ICD-10 cm/pcs documentation: Adding “wordsmith” to your Coders’ job function!

ICD-10 cm/pcs documentation:  Adding “wordsmith” to your Coders’ job function!

As the countdown to the ICD10 implementation draws ever closer, one of the new challenge is to overcome and understand many of the new “words” that are in the code books, and knowing what they mean, and to discover if the documentation holds up to that new coding definition.

According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or an especially skillful writer.  As a coder,  think about this.  Most coders fall into this category of expertise.  Coders are constantly challenged by the documentation noted from providers, to applying that which is written into a numeric format; such as ICD-9cm.  However, when ICD-10cm is implemented, coders will need an excellent understanding of, not only, medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the diagnoses per the documentation in the new ICD-10cm format.

Many new terms have been put forth to coders, and certain codes will now require documentation to be more precise and complete to give us the best “picture” of the care the patient received via a numeric format.  Our challenge as good coders, is to communicate these new criteria to our providers, so we can all share the same understanding of the words needed to document important patient information.  Providers don’t normally have the inside track to what criteria or “words” need documented in ICD-9, and now we are challenged even more by the specificity needed in ICD-10.  A coder, or clinical documentation specialist is going to be looked up to as the expert to help educate and inform providers how to document more clearly, to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions.  If we succeed in this endeavor, everyone benefits.

Let’s start with some unusual words, found throughout ICD-9 and ICD-10.  Coders will need specificity in documentation.  Physicians and providers are accustomed to documenting descriptive and narrative processes in the patients’ medical record documentation (eg H&P, Operative Note, Discharge Summary etc) .  The impending go-live of ICD-10 will challenge us to “come together” with our physicians and providers to utilize specific, descriptive narratives to enable coders to append the correct ICD-10 diagnosis once the go-live date has come into effect.  In the example below, note the word “iatrogenic”

Outlined below is a challenging documentation excerpt.  The provider needs to more clearly document not only the procedure, but the diagnosis of the particular case.  In order to get this criteria “up to standard”  we, as coders will need to clearly understand what the procedure is, and why it’s being performed, then accurately code the current ICD-9 diagnosis.  Once that is done, we should cross-code/dual-code for ICD10.cm to determine if the documentation can hold up to an appropriate and specific ICD-10cm code, prior to go-live on October 1, 2014.

Coding excerpt:  “………. the intention was on placing the Port-A-Cath in the left neck, given that this is the side of the patient's pathologic lung (eg lung cancer) , and we did not want to risk him having a pneumothorax in his right lung.  At this point, we considered that there was a very low likelihood of the patient having an iatrogenic pneumothorax.  The patient has a pleurodesis on the left, and likely has a trapped left lung already. Our concern is to avoid a pneumothorax in both lobes.”

As we focus on the words “iatrogenic”, “pneumothorax” and “pleurodesis”  We should verify what those definitions are in the medical dictionary.  There are many types and definitions of pneumothorax, and pleurodesis.  
  Eg…
 primary pneumothorax:  is one that occurs without an apparent cause and in the absence of significant lung disease
 secondary pneumothorax occurs in the presence of existing lung pathology
 closed pneumothorax: air leaks from a discontinuity in the lung into the pleural cavity.
 false pneumothorax: artifactual increased radiolucency of the thorax resembling free air in the pleural cavity.
 iatrogenic pneumothorax: may occur following intrathoracic surgery or in association with procedures which involve entry into the pleural cavity, such as thoracentesis or placement of a chest drain.
 open pneumothorax: caused by an open wound in the chest wall.
 spontaneous pneumothorax: due to an unknown cause.
 tension pneumothorax: a particularly dangerous form of pneumothorax that occurs when air escapes into the pleural cavity from a bronchus but cannot regain entry into the bronchus. As a result, continuously increasing air pressure in the pleural cavity causes progressive collapse of the lung tissue. If not relieved, it can lead to lung collapse and mediastinal shift.

Of course, the main diagnosis for the placement of the port-a-cath, is the lung neoplasm, (which in itself, neoplasms can be a coding challenge)  but a complication from this specific port-a-cath procedure, could result in a pnumothorax coupled with the fact the patient already has a pleurodesis.

Upon review of this small documentation example, it brings to light many documentation issues that arise in our quest for good documentation for coders to follow.  To get optimal coding specificity for each medical specialty, it is, and will continue to be, critical that coders communicate with the physicians and providers in a way that both get what they need, to achieve good, positive outcomes. (revenue, and quality patient care).  The coder is charged with translating the medical care documentation into a code-set, to be used  for payment and data analaysis; the provider needs to document the care of the patient for quality and medical necessity of care, combined with medical ethics and thus,  accuracy, for what was truly provided during the patients’ length of stay.

