? So, in this case, it’s similar to the other example that we talked about with I’m linking or breaking the link between the bleeding in the diverticulosis.
38:54	We can encode the diverticulosis but we’re not going to code and not add the MCC of diverticulosis of large intestine without perforation or apsis with bleeding.
39:06	So, we can see here, because we’re using the hemorrhoids as RPD X after study. Of course, that was the most likely source of our bleeding. We have a DRG of 394. It actually goes down a little bit.
39:17	We still have RCC with the post haemorrhagic, anemia.
39:23	Et cetera.
39:29	OK, so someone’s saying wouldn’t likely be possible, So remember, this is inpatient right, or that we’re talking about … here.
39:36	So what’s the guideline for possible probable on discharge after study?
39:44	So, no. We’re not going to link it to the Diverticulitis because they’re telling us the most likely source is the external hemorrhoids.
39:58	OK, so going out step further and asking about the anticoagulants, that is another opportunity. Is that going to be our PD X though? Was that that did that, that?
40:06	What is it that D 68, 3 2 off the top of my head anticoagulant due to what is the extrinsic circulatory circuit cheating, anticoagulant? It’s not going to be our PD X, though. In this case, If we do query for that, Or if we see documentation for that, Would that be the Principal Diagnosis, in this case?
40:42	OK, good, so I thank you, Andrew. So he’s so we have one person saying, no, it wouldn’t be the PBX. It’s not, it’s not doesn’t require the thrust of treatment, it’s just another CC on the account. They just stop the medication and resumed it by discharge. They didn’t specifically, you know, treat them with, you know, reversal agents and transfuse them with, you know, fresh frozen plasma and, you know, try to correct that ….
41:09	Yeah, it can be the focus of if the treatment was focus that holding a reversing the effect, in this case, it really seems like the focus was her drop in hemoglobin per there. You know, them working up the cause of the GI bleeding. Again, it’s not going to be the same in every particular case. So, I want to stress that this isn’t going to be for every single case, We’re just looking at examples to aid in your decision making, and to kind of, so we kind of think through our guidelines that we have.
41:45	OK, so going back, Um, I wanted to address one more.
41:59	OK, so someone is saying we wouldn’t link it to the Diverticulosis, because it’s not linked to the Diverticulosis, but what it? But because of the width guideline, what if they didn’t say it was due to the hemorrhoids? How would the change how would that change the coding here if they just said GI bleeding, but they didn’t link it to anything?
42:17	Because of the width guideline.
42:22	So because of the width guideline, if you lookup diverticulosis and it says width bleeding, OK.
42:33	So, good, so you would link it. In that case if they didn’t give us a specific source of the bleeding because of the width, you would link it to the diverticulosis.
42:41	In this case you wouldn’t link it to the external hemorrhoids because we don’t have a with bleeding, but we would link if this would be a difference between a DRG 378 and a Georgi 394.
42:52	If this documentation was different.
42:57	Good. Great. Great job everyone.
43:02	Great. Yep, yep, then you’d be able to link the bleeding to the diverticulosis great job, so that’s what I’m getting at with these examples, is, we want to keep that with guideline in mind. Did they link it to something specific?
43:13	If they didn’t, then we have to follow our with guidelines, or potentially query, Right? So, to sum up, kind of the coding errors that I see with GI bleeding.
43:25	The specific cause or relationship was not stated but the GI bleed was coded without the combination code in the presence of a condition where the width guideline applies.
43:33	So, if they have GI bleeding and they find gastritis and diverticulosis, we can link it, right?
43:39	Because of the width guideline, they don’t give us a specific cause, we can link it to anything that has a width and then gotten in our Tabular.
43:48	Obviously, we want specificity, right? I mean, we may want to query that.
43:53	The call and another, Kate.
43:54	Another example is the causal relationship was stated, but the combination code was not utilized, so we have them specifically saying the GI bleeding. You know, we have the code or coding GI bleed, unspecified as the principal, but they linked it to the Gastritis.
44:09	So, we want to keep that in mind when we’re coding these charts. If we have an unspecified GI bleed, any unspecified code is our principal diagnosis, we should take be taking our second look. Do I have an opportunity? Because of the with, With guideline to linkage, we have a query opportunity here, et cetera. Do I have a guideline that says that this shouldn’t be the Principal diagnosis? Do I have tabular notes that say, this should be sequence first?
44:33	You want to think through that Even with the CHF, I see coders putting, you know, the height, the CHF code first, When they have hypertensive heart disease.
