December Coding Tip Corner

As we come to the end of 2022 and look forward to 2023, this is a look back at what we did well and what we have yet to do better!

First and foremost, give everyone in your office (and yourself!) a round of applause, as for the second year in a row, we have achieved FIVE Stars! This is no small feat, and it showed great collaboration from the people working the front desk taking calls to the providers in the office and everyone in between who reached out to members directly or had a role in documentation. THANK YOU! Let’s keep that momentum going! It is evident that you are providing great care.

Now for the work we have yet to accomplish. The hardest part is already being done — the patient is being seen. It is just a matter of taking the next step and documenting all findings/changes during the visit. 

Avoid the pitfalls of the EMR

If you can do this one change at the beginning of the year, it will avoid a major coding error moving forward. Why not designate January (or the first time the patient comes into the office) to cleaning up the patient’s account?

Here’s one way to do this: Remove or term any “old/resolved diagnosis” that may be under the “reason for the visit” section.

One diagnosis/condition found under that section which often causes a coding error is the CVA. We have found CVA coded repeatedly year over year.  This code is only to be used as the stroke is occurring. It is extremely rare for this to be happening in the doctor’s office. The CVA can be coded only during the hospital stay. Once the patient is discharged from the hospital, regardless of the discharge destination, it is either coded as a history of a CVA or a residual or late-effect condition post CVA.

Also please note if there is any residual as a result of the CVA, this is to be captured once discharged and captured at least on an annual basis as long as the residual continues. When capturing the residual for a CVA, always link the residual clearly to the CVA.

A Common Example: 

CC: Physical exam, noted patient drags left leg.  

PMH: CVA 2019 no residual      

This type of documentation does not meet the standard for acceptance with CMS requirements. It was often noted in record reviews over the past two years. Another common coding error is a conflict in the note as shown in the example above. A positive finding is noted in the history and physical exam, and the opposite is noted in the assessment. The positive finding cannot be accepted, as it is a direct conflict in the note.

Frequently Misused or Inaccurately Coding (MESH)

• M = Major Depressive Disorder: If your patient has a major depressive disorder, take the extra minute to define it completely: Mild, Moderate, Severe Single, Recurrent Remission, Full, Partial. If the type of depression cannot be determined, you may code for the depression unspecified F32.A.
  
  
• E = Embolism Must be Noted as Chronic: Acute vs. Chronic — An acute PE is a new embolism that requires the initiation of anticoagulant therapy and supportive cardiorespiratory care. It is a potentially life-threatening condition that requires inpatient treatment. 
  
  It is unlikely an acute PE would be diagnosed in a physician office setting. The provider must specify that a PE is “chronic” in order to code it as chronic PE. 
  
  There are no specific guidelines or timeframes for when a PE is considered chronic. Provider documentation of “chronic PE” is sufficient, regardless of when the PE was first diagnosed. 
  
  When a PE is documented as “recurrent,” that means the condition has occurred more than once. It does NOT mean that the PE is currently present and does NOT mean that it is chronic. A PE documented as “recurrent” should not be coded as current/active unless there is MEAT to support it as a current condition.
  
  
• S = Stroke: Once a patient has been discharged from their inpatient stay or transferred for care of late effects from their stroke, use of the diagnosis code for acute stroke is no longer appropriate. 
  
  Codes (s) for “history of stroke” or any residual/sequalae documented as being related to the stroke should be captured when the patient is seen after discharge and captured on a yearly basis moving forward as long as the residual persists.
  
  
• H = Heart Attack (Myocardial Infarction, MI): MI specified as acute or within a stated duration of four weeks (28 days), not a month. 
  
  Code I21.X, subsequent MI, is an acute MI occurring within four weeks (28 days) of the previous MI, code I22.x. 
  
  Old MI healed, or past MI (out of 28-day range) diagnosed by EKG or other investigation, currently presenting no symptoms, code I25.2.
  
  

Missed Opportunities on an Annual Basis (TOAD)

Codes that tend to be chronic in nature, lasting a year or even until death. These are conditions that are being treated on an ongoing basis, but they are not being captured on an annual basis for the patient.

Missed opportunities = TOAD

T = Transplants
Status Codes (not all inclusive)

• Bone Marrow
• Kidney
• Heart
• Lung

Transplant complication (not all inclusive)

• Rejection
• Infection
• Failure

O = Ostomies
Status Code (not all inclusive)

• Colostomy
• Ileostomy
• Tracheostomy
• Gastrostomy
• Urostomy

Stoma Complications (not all inclusive)

• Skin irritations
• Stoma leaks
• Retracted stoma
• Prolapse stoma
• Blockage/Malfunction
• Parastomal hernia
• Bleeding

A = Amputations
Status Code (not all inclusive)

• Acquired absence of right or left great toe
• Acquired absence of other toes
• Acquired absence of right or left foot
• Acquired absence of AKA
• Acquired absence of BKA

Amputation Complications (not all inclusive)

• Infection
• Dehiscence
  
  

D = Diabetes and or Dialysis
Status Code Diabetes (not all inclusive)

• Type 1 Diabetes without complications
• Type 2 Diabetes with complications

Diabetes with Complications (not all inclusive)

• Type 1 diabetes with diabetic neuropathy, unspecified
• Type 1 diabetes with foot ulcer
• Type 2 with diabetic neuropathy, unspecified
• Type 2 with diabetic foot ulcer

Status Code Dialysis (not an all-inclusive list)

• Encounter for fitting and adjustment of extracorporeal dialysis catheter
• Patient’s noncompliance with renal dialysis
• Dependence on renal dialysis

Dialysis Complications (not all inclusive)

• Dialysis – associated hypotension
• Dialysis – disequilibrium
• Air embolism
• Missed dialysis (pulmonary edema)

AV Fistula complications

• Clotting of AV fistula
• Infection of AV fistula
• Hemorrhage of AV fistula
• Vascular insufficiency from AV fistula
• AV fistula aneurysm/pseudoaneurysm
• High-output heart failure from AV fistula