# Presentation: 028829

## Documentation & Coding Strategies for Obtaining Complete Documentation

- Presented By:  Terri Hall, MHA, RHIT, C.P.C.
-          HIM/RM Consultant
-         Billings Area Office
-     Source HcPro Teaching Tools: Dr. Robert S. Gold & 			        Gloryanne Bryant’s

## What Will Be Covered And What You Will Learn

- E&M Documentation Requirement & How To Audit
- Disease Specific Documentation Requirements for Physicians
- Disease Specific Questions Coders can ask providers in obtaining more specificity.
- Acute MI, Anemia, Chest pain/angina, COPD, Co-morbidities, CAD, Debridement, Dementia, Fracture of Femur, GI Bleed, Heart failure, Hyperglycemia, Malignancies, Pneumonia, Pulmonary edema, Renal failure, Respiratory failure, Seizures, Sepsis, Stroke/CVA, Syncope & Trauma.

## How CPT Coding Works

- Seven Components used in CPT’s description for patient encounter:
- Detail of history
- Extent of physical exam
- Complexity of medical decision making
- Extent of counseling
- Coordination of care with others
- Nature of patient’s problem (s)
- The time required *
- * Unless time spent at an encounter exceeds published standards (50% of Visit), the three key components, (history, physical, complexity of medical decision making determine the correct code usage.

## How CPT Coding Works

- The amount of paperwork (H&P) must correspond to the severity of illness to justify the medical necessity of your action plans.
- Example:  Doing a full blown H&P for a small thumb laceration will not get you a high level of pay.

## How CPT Coding Works

- The final determining factor for level of service is usually the Complexity of Medical Decision Making.
- Medical Decision Making has three elements:
- Patient Risk – Minimal, Low, Moderate, High
- Amount of data reviewed/ordered (lab, x-ray)
- The number of diagnoses/management options
- Note:  The provider’s documentation is rated or scored based on documentation components present and this score determines the CPT code used to bill for the provider’s service.

## How To Analyze a Provider’s Documentation In Determining The Correct CPT Code

- Since the key to coding is with the Patient Risk, start with “Risk Assessment.”
- Then look at the “Amount & Complexity of Data” and “Number of Diagnoses/Management Options” to obtain your score.
- 	Note:  Now that you know the complexity of your MDM you can determine the “level of service”

## Example:  MDM TableNote: The lower of the two highest components determines the level of the MDM

| Risk | Data | DX/Mgt | Complexity MDM |
| --- | --- | --- | --- |
| Min | 1 (min) | 1 (min) | Straightfwd |
| Low 
(xx) | 2 (lim) | 2 (lim) | Low |
| Mod | 3 (mod) (xx) | 3 (mult) (xx) | Moderate |
| High | 4 (exten) | 4 (exten) | High |

## E&M Billing Guide – Outpatient & Office (History (Key Component – Circle One)

| Type of History | Key | Definition & Required Documentation |
| --- | --- | --- |
| Problem Focused | F | CC+Brief HPI (1-3) |
| Expanded Problem Focused | E | CC+Brief HPI (1-3) + Problem Pertinent ROS (1) |
| Detailed | D | CC + Ext HPI (4) + Ext ROS (2-9) + Pertinent PFSH (1) |
| Comprehensive | C | CC + Ext HPI (4+) + ROS (10+) + Complete PFSH (2-3) |

## E&M Billing Guide – Outpatient & Office(Examination (Key Component – Circle One)

| Type of Exam | Key | Definition |
| --- | --- | --- |
| Problem Focused | F | Affected body area or organ system (1-5) |
| Expanded Problem Focused | E | + Other symptomatic/related organ system (6+) |
| Detailed | D | Extended exam of affected area (s) or related organ system (s) (7 +) with more depth |
| Comprehensive | C | Complete single system specialty exam  or complete multi system exam (8+) |

## E&M Billing Guide – Outpatient & OfficeMedical Decision Making (Key component –Circle one ): 2 of 3 Required

| Diagnosis/Options | Data | Risk | = Complexity | Key |
| --- | --- | --- | --- | --- |
| Minimal (1) | Minimal or None | Minimal | Straightforward | S |
| Limited (2) | Limited (2) | Low | Low | L |
| Multiple (3) | Moderate (3) | Moderate | Moderate | M |
| Extensive (4+) | Extensive (4+) | High | High | H |

## New Office Visits (Key Component must meet/exceed requirements to qualify for the E/M code) Office Visit, New Patient 3 of 3 Required (HPI, Exam, MDM)

| E&M Code | History | Exam | Med Dec Making | Avg. Time |
| --- | --- | --- | --- | --- |
| 99201 | F –Problem Focused | F-Problem Focused | STRW. | 10 |
| 99202 | E –Expanded Problem Focused | E –Expanded Problem Focused | STRW. | 20 |
| 99203 | D -Detailed | D -Detailed | LOW | 30 |
| 99204 | C Comprehensive | C
Comprehensive | MOD | 45 |
| 99205 | C
Comprehensive | C  Comprehensive | HIGH | 60 |

## Established Office Visit2 of 3 Required (HPI, Exam, MDM)

| E&M Code | History | Exam | Med Dec Making | Avg. Time |
| --- | --- | --- | --- | --- |
| 99211 | N/A | N/A | N/A | 5 |
| 99212 | F  Problem Focused | F Problem Focused | STR-W | 10 |
| 99213 | E  Expanded Problem Focused | E Expanded Problem Focused | Low | 15 |
| 99214 | D  Detailed | D Detailed | Mod | 25 |
| 99215 | C Comprehensive | C Comprehensive | High | 40 |

## Office ConsultationNew or Established Patient 3 of 3 Required (HPI, Exam, MDM)

| E&M Code | History | Exam | Med Dec Making | Avg. Time |
| --- | --- | --- | --- | --- |
| 99241 | F | F | STR-W | 15 |
| 99242 | E | E | STR-W | 30 |
| 99243 | D | D | LOW | 40 |
| 99244 | C | C | MOD | 60 |
| 99245 | C | C | HIGH | 80 |

## Inpatient Care(Key components must meet/exceed requirements to qualify for the E/M code)3 of 3 Required

| E&M Code | History | Exam | Med Dec Making | Avg. Time |
| --- | --- | --- | --- | --- |
| 99221 | C/D | C/D | S OR L |  |
| 99222 | C | C | M |  |
| 99223 | C | C | H |  |
| Subsequent |  |  |  |  |
| 99231 | F | F | S Or L |  |
| 99232 | E | E | M |  |
| 99233 | D | D | H |  |
| Discharge Day Mgmt. |  |  |  |  |
| 99238 | Hospital D/C Day Mgmt. | ___ | ___ | 30 MINUTES |
| 99239 | “ | ___ | ___ | + 30 |