44:41	That doesn’t make sense, right? Because of the sequencing our instructional notes that saying to code first, the hypertensive heart disease.
44:50	That’s just another example. Another one we talked about this on our last wrote, Roundtable on non essential modifier so coating a hemorrhage. Melanoma with Kaleidoscope. … hemorrhage is a non essential modifier for …. So we’re not going to be coding a hemorrhage separately obviously. If the hemorrhage isn’t related to that, then that’s a different that’s going to be a different story. Also, sequencing errors a salvage of viruses in cirrhosis. So if the patient has a … viruses and they have cirrhosis, please check your indexing. Because there is an option for …
45:18	in the code book, which assumes the relationship there gastric viruses is another another another issue, or other rectal viruses. There is no in cirrhosis under those, but be careful with your …, right? And there’s also instructional notes there to make sure that you’re sequencing those correctly as well also coding. Or not coding coagulation disorders, either drug induced or due to an underlying disease process.
45:42	So a lot of patients that have liver disease do have underlying know deficiencies because of their liver disease and vitamin K are the quagga, apathy is due to their underlying leads. You know, they have underlying … due to their liver disease. So you want to be careful, you want to make sure you’re picking those up as well. On your GI bleed, or those are things to look out for when you’re coding GI Bleed cases, commonly missed query opportunities, we we still see a ton of these missed possible query for ….
46:13	So, unspecified anemia. If you have an unspecified anemia and they have active bleeding. You have a, you know, heme positive test, you have, you know, bright red blood of …, dom, you have whatever the case. Maybe even if it is not a GI bleeding case, but you have no the patient bleeding, you know, they’re bleeding out of their nose, there bleeding, you know, from a wound, that might be an opportunity for a query opportunity. They transfused them for low hemoglobin. They administered iron. We also saw in that case they gave them epogen because they were a Jehovah’s Witness, and they they didn’t want blood products. They monitored hemoglobin over a period of days.
46:48	Um, pathological findings. This is another one where we see missed query opportunities.
46:54	So the patient had a bleeding mass, it was identified as cancer on the path report the color did not query for the neoplasm and assigned the cancer as a PDF. We can’t cut off the pathology report again.
47:05	This is, this is mainly, this is for inpatient, I should say, and or coded the mass and did not query for the final pathology. So they just coded mass, but it came back as cancer.
47:15	That’s something if you know that’s an unspecified code, we should be querying.
47:18	This kind of ties into our last topic about specificity.
47:23	Then, corresponding diagnosis, or severity for malnutrition, a lot of times, with GI bleeding or cases of GI bleeding, we see malnutrition. You know, if a patient is on t.p.n., or two feeds.
47:38	Know, they have a low BMI, they have weight loss. And, again, most organizations that I’m aware of, they use aspirin criteria. Obviously, we can’t code based on aspirin criteria, but we can submit a query for malnutrition if we if it’s clinically significant, right? Muscle wasting weakness. Reduce crump, grip, strength, low albumin. I know that’s not one of the aspen criteria. But provider still use it.
47:57	And again, our coding isn’t based on clinical criteria that the provider uses, right? It’s based on how the the provider diagnosis the patient and their own criteria. That they’ve been, you know, schooled in dry, skin, poor wound, healing, edema, anemia. So you see these conditions, and you see the patients on Tube feeds. Their on t.p.n., they’re getting nutritional replacement. That might be, you know, something that you see some of these things in association with malnutrition, you know, we should be querying for severity. If it’s going to, you know, everyone has their own policy and procedure about quarrying, some places want to be queried for just DRG changes, severity of illness. Some places want everything you know some organizations want Everything queried if they have an unspecified code also specificity for a schema colitis.
48:44	Just keep in mind that acute filament is of MCC versus chronic unspecified as a CC, then, finally, miss coding or sequencing errors of D 68 3 2 hemorrhagic disorder due to extrinsic … with hemorrhagic disorder. So a couple of things there. We have ms. coding of that, but we also see coders coding this. When the patient doesn’t have a hemorrhage, they just have an elevated INR due to Coumadin you wanted this code is specifically when a patient has a hemorrhage. So just be careful with that. We do have an abnormal coagulation diff. You know if they’re specifically reversing the anticoagulation or they have an elevated INR but they didn’t actually progressed to hemorrhaging yet. That might be an opportunity to use the abnormal INR. But you want to make sure that they actually have a hemorrhage before you use D 68 3 2.
49:32	OK.
49:35	And here’s a summary of everything that we just talked about. I’m not going to read the slide, but it’s everything we essentially just talked about in a summary on this slide.
