Health Information Management

Tips for problematic complications and comorbidities, A-Z

JustCoding News: Inpatient, November 11, 2009

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Many clinical documentation improvement (CDI) specialists and coders struggle with the CC and MCC lists due to their length, complexity, and specific documentation requirements. However, William Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, offered coders the following tips for improving CC recognition in the medical record to ensure appropriate capture during the July 23 HCPro audio conference “The CC and MCC MS-DRG Lists: A Clinical Review.”


Acute blood loss anemia (code 285.1): Beginning in October 2008, CMS removed chronic and unspecified blood loss anemia from the CC list. For example, physicians now must document the phrase “acute blood loss anemia” instead of “blood loss anemia” when describing a patient with a gastrointestinal bleed.

However, Haik notes that the word “acute” is a nonessential modifier for patients with postoperative blood loss anemia. (When you look up anemia, postoperative, due to acute blood loss in the alphabetic index of the ICD-9-CM Manual, you will find parentheses around the term acute, which means that the physician does not have to document “acute” for a coder to report code 285.1.)

“Some of the encoders lead you to using the word ‘acute,’ but it’s not necessary to query the physician as long as the physician documents ‘postoperative blood loss anemia,’ ” Haik says.

Angina, unstable (code 411.1): Despite some misconceptions, a coder may report unstable angina without querying the physician when the physician documents any of the following diagnoses:

  • Progressive angina
  • Accelerated angina
  • Initial (new onset) angina

Because angina unspecified is not a CC, some CDI specialists and coders query physicians using terms such as “unstable” or “preinfarction” angina. However, physicians may balk at these queries and state that the patient does not qualify for these more severe types of angina.

Haik recommends a different line of questioning: “A softer term, such as progressive, accelerated, or new onset [initial] angina may be more appropriate, and all group under [code] 411.1,” he says.

CDI specialists and coders should suspect and, therefore, query for progressive or accelerated angina in patients with a known history of chronic angina whose chronic angina becomes accelerated (i.e., it occurs from less activity than is typical), Haik says. In contrast, unstable angina requires aggressive physician intervention, such as IV nitroglycerine/morphine treatments.

When a physician documents acute coronary syndrome (ACS), he or she may not mean that the patient has angina, even though ACS, according to coding guidelines, also groups to 411.1.

“ACS is a spectrum of disease relating to ischemic heart disease—it could be a patient with unstable angina, or it could be a patient with an acute myocardial infarction,” Haik notes.

When a patient is admitted with acute chest pain and has elevated biomarkers such as elevated creatine phosphokinase (CPK) or troponin levels, query the physician to further specify the ACS as a subendocardial or transmural myocardial infarction.

Asthma (code 493.xx) with acute exacerbation or status: Look for acute exacerbation of asthma in patients who have pneumonia, are wheezing, and for whom the physician treats the asthma by ordering an administration of drugs such as Solu-Medrol® or Prednisone.

“Those drugs are not used for pneumonia; they are used to reduce inflammation in a patient who has a reactive airway disease such as asthma,” Haik says. If this clinical picture is present, query the physician for acute exacerbation of asthma.

Atelectasis (code 518.0): When a radiologist provides documentation of an isolated radiographic abnormality, and the attending physician does not address it (e.g., through treatment or further evaluation), do not query the physician for this condition.

“These and isolated laboratory abnormalities are being targeted by [Recovery Audit Contractors] for inappropriate reporting of additional diagnoses,” Haik says.

Bacteremia (code 790.7): When a physician documents positive blood culture, it is a synonymous term for bacteremia within ICD-9-CM. Therefore, a CDI specialist or coder does not need to query the physician to report bacteremia.

Body mass index (BMI) less than 19 or greater than 40 (code V85.x): A coder may report a BMI code based solely on a nutritionalist’s documentation; however, a physician must be the one to document an associated condition (such as obesity in a patient with a BMI greater than 40) if it exists.