## Auditing E&M Documentation

- CMS Medicare Part B
- HGSA Administration Documentation Worksheet

## History(If one column contains three circle = type of history.  If no column contains 3 circles, the column containing a circle farthest to the left = type of history)

**HPI: Status of Chronic Conditions**
- 1 condition
- 2 conditions
- 3 conditions
**HPI** – **History of Present Illness**
- Location	Duration	Modifying Factors
- Quality	Timing	Associated S & S
- Severity	Context
**ROS: Review of Systems**
- Constitutional	Respiratory	Integum
- Eyes			GU	Neuro
- Ears, Nose, Throat	GI	Psych
- Cardio/Vascular	Muscule	Endo
- Hem/Lymph		All/Immuno	All Other
**PFSH: Past, Medical, Family, Social**
**Past History: **:The patient’s past experiences with
-  		   illness,operation, injuries, &
- 		   treatments
**Family:** 	   A review of medical events in the
- 		   patient’s family, hereditary or at risk
**Social:** 	   Past and Current Activities

**	**_**PF**__	__**EPF    Detailed   Comp**_
**	****-****	****1-2   ****                            ****3 **
**Brief        Extend      ****Complete**
**1-3****	****4                 4+**
**Pert.****	****Extend      ****Complete**
**(1)****	****	****2-9 **
**	****	****Systems               **
**None           Pert. (1)****	****Complete ****	****	****	****(2or 3)**

## Examination

| Limited to affected body area or organ system (one body area o0r system related to problem) | PROBLEM FOCUSED EXAM |
| --- | --- |
| Affected body area or organ system and other symptomatic or related organ system (s) (additional systems up to  total of 7) | EXPANDED PROBLEM FOCUSED EXAM |
| Extended body area or organ system and other symptomatic or related organ system (s) (additional systems up to total of 7+ or more depth than above. | DETAILED EXAM |
| General Multi System exam (8+ or mor3e systems) or complete exam of a single organ system (complket4e single exam not defined in these instructions. | COMPREHENSIVE EXAM |
| Body Areas:
Head – Back (Spine) –Chest (breast/Axillae), Genitalia (groin/buttocks), Abdomen, Neck, Each Extremity
Organ Systems:
Constitutional, Eyes/Ears/Nose/Throat, Cardiovascular, Resp, GI, GU, Musculo, Skin, Neuro, Psych, Hem/Lymph/Imm | 1 Body        Up to 7 Systems         7+         8+
Area or
System

PF              EPF                            D             C |

## Number of Diagnoses or Treatment Options(Multiply the number in columns B & C and put the product in column D.  Enter a total for column D)

|       A | B Times(X) | C | = D |
| --- | --- | --- | --- |
|  | Number | Points | Result |
| Self Limited or Minor (stable, improved or worsening) | Max = 2 | 1 |  |
| Est. Problem (to examiner), stable, improved |  | 1 |  |
| Est. Problem (to examiner), worsening |  | 2 |  |
| New Problem (to examiner), no additional workup planned |  | 3 |  |
| New Problem (to examiner), additional workup planned |  | 4 |  |
| Table A |  |  | Total |

## Risk of Complications and/or Morbidity or Mortality (Table B)

| Level of Risk | Presenting Problem | Diagnostic Procedures Ordered | Management Options Selected |
| --- | --- | --- | --- |
| Minimal | One self limited or minor problem e.g., cold, insect bite, tinea corporis | Lab tests with venipuncture, Chest x-ray, Urinalysis, Ultrasound, KOH prep  | Rest Gargles, elastic bandages, superficial dressing |
| Low | Two or more self limited or minor problems One stable chronic illness, well controlled, acute uncomplicated illness or injury | Physiologic tests not under stress, non cardiovascular imaging studies with contrast, superficial needle biopsies, clinical lab tests requiring arterial puncture, skin biopsies. | Over the counter drugs, Minor surgery with no identified risk factors, physical therapy, Occupational therapy, IV fluids without additives. |
| Moderate | One or more chronic illne3sses with mild exacerbation, progr3ession, or side effects of treatment, two or more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, acute complicated injury | Physiological tests under stress, cardiac stress test, Diagnostic endocopies with no identified risk factors, Deep needle or incisional biopsies, Cardiovascular imaging studies with contrast and no identified risk factors, Obtain fluid from body cavity (LP) | Minor surgery with identified risk factors, Elective major surgery, Prescription drug management, Therapeutic nuclear medicine, IV fluids with additives, Closed treatment of fracture or dislocation without manipulation |
| High
 | One or more chronic illnesses with severe exacerbation, Acute or chronic illnesses or injuries that may pose a threat to life or body function, Abrupt change in neurological status
 | Cardiovascular imaging studies with contrast with identified risk factors, Cardiac eloectrophysio9logical tests, Diagnostic endoscopies with identified risk factors, Discography
 | Elective major surgery, Emergency major surgery, Parenteral controlled substances, Drug therapy requiring intensive monitoring for toxicity, Decision not to re3suscitat or to de-escalate care because of  poor prognosis |

## Amount and/or Complexity of Data Reviewed(Table C)

|                 Reviewed Data |                              Points |
| --- | --- |
| Review and/or order of clinical lab tests |                                                  1 |
| Review and/or order of tests in the radiology section of CPT |                                                  1 |
| Review and/or order of tests I the medicine section of CPT |                                                  1 |
| Decision to obtain old records and/or obtain history from someone other than patient |                                                  1 |
| Discussion of test results with performing physician
 |                                                  1 |
| Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
 |                                                  2 |
| Independent visualization of image, tracing,or specimen itself (not simply view of report)
 |                                                  2 |

## Final Result For Complexity = Tables A, B, C.

| A | Number diagnoses or treatment options | Less Than  or equal to (1) 

Minimal | (2)

Limited | (3) 

Multiple | Less than or equal to (4)

 Extensive |
| --- | --- | --- | --- | --- | --- |
| B | Highest Risk | Minimal | Low | Moderate  | High |
| C | Amount and complexity of data | Less than or equal to (1) Minimal or low | (2) 

Limited | (3)

Multiple | Less than or equal to (4)

Extensive |
|  | Type of Decision Making | Straightforward
99212 | Low Complex
99213 | Moderate Complex
99214
 | High Complex
99215 |

## Level Of Service Table (5)

| New Office (3)                      Established  (2) |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| History | PF | EPF | D | C | C | Minimal Problem that | PF | EPF | 1D | C |
| Exam | PF | EPF | D | C | C | may not require
Presence | PF | EPF | D | C |
| Complexity of MDM | SF | SF | L | M | H | of  physician | SF | L | M | H |
| Average 
Time | 10 | 20 | 30 | 45 | 60 | 5

