Wiki Need clarification on DM w/complication codes

[LuckyLily]

In the A/P the provider puts:

E11.21-T2DM w/diabetic nephropathy
E11.42-T2DM w/ diabetic polyneuropathy
morning FBS 160-200
Plan: increase Levemir to 10 U daily

My question. The provider documented what is needed for the DM but does not address the nephropathy or polyneuropathy anywhere in the note. Does the MD have to state something about these conditions as well? Or since the MD put it in the A/P its okay to capture these two HCCs?

If you have an article about this or a resource it would be appreciated.

 

[Pathos]

Perhaps this is just an internal policy, but we do not code anything that is not specifically addressed somehow by MEAT (except for the 9 Common Chronic Conditions...to an extent). In your example, because the neuropathy was not addressed in any other way, I would not pick up either neuropathy. However, because DM is one of the 9 Common Chronic Conditions, I would grab E11.9 + Z79.4 (insulin - Levemir).

Hope that helps. AAPC released an article this year in March on "Make the Connection "With" Casual Relationship", which I found helpful.

Hope this helps!

 

[Munzueta]

I will agree with Thomas as well. Now, to better understand your case, I think we will all need more information about the encounter in general. You are stating that the provider said DM w neuropathy and nephropathy but with no supporting documentation of treatment. Of course the linkage is there so there is no need to be concerned about using the combo codes for this case.

The main concern is, was this truly treated? What was the patient seen for? was the patient seen for another condition and the DM complications were secondary codes? I see it all the times, specially in the hospital setting, where providers will copy all DXs from the PMH and list them on the discharge summary and give you a long list of 10 DXs but only 1 was treated, and the other ones were not mentioned once. So alot of the times, they do something about those additional conditions, but they always say, if its not documented, it didnt happened. Just because they list a diagnosis, we really can't say that its a valid condition that was treated, how would an auditor see this? how would someone from the outside see this?

I see this as a good opportunity for physician education. I've noticed depending on where you work, it can also affect, as some people might say "thats not part of the coding" but then again, as a coder, and following your coding ethics, if you see a patient with no history of cancer, being seen for htn, and then the provider out of no where says breast cancer, will you just code it because he said so? what about the patient's record? what about the future consequences of a misleading or incorrect diagnosis? In my setting, we've learned to query conflicting documentation, inappropriate, or misleading, specially if there is no supporting documentation.

hope this information helps.

 

[rmwinder]

I will agree with Thomas as well. Now, to better understand your case, I think we will all need more information about the encounter in general. You are stating that the provider said DM w neuropathy and nephropathy but with no supporting documentation of treatment. Of course the linkage is there so there is no need to be concerned about using the combo codes for this case.

The main concern is, was this truly treated? What was the patient seen for? was the patient seen for another condition and the DM complications were secondary codes? I see it all the times, specially in the hospital setting, where providers will copy all DXs from the PMH and list them on the discharge summary and give you a long list of 10 DXs but only 1 was treated, and the other ones were not mentioned once. So alot of the times, they do something about those additional conditions, but they always say, if its not documented, it didnt happened. Just because they list a diagnosis, we really can't say that its a valid condition that was treated, how would an auditor see this? how would someone from the outside see this?

I see this as a good opportunity for physician education. I've noticed depending on where you work, it can also affect, as some people might say "thats not part of the coding" but then again, as a coder, and following your coding ethics, if you see a patient with no history of cancer, being seen for htn, and then the provider out of no where says breast cancer, will you just code it because he said so? what about the patient's record? what about the future consequences of a misleading or incorrect diagnosis? In my setting, we've learned to query conflicting documentation, inappropriate, or misleading, specially if there is no supporting documentation.

hope this information helps.

I agree with you... of course, one would not assign a breast cancer code if it were in the A/P without further support, such as continued treatment. I was operating on the fact that the original poster's record had a FBS report and instructions to continue Levemir. So there's no question that the pt has DM. The only question is whether or not the patient truly has nephropathy and polyneuropathy. Of course, in MRA, if there is a better encounter to support those conditions, then all we have to do is capture the code from the better encounter. And if the original poster is in a position to query, then that too is the best practice. All I'm saying is that in a patient with known DM, the physician saying in his assessment that the patient has a linked condition...it isn't up to us to change the code to E11.9. The physicians definitive statement was E11.21 and E11.42. If I am a coder in the office with the physician, I would ask for more information. If I am a coder/auditor in a remote office, I'd look for further clarification from my company's official guidelines. My company follows CMS and AHA Coding Guidelines. But I totally understand and agree with what you are saying. My employer always says to use our critical thinking skills. I would definitely not bump that down to a E11.9 though.

