ACDIS day2-2 track4-1 pres 0513 Michelman UPDATED2. Leading cause of death secondary to nosocomial infections 3. 48 hours after admission48hours after admission 4. No evidence of infection

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Physician Documentation: Still a Major Issue

Mark Michelman, MD, MBAVice President of Medical Affairs/Physician Coding and Clinical Documentation AdvisorMorton Plant Mease Health CareClearwater, Fla.

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Learning Objectives

• Describe various types of pneumonia and treatment, TIA vs. CVA issues, and CHF documentation issues

• Explain acute and chronic renal failure pterminology, MI vs. chest pain clarification, and UTI vs. sepsis issues

• Identify potential sources of queries from lab tests

• Describe the impact of nonresponses to queries on physicians and hospitals

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TIA/CVA

TIA>30 seconds duration<24 hours resolved

CVAnew onset symptomsresidual at 24 hrs

CT, MRI if abn must be documented

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ABCD Score

• Predictive value of identifying hospital TIA patients who have a high risk of early stroke (first 2 days after TIA)

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ABCD Score

• Age > 60 years• BP nl vs. increased (140/90)• Clinical features of TIA

– Unilateral weakness– Unilateral weakness– Isolated speech disturbance– Other

• Duration of Sxs– <10 min– 10–59 min– >60 min

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Modified ABCD ScoreModified ABCD ScoreD Squared (Diabetes Mellitus

Present or Not)

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mNIHSS Score for Stroke

• 11-item scoring tool to assess the effect of the stroke and help predict outcome

• Originally 15 items NIHSSOriginally 15 items NIHSS

• Won’t help clin doc team

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Bronchitis vs. Pneumonia

• Productive cough

• Fever

• Pulmonary findings

• X-ray findings

• ABX

• LOS

• May be very little difference

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Symptoms of Pneumonia

• Maybe none

• Cough

• Fever

• SOB

• Chills

• Sweats

• Hemoptysis

• Pleuritic pain

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Physical Findings of Pneumonia

• Maybe none

• Tachycardia

• Tachypnea

• Temperature

• Rales, rhonchi

• Decreased BS

• Increased fremitus

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Dx of Pneumonia

• Chest x-ray

• CBC

• Procalcitonin

• Sputum Gram stain, culture

• Blood culture

• Legionella antigen

• CT (serendipity)

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Types of Pneumonia

• CAP: Community-acquired pneumonia

• HCAP: Healthcare-associated pneumonia1. HAP: Hospital-acquired pneumonia

2. VAP: Ventilator-associated pneumonia

• Aspiration

• Gram-negative

• TB

• Fungal

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Community-Acquired Pneumonia

• 20% inpatient

• Onset outside hospital

• 600,000 cases/year

• 45k deaths/year

• Mortality 10%–14%

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Risk Factors for CAP

• ETOH

• Asthma

• Immunosuppression

• Age >70

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CAP Etiology

• Strep. pneumonia

• Mycoplasma

• Chlamydia

• Respiratory viruses (influenza, adeno)

• H. flu

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CAP Rx

• Rocephin, Zithromax

• Quinolones

• If pen allergy, Aztreonam + moxifloxacin

• Pseudomonas risk (ETOH, severe COPD, bronchiectasis, chronic steroids, frequent ABX): Piperacillin-tazobactam + Cipro (or Levofloxacin) or cefepime + Cipro, or Meropenem + Cipro

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Hospital-Acquired Pneumonia

1. Very common cause of hospital infections

2. Leading cause of death secondary to nosocomial infections

3 48 hours after admission3. 48 hours after admission

4. No evidence of infection prior to admission

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Healthcare-Associated Pneumonia (HCAP)

Predisposing conditions:1. Hospitalization >48 hours2. Hospitalization >2 days prior 3 months3. SNF3. SNF4. ABX preceding 3 months5. Chronic dialysis6. Home infusion7. Home wound care8. Family member with MDR infection

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HCAP Rx

• Cephalosporins

• Quinolones

• Unasyn

• For late-onset or MDR disease:

– Imipenem, Meropenem, Aminoglycosides, Vanco, Linezolid

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Risk Factors for MDR

• Chronic vegetative state

• Tracheostomy

• Percutaneous feeding tube

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Aspiration Pneumonia

• Predisposing causes:– Vomiting– Coma (OD)– Swallowing disorder, obstructionSwallowing disorder, obstruction– ETOH– Sedation/anesthesia– Seizures– CNS/neurological (ALS, MS, CVA)– Periodontal disease – Ventilator

