2. Kay Piper, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer Lead Auditor-Analyst Compliant Documentation Improvement Program SSM Healthcare St. Louis, MO Dear CDI—Please Help! Resolving CDS and Coder Disagreements

3. Learning Objectives 3 keys for resolving disagreements 7 tools for answering tough questions 6 steps for developing consistent, defendable answers 4 strategies for promoting CDS/coder compliance

4. CDMP-CDIP-PA-HIM Coder Team Regional Compliance 1 PA, 2 Coders, 1 Coder-RN, 1 RN Large Urban Hospital 6.5 CDS 1 PA 10 Coders Large Community Hospital 4 CDS 1 PA 9 Coders Large Urban Hospital 5.5 CDS 1 PA 9 Coders Children’s Hospital 0 CDS 0 PA 8 Coders Medium, Community Hospital 4 CDS 1 PA 5 Coders Medium Community Hospital 3 CDS 1 PA 4 Coders

5. 3 Keys to Resolving Disagreements

6. 7 Tools for Answering Tough Questions 1. Epic electronic health record 2. 3M encoder with references 3. Physician advisor 4. Regulations: CMS, MAC 5. Books: coding, DRG, clinical 6. Industry & medical websites 7. Logic, tact, compassion

7. 6 Steps for Developing Consistent, Defendable Answers 1. Define question 2. Sort facts 3. Research, research, research 4. Develop answer draft 5. Finalize answer 6. Educate

8. 4 Strategies for Promoting CDS and Coder Compliance 1.Referral file 2. Educational summit 3. Quizzes, flow sheets, posters, newsletters 4. Team policies

9. Now, the Tough Questions

10. Why Is 31.74 Trach Revision Not Grouping to Tracheostomy DRG 004? Dear CDIP, PDX is 038.9 Sepsis, SDX is 518.81 Acute respiratory failure, and procedure is 31.74 Revision of tracheostomy. Patient had trach already and it was revised this admit. Why am I getting DRG 853 Infectious & parasitic diseases w OR procedure w MCC? Why does it not group to DRG 004 Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj OR? Shouldn’t the coder assign 31.29 Other permanent tracheostomy since this is a permanent tracheostomy and since it would get us to the trach DRG? ~Befuddled

11. Tracheostomy Operative Report PRE & POSTOPERATIVE DIAGNOSIS: Respiratory failure with ventilatory dependence PROCEDURE: Revision tracheotomy, open Previous tracheotomy incision had significant hypertrophic scar, which was resected … there was significant scar tissue on the trachea itself. Trachea was dissected on both sides. Second tracheal ring was used for creation of a Bjork flap. It was folded down and secured to subcutaneous tissues with a 3-0 Vicryl suture.

12. Why Is SDX 585.6 ESRD Not an MCC? Dear CDIP, Is 585.6 ESRD no longer an MCC? The patient had ESRD—which it looks like the coder coded. Coder has DRG 617 Amputation of lower limb for endocrine, nutrition, & metabolic disorders w CC. She is not counting 585.6 ESRD as MCC: PDX—250.80 DM w other manifestation SDXs—730.27 Osteomyelitis of foot, 585.6 ESRD PXs—84.12 Transmetatarsal amputation of toes I’m [CDS] using 585.6 ESRD as my MCC. I have DRG 616 Amputation of lower limb for endocrine, nutrition, & metabolic disorders w MCC. How did I get DRG 616? What is different in the coder’s coding? What happened since the software update last week? ~Stunned

13. Is It Double Dipping to Use 443.29 Dissection of Artery as an MCC? Dear CDIP, Should code 443.29 Dissection of other artery be added as a secondary diagnosis? It’s the only MCC. The coder and I agree that 998.2 Accidental puncture/laceration during a procedure needs to be assigned because the physician clarified it was a complication. But should we add 443.29 and get extra payment for the MCC? Coding Clinic 3rd Q 2009 instructs to code artery dissection only if the physician stated it was a complication & required additional surgery/repair, etc. In our case, the surgeon stated the dissection was a complication and additional repair was done. ~Puzzled

