Cracking the codes

A few basic documentation tips can go a long way toward maximizing reimbursement.

A few basic documentation tips can go a long way toward maximizing reimbursement from the Centers for Medicare and Medicaid Services (CMS) for inpatient care, said Richard D. Pinson, FACP, in a session at Hospital Medicine 2010.

First, use the word “acute” whenever appropriate; otherwise a diagnosis is assumed to be chronic, which typically reaps a lower Medicare reimbursement. Also, be as specific as possible, avoid the use of symptoms—such as syncope or chest pain—and focus instead on diagnoses, he said.

“Remember the ‘uncertainty rule,’” said Dr. Pinson, a partner in HCQ Consulting, LLC in Houston. “The terms ‘probable,’ ‘possible,’ ‘likely’ and ‘suspected’ all are coded for inpatients as if the diagnosis was established. So if I say a patient has pneumonia probably due to staph or gram-negative, then I will be able to code a staph or gram-negative code, if that patient was treated as such. This allows us to be more specific when we are not certain.”

For the most part, documentation written by nurses, nutritionists, and respiratory and physical therapists can't be used in coding, with a few rare exceptions: You can code from anyone's note on BMI, and you can code from a nurse's note on the stage of a decubitus ulcer, Dr. Pinson said.

Imaging and pathology reports, labs and echocardiograms can't be used for coding, he added.

“So that's why those documentation specialists come to you with a patient who has a sodium of 120 and say, ‘Doctor, does this patient have hyponatremia?’ Well, of course they do. It's a ridiculous question. But unless we write the words into our medical record, they can't use it,” Dr. Pinson said.


Sepsis is now the number two hospital diagnosis in the U.S., Dr. Pinson said. Importantly, the sepsis diagnosis is different from that of severe sepsis; it essentially involves having a patient with an infection who looks sick, and has two or more of the following:

  • Fever (≥101°F) or hypothermia (<96.8°F)
  • Heart rate >90 beats/min
  • Respiratory rate >20 breaths/min
  • White blood cell count >12,000 or <4,000 or bands >10

“This is not a patient who necessarily requires intensive or critical care. I consider this to be early or mild sepsis, and it's to be distinguished from life-threatening, get-out-your-protocol-and-put-in-central-lines infection,” Dr. Pinson said. “Acute organ dysfunction due to sepsis is classified as ‘severe sepsis.’”

When documenting either sepsis or severe sepsis, one must clarify the cause by writing something like “sepsis/SIRS [systemic inflammatory response syndrome] due to urinary tract infection,” Dr. Pinson said. Common causes of sepsis to document include urinary tract infection, cellulitis, abscess, diverticulitis and cholecystitis.

“With any patient with an infection, I'm always looking at the temperature, white blood cell count, pulse and respiration to see if I shouldn't document SIRS or sepsis,” Dr. Pinson said.


Pneumonia is difficult to nail down in the coding rules, Dr. Pinson said. Unless a hospitalist specifies the patient's diagnosis as aspiration pneumonia, or notes he or she is being treated for pneumonia caused by a specific organism, the default code will be simple pneumonia, he said.

“So, you need to make it clear what you are thinking. Remember the uncertainty rule, because cultures are practically useless in most cases. When you choose anything other than the typical community-acquired pneumonia antibiotics, you need some documentation that you think the pneumonia is possibly due to [a specific organism]” like staph/MRSA, gram-negative rods or anaerobes, Dr. Pinson said.

Also consider whether your case could be aspiration pneumonia. “I think aspiration pneumonia is underdiagnosed in the world,” Dr. Pinson said. Its risk factors include recently vomiting or having a nasogastric tube; having an impaired gag reflex, dysphagia or gastroesophageal reflux disease; being elderly, debilitated and bed-confined; abusing alcohol; and having a positive swallowing study.

