Fibromyalgia and RA
Hello,
Patient has fibromyalgia and RA does not take their meds pt says "deals with it on their own and denies any current flare of symptoms" MD's state on the inpatient chart for pt to follow up with their PCP and Rheum Dr. Coder did not code either dx and she cites back that these dx do not get reported because pt not on meds and no bearing on current hospital stay. Any thoughts? I thought these dx would be reported as they are chronic conditions that never go away, impacts quality of life and limits daily activities. Symptoms of varying intensities increase and decrease over time. Patients with fibromyalgia have trigger points on the body that are painful when touched. So wouldn't this affect the patient care and have bearing on current stay?
Thanks,
Comments
Per UHDDS reporting guidelines, diagnoses that have no impact on patient care during the hospital stay are not reported even when they are present. Diagnoses that relate to an earlier episode and have no bearing on the current hospital stay are not reported. For UHDDS reporting purposes, the definition of ‘other’ includes only those conditions that affect the episode of hospital care in terms of any of the following:
• Clinical evaluation
• Therapeutic treatment
• Further evaluation by diagnostic studies, procedures, or consultation
• Extended length of hospital stay
• Increased nursing care and/or other monitoring”
Unless the above criteria are met, the dx is not reported. An example I encounter on a regular basis is that of obese patients. Per Coding Clinic "Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented". However, due to the ICD-10 conventions and guidelines take precedence over Coding Clinic, unless there is a dietary/nutritionist consult, or specific documentation that the obesity is impacting the current episode of care we don't code.
re: example with obesity. Can you please indicate the portion of the ICD-10 Guidelines that speak to your statement:
However, due to the ICD-10 conventions and guidelines take precedence over Coding Clinic, unless there is a dietary/nutritionist consult, or specific documentation that the obesity is impacting the current episode of care we don't code
Here is an example in which no active treatment is rendered, but a condition is reportable.
Patient is admitted for PNA. PMH includes DM Type 2, Diet-controlled. Blood sugars are monitored and nursing checks BS before each meal. Patient continued on diabetic diet. Although not treated, ongoing monitoring is provided - the condition should be reported.
extracted from AHA Coding Handbook
P. Evans, RHIA, CCDS
Example two, same source:
Diabetic patient admitted for pressure ulcer. H&P notes s/p BK amputation. Per this handbook - "this condition requires additional assistance and is reported".
I can think of many such conditions that impact the care rendered by an RN, making that condition reportable.
Thanks Paul! I was beginning to think that what the coding world viewed as increased nursing care wasn't the same as how a nurse views increased nursing care.
I'm sure it would be helpful if nurses documented how many people were required to turn/bath a patient, place a foley or NG tube ect.. In my experience, if a patient requires frequent neuro checks then it's an order by the MD. There are specific areas to document frequent neuro checks, and it's not usually placed in the narrative. Maybe talk to your nurses and let them know what documentation would be helpful. We really are receptive as long as you explain to us why it is needed. :-)
When Dee Banet, RN, MSN, CCDS, CDIP, and her CDI team sent out a claim for a surgical patient with body mass index (BMI) greater than 40 with morbid obesity as a secondary diagnosis, they did not expect the claim to be denied; after all they had provider documentation along with the associated diagnosis. However, the payer denied the claim, stating it did not meet the criteria to be coded as a secondary diagnosis—including proper documentation to support increased care and monitoring treatment.
“We have appealed endlessly with Coding Clinic for guidance for this diagnosis,” says Banet, who is the CDI director at Norton Healthcare in Louisville, Kentucky. “All [of our claims] have been denied [again] and the monies recouped.”
In a recent discussion on the ACDIS Forum, Banet asked ACDIS colleagues if they experienced similar audits, and sought advice on how to handle them. “We want to address this on the front end and educate providers to capture information like we would any other diagnosis,” said Banet. “My fear is that failure to capture this important statistical information on our patient population will affect our data in many ways aside from reimbursement.”
