Health Information Management

News: Review coding, documentation guidelines for latest RAC target-neoplasms

CDI Strategies, September 2, 2010

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Confusing coding guidelines and insufficient documentation have made neoplasms a target area as HealthDataInsights—the RAC for Region D—recently said it will take a closer look at MS-DRGs 837–948.

“…[T]here are opportunities for error within this subset of MS-DRGs,” says Paul Evans, RHIA, CCS, CCS-P, data quality coordinator at California Pacific Medical Center in San Francisco.
Coders and CDI specialists should join forces to educate physicians about what constitutes thorough documentation, says Jane E. Werner, RHIT, CCS, vice president of compliance and healthcare classification services at First Class Solutions, Inc., in Maryland Heights, MO.
Physician documentation of neoplasms can vary greatly, making the coder’s job difficult, says Werner. For example, consider the following two excerpts, the second of which requires a query for clarification, and use them to educate physicians:
  • “The patient has a history of breast cancer with mastectomy in 2003. Chemotherapy completed for breast cancer with current metastasis to brain and liver.”
  • “Patient has metastatic breast cancer.”
When reading physician documentation, ask these important questions to help determine the principal diagnosis:
  • Is the primary cancer present or has it been eradicated?
    • If eradicated, don’t report it as an active cancer. Instead, report a personal history V code.
  • Is treatment directed toward a primary or secondary site?
    • When treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this is code V58.1x. When a patient is admitted due to a primary neoplasm with metastasis, and  receives treatment directed toward a secondary site only, designate the secondary neoplasm as the principal diagnosis.
  • Are there any other conditions that may have warranted admission?
    • If a patient with a known cancer is admitted and treated only for anemia, the anemia is the principal diagnosis. Refer to Coding Clinic, first quarter 1991, which includes a related scenario.
  • Is the patient admitted for dehydration due to the malignancy?
    • When the admission is for management of dehydration due to the malignancy or the therapy (or both)—and the patient only receives treatment for the dehydration—sequence the dehydration first followed by the code(s) for the malignancy. Be sure to review Coding Clinic, second quarter 2005, pp. 9–10, which includes an important clarification of this guideline.
Editor’s Note: This article first appeared in the August edition of Briefings on Coding Compliance Strategies.

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