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Commas, adjectives and an occasional noun
In one hospitalist’s opinion, all diagnoses should be qualified

Keywords: ICD-9 coding: use adjectives and descriptions to document higher level codes and complexity


by David Frenz, MD



Published in the October 2009 issue of Today's Hospitalist

WHEN IT COMES TO DOCUMENTATION and reimbursement, physicians control three key components: the history, the exam and the medical decision- making.

Because the first two are relatively straightforward, they typically aren’t the basis for disputes over charges. However, coders and third-party payers frequently challenge what we report on medical decision-making, which is much more subjective and often determines how much we’re paid.

Feuds over charges boil down to this: We were there, they were not. To avoid arguments—and to maximize what we’re paid—it’s our responsibility to justify what we charge by adequately describing
A few carefully chosen words in your documentation can help paint the appropriate clinical picture.

the clinical circumstances.

To do so, we need to include a few carefully chosen words in our documentation to paint the appropriate clinical picture. That means making truthful but judicious use of commas, adjectives and some occasional nouns. “Heart failure, Stage C, with severe exacerbation” or “Chronic kidney disease, Stage 4, with superimposed acute renal failure” provides a much more challenge-proof (and lucrative) description than “heart failure” or “renal insufficiency.”

A lesson from addiction medicine
I came to understand the importance of commas and adjectives through my work with addiction. In addiction medicine, our main diagnostic tool is the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV-TR), published by the American Psychiatric Association.

Many DSM diagnoses are rife with “course specifiers,” which have to do with severity. That got me thinking that hospitalists can—and probably should—be doing the same kind of qualification for all our diagnoses.

Take, for instance, a patient admitted following a near-syncopal episode. His medical history is notable for chronic low back pain, managed with methadone, and for peripheral edema treated with a loop diuretic. Lab abnormalities on presentation include hypokalemia and hypomagnesemia, while a resting electrocardiogram demonstrates significant QT prolongation.

You could list the patient’s admitting diagnoses as “hypokalemia, hypomagnesemia and prolonged QT.” A conservative coder might spot you a 99222 (level 2 admission, moderate complexity) but make you justify billing the higher 99223 (level 3 admission, high complexity).

However, a level 2 code doesn’t fully capture the patient’s medical complexity. Instead, a primary diagnosis of “Prolonged QT interval, likely acquired, severe” makes a much more compelling case for billing a 99223, particularly if you also describe the hypokalemia and hypomagnesemia as “severe.” You can make your case for these diagnoses being severe by documenting the need for parenteral replacement therapy, intensive lab surveillance and continuous cardiac monitoring.

Note that I’m opting for the more serious diagnosis as the primary one. (Don’t order diagnoses by free association, but arrange them in a way that reflects higher intelligence.) The ability to charge the highest admission code, rather than the intermediate one, hinges on only a few key words. But the difference in reimbursement is substantial: 48%.

Describing severity
Most of the nouns and adjectives we use to qualify diagnoses have to do with disease severity. According to the Centers for Medicare and Medicaid Services (CMS), three elements go into determining medical decision-making:

• the number of diagnoses or management options;

• the amount and/or complexity of data to be reviewed; and

• the risk of significant complications, morbidity and/or mortality.

In the hospital, disease severity is a reasonable surrogate for the last two elements on this list, and you can describe it in many ways. First, physicians should be very familiar with accepted classification systems that allow you to choose within a severity range. (See "Describing disease severity," below.)

Many of these classification systems have already been translated into CPT codes. Even the ones that haven’t support your medical decision-making.

Favorite adjectives
As for adjectives, the best basis for assigning severity for many conditions, including most lab abnormalities, is your own clinical judgment. You can couch anemia severity, for example, in terms of oxygen delivery needs, risk for end organ damage or transfusion requirements. Likewise, you can qualify hypokalemia severity according to the risk of complications such as cardiac arrhythmia or the route or intensity of replacement therapy.

Finally, the patient’s subjective experience or “disease” is another key way to describe severity. Ask patients to rate, for example, their post-operative pain or the discomfort associated with opioid withdrawal syndrome.

Here are some of my favorite adjectives, with an occasional noun:

  • Mild, moderate, severe, critical
  • Acute, subacute, chronic, acute-on-chronic
  • Improved, unimproved
  • Controlled, uncontrolled
  • Stable, unstable
  • Compensated, decompensated
  • Corrected, replaced
  • Multifactorial
  • Prior history


David Frenz, MD, is a hospitalist for the HealthEast Care System in St. Paul, Minn., who wants to acknowledge the help of coder Susanne Linssen. Dr. Frenz is board certified in both family medicine and addiction medicine and serves as system medical director for addiction medicine. He can be reached at dafrenz@healtheast.org.








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