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0:05 Everyone, Good morning, or good afternoon. This is Janice Tour lucky. I’m flying solo today, can everyone just let me know if they could see my screen, and he also hear my voice, would be great in the question box.
0:22 Awesome, thank you so much.
0:26 All right, so let’s get officially started now that I know everyone can hear me.
0:31 All right, So, hi everyone. Welcome to Roundtable 155. Thank you for taking your time out of today to join us today. As I mentioned, my name is Janice Turner Lucky for anyone that’s new here. I’m the …
0:44 Director of Advent Advanced Education. And, today, we’re going to take a deeper dive, or somewhat of a dive, into Missed Query opportunities. So, things that we’re seeing as trends in the … query opportunities. And, this is from a coding perspective, right?
1:00 Know, we have, we have, you know, we just wanna look, take a look at those, again, more from a coding perspective, rather than like a CDI perspective. So, some housekeeping items, there’s no call in numbers, the format of streaming only, to allow as many people to attend as possible. Today’s today’s webinar will be available on demand after the live session, and will be accessible through the link that will provide in our follow-up e-mail. We also have a slide at the end that also includes the information that I’m speaking about. So please download the handouts, please also make sure that your opt in for our e-mails coding roundtables at …
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2:06 On that note, it was brought to our attention that the last CEU that was uploaded, had the year 20 22, as the year, so we fixed that. If you haven’t had the opportunity to get the fixed copy, it was a fixed within, I think, 24 hours of you guys letting us know that. It was listed as 2022. That always happens in the beginning of the year, right? We forgot to change the year. So, thank you for bearing with us on that.
2:33 We did correct that, So, again, if you need to correct the correct version, it should still be still be up there during the webinar. You can download the handouts and enter any questions, comments that you have, and I’ll do my best to answer any questions at the end of the session.
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3:33 It’ll help us understand if there’s anything that we can do to help your organization, et cetera.
3:40 So, again, thanks for your attention, and we’re going to get underway.
3:46 OK.
3:49 Alright, so let’s get started here. If I can get my slides to move, there we go. So, first up, our agenda for Today, Trends and Ms. query opportunities should be an IES. Sorry about that. We have something happened with my formatting there. But anyway, symptoms. We’re gonna talk about symptom codes as the principal diagnosis. Specificity matters, etiology of fractures, and etiology of plural, fusions, and these are ones that we’ve been seeing quite a bit of missed opportunities. Obviously, I only have an hour. So I tried to pick ones that were, again, trends in ms. query opportunities, Things that we saw numerous times in numerous different fashion. And I thought, this was a joke.
4:30 I was trying to find a coding one, but I couldn’t find a good coding, coding, a cartoon, but I thought this was kind of a good way of thinking about it. You know?
4:40 We’re trying to read between the lines, trying to figure out, you know, what’s going on with the case? And it’s, you know, you kinda give up, there’s no use trying. And then no matter how hard, I try, I can’t read between the lines. So basically, my purpose today, no, or I should say when you try to read between the lines, you try to understand what someone in plot is implying, In this case, physician documentation or provider documentation. They don’t openly, they might not openly state what they’re trying to say. You know, that’s always a work in progress, right? We need them to, we need the providers to say certain things in order for us to code it.
5:16 So my purpose today is to kind of review some of those commonly missed Ms. Curry opportunities to help us identify clues, I guess, clues in quotes between the lines, right. Looking for those clues between the lines as we’re going through the chart to say, should I query this? Should I not query this? Is the conflict?
5:35 Is the documentation conflicting, do I have enough, am I following coding guidelines, et cetera, et cetera. And I want to mention, we’re all at different levels, you know, in our coding career. We might have some beginners. We may have some people that are still training. We all have different background. Some of us might have more of a clinical background. Some of us might have just when, you know, have an him background, so, you know, these may be somewhat obvious to, some, but not obvious to others, so please, we highly value participation and value your comments and opinions on, you know, throughout this presentation. If you want to share your experience, many tips and tricks that you might want to share about. You. Know, when you see these cases, whether you know, I’m just gonna throw etiology of fractures when we discussed that, if you want to throw that out, I can read those comments and share those with everyone, you know, as we go through these scenarios.
6:28 So I’m just reading some of the comments. You can never go wrong with peanuts cartoon.
6:34 Millimeter, All right. So I’m gonna get started here.
6:38 Hopefully you like these, I tried to pick some that were, you know, these are little scenarios, so I did my best to try to pick the ones that I had enough information to kind of talk about, in detail without having to review a whole chart, right? So there may be a little bit of detail detail missing, but we can kind of, you know, still have a discussion about it, and see, you know, kind of look for those clues and read between the lines of something that we need in order to code. You know, something. So, let’s take a look, our symptoms, as, I don’t know why I messed that up. Symptoms as the Principal diagnosis.
7:16 So, our first case, and this is a very basic, a rundown of what’s going on with the patient. But you can see the original codes there, take a look at those. But the patient was admitted with dizziness.
7:29 The patient with a history of prior stroke in January Neurology console on 611 states, dizziness rollout, stroke versus recruiting of old Stroke Symptoms review, of the record found documentation regarding an MRI finding of Intracranial stenosis. The MRI states moderate and severe stenosis. The cerebellar arteries, The neurology consult question: The possibility of dizziness due to a prior stroke. The final diagnosis listed on the discharge summary was simply dizziness. So is there a missed query opportunity here with the source code it as dizziness we have atrial flutter code, it as a C C obviously, we don’t have all the information for all these other codes. We have personal history of TIAA and stroke.
8:11 Code it.
8:13 What does everyone’s thoughts on this?
8:20 Mmm hmm.
8:22 And as I wait for some, some comments, here, what you guys think is a Miss Query opportunity, they talk about recruited, and we see that … quite a bit in the documentation documentation. So, what is recruited …
8:35 mean, um, it means, it refers to a re-appearance or relapse of previously resolved symptoms of remote ischemic stroke.
8:42 So, a late effect Sequoyah.
8:48 Consider, query. So, what do we can work? What are we considering a query for?
8:59 Is there a MIS query opportunity and what is it?
9:02 What is the red flag if you have this as your principal diagnosis, OK?
9:11 Even when I see people saying layed effective stroke, but even more basic than that, what is our code as our principle?
9:23 OK, good, so we have a, we have a symptom code, right? As the Principal Diagnosis. That’s always kind of a light bulb is there. So, when I’m seeing a symptom code is the Principal Diagnosis, this is probably always going to hit some type of, flag it, some type of auditing bucket, smart, review, whatever you have at your organization. When you have a symptom code as your principal diagnosis. Now, this, you know, we’re not, sometimes, we can have a symptom code, is the Principal Diagnosis, but it’s really minimal cases where that should happen. There’s, you know, after study. They don’t know the cause of the presenting symptom.
9:54 But there are some indication in this documentation that they potentially no they potentially know what’s going on with this patient. There’s a suggestion in the console, obviously. We don’t know after study, if they still thought that it was on the initial console a few days, you know, at the time of admission to the east, and they’re also on the MRI findings. They noted they did have some type of stenosis. They didn’t state the significance of that stenosis. Maybe it’s a TIA right due to the stenosis. So, there’s a couple of things going on here that suggest that there might be a suggestion that we do.
