Health Information Management

Examine documentation for clinical indicators that provide context for MCCs

JustCoding News: Inpatient, March 28, 2012

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Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. This can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.

Brain compression and herniation

Let’s take a closer look at the MCC list for fiscal year 2012, specifically the reporting of brain compression and herniation (code 348.4).

If the physician documents a midline shift of the brain for a patient who has a tumor or a bleed, query the attending physician for clarification on whether that is consistent with brain compression, said William E. Haik, MD, CDIP, director at DRG Review, Inc., in Fort Walton Beach, FL, who spoke during HCPro’s January 4 audio conference, “FY2012 CC/MCC List: A Clinical Review of Documentation Requirements for MS-DRGs.”

Clinically speaking, if the documentation references a midline shift then this naturally indicates compression of the brain. However, Coding Clinic, Third Quarter, 2011, p. 11, stated that coders cannot make this assumption and must query the attending physician when brain compression is not explicitly documented. When the physician treats the patient with Decadron® or surgery, this intervention supports the need for a query regarding brain compression, Haik said.

Physicians more commonly document cerebral edema but if the medical record reflects that the physician treated the patient with Decadron, surgery, or IV mannitol, it’s appropriate to query physicians regarding patients who have tumors or bleeds or for trauma patients. Therefore the query should request information as to whether the coder should report cerebral edema (code 348.5) as an additional diagnosis.

Cerebral hemorrhage

Coding Clinic, Third Quarter, 2010, p. 5, addressed the coding of iatrogenic and spontaneous cerebral hemorrhage (codes 431 and 997.02), and reinforced the position that coders should report these conditions for patients with a cerebral infarct who have a change in neurological status. This often prompts a CT scan, which shows bleeding into a cerebral infarct. This can occur spontaneously or secondary to a tissue plasminogen activator (tPA) infusion.

Pressure ulcers

For decubitus ulcers, coders may refer to wound care nurse documentation to code the stage of the ulcer, however, they may reference only the physician documentation regarding the site and the type of ulcer, Haik said.

“The clinical pearl here for a [clinical documentation improvement specialist] is that if the nurse merely documents the narrative description of the ulcer but doesn’t put the stage down—for instance, full-thickness skin loss—that’s an inclusion term in ICD-9-CM under code 707.23,” Haik said.

Therefore coders can report the stage based on the description, even though the nurse may not have stated “stage III.” The same holds true for a stage IV ulcer, Haik explained. An inclusion term is one that clinicians may use as descriptors for a particular code.

It’s important to note, however, that decubitus ulcers that are hospital-acquired conditions do not count as MCCs. Look at the ED documentation, and if a stage I ulcer is documented, and subsequently progresses during hospitalization to a stage III ulcer, then report the stage III ulcer as present on admission (i.e., indicator Y), meaning it does qualify as an MCC and doesn’t count against the facility from a quality perspective, Haik said.

Chronic kidney failure

Physicians learn in medical school that stage 5 chronic kidney failure indicates the patient is on dialysis. However, ICD-9-CM defines stage 5 as a glomerular filtration rate of less than 15, not necessarily needing dialysis, Haik said. However based on the excludes note under code 585.5, if a physician documents chronic stage 5 kidney disease and the patient is on dialysis, coders may report code 585.6 for an MCC.

Mallory-Weiss syndrome

ICD-9-CM terminology oftentimes does not coincide with common verbiage physicians document in the record. For example, physicians may document an esophageal tear for a patient after forceful vomiting and with a gastrointestinal bleed.

“You would then have to query the attending physician to determine whether this is Mallory-Weiss syndrome [code 530.7] since it’s not indexed in ICD-9-CM as an esophageal tear,” Haik said.

Severe malnutrition

Coding Clinic, Third Quarter, 2009, p. 6, clarified that it’s inappropriate for providers to report malnutrition condition Kwashiorkor (code 260) unless the physician explicitly documents this specific condition.

“This condition has been targeted by the [Office of Inspector General], and providers from California will know that several hospitals out there got raked over the coals for the reporting of Kwashiorkor when the physician only documented moderate protein malnutrition,” Haik said.

Although there is no nationally agreed upon criteria, Haik said he reports severe malnutrition only when the case meets fairly severe biometrics:

  • Ideal body weight of less than 70%
  • Pre-albumin of less than 5
  • Albumin of less than 1.5%
  • Lymphocytes of less than 1,5000/uL

Acute renal failure

When acute renal failure (codes 584.5–584.8) is associated with a specific renal lesion, it’s an MCC, Haik said.

“Far and away the most common renal lesion occurring in a hospitalized patient is acute tubular necrosis (ATN),” he explained. Oftentimes this occurs in patients who are severely dehydrated, particularly when it’s associated with hypotension that requires vasopressors, or when they have an underlying condition, such as sepsis.

Additionally, certain medications (e.g., radiocontrast media, some chemotherapeutic drugs, or antibiotics) may also cause ATN. As kidney tubules are responsible for the excretion of nitrogenous waste and reabsorption of water, as well as electrolyte and acidosis balance, tubular necrosis typically results in a significant and sustained rise in the blood urea nitrogen (BUN) and creatinine.

But be cautious about reporting acute renal failure due to an ATN simply based on laboratory findings alone, Haik said. A patient may merely have pre-renal azotemia, which occurs when there’s not enough blood flow to the kidney to allow for proper excretion of BUN and water. Pre-renal azotemia can result in the BUN rising much higher than the creatinine, meaning the BUN-creatinine ratio can be greater than 20 to 1.

Clinical conditions (e.g., severe heart failure, ascites, and dehydration) may result in pre-renal azotemia secondary to insufficient blood flow to the kidney

Acute respiratory failure

Consider new code 518.5x for respiratory failure and insufficiency following surgery and trauma. This is defined as the need for unanticipated intubation or prolonged intubation with mechanical ventilation for usually more than two days, Haik said.

Therefore, patients who have fairly minor procedures but are on a ventilator for greater than two days probably have postoperative respiratory failure.

“The caution here, however, is that even though it is an MCC, the Agency for Healthcare Research and Quality looks at that as a quality problem,” Haik said. “So if you get enough of those, you might get dinged by them even though you may get paid more money.”

Another potential pitfall that leads to inappropriate reporting of acute respiratory failure is that physicians and pulmonologists who surgeons may have called in for consults to manage patients postoperatively may document acute respiratory failure simply because the patients are initially on mechanical ventilation.

“This is an example of documentation habits that you may want to address with your medical leadership regarding the documentation of a postoperative respiratory failure that may not meet the standard definition,” Haik said.

Additionally, he added, “patients usually require some high-flow oxygen or frequent arterial blood gas monitoring to substantiate the reporting of acute respiratory insufficiency following surgery and trauma.”

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at

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