In this episode, Kristen Eglintine, BESLER’s Senior Manager of Revenue Integrity Services of Coding and Projects, provides us with a glimpse into BESLER’s next free Webinar, Navigating Coding and Documentation Challenges for High-Volume Diagnoses, presented live on Wednesday, April 16, at 1 PM ET.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- What we can expect from this webinar
- What benefits that hospitals receive from accurate medical coding
- High-value diagnoses that will be discussed during the webinar
- Some challenges that coders face with these diagnoses
- How poor documentation leads to inaccurate coding
- Tips for coders and CDI specialists on coding encephalopathy, CHF & AKI
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Kristen Eglintine, BESLER’s Senior Manager of Revenue Integrity Services of Coding and Projects. In this episode, Kristen will provide us with a glimpse into BESLER’s next free Webinar, Navigating Coding and Documentation Challenges for High-Volume Diagnoses, that we’re presenting live on Wednesday, April 16, at 1 PM Eastern Time. Welcome back, and thank you for joining us, Kristen.
Kristen Eglintine: Hi, Kelly. Thank you. I appreciate being asked back.
Kelly: All right. Well, let’s go ahead and jump in today. So, you’re presenting Navigating Coding and Documentation Challenges for High-Volume Diagnoses on April 16th. And you tell us a little bit about what we can expect from this webinar.
Kristen: Absolutely. Thank you again, Kelly, for having me back. Thanks to all of you who are listening and spending a few minutes with us today. By definition, medical coding translates the diagnoses, treatments, procedures that occur during a patient’s visit into standardized codes that all the payers use to determine reimbursement. Accurate medical coding plays a critical role in our healthcare system, and it does serve as the foundation for billing and patient care and compliance. So, for this webinar, I’m going to discuss three high-volume diagnoses that we all find challenging to code. These diagnoses are reported frequently. They tend to have documentation gaps, and they significantly impact reimbursement.
Kelly: Wow. Sounds like you’re going to cover a lot during that webinar. So, what would you expand on some benefits that hospitals receive from accurate medical coding?
Kristen: Specifically, and probably the first thing that comes to mind would be proper reimbursement. Insurance companies rely on the codes that we report to pay for services. So, if an account is not coded properly, the hospital may not receive all of the funds they deserve for the services they provided. Another benefit from accurate coding would be patient care. So correct coding helps track patient care data, allows the providers to deliver the best care possible. A third benefit would be a decrease in compliance issues. Healthcare is one of the most regulated industries. Coders must adhere to guidelines, and incorrect coding can become compliance issues that could eventually lead to legal penalties and fines.
Kelly: Those sound pretty significant. So, what high-value diagnoses will you be discussing during the webinar?
Kristen: So, for this webinar, I’m going to cover three conditions: encephalopathy, congestive heart failure or CHF, and acute kidney injury or AKI. I’ll be focusing on these conditions because the clinical definition isn’t always static. So, over the years, whether guidelines or protocols or clinical criteria have changed, making these diagnoses challenging to code accurately. Because of the high volume of stays and the high dollars involved with these, it’s important that coders understand these conditions and have the tools to code them correctly.
Kelly: Most definitely. So, what are some of the challenges that coders face with these diagnoses?
Kristen: Two challenges coders and CDI face with these conditions are specificity and documentation. Specificity can turn a CC into an MCC on an account. Let’s quickly look at encephalopathy. Encephalopathy is a symptom-based diagnosis, and coding requires specifying the underlying condition or disease process. So, specifying that. If the patient has hepatic encephalopathy, the coder must identify the underlying liver disease, that could be cirrhosis or liver failure. And then similarly, for metabolic encephalopathy, the coder must identify the underlying conditions such as hyper or hyponatremia. Encephalopathy can be acute or chronic. There’s also acute metabolic or acute toxic encephalopathy. Acute metabolic encephalopathy is an MCC while unspecified encephalopathy is just a CC. So that illustrates what I had said where specificity can turn a CC into an MCC on an account, which therefore impacts reimbursement.
