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Tag Archives: Coding

ICD10 coding for woman when male infertility is the cause of treatment

Hi all,

I’m hoping for some input on coding ICD10 for a woman receiving fertility treatment – IUI – when the male is infertile. Our providers keep using N46.9 – Male infertility for the woman, but, of course, it rejects as gender mismatch. Would Z31.81 (Encounter for male factor infertility in female patient) be an appropriate billable code for this situation? Any other input?

Medical Billing and Coding Forum – OB/GYN

Giving a coding presentation to SIU dept with no coder.. help?

I am speaking/giving a presentation on 7/7 on general coding information and coding error trends and how they relate to fraud and abuse to a government payer SIU dept. I have only ever spoken with providers and coders on coding and CDI related topics. I have never spoken with someone who is not well versed in coding guidelines or documentation guidelines.

Is there anyone here that has presented to a group of SIU’s or that IS an SIU that would be willing to connect with me through email?

My email is

thanks in advance!

Medical Billing and Coding Forum – Auditing General Discussion

Coding Manager Needed

Coding Manager
The Coding Manager will be accountable for successfully managing the Medical Coding team, audit documentation and coding practices to ensure accuracy in the data provided to CMS. The Manager will provide coding expertise as well as administrative oversight to ensure successful integration of AHC’s HCC initiatives.
General Duties/Responsibilities:
• Monitors coding & abstracting productivity and quality to ensure coding quality & performance improvement standards are maintained, achieved & improved.
• Establish performance guidelines in terms of quality and productivity measures
• Manage and maintain a comprehensive tracking and management tool for Coding workload and prioritization.
• Manage Coding activities for all assigned coders and ensure that all tasks are completed in a timely manner.
• Maintain a comprehensive tracking and management tool for assigned IPA’s within Alignments Healthcare provider network.
• Ensures compliance with all applicable federal, state &local regulations, as well as with institutional/organizational standards, practices, policies & procedures.
• Assist with CMS Data Validation activities, including suggested record selections, tracking and submission, in conjunction with Risk Adjustment leadership team.
• Keep updated on new statutes/regulations/policies and distribute updates as required
• Provides guidance in the coding/abstraction, production, and quality assurance, auditing and training activities
• Ability to work independently in a fast-paced environment
• Excellent verbal, written, and interpersonal communication skills
• Dependable, great attitude, highly motivated and a team player
• Possess strong organizational skills and attention to detail
• Other duties as assigned to meet the organization’s needs.
• Some travel as necessary (>10%)
Supervisory Responsibilities:
Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
Minimum Requirements:
Minimum Experience:
• Three-five years of coding in a medical group or health plan setting required; Professional Coding experience required.
• Previous use of EMR systems
• Proficient user in MS office suite
• Bachelor’s degree in Business Administration, health Care Management or in a related field or equivalent experience desired.
• Certified Coder required, CCS, CCS-P, CPC, Certified Auditor a plus.
• Experience with strategic planning in risk mitigation.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Link to apply: www.

Please copy and paste to browser.
For more information, please contact Tuyet Lu
Sr. Manager, Talent Acquisition
Alignment Healthcare
1100 W. Town & Country Road, Suite 1600
Orange, CA 92868
Office: 657-218-7537

Medical Billing and Coding Forum – Employment General Discussion

New to anesthesia coding

I’ve recently started billing anesthesia claims for a ASC and I’m having trouble getting BCBS to pay these claims and of course no one at BCBS can answer my question.

Are anesthesia claims billed on a 1500 or UB 04? That’s all I need to know. I’m entering these claims on the BCBS website and something isn’t right. Not sure if I’m entering something wrong or not entering something. The only thing I can get out of BCBS is that it’s not on the correct form.

Thanks in advance for any help.

Teresa D

Medical Billing and Coding Forum – Anesthesia

Independent Coding Contractors

If anyone provides independent contract coding please consider a listing at

Each participant receives a mini website in where they can display a list of services and other pertinent details. Participants benefit from our 40,000 weekly views and will be included in all marketing efforts.

If interested please view the following link or contact me directly.


Mark Sluyter

Medical Billing and Coding Forum – Hematology/Oncology

CPC, CANPC, CCVTC searching for a medical coding position

6154 Black Mallard Place, El Paso, TX 79932; Karolinska Institutet, 171 77 Stockholm, Sweden;,, 678-427-6511 cell, 915-642-4269 home

GOAL: Medical administration including coding, billing, audit, compliance, analysis, and training.
Expertise in medical coding, billing, auditing, compliance and medical records administration with 4 years of experience as CPC, CANPC, CCVTC. Presently employed full-time. In addition, deep knowledge of anatomy, physiology, disease processes, surgery and medicine with 3 years in-patient hospital experience in medical care.