The coding query process can help.  The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm  training for the coder,  providers and physicians will be a critical point for ICD-10cm and pcs coding success.  Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.

The need for good documentation brings us back to the term “wordsmith”.  Again, both the coder and the physician/provider will need to add this to their job proficiencies.  A good way to get the conversation started with your physicians/providers’, is to conduct a review of the current physician/provider documentation by the coder.  The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice.  If the coders’ are currently struggling with appending these “difficult” diagnoses now, utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes.  Document and analyze what is found.  This quick analysis will help define where better documentation is needed for both the coder and provider.   Below outlines this quick process to help enhance communication processes for both the coder and the physician/provider of care.

1. Ask the coder(s)  and provider(s) for the top 5 mis-coded or difficult to code diagnoses
2. Pull the operative/procedure notes that were associated with these diagnoses
3. Cross-code the documentation with both ICD-9 and ICD-10 codes
4. Identify areas that need to be clarified for the coder with the physician or provider
5. Schedule a meeting (face to face)  with the coder and the provider and include
a. The actual provider notes
b. The ICD-9 codes (using the code -book)
c. The ICD-10 codes (using the code-book)
Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.

Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10

Documentation Challenges for Integumentary/Skin and Dermatology Coding

A quick refresher on dermatology coding documentation!!!

Dermatology coding seems to be fraught with many difficult aspects for coders that have to code from the integumentary system.  This can range from misunderstanding benign, malignant, and uncertain behavior, lesion, mass, Shaving, biopsy, destruction, simple, intermediate, complex repair, and sizing such as length, depth, width, circumference, elliptical, and don’t forget knowing the differences between centimeters (cm) and millimeters (mm).  As expected dermatology specialty coders are very adept at easily coding within this section, but coders who are proficient in a specialty that occasionally touches this area, such as Urology, Gynecology and Family Practice, may have more difficulty with this section of CPT.

Dermatologists are very adept at getting their coders what they need to code correctly, but for the other providers of care, this may not be the case.  Coders that need to code dermatology related procedures need to have a good understand of what a skin condition really is.  Documentation by the provider is very helpful, but having a good understanding of what the physician documents and how the coder interprets that documentation is a critical and key component to successful coding.  Common skin condition terms may be used, the list below outlines conditions commonly noted in patient record documentation.

Common Skin Condition terms:

 Atrophic = Thin, wrinkled
 Blister = fluid filled bump
 Crust/scab = formation of dried blood, pus or other skin fluid over a break in the skin
 Excoriation = a scratch
 Hives/Wheals = a pink or white swelling of the skin
 Lichenification = Skin that has become thickened, hardened or leathery
 Macule = a flat, discolored spot
 Nodule/Papule = solid raised bump(s)
 Raised bumps = bumps that stick out above the skin surface
 Patch = flat discolored spot/area
 Pustule/Pimple = Inflamed, elevated lesion that appear to contain flue or pus
 Scales = dead skin cells that form flakes
 Scar/Cicatrix = fibrous tissue that forms after a skin injury
 Keloid scars = Thick, rounded, or irregular clusters of scar tissue that grow at the site of a wound on the skin
 Port Wine Stain = congenital capillary malformation
 Hemangioma = Vascular birthmark
 Telangiectasia = small blood vessels that are located under the surface of the skin.
 Warts = growths of skin or membrane that are not malignant
 Hidradenitis = Inflammation of the sweat glands

Documentation areas of concern are also made more difficult if the physician or provider does not give a good clear description of the procedure being performed.  The physician may state that they are going to biopsy a lesion, when in essence; they really are performing a “shave”.  If you, as a coder are unclear regarding the documentation, query the physician, and ask for clarification to be amended to the note.  Once that is completed, then code then bill your claim to the insurance carrier.  Being aware of the financial reimbursements is critical for coders.  The RVU’s for the biopsy code 11100 may be more or less than the RVU's attached to a shave removal code.  It is in the best interest of all to accurately record what was performed by the provider.  By coding accurately with the most accurate and appropriate procedure codes, reimbursement can be expedited.  If by chance reimbursement is denied, then your documentation will support all that is coded and billed.  In the scenario below, the unacceptable documentation is from an actual case study from a family practice chart.

Unacceptable Documentation:  A quick biopsy was performed on both lesions; left calf and right thigh, above the knee.  Biopsy site checked for bleeding.  Hemostasis was achieved, a local antibiotic was placed and the site was bandaged.  Both specimens sent to pathology.

