Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CHAPTER 26 INPATIENT CODING

2 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Selection of Inpatient Principal Diagnosis Condition established after study (tests)Condition established after study (tests) Chiefly responsible for patient admissionChiefly responsible for patient admission Applies to all non-outpatient settingsApplies to all non-outpatient settings –Acute care, short term, long-term and psychiatric hospitals –Home health agencies; Rehab facilities; Nursing homes, etc.

3 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Selection of Inpatient Principal Procedure Code from ICD-9-CM Volume 3Code from ICD-9-CM Volume 3 Principal procedure is:Principal procedure is: –Definitive treatment rather than Diagnostic or exploratoryDiagnostic or exploratory –Necessary to take care of a complication –If two procedures meet criteria Report one most closely related to principal diagnosisReport one most closely related to principal diagnosis(Cont’d…)

4 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Selection of Inpatient Principal Procedure (…Cont’d) Procedure is significant if it: Is surgical in natureIs surgical in nature Carries a procedural riskCarries a procedural risk Carries an anesthetic riskCarries an anesthetic risk Requires specialized trainingRequires specialized training

5 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnosis and Services Diagnosis and procedure MUST correlateDiagnosis and procedure MUST correlate Medical necessity must be established through documentationMedical necessity must be established through documentation No correlation = No reimbursementNo correlation = No reimbursement

6 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.A. Symptoms, Signs, and Ill-Defined Conditions Chapter 16Chapter 16 Inpatient coders do NOT code when definitive diagnosis has been establishedInpatient coders do NOT code when definitive diagnosis has been established

7 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.B. Two or More Interrelated Conditions Two or more interrelated conditions existTwo or more interrelated conditions exist Either could be principal diagnosisEither could be principal diagnosis Either sequenced firstEither sequenced first Unless indicated otherwise by:Unless indicated otherwise by: –Circumstances of the admission –Therapy provided –Tabular List of Alphabetic Index (Cont’d…)

8 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.B. Example of Interrelated Conditions (…Cont’d) Mitral valve stenosis and coronary artery disease (two interrelated conditions)Mitral valve stenosis and coronary artery disease (two interrelated conditions) –Either can be principal diagnosis –Either sequenced first MVS and CADMVS and CAD CAD and MVSCAD and MVS –Resource intensiveness affects choice Mitral valve stenosis is presumed by ICD-9-CM to be of rheumatic originMitral valve stenosis is presumed by ICD-9-CM to be of rheumatic origin

9 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.C. Two or More Equal Diagnoses Either can be sequenced firstEither can be sequenced first –Example: Diagnosis of viral gastroenteritis and dehydration if both are treated VG and DVG and D D and VGD and VG If only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration firstIf only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration first

10 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.D. Comparative or Contrasting Conditions “Either/or” diagnoses“Either/or” diagnoses –Code as confirmed in the inpatient setting If determination CANNOT be made, either can be sequenced firstIf determination CANNOT be made, either can be sequenced first Example: Pneumonia or lung cancer can be eitherExample: Pneumonia or lung cancer can be either P or LCP or LC LC or PLC or P –If both aggressively treated

11 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.E. Symptom(s) Followed by Contrasting/Comparative Diagnosis Symptom code sequenced firstSymptom code sequenced first Then other diagnosesThen other diagnoses Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD)Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD) –Sequence first chest pain –Followed by gastric reflux or PUD –Rule: code first underlying condition causing the symptom –If it is necessary to code symptom to explain resources used, code also

12 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.F. Original Treatment Plan Not Carried Out Principal diagnosis becomesPrincipal diagnosis becomes –Condition that after study was reason for admission as inpatient –Treatment does NOT have to be carried out for condition (Cont’d…)

13 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.F. Example (…Cont’d) Patient admitted for elective surgery, develops pneumonia, surgery cancelledPatient admitted for elective surgery, develops pneumonia, surgery cancelled –Code reason for surgery first –Code “Surgical or other procedure NOT carried out because of contraindication” (V64.1) –Also code pneumonia