Medical coding (ICD-9-CM, CPT, HCPCS), proficient coding with ICD-10-CM including Ophthalmology and Cardiology. Certified AAPC Anesthesia/pain Management Coder and Certified CCVTC Cardiovascular and Thoracic Surgery Coder. Expecting AAPC certifications in CCC Cardiology coding, CPMA, CPPM, CPHRM. Deep knowledge of anatomy, physiology, and disease management, expertise in use of medical coding software, professional conduct HIPAA and joint commission, Registered Health Information Administrator (RHIA) training, medical records analysis and management, HCC, Epic-like training, extensive clinical research and training experience, training in all areas of medicine and patient care. Well-versed in correct grammar and spelling, Excel, Word, PowerPoint, Outlook, and have strong work ethics, leadership, and self-management discipline.

Certified Cardiovascular and Thoracic Surgery Coder (CCVTC), American Academy of Professional Coders (AAPC), Salt Lake City, UT, March 2017
Passed CCVTC exam, American Academy of Professional Coders, Salt Lake City, UT, March 2017
Certificate, ICD-10-CM specialty cardiology code set training, American Academy of Professional Coders, Salt Lake City, UT, 9/2016
Certificate of Cardiology coding and Certificate of General Surgery and Anesthesia coding, Greenville Tech, 2/2016
MOOC certificate of attendance Health Data Analytics with MS Excel, St. Scholastica, MN, December, 2015
Certificate of Achievement, Coding-Baseline-ICD-10 Inpatient Diagnostic, Precyse University, USA December 4, 2015
Certified Anesthesia and Pain Management Coder (CANPC), American Academy of Professional Coders, August, 2015
Certified Outpatient Coder (COC), AAPC, June, 2015
Passed CANPC exam, AAPC, August, 2015
Passed COC exam, AAPC, June, 2015
Certified Professional Coder (CPC), AAPC, March, 2015
Passed CPC Exam, AAPC, October, 2013
Certified Coding Specialist-physician based (CCS-P) and passed exam, AHIMA, May, 2015
Certificate of ICD-10-CM proficiency, American Academy of Professional Coders (AAPC), January, 2014
Certificate of ICD-10-PCS proficiency, AAPC, January, 2015
Certificate of CPMA Medical Auditing, AAPC, December, 2015
Certificate of CPPM Practice Management, AAPC, January, 2016
Certified Medical Administrative Assistant (CMAA), National Health Career Associates (NHA), November, 2014
Certified Billing and Coding Specialist (CBCS), NHA, November, 2014
ICD-10-PCS Code set training (16 hours), American Academy of Professional Coders, Salt Lake City, UT, 1/2015
ICD-10-CM General code set training (16 hours), American Academy of Professional Coders, Salt Lake City, UT, 1/2014
Triple Certificate in administrative medical specialist, medical coding and billing, +medical terminology (360 Hours), University of Georgia, 3/2015
Graduate, Medical Coding Specialist Course (87% B average) (600 Hours), U.S. Career Institute, 2012-2013
Licentiate (M.S.) degree, Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, October, 2006
B.S. in Molecular Biology, Summa Cum Laude, Vanderbilt University, Nashville, TN, 1993

Remote Medical Coder and auditor for Altegra Health, USA, 1/2016 to present (gained equivalent of one year four months experience)
Performing coding medical records for clinics, doctors offices and hospitals including allergy, immunology, internal medicine, cardiology, dermatology, ophthalmology, pulmonology, pediatrics, OB/GYN, general surgery, orthopedic surgery, emergency medicine, radiology, anesthesia and pain management. Completed coder refresh and compliance training.
Remote medical coder, HGS USA, LLC, Peoria, IL, 9/2015 to 2/2016
Performed medical coding at 50 hospitals in USA. Coded electronic health records for inpatient and outpatient. Assignments from Hinsdale clinic services; Florida Waterman; Florida Hospital; and Tampa Hospital. Abstracted medical coding. Managed medical records. Utilized software Cerner, Dolbey, 3M Encoder Systems, Powerchart, and Sunport.
Medical coding trainee, CPC-A ICD-10 Practicum, American Academy of Professional Coders, 11/2015-7/2016
Performed coding utilizing ICD-10-CM codes for diagnosis. Did coding on 600 medical records with ICD-10-CM, CPT, and HCPCS for one year equivalent work experience. Abstracted codes from E/M encounters, hospitals, office visits, operating room, radiology reports, and pathology reports.
In-patient hospital rounds including ICU and CCU at Emory University School of Medicine, Yale-New Haven Hospital (Waterbury, CT), and Brown University/Lifespan Hospitals. 1995-1999.
Medical Researcher and Teacher at Karolinska Institutet, Stockholm, Sweden, 2000 to 2010
Proctor, National Board of Examiners in Optometry (NBEO), Stockholm, Sweden, 2003 to 2005

