CDI: To Query Or Not To Query

Unclear code descriptions and undefined diagnostic terms abound in ICD-10 CM. 

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How are coders and CDI specialists to know what do do?  Well again, it all goes back to the physician.  Do we query or not query?  We must decide.

Many facilities are developing clinical definitions regarding new terms and descriptive diagnostic modifiers.   Developing clinical definitions will assist in the physician query process going forward but be sure physicians are involved and agree with your plan.

Example- New codes for atrial fibrillation are without definition. 

The ICD-10 Alphabetic Index shows the following tabular entries for atrial fibrillation:

  • 148 Atrial fibrillation and flutter
    • I48.0 Paroxysmal atrial fibrillation
    • I48.1 Persistent atrial fibrillation
    • I48.2 Chronic atrial fibrillation
      • Permanent atrial fibrillation
    • I48.3 Typical atrial flutter
      • Type I atrial flutter
    • I48.4 Atypical atrial flutter
      • Type II atrial flutter
    • I48.9 Unspecified atrial fibrillation and atrial flutter
      • I48.91 Unspecified atrial fibrillation
      • I148.92 Unspecified atrial flutter

This coding quandary leaves the coder querying the physician each time atrial fibrillation is not specified.  The most recent clinical definitions of afib are:

Paroxysmal Atrial Fibrillation (I48.0)
In paroxysmal (par-ok-SIZ-mal) atrial fibrillation (AF), the faulty electrical signals and rapid heart rate begin suddenly and then stop on their own. Symptoms can be mild or severe. They stop within about a week, but usually in less than 24 hours.

Persistent Atrial Fibrillation (I48.1 CC)
Persistent AF is a condition in which the abnormal heart rhythm continues for more than a week. It may stop on its own, or it can be stopped with treatment.

Permanent Atrial Fibrillation (I48,2)
Permanent AF is a condition in which a normal heart rhythm can't be restored with treatment. Both paroxysmal and persistent AF may become more frequent and, over time, result in permanent AF.

 
Laura_Legg_HRG_Director-HIM-Optimization

Laura Legg
Executive Director of Revenue Integrity and Compliance for Healthcare Resource Group, Inc.

 

Laura Legg, RHIT, CCS, CDIP, AHIMA Approved ICD-10 CM/PCS Trainer, has over 30 years of health information management experience working with acute care hospitals, critical access hospital, and home services.  Laura is an experienced leader, consultant, coding expert, trainer and auditor. Laura is also an experienced speaker and is often called up to speak for national and state AHIMA meetings. 

Laura continues to help optimize and improve operations for HIM Departments across the nation as HRG's Executive Director of Revenue Integrity and Compliance.

Ready to have Laura and HRG optimize your cdi program?