When to query unspecified diagnoses

Over-querying is a common concern in CDI. It can influence productivity and workflow. It can cause delays in documentation and coding processes. It can also overwhelm and frustrate physicians, who in turn may be less likely to support or engage with CDI program efforts.

 

The transition to ICD-10-CM/PCS has brought a number of documentation challenges, including an increase in unspecified diagnoses. This means the number of queries will likely increase as well. It’s up to CDI specialists to have a sufficient degree of knowledge in their toolkits so they know when it’s appropriate to query and when it isn’t.

 

Each facility should have a specific plan in place between CDI and coding for how to handle unspecified diagnoses, says Katy Good, RN, BSN, CCDS, CCS, CDI coordinator at Flagstaff Medical Center in Arizona. Her facility opted to focus primarily on two things when it came to ICD-10 specificity–related queries:

 

“Over time, as our comfort with ICD-10 increases, I predict that we will expand the areas that we query,” says Good. “However, we are cognizant of the impact of queries on providers and want to make sure we are not overwhelming them. Initially, we will focus on the ‘needs.’ As documentation issues resolve in certain areas, I am sure we will begin focusing on other [opportunities].”

 

The CDI specialists at Sutter West Bay in San Francisco issue a query if additional information is needed to provide clarity in order to compliantly bill, and if that additional information will impact reimbursement, says Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation and coding integrity.

 

“This includes diagnostic coding as well as PCS if the bill can’t be dropped due to lack of specificity,” he says.

 

CDI specialists also issue queries if any quality metric could be affected, such as SOI/ROM, sepsis survival rate, value-based purchasing, and any other metric affected by risk-adjusted methodology, Evans says.

 

For example, if a physician performs a vascular bypass, should the CDI specialist query the physician to obtain information regarding the specific vein that was harvested for the procedure? What about the type of joint surface—do you default to synthetic if it is not specified? Evans says no. The precise materials are needed to assign a code. If the documentation does not allow for that level of specificity, there could be an opportunity to query the physician.

 

Unspecified codes in ICD-10 should be used when “it most accurately reflects what is known about the patient’s condition at the time of that particular encounter,” according to CMS.

 

Choosing a more specific code when documentation in the record does not support such action would be inappropriate, CMS says. “Each healthcare encounter should be coded to the level of certainty known for that encounter.”

 

So now that we know that we should always query for unspecified diagnoses and document to the highest level of specificity possible, let’s look at a few other diagnoses.

 

First, let’s refresh and discuss principal diagnoses and secondary diagnoses.

 

 The principal diagnosis is defined as “the condition, after study, which occasioned the admission to the hospital,” according to the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2016. It is not necessarily what brought the patient to the emergency room, but rather what occasioned the admission.

 

In a recent blog post, Laurie Prescott, MSN, RN, CCDS, CDI education director for HCPro in Danvers, Massachusetts, presented the following scenario:

 

 

The principal diagnosis in this instance is the osteoarthritis. Acute myocardial infarction (the STEMI) is not the principal diagnosis because it was not the “condition that occasioned the admission,” says Prescott.

 

Finally, let’s take a look at “other” or secondary diagnoses. The Uniform Hospital Discharge Data Set defines “other diagnoses” as:

According to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, to be considered a secondary diagnosis, the condition must require any of the following:

Secondary diagnoses include diagnoses the patients bring with them that must be considered when treating the principal diagnosis, as well as diagnoses that develop subsequently and will affect the patient care for the current admission.

 

To further expound on the example above, the patient admitted with the principal diagnosis of osteoarthritis also has a history of Type 2 diabetes, chronic obstructive pulmonary disease, and coronary artery disease. These conditions would be coded as secondary diagnoses because they will require treatment and monitoring during the patient stay, says Prescott. The acute STEMI that developed subsequently will also be coded as a secondary diagnosis because it developed after admission.

 

CDI specialists should know the criteria for the chronic systematic conditions that should be reported regardless, such as diabetes or chronic obstructive pulmonary disease, says Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer. “The presence [of such conditions] alone will impact the care.”

 

This leads us to another issue prevalent in ICD-10: families of codes.

 

For the first year of ICD-10 use, CMS will not deny or audit claims based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct “family of codes.” But this doesn’t extend to hospital reporting, which leads many to question whether or not payers will reimburse claims that include unspecified codes.

 

Hospitals are allowed to use unspecified codes. According to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting:

There are plenty of cases where unspecified codes are justified. The bottom line is the documentation has to accurately reflect the patient diagnoses and the care provided. “Whatever condition, disease, or problem the patient has,” says Bryant, “it must be documented so it can be properly coded.”