49:43	So, just for time’s sake, I’m going to move on to the next slide.
49:49	And just other references.
49:51	So we talked about the one example about no GI bleeding due to multiple conditions, And they didn’t specifically link it to anything, we have that Coding Clinic, GI bleeding, secondary to gastric ulcer or hemoglobin positive, still finding, uncertain, diagnosis, presumed related condition in the outpatient setting. So we do have that. Also, if you’re an outpatient coder and you’re interested in that, we have, there is a coding clinic on that as well. And then GI bleeding due to acute ischemic colitis. That talks about the non essential modifier. It’s an ICD nine, but it still applies to ICD 10 because the hemorrhage is still a non central modifier with colitis. It’s just a good example that I like to reference. So those are all additional examples. If it’s something that you still struggle with, I would reference these when coding your GI bleeding cases.
50:37	And here’s our other procedures. We’ll talk about this on another presentation, but just keep in mind that please make sure you’re checking your references in related to coding, GI Bleed cases and control of bleeding.
50:49	I do see, you know, GI bleeding with Epinephrine, injection, etcetera. Please double check these. When you’re coding these, I do see some errors. No, In most cases, it’s not affecting the DRG. Maybe if you missed a coil embolization or something but these generally aren’t going to change or DRG assignment. But, we want to make sure that we’re coding to the most accurate code, right? So, OK, Center as another one we should know that’s another one. We should be on another drug. It’s a reversal agent. We should be looking for that as well.
51:22	So now back to our next case study. Um, this is possible at mist MCC.
51:29	And you can see the original codes.
51:30	We have …, UTI, …, Chronic Kidney Disease, et cetera. We see here this is a patient, a 91 year old. And I’m just bringing, in this case, I’m just bringing to your attention.
51:43	no, bringing awareness about this MCC because I’ve seen this miss before.
51:47	So the patient is coming in. They’re having a workup for ambulatory disfunction they know on their MRI that they have acute … us and osteomyelitis.
51:57	They have some power vertebral, flag them on with infiltrates. They’re referencing the MRI here, or they have an 11 mm abscess. in the left psoas muscle.
52:07	They have severe knauss stenosis, um, they also, on the next progress note, they say they have asked possible … us.
52:17	They also have 11 mm, so it’s abscess. Again, they say … abscess. Status post CT guided lumbar biopsy procedures finding noted soft tissue noted.
52:29	Antibiotics were started empirically after the biopsy, will need 868 weeks of IV antibiotics, et cetera. The discharge summary says, So as abscess reviewed by doctor, indicates the slowest abscess say is too small to drain. The document ostia, despite us, you’ve seen by infectious disease, et cetera, and they recommend certain antibiotics.
52:53	So, what is our Miss CC? We see that the Ostia was coded, we see the … was coded. What else is missing from this?
53:09	I see one person saying abscess.
53:19	OK, good. So, so this abscess is something that was miss I’m bringing you. I wanted to bring awareness about the … abscess. The recommendation was to add K 6100 to the … muscle abscess that will add an MCC to the case. So you can see here, it went from 478, 2.35, 8, 4, 2, a 477, 3.3, 5, 8 9 reworked DRG. And they were addressing it, although it was too small to be drained, the patient still had the condition. Now, the coder may have been questioning this. They may have said, well, I wasn’t sure if they actually had the psoas muscle abscess. It wasn’t really clear to me. Well, if that’s the case, you see it impact has an impact on the DRG assignment. You can always query for clarification, right? If you’re not sure if they, if they actually think the patient has this psoas muscle abscess, So just to keep that in mind, it was thought to be too small to drain, but they still had it, right? And they’re still treating it.
54:14	So that was a missed CC opportunity just to go through the pathway here abscess Psoas muscle case 68 1 2 and then we have, it’s under the disorders of retro peritoneum and you could see here, so a muscle connects from the spinal areas. So if they have a lumbar spine, ostia are discarded as you can see this, the connection of the psoas muscle is right at the lumbar spine area. And then it also connect. It connects here. The connection here is that the femur.
54:45	So it’s usually related to disease in the lumbar vertebrae. It can extend into the psoas muscle. So if you see … if you see osteomyelitis of the spine, the potential for an MCC with this psoas muscle abscess is quite high.
54:59	And so, that’s why I’m bringing this to everyone’s attention as possible, know, a pass it. Just bring that to everyone’s awareness. That’s something to look out for when you’re coding these … cases.
55:17	Um, OK.
