“What a Difference A Day Makes”-The coding changes and rules affecting quality

Aug. 24, 2016 / By Cheryl Manchenton, RN

I had the pleasure of attending another couple of conferences lately where I heard some whispered statements such as “Did you hear about all the new codes? Who needs this many codes?” This of course made me think of the old standard “What A Difference A Day Makes” when it comes to the coding changes in October.

But first things first. Let’s talk about what we already have and why attention to detail matters. When the ICD-10-CM/PCS codes were created, they allowed for greater specificity of diagnoses and procedures. Now here’s the “rub.” We have more specificity, so auditors and Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are holding us to specific codes and sometimes disallowing an unspecified code for coverage.

Case in point: a patient with a diabetic, non-healing ulcer underwent an excisional debridement including muscle. The appropriate diabetic code was assigned, but an ulcer with an unspecified stage was coded and the case was denied for payment. Fortunately for the organization, the provider had documented the depth in his/her progress notes and operative note and the organization was allowed to resubmit with the correct code assignment. The claim was then paid. In another case, the organization was not paid for pacemaker insertions on patients with unspecified bradycardia as principal diagnosis unless a secondary diagnosis of some sort of arrhythmia or bundle branch block was also reported.

In the rush of getting cases reviewed concurrently and out the door quickly for billing, the importance of paying attention to detail cannot be overemphasized.

But let’s look at a specific new set of codes that might impact quality scores!

There is now further specificity for the type of 3^rd degree perineal laceration: O70.02*. The code was expanded to include a class 3a, 3b, 3c and unspecified 3^rd degree laceration of the perineum. 3a denotes a partial tear of the external anal sphincter involving less than 50 percent thickness, 3b indicates greater than 50 percent of the external anal sphincter is torn and 3c denotes the internal sphincter is torn. When is the last time you saw detail of the type of third degree in a provider note? I do not believe it is presumptuous to think the quality organizations may utilize certain of these codes and exclude others. So documentation specificity to ensure accurate reporting of complications during delivery will matter over the next couple of years as they collect meaningful data to determine which codes will be utilized.

Another example of when specificity matters is in the case of DVTs in post-surgical patients. AHRQ has revised their criteria to not penalize hospitals for clinically insignificant distal vein thrombi. It matters in how/where the DVT is documented by the provider (and by the technician performing the diagnostic test) and behooves the CDI and HIM staff to carefully review ultrasound and other imaging studies so the specific vein/location may be identified for the most specific code possible.

I will speak more on the effect/potential effect of some of the new coding guidelines, codes and AHRQ metrics in my next blog, but I want to close this with a bit of a lecture (visualize me peering over my granny glasses at you). For many years the industry has asked for better methodology, metrics and codes for complications. But when all of these new codes came, I heard more grumbling than celebrating. We can’t have it both ways. Explore, study and use the new codes and metrics given to us so we can have meaningful data that will hopefully help us improve the actual quality of care we provide to our patients. What a difference a day makes indeed!

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.