Acceptable Documentation:  A quick biopsy was performed on both lesions; left calf and right thigh above the knee. Lesion on the left calf was 1.0 cm and completely shaved (CPT code 11301)  The lesion on the right thigh is 1.2 cm.  A 3mm punch was used to biopsy this lesion. (11100) All sites checked for bleeding.  Hemostasis was achieved, and a local antibiotic was placed on each site and bandaged.  Both specimens sent to pathology.

In the examples above, a coder would have a very hard time accurately coding what the physician performed.  By having the physician notate just a bit better, it clearly reflects what was performed (eg. the “shave removal” of the complete ankle lesion, and the “punch biopsy” of the lesion on the thigh).   Of course, as a coder you always have to remember the modifiers to accurately “unbundle” the separately identifiable lesions.  Carefully review modifiers 51, 59, RT and LT just to ensure that your coding is up to par.

Hidradenitis – A commonly mis-coded condition

Hidradenitis is commonly incorrectly documented and or mis-coded.  Hidradenitis is simply an inflammation of the sweat glands.  In regard to Hidradenitis, a physician may simply states what he documents as a sign or symptom rather than a definitive diagnosis.  Oftentimes, Hidradenitis is referred to as an ‘abscess’ in the underarm area, and does not state that the condition is a Hidradenitis.  As a coder, you may be unaware that CPT codes 11450 - 11471 are used for the specific treatment of hidradenits for excision and repair.  CPT code 10060 incision and drainage of abscess also refers to Hidradenitis.  If you suspect that the patient may have Hidradenitis, but the physician has not documented it, a quick query will clear up the confusion.  The CPT lay description notes it as

…..” a chronic suppurative disease that produces scarring of the skin and subcutaneous tissue. Clinically visible are at least two blackheads with several surface openings, subcutaneous communication, and subsequent abscess formation in the axillary region. The abscesses lead to extensive scarring of the dermis. The physician performs a wide excision of the abscess. The excision site is left open to heal by granulation or may be sutured simply or in layers for 11450. Report 11451 if complex repair requires local pedicle flap coverage or skin grafting.”

In addition, this condition is reported with ICD-9 diagnosis of 705.83 and in ICD-10cm as  L73.2

CPT has specific codes for the treatment of hidradenitis using excision and repair (codes 11450 – 11471) .  However, if the physician is simply performing an incision and drainage of the hidradenitis, then CPT codes 10060-10061 would be appropriate.  If you do not use CPT for your procedure codes and utilize ICD-9 Vol3, Code 86.3 and will be using ICDd-10pcs 0HB5XZZ


Operative Case Study: Excision of bilateral chronic hydradenitis.
Patient had previous excision of axillary hydradenitis x 2 years ago,  however, had residual disease in both axilla with chronic re-draining of the cyst from hydradenitis. There is an area in each axilla which is to be excised today.

PROCEDURE: Under local infiltration with anesthesia, an elliptical incision is first made on the left side to encompass the area of chronic hydradenitis of 3.5 cm by 4 cm. Wound was then irrigated with saline. The the wound was closed utilizing a layered closure with interrupted 3-0 Vicryl. The skin layer itself was closed using interrupted 5-0 nylon.  Attention is now directed to the right side where a similar procedure was carried out encompassing the involved area measured as 2.3 cm x 4 cm with the closure being identical to the opposite side. All of the active areas of hydradenitis were completely excised.

In this case study, it would be appropriate to code/bill with either of the CPT choice scenarios outlined below.

CPT (Choice #A) 11450.50
(bilateral modifier Modifier 50 as the Bilateral Modifier to designate procedure performed on both right and left axilla

CPT (Choice #B) 11450.RT
 11450.51.LT   Modifier 51 as the second procedure performed, with designation of RT and LT.

DX: 705.83 ICD-9 L73.2 ICD-10cm


Wound/Lesion Documentation

Wounds, Lesions and skin injuries are very common occurrences that are treated by all types of specialties not just in a dermatology specialty.  When providing care for these type of issues, a detailed description is very helpful.  The list below is very helpful for coders to review and share with the providers.  It makes coding much easier when a full “picture” of the procedures was clearly defined.  Here’s a quick listing
1) Location:  Documentation of the exact area and location where the lesion or wound is located.
a) Left calf, right upper arm, face above left eyebrow etc…

2) Size: Document the measurements of the wound or lesion(s)
a) Measure the length (vertically) of the wound at its longest point.
b) Measure the width (horizontally) of the wound and record these numbers
c) Measure the circumference  (around)
i) . This information will be used to determine whether the wound is growing or getting smaller over time.
d) Measure the depth of the wound in terms such as millimeters or centimeters, or if included subcutaneous tissue, muscle or fascia, etc… (usually to be noted post excision or biopsy)