Cachexia (code 799.4): When a physician documents the term “cachexic” in a patient’s history and physical exam, a coder may report code 799.4 provided that the physician treats it (such as with the dietary supplement Ensure).

Cardiomyopathy (excluding ischemic) (code 425.x): Cardiomyopathy does not act as a CC when the physician documents unspecified congestive heart failure as the patient’s principal diagnosis. In this instance, a CDI specialist or coder should query the physician in an attempt to specify the patient’s type of heart failure (i.e., acute or chronic, diastolic or systolic).

Colitis: Infectious colitis is a CC, but viral or unspecified colitis is not. Physicians often administer antibiotics such as Levaquin® or Cipro® to treat a colitis patient’s diarrhea, Haik says. In these instances, the CDI specialist or coder should query the physician as to whether he or she is treating a bacterial infection—even if the physician cannot specify the type of bacteria. When the physician answers in the affirmative, a coder may report bacterial colitis, which is a CC.

Colon, redundant (code 751.5): This is an unusual additional diagnosis and resides in chapter 14 of the ICD-9-CM Manual (congenital anomalies). Review the diagnostic impression of the colonoscopy report for evidence of redundant colon in patients admitted for gastrointestinal conditions.

Chronic obstructive pulmonary disease (COPD), acute exacerbation (491.21): COPD with acute exacerbation may serve as a coequal principal diagnosis in a patient with pneumonia. When a coder sequences acute exacerbation of COPD as the principal diagnosis, the case groups to MS-DRG 190 with a relative weight (RW) of 1.3030. However, when a coder sequences pneumonia first, the final MS-DRG is 194 with a RW of 1.0056. But remember that you must follow the definition of principal diagnosis (i.e., the condition that, after study, was found to be chiefly responsible for that patient’s episode of care) when sequencing these two conditions.

Drop in hematocrit (code 790.01): When a physician does not document acute blood loss anemia in a clinically appropriate circumstance, a CDI specialist or coder may query the physician for a drop in the hematocrit. However, note that ‘anemia’ is an excluded term for code 790.01, which means that when the physician documents it in the record, a coder may not report 790.01 based on this term alone. “At that point, you would have to ask the physician to specify acute blood loss anemia if it is clinically applicable,” Haik says.

Drug-induced delirium (code 292.81): Physicians often document confusion or “sundowners” secondary to postop pain medications in the medical record. When this occurs, query the physician to determine whether the condition can be further specified as drug-induced delirium.

Esophagitis, acute (code 530.12): Note that many physicians document the term “esophagitis,” which is not a CC. However, acute esophagitis is a CC, so query for it in clinically appropriate circumstances (e.g., when a patient receives treatment for esophagitis).

Hemiplegia and hemiparesis: Physicians frequently document left- or right-sided weakness, particularly for patients with a previous or current cerebrovascular accident (CVA). This presents an opportunity to query the physician to specify whether the left- or right-sided weakness is a late effect of the CVA (code 438.2) or as hemiplegia and hemiparesis (code 342.xx).

Heart failure, chronic, systolic, and/or diastolic (428.x2): Systolic heart failure is the inability of the ventricle to contract normally and forcefully, typically diagnosed by a review of the patient’s echocardiogram. The echocardiogram may show left ventricular wall dysfunction (i.e., dyssynergy) or akinesis (i.e., when no part of the wall contracts). A second indicator of systolic heart failure is the patient’s ejection fraction (EF), which is the percentage of blood ejected from the left ventricle during systole. A typical patient’s EF is approximately 60% to 70%. When the medical record indicates an EF of less than 40%, the CDI specialist or coder should query for systolic heart failure, Haik says.

Patients in diastolic heart failure may have a normal EF because their ventricle contracts normally. However, their ventricle does not fill adequately with blood. This is because the ventricle may be too stiff to expand and accommodate its normal blood volume or may be due to increased muscle wall thickness, which results in reduced ventricular cavity size. Therefore, patients with diastolic heart failure have a significant reduction of blood in their ventricle and a subsequent reduced cardiac output despite having a normal EF.

