Brush up on sequencing as RAC complex reviews get … up on sequencing as RAC complex reviews get...

Brush up on sequencing as RAC complex reviews get under way

As RACs begin to roll out complex reviews and re-

quest medical record documentation, compliant coding

will continue to take center stage. And although correct

coding is vital, sequencing codes is equally as important

because it affects MS-DRG assignment and payment.

Sequencing is something with which coders contin-

ually struggle, says Shannon E. McCall, RHIA, CCS,

CCS-P, CPC, CPC-I, CCDS, director of HIM and coding

at HCPro, Inc., in Marblehead, MA. That’s because the

circumstances of some admissions are somewhat debat-

able, leaving a big question mark in terms of which diag-

nosis is principal, McCall says.

In addition, there are a whole slew of rules to follow.

A cursory look at the ICD-9-CM Guidelines for Coding and

Reporting reveals a plethora of sequencing requirements,

some of which only apply to certain code sets.

It’s a lot of information to digest and remember, says

McCall. And although encoders can assist with sequencing,

coders have the final say in determining which diagnosis

is principal. If the patient underwent multiple procedures,

coders must also determine which one is principal. The

principal diagnosis, principal procedure, and any relevant

CCs or MCCs map to a particular MS-DRG (i.e., payment

to the hospital).

Know the definition of principal diagnosis

Fundamentally, coders should understand that the

Uniform Hospital Discharge Data Set defines the prin-

cipal diagnosis as the condition found after study to be

chiefly responsible

for the admission.

“It’s not al-

ways just about

what [the patient]

comes in for,” says

McCall. “They

could come in for chest pain and then after study find the

patient is actually having [a myocardial infarction (MI)]. It

could be an underlying cause to the symptom that might

not be clear-cut without performing additional tests.”

In some instances, there may be more than one con-

dition that meets the definition. For example, a patient

is admitted for uncontrolled diabetes mellitus and acute

exacerbation of chronic obstructive pulmonary disease

(COPD). A physician treats both conditions equally and

provides diagnostic workup and/or therapy for both.

The ICD-9-CM Guidelines for Coding and Reporting state

that when two conditions meet the criteria to be as-

signed as the principal diagnosis, coders may sequence

either of the diagnoses first. The only exception to this

is when guidance in the alphabetic index, tabular list,

or coding guidelines specifically state which diagnosis

The Uniform Hospital

Discharge Data Set defines

the principal diagnosis as the

condition found after study

to be chiefly responsible for

the admission.

> continued on p. 2

February 2010 Vol. 13, No. 2

IN THIS ISSUE

p. 5 Surgical complicationsKnow when to report codes for complications due to surgery.

p. 8 Case study: IRF preparation for RACsLearn how two inpatient rehabilitation facilities prepared for RAC record requests.

p. 10 The quick list: New IRF coverage requirementsUnderstand new inpatient rehabilitation facility coverage requirements that became effective last month.

p. 11 Clinically speakingRobert S. Gold, MD, addresses the importance of identifying the causes of cardiomyopathy.

Inside: Coding Q&A

Briefings on Coding Compliance Strategies February 2010

© 2010 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

should be principal. Coders often choose the diagno-

sis that would yield the higher-weighted MS-DRG, and

there is nothing that precludes them from doing so, says

McCall.

On the other hand, there may be cases in which two

conditions appear to meet the definition when, in fact, they

don’t, she adds. For example, a patient is admitted for an

overdose of cocaine. The patient is also experiencing re-

spiratory failure due to the overdose. Although a coder

may be tempted to assume that either the poisoning or

Sequencing < continued from p. 1

respiratory failure could be sequenced first, there is a cod-

ing guideline that states otherwise.

The ICD-9-CM Guidelines for Coding and Reporting state

that when coding a poisoning or reaction to the improper

use of a medication (e.g., wrong dose, wrong substance,

or wrong route of administration), the poisoning code is

sequenced first, followed by a code for the manifestation.

In the example described above, the manifestation is

the respiratory failure, which would be sequenced sec-

ondary to the poisoning code from the 900 range, says

McCall.

Understand sequencing for sepsis

These days, RACs are targeting certain MS-DRGs to de-

termine whether they were assigned correctly. Sequencing

plays a large role in this because it helps determine the

MS-DRG assignment, says McCall.

In December, Connolly Healthcare—the RAC for Re-

gion C—announced 24 approved DRG validation issues.

Visit Connolly’s Web site at http://tiny.cc/9eOIM for a list

of the 24 DRGs, as well as a description of each issue, dates

of service, affected providers, and additional details.

Most coders won’t be surprised by the fact that MS-

DRGs 871 (septicemia without mechanical ventilation

96+ hours with MCC) and 872 (septicemia without me-

chanical ventilation 96+ hours without MCC) appear

on Connolly’s list, McCall says. She speculates that one

of the reasons Connolly could be targeting these DRGs

is to ensure that septicemia was correctly sequenced as

the principal diagnosis.

“Septicemia can always be difficult to sequence. The

guidelines try to be clear-cut, but sometimes they’re not

when you’re trying to code for an actual admission,”

says McCall.

Coders must first identify whether the patient had sep-

sis upon admission. According to the ICD-9-CM Guidelines

for Coding and Reporting, if sepsis or severe sepsis is POA and

it meets the definition of principal diagnosis, assign the sys-

temic infection code first (e.g., code 038.xx for septicemia).

This newsletter has prior approval by the American Academy of Professional Coders for up to 10 CEUs per year. Granting this approval in no way constitutes endorse ment by AAPC of the program, content, or the program sponsor. Go to www.aapc.com/education/CEUs/ceus.html or call the AAPC at 800/626-2633 for more information.