A number of Forum users were surprised. One user says they are never questioned about this diagnosis. Another suggested sending the payer clinically supported documentation (i.e., an article from a medical journal) on morbid obesity and numerous associated health effects. Another user cited Coding Clinic, Third Quarter 2011, p. 3–4, which states:
Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider.
In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. The diagnosis of obesity is one of the more difficult documentation matters that CDI specialists likely face, said Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, an E/M and procedure- based coding, compliance, data charge entry, and HIPAA privacy specialist, in a recent article published in JustCoding. According to the National Institutes of Health (NIH), morbid obesity is defined as:
The NIH breaks down obesity intoclasses:
By using the information documented in the record, coders can report the BMI from a dietitian’s note or from the physician’s documentation, says Webb. However, if the numeric BMI falls into the “class” status, the facility can report and code this as a Class I, II, or III obesity state. The obesity documentation still has to be clearly defined within the medical record. With that, there should be a correlation from the physician to support the obesity code assignment and how it is currently impacting the patient’s current care and ongoing plan, according to Webb. Additionally, the Uniform Hospital Discharge Data Set (UHDDS) definition of “other diagnoses,” or secondary diagnoses, describes those conditions that coexist at the time of admission, or develop subsequently, and that affect the patient care for the current care episode.
To be considered a secondary diagnosis the condition must require any of the following:
The many ramifications of increased nursing care—the propensity to develop an ulcer of the skin, difficulty for the nurse or physician in performing a full exam, modification of dosing by the provider, and difficulty obtaining clear views of internal sites while undergoing various radiological studies—represent just a few reasons obesity is always reportable, says Paul Evans, RHIA, CCS, CCS-P, CCDS, regional clinical documentation manager for Sutter
West Bay in San Francisco. When dealing with denials that cite Coding Clinic, Evans suggests CDI teams know the rules well themselves and make sure the payer complies with the Official Guidelines for Coding and Reporting, which states: adherence to these guidelineswhen assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act. Rules governing code assignment follow a strict structure: first the rules in the Tabular List of the code set, then the Official Guidelines for Coding and Reporting, then the AHA’s Coding Clinic for ICD-10-CM/ PCS (previously Coding Clinic for ICD-9-CM).
“It is very obvious that [morbid obesity] is reportable,” Evans responded on the ACDIS Forum. “I continue to be concerned that folks appear to ignore or ‘selectively’ use advice issued in Coding Clinic, which is our ‘Bible’ and applies to everyone, including insurance companies. I can tell you anecdotally that when I have called such third parties and discussed basic concepts of coding and compliance, they were ill-informed.”
When faced with a denial for obesity, CDI teams need to not only ensure that the documentation is complete and accurate, but also back up their appeal with items like scholarly articles and official guidance that show why the condition influences patient care—which, according to Coding Clinic, is always the case. “Obesity is always reportable,” says Evans. “Period.”
Editor’s note: Get involved in the CDI conversation and post your questions, conundrums, tips, and training tricks in the new ACDIS Forum at forum.acdis.org. Katherine Rushlau is the ACDIS editor. Contact her at krushlau@acdis.org.
Thanks, Michelle
But, I am confused by the statement you made and wonder have I missed something pertinent for the issue of obesity? From what I understand, Morbid Obesity, by definition, ALWAYS impact care and something such as a consult is not required in order for it to be reported? Have missed a new development in coding and reporting?
However, due to the ICD-10 conventions and guidelines take precedence over Coding Clinic, unless there is a dietary/nutritionist consult, or specific documentation that the obesity is impacting the current episode of care we don't code.
P. Evans
TGIF!
Michelle: Thank you for getting back to me as I thought I had missed something on this topic in either Coding Clinic and/or ICD-10. I am of the opinion that Morbid Obesity, by definition, always satisfies criteria for coding and reporting. I say this because some of our members have had questions on this topic as 3rd parties have issued denials for it as a secondary condition. I believe it is incorrect for a 3rd party to state that morbid obesity is not relevant.
Paul Evans, RHIA CCDS