I was contacted by researchers at Vanderbilt University (Murli Mishra MD, PhD) to participate in a study assessing the effectiveness of newsletters in the education of medical professionals at different levels from medical students to practicing professionals.

(The following is directed towards inpatient providers. Outpatient providers know they must drop their own ICD-10-CM codes.)

We physicians aren’t coders. No one expects us to be.

Yet, we must understand how our documentation is converted to coding.

Why?

Codes are used for billing, our quality metrics, data and research, etc. Understanding coding is also key to receiving less queries.

Sometimes coding doesn’t make sense and I’m the first to call that out.

But coding is about specificity and optimizing your documentation for specificity will cause you to be clearer… Which is a win for communication.

That’s why this newsletter is called “Clarity 101”, not “Coding 101.”

Two years ago I went on the Critical Care Scenarios podcast to discuss documentation and coding. We were discussing respiratory failure and they asked a good question:

“What do we NEED to document for coding?”

The answer?

The diagnosis. That’s it.

… And MEAT (more below).

Much of what I talk about to “bulletproof” your diagnosis is to fight against insurances and the increasing practice of denying diagnoses (and therefore payment for them). That is, you need to prove with documentation that your diagnosis is clinically valid.

That’s an insurance problem. Not a coding problem.

🐸 Status (TOAD) Conditions 🐸 

You’ll often hear me say you need MEAT to get credit for a condition. Meaning you must document how you are either monitoring, evaluating, assessing, or treating it.

Status conditions are different. They are always relevant.

As described in the ACDIS podcast, these are also conditions that are often missed - like walking through a forest and stepping over a toad you didn’t even notice.

These include:

• Transplants

• Ostomies / Obesity

• Amputations / AIDS

• Dialysis / Devices (such as pacemakers)

Each amputation can impact your metrics — even amputation of the right pinky toe. So, mention it in your physical exam and it gets coded because it doesn’t require MEAT.

Speaking of Obesity, Just the BMI isn’t enough. You must also have a “nutritional diagnosis” with the BMI. Specify the severity as well. I discussed my preferred documentation of obesity here.

Don’t think transplants are looked over? I can’t tell you how many times I see medications like prednisone, tacrolimus, and cellcept on a med list and see no documentation of a transplant. I then have to go digging in the record or ask the patient.

Linkage

Many conditions don’t occur in isolation. They are due to other things.

Clear linking language:

• Due to

• Secondary to (coders have told me they DO understand and accept “2/2”)

• As a result of

• From

Bad linkage language:

• After

  • “Weakness after a stroke.” Is it due to the stroke or occurred coincidentally after the stroke? “After” is unclear.

• In the setting of

This is also becoming an “insurance problem” as insurances are denying Sepsis if it’s unclear that their end organ damage was DUE TO sepsis.

Reza Manesh, a brilliant diagnostician and co-founder of The Clinical Problem Solvers, posted this on Twitter:

The “Why Cascade” from a clinical side.

The “Due to Cascade” from a coding side.

Either approach should cause clinicians to get to the underlying etiology.

History Of

“History of” in coding means the condition is no longer active.

This is a common problem with malignancies.

Example: someone documents “history of breast cancer” but the patient is still receiving Tamoxifen. That patient is still on therapy. That condition is still active. You’ll get a query to clarify.

A common exception is strokes. People can have “a history of a stroke” but still have residual deficits from that stroke. They are not still actively stroking, but how do you document to capture that?

Good news, there’s a code for that.

There are specific codes for personal histories of strokes with or without residual deficits. “History of” is right there in the code. Just be clear about residual deficits or not.

This is important for outpatient providers who often see patients AFTER a hospitalization for a stroke. “Acute CVA” is often copied forward. But when you document / code this, this suggests you are actively treating an acute CVA in your office (which would be substandard care). So, you should use personal history of documentation / codes instead. The same goes for follow ups for UTI, Pneumonias, etc that are no longer on treatment.

This is the basis of my recommendation for using “with” rather than “past medical history of” in HPI’s.

Ruled Out vs Resolved

“Ruled Out” means a diagnosis was considered but ultimately found not to exist. We often treat conditions empirically but if it’s unclear, inpatient coders will code that condition as if it exists. However, saying “ruled out” will get it removed from coding. Just make sure to delete it from your subsequent notes. I use this often with sepsis, UTI’s, etc.

If something was treated and is no longer active, then use “resolved.” Do not just delete it from your note because it won’t be clear to coders if it was ruled out or resolved, and you’ll get a query.

Diagnoses of uncertainty, such as “Pneumonia due to suspected gram negative organism” can be used inpatient. 👇️ 

Causative Organism

The coding of infections, such as pneumonias, sepsis, etc. are guided by the causative organism. That’s why the causative organism in pneumonias are much more important than the “location” the pneumonia was acquired (CAP vs HCAP).

These organisms can be presumed due to risk factors. We are often treating these with certain antibiotics but fail to mention those presumptive organisms. So, be specific and mention those presumptive organisms.

Post-Op

The word “post-op” tells coders there’s a relationship between a procedure and whatever condition you’re documenting.

If you want to avoid accidentally documenting a complication, avoid using the word “post-op” to indicate a period of time after a procedure occurred.

“Post-op respiratory failure” = Complication

“Acute respiratory failure with hypoxia due to COPD exacerbation” = Not a complication.

Poisoning versus Adverse Effect

As I discussed in my newsletter on encephalopathy, if someone has toxic encephalopathy from a medication, be sure to include if the patient improperly took their medication or not.

Why? It impacts the coding.

• Poisoning = improper medication use (wrong med, wrong dose, wrong route, etc.)

• Adverse effect = medication taken correctly but there has been undesired or unwanted effects.

You don’t have to know the coding. Just document the improper use versus not.

AKI on CKD

There’s no such thing as “Acute on Chronic CKD.” It’s not like heart failure.

There’s also no code for AKI on CKD. When this occurs, coders code the two separate conditions. One for AKI. One for the CKD.

Make sure to specify the stage of the CKD.

Ideal documentation:

“Acute Kidney Injury superimposed on CKD Stage IIIa”

Lastly

Don’t forget to document Acute versus Chronic versus Acute on Chronic. This is huge for heart failure. And specifically for heart failure, remember systolic versus diastolic (HFrEF, HFmrEF, and HFpEF work too).

And if there is laterality, such as amputation or cellulitis of an extremity, make sure to document which side of the body it’s on.

That’s all for now and don’t forget to participate in Vanderbilt’s study on newsletters here.

Cheers,

Robert

Thanks to Laura Samson, RN BSN CCDS, Lisa Dugas, CCS CRC, and my wife Kara (grammar - yes I need that) for editing this newsletter!

When you’re ready, there are two ways I can help you:

Check out The Practical Guide to Attending Documentation.

• CME approved for 3.5 hours! Use your CME funds!

• Bill confidently (and reduce downgrades) and know what’s ACTUALLY needed for billing.

• Spend less time writing notes

• Use notes to PREVENT getting sued

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Impress your attendings and improve your evaluations.

• Prepare for real-world productivity pressures

• Gain the confidence to write shorter yet more effective notes.

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