 

[rmwinder]

Just going to leave this right here! From ICD-10 guidelines in the front of everyone's book... Of course, use your best judgement. If a doctor documents a critical care code only to be used in an acute care setting, and he doesn't document the patient going right to the hospital, then, no, don't capture that, even if it is the A/P.

 

[Pathos]

So I have had a little time to think on my response before posting, as my answer will be multilayered. Also, my name is not Thomas, although I like Edison's quote at the bottom of my signature line

First things first, I work for a payer so how we handle Risk Adjustment is a bit differently than on a provider side. That being said, we are all still dealing with the basic rules of Risk Adjustment, however the reporting might differ a bit.
Second, and I missed the "nephropathy" when I read the original poster's entry (a case of the Mondays perhaps), however my argument will still stand. As you probably know, Diabetes is one of the 9 Common Chronic Conditions that can be coded with little to no documentation support (meaning no need of other MEAT or TAMPER). In my eyes that ONLY pertains to the "vanilla" DM or E11.9/E10.9, and not any associated or linked casual relationship with DM. I will need to dig up my references (busy week for me), but I have references on this. For me to pick up such a linked condition, the nephropathy/neuropathy must have some type of MEAT or TAMPER associated with it or I will grab the vanilla DM instead along with an EDU note. This is also based on CMS audit results and a former CMS RADV level 2 auditor, aka my manager. Again, I will see if I can dig up references as support, but I just don't have time right now.
Third, while I do not think you are wrong @rmwinder , be careful with using such a broad brush as Guideline 19 for everything. Yes, we need to follow what the provider documents, and yes we all follow CMS and AHA Coding Guidelines, however there are some grey areas that can be left up to some interpretation. Like @Munzueta said, I would never code a Malignant Neoplasm code solely based on the provider listing the condition and otherwise NO MEAT. There is a specific Coding Clinic on this (again busy busy week for me) which I will need to pull up some other time.
Fourth, and I think this is also important. I recently plugged into an AAPC webinar on Risk Adjustment, and the presenter talked about the amount of Risk your company is willing to take. We know there are grey areas in coding, as everything is not black/white, however on those harder topics the organization you work with will need to take a stance on how "risky" they want to be in terms of Risk Adjustment. While you might "get away" with a substandard documentation of MEAT on some conditions, CMS will sometimes go back and audit you several years back. Health Plans recently received a HUGE Contract RADV audit with record retrieval back from 2013-2014, and I am sure you can imagine the problems such an old audit can potentially cause. I got more on this, but suffice to say, when CMS is out for blood, they are OUT for blood.

Lastly, thank you for challenging me @rmwinder as this helps keep me on my toes and keep my information straight.

I hope this is helpful!

 

[rmwinder]

@Pathos as it happens, I am not entirely comfortable with my responses. I am still looking into this too. In fact, I know I had the RADV audit rules document somewhere, and was trying to find time to see if there was any further guidance in that, but I cannot find it right now. I do believe you are correct...but I also know that RA guidelines state that for diagnoses in the Assessment: "Normally, these conditions should all be coded unless there is conflicting or contrary documentation in the encounter note (i.e. the rest of the documentation in the note is not inconsistent with the condition)". But still, it does feel weird, and I, myself, want a clearer answer. However, I wouldn't feel right in coding "Vanilla DM" (I love that, by the way!) when the doc said E11.42 either!

I also work for a payer, and I while I am sure I have had this scenario (I would think), I do not recall being dinged on an audit of my work. I'll keep looking also.

 

[mitchellde]

The way I look at this is the quidline specifies that the providers STATEMENT that a condition exist is sufficient. The provider list a code with its standard nomenclature is not the same as a providers diagnostic statement. This was also covered in a coding Clinic 1st quarter 2012. In this it was stated that a provider indicating a code with its descriptor could not be substituted for a diagnostic statement. A diagnostic statement must be in the providers own words that a condition exists. so in my mind the original post does not indicate a diagnostic statement for the diabetic complications. If the documentation were to mention that the patient has nephropathy and or peripheral neuropathy and the assessment then goes on to address the diabetes then yes I would code one or both as complications.