99211 | 10

99212 | 15

99213 | 25

99214
 | 40

99215 |
| Level | I | II | III | IV | V | I | II | III | IV | V |

## Time

| If the physician documents total time and suggests that counseling or coordinating of care dominates (more than 50%) of the encounter, time may determine level of service.  Documentation may refer to prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider |  |
| --- | --- |
| Does documentation reveal total time? Face to face in outpatient setting unit/floor or inpatient setting | Yes                   NO |
| Does documentation describe the content of counseling or coordination of care? | Yes                   NO |
| Does documentation reveal that more than half of the time was counseling or coordinating care? | Yes                   NO |

## 1995 Exam Criteria (No Single System Available)

- Problem Focused Exam: 1 system/area
- Expanded Problem Focused:  2-4 system/areas
- Detailed Exam: 5-7 body systems
- Comprehensive Exam: 8 or more systems/areas
- 	**Body Areas**: neck, head and face, abdomen, chest, back including spine, upper and lower extremity, genitalia, groin, buttocks

## 1997 Exam Criteria

- You may use either the 1995 or 1997 CMS guidelines but only the 1997 Guidelines offer single system exams.
- How many exam elements in how many systems were documented in the medical record.
- Remember – counting elements is a technique of the 1997 CMS Guidelines and when defending a failed audit consider using the 1995 CMS Guidelines where body systems rather than elements are counted

## Single Organ System Examinations

**Problem Focused Exam**: should include performance and documentation of 1-5 elements identified by a bullet, whether in a shaded or un-shaded box. **General Multi-system exam is same.**
**Expanded Problem Focused**: should include performance and documentation of at least 6 elements identified by a bullet whether in a shaded or un-shaded box.  **General Multi-system exam is same**.
**Detailed Exam:** examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, etc.
**Comprehensive Exam**: should include performance of all elements identified by a bullet, whether in a shaded or un-shaded box.  Documentation of every element in a shaded box and at least one element in a n un-shaded box is expected.

## General Multi-System Exam

**Problem Focused Exam**: same as single organ system exam.
**Expanded Problem Focused Exam**: same as single organ system exam.
**Detailed Exam:** should include at least 6 organ systems or body areas.  For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected.  Alternatively, a detailed exam may include performance and documentation of at least 12 elements identified by a bullet, in two or more organ systems or body areas.
**Comprehensive Exam**:  Should include at least 9 organ systems or body areas.  For each system/area selected, all elements of the exam identified by a bullet should be performed, unless specific directions limit the content of the exam.  For each area/system, documentation of at least 2 elements identified by a bullet is expected.

## Why Is It Important To Get Our Physicians On Board With Coding and Reimbursement Rules & Regulations?

- Insurance Companies pay less for medical and surgical care today and more for paperwork!
- Physician Profiles and Scorecards kept by Insurance Companies gauge coding, billing and reimbursement activity for each provider!
- Therefore Physicians must learn how to play the game. By understanding the rules we can improve coding accuracy and increase reimbursement.
- Standardization of documentation, coding, billing activities will lead to better patient care and as an added incentive increased efficiency and increased reimbursement!

## Disease Specific Documentation

- Physician Documentation & Specific Coding Questions

## Documentation Requirements for Physicians for Acute Myocardial Infarction (MI)

**Objective:  To reflect the true severity of illness and the risk of mortality of your patient, to validate assignment of proper codes and to support your professional profile in cases of MI, the following should be documented in the MR for all MI cases.**
**Did the patient, after workup, likely have an MI, NSTEMI or STEMI) if so, document it in progress notes and upon discharge.**
**Did the patient present with CHF, pericarditis, or other post-MI symptoms when the initial MI occurred within the past either weeks?, Also, is this the first hospitalization for that acute MI?**
**Did the patient have the MI prior to admission, or did this event occur after admission?  Document the principal diagnose that actually led to the decision to admit.**
**Does the patient have a background of heart disease, such as chronic systolic or diastolic health failure, valvular disease, ischemic, or hypertensive or alcohol cardiomyopathy?**
**Did the patient have an arrhythmia during the hospital stay that was noted and that may or may not have required treatment?  If so, name that arrhythmia and the decision.**

## Adverse Effect of Medication In Myocardial Infarction – Physician Documentation

- Take the following actions in cases of adverse effects of drugs.
- Document the patient’s signs and symptoms of the adverse effect of the medication you believe is the cause, and use the term “due to...”
- Document drug-drug interactions; specifically, name the drugs and the adverse effect.
- Document patients who take multiple drugs and who may be influenced by multiple side effects. Specify whether this is the cause of specific symptoms.
- Document predisposing factors, such as other disease the patient has, dietary issues, or over the counter drug use.
- When respiratory depression is due to drug use, specify/document whether the case involved proper dosage, over dosage, or use of illicit or illegal drugs.

## Medical Record Review for MI

**Review the MR documentation for specific signs and symptoms relating to an MI (e.g., elevated troponin, EKG changes/radiating chest pain) when the patient presents with chest pain.**
**Look for codes for an acute MI that is transmural in the 410-0X-410.6X series.  The code 410.7X identifies the infarction as subendocardial, which means that it did not extend to the full thickness of the myocardial wall.**
**Use code 410.9 to describe an MI that indicates the site if “unspecified.”  Don’t assign this code unless there is no further clarifying documentation in the MR, or no clarification from a physician query.**
**Use the fifth-digit sub-classification for 410.xx, which reflects the episode of care, such as current, subsequent, or unspecified  Assign the fifth digit 0 for unspecified only when the documentation fails to provide further information or specifics.**
**Review the clinical documentation when an MI evolves into right ventricular failure and progresses to CHS.**
**Review nursing notes, especially ICU notes, for other conditions that were treated but not documented by the physician. Arrhythmias and atrial fibrillation often occur, use a query to clarify the condition.**
**Watch the documentation for “post myocardial infarction hypotension”  (Code 458.8)**

## MR Review for Adverse Effects of Medication in an MI

- Review the clinical documentation carefully when a condition is due to a drug, medicinal, or biological substance (e.g., allergic reaction due to a drug, an arrhythmia due to a prescribed medication).
- Code the adverse effect first when the correct substance was administered as prescribed but it resulted in an adverse effect, which is often a sign or symptom.
- Use the ICD9CM 960-979 code series when the substance was used incorrectly and the case is classified as a poisoning.
- Review the medical record documentation for a drug interaction that may have occurred.
- Code the drugs responsible for an adverse effect (codes E930-E949)
- Review the documentation in the MR carefully or query the physician for further clarification when he or she uses the term “toxic effect or toxicity,” which means that there is an adverse effect of a correctly administered, prescribed drug.