Editorial Advisory Board Briefings on Coding Compliance Strategies

Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $249/year. • Briefings on Coding Compliance Strategies, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

William E. Haik, MD Director DRG Review, Inc. Fort Walton Beach, FL

Lyn Henry Director, Billing ComplianceUniversity Medical Associates University of Nebraska Medical Center Omaha, NE

Diane Jepsky, RN, MHA, LNCPresident and CEOJepsky Healthcare Associates Sammamish, WA

James S. Kennedy, MD, CCSDirectorFTI Healthcare Brentwood, TN

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDSDirector, Coding and HIMHCPro, Inc. Chesterfield, VA

Arlene F. Baril, MS, RHIAExecutive Vice President, HIM ServicesPHNS, Inc. Dallas, TX

DeAnne W. Bloomquist, RHIT, CCS President and Chief ConsultantMid-Continent Coding, Inc. Overland Park, KS

Sue Bowman, RHIA, CCSDirector, Coding Policy and ComplianceAmerican Health Information Management Association Chicago, IL

Gloryanne Bryant, RHIA, CCS, CCDSRegional Managing Director of HIM Kaiser Foundation Health Plan Inc. & Hospitals Oakland, CA

Darren Carter, MDPresident/CEO Provistas New York, NY

Group Publisher: Lauren McLeod

Executive Editor: Ilene MacDonald, CPC

Managing Editor: Geri Spanek

Contributing Editor: Lisa Eramo, CPC, [email protected]

February 2010 Briefings on Coding Compliance Strategies


Next, assign code 995.91 for sepsis or code 995.92 for

severe sepsis. Lastly, assign a code for the localized infec-

tion (e.g., code 486 for pneumonia).

The ICD-9-CM Guidelines for Coding and Reporting also

state that when sepsis develops during the encounter

and is not POA, coders should assign the systemic infec-

tion and sepsis as secondary diagnoses.

It’s a common misconception that the systemic infec-

tion should always be sequenced first when a patient de-

velops sepsis during an admission, says McCall. “This is

exactly why RACs are targeting this,” she explains. “Peo-

ple are assigning the DRG for septicemia when, in fact,

the patient may not have had the sepsis when he or she

was admitted.”

Coders must recognize whether the systemic infec-

tion also meets the definition of a principal diagnosis

before sequencing it as the principal diagnosis. In some

instances, the localized infection could be principal, says

McCall.

Take a look at other sequencing-related issues

Connolly is also targeting several MS-DRGs that indi-

cate operating room (OR) procedures that are unrelated

to the principal diagnosis. For example, a patient is ad-

mitted for COPD. While the patient is in the hospital, he

or she falls and must undergo an open reduction of a hip

fracture.

“You’re going to have a procedure that doesn’t have

anything to do with why the patient was admitted. This

happens, but it shouldn’t happen routinely,” says McCall,

adding that when the fall and subsequent fracture oc-

curs in a hospital, it could potentially affect MS-DRG as-

signment and reimbursement because it is considered

hospital-acquired.

Not surprisingly, these MS-DRGs have relatively high

weights, making them particularly enticing for RACs, says

McCall. For example, MS-DRG 981 (extensive OR proce-

dure unrelated to principal diagnosis with MCC) has a rel-

ative value weight of 5.0389. MS-DRG 987 (nonextensive

OR procedure unrelated to principal diagnosis with MCC)

has a relative value weight of 3.4020.

Proper sequencing can help ensure compliance with

these and several other procedure-based DRGs, McCall

says. In addition to correctly sequencing the principal di-

agnosis, coders must also identify the principal procedure

(i.e., generally the one performed for definitive rather

than diagnostic or exploratory purposes). When a pro-

vider performs more than one procedure for a definitive

purpose, coders should choose the one that most close-

ly relates to the principal diagnosis, according to Coding

Clinic, October 1990.

For example, a patient is admitted for an MI and later

develops acute cholelithiasis with cholecystitis. A physi-

cian performs an open cholecystectomy for the gallstone

and an angioplasty to treat the MI. Although both pro-

cedures are performed for definitive purposes, the angio-

plasty is principal because it most closely relates to the

MI, the principal diagnosis.

Hospitals can perform a proactive audit by running a

list of cases that fall into these MS-DRGs and asking the

following questions:

➤ Should the case have grouped to this MS-DRG?

➤ Was there a diagnosis that truly warranted the proce-

dure performed?

➤ Was the principal diagnosis assigned correctly?

➤ Was the principal procedure assigned correctly?

See p. 4 for more tips to ensure proper sequencing. n

Note new limits for RAC DRG validation audits in 2010

On December 1, 2009, CMS published new limits for

record requests related to DRG validation audits. The new

limit is a maximum of 200 record requests per campus (not

NPI) per 45-day period—at least through March 2010. Be-

ginning in April, providers or suppliers who bill in excess of

100,000 claims to Medicare may receive up to 300 requests

per campus. In addition, CMS will allow the RACs to re-

quest permission on a case-by-case basis to exceed the cap

beginning in July 2010. Visit http://tiny.cc/I2AdO for more

information.



Four tips to ensure proper sequencing

Sequencing has always been an important part of correct

code assignment. In light of complex RAC reviews, coders

need to ensure compliance when determining which diag-

nosis and/or procedure is principal. The following are some

general tips to ensure compliant sequencing:

➤ Be on the lookout for manifestation codes. Re-

member that manifestation codes, which indicate a separate

disease caused by an underlying disease, should always be se-

quenced as a secondary diagnosis. These codes are italicized in

the tabular index of the ICD-9-CM Manual, and some publishers

shade the code descriptions to indicate that they are manifes-

tation codes. They are italicized and written in brackets in the

alphabetic index.

For example, patients with diabetes mellitus may develop

nephropathy. If the underlying cause of the renal disorder is

the diabetes mellitus, it will be coded as a manifestation. Dia-

betes is a disease that affects the endocrine system, whereas

nephropathy affects the renal system.

