ISSUE
The
HIMformer
08
October 2012
THE LATEST IN HEALTH INFORMATION AND REVENUE CYCLE MANAGEMENT
In this issue
ICD-10 Corner
On August 24, 2012, the
Department of Health and
Human Services (HHS)
announced the much-awaited
de c i s i o n r e g a r di n g t h e
implementation date for ICD10-CM/PCS. The revised date
is now October 1, 2014. The
announcement was met with
the typical hurrahs and boos
that we have come to
anticipate over what is
certainly one of the more hotly
debated topics in the current
healthcare
discussion.
Regardless of whether you
welcomed the decision or
bemoaned the fact that there
is only a year’s delay in
implementation, it’s time to
get back on track with
transition plans.
With less
than two years to go, there is
much to do.
The Centers for Medicaid and
Medicare Services (CMS)
published a MedLearn Matters
article on the final rule which
can be found at http://
www.cms.gov/Outreach-andEducation/Medicare-LearningN e t w o r k - L N /
MLNMattersArticles/
downloads/SE1239.pdf.
The final rule was published in
the Federal Register on
September 5, 2012 and can be
found at the following link.
http://www.gpo.gov/fdsys/
pkg/FR-2012-09-05/pdf/201221238.pdf
While it is still early in the
process, HIM On Call can
report
that
we
are
experiencing roughly a 50%
decrease in productivity in
coding inpatient cases. We
have dedicated significant
resources towards training and
positioning our company to
assist you with staffing needs
at the time of transition. Our
early efforts at readying our
workforce tend to support the
general estimates we have all
heard of a 40 – 60% decrease in
productivity.
Coding Clinic Corner P.2
ICD-10 Corner P.1
The Journey towards ICD-10 P.1
Coding Guidelines Review - HIV/AIDS P.2
The Journey towards ICD-10
Implementation activities are “back
on track” for a transition date of October
1, 2014 and nowhere was that more evident than at the AHIMA National Convention in Chicago earlier this month. As
opposed to last year when it seemed that
virtually every vendor in the hall was promoting ICD-10 readiness, this year the
focus all seemed to be drawing your attention to the nitty-gritty issues of what will
be required for a successful transition and
implementation – Clinical Documentation
Improvement.
Technology firms are working on revolutionizing how we capture physician information – from templated, structured documentation styles in certain EHR applications to speech recognition technology,
there has been a groundswell of support to
help improve data capture and streamline
the process. Clinical Documentation Improvement (CDI) is the latest horizon to
be embraced by these firms.
In order to effectively prepare for the transition, facilities should be taking a hard
look at CDI efforts. Has there been continuing physician education taking place?
Has anyone identified the enhanced areas
that need to be addressed in order to code
to the highest level of specificity in ICD10? Areas such as Obstetrics and Ortho-
pedics, not necessarily impacted by
traditional Medicare-population focused CDI programs, are at the forefront of requiring a new level of physician documentation and specificity.
Documentation integrity studies
should be considered in order to provide facilities with a baseline from
which to expand physician education. Such studies should identify
any additional documentation specificity needed to either formulate additional physician education efforts
or revisit the current scope of existing CDI programs. This is a once-in
-a-lifetime opportunity to improve
relations with our physicians while
improving the odds for a successful
transition to ICD-10. The education
we can provide physicians at the facility level will carry back to the office setting and create the proverbial
“win-win” scenario that we all crave.
“Nothing is more expensive than a
missed opportunity.” - H. Jackson
Brown Jr.
Coding Clinic Corner
Coding Guidelines Review—HIV AIDS
Coding Clinic for ICD-9-CM, Second Quarter
2012 contained three (3) clarifications
regarding previously addressed coding issues.
Issues involving catheter-related urinary tract
infections, the clinical definition of a low
anterior resection and the definition of sepsis
syndrome were all responded to by the
publishers indicating that physician queries
were appropriate.
It was emphasized that coders could not
infer a causal relationship in the occurrence of
urinary tract infections (UTIs) in the presence
of indwelling catheters and that the physician
must clearly state the relationship in order to
assure appropriate coding.
Clarification was also sought regarding
previous information posted in 1996 and 2010
that appeared to provide added clinical
descriptions of a low anterior resection. As
with the question surrounding catheterrelated UTIs, readers were encouraged to
consult with the surgeon to clearly understand
the extent of the surgical procedure.
Lastly, the issue of the term “sepsis
syndrome” was presented.
Again, the
publishers reflected that the vague nature of
the term would prompt the coder to query the
physician in order to fully identify the
condition and all the related codes.
Sepsis has been an ongoing issue with
many physician specialty groups opining that
the terminology used to describe the varying
sepsis conditions is arcane and out of date.
The fact that the vocabulary used in
describing the conditions has not kept pace
with coding guidelines or vice versa only
serves to support the continued need for
experienced, qualified coders, even in the
face of the many technology advancements
such as computer assisted coding. These
clarifications also enforce the need for
continued physician education as we advance
towards the ICD-10-CM/PCS implementation
date.
In order to effectively prepare for the ICD-10 transition, it’s important to make sure that we fully understand current ICD-9-CM coding guidelines in order to
strive for and achieve a high level of coding accuracy. This issue will focus on a review of the HIV/AIDS
Coding Guidelines.
1. Code only confirmed cases.
Following this guideline does not require documentation of positive serology or culture for HIV;
the provider’s diagnostic statement that the patient is HIV positive, or has an HIV-related illness
is sufficient. Note that this is an exception to
hospital inpatient guidelines that allow for the
coding of presumed cases.
