Coding, Classification & Reimbursement


  • 1.  I13._, HTN/CKD/CHF

    Posted 04-09-2018 14:52
    ​I apologize for the length of this ahead of time!  I'll try to summarize as much as possible.   :)

    We are being asked to review the coding of any patient with a "triad" diagnosis.  Our CHF staff are being "dinged" by Medicare for not seeing patients that have CHF coded.  They are in turn coming back to Coding and saying that we are coding CHF on patients that don't have CHF or they don't think that CHF/Triad should be the PDx..

    A few examples:
    1. Patient has ESRD, HTN, and chronic systolic CHF (all being treated).  The patient is admitted for treatment of the ESRD.  They feel we should assign N18.6 as PDx rather than the I13 code.

    2. Patient has acute on chronic CHF, CKD and HTN and develops sepsis the day after admission.  They feel we should list the sepsis as PDx "because the patient was so sick".

    Is anyone else having issues explaining certain coding scenarios to their CHF Committees?  I have given them the coding guidelines and Coding Clinics, and both CDI and Compliance have both been involved in the discussions and for most situations they have agreed with our Coding, but we are continually having to explain ourselves.  I'm just wondering if anyone else has this issue and how you've dealt with it?

    Thank you!

    Christine Leiphart
    Inpatient Coding Supervisor

  • 2.  RE: I13._, HTN/CKD/CHF

    Posted 04-09-2018 15:07

    Christine- I am a CDI consultant at a hospital with this identical issue.  The issue is multifocal:


    1. The CHF staff are looking at DRGs – which are too big a bucket for what they need to do.  They need to be looking at the cases with individual codes so that they can eliminate as appropriate.  Work with your IT or BI staff to get your CHF staff a report which will give all the individual diagnosis codes as well as the DRG.
    2. I provided education to the CHF staff and the hospitalists and  cardiologists on the CHF/Hypertension/Renal diagnoses.  It is not intuitive to clinicians that they have to say that the CHF is NOT due to a diagnosis – but that is what they have to do.  I put together a logic flow chart that was very helpful to the clinicians.
    3. We also educated the CHF staff – and sat them down at the encoder and had them work through a couple of records.  Not to teach them how to code, but to teach them about the constraints of coding.
    4. We added an early CDI resource and have the CHF staff reviewing inpatients as soon at they are admitted – and are considering adding a CDI resource in the ED to catch these patients as early as possible.


    If you pm me I would be happy to talk to you.



  • 3.  RE: I13._, HTN/CKD/CHF

    Posted 04-18-2018 17:48
    Regarding N18.6 as PDx, N18.- has following note:

    Code first any associated: diabetic chronic kidney disease (E08.22, E09.22, E10.22, E11.22, E13.22) hypertensive chronic kidney disease (I12.-, I13.-)

    I wonder if the payers even know about "code first" rules that would make certain diagnoses invalid as Principal because they violate Code First?

    Since the Guidelines state on page 1 "Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings."

    In my opinion, coding that deviates from guidelines is out of compliance with the HIPAA requirement that we use ICD-10 codes correctly!

    Bill Roush, RHIT, AHIMA-Approved ICD-10-CM Trainer

  • 4.  RE: I13._, HTN/CKD/CHF

    Posted 04-19-2018 07:01
    ​I don't think the payers know about the code first guidelines. I code for Home Health and SNF and in Home Health we list the primary code based on what the focus of care is... we do follow the coding guidelines so when the patient has hypertension, CHF and CKD we list the hypertension first even though the focus of care is on the CHF.

    I am pretty sure the payers are not aware of most of the code first guidelines cuz forever we didn't realize that there was a code first note for CAD. So if the patient has CAD, hypertension, CHF and CKD the CAD is also coded prior to the hypertension. If they had an MI that also is listed prior to hypertension. So if you have a patient with primary care focused on CHF and they had MI in last 4 weeks, plus CAD, hypertension, CHF and CKD you would code it as follows:


    Even though the CHF might be focus it is not listed's now your 4th code. In Home Health it's a big deal cuz only the first 6 dx codes count.