“The patient likely wouldn’t have the nephropathy if he

or she didn’t have the diabetes mellitus,” says Shannon E.

McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of

HIM and coding at HCPro, Inc., in Marblehead, MA. Thus, the

diabetes is sequenced first. The manifestation (nephropathy)

is sequenced as a secondary diagnosis.

Not every underlying condition will have a manifestation,

but many diseases (such as diabetes) can cause problems and

manifestations in other body systems, so coders must be on

the lookout for these additional codes, says McCall.

When physicians are treating specific manifestations, they

don’t always do a thorough job of documenting the under-

lying disease that caused the manifestations, says Darren

Carter, MD, president and CEO of Provistas in New York.

Underdocumentation frequently occurs when a patient un-

dergoes surgery to treat a particular manifestation and the

surgeon neglects to document the underlying condition,

says Carter.

For example, a patient undergoes the removal of a spleen

due to splenic sequestration, a condition in which the spleen

fills with blood and becomes enlarged and potentially life-

threatening. Although the surgeon will most likely document

the splenic sequestration, he or she may not document the

underlying blood dyscrasia, such as spherocytosis, which is

a hereditary condition in which red blood cells are sphere-

shaped rather than biconcave disk-shaped.

Underdocumentation can also occur in other cases. For ex-

ample, when a physician documents graft-versus-host disease,

he or she may not document the underlying cause of the dis-

ease (e.g., complication of a blood transfusion or transplanted

organ) or any of its manifestations (e.g., desquamative derma-

titis, diarrhea, elevated bilirubin, or hair loss).

Coders should let the ICD-9-CM Manual guide them in

terms of identifying manifestations and underlying conditions.

As previously stated, the manual typically italicizes this infor-

mation, and coders can use it as a starting point when look-

ing through the record for clues, says Carter.

Coders should also read through all documentation when

looking for the underlying condition. “Frankly, it could be

anywhere in the record,” says Carter, adding that although

coders can’t code directly from test or lab results, these sources

of information can be helpful when posing a query.

➤ Know how to sequence multiple codes for a sin-

gle condition. Although some conditions that affect multiple

body systems require two codes to describe the underlying

condition and any manifestation, there are other single con-

ditions that also require more than one code. Conditions that

require multiple codes include “use additional code” notes in

the tabular index.

For example, infections that are not included in Chapter 1

may require a secondary code from category 041 (bacterial

infection in conditions classified elsewhere and of unspeci-

fied site) to identify the bacterial organism. According to the

ICD-9-CM Guidelines for Coding and Reporting, the sequencing

rule is the same as the etiology and manifestation pair—a “use

additional code” indicates that a secondary code should be

added. The guidelines also state the following:

“Code first” notes are also under certain codes that

are not specifically manifestation codes but may be due to

an underlying cause. When a “code first” note is present

and an underlying condition is present, the underlying con-

dition should be sequenced first. “Code, if applicable,

any causal condition first,” notes indicate that this code

may be assigned as a principal diagnosis when the causal



Think twice before assigning codes for surgical complicationsEditor’s note: This article is based on information presented

during HCPro’s November 20, 2009, audio conference, “Surgical

Complications: Clinical Documentation Improvement for Com-

pliant Coding and Accurate Quality Measures.” For more infor-

mation or to purchase a copy, visit www.hcmarketplace.com/

prod-8156/Surgical-Complications.html.

CDI programs can greatly enhance documentation, but

what happens when a hospital’s risk-adjusted complication

index and/or risk-adjusted mortality index rise as a result of

perceived complications that aren’t actually complications?

This can happen when coders report complication codes

for conditions that are unrelated to the surgery or that ex-

isted prior to the surgery, said Robert S. Gold, MD, CEO

of DCBA, Inc., in Atlanta. When codes are incorrectly as-

signed, the complication then appears to directly relate to

the surgeon’s—or hospital’s—oversight, Gold said.

Set the record straight

Until the POA indicator came along, Clarian Health

in Indianapolis was reporting multiple complications

that weren’t entirely accurate, said Lena Wilson, MHI,

RHIA, CCS, HIM operations manager at Clarian. “Our

academic medical facilities were really getting dinged for

these complications when patients actually had them

when walking through the door,” said Wilson.

Although Wilson noted that the POA indicator helped

paint a more accurate picture, another piece of the puz-

zle was to educate coders about what truly constitutes a

complication.

Consider this example: A patient undergoes a surgical

procedure and then develops subcutaneous emphysema.

Before assigning a complication code (998.81), Gold

pointed out that there are a whole slew of questions

coders must ask. First, coders must determine whether

the emphysema was POA prior to admission. If it was

POA, then it couldn’t possibly be a complication of the

surgery because the patient had the condition prior to

admission.

If it wasn’t POA, it could be a complication. When the

procedure is elective rather than trauma-related, there

> continued on p. 6

condition is unknown or not applicable. If a causal condi-

tion is known, then the code for that condition should be

sequenced as the principal or first-listed diagnosis.

➤ Don’t be afraid to query. There will be circum-

stances in which physicians simply don’t provide enough

information, whether it be the underlying condition that pre-

cedes the manifestation or the manifestation itself.

Understanding disease etiology and pathophysiology

is important, particularly when there are manifestations

of a disease that must be sequenced as secondary, says

Carter.

When there is a code-first requirement and documen-

tation doesn’t include the underlying condition, query

the physician for more information, Carter says, adding

that “there is no harm in bringing that up to the doc-

tor.” When coders are unsure whether a condition is a

manifestation of a particular disease, they should also ask

the physician, he says.

Remember to leave questions open-ended to avoid yes-or-no

answers when posing queries, unless the query is about a POA

indicator, says McCall. For example, it’s okay to state the follow-

ing to the physician: “Please indicate the underlying condition for

the nephropathy.” But don’t phrase the question as, “Is diabetes

mellitus the underlying cause of this patient’s nephropathy?”

