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Clinical Coding Expert NewsSeptember-October 2003This issue is available in Adobe Acrobat format.
Don't Neglect the Effect of DRG CC SplitsInform doctors, coders, case managers, finance staffIn the 2004 final rule for the inpatient prospective payment system (PPS), a number of diagnosis-related groups (DRGs) were split according to the presence or absence of complications and comorbid conditions (CCs). These changes affect coders, anyone who documents in the medical record, and your facility’s bottom line. During a recent HCPro audioconference, “2004 DRG update: How to analyze the impact and educate your staff,” Gloryanne Bryant, RHIT, CCS, director of coding compliance and HIM for Catholic Healthcare West in San Francisco, explained the rationale for CC splits and offered tips for adapting to the changes. DRGs 531/532—replace DRG 4Spinal procedure with and without CC DRG 531 has a relative weight of (LOS) of 6.8 days, while DRG 532 has a relative weight of 1.4482 and an average LOS of 2.9 days. “The relative weights of these are significant, so you should share this with your case managers and utilization review, as well as your finance department,”says Bryant. “From a coding perspective, we want to be sure we capture our CCs.” DRGs 533/534—replace DRG 5Extracranial vascular procedures with and without CC DRG 533 has a relative weight of1.6678 and an average LOS of 2.7, and DRG 534 has a relative weight of 1.0748 and an average LOS of 1.6. “Talk to your physician surgeons who perform the intercranial vascular procedure about documenting reportable conditions,”Bryant advises. “Make sure your coders are aware of coding guidelines and what they can use for supporting documentation.”For example, coders can use the anesthesia record. However, if there’s conflicting information between the anesthesia record and the rest of the record, coders should query the physician. DRGs 537/538—replace DRG 231Local excision and removal of internal fixation devices except hip and femur with and without CC DRG 537 has a relative weight of1.18185 and an average LOS of 4.7, and DRG 538 has a relative weight of .9919 and an average LOS of 2.1. “We’ve always had a challenge with orthopedic surgeons’ documentation in particular,”says Bryant. “Their focus is always on the orthopedic condition, and thus we often don’t see the documentation of, say, the diabetes or cardiac condition. They wait for that to be documented by the other specialists.” Coders need to work with medical staff to get documentation on these other conditions, she says. “Certainly, if they’ve called in a specialist, you want to be able to identify that there’s no conflicting information with the attending [physician] so that you can use the information from that documentation.” DRGs 539/540—replace DRG 400Lymphoma and leukemia with and without CC DRG 539 has a relative weight of3.3846 and an average LOS of 7.4, and DRG 540 has a relative weight of 1.2891 and an average LOS of 2.9. The difference in LOS is significant, Bryant notes. “I would anticipate that if we did an analysis of our DRG 400 patients, we would find that the majority probably do have a CC,”Bryant says. “People with lymphoma or leukemia often have other problems and medical conditions.” As part of your action plan, “go back and analyze these DRGs in particular and look at their CC reporting over the last year to see where you’re going to fall. Are more of my cases going to be without CC? Am I going to lose relative weight and LOS coming into this new fiscal year or am I going to see more of my cases going into the ‘with CC’ DRGs?” DRGs 1/2—revisionsCraniotomy age > 17 with and without CC DRGs 528, 529, 530—newIntracranial vascular procedure with a principal diagnosis of hemorrhage Ventricular shunt procedure with and without CC CMS analyzed areas with high costs in order to identify diagnoses to break apart, and cerebral hemorrhage got the treatment. The change created DRG 528, which has a relative weight of7.2205 and an average LOS of 14.20. “This is significant. I’m sure you’re going to hear from some of your clinicians and case managers that they’re very pleased to see that significant of a difference there,”Bryant says. Another result of the analysis was the creation of DRGs 529 and 530 – ventricular shunt procedure with and without CC. These are another example of cases where it’s important to capture your comorbidities and complications, Bryant says. Educate, train, and prepare for more splits“Documentation and DRG changes are tied hand in hand,”says Bryant. “It’s essential that coders receive education relative to the revisions.”It’s also important to educate other clinicians who help physicians to write complete and accurate information. “From a coding and documentation perspective, we need to be sure that physicians understand that they should be reporting secondary conditions,”she says. “These conditions should be documented in the medical record and then coded and reported.”Documentation might include tests and services, evaluation, and increased nursing care or monitoring. These splits may be just the beginning, according to Bryant. “We might anticipate further splitting of DRGs that do not currently have that type of classification in the future.” Adapted from an article in Briefings on Coding Compliance Strategies.
