November 2017

Ask the Experts: Documentation, Coding Issues Abound
For The Record
Vol. 29 No. 11 P. 5

Question:
Since the implementation of an EMR in our organization, it has become evident through documentation reviews that subsequent progress notes are being carried forward for several days of service with only a few extra words inserted for changes in plan. Often the exam is completed with the same documentation repeated. A provider uses this functionality (copy-paste) quite regularly, including repeating the radiology interpretation which can sometimes be several pages depending upon the number and type of tests, eg, CT, X-ray, ultrasound. Do you have any guidance or suggestions as to how to discourage this practice? Our Medicare contractor posted that rather than randomly pulling dates of service for review, a new process implemented has several successive dates of service reviewed. I would appreciate knowing whether other organizations are experiencing this in the hospital setting.

Anne Leask, CPC
Lincoln Medical Partners
LincolnHealth
Damariscotta, Maine

Response:
This is a difficult dilemma. Most physicians are using the EHR by pulling in information and copy-pasting. Some are using smart text or pulling in phrases that might not be appropriate for the particular patient. Many times the templates need to be reviewed and changed to discourage this practice and allow for more free text instead of clicking information and pulling it into the patient encounter. Many practices use the EHR's templates built into the system but never customize them for the practice, which should be discouraged. All templates should make sense for the provider while maintaining compliance. Providers who use clicks only to pull in information are more vulnerable than the provider who actually creates the majority of the note.

I would recommend that you share with the providers the Office of the Inspector General's (OIG) whitepaper "CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs." One of the more problematic issues is generating or pulling in other documentation that might not be relevant to the patient encounter. This can be referred to as "overdocumenting," the purpose of which is to create an appearance that supports billing a higher level of service. Many times when the provider pulls information into the documentation from a previous visit, it might not be relevant to the reason for the visit or care. That can be problematic, as an auditor would either question or disallow this information from being included in the level of service.

The other problem with the copy-paste function in the EHR is that if the physician does not change the documentation for the patient visit or changes very little, it gives the illusion of cloning. When a physician copies and pastes and fails to ensure the accuracy of the documentation, it not only is inaccurate and may inflate the level of service but could also jeopardize patient care. Inflated or duplicated claims could be viewed as fraudulent.

One way you might encourage your providers to make changes is to audit three to four dates of service for one patient and show them the similarities in the documentation. You might even take three to four patients and pull three to four dates of service per patient consecutively and compare. If you can spot the cloning, so can a payer. Sit down with each provider, go over your results and explain the problem, and work with the provider to find solutions to fix it. The other option is to hire an outside consultant to audit 10 records per provider and have the consultant address it with the provider. Whichever way you decide to proceed, change will not happen overnight. You will need to first point out problems with copy-paste to the provider and then work toward a solution.

You can download the OIG whitepaper at https://oig.hhs.gov/oei/reports/oei-01-11-00571.pdf.

— Deborah Grider, CDIP, CCS-P, CPC, CPC-I, CPC-P, COC, CPMA, CEMC, is senior health care consultant at KarenZupko & Associates, an American Medical Association author, an AHIMA-certified clinical documentation improvement practitioner, and an approved ICD-10-CM instructor.

 

Question:
If the provider documents for family history, "Family history reviewed; no pertinent family history," is this credited toward a complete past, family and/or social history (PFSH)?

I would like to clarify that the providers thoroughly document past history and social history. The question I have specifically refers to family history and the relevance of family history to a 92-year-old patient or an infectious disease patient. If the documentation indicates that he has asked whether there is any pertinent family history relevant to the presenting problem, is that sufficient to be credited for a complete PFSH? Would documentation that there is no family history of recurrent infections be adequate for family history?

In summary, the past history and social history are always documented in compliance with documentation guidelines. It is just the family history element and whether documenting "Family history reviewed; no pertinent family history" would be adequate that are in question.

Anonymous

Response:
It would appear that in this circumstance, we are assuming the past medical history and social history are already satisfied and the reader is asking whether "Family history reviewed; no pertinent family history" is enough to satisfy the third and final element.

