In The Know

ACTIVATION SERVICES: SAFETY PRECAUTIONS IN A COVID ENVIRONMENT

Posted by Samantha Serfass on September 1, 2020 in Blog, News

ACTIVATION SERVICES: SAFETY PRECAUTIONS IN A COVID ENVIRONMENT

Hospitals and clinics across the nation have slowly begun to adjust to the new normal, allowing for elective surgeries to once again be seen on their OR schedule boards. With a recommendation from the CDC to have a steady 14 day decline of new COVID patients, new guidelines on how to safely open back up all areas of the hospital have begun. 

Organizations such as the CDC, CMS, OSHA, AHA and the American College of Surgeons have provided not only recommendations but also self-evaluation tools to help identify how to safeguard each hospital’s specific environment.

In order to better help keep an environment and the patients safe, the CDC recommends:

  1. Specialized training in infection prevention and control (IPC) to provide on-site management of the IPC program
  2. Having a plan for visitor restrictions
  3. Grouping patients together to minimize risk

4. Temperature Check points: before entering the facility, providers, consultants and patients must be administered a temperature check to help ensure the safety of patients, employees and others.

While healthcare organizations strive to open all aspects of their health systems – ensuring patient safety becomes a center focus. Patients must feel safe to physically go back to their healthcare providers.  The Leapfrog Group is a patient facing, data driven organization that grades hospitals on many different attributes, including safety. Leapfrog updates the safety grades once every 6 months.   

Excite Health Partners recently provided safe Activation Services for both a Cerner and an Epic client with varying Leapfrog safety ratings.  Although the slight difference in safety ratings between the two environments was minimal, noticeable differences were seen. Restrictions placed on high-touch areas as well as controlled patient flow were two of the notable differences. While performing our most recent activations, Excite Health Partners worked to not only keep the client and patients safe, but our consultants as well.

We implemented several additional safety precautions:

  • MOBILE HAND SANITIZERS: Hand sanitizer is only good if you use it, and often it’s not available right after you come in contact with high-touch surfaces (example: Door handles, elevator button, and coffee machines).  Excite provides our consultants with mobile containers of hand sanitizer that can easily be hooked onto someone’s belt or slacks.
  • FACE MASKS:  As part of the CDC guidelines, face masks must be worn at all times while working within the healthcare system. We provided our consultants with a custom Excite face mask to not only meet the requirement but help identify our consultants as Excite support.
  • FACE SHIELDS: In high-risk areas, like the Emergency Department, face shields work to help better protect those from coming into contact with potential COVID cases. We provided our support staff with face shields, allowing our consultants who assisted in high-risk areas to be properly equipped in a safer environment.

We help the client cut down on cost by providing our own protective equipment to the consultants without any cost to our clients.  We also ensure our consultants follow all safety policies and guidelines of the hospital, CDC and adhere to all Excite guidelines surrounding personal hygiene.

As hospitals begin the process of reopening all services, Excite Health Partners can be a safe and valued partner to help your patients feel safe while getting your systems back up and fully running. Contact us today to get started.  

Todd Klein, CIO & VP of HIT Services

COVID MS-DRG Payment Increases, Adjusting the Temporary Adjustment

Posted by Samantha Serfass on August 25, 2020 in Blog, News

COVID MS-DRG Payment Increases, Adjusting the Temporary Adjustment

Through section 3710 of the CARES Act, one of the ways CMS has adjusted guidelines to support hospitals through the COVID pandemic was to temporarily increase the weighting factor on MS-DRGs by 20% for patients with a coded diagnosis of COVID.  This 20% increase helps to offset the additional resources and costs incurred with treating COVID cases.

Through a recent Med Learn Matters release on August 17, 2020, CMS announces an adjustment to this temporary increase. 

“To address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record.”

When patients with positive results outside of the hospital are hospitalized, hospitals will either have to perform their own test, or obtain a copy of the positive test to add to the patient’s medical record.  A positive test result from outside of the hospital added to the medical record is acceptable in meeting this new requirement. 

If a patient has a clinical diagnosis of COVID-19 without a positive test result in the record, effective with claims dated on or after September 1, 2020, a hospital can decline the additional 20% payment.  If they fail to do so, they will be at risk for repayment to CMS.

