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Coding and Documentation Challenges for Key Diagnoses Webinar [PODCAST]

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In this episode, we’re pleased to welcome back, Kristen Eglintine, Coding Analyst Supervisor at BESLER, to give us a glimpse into the upcoming BESLER Webinar, Coding and Documentation Challenges for Key Diagnoses, on Wednesday, July 26th, at 1 PM ET.

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Highlights of this episode include:

  • What circulatory conditions will be discussed
  • Challenges coders face with these diagnoses
  • How poor documentation leads to inaccurate coding
  • What hospitals can do to ensure they are reimbursed properly

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back, Kristen Eglintine, a coding analyst supervisor here at BESLER. In this episode, Kristen will give us a glimpse into the upcoming BESLER webinar, Coding and Documentation Challenges for Key Diagnoses, that we’re hosting on Wednesday, July 26th, at 1:00 PM Eastern Time. Welcome back, Kristen, and thank you for joining us.

Kristen Eglintine: Hi, Kelly. Thank you for having me back.

Kelly: Well, great. Well, let’s go ahead and jump in. So, you’re presenting a webinar on July 26th, 2023, called Coding and Documentation Challenges for Key Diagnoses. In the fall of 2022, BESLER hosted a webinar on Coding and Documentation Challenges for High-Volume Diagnoses. How is this one different?

Kristen: Well, first of all, I just want to thank everyone out there, to all of you who are listening and spending a few minutes with us today. This one will be different. Last fall in 2022, BESLER hosted a webinar on Six High-Volume Diagnoses, conditions where the clinical definition isn’t static. Over the years, protocols and clinical criteria have changed. So those diagnoses were challenging to code accurately. This time around, I’m going to focus on five key circulatory conditions that are reported frequently that tend to have documentation gaps and significantly impact reimbursement. While the theme of the webinar, Coding and Documentation Challenges is the same, the diagnoses are different.

Kelly: Thank you for explaining that. And so, what circulatory conditions will you be discussing this time around?

Kristen: Heart failure for sure leads the list, followed by MIs, cardiac dysrhythmias, cerebral infarctions, and coronary atherosclerosis or CAD. These 5 circulatory conditions are among the 20 most common principal diagnoses reported over the years. There were 1.1 million inpatient stays for heart failure with over $14 billion in aggregate costs in 2018. So, this is going back before COVID. The landscape changed slightly with COVID over the years. I think we’re going to get back to these type of numbers in the future. So, I’m reporting some information from that year to give you some context. MIs had 650,000 inpatient stays, and again, for over $14 billion in aggregate costs. Cardiac dysrhythmias had 620,000 stays for $7,500,000,000. Cerebral infarctions had 533,000 stays for $8 billion. And CAD had 358,000 stays for almost $9 billion. So, as you can see, when you combine all of these diagnoses, they accounted for about 12% of all inpatient stays and 13% of aggregate costs. Stays for two of these diagnoses. MIs and CAD, are costly compared to the most top diagnoses. Each of these average more than $20,000 per stay. So, because of the high volume of stays and the high dollars involved, it’s important for coders that they understand these conditions and that they have the tools to code them correctly.

Kelly: Most definitely. So, Kristen, what are some of the challenges coders face with these diagnoses?

Kristen: One of the many challenges coders and CDI face with circulatory conditions is specificity across the board. Let me give you a few examples. Coding of cerebral infarctions provides many challenges as the ICD-10 code set, they’re specific to sites and the affected arteries, and then as to the cause of the infarction, such as an embolism or a thrombus. Coding of a sequelae of a stroke or infarction also demands a level of detail often missing in medical records. Documentation needs to be clear as to all deficits from the stroke. So, we can code everything. Specificity also applies to cardiac dysrhythmias. Cardiac dysrhythmia is, in simple terms, just an abnormal heartbeat, and is one of the most common cardiac conditions reported. So again, despite the simplicity of the condition compared to others, there are several different types of dysrhythmias, and the ICD-10 CM classification captures all of the different types and different levels of severity. Heart failure can be tricky to code because you may see numerous acronyms in the documentation. And then you need to decipher whether it’s chronic heart failure or acute or acute on chronic. Coders must also determine if the heart failure is linked to other associated conditions such as chronic kidney disease and/or hypertension.