## Alcohol/Substance Use/AbuseDocumentation for Physicians

- Clarify/document in the MR when a patient sometimes drinks alcohol but does not have an abuse or dependence problem.
- Specify/document, if the patient has a history of alcohol problems, whether this is a case of periodic or episodic abuse (e.g., weekend drinker) or whether the patient is alcohol dependent.
- Specify/document whether the patient has other body system effects of alcohol or drug abuse or dependence and name the related disease process.
- Document whether you believe that a patient is an occasional abuser or is dependent on alcohol or illegal or controlled drugs.
- Wrote down/document whether the patient suffers from substance abuse and name the substance, (writing (+) coc or (+) barb or (-) ETOH means nothing clinically.  Coding staff may not apply codes from a positive lab test per guidelines.

## Alcohol/Substance Use/Abuse What MR Should Ask The Physician

- Ask the physician for clarification if the MR indicates that the patient sometimes drinks alcohol but...does not have a problem or does not state whether there is an abuse or dependence.
- Seek more specific documentation when coding an alcohol abuse or dependence ICD9CM code if the documentation indicates periodic or episodic abuse (e.g., weekend drinker) or if the patient is alcohol dependent.
- Ask the physician to specify/document whether the patient has other body system effects of alcohol or drug abuse or dependence, and name the related disease process.
- Clarify with the physician whether the patient is an occasional abuser of or is dependent on alcohol or illegal/controlled drugs.
- Educate physicians that documenting or writing (+) cod, (+) barb, or (-) ETOH does not provide enough information for coding.
- Assign the proper ICD 9 CM procedure codes for therapy for alcohol and/or drugs for rehab, detox, or combined alcohol rehab and detox.

## Anemia –Physician Documentation

- Document if the patient has anemia due to blood loss from a disease process and name that disease process (e.g., acute blood loss anemia from fracture of the femur; chronic blood loss anemia from right colon cancer, end stage renal disease or bone marrow suppression and document it as a “link”, i.e., Anemia of ESRS.
- Document if patient develops anemia from excessive blood loss from GI tract, from urinary tract, due to retroperitoneal bleed, during surgery due to a true hematologic problem or due to a complication (inadvertent entry into the femoral vein during a herniorrhaphy) or due to being on long term anticoagulants.

## Anemia – MR Review

- Review clinical documentation including progress notes and physician orders for tests related to condition of anemia.
- Review the lab findings, (hgb/hct.
- Review the blood values following a surgical procedure.  Look at hgb/hct before and after surgery.  Query the physician, coding guidelines prohibit coders from coding from lab findings and values alone.

## Chest Pain/Angina – Physician Documentation

- Document the origin of the chest pain, i.e., cardiac, non-cardiac).
- Specify/document, if it is angina, whether it is stable, unstable, acute MI, acute pericarditis, or myocardial contusion, etc.
- Document if you know the primary source of the angina (e.g., CAD, aortic stenosis, hypertrophic cardiomyopathy, pulmonary artery hypertension, Prinzmetal’s coronary spasm).
- Document whether the pain represents secondary cause of unstable angina, and specify whether it is due to tachyarrhythmia, bradycardia, anemia, or metabolic demands, such as thyrotoxicosis, etc.
- Specify/document whether the chest pain is related to a condition, such as musculoskeletal, pleuritic, GERD, gallbladder, Tietze’s Syndrome, etc.

## Chest Pain/Angina MR Review

- Document and code chest pain to the most specific code possible.  There are several different classifications of chest pain (e.g., musculoskeletal, chest, pain, respiratory chest pain, pre cordial chest pain).
- Obtain or code the underlying cause of the chest pain (e.g., cardiac or non cardiac chest pain when the documentation supports the diagnosis of chest pain.
- Be aware, presenting symptoms of chest pain if often diagnosed as “angina” which is a manifestation of ischemic heart disease or an MI.
- Review for the specific type of angina, there are several.
- Query the physician for a more specific type of angina (e.g.., unstable, stable, prinzmetal.
- Ask for further clarification as to th cause of the angina (e.g.., CAD)

## COPD –Physician Documentation

- Document whether the patient has acute bronchitis or acute exacerbation of chronic bronchitis or has stable COPD or other chronic lung disease.
- Document whether the patient has acute exacerbation of Chronic asthmatic bronchitis when chronic asthma has led to chronic lung disease.
- Document if patient has acute respiratory failure upon admission, even it if did not require intubation.
- Document if the patient has chronic respiratory failure and needs home oxygen and other treatments.
- Document the likely etiology of this acute event (e.g., allergy, cold, viral or bacterial bronchitis, pneumonia, other cause.
- Document if you think this patient’s exacerbation was likely caused by aspiration (microaspriation related to GERD or laryngeal dysfunction, etc.) and requires evaluation or treatment of the aspiration risk (aspiration bronchitis or aspiration pneumonitis).

## COPD – MR Review

- Documentation should reflect the stage of the lung disease for accurate coding.
- Assign code 496, COPD (NEC) even when there is only documentation to support this code in the H&P per AHA coding clinic. (Chronic Conditions – always code them).
- 496 excludes COPD specified as obstructive chronic bronchitis, chronic asthmatic bronchitis, asthma with chronic obstruction and emphysema.
- Always code COPD if the Anesthesiologist documents it, per AHA Coding Clinic.
- Review COPD patients for acute respiratory failure upon admission even without any intubation or mechanical ventilation.

## Comorbidities – Physician Documentation

- Document in your H&P whether the patient has other diseases that you or another physician are following and name those diseases.
- Document in your H&P the medications that the patient is currently taking and for what diseases they are prescribed.
- Note/document all conditions (risk factors) that exist that could affect the patient’s ability to tolerate surgery, result in problems during or after an operation, or affect the hospitalization.
- Name/document a diagnosis whenever the condition of the patient changes while he or she is in the hospital and you order test or treatments.
- Name/document in the operative report any complications that occur during the operation and require corrective action.
- Clarify/document in the PN when a patient has anemia that resulted from a disease process and not from the surgery for that disease process.

## Comorbidities – MR Review

- A comorbidy is a preexisting condition that in 75% of the population extends the length of stay by one day.
- Report comorbid diagnoses as secondary conditions/diagnoses to help capture severity, acuity, and risk of mortality.
- Review the H&P and Consults to gather other diseases the patient may have and code them per AHA coding Clinic.
- Code all documented conditions (e.g., risk factors) that affect the patient’s ability to tolerate surgery, could result in problems during or after an operation, or could affect hospitalization.
- Review the documentation in operative report and determine if any complications occurred during surgery and required corrective action.