14. What Is the DRG and What Is the Procedure Code? 54.59 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy Dear CDIP, The coder sent me the Coding Clinic on this case. Which DRG is right? The coder assigned procedure 54.11 Exploratory laparotomy and got DRG 356 Other digestive system OR procedure with MCC. I assigned procedure 54.59 Other lysis of peritoneal adhesion and got DRG 335 Peritoneal adhesiolysis. ~Flipping a Coin Coder’s e-mail to the CDS: “The physician doesn't mention the adhesions in his op note. We don't code lysis unless it extends the OR time and the physician documents it as being unusual. See the Coding Clinic below:”

15. 54.5 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy PREOPERATIVE DIAGNOSIS: Acute appendicitis POSTOPERATIVE DIAGNOSIS: Small bowel obstruction Procedure: Mini-laparotomy with adhesiolysis Findings: Appendix was not found. There was a knotted loop of terminal ileum with multiple layers of small bowel and tied with each other. The patient did not have an appendix, seems it was removed during one of her previous operations and she was unaware of that. … I incised abdominal fascia and entered abdominal cavity. I immediately identified the cecum. I followed the tibia distally into cecum. On inspection, I could not identify the appendix. I carefully inspected by palpating along medial aspect and indeed a mass was palpated. I brought this up into the field and indeed a portion of the terminal ileum was all knotted onto itself. I had to dissect down and it freed up very nicely. It appears that she was having a small bowel obstruction of the site. The small bowel allowed to lay without twisting onto the omentum and the fascia closed. 15

16. When Do I NOT Query for Excisional Debridement? Dear Query Author, We reviewed your query for 86.22 Excisional debridement of skin and subcutaneous tissue in an audit. You did a great job remembering that 86.22 requires specific descriptions. Unfortunately, this case did not need a query. ~CDIP Why is this query unnecessary?

17. When Do I NOT Query for Excisional Debridement? Encounter diagnoses: Cellulitis and abscess, left breast, diabetic Procedures: Incision and drainage of abscess L breast anesthetized with 1% lidocaine c epi 4mLs and Betadine prep. Small incision made c 11 blade scalpel over fluctuant area—revealed 1cm deep ulceration/abscess. Debridement of necrotic tissue from wound edges. Pus removed and sent for culture. Explored for loculations. Irrigated c NS. 1/4" gauze packing inserted. Nonadhesive dressing applied. Pt tolerated well without complications.

18. When Do I NOT Query for Excisional Debridement? Coding query: Please clarify whether an EXCISIONAL DEBRIDEMENT was performed in the ER & clarify the tissue excised: skin & subq ONLY, fascia or other. PHYSICIAN CLARIFICATION: Per addendum note: In reference to my ED note on 5/15/2010, this clarifies the extent of wound debridement. The debridement which I performed during the I&D of her left breast abscess was excisional with scissors involving the epidermal and dermal tissue. Nonexcisional debridement of necrotic and exudative tissue was performed on the visible subQ inside the abscess cavity as well.

19. Why Was Current CVA Coded for Cranioplasty Procedure? Dear CDIP, Patient was scheduled for surgery as a follow-up to her previous SAH/aneurysm repair/clipping, which happened in May 2011. Pt is a planned admit from rehab and this is not a new bleed or aneurysm. The coder assigned 430 Subarachnoid hemorrhage. Shouldn't the SAH be HX of code 438.89 Late effect of CVA and not the actual DX [current CVA]? ~Rock Paper Scissors

20. Why Was Current CVA Coded for Cranioplasty Procedure? HISTORY AND PHYSICAL: “2 mos s/p craniotomy for aneurysm and bone flap removal. LUE plegic. LLE paretic Surgical site sunken. Right pterional region.” OPERATIVE REPORT: PRE & POSTOP DX: Right cerebral CVA secondary to aneurysm PROCEDURE PERFORMED: Autograft cranioplasty PROCEDURE: Previous craniotomy scar was reopened. Previously removed bone flap, which had been returned to the operating room soaking in bacitracin irrigation, was fitted into position and was secured to surrounding calvarium in good anatomical position.