“CMS may conduct post-payment medical review to confirm the presence of a positive COVID-19 laboratory test and, if no such test is contained in the medical record, the additional payment resulting from the 20 percent increase in the MS-DRG relative weight will be recouped.”

The full article can be found here.

Lisa Marks, VP of HIM Services

THE GREAT OUTDOORS: CODING BUG BITES, SUNBURN, OUCH, ETC.

Posted by Samantha Serfass on August 4, 2020 in Blog, News

THE GREAT OUTDOORS: 

CODING BUG BITES, SUNBURN, OUCH, ETC.

For most people, warm summer months mean a trip to the beach, lazy days by the pool, or cooking on a grill in the evening. Spending quality time with your family outdoors can unfortunately also bring certain perils – mosquitoes, ticks, chiggers, and spiders enjoy the summer weather as much as we do. A recent New York Times report states that the number of people getting diseases from insects has more than tripled in the United States. When coding an insect bite, an ‘S’ code is assigned which indicates the location of the bite.  For example:

  • S00.262A Insect bite (nonvenomous) of left eyelid and periocular area, initial encounter
  • S30.860A Insect bite (nonvenomous) of lower back and pelvis, initial encounter
  • S30.861A insect bite of the abdomen, initial encounter
  • S70.362A Insect bite (nonvenomous), left thigh, initial encounter
  • S50.861A Insect bite of right forearm, initial encounter
    Code W57.XXX- (A, D, or S), bitten or stung by nonvenomous insect and other nonvenomous arthropods, is an external cause code used to describe the cause of an injury or other health condition. According to ICD-10 guidelines, no external cause code from Chapter 20 is needed if the external cause and intent are included in a code from another chapter. Since a code for an insect bite would indicate the cause of injury and as intent is not applicable, a code from category W57 does not have to be reported in conjunction with codes for insect bites. A code from category W57 may be reported if an insect bite results in a complication such as a localized infection that requires treatment.

The CDC tells us that about 300,000 Americans get Lyme disease each year, but only 35,000 cases are reported. Wooded areas are home to deer, and deer carry ticks who in turn cause Lyme disease which is a bacterial disease. The symptoms of Lyme disease may involve multiple body systems including the skin, joints, and nervous system. For example:

  • A69.20 Lyme disease unspecified
  • A69.21 Meningitis due to Lyme disease
  • A69.22 Other neurologic disorders in Lyme disease (Cranila neuritis, meningoencephalitis, polyneuropathy)
  • A69.23 Arthritis due to Lyme disease
  • A69.29 Other conditions associated with Lyme disease

Recreational water illnesses (RWIs) are caused by different types of bacteria that can be transmitted through water used for recreational purposes. Swimmers are susceptible to diseases spread through water such as E. coli and Giardia. Contaminated water in swimming pools, hot tubs, water parks, lakes, rivers, and oceans can expose recreational water enthusiasts to these diseases. For example:

  • E.coli is a type of bacteria present in the intestines of people and animals. While most strains of E.coli are not harmful, some types can cause illness such as diarrhea, abdominal pain, fever, and sometimes vomiting. Severe infection can cause bloody diarrhea, dehydration, or even kidney failure. The ICD-10 code for E.coli is B96.20, Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere
  • Giardia, another intestinal infection, causes abdominal cramps, bloating, nausea and bouts of watery diarrhea. Though the infections usually resolve in a few weeks, intestinal problems may persist, even after the parasites are gone. The ICD-10 code for Giardia is A07.1, Giardiasis [lambliasis].
  • Norovirus is a major cause of acute gastroenteritis and can lead to the sudden onset of severe vomiting and diarrhea. This highly contagious virus is commonly spread through contaminated food or water or close contact with an infected person. It can cause diarrhea, abdominal pain and vomiting 12 to 48 hours after exposure. Norovirus is classified to ICD-10 code A08.1, Acute gastroenteropathy due to Norwalk agent.
  • Cryptosporidiosis or Crypto is caused by cryptosporidium, a microscopic parasite that causes a diarrheal disease. Other symptoms include stomach cramps or pain, dehydration, nausea, vomiting, fever, and weight loss. On the other hand, some people with Crypto will have no symptoms at all. Those with weakened immune systems may develop serious, chronic, and sometimes fatal illness. The ICD-10 code is A07.2, Cryptosporidiosis