## Coronary Artery Disease – Physician Documentation

- Specify/document whether the cause of cardiomyopathy or chest pain, if present, is coronary occlusive disease (ischemic cardiomyopathy).
- Specify/document if your patient has CA Bypass grafting CABG and whether the symptoms are due to disease of the remaining native vessels or due to occlusion of bypass vein or artery or other graft.  Name the vessel or graft material if know.
- Specify/document if patient has had angioplasty and stent and the current symptoms are due to occlusion of other native vessels or of the stent.
- Specify/document the cause if a patient with CAD suffers angina because of anemia or tachyarrhythmia or other secondary cause.

## Debridement – Physician Documentation

- Document (whether done in operating room or at the bedside) whenever the procedure was done sharply (with scissors or knife) with a goal of removing necrotic tissue from a wound (like an ulcer), infection, or burn down to healthy granulation tissue.
- Document whether the procedure was merely cleaning up the edges of a laceration prior to closure.
- Document whether the procedure represented removing abraded, dirty tissue or bone fragments prior to closure or fixation of an open fracture.
- Clarify/document whether the procedure was “debridement” of toenails to differentiate it from “debridement” of a foot ulcer.
- Designate/document when a method other than sharp technique was used.

## Debridement – MR Review

- There are two procedure codes for debridement (86.22, Excisional debridement, and 86.28, Non excisional debridement of burn, infection, or wound, but only one can significantly affect severity acuity data.
- Non Excisional is the removal of devitalized tissue via washing, brushing, or flushing.
- Excisional is removal of necrotic/devitalized tissue via cutting using a sharp instrument (e.g., scissors, scalpel, or similar tool/technique).
- Has the debridement been done by a Physician  or a Physical Therapist,  coding guidelines allow for the coding of excisional debridement when performed by a non physician.
- Do not code the debridement when the procedure was merely cleaning up the edges of a laceration prior to closure.
- Review whether the procedure was debridement of toenails versus debridement of a foot ulcer.

## Dementia – Physician Documentation

- Document the likely cause of a patient’s dementia, which is often a symptom of something happening, such as generalized cerebrovascular ischemia, Alzheimer’s disease, or toxic effects of drugs, etc.
- Document whether the patient likely has an organic cause or psychological cause of the presentation of dementia.  An elderly patient may have psychological problems that supersede the decreased brain function as well.  Be sure to clarify.
- Document if there is an infection, sepsis, dehydration, or specific organ failure that is causing the dementia.  Be specific when clarifying the relationship between that process and the mental status change.
- Document the relationship of the mental status change to any other disease process.

## Dementia – MR Documentation

- Dementia is characterized by the development of multiple cognitive deficits, such as memory impairment, functional impairment, and cognitive disturbances, such as aphasia, apraxia, or agnosis.  Review the daily progress notes and the ROS.
- Understand that Dementia is often a symptom of something else, such as Generalized Cerebrovascular Ischemia, Alzheimer’s disease, or toxic effects of drugs.  Ask the physician to identify the likely cause.
- Dementia can also be related to infection, sepsis, dehydration, or specific organ failure, query the physician to clarify.
- Remember the coding guidelines, which states that when assigning codes 294.10 and 294.11, code first the underlying disease associated with the dementia, such as Alzheimer’s disease or Huntington’s disease.
- Look for several different types of dementia or cerebral degeneration because advances in the treatment and study of dementia have allowed for the expansion of dementia code classification. (294.10-294.11)

## Fracture Reduction of Femur/Physician Documentation

- Document in the operative note whether you reduced the fracture at all (impacted and in good alignment) and whether you did so prior to the incision or after the incision.
- Don’t call closed reduction, open internal fixation, ORIF.  Surgeons bill by CPT code, defined y whether the injury was a neck fracture or was supra, inter, or subtrochanteric.  Hospitals bill by ICD9 procedure code defined by when the fracture was reduced, but they all imply open internal fixation.
- Document whether the patient lost enough blood from the fracture to warrant follow up or transfusion.  This is NOT a complication of surgery, it is acute post traumatic hemorrhagic anemia.
- Document other chronic, stable conditions that are under treatment, even if being follow up by another physician in the hospital stay.
- Document a diagnosis for any treatments instituted, such as acute urinary retention, atelectasis, or volume overload, don’t just treat the condition without naming it.

## Fracture Reduction of Femur – MR Review

- Review Operative Note for coding of surgical reduction of femur fracture, pay attention to a reduction prior to the incision being made.
- Make sure the documentation notes WHEN the fracture was reduced, sometimes surgeons us the language of closed reduction, but thy mean ORIF.
- A significant drop in hgb/hct is  NOT a complication (posttraumatic hemorrhagic anemia).  Look for treatment, monitoring, follow up or a transfusion, look for documentation of anemia.
- Query the physician for any chronic, stable conditions that are being treated, coding from a consultant’s note is acceptable as long as there is no conflicting diagnostic information from the primary physician.

## Gastrointestinal (GI) Bleed – Physician Documentation

- Document if the patient’s bleed is causing anemia and if it anemia due to acute blood loss or due to chronic blood loss.
- Document if you suspect that the cause is upper GI or lower GI until studies have been done to prove it.  Remember, rectal bleeds originate in the rectum.  If the bleed is melena or hematochezia, use those terms instead.
- Clarify/document whether tests indicate a GI tract lesion and whether you think the lesion is the origin of the GI bleed.
- Specify/document which lesion you believe to be the cause of the bleed if you discover two or more lesions.
- Specify/document that you DON’t know the cause of the bleed.

## Gastrointestinal (GI Bleed) MR Review

- Ask the physician if the GI bleed is causing anemia, and is it acute or chronic blood loss.
- Is the bleed from the upper or lower GI?
- Follow ICD guidelines for coding GI hemorrhage, which can manifest itself in several ways:
- Hematemesis, indicating acute upper GI hemorrhage, melena, indicating upper or lower GI hemorrhage, occult, bleeding seen on laboratory exam only, and Hematochezia, usually indicating blood in the rectum.
- Be aware if patient present with an acute hemorrhage, the initial focus of treatment is usually an assessment and restoration of the individual’s blood volume using IV fluids and blood transfusions.
- Coding sequencing depends on the circumstances of admission per coding rules, if the thrust of treatment is directed toward control of the bleeding, identify the GI hemorrhage as the principal or primary diagnosis, however, remember that if the bleed is minimal, easily controlled, and the major thrust of treatment is directed at the “underlying cause”, code and list the condition as principal/primary diagnosis with an additional code for the bleed.

