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

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: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.

 

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: http://bok.ahima.org/PdfView?oid=301829.

 

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 provider to support their diagnostic and procedural documentation by making a specific reference to the clinical basis of the diagnosis, and also by noting the absence of specific expected criteria such as radiographic findings, lab values, or patient manifestations.

External auditors in turn need to be following the same rules and coding guidelines as we do. Reviewers for facilities plagued by copious denials are finding auditors making up their own rules, using obsolete or outdated criteria, and clearly not understanding basic terminology used in the 2017 IPPS final rule.

DRG downgrading may be illegal, and some states intend to find out using state level legislation. Downgrading is, at the very least, disregarding the physician’s clinical judgment. We can’t forget who has eyes on the patient. Coders and CDI specialists should take documentation one step further and ask physicians to document their thought processes, the clinical indicators they are seeing, and their rationale for diagnosis determination.

Remember, coding is not based on clinical criteria. Coders cannot disregard physician documentation based on clinical indicators in the patient record, so, we will always need to ensure documentation is complete, accurate, and reflective of the patient’s clinical condition.

 

Editor’s Note:

Laura Legg, RHIT, CCS, CDIP, is an AHIMA-approved ICD-10-CM/PCS trainer, and director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. For questions, please contact editor Amanda Tyler at atyler@hcpro.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

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Coding for Cervical Cancer Screening – Pap test results, definitions and ICD-10

This was originally written back in April of 2016….  
4/23/2016
Cervical Cancer Screening – Pap test results, definitions and ICD-10
A Cervical cancer screening test, also known as a Pap (Papanicolaou test) is used to find abnormal changes in the cells of the cervix.  If abnormal cells are found, those cells can potentially mutate into cancer cells within the cervix.   Cervical cancer screening includes the Pap test and, some providers also perform an HPV (Human Papilloma Virus) test. 
When the provider performs a screening or diagnostic Pap test, both tests use cells taken directly from the cervix. The cells that are removed from the cervix, put into a special liquid and sent to the laboratory for testing.  If only the Pap test is performed, the cells are reviewed and examined to see if any “abnormal” cells are present with “normal cells”.  When the HPV testing is performed, the cells are then reviewed to see if the HPV virus is present within that sample.  Most pathology labs will sample for 13 or 14 of the most common high-risk HPV types. 
According to ACOG (The American College of Obstetrics and Gynecology), the main cause of cervical cancer is infection with HPV. Unfortunately, there are many types of HPV, and some of the HPV infections are considered “high-risk” types.  It has been determined that with the most common cases of cervical cancer; most cervical cancers are narrowed down to two high-risk types of HPV—type 16 and type 18.  It is the abnormal cell types that can be found with these screening tests.  Abnormal changes can range from mild to a full blown case of cervical cancer.
Pap tests are most commonly procured at the time of the well woman exam, and are performed primarily as a screening tool for cervical cancer.  However, with the Pap test, sometimes the cells from the vagina are taken if the woman does not have a cervix. 
Pathology Acronyms and Definitions
As coders, we must know and understand all definitions that affect the diagnosis codes that we append to the procedure codes.  It is extremely important that we do not append an incorrect diagnosis to a patients’ medical record or billing.   The acronyms for cervical cancer screening tests are numerous.  Many of these terms have similar sounding verbiage, yet the definitions do not mean the same things. 
When reviewing the pathology documentation, the term ASCUS, is commonly seen.  This acronym means “Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASCUS)”.   Squamous intraepithelial lesion (SIL) is an acronym used to describe Pap test results. “Squamous” refers to the type of cells that make up the tissue that covers the cervix. SIL is not a diagnosis of pre-cancer or cancer.  In ICD-10 the term SIL is not noted, however, ICD10cm does refer to many of the other acronyms associated with pathology cells and cell types that are found with the Pap test.
The Pap test is most commonly performed as a screening test for changes to the cells within the cervix, but can also be used as a diagnostic tool too.   The changes in cell types found on the cervix can be a possible pre-cursor to a cervical cancer, or can be completely benign. If the changes in some of the cells cannot be exactly diagnosed, or noted by how severe the changes are in cervical cells, this would be documented on the pathology report as an ASCUS pap finding. 
To correctly code for an ASCUS pap we would look at the code of R87.610.  (R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US).  The R87 code set is part of the codes that are symptoms, signs and abnormal clinical and laboratory findings.  In addition to the ASCUS documentation on a pap result, the terms LGSIL and HGSIL may also be found.   LGSIL acronym stands for “Low grade squamous intraepithelial lesion on cytologic smear of cervix” . The term HGSIL is for the notation of “High grade squamous intraepithelial lesion on cytologic smear of cervix”.
Abnormal cytological findings in specimens from female genital organs
*      R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
*      R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
*      R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
Atypical squamous cells, cannot exclude HGSIL the possibility that there have been changes in the cervical cells found that raise concern for the presence of HGSIL.
Atypical glandular cells (AGC)—Glandular cells are another type of cell that makes up the thin layer of tissue that covers the inner canal of the cervix. Glandular cells also are present inside the uterus. An AGC result means that changes have been found in glandular cells that raise concern for the presence of pre-cancer or cancer.
If the term cervical dysplasia is documented, this term indicates that abnormal cells were found on the surface of the cervix.  A cervical dysplasia is classified as mild, moderate or severe, depending on the appearance of the abnormal cells.  Cervical dysplasia can disappear on its own or, it can develop into a more malignant form such as a neoplasm/cancer. Cervical dysplasia is also known as a Cervical Intraepithelial Neoplasia, or denoted as CIN. 
In ICD-10, if the term “mild cervical dysplasia” is documented and/or the term CIN I the corresponding code in ICD-10cm is to be coded to N87.0.    If the term “moderate cervical dysplasia”  and/or CIN II is documented, those terms correlate to be coded as N87.1.    However, if the term “severe cervical dysplasia”  and/or CIN III is documented , ICD-10cm guides us to the code set of D06.# and is denoted in ICD-10cm as a carcinoma in situ of the cervix uteri.   If the provider did not specify if the dysplasia is mild, moderate or severe, then the unspecified code of N87.9 should be chosen.   If the documentation is noted to be severe, then the code chosen in the D06’s needs to be specified as to endocervix, exocervix, other parts of cervix, or unspecified.   As you can see from the codes below a severe dysplasia is considered to be a carcinoma, in situ; meaning it is contained within the cervix . 
D06 Carcinoma in situ of cervix uteri
http://www.icd10data.com/images/2.gifD06.0 is a specific ICD-10-CM diagnosis code D06.0 Carcinoma in situ of endocervix
http://www.icd10data.com/images/2.gifD06.1 is a specific ICD-10-CM diagnosis code D06.1 Carcinoma in situ of exocervix
http://www.icd10data.com/images/2.gifD06.7 is a specific ICD-10-CM diagnosis code D06.7 Carcinoma in situ of other parts of cervix
http://www.icd10data.com/images/3.gifD06.9 is a specific ICD-10-CM diagnosis code D06.9 Carcinoma in situ of cervix, unspecified
 N87 Dysplasia of cervix uteri
http://www.icd10data.com/images/2.gifN87.0 is a specific ICD-10-CM diagnosis code N87.0 Mild cervical dysplasia
http://www.icd10data.com/images/2.gifN87.1 is a specific ICD-10-CM diagnosis code N87.1 Moderate cervical dysplasia
http://www.icd10data.com/images/3.gifN87.9 is a specific ICD-10-CM diagnosis code N87.9 Dysplasia of cervix uteri, unspecified
Glandular cells are another type of cell that make up the thin layer of tissue that covers the inner canal of the cervix.  Atypical glandular cells (AGC) can also be denoted on the pathology report, and those cells may be present in the specimen that was procured at the time of the Pap test.  These glandular cells also are present inside the uterus.  If a pap test denotes the patient has an AGC result, this represents changes have been found in glandular cells, which raises the concern for the presence of pre-cancer or cancer not only on the cervix, but a possibility of cancer cells that may be present in the uterus.
If the patient does have an abnormal cervical cancer screening (Pap) test result, the patient may require further testing. The first line of treatment is most often a repeat Pap test or a repeat Pap test and include testing for high-risk types of HPV.  Additional testing or procedures are recommended as a follow-up to some abnormal test results.  In addition to the Pap test, the provider may want to perform a colposcopy, biopsy, and endocervical sampling.  A colposcopy procedure is an examination of the cervix with a magnifying device that includes the tools to take a more in-depth sample of the cervix or targeted area on the cervix.
If an area of abnormal cells is seen, the physician may decide to perform a cervical or vaginal biopsy.   An endocervical and possibly an endometrial sample biopsy also may be done if the initial pap did show AGC.  As with any screening or diagnostic testing, follow up with the provider is crucial. 
When coding any of these tests, be sure that all results are clearly documented by the provider.   When coding for the initial procurement of the pap test, the codes below would be used  to bill for the procedure/procurement of the pap specimen, and for connecting the diagnosis driver to the screening process through the designation of an E&M code for the Wellness/well-woman exam. 