Coding Tips for Vascular Access DevicesWhen dealing with vascular access devices, a coder needs to read the operative report carefully and get all the details before attempting to code the procedure. Knowing the types and purposes of vascular access devices will help the coder better understand each possible coding situation. The most common vascular access devices for renal dialysis include grafts, fistulas, and shunts. The physician determines the type of device to use based on the patient’s vein access. Arteriovenous (AV) fistulas and AV grafts are the two most common access devises used for hemodialysis. Tiffany Neally, RHIA, CCS, director of quality/remote coding manager for Precyse Solutions of King Prussia, PA, offers the following general coding tips:
AV graft codingThe arteriovenous graft (AVG) is an artificial blood vessel used to join an artery and vein. AV grafts are most commonly placed in the upper arm or thigh. They are used for patients whose own blood vessels are too small for fistula construction. Often these patients are elderly or have preexisting diabetes mellitus. The graft, which may be either straight or looped, is close to the surface of the skin for easier needle insertion. The graft may be of an artificial material, such as polytetrafluoroethylene or Gortex, or can be obtained from the patient’s own body, (e.g., the vein in the thigh). Assign ICD-9-CM 39.27 followed by either CPT code 36825 (harvesting of patient’s vessel) or CPT code 36830 (artificial graft). AV fistula codingAV fistulas are more commonly placed in the lower arm, forearm, or wrist. They are created internally and used for prolonged periods of time. Inserting a fistula involves a small operation to join an artery and vein, allowing arterial blood to flow directly into the vein. Due to the arterial pressure, the vein increases in size and its walls thicken. It is then easier to put a needle into this vein to allow blood to flow through the dialyzer using the blood pump on the machine. Assign ICD-9-CM code 39.27 followed by CPT code 36821. Temporary access codingTemporary or immediate accesses placed under the skin are immediately ready for use in cases when urgent dialysis is needed and the patient cannot wait weeks for the AV fistula to be ready for use. These include the following:
For temporary access by way of the subclavian or jugular vein, code ICD-9-CM code 38.95 following CPT code 36489 (percutaneous). Declotting of the AV shunt/fistulaThe physician may flush the shunt with a solution containing enzymes to dissolve the clot. Code this with ICD-9-CM code 99.10 or 99.20 following CPT code 37201. The physician may insert a balloon catheter into the shunt to relieve the clot. In this case, assign ICD-9- CM code 39.50 followed by the CPT code 3547x (the site will determine the final digit). Revision of the AV shunt (includes removal with replacement)The shunt is dissected free. The revision is made to the shunt at its juncture to the vein and or artery. If necessary, a new shunt is created with a graft that is obtained from a new site or artificial materials. Assign ICD-9 code 39.42 for AV shunt. Assign ICD-9 code 39.94 for a vessel-to-vessel cannula followed by CPT code 36832 without thrombectomy or CPT code 36833 with a thrombectomy. Editor’s note: Adapted from an article in Briefings on APCs. For more information, call 800/650-6787.
CDM FocusAutomated Charge Description Master Analysis ToolToday, hospitals are searching for better ways to improve the efficiency of analyzing their Charge Description Masters. Recently, many facilities have begun using automated solutions, including a new suite of products announced by BESLER/I HS. Here are a few of the most frequently asked questions about one of these products – CDM Focus: What is CDM Focus?CDM Focus is part of a comprehensive family of revenue enhancement products, including charge- master maintenance, strategic pricing, comparative pricing and other APC & DRG coding and reimbursement solutions. What Makes CDM Focus Unique?CDM FOCUS is a totally Web-Based Internet application that features advanced Microsoft. NET technology, extensive resources and superior cost effectiveness. How was CDM Focus developed?CDM Focus was developed by BESLER, a consultancy company whose reputation for excellence began in 1986. For over twelve years the company has specialized in chargemaster coding and revenue cycle management, utilizing software as a critical component of this process. The intelligence contained in this software is now available from I HS in CDM Focus on a national basis What types of Analyses does CDM Focus provide?CDM FOCUS allows the user to perform a variety of extensive analyses and generate reports, including Diagnostic reports, APC Status Indicator Reports, Financial Reports, Chargemaster Summary Reports, Impact Reports, HCPCS Validation Reports, Chargemaster Consistency Reports, and Other Validation Reports. These reports provide detailed information on a wide range of subjects, including:
What types of report formats are available with CDM Focus?CDM Focus offers a large number of flexible standard web-based report formats. Users may customize their view of the data through department filters and flexible sorting. Unlike a static report, the user may drill down to the individual chargemaster line item for viewing or editing. The online reports may be exported to PDF for printing, and the chargemaster may be exported to Excel or Microsoft Access for additional processing or custom reporting. How frequently are updates made to CDM Focus? Since CDM Focus is a web-based system, updates are available immediately to all clients as new CMS program memoranda are released (daily if necessary). Regular summaries of the latest changes and program and resource updates (HCPCS and CPT updates, CMS program memoranda, etc.) are also sent via email to all CDM Focus clients as often as needed. These changes are immediately and automatically reflected in the system with no client intervention. How quickly is data processed with CDM Focus?CDM FOCUS is designed to provide the best of both worlds – quick transactions with the benefits of a hosted solution. All processing takes place on powerful servers, so there is no need to transfer large amounts of data back and forth between a browser and the servers. The data is analysed with set-based logic – report results are determined the same way, whether there are 10 line items involved or 10,000. To provide even faster response times, CDM FOCUS utilizes advanced compression software that works automatically without any user intervention or additional software. What types of additional support and consulting services are available with CDM Focus? CDM FOCUS includes unlimited support. Additional consulting services are available to those customers who need it, whether due to lack of resources or skill set in CDM FOCUS PLUS, which combines three additional levels of expert consulting to supplement or replace the hospital’s resources. How easy is it to implement CDM Focus? Since CDM Focus requires no additional hardware or software, other than a computer with a web browser, implementation is quick and easy. Where can I get more information about CDM Focus?Call 1-800 634-0496 and ask to speak with an IHS Account Executive.