21. Now, the Answers Answers to case scenarios will be made available for download after the seminar.

22. Why Is 31.74 Trach Revision Not Grouping to Tracheostomy DRG 004? Dear CDIP, PDX is 038.9 Sepsis, SDX is 518.81 Acute respiratory failure and procedure is 31.74 Revision of tracheostomy. Patient had trach already and it was revised this admit. Why am I getting DRG 853 Infectious & parasitic diseases w OR procedure w MCC? Why does it not group to DRG 004 Trach w MV 96+ hrs or PDX except face, mouth & neck w/o major OR procedure? Shouldn’t the coder assign 31.29 Other permanent tracheostomy since this is a permanent tracheostomy and since it would get us to the trach DRG? ~Befuddled

23. Tracheostomy Operative Report PRE & POSTOPERATIVE DIAGNOSIS: Respiratory failure with ventilatory dependence. PROCEDURE: Revision tracheotomy, open. Previous tracheotomy incision had significant hypertrophic scar, which was resected … there was significant scar tissue on the trachea itself. Trachea was dissected on both sides. Second tracheal ring was used for creation of a Bjork flap. It was folded down and secured to subcutaneous tissues with a 3-0 Vicryl suture.

24. 3 Keys to Solving QuestionFactsResources Was this a new trach or a revised trach? Was the procedure coded correctly? Please explain the grouper logic Trach was revised—cannot assign an original creation ICD-9-CM code book and encoder DRG Expert book CMS DRG ICD-10-CM Conversion Project MS-DRG Definitions Manual

25. Why Is 31.74 Trach Revision Not Grouping to Tracheostomy DRG 004? Dear Befuddled— 31.74 Trach revision and DRG 853 are correct Grouper logic 31.74 = OR procedure MS-DRG Definitions Manual, 3M nosology help message DRG 853–855 Principal diagnosis from MDC 18 Infectious and Parasitic Diseases Plus ANY operating room procedure

26. Why Is 31.74 Trach Revision Not Grouping to Tracheostomy DRG 004? Revised Tracheostomy MDC DRG__________________ “New” Tracheostomy DRG__________________

27. Why Is SDX 585.6 ESRD Not an MCC? Dear CDIP, Is 585.6 ESRD no longer an MCC? The patient had ESRD—which it looks like the coder coded. Coder has DRG 617 Amputation of lower limb for endocrine, nutrition, & metabolic disorders w CC. She is not counting 585.6 ESRD as MCC: PDX—250.80 DM w other manifestation SDXs—730.27 Osteomyelitis of foot, 585.6 ESRD PXs—84.12 Transmetatarsal amputation of toes I’m [CDS] using 585.6 ESRD as my MCC. I have DRG 616 Amputation of lower limb for endocrine, nutrition, & metabolic disorders w MCC. How did I get DRG 616? What is different in the coder’s coding? What happened since the software update last week? ~Stunned

28. 3 Keys to Solving QuestionFactsResources Why is 585.6 not counting as an MCC? Is there a problem with the software update? Can you explain the grouper logic? 585.6 ESRD is excluded as an MCC when 250.80 is PDX DRG Definitions Manual for MS-DRGs Version 28 CMS website on final rules for MS-DRGs FY 2011

29. Why Is SDX 585.6 ESRD Not Grouping to DRG 616 w/MCC? 2-2

30. Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual Version 28.0 Appendix C Complications or Comorbidities Exclusion List 585.6 End-stage renal disease 249.40–249.41, 249.80–249.91Secondary diabetes w renal, other, unspecified 250.40–250.43, 250.80–250.93Diabetes w renal, other, unspecified 274.10, 274.19Gouty nephropathy 580.0–591Kidney infections, diseases 593.0–593.2, 593.89–593.9Kidney disorders: nephroptosis, hypertrophy, cyst 599.70–599.9Hematuria, urethral and urinary disorders 753.0–753.3, 753.9Urinary system congenital anomalies

31. Is It Double Dipping to Use 443.29 Dissection of Artery as an MCC? Dear CDIP, Should code 443.29 Dissection of other artery be added as a secondary diagnosis? It’s the only MCC. The coder and I agree that 998.2 Accidental puncture/laceration during a procedure needs to be assigned because the physician clarified it was a complication. But should we add 443.29 and get extra payment for the MCC? Coding Clinic 3rd Q 2009 instructs to code artery dissection only if the physician stated it was a complication & required additional surgery/repair, etc. In our case, the surgeon stated the dissection was a complication and additional repair was done. ~Puzzled