Poison oak, ivy and sumac are present on hiking trails or around campsites. Contact with these plants can cause redness, itching, swelling, and blisters. The rash usually appears 8 to 48 hours after contact. Even inhaling the smoke from a burning plant can cause a reaction which includes breathing difficulties. For example:

  • L23.7 Allergic contact dermatitis due to plants, except food

Damage to the skin as a result of overexposure to the natural sun (sunburn) can cause redness, swelling, blisters, pain, and flu-like symptoms. ICD-10 coding of sunburns allows complete coding based on the severity of the burn. For example:

  • L55.0, sunburn first-degree sunburn
  • L55.1, sunburn of second degree
  • L55.2, sunburn of third degree
  • L55.9, sunburn unspecified

This list of ailments associated with working and playing outdoors is not exhaustive and includes only the most common. To help you stay healthy, it is important to take preventative measures when outdoors such as wearing light-colored, loose cotton clothing, using a higher SPF sunscreen, and avoiding exposure to direct sunlight during peak sun hours.

Cynthia Alder-Smith, RHIT CCS

Auditor, Educator Excite Health Partner

Reaching Across The Divide: Bringing Coding, CDI and Medical Staff Together to Improve Documentation Outcomes

Posted by Samantha Serfass on July 16, 2020 in Blog, News

Reaching Across the Divide: Bringing Coding, CDI, and Medical Staff Together to Improve Documentation Outcomes

There have been many articles over the years published about the importance of physician specialties communicating and coordinating patient care.  The result is a shared knowledge of care plans, timely discharges of patients, and improved clinical outcomes.  Various models were implemented as facilities adopted the use of intensivists or hospitalists acting as “captains of the ship.”  There is an opportunity to duplicate this model between coding, CDI, and the medical staff.  Such a collaboration can reduce documentation issues and improve revenue flow by reducing denials.

Three areas where there is potential for a large impact by utilizing a combined collaborative model are:

  1. Development of facility approved clinical and documentation indicators for high risk or high volume diagnoses,
  2. Assistance with payer denials and subsequent appeals,
  3. Medical staff education.

Documentation requirements for accurate reflection and code assignment have become much more complex with the initiation of the ICD-10-CM and ICD-10-PCS code sets.  These code sets are based on high levels of specificity which, if not initially documented by the physician correctly, result in numerous concurrent and post-discharge queries.  These queries not only delay final billing and reimbursement, they can be a source of frustration for the physicians.

Many facilities have a program where the coder and CDI work together on documentation and DRG reconciliation.  CDI’s are often tasked with monitoring for concurrent documentation needs and querying the physician if further specificity is needed.  Likewise, retrospective queries are performed either by coding or CDI.  Because the physicians also play the most important role in documentation, facilities should consider enlisting the help of physician champions – those physicians who understand the importance of detailed documentation and are willing to work with coders and CDI staff along with medical staff to make improvements. 

Healthcare organizations across the country have been experiencing clinical denials from payers resulting in a lower MS-DRG reimbursement.  Some of the most common denials are for acute kidney injury and acute respiratory failure as principle or secondary diagnosis.  Although the ICD-10-CM/PCS Official Guidelines for Coding and Reporting state that clinical indicators should not be used in determining if a diagnosis should be reported, payers still compare the clinical picture to the indicators as the basis for their denials.  Enlisting the assistance of a physician in the denial/appeal process can be extremely beneficial because of the level of clinical knowledge and ability to detect nuances in the treatment in support of the denied diagnosis.  Having a physician champion is also helpful in the appeal process if dealing with a physician reviewer on the payer side.

Focus areas of improvement can be developed from various sources.  Coding and CDI can rank problematic diagnoses based on denials from outside payers and the top five or 10 reasons for concurrent and retrospective queries.  Using this data, coding and CDI professionals can work with the physician champion to develop education and documentation guidelines for the medical staff to ensure clear, concise representation of the diagnoses in question.  The diagnosis of AKI not meeting RIFLE*criteria, type and acuity of heart failure (systolic, diastolic, combined, acute, chronic), presence of acute respiratory therapy, depth and type of wound debridement are just a few of the high risk/high volume areas where facilities see the most external denials or internal queries.