For more information about creating a compliant query,

visit http://tiny.cc/cLZFl for AHIMA’s practice brief Managing

an Effective Query Process.

➤ Perform proactive audits. Hospitals can perform

proactive audits to ensure correct sequencing by examining

rejections that include Medicare Code Editor 6 (manifestation

code as principal), says Carter. Rejections bassed on this edit

indicate sequencing problems, he says.



is a higher likelihood that this is the case. When the em-

physema is an incidental finding and doesn’t receive spe-

cific attention and treatment, coders should not report

it at all, Gold said, adding that when in doubt, coders

should query the physician.

Coders should ensure that they don’t assign a compli-

cation code for something that relates to the actual pro-

cedure, Gold noted. For example, don’t assign code 998.2

(accidental laceration) when a surgeon documents that

an enterotomy was made in relation to the insertion of a

jejunal feeding tube.

Another area of confusion is deciphering when con-

ditions are postoperative complications of surgery, as

opposed to conditions that are not due to the surgery de-

spite occurring during the postoperative phase, said Gold.

For example, documentation of postoperative hy-

pertension could be confusing for coders when the hy-

pertension is actually due to postoperative pain that

resolves after the first dosage of pain medication. Unless

a coder queries the physician, he or she may be tempt-

ed to report a code for cardiac complication of surgery

(code 997.1).

Gold said he often advises surgeons to avoid docu-

menting the term “postoperative” in the postoperative

period unless the condition is truly a complication so as

to avoid confusion for the coder.

Gold and Wilson said coders should pay attention to

the following commonly misreported conditions and ask

these relevant questions:

➤ Anoxic brain damage (code 997.01): Before re-

porting this code, determine whether it occurred pre-

operatively. Was it caused by the disease itself (e.g.,

pulmonary embolism or an inhaled foreign body)?

Was it due to anesthesia and not the surgery?

➤ Heart failure during or after a procedure (code

997.1): Was the heart failure POA? Was it due to the

anesthesia and not the surgery? Even when a patient

is admitted for postoperative premature atrial con-

tractions after an outpatient procedure, the physician

must specifically state that the condition was a com-

plication of the procedure before a coder can assign

997.1, said Gold.

➤ Peripheral vascular complication (997.2): This

code denotes phlebitis or thrombophlebitis during

or resulting from a procedure. Coders should deter-

mine whether either condition was due to the sur-

gery or an indwelling device, a transfusion, or an

IV line before assigning the complication code, said

Wilson.

➤ Ventilator-associated pneumonia (997.31): Was

the pneumonia present before the patient was put

on a ventilator? Did it lead to the need for the ven-

tilator? Was the pneumonia POA? The pneumonia

may have been the reason the physician inserted the

ventilator—not the result of the patient’s use of the

ventilator, said Gold. Look for clues that might in-

dicate this is the case, such as a positive chest x-ray,

mention of the condition in ER physician documen-

tation, or documentation of the condition as a differ-

ential diagnosis, he added.

➤ Postoperative stroke (997.02): Was the stroke

related to the procedure performed? For example,

when a physician operates on a carotid artery and

the patient has a stroke after the procedure, it’s rea-

sonable that the stroke could be due to the surgery,

said Gold. However, if the patient presents for an un-

related surgery, such as the removal of an ingrown

toenail, it is highly unlikely the procedure could have

caused the stroke. “Clarify with the physician if you

have a question about whether it was indeed related

to the surgery or whether it was totally unrelated to

the surgery,” said Gold.

➤ Digestive system complications (997.4): Was the

ileus (i.e., temporary arrest of intestinal peristalsis)

POA? Was the ileus caused by the disease? When a

patient presents with a ruptured appendix and ileus,

it’s likely that the patient will also have ileus post-

operatively, said Wilson. If the physician documents

Surgical complications < continued from p. 5



postoperative ileus, it will be coded as a complication

when, in fact, the condition was POA and not a re-

sult of the procedure for the removal of the appendix.

“You really need to work with your surgeons to un-

derstand their treatment modalities for ileus,” said

Wilson. “Was this truly an ileus, or was this patient

constipated and the bowel was just slow to return to

normal function after the GI procedure?”

➤ Urinary complications (997.5): Was the urinary

retention due to surgery or the patient’s preexisting

benign prostatic hyperplasia? Did a stone that was

POA become symptomatic after a procedure? Was

there an underlying condition that wasn’t documented

initially?

➤ Hemorrhage complicating a procedure (998.11)—

Do not assign hemorrhage as a complication of a pro-

cedure when the blood loss is from the disease itself,

such as bleeding esophageal varices, angiodysplasia,

or a fractured femur.

➤ Hematoma complicating a procedure (998.12)—

Do not assign a hematoma as a complication of a pro-

cedure when the physician doesn’t treat it and instead

discharges the patient in the same time interval as

someone with no hematoma.

➤ Disruption of internal and external operation

(surgical) wound (998.31 and 998.32 respective-

ly)—Do not assign these complication codes when the

surgeon purposely leaves the wound open. This can

occur when the patient has a perforated viscus with

gross peritoneal contamination. It can also occur as a

temporary measure to prevent abdominal compart-

ment syndrome as in liver transplants.

➤ Post-operative anemia due to acute blood loss

(285.1)—Was it POA? Was it due to blood loss or

some other process? “If it’s due to blood loss, you

have to clarify whether it was due to chronic blood

loss from the tumor or acute blood loss from resec-

tion of the tumor,” said Gold. Ask whether it was due

to the disease, a ruptured aortic aneurysm, multiple

traumas with liver laceration, or a fracture of the fe-

mur. Also ask whether the low level of hemoglobin

was due to dilution, and ask whether it resolved

without treatment.

