1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. THE COMPLETE DIAGNOSIS CODING SOLUTION THIRD EDITION Chapter 23 Hospital (Inpatient) Diagnosis Coding 23-1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes 23.1 Evaluate concurrent and discharge coding methodologies. 23.2 Understand the Official Guidelines specific for inpatient reporting. 23.3 Apply the proper application of present on admission (POA) indicators. 23-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes (cont.) 23.4 Determine the impact of diagnosis- related groups on the coding process. 23.5 Identify complications and co- morbidities. 23.6 Recognize the importance of the Uniform Hospital Discharge Data Set (UHDDS). 23-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Co-morbidity Complication Concurrent coding Diagnosis-related groups (DRG) 23-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Hospital-acquired conditions (HAC) Major complications and co-morbidities (MCC) Present on admission (POA) Uniform Hospital Discharge Data Set (UHDDS) 23-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction For the most part, hospital encounters and outpatient encounters use the same guidelines and the same coding process. However, emergency room and outpatient surgery departments, even though they may be under the same roof as the inpatient acute care facility, will typically be coded as outpatient encounters. 23-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Concurrent and Discharge Coding In some cases, professional coding specialists may do what is called concurrent coding. This means that coders actually go up to the nurse’s station on the floor of the hospital and code from the patient’s chart while the patient is still in the hospital. Learning Outcome: 23.1 23-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Concurrent and Discharge Coding (cont.) Concurrent coding enables the hospital to gain reimbursement to date without having to wait until the patient is discharged, improving cash flow for the facility. Learning Outcome: 23.1 23-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Concurrent and Discharge Coding (cont.) The most important documentation to look for includes: –Discharge summary or discharge progress notes –Hospital course –Discharge instructions –Discharge disposition –Death/discharge summary Learning Outcome: 23.1 23-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Official Coding Guidelines The Official Coding Guidelines located in your ICD-10-CM book will provide you guidance. In two instances, the guidelines direct inpatient coders differently than outpatient. Learning Outcome: 23.2 23-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Official Coding Guidelines (cont.) Uncertain Diagnosis For outpatient coding you are not permitted to ever code something identified by the physician in his or her documentation as “rule out,” “probable,” “possible,” “suspected,” or other similar terms of an unconfirmed nature. Inpatient coders are permitted to “code the condition as if it existed or was established.” Learning Outcome: 23.2 23-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Patient Receiving Diagnostic Services Only In the outpatient world, the guidelines instruct you to wait until the test results have been determined and interpreted by the physician as documented in the final report before coding. At that time, confirmed diagnoses, or the signs and symptoms that were documented as the reason for ordering the test, are reported. Learning Outcome: 23.2 23-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Patient Receiving Diagnostic Services Only (cont.) When you code for inpatient services, abnormal test results are not reported unless the physician has documented the clinical significance of those results. Learning Outcome: 23.2 23-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Patient Receiving Diagnostic Services Only (cont.) The guidelines reiterate that if the coding professional notices abnormal test results and documentation is unclear from the physician, it is “appropriate to ask the provider whether the abnormal finding should be added.” Learning Outcome: 23.2 23-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Present on Admission Indicators Present on admission (POA) indicators are required for each diagnosis code reported on the UB-04 and 837 institutional claim forms. Learning Outcome: 23.3 23-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. General Reporting Guidelines According to CMS Publication 100-04, “Present on admission is defined as present at the time the order for inpatient admission occurs—conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.” Learning Outcome: 23.3 23-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. General Reporting Guidelines (cont.) Professional coders must carefully review the admitting physician’s submitted history and physical (H&P)—the documentation that supports the order to admit the patient into the hospital—to determine whether the condition was identified at the time. Learning Outcome: 23.3 23-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. General Reporting Guidelines (cont.) Gathering POA data helps identify hospital-acquired conditions (HACs). A hospital-acquired condition is an illness or injury that the patient contracted solely due to the fact that he or she was in the hospital at the time. Learning Outcome: 23.3 23-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. POA Indicators POA indicators are used to clearly identify whether the signs, symptoms, and diagnoses reported on the claim form were documented by the admitting physician at the time the patient was admitted into the hospital. The indicators are : –Y Yes –N No –U Unknown –W Clinically Undetermined –1 Exempt Learning Outcome: 23.3 23-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Diagnosis-Related Groups In addition to dealing with diagnosis and procedure codes, hospitals must work with diagnosis-related groups (DRGs) for Medicare reimbursement under Medicare Part A—Hospital Insurance. Each DRG has a payment weight assigned to it determined by the typical resources used to care for the patient in that case. Learning Outcome: 23.4 23-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Principal Diagnosis The principal diagnosis assigned is one of the factors used to determine which DRG is most accurate. Remember that the principal, or first-listed, diagnosis as defined by the guidelines is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Learning Outcome: 23.4 23-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Complications and Co-morbidities As each diagnosis is evaluated for its standard of care, CMS understands that a patient in a hospital may have multiple conditions or concerns (signs, symptoms, diagnoses) that are interrelated and create a more complex need for care. These may be complications and/or co-morbidities (CCs). Learning Outcome: 23.5 23-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Complications and Co-morbidities (cont.) In some cases, regardless of the precautions taken, complications of a procedure or treatment may arise during the patient’s stay. Such a condition must be coded and reported to support the medical necessity for the treatment provided to resolve the concern. Learning Outcome: 23.5 23-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Major Complications and Co- morbidities Typically, a major complication and co- morbidity (MCC) is a condition that is systemic, making treatment for the principal diagnosis more complex and/or making the health concern life-threatening. Learning Outcome: 23.5 23-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Uniform Hospital Discharge Data Set The Uniform Hospital Discharge Data Set (UHDDS) is a collection of specific data gathered about hospital patients at discharge. The information pulled from hospital claim forms is related to demographic and clinical details. Learning Outcome: 23.6 23-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Uniform Hospital Discharge Data Set (cont.) Demographic data include: Gender Age Race and ethnicity Geographic location Provider information Expected sources of payment Length of stay (LOS) Total charges billed by the hospital Learning Outcome: 23.6 23-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Uniform Hospital Discharge Data Set (cont.) Clinical data collected evaluate: Type of admission, described as scheduled (planned in advance with preregistration at least 24 hours prior) or unscheduled Diagnoses, including principal and additional diagnoses Learning Outcome: 23.6 23-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Uniform Hospital Discharge Data Set (cont.) Clinical data collected evaluate (cont.): Procedures, services, and treatments provided during this admission period External causes of injury, determined by the reporting of external cause codes Learning Outcome: 23.6 23-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary The coding process remains the same for inpatient and outpatient services for which coders are determining and reporting accurate diagnosis codes. 23-29