“Ask Dr. Remer:” Bridging the Gap Between Coders and Clinicians

EDITOR’S NOTE: As you may know, Dr. Erica Remer is a consultant, in addition to serving as co-host of the long-running Talk Ten Tuesdays weekly Internet broadcast.  Broadcast listeners routinely pose thought-provoking questions, prompting her TalkBack segments, but she also presents a free webcast on LinkedIn every several months, Ask Dr. Remer, to answer questions not addressed on air. What follows are some of her thoughts recently shared in such a fashion.

Last week, I held my fifth “Ask Dr. Remer” webcast. I thought I might share some of the interesting topics I touched on, today. It is fascinating to me how questions often reveal a gap in knowledge, depending on the questioner. Providers often ask questions demonstrating a lack of understanding of how coding works, and coders sometimes ask questions presenting an opportunity to explain finer points of clinical medicine. I usually find multiple points to bring to light from each question, however.

The first topic was whether thrombocytopenia (the condition of having low platelet counts) would get coded if a patient has severe preeclampsia. This gave me the chance to explain the concept of “integral to” or “inherent to.” If a condition invariably or almost always is associated with another sign, symptom, or condition, you often don’t code it. It is considered “inherent.” Fever or cough with pneumonia would be examples. However, there are often situations in which conditions may be seen concomitantly but are not considered inevitably or even routinely linked. Both conditions would then be codable.

Thrombocytopenia is part of the diagnostic criteria for a condition closely related to preeclampsia: HELLP syndrome. This stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. My opinion is that thrombocytopenia is inherent to HELLP syndrome because the low platelets help define the syndrome. However, even though thrombocytopenia may be noted in severe preeclampsia, it would not be considered inherent and should be separately coded.

In another scenario, someone had explained to me that their providers were using the phrase “toxic encephalopathy” – because the patient looked toxic. This was so enlightening! Indeed, any patient with encephalopathy will look sick! My view is that “toxic encephalopathy” indicates an exposure to a toxin, be it a prescribed medication, illicit drug, or environmental toxin. There should be another code indicating the toxin (adverse effect or poisoning) that will include intent (i.e., accidental, intentional self-harm, assault, or undetermined).

Another clinician asked me what to do about noninfectious systemic inflammatory response syndrome (SIRS) and sepsis not being allowed to be coded together in the setting of a sickle-cell patient in pain crisis who developed a urinary tract infection. I discussed the elements of SIRS and how they shouldn’t be an appropriate response to the clinical insult, whether it is infection or some other condition, like trauma or pancreatitis. In my opinion, I would not sanction capture of SIRS in a scenario in which a patient has deranged vital signs due to pain. I went through the guidelines regarding R65.1- (SIRS of non-infectious origin not being picked up if an infection is eventually identified as the source of the abnormal vital signs) and introduced the Coding Clinic advice regarding coding of two conditions with Excludes1 instructions if they are deemed unrelated.

In complete disclosure, I live squarely in the “organ dysfunction should be present in order to pick up R65.11” arena, just as I believe that sepsis requires organ dysfunction. I think tachycardia, tachypnea, fever/hypothermia, and elevated/decreased white blood cell count are just too common, arising from myriad etiologies.

Finally, I discussed hypertensive heart and/or chronic kidney disease (CKD). A provider bemoaned the fact that coders use it as the principal diagnosis, which is affecting their institution’s heart failure readmission metrics, and they wanted to know how to avoid this.

It has been my observation that many providers are only familiar with I10, Essential hypertension, and they are not aware that there are entire other code sets dealing with hypertension in the context of heart disease or chronic kidney disease. Good coders know that there is a presumption that heart failure in a patient with hypertension should be coded with an I11.- or I13.- ICD-10-CM code. I explained that it isn’t due to the “with” convention; the converse is true. The reason the “with” convention applies is because these conditions are so frequently linked clinically that the association can be assumed, and that is why the title has “with” in it.

Providers should think in ink. If they do not think that hypertension is the reason for the heart failure or CKD, they should link those conditions with the alternate cause. Also, if they think some other disease process, after study, was the condition that occasioned the admission to the hospital, they should document that explicitly. Feel free to check out Ask Dr. Remer when I livestream in the future or peruse past editions on demand now. And keep sending us your thought-provoking questions (cbuck@medlearnmedia.com). You may just hear me answer them on an upcoming Talk Ten Tuesdays!