Watch for exclusions

Many of the conditions above have detailed and lengthy

excludes notes that may require coders to assign other

more specific complication codes.

For example, code 997.01 excludes cerebrovascular

hemorrhage or infarction (997.02). Code 997.1 excludes

several conditions that are long-term effects of cardiac

surgery or due to the presence of a cardiac prosthetic de-

vice (429.4). Code 997.4 includes a long list of exclusions

that require coders to look elsewhere in the ICD-9-CM

Manual when assigning codes. Coders should read the

excludes notes before making a final decision regarding

code assignment, said Wilson.

Beware of codes for device complications

Not all complication codes denote a complication due

to the procedure or surgeon. For example, certain codes

denote complications due to devices. Code 996.1 indi-

cates that a catheter tip broke off and caused a compli-

cation. Code 996.56 indicates there was a mechanical

complication of a peritoneal dialysis catheter, such as

when the device shifts and requires repositioning. Code

996.49 indicates there was a mechanical complication of

an internal orthopedic device, implant, or graft, such as

when loose orthopedic sutures cause pain and must be

removed.

“These are really just informational codes that describe

the malfunctioning or breakdown of the device itself and

are not attributable to anything the physician may have

done to cause this to occur,” said Wilson. n

Contact Contributing Editor Lisa Eramo

Telephone 401/780-6789

E-mail [email protected]

Questions? Comments? Ideas?



Adventist. Logging and tracking information was equal-

ly as important, said Watson. “Make sure you get receipts

for everything you send,” she said. “There were many

times where we had to prove that we had sent our appeal

in a timely manner and that it was received in a timely

manner in order to preserve our appeal rights.”

Tracking responses to appeal letters, including de-

cisions to overturn appeals, is also important, Watson

said. She recalled the need to fax decision letters prov-

ing that the facility had won cases before its money was

returned.

Glendale Adventist now conducts concurrent audits

using Medicare’s eight coverage criteria. (Access the cri-

teria at http://edocket.access.gpo.gov/2009/E9-25544.htm.) In

mid-December 2009, the facility added new documenta-

tion requirements applicable to all discharges occurring

on or after January 1, 2010. For example, audits ensure

that physician documentation includes a preadmission

screening, a postadmission evaluation, and an individual-

ized plan of care. (See p. 10 for more information.)

Strict adherence to Medicare criteria is likely to pro-

duce many successful third-level appeals, said Watson.

For example, IRF criteria require that a physician with

specialized rehabilitation training provides close medical

supervision. Glendale Adventist physicians help satisfy

this requirement by ensuring that history and physicals

include a comprehensive picture of patients’ clinical sta-

tus, including principal diagnosis, comorbidities, labora-

tory results, diagnostic testing, medications (including

frequency of use), and consultations.

Physicians also provide summary statements that list

the reasons why patients require IRF admission and can-

not be treated safely at a lower level of care.

Medicare criteria also state that IRFs must provide

24-hour nursing care. Watson said her facility found that

its nurses did much to manage cases, prevent complica-

tions, and provide carryover from therapy, but what they

Two California facilities continue to draw on their ex-

perience during the RAC demonstration. Representa-

tives of those facilities shared those experiences during

HCPro’s November 18, 2009, audio conference, “RACs

and Inpatient Rehab: Understand the Top Demo Targets

to Survive Audits.” This is just a portion of what they

said. (Visit http://tiny.cc/YNTCh for more information.)

Glendale Adventist Medical Center

PRG-Schultz deemed only eight of 440 record requests

that Glendale Adventist Medical Center in Glendale, CA,

received during the RAC demonstration project appropri-

ate for an inpatient rehabilitation facility (IRF) stay.

The requests for records and subsequent denials were

based primarily on lack of medical necessity and deter-

minations that care could have been provided in a lower-

level setting, such as a skilled nursing facility. Nearly all

of the requests pertained to orthopedic cases, specifically

total joint replacements.

“As you can guess, we had large dollar amounts tak-

en back. This was a severe financial hardship on our fa-

cility,” said Marion Watson, PT, MBA. Watson serves

as director of rehabilitative medicine services for the

450-bed hospital, which includes a 28-bed acute reha-

bilitation unit. During Glendale Adventist’s most chal-

lenging month, PRG-Schultz recouped $450,000 from

the facility. In total, it recouped $4.3 million during the

demonstration.

Like many other IRFs or acute care hospitals with reha-

bilitation units nationwide, Glendale Adventist appealed

most of its denials. First- and second-level appeals typically

were upheld, but third-level appeals resulted in a favorable

ruling for the facility, said Watson. To date, PRG-Schultz

has repaid nearly $4.2 million of the amount it originally

recouped.

A strong RAC team and an appointed RAC coordinator

helped ensure a smooth appeals process at Glendale

California-based IRFs reflect on their experiences during RAC demonstration project to prepare for future audits



CPT codes (excluding modifiers -KX and -59). DCS

Healthcare (Region A) probably will include untimed

codes as well, Twist speculated.

Note: See below for a list of RAC Web sites that in-

clude up-to-date information about approved issues

and other helpful resources.

The bill error/correction report can facilitate a root-

cause analysis of errors related to untimed codes, said

Twist. “Look at your billing compliance report. What are

your billers fixing? If your billers are going back and cor-

recting [an error], it’s time to go back and fix it from a de-

partment charging level,” she said, adding that Methodist

Hospital created an adjustment code with a zero-dollar

amount to track these cases and run reports. n

did wasn’t well documented. “We made it a point to note

that because of the 24-hour nursing, many of our pa-

tients did not develop further complications,” she said.

The facility generally closely monitors its orthopedic

cases to ensure that they meet medical necessity and that

documentation clearly reflects the need for an IRF stay,

said Watson. “We are still admitting orthopedic patients

to our unit; however, we’re being extremely careful to

ensure that they meet the eight admission criteria,” she

said, noting that the result has been fewer orthopedic

admissions.