Common causes for chronic systolic heart failure are ischemic heart disease and idiopathic cardiomyopathy. Common causes of diastolic heart failure are hypertension (especially in females) and hypertrophic cardiomyopathy.

Note that in many patients with chronic heart failure, abnormalities of both ventricular contraction and relaxation coexist; therefore, chronic systolic and diastolic heart failure may occur simultaneously.

Malnutrition (code 263.9): Malnutrition is one of those rare examples “where the less you specify it, the more likely it is to be a CC,” Haik says. That’s because malnutrition, unspecified is a CC, whereas moderate or mild malnutrition are not.

According to Haik, some clinical criteria to consider for malnutrition include the following:

  • Ideal body weight > 70, < 85
  • Pre-albumin > 5, < 15
  • Albumin > 1.5, < 3.5

Neuropathy, autonomic, peripheral (code 337.1): This condition may exist in patients with diabetes or amyloidosis.

Pathological fracture (code 733.1x): CDI specialists and coders need to phrase their physician queries carefully regarding pathological fractures, Haik says. For example, many physicians will not respond to queries in which a CDI specialist or coder asks whether a patient with osteoporosis has a pathological fracture.

“When we as physicians hear the term ‘pathological,’ we tend to think ‘cancer with metastasis,’ but ICD-9-CM defines pathological fracture as occurring with less than the expected amount of trauma,” he says.

Therefore, couch your query by asking the physician whether a patient’s fracture was nontraumatic, osteoporotic, or spontaneous. These are synonymous terms with pathological and do not require a further query.

Renal failure, chronic, stages IV and V (code 585.x): Physicians often document the nonspecific term “chronic renal insufficiency” or chronic renal failure without providing the stage. In these situations, review the patient’s glomerular filtration rate (GFR), located in the basic metabolic profile. Haik suggests querying for stages IV and V based on the following criteria:

  • Stage IV: GFR < 29
  • Stage V: GFR < 15 (and the patient is not on dialysis)

Respiratory failure, chronic (code 518.83): Query for this diagnosis when a stable patient with COPD or interstitial lung disease is on chronic home oxygen therapy, or when the medical record contains evidence of oxygen dependence.

Respiratory insufficiency and/or distress, acute (code 518.82): Do not report this as an additional diagnosis when the physician documents acute exacerbation of COPD, since acute respiratory insufficiency and/or distress is considered integral. However, when a patient is admitted with pneumonia, acute respiratory insufficiency and/or distress is a qualifier for how sick the patient is. Query for the presence of this diagnosis based on the following criteria: PO2 > 60, < 70 with symptoms and treatment.

Rhabdomyolysis (code 728.88): Physicians tend to abbreviate this diagnosis using an up arrow CPK. This presents an opportunity to query the physician for rhabdomyolysis.

Schizophrenia, most types, except unspecified (295.xx): Physicians frequently fail to document the type of schizophrenia. Ask the physician to document whether the schizophrenia is chronic, because chronic undifferentiated schizophrenia (code 295.6) is a CC. An appropriate instance for query is the presence of documentation indicating that the patient is on long-term psychotropic drugs.

Thrush (code 112.0): Physicians often document “sore mouth” instead of this diagnosis, Haik says. CDI specialists and coders should look for documentation of drugs used to treat thrush, which include Mycostatin® and Diflucan®, to form an appropriate query.

Urinary tract infection (UTI) (599.0): Coders may report UTIs when physicians document them in the medical record even when they are only treated with oral antibiotics. However, in those circumstances when the physician only documents “pyuria,” a CDI specialist or coder must query the physician for further specification of a UTI prior to reporting code 599.0 as an additional diagnosis.

Editor’s note: This story was originally published in the October issue of the CDI Journal. Learn more about the Association for Clinical Documentation Improvement Specialists.

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