10:28 They do have a possible cause. We do have a possible cause, as the PD x-ray and an inpatient setting, we can encode a possible or probable as our principal diagnosis.
10:40 Obviously if this was a, you know, observation case, it would be a little bit different, but for an inpatient case, we can code probable or possible, we don’t know, at this point they didn’t follow through with that documentation after study if that is if we have an underlying cause. So I mean that’s kind of like the first, The first thing that I want everyone to take note of is when you have a symptom code as your Principal diagnosis and I know, should I queried, do I have something that would suggest that there may be an underlying cause. So maybe I’ll use the most basic example. I mean, I don’t know how many patients we see being admitted for this anymore, but we have chest: a patient presents with chest pain, right? A patient presents with chest pain. They, they’re rolling out an MI. They’re rolling out different causes. They roll it out, everything is negative, but they discharge the patient on a PPI or they discharge the patient on an end sad.
11:41 And they don’t really say, You know, or We think it’s musculoskeletal, we think it’s gird or, you know, they don’t list step. They’re treating the patient or discharging the patient on, you know, a PPI, they probably suspect that it’s gird. Even though they’re not telling us that, that is a potential opportunity to say, what is the possible source that you’re treating this patient for for that presenting symptom.
12:10 Hmm.
12:11 So, if I have a question about recruit aunts.
12:18 That would be coded as a late effector sequoyah of the stroke.
12:25 OK, so let me go, I don’t remember, I know we have a coding clinic on. I don’t know if that’s like an officially published coding clinic or if that OIT might just be one in in our toolbox.
12:36 I forget if it’s officially published or not.
12:41 So, kind of, I mean, you guys, I prefer you not to look ahead, because I give you the answers, but, so, to kind of sum up that case, we have our revised codes. We submitted a query for the etiology of the patients presenting symptoms of dizziness. The query response affirms. the patient’s dizziness is due to the Prior Stroke, you can see here.
13:04 This resulted in a rework DRG from 149 dissed equilibrium zero point 7 three 5 five two oh, five seven 1.26 42.
13:18 And of course, I do mention the use of Sign and symptoms codes we can obviously no use unspecified codes, they are acceptable. But obviously, we want to code this to the most no definitive diagnosis that we can if they’re treating them for a possible condition.
13:37 So, the question, I have another question, Do we have a chat tab? This is the quote, If you’re using the question box, that is the chat tab.
13:45 It’s just labeled as Questions.
13:53 Yeah.
13:54 All right.
13:56 Then, also, I think this came up with discussion when we are talking about this.
14:01 You know, the Neurologist’s initially initially talked about it potentially being due to recruited currents of the stroke symptoms of course, after study. Did they still suspect that it wasn’t really clear in the chart if they still suspected that. But also another thing we want to remember is that a consultant can be saying or different physicians sometimes will say different things.
14:24 Sometimes we see the pulmonologist saying, No, non infectious inflammatory pneumonia. And the attending is saying, oh, no, we think this is bacterial pneumonia.
14:36 They have a disagreement, right.
14:38 So, if there is documentation from different physicians that conflicts, we want to seek clarification. Obviously, if they’re just giving more specificity if the one doctor saying CHF and the consultant is saying, systolic CHF, that’s just greater specificity that’s not in conflict with anything.
14:56 But if one doctor is saying, you know, it’s due to this, and another just doctor saying is due to this, that’s a conflict of documentation. Right? Or, the one doctor says, We’ve ruled it out, The other doctor says possible probable.
15:10 No, that’s a conflict of documentation.
15:12 I just wanted to add that as another cautionary tale here.
15:17 And, of course, also, we want to remember that we can code uncertain diagnosis probable, or suspect it likely questionable possible still to be ruled out, compatible with consistent with on discharge. Of course, this is for inpatient.
15:33 I see a lot of it. It says, or other similar terms, indicating uncertainty code, the condition as it existed or is.
15:38 Establish the basis for this.
15:43 For these guidelines, or the diagnostic workup arrangements for further workup an initial therapeutic approach that correspond most closely with the established diagnosis. And it says, at the time of discharge.
15:55 Now, I see different interpretations at the time of discharge. I see some people saying, well, it has to be on the discharge summary, and really, if they’re treating something as possible or probable and it’s not listed on the discharge summary, it doesn’t mean you can’t code it. I mean, it could be a two month stay, right?
16:12 And if they treated the pneumonia for the first two weeks of the stay with antibiotics and they didn’t rule it out, and they’re consistently treating it, but they never brought it up to the discharge summary, it was still treat it right.
16:24 Even though, at the time of discharge, it wasn’t documented.
16:28 Because the patient was here for a lengthy period of time.
16:31 That’s just one example, and I know that could be a bit tricky, but I know, I know there, and we also wrote a coding clinic about this. They said, it doesn’t have to be on the discharge summary. We have to use all of the documentation available to us. Obviously, the chart can be tricky on that. I’ve actually, I’m not going to spend a lot of time on this. I’m just bringing that up at the time of discharge does not mean it has to be on the discharge summary. And I know facilities do have policies on that, so follow your facility policy.
16:58 I just, I think people get hung up on that a lot of the time.
17:03 Um, that could be a whole nother hour discussion.
17:06 So, I don’t want to take too deep of a dive there but just kind of a word or a thought that came to mind as I was reading that.
17:19 Yeah.
17:21 OK, case number 2 and 88 year old female is admitted with blood in her diaper are found to have significant. He mature, yet, in a bladder, mass, diagnosed via cat scan of the abdomen.
17:30 The treatments include an abdomen, abdominal, CT, continuous butter, irrigation, and a transfusion, the cat scan showed the urinary bladder was distended and contains a 10 centimeter hyper dense. mass in the past year aspect of the urinary bladder, this may represent a large co-operative bladder neoplasm is not excluded urological console is advised. The mass in the pasture aspect of the urinary bladder consistent with the large caught An underlying neo pleasure is not excluded neurological consultation is advised other indicators.
17:58 The patient has had found out he mature yet fully was pleased with Clot, evacuated, CBI, was initiated, CT shows bladder mass with active hemorrhage, patient was given one unit of plot packed red blood cells, anemia secondary, he mature is secondary to possible bladder cancer.
18:16 Remember our possible probable. Does that apply to cancer?
18:20 Follow up the maturity a dementia anemia secondary, acute bylaw, splatter, mass diagnose fear. Cat scan of the abdomen no further study needed as her son would like to have home hospice discharge includes anemia severe, he macharia they brought the patient to the ER, she got one unit of blood, she had a CBI, help clear that he mature your post being admitted to the hospital. What is the query opportunity here?
18:47 Hmm, hmm, hmm, and while I wait for some comments, one of the comments I have is: we accept Possibles. Just one of the comments from some of the people in the comments section, is, they also take documentation from the last progress note, and that’s kind of the process I’ve seen at other facilities. And, to be honest, I mean, it should be.