## Heart Failure/Physician Documentation

- Document the etiology of the cardiomyopathy (hypertensive heart disease, ischemic heart disease, valvular and which valve (s) viral, alcoholic, etc.).
- Document known results of cardiac function studies and state whether they reflect failure due to left ventricular systolic dysfunction, left ventricular diastolic dysfunction, or both.
- Clarify the patient’s heart failure status (due to chronic left ventricular systolic or diastolic dysfunction) and whether the current episode reflects acute decompensation (e.g., patient with chronic diastolic failure due to hypertensive heart disease with acute systolic decompensation due to (NQWMI).
- Document whether the patient had an acute MI within eight weeks of this episode and whether the acute MI was the cause of this eipisode of decompensation.
- Name/document the relationship if this is a CRF patient and volume overload or noncardiac pulmonary edema led to the decompensation of CHS.

## Heart Failure-MR Review

- Clinical aspect of heart failure:  Heart failure occurs when the heart is unable to pump sufficient blood throughout the body. Signs and symptoms of HF are edema, fatigue, and dyspnea (SOB) at rest or during exercise.
- Review documentation for the results of cardiac function studies and not if the physician stated if the reports reflect failure due to left ventricular systolic dysfunction, left ventricular diastolic dysfunction, or both.
- Ask the physician if the patient’s chronic heart failure status is “due to chronic left ventricular sysotlic or diastolic dysfunction and if the current episode reflects acute decompensation (e.g., patient with chronic diastolic failure due to hypertensive heart disease with acute systolic decompensation due to subendocardial myocardial infarction (SEMI).
- Be aware that the October 2002 ICD code category 428, Heart failure, was modified to provide greater specificity regarding the ype of heart failure (e.g., congestive, systolic, diastolic, and combined diastolic and systolic). Is the HF unspecified, acute, chronic, or acute on chronic ( a condition that refers to a patient who has CHF and also experiences an acute flare up).

## Hyperglycemia- Physician Documentation

- Document whether the patient has diabetes.  Define whether it is controlled or uncontrolled.  Although HbA1C determination by be helpful, your clinical impression is just as important.
- Document if patient has Type 1 (i.e., doesn’t make insulin) or Type 2 (i.e., is resistant to insulin) or other specified type of diabetes.  If this is an adult onset DM taking insulin, document Type 2, taking insulin, and not “insulin dependent (avoid using the terms IDDM and NIDDM).
- Name the infectious source if this episode was precipitated by an infection. If patient has sepsis from a source, name/document “sepsis due to.  If related to an indwelling device (e.g., cardiac valve, Foley catheter, Vascular access device), name that device as the source.
- Document if patient has other manifestations of diabetes (e.g., gastroparesis, diabetic renal failure, blindness, or neuropathy).
- Name/document the reason for hyperglycemia (e.g., steroid therapy, other endocrine dysfunction, etc.,) if this patient is NOT diabetic.

## Hyperglycemia-MR Review

- Review findings of HbA1C to determine if patient has controlled or uncontrolled diabetes, query the physician if necessary.
- Look for terminology, for instance, diabetes Type I refers to the body’s lack of making insulin).  Type 2 is a resistance to insulin. The physicians documentation should state for the Adult Onset Diabetic, taking Insulin:  Type 2 taking insulin and not insulin-dependence.  Physicians should avoid stating IDDM and NIDDM.
- Review other documentation to determine if patient has other manifestations of diabetes (gastroparesis, diabetic renal failure, blindness, or neuropathy).
- Query the physician  if the reason for the hyperglycemia has not been documented (e.g., steroid therapy, other endocrine dysfunction, etc.) if the patient is NOT diabetic.
- Remember, insulin therapy may be required in some cases to correct symptomatic or persistent hyperglycemia.
- Review the documentation to determine whether hyperglycemia occurred in secondary diabetes induced by steroid use, or query the physician.

## Malignancies – Physician Documentation

- Identify/document the primary source of the malignancy and whether that primary source is still being treated or has been treated and is no longer present.  Do Not Use The Term “History of” if the malignancy is still present.  Only use this term if the primary source is totally gone.
- Identify/document whether there is a recurrence at the same site or a reappearance at a different site (i.e., metastasis and to what site).
- Clarify/document the organ of reappearance vs. the organ of origin (“lung met” could be interpreted as either metastasis of testicular cancer to the lung or metastasis of lung cancer to the brain, unless you are specific.
- Clarify in your documentation whether current symptoms are related to direct invasion of the malignancy, related to the pressure effect, or totally unrelated to the presence of the malignancy.
- Document a malignancy as a malignancy if a scan or x-ray confirms it. “Mass” is not “cancer.” “Tumor” is not “cancer.”  You don’t’ need biopsy confirmation if you believe it is a malignancy.

## Malignancies – MR Review

- Review documentation that says History Of, which could indicate that the malignancy is still present.
- What is the primary source of the malignancy and is it still being treated or it has been treated and is no longer present.
- Is there a recurrence at the same site or reappearance at a different site (i.e., metastasis and to what site).
- Are current symptoms related to direct invasion of the malignancy, related to the pressure effect, or totally unrelated to the presence of the malignancy.
- Remember that the words “mass” and “tumor” do not mean “cancer.”

## Pneumonia – Physician Documentation

- Evaluate the patient’s risk of aspiration as the cause of the pneumonia from the perspective of debilitating GERD, alcoholism, bed ridden status, pharyngeal dysfunction, etc.  Document if this is a case of aspiration pneumonia.
- Evaluate the patient’s risk factors when the case likely represents pneumonia due to aerobic gram negative rods from the perspective of health care acquired or NH acquired pneumonia, pneumonia of the elderly, pneumonia in a diabetic, or pneumonia in an immunocompromised host.
- Document whether you are using antibiotics to treat specific organisms that you believe caused the pneumonia, (e.g., anaerobes, pseudomonas, strep, Methicillin-resistant Staphylococcus Aureus (MRSA) etc.). – Even in the absence of positive sputum culture.
- Example:  If you believe that this case represents pneumonia, despite a normal chest x-rayijn a patient who is dehydrated or otherwise does not demonstrate an infiltrate, clarify this in the MR.

## Pneumonia – MR Review

- Pneumonia coding for inpatient settings have been under scrutiny for more than eight years and the OIG continues to look at the pneumonia DRG.
- Look for coding guidelines by AHA Coding Clinic Second Quarter 1998.
- Don’t assume the type of pneumonia from the laboratory exam or results.
- Look for the physician to link the organism or cause (e.g., Klebsiella) of the pneumonia before you assign the specific pneumonia type (e.g., Pneumonia due to Klebsiella, 482.0).
- Remember that a gram stain is NOT conclusive evidence of a gram-negative pneumonia.
- Was the patient admitted from a NH or has a history of a CVA with dysphagia, which could be indicative of aspiration pneumonia.
- Assign code 486 if no organism is found and no further documentation provides specificity.