Clinical Coding Expert – Step by Step:Speeding up The Coding ProcessDid you know Clinical Coding Expert has many features to enable you to speed up the coding process? We’ll cover some of them during the next few issues. Synonyms and abbreviations can be added to the encoder to easily search for words in the Encoder. Many synonyms are present, but you can customize the searches with your own terminology. You do this using a Notebook called Keywords. First we must open the notebook. When in the encoder, click on File at the top left of the screen. Click on Open Notebook in the pull down menu. )
Double Click on the encoder folder. )
Then Double Click on the clink folder. (Figure 3) )
Double Click on the keywords.nbk file name on the left of the screen. (Figure 4) )
Let’s add CHF to Congestive Heart Failure. In order to do so, we must highlight 428.0 Congestive Heart Failure in the tabular context. Click on 3 - ICD and then the search icon at the bottom left of the screen. Type 428.0 and click on the search icon. We are now positioned and highlighting 428.0 in the tabular context. (Figure 5) )
Click on the Edit at the top left of the screen. Click on Edit Notebook in the pull down menu. (Figure 6) 
The NoteBook Editor window opens which allows you to enter synonyms or abbreviations. Just type in the synonym you want and click OK when finished. For our example, type CHF and click OK. You’ll notice the NOTES icon at the bottom left of the screen is now accessible. We need to compile the keyword so that it will be found during searches (you can add as many abbreviations and synonyms as you need before compiling). Click on File at the top left of the screen. Click on Compile User Keywords in the pull down menu. (Figure 7.) 
The system wants to know which notebook contains the keyword. Double click on keywords.nbk file. You are asked to confirm that you are building an auxiliary keyword file. Click on Yes. (Figure 8) 
The system will display a Keyword Build Successful message. Click on OK. (Figure 9) 
You will now be able to search for CHF as an abbreviation. You can add as many synonyms and abbreviations as you need. This is your system so utilize all these features. Abbreviations and synonyms are just one of many examples how Clinical Coding Expert helps you to code easily and correctly.
AHIMA pressures HHS to scrap ICD-9In a strongly worded letter dated July 24, 2003 AHMIA’s CEO, Linda Kloss urges the Department to take quick and decisive action to adopt ICD-10-CM (International Classification of Diseases, 10th edition, Clinical Modification) and ICD-10-PCS (International Classification of Diseases, 10th edition, Procedure Coding System) to replace the obsolete ICD-9. Ms. Kloss cites the following risks of further delay: 1. The US is out of step with all other developed countries that have already adopted the 10th edition of the ICD. Other countries use it to classify the incidence of disease as well as the causes of death. The US is using ICD-10 for cause of death reporting only and ICD-9 for disease reporting. Our national data systems are being rendered useless. SNOMED. A map is the crosswalk from the clinical reference terminology to the classification system. It makes no sense to build a map to an obsolete classification system. In fact, maps from SNOMED-CT and ICD-10 are under development for use in other countries and the US will benefit from this work.. Availability of computer-aided coding applications would relieve the shortage of expert coders. Despite the compelling reasons for the immediate adoption of ICD-10-CM and ICD-10-PCS, there is still confusion and misinformation leading to inaction. Others allege that: 1. The new systems are too complex for the skills of coders. AHIMA and CMS reveal that the improved specificity aids coders and results in more accurate data. This is simply not the case. Industry testimony before NCVHS in 2002 revealed that major vendors have already made provisions for ICD- 10 and need only a reasonable implementation schedule to make the transition. Ms. Kloss says HHS must move from the paralysis that seems to have characterized the debate about code sets toward a firm and expedited update schedule.
