Effective Coding Under MS-DRGscampus.ahima.org/audio/2008/RB021408.pdf · Faculty AHIMA 2008 Audio Seminar Series ii Sharalyn Milliken, RN, JD, CPC-H Ms. Milliken is a senior consultant

© Copyright 2008 American Health Information Management Association. All rights reserved.

Effective Coding Under MS-DRGs

Audio Seminar/Webinar February 14, 2008

Practical Tools for Seminar Learning

Disclaimer

AHIMA 2008 Audio Seminar Series i

The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. CPT® five digit codes, nomenclature, and other data are copyright 2007 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education, the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: (1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; (2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and (3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. The faculty has reported no vested interests or disclosures regarding this presentation.

Faculty

AHIMA 2008 Audio Seminar Series ii

Sharalyn Milliken, RN, JD, CPC-H

Ms. Milliken is a senior consultant with FTI Consulting based in Atlanta GA. For the past 20 years, her experience in healthcare spans many different venues such healthcare lawyer, consultant, documentation compliance specialist, coder, and case manager. Sharalyn has a Bachelor of Science Degree in Nursing from the Ohio State University and a Juris Doctorate Degree from Capital University Law School. Her expertise includes healthcare compliance, clinical documentation improvement, coding, DRG assignment and regulatory research. In 2002 while at OhioHealth, her department was awarded the prestigious National Council of Ethical Organization’s “Best Practice Award” for their Clinical Documentation Program. Email: [email protected]

James S. Kennedy, MD, CCS

Dr. Kennedy is a Director with FTI Healthcare based in Brentwood, TN. Trained as a general internist at the University of Tennessee in Memphis, Dr. Kennedy’s experience includes medical private practice along with successful entrepreneurial healthcare-related startups in the public and private sector. His expertise includes physician-hospital leadership, healthcare systems improvement, healthcare documentation, coding, DRG assignment compliance, and government relations. Dr. Kennedy recently completed the AHIMA book, Severity-Adjusted DRGs: a MS-DRG Primer. Contact Dr. Kennedy at 615-479-7021 or [email protected]

Table of Contents

AHIMA 2008 Audio Seminar Series

Disclaimer ..................................................................................................................... i Faculty .........................................................................................................................ii Today’s Goals ................................................................................................................ 1

Polling Question ................................................................................................. 1 Definition of a DRG ........................................................................................................ 2 Patient Condition Components......................................................................................... 2 ICD-9-CM

Principal Diagnosis and Secondary Diagnosis ........................................................ 3 Chronic Conditions – Coding Clinic 3Q 2007 .......................................................... 4

Historical CMS-DRG System Structure .............................................................................. 5 MS-DRGs....................................................................................................................... 5

Base DRGs......................................................................................................... 6 CC Changes ....................................................................................................... 6 Impact of Prev. MD Documentation...................................................................... 7 Most Common “Single Deleted CC” ...................................................................... 7 New CCs/MCCs................................................................................................... 8 V Codes............................................................................................................. 8 CC/MCC Structure............................................................................................... 9 Documentation and Coding Adjustment................................................................ 9 Conclusion ........................................................................................................10

Assessing our Circumstances MS-DRG Statistics..............................................................................................11 CC and MCC Capture .........................................................................................11 Other MS-DRG Metrics .......................................................................................12 CC Capture Rate................................................................................................12 Other Metrics ....................................................................................................13

Specific Issues in CC and MCC Capture Principal Diagnosis – Principal Procedure .............................................................14 Present on Admission Requirement .....................................................................14 Pressure Ulcers .......................................................................................15

Deleted CC COPD – Asthma – Hypoxemia.............................................................................15 CC-MCC Differentiation Acute Respiratory Failure .........................................................................16 Exacerbation of COPD/Asthma .................................................................16 Congestive Heart Failure ....................................................................................17

Heart Failure .............................................................................................................17 Heart Failure Differentiation ...............................................................................18 Cardiomyopathies..............................................................................................18 Systolic/Diastolic Heart Failure............................................................................19 Pericarditis........................................................................................................19

