Those pesky complications

annnd2009@gmail.com

I hope I can give enough info on this.

A patient had a cystoscope done and during the process, there was “excessive bleeding due to friable prostate tissue” “cautery”...this got coded as a complication …should it have?

It wasn’t that the technique was an issue it was the patient anatomy…thoughts? way it may be written to avoid complication? I talked to the coding manger about querying to clarify and if the doc said it wasn’t a complicaiotn that it shouldn’t be coded but she said it would go there and she didn’t have a choice…I appreciate any input you may have.

Thank you,
Ann Donnelly,RN,BSN,CCDS


Oh another complication —

I tried to present the fact that after CPR rib fractures should not be coded because rib fractures were integral to GOOD CPR (and if integral to procedure - should not be coded)…thoughts?

cmorell

Complications must be documented as a complication by the physician

http://www.justcoding.com/259836/Know-when-to-report-postoperative-complications

By getting additional documentation about the cause, whether it was POA etc. may support code assignment of an E-code that will "negate" the complication.

Charrington "Charlie" Morell

annnd2009@gmail.com

I sometimes feel we as Cdi latch on to that more than coding. I've tried that argument on both the "friable prostate" and rib fractures from cpr. I was thinking similarly. The prodtate's friable state was not known until involved in the procedure but (obviously) didn't develop during surgery. I wondered if anyone might know of a way to say "friable prostate (present on admission)"

We are still working to find more common ground. I'll share(and appreciate) the article.

Thanks
Ann

jriley

Hi all.

The friable prostate is NOT a complication unless the surgeon so states which he/she did not. Experienced coders should know better, but sometimes they fall into bad habits or don't keep up with guidelines and coding clinic information.

However, coders are correct in assigning a dx for any rib fxs that occur as a result of CPR. They should NOT be coded as a complication, just straightforward fractures. Here is an exerpt from Coding Clinic 1st q. 2013 regarding this situation:

Rib fracture due to cardiopulmonary resuscitation

Coding Clinic, First Quarter 2013 Page: 15 Effective with discharges: March 27, 2013

Assign code 807.00, Fracture of rib(s), sternum, larynx, and trachea, rib(s), closed, rib(s), unspecified, and code E879.8, Other procedures without mention of misadventure at the time of procedure, as the cause of abnormal reaction of patient or of later complication, Other specified procedures. Fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not uncommon and a known risk; therefore, this would not be classified as a complication. Although the fracture is not considered a complication, the E-code is assigned to provide information about how the fracture occurred.


Judy

Judy Riley, RHIT, CCS, CPC
Manager Coding/CDI
LRGHealthcare
ext. 3315

annnd2009@gmail.com

Its not the friable they are coding as complication. It's the friable prostate that caused the bleeding...the bleeding (hemorrhage) requiring cautery that is complication. But if it's his fragile anatomy should it be complication for surgeon?

Thanks for the info on rib fractures.

jriley

Right I get that, but bleeding complicating a procedure does code to a complication, 998.11. There is no code for "friable prostate." HOWEVER, if I were the coder I would query the physician to make sure that the bleeding did in fact complicate the surgery. If in the surgeon's view, the bleeding made his work more difficult, then coding the complication is appropriate. The code does NOT imply that there is a medical or surgical error, only that the bleeding was a problem.

As a side note, the surgeon will submit his claim for services using a CPT code for the surgical procedure. If the bleeding made his work more difficult and added to the complexity of the case, and we capture that with 998.11, it supports appending a modifier -22 to his CPT code to denote that increased surgical work was needed in this case, if in fact it was. The modifier impacts his professional reimbursement for the case.


Judy

Judy Riley, RHIT, CCS, CPC
Manager Coding/CDI
LRGHealthcare
ext. 3315

evanspx@sutterhealth.org

I like the way you linked the diagnostic specification to the need to apply the appropriate modifier. It can be helpful to demonstrate to a physician how documentation and coding reported for the acute site may impact that same physician's billing. Excellent point.

Paul Evans, RHIA, CCS, CCS-P, CCDS

jriley

Yes, I got lots of "oohs and ahhs" when I discussed this with a group of orthopedic surgeons last summer!
I think a light bulb turned on for them.