19:08 I mean, I get why people do say it has to be in the discharge summary, You want to have complete and accurate documentation. I’m not going to argue with that. That’s why I said, Follow your facility policy and procedure, but a lot of times, there is clear and concise documentation that they did treat the patient for a possible probable condition, it just they didn’t know document every single diagnosis on the discharge summary.
19:35 So someone said, …, we have documentation of acute blood loss anemia. So I don’t think we need to query for that.
19:45 Probables never diagnosis, I’m not sure what that means.
19:59 OK, so, good, so, I’m seeing some people saying, at the time of discharge, do they still think that this tumor is bladder cancer?
20:05 There’s, you know, they’re kind of saying possible bladder cancer, then they say mass again, then they list a mass neo, is it a neoplasm, is it a mass, you know, to get the most accurate documentation, it probably should be, you know, did they, it’s gonna change our coding, right?
20:23 If it’s a neoplasm versus a mass, so we should probably get clarification. Do they still think it’s a bladder neoplasm, they’re kind of going back and forth, it’s declawed, it’s a mass. They see a mass, but it could be a clot.
20:36 It could be a bladder mass with a clot.
20:39 Et cetera. So, did they rule out this mass, and is it do they suspect that it’s cancer, That’s kind of where we’re going with this.
20:46 And the reason this matters, right, think about our coding neoplasm guidelines, and we’re going to talk about that in the upcoming upcoming slides.
20:57 Um, but the coder originally code, it, Hema …, And what is that code, what what, what is, what is the red flag that I told us to to to kind of think about earlier?
21:23 Hmm, hmm, OK, good so it’s a symptom code, right? So, we’re gonna, you know, the symptom code. If I’m going to code a symptom code, I want to be really clear that they don’t know the cause of this presenting symptom. It’s in the symptom chapter. Is there a possible probable cause of an underlying symptom here under a definitive diagnosis here, instead of coding this? very non-specific cause. Decoder, decodes, acute post hemorrhagic anemia. They have some other things going on. You can obviously tell this is before the October Updates based on the code there for the dementia.
22:01 But you can see here that we have a DRG 696 is the kidney and urinary tract signs and symptoms DRG a very low relative weight. There was some indication that it could possibly do to be due to an underlying mass or neoplasm.
22:17 So, what’s the guideline when we have a symptom code associated with a neoplasm?
22:37 OK, so if the sign and symptoms, we have a sign and symptoms, and signs and symptom chapter, and its associated with the neoplasm, we code, the neoplasm. as our principal diagnosis, in this case, We don’t know for sure. If the …
22:50 was due to the neoplasm, whether it’s a neoplasm, or just the mass, we weren’t sure if that he mature was directly caused by that mass, it wasn’t clearly documented in the documentation. So we want to clarify. Was that he mature ya. Or clot in the in the bladder? It looks like the code, or did you also code? I think clot goes to other specified disorder or bladder.
23:16 But, you can see there that let’s take a look at the actual query.
23:23 This is, was the suggestion, a query is warranted prior to adding C 60, 79 malignant bladder, neoplasm of the bladder as the new principal and sequencing the original principle, R 31 as a secondary review of the medical record. Found documentation of … was as which is a symptom code, Bladder cancer restate it as a possible but no further study was done. As a patient was placed on home hospice patient at the family’s request A courier queries that is, is being suggested to determine the etiology of the …. Depending on the query responses, will rezone, MS DRG increased from 696 to 699? So, you can take a look here, This was the query that was submitted.
24:02 Here’s the question: We have, the patient was admitted with, with he macharia, Um, they were found to have a distended bladder with a mass, neoplasm couldn’t be excluded. And, of course, we can’t code off a CT scan, right? That was, just note it. And that was just noted in the in the cat scan.
24:22 She was found to have significant macharia, the cat scan does show a bladder mass and so they, they advise for clear documentation that we should probably query for the underlying cause. They gave some choices here. Please, further clarify the most likely or suspect to underlying cause of the patient’s hematocrit area. Is it due to a bladder mass possible bladder cancer?
24:44 He maturity due to bladder massive unknown etiology, other clinically unable to determine, et cetera, et cetera, and the response was, he maturing due to bladder mass possible bladder cancer, and they said they modified the problem list. But, anyway, so, just to get clarification on that at the time of discharge, was it apart still suspect to be a possible bladder cancer? It came back as yes, so they went with the bladder cancer as the principal. Now if it was due to the bladder mass, You know, the bladder mass would probably be coded as the principal I don’t believe that’s in the symptom chapter, right? And that would be the definitive cause of the …. I think someone had a question about that.
25:28 And if there’s no cause, if they didn’t know the Cause, then we would just use the ….
25:39 OK.
25:42 And, so, as we go through this next case, I want you guys to think about, well, how does this differ from case number two?
25:50 The case that we just went through?
25:52 So this is 71 year old patient, with a history of bladder cancer, with long mats, presented from rehab with reported fever of 106.3. He was admitted with fever and suspected UTI after study has UTI was ruled out as urine culture was negative. He was treated with ID consult Dawson ….
26:13 For the discharge summary, the etiology of the fever remained unclear.
26:18 The ED patient presented to the ED with which from an for, fever, up to 160 does state. He has pain in his abdomen presented, from rehab for fever, et cetera, abdominal pain, he continues with his home opiate pain meant regimen, urine culture drawn. Your analysis positive started on’s Dawson.
26:38 Fever UTI etiology unclear felt initially secondary to UTI as he has recurrent infections with similar presentations. However, urine culture was negative. So how does this differ from the first case?
27:02 We have fever, right? That’s a symptom code. Are we going to code the cancer in this case?
27:13 OK, good, so basically we don’t know the cause they specifically say They don’t know. The cause of fever remains unclear. So in this case, we think I think it’s OK, are we? I think most of us will think it’s OK to go with the fever, because they’re specifically telling us they don’t know the cause of the fever. It’s an unclear cause. They ruled out the UTI.
27:33 Um, they specifically role that the UTI we don’t have any other source of fever documented in the, in the record, so there’s no other potential sources of fever that they’re treating. So, I think, in this case, that’s how it differs. It’s not specifically treating.
27:51 Um, they’re not specifically treating any specific disease process, so, after study, in this case, I’m not sure why the coder went with fever. Other than that, the fever was a symptom code, and the patient did have a bladder tumor.
28:07 So, we want to make sure that if the patient does have a symptom, that’s it has to be attributed to the the actual cancer to use, the cancer code, is the principal. That’s the only thing I could really think of that we missed we misapplied the coding guideline there.
28:23 So in this case, the DRG actually was a downgrade from 687 to 864 on this one.
28:35 I mean, there’s some other potential. I mean, they have encephalopathy, unspecified, I mean, I don’t know what else is going on with that case, but that was the main change in the DRG.
28:46 OK, so taking a look, I see the reason I’m, I know I’ve talked about these references before.
28:52 The reason I’m talking about them again, is because we consistently see errors with neoplasm coding.
29:00 So, we have to think through our process, when we have neoplasm.