Methodist Hospital

During the RAC demonstration, most audits at Meth-

odist Hospital, a 460-bed acute hospital in Arcadia, CA,

pertained to orthopedic cases in its 12-bed acute rehabili-

tation unit. The hospital also experienced a small volume

of denials pertaining to timed code billing errors for occu-

pational, physical, and speech therapy claims. The RAC

recouped approximately $2 million during the demon-

stration project.

Like Glendale Adventist, Methodist Hospital took

a closer look at physician documentation, said Tanja

Twist, MBA/HCM, director of patient financial servic-

es. The facility also implemented a clinical documenta-

tion improvement program to help educate physicians.

Documentation and coding of untimed codes (i.e.,

those for which the procedure is not defined by a spe-

cific time frame) was one area of improvement. For ex-

ample, the CPT code for speech therapy states that it is

per session—not per each 15 minutes. Some IRFs may

incorrectly bill for each 15 minutes of therapy provided,

resulting in excessive units, said Twist.

Methodist Hospital worked to ensure that the number

of units billed on claims matched services documented

in daily care notes, said Twist. There shouldn’t be more

than one unit billed per date of service per patient, she

explained.

Several RACs—Connolly Healthcare (Region C),

HealthDataInsights, Inc. (Region D), and CGI (Region

B)—have begun requesting records that include untimed

Ten must-have RAC resources

Stay up to date on all approved issues in each of the

four RAC regions regardless of where you’re located. Book-

mark and periodically check these Web sites if you don’t

already:

➤ www.dcsrac.com (DCS Healthcare, Region A)

➤ http://racb.cgi.com (CGI, Region B)

➤ www.connollyhealthcare.com (Connolly Healthcare,

Region C)

➤ http://racinfo.healthdatainsights.com (HealthDataInsights,

Inc., Region D)

Visit the CMS Web site at http://tiny.cc/wwu6a for gen-

eral information about the timeline for complex versus au-

tomated reviews.

Do you know who your RAC project officer is? The fol-

lowing is a list of contacts by region:

➤ Region A: Ebony Brandon, 410/786-1585

➤ Region B: Scott Wakefield, 410/786-7301

➤ Region C: Amy Reese, 410/786-8627

➤ Region D: Kathleen Wallace, 410/786-1534

HCPro’s Revenue Cycle Institute Web site provides de-

tailed, timely RAC analysis. For more information, visit http://

blogs.hcpro.com/revenuecycleinstitute. Finally, subscribe to the

free biweekly RAC Report at http://tiny.cc/z8pLk.



should identify any relevant changes that may have oc-

curred since the preadmission screening. It should also

include a documented history and physical exam and

a review of the patient’s prior and current medical and

functional conditions and comorbidities.

➤ Ensure an individualized overall plan of care.

The plan of care—which is based on information from the

preadmission screening, postadmission evaluation, and

therapy assessments—should be unique to each patient.

Templates are discouraged because they are not patient-

specific, said Seagrave. A rehab physician must provide the

plan within four days of an IRF admission. He or she must

document the estimated length of stay; the medical prog-

nosis; anticipated interventions, functional outcomes, and

discharge destination; and expected therapy.

➤ Keep admission orders. At the time of admission,

a physician must generate admission orders that stay in the

patient’s medical record at the IRF.

➤ Retain the IRF patient assessment instrument

(PAI). The IRF-PAI must also be included in the patient’s

medical record at the IRF. The IRF-PAI must correspond

with all of the other information in the patient’s IRF medi-

cal record.

In addition to these new documentation requirements,

there are several new IRF medical necessity criteria, in-

cluding the need for the following:

➤ Multiple therapy disciplines

➤ Participation in an intensive rehabilitation therapy

program (Note: The patient must also demonstrate

the ability to participate in such a program)

➤ Face-to-face visits by a rehabilitation physician or

other licensed treating physician with specialized

training and experience in rehabilitation at least

three days per week throughout the IRF stay

➤ An interdisciplinary team approach to the delivery

of care n

CMS is taking a closer look at admissions to inpa-

tient rehabilitation facilities (IRF) thanks to new doc-

umentation and coverage requirements. The changes

are effective for all IRF discharges occurring on or after

January 1, 2010. The agency discussed its new require-

ments during a November 12, 2009, conference call. To

download the presentation materials from the call, visit

www.cms.hhs.gov/inpatientrehabfacpps and click on “Cov-

erage Requirements.”

The following are five suggestions to ensure documen-

tation compliance:

➤ Perform a comprehensive preadmission

screening. CMS believes the screening process is the

main factor in identifying appropriate candidates for IRF

care, Susanne Seagrave of CMS’ Division of Institu-

tional Post-Acute Care said during the call.

Comprehensive screenings should include documen-

tation of a physician’s decision-making process for each

individual patient. Checklist forms are not acceptable,

said Seagrave. Conduct screenings within the 48 hours

immediately preceding the IRF admission. If the screen-

ing was conducted more than 48 hours prior to the ad-

mission, providers must document an update within the

48-hour time period.

Although Seagrave said that CMS would not provide

a list of clinicians who can perform the screening, she

noted that clinicians must be licensed or certified. They

must also be appropriately trained to assess the patient’s

medical and functional status, as well as his or her risk

for clinical and rehabilitation complications.

The rehabilitation physician must document his or

her review and concurrence with the findings and re-

sults of the preadmission screening after the screen-

ing is completed and prior to the IRF admission, said

Seagrave.

