Clinical Specificity in Documentation

Clinical specificity involves having a diagnosis fully documented in the source medical record instead of routinely defaulting to a general term for the diagnosis. It is important to understand medical terminology in order to identify terms in the medical record that may be a more specific description of a general term. Communication with the physician is perhaps one of the key elements in improving documentation skills that allow for more specific coding. The following examples are guidelines and specific conditions selected from various chapters of ICD-9-CM (e.g., Circulatory, Respiratory, Neoplasm, etc.) that are representative of documentation and coding decisions that impact HCCs.

The first three examples involve situations in which a physician may use the most common code for all forms of a disease and conditions. Remember, this practice has had no impact in the past on physician reimbursement. With the Risk Adjustment models, physicians must be careful to code the correct forms and manifestations of diseases and conditions.

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Anemia (285.9) is the most commonly coded form of anemia in physician offices. However, there are many types of anemia. Some are in the models and some are not. If the term “neutropenia” is used to describe the anemia, it must be coded to the more specific diagnosis code 288.0 (agranulocytosis), which groups to HCC 45. “Refractory” anemia is coded 238.7 (HCC 44). It is important that physicians code

hese types of anemia accurately. t

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prior to developing neumonia (507.0 HCC 111), the more specific code should be reported.

l ot jor” or “recurrent”, then code 311 (depression, not

to condition when that condition is still active. Both of these errors can impact risk Pneumonia (486) unspecified is not in the model. If the organism responsible for the pneumonia (HCC 111-112) is known or if the physician documents that the patient aspirated

p

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Mental disorders in the HCC models require particular attention to specific wording in documentation and coding. Episodic mood disorders (296.XX, HCC 55) are mental diseases that

include mood disturbances such as major depression (296.2X-296.3X). Physicians are encouraged to carefully document the characteristics of the mood disturbance (e.g., mania, depression, single episode, recurrent episode, circular) and use specific mental disorder terminology in the final diagnosis. The coder is cautioned to exactly code only the narrative provided by the physician in the final diagnosis and not make any further assumptions based on the patient work-up. For example, in coding depression, carefu use of the ICD-9-CM index directs the coder to the correct type documented. If the physician does n

ocument specific descriptor terms such as “ma d

otherwise specified, not in the model) is used.

Use of “history of.” In ICD-9-CM, “history of” means the patient no longer has the condition and the

diagnosis often indexes to a V code not in the HCC models. A physician can make errors in one of two ways with respect to these codes. One error is to code a past condition as active. The opposite error is code as “history of” a

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The diagnosis statement “history of hip fracture” is not coded as a current hip fracture (820.8, HCC 158 but with a V code for orthopedic aftercare (V54.XX) or history of injury (V15.5), if appropriate. Neither

history of” code is in the HCC models. If a patient has a current

), acute condition, then the “history of” used to describe the recent occurrence.

of” a

necessarily an example of incorrect coding, it may indicate that e physician office is not coding correctly. Again, communication and clear documentation are essential

tation and medical terminology practices of the physician. Coders must be careful ot to assign a diagnosis to conditions that are not specified by the physician and cannot be validated by

mary) (170.9, HCC 9) vs. a

bone is

HCC models. Even if the type of cancer included in HCC 7 is of a different site Cs 8, 9, and 10, the HCC “

wording should not be

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The physician may actually intend to communicate that a condition is ongoing, but note the “history condition. An example of this is “history of Hepatitis C” (V12.09 personal history of other infectious disease). Hepatitis C generally presents as a chronic condition (070.54, HCC 27) that is rarely fully eradicated. While assigning V12.09 is not

th

to make the appropriate determination.

Correct use of associated terms. Some conditions are described by more than one term depending

on the clinical presen n

the medical record.

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Cancer coding requires detailed specificity. Several different HCCs exist for cancer, and assigning

the appropriate HCC requires closely following the cancer coding guidelines. The HCC varies depending on whether the cancer is a primary site or a secondary site. Coding guidelines state that if the malignant status is not specified, then code to the primary site, except for the following: bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retro peritoneum, and spinal cord. Applying this rule assures that the correct HCC for secondary malignant neoplasm is assigned rather

an an HCC for primary malignant neoplasms. [For example, bone cancer (pri th

bone c ncer (secondary) (198.5, HCC 7). Since the cancer is not specified as primary or secondary, and one of the sites listed above, the correct HCC is 7.]

Cancer codes are part of a multi-category HCC hierarchy. It is not unusual for a patient to have more than one type of cancer. However, only the most severe and costly form of cancer is recognized in the

or origin than any other cancer the patient has and is included in HC models drop it.

Complete Neoplasm guidelines are included in the Resource Guide.

6.4.3.1 History and Physical (H&P), and Lab and Pathology Reports – Guidance

Some organizations have inquired about the use of the History and Physical (H&P), and Lab and Pathology Reports for data submission and medical record review. If an organization decides to use either as a source for justify ICD-9-CM code submission and/or subsequent medical record review, the

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following guidance must be taken into account when considering the appropriate ICD-9-CM coding guidelines to be used.

Inpatient Documentation – History and Physical (H&P) Guidance

CMS recommends submitting diagnoses and medical records documentation based on a complete inpatient medical record for a hospital inpatient stay. If an organization chooses to use H&P as stand- alone documentation for submitting ICD-9 codes or medical record documentation for validation, the following guidance applies:

• H&P as part of the inpatient full medical record − Will not contain reportable final/confirmed diagnoses − Typically contains

Admission symptoms and co-existing conditions as well as

Admission/working diagnoses, which may or may not be one of the final diagnoses for the inpatient admission

Note that upon medical record review, discharge/final diagnoses– not the H&P alone –will be reviewed in accordance with the Inpatient ICD-9 coding guidelines

• H&P representing an independent physician visit from an inpatient stay

If a physician submits a separate claim/encounter to the organization based on his/her evaluation of the patient as reflected on the H&P

− H&P (face-to-face encounter) is viewed as a physician visit − Reportable diagnoses documented in the H&P

Could be used as final

Could be used for risk adjustment; HOWEVER,

The medical record documentation will be reviewed in accordance with the Outpatient ICD-9 coding guidelines

• H&P Conclusion

The following applies for both data submission and data validation requirements − Risk Adjustment is based on final/confirmed diagnoses.

− Risk adjustment diagnoses should only be submitted based on the H&P alone when there is an independent physician claim associated with the diagnosis.

− Upon validation, if an organization submits an H&P as stand-alone documentation, the Outpatient guidelines will be applied to determine if there is a confirmed diagnosis.

Lab and Pathology Reports

The following guidance must be taken into account when considering data or medical record submission from lab and pathology sources.

• Official Guidelines for Coding and Reporting (Section III, B. Abnormal Findings)

• “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicated their clinical significance.”

• Coders should not arbitrarily assign a final ICD-9 code based solely on an abnormal finding • Written interpretation (alone) of a tissue biopsy is not equivalent to the attending/referring

physician’s complete clinical assessment used to assign a diagnosis.

• If submitting risk adjustment data or medical records based on pathology, note the following: − Outpatient pathology facilities are unacceptable risk adjustment provider sources

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− Physician pathology (i.e., specialty code 22) is acceptable for risk adjustment. When submitting risk adjustment diagnoses or medical records based on physician specialty code 22 refer to the guidance stated in this section.

AND

− Medical records submitted as stand-alone documentation from these sources will be reviewed in accordance with the Outpatient guidelines and will likely result in a risk adjustment discrepancy since these source do not typically render confirmed diagnoses.