29:05 And, and I was at third quarter, the newest one of the newest coding clinics, they do give us better examples, or more examples, not really better, but more examples of how to apply the guidelines. So the first guideline, we have guideline we have in the Neoplasm Chapter Assigned symptoms and abnormal findings listed in Chapter 18. And this goes along with our … one. We also have 1 from 20 17 related to prostate malignancy, And you have to remember, if you’re looking back at old coding, clinics are guidelines for IE nine, are different, are slightly different for neoplasm and I 10. So be careful that you’re looking at the most recent coding clinic and guidelines, when you’re applying the guidelines for neoplasm.
29:50 So, some symptoms signs an ill defined conditions. Listed in Chapter 18, characteristic of are associated with an existing primary, cannot be used to replace the malignancy as principle first listed, regardless of the number of admissions, or encounters to treat. And care for the neoplasm.
30:04 So, we have an example, kind of, kind of, similar to the example with the bladder cancer, where they talk about an ICD nine coding clinic that provided advice to sequence the gross he maturity as the principal for a patient who is currently undergoing treatment for prostate cancer and was admitted for Grossi materia. With significant drop in hemoglobin, the patient had been unable to pass urine, and was only passing frank blood clots while in the hospital 12 units of blood transfused, bladder irrigation was done. now the human. Now, that he mature, isn’t a Chapter, 18 code in ICD 10 CM, does the guideline in Section two A regarding codes for signs, symptoms, and ill defined conditions apply? And change the previously published advice in regards to the Principal Diagnosis? And the answer is, The official guidelines for coding and reporting stick states codes for signs and symptoms. And, it’ll defined conditions from chapter 18 are not to be used as a principal, whenever related, Definitive diagnosis has been established based on this guideline. And the fact that, he, maturity is classified as a symptom An ICD 10 code C, 61 malignant. Neoplasm of The prostate would now be assigned as the principal with code are 30. 1 would be assigned as a secondary.
31:06 This is also consistent with the neoplasm guidelines regarding signs symptoms and abnormal findings in Chapter 18 associated with …. This previously published device was based on the application of the guidelines regarding the selection of principle, An ICD nine did not classify he mature in the symptom chapter. This is an example of differences in ICD 10 compared to ICD nine.
31:29 OK, so then we also have, on the other end of the spectrum, we also have encounters for complications associated with a neoplasm. So, in this bucket, I have things that aren’t simply aren’t signs and symptoms. The example they given the coding guideline is When a patient when it encounters for management of a complication associated with neoplasm such as dehydration, dehydration isn’t in the Chapter 18, right?
31:53 And the treatment is only for the complication complication is coded first, followed by the appropriate codes for the neoplasm.
31:59 This is an exception to the guideline or the exception to this is anemia, et cetera. We know there’s a guideline for sequencing of anemia, So the, the first coding Clinic, that is one of the first coding clinics that addresses this and applies the guideline, is this biliary obstruction due to have … a malignancy. Back in 20 16? Most of us are aware of this, but I still constantly see coding changes again. You have to think about, is it in the sign and symptom chapter, or is it a complication there, only, treating the complication?
32:32 So a 69 year old patient with non respectable hepatic cellular carcinoma status post radio embolization presented, With two weeks of progressive hyperbole roomier you went underwent endoscopic. Retrograde, collegial pancreas …, which revealed biliary abstraction from HCC progression, The provider perform failure biliary sphincter automate an insertion of biliary stent into the common bile duct. There’s confusion as to whether it’s appropriate to sequence the carcinoma as the principal since it is the underlying cause of the obstruction or whether the obstruction is sequenced as the principal diagnosis since it was the reason for the admission and no treatment was directed to the carcinoma. What is the crux sequencing of the biliary obstruction and … carcinoma.
33:12 So, in this case, they they, they told us to assign the obstruction. The obstruction was the focus of treatment since therapy was only director of obstruction and not the malignancy, the Obstructionist sequences the principal diagnosis followed by the C 22 and that goes along with the coding guideline that we just talked about when a patient is admitted for a complication associated with the malignancy.
33:35 Yeah, so good comment. Just, I also keep asking myself, this is a comment from what condition is chiefly responsible for the patient’s admission. What is the definition of principal Diagnosis? And, of course, that gets a little bit tricky with our neoplasm right, because we kind of have different guideline, a couple of different guidelines when it comes to neoplasm, so is it in the symptom chapter?
33:57 But if we think about coding signs and symptoms, no, we’re not going to code a symptom code when we have a definitive diagnosis as our principal diagnosis, right? So now in third quarter 2022, they did come out with more examples about assigning complications versus the malignancy as the principal.
34:15 We did discuss these on prior webinars, I think, when we went over third quarter coding clinic.
34:23 So the question is, A patient with known adeno of the lower third of the esophagus was admitted with a taxi or double vision. work of revealed new brain hemorrhage and brain maps as the cause of the patient’s symptoms. The patient underwent surgical resection of the metastatic brain lesion. So in this case, they’re specifically treating the lesion, they were also admitted with the hemorrhage, which is a complication of the brain mats.
34:44 But in this case, we can assign the malignancy, because they’re treating, specifically treating the the, the the menace, the metastatic lesion, right there surgically treating, providing definitive treatment by excision of the brain mats. And it’s not primarily being directed to the hemorrhage.
35:06 They also say we can assign those, you know, the, the signs and symptoms of the hemorrhage, as well, the taxi or the …, they’re not integral to that, depending on where that hemorrhage or brain mass is, they might present with different symptoms.
35:22 Next, we have …, and breast cancer with Brain met, so patient has known breast cancer, with metastatic Metz to the brain, presented to the Emergency Department with Altered mental status. Imaging revealed status metastatic brain cancer with increased … cerebral edema. At the time of discharge, the provider suspected the progressive cerebral edema around, around the known, metastatic brain lesions was contributing to the patient’s change in mental status, which improved the steroids therapy.
35:48 What are the appropriate code assignments? So in this case, the treatment was directed at the cerebral edema, right? Sarah therapy is being used to treat the cerebral edema. We can code. that is the real code, that it’s not in the symptom chapter, right? It’s a specific complication of the brain mats. We’re going to code the secondary sites of the brain, the malignant neoplasm of the breast, the presenting symptom of a change in mental status was due to the … cerebral edema.
36:14 So we can change that slightly, right?
36:16 And say they presented, with change in mental status, and they were found, to have brain mats change in mental status with the symptom code, right? And then we’d go with the brain mats after study. This case, the patient, had a known brain mats, and that was found to be due to the progressive cerebral edema, and they’re specifically treating the patient with steroids therapy for the cerebral edema specific complication.
36:40 Is because the it’s only addressed the encounters for management of a complication. We’re going to code the complication first.
36:55 Next we have.
36:58 Is this the same one?
37:02 Yeah, this is sorry, I copied and pasted the same one twice. OK, so that’s, that’s for, that’s that section when we have symptoms, I included the neoplasm. The different examples of … because I again, I see that coders mix up the whole guideline, the symptoms if What, if they’re in the sign and symptom chapter. Versus, And not in the sign and symptom chapter, you want to think through that guideline. Have your guidelines up if you need to Know, the more you code then it will become second nature to you. But you have to think through that process. Is it a complication of the Neoplasm?