Deleted CC – Angina Pectoris .........................................................................................20 Atherosclerosis of CABG Graft ........................................................................................20 Elimination of Major CV Diagnoses as Principal/Secondary Diagnoses ................................21 Example - Acute MI POA Not a MCC................................................................................21 Deleted CC – Atrial Fibrillation ........................................................................................22 CC-MCC Differentiation – Ventricular Arrhythmias ............................................................22 Deleted CC – Hypovolemia.............................................................................................23 Electrolyte Imbalances...................................................................................................23 Deleted CC – CKD/CRI NOS ...........................................................................................24

Table of Contents

AHIMA 2008 Audio Seminar Series

Deleted CC – Chronic Blood Loss Anemia ........................................................................24 ICD-9-CM Official Guidelines for Coding and Reporting ....................................................25

Acquired and Nonspecific Aplastic Anemia ...........................................................26 Myelodysplastic Codes .......................................................................................26 Hypercoagulable Syndrome ................................................................................27

Deleted CC – Uncontrolled Diabetes................................................................................27 Diabetic Ketacidosis – MCC.................................................................................28 Nonketotic Hyperosmolar State – MCC ................................................................28 Other CC Alternatives with Diabetes....................................................................29

Altered Mental Status ....................................................................................................29 Encephalopathy.................................................................................................30 TIA vs. Stroke as CC/MCC ..................................................................................30 Seizures ...........................................................................................................31 Schizophrenia ...................................................................................................31

Malnutrition .............................................................................................................32 Chemical Dependency ...................................................................................................32

Options to Consider in Chemical Dependency.......................................................33 Bacteremia vs. Septicemia – Sepsis.................................................................................33 Others .............................................................................................................34 Resources ....................................................................................................................34 Audience Questions Appendix ..................................................................................................................38 DRG Documentation Tips ......................................................................................39 CE Certificate Instructions .....................................................................................41

NOTE: Additional Appendix “MS-DRG CC/MCC List Final Rule” can be downloaded at

http://campus.ahima.org/audio/2008seminars.html


AHIMA 2008 Audio Seminar Series 1 CPT® Codes Copyright 2007 by AMA. All Rights Reserved

Notes/Comments/Questions

Today’s Goals

Provide an overview of MS-DRGs and its impact upon short-term and long-term acute care hospitalsReview the pathophysiology of the new CC-MCC structure as to support physician documentation and query.Outline an organized process that accurately captures and reports CCs and MCCs in administrative coded data sets

1

Polling Question

How has MS-DRGs affected your facility?

*1 Our case mix index has risen; we couldn’t be more pleased.

*2 Our case mix index has risen; we still have opportunity

*3 Our case mix index is about the same; our CC and MCC has some issues.

*4 Our case mix index has fallen and we can’t get it up.

2




Definition of a DRG

A Diagnosis Related Group (DRG) is a group of clinically coherent conditions with a similar pattern of resource intensity primarily determined by: • Principal diagnosis: • Significant additional diagnoses

• Present on admission status may matter:• Procedures

3

Patient Condition Components (M.U.S.I.C.)

Manifestation• e.g. – Chest pain (angina, pleuritic pain, heart burn); Altered

Mental Status (Acute Delirium, Chronic Dementia); FeverUnderlying Pathology• e.g. – Coronary artery disease, GERD, pleurisy, toxic

encephalopathy from prescribed medications, pneumoniaSeverity• Angina – At rest, Accelerated – progressed to MI• Sepsis – without or with organ dysfunction (severe sepsis)

Instigating or Precipitating Cause• Recent surgery• Medication noncompliance

Consequences• Acute Systolic Heart Failure• Acute Respiratory Failure• Acute Renal Failure 4




ICD-9-CMPrincipal Diagnosis

Defined by the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”• The circumstances of admission, the diagnostic

approach and the treatment rendered factor into principal diagnosis selection.

5

ICD-9-CMAdditional Diagnosis

ICD-9-CM states that for reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: • clinical evaluation; • or therapeutic treatment; • or diagnostic procedures; • or extended length of hospital stay; • or increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”

6




Coding Clinic, 3rd Quarter, 2007Chronic Conditions

One of the QIOs will not allow the inclusion of COPD as a secondary diagnosis when it is only mentioned as a history of COPD and no active treatment is documented. Am I correct in stating the presence of a documented history of COPD in the physicians history and physical on an inpatient record is enough to code COPD as a secondary diagnosis, since this is a chronic condition that always affects the patients care and treatment to some extent?If there is documentation in the medical record to indicate that the patient has COPD, it should be coded. Even if this condition is listed only in the history section with no contradictory information, the condition should be coded. Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization, 7

Poll Results

8




Historical CMS-DRG System Structure

Did not account for patients with greater severity of illness• CCs had the same weight no matter how severe• Designated a CC by an increase in LOS by

at least one day in 75% of the patients

Paired DRG system only required one secondary diagnosis to assign a CC• Patients with multiple CCs given same

resource weight as those with one.