So if my understanding of the premise is correct, then yes, that would satisfy the requirement. All three elements needed to be reviewed, and, if there is no pertinent family history, the physician indicates that he or she reviewed the family history, and found nothing pertinent, he or she still reviewed family history and documented to that effect.

— Jonathan M. LaFleur, BSN, RN, CCS, is an auditor at HRS.

 

Question:
How would you code hematuria due to a traumatic Foley catheter insertion?

Marcy Blitch, RHIA, CCS, CIC
AHIMA-approved ICD-10 trainer
Education Manager, Coding Services

Response:
Coding Clinic, 1st Quarter 2014, pages 12–13, says that this would be coded to a complication, as it was due to the procedure, if "traumatic Foley catheterization" is documented. On page 13, the same Coding Clinic addresses red blood cells in the urine following a Foley catheterization and states that unless the physician documents traumatic catheterization with a specific injury or complication, it would not be coded as a complication of the procedure. Some cases may require a query to clarify whether there is an injury or whether in fact the hematuria is a complication of the catheterization if the documentation is vague. Otherwise, hematuria complicating a traumatic catheterization would be coded to T84.89XA and R31.9.

— Karen Cooper, RHIT, is an IQC reviewer at Navigant.

 

Question:
How do you code diabetes mellitus with hyponatremia?

Marcy Blitch, RHIA, CCS, CIC
AHIMA-approved ICD-10 trainer
Education Manager, Coding Services

Response:
There is no assumed link between hyponatremia and diabetes per the index, nor is there further guidance in the Coding Clinic. If the hyponatremia is described as being a complication of or due to the diabetes, it would be coded to E11.69 or E10.69, depending on the type (1 or 2). An additional code would be assigned for the hyponatremia, E87.1. If there is no relationship established/documented, the diabetes and hyponatremia would be coded separately (for example, E11.9 and E87.1).

— Karen Cooper, RHIT, is an IQC reviewer at Navigant.

 

Question:
What ICD-10 diagnosis code would you use to code a visit for a removal of a biliary stent with no complications?

An RHIA in South Dakota

Response:
Z46.89, Encounter for fitting and adjustment of other specified devices.

The AHA Coding Handbook, page 127, states, "Aftercare visit codes (Z42 to Z51) are used when the initial treatment of a disease has been completed but the patient requires continued care during the healing or recovery phase or for long-term consequences of the disease. The aftercare code is not assigned when treatment is directed at a current acute disease … Admission for aftercare management ordinarily involves planned care, such as the fitting and adjustment of an external prosthetic device (Z44.1-), attention to an artificial opening (Z43.-), breast reconstruction following mastectomy (Z42.1), or removal of an internal fixation device (Z47.2)."

— Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, is an AHIMA ICD-10-CM/PCS trainer certificate holder and director of coding quality and professional development at TrustHCS.

 

Question:
How would I code someone who fell and broke her ankle getting out of a car after a motor vehicle accident and was admitted to our SNF [skilled nursing facility] for rehab?

I'm just not sure of the order.

V89.2, Person injured in unspecified motor-vehicle accident, traffic

S82.891S, Other fracture of right lower leg, sequela

W19.XXXS, Unspecified fall, sequela

An HIM coordinator in New York

Response:
According to official ICD-10-CM sequencing guidelines, the injury should always be coded first, followed by the explanation of how the injury occurred (external cause codes V00 to X58). Therefore, the first code should be from category S82-. (You'll need additional information in order to code to the highest code specificity such as laterality, anatomic site, and episode of care.) If the provider is required to provide external cause codes, consider adding the following: W17.89XA, Other fall from one level to another, initial encounter, along with the code to explain the vehicular accident (V00 to V89). To code from the limited information provided would render a result that includes only unspecified codes. However, if you refer to the code ranges provided here, you should be able to locate the correct codes with the more detailed information provided in the medical record.

— Aimee Wilcox, MA, CCS-P, is director of education at FindACode.com.