Vol. 16 •Issue 19 • Page 12
Unbundled Coding for Inpatient Services
Many coding professionals understand the concept of “unbundling” as it relates to CPT, HCPCS and outpatient coding. But is there such a thing as “inpatient unbundling?” In a sense there is: when a combination code is assigned as a principal diagnosis and a condition that is included in that combination code is then coded separately. Or in another scenario, a symptom code that is clearly related to the principal diagnosis is assigned as a secondary condition. Sometimes this inappropriate coding results in data quality issues but in others, the DRG may be impacted, thus promoting a compliance risk situation. There may be a prevailing sentiment in the coding world that coding “more is better,” but each code should be assessed to determine its suitability for inclusion in the final codes billed.
A patient is admitted with an incisional hernia that was found to be obstructed. Combination code 552.21 (Incisional hernia, with obstruction) includes both conditions. However, there is a separate code for bowel obstruction (560.9: Intestinal obstruction NOS) and when it is assigned, it acts as a CC (complication/comorbidity) for the case, inappropriately increasing reimbursement. See Example 1.
This is clearly inappropriate coding, as demonstrated by the EXCLUDES note under category 560: [Intestinal obstruction without mention of hernia]
EXCLUDES: intestinal obstruction complicating hernia (552.0-552.9)
When reviewing these conditions in the tabular portion of ICD-9-CM (Volume 1), the coder has two opportunities to determine that these codes should not be assigned together (and unbundled). One is the EXCLUDES note referenced above, and the other is in the code title of category 560: without mention of hernia. Many coders would protest that they would never assign these codes one right after the other. But the problem may stem from the use of exclusively logic-based encoders and the resulting fact that many coders rarely or never open a coding book to review the original structure of the coding system, along with the “includes” and “excludes” notes. Many of these inappropriate unbundling situations occur when the principal diagnosis and several other secondary diagnoses have been coded. The coder then reviews the remainder of the medical record to ensure that no other conditions should be coded.
Perhaps a GI series radiology report is available and indicates intestinal obstruction; the coder remembers that the physician has documented obstruction elsewhere in the record and so determines that this is a “codable” diagnosis. The secondary, unbundled code is then assigned, without realizing that this condition is already included in the principal diagnosis. Each coder should carefully review all codes assigned on a case before dropping it for billing, to ensure that each code “makes sense” and doesn’t duplicate another code or deviate from coding guidelines.
Another example involving a combination code assigned with a separate code that is included in the combination, relates to the very common condition of cholecystitis and cholelithiasis. A patient is admitted with gallstones (cholelithiasis) and acute cholecystitis. Combination code 574.00 (Calculus of gallbladder with acute cholecystitis) includes both conditions. There is a separate code for acute cholecystitis (575.0) and when assigned, the complexity level and DRG relative weight increase. See Example 2.
This example involves unbundling a closely related code from one that more accurately describes the condition. For example, a patient is admitted as an inpatient from the ambulatory surgery area in postoperative shock. There is a specific code for this condition (998.0) in the Complications of Surgical and Medical Care section of ICD-9-CM. There is also a code for shock (785.59) in the Symptoms, Signs and Ill-Defined Conditions section, but there is an EXCLUDES note indicating that code 998.0 should be assigned instead. The appropriate principal diagnosis code for the post-op shock is 998.0, but when a secondary code is added for the shock, NOS (which is included in the 998.0 code), the case complexity, DRG and relative weight are all increased inappropriately. It may be that the coder assigned the principal diagnosis appropriately and then saw “shock” documented in the progress notes and determined that it was a “codable” condition apart from the principal diagnosis. See Example 3.
A final example of inpatient unbundling involves assignment of what would typically be considered a more general code in lieu of a more appropriate specific code. For example, a patient was admitted with a hip fracture and had an open reduction, internal fixation (ORIF) procedure performed. Postoperatively, it was noted that the patient had some significant sleep apnea, a respiratory consult was obtained and treatment provided. A secondary code of 780.57 should be assigned for the sleep apnea, but if code 786.03 (Apnea) is also assigned, it acts as an inappropriate CC for the case. See Example 4.
It’s important for coding staff to understand the implications of each and every code assigned, particularly because the Centers for Medicare and Medicaid Services (CMS) has indicated that a severity related DRG grouping system will be implemented, possibly as soon as FY 2008 (effective Oct. 1, 2007). In a severity setting, secondary codes that may not be appropriate for the case according to coding guidelines may impact severity level assignment. Facilities in states that have implemented severity systems indicated a tendency for coding staff to assign diagnosis codes for “anything and everything” that appears in the medical record. When each code impacts the severity level assigned for the case, this is not an appropriate method of coding. For obvious reasons, compliance risk is a serious issue that should be considered. More than ever, coders must strive to avoid simply looking up the words and entering the codes, without a focused thought-process and review of how each of the codes interact with each other. Long-term data quality for both the specific facility and for the aggregate hospital dataset that results from all coded information depends upon it!
Test your knowledge with the quiz below:
1. A patient presents to the facility for surgery for a recurrent unilateral femoral hernia. At the time of surgery, gangrene was also found. The appropriate codes for this visit are:
a. 551.01, 53.29
b. 551.03, 785.4, 53.29
c. 551.01, 785.4, 53.29
d. 551.03, 53.21
2. A pregnant patient (29 weeks gestation) is seen in the hospital setting for false labor and was found to have anemia, which was treated. The appropriate codes for this visit are:
a. 644.01, 648.21
b. 644.03, 648.23, 285.9
c. 644.03, 648.23
d. 640.03, 648.23, 285.9
3. A patient was brought to the emergency department with signs and symptoms of meningitis. He was admitted and the meningitis was found to be due to a salmonella infection. The appropriate codes for this visit are:
a. 322.9, 003.9
b. 003.21, 322.9, 003.9
d. 003.21, 322.9
This month’s column has been pre-pared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services at HSS, an Ingenix company (www.hssweb.com).
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
Answers to CCS PREP!: 1. a. The hernia was specified as unilateral, but included gangrene, so the combination code 551.01 should be assigned. No additional code for gangrene (785.4) should be assigned. There is no mention of graft or prosthesis used in the surgical procedure so code 53.29 is most appropriate; 2. b. Code 644.03 is the appropriate principal diagnosis because the threatened labor involved a gestation between 22 and 37 weeks. Code 648.23 is most accurate for an anemia on an antepartum visit. The pregnancy combination code does not specify the type of anemia so there is an instructional note indicating that an additional code should be assigned for the anemia; 285.9; 3. c. The only code that is necessary to fully describe meningitis due to salmonella is combination code 003.21.