Judy

Judy Riley, RHIT, CCS, CPC
Manager Coding/CDI
LRGHealthcare
ext. 3315

cmorell

Does anyone have any queries for complications that they wish to share?



Charrington "Charlie" Morell

Snook@fmchealth.org

Does anyone out there think there are CDI opportunities regarding treatment of drug and alcohol withdrawal? We have a new Medical Stabilization unit where we provide these services electively. Thank you for any information you can give me.

Mary L Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
401 N. Ewing St.
Lancaster, Ohio 43130
740-698-4443

julie.cruz-sje

Here is a sample of what we use. We edit as necessary.

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

cmorell

thank you so much for sharing Julie!

Charlie Morell

annnd2009@gmail.com

Hi,

We talked to one of our surgeons and he brought up an interesting point...

On the OR report there is a section labeled (and I think most/all facilities do) complications. He said, " IF we said None how can you code a complication? You are coding something differently than what we say?" We said, it's rarely (i really don't know if I recall ever) filled out with anything other than "none" so is it reliable? He felt it was used acurately and felt that representing what he felt were complications was integral to his training and he felt strongly that it was very important. I also said he felt we there should be a policy stating anytime coding feels a complicaiton is present by the way it is written and that section says "none" we should HAVE TO QUERY face-to-face with surgeon.

There are obvious issues and vantage points but I still thought it was a good point- who are we to say it is when they say it is not and coding guidelines state physician must state it is a complication and if any disparity---query.

I just thought taking a peek at your facilities OP report and section might be a good concrete starting point to a policy to engage physicians. Our facilities new surgeon contracts are tied to complicaitons rates and NOW they "want to work as a team to do the right thing...when can we come present?"

Ann

I love hearing everyone's input on complications!!! Thanks to everyone!

julie.cruz-sje

I agree to a point with the surgeon; however, I also feel that "none" is often utilized without thought and is too vague. I had an orthopedic physician document "none" for a knee replacement, but in the body of his op note states an artery was accidently knicked and the vascular surgeon was called in to assist with repair. Query response was a complication.
I also feel that they use it as a blanket statement to cover "everything" but in actuality we need more specificity regarding each complication as it arises beyond the actual procedure and during the post-op period (ie: delirium d/t medications; atelectasis w/low grade fever; hypotension requiring vasopressors, etc...).

Complications are tedious, but clarification is crucial for most facilities trying to keep a handle on their complication rates.

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

annnd2009@gmail.com

I agree I was just saying that it is a good conversation with docs to show them WHY we query...and we aren't trying to "infer" but their inconsistency (maybe not all docs but as a group) creates this issue.

Good to have a great example like you have, it's something I would love to have for an example to show them!! If you have it and can share with the PIH off i'd love to show it at the meeting we are going to.



Ann
annnd2009@gmail.com

julie.cruz-sje

I'm sorry, I don't have it. It was a couple years ago, and have no idea how I might retrieve it after several program upgrades etc...
I just remember this case specifically as many times the body of the op note does not match the procedure title or the fact that there were NO complications documented.
I don't find the "complication" prompt reliable at all.

But the surgeons get an "A" for effort!


Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

evanspx@sutterhealth.org

Valid points: However, that particular portion of the Operative Report is not always 'reliable' - I have reviewed/coded 'many' surgical cases labeled as 'no complication'. However, in some of these same reports, colleagues and surgical specialist have been called in 'stat' in order to report torn, punctured, or ruptured vessels and/or organs.

Just wanted to echo similar points made by others on this particular message chain.

Paul Evans, RHIA, CCS, CCS-P, CCDS

annnd2009@gmail.com

Hi

I do understand what everyone is saying. And I agree that it always seems to say none. I said this to the surgeon. He did not agree. Maybe he is one of the ones who uses it. I'm just saying. I thought it might warrant bringing to surgical groups attention. So that the understand. Evidence needs to show it is a reliable place to validate. It might be a common area all CDI/coding groups could reiterate and maybe they WILL use it correctly. It would be very useful and ALREADY IN PLACE. If we can change the old "pencil whip" habit.

Ann

evanspx@sutterhealth.org

Ann: I understand, and agree, with your points. Perhaps, if we carefully and properly query often enough in order to confirm truly clinically significant and valid complications, we may affect change, one surgeon at a time.