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X-ray Findings (Aspiration)

• Posterior segment upper lobes, superior segment, basal segment lower lobes

• May present with abscess, empyema

• Abnormal swallowing study• Abnormal swallowing study

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Aspiration Pneumonia Sxs

• May be none

• Fever

• Anorexia

• Weight loss

• Cough

• Sputum

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Rx Aspiration Pneumonia

• Cover anaerobes and Gram-negs

• Clindamycin

• Unasyn

• Quinolones

• Imipenem

• Ticarcillin

• Carbapenem

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Ventilator-Associated Pneumonia

• Pneumonia occurs 48–72 hours after intubation

• Rx: Rocephin, quinolones, Unasyn, Ertapenem

• If MDR, Cefepime, Genta, Tobra, Vanco

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New Algorithm for VAP

• CDC

• January 2013

• 48 hours of decreasing FiO2, PEEP

• Temp >38c or <36c or WBC >12,000 or <4,000

• New antimicrobial agent

• Then secretions, cultures, etc.

• Five pages

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Gram-Negative Pneumonia

• Risk factors:

–SNF

–Frequent hospitalizations

–Frequent broad spectrum ABX

–DM, CHF, renal failure, COPD

–Alcoholism, liver disease

–Chronic immunosuppression

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Rx Gram-Neg Pneumonias

• Antipseudomonal cephalosporins(Cefepime, Ceftazidime)

• Antipseudomonas carbapenem(Imipenem Meropenem)(Imipenem, Meropenem)

• Beta lactam/B-lactamase inhibitor(Piperacillin-Tazobactam)

• Aminoglycosides(Genta, Tobra, Amikacin)

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Pneumonia Documentation Issues

• Hx – inadequate documentation

• PEx – inadequate documentation

• X-ray – none or normal

• Rx inappropriate

• Lack of medical necessity

• ?Bronchitis vs. COPD with exacerbation

Need to query to clarify the above

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Pneumonia With Neg X-ray

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When to Query for Pneumonia Type

• Not common ABX

• SNF before hospitalization

• Immunosuppressive meds

• PEG tubes

• Other predisposing factors

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When to Query

• Suspect any of the following:

–MRSA

–Aspiration

–Gram-negatives

–On vent

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Chest Pain vs. MI

• EKG• Troponin• Physician must document findings

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Chest Pain vs. MI

• Hx• PEx• EKG• Troponin, CPKMB• Coding issues

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Troponin Elevations

• Abnormal renal Fx• CHF• Pulmonary embolus (PE)• Myocarditis• Myocarditis• Pericarditis• PCI (CPK-MBX3)• Bypass surgery (CPKMBX5)

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Positive Troponin, CPK-MB fraction

• NSTEMI

• STEMI

• Non-Q-wave MI

• Post interventional cath expected

• Post bypass surgery expected

• Physician hesitancy to call MI(label pt as MI, complication of procedure)

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Positive Troponin Issues

• Physicians, cardiologists inconsistent documentation

–NSTEMI

STEMI–STEMI

–Q wave MI

–Troponin “bump, blip, elevation”

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Why Respond to MI Query

• Impact:

– LOS

– Severity of illness

– Expected mortality

– Reimbursement

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Coding Dilemma

• Chest pain admission

• EKG shows AMI, positive troponin

• Neither documented by physician

• No response to query

• Code will be chest pain

• Cardiac abstraction will be AMI

• AMI database differs

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False Positive Troponin POC

• Inpatient status

• Telemetry

• CCU/ICU

• Cardiology consult

• Stress test

• Cardiac cath

• Only one troponin issue

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Unstable Angina (Incorrect Dx)

• Inpatient status

• Telemetry

• CCU/ICU

• Cardiology consult

• Stress test

• Cardiac cath

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Unstable Angina

• Hx CAD

• Changing pattern:

–Pain more frequent

–Pain lasts longer

–Occurs with minimal activity

–Occurs at rest, night

–Less response to NG

–NL EKG, enzymes

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Acute Coronary Syndrome

• Unstable angina (codes to ACS)

• Accelerated angina (codes to ACS)

• NSTEMI

• STEMI

• Non-Q-wave MI

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Impact of No Query Response

• Lesser Dx

• SOI

• Expected mortality

• LOS

• Reimbursement

• Physician profile

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Sepsis, Urosepsis, UTI

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Sepsis

• Bacteremia (blood cultures at least ordered)

• Systemic manifestation to above

1. Change in mental status –confused, lethargic, obtunded comatose

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Sepsis (cont.)

