Note from the Instructor: Coding Clinic, second quarter 2021, high and lowlights

By Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC

The American Hospital Association’s (AHA) Coding Clinic always produces surprises. Most people remember the day their first child was born, or the day they moved into their home. I remember the day we were allowed to report heart failure with reduced ejection fraction (HFrEF) as systolic heart failure, or the day flash pulmonary edema could finally be reported as an acute pulmonary edema. There was a party and champagne popping in the Prescott household.

There are also Coding Clinic releases that prove to be a disappointment. The second quarter 2021 release was one that left me questioning the meaning of life…or at the very least the meaning of Official Guidelines for Coding and Reporting. No champagne, but perhaps a couple shots of whisky. Leaning my head down on the bar crying…

So, shall I start with the good news? Or the bad news? Since I can’t hear you through the computer, let’s start with the highlights.

Highlights

The good news was related to level of consciousness (LOC) and head injuries. The question describes a patient with a traumatic subarachnoid hemorrhage who was initially noted to have a loss of consciousness for approximately 30 minutes at the time of injury. Upon admission, the patient was alert and oriented, but neurological status declined, and he became unresponsive and comatose without regaining consciousness.

The question is related to the code’s seventh character and asks which character is assigned for the LOC (the initial LOC at the time of injury or the character specifying the longest duration). The answer was to assign S06.6X6A to classify traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without a return to pre-existing conscious level. The condition would be reported as present on admission. Their reasoning was the injury was present on admission, and the loss of consciousness is part of the disease process.

On p. 3, we are instructed to report documentation of “static encephalopathy” as code G93.49, Other encephalopathy. The instruction reminds us that when encephalopathy is linked to a specific condition, it is appropriate to use the code describing “other encephalopathy” since codes describing “other” or “other specified” are used when the information in the medical record provides detail for which a specific code does not exist. Static encephalopathy is a broad term describing a chronic, non-progressive brain disorder in children.

When the documentation describes a major neurocognitive disorder with an unknown etiology, we are directed to F03.90, Unspecified dementia, without a behavioral disturbance. The instruction states, “Although, ‘Major neurocognitive disorder without behavioral disturbance’ is an inclusion term under code F01.50, Vascular dementia without behavioral disturbance, in this case, the etiology is unknown. Therefore, it would not be appropriate to assign a code for vascular dementia.” 

My sarcastic response is that perhaps we should remove that inclusion term from below F01.50? But I digress.

There is direction related to reporting the Glasgow coma scale (GCS) that asks if it would be appropriate to report the most severe GCS score if the patient’s score worsens after admission, but within the first 24 hours. The questioner is asking this question because the seventh character of the GCS codes further specifies the time the patient was assessed:

The seventh character values available are:

• 0—Unspecified time
• 1—In the field (EMT/ambulance)
• 2—At arrival to the emergency room
• 3—At hospital admission
• 4—24 hours or more after admission

The answer stated that “ICD-10-CM does not classify scores that are reported after admission but less than 24 hours later. Therefore, only assign one code that represents the GCS score at the time of admission with a POA of ‘Y.’ ”

My interpretation of this guidance is that if only one code can be identified as present on admission, I would apply just one character (indicating the most severe) either a 0, 1, 2, or 3. And I would consider anything within the first 24 hours as being present on admission. Any GCS scores, documented after the first 24 hours would be identified as not present on admission. I admit, my interpretation is venturing into the grey zone; the direction is not a clear black or white.

Lowlights

Now if you would like to “belly up to the bar” I shall share with you the question that left me quite disturbed. The question says that, during a laparoscopic salpingo-oophorectomy, the surgeon noted an incarcerated loop of small bowel adherent to a ventral hernia sac. The documentation stated that after take down, the bowel was discolored with multiple serosal tears. The incision was then extended, the loop of bowel was brought out through the incision, and the segment with the serosal injury was excised. The provider was queried and stated the serosal tear was “Unavoidable during extensive lysis of adhesions, not intraoperative complication.”

The question related to this scenario asks whether any bowel injury requiring excision be considered clinically significant and reportable, and how the serosal injury and repair by excising the small intestine would be coded.

Although I do understand this is a disturbing turn of events for both the patient and surgeon, the answer left me a bit speechless. The answer instructed us to assign code K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure to capture the serosal injury to the small intestine. The rationale offered was that although the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery.

You may question why this answer has driven me to drink. The answer is basically stating that the provider is incorrect, that this was a surgical misadventure and go ahead and report the accidental puncture. This is the opposite of what the Official Guidelines instruct us to do. Section 1.B.16 states:

Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

My father raised me to follow the rules and I would never tell you to specifically ignore regulatory advice. But in this instance, I believe you need to work within your organization to understand how and when this advice applies and how to consistently apply it. You should confirm with your coding team how widely this advice should be applied to other encounters, other surgeries, other injuries. I suggest an exercise in caution. I strongly believe part of our mission is protecting the providers, ensuring that the intent of their documentation is accurately reported. This decision defies that reasoning.

Please understand, I do not mean we work to cover up complications or misadventures. But we must also understand that the only individual who can determine if there is a surgical complication is a surgeon. Therefore, when such cases are in question a peer review might be called. This is not a determination a CDI or coding professional should be making.

So, as I close, sitting with my head resting on the bar, I will also speak to my father’s advice that if you don’t like a rule, you still have to follow it, but you can also work to change the rule. Please, everyone let’s make some noise. Let’s challenge the status quo. This advice should be rescinded. If you agree, let the AHA know your feelings.

Editor’s note: Prescott is the CDI education director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.