1. QUALITY DATA: CODING GUIDELINES BIO 312 E Erin Frankenberger & Michelle Wisniewski

2. Provided by CMS and NCHS Found in the beginning of the ICD-9-CM Codebook, or on the AMA website These are a "set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself" ICD-9 CODING GUIDELINES

3. UNCERTAIN DIAGNOSIS A record may have documentation that may include the words "probable", "suspected", "questionable", or "rule out“ In an outpatient setting, these conditions should not be coded However, the conditions should be coded to the highest degree of certainty for that encounter (symptoms, signs, etc.)

4. UNCERTAIN DIAGNOSIS When faced with an uncertain diagnosis in an inpatient setting, the rules are a bit different If the diagnosis is documented at the time of discharge and includes the terms "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", the condition should be coded as if it existed

5. UNCERTAIN DIAGNOSIS Even with these rules pertaining to uncertain diagnoses, you must still remember to look for diagnostic workup, observations, and the initial therapeutic approach to confirm the actual presence of a specific diagnosis

6. QUERY PROCESS When a coder is unsure of a code assignment, the physician who provided the documentation should be queried As per the AHIMA Standards of Ethical Coding: "Query the provider for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure..."

7. DOCUMENTATION EXPECTATIONS The primary purpose of the health record is to document patient care It is also a tool for professionals to communicate with each other regarding the patient care According to CMS, documentation is expected to be "legible, complete, clear, consistent, precise, and reliable"

8. DOCUMENTATION EXPECTATIONS In addition to providing clear documentation, physicians are also required to abide by the medical staff bylaws and be proactive in the development of query policies and procedures

9. EXAMPLE An 84-year old patient was admitted into the hospital complaining of shortness of breath, leg edema, a left upper extremity mass and a decubitus ulcer on her heel Examination of the patient revealed a lengthy list of problems, including congestive heart failure, possible pneumonia, atrial fibrillation, and dementia The patient underwent x-rays, blood work, an echocardiogram and other diagnostic testing to confirm the above diagnoses The patient’s treatment plan included medication, physical and occupational therapy and consultation

10. EXAMPLE The patient was assigned an ICD-9 code for pneumonia as a secondary diagnosis However, the assignment of this code was rejected by the Recovery Audit Contractor during an audit The RAC rejected the claim on the grounds that the diagnosis of pneumonia was not supported by clinical evidence

11. EXAMPLE The following is an excerpt the RAC’s document:

12. EXAMPLE This discharge summary includes the pneumonia diagnosis, as well as the medication that was given as treatment.

13. EXAMPLE This was taken from the history & physical which supports the diagnosis of pneumonia

14. EXAMPLE This is taken from the x-ray report which also supports the presence of pneumonia

15. EXAMPLE The coder was justified in assigning pneumonia as a secondary diagnosis Even though it is documented that the pneumonia is “questionable”, there is substantiating documentation that supports this diagnosis The patient was not only given antibiotics, but there was also evidence of pneumonia in the history & physical and X-ray

16. REFERENCES http://www.jfponline.com/fileadmin/content_pdf/fpn/archive_pdf /vol38iss14/70932_main.pdfhttp://www.jfponline.com/fileadmin/content_pdf/fpn/archive_pdf /vol38iss14/70932_main.pdf http://www.vhca.org/IlluminAgeApps/whatsnewApp/files/613A4 4DAC.pdfhttp://www.vhca.org/IlluminAgeApps/whatsnewApp/files/613A4 4DAC.pdf http://www.californiahealthline.org/articles/2013/9/4/oig- medicares-recovery-audit-program-more-accurate-than- believedhttp://www.californiahealthline.org/articles/2013/9/4/oig- medicares-recovery-audit-program-more-accurate-than- believed http://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/recovery-audit- program/index.html?redirect=/rac/http://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/recovery-audit- program/index.html?redirect=/rac/ http://www.ama- assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_ full.pdfhttp://www.ama- assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_ full.pdf