 

[Munzueta]

The way I look at this is the quidline specifies that the providers STATEMENT that a condition exist is sufficient. The provider list a code with its standard nomenclature is not the same as a providers diagnostic statement. This was also covered in a coding Clinic 1st quarter 2012. In this it was stated that a provider indicating a code with its descriptor could not be substituted for a diagnostic statement. A diagnostic statement must be in the providers own words that a condition exists. so in my mind the original post does not indicate a diagnostic statement for the diabetic complications. If the documentation were to mention that the patient has nephropathy and or peripheral neuropathy and the assessment then goes on to address the diabetes then yes I would code one or both as complications.

I see your point, definitely this is tricky depending on how we all see it. ☺

 

[LuckyLily]

Thank you all for responding to my original post. I find this a grey area as well.

This has led me to think about when a Podiatrist sees a patient and uses the dx of E11.49-T2DM w/other neurological complication or E11.51-T2DM w/diabetic peripheral angiopathy w/o gangrene. The Podiatrist is addressing the complications in foot exams, but not the DM. Would they then have to provide a status or statement about the DM.

I'm just trying to see what others do. I see it as the MD is giving the full diagnosis statement even though a portion of it is not addressed.

 

[rmwinder]

DM is one

The way I look at this is the quidline specifies that the providers STATEMENT that a condition exist is sufficient. The provider list a code with its standard nomenclature is not the same as a providers diagnostic statement. This was also covered in a coding Clinic 1st quarter 2012. In this it was stated that a provider indicating a code with its descriptor could not be substituted for a diagnostic statement. A diagnostic statement must be in the providers own words that a condition exists. so in my mind the original post does not indicate a diagnostic statement for the diabetic complications. If the documentation were to mention that the patient has nephropathy and or peripheral neuropathy and the assessment then goes on to address the diabetes then yes I would code one or both as complications.

With EMR's being the 'norm' now the following snip I've included is what you'll come across a majority of the time. What makes it acceptable is the Description column. We all know we cannot confirm a diagnosis code by the code...the alpha-numeric code itself, but the description of the code is perfectly acceptable as the physician's statement of a condition. It's almost a given with an EMR. Granted, a nice connecting Plan to each diagnosis is optimal, but this is the physician saying "this is what the patient has". There's support for the prostate ca, because of other info in the body of the note which I have not included, but where is any support for the Atherosclerosis of Aorta? There isn't anything else within the note. It is one of those conditions that is considered to be 'life-long', but I have no idea where the physician got that information. But I will confirm it because the doctor assesses that this patient has it.

 

[mitchellde]

Unfortunately the AHA coding Clinic was really clear in its report that the diagnosis must be in the providers own words and not the standardized code number with its description. I don't think what you have posted will work in the long run. I work for two different clients and we are not allowed to use these for coding purposes for either client.

 

[Pathos]

Based upon what you have given us (the image above), I would not report any of the HCCs. I would need to see the rest of the note in order to locate any MEAT or TAMPER for HCC coding support. Otherwise I 100% agree with Debra, in the sense that any HCC code reported must be fully supported, and listing a bunch of codes with coding descriptions is not MEAT, according to my references and my training. You would take a HUGE risk if you reported I70.0 based on the above, as I do not recognize any MEAT for that condition.

Thank you all for responding to my original post. I find this a grey area as well.

This has led me to think about when a Podiatrist sees a patient and uses the dx of E11.49-T2DM w/other neurological complication or E11.51-T2DM w/diabetic peripheral angiopathy w/o gangrene. The Podiatrist is addressing the complications in foot exams, but not the DM. Would they then have to provide a status or statement about the DM.

I'm just trying to see what others do. I see it as the MD is giving the full diagnosis statement even though a portion of it is not addressed.

This one can be a little tricky. Because of the Common Chronic Conditions rule, where DM is one of the nine conditions, I would pick up E11.9. However, if neuropathy and PVD/peripheral angiopathy were properly addressed and supported by MEAT, you could argue this casual link and bill both. Again, depending on documentation as every single note is unique, which is a major reason why Risk Adjustment coding is so hard to make blanket rules and black/white statements.
However, I would probably report both complication codes if I could find the casual link in the documentation.


Hope this is helpful and not further confusing!

 

[rmwinder]

Unfortunately the AHA coding Clinic was really clear in its report that the diagnosis must be in the providers own words and not the standardized code number with its description. I don't think what you have posted will work in the long run. I work for two different clients and we are not allowed to use these for coding purposes for either client.

Is there any way you can supply the AHA Coding Clinic you are referring to?