55:19	So this final case is a missed, it’s a query opportunity and that’s an opinion I personally didn’t think it needs to be queried, but also in mist MCC.
55:29	So that they recommended coding, adding a secondary code for acute pancreatitis without necrosis or infection.
55:37	They stay in the record that the patient had some elevated lipase throughout the stay. They did have a … They ended up having … after study but during the stay there there are lipase started going up and up and up after that. … just kind of sum this up.
55:56	They started documenting post … Pancreatitis is …
56:00	levels, were slightly elevated He did have some evidence of post ERC pate pancreatitis, but he is improved.
56:08	Doing much better. Today. He says, Is abdominal pain? It’s much better. His liver function tests have decreased. His lipase is normalizing.
56:16	Um, and he they go on and on about this post ERC pancreatitis, maybe it wasn’t listed on the discharge summary, for whatever reason I’m not sure.
56:24	But for clarification, the organization did want a query submitted for this before adding that the acute pancreatitis. So the query opportunity the query was submitted. And here is the sample query. And after the provider answer, the patient has acute post, the RSVP pancreatitis without necrosis or infection this person. This was procedure related.
56:51	And they kind of sum it up here, all the clinical information. That’s that’s about that as part of this chart. So, I did want to also bring this to our attention, as well.
57:04	I did previously talk about this on a post ERC pancreatitis, on a roundtable roundtable 130. If this is something that you’re interested in, please refer to that roundtable. This was another one that came through post …. Pancreatitis is a specific diagnosis. I know some people might argue saying, what was it pancreatitis, Postini RCP, um, But it is a specific, in this particular case post. Your CV pancreatitis is a specific diagnosis.
57:32	Pancreatitis … it’s also known as opposed to RSVP induced pancreatitis. It’s also known as …. I mean, I do put some of the slides from that roundtable within this dot this document for your reference. There’s some risk factors. What it is. So I’m not going to wear rate. You know, go through this word for word the pathogenesis why It occurs after a post ERC P, what puts the patient at greater risk, et cetera. And we talked about this on Roundtable 131 30, but I did want to mention, you know, coding complications.
58:04	Is this more than a routinely expected condition or occurrence? We want to make sure that we’re seeing a cause and effect relationship document it. If you weren’t sure, you can always query, like, this facility did. In this case, post ERC pancreatitis is a specific diagnosis, You can research this, you can go online to any of your references, and find that this is a specific diagnosis It’s commonly seen on post ERC P They actually have clinical criteria, consensus criteria, on this.
58:33	I know we don’t typically use that for coding, but there are consensus create criteria for this.
58:41	So, commonly we see these patients being seen as an outpatient ERC P and then they’re admitted post ERC P, because they develop severe abdominal pain. And there are they start trending their lipase, and it keeps going up and up and up. And they’re admitted for an N.p.o., and they’re saying that they’re P post ERC pancreatitis, and that’s why they’re being admitted.
59:02	The one thing that I’m going to say, I didn’t agree with was, not just adding the acute Pancreatitis code, but there is a code we should be coding K 9189. When there’s that clear cause causal relationship between the post ERC pancreatitis and the acute the acute pancreatitis is related to that post procedural step, post-production CGI complication. We have K 9989 other post procedural complications, and then we’re going to add the code for Pancreatitis. Katie 5 9, Oh, and then we also have that in our guidelines, I should have updated that for 2022.
59:36	These codes should be sequence first, to the complication code, followed by code for the specific complication, if applicable. And then, I have also here, on the left-hand side of the screen, typical management of acute Pancreatitis, whether it’s post ERC P or not, the treatment is pretty much the same. They’re gonna give IV fluids. They’re gonna get pain medication, or they may or may not give antibiotics.
59:55	They’re gonna fast the patient, on progress, the patient to clear liquids it’s going to be a low fat diet.
60:02	Then, in severe cases, you may even see them putting a feeding tube, severe acute pancreatitis. And then, also, they, they may do a cat scan or MRI to look for a pancreas, inflammation, pseudo, cyst, abscess, or other causes. And then they’re going to also manage, manage the Pancreatic Enzymes, MLAs and lipase, so just a quick rundown of treatment for our pancreatitis.
60:29	And here’s the consensus criteria.
60:30	We have 1 from 19 91, Sometimes it’s referred to cotton cotton criteria. You may see that in the documentation we also have the 24,012 Atlantic classification. And then we have the 2014 European Society of GI endoscopy.
60:45	Now, we have both of these classifications. You can read through these for clinical information. However, just to refer back to the most recent one that I was able to find, was that they recommend that either of the two definition be used. So it doesn’t matter. It’s interesting that they say that, but you can use either of these.