The last area of impact that is extremely important for a successful collaboration is education.  All of the work done to this point is important but will not promote change unless all of this information is shared with the entire medical staff (including residents and medical students) and their associated allied health professionals.  This can be done within specialty meetings, grand rounds, or by working with Medical Staff Education to develop small educational seminars. 

Successful collaboration of the three main stakeholders and promotion of the information to medical staff will result in a better understanding of the documentation requirements for correcting coding and reporting and will also have a mitigating impact on retrospective denials.

*RIFLE criteria – Risk, Injury, Failure, Loss, End-stage – grades of severity for classification of acute kidney injury with specific parameters in determining the presence of the injury based on acute rise and duration of a patient’s serum creatinine.

Robyn McCoart, RHIT, Managing Auditor Excite Health Partners

Reference: Hughes, Piper Julie, MD. Updated 8/7/2018. What Are The RIFLE Criteria for Acute Kidney Injury (AKI)? Retrieved 6/30/2020

Virtual Go-Live: A New Approach To Support Health Systems

Posted by Samantha Serfass on June 30, 2020 in Blog, News

VIRTUAL GO LIVE:

A NEW APPROACH TO SUPPORT HEALTH SYSTEMS

As the HIT industry continues to change, the demand to reduce on-site presences of traveling ‘At the Elbow Resources’ for a Go-Live continues to rise. Hospital systems also need to decrease the costs for activation support.  Providing virtual support at Go-Live can tackle both of these issues.

A virtual Go-Live occurs when a health system uses technology to virtually train their end-user staff and to help support them remotely after go-live. In most cases, health systems will still need some onsite lead resources to assist with end-users communication and escalation.

Virtual Go-Live staff will act as the on-call help desk support team. Clinicians and support staff will access the end user’s desktop remotely and walk them through the trained workflows – addressing any questions they may have via virtual “command center”.

By creating a custom icon on the desktop, an end-user can quickly connect to a support team.  These team members can assist the end-user by shadowing them while communicating via message or by phone. End-users can also email and video conference with support staff but the preferred method of communication used is based on each organization and the end-users specific challenges.

Virtual Go Live staff will act as the on-call help desk support team. Clinicians and support staff will access the end user’s desktop remotely and walk them through the trained workflows – addressing any questions they may have via virtual “command center”.

The support staff can offer assistance in two ways. First by either verbally walking end-users through issues; this can be done over a simple phone call. The second way the support staff can offer assistance is by gaining access remotely to the PC to show the end-user how to resolve the issue. It is critical to provide support staff that is extremely knowledgeable about the details surrounding the workflows.

ADVANTAGES

  • Quick set-up with multiple ways to communicate with end-users
  • Onboarding and travel costs are eliminated
  • Providers have more flexibility in “attending” classes/webinars
  • Pre/post Go Live “walkthroughs” including personalization labs that can be scheduled to train on feature and functionality

There are two key factors to consider when implementing a virtual Go-Live: the people and the process. Excite Health Partners not only has the experienced professionals to assist with a virtual Go-Live, but we also have the ability to tailor our processes to best fit the unique needs of each facility.

People: Virtual ATE Support places a large emphasis on having the right talent. Resources that intimately know the EHR screens which support the workflows, understanding the job responsibilities of the end-user and having superior communication skills are vital.  Excite has conducted over 30 activations over the years and has a database of nearly 25,000 support staff who we’ve already worked with. After each Go-Live engagement, we update the profiles of our support staff so performance expectations can be set appropriately allowing everyone to be set up for success.

Process: Excite comes to the table with a set of standard processes that addresses available support staff communicating issues and initial communication to end-users.  Our resources are trained to process escalating issues, handoffs, documenting throughout the life cycle of the ticket and finally creating new tips and tricks. Many times, our client will have specific needs around documentation and processes. Excite works with each individual client to meet their unique needs while remaining flexible in our business operations.  