37:37 It’s not in the symptom chapter is that the treatment directed just that the complication and if it’s a symptom, even though it, maybe it’s like that he mature your case, it’s a symptom and maybe the treatment is just directed at the symptom code or the symptom.
37:50 It would still be the neoplasm because we know the definitive diagnosis.
37:54 It’s not in a, considered a complication at that point until we have a definitive, you know, something outside of that symptom chapter, OK? Specificity matters.
38:07 And why are we talking about this?
38:08 Let’s look at a few examples, OK?
38:13 As we go through this case, what is the missed MCC? You can see the original codes there, and or a query opportunity.
38:21 So we have an elderly female, past medical history of OS, a COPD, chronic hypoxic, respiratory failure on 4 to 5 liters baseline O two O SH heart failure with preserved ejection fraction.
38:37 Call it Let me know, guys, what is heart failure with preserved ejection fraction?
38:40 I actually saw some errors on this as well, hypertension, diabetes, or atrial fibrillation in the ED patient, noted to be a toxic to 86% on five leaders, so tie traded up to six liters.
38:55 Has not You see papen over a year due to significant discomfort, sitting felt like she was getting beat up, acute on chronic respiratory failure with hypoxia. Acute on chronic etiology includes diastolic heart failure exacerbation and the setting of significant bilateral lower extremity edema. Unclear how much of this is chronic versus from heart failure worsened or the … versus COPD exacerbation. Unclear patients properly taking …, advair, increased cough with phlegm production, versus progressive, obstructive sleep apnea, Obesity, hyper ventilator, ventilator syndrome. The patient was noted to have significant oxygen saturation, zone, alteration of blood gasses requiring increased oxygen levels, pulmonary console, CPAP, and continuation of Advair discus, albuterol inhalation of beautiful inhalation solution pardon his own.
39:43 The documentation states the patient has an exacerbation de compensation of heart failure. So if we see exacerbation de compensation, what does that equivalent to? Let me know in the comments. Next we have ED progress notes, patient feels significantly shorter, Breath Give IV Lasix.
40:01 Spoke with X with X And patients will be admitted to doctor X final impression. COPD exacerbation, CHF exacerbation, discharge summary, acute D compensated, heart failure in the ED. The patient was noted to be hypoxic to 86 on 5 leaders. So, tie traded up to six leaders. Chest x-ray revealed cardio … with increased vascular congestion as well as significantly elevated BNP. Repeat two D echo showed RV dilation moderately reduced RV systolic function. Elevated pulmonary artery systolic pressure, Mild … aortic stenosis and preserved LV systolic function. Patient given dose of … in the ED and remained on Lasix, IV … for three days before transitioning to at least 640 milligrams PO, her Disney improved and she’s oxygenating Well back on home. five leaders, OK? Let’s take a look at the comments here.
40:56 Ah.
41:01 There’s a lot of comments going on while I was reading that, OK.
41:04 Let’s keep going. Let me get back to this section OK. Good, so preserved. My first question was heart failure with preserved ejection fraction, or H F P F, its diastolic.
41:15 Right, OK, good preserved, EF equals diastolic. And so when I ask about preserved ejection fraction, do we have a higher low normal ejection fraction? What exactly does that mean?
41:30 If we have objection fraction, I don’t know of 60%, does that mean we have a preserved ejection fraction?
41:43 OK, good. So the comments are, acute de compensated, heart failure Is a missed CC MCC here? It looks like the coder coded this two, chronic diastolic. It was documented. No.
41:58 Pretty well throughout the chart that this was an exacerbation de compensation. You can see they’re treating them with Ivy Lee, six day or their diary, seeing the patient.
42:09 It showed vascular congestion on the chest X-ray and elevated BNP brite.
42:14 These are all signs that the patient has. Also, they have, sorry. I forgot what I was going to say. They’re also hypoxic. So these are all signs that the patient has a de compensated heart failure. Right?
42:29 OK, so, the question, one person is saying maybe that acute and chronic heart, acute on chronic respiratory failure.
42:40 There is one note in the H and P that says, acute on chronic, It wasn’t consistently documented throughout the chart. So, I think that’s the query opportunity here. So, we have consistent documentation that’s going to be our only MCC right. We want to make sure that we have consistent. They didn’t have a history of being on 4 to 5 leaders. They did go down to 86% on five leaders and they did tie treat the patient up to six leaders.
43:08 Of course, I don’t have all the documentation, but they also were placed on CPAP, so that would indicate that the patient probably has acute on chronic, acute on chronic.
43:18 In this case, you could see their code or code at the CPAP as well, um, so the coder did initially just code this as chronic.
43:26 So, the thought here was that it was probably best to query for it to see if the patient actually had acute on chronic respiratory failure. The documentation was was not consistent throughout the chart. I’m just giving a little bit more information than this provides.
43:44 But, the first thing I want to show, even if we weren’t sure about D compensation, you know, again, I mentioned this earlier, that everyone is on a different, is, you know, on their journey, you’re on there, you know, may, they might be new to coding. So, just to take a look if you’re, you know, D compensation is, does go to acute and chronic.
44:04 You can see that here in the alpha index, and also the query here, can respiratory distress and hypoxia …
44:10 be further specified, and they asked, they asked the doctor to clarify this and the answer was acute on chronic hypoxic and … respiratory failure.
44:20 So they changed that to acute and chronic coat cotes here.
44:27 They said that the there was conflicting documentation in the record. There’s that one note in the H and P that said acute on chronic. But the rest of the chart didn’t indicate, they kind of used interchangeably, interchangeable terms there. So for complete and concise documentation, they thought a query would be best before just changing that to our only MCC here.
44:49 Here’s the coding clinic.
44:50 This is rather, it’s quite old, 2013 talking about de compensate, it indicates a flare up, and we can use acute and chronic.
44:59 It’s acute phase of a chronic condition.
45:02 Now, for those of you that may be newer to coding, or, I do have our little cheat sheet here, I’ve probably shared this before, the terms, the descriptions.
45:13 No, lo, which I asked the question earlier, diastolic would be a normal, a normal ejection fraction, so over 50 versus a systolic would be under that, right. Reduced, low, mid range, or maia, leave reduce, those are all terms indicating systolic. I put the references here and then D Compensated acute on chronic exacerbation. Acute on chronic and the history of is chronic, as well.
45:38 I see a lot of people still coding unspecified when they have a history of, um.
45:46 So, just put that in here, and then we also have the same thing for diastolic. The one question I do have, we have preserved diastolic dysfunction with recovered, recovered ejection fraction, is also another term for diastolic.
46:00 Now, I had a recent question, recently, about people seeing the dot, the word, the wording of improved ejection fraction. Any thoughts on improved ejection fraction? I have my thoughts on it.
46:20 There’s, no, I don’t believe there’s a coding clinic on improved ejection fraction.
46:29 I think it’s abbreviated what HF IES.
46:39 Yes, OK, it looks like everyone is saying Exacerbation as acute and chronic OK, good, everyone.
46:52 Trying to get to the end of these comments.
46:58 Yes, go back.