 

[Pathos]

I can provide an excerpt of the 2015 Fourth Qtr edition of AHA Coding Clinic. This service is a subscription, so I cannot just provide a complete copy of it:

"Question:
[...]We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number?"

"Answer:
Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient’s diagnosis, condition and/or problem. It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. [...] It is the provider’s responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes."

I hope this helps!

 

[rmwinder]

I can provide an excerpt of the 2015 Fourth Qtr edition of AHA Coding Clinic. This service is a subscription, so I cannot just provide a complete copy of it:



I hope this helps!

Thanks for the Coding Clinic! I actually have access to the Coding Clinics back through 2014, and I agree, the providers may not just list the Alpha-Numeric code in the diagnostic statement. In other words...they cannot just put E11.36 in the Assessment and expect that to be sufficient. But that does not mean that a physician cannot use the exact wording in ICD-10 to describe the diagnosis. They are allowed to say "Type 2 diabetes mellitus with diabetic cataract" ---which is the exact wording in ICD-10 for E11.36. Best practices would include writing a corresponding plan for each diagnosis in the Assessment.
However, according to CMS guidelines for ICD-10 coding for Medicare Part C and D, as well as the Official ICD-10-CM guidelines, and AHA Coding Clinic (See above excerpts from me).... and I think RADV guidelines say this, but I'd have to put my hands on that... The above sources say:
--Diagnosis in Assessment: Normally, these conditions should all be coded unless there is conflicting or contrary documentation in the encounter note (i.e. the rest of the documentation in the note is not inconsistent with the condition).-- Basically, if the rest of the note does not contradict the diagnosis in the assessment.

My previous employer always made a big deal of getting us educator/auditors to get the Providers to move all chronic condition codes to the A/P. We had to go to the physician offices and teach them MRA. We auditors were always complaining, telling our company that a diagnosis could be outlined in the HPI, and we could pick it up from there...but this guidance from all these sources is why they wanted it moved to the Assessment. When the Physician notes a diagnosis there...He or She is saying definitively that the patient has this disease, and the physician's MDM is based on the Assessment.

It makes us all nervous to not have any support for those diagnoses like the original poster was talking about, but if the official guidance is to pick those up "unless there is conflicting or contrary documentation in the encounter note"..we can do it without fear of reprisal because that is the guidance. Really, that's our support. As coders, we want support, and we can get hung up on 'support' so much that we feel like we can override the physician. But we have to remember that we can't.

Of course, if anyone comes up with any other sources to lend more weight one way or the other, please post it. I'm kind of fascinated with this now. Like I say, I'm an auditor, I review other coders work, and mine gets reviewed regularly. I have never been dinged on capturing a diagnosis from the Assessment. And again, there are conditions you have to be careful with, like cancer. Thank You!

 

[mitchellde]

I was referring to first quarter 2012 which was more indepth and detailed but the 2015 works also. It was in the 2012 version where they stated it must be in the providers own words. I think selecting a code number that is accompanied by the standardized description is the same as selecting just the number. it is not the same as stating the diagnosis in their own words.

 

[Pathos]

In this day and age of EHR, we should all be familiar with copy+paste/pulling "cloned" information into the chart. Another problem is when the provider selects the diagnosis from a limited number of preloaded diagnoses, the selection might not be always correct or appropriate. The fact that the alpha numeric code is listed with the code book description is not enough to support MEAT in my book. The provider only selected a code, and should somehow address the condition appropriately somewhere in the chart. For example:

F33.0 - Major Depression, Recurrent, Mild

Stable on Seroquel.

This clearly indicates that the provider is acknowledging the existence of the condition and is supporting with MEAT.

F33.0 - Major Depression, Recurrent, Mild

This only states the code and description, and does not show anything beyond what was pulled from the ICD-10 or EHR. I would be very hesitant to report this code, unless there was something else in the chart to support this condition.

I'll see if I can find more supporting references to my claim later.