➤ Ensure documentation of the postadmission

physician evaluation. The postadmission evaluation

The quick list: These five tips can help providers meet new IRF documentation and coverage requirements


by Robert S. Gold, MD

Cardiomyopathy is typically a long-last-

ing disease (-pathy) of the heart (cardio-)

muscle (-myo-). The American Heart As-

sociation (AHA) and the American College of Cardiol-

ogy (ACC) published the stages of heart failure in 2001.

These stages are distinctly different from the classes of

heart failure published by the New York Heart Associa-

tion (NYHA). However, despite these differences, many

physicians confuse stages with classes. The good news is

that coders can help clear up this confusion.

AHA and ACC stages of heart failure

Stage I heart failure connotes the presence of a disease

that can lead to problems with the functioning of the

left side of the heart (i.e., cardiomyopathy). During this

stage, there are no measurable effects. Note, however,

that when left untreated, stage I heart failure can lead

to chronic heart failure.

Stage II heart failure involves progression of the dis-

eased muscle of the heart, resulting in measurable effects

that a physician can identify. This dysfunction is due to

changes in the heart muscle structure in response to the

disease process (i.e., the cardiomyopathy). In some cases,

the ventricle starts to dilate, and in other cases, the ven-

tricle starts to hypertrophy. The dilation often is associated

with systolic dysfunction, a measurable reduction in the

patient’s ejection strength. The ventricular hypertrophy

often is associated with an inability to fill the ventricle

during diastole. This is referred to as diastolic dysfunction.

During stage II, the patient doesn’t yet have symptoms

of heart failure due to the dysfunction. It’s still not chronic

heart failure. Physicians should closely monitor the myo-

cardial dysfunction to determine whether they can prevent

the heart muscle from progressing to the next stage.

During stage III heart failure, the patient has symptoms

due to the dysfunction that are directly related to the

cardiomyopathy. When the symptoms begin, the patient

has chronic heart failure. The patient will continue to have

chronic heart failure until receiving a new heart. Stage III

is divided into two major subgroups: mild chronic heart

failure and moderate chronic heart failure.

When the patient progresses to Stage IV (severe chron-

ic heart failure), mechanical support (e.g., pumps or a

new heart) is necessary for survival. When all efforts

have been exhausted, the patient may require palliative

care, as this is considered end-stage heart failure.

NYHA classes of heart failure

The NYHA classification groups patients who already

have chronic heart failure. Classes one, two, and three

denote progressively worsening physical limitations,

ranging from no limitation to severe limitation. Class

four is end-stage. Classes one, two, and three translate

to stage II chronic heart failure according to the AHA

and ACC, whereas class four patients translate to stage

IV heart failure.

Each AHA and ACC stage denotes an increase in dis-

ease and cardiac muscle functional abnormality until the

patient develops chronic heart failure. However, each

NYHA class denotes an evolution in the patient’s physical

limitations and debility due to the chronic heart failure

that is always present.

Physicians frequently diagnose cardiomyopathy but

don’t document the condition explicitly. For example,

a patient may have a massively dilated heart with very

weak muscle strength and low cardiac output. A physician

Get to the heart of the causes of cardiomyopathy


> continued on p. 12

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➤ Hypertensive cardiomyopathy. This refers to hyper-

tensive heart disease (402.xx and 404.xx series).

➤ Valvular cardiomyopathy. This condition is rep-

resented by left ventricular hypertrophy due to aor-

tic stenosis. It also can occur when the left ventricle

is dilated due to mitral regurgitation. Other valve dis-

orders and scenarios also can cause functional abnor-

malities that can lead to the condition. Report 428.9

and the code for the specific valve(s) involved.

➤ Amyloid heart and alcoholic cardiomyopathy.

These conditions have their own codes, as does toxic

cardiomyopathy. The latter can occur in postchemo-

therapy patients who have dilation and very low ejec-

tion fractions after a doxorubicin treatment.

The bottom line is that coders must request clarifica-

tion. When a physician uses the term “cardiomyopathy”

to represent chronic systolic failure, ask for documenta-

tion of the cause. Don’t accept “non-ischemic” unless the

physician really can’t identify the disease that caused the

patient’s chronic heart problem. n

Editor’s note: Gold is CEO of DCBA, Inc., a consulting firm

in Atlanta that provides physician-to-physician programs in

clinical documentation improvement. Reach him by phone at

770/216-9691 or by e-mail at [email protected].

may suspect chronic systolic left ventricular (or biven-

tricular) failure but not document the disease (i.e., the

cardiomyopathy).

Causation and understanding the role of the

International Classification of Diseases

The International Classification of Diseases (ICD) is a

categorization of disease processes that is further broken

down by causation. For example, one code represents

anemia due to chronic kidney disease. Another repre-

sents acute posthemorrhagic anemia. When a physician

doesn’t specify a cause, coders must report a code for

“anemia with an unknown cause” (i.e., 285.9, which

denotes anemia, unspecified).

ICD-9 requires coders to obtain information about the

cause of the patient’s cardiomyopathy. When physicians

don’t document this information, coders must assign the

default code (425.4, other primary cardiomyopathy). How-

ever, common sense tells us that virtually no Medicare pa-

tients have primary cardiomyopathy. They almost always

have a sick heart muscle due to some other cause, such

as ischemic cardiomyopathy. Physicians often identify this

cause but don’t document it because they aren’t aware

that coders need the information.

Three other common causes of cardiomyopathy

worth noting include the following conditions:

Cardiomyopathy < continued from p. 11

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We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Contributing Editor Lisa Eramo at [email protected].

February 2010

Coding Q&AA monthly service of Briefings on Coding Compliance Strategies

Clarification: The answer to the question regarding

ICD-9-CM guidelines for coding anemia due to antineoplastic

chemotherapy in the December 2009 BCCS included con-

flicting information. Coders should report 285.22 for anemia

secondary to a malignancy. Code 285.3 denotes anemia due

to chemotherapy.

