Coding, Classification & Reimbursement

Coding Changes due to Clinical Review

  • 1.  Coding Changes due to Clinical Review

    Posted 06-13-2018 12:31
    ​Hello!

    Per the 4th QTR Coding Clinic page 149, "if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician's diagnosis, that is a clinical issue, but it is not a coding error."

    Has anyone had a coding change based on a clinical review counted against them in their accuracy statistics?  Did you do anything about it?  Were your coding accuracy statistics corrected?  Are you made aware the requested change was based on a clinical review at the time the change is requested?

    Thank you,

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    Lawrence Barr
    President
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  • 2.  RE: Coding Changes due to Clinical Review

    Posted 06-14-2018 10:04
    I interpret the Guideline to mean that if the physician states a condition exists, that is sufficient.  We should not be questioning his/her diagnosis based upon clinical indicators. However, the Guidelines also state that all diagnoses must meet the definitions of either Principal Diagnosis or Additional Diagnoses. So just because the physician documents a diagnosis is not a sufficient reason for it to be assigned a code. I don't think the rationale that just because a physician documents a diagnosis is justification for it to be coded.

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    Karen Neal
    Coding Quality Auditor
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  • 3.  RE: Coding Changes due to Clinical Review

    Posted 06-15-2018 08:12
    ​Hello!

    Thank you for your input.  However, you did not answer any of my questions. Let me clarify using a different example.

    A patient is admitted in respiratory distress.  The attending documents "respiratory distress due to acute CHF and COPD exacerbation".  The attending uses the same description throughout the record.  When listing the individual diagnoses the attending always lists the acute CHF first.  The attending calls in a cardiology consult, administers diuretics and orders serial chest x-rays.  On discharge the attending's final diagnostic statement again documents "respiratory distress due to acute CHF and COPD exacerbation".  Based on the physician's documentation, the coder applies the Guideline of 2 or more diagnoses equally meeting the definition of principal and sequences the CHF as principal.  Later, as a result of clinical review, the clinician determines the patient was not admitted for acute CHF based on clinical indicators and requests resequencing of the principal diagnosis.  It is clearly indicated that the coding change is based on "clinical review" which according to the Guidelines is beyond the coders expertise.

    According to the cited Coding Clinic, such changes are not considered "coding errors".  I want to know if any other coders are having such changes counted against them in their accuracy statistics?

    Coders rely on accuracy statistics.  They should be accurately calculated.  Required coding changes resulting from clinical review should be specifically identified and not counted as coding errors.  I also believe the results of such clinical review should be discussed with the provider in question before requiring the change be made.  In essence, the clinical reviewer is calling into question the provider's expertise.

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    Lawrence Barr
    President
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  • 4.  RE: Coding Changes due to Clinical Review

    Posted 06-16-2018 09:43
    I was not aware that coders were being assessed errors based upon internal Quality Reviews such as, Mortality Review, CHF Review, etc, for  cases reviewed by clinicians and determined to be a different PDX than what the coder selected. I thought the coder's quality was based upon monthly quality reviews performed by audit staff on randomly selected productivity for the month. So if this account was randomly selected and qualified for the 2 or more diagnoses equally meeting the Principal Diagnosis Guideline and the coder selected the most optimal DRG, then the auditor would not have considered this a DRG error.  I know since the Clinical Criteria Guideline has been in effect, I have not seen any coders assessed errors for choosing a PDX that supposedly didn't meet clinical indicators. Maybe I'm still missing your point?

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    Karen Neal
    Coding Quality Auditor
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  • 5.  RE: Coding Changes due to Clinical Review

    Posted 06-17-2018 08:17
    ​Hello!

    No, you are absolutely getting my point.  The review was conducted approximately 6 months after the original coding for Focused CHF review.  After some back and forth, it was pointed out the requested sequencing change was specifically based on "clinical review".  It was pointed out that coder's are not qualified to make such reviews.  In the subsequent quarterly coding accuracy report the case was counted against the coder as a DRG change.

    I am trying to get an idea if this is an isolated situation or not.  I am wondering if incorrect calculation of a coder's accuracy statistics is an ethical breech?

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    Lawrence Barr
    President
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  • 6.  RE: Coding Changes due to Clinical Review

    Posted 06-18-2018 10:32
    ​It seems a bit odd to me that what you describe would be considered a "clinical" issue if said insurance company feels the acute CHF diagnosis is accurate, just not meeting the definition of a principal diagnosis.  This would then be considered a coding error.  In my opinion, if the reviewer determined that there were no clinical indicators to support the acute CHF, then it would be a clinical validation error.

    We keep tract of all our inpatient DRG revision requests and note who the coder was on the account and whether or not the "denial" is the result of a clinical validation issue or a coding issue (such as sequencing).  However, I do not believe our information is used to "ding" the coder, but provider more of an educational opportunity.  These days, the large majority of our DRG revision request are related to clinical validation rather than true coding errors.

    I went back and looked at our last external audit report.  Accuracy is determined based on the following:  DRG coding accuracy (coding accuracy based on documentation available at time of review), DRG documentation adequacy (provider query recommended to clarify diagnosis of procedure), and other DRG payment variables.  Accounts were reviewed for "coding error", "needs query",  "need query f/u", and "clinical validation".  Results are presented at the overall level, not by coder.

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    Greta Ryan, RHIA, CCS, CCS-P
    Coding & Compliance Analyst
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  • 7.  RE: Coding Changes due to Clinical Review

    Posted 06-19-2018 08:47
    ​Hello!

    I never made any mention of an "insurance company".

    On Admission, the attending documented, "Acute Hypoxemic Resp failure -COPD exacerbation and CHF".  This was consistently documented throughout the record.  In the discharge summary Hospital course the attending documented  "Acute diastolic HF And Pul hypertension".  The consulting cardiologist documented ""Patient has no documented prior cardiac history, denies ever seeing cardiologist" and "Patient admitted for COPD and acute diastolic CHF management".  The patient had hypertension so the appropriate HTN code was assigned.

    The following excerpts are from the facility's Internal Audit manager:

    "A clinical review of this case was done. The decision to select COPD as PDX was not based soley on the treatment but the entire clinical picture. AFTER study, COPD was found to be the condition which warranted the admission. If this case is reviewed by RAC or OIG under their 'clinical validation audits' we can not support the higher weighted DRG."  "Since a clinical review of the chart was done and we have been informed that after study the reason for the visit should be his COPD."  "As per the OIG, clinical validation is beyond the scope of a coder."  The auditor also stated, "His EF was 55% which is in the normal range as far as CHF is concerned."  This implies both the attending and consultant misdiagnosed the patient.  I wonder if this was discussed with either of them prior to requiring the change.  Remember, the attending is ultimately responsible for the documentation in the record.

    This record was counted in the coder's accuracy statistics as a DRG Change.  I find it a bit odd that I had to go into so much detail to get what I thought are a few simple questions answered.




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    Lawrence Barr
    President
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  • 8.  RE: Coding Changes due to Clinical Review

    Posted 06-15-2018 12:18
    Lawrence Barr,

    What year of Coding Clinic are you referring to in regards to the coding change based on clinical review? I have read the posts a few times and am not seeing the year. I would like to look it up, as I do not recall seeing this topic in the 2017 or 2018 CC's.

    Thank you for your time.

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    Michelle
    Coding Student
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  • 9.  RE: Coding Changes due to Clinical Review

    Posted 06-16-2018 07:38
    ​Hello!

    It is the 4th QTR 2016 Coding Clinic beginning on page 147.


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    Lawrence Barr
    President
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