Symposium Spotlight: Pinson talks diabetes

Editor’s note: Richard Pinson, MD, FACP, CCS, is a principal and co-founder of Pinson and Tang, LLC. Dr. Pinson will be presenting on Day 2 of the 2018 ACDIS Symposium: Outpatient CDI. The title of his presentation is “Diabetic complications: Diagnosis, documentation, coding, and compliance.” This year’s symposium takes place November 8-9 at the Hilton Orlando Lake Buena Vista—Disney Springs Area.

ACDIS: Why does diabetes represent one of the biggest outpatient target areas for CDI specialists?
Pinson: Diabetes without a complication is not assigned to a hierarchical condition category (HCC) which affects physician and hospital pay-for-performance programs. Physicians commonly fail to document that they are evaluating or managing diabetic complications and end up coding only uncomplicated diabetes.

ACDIS: We often hear the amputation status example as a reason for the importance of capturing diagnoses year-over-year as they relate to risk adjustment factors and HCC capture. Can you explain this example a little more in-depth for those who might not be familiar with it?
Pinson: Amputation status for toes, mid-foot (transmetatarsal), below the knee, and above the knee are assigned to one of the highest weighted HCCs (#189). Providers may fail to document and address the current status of the amputation stump concerning symptoms or by examining it annually thereby losing the opportunity for inclusion of this important HCC in their risk/severity adjustment.

ACDIS: If the patient presented for a recheck regarding diabetes lab work but the physician states the patient is “doing well overall,” while the patient states “her sugars are running a little too high around 250-260,” how would the CDI specialist query? Or would this be better addressed in a larger practice-wide educational session for physicians?
Pinson: First of all, comprehensive HCC education for providers in the outpatient setting is crucial for any outpatient CDI program. Since hyperglycemia is defined as a blood sugar greater than 140mg/dl, the outpatient CDI specialist could, citing the elevated blood sugar, query the provider regarding: hyperglycemia, poorly controlled, inadequately controlled, or out of control to assign the complication code for diabetes with hyperglycemia (HCC 17).

“Uncontrolled” diabetes must be specified as meaning either hyperglycemia or hypoglycemia.

ACDIS: Establishing a cause-and-effect relationship between documented conditions, such as manifestation/etiology, complications, and conditions/diagnostic findings is one of the reasons the ACDIS/AHIMA query practice brief tells us to query physicians. Are cause-and-effect relationships as important to pay attention to on the outpatient/physician practice side as they are on the inpatient side?
Pinson: Cause and effect relationships are crucial primarily for diabetic complications.

ACDIS: Fun Question: Do you prefer the Star Wars or Star Trek series and why?
Pinson: Star Wars, because it powerfully embodies the eternal struggle of good versus evil on a cosmic scale.