Coding AuditsAn Integral Component of HIM OperationsIf you know for a fact that your medical records always fully support the codes on your bills to the insurance company, read no further. If, however, your facility is like most, then your coding error rate could be running as high as 50 percent. So if you have never conducted a coding audit, or it has been more than a year since your last audit, or the last audit identified problems, then now may be the time to consider an audit. The penalties for noncompliance with the Medicare rules under the civil statutes are enormous; it only takes a small error rate to run up huge fines. It is not recommended that the HIM department conduct the audit. However, it can initiate it and maintain an active role in the planning, fieldwork, and report-writing phases. The internal audit department and Chief Compliance Officer should take the lead and ensure that HIM is included in the entire process. HIM should be focused on coding and abstracting, and storage and retrieval, which are integral in planning and conducting a coding audit. The HIM department, whether outsourced or in-house, has expertise which is vital to the audit. Most audits can and should be conducted in-house with in-house staff. If your facility has no real auditing expertise then you should seek the help of a competent auditing firm. It does not have to be a big accounting firm. Most small accounting firms have staff with auditing experience that can perform just as well as a large firm, but at a much lower price. Choose a company with experience in healthcare auditing. If you already retain an outside firm to audit your billings, you may want to do an audit anyway. Not all audit vendors always perform as you would expect. You do not need to hire a law firm to conduct or help with an audit unless you suspect that your facility been engaged in intentional wrongdoing. But remember, you are ultimately responsible for errors, regardless who does the audit. One of the most debated areas of auditing is sample selection: how should the sample be selected, from where, and how big should it be? This is also the source of most mistakes made in an audit. Statistical sampling should not be the responsibility of the HIM staff. HIM should stay focused on reviewing the coded medical records selected for audit. It may be prudent to hire a consultant to set up the statistical sampling plan if the expertise is not available in-house. This person will be worth every penny.
Salary survey shows region, hospital-size play big role in take-home payThe size of your hospital can make a big difference in your salary, job requirements, and credentials and experience, according to MRB’s 2003 salary survey. Although more than 60% of HIM directors at hospitals with more than 300 beds earn in excess of $70,000, only 33% of HIM directors at medium-sized hospitals (150-300 beds), and 11% of HIM directors at small hospitals (fewer than 150 beds) earn that much. That doesn’t surprise Angela Picard, program director of the health information management programs at St. Petersburg (FL) Junior College. “Usually the larger facilities have a lot more complexities,” she says. “For instance, they may be research facilities, they may have trauma centers or more high level medical care, or they may also have medical interns and other things that make record management more complicated.” Larger hospitals are more likely to employ HIM directors with more education and credentials. For example, all three size categories had a similar percentage of HIM directors with a bachelor’s degree, but the numbers vary significantly when it comes to master’s degrees. At large hospitals, 22% of HIM directors have a master’s degree, compared to16% and 9% at medium and small hospitals, respectively. Nearly three-quarters of HIM directors at large hospitals have their RHIA credential, compared with 64% at medium hospitals, and 50% at small hospitals. Picard believes larger facilities are more likely to employ an HIM director with a master’s degree “because of the business component of health care. It’s always been a business but more so than ever-especially reimbursement issues with the HIPAA regulations.” An RHIA might be more valuable to a larger facility than an RHIT, says Picard, because the credential involves more training in the management that comes into play with the complexities of larger hospitals. “That doesn’t mean the RHIT doesn’t have that skill set, but I could see where [a large hospital] would be looking for the higher credential.” Max Mitchell, MA, executive vice president and chief financial officer of placement firm Stern & Associates, based in Tampa, says salaries tend to be higher in regions of the country where people move around more frequently. “People on the West Coast tend to be more mobile,”he says. “They don’t think really hard about moving compared with someone from Pennsylvania or Ohio. A large percentage of people living in California are not natives so they don’t have a large family commitment holding them there. They don’t have to think about it as seriously if a better offer comes along.” That plus the high cost of living may explain why our survey showed that more people in the Pacific than in any other region earn more than $70,000. “We just placed someone at $103,000 and have many others making more than $100,000,”Mitchell says. “Directors out there at any facility of any size are going to command at least $90,000-$95,000.” “There are definitely people out there making between $125,000 and $150,000, and a fairly large number making between $100,000 and $125,000, mostly in California, Mitchell says. He has found that benefits, as full relocation costs, temporary housing, and sign-on bonuses of up to $10,000 are common. Adapted from a Medical Records Briefing article. For more information, call 800-650-6787 or e-mail customerservice@hcpro.com.
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Doreen M. Bernier