When each new year arrives, many of us make resolutions. The most common resolutions involve losing a few pounds or becoming more organized. But now that 2013 has arrived, ICD-10 implementation has drawn closer – and procrastination is not an option! It comes highly recommended that your new year’s resolution list this year include the opportunity to address “coding clutter.” Interesting terminology, but what exactly does this mean? The textbook definition of clutter is “a disorderly state or collection.” Therefore, I ask you, is your facility coding and collecting data that is not actually meaningful? If you are unsure, or believe the answer is yes, read on.
Excessive coding may be costing your facility time and money. A documentation review can reveal areas that potentially could be strengthened by new policies and procedures governing what to code and what not to code. Many years ago, official coding guidelines addressed the reporting of additional diagnoses. Is your facility following these guidelines? If not, do staffers have a legitimate reason for collecting data above and beyond what is required? The guidelines state, for reporting purposes, that the definition of “other diagnoses” is interpreted as additional conditions that affect patient care. Such conditions may require:
- Clinical evaluation;
- Therapeutic treatment;
- Diagnostic procedures;
- An extended hospital stay; or
- Increased nursing care and/or monitoring.
In addition to the coding guidelines, the UHDDS (Uniform Hospital Discharge Data Set) further clarifies the use of secondary codes by directing providers not to include diagnoses that relate to an earlier episode that has no bearing on the current hospital stay. UHDDS definitions apply to inpatients in short-term, long-term or acute care, plus psychiatric hospitals, home health agencies, rehab facilities or nursing facilities.
Beyond reporting for reimbursement, facilities collect data to support quality measures and risk or severity adjustments, as well as their own internal data needs. So it is time to ask yourself, “When was the last time an analysis of coding and a review of policies and procedures was performed by our organization? “
One of the most common examples of “coding clutter” is assigning codes for signs and symptoms that are an integral part of a disease process.
The following case study is a real-world example from an inpatient bill:
410.71 Acute myocardial infarction
682.6 Cellulitis of leg
681.10 Cellulitis of toe
703.0 Ingrowing nail
403.90 Hypertensive chronic kidney disease
585.9 Chronic kidney disease, unspecified
790.5 Abnormal serum enzyme level
729.5 Pain in limb
729.81 Swelling of limb
Before reviewing the documentation in the health record, one typically might question the coding of pain and swelling of a limb for a patient with cellulitis. It is possible that the pain is in a different limb than the cellulitis, but it’s also worth investigating. As a side note, this generic “pain in limb” ICD-9-CM code will change in ICD-10-CM, through which you can identify whether it was in the right forearm, the left leg, etc. What about assigning a code for an abnormal serum enzyme level? What are your policies for coding abnormal test results? New and inexperienced coders have a tendency to code everything they read. In this case, I would be surprised if the physician really documented an ingrown toenail – it seems that the patient has far more critical issues than that! This practice can clog databases with useless codes, not to mention demand the additional time it takes to assign the codes.
History of Codes
In another inpatient case study, there were a total of 32 codes for diagnoses, of which nine were “history of” codes. There is no doubt that “history of” codes, such as history of cancer or coronary artery bypass surgery, could impact the care of a patient and would provide value when profiling the patient’s illness. However, assigning V43.64 (hip joint replacement) on a patient who was admitted for a failed hip prosthesis doesn’t make sense. Is there a reason to assign numerous “history of” codes for an 89-year-old patient with sepsis? Is it necessary to assign four “family history” codes abstracted from the prenatal record of a healthy 24-year-old patient? Answers to these questions will help to eliminate excessive coding.
When reviewing policies for coded data, don’t forget about procedure codes. Are you assigning 99.04 for blood transfusions? If so, there needs to be readily accessible documentation that describes the approach (percutaneous or open) and route of administration (peripheral vein, central vein, etc.). ICD-10-PCS requires this additional documentation to be available before assigning the code. Currently, some facilities do not assign 99.04, but collect the data from other internal sources. Use of unspecified codes also should be analyzed for proper use. Is there any reason to assign 99.99 (other miscellaneous procedures) on an inpatient stay?
Leading the way to a Smoother Transition to ICD-10-CM
Eliminating coding clutter will refocus your attention on the importance of coding. Creating consistent policies for data collection of secondary diagnoses will help pave the way for a smoother transition to ICD-10. So if you haven’t already performed a policy and documentation review, it’s not too late to add this to your list of New Year’s resolutions!
Taking the time to be well-prepared for the advent of ICD-10 sounds like a smart resolution to me.
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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