By Cynthia Tang,  RHIA, CCS, CRC

From the very beginning, Dr. Richard Pinson and I have taught hospitals that coding specialists, not just nurses, can and should perform the CDI function. We have always included coders in our training sessions and advised hospitals to consider coders for the CDI role. Just as CDI specialists benefit from learning coding guidelines and principles, coding specialists can and should learn the clinical criteria.

As an employer, you may benefit from a team approach with both CDI specialists and coding professionals who are able to identify documentation issues that will result in meaningful changes to the ultimate codes and reimbursement.  Making the most of both areas of expertise results in a more efficient and productive CDI function.

How can a coder be an effective part of the CDI function?

• For coders, enhancing their understanding of diagnostic criteria and the disease processes will give them the ability to see all clinical relationships pertinent to the patient’s conditions.
  
• More knowledge of these diagnostic criteria and disease processes will give coders more confidence as an equal partner in the CDI team and able to provide their non-coding colleagues with additional insight to the intricacies and challenges of the coding systems.
  
• More clinical knowledge will alert coders to the need for queries when the documentation is lacking and will help the coder to prepare a more appropriate and effective provider query.
  
• As a final benefit, coders with a firm grasp of the diagnostic criteria and disease processes may decide to take the leap and advance their career as a CDI specialist. 

When we first created the CDI Pocket Guide®15 years ago, CDI was an emerging field and there was no reference tool available. Hospitals had to hire an expensive consulting firm, and even then, the educational materials were large three-ring binders containing hundreds of pages of information that was virtually impossible to reference and often the coders were left out. 

The CDI Pocket Guide® was written with both coding and CDI professionals in mind. It offers coding and CDI specialists the tool they need to quickly and easily access the clinical definitions, diagnostic criteria, treatment considerations and specific challenges for the key clinical conditions encountered in the hospital. The CDI Pocket Guide® has become the most highly respected unofficial source for authoritative CDI information. Thousands of coders and CDS have come to rely on it, often telling us it’s their “CDI bible.”

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Does the recent Coding Clinic advice regarding accidental puncture and laceration contradict Official Coding Guidelines for coding Complications of Care?  The short answer is No. Here’s why.

In Coding Clinic 2021 Second Quarter, the following scenario was presented:  “During a laparoscopic salpingo-oophorectomy, the surgeon noted an incarcerated loop of small bowel adherent to a ventral hernia sac. After take down, the bowel was discolored with multiple serosal tears. The incision was then extended, the loop of bowel was brought out through the incision and the segment with the serosal injury was excised. It seems that serosal tears requiring excision would be clinically significant. However, in this case, the provider documented the injury was inherent to the nature of the procedure. On query, he stated the serosal tear was ‘Unavoidable during extensive lysis of adhesions, not intraoperative complication.’  Would any bowel injury requiring excision be considered clinically significant and reportable? How is the serosal injury and repair by excising the small intestine coded?

In response, Coding Clinic answered, “Assign code K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure, for the serosal injury of the small intestine. Although after query the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery.”

Get our CDI Pocket Guide® to learn more about the documentation and coding of complications of care.

This may at first seem contrary to the idea that physician documentation governs code assignment of complications of care; however starting with the 2017 Official Coding Guidelines, Section I.B.16 for Documentation of Complications of Care was modified to read (modification in bold):

“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.” 

This phrase “unless otherwise instructed by the classification” was added one year after ICD-10 was implemented in FY2016. This instruction was added to reflect the significant refinement and reorganization of the complication of care codes within ICD-10. 

In many situations, complication of care codes are now assigned simply because they occur intraoperatively or postoperatively, and therefore do not require a cause and effect relationship or specific provider documentation that a condition is a “complication.”

In this case, the serosal injury occurring during the procedure is assigned to code K91.71, which specifies “accidental puncture or laceration during a procedure.” Therefore, the Tabular entry governs code assignment.

The serosal injury was clearly documented and was clinically significant particularly since an additional surgical procedure was performed to treat the injury. A query would not be required since the documentation was clear and not conflicting or confusing – even though the surgeon documented it was unavoidable due to extensive lysis of adhesions.    

Keep in mind that although conditions classified as complications of care are typically unexpected or unusual outcomes by the care rendered, the term “complication” as used in ICD-10 does not necessarily imply that improper or inadequate care was provided or it was a “surgical misadventure.” And many times it isn’t. Particularly with surgeries, there is always a risk of complications which do occur. 

What’s important is for these to be tracked so we have good data to improve the quality and outcomes for our patients. If we’re not coding these conditions when they occur, how can we improve the care we’re providing? 

In summary, the ICD-10-CM codes for complications of care, the 2017 Official Coding Guidelines change, and Coding Clinic instruct us to code accidental punctures and lacerations that occur during a surgical procedure that are clinically significant. It is not necessary to query providers for a cause and effect relationship or whether it complicated the procedure. An accidental puncture and laceration code should be assigned unless the documentation is unclear or the condition does not meet the definition of an additional diagnosis.

(c) 2021 Pinson & Tang

Historically, a body mass index (BMI) ≥ 40 has been defined as “morbid” or “extreme” obesity. The World Health Organization (WHO) categorizes obesity by three classes with Class 3 “morbid” or “severe” obesity as BMI ≥ 40.

The “Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults” was developed by the National Institutes of Health (NIH) and the North American Association for the Study of Obesity using evidence-based methodology for assessing and treating overweight and obese patients.

This report introduced the term “clinically severe” obesity. Clinically severe obesity is defined as: BMI ≥ 40 or a BMI ≥ 35 with serious comorbid conditions that may warrant weight loss surgery. 

According to the NIH report, those diseases or conditions that denote serious comorbid conditions and high absolute risk are established coronary heart disease, other atherosclerotic diseases, type 2 diabetes, and sleep apnea. Three or more of the following risk factors also confer high absolute risk: hypertension, cigarette smoking, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impaired fasting glucose, family history of early cardiovascular disease, and age (male ≥ 45 years, female ≥ 55 years).

The NIH definition conforms to the indications for bariatric surgery. The NIH further indicates that a BMI of 35-39.9 without comorbidity is “obesity.”

From a coding standpoint, ICD-10 code E66.01 includes both “morbid” and “severe” obesity. If morbid or severe obesity is documented for a patient with a BMI 35-39.9 and who has a serious comorbid-related condition, code E66.01 is assigned. On the other hand, if no serious comorbid condition is documented within the record, code E66.01 is not clinically valid.  

Get our CDI Pocket Guide® for more information about obesity and BMI.

(c) 2021 Pinson & Tang