Coding and documentation veterans Sue Belley and Donna Smith take a break from hospital visits and client consultations to trade tales about coding mishaps, ICD-10 enigmas, the latest regulatory twists, and why it’s nearly impossible to get physicians to document diagnoses in correct coding terminology. A back-and-forth take on the real world of HIM.
Sue: So Donna, I’ve been doing some investigating….
Donna: Here we go again.
Sue: I’ve been thinking about the coder having to identify the type of contrast agent used in cardiac caths and other fluoroscopic procedures for ICD-10-CM coding.
Donna: (places hands over ears) La la la – I can’t hear you!
Sue: This is no time to be burying 
your head in the sand! I remember all the caths we did when I was a coding manager. The type of contrast used wasn’t in our cardiac cath report, and besides, coders don’t have to worry about contrast in ICD-9. If coders spend a lot of time looking for a relatively miniscule thing in the whole scope of coding, it’s going to be bad for productivity!
Donna: So what do you think would fix this, Sue? It sounds like a documentation issue, but it’s not the sort of question you take to the physician. Contrast is usually documented in the procedure flow note, which coders don’t need to review today. Rather than querying the physician or searching through the note, we need a way to bring the contrast type into the cardiac cath report.
Sue: Right. The information has to be pulled from the cardiac cath database and inserted into the report because it’s part of the legal medical record. But wait, that’s not all! It’s not just the contrast type; we also need to determine if the contrast is high or low osmolarity.
Donna: Well, that complicates things. If coders find a contrast name in the report, couldn’t they Google it to find out if it’s low or high osmolarity? But the question is should coders have to take time out of production to Google for this information?
Sue: No way! Coders need this information at their fingertips. They need to know the contrast agents used at their facility and how they are categorized for osmolarity.
Donna: Yep, I agree. But there’s another potential problem. You know some people will say, “Oh, nobody uses anything but low osmolar agents, so you can just code everything as low.”
Sue: Which isn’t true.
Donna: Exactly! You just can’t make assumptions like that.
Sue: For one thing, it’s a patient safety issue. Sometimes giving contrast can cause adverse effects. You know, like acute tubular necrosis of the kidney. Today, with ACOs, Patient Safety Indicators and so on, everybody has to be concerned with minimizing complications. That’s how ICD-10 will help us. If a patient develops a contrast-induced reaction, we can use the codes to map back to the type of contrast given.
Donna: So the bottom line is that osmolarity has to be accurately coded. Making sure the contrast type gets documented in the cardiac cath report is the first step. Then the Coding and CDI teams should work with the clinical staff to identify all the different contrast types used in the facility as well as their osmolarity. Take this information and develop a reference chart for coders and CDI specialists. Ta-da! You’ve eliminated the risk of inaccurate coding.
Sue: And you’ve helped reduce the drag on productivity. Not bad, Donna.
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Knowing whether the osmolarity of the contrast material is high or low is not enough. One must also code based on the strength of the contrast (mg iodine per ml concentration) and the dose given (per ml = unit of measure). One cannot code the contrast correctly without these data.
Thank you, Debra, for the comment. You are certainly correct in that the osmolarity is determined based on the mg/ml iodine concentration per ml. However, there are multiple references, including CMS in HCPCS, that define which agents fall into HOCM and LOCM. The coder does not need to determine this. We recommend asking the radiology department to provide a list of common agents used in the facility with the determination of high, low or other osmolarity.