For coders and clinical documentation improvement (CDI) specialists, the nuances and changes regarding coding superbug infections remain as dynamic as the pathogens themselves. Medication resistance, and especially antibiotic resistance, can be a challenging issue in the coding world.
The bacteria in question include enterococcus, staphylococcus, klebsiella, acinetobacter, pseudomonas, and enterobacter. In this article, we will examine a few of the recent coding guideline changes related to superbug infections, resistance, and new guidelines when infections are acquired in the hospital.
A Growing Cost Concern
The nuances of coding the superbugs can have a significant impact on revenue streams – especially if these infections are contracted during a hospital stay. A study published in the American Journal of Infection Control determined that one of these superbugs, clostridium difficile (c. diff) contributed to an increase in hospital costs of approximately 40 percent per case, or an average of $7,286. Costs were even higher for patients contracting renal impairment ($8,942), immunocompromised status ($8,692), and concomitant antibiotic exposure ($8,545). Given the high cost of these cases and risk factors for contamination, ensuring correct identification, coding, and nationwide tracking of superbug infections is critical.
New Zika Codes and C-diff, MRSA Codes
A quick look at the Zika virus illustrates just one example of how superbugs can be rapidly introduced to the coding scene. Unknown to U.S. coders only one year ago, the ICD-10 code set now contains Zika codes. Zika will come in as a CC and impact reimbursement for healthcare providers.
A92 Other mosquito-borne viral fever
A92.5 Zika virus disease
Zika virus fever
Zika virus infection
Also, effective Oct. 1, 2016, the 2017 updates include codes for c. diff and MRSA as hospital-acquired infections (HACs). The addition of c. diff and MRSA to the HAC list marks a big potential impact for providers. Hospital-acquired infections are particularly difficult to treat, manage, and code.
Superbugs Common for Immunocompromised Patients
Most patients who contract superbugs are already immunocompromised due to cancer, long-term medication protocols, extended inpatient admissions, or other factors. A common scenario involves patients who undergo surgical procedures and then develop MRSA infections. These painful infections quickly spread to other organs and body systems, requiring progressively stronger narcotics.
Also, since the immune systems of these patients are already compromised due to surgery and the underlying condition, superbugs build powerful resistance to medications, and such cases often become increasingly harder and more costly to treat. The progression of infection in these cases must be carefully noted and coded to ensure proper reimbursement.
Coding Medication Resistance
Coders should assign all available ICD-10 codes to reflect medication resistance. There are ICD-10 codes for resistance to 22 different types of medications, including codes for resistance to multiple medications, which might certainly be applicable in the scenario described above. This is a new change in 2016, so it’s important that coders are aware of it.
Reporting these resistant infections corrections is crucial for statistical purposes, and for tracking the superbugs across the U.S. While the codes for medication resistance don’t impact the DRG, they are usually high-dollar cases with long lengths of stays. Resistance codes are Z codes.
Here are three coding steps to take:
- Identify the infection/type of bacteria.
- Assign a Z code to describe the resistance (e.g. resistance to antimicrobial drugs – Z16.10-Z16.39).
- If the patient has been on a lot of antibiotics, this should also be coded.
Supporting documentation for coders to review includes all culture reports, physician progress notes, medication administration records, and any other ancillary testing used to identify resistance. Today, coders must rely on physician documentation to code a medication resistance. Since resistance codes do not impact the DRG, a coding query is not applicable. However, we expect future guidance from the Centers for Medicare & Medicaid Services (CMS) to open the door for CDI and coding queries for cases in which resistance occurs, but is not documented by the physician.
More on MRSA
Because MRSA is so resistant to treatment, there are most certainly added precautions and costs with MRSA patients. For MRSA to be coded as an active infection and HAC, it would have to be proven that the patient contracted MRSA while in the hospital, leading to a CC. Hospital-acquired versus present-on-admission is a very important distinction in MRSA cases.
However, MRSA should also be picked up by the coder if the patient is a carrier. Carrier status is usually designated by a note in the chart. Z codes should be used for:
- Carrier status (Z22.32 – Carrier or suspected carrier of methicillin-resistant staphlyococcus aureas)
- Colonization status
- Personal history
MRSA is the only one of the organisms that has a specific code that identifies both the bacteria and the antibiotic it’s resistant to (B95.62—MRSA infections as the cause of diseases classified elsewhere).
Superbugs Hit Outpatients Too
Outpatients are not immune to superbugs, and this is an area where coders need some heightened awareness. For example, a patient may enter through the emergency department (ED) for a urinary tract infection and be prescribed a standard antimicrobial. However, following the ED visit, the urinary culture may test positive for E. coli. The physician must be notified and a stronger antibiotic prescribed for the patient.
These scenarios present unique challenges for coders, as the microbiology culture is usually posted a few days later, after the case has been coded. Coders can’t code the bacteria unless the ED physician goes back and makes an addendum to ED report or progress note – which is not common practice and only happens in a few cases.
A Final Word
For inpatients with hospital-acquired superbug infections, no matter how they may have been contracted, the hospital’s costs for treatment of the infections are not payable under CMS guidelines. Therefore, it’s important that physicians, CDI specialists, and coders go the extra mile to identify, document, treat, and code these infections as early as possible.