47:02 Someone does have I mean, the PBX is 11. I think they also had hypertension. That was the PBX, think someone was mentioning that. The H that should be, so if we all know our coding rules, they never say, you know, they have CHF, and they also have hypertension. So we assume the relationship there unless they tell us a specific cause, which I don’t think believe they did.
47:24 Good point, thank you for pointing that out.
47:31 OK, so wouldn’t it be in the same as recovered? So I have a couple of thoughts about improved. So, what if there, they were at 25% injection fraction, but they improved to, I don’t, know, 45%, they’re still systolic, right?
47:46 I don’t know. I mean, I don’t know.
47:48 I, that’s my kind of thought and there’s no official advice on it.
47:52 But that’s kind of my thought that we know we probably should get clarification on the improved portion of it. That’s just my thoughts.
48:01 Obviously, it might You might know it’s improved to 50%, but I don’t think there’s anything in the official guidance that we can go with. And we can code improved two diastolic.
48:15 Exactly If that was my. So thank you, Allison. That wasn’t the same comment that I have. It doesn’t really tell us much, right? You can go from 10 to 20, or it could go from 30 to 50, or, et cetera.
48:28 Um, that’s exactly what I was thinking.
48:35 OK, so let me go back.
48:40 OK, so this is a good one.
48:42 I may have discussed this one before for specificity. So, taking a look at the codes while I’ve read this.
48:53 The another thing that I want everyone to react to you when you’re coding is that unspecified code.
49:00 Do you think getting greater specificity of that … is going to change the DRG, and obviously, if you looked ahead, you already know the answer to this?
49:08 But, this patient has a history of …, epidural flag them on their being treated for enter a backdoor cloquet status post completion of six weeks of 17. On 226 presented, again, with back pain, They’re found to have infectious disk itis previously diagnosed with ostia of the lumbar region and treated with IV antibiotics and ultimately off antibiotics for several weeks. Patient status pain worsen over several days and MRI was done that showed progression of his known … osteomyelitis.
49:42 He was sent to the ED for admission, ostia of the vertebrae lumbar region. Despite receiving appropriate antibiotics patient has recently been an increasing pain. Disk biopsy on 321, showed acutely inflamed disk, culture with sensitive to carve a pan AM’s CT, abdomen pelvis worsening of bony changes involving disk, ostia at L three L. for. The discharge summary says admitted to the Hospital for Recurrent …
50:10 for …, had previously completed six weeks of cephas came, sorry, … team. …, while hospitalized p.i.c.c.
50:20 line was placed, antibiotics changed to your you’re a pan am a discharge, and he was set up for home antibiotics with one gram.
50:28 You’re a pan am, which was, which was, will continue until 5, 3. And you were hospitalized for a recurrent infection of your lumbar spine, which is called … and …. So, again, React to your unspecified codes, you can see this DRG went to medical back problems. Also react to your DRG, right?
50:46 Patient is treating for being treated for an infectious …, does that DRG make sense?
50:55 Is there another code we can use instead of an unspecified, lumbar spine? Discard us is an inflammatory … is that it infectious despite us? Let’s take a look and see if we can locate a more specific code.
51:09 And even if we didn’t, I mean, even if we, you know, let’s take a look, if they didn’t document it as infectious. But they’re treating the patient with antibiotics because, and we’re kind of reading between the lines here because they’re treating it with antibiotics. It’s a, it’s a potential source for a query, right?
51:25 Because if we take a look at the, the index here, we go to …, we have lumbar Region.
51:32 We go to infection. We have Piyo Jen Act, or, I should go to …
51:37 Biogenic, meaning, Infection, which is causing puss, known as … producing infections. Does that mean the same thing? Let’s keep looking.
51:47 If I go to Infection Intro Virtual disk, …, there’s a more specific code here. If I go to the code book, we go to Infection of …. Disk Piyo Genetic becomes a non essential modifier lumbar region. We have a more specific code here. Code also an additional infectious agent.
52:08 That code to me makes much more sense than an unspecified ….
52:13 So the suggestion is to delete that code, make it the more specific code. Also, you can see that DRG that rework DRG is to ah steel DRG.
52:24 The other thing is, I mean, we didn’t have to query this, but I wanted to point this out. We may need to query.
52:30 Is that an alternative here, is they’re admitted with both … and ….
52:34 So, alternatively, if this was clinically support it in the documentation, which I think it was at the ostia, could have also been used as the Principal Diagnosis, and we could have re sequence this, and still got to this DRG and we wouldn’t have needed A, We wouldn’t have needed a query.
52:52 Um, we also have other Assisi’s here, um, potentially if we needed a SEC, we may have needed to query, if we didn’t have these other CC’s, but I just wanted to show you. again, we’re in the specificity matters.
53:08 So, if you have this unspecified code, make sure that you’re looking for greater specificity.
53:15 It’s kind of where I’m going with this.
53:16 Again, we didn’t necessarily need to query in this case, but again, we may need to query, so we’re looking for clues or things.
53:24 Reactions, I want everyone to react to that and say, do we have a greater specified code that makes this a better?
53:32 Makes this better, let me take a look and see what I have other codes I have available.
53:38 Then does the DRG makes sense they’re treating the patient for an infection of the back, not a medical back problem, They don’t have, like, spawned a locis or something or, you know, they’re not being treated with PT, OT, and pain medication, they’re being treated with IV antibiotics, and they required a bone biopsy or disk, a disk biopsy.
53:57 Et cetera.
54:01 So just some words, some words about that case. The next case, again, what are the possible … options here? What are the possible query opportunities? These should be a little bit quicker.
54:15 A patient presents from subacute rehab was noted to have an ultrasound of her lower extremity positive for DVT.
54:23 She also has a history of a recent CVA in the ED. So she had a CTA of the chest an echo of vir console lovenox.
54:33 The diagnostic CT showed acute bilateral pulmonary emboli, involving both the left and right just domain pulmonary arteries and extending into the segmental, arteries of both the upper and lower lobes. Significant caught burden no saddle embolism elevated RV LV ratio suggestive acute, right heart strain. The echo showed right ventricle the cavity size is mildly increased. The ED said case discussed. I spoke with the radiology resident and patient has a clot in the left and right just domain pulmonary arteries as well as signs of: Right? Heart strain echo ordered by the doctor patient, previously receives or although they had a console, she had a CT chest was positive again for the PE. You already talked about that T is pending on therapeutic lovenox, appears human diametrically stable postdocs, and 96% on.
55:22 three leaders patient’s history examine pertinent labs or in diagnostics were discussed continue anticoagulation await tests, DIR will follow. The hospitalist noted that the patient had a two D echo preserved ejection fraction and right heart strain. Further plans for VR, discharge summary notes. The patient presents with left sided chest pain found to have acute bilateral pulmonary emboli with signs of freight RV strain on CT initially initiated on Lovenox.
55:53 Yes.
56:01 What are the possible PD X’s are what and what is the possible query opportunity here.
56:16 Yeah.
56:20 And while I wait for that, someone’s saying, I don’t understand why I 50.33 is not MCC. It is an MCC.
56:28 Decoder did encode it.
56:33 On the original coding.
56:37 If that answers your question.