2. Abnormal vital signs (VS)• fever, tachycardia, hypotension

3. Dehydration

4 ABX IV4. ABX IV

5. LOS >48 hrs

6. Increased severity of illness, expected mortality

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Urosepsis/SepsisArgument for Physician Response

• Not sepsis

• Low severity of illness score

• Low expected mortality

• Short LOS

• No response to query – coded UTI

• **No urosepsis code in ICD-10

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CHF Documentation Issues

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CHF

• Heart failure

• Left ventricular dysfunction

• Compensated CHF

• Decompensated CHF

• Cardiomyopathy

• None of the above impact LOS, SOI, expected mortality, reimbursement

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Types of Heart Failure

• Systolic – poor contraction left ventricle decreased EF (<40)

• Diastolic – inability of ventricle to relax and fill, stiff nl EFstiff nl EF

• Systolic and diastolic – combo of above

• High output states – chronic anemia, thyrotoxicosis

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HF Acute vs. Chronic

• Acute – sudden onset

• Chronic – persists over long time

• Acute and chronic – persists over long time with sudden acute exacerbationsudden acute exacerbation

• Caution! Compensated and decompensatedHF may be acute on chronic HF

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Noncardiogenic Pulmonary Edema

• Fluid overload (dialysis noncompliance, acute renal failure); may be HF and ARF

• Noxious gas inhalation

• Acute respiratory distress syndrome

• Severe hypoalbuminemia

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HF Classification NYHA

Class I Sx minimal activity

Cl II S di i

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Class II Sx ordinary exertion

Class III Sx less than ordinary exertion

Class IV Sx at rest

HF Class ACC/AHA

Stage A high risk for HF, no Sx

St B heart disease, no Sx, leftStage B , ,ventricular dysfunction

Stage C prior or current Sxs

Stage D advanced heart disease, verysymptomatic, or refract HF

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Why Classify CHF

• Severity of illness

• LOS

• Expected mortalityp y

• Reimbursement

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Etiology LHF

• Hypertension• CAD• Valvular• Alcohol• Idiopathic

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Clinical Picture LHF Sxs

• SOB• DOE• Orthopnea• PND• Fatigue• Weakness• Dizziness

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PEx LHF

• Pulmonary congestion• 3d heart sound (gallop)• Tachycardia (hr x sv = cardiac output)• BP nl or decr.• Cool distal extremities

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Etiology RHF

• Primary cardiomyopathy• Infiltrative disorders (amyloid, sarcoid)• Storage diseases (hemochromatosis)• Valvular disease• Pulmonary disease

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Sxs RHF

• SOB• Fatigue• Edema• Vague GI Sxs (nausea, bloating, etc.)

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PEx RHF

• Jugular venous distention• Hepatomegaly• Ascites• Peripheral edema

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Clinical Picture ofCHF and EF of 60 ?Dx

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BNP (B-type natriuretic peptide)

• Increases with:–CHF

–Abn. renal Fx

–Age

–COPD (probably due to rt. ventricular strain)

–PE (R heart strain)

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Suspect Dx of HF

• X-ray (cardiac enlargement, effusions, hilarcongestion, Kerley B lines)

• BNP significantly elevated• Echo (systolic vs. diastolic dysfunction)• Cath findings

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Diagnosis documented No CC CC Major CC

•Heart failure

•Ventriculardysfunction

• CHF •Left heart failure

•(Chronic)systolic HF

•Acute systolic HF

•Acute on chronic systolic HFdysfunction

•Cardiac decompensation

systolic HF

•(Chronic) systolic& diastolic HF

systolic HF

•Acute diastolic HF

•Acute on chronicdiastolic HF

•Acute diastolic &systolic HF

•Acute on chronicdiastolic & systolic HF

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HF Rx(Look for Query Opportunity)

• Determine etiology and address (BP, valve, etc.)

• Diuretics

• ACE inhibitors

• ARBs

• Beta blockers

• Aldosterone antagonists

• Digoxin

• Dobutamine

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Potential Query Issues(Could Be CHF)

• ACEs, ARBs, diuretics unaddressed

• Unexplained edema, pulmonary congestion

• Unexplained SOB

• Unexplained cardiomegaly

• Unexplained pleural effusions (usually bilat.)

