Are your secondary diagnoses fully "cited?"

???? Section III of the ICD 10 CM coding guidelines speaks about a specific UHDDS general rule in assigning codes for: “other diagnoses” interpreted as additional conditions that affect patient care in terms of requiring:

C - clinical evaluation or

I - increase in nursing care and/or monitoring or

T - therapeutic treatment or

E - extended length of stay or

D - diagnostic procedures

???? UHDDS further defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay."

???? This guideline might not have gotten enough attention in the past or might had been purposely ignored, so that non-vetted additional #diagnoses without establishing the medical necessity are coded to rack up hospital payment. But because of the surge of denials and the more intense campaign against fraudulent CLAIMS by national government agencies (NGS), including Medicare (CMS), perhaps this part of section 3 rule is now worth revisiting. ?

???? I coined (rearranged) this mnemonic (CITED), which is originally written as CTDEI, for my students so they can easily remember these fundamental criteria in assigning secondary diagnoses.

Clinical evaluation.

·????? Oftentimes, patients get admitted with comorbidities that are remotely relevant to the chief reason why patient needs care in an acute setting. Though these conditions may not be central to the patient’s current therapeutic needs, a provider may clinically evaluate a specific co-morbidity if they find a reason that said condition may affect the medical intervention that the patient needs to undergo. The key phrase is clinical evaluation, in which the condition should be documented as current and relevant. Just because a clinical criterion is reported, that doesn’t mean a condition is current. A good example is when a high BMI is documented, but nowhere in the note that obesity or morbid obesity is mentioned; this should remind a coder to not assume the presence of the condition by merely basing it on the #BMI. Therefore, a diagnosis code for obesity/morbid #obesity in this scenario should not be assigned.

Increase in nursing care and/or monitoring

·?????? Nursing hours spent in caring for patients are monitored for good reason. Patient care and safety are paramount for every hospital admission. Patients who are sicker need more nursing care, hence additional nurse staffing is often necessitated. ?However, there are times when patient’s exacerbation of health condition occurs during admission, which can be considered as “hospital acquired complications” (HAC).? This occurrence of HAC may cause an increase of the #DRG (diagnostic related group). Understand, that not all DRG increase convert to higher reimbursement.? If higher DRG is prompted by #HAC, hospitals don’t get paid for that DRG bump. Conversely though, due to the impact in patient’s safety (PSI), healthcare facilities could end up getting penalized, especially if the incidence of HACs becomes a pattern. In order to avoid such occurrences, healthcare organizations need to have a closer look at their patient safety program. ?If adjustments are merited, quick action(s) should be undertaken to ensure that patients are well cared and optimally treated during hospitalization. ?#Nursing hours need to be appropriately allotted purely for treating patient’s conditions that are present on admission (POA). This will ensure payment based on the true final DRG.

Therapeutic treatment

·?????? Nothing is more direct than what the requisite implies as: “IF TREATED, CODE IT.”? When patients get admitted, hospitals’ main goal is to treat the “principal diagnosis” (PDX) that is chiefly responsible for occasioning the admission for acute care. – “I just quoted the #UHDDS rule in selecting the (PDX)." However, since many of these co-morbidities (pre-existing diseases) are related to the #PDX, said additional conditions may in the process, be also treated therapeutically. Therefore, it is only fitting for these treated diagnoses to be coded as well.

Extended length of stay

·?????? Payers’ review/audit of CLAIMS forebodes a question: what made the patient stay this long, or does the patient even needed to be admitted in the first place? Length of stay is measured for cost effectiveness relative to expected DRG for every admission. In a resource-intensive clinical setting, every added stay must meet the criteria for medical necessity. Two of the top reasons for a longer extended stay than originally forecasted are: number one, patient developed some complication(s) and second, patient has co-morbidities (secondary conditions) that add complexities to the medical case, which made intervention become more intensive and that patient recovery takes more (longer) days. Should hospital stay be extended due to the above reasons, hospital finance team hopes it’s because of the latter rather than the former.

Diagnostic procedures

·?????? To establish the validity of a diagnosis, tests need to be performed in the form of a bloodwork (laboratory) or imaging. The kind of tests that providers order depends on the patient’s presentation upon admission to the hospital. The most common ones that doctors order are metabolic panels (BMP or CMP) and complete blood count (CBC). Both, tell stories why patient needed to be admitted. Because these tests are comprehensive, they may also reveal abnormal findings that provide clinical information on patient’s pre-existing conditions. Additionally, abnormal findings gathered from these results can be construed as incidental, in which case, the ICD 10 CM coding guidelines clearly stated that incidental findings that are not confirmed by the provider in their notes, shouldn’t be coded. Meaning, that labs and imaging results and impressions alone are not enough good reasons to justify the assignment of the codes, especially if they don’t affect current care. For conditions to be captured for code assignment, a provider will need to be intentional in ordering for specific diagnostic test or procedure, and results should be confirmed and documented in the note.

???? In summary, all healthcare providers expect to get paid optimally. A hundred percent reimbursement is next to impossible, but denials can be mitigated by accurate/diligent coding. By merely citing pre-existing co-morbidities, which are commonly reflected in patient’s “active problem list” is not an affirmation of the conditions’ active status. ?This is why hospitals need a more robust CDI program that can bridge the gap between clinicians and the revenue management team. The success of the CDI program depends on the participants’ level of commitment or “buy in.”? Each team member must understand the CDI program’s vision, mission and their role in the program and take that to heart. ?No opportunity should be missed, and no resources should go to waste. The enhanced collaboration among coders, CDI and providers is highly sought, not only for #reimbursement purpose but most importantly, to function as one solid care team that provides the best patient care for best patient treatment outcome. By adhering to this principle, organizations can be assured of getting the maximum reimbursement, and the highest STAR RATING possible.

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The author is a lead CDI for ED at UC Davis Medical Center. He is an active educator @valleymedicalcoding that trains and prepares candidates to sit for AHIMA’s CCS certification exam. He also provides consulting services to home health agencies on coding, billing, CDI, OASIS and POC. For class schedule you can DM or send an email to [email protected]

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