3) Symmetry and appearance:  Document if the wound or lesion has symmetrical or asymmetrical/irregular borders, or a raised or flat appearance, pustular, or hard, horn shaped etc…

4) Characteristics: Document the characteristics of the lesion/wound, such as color, odor, draining, (eg reddish-purple nodule, green tinged  odorless drainage, brown foul smelling pus )

5) Tissue type: Document if the tissue is granulating, keloidal, friable, necrotic. in addition to drainage or odor.
a) Different areas of a wound or lesion may contain different types of tissue.  If possible have the provider make a rough sketch of the lesion and/or wound.  Even better is if a digital or instant photo is recorded of the lesion and placed in the documentation


6) Document specific treatment provided  during the encounter:
a) Incision and Drainage
b) Excision of lesion/wound via Shave, scalpel,
c) Biopsy using punch, or excision
d) Destruction via laser, cryosurgery,, chemical, thermal, laser

7) Benign or Malignant: Review the documentation to verify from pathology if the lesion or wound is benign or malignant.
a) If not noted, wait until you receive a pathology report before coding.
b) If not sent to pathology, code as “benign”

8) Repairs: Simple, Intermediate or Complex, make sure the documentation supports a simple, intermediate or complex repair.
a) Don’t code for a complex repair if the documentation supports only a simple repair.
b) CPT has very clear guidelines for documentation of simple, intermediate and complex repair criteria.

The bottom line to successful documentation and coding for Integumentary/Skin and dermatology areas remain good communication between the coder and the provider of care.  When in doubt, hold your code until you can clarify what was actually performed, then ask your physician to amend or clarify within the record what was performed.  All documentation should “match” what was coded and billed. Not only will good communication between the provider and coder enhance the documentation and coding, but also the confidence of the provider that their coder is committed to correctly coding, and billing and being reimbursed for all services rendered.

Clinical Documentation: Tips and Hints

I wrote the article below for Dr. Rob Olson with 

ObGynHospitalist.com   This information is applicable for all specialties.   enjoy!   L : )

     We have all heard the adage “if it wasn’t documented, it wasn’t done”.  However, for physicians, the fast pace of the job can get in the way of the accuracy of documentation. The way to remain fiscally solvent, is by accurate coding and billing, and providing good patient care.  Clinical Documentation is a fundamental piece of the total job function. 

     The importance of clinical documentation cannot be underestimated.  Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care.  Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream.  If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster.  Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.

     The term ‘medical necessity’ has become commonplace verbiage with insurance carriers.  Your clinical documentation will be the first thing requested for audit or review, if there is a question regarding payment for your services.

     Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.  

A)  The medical record should be complete and legible

Documentation for each encounter should include:

§    Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;

§    Assessment, clinical impression or diagnosis

§    Plan of care

§    Time spent (eg face to face/counseling-coordination of care)

o        Documented time in

o        Documented time out

o        Documented total time spent (eg at bedside, on monitor(s), etc)

§    Date and Signature

§    The rationale for ordering diagnostic and other ancillary services

§    Past and present diagnoses (If pertinent to the encounter)

§    Appropriate health risk factors should be identified (if pertinent to the encounter)

§    Patient’s progress, response to and changes in treatment and/or revision of diagnosis

B)  Avoid Ambiguous Language

Eg.. “Non-contributory” : The term “non-contributory” is  good example of ambiguous documentation.  In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed... while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported.   Be clear, concise and relevant by avoiding using the term “non-contributory”.

Another term that can be misconstrued is “abnormal”  be sure to clarify, qualify, or quantify  what is “abnormal”.

C)  Clarify your diagnosis

“For a presenting problem with an established diagnosis the documentation should reflect whether the problem is:

a)       improved, well controlled, resolving or resolved; 

b)        inadequately controlled, worsening, or failing to respond/or change as expected

“For a presenting problem without an established diagnosis, the assessment or clinical impression can be

stated

a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone) 

b) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)

D) Ordering of Tests and Procedures

Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures

§    document ‘what’ test/procedure is being ordered.  (i.e. Fetal NST, fetal fibronectin)

§    document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)

E)  Omitted Information

In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however,  should be used infrequently.

Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:

•Create a new entry for the additional information

•Do not annotate in the margins to add information

•Keep all entries chronological and in record sequence

•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”

•Use the actual date of the addendum, amendment or late entry

•Reference the original entry or document by indicatingthe date of the service

•Always sign the additional entry or document

     Documentation will always be a “necessary evil” in the role of healthcare and reimbursement.  The conversion to ICD-10 cm will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system.  Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.