32. 3 Keys to Solving QuestionFactsResources Does 443.29 further add anatomical artery is involved? Or is it redundant since 998.2 indicates laceration (tears)? Is the extra reimbursement appropriate? Balloon inflation caused tear of coronary artery during a stent placement Physician clarified it was a complication Coding Clinic, professional websites, 3M nosology, CDMP vendor Consultant from Coding Clinic answered our request for clarification

33. 443.29 Dissection of Artery Dear Puzzled, We received the following answer from Coding Clinic: “Assign 997.2, Peripheral vascular complications, and 443.29, Dissection of other artery.”

34. Coding Clinic’s Answer on 443.29

35. 443.29 Dissection of Artery Dissection of artery occurring during coronary angioplasty Coding Clinic, First Quarter 2011, pp. 3–4 Effective with discharges: April 27, 2011 Question: C oronary angioplasty with stent deployment. Intraoperatively, patient became symptomatic. Angiogram showed proximal mid-portion dissection. Balloon inflated multiple times. Stented distal portion next to previously deployed stent with subsequent balloon inflations. Third stent placed in proximal portion of vessel with balloon inflation. Additional arteriogram showed dissection was controlled and vessel was widely patent. Provider answered query—dissection was a complication. Which code: 997.1, Cardiac complications, or 998.2, Accidental puncture or laceration during a procedure? How do you code a clinically significant dissection occurring during PTCA?

36. 443.29 Dissection of Artery Dissection of artery occurring during coronary angioplasty Coding Clinic, First Quarter 2011, pp. 3–4 Answer: Assign code 997.1, Cardiac complications. Provider documented that it was a complication. Code SDX 414.12, Dissection of coronary artery to further describe complication. Vessel dissection at PCI site fairly common. Approximately 50% of patients immediately after PCI. Most often minor and clinically insignificant, does not interfere with antegrade blood flow, nor affect the procedural outcome. 998.2, Accidental puncture or laceration during a procedure Not appropriate—no accidental vessel puncture during PTCA.

37. 443.29 Dissection of Artery, 6-6 Dissection of artery occurring during percutaneous coronary intervention Coding Clinic, First Quarter 2011, p. 4 Question: What do you code for the diagnosis? Known coronary artery disease (CAD) Admitted for percutaneous coronary intervention. Kissing balloon angioplasty done due to plaque migration. Associated with a small native right coronary artery dissection just distal to stent. “Drug eluting stent placed in distal right coronary artery extending to left ventricular branch and jailing the posterior descending coronary artery." Answer: Query—Was dissection clinically significant? Stenting does not mean dissection is clinically significant. If provider confirms complication: 997.1, Cardiac complications, and 414.12, Dissection of coronary artery If the provider indicates that the dissection is not clinically significant, do not assign a code.

38. What Is the DRG and What Is the Procedure Code? 54.59 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy? Dear CDIP, The coder sent me the Coding Clinic on this case. Which DRG is right? The coder assigned procedure 54.11 Exploratory laparotomy and got DRG 356 Other digestive system OR procedure with MCC. I assigned procedure 54.59 Other lysis of peritoneal adhesion and got DRG 335 Peritoneal adhesiolysis. ~Flipping a Coin Coder’s e-mail to the CDS: “The physician doesn't mention the adhesions in his op note. We don't code lysis unless it extends the OR time and the physician documents it as being unusual. See the Coding Clinic below:”

