January 29, 2018

Clarity on “Chronic” Conditions

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Answers to listeners’ questions posed during last week’s edition of Talk Ten Tuesdays are provided here by the author.

There is a disconnect among coders and clinicians regarding the concept of “chronic” conditions. All clinicians have interviewed a patient who denies any past medical history, but when confronted with their medication list, they will admit to having high blood pressure and high cholesterol. If controlled, the patients just don’t think of those conditions as being chronic.

Providers don’t think of “past medical history” as being “history of,” in the coding sense. The latter, “personal history of,” lands a code in the Z85-87 subcategories, whereas chronic conditions are listed in the system-specific sections.

There are problem lists in many organizations that are meant to be a running ledger of conditions a patient has or has had. If the problem list is maintained, it is a source of truth for patient care. If it is not maintained (no dates of resolution, no conversion of acute problems to chronic or historical conditions, etc.), it is just a headache. Many organizations opt to not code from those lists, and I support that.

A question came in regarding whether the problem list along with the medication list is adequate to support chronic condition coding in the ED. My answer is that making diagnoses in the ED is no different than making diagnoses anywhere else. A best practice is to document diagnoses you are actively investigating, treating, or assessing as it pertains to the impact they may have on the conditions you are actively addressing. You should not be diagnosing or coding conditions that have no bearing on today’s encounter.

When I teach providers, I use this example: a “history of” congestive heart failure would mean that the patient used to have heart failure but has since undergone a heart transplant or other procedure and no longer has it. If the patient is on medication chronically, he or she has chronic congestive heart failure. I am trying to highlight the difference in the terminology between coding and clinical practice. The disconnect stems from the fact that listing a condition in the past medical history isn’t intended to relegate a condition to “history of” for a clinician.

In my TalkBack segment on Talk Ten Tuesdays from last Tuesday, this example set off a firestorm of comments and questions. Let me clarify:

  • If a provider doesn’t mention the condition at all, but you note the patient is on meds for heart failure (HF), and prior admissions note HF, you can’t code it, but it should clue you in that the patient may have chronic HF. It needs to be documented in this encounter. You should query.
  • If a provider lists HF in a problem list that your institution doesn’t code from, don’t pick it up without query.
  • If a provider lists “HF” in the PMH section your institution utilizes, you may pick up I50.9, heart failure, unspecified, but there is no “chronic heart failure, unspecified” code, like there are type-specified HF, acuity-unspecified codes. If they were to document “chronic heart failure,” you just get I50.9.
  • If a provider lists type-specific HF such as “history of diastolic congestive heart failure,” as per CC 2008 Q3, you are permitted to pick up the “chronic type-specific heart failure” code.
  • If the provider documents “ADHF (acutely decompensated heart failure),” you can only pick up the I50.9 code. As I said above, there are no acuity-specific, HF, type-unspecified codes. “Compensated” means “chronic,” and “decompensated” means “acute on chronic.” You may compliantly convert that verbiage.

But back to chronic conditions in the hospital setting. Up until now, we have not really been attentive to most chronic conditions if they are not risk-adjusting in the DRG arena.

Hierarchical condition categories, or HCCs, have thrown a twist into this system. Chronic conditions can be resource-intensive, so they may have an impact on the population health risk adjustment model when they have none on the inpatient model. Forty percent of HCCs are neither complications or comorbidities (CCs) nor major CCs (MCCs).

(For the CMS-HCC model, go online to https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html . For the methodology on HHS-HCCs, see https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/RA-March-31-White-Paper-032416.pdf.)

I always advocate for as much specificity as possible because I believe that this fully conveys the complexity and severity of each patient. However, there are conditions that are HCCs listed without specificity, for instance atrial fibrillation. Although persistent afib is the only CC inpatient, any type of atrial fib is included in HCC 96, Specified Heart Arrhythmias.

But which conditions do I see providers giving limited details for in their documentation, leading to suboptimal specificity in codes that make a difference? Here are some examples.

Diabetes is a three-tiered HCC set: with acute complications, with chronic complications, and without complications. I suspect that the most common diagnosis often left on the table is -.65, type-specific diabetes mellitus with hyperglycemia. Providers often just list “diabetes,” but note that there is persistently elevated glucose in the labs. Query them to get them to add the “with hyperglycemia” qualifier. Talk about low-hanging fruit!

To answer another question sent in, you can’t make that inference from an elevated A1C. The provider must document “with hyperglycemia.” Additionally, “uncontrolled” diabetes mellitus can’t be taken to “with hyperglycemia.” The reasoning is that a brittle or uncontrolled diabetic could have episodes of hyperglycemia or hypoglycemia, so the provider must clarify which is the current condition being treated.

The next condition is atherosclerosis. Although I73.9, peripheral vascular disease, unspecified lives in HCC 108, if what you really have is a patient with atherosclerosis of a leg with ulceration, you should really be in HCC 106 – which, according to the hierarchy, should yield a risk adjustment factor of 1.461 instead of 0.298. The provider should give the specificity of vessel and the linkage of symptoms or sequelae like claudication, rest pain, ulceration, or gangrene. Be sure to refer to the most up-to-date Disease Hierarchies – 106, Atherosclerosis of the Extremities with Ulceration or Gangrene, supersedes 107, 108, 161, and 189.

Lastly, most traumatic injuries specified as HCCs are for the initial encounter, which means that after the year in which the definitive therapy is undertaken is over, the condition should drop off. However, sequelae of major head trauma and skull fractures are also nestled in HCC 167, Major Head Injury. This means that if a patient has some persistent neurological condition as the result of a previous head injury, capturing the S06 code with the seventh character of “S” (for sequela) can pick up the 0.191 RAF.  

Tying in to last week’s Talk Ten Tuesdays, chronic traumatic encephalopathy (CTE), or postconcussional syndrome, has an Excludes1 for current concussion (S06.0-). If CTE can occur from repetitive head trauma, which doesn’t need to be of the severity of a concussion, then could an additional code be S06.0X-S, indicating a sequela from a previous concussion, if a specific incident can be pinpointed? I don’t know the answer to this – I am not a coder, I just play one on the Internet.

We must continually promote clinicians giving maximum specificity for all diagnoses, to include acuity, site-specificity, and linkage. This practice gives us the most accurate codes, which may be CCs, MCCs, and/or HCCs.

Our goal, in addition to taking excellent medical care of our patients, is to see that the patient looks as sick in the medical record as he or she does in real life.

Program Note:

Register to listen to Dr. Erica Remer during today’s edition of Talk Ten Tuesdays.

Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As Physician Advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July, 2016. Dr. Remer is a member of the ICD10monitor editorial board and co-hosts Talk Ten Tuesdays.

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