Volume 1, #1

May 2004

In this issue:

• Coding News
  • Subsequent Hospital Care Codes
  • Physician Documentation Guidelines
• Smooth Operations
  • New & Familiar Faces
• Compliance Corner
  • Documenting Sepsis
  • ICD-9 CM/Coding Definitions
  • Documentation Do’s
  • Documentation Don’ts

Coding News

Subsequent Hospital Care Coders

By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management

How can a physician get paid when he or she is called to the floor to provide treatment for an inpatient when that treatment does not include a procedure nor meet the requirements for critical care? These types of services usually do not meet the requirements for a consultation service code. We posed this question to CMS and received their direction to use the Subsequent Hospital Care E/M codes, 99231-99233.

If the documentation criteria noted above are met, one of these codes may be assigned even if the patient was seen by the ED physician earlier in the day. In this case, the ED E/M would be assigned in addition to the appropriate subsequent care code. Likewise, if a procedure is performed during the encounter on the hospital inpatient unit, provided sufficient documentation is present, both the procedure and subsequent care code may be assigned. If the ED physician sees an inpatient multiple times on a single calendar date, the documentation for all visits will be used to determine the overall subsequent care E/M level.

The most important issue from a coding perspective is making sure the coder is aware of the inpatient encounter and has the documentation available for coding. Your LYNX coding manager will contact you to discuss adding these codes to your chargemaster and determine how the documentation will be made available for LYNX coders to review.

Physician Documentation Guidelines

CPT and the AMA have been talking about, developing, debating and testing clinical examples as a method for coding and auditing E/M levels for the last several years. Testing and audits performed at LYNX identified several concerns with this approach. Other testers had similar results. Clinical examples would have replaced both the 1995 and 1997 CMS Documentation Guidelines that are in use today. The May 10, 2004 Part B news reports that the AMA CPT Editorial Panel has voted to stop work on the clinical examples project. So for now, CMS says that physicians may continue to use either the 1995 or 1997 guidelines, whichever is more advantageous to the physician. LYNX coders will continue to use the 1995 guidelines for coding and auditing your ED records.

Operations Insight

New & Familiar Faces

By Shannon Weintraub, MBA
Director of Coding Operations/QM

As many of you are aware, we have recently undergone a reorganization of our management structure within the Coding Services Department at LYNX Medical Systems. As a result, we have added additional personnel to better serve the needs of our clients. I would like to take this opportunity to introduce you to the new and reacquaint you with those that you’ve come to depend upon:

New :: Wendy Gravely, MBA comes to LYNX with 10 years of healthcare experience, managing decision support, finance and internal consulting functions within Group Health Cooperative’s delivery system and at Premera Blue Cross.

Stacy Land has past experience as a practice manager and consultant for individual medical practices, including creation of two new clinics. She has been a Coding Operations Manager with LYNX for two years.

Laura Bennett, RHIT has worked at LYNX for more than 6 years. During her time at LYNX, she has taught both coder and physician education classes, managed our QM Department and has worked with our Coding Review Services (CRS) Clients as client manager.

Sally Strand, RN has been with LYNX for 15 years. She brings a clinical background in the Emergency Department, coding expertise and a solid foundation for providing consistently outstanding service to her clients.

Speaking of customer service—this is a top priority at LYNX as we are consistently looking to enhance the service we provide for you. Should you have any questions, please feel free to contact anyone of the managers above, Candace Shaeffer or me at 1.800.767.5969.

Compliance Corner

Documenting Sepsis—Coding Style May Enhance Reimbursement

Physicians often use the terms sepsis and septicemia interchangeably in their documentation. However for the purpose of coding and billing, they are not the same at all. The ICD-9 codes for sepsis, septicemia and systemic inflammatory response syndrome (SIRS) were updated with the 2004 ICD-9-CM code release. A diagnosis of SIRS or sepsis may support a higher level of physician service, whereas “urosepsis” most likely will not.

ICD-9 CM/Coding Definitions

Septicemia—a systemic disease associated with the presence of pathogenic microorganisms or their toxin in the blood

SIRS—systemic inflammatory response syndrome is the systemic response to infection or trauma. Diagnosing criteria includes two or more of the following:

• Temperature greater than 38° C (100.4° F ) or less than 36°C (96.8°F)
• Heart rate greater than 90 beats/min
• Respirations greater than 20/min
• White blood cell count greater than 12,000/mm3 or less than 4,000/mm3 or less than 10% immature neutrophils

Sepsis—SIRS due to infection (this definition supersedes any previous definitions where sepsis was equated with septicemia)

Severe Sepsis—SIRS associated with organ dysfunction (failure), hypoperfusion, and perfusion abnormalities

Septic Shock—a division of severe sepsis, where patients experience combined decreased systemic vascular resistance (SVR). Septic shock is sepsis with hypotension, a failure of the cardiovascular system. Therefore, septic shock meets the definition of severe sepsis.

Documentation Do’s

Document either “SIRS due to infection with organ dysfunction,” “septic shock” or “severe sepsis”:

If the diagnosis is “Bacteremia,” “Viremia” or “Septicemia”— include the causative organism if known (E. coli, staphylococcal, pneumococcal, H-influenzae, pseudomonas, unknown gram negative or gram positive)

If the patient is experiencing a systemic response to an infection (two or more of the criteria for SIRS listed above are met) document “SIRS due to infectious process” or “Sepsis” and include the underlying cause if known (eg. E. Coli sepsis, “pneumococcal septicemia”, “unspecified septicemia”)

If the patient is experiencing organ dysfunction related to infection, a lways document the associated organ dysfunction such as:

• Acute renal or respirator failure
• Document the underlying causative organism, if known.

Documentation Don’ts

Avoid documenting a type of sepsis as an anatomical area. Urosepsis is one example (this codes as an UTI unspecified). Instead, document:

• UTI with fever and dehydration or
• SIRS due to a UTI
• Septic shock due to E. coli or unknown organism