As the need for virtual Go-Lives continues to increase, our experienced team has the tools to tackle your next project. Excite Health Partners can help offer the right talent, resources and approach to not only reduce onsite presence but also lower activation support cost.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

Harnessing Remote Resources for Internal Coder Training

Posted by Samantha Serfass on June 23, 2020 in Blog, News

HARNESSING REMOTE RESOURCES FOR INTERNAL CODER TRAINING

In the ever-changing world of health information management, the ability to train and maintain knowledgeable and highly qualified coding specialists is a necessity.  Shrinking budgets, lack of available training staff, tools, time, and focus on keeping current workloads current are just a few of the challenges impeding a facility’s ability to train current or new incoming coders.  With the emphasis on quick turn-around to keep Discharge Non-Final Billed (DNFB) and Accounts Receivable (AR)  at a minimum,  supporting coders in learning other coding specialties takes time away from sole focus on their designated patient type.

A 700- bed facility had talented internal coders who expressed the desire to progress into other patient types; however, the facility did not have the bandwidth to perform the training and education internally.  Through an existing relationship, they reached out to Excite Health Partners seeking support with expanding existing coders’ skill sets.   

The first step in the project was to define the Scope, Goals, Timelines, Challenges to the project with respective solutions, and outline Project Details.

THE SCOPE

The client needed the education to span multiple coding modalities:

  • training new coders to perform outpatient ancillary coding,
  • train current outpatient ancillary coders to be proficient in emergency department coding,
  • and to educate current emergency department coders on ambulatory surgery and observation coding. 

THE GOALS:

Numerous benefits drove the facility to support this investment in their coders:

  • well-rounded coder skills to support fellow coders;
  • cross-coverage during vacations and sick time;
  • reduced need to call in additional contract coding support;
  • improved marketing for new coders demonstrating the facility’s commitment to supporting expanding coders’ career path;
  • improved coder morale and coder loyalty;
  • improved coder confidence;
  • coders felt like they were a part of a team working together to achieve a common goal.

THE TIMELINES:

All education would be performed in specific timeframes, with the ancillary training set at 6 weeks, emergency coding requiring 8 weeks, and ambulatory surgery/observation coding spanning 12 weeks.

THE CHALLENGES:

There were three primary challenges we had to tackle:

  • Maintaining current workloads while the coders were training.
    • Excite Health Partners provided additional staffing to the client to cover productive hours lost during internal staff training.
  • Creating an educational program for the ambulatory surgery/observation trainees that would effectively cover all body systems and related procedures while moving at a pace that would meet the client’s 12-week training expectation.
    • Two body systems and related procedures were covered weekly with practice exercises to apply information covered.
  • Ensuring an effective remote training/education environment.
    • Remote training sessions were interactive and inclusive in nature, using 1:1 phone calls and group screen-sharing applications.
    • Following classroom and education time, the coders would then code “live” accounts for the duration of their training. 

THE PROJECT DETAILS

A total of eight coders were trained in ancillary and emergency department coding, four for each modality.  These two training sessions were performed simultaneously, with the 8-week emergency department training starting first for two weeks, then adding the ancillary training for the remaining 6 weeks.  Each training session began with review of basic outpatient coding guidelines and also review of the facility’s specific outpatient coding policies.  After the initial training sessions, ED trainees were expected to code a total of 40 charts per week, not exceeding 10 charts per day.  The ancillary coders submitted 50 charts a week.  On a daily basis, the educator would review the accounts for coding accuracy and make recommendations for any changes.  All audit results were sent back to the coder at the end of the day for review.  Once a week, the educator and coder had individual meetings scheduled to review the audit results and discuss any issues.  Once all meetings had occurred for the week, the educator would submit progress reports to the facility’s coding management team, reflecting the coder’s progression towards overall 95% coding accuracy.

The training program for the ambulatory surgery/observation coders was developed in a different manner.  Because a thorough understanding of anatomy and physiology is needed to code surgeries, it was important to include review of individual body systems and related surgeries prior to the coders moving to coding actual charts.  The educator met with the coders in a virtual classroom setting twice a week.  During each class time, the educator focused on one body system.  This focus included anatomy and physiology of the body system, review of common surgeries on the body system, and review of coding resources pertaining to those particular surgeries.  On completion of the class time, the coders would be given simulated system-specific operative reports to code.  Their coding were returned to the educator, who would audit the codes and respond with feedback.  Throughout the week, the coder and auditor would have calls to review and discuss the audit findings, and at the end of the week the coder’s weekly score would be provided to the facility’s management staff.  Once all body systems had been covered, then the coders were assigned 25 actual charts to code on a weekly basis, following the same auditing/feedback/scoring format.

