ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
Coders tell a patient’s story with a principal diagnosis and additional diagnoses, some of which are CCs or MCCs. William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and Cheryl Ericson, MS, RN, CCDS, CDIP, explain the value of educating physicians and coders about CCs and MCCs.
Patient Safety Indicator 15 tracks events during surgical procedures that can hurt patients, but not whether the patient actually suffers harm from the event. Robert S. Gold, MD, identifies some of the challenges involved with this quality measure.
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘"with’" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
Coders and clinical documentation improvement specialists need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs. Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, discuss some common CCs and MCCs.
PSI 15 measures the hospital's risk-adjusted rate of accidental punctures and lacerations. PSI 15 has the highest weight in the PSI 90 composite under both the Hospital-Acquired Condition Program and the Hospital Value Based Purchasing Program. Coders and CDI specialists can improve performance for PSI 15 by ensuring complete documentation and correct ICD-9-CM code assignment for PSI 15?pertinent inclusions, exclusions, and risk adjustment variables.
Heart failure is the intrinsic inability of the heart to supply target organs with sufficient nutrient flow to function normally. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review the clinical and coding guidelines for heart failure.
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
In ICD-10-CM, coders will use a seventh character, not an aftercare code, to identify follow-up treatment for an injury. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, Kristi Pollard, RHIT, CCS, CPC, CIRCC, and Anita Rapier, RHIT, CCS, explain how aftercare coding will change in ICD-10-CM.
Patient Safety Indicator 90 evaluates hospital performance for defined in-hospital complications and adverse events. Find out more about how clinical documentation and coding can affect this measure in the first of a four-part series.
Even through ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze, c oders and CDI specialists still need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs.