## Pulmonary Edema – Physician Documentation

- Was this an acute MI (including non-Q wave MI (NQWMI), ventricular tachycardia, pulmonary embolism, or fat embolus)?  If so, document it as the cause of the pulmonary edema.
- Was there chest trauma, rapid deceleration, sepsis, or acute respiratory distress syndrome (ARDS)? If so, document that as the cause of the pulmonary edema.
- If this volume overload related to renal failure with an otherwise stable heart?  If so, document it as non-cardiac pulmonary edema.
- Example:  Does the patient have hypertensive ischemic, toxic, metabolic, or viral cardiomyopathy as the cause of CHF with pulmonary edema? If so, name/document it as it relates to the Congestive Failure and Pulmonary Edema.

## Pulmonary Edema-MR Review

- Assign Postoperative pulmonary edema NOS ( without adult respiratory distress syndrome) to ICD 9 code 518.4, unless documentation indicates the pulmonary edema id due to left ventricular failure (428.1 or CHF 428.0.
- Code postoperative pulmonary edema due to fluid overload as 518.4 and 276.6, follow AHA Coding Clinic guidelines.
- Determine from the documentation if there is volume overload related to renal failure with an otherwise stable heart.  If present, the physician should document it as “non-cardiac pulmonary edema is present. If the documentation is unclear query the physician.
- Remember the Postoperative pulmonary edema with adult respiratory distress syndrome is assigned to 518.5.  Conditions assigned to code 518.5 include those with pulmonary edema.

## Renal Failure – Physician Documentation

- Acute renal failure is NOT the same as acute renal insufficiency.  If the creatinine rises 0.5 mg higher than the patient’s normal level or the glomerular filteration rate (GFR) is reduced 50%, this is consistent with failure.
- Document the cause of the acute renal failure (e.g., severe dehydration and acute tubular necrosis, sepsis, rhabodomyolysis, obstruction, etc.).
- Determine the stage of chronic kidney disease (CKD) in all patients with either chronic renal insufficiency (CRI) or chronic renal failure 9CRF). Using the stages will determine severity of illness.  Although CRI or CRFis now useless for that determination, you can still use ESRD.
- Use the GRF calculator (MDRD or Cockroft) to determine GFR and convert it to the appropriate CKD stage.  Document it in inpatient or outpatient MR.  The complexity of medical decision making also depends on this information.
- Note:  When a patient has CKD, regardless of stage, document the cause of the renal disease (HTN, diabetes, chronic pyelo, etc.).

## Renal Failure – MR Review

- Educate physician to avoid the term “renal insufficiency” if they mean “renal failure.” Specify renal insufficiency have the physician specify it as either acute or chronic because renal insufficiency alone does not index in ICD9 beginning October 2005.  Renal Insufficiency due to a procedure is (997.5).
- Review MR for elevation of BUN and Creatinine as a transient event due to mild dehydration or obstruction, and document the cause of the “azotemia.”
- Remember for “irreversible CRF or CRD the treatment of choice is documented in the MR might be either dialysis or transplantation.  The diagnosis of ARF or ARD may be temporary, and the patient’s renal function may recover after certain interventions.
- Be sure when a patient has hypertension and renal disease/failure, the documentation reflects whether the renal disease if from another cause, and, to avoid incorrect coding, query the physician.

## Respiratory Failure – Physician Documentation

- Document if patient has respiratory failure in addition to any other diagnoses in this case.
- Document whether the respiratory failure is acute, chronic, or with acute decompensation (acute-on chronic).
- Name/document the basis disease causing the Respiratory Failure.  Clarify the acute process on top of a chronic disease (e.g., acute respiratory failure due to pneumonia in a patient with chronic respiratory failure from multiple sclerosis).
- Document clinical signs, symptoms, and any lab findings to support the diagnosis of acute respiratory failure.
- Document in the PN and DS if the patient had acute respiratory failure upon admission.

## Respiratory Failure – MR Review

- Review the clinical documentation when patient has respiratory failure...
- Look for documentation to specify whether the respiratory failure is acute, chronic, or Chronic Respiratory Failure with acute decompensation (acute-on-chronic) is present.
- Review the documentation to identify the basic disease causing the respiratory failure or the acute process on top of a chronic disease (e.g., acute respiratory failure doe to pneumonia in a patient with CRF from multiple sclerosis).
- Review PN for acute respiratory failure upon admission.
- Review ICD9 chapter specific guidelines (e.g., obstetrics, poisoning, HIV, newborn) that provide sequencing directions that take precedence.
- Note: RF may be listed as a secondary diagnosis if it occurs after admission.

## Seizures – Physician Documentation

- Document clearly whether you believe that the patient had a seizure (post-ictal state) or other cause of alteration of consciousness.
- Document the relationship between other existing diseases (e.g., recent or old stroke, recent or old head trauma, brain tumor, febrile convulsion, drug overdose, alcoholism, diabetes out of control, viral or other infection, sepsis, etc.) and the seizure.
- Clearly state/document whether you determine that a known seizure patient aspirated at the time of the seizure event and when the respiratory problem prompted admission.
- State/document if the patient has epilepsy, to differentiate from other causes of seizure.  Name the type (e.g., partial epilepsy, grand mal, petit, mal, etc.).
- State/document whether this event was initially thought to be a seizure and you determined that it was not a seizure.

## Seizures – MR Review

- Look to see if the patient clearly had a seizure (post-ictal state) or other cause of alteration of consciousness.
- Did the physician indicate the relationship between other existing diseases and the seizures such as recent or old stroke, recent or old head trauma, brain tumor, febrile convulsion, drug overdose, alcoholism, diabetes out of control, viral or other infection, sepsis, etc.)
- Was there a respiratory problem associated with the seizure, did the patient aspirate during the seizure?
- Does the patient have epilepsy, if so, what kind.

## Sepsis – Physician Documentation

- Document the source of the infection, if known.
- Document the patient’s signs and symptoms of sepsis.
- Document the presence of organ failure (e.g., acute renal failure, septic shock, acute respiratory of hepatic failure, or metabolic encephalopathy related to sepsis).
- Document whether positive blood cultures are clinically significant or contaminants.  Remember, absence of positive blood culture DOES NOT preclude the diagnosis of sepsis.
- Document predisposing factors (e.g., immunocompromise, as in diabetes, steroid therapy malnutrition, immunoglobulin deficiency, or chemotherapy, etc.).
- Document the likelihood of a relationship to implanted devices, such as heart valve (Endocarditis), indwelling Foley catheter, vascular access device, etc.
- Avoid using terms such as “Urosepsis” as a substitute for sepsis, as these words reflect a lower severity and acuity of your patient.
- Specify whether a bacteremia is due to a septic condition in the body or is transient due to a procedure or unknown cause.