Marquis Who’s Who in Medicine and Healthcare 2006-2007
Presented and planned lectures on cardiology, CANPC anesthesia and pain management coding, CCVTC cardiovascular and thoracic surgery coding to AAPC, Southwest University forums, and TXHIMA
Published a book on CANPC Anesthesiology coding essentials for successful anesthesiology coding through AAPC
Nominated for vice president AAPC local chapter in El Paso, TX

Medical Billing and Coding Forum – Resume Postings

Frequently Asked Questions for Medical Coding and Billing Students

Hello Professional Medical Coding and Billing Students! Here are some frequently asked questions and their answers to your program: Q: How do I navigate to the next module? A: The Program Modules navigation tool is on the left side of each page in the program. • Click the plus sign (+) to view the list of modules in the program. • Click the module name to navigate to the first page of that module. Use this menu each time you navigate from one module to the next. Refer to the Program Navigation unit of the Program Orientation module for more…
Career Step Coding and Billing Blog

Briefings on Coding Compliance Strategies, November 2016

Navigating the 2017 pressure ulcer coding changes in newly released guidelines

By Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

As if coders and clinical documentation improvement specialists aren’t under enough pressure as it is, the advent of the 2017 Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding. The guidelines can be viewed here:

Considering that these conditions impact length of stay, require additional monitoring and nursing care, and ultimately affect reimbursement for facilities, it’s no wonder coding for these conditions is under increased scrutiny. However, with a solid understanding of these types of ulcers, taking the time to read and understand the coding requirements can alleviate the "pressure" of ulcer codes.


New terminology

In April, the National Pressure Ulcer Advisory Panel (NPUAP) revised the pressure injury staging system, which can be found here: Since then, the NPUAP has received positive feedback regarding the system, and in August, The Joint Commission adopted the new terminology.


The definitions for each type of pressure injury are now:

  • Stage 1 pressure injury: Non-blanchable erythema of intact skin
  • Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis


  • Stage 3 pressure injury: Full-thickness skin loss


  • Stage 4 pressure injury: Full-thickness skin and tissue loss


  • Unstageable pressure injury: Obscured full-thickness skin and tissue loss


  • Deep tissue pressure injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration


The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer. These are similar to the codes from the L89 category in ICD-10-CM, however, the system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.

The NPUAP no longer uses the term "pressure ulcer," and has replaced it with "pressure injury," since stage 1 and deep tissue injuries describe intact skin, not open ulcers. The system also introduced the new term DTPI with this update.


Incorporating these changes in ICD-10

CMS has been in discussion with the NPUAP to in-corporate the new terminology, however, these terms are not used in the 2017 ICD-10-CM/PCS code update. The incorporation of the pressure ulcer terminology will be directed by both CMS and The Joint Commission, and NPUAP is currently working to introduce the changes to the code definitions.


According to the NPUAP:


Some documentation requirements for pressure ulcer coding, such as using non-physician documentation for identifying pressure ulcer stages, hasn’t changed from 2016 to 2017. What has changed for 2017 is the requirements for coding the progression of stages.

For ulcers that were present on admission (POA) but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. Furthermore, if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

These new coding requirements differ greatly from 2016 guidance which required only the highest stage of the pressure ulcer to be reported for pressure ulcers that evolve into a higher stage during the admission.

These new requirements could have an impact on hospital-acquired condition (HAC) reporting, considering stage 3 and stage 4 pressure ulcers with POA indicators of either a N- No or U-Documentation is insufficient are considered to be HACs, and also are classified as major complications or comorbidities.

