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August 2, 2011 CBCC Conference Call

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Community-Based Collaborative Care Working Group Meeting

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  1. (5 min) Roll Call & Accept Agenda
  2. (25 min) SHIPPS Domain Analysis Model discussion
  3. (30 min) HL7Confidentiality Code Project


Definitions for some terms used throughout this discussion:

  • Uncertain Diagnosis: a diagnosis that is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty. Uncertain diagnosis is synonymous with "rule-out" diagnosis.
  • Inpatient encounter: Includes acute care, short-term, long-term care and psychiatric hospitals; home health agencies; rehabilitation facilities; nursing homes
  • Outpatient encounter: Doctor office/clinic visits, and hospital-based outpatient services including emergency department, observation, or outpatient surgery visits
  • Principal Diagnosis: The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient o the hospital for care.” The UHDDS definitions are used by health care organizations to report inpatient data elements in a standardized manner. The UHDDS definition of principal diagnosis applies only to encounters that occur in non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehabilitation facilities; nursing homes, etc)
  • First Listed Diagnosis: In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. This is the reason for the encounter. In determining the first listed diagnosis, the coding conventions of ICD-9-CM, as well as the general and disease-specific guidelines take precedence over the outpatient guidelines. First listed diagnosis is formally known as "Primary Diagnosis".

Issue: It is likely that a number of erroneous diagnoses may be attributed to patients when the source is claims data. Inaccurate coding may result in codes describing actual diagnoses when in fact, ICD-9-CM diagnosis codes (from the 001 - 999 categories) were used in lieu of the appropriate unconfirmed/rule-out, family history of, or personal history of a particular diagnosis.

Rule-out (Uncertain Diagnosis)

  • How are these distinguished from actual diagnoses in claims data?
  • What are the issues related to the ways in which each of these diagnosis "types" are coded?
  1. Coding Inpatient versus Outpatient Encounters
    • There are differences in the way uncertain diagnoses are coded depending on whether it is an “inpatient” or “outpatient” encounter. Even when coding is done following all appropriate guidelines, it may be difficult to tease out unconfirmed diagnoses from actual instances, especially from inpatient encounter data due to these coding guidelines:
      • Inpatient encounters: If the diagnosis documented at the time of discharge is qualified as an uncertain diagnosis, code the condition as if it existed or was established (from categories 001 - 999). The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
        • Note: This guideline is applicable only to inpatient encounters (short-term, acute, long-term care and psychiatric hospitals). Additional (secondary) diagnoses that are defined as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay should also be coded. Diagnoses that relate to an earlier episode which have no bearing on the current inpatient encounter should not be coded. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment
      • Outpatient encounters: Do not code diagnoses documented as Uncertain Diagnosis. Instead, code the condition(s) to the highest degree of certainty for that encounter/visit, such symptoms, signs (780-789), abnormal test results (790 - 796), or other reason for the visit (797 - 799). Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals
    • V codes may be used as either a First Listed in the case of outpatient encounters or Principal Diagnosis code in the inpatient setting, or as secondary diagnoses codes, depending on the circumstances of the encounter. However, in the case of outpatient encounters, only certain V codes may only be used as First Listed, while others only as secondary codes
  2. Inappropriate use of ICD-9 diagnosis codes for ordering diagnostic services may claims skew data
    • When clinicians create requisitions for diagnostic tests (lab tests, radiologic studies, etc.), they are required to supply “reason for test”.
    • Clinicians are not are not trained in the subtleties of proper coding practice, and therefore may use an unconfirmed diagnosis rather than the presenting signs and symptoms during the encounter as the reason for test
      • This results in ICD-9 codes for unconfirmed diagnoses appearing in claims data rather than appropriate codes as billable services are associated with the encounter which generated the order
    • Symptoms, Signs, and Ill-defined conditions are coded from Section 780.0 - 799.9
    • When diagnostic testing yields abnormal results but they are not definitive for a specific condition or disease, and the patient does not have clinical signs or symptoms, codes from categories 790 – 796 (Nonspecific Abnormal Findings) should be used to indicate non-specific abnormal findings. These codes support the medical necessity for follow up encounters or additional testing to confirm or rule out a condition
    • The V-code category – Supplementary classification of factors influencing health status and contact with health services (V01-V89) deals with occasions when circumstances other than a disease or injury classifiable to categories 001-999 (the main part of ICD) are recorded as "diagnoses" or "problems." This can arise mainly in four ways:
      • a) When a person who is not currently sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue; to receive prophylactic vaccination, health screening or counseling; or to discuss a problem which is in itself not a disease or injury. This will be a fairly rare occurrence among hospital inpatients, but will be relatively more common among hospital outpatients and patients of family practitioners, health clinics, etc.
      • b) When a person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change). A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated or a sign or symptom is being studied.
      • c) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some current illness or injury classifiable to categories 001-999. In this circumstance, the V code should be used only as a supplementary code and should not be the one selected for use in primary, single cause tabulations. Examples of these circumstances are a personal history of certain diseases, or a person with an artificial heart valve in situ.
      • d) Newborns, to indicate birth status

Family history of a diagnosis

  • Appropriate codes for a family history of diagnoses should be taken from the V16 - V19 range

Personal history of a diagnosis

  • Appropriate codes for personal history of diagnoses (not current/active diagnoses) should be taken from the V10 - V15 range
#ICD-9-CM Limitations:
  • Each unique ICD-9-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code.

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