It’s important for CDI to get specific clarification from the physician when only encephalopathy is documented. So even when the cause is known, such as metabolic issues, it’s best if the physician can be specific within the documentation. This makes it easier for an auditor or a validator to follow the treatment and/or monitoring that is being given for that diagnosis of encephalopathy. And then similar to encephalopathy, specificity also applies to coding congestive heart failure. Another example, congestive heart failure can be acute or chronic. It can be systolic or diastolic or it can be combined systolic and diastolic. So again, another example where documentation is important to accurately code this condition.
Heart failure is tricky. There’s also a use of acronyms. In addition to numerous guidelines and coding clinics advising us on code selection or sequencing, you may see numerous acronyms in the documentation. And then coders need to decipher whether it is chronic or acute or acute on chronic. Coders must also determine if the congestive heart failure is linked to other associated conditions such as chronic kidney disease and/or hypertension. Coders have guidelines that instruct them that “with” should be interpreted to mean “associated with” or “due to.” So, if there is documentation that states a patient has heart failure with hypertension, you will report a different code, a combo of an I-11 in addition to your I-50 rather than an I-10 in your I-50 code.
Kelly: Great. Thank you for sharing that with us. And it sounds like documentation is really important. So can you provide an example of how poor documentation leads to inaccurate coding, which can negatively impact reimbursement?
Kristen: Yeah, yeah. Great question. So, to just build off of the previous answer, without proper documentation, it’s difficult to code encephalopathy, congestive heart failure, or AKI accurately. And when these diagnoses aren’t coded accurately, DRG assignments and reimbursement are affected. Poor documentation on congestive heart failure can cost a hospital thousands of dollars. If congestive heart failure is linked to hypertension, the I-11 or I-13 code could be sequenced as PDX versus the I-50, moving a claim from the MS-DRG of 292, which is heart failure with a CC, to 291, which is heart failure with an MCC. Again, two different DRGs, two different reimbursement rates. Or let’s say the patient doesn’t have hypertension and your documentation states congestive heart failure only, and it doesn’t specify acuity or type. The coder then has to report an I-59 just for congestive heart failure, unspecified, rather than acute on chronic congestive heart failure. Those are just a couple of examples of where you’ll see poor documentation impacting DRG assignments.
Kelly: Thank you for sharing those with us. So, what tips will you be sharing for coders and CDI specialists on coding encephalopathy, CHF, or AKI?
Kristen: I’ll be sharing a lot of like the do’s and don’ts on the webinar, but one that stands out is the importance of CDI programs as they can be extremely helpful by bridging the gap between the physician documentation and coding. We always recommend hospitals have the best documentation practices in place, such as the following. Documentation must be provided. Coders cannot assume diagnoses exist based on a medication list in the patient’s file or physician orders. All conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management should be documented and coded. Coders cannot code current conditions from problem lists from medical history or from super bills. Providers should document the etiology, type, and acuity of their conditions. Providers should document any additional or secondary conditions and any causal relationships that exist between them. Now for coders, the most important tip for accurate coding is really just a thorough understanding of the guidelines. Coders should familiarize themselves with the coding and documentation requirements for high volume diagnoses and stay up to date on relevant coding clinics. Being aware of what diagnosis codes are most at risk for miscoding and then following coding and documentation guidelines are ways to help ensure the most accurate diagnoses are reported.
Thank you all for listening today. It’s been my pleasure to spend a few minutes talking to you about the challenges of coding. I invite everyone to attend our upcoming webinar to learn more about coding and documentation challenges surrounding encephalopathy, congestive heart failure, and acute kidney injury. The webinar will be on Wednesday, April 16th, at 1 PM Eastern Standard Time and I look forward to talking to you then.
Kelly: Wow, thank you so much Kristen for sharing all this great information with us and giving us this sneak peek. And like you said that webinar is on April 16th, at 1 PM Eastern Time, and as a bonus you can earn CEU. Thanks again Kristen.
And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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