61:03	Are of provider may use either one of these two, diagnose the patient. But these help, you know if you’re seeing pancreatitis, I wanted to know include some clinical information for those of us that may not be, you know, have clinical clinical background so that we can use this to kind of make better decisions, are going to query something. I’m not going to query something.
61:22	Should I reach out to my CDI person partner and see if they think I should? You know this is why I’m referring it to you. I see an elevated lipase. I see severe a sudden. You know, abdominal pain.
61:37	Et cetera. After a you know, an ERC P, or maybe it’s not after ERC P, you just think they might have pancreatitis, That might be something that you can, you know, include in your statement to your CDI stuff, or vice versa.
61:50	And then finally, to sum this up latter Audi and specificity, just to kind of quickly go over this, I know I’m out of time. But just keep in mind, I want to throw this out here. That latter reality, we have an updated guideline that we can use other providers documentation for …. So, when Ladder Reality is not documented by the patient’s provider or code assignment for the affected side, maybe based on medical record documentation from other clinicians, if there’s conflicting medical record documentation, then we can be done. We can query codes for unspecified side should really be used. And then, we have the updated guidelines for 14 documentation by clinicians, other than the patient’s provider. You could see their … was added to the exceptions for documentation by other provider, so we can take … from other providers. We have talked about blood alcohol level, so I’m not gonna go into that right now.
62:43	But this is it kind of a sample case review of the top code concepts that we should be looking at that have been lacking specificity, lacking latter reality, specificity that you may want to consider in, you know, in your reviews. I know some people do smart review, Some people review all cases, whatever the case may be. These are things that we should be looking out for, For lack of specificity, or lack of …, because we now can take the latter Audi from other providers, whether this is inpatient or outpatient. We have arthritis and bone disorder, so if it is it the left knee, the right knee, is it, you know, a pathological fracture involving the you know.
63:22	And then the left or right hip are femur. These are all examples. I let me see my real examples here we had arthritis, staphylococcus, or arthritis, the coder coded as unspecified joint.
63:36	You know, maybe it was documented in the, by the provider, but, somewhere in the chart, they probably said which joint it involved was at the left, or, right?
63:44	Um, next, we have cellulitis, was it the right hand or the left hand, Was it the, you know, right leg or the left leg?
63:52	I mean, we can take latter reality now, off of other providers documentation, right? So, we should really be looking at specificity here and making sure that we’re not leaving that out complex regional pain syndrome. As it delay the left leg, the right leg embolism that includes thrombosis as well. So, should we be seeing acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity? When we can use other providers documentation? And not just other providers, documentation?
64:20	You guys tell me, what other documentation can we use if the patient has a fracture of, you know, a fracture?
64:27	Can we use something else other than, No, no, a nursing note that says, it’s the left or right leg.
64:33	Um, what else can we use?
64:35	Why continue on here? Hemiplegia, that’s another one. Is it the, you know, left or right side? That’s another one. that involves ladder ality traumatic fracture so if it’s is it the right or left orbit?
64:47	Is it the, you know, left or right? Maxillary, Beaune, is it the, you know, like we have, we can now use ladder reality from other Providers documentation? So, again, these are some other examples.
64:58	Conclusion of the lung, unspecified initial encounter. Should we be seeing conclusion of the lung unspecified?
65:06	Internal fixation device, is it the leg? Is it the right leg? I mean, it’s unspecified. But that might be another if it’s a complication of an internal fixation device, bladder. Reality, again, that was something involving … pressure ulcer.
65:17	This thing also includes non pressure ulcers on my it didn’t fit the whole description here for some reason. But pressure ulcers and ulcers, unspecified, is it the left or Right?
65:28	Heal, for example, Should we be using unspecified when we now can use … from other providers notes Unspecified II, So is it the left or right eye?
65:39	Again, …, this is all from coding, from, from, for Fiscal October first, right? When the guideline changed. So you can see here are the trends. You can see arthritis, you can see our Embolisms or hemiplegia as our injuries.
65:54	We should really be paying attention to our specificity and …, so that’s kind of what I just wanted to end with to kind of, you know. Make sure that we’re looking at that as coders, as QA staff.
66:05	That’s something that we should be paying attention to. We really shouldn’t be seeing too many unspecified codes, when we have can use that. Also, going to my question about, what else, other guideline guidance do we have?