9

MS-DRGs

Implemented October 1, 2007Still have 25 MDCs• Pre-MDC and DRGs with all MDCs remain

745 total MS-DRGs • Increase from 538 CMS-DRGs• Base DRG structure basically the same• Complete overhaul of the CC structure

10




MS-DRGsBase DRGs

For the most part, base DRG structure remains except for:• Creation of 1 new DRG• Elimination of 43 age

differentiations (e.g. 0-17, Diabetes age <35)

• Usual and customary minor changes in base DRGs (see subsequent slides)

• Consolidations of 34 low-volume DRGs into other DRGs

335 Base DRGs remain• Pre-MDC (e.g. trachs)• Surgical Procedure unrelated

to Principal Diagnosis• Simple/Complex Pneumonia• Excisional Debridement as

major O.R. Procedure• HIV w and w/o Major Dx• Major GI Dx• Major Esophageal Dx • Major Hematological Dx• Major Bladder Procedures• and others all remain

11

MS-DRGsCC Changes

Major revision of CC structure• CCs based on resource utilization rather

than length of stay• Removal of many CCs that do not impact utilization.

• Creation of Major CC (MCC)• Expansion of CC/MCC through most of the base DRGs• Still only need one CC or MCC to change weight

Elimination of • Major Cardiovascular Diagnoses

• Problematic since acute MI or acute systolic heart failure as a principal diagnosis no longer changes the DRG

• Complex Diagnoses for Cardiac Catheterization, and • Complicating Diagnoses for Acute Myocardial Infarction.

12




MS-DRGsImpact of Prev. MD Documentation

Congestive Heart Failure (428.0)• CMS noted that resource utilization did not change significantly

when physicians documented (and coders coded) CHF• Unfortunately, decompensated CHF codes to 428.0

• The presence of more specific codes led to elimination of CHF as a CC

Malnutrition• Most physicians do not specify mild or moderate malnutrition• CMS found that malnutrition changed resource utilization

whereas mild or moderate did not. As a consequence, malnutrition is a CC whereas mild/moderate malnutrition is not

• CMS Medical Officers did not accept feedback on this issue and change the methodology.

13

Most Common “Single Deleted

CC”

Coders need a strategy

to find alternatives

14




New MS-DRG CCs/MCCsCCs

Many SPECIFIEDunderlying infections, obstetrical/neonatal conditions, and malignanciesCrohn’s Disease and Ulcerative ColitisTransient Ischemic AttackThiamine DeficiencyChronic osteomyelitisCABG Graft StenosisPrecipitous Drop in Hematocrit

MCCsMany SERIOUS open fractures, underlying infections and OB/neonatal conditions (e.g. encephalitis, abortion with shock)Bile duct obstructionEncephalopathy

