Kate Peterson Stanley, MD

Historically, healthcare providers have used the medical chart to document a patient’s condition and treatment plan in order to record their encounter and communicate with others. Over time, the written record morphed into evidence required for payment of services and measures of medical care quality. With the advent of the electronic medical record and advanced computer systems, provider documentation now serves multiple purposes. In addition to patient care, it is associated with reimbursement for both health providers and patient care facilities. Quality, accuracy, and consistency of documentation are now more important than ever to ensure it clarifies the care received by the patient and supports payment for the care provided. In this month’s column, the role of provider documentation and ICD-10 diagnosis coding to support facility billing will be delineated. In addition, tips to assist the medical provider in capturing the complexity of a patient’s condition within the medical record will be highlighted.

Many providers are unaware of what occurs behind the scenes with their medical documentation. Within the bowels of health facilities, coders translate the providers’ words into medical codes, which are subsequently used for reimbursement, quality reporting, and facility benchmarking. This includes codes from the International Classification of Diseases (ICD) Code Set. This set of codes is used by the World Health Organization to classify global mortality data. Each code has seven digits that categorize diseases, medical conditions, and injuries into different groups. Currently, it is in its 10th version. In the United States, the Centers for Disease Control have adapted and modified the code set (ICD-10-CM), which is used for standardization and reimbursement of health care services. ICD-10-CM diagnoses codes are combined with medical provider billing codes (CPT codes) and sent to both government and non-government insurers for reimbursement of medical services. Many providers may not realize that these codes are also used to organize hospital cases into groups for payment of facility services. Facility services include the materials and services used to “make the magic happen” such as the lights in the hospital room, nursing care and patient monitoring equipment. Thus, the facility depends on the accuracy of medical provider documentation for facility reimbursement.

The quality of the medical record documentation matters for both care and reimbursement. Medical facility coders use the information documented by the provider to determine which ICD-10-CM codes are submitted for claims reimbursement. Providers are increasingly being asked to participate in determining the appropriate ICD-10-CM codes. Inaccurate, incomplete or inconsistent documentation of the patient’s condition, complexity or abnormal findings may result in under or overpayment for hospital services. Health providers often describe conditions as opposed to using a diagnosis or ICD-10-CM code to communicate the patient’s illness or injury. However, coders do not have the authority to infer diagnoses from the medical descriptions or interpret data in the medical record. However, coders may seek clarification from providers via a query. Ensuring that the complexity of the patient’s condition is reflected in the record improves the quality of care by communicating patient acuity to other providers and payers, which results in reimbursement for the extra services required to care for complex patients.

How can the medical provider ensure they are accurately documenting the patient’s condition? First, determine if the patient’s diagnoses “MEAT”s criteria: if a condition is Measured, Evaluated, Assessed, or Treated, it is the clinical significance that is documented in the medical record. This includes illnesses that prolong hospitalization, require additional medical resources, or impact future health care needs. Chronic conditions that affect ongoing care are also included. However, despite previous interventions, conditions that have resolved are not reported for coding purposes. Additionally, coders may not report abnormal laboratory or diagnostic results for reimbursement without an interpretation and explanation within the documentation regarding their impact on the patient’s condition. The MEAT criteria can guide the provider in accurately capturing the patient’s acuity and complexity.

Next, commit to a diagnosis. Providers are taught to describe what they see and hear in the medical record, but they often fail to name the condition they are treating. Coders cannot assume a diagnosis from the medical record. ICD-10-CM diagnostic coding can bridge this gap because it is a common language that is used across the health care continuum. Increasingly, providers are required to use the ICD-10-CM codes within their documentation. However, they often struggle to designate an ICD-10-CM diagnosis when faced with uncertainty. In these situations, the provider should use their best judgment based on their clinical expertise, even when final tests or study results are not available. For hospitalized patients, inpatient coders are permitted to code for diagnoses when the provider uses terms such as “borderline, probable, possible, still to be ruled out, likely, suspected, appears to be, consistent with, indicative of.” Choosing an ICD-10-CM diagnosis code to “describe” the patient may not change the provider’s clinical assessment and decision-making, but it will improve communication between the provider and coder.