66:21	What other guidance do we have? We can also use our X-rays, right? We have two different coding connects. I’m not gonna sit here and read them, but we have two different coating connectors that says that we can use the X-ray for specificity. We can’t code off the x-ray, but we can encode specificity of the x-ray and this one is regarding.
66:41	This is regarding fractures, and then we also have one about sites of cerebral infarctions and hemorrhage. So that’s basically what I wanted to end with, so thank you so much for attending.
66:56	You can download your CEU as Scott mentioned. We have our link here in the documents. You have two weeks from today to download it. You should get an e-mail. If not, please keep note that this, this, this link is provided to you during the live webinar, so, you can go ahead. Please, allow some time for it to get uploaded. If it’s not there, please check back tomorrow morning.
67:18	It does take some time for them to get that uploaded.
67:21	So, And we also provide our e-mail for whatever reason, if you’re not able to, to download that. So, that’s all I have for today, guys. I hope you found that helpful. Some reminders, or some, some, you know, I had a request to include some clinical information in there for coders that may not be as savvy with that, hopefully that helped a little bit. I only have an hour, so I’ll try to squeeze in as much as possible.
67:48	Hopefully going over some with examples, helped those of you that struggle with that, and that’s all I have for today. Let’s see. I will stay on for a couple more minutes to answer any other questions.
68:09	OK, so going back to our GI bleed, if it’s specifically this is just a comment that I’m reading if it’s specifically documented that the bleed was due to something like hemorrhoids. The other issues, Diverticulitis would not Woodcote because it without bleed.
68:23	So, yeah, so if they specifically tell us the cause of the bleeding, that’s on linking it, right? If we go back to our un linking, if they’re telling us a specific source of the bleeding, then we would no longer link that to the other sources.
68:36	We only link it to all sources with with a width in the Tabular index When we, they don’t specifically give us the source.
68:50	OK, so going back to that other, examples where someone, the GI bleeding example with the anemia would not query for the CHF acuity.
68:59	There’s no support, so we didn’t see, I didn’t particularly see any support.
69:05	For CHF acuity, as they said, something about IV Lasix. I don’t remember reading anything about IV Lasix. I mean, it’s something that we can consider looking at the whole chart. Again, this is just a snippet of the chart, but other things we wanna look for, symptoms, right? I think someone I think someone did indicate, so you’d look for a …, shortness of breath, elevated BNP.
69:26	Know, plural, fusions, Pulmonary edema, lower leg it, leg edema, those are all things that we would look for. You know, to indicate there, I’m not naming all of them obviously, but those are all things that we’re going to consider when we’re thinking about CHF exacerbations. Did they give them IV Lasix? IV Lasix can be given, be given for other reasons besides CHF. Right.
69:50	So we want to keep that in mind, as well.
70:01	OK, so going in … Case and GI Bleed case, if it was not linked, we can code to both diverticulitis with bleeding. So we wouldn’t link it to the hemorrhoids. Someone’s saying that we would like it to the hemorrhoids based on the CC with multiple sources of bleeding, Go back and read that coding clinic again. It doesn’t say we can link it to the hemorrhoids. If they don’t say the source, we can link it to the Diverticulosis and the gastritis because of the width guideline.
70:31	Um.
70:37	If they State that it could be due to both, yes, Then we can code diverticulitis with bleed and the hemorrhoids with, you know, it’s not a with bleeding with for dot for hemorrhoids we code the hemorrhoids versus the Diverticulosis with …. Yep, that’s actually that’s absolutely correct. Thank you for bringing that up.
70:54	OK, so typically, someone saying, well, what, because their unfair tonics, couldn’t it, couldn’t it be, I’m not sure what you’re referring to, but protests they’re going to typically give patients with GI bleeding, protonix, as a prophylactic measure.
71:07	And also, they give almost everybody that comes into the hospital, protonix, if they’re coming in with GI issues. So.
71:19	I would be careful about using that as your, you know, clinical information.
71:31	OK?
71:39	OK, so, why isn’t the oblong, So going back to the GI Bleed case, why isn’t awa the PD acts as it was? The only thing? Really treat it?
71:48	Anybody want to comment on that?
71:49	I know we still have quite a few people on what required the thrust of treatment?
71:57	Could you argue that … could be the PBX?
72:00	But you also wanna looked at look at optimization.
72:04	Not every case is going to be the same. Sometimes you will have oblate as the PBX, depending on the circumstances.
72:11	In this case, they did an endoscopy to look for the source of the bleeding.
72:17	To me, that’s a little bit more invasive than just giving the patient an IV medication. They actually had to put the patient under anesthesia. They did a colonoscopy looking for a source of the bleeding.