14 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.G. Complications of Surgery and Other Medical Care If admission is for treatment of a complication from surgery or other medical careIf admission is for treatment of a complication from surgery or other medical care –Sequence complication code as principal diagnosis –If complication is classified to series and code lacks specificity to describe complicationand code lacks specificity to describe complication an additional code for the specific complication should be assignedan additional code for the specific complication should be assigned

15 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.H. Uncertain Diagnosis If diagnosis at time of discharge states:If diagnosis at time of discharge states: –“probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” –Code condition as if condition existed until proven otherwise (inpatient facilities code this) –Physicians report a definitive diagnosis or signs/symptoms (Cont’d…)

16 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.H. “Cough and fever, probably pneumonia” (…Cont’d) Inpatient: Code pneumonia, do NOT code cough and feverInpatient: Code pneumonia, do NOT code cough and fever Outpatient: Code cough and fever, do NOT code pneumoniaOutpatient: Code cough and fever, do NOT code pneumonia –Code symptoms in outpatient setting if a definitive diagnosis is not documented

17 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.H. Uncertain Diagnosis Two exceptionsTwo exceptions –Code 042 AIDS should only be assigned for confirmed cases –Code Avian influenza should only be assigned for confirmed cases

18 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.I. Admission from Observation Unit Patient admitted to observation for medical condition which worsens or does not improvePatient admitted to observation for medical condition which worsens or does not improve Patient admitted to same hospital for same conditionPatient admitted to same hospital for same condition Principal diagnosis is medical condition which led to admissionPrincipal diagnosis is medical condition which led to admission

19 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.I. Admission from Observation Unit Patient admitted to observation to monitor condition (complication) following outpatient surgeryPatient admitted to observation to monitor condition (complication) following outpatient surgery Is then subsequently admitted as an inpatient to same facilityIs then subsequently admitted as an inpatient to same facility Principal diagnosis is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”Principal diagnosis is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”

20 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.J. Admission from Outpatient Surgery Patient receives surgery in the outpatient surgery departmentPatient receives surgery in the outpatient surgery department Is subsequently admitted for continuing inpatient careIs subsequently admitted for continuing inpatient care Guidelines for assigning principal diagnosis for inpatient admission:Guidelines for assigning principal diagnosis for inpatient admission: (Cont’d …)

21 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section II.J. Admission from Outpatient Surgery (…Cont’d) –If admission is due to a complication, assign the complication as principal diagnosis –If no complication or medical condition is documented as reason for admission, assign the reason for the outpatient surgery as the principal diagnosis –If admission is for another condition unrelated to the surgery, assign code for unrelated condition as principal diagnosis

22 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section III. Reporting Additional Diagnoses Definition of “other diagnoses” is additional conditions that affect patient care requiring: –Clinical evaluation or –Therapeutic treatment or –Diagnostic procedures or –Extended length of hospital stay or –Increased nursing care and/or monitoring

23 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section III. Reporting Additional Diagnoses Guidelines when neither Alphabetic Index nor Tabular List provide direction: Diagnosis reported in discharge summary should be codedDiagnosis reported in discharge summary should be coded Resolved conditions or status-post procedures from previous admissions that do not have bearing on current stay, should not be codedResolved conditions or status-post procedures from previous admissions that do not have bearing on current stay, should not be coded History codes (V10-V19) if impact on current care or influences treatmentHistory codes (V10-V19) if impact on current care or influences treatment

24 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section III.B. Abnormal Findings Abnormal findings of laboratory, x-ray, pathologic and other diagnostic tests:Abnormal findings of laboratory, x-ray, pathologic and other diagnostic tests: –Not reported unless provider indicates their clinical significance –If findings are outside normal range and provider has ordered other tests to evaluate condition or treatment, query provider if abnormal finding should be reported

25 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section III.C. Uncertain Diagnosis If diagnosis documented at time of discharge, is listed as:If diagnosis documented at time of discharge, is listed as: –“probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out” or similar uncertain wording –Code condition as if it existed –Basis is that diagnostic workup, further workup and initial therapeutic approach will correspond to the established diagnosis

Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 26 INPATIENT CODING