Diagnosing X-Ray findings
With the recent reform of coding guidelines, secondary diagnoses are more important than ever before. The diagnosing (and subsequent coding) of your secondary diagnosis can only come from the attending physician’s diagnosis in the H&P and progress notes or from consulting physician’s diagnosis (consult and progress notes).
Diagnosis codes can not be taken from:
1) Physician’s orders e.g. “Chest x-ray in a.m. re: pleural effusion”. The pleural effusion is not coded unless it is diagnosed in the H&P, consultation, or progress note.
2) “Diagnostic studies” portion of your H&P/consult. This is often a repeat of the radiologist wording. Therefore, it is not considered “your” diagnosis.
3) Diagnostic studies e.g. radiology reports. Although the Radiologist is an M.D., he or she is not involved in the care and treatment of the patient. And, often times give multiple possible diagnosis e.g. “Bibasilar infiltrate secondary to atelectasis and or pneumonia”.
Common “radiographic” secondary diagnosis that increase/show proper severity of illness:
· Ascites
· Atelectasis
· Bowel Obstruction (any section, any amount e.g. partial)
· Hydronephrosis
· Infiltrate
· Pleural effusion
· Pneumothorax
· Pulmonary Edema
· Subcutaneous Emphysema
As a reminder, all insurance companies (including CMS) only see the codes from a certified coder (and the bill). Insurance companies do not receive copies of the chart, x-ray reports, lab work, etc….. (Unless there is a focused review). The coder can only code from your diagnosis. If it is not written/dictated as one of your diagnosis, it will not be coded.
By showing proper severity of illness (through coding your diagnosis), proper profiling takes place. All insurance carriers profile hospitals and physicians. From an in-patient stand point, all they have to go by is the coded bill. With proper severity of illness indicated (by including all secondary diagnosis), your profile and NCMC will be correct. Without secondary diagnosis, the chart will be coded as a simple case with zero complicating conditions.
History of CVA vs. late effects that can be coded
When treating a patient for other disease processes (e.g. Pneumonia) who have had a stroke in the past, remember these important guidelines.
1) H/O (anything) will not be coded/considered for severity of illness. The current or on-going problems associated with that history will be coded. The coder looks at “H/O” as an old, solved, problem/diagnosis. And, it is not considered relevant to the current condition.
2) A few late effects of a CVA will be coded and DO increase severity of illness. These include:
a) Aphasia
b) Hemiplegia
c) Hemiparesis
d) Anoxic brain damage
e) Encephalopathy
f) Coma
g) Locked-in-state
3) The last 3 (Encephalopathy, Coma, Locked-in-state) are considered MCC’s (Major Complicating Conditions). Therefore, they take your case to the highest level of severity.
G.I. Hemorrhage and Anemia – Two separate diagnosis
When documenting G.I. Hemorrhage and Anemia consider this:
1) If G.I. Bleed is the principal diagnosis and the patient is anemic, list anemia as the secondary diagnosis.
2) Then, consider if the anemia is “Acute Blood Loss Anemia”.
3) Does the patient have a chronic anemia, iron-deficiency anemia, or disease associated anemia? If so, is it possible that they have acute blood loss anemia on top of a chronic anemia?
4) “Acute Blood Loss Anemia” is the only anemia documentation that increases severity.
5) Written any other way including “severe anemia”, “blood loss anemia”, “acute anemia”, “iron-deficiency anemia”, etc…codes as chronic anemia.
Heart Failure – Drop the C and add the D or S
Effective October 1, 2007 “CHF” was removed as a comorbid condition from coding guidelines. In order for heart failure to be listed as a comorbid condition, it must be diagnosed with severity and type of heart failure. When diagnosing heart failure consider (when possible):
Severity Type
Acute Systolic
Acute on Chronic Diastolic
Chronic Combined Systolic and Diastolic
Chronic (Systolic or Diastolic) Heart Failure – It counts!
As we have been learning, secondary diagnosis are more important than ever before. Most chronic conditions do not increase severity. However, in the case of Heart Failure it does. Because it takes extra resources such as Lasix, Potassium, oxygen, daily weight, fluid monitoring, etc.., the coding guidelines left this chronic condition in as a complicating condition that is reimbursed. The change is we have to know Systolic or Diastolic for it to count.
If Systolic or Diastolic Heart Failure is known as a chronic condition, diagnosing so will increase severity and give you credit for managing the condition.
Replace this:
CHF-Stable
H/O CHF
Compensated CHF
With this:
Chronic Systolic Heart Failure
Chronic Diastolic Heart Failure
This will bring your cases such as Simple Pneumonia (with chronic heart failure) up to the mid-level of severity.
As a reminder coding guidelines dropped “CHF” as a secondary diagnosis. It was replaced by Systolic and Diastolic Heart Failure.
Drop the “C” Congestive
Add the “S” Systolic or “D” Diastolic
(when known)
Cardiac/Circulatory system diagnosis
The recent overhaul of complicating conditions that count/increase severity of illness, has left us with very few in the cardiac/circulatory system. Old favorites that no longer count are CHF and Atrial Fibrillation.
The following diagnoses do increase severity of illness:
Diastolic Heart Failure (Acute, Acute on Chronic, or Chronic)
Systolic Heart Failure (Acute, Acute on Chronic, or Chronic)
Left Heart Failure
Atrial Flutter (Arrhythmias must be diagnosed in progress notes/H&P….coders can’t code from an EKG).
Ventricular Fibrillation
Ventricular Flutter
Cardiomyopathy
Most “Hypertension” diagnosis have been dropped. These include Uncontrolled Hypertension, Hypertensive emergency, and Hypertensive urgency just to name a few.
The following “hypertension” diagnosis do count/increase severity of illness:
Accelerated Hypertension
Essential Hypertension
Malignant Hypertension
Portal Hypertension
Pulmonary Hypertension