A patient with diabetes also has steroid-induced

hyperglycemia. Should I report a code from the

249 category (secondary diabetes) or the 250 catego-

ry (diabetes type 2)? The documentation states “un-

controlled diabetes mellitus, type 2, exacerbated by

steroids.”

Report ICD-9-CM code 250.02 to denote diabetes

mellitus without mention of complication, type 2 or

unspecified type, uncontrolled. Also report code E932.0

(adrenal cortical steroids causing adverse effects in thera-

peutic use).

If the diabetic patient has any diabetic manifestations

(e.g., neuropathy [250.62] or nephropathy [250.42]), report

these conditions instead of 250.02. Also report the corre-

sponding italicized manifestation code(s) in accordance with

the ICD-9-CM Official Guidelines for Coding and Reporting,

Chapter 3, a. 4., which states in part:

Assigning and sequencing diabetes codes and

associated conditions

When assigning codes for diabetes and its associ-

ated conditions, the code(s) from category 250 must be

sequenced before the codes for the associated conditions.

The diabetes codes and the secondary codes that cor-

respond to them are paired codes that follow the etiology/

manifestation convention of the classification (See Section

I.A.6., Etiology/manifestation convention).

Don’t report a secondary diabetes code for a patient

who has primary diabetes mellitus. Refer to the ICD-9-CM

Official Guidelines for Coding and Reporting, Chapter 3,

a. 7., which states in part:

Secondary Diabetes Mellitus

Secondary diabetes is always caused by another con-

dition or event (e.g., cystic fibrosis, malignant neoplasm

of pancreas, pancreatectomy, adverse effect of drug, or

poisoning).

Although this patient with known type 2 diabetes is

experiencing uncontrolled diabetes due to the presence or

adverse effect of steroids, this is not the same as secondary

diabetes. In this scenario, the uncontrolled diabetes is only

temporary. Elevation of glucose is a known side effect of

steroids, and the patient will continue to be a type 2 dia-

betic once the steroid treatment is discontinued.

What principal diagnosis should I assign for the

following two scenarios?

Scenario 1: A patient presents with aspiration pneu-

monia after choking on food prior to admission. He is

started on IV antibiotics and aspiration precautions. He

has a history of aspiration pneumonia from difficulty

swallowing. A physician documents sepsis blood cultures

positive and continues the patient on IV antibiotics.

Scenario 2: A patient presents with diarrhea due

to failed outpatient treatment of C. diff colitis. Prior

to admission, the patient engaged in long-term use

A supplement to Briefings on Coding Compliance Strategies

> continued on p. 2

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, Inc. Copyright © 2010 HCPro, Inc., Marblehead, MA. Telephone: 781/639-1872; fax: 781/639-2982. CPT codes, de scriptions, and material only are Copyright © 2010 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

of antibiotics that led to the development of C. diff

colitis. Upon admission, the patient is given IV vanco-

mycin. Sepsis also is documented on admission, and

the patient continues treatment with IV antibiotics.

I understand that sepsis is a systemic infection; how-

ever, it is not always the cause of other conditions. For

example, it didn’t cause the aspiration pneumonia in

scenario 1. It also didn’t cause the C. diff colitis in

scenario 2.

In both examples, report sepsis as the principal diag-

nosis if it was POA. See the ICD-9-CM Official Guide-

lines for Coding and Reporting, I.C.1.b.3—Sepsis/Systemic

Inflammatory Response Syndrome (SIRS) with localized

infection. It states that when the reason for admission is

both sepsis, severe sepsis, or SIRS and a localized infec-

tion (e.g., pneumonia or cellulitis), a code for the sys-

temic infection (038.xx, 112.5, etc.) should be assigned

first. Next, assign code 995.91 or 995.92 followed by

the code for the localized infection.

If the patient is admitted with a localized infection, such

as pneumonia, and sepsis/SIRS doesn’t develop until after

admission, refer to I.C.1.b.2.b. This is a sequencing direc-

tive to code the sepsis first and the underlying infection

(such as aspiration pneumonia or C. diff colitis) as a second-

ary diagnosis when sepsis is POA. The directive also states

that when sepsis is not POA, coders should report it as a

secondary diagnosis.

When it’s unclear whether the patient was septic on

admission, coders should query physicians for additional

clarification. See the ICD-9-CM guidelines (1.C.1.b.2.c),

which state:

Sepsis or severe sepsis may be present on admission

but the diagnosis may not be confirmed until sometime

after admission. If the documentation is not clear whether

the sepsis or severe sepsis was present on admission, the

provider should be queried.

Selection of the principal diagnosis depends on whether

the sepsis is POA. In many cases, an underlying infection

will have an etiology; however, coders must consider the

circumstances of the admission and whether sepsis was

POA before assigning the principal diagnosis.

DeAnne W. Bloomquist, RHIT, CCS, president and chief

consultant at Mid-Continent Coding, Inc., in Overland Park,

KS, answered the previous two questions.

How should I code gastric lap band erosion with in-

fection? The ICD-9-CM Manual instructs coders to

report code 997.4 (complications of bariatric surgery).

However, I think this code is only for complications that

are organic in nature (i.e., obstructions). When a gastric

band migrates, could this be considered a mechanical

complication? If so, should I report code 996.59 (me-

chanical complication of other specified prosthetic

device, implant and graft not elsewhere classified)?

American Hospital Association representatives acknowl-

edge that a code doesn’t exist for this complication.

Report code 997.4 (complications of gastrointestinal

tract) as the ICD-9-CM Manual instructs. Code 996.xx

(complications peculiar to certain specified procedures)

excludes 997.4. To find code 997.4, look in the alphabetic

index under “Complications, stomach banding,” which

will lead you to code 997.4. In the tabular list, 996.xx

excludes 997.4.

Paula Archer, managing consultant at BKD, LLP, in Little

Rock, AR, answered the previous question. n

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