2. Asymptomatic human immunodeficiency virus
V08 is to be applied when the patient without any
documentation of symptoms is listed as being
“HIV positive”, “known HIV”, “HIV test positive”
or similar terminology.
Do not use this code if the term “AIDS” is used or
if the patient is treated for any HIV-related illness
or is described as having any condition(s) resulting
from his/her positive status; use 042 in these cases
3. Encounters for testing in HIV
Use V73.89 (screening for other specified viral disease) if a patient is being seen to determine his/
her HIV status.
Use V69.8 (other problems related to lifestyle) as
a secondary code if an asymptomatic patient is in
a known high risk group for HIV.
Use V65.44 (counseling) if counseling is provided
during the encounter for the test or if the patient
returns to be informed of their test results and
the results are negative.
795.71 – Assign to patients with inconclusive HIV
serology, but no definitive diagnosis or manifestations of the illness (Inconclusive serologic test for
HIV).
Coding Guidelines Review—Continued...
V01.79 – Exposure to HIV virus
Note – Patients previously diagnosed with
any HIV illness (042) should never be assigned to 795.71 or V08.
4. Patient with HIV disease admitted for unrelated condition:
If a patient with HIV disease is admitted
for an unrelated condition (such as a traumatic injury), the code for the unrelated
condition (e.g., the nature of injury code)
should be the principal diagnosis. Other
diagnoses would be 042 followed by additional diagnosis codes for all reported HIVrelated conditions.
Whether the patient is newly diagnosed or
has had previous admissions/encounters for
HIV conditions is irrelevant to the sequencing decision.
5. HIV infection in Pregnancy, childbirth and
the puerperium
A patient admitted (or presenting for a
health care encounter) because of an HIVrelated illness should receive a principal
diagnosis code of 647.6X…followed by 042
and the code(s) for the HIV-related illness
(es).
Codes from Chapter 15 always take sequencing priority
6. Patient admitted for HIV-related condition
If a patient is admitted for an HIV-related
condition, the principal diagnosis should be
042, followed by additional diagnosis codes
for all reported HIV-related conditions.
What are HIV-related conditions?
HIV-related conditions are a source of confusion for coders. Most, if not all of this confusion arises from the evolution of codes created
and subsequently deleted since the AIDS and
HIV diseases were first identified and categorized.
A prior code structure that went into effect
10/1/86 created a coding table not unlike the
Table of Drugs or the Hypertension table that
identified varying categories of AIDS and identified related conditions deemed to be consistent with the presentation of AIDS at that
time. Categories 042-044 identified categories
such as HIV with infections, causing infections,
with malignant neoplasms, causing specified
diseases of the CNS, causing other disorders
involving the immune mechanism, causing
specified acute infections, etc. Coding guidelines at the time required the coder to use only
one code most related to the reason for admission and representative of the associated or
complicating conditions identified for the patient.
Due to continued confusion regarding the appropriate use of the categories, effective
10/1/1994, the classifications were reduced to
a single code – 042.
The distinctions in the original categories were
no longer clear cut and it became impossible
to keep lists associated with these code categories up to date. This was information provided by the CDC which took an active role in
the creation of the HIV/AIDS codes. The CDC
went on to say that due to both the lack of
clear guidelines and the restrictions to use only
one code from the category range have created confusion and inconsistent coding.
Code 042 includes all cases of physiciandiagnosed AIDS, whether asymptomatic (e.g., a
diagnosis based on CD4+ T-lymphocyte criteria
alone) or symptomatic.
Code V08 has been created for asymptomatic
HIV infection.
To use these codes correctly, the physician
must provide complete information about the
manifestations of the HIV-related illnesses and
their relationship to HIV. Persons who assign
Coding Guidelines Review—Continued...
codes should not assume that conditions are
HIV related unless the physician so indicates.
Opportunistic illnesses common in persons diagnosed with AIDS include Pneumocystis carinii pneumonia, cryptosporidiosis, histoplasmosis, bacterial infections, other parasitic,
viral, and fungal infections, and some types of
cancer. Tuberculosis is the leading HIVassociated opportunistic infection in developing countries. – “UNAIDS Terminology Guidelines, October 2011”. Examples of associated
illnesses considered common in patients diagnosed with AIDS include:
* Kaposi’s sarcoma and lymphoma
* Cryptococcal meningitis
* Cytomegaloviral disease
Consider the following coding scenarios:
A 42 year old man with history of HIV and migraines, on nortriptyline 50mg at bedtime. He is
also on Atripla. His most recent CD4 count was 382
and his viral load was undetectable.
Assesment: 42 year old man with HIV and migraines. Increase nortripltyline to 75mg at bedtime.
____________________________________________
61 year old female seen for routine GYN care...her
most recent CD-4 was 534 and viral load was less
than 50
Assessment: 61 year old female for GYN exam—
History of HIV—asymptonmatic
____________________________________________
An asymptomatic HIV-positive patient was admitted
for Interleukin immunotherapy. What is the appropriate principal diagnosis for the patient?
For all of the above coding scenarios, when considering the current guidelines, the appropriate answer is V08.
Coding TIP: When in doubt, query!
Announcements
Credits
H.I.M. ON CALL, Inc. would like to welcome
Mercy Ngungu to the team! She is our new
Project Director!
Editor in Chief
Joseph J. Gurrieri, RHIA, CHP
Contributors
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ISSUE
The
HIMformer
THE LATEST IN HEALTH INFORMATION AND REVENUE CYCLE MANAGEMENT
08
October 2012