Finally, be specific. Based on clinical judgment, choose an ICD-10CM diagnostic code that best describes the patient’s condition. In situations where a diagnosis is unknown, code for the presenting symptom that resulted in the evaluation. If a patient has a clinical syndrome, the code for the syndrome is used rather than each finding. However, if a finding within the syndrome has an additional clinical implication, the significance of that finding should be clarified. For example, if a child has Trisomy 21 with atrioventricular canal and clinodactyly, atrioventricular canal adds additional complexity to the patient’s care. Clinodactyly, on the other hand, is an intrinsic feature of Trisomy 21 and does not change the acuity of the patient’s condition. Lastly, abbreviations result in incomplete and confusing documentation and should be avoided. ARF can mean either acute respiratory failure or acute renal failure. Coders are not allowed to determine diagnoses from abbreviations unless stated within the coding rules, or they are part of the facility’s official list of abbreviations. Specific and clear documentation of the patient ‘s illness leads to more accurate coding.

Neonatal conditions have their own set of ICD-10-CM codes known as the perinatal codes, which begin with the letter (P00-P96). These codes are used for neonatal conditions that originate in the perinatal period, which is defined as the day of birth through 28 days of life. These codes are used regardless of the patient’s age as long as they apply to the patient’s current condition. This includes chronic conditions such as prematurity or bronchopulmonary dysplasia if they affect the presenting encounter or treatment. Codes from other ICD10-CM categories that provide greater specificity about a patient’s condition may also be used. Congenital diagnoses are designated by the letter Q (Q00-Q99). Clarifying whether a condition occurred before or after birth can affect a facility’s quality metrics which may have future implications as insurers move toward quality-based reimbursement models. Finally, documenting the birthweight and gestational age of the neonatal patient may be obvious to most neonatologists, but stating that the patient is premature in addition to other characteristics assists the facility in capturing the complexity and resources used to provide to care these tiny patients require.

The purpose of the medical provider’s documentation continues to expand beyond the medical care of the patient. Ensuring that the written record accurately reflects the complexity of the patient encounter assists both provider and facility reimbursement. ICD-10CM can be used as a common language between the provider and coders to communicate patient conditions. Using the MEAT criteria, committing to a confirmed or presumed diagnosis, and documenting in a specific and accurate manner enhances the care and communication required to provide quality care to patients. Developing a relationship with the inpatient coders at your facility can assist in better understanding the nuances ICD-10-CM coding related to specific specialties such as neonatology and improve the reimbursement for the neonatal ICU in which you work.

Patient Question:

You admit a 4 hours old 27-week 950-gram premature male infant who was transferred to your facility. He was delivered vaginally after the mother presented with fever and premature labor. On admission, the infant has respiratory failure and requires Bubble CPAP 6, FiO2 28%. The chest radiograph shows underinflated lungs and a diffuse reticular granular pattern consistent with respiratory distress syndrome. Blood culture was obtained, and antibiotics were started prior to transport because of maternal chorioamnionitis. The infant has tachycardia, and you are concerned the infant may have sepsis.

What is the correct CPT code: A) 99477 B) 99468 C) 99471

The correct code is B: 99468 – Initial inpatient neonatal critical care, per day for the E/M of a critically ill neonate, 28 days or less. This patient meets the definition of critical care secondary to respiratory failure due to RDS requiring CPAP.

99477 represents the code for initial hospital care, per day, for the E/M of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services. As stated above, this patient’s condition qualifies him for critical care services.

99471 represents the code for initial pediatric critical care, per day, for the E/M of a critically ill infant or young child, 29 days through 24 months of age. This is not the correct answer because the patient described above is a newborn infant.

List the ICD-10-CM codes for this patient:

1. Prematurity, extreme 27 weeks P07.26
2. Low BW, extreme, 750-999g P07.03
3. Respiratory Distress Syndrome (RDS) P22.0 (For the purposes of facility coding, respiratory failure is inherent in the code for RDS; therefore, Respiratory failure of the Newborn P28.5 is not used with RDS P22.0).
4. Infant affected by maternal chorioamnionitis P02.78
5. Sepsis, neonate unspecified P36.9 (although this diagnosis may be uncertain, it is the best diagnosis to describe the acuity of the patient at this time. It can be changed when more information is available).

References:

1. Committee on Coding and Nomenclature, American Academy of Pediatrics. (2014). Coding for Pediatrics 2014 (19th edition.) (E. Liechty, Ed.). American Academy of Pediatrics.
2. Duncan, SD, Martin, GI & Pearlman, SA. (Eds.). (2016). A Quick Reference Guide to Neonatal Coding and Documentation (2nd edition). American Academy of Pediatrics.
3. Savage, L. (Rv). (2017). Pediatric CDI: Building Blocks for Success. (L. Archibald, Ed.). HCPro.

Disclosure: The author has no disclosures.