56:47 OK, so I’m just making a comment about a new working definition with improved ejection fraction that includes a baseline, left ventricular ejection fraction, of less than 40% with a, with A, Greater Than Inc, 10% increase from baseline, OK?
57:06 The second measurement of greater than 40%.
57:13 That’s a good one. They might have to address that encoding clinic. Thank you for pointing that out.
57:24 Wouldn’t that be reading between the lines? Yep.
57:35 Someone else is saying that, they say it’s the same, improved and recovered as the same thing.
57:40 I don’t know if they addressed improved encoding clinic. They just addressed and recovered, So until that’s officially published, that’s not an official source to me. Until that’s officially published, I’m not going to be going with some random person on the Internet.
58:07 Um.
58:17 OK?
58:23 OK, so ones having: So, I can’t think we’re kind of, I’ll go back to that one. Let me go back to the … and D M I think they specifically said it was, it was due to something else, right, It was due to the disk, the ostia was due to the ….
58:45 OK, good. So going back to the P, I see some people answering query for acute core Pullman now.
58:52 OK, it looks like everyone’s getting this right, harks strain, documented pulmonary embolism.
58:57 OK, good, so for those of us that may not be aware of that, again, we have this original coding. We have other pulmonary embolism without acute core pulmonary. So, if I was looking for specificity, like we did with the discarded, some kind of building upon that.
59:16 I’m kind of building upon what we’re talking about.
59:23 In terms of reacting to a an unspecified code, or a code that needs greater specificity, so what is if I was looking at this, OK? What is acute core pulmonary pulmonary, or pulmonary do, I have documentation to potentially query For that? We’ll talk about that.
59:42 But going back to the improved. I’m kind of going all over the place here, because all the comments that are coming in, but going back to reading between the lines.
59:52 Know, that’s kind of what I’m going for here, is we see something in the documentation, but they don’t come out and say it. Right? So going using that improved ejection fraction. Is there anything? If there’s an injection, if it says improved ejection fraction. And we see that the rejection fraction is now 50%, Then to me, that’s reading between the lines and let’s say, Let’s query for diastolic, right?
60:15 Again, some people may have that in their policy that their coding improved to diastolic, but until that’s officially published, I’m not going to advise that.
60:23 And, again, I’m not going to use some official, like some random person on the Internet, as just like I wouldn’t expect you guys to. You know, 100% agree with everything that I say, because I’m, again, I’m just a random person as well. I want to have, you know, some advice that’s officially published by Coding Clinic, and I always advise submitting those to get official advice to Coding Clinic.
60:46 Um, they’re one of the co-operating parties that kind of create the rules and guidelines that we follow, one of them, anyway.
60:56 OK, so let’s go Let’s talk about acute core Pullman L Or let’s go to the original coding. The coder coded this as just other pulmonary embolism we didn’t have enough documentation to code, is to acute core pulmonary. Home now, but we did have evidence of right heart strain, indicating that they have some right heart failure due to this pulmonary embolism.
61:19 So they did suggest a query for, for this, to see if they had acute core pull me now, and they said, Yes, based on the cat scan. And the T T, the options here, or with or without or other, are unable to determine. And they said, yes, they do have acute core pulling out. To be honest, it’s a little bit confusing, because acute … is also another, another name for right heart failure.
61:42 However, um, usually acute core pulmonary is in the setting of pulmonary disease, right?
61:52 When we see, um, a sudden, high degree of occlusion in the pulmonary arteries, we see a dilation of the right ventricle, the right Oracle, which may be best termed as acute KORA Pullman. Now, I want to make, make a note here that there is presently no consensus definition for this.
62:13 So, depending on what what source you’re using, there may be different criteria that different people are.
62:19 You’re utilizing to make this diagnosis.
62:22 So, in general, general, I mean, in all of the definitions that I looked up, it’s termed as a sudden dilation of the right ventricle. Now chronic, we see pulmonary hypertension chronic …
62:34 now, as associated with a progressive enlargement of the right side of the heart, secondary to certain pulmonary diseases.
62:41 Now, in the definition, I saw that, um, right, heart or right heart failure due to left heart failure, or congenital heart disease is not considered core Puma now. So that was kinda the differential there. I know we have codes for both, depending on how you index them, That’s kind of what I found was able to find and in the references, you know, if you’re indexing that, they talk about core pulmonary being defined as an alteration of structure, sorry, perch iffy.
63:09 So chronic, if it’s chronic, you’re gonna see hypertrophy just like we see hypertrophy with, you know, with heart failure hypertension.
63:19 Of the, you know, if the left side of the heart, for example, and function of the right ventricle of the heart is caused by primarily a disorder of the respiratory system, resulting in pulmonary hypertension.
63:32 So when we see that dilation or sudden dilation of the right ventricle, the thought is, is that it’s probably due to a PE and that they’re in acute core Pullman L Another name for that is, Right, Heart Failure.
63:47 So, here’s just a summary of kind of signs and symptoms. I’m not going to read through this and treatment kind of some of the things that we saw in the documentation. The symptoms, the destiny of the dilation. They’re also known as write one tricolor strain T for diagnostic tests. Electrocardiogram, DQ scanning, right? Heart cath is typically not done with this, but usually done with more chronic. And then treatment is usually aimed at treating the underlying condition. That’s where they consulted with, with IR, right? In case they had to do.
64:25 a thrombectomy and the …
64:26 domain, then also they may need to give daya recess the treat that elevated right ventricular filling volume.
64:39 OK, now a couple of, I think I have time to talk about these eight, well, maybe not.
64:46 I’ve probably talked about this but quickly.
64:50 We have loss of consciousness with specificity with TB eyes. You can see here this was coded as unspecified, duration. It was documented as denied loss of consciousness in the documentation. This one wasn’t warranted a query. They specifically said the patient denied loss of consciousness. If however, the documentation was unclear, a query will be warranted. And the reason I’m mentioning this one, is because I see a lot of changes related to this.
65:21 They specifically denied loss of consciousness. You could see there the DRG change. Lesson learned here is a six character assignment for loss of consciousness does matter. For MS DRG assignment.
65:34 You can see there the difference in the DRG.
65:39 You ever code also know, don’t forget to code your open wound of head or on a skull fractures. And also some other tips, the other things that we see with this is, you know, should we submit a query for loss of consciousness? Is it unclear? Is there even loss of consciousness? How long is the loss of consciousness?
65:57 Also, is this is a traumatic injury versus a non traumatic injury is a CVA, a hemorrhagic CVA. Sometimes the documentation is unclear in regards to that as well.
66:09 Um, I didn’t really have a good example for that, but I do see that a lot, as well as a suggested query.
66:18 You can see here, it was thought to be possibly non traumatic.
66:23 I don’t have the case notes here, but you can see here.
66:28 It went from DRG. If we changed that to non traumatic, it went from 0 83 to DRG oh 65.
66:36 So that does make a difference in the DRG assignment as well.
66:41 Then of course, we now have our unknown unknown loss of consciousness which I put a coating note here, unknown loss of consciousness. If we don’t know if the doctor doesn’t know or the provider doesn’t know, it’s still codes to the traumatic stupor with coma greater than one hour.