For instance, I am attaching a copy of a similarly difficult issue - ILEUS. Note this query references NSQIP Definitions, and I would hope most clinicians agree with the validity of this particular definition.

Review (and coding) of surgical complications is what I personally view as the most difficult challenge for all of us. We must always take to issue such queries with clinical integrity, as this can foster acceptance of the CDI role.



Paul Evans, RHIA, CCS, CCS-P, CCDS

cynthia.hudson@christushealth.org

Thanks Paul. I agree. The form may be completed by OR staff not even the physician. Also, there may be an actual complication that is not realized until after surgery i.e. a retroperitoneal bleed where someone has to go back to the cath lab for repair. I would be worried to just use the one entry on the form. It really is looking at the record every day and seeing what is going on with the patient.

Syndi Hudson, RN, CCM

CDI Specialist

Christus Santa Rosa New Braunfels

600 North Union

New Braunfels, Texas 78130

cynthia.hudson@christushealth.org

830-643-6116 (Office)

830-643-5139 (Fax)



"I press on toward the goal to win the prize for which God has called me." Philippians 3:14

jschoonhoven

Julie,
I appreciate your sharing the format you use.
Can you also tell me what EMR you use? My program is not fully EMR yet, but will be transitioning to EPIC soon. We are having a tough time developing the query process we will use. I'd love to have insight into what works for others?

Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

julie.cruz-sje

We use Meditech for our electronic queries. Most are "canned" texts/queries that a "team" of CDI specialists from all of our Ministries worked on collaboratively and developed. We can edit/amend the CDI portion of the query if needed. Of course, we couldn't come up with a query for everything, so we have developed some of our own "home-grown" (like surgical complications) so as not to build from scratch every time we query a complication. We also use 3M 360 which interfaces with Meditech.

I don't think there's a system out there that is "perfect"....but one can dream!

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

jschoonhoven

Thanks.
It's a struggle to devise ethical, reliable, and user-friendly processes!

Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

julie.cruz-sje

Truth!!

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973

evanspx@sutterhealth.org

We use EPIC and we generate electronic query formats for a number of defined conditions...we also have a 'generic' shell that we can use for ad hoc queries as it is not feasible to design and build a query for all conditions. It took quite a bit of work to build and design the query forms. When we initiate a query in EPIC, we write a coding query progress note that drops directly into EPIC, and this query note is designed to be countersigned by the responding clinician.




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

annnd2009@gmail.com

I am curios too? I'm new to meditech and was told it wasn't capable. I had it on Epic...

Can you email any info ? I don't see email for you...

Thanks
Ann
Annnd2009@gmail.com

cmclose@saintfrancis.com

Paul~
I am interested in your coding query progress note that drops into Epic. Do you have a generic example you could share?

Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603

jschoonhoven

Paul,
That is one method we too are exploring. Our greatest challenge - so far unsolved- is how to have a query available to all responsible providers for the patient. EPIC seems designed to work with the query assignment being to the provider rather than 'attached' to the patient. We really hope to avoid having to re-assign queries as the attending changes (frequent change of hospitalists primarily) and have hit a wall at this point in attempts to resolve this.

Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

evanspx@sutterhealth.org

I can't find a way to copy and paste a query from MIDAS into a format that allows me to send a copy?




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

evanspx@sutterhealth.org

Hi, Janice

Unfortunately, you have described our precise challenge, as well. We can only address our query to one clinician, and we do so by asking that person to 'countersign' our CDI query progress note. However, the note is visible to all, so our Attending will 'encourage' the Resident to address the note sent to the Attending, with the Attending subsequently signing the Resident's note.

If we get no response, we can send an e-mail via EPIC to the attending as a prompt: it is possible to reassign, but a bit problematic and time-consuming.



Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

julie.cruz-sje

Ellen, what is your e-mail address?
Mine is Julie.cruz-SJE@stjoe.org

I can refer you to someone that is happy to assist you in your quest!

Julie Cruz RN, CDS

Clinical Documentation Specialist
St. Joseph Health
2700 Dolbeer St
Eureka, CA 95501
wk: 707-445-8121 ext. 7550
cell: 707-267-0973