American Hospital Association Coding Clinic guidance from First Quarter 2009 stated that the National Quality Forum excludes progression of pressure ulcers that were present on admission as a serious reportable event (SRE), also called a "never event." The intent was not to penalize facilities for progression of a pressure ulcer that was POA, as these are difficult conditions and even with the best preventive measures in effect, ulcers may evolve to a higher degree. The revised guidance for 2017, which is necessitating that two codes be used to identify the different stages of a site, feels as if it’s changing the standpoint of whether the pressure ulcer evolution is now an SRE.

The latest Coding Clinic, Third Quarter 2016, has updated guidance for pressure injury terminology. They acknowledge the changes in definition by the NPUAP from pressure ulcer to injury and advise:

For a DTPI, there is an entry in the Alphabetic Index under "injury, deep tissue," with further guidance which states: "meaning pressure ulcer ? see ulcer, pressure, unstageable, by site." Therefore, per Coding Clinic, code a DTPI as an unstageable pressure ulcer by site.


What is in the future for coders?

Can coders expect to see changes in pressure ulcer terminology soon? The most recent Coding Clinic did not give a time frame for updates, thus the potential impact on hospital reimbursement is something we can only speculate on at this point. If a pressure ulcer evolves from a stage 1, 2, 3, or 4 during an inpatient admission, these ulcers could be identified as an HAC and therefore impact the diagnosis-related group.


Editor’s Note: 

Commeree is a coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts. She has many years of experience in the healthcare industry involving coding, auditing, training, and compliance expertise. This article originally appeared on JustCoding, and opinions expressed are that of the author and do not represent HCPro or ACDIS. For questions, contact editor Amanda Tyler at


A new sepsis definition: Finding coding compliance at a crossroads

This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS.


In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’ SEP-1 core measure), and ICD-10-CM coding compliance.

We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a "life-threatening organ dysfunction caused by a dysregulated host response to infection," differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term "severe sepsis," and discussed that the definition change impacted ICD-10-CM code assignment and compliance.

Definitions and clinical indicators in Sepsis-2 are available at, and definitions for Sepsis-3 are available at CMS’ definition of sepsis and severe sepsis for the SEP-1 core measure is available at


Coding Clinic update

Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated "coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis)."

Coding Clinic went on to write (emphasis mine):


In my opinion, this means that Coding Clinic is saying ICD-10-CM still embraces the coding of infections without sepsis, with sepsis but without organ dysfunction, and with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis), if the diagnosis is incorporated by the documenting physician. The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.

Alternatively, while Sepsis-3 states that the word "sepsis" requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents "severe sepsis" or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term "sepsis" (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.


Coding Clinic, Fourth Quarter 2016

As we discussed last month, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):


In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147?149 stated (emphasis mine):


Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI. Access these at and


Coding Clinic then went on to say that (emphasis mine) "a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system."

While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in the literature.

As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded. I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.

Solving the problem

In developing a sepsis strategy in light of these Coding Clinics, allow me to remind all of you that there are three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock unless he or she states what environment they are in. These are:

  • Clinical language ? Physicians have a language that we use in direct patient care that communicates well with other physicians; we learned this language in medical school, in residency training, and in reading our literature. Every physician knows what "urosepsis," "unresponsiveness," and "neurotoxicity" is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so that we can report them using the ICD-10-CM conventions. Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT) is a clinical language we use in our problem lists and so is Sepsis-3. ICD-10-CM is not. Not all physicians embrace Sepsis-3, thus some may wish to label a patient as having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them. See the articles listed above.
  • Coding language ? As discussed, Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without and with organ dysfunction, bases coding on the individual physician’s criteria and documentation, and requires clinical validation using reasonable criteria prior to code assignment.
  • Core measure language ? Defining cohorts with core measures, such as SEP-1, is a clinical abstraction based on clinical criteria and not necessarily based on what a physician writes. For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than that of Sepsis-3. Remember, however, that in 2017, if a physician documents severe sepsis and R65.20, and severe sepsis is coded, that record will be held accountable for the SEP-1 even if it doesn’t meet the SEP-1 criteria. View this regulation at

Therefore, allow me to suggest the following strategy to ensure a balance of compliance with all three of these environments:

1.Standardize the definition and documentation of severe sepsis first. I believe that the Recovery Auditors (RA) are looking for records with sepsis codes that do not have R65.20 or R65.21 (septic shock) as a secondary diagnosis as to deny these codes and their resultant DRGs. In so doing, I believe that the definition of severe sepsis should be negotiated with and standardized by the medical staff, which could incorporate any or all of the following three criteria:


No matter what criteria is used, be sure to coordinate its development and deployment with your quality, clinical documentation integrity, and coding staff so that if a physician documents severe sepsis or septic shock, the SEP-1 algorithm can be implemented.

