January 29, 2024

Top Questions from the Coding Clinics from 2023 Webinar

Looking for more information about Coding Clinics from 2023? BESLER’s Senior Coding Analyst of Revenue Integrity Services Victoria Hernandez answers your questions from the recent webinar.

To watch Victoria’s Coding Clinics from 2023 Webinar, click HERE.

What is the role of querying in outpatient hospital settings – I.E., emergency room or urgent care?

The query practice would apply to all settings. I understand it may be challenging to query ED doctors, so I’ve seen various hospitals/organizations develop their internal policies and procedures on these cases.
Is it correct to code Torturous Colon as congenital disorder. Audit said yes, I said no.

I searched in the Alphabetic Index under “tortuous”, then “organ or site, congenital NEC – see Distortion”, then “Distortion(s)(congenital)”, then “organ”, then “or site not listed – see Anomaly, by site”, then “Anomaly, anomalous (congenital)(unspecified type)”, then “colon Q43.9”. I searched Q43.9 in the coding tabular and selected Q43.8 other specified congenital malformations of intestine. You may also find tortuous colon and redundant colon used interchangeably and redundant colon also codes to Q43.8 other specified congenital malformations of intestine. If documentation in the record is contradicting a congenital disorder, you may query the provider for clarification.
How about a patient came for Covid testing, and it was positive…what should we code?

The ICD-10-CM code for the COVID screening is Z11.52 encounter for screening for COVID-19. If the provider confirms that the patient has COVID-19, the code assignment is U07.1 COVID-19. A good reference is the AHIMA and AHA Frequently Asked Questions Regarding ICD-10-CM/PCS Coding for COVID-19. The two latest revisions are from May 10, 2023, and May 22, 2022.
A patient was admitted specifically for comfort care. Is it appropriate to use palliative care as PDX?

Yes, if the reason for the encounter is to specifically receive palliative care and it meets UHDDS definition of principal diagnosis, Z51.5 encounter for palliative care would be assigned as the principal diagnosis. You may also refer to AHA Coding Clinic 1st Quarter 2017, pages 48-49 Palliative care.
If a patient is admitted “in” CHF and also has a HX of diastolic CHF, is it okay to code it as acute and chronic diastolic based on the statement of “in” CHF? No acute or decompensation or exacerbation is documented.

Unfortunately, the word “in” isn’t enough supporting documentation to assign acute and chronic. This scenario would warrant a query to the provider for both type and acuity of CHF for that admission.
If you present a query for clinical validation (i.e., Acute Respiratory Failure documented consistently without clinical indicators; signs, symptoms, treatment, lab or diagnostic testing to support the diagnosis); and the physician does not respond or responds without citing his/her rationale for the diagnosis, do you code it or not?

I would first make sure that the query sent to the provider is complete with all the appropriate information from the record. This should include everything you mentioned in your question and if the physician confirms the diagnosis, it would be coded.
Would uncertain diagnosis be coded during hospital stay?

Since “hospital stay” may involve both inpatient and outpatient (i.e., Observation, Ambulatory Surgery, ED), I’ll provide references on uncertain diagnosis for both patient settings. For the inpatient setting, you may refer to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Section III.C. Uncertain Diagnosis, “If the diagnosis is documented at the time of discharge is qualified as ‘possible,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or similar terms indicating uncertainty, code the condition as if it existed or was established. NOTE: This guidelines is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.” For the outpatient setting, Section IV.H., Uncertain diagnosis states “Do not code diagnoses documented as ‘probable’, ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”
Outpatient: Even if the rad report will say dx vs dx., code both?

Unfortunately, no, we may not code either. “Versus” is not reportable in the outpatient setting. We may report the documented signs and symptoms if no definitive diagnosis has been made which is referenced in the ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Section IV.D. Codes that describe symptoms and signs.
For outpatient labs, if a screening lab is ordered, does the Provider need to “say” Screening of…to code a screening Z code? Or based on the service can this be added to the account?

The specific word “screening” does not always need to be documented to assign Z code(s) for screening. For example, Section I.C.1.a.2.h. Encounters for testing for HIV, “If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus” and for preoperative testing which includes COVID-19, code Z11.52 encounter for screening for COVID-19. You may refer to the specific sections in the coding guidelines, as applicable, and if unclear, query the provider.
What is a Present on Admissions Indicator, and how would we find it?

You may refer to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Appendix I Present on Admission Reporting Guidelines for detailed information.
If a condition is linked to multiple etiologies as “contributing to DM”, is it appropriate to be coded as diabetic? We did not in the past.

If documentation states, “contributing to DM”, that presumes a causal relationship between the condition and diabetes. We may use ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Section I.A.15. “With” as reference.
We put palliative care code in the top 8, but we have never been told to put the DNR in the top six. Is this correct?

Some facilities/organizations have internal policies and procedures specific to Palliative care and/or DNR status. Since both do apply to advance care planning, I’ve seen recommendations on reporting in the UB-04, especially when there are more than 10+ diagnoses codes (not mandated to my knowledge, though).
If the MD documents volume overload, is that the same code as fluid overload?

I have seen volume overload and fluid overload used synonymously, but not all situations, patients and cases are the same. If further clarification is needed, I recommend querying the provider.
Diagnosis question… Would you code Vit D Deficiency if the physician documented “low Vitamin D”?

I wouldn’t automatically assign “low” as “deficient”. I would query the provider for clarification. It would be best for the doctor to enter the actual diagnosis.
How about fluid overload with CHF. Do you still the fluid overload separately?

If the fluid overload is related to the CHF, it would not be coded separately, but if the provider documents that the fluid overload is unrelated to CHF, then it would be coded.
If patient has GI bleed and anemia is not specified, is it D649 or blood loss anemia?

If the anemia is not specified, it would not be appropriate to assign blood loss anemia; however, the coder may query the provider for clarification on specificity.
What if the physician documents Sepsis, but the indicators are not there. You query and the physician responds that Sepsis is still present. Do you code Sepsis in this case?

If the coder sent a nonleading, clear and detailed query to the provider, and the provider documents that the sepsis is still present, then sepsis would be coded. The coder took the proper steps and exercised due diligence in this case, and this aligns with the ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Section I.A.19. Code assignment and Clinical Criteria, “The assignment of a diagnosis is based o the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.” You may also refer to AHA Coding Clinic 4th Quarter 2016 pages 147-149, Clinical criteria and code assignment, “The guideline noted addresses coding, not clinical validation.”
For newborn guideline I.C.16.a.6. “Code all clinically significant conditions… has implications for future health needs”, would it be appropriate to report family HX codes on a newborn delivery encounter when no additional workup was done past routine? For example, family HX of cancer, asthma.

It can go both ways. Some facilities/organizations prefer everything reported and would consider those as implications for future health needs. Some facilities/organizations have internal policies and procedures (i.e., Always Code List, Do not Code List, etc.). I would not make the coder wrong for reporting a cancer family history, especially since there’s no impact to the DRG, but it paints a full picture on the newborn’s family history.
If a patient is made CMO and officially discharged home with hospice; however, patient expires while being transported (still in the hospital) would the dispo be Expired or Home Hospice?

A good reference would be Specifications Manual for Joint Commission National Quality Measures. One of the bullet points states “If there is documentation that further clarifies the level of care that documentation should be used to determine the correct value to abstract. If documentation is contradictory, use the latest documentation”.