39. 54.59 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy? Coding Clinic 4Q 90:18–19 Lysis of Adhesions Do not code adhesions and lysis just because they are mentioned in an operative report. Surgeon must determine if adhesions and the lysis are significant enough to code. Intestinal obstruction is most often caused by adhesions from previous surgery. In that case “lysis of adhesions is usually the major procedure performed and both the diagnosis of adhesions and the procedure for lysis should be coded.” Strong adhesion bands can block access to an organ being removed. Surgeon must cut the adhesive before the operation go forward. In this case, assign Dx code for Adhesions and Px code for Adhesiolysis. Coding Clinic 4Q 90:18–19 Lysis of Adhesions Don’t code adhesions that aren’t “being organized” and that don’t cause symptoms, or that don’t make the surgery more difficult. These are minor adhesions exist—they are easily lysed. The adhesiolysis is inherent to the principal procedure. Example 1: Adhesions around gallbladder are common and when taken down, the lysis is an integral part of the cholecystectomy. This is an incidental finding. Coding Adhesions and Adhesiolysis is inappropriate. Example 2: Gallbladder is encased in a strong band of adhesions. Surgeon does extensive lysis in order to remove gallbladder. In this case, coding of the adhesions and lysis is appropriate.

40. 54.5 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy? PREOPERATIVE DIAGNOSIS: Acute appendicitis POSTOPERATIVE DIAGNOSIS: Small bowel obstruction Procedure: Mini-laparotomy with adhesiolysis Fndings: Appendix was not found. There was a knotted loop of terminal ileum with multiple layers of small bowel and tied with each other. The patient did not have an appendix, seems it was removed during one of her previous operations and she was unaware of that. … I incised abdominal fascia and entered abdominal cavity. I immediately identified the cecum. I followed the tibia distally into cecum. On inspection, I could not identify the appendix. I carefully inspected by palpating along medial aspect and indeed a mass was palpated. I brought this up into the field and indeed a portion of the terminal ileum was all knotted onto itself. I had to dissect down and it freed up very nicely. It appears that she was having a small bowel obstruction of the site. The small bowel allowed to lay without twisting onto the omentum and the fascia closed.

41. 3 Keys to Solving QuestionFactsResources Was adhesiolysis a significant procedure? Adhesiolysis was done for definitive treatment Coding Clinic Jan-Feb 1987 pp. 11–12

42. 54.5 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy? Dear Flipping, Yes, code the 54.59 Adhesiolysis. Do not assign a 54.11 Exploratory laparotomy. There are many coding rules, and sometimes we need to revisit them to keep them straight. The adhesiolysis coding rules apply when adhesiolysis is performed in addition to a definitive procedure. Then we do need to know if the adhesiolysis was significant as a separate procedure, or just a component of the more extensive procedure. In this case, that rule does not apply. The only other procedure done was exploratory laparotomy—it’s less extensive than adhesiolysis. In this case we follow the rule to code the definitive procedure.

43. 54.5 Lysis of Adhesion vs. 54.11 Exploratory Laparotomy? Exploratory procedure followed by definitive surgery Coding Clinic, January-February 1987 pp. 11–12 Question: When an exploratory procedure is followed by definitive surgery, should the exploratory portion of the procedure be coded?

44. What Is Correct Procedure Code: 54.5 Lysis of Adhesion or 54.11 Exploratory Laparotomy?, 8-9 Exploratory procedure followed by definitive surgery Coding Clinic, January-February 1987 pp. 11–12 An exploratory procedure followed by definitive surgery Code only the definitive surgery Definitive surgery Requires incision into a space allowing for investigation of nearby structures Is often preceded by exploration of the space Examples – Restore or repair disunited, injured, or deficient body parts – Remove diseased or injured tissues – Extract foreign matter – Assist in obstetrical delivery

45. When Do I NOT Query for Excisional Debridement? Dear Query Author, We reviewed your query for 86.22 Excisional debridement of skin and subcutaneous tissue in an audit. You did a great job remembering that 86.22 requires specific descriptions. Unfortunately, this case did not need a query. ~CDIP Why is this query unnecessary? 45

46. When Do I NOT Query for Excisional Debridement? Encounter diagnoses: Cellulitis and abscess, left breast, diabetic Procedures: Incision and drainage of abscess L breast anesthetized with 1% lidocaine c epi 4mLs and Betadine prep. Small incision made c 11 blade scalpel over fluctuant area—revealed 1cm deep ulceration/abscess. Debridement of necrotic tissue from wound edges. Pus removed and sent for culture. Explored for loculations. Irrigated c NS. 1/4" gauze packing inserted. Nonadhesive dressing applied. Pt tolerated well without complications.

