Ask the Expert

This month’s selection:

I have three coding questions. All three are emergency department (ED) patients, outpatient.

1. Code history of drug abuse, cannabis, cocaine, etc.
2. Patient comes in chief complaint cough, has HIV and is on medication for HIV. No other symptoms mentioned in documentation. Final diagnosis is bronchitis. Doctor does state work up for sepsis and lactate level.
3. Coding epilepsy only mentioned in history. Not final diagnosis.

— A coder in an Ohio acute-care facility

Response:

I can at least discuss some of the issues with each one. First, does the condition even qualify for coding? Did it affect care on the encounter via clinical evaluation, therapeutic treatment, diagnostic testing, extended length of stay, or increased nursing care and/or monitoring? Does it meet one of the exceptions that are always coded (eg, hypertension, diabetes, obesity, or COPD).

On the first case, for example, the information has to affect care on the encounter in some way. Was the drug abuse history 20 years ago, or is the patient still using now? If the patient is in the ED for a urinary tract infection and doesn’t get drug testing or even counseling for his drug abuse history, then it wouldn’t be coded. If they’re here for hypertension after recent cocaine abuse, then it should be picked up, and the code is based on how specific the history is documented. If the doctor says that the reason the patient is in the ED is “history of drug abuse,” somebody needs to go explain to the doctor that the documentation is vague and needs to be clarified. “Dear Dr. Kleinflitzer: There’s all kinds of people sitting at home on the couch who have a history of drug abuse. Why did this one need to come to the ED? Intoxication? Altered mental status? Overdose? Of which substance? Something else?”

The HIV patient … If you look up “Human Immunodeficiency Virus” in the index, it directs you to the code for AIDS, but is that right for this patient? The coder isn’t supposed to default to “HIV positive only” but neither should we report somebody as having AIDS if that hasn’t been confirmed. I’d want to query the physician, “Does this patient have AIDS or not?” The first listed diagnosis would be the bronchitis. Official coding guidelines for selection of first listed diagnosis, outpatient section, and HIV coding guidelines. As for the workup for sepsis and lactate levels, if there’s no final diagnosis, were there any symptoms to code? See, here again, it depends on what else the chart says. And pretty much everything goes back to Official Coding Guidelines.

“A history of epilepsy” also depends on what the chart says. This is a chronic condition that might affect medical decision making on this encounter, but then again it might not. Is the patient still on meds? Does the patient get any care or medication that requires consideration of this history? Was the history 20 years ago but the patient isn’t on any meds and hasn’t had a seizure in all that time, or did he or she pass out in the parking lot, and somebody thinks it might be epilepsy? Not enough information to assign—or not assign—a code.

Some facilities just code every noun in the chart, but that’s certainly not any kind of coding rule. The rule is that for unclear, ambiguous, or conflicting documentation, the coder is to query the physician. The source, once again, is Official Coding Guidelines.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 26 years.