Hospital Outpatient Documentation Under Scrutiny

Hospital Outpatient Documentation Under Scrutiny

Until the implementation of ICD-10, documentation improvement was seen as an inpatient process. Hospitals were keenly aware that imprecise or nonspecific clinical documentation could result in coding accounts that group to lower DRGs; and thus, less reimbursement. So, the Clinical Documentation Specialist role has become vital to ensure that the documentation in the medical record accurately reflects the acuity of the patient’s condition, further to ensure correct reimbursement for inpatient hospital services.

LCDs Drive Documentation

Now, with Local Coverage Determinations (LCDs) becoming more specific and including specific ICD-10-CM diagnosis codes, it’s vital for coders to review outpatient facility and physician medical records to ensure that the documentation is specific, and that it contains all of the elements that truly reflect the patient’s condition and the medical necessity for providing services.

For example, consider a report for a lumbar kyphoplasty procedure (22513) to repair a fractured vertebra. The surgeon documents:

INDICATION:  Mrs. Young is an 83-year-old female with a compression fracture of the L4-L5 vertebra which resulted from a fall in her bathroom last evening. She has been brought to the OR for a kyphoplasty (vertebral augmentation) procedure.

Is this sufficient documentation to code the diagnosis and prove the medical necessity for the procedure? Without looking at the LCD for kyphoplasty, it certainly looks medically necessary to surgically repair a fractured vertebra.

An inexperienced coder may assign an ICD-10-CM code from the S32.XXX section for traumatic lumbar vertebral fracture because the patient fell in the bathroom; however, this claim would be denied for lack of medical necessity.

Let’s see how the documentation and coding could be improved.

The Noridian LCD for Vertebral Augmentation (L34106) says that kyphoplasty is indicated for:

“A ‘recent’ osteoporotic or osteopenic compression fracture of the lumbar or thoracic vertebrae with persistent debilitating pain that has not responded to accepted standard medical treatment.”

Further investigation of the claim indicates that the kyphoplasty was not covered because there was no indication in the medical record that the fracture was caused by osteoporosis or osteopenia. The coder should query the physician to see if the patient had either of these bone disorders.

Assuming the physician adds an addendum to the operative report that the patient had osteoporosis, how would you code the fracture?

When coding fractures, the coder needs to determine whether the fracture is traumatic or pathological. At first glance, the fall in the bathroom could lead the coder to a traumatic fracture; however, the ICD-10 CM coding guidelines for Chapter 13 give this guideline for osteoporosis with current pathologic fracture:

“Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.”

After receiving the amended operative report, the coder should assign code M80.88XA. Individual MACs from different regions may have different LCD requirements. Therefore, the coder must reference the specific LCD for their provider type and region of the country.

As October 1, 2016 fast approaches, physicians’ offices and coders need to review all of their denials for procedure and all of the LCD articles for these procedures to review any documentation improvement needs to reduce unnecessary denials.

Documentation Improvements

Documentation improvements may require:

  • Documentation of laterality – fractures, breast biopsies, etc.
  • Specific disease process – pathological versus traumatic fracture
  • Acuity – chronic versus acute CHF, asthma, or bronchitis
  • Listing current medications – long-term use of anticoagulants or aspirin
  • Mention of the type of imaging performed in interventional radiology procedures

In addition, when surgical interventions are performed, the LCDs generally require the surgeon to indicate which conservative treatments had been tried, and the results of those attempts. Coders need to educate their physicians to document, in the medical record for the visit when the decision for surgery was made, all of the conservative treatments that have been tried prior to the decision for surgery. A brief summary of conservative treatments that failed should also be mentioned in the indications section of the operative report.

One aspect of specific documentation that gets overlooked is continued documentation of a condition. For example, after first being diagnosed, a breast cancer patient’s medical record will undoubtedly state which breast was involved. The breast biopsy report will naturally mention which quadrant was biopsied. Thus a carcinoma of the left upper outer quadrant would be coded C50.412. However, the order for the insertion of a central venous access to administer chemotherapy may only mention the indication as breast cancer, which will be coded with the non-specific code C50.919, Malignant neoplasm of unspecified site of unspecified breast. Depending on what procedure is performed and how the LCD is written, this type of documentation may not pass the LCD medical necessity edits.

Coders, physicians, and medical practice managers need to review their documentation to ensure that the documentation specificity carries forward though out the patient’s treatment for the disease treatment in order to ensure that nonspecific documentation and coding does not slip back into the medical record after the first diagnosis of the disease.


Karen Chappell

Karen D. Chappell, EJD, MBA, CHC, CCS, CIRCC, CPMM, LPN
Ms. Chappell has 25 years of outpatient compliance audit experience, CDM maintenance review, and Revenue Integrity operations experience. She is a leading subject-matter expert in CMS and OIG regulations. Ms. Chappell is a coding education and curriculum writing consultant.

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Karen D. Chappell, EJD, MBA, CHC, CCS, CIRCC, CPMM, LPN Ms. Chappell has 25 years of outpatient compliance audit experience, CDM maintenance review, and Revenue Integrity operations experience. She is a leading subject-matter expert in CMS and OIG regulations. Ms. Chappell is a coding education and curriculum writing consultant.

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