47. When Do I NOT Query for Excisional Debridement? Coding query: Please clarify whether an EXCISIONAL DEBRIDEMENT was performed in the ER & clarify the tissue excised: skin & subq ONLY, fascia or other. PHYSICIAN CLARIFICATION: Per addendum note: In reference to my ED note on 5/15/2010, this clarifies the extent of wound debridement. The debridement which I performed during the I&D of her left breast abscess was excisional with scissors involving the epidermal and dermal tissue. Nonexcisional debridement of necrotic and exudative tissue was performed on the visible subQ inside the abscess cavity as well

48. 3 Keys to Solving QuestionFactsResources What is correct procedure code for debridement of breast abscess? Surgeon debrided breast abscess Coding Clinic ICD-9-CM Alphabetic Index

49. When Do I NOT Query for Excisional Debridement? Example: best practice procedural statement “Necrotic tissue was excisionally debrided with a #4 blade. This was down through the subcutaneous tissue to until bleeding tissue was achieved. Wound measured 2 cm x 3 cm.” “Excisional STAIND” Size = measurement across wound Technique = excised, scrapped, cut out, cut away Appearance = w ound AFTER debridement: pink, bleeding, healthy Instrument = blade, not VersaJet, gauze Nature of the tissue = necrotic, non-viable Depth = tissue layer excised; not depth in centimeters

50. Caution for STAIND Excisional Debridement Query Caution for 86.22 Query for STAIND is not needed for certain body sites that have their own debridement codes Do not query for STAIND 08.20Removal of EYELID lesion/tissue 18.29 Excision/destruction of lesion of external EAR 27.43 Excision of lesion/tissue of LIP 21.32 Local excision/destruction of lesion of NOSE 49.39 Local excision/destruction of lesion/tissue of ANUS 71.3 Local excision/destruction of VULVA & PERINEUM 85.21 Local excision of lesion of BREAST 86.75 Revision of PEDICLE GRAFT/SKIN FLAP

51. Why Was Current CVA Coded for Cranioplasty Procedure? Dear CDIP, Patient was scheduled for surgery as a follow-up to her previous SAH/aneurysm repair/clipping, which happened in May 2011. Pt is a planned admit from rehab and this is not a new bleed or aneurysm. The coder assigned 430 Subarachnoid hemorrhage. Shouldn't the SAH be HX of code 438.89 Late effect of CVA and not the actual DX [current CVA]? ~Rock Paper Scissors

52. Why Was Current CVA Coded for Cranioplasty Procedure? HISTORY AND PHYSICAL: “2 mos s/p craniotomy for aneurysm and bone flap removal. LUE plegic. LLE paretic Surgical site sunken. Right pterional region.” OPERATIVE REPORT: PRE & POSTOP DX: Right cerebral CVA secondary to aneurysm PROCEDURE PERFORMED: Autograft cranioplasty PROCEDURE: Previous craniotomy scar was reopened. Previously removed bone flap, which had been returned to the operating room soaking in bacitracin irrigation, was fitted into position and was secured to surrounding calvarium in good anatomical position.

53. 3 Keys to Solving QuestionFactsResources What is the principal diagnosis? How do I code CVA in this case? CVA occurred two months ago Cranioplasty is for cranial deformity, i.e., “surgical site sunken” Coding Clinic 1Q 2006 pp. 6–7

54. Why Was Current CVA Coded for Cranioplasty Procedure? Dear Rock, 430 SAH is incorrect. PDX is 738.19 Other acquired deformity of head. Assign SDX 438.xx Late effect CVA and 342.90 Hemiplegia/paresis per H&P. Bone flap replacement s/p decompressive hemicraniectomy CC 1Q 06:6–7 Question: Patient had decompressive hemicraniectomy prior admit. Patient's bone flap was removed and saved. Now readmitted for planned replacement of bone flap. Hemicranioplasty is done using the saved bone flap. How is this coded? Answer: 738.19, Other acquired deformity of head, Other specified deformity 02.06 Other cranial osteoplasty for hemicranioplasty using saved bone flap

55. In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook. Questions