## Sepsis – MR Review

- Understand the clinical signs and symptoms of sepsis and severe sepsis.
- Determine if there is a source of the infection.
- Does the patient have organ failure (e.g., acute renal failure, septic shock, acute respiratory or hepatic failure, metabolic encephalopathy related to sepsis?
- Review the laboratory workup to see if there are any positive blood cultures, which may be clinically significant or contaminants.  Remember, absence of positive blood culture does not preclude the diagnosis of sepsis.
- Review for any predisposing factors (e.g., immunocompromise, as in diabetes, steroid therapy, malnutrition, immunoglobulin deficiency, chemotherapy,etc.).
- Follow coding instructions if the physician documented any likelihood of a relationship to implanted devices, such as heart valve, indwelling Foley catheter, vascular access device, etc.

## Stroke/CVA Physician Documentation

- Document whether you determine that the patient had a hemorrhagic stroke (e.g., intracerebral hemorrhage, subarachnoid hemorrhage, etc.) or had an occlusive or embolic cerebral infarction.
- If you diagnosis cerebral infarction, document whether it was due to primary intracerebral occlusion, carotid disease with embolism, or cardioembolic stroke.
- Document whether the patient had an evolving stroke that was aborted by enzyme or anticoagulant therapy.
- Document whether the study revealed carotid artery disease as the cause of the patient’s current symptoms, and explain whether this hospitalization was because of current cerebral infarction (true stroke) or non-infarction cerebral embolism (TIA).
- Avoid using terms such as reversible ischemic neurological deficit (RIND),  CVA, or only stroke as they may be misconstrued and lead to a code that does not represent the true condition.

## Stroke/CVA - MR Review

- Be aware that that October 2004, changes occurred in the ICD9 code index for the conditions of “stroke and CVA.”  The term under code 436 were removed and were re-indexed to the default code of 434.91, cerebral artery occlusion, unspecified with cerebral infarction.
- Review documentation closely to see if the patient had a hemorrhagic stroke (e.g., intracerebral hemorrhage, subarachnoid hemorrhage, etc.) or had an occlusive or embolic cerebral infarction, as this will affect the code assignment and severity/acuity data.
- Review the MR for a diagnosis of cerebral infarction, whether it was due to primary intracerebral occlusion, or whether it was probably carotid disease with embolism or cardioembolic.
- Check to see if the patient had an evolving stroke and was aborted by enzyme or anticoagulant therapy; the ER record documentation may contain this information.
- Look for a study that may reveal carotid artery disease as the cause of the patient’s current symptoms, was this hospitalization for a current cerebral infarction or non-infarction cerebral embolism (TIA).
- Using terms of RIND, (reversible ischemic neurological deficit) CVA, or only “stroke,” as they may be misconstrued and lead to codes that do not represent the true condition.
- Assign codes for the “residuals” from an old CVA as an additional code.
- Assign code 99.10, injection or infusion of thrombolytic agent, if tissue plasminogen activator (TPA) is given/infused or injected.

## Symptoms – Provider Documentation

- Document distinctly the relationship between signs and symptoms on admission and the diagnoses determined after work-up/study.
- If a symptom may be due to either of two (or more) diagnoses that you have established that the patient has, state/document this information distinctly.
- If a patient’s symptoms could be due to several diseases, none of which you are sure the patient has, state/document so distinctly.
- Document the diagnosis that you believe exists whenever you order studies or treatments while the patient is in the hospital.
- Note: For cardiac arrest or cardiorespiratory arrest, document the most likely cause of the event.  If you can’t determine the specific cause, document the likely body system believed to be the origin of the arrest (e.g., central nervous system, cardiovascular, respiratory, sepsis of unknown origin, etc.).

## Symptoms – MR Review

- Codes from ICD9 Chapter 16 cannot be used a principal diagnoses or reasons for outpatient encounters when the related diagnoses have been established.
- Look for documentation that distinctly identifies the relationship between signs and symptoms on admission and the diagnoses determined after work-up/study.
- Follow coding guidelines for correct sequencing, if, after reviewing the documentation, you believe that a symptom may be either due to either of two (or more) diagnoses, if necessary, query the physician.
- Query the provider to see if the patient’s symptoms could be due to several diseases, none of which meets the definition of a principal diagnosis.
- Did the physician document the diagnosis that he or she believed existed whenever studies or treatments were ordered while the patient was in the hospital?
- Query the physician for the origin or cause of the arrest for cardiorespiratory arrest or cardiac arrest diagnoses.

## Syncope – Provider Documentation

- Did the patient have an identifiable event, such as post-micturition syncope, cough-related syncope, frightening event, or sudden positional change?  If so, name that in the MR as the cause of the syncope.
- Was there causative dehydration, arrhythmia, or drug-drug interaction? If so, name the cause.Did the patient just rip and fall?  If so, document it in the MR rather than calling it syncope when it wasn’t.
- Did the patient have an acute myocardial infarction (MI) stroke or sepsis?  If so, name the condition as the cause of the syncopal episode.
- Did the patient have acute cerebrovascular insufficiency, or does he or she have signs of chronic cerebrovascular ischemia with an acute insufficiency event?  If so, name it as the cause of the episode.

## Syncope – MR Review

- Clarify with the physician whether the patient had an identifiable event, such as post-micturition syncope, cough-related syncope, a frightening event, or sudden positional change.
- Was Dehydration the cause of the syncope?
- Did the patient trip or fall?
- Did the patient have an MI, stroke, sepsis?

## Trauma – Physician Documentation

- Document the presence or history of concussion or cause of transient loss of consciousness, even if it was resolved by the time you saw the patient.
- Document whether the patient had an hypovolemia or hypovolemic shock on presentation.
- Document the number of ribs fractured.
- Document the fracture or dislocation of each bone and whether each was treated by stabilization or surgery or no treatment.
- Document when a patient has pulmonary contusion with or without respiratory failure.
- Name the cause (e.g., fat embolism, pulmonary contusion, shock ling, alcohol or drug abuse) if the patient has acute respiratory failure.
- Include all diagnoses established from admission of the trauma case at the time of discharge.

## Trauma – MR Review

- Be aware that trauma coding often involves detailed review of the ER and inpatient record documentation.
- Review the emergency trauma record carefully.
- Review the information about a concussion or a transient loss of consciousness/the specific length of time during which consciousness was lost.  Nursing notes may provide some clues (can’t code from NN).
- Code all rib fractures, note that, in trauma cases, multiple fractures may have occurred.
- Read over the patient’s vitals.  If hypovolemic shock occurred, que4ry the physician for additional documentation or clarification if necessary.
- Review carefully the documentation when coding an acute respiratory failure in a trauma case to dete4rmine whether the respiratory failure is due to the trauma or the drugs.

## Thank You....