THE CONCLUSION:

The current coding team is now more well-rounded, confident, and able to support the various incoming workload types of the facility.  The facility now has more flexibility in workload assignments with the multi-skilled coding team.  Within three months of the end of the training sessions, the facility had an external audit performed on all of their coders.  Particular attention was paid to those coders who had recently attended the education, with all having done well with passing scores.

“I was thrown into the External Audits and I passed with a 98%!! I couldn’t believe it! This has made my entire day.  I’m over the moon LOL!   Thank you so much for the training and the assistance that you gave us. This is why we have been so successful!”  — Ambulatory Surgery Coder

Excite Health Partners is here to partner with you on your education and training projects and support any level of coder development, education, and training needs.  We are ready with experienced coder educators that can train coders into separate service types and offer education to coders on specific coding topics.  All education and training projects are tailored to each individual client’s needs and goals.

Robyn McCoart, RHIT, Managing Auditor Excite Health Partners

FAST HEALTHCARE INTEROPERABILITY RESOURCES: DISCUSSING WORKFLOW AND INTEGRATION

Posted by Samantha Serfass on June 16, 2020 in Blog, News

FAST HEALTHCARE INTEROPERABILITY RESOURCES: DISCUSSING WORKFLOW AND INTEGRATION

The first version of FHIR was published Feb 2014, by the HL7 International organization.  FHIR was developed in part because of the lack of the HL7 standards to easily share real time data across a variety of EHRs.  FHIR is an intraoperative data integration tool/language which allows EHRs to deviate from exchanging complex Clinical Document Architectures (CDAs).

FHIR takes advantage of open API using a structured language to access and modify discrete data. Built on HL7 and HTTPS protocol, FHIR allows for real-time data gathering from multiple specific segments of data. In 2018 Apple announced its iPhone Health application. This app would allow viewing of end user’s medical record, via FHIR.  John Hopkins, Cedars- Sinai and other large hospital organizations supported the effort.  

EHRs like Epic and Cerner have supported the use of their open API’s via FHIR and SMART. Within the SMART App Gallery Store, hundreds of applications from Care Coordination, Patient Engagement Disease Management and COVID-19 use FHIR to access systems and provide specialized support for end users. By using SMART on FHIR, developers can create applications rapidly at a fraction of the cost. These new tools and technologies have helped to improve telehealth solutions.

Excite Health Partners is a partner with SnapMD. SnapMD is a top rated KLASS telehealth solution which can be utilized within the whole hospital system. By leveraging both SnapMD and the hospitals systems open APIs we can help support a smooth workflow for patients and providers.  It is paramount when integrating the systems SMART on FHIR is used to support the right clinical & patient processes. Use Cases are identified within each specialty of care and which devices are leverage throughout each type of patient interaction.  

To confirm the bills are dropped for reimbursement, it’s important to ensure the use cases and workflows are seamless and efficient while supporting proper sharing and storage of the data. SMART on FHIR is the way of the future and provides not only a reduced cost but also a rapid integration, allowing hospitals implement and utilize these systems quicker.

Whether an organization chooses to store clinical notes and discharge summaries within their EHR or in a telehealth solution, such as SnapMD, Excite Health Partners can offer the right support. Once the desired workflows are established, Excite leverages our technical expertise to provide the integration required to support efficient operations.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

Multisystem Inflammatory Syndrome in Children Associated with COVID-19

Posted by Samantha Serfass on May 28, 2020 in Blog, News

Multisystem Inflammatory Syndrome in Children Associated with COVID-19

As we have begun to see more and more cases of COVID-19, the majority of the more severe cases have been found to be in the elderly population or people with underlying chronic conditions affecting the ability of the immune system to fight illness.  We have yet to see many cases of confirmed COVID-19 in infants and children.  However, recently there have been reports of children and adolescents with a multisystem inflammatory condition with symptoms similar to those seen in Kawasaki disease and toxic shock syndrome and required admission to intensive care units.  It is thought that this multisystem inflammatory syndrome may be related to COVID-19. [1]