66:56 With or without MCC, similar to the loss of consciousness of an unknown duration, but be careful with that. Sometimes they say brief loss of consciousness, et cetera.
67:05 So unfortunately, we didn’t get to the rest of these. I’m going to end with that. Of course, we have are using the path report for specificity. You can read through that example, it is a somewhat basic example. I will stay on for questions.
67:21 Then etiology of fractures. This is talking about past pathological fractures.
67:27 We can add this to the next, the next slide, the next next webinar that we have on, on queries. But it’s there if you want to read through it, just so you’re more aware of what we look for when querying for pathological fractures.
67:44 OK, so, I’m going to stop here and go through questions, because we’re out of time, um, and address some of the other comments.
67:58 Going back to this example, we potentially do have the PE, we potentially have PE versus the DVT, as well because they present it with both.
68:10 Um, and a query for the acute port core. Core Pullman also good.
68:19 Need to query for AS. I’m not sure what that means.
68:27 Has an aortic stenosis? I don’t remember.
68:29 Sorry.
68:43 I have other people just saying improved. I’m not sure, it, I don’t think it means recovered completely.
68:49 If you look at, you know, some published advice, they do say it means recovered, but again, I would need the officially published.
68:58 Um, and some people are interpreting improve could mean either systolic or diastolic needs clarification.
69:08 Um, lot of comments on that.
69:14 Its heart failure is present on admission and they have an exacerbation. It would be acute and chronic. Yep, that’s correct.
69:25 Ah.
69:30 And thanks again Susan, for sharing that article off to do some more research on that.
69:41 Someone just mentioning that will hopefully they’ll provide guidance on that. So, I think I had someone earlier ask, how do we submit coding questions to Coding Clinic? You can simply site, go to coding Clinic. The website, and sign up for, anyone can submit questions. You can simply go there and sign up for an account, and submit your questions.
69:59 The only thing is, you have to submit redacted information with your question. Usually if you submit questions without.
70:11 corresponding documentation, they will deny your request. Even if it’s a basic question, I usually will get back. You need to submit documentation, even if it’s, like, you know, How do you code acute on chronic systolic heart failure? They still asked me for documentation. I mean, that’s a very basic example, but sometimes my questions are very are like that, and they still want documentation, so that’s just a word of caution there that you need to submit redacted. PHR are Redacted.
70:41 Documentation.
70:44 And also, it takes a long time to get responses, so if you’re looking for a quick response, You probably won’t get one.
71:02 So, there is an assumed relationship with …, and D M, that is correct. You want to look to see what the cause is, I don’t know, Did they say DM in that case? I think there is documentation that it wasn’t. It was, it was related to something else. I can’t remember the exact case on that, But, but, you yes, there is usually an assumed relationship with OSU and diabetes.
71:27 I think I, sort of answered that before, um.
71:38 OK, good, so just to point Bice, one of the, some of the, some of the queries may not make a change to a DRG or …. I’m a visual change at that. The CDS would see, but it could have the quality impacts equality in impact for other organizations, which is true. It could be an HCC. It could be a quality indicator four.
72:02 It could be a quality indicator mm, hmm.
72:18 Yes, there’s an assumed relationship with it between Austrian and Diabetes. However, if they state that it’s due to trauma, or they do to an under, they break the link right, if there’s, if It’s due to something else.
72:49 So there is a little bit of to me, there is a little bit of overlap. So the question is would we query for acute for heart strain being acute heart failure to me. Right it’s Acute Heart Failure Kupe … Now is acute Heart Failure Due to PE.
73:07 So I probably would just be coding the Combination Code.
73:14 I’m not sure I would have to I would probably have to enter that to see if there’s an excludes, None and excludes. But if they cancel each other out with MCC, I don’t know without entering it.
73:29 So, someone saying a PE with acute core pulmonary for MCC DVT is a PBX. I think there’s a reason they wanted to go with the PE versus the DVT. I think that was the main reason for admission. I think they’re actually an observation initially, and then they changed them, too. But just the thought process of what could potentially be the PBX was kind of what I was going for there.
73:54 Um, try not to get too into the weeds with those examples. But yeah, that if you if that, if the DVT and the PE were both reasons for admission, you want to look to optimize, right?
74:05 If they are both treated equally?
74:11 Yes.
74:15 Hmm, hmm, hmm, hmm.
74:36 Someone mentioned, was that, oh, To chronic. I’m not sure. Again, there are only little snippets. So, some of these things you could, you could be looking for things that are kind of beyond what I was going for.
74:49 Oops.
75:08 I’m reading questions guys, though, if there’s a pause, and you can’t hear me, that’s because I’m reading the questions and answering them.
75:19 China.
75:28 That’s true, too, of, right, heart strain on echo doesn’t always equal heart failure. That’s why we have to query, Right?
75:41 But that example said that we shouldn’t code acute CHF. I don’t know. Why is everyone saying that? It didn’t say that said, the coder didn’t code it.
75:50 Let me go back to that example.
75:53 The code, this is the original or let me go back, is this: The coder didn’t code the code or code it chronic?
76:00 Oh, did I flip these?
76:04 The coder, these are the original codes. Decoder originally didn’t code. They only put it chronic diastolic heart failure.
76:11 The revised codes were to code acute on chronic heart failure.
76:17 It’s Oh! I think that someone’s asking why that as an MCC so. I think they fix that. This was probably before they fixed the edit, I think they fixed it, we’re now they should act as an MCC.
76:29 Um, just probably before they fixed the whole MCC edit. Sorry about that. I didn’t notice that it wasn’t listed as an MCC.
76:38 Um, so back, I think for fiscal year 20, 22, they hope they fixed, you know, some, when you entered acute, If you coded 11 or 12, or 13 as a PDF. Sometimes, if you entered the cute CHF as a secondary sometimes, they would act as an MCC. And sometimes it, Wouldn’t they actually fix that for fiscal year 20 22, so, this, this might have been an older case that I used.
77:06 But it should still, it should be an MCC at this point?
77:13 I think that was the question, sorry, if I’m misunderstanding.
77:18 Guys, so, I talked about this if you were on time. I talked about the CEUs.
77:25 The it’s in this, it should be in the handout section. You can download it at any point.
77:33 You don’t need to wait for for me to talk about it or and you also get the e-mail so you guys can sign off at any point once I end the presentation.
77:45 So at the end of the presentation so you will receive a follow-up e-mail with a link to the CEU. Also in the handout section there is a link to the CEU for you to download.
78:02 You have to give us a minute to upload it. We don’t want people downloading it before the end of the webinar, so as long as you have the link, I would go back tomorrow morning and download it. Or even by the end of today. I’m still on the webinar. So, the people that upload it, have not received the OK for me to down to upload it yet.
78:26 It’s not upload it yet.
78:28 So Give me a second, just give me a couple minutes to get it out to marketing, so they can upload it.
78:45 I think I got up to all the questions.
78:47 But if not, shoot me an e-mail.
78:54 And we’ll get back to you on your question.
78:58 All right, everyone. Have a great day.
79:01 Until next time.
79:13 So someone’s asking about a PC, This is not approved for a PC, It’s AHIMA only?