Ask the Expert

This month’s selection:
In auditing our cases to see if the diagnoses obtained by queries were being picked up by our coders, my coworker and I discovered something that worried us. The myocardial infarctions (MIs), mainly non-ST-elevation myocardial infarctions (NSTEMIs), that occurred after admission were not being coded as such. For example: a patient came in to have gallbladder surgery and later his or her cardiac enzymes became elevated. The patient did not present with chest pain on admission and may never have chest pain. The physician may order cardiac consult, may put the patient on a Heparin drip, and both of the physicians are calling it NSTEMI, but still it is coded as an unspecified or nonspecific form of cardiac disease. I cannot tell you the exact number but it was something like 429.2. After pressing them for a reason, we were finally told they were instructed by memo not to code these MIs as MIs. That memo was from a physician in another department (quality and/or compliance). We were told it was being done so the physicians’ numbers would look better on things like Healthgrades and so that the staff physicians did not have to follow the Core Measures guidelines. Now, I do not have coding education except for what I’ve learned on the job but, to me and my coworker, that just seemed wrong. We thought if a condition was present and acute and especially if the doctor said they had an MI, you had to code it as such. Can you tell me what you think?

Karen
Cincinnati, Ohio

 

Response:
The scenario you describe is problematic on several fronts.

First, from a reporting standpoint, the Uniform Hospital Discharge Data Set (UHDDS) mandates that “other” (or secondary) diagnoses must be coded and reported. The UHDDS, initiated in 1974 by the U.S. Department of Health, Education and Welfare and revised in 1984, mandates the collection and reporting of a minimum set of data on all hospital Medicare and Medicaid patients. It has also become the standard used by nonfederal public and private entities. The UHDDS provides the following definitions for principal and secondary diagnoses, including other (or secondary) diagnoses:

“Other reportable diagnoses are defined as those conditions that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode. Diagnoses that have no impact on patient care during the hospital stay are not reported even when they are present. Diagnoses that relate to an earlier episode and have no bearing on the current hospital stay are not reported. For UHDDS reporting purposes, the definition of ‘other’ includes only those conditions that affect the episode of hospital care in terms of any of the following:

• Clinical evaluation

• Therapeutic treatment

• Further evaluation by diagnostic studies, procedures, or consultation

• Extended length of hospital stay

• Increased nursing care and/or other monitoring”

Based on the scenario you described, the NSTEMI documented by the physician(s) meets UHDDS reporting guidelines for other diagnoses because it needed to be clinically evaluated (via cardiac consult) and it was therapeutically treated (with Heparin drip). Therefore, it should be coded and reported. By not coding the NSTEMI, the organization is out of compliance with federal guidelines.

Second, coders credentialed by the AHIMA are bound by the AHIMA’s Standards of Ethical Coding. The standards assist coding professionals in making ethical decisions when faced with challenges such as you outlined. The scenario described places the coding professionals in the position of potentially violating their professional ethics, which could lead to the loss of their credential.

AHIMA standards that speak to this situation include standards 1, 2, 3, 5, 6, and 9.Most pertinent is standard 6, which states that coders must:“Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.”

Under 6.3 it continues, “Coding professionals shall not: Inappropriately exclude diagnosis or procedure codes in order to misrepresent the quality of care provided. Examples: Following a surgical procedure, a patient acquired an infection due to a break in sterile procedure; the appropriate code for the surgical complication is omitted from the claims submission to avoid any adverse outcome to the institution. Quality outcomes are reported inaccurately in order to improve a healthcare organization’s quality profile or pay-for-performance results.”

Third, the facility may lose diagnosis-related group (DRG) reimbursement if the NSTEMI is not coded. The NSTEMI is a major complication/comorbidity (MCC) in the DRG system. If it is the only MCC on the case and it is not coded, the hospital would be paid at the lower DRG rate.

Fourth, the clinical picture for this patient is inaccurately portrayed from a severity of illness and risk of mortality perspective. A patient with an NSTEMI is sicker and has a higher chance of dying. The fact that the hospital is caring for a sicker patient and utilizing more resources to do so is lost. This results in a skewing of publicly reported data such as state mortality reports, hospital rankings, etc. It also is misleading to the public regarding quality of care delivered and outcomes achieved by the facility.

Finally, the purpose of the Joint Commission on Accreditation of Healthcare Organizations Core Measures program is to improve the quality of healthcare delivery by measuring hospital performance as derived from evidence-based research for certain diagnoses (the NSTEMI in this case). When the NSTEMI is not coded or reported, any evaluation of the hospital’s quality of care is inaccurate, which does not serve the patient, the provider, the hospital, or the payer.

This situation should be resolved immediately. I suggest that you discuss the issue with your facility’s director of compliance and request his or her assistance in correcting the matter.

— Susan E. Belley, RHIA, is manager of the ICD-10 education program at 3M Health Information Systems.