Kawasaki Disease

Kawasaki disease is an acute febrile illness usually occurring in children younger than 5 years of age.  The fever usually lasts at least 5 days and is associated with rash, swelling of the hands and feet, swollen lymph glands in the neck and irritation and inflammation of the mouth and throat.[2]

Toxic Shock Syndrome

Toxic shock syndrome is another condition that typically presents with a high fever.  Associated symptoms include hypotension, diffuse erythematous rash, and organ dysfunction in at least two organ systems that may progress rapidly to severe shock.  Toxic shock syndrome is typically caused by staphylococcal or streptococcal bacteria.[3]

On May 14, 2020, the Centers for Disease Control and Prevention (CDC) released an official health advisory which provided background information on several cases of multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) along with a case definition of the syndrome.  Cases have been reported in U.S. and other countries. [4]

Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C):

  • Age 21 years or younger presenting with fever
  • Laboratory evidence of inflammation
  • Evidence of clinically severe illness requiring hospitalization
  • Multisystem organ involvement (2 or more organ involvement)
  • No other plausible diagnosis
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

The CDC is recommending that healthcare providers who have treated or are currently treating patients meeting the criteria for (MIS-C) should report suspected cases to their local, state, or territorial health department.[4]

Coding Guidance:

As of April 1, 2020, there is no official coding guidance for MIS-C.  MIS-C cannot be indexed in the ICD-10-CM Alphabetic Index therefore coders must follow the guidance in ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.15:  Syndromes.  This instructs the coder to assign codes for the documented manifestations of the syndrome.  Any additional symptoms that are not an integral part of the disease process may be reported when the condition does not have a unique code.

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Sandy Hall, Coding Education Auditor; CCS, COC, CPC


[1] https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19

[2] https://www.cdc.gov/kawasaki/index.html

[3] https://www.merckmanuals.com/professional/infectious-diseases/gram-positive-cocci/toxic-shock-syndrome-tss

[4] https://emergency.cdc.gov/han/2020/han00432.asp

HEALTHCARE: THE NEW NORMAL

Posted by Samantha Serfass on May 21, 2020 in Blog, News

HEALTHCARE: THE NEW NORMAL

As states across the US begin the process of reopening, establishing a sense of normalcy becomes a top priority. Healthcare systems are facing a significant challenge as they work to resume normal operations while still focusing efforts on decreasing the virus.

It is estimated the American healthcare system has lost $200 billion dollars resulting in the job loss of over 1.4 million healthcare workers. While healthcare systems begin to resume full services, several key factors are important to consider.

In March, the CMS first recommended limiting the non-essential care in an effort to save critical PPE supplies. As healthcare systems reopen and PPE supplies still remain limited, the CMS has updated its recommendations for facilities in order to allow health systems to safely provide nonemergent non-COVID-19 care. The CMS will continue to publish recommendations and updates to existing guidelines to help carefully phase in normal hospital operations. More information on the guidelines and regulations established by the CMS for phase one can be found here.

Healthcare IT departments have shifted gears to best assist their hospitals during COVID-19. Hospitals across the US have pressed “pause” on many projects unless considered critical – shifting their focus to support COVID-19 initiatives.

Tim Pugsley, CIO for Titus Regional Medical Center in Mount Pleasant, TX, has dispatched analytics, informatics and technical teams to support their clinical leaders across many platforms. They have created new dashboards which track PPE consumption rates, temperature tracking for staff, video visit encounters and record call center statistics for the CV-19 hotline.  In addition, they have updated their EHR to record the latest COVID-19 documentation requirements all while supporting a remote workforce.

TRMC has also expanded their telehealth presence. Prior to COVID-19, TRMC focused on telehealth equipment in the ambulances and extending specialty care to outlying communities. Since the pandemic, they have enabled video visits in TRMC operated and independent ambulatory clinics, inpatient floors and on the COVID unit. Patient’s visitors also have an option to become “virtual visitors” enabling them to interact with loved ones.

                 “We understand the importance of social interaction with family and friends. To address that need, we supply the patient with a tablet and technology to have a video interaction” added Pugsley.