Any nosocomial term in the notes will be coded as simple pneumonia, as will any community-acquired pneumonia, including pneumococcal, viral, Haemophilus, mycoplasma and Chlamydia pneumonias, Dr. Pinson said. Documentation of Legionnaire's disease, lung abscess and empyema will be coded as complex pneumonia, he said.

Respiratory, heart and renal failure

“Insufficiency” is a meaningless term when it comes to coding and diagnosis, whether used to describe respiratory difficulty or kidney function, Dr. Pinson said.

“Acute respiratory failure: For correct coding, you can't use any words other than this to describe this condition,” Dr. Pinson said. “In other words, severe dyspnea, respiratory distress, respiratory insufficiency, hypoxemia—they are meaningless.”

Acute respiratory failure can be correctly diagnosed if the patient has difficulty breathing and an arterial blood gas (on room air) of:

  • pO2 <60 mm Hg, or SpO2 ≥88% (for type I, hypoxemic respiratory failure); or
  • pCO2 >50 mm Hg + pH <7.35 (for type 2, hypercapnic respiratory failure)

Mechanical ventilation or bi-level positive airway pressure (BiPAP) is often needed but isn't required for diagnosis, Dr. Pinson added.

For managing patients with congestive heart failure comorbidity, CMS won't pay unless the hospitalist specifies whether the patient has diastolic, systolic (i.e., an ejection fraction <40%), or both combined. An echocardiogram should show systolic or diastolic dysfunction. Then, CMS will want to know if the heart failure is acute, chronic or acute-on-chronic.

For coding, a working definition of acute renal failure is an increase in creatinine of 0.5 mg/dL within two weeks, or an increase of 20% if the baseline creatinine was greater than 2.5 mg/dL. Dehydration is the most common cause of acute renal failure, and should be documented as such (i.e., “acute renal failure due to dehydration”).

For patients with chronic kidney disease documented as stage 4 (a glomerular filtration rate [GFR] of 15 to 29 mL/min]) or stage 5 (a GFR <15 mL/min), one can use the code for a complication or comorbidity (CC). “Creatinine has to be stable, obviously, to determine the stage. It can't be in flux,” Dr. Pinson said. “Most labs nowadays are reporting the GFR in association with the patient's creatinine.” End-stage renal disease with a need for dialysis (ESRD) is coded as a major comorbidity (MCC), he added.

Altered mental status

Many patients are admitted to the hospital with documented altered mental status. Yet “this is a symptom that has no significance in terms of assigning a code,” Dr. Pinson said. “For every patient who has an altered mental status, think about whether it would be appropriate to diagnose it as encephalopathy.”

Encephalopathy is a generalized alteration in mental function due to an underlying process that is usually systemic and usually reversible, he said. Typical toxic causes of encephalopathy are drugs, chemicals, alcohol and medications. Metabolic causes include fever, dehydration, electrolyte imbalance, acidosis, hypoxia, infection and sepsis. “So if your patient has altered mental status and you fix this stuff and it clears up, then they had encephalopathy. It's important to use that word,” Dr. Pinson said.

Coding pearls

A couple of other pearls from Dr. Pinson:

  • To get credit for hypertension that requires urgent treatment, one must use the term “accelerated.” This applies to a systolic reading greater than 180 mm Hg, a diastolic reading greater than 110 mm Hg, end-organ involvement, or symptoms like headache, chest pain, angina and shortness of breath. “Words like ‘crisis,’ ‘urgent,’ ‘severe’ and ‘uncontrolled’ are coded as benign hypertension,” Dr. Pinson said. “If you say ‘accelerated hypertension with hypertensive emergency,’ then you are fine.”
  • For a patient with chest pain whose initial testing was unremarkable, one must be as specific as possible about the suspected or probable cause. Some preferred diagnostic terms in this situation are “chest wall pain,” “pleurisy,” “costo-chronditis,” “hiatal hernia,” “hyperventilation syndrome” and “biliary colic,” among others.