Also, be sure that physicians explicitly link organ dysfunctions to sepsis, or preferably, use the term "severe sepsis" so that R65.20 is not inadvertently missed by the coders. If a clinical documentation specialist or coder obtains a record supporting R65.20, be sure to notify the SEP-1 manager to determine if it qualifies for the SEP-1 core measure.


2.Develop a facilitywide definition for sepsis without organ dysfunction. As noted last month, many physicians do not believe that organ dysfunction is required to diagnose sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, we must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding validation purposes. When it is documented by a provider without evidence of acute organ dysfunction, this statement can be used to rebut the RA’s denials. These will be handy if we are appealing beyond the first level.

3.Remind the RA that the ICD-10-CM guidelines are part of HIPAA and that coding is based on provider documentation. I’m sure that all of our contracts with private payers state that we will comply with federal laws, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign codes based on provider documentation, and not so much on what the RA thinks, and that Coding Clinic, First Quarter 2014, pp. 16?17, states that "the official guidelines are part of the HIPAA code set standards," we don’t want the RAs to violate HIPAA or our contracts with payers. This may require that our hospital attorneys or compliance officers weigh in, given that RAs have been known to deny codes based on provider documentation and want us to do the same.



Please recognize that this topic is very controversial and that the opinions expressed here are solely my own. I encourage all of us to discuss Sepsis-2, Sepsis-3, SEP-1, the 2017 Official ICD-10-CM Guidelines, and these Coding Clinics with our compliance officers and/or attorneys so that we can best support policies and procedures ensuring complete, precise, and compliant coding of sepsis in light of Sepsis-3. If you have success stories, please share them with me and the editor here at BCCS.


Editor’s note:

This article was part two of a two-part series. You can read part one in BCCS’ October issue. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.


Has your CDI program shifted its focus for optimal PSI 15 performance?

by Shannon Newell, RHIA, CCS, and AHIMA-approved ICD-10-CM/PCS trainer

The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).

Your clinical documentation improvement (CDI) program has likely focused on this measure due to the well-established challenges associated with accurate reporting of procedure-related accidental puncture/lacerations. Given the changes to PSI 15, should your CDI team shift its focus to promote and support accurate data integrity for this measure? Let’s take a look.

A fundamental understanding of patient safety indicator measures

Optimal data integrity for PSIs requires that we have the appropriate clinical documentation and reported ICD-10 codes to accurately reflect the following:

  • The numerator: The numerator for PSI 15, also called the "outcome of interest," reports the actual number of cases which experienced the accidental puncture/laceration.
  • The denominator: The denominator for PSI 15, also called the "cohort," establishes the population which is screened to identify the outcome of interest.
  • Risk adjustment: Denominator comorbidities, which have a statistically demonstrated impact on the likelihood of a patient incurring the patient safety event. The risk adjustment methodology establishes the expected number of discharges with the outcomes of interest.


The inputs above?numerator, denominator, risk adjustment?are used to calculate our observed over expected performance. CMS compares our performance to that reported by other hospitals, and our reimbursement may be then impacted if we do not appear to manage patients well.

For example, in the Hospital Acquired Condition Reduction program, if our performance for PSI 90 does not meet established thresholds, then our Medicare fee-for-service reimbursement is reduced by 1% the next CMS fiscal year (October 1?September 30) for every claim we submit.


The new PSI 15?what counts?

The revised measure specifications for PSI 15 have altered the numerator (outcome of interest). The denominator, or cohort?which represents the population at risk?has also undergone a noteworthy change).

The revised numerator and denominator greatly narrow the pool of discharges screened for accidental punctures or lacerations as well as those flagged with outcomes of interest.

From a CDI perspective, the likelihood of incorrectly reporting accidental puncture or laceration for the discharges included in the newly defined measure is greatly diminished.


PSI 15: Are you focused on risk adjustment?

Given that our performance for PSI 15 is assessed using our observed over expected rate of procedure related accidental puncture or lacerations, the CDI team’s focus may be better spent on strengthening the capture of comorbidities relevant to risk adjustment.

The AHRQ risk adjustment methodology looks for multiple comorbidities to calculate the predicted likelihood of accidental punctures/lacerations for each discharge.