72:27	To me, the GI this, the workup for the source of the bleeding was a little bit more invasive and required the thrust of treatment over an ….
72:35	But again, someone can argue that … could be the peak, the PBX, but to me, if there’s an underlying reason they have ABO, they want to control the bleeding, right, Or limit the bleeding.
72:45	You can, You can, depending on the case, you can argue, it’s not going to say, it’s always, it’s never going to be oblong. In some cases, you might have a known history of chronic GI bleeding and they’re coming in with acute on chronic anemia. They just transfused the patient and send them home. They have a known GI bleed. They don’t want any more work up, that might be a case where you have … as the Principal Diagnosis. I’ve seen so many different cases, it’s, someone else may be able to throw out some more cases where you’ve used …, the Principal Diagnosis.
73:17	It was actually on discharge likely sources or external hemorrhoids. It was actually on the day of Discharge and then in a discharge summary, I might have not included it there, but it was.
73:27	Um.
73:31	Um, I could then could link it to the Diverticulosis with bleed.
73:43	Just reading, There’s a lot to read here. Sorry.
73:53	OK, so I recently got dinged for this, no definitive source so I picked up all the codes with no bleeding, so do they specifically say no source?
74:03	Found?
74:04	I mean, that’s actually a good, another good one to, if they say, no, source found, and they list diverticulosis and gastritis.
74:12	And they say, None of these are sources of the bleeding. How how are we going to code that guys?
74:17	That’s another good point.
74:21	But, it’s everyone’s thoughts on that.
74:30	So in saying there’s a great coding clinic about melina when there’s no width. So be careful about which Coding Clinic you’re coding clinics you’re looking at, because our guideline has changed in ICD 10. I believe you may be referring to an old Coding Clinic. An ICD nine, where we had different guidance on that.
74:46	However, what if they say there’s no source found?
74:49	That’s actually a great question. There’s no source found. And they, but they do see that the patient has diverticulosis and gastritis.
75:22	Let me go down.
75:27	OK, good, so if no sources identified, thank you.
75:30	If no sources, if they specifically, I’m saying this is, they’re specifically stating this, they’re specifically stating no sources found for their GI bleeding, It’s out of proportion, it’s out of proportion to what they found on …. We’re gonna work the patient up for other sources.
75:46	Aren’t they breaking the link?
75:50	If they’re saying that no source was found, meaning, you know.
75:57	The patient has no source found. It’s out of proportion to you know. The findings on the E G D or colonoscopy.
76:06	I, I mean, I think that you have to be a little bit careful with that, just because sometimes they mean that there is no bleeding found, but it doesn’t mean that the source wasn’t found, so you have to be careful with that documentation. But yeah, if they specifically say we’ll continue GI workup, no source found, they might have saw some mild gastritis. To me, they’re breaking the link.
76:34	Yes, if they just wait, if they just say GI bleeding as the final diagnosis, they don’t say the source was found or not found, then we can link it to any of them.
76:45	So, I’m just throwing out some thought provoking questions because I see different interpretations by different providers on the no source foun thing.
76:54	So since someone brought it up, I’ll talk about it.
76:57	We have some facilities or organizations that say they’re breaking the link, because they say no source was found.
77:03	And then we have other facilities that may query for that because they know the interpretation of the noise source, Foun can be, no, no bleeding was found, but they still had five other sources, depending on how you’re interpreting that.
77:18	Some facilities will query that instead of just assuming or not assuming the the, the link was broken.
77:25	So that’s another topic for another, a different topic for discussion. But thank you.
77:29	I mean, that’s actually a great discussion point.
77:34	Hopefully that’s not confusing. Anybody?
77:41	OK.
77:45	Can you code them as both with hemorrhage since there was a hemorrhage and both were found? So again, we want to think through the width guideline.
77:54	In most cases, you’re probably going to link them to both, unless they specifically break the link. And breaking the link would be there, linking it to something specific.
78:04	So they’re saying the bleeding is coming from the colon cancer, The bleeding is specifically coming from the ulcer, but they also have another condition. If they don’t link it to anything, then we can link it to all of the conditions that were found during this day. The one caveat there, as someone brought up, is, if they say, no source was found, we’re going to continue GI workup as an outpatient, maybe they’re going to do a CAHPS.
78:28	So endoscopy, um, et cetera. And again, there’s different different differing opinions on that based on the facility that I’ve worked with.