    Brenda Mohs
    Essentia Health-Sandstone

  • 5.  RE: I13._, HTN/CKD/CHF

    Posted 04-19-2018 13:43
    I agree with you, Christine!

    This is clearly a case of Guidelines in Chapter 9 (I.C.9.a.3) - Hypertensive Heart & Chronic Kidney, I13.--. The guidelines state that Chronic Kidney Disease should be assigned as a SECONDARY CODE. In Tabular, we have section instructions telling us to assign a ADDITIONAL codes for both Heart Failure (I50.--) and Chronic Kidney Disease (N18.--)

    The chapter guideline notes state the classification presumes a causal relationship and links the conditions. It explains that these conditions should be coded as related EVEN IN THE ABSENCE of provider documentation explicity linking them. This is always a little uncomfortable in my book -- maybe a quick query to get this documentation is in order?? -- but at least we coders have a legal defense, as it were, for coding these conditions without linkage documentation.

    As we know, the PDx is the Dx that, after study, is responsible for the admission. So in your Sepsis example -- if the sepsis clearly developed sometime after admission, it could not be the PDx. And furthermore, that would get a big, fat "N" for POA. We coders know that the "seriousness" of a condition is NOT always the principle condition.

    Would it be possible to explain to whomever you're dealing with at Medicare that you will not be compliance if you code things differently? This is a textbook example (based on the info you provided) of following guidelines. I'm surprised you're getting push-back from Medicare and not a third-party payor.

    I'd love to hear more from the rest of the community.

    Thank you!
    Cynthia Kibbe

  • 6.  RE: I13._, HTN/CKD/CHF

    Posted 04-23-2018 13:42
    Thanks Cynthia, yes, we've explained things to them several times in several different ways and they continue to "argue" their point.  We have involved Compliance, and we're planning to meet with them again to try and explain things again but it's getting very frustrating as you can imagine. :)

    Christine Leiphart
    Inpatient Coding Supervisor

  • 7.  RE: I13._, HTN/CKD/CHF

    Posted 04-24-2018 11:52
    Gosh, Christine, that is a tough one. If they haven't already, management might have to get involved. Good luck with this and let us know what happens. I am sure you are not alone!

    Thank you!
    Cynthia Kibbe

  • 8.  RE: I13._, HTN/CKD/CHF

    Posted 04-24-2018 12:27

    I don't think you can assume that all payers are unawere of the Code First requirements.  I work for a payer, and we are keenly aware that ICD-10 has the force of law, and that those guidelines must be followed.

    THat being said, there are times when a payer may not have yet fixed a particular edit, the day that guidelines are released. Most use vendors to supply code sets and coding edit software. Those may be delayed or (occasionally) incorrect.  I think that's sometimes a bigger issue when guidelines get released off-cycle.

    When there are issues with a payer, the best course of action is to work through your provider services/network management representative to get them corrected. If you are not contracted, you may have to do a little digging to find the right person in the claims department.

    Jeannette Hernandez

  • 9.  RE: I13._, HTN/CKD/CHF

    Posted 04-24-2018 13:44
    Oh yes Cynthia, management from Coding, CDI and Compliance have been involved. LOL    We have another meeting with them in a few weeks, so keep your fingers crossed!  :)

    Christine Leiphart
    Inpatient Coding Supervisor

  • 10.  RE: I13._, HTN/CKD/CHF

    Posted 04-24-2018 13:47
    Oh and this isn't a payor issue with Medicare not paying the claims, this is our CHF departments being "dinged" (as they call it!) for not seeing all patients with CHF/Triad dx as the PDx.   We aren't having these discussions with Medicare, but with our CHF staff.

    Thanks everyone. :)

    Christine Leiphart
    Inpatient Coding Supervisor

  • 11.  RE: I13._, HTN/CKD/CHF

    Posted 04-24-2018 13:56

    It's an issue with the 30 day readmission.  I haven't found that explaining coding logic to clinicians does any good at all  - ICD coding isn't clinically logical.  You can only bang your head against the wall for so long.  The hospital will get penalized when there are too many patients being readmitted in certain categories – and CHF is the hot one.