While preparing to reopen, Telehealth initiatives are the front runners for helping to safely allow these healthcare systems to better assist, treat and safely diagnosis their patients while working to decrease the possibility for COVID-19 exposure. Titus Regional Medical Center’s clinical leaders are developing a strategy and tactical plans to safely provide care by partnering with physicians and key stakeholders. Policies and procedures are reviewed constantly to adapt to the changing landscape and processes continue to evolve to support our community, our providers, and our staff.

As elective services begin to slowly reopen, Titus has leveraged their telehealth solution to keep the community informed. Through the use of MyChart, public radio and social media platforms – like Facebook – Titus has been able to communicate with the community about the virus, guidelines, and regulations being implemented.

Telehealth will continue to play a vital role as phase one of reopening begins to occur. CMS will likely start to remove the waivers they once had in place for telehealth solutions (for example, enforcing HIPAA compliance). Ensuring your telehealth solution is effective and compliant is more crucial than ever. Demonstrated by TRMC, telehealth solutions allow healthcare systems to safely and efficiently communicate, treat, and assist patients during this pandemic.

Excite Health Partners offers the knowledge and experience to implement the right fit telehealth solution. We can develop new workflows and data integration, improve the efficiency of care and help recover revenue. As healthcare systems continue to adapt during these unprecedented times, we can help ease the burden of implementing the best telehealth solution to meet your organization’s needs.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

Posted by Samantha Serfass on May 6, 2020 in Blog, News

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

During this COVID-19 crisis, coders are beginning to see the providers document cytokine storm as a secondary diagnosis in patients who have been diagnosed with a primary diagnosis of COVID-19.

Some of the acutely ill COVID-19 patients are developing a cytokine storm which is a Cytokine Release Syndrome (CRS). The sickest patients are the ones who have CRS that can lead to the patient developing secondary hemophagocytic lymphistiocytosis (sHLH) which then causes the patient to develop acute respiratory distress syndrome (ARDS).1

CRS “is caused by a large, rapid release of cytokines into the blood from immune cells” “Cytokines are immune substances that have many different actions in the body.” In some patients, excessive or uncontrolled levels of cytokines are released which then activate more immune cells, resulting in hyperinflammation. It is the overreaction of the immune system.

Coders and CDI Specialists should be very careful when querying the provider for clarification of cause of the signs/symptoms and/or clinical indicators for appropriate code assignment. 1,2 The symptoms of CRS can mimic other conditions.

Cytokine storms can be seen in the below conditions which have similar pathophysiology but have very different treatment options. Therefore, it is imperative to capture the conditions correctly through coding.

  • Sepsis
  • Non-infectious SIRS
  • Macrophage activation syndrome (MAS)
  • Secondary hemophagocytic lymphohistiocytosis

Possible Signs/Symptoms of CRS:

  • Trouble breathing
  • Low blood pressure
  • Rapid heart rate
  • Fever
  • Headache
  • Nausea
  • Rash
  • Multi-organ dysfunction – in severe cases

Possible Laboratory Clinical Indicators of CRS:

  • Elevated serum ferritin2
  • Markedly increased interleukin-6 (IL-6)2
  • High levels of C-reactive protein2
  • Elevated blood nitrogen levels5
  • Elevated D-dimer5

Coding Guidance:

Currently, as of April 1, 2020, neither CRS nor cytokine storm can be indexed in the ICD-10-CM code book.

Per the AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37, with there not being a specific code for CRS and it cannot be indexed in the code book, coders must follow the ICD-10-CM Official Guidelines for Coding and Reporting Section I.B.15 Syndromes where there are instructions to code the manifestations of the syndrome based on physician documentation. Any additional manifestations that are not typically integral to the condition may also be assigned if the condition does not have its own unique code. 4

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Lorrie Strait, RHIT, CCS

Manager HIM Services, Excite Health Partners

References:

  1. https://www.icd10monitor.com/covid-19-and-secondary-hemophagocytic-lymphohistiocytosis-shlh-versus-sepsis
  2. https://www.physiciansweekly.com/cytokine-storm-the-sudden-crash-in-patients-with-covid-19/, April 8, 2020
  3. https://www.cdc.gov/nchs/data/icd/Topic-packet-Sept-2019-Part2.pdf
  4. AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37
  5. Merck Manual, www.merckmanuals.com