78:41	I mean, if I can give you my opinion, is that, if they say, no source found, then they’re saying that no source was found, meaning that they’re going to continue to the workup. And they’re going there. You know, we’re not going to link it to the other causes, but, again, I do see both sides of that coin, depending on how you interpret that.
79:07	OK, so someone else, yep. And this is why the MD doesn’t clearly state due to something else. So the causal relationship is assumed.
79:14	Yep, that’s how some facilities are interpreting it.
79:20	Someone’s saying but bleeding does not need to be present on exam. So that’s the question, Are they saying the bleeding is an existing, are they saying that the source of the bleeding as an existing, and that’s my kind of problem with that too.
79:34	Yep. So, EG, defining diverticulosis and gastritis with no evidence of active bleeding, coding Clinic says you can still linked to both. Yep, that’s correct. We’re talking about when they’re saying the findings are out of proportion to what was found. They don’t think they found. They don’t think the gastritis or the, the diverticulosis or their source, they’re getting any. Can you work up? They’re going to do a small maybe they think it’s a small bell, AVM, etcetera. They don’t know the source. We’re talking about C, it can be confusing, right? What do they mean by no source found? They mean no source of bleeding found, they mean what do they mean by that?
80:12	So your facility may take a stance on that. I, again, I wasn’t planning on getting into that specific documentation, but it’s something good to discuss.
80:29	No, bleeding does not need to be present on exam.
80:34	That would be different than what we’re talking about now.
80:43	I think I answered all the questions. I know we kind of throw in that caveat. Caveat caveat at the end. I mean, that’s a discussion point you can discuss with your peers, your co-workers, your man coding manager, on how you’re addressing that. When they say no source found. I definitely I’ve seen facilities take a stance on that.
81:06	So that might be a good one, an opportunity to submit that documentation to Coding Clinic to provide a clear-cut answer on that. and how they’re interpreting it?
81:17	And again, every case is different. So it’s kind of hard to have a blanket statement for those. I would take that on a case by case basis.
81:28	Oh, awesome. I see someone saying, We’ve completed a pig, heart transplant. the University of Chicago. That’s great, that’s awesome.
81:37	That’s really cool, I know we talked about that earlier.
81:43	OK, all right guys, I don’t have anything else. If you do have continued questions, comments, concerns, please use the e-mail that’s provided on the slide psi X roundtables at … dot com. Again, these are only approved for AHIMA. Say these aren’t approved for APC if you’re a …, and please, please refer to our psyops coating Roundtable Group for more information about CEUs.
82:10	All right, guys, take care. Until next time, bye!
82:26	Hmm.
82:37	Thanks, everyone.
82:44	Yeah.
83:04	Um, OK, I’m still getting questions.
83:11	I’ll answer two more, just because I’m still getting a lot of questions.
83:14	So, what about a patient has p.v.d., then was newly diagnosed with …? Would you still link the two?
83:21	Um, so based on the with, with guideline, unless they specifically give you a cause of a different cause of the p.v.d., you would still be linking it to the diabetes type two.
83:32	Um.
83:37	Because they specify that the MD has to clearly state the bleeding is due to something else. So that’s the problem with that guideline, is that they give us different advice about if they say it’s due to a specific cause.
83:49	Um, so I have seen people interpreting that different ways. So, if you do have specific examples, I would highly recommend submitting those for Coding Clinic advice, as my final say on that.
84:11	If when note state CHF is due to non ischemic cardiomyopathy, patient has a history of hypertension and valve disease.
84:19	If the provider states that the cause is non ischemic cardiomyopathy, is it OK to still link the hypertension in CHF?
84:26	That’s actually a good question, because it’s the non ischemic cardiomyopathy due to hypertension.
84:34	Um, you might need to get clarification on that.
84:38	That’s kind of a bit of a, you know, something, if there’s telling you the specific cause of the non ischemic cardiomyopathy.
84:44	I think you’re OK with not linking it, but one can argue that non ischemic cardiomyopathy can be due to hypertension, it may be a query opportunity if it’s going to change or DRG.
84:58	So, another option is to query the attending. If you’re unclear of the source of the of … findings, that’s actually a great, a great suggestion.
85:13	The MD doesn’t. You know, I already read that one. OK, so that’s where I’m going to end it. I think that was the last few questions. Sorry, I keep ending it and then staying on. But I just wanted to make sure I address all the questions, and I have a few minutes. So, Anyway, I think that’s really, really the end. If you stayed on, thank you so much. I’m sure most of you have left.
85:30	But if you’re watching the recording, you have a little bit more information. So, anyway, thank you, everyone, take care, have a great rest of your week, and until next month, as regards.

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