    I think that within about two years there will be a different direction in how to code this triad – it is totally illogical to force clinicians into stating when something is NOT due to hypertension – they just don't think that way.   I am using documentation decision trees with my clients and not even discussing coding rules.  The approach is working better.  We have also made very carefully structured templates for H&P's and worked with our ER docs as well.  Another place to work on is case management if you have them in the ER – you want to get on that documentation ASAP as the ER documentation can color the whole stay.    The inhouse clinical documentation specialists identify patients within a day of admission that are going to fall into this category (or who are probably going to fall into this category) and identify appropriate clinical staff proactively.  This  doesn't fix overnight – but we have seen a significant improvement over the last 2-3 months.


    Sent from Mail for Windows 10


  • 12.  RE: I13._, HTN/CKD/CHF

    Posted 05-02-2018 13:29
    I feel like I'm reading my own writing when I see your posts! :-).  I spend a lot of time explaining to non-coders that ICD-10-CM is often counter-intuitive to how physicians think...clinically it makes no sense.  I have found I get further with clinicians by acknowledging that the rules don't make clinical sense up front.  Then, they start to understand that it isn't that coders are "stupid" (a complaint I've heard from clinicians), but that we have rules imposed on coding that we MUST follow.

    When you look at things like the Agency for Healthcare Research and Quality (AHRQ)  HCUP Chronic Conditions file, you immediately see the disconnect in clinical thinking and coding guidelines.  Their Chronic Condition file --based on physicians concept of "chronic" includes some of my all time favorites:

    • Virtually all cancers
    • Acute MI
    • Acute CVA
    • Acute Renal Failure,
    • and on and on and on. 

    I actually wrote to them and explained that anyone using their file to analyze coding patterns or to create health programs would run into problems. When I explained how ICD-10 perceived chronic, they were surprised. I don't know if the next version of the HCUP file will look any different, but I do know that anyone taking the file as gospel will run into coding problems.

    I understand that ICD-10 isn't always used for coding--but unless you know how it's constructed and why, errors will occur.  You have to know the rules before you break them for purposes other than coding.

    Jeannette Hernandez

  • 13.  RE: I13._, HTN/CKD/CHF

    Posted 05-02-2018 13:35

    Right on, Jeannette.  I am finding that very specific education on what has to be documented in the medical record – without mentioning anything about coding – is the most productive approach.   We use very structured documentation templates – and incent the hospitalists with "how to have less queries" (and chocolate bars and coffee cards to starbucks).  Teaching nonclinicians coding rules isn't productive – it does not compute.  I teach them how they have to DOCUMENT and don't mention the coding.



  • 14.  RE: I13._, HTN/CKD/CHF

    Posted 05-05-2018 17:09
    ​Hi Christine, I'm curious, when you say the patient was admitted for the ESRD, do you mean for dialysis? If so, I would agree that the ESRD should be the PDX. Also, there's a Coding Clinic 2013 4Q in which the patient has lupus nephritis and was admitted for the end stage renal disease. The advice states that since the focus of treatment was on the ESRD, it would be sequenced as the PDX, and that although the lupus was a contributing problem, it is not the focus of treatment. So in the specific case you're referencing, the scenario would be the same. Each patient's case of course would stand on its own.

    Dianna Bethany
    RHIT, CCS, CDIP, ICD-10 Trainer

  • 15.  RE: I13._, HTN/CKD/CHF

    Posted 05-06-2018 15:20
    Yes we too seem to always have to.explain our coding to billing staff. Even when we provide to them the guidelines. It gets frustrating.

    Does anyone have any good process or techniques they use to inform billing staff that we are coders and code based on guidelines and documentation. Seems to be a constant struggle.

    Help with this wou kd be greatly appreciated.

    Thank you!


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