Health Information Management

Understand the complexity of coding for conditions that aren't named in documentation

JustCoding News: Inpatient, October 14, 2009

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by Joel Moorhead, MD, PhD

Editor’s note: This is the first article in a two-part series. Part one addresses coding from insufficient documentation. Part two will address coding challenges associated with documentation that does not match ICD-9-CM code descriptions.

Physicians may document clinical indicators of significant conditions, but they may not actually name the conditions themselves.

The American Health Information Management Association (AHIMA) query brief titled “Managing an Effective Query Process” advises coders to query physicians “to obtain a condition for which clinical indicators are present but the provider does not indicate the actual condition itself.”

This practice brief provides helpful guidance for when it’s appropriate to query physicians to obtain the information you need to code all significant conditions that affect resource utilization and reflect complexity of patient care.

Consider the following examples.

Documentation includes clinical indicators, not condition

Functional quadriplegia: ICD-9-CM code 780.72 defines functional quadriplegia as “complete immobility due to severe physical disability or frailty.” Coders may never see the term ‘functional quadriplegia’ documented in a medical record; however, documentation may include ‘complete immobility’ for patients who are frail or who have disabling physical conditions.

Nurses’ notes may include documentation stating the patient is ‘total care.’ The patient may have additional conditions that are associated with functional immobility (e.g., decubitus ulcers, extremity contractures, and advanced dementia).

Most or all hospitals require staff members to document the patient’s Braden Score to assess his or her risk for pressure ulcers. Note the following Braden scores:

  • 1: Indicates complete immobility
  • 2: Indicates very limited mobility, meaning the patient makes slight changes in body or extremity position but is unable to make frequent or significant changes independently

Some hospitals have developed standardized query forms to obtain clarification regarding functional quadriplegia.

Other ‘functional’ conditions: In the ICD-9-CM Manual’s Alphabetic Index, the heading ‘Functional,’ states only “See condition.” ICD-9-CM listings and definitions that contain the word ‘Functional’ include, but are not limited to, the following:

  • Code category 306.xx (Physiological malfunction arising from mental factors), which should be assigned for functional disturbances or interruptions due to mental or psychological causes (e.g., psychogenic paralysis, cardiac neurosis) that do not involve tissue damage. The attending physician may document a functional disorder without tissue damage that could correspond to the respiratory (code 306.1), cardiovascular (code 306.2) or other body system listing under code category 306.
  • Code 788.91 (Functional urinary incontinence), which refers to incontinence “due to cognitive impairment, or severe physical disability, or immobility.”

Systemic inflammatory response syndrome (SIRS): According to the ICD-9-CM Official Guidelines for Coding and Reporting that took effect October 1, systemic inflammatory response syndrome or SIRS (code 995.9) “generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis.”

The American College of Chest Physicians/Society of Critical Care Medicine Consensus Criteria for SIRS (Hall JB, et. al. Principles of Critical Care (2005), p. 700) states that the presence of two or more of the following clinical findings supports a diagnosis of SIRS:

  • Temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F)
  • Heart rate greater than 90 beats per minute
  • Respiratory rate greater than 20 per minute or pCO2 less than 32 mm Hg
  • White blood cell (WBC) count greater than 12,000/µL, or less than 4000/µL, or less than 10% bands

Clinical manifestations of acute organ dysfunction (Hall JB, et. al. Principles of Critical Care (2005), p. 701) include, but are not limited to, the following:

  • Hypotension
  • Acute elevation of serum creatinine
  • Elevation of pancreatic or liver enzymes
  • Impaired mentation
  • Hyperglycemia

It is common for a patient admitted with infection or trauma to have two or more of the SIRS criteria symptoms and additional manifestations of organ dysfunction. For example, a patient who is admitted with altered mental status, urinary tract infection (UTI), fever, and an elevated WBC count. Attending physicians would most likely manage the UTI on an outpatient basis or in a nursing facility when the UTI is uncomplicated.

The patient’s systemic illness in these admissions is often consistent with the ICD-9-CM definition of SIRS. Such admissions often appear to be due as much to SIRS as they are to the patient’s UTI. Therefore, consider querying the physician. List the patient’s symptoms and evidence of organ dysfunction. Ask the physician to provide a diagnosis when the documented abnormalities indicate a significant medical condition.

SIRS is one example of a condition for which the physician may document components but not the condition itself.

Documentation includes components of a syndrome, but not the syndrome

Dysmetabolic syndrome X: Coding Clinic, fourth quarter, 2001 states that “Dysmetabolic syndrome X refers to a cluster of related disorders that share an underlying metabolic cause (e.g., insulin resistance without elevated blood sugar level, dyslipidemia, obesity, and blood pressure elevation). Syndrome X is considered to be a major risk factor for coronary artery disease and hypertension.”

This Coding Clinic notes that CMS created code 277.7 (Dysmetabolic syndrome X) to uniquely identify this syndrome at the request of the American Association of Clinical Endocrinologists.

It is common for physicians to consider the combination of diabetes, obesity, hypertension, and hyperlipidemia to be consistent with dysmetabolic syndrome X, or ‘metabolic syndrome.’ This pattern of risk factors is likely to be significant for patients admitted for chest pain and other possible cardiovascular disorders.

As with SIRS, it may be reasonable to query the physician to provide a diagnosis when the documented abnormalities indicate a significant medical condition.

Infant of a diabetic mother: Coding Clinic, fourth quarter, 2004 states the following:
“Assign code 775.0 (Syndrome of ‘infant of a diabetic mother’) for a newborn with macrosomia and a diabetic mother. It is not necessary for the physician to document that the macrosomia is ‘due’ to the syndrome.”

Sometimes physicians clearly describe and document a patient’s medical condition, but there is a disconnect between the terminology that practicing physicians generally use and terminology favored by ICD-9-CM. Part two of this article will discuss these terminology issues, as well as other situations in which the physician or allied health team members document clinical indicators but not the condition itself.

Editor’s Note: Joel Moorhead MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Baltimore, MD. E-mail him at

To view the AHIMA practice brief, click here. Then click on “All current practice briefs in chronological order by publication date” and scroll down to the brief.

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