CPT codes 99384 – 99387 (new patient)
CPT codes 99394 – 99397 (established patient)
ICD-10: Z12.4 Encounter for screening for malignant neoplasm of cervix
ICD-10: Z12.72 Encounter for screening for malignant neoplasm of vagina
ICD-10: Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
HCPCS: Q0091 Screening Pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
            Note: The HCPCS Code Q0091 is a HCPCS code developed by Medicare for services provided to Medicare patients.  Medicare allows payment of code Q0091 for the collection of the pap specimen itself, and should only be reported if performed as a screening process.  The Q0091 is not to be reported if the pap testing is performed for a diagnostic or medically indicated reason.
In the table below, the most common CPT and HCPCS codes reported out by the laboratory for testing
Code Number
Description
CPT-4
87620
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique (Deleted 12-31-2014)
87621
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique (Deleted 12-31-2014)
87622
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus (HPV), human, quantification (Deleted 12-31-2014)
87623
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) (New 01-01-2015)
87624
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (New 01-01-2015)
87625
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed (New 01-01-2015)
88142
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision (ThinPrep)
88143
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening under physician supervision
88147
Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
88148
Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision
88152
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening under physician supervision
88154
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88166
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening under physician supervision
88167
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88174
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
88175
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision
HCPCS (normally used for Medicare patients)
G0123
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
G0124
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
G0141
Screening cytopathology, smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
G0143
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision
G0144
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision
G0145
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
G0147
Screen cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
G0148
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
P3000
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, by technician under physician supervision
P3001
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, requiring interpretation by physician
Wrapping it up
As a coder, remember to code what you know, and do not assume a correlation, or that similar “sounding” terms really mean the same thing.   If in doubt, or the documentation does not appear to be clear or is confusing, query the provider.  Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record.  Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician.  If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.   

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