Procedure unlikely with diagnosis The CCE identifies surgical procedures for which no related diagnosis, either principal or secondary, is recorded. An example of this problem is a coronary artery bypass performed on a patient whose claim does not contain a diagnosis of heart disease. Two probable causes of this problem include omission of a related secondary diagnosis, or an improperly coded diagnosis or procedure. O.R. Procedures coded are not usually performed for principal diagnosis When all the O.R. procedures performed are unrelated to the principal diagnosis, the CCE reports this condition. Although such an occurrence isn't necessarily an error, it is unusual enough to warrant a review of the principal diagnosis, secondary diagnosis, and all procedures on the claim. Likely causes of this condition include: 1) a coding error in principal diagnosis, 2) coding one of the secondary diagnoses as principal diagnosis, 3) mis-coding of one of the procedures. Principal diagnosis suggests surgery but no O.R. surgery performed There are some diagnoses for which patients are seldom admitted to the hospital without having surgery performed. Examples of such diagnoses are: acute appendicitis, carpal tunnel syndrome, senile cataract. The CCE identifies diagnoses normally associated with surgery. If a patient has one of these diagnoses as a principal diagnosis, but no surgical procedures were performed, the CCE identifies the condition. While such an occurrence is not necessarily an error, it is unusual enough to warrant a review of the claim to check if a surgical procedure was performed but not coded. Symptom code as principal diagnosis A symptom code should not be used as a principal diagnosis unless a more specific code is not available. An example of a symptom code is chest pain. Clinically unreasonable length-of-stay (high or low) From a clinical perspective, it is highly improbable that patients with certain diagnoses and procedures could legitimately have length-of-stays less than or greater than a specific number of days. Such clinically unreasonable high and low length-of-stays are identified by the CCE for specific diagnoses and procedures. Questionable admission There are some diagnoses which are not usually sufficient justification for admission to an acute care hospital; for example, benign hypertension. Age conflict The CCE detects inconsistencies between a patient's age and any diagnosis on the patient's claim. Examples of such conflicts are: a 5-year-old patient with benign prostatic hypertrophy, or a 78-year-old delivery. In such cases either the diagnosis or the age is presumed to be incorrect. Sex conflict The CCE detects inconsistencies between a patient's sex and any diagnosis or procedure on the patient's record. Examples of such conflicts are: a male patient with cervical cancer, or a male patient with a hysterectomy. In such cases either the patient's diagnosis, procedure or sex is incorrect. E-Code as principal diagnosis E-codes describe the circumstances that caused an injury, not the nature of the injury. An E-code should not be used as a principal diagnosis. Manifestation Code as Principal Diagnosis Manifestation codes describe the manifestation of an underlying disease, not the disease itself. A manifestation code should not be used as a principal diagnosis. Non-Specific Principal Diagnosis A set of diagnosis codes, particularly those described as "not otherwise specified," are identified by the CCE as non-specific diagnoses. Although these codes are valid according to the ICD-9-CM coding scheme, more precise codes should be used for the principal diagnosis. Open Biopsy Check Biopsies can be performed surgically, (a body cavity is entered surgically), percutaneously, or through an endoscope. In general, for most organ systems, open biopsies are performed infrequently. There are explicit ICD-9-CM codes for open and non-open biopsies. Since the distinction made by the different biopsy codes is not applied uniformly, the CCE identifies all biopsies that are coded as open biopsies. Using the non-open biopsy code will generally result in assignment of the patient to a less costly DRG. Unacceptable Principal Diagnosis Selected "V" codes describe a circumstance which influences an individual's health status but is not a current illness or injury. These V codes are considered unacceptable as principal diagnosis. For example, a family history of ischemic heart disease (V173) would be an unacceptable principal diagnosis. Non-Specific O.r. Procedure A set of O.R. procedure codes, particularly those described as "not otherwise specified," are identified by the CCE as non-specific. Although these codes are valid according the ICD-9-CM coding scheme, more specific codes should be used. Duplicate of Principal Diagnosis Whenever a secondary diagnosis is coded the same as the principal diagnosis, the secondary diagnosis is identified by the CCE as a duplicate of the principal diagnosis. Bilateral Procedure Certain codes do not accurately reflect procedures performed in one admission on two or more different bilateral joints of the lower extremities. A combination of these codes show a bilateral procedure when they could be procedures performed on a single joint (i.e., duplicate procedure). Invalid Diagnosis or Procedure Code The CCE checks each diagnosis and procedure code entered in the record against a table of valid ICD-9-CM codes. If a code is not found in the table the record is flagged as in error. Invalid 4th or 5th Digit The CCE identifies any diagnosis or procedure code that requires a 4th or 5th digit. The code entered may have the 4th or 5th digit missing or not be valid for the code in question. Duplicate Code When the CCE detects the same ICD-9-CM diagnosis or procedure code more than once in a record, the record is flagged as a possible error. Evaluate as Principal Diagnosis When a disease or condition is a symptom of, or the result of, some other underlying disease and is recorded as the principal diagnosis, the CCE will identify when there is a more specific secondary diagnosis that should be evaluated as principal. Requires Secondary Diagnosis There are a few "V" codes which when used as the principal diagnosis in a record, require a secondary diagnosis. The CCE will check these codes for the presence of a secondary diagnosis. Diagnosis Conflict Edit The CCE identifies when two or more diagnoses conflict with one another from a clinical perspective. Procedure Conflict Edit The CCE identifies when two or more procedures conflict with one another from a clinical perspective. Maternal and Fetal/Newborn Edit A maternal diagnosis code and a fetal/newborn diagnosis code should not appear on the same discharge record. When the CCE detects a maternal diagnosis code and a fetal/newborn diagnosis code together the record is flagged as an error. Invalid or Unknown Age CCE allows entry of patient age from 0 through 124 years. Any other entry is considered an error.
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