Adele King, RHIA, Manager, Clinical Coding
Health Information Management (HIM) Department
In order to provide you with information related to clinical documentation and coding, Clinical Coding Corner will be a regular feature of Progress Notes.
As you may have already heard or read, CMS (Centers for Medicare/Medicaid Services) released the inpatient prospective payment system (IPPS) final rule for fiscal year 2009 on July 31, 2008. The final changes aim to “promote the Administration’s goal of transforming Medicare to a prudent purchaser of health care services, paying for quality of services, not just quantity.” The focus is on patient safety, which means changes to how we look at hospital acquired conditions (HAC). CMS added three HACs to the original eight that were identified last year. These conditions are felt to be reasonably preventable through evidence based care:
- Foreign Object Retained After Surgery
- Air Embolism
- Blood Incompatibility
- Pressure Ulcer Stages 3 & 4
- Falls and Trauma (Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
- Catheter-Assisted UTI
- Manifestations of Poor Glycemic Control (poor control of blood sugar levels, primarily diabetic hyperosmolarity, ketoacidosis, and hypoglycemia coma
- Surgical site infection, mediastinitis, following CABG
- *Surgical site infections following orthopedic surgeries
- *Surgical site infections following bariatric surgery for obesity
- *Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures
*New for FY 2009
As of October, 1, 2008, a case will group to a lower weighted MS-DRG if one of the above HACs is identified as Not Present on Admission. In other words, Medicare will no longer pay the additional cost for these conditions as CC or MCC if hospital acquired (not documented as Present on Admission). If the condition is not present on admission and it is the only complication/comorbidity (CC) or major CC (MCC), the case will group to the lower weighted DRG without CC.
Pressure ulcers, is one of the original eight (8) HACs chosen as the first topic to share excerpts from the following article written by James S. Kennedy, MD, CCS: Dr. Kennedy is a general internist and director at Brentwood, TN – based FTI Healthcare, which specializes in medical management, case management, clinical documentation, and quality reporting.
A Minute for the Medical Staff
Stage pressure Ulcers: specify origin and location so coders can reflect patient severity and assign proper codes
Pressure ulcers, a condition that CMS designates as preventable, specifically Stage 3 or 4 hospital acquired pressure ulcer, that is, not present on admission (POA), will not incur additional inpatient reimbursement. Stage 3 or 4 pressure ulcers are major complications and comorbidities (MCC) that add $8400 to an average base surgical admission if present on admission. Unfortunately, coding staff is only able to code conditions that are clinically documented by the physician. The National Pressure Ulcer Advisory Panel stages pressure ulcers:
- Suspected deep tissue injury – discolored areas of intact skin, blood-filled blisters
- Stage 1- intact skin with nonblanchable redness, color change of localized area
- Stage 2 – partial thickness loss of dermis, shallow open ulcer with red pink wound
- Stage 3 – full thickness tissue loss without visible bone, tendon, or muscle
- Stage 4 – full thickness tissue loss with exposed bone, tendon, or muscle
- Unstageable – full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
Visit www.npuap.org/pr2.htm for more information on these stages and descriptions.
Physician documentation of the pressure ulcer POA, Present on Admission status and presence is critical. Specifying the origin and location of the pressure ulcer is important. Most nonpressure, venous stasis, diabetic, or otherwise unspecified pressure ulcers are currently only complications and comorbidities (cc), whereas most specifically located pressure ulcers (e.g. buttocks and heels) are currently MCCs. Associations with diabetic neuropathies or vasculopathies add specificity and, in many cases, increase physician medical decision making and hospital reimbursement.
Infected ulcers that cause a systemic inflammatory response syndrome (sepsis) add even greater weight when they are POA, especially when the physician performs an excisional debridement.
All ulcers and their precipitating CCs or MCCs require treatment if they are to heal properly. Some require debridement performed by a physician, nurse, physician’s assistant, or physical therapist. Physician documentation of whether tissue is excised and the depth to which it is excised (skin, fascia, muscle, or bone) is vital, particularly when performed outside the OR. Coding guidelines and advice for sharp or undefined debridement requires coders to query the physician for further detail.
Remember that CCs and MCCs factor into risk-adjustment methodologies, thus, documenting them is crucial.
Thank you for taking the time to document with as much detail as possible the care that you give your patients. It not only helps the clinical coders to accurately code the diagnoses and procedures, most importantly, it provides continuity of patient care by serving as vehicle of communication for caregivers to evaluate, plan and monitor patients’ care plans.
NOTE: A Minute for the Medical Staff is an exclusive service for subscribers to Medical Records Briefing. Reproduction of A Minute for the Medical Staff within the subscriber’s institution is encouraged. Reproduction in any form outside of the subscriber’s institution is forbidden without written permission.