 

[mitchellde]

Here is one for you.. Provider chose code A52.16 for Charcots arthropathy., in the assessment and plan portion of the note. The problem is since that is the code and description inserted into the assessment, that is the code the coder put on the claim. when it was then disputed (with my help) the coder adamantly stated this was the diagnosis assigned by the provider. The only problem is , it was not. The provider in the exam and discussion clearly intended this to be charcots arthropathy of the ankle due to diabetes which is an entirely different code. this patient has never had syphllis which is the basis for A52.16. The provider had no idea because he only saw the number and the standardized description and did not know. this is the problem with using the standard code number with description from the book,. The providers narrative must be the diagnosis

 

[rmwinder]

Here is one for you.. Provider chose code A52.16 for Charcots arthropathy., in the assessment and plan portion of the note. The problem is since that is the code and description inserted into the assessment, that is the code the coder put on the claim. when it was then disputed (with my help) the coder adamantly stated this was the diagnosis assigned by the provider. The only problem is , it was not. The provider in the exam and discussion clearly intended this to be charcots arthropathy of the ankle due to diabetes which is an entirely different code. this patient has never had syphllis which is the basis for A52.16. The provider had no idea because he only saw the number and the standardized description and did not know. this is the problem with using the standard code number with description from the book,. The providers narrative must be the diagnosis

Certainly. That's why we are certified to catch those sort of things. In that scenario, you'd definitely delete the one and capture the correct one. I am in no way saying just capture everything in the A/P and be done with it.
1. If no support - Query
2. If you cannot query - if you work for a payer - go to your company guidelines and the ICD-10 guidelines and AHA Coding Clinic guidelines...Which say: Diagnoses in the Assessment: Normally, these conditions should all be coded unless there is conflicting or contrary documentation in the encounter note

Maybe that's the problem...we're talking apples and oranges. If I worked in a physicians office, there'd probably be a stack of queries!

I don't know. All I know is that sometimes it is appropriate to let the diagnosis in the assessment to go through even if it isn't glaringly supported. If it isn't contradicted. Otherwise, the audit results on my auditing work would just be horrible! I work for a huge payer, and they try to follow CMS and RADV guidelines to the letter. In the end, we have to follow our company's rules. Maybe that's the difference.

Happy Auditing/Coding!

 

[Pathos]

I would caution your rhetoric here. Your setup is that your company follows CMD and the RADV guidelines to the letter, and suggest that the rest of us don't. While I do believe we might have hit a stand still or passe if you will, there is no need to thumb your nose at the rest of us here. Yes, there is wide variety mix of coders and the employers we work for on the AAPC forum, but please do not think that we disregard the CMS and RADV guidelines. We are all very passionate and take pride at what we do, and have done this for a long time. I work for a large payer, as you...sounds like others work for physicians; however we are pretty successful at what we do as we follow CMS and the resources given to us, even to the letter as you say.

 

[Pathos]

@rmwinder thank you for proving my point here. While I welcome and even promote other people point's of views, ideas and suggestions any day, along with their interpretation of rules and guidelines; I do not care for passive aggressiveness and blatant verbal attack on users here on the forum. You often mention that your office follows CMS and AMA rules and regulations, which is great as we all should do so. However, when you write that :"I work for a huge payer, and they try to follow CMS and RADV guidelines to the letter. In the end, we have to follow our company's rules. Maybe that's the difference.", how can you not suggest that you and your company does the right thing, and the rest of us don't. You literally state "Maybe that's the difference." That is where I see you thumbing your nose at the rest of us. That is where your passive aggressiveness jumps out. I do not see this as a type of personal arrogance, but trying to protect my fellow coders' reputation.

However, with everything said, perhaps this is simply a case of a clash of strong personalities. We clearly both feel very strongly about the topic, albeit our viewpoints are different in certain aspects. At the end of the day, I do believe we both can agree that the CMS and AMA rules and guidelines trumps any local company policies. At the end of the day, that is what should matter and will determine whether we pass a RADV audit or not.

I like your fire and commend your spirit, @rmwinder , all I ask is to consider how your wording might be interpreted and seen by other people.

 

[Munzueta]

I think this thread is now going a different route!

One thing I can say, is that when we write a message or post anywhere, whether its here on the AAPC, facebook, emails, twitter, etc, is that when we read it we can assume a tone.
@rmwinder and @Pathos
Keep in mind coding can definitely be gray, meaning there are guidelines, cases, instructions that can be read in different ways. I've always say, you can give a 1 record to 10 coders, and you will get different codes!

So I think there was some miscommunication and maybe some of the statements made by both of you sounded like you were showing off, or making someone feel less, but as I read it, I dont think that was the case, when you type something, and read it, there is really no emotion behind it, if you know what I mean.

afterall, we all do the same thing for a living, so how about we just take a break from this thread?!

 

[racheljonestn@yahoo.com]

Was there anything else you could glean from the record? Like meds, or labs, or musculatory pain, etc?