In these cases, coders have guidelines that instruct them that the word with should be interpreted to mean associated with or due to. So, if there is documentation that states a patient has heart failure with hypertension, you reported a different code, which is a combo code, in addition to your I-50, rather than just hypertension and heart failure separately. And I’d be remiss if I didn’t mention the difficulty coding MIs. Documentation requirements for accurate coding of an MI is the location of the infarct. So, for example, is it on the interior wall or the inferior wall, the onset or duration of the MI? So, when did the am I occur? Has it been less than four weeks? Documentation should also include the etiology of the MI. Was the event related to a plaque rupture, an erosion, or a dissection that resulted in the intraluminal thrombus? Or was the event related to a supply-demand mismatch? All of these factors play a role in code selection.

Kelly: That sounds quite challenging indeed. Can you provide an example of how poor documentation leads to inaccurate coding, which can negatively impact reimbursement?

Kristen: Yeah. So let me just continue on with the MIs as an example. So, demand ischemia and a Type 2 MI can often be reported incorrectly as both are due to supply-demand mismatch, and both have evidence of ischemia. These conditions are reported differently and have different reimbursement rates. Troponin levels determine what code to report. So, if a patient’s troponin level increases, more than likely the patient suffered a Type 2 MI due to demand ischemia. This is reported with an I-21 code, and this is an MCC, so a big deal. If troponin levels aren’t documented clearly or documentation is insufficient to report a Type 2 MI, the coder is forced to report demand ischemia only with an I24 8 code, and that is only a CC. So poor documentation on MIs like this can cost a hospital thousands of dollars.

Kelly: Yeah, I bet it does. Is there anything a hospital can do to ensure they are reimbursed properly?

Kristen: CDI programs come to mind first. The increasing complexity of medicine has been met within corresponding increase and complexity of medical documentation, and CDI Programs help. CDI Programs can be beneficial. They help bridge the gap between the physician documentation and coding. The positive financial impact of a CDI Program isn’t just limited to initial payments of claims, but also can help eliminate unnecessary queries to physicians, and even more importantly, they can head off unfavorable audits. And then in addition to CDI Programs, I would say, hospitals should have documentation best practices in place such as documentation must be provided. Coders cannot assume diagnoses exist based on medication lists or a physician order. All conditions that coexist at the time of an encounter and require or affect patient care, treatment, or management should be documented and then coded.

Coders cannot code current conditions from problem lists or medical history. So, it’s important that the physicians just don’t say past medical history of CHF. That is actually brought into the discharge summary into current documentation so it can be picked up. Providers should document the etiology, the type, and acuity of congestive heart failure whenever possible. I see a lot of queries for the acuity of CHF out there. Providers should document any additional or secondary conditions and any causal relationships that exist between them. And those are just a few examples of some best practices you could put in place to ensure your coders have every tool and everything they need to report accurately. I do invite everybody to attend our upcoming webinar to learn more about coding challenges surrounding these circulatory conditions I just spoke of. And again, as Kelly mentioned, the webinar will be on Wednesday, July 26th at 1:00 PM Eastern Standard Time. I do hope you can join us. I look forward to it. We will get into those five circulatory conditions and much more detail. And I thank you all for listening today.

Kelly: Well, thank you so much, Kristen, for joining us and for sharing this glimpse into that upcoming webinar on July 26th. As a bonus, there’s also going to be CPE offered. Thanks again, Kristen.

Kristen: Thank you, Kelly. Have a nice day.

Kelly: Thank you. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time….

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.


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