The revision to the discharges included in the narrowed cohort has also impacted which comorbidities affect risk adjustment. This makes sense given that these comorbidities must be clinically relevant to the numerator and denominator. The number of comorbid categories has been reduced from 13 to 11. Some of the categories remain the same, some have been deleted, and new ones have been added.



Keeping abreast of revisions to claims-based measures is an expanded responsibility for today’s CDI program. These measures impact both reimbursement and quality profiles. Positioned with this information, the CDI program can then shift efforts to promote and support clinical documentation capture and accurate reporting of codes associated with areas of the greatest vulnerability and impact.



Editor’s note:

Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at (704) 931-8537 or Opinions expressed are that of the author and do not represent HCPro or ACDIS.


New clinical criteria definitions in 2017 Official Guidelines up the ante for coders

by Laura Legg, RHIT, CCS, CDIP, and AHIMA-approved ICD-10-CM/PCS trainer

The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.

Up the ante means to increase the costs, risks, or considerations involved in taking an action or reaching a conclusion. With the new coding guideline for clinical validation that went into effect October 1, the stakes remain high for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.

It is not that the information was not there before, but now the issue is finally getting attention. When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present. But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this has been a haunting issue for a very long time.

The ICD-10-CM Official Guidelines for Coding and Reporting are the foundation from which coders assign codes. Coders need to review the new guidelines in detail to understand the changes and implications for their facilities.

The Centers for Disease Control and Prevention published these new guidelines which can be read in their entirety here:


Taking a closer look

The coding guideline for section A.19 (code assignment and clinical criteria) has been labeled as controversial and, at this point, we have more questions than answers. Denials issued by payers due to the absence, or perceived absence, of clinical indicators by which the payer lowers the DRG is now being called DRG downgrading and it’s getting attention.

The code assignment and clinical criteria states:


Physicians and other providers document a patient’s condition based on past experience and what the clinician learned in medical school, which often differs from clinician to clinician. When you put a patient in front of a group of clinicians you will most likely get differing documentation. So how do we fix that?

The diagnosis of sepsis is a good example. There does not appear to be a universally accepted and consistently applied definition for the condition of sepsis.

In a patient record with the principal diagnosis code of sepsis, followed by the code for the localized infection, pneumonia, a payer denial could occur.

Payer denials often deny the sepsis diagnosis code stating that "the diagnosis of sepsis was not supported by the clinical evidence. Therefore, as a result of this review, the diagnosis code A41.9 [sepsis, unspecified organism] has been removed and the principal diagnosis re-sequenced to code J18.9 [pneumonia, unspecified organism] for pneumonia and to the lower paying DRG 193." This is now being referred to as a DRG downgrade. DRG downgrades can occur for different reasons including both DRG coding changes and clinical validation downgrades.


What is a coder to do?

What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart? Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of this coding guideline to coding practices.

Remember the section that reads: "the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient."

This represents a catch-22. If the diagnosis is not clinically validated, both recovery auditors (RA), as well as commercial insurance auditors, are going to deny the claim. On the other hand, if coders or the facility decide not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.

AHIMA’s 2016 Clinical Documentation Toolkit offers this advice:

The toolkit is available here:


Increasing clinical documentation

As the healthcare industry experiences an increased number of external audits, both federal and private, the need to up the ante on clinical documentation has become essential. The answer is not to let this guidance prompt lazy documentation, which has far reaching consequences, but to use it as a catalyst for improvement.

The goal of any clinical documentation improvement (CDI) program is to ensure a complete and accurate patient record, and this cannot be done without the presence of documentation supporting the clinical indicators and clear and consistent documentation regarding the condition. The provider’s documentation of their full thought process will accomplish this. If medical staff can come together and agree upon a definition for a certain condition, they can begin the process of being consistent with how the description is presented in the patient record.

CDI specialists and coders should not use the new guideline as an excuse not to query. Coders are not clinicians and, therefore, should not be expected to evaluate clinical criteria. Coding and CDI were separate functions, but, as audits from outside organizations expand, there is more emphasis on correct coding, DRG assignment, and the use of clinical criteria to support the reported codes, which means these entities need to work together.

The American Hospital Association’s Coding Clinic for ICD-10 instructs coders not to use background clinical information contained in their responses for code assignment. This information is only provided so the coders can make a judgment to query where there is incomplete documentation. Coders and CDI staff should review all chart documentation and data, and query when necessary to clarify inconsistencies in physician documentation.

Query the provi – Briefings on Coding Compliance Strategies