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CHF Documentation

• Is it CHF?

–L or R sided?

• Systolic or diastolic?

• Combination?

• Is it fluid overload (renal failure)?

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CHF Query Specificity Unclear

• CHF, CAD, hypertension, low EF – systolic

• CHF, nl EF – diastolic

• Add acute, chronic, or both

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No patient should be admittedto the hospital with “just” CHF

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Renal Failure Acute, Chronic

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Acute Kidney Injury

• Replaces acute renal failure

• Is the only NKF description for any injury/insult to the kidney of 90 days or less

• Can be due to glomerulonephritis interstitial• Can be due to glomerulonephritis, interstitial nephritis, infection, drugs (Vanco), etc.

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Acute Kidney Injury (cont.)

• Increase in creatinine >0.5 mg/dl• Rise in creatinine >25%• Decrease in GFR by 50%

All above from the baseline value

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Changing Terminology

• Prerenal azotemia: Elevated BUN/creatinineratio due to prerenal physiology

• ATN: Usually due to dehydration, hypovolemia, hypotension, shockhypotension, shock

• Renal insufficiency: Merely a stage of CKD

• Prerenal failure: No longer used

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CKD Stages

Stage I kidney damage with nl or high GFR or >90 No CC

Stage ll kidney damage with mild decr. in GFR 60–90 No CC

Stage lll moderate decrease in GFR 30–59 No CC

Stage lV severe decr. in GFR 15–29 CC

Stage V kidney failure <15 CC

ESRD Stage V with dialysis MCC

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Chronic Renal Failure

• Nl renal Fx – creatinine 0.6–1.3

• Renal failure chronically above

• GFR based on creatinine determination

• Creatinine impacted by age, muscle mass, chronic liver disease, malignancy

• Decreased muscle mass can have nlcreatinine but decr. GFR

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Clues to Chronic Renal Failure(When to query)

• Creatinine, GFR chronically abnormal

• Increased K

• Acidosis, GFR <60

• Increased phosphorus, GFR <20

• Anemia, GFR <60

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Symptoms of CRF

• None

• Fatigue

• Weakness

• Anorexia, N,V (late stages)

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Impact of No PhysicianResponse to the Following Queries

• Chest pain vs. AMI

• TIA vs. CVA

• UTI vs. sepsis

• CHF vs. acute systolic failure

• Bronchitis vs. pneumonia

• Renal insuff vs. acute kidney injury

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Why Should the Physician Respond? (What’s in It for Me?)

• Severity of illness score• Expected mortality• Physician’s profile• Physician’s reimb. (bundled payments)• Potential exclusion from CIN, ACO

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What’s in It for the Hospital WithNo Physician Response to Query?

• MCC/CC vs. none

• Potential impact on LOS

• Potential impact on SOI and expected mortality

• Impact on reimbursement

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How to Address Physician Nonresponse to Queries

1. PA phone call to physician

2. If EHR, “hardstop” if no response

3. Incomplete medical record (associated penalties fines suspensions)(associated penalties, fines, suspensions)

4. 1:1 department chairperson

5. Requested meeting with MECMandated action – temp suspension, NPDB

6. Part of 6-month OPPE

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Blood Abnormalities:Multiple Explanations

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Troponin Elevations: Not Just AMI

• Abnormal renal Fx

• CHF

• PE

• Myocarditis

• Pericarditis

• PCI (CPK-MBX3)

• Bypass surgery (CPKMBX5)

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BNP (B-type natriuretic peptide):Not Just CHF

• Increases with:

–CHF

–Abn. renal Fx

–Age

–COPD (probably due to rt. ventricular strain)

–PE (R heart strain)

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Erythrocytosis

• Polycythemia vera

• Erythrocytosis secondary to hypoxia

• Erythropoietin

• Severe dehydration

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Leukocytosis

• Bacterial infection

• Steroids

• Lithium

• CLL

• CML

• Myelofibrosis

• Myelodysplasia

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Procalcitonin

• Sepsis

• Pneumonia

• Rarely with burns, trauma, extensive surgery, necrotizing pancreatitis fungal infectionsnecrotizing pancreatitis, fungal infections

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Thank you. Questions?

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ACDIS day2-2 track4-1 pres 0513 Michelman UPDATED2. Leading cause of death secondary to nosocomial infections 3. 48 hours after admission48hours after admission 4. No evidence of infection