15

V-Codes in MS-DRGs - CCs

HEART ASSIST DEV REPLACEV4321

TRNSPL STATUS-INTESTINESV4284

TRNSPL STATUS-PANCREASV4283

TRSPL STS-PERIP STM CELLV4282

TRNSPL STATUS-BNE MARROWV4281

LIVER TRANSPLANT STATUSV427

LUNG TRANSPLANT STATUSV426

HEART TRANSPLANT STATUSV421

KIDNEY TRANSPLANT STATUSV420

BMI 40 AND OVER, ADULTV854*

BMI LESS THAN 19, ADULTV850*

SUICIDAL IDEATIONV6284

ATTEN TO GASTROSTOMYV551

MECH COMP RESPIRATORV4614

WEANING FROM RESPIRATORV4613

RESP DEPEND-POWR FAILUREV4612

RESPIRATOR DEPEND STATUSV4611

ARTFICIAL HEART REPLACEV4322

*Coding Clinic – 4th Quarter, 2005 – pages 96-9816




MS-DRGCC/MCC Structure

Overall statistics• Without CC -41.1%• With CC – 36.6%• With MCC – 22.2%

Code differentiation• MCC – 1,096 • CC – 4,221• Non-CC – 8,232

MS-DRG CC/MCC Structure• CC does not matter

• e.g. MS-DRG 313 – Chest Pain• No CC | MCC

• CC carries no weight.• Must have MCC to change DRG

• No CC | CC/MCC• CC and MCC have equal weight

to change DRG• No CC | CC | MCC

• CC and MCC have differing impacts to change DRG

Lists available on CMS website: http://www.cms.hhs.gov17

MS-DRGsDocumentation and Coding Adjustment

“Coding and Documentation Adjustment”• 0.6% reduction – FY2008• 0.9% reduction – FY2009

• Can be more or less based on CMI changes experienced during the first few months of MS-DRGs

• 1.8% reduction – FY2010

Applies only to short-term acute care hospitals; LTACHs exempt from this

18




MS-DRGsConclusion

MS-DRGs is the most radical change in DRG methodology implementedRAND study shows that MS-DRGs better predict resource utilization than CMS-DRGsMS-DRGs are not going away• We have to address the issue

19

Assessing our Circumstances

20




MS-DRG StatisticsCMI Statistics• Total CMI• Total CMI w/o Pre-MDC• Medicine CMI w/o OB-Peds• Medicine CMI w/o OB-Peds, IP

Psychiatry, Ventilators, and Rehabilitation

• Surgery CMI w/o OB-Peds• Surgery CMI w/o OB-Peds,

and Pre-MDC• OB-Neonatal CMI

Medicine RW analysis – compared to all Medicine DRG (OB-Peds-Vents Excluded)• Medicine DRG w/RW >0.9 • Medicine DRG w/RW >0.6 but <0.9• Medicine DRG w/RW <0.6

Total CC/MCC Capture Rate• Total• Medicine Cases• Surgery Cases

Service Line CC/MCC Capture• Cardiothoracic surgery

• CV Surgery MCC rate• Valve/Chest surgery CC/MCC

rate

• Cardiology CC/MCC rate• General Surgery CC/MCC• Orthopedics CC/MCC• Neurosurgical CC/MCC• Urological CC/MCC• OB-Neonatal CC/MCC

• Important if private insurance pays on MS-DRG basis

Metrics in red worth following on a monthly basis 21

CC and MCC Capture

CC Capture Rate• Numerator:

• DRGs with CCs• DRGs whereby CCs and MCCs

equally affect the DRG• Denominator

• DRGs without CC/MCC whereby a CC can change the DRG

• DRGs without MCC excluded since a CC does not change the DRG

MCC Capture Rate• Numerator

• DRGs with MCCs• DRGs whereby CCs and MCCs

equally affect the DRG are excluded.

• Denominator• DRGs without MCC• DRGs without CC/MCC where

a MCC changes the DRG to a higher relative weight than a CC

• DRGs w/o CC/MCC where CC or MCC have equal effect in changing it are excluded

No standard method available. These are suggested as a way to measure Clinical Documentation and Coding improvement efforts 22




Other MS-DRG MetricsComplex to Simple PneumoniaPneumonia to COPDAcute Respiratory Failure to COPD/CHFCOPD to AsthmaSepsis to UTI/PneumoniaStroke to TIASepsis to Other Respiratory Diagnosis with ventilator over 96 hours

Pathological Fracture to Medical BackMI with CC or MCC to MI without CCCardiac Cath with MCC to Cardiac Cath w/oDVT with CC to DVT w/o CCGI bleed with CC to GI bleed without CC

Example: Complex to Simple Pneumonia RatioVolume of 177, 178, 179

Volume of 177, 178, 179, 193, 194, 195National Medicare volumes available at:

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/FY2008Table7A.zipin the final rule or can be calculated from the MedPAR 23

Example:CC Capture Rate in UGI Hemorrhage

MS-DRG Medicare StatisticsUGI Hemorrhage

36.0%UGI Hem w/o CC37944.8%UGI Hem w/CC37819.2%UGI Hem w/MCC377

285.1 – Acute Blood Loss Anemia is a CCMost patients admitted with an Upper GI bleed have

acute blood loss anemia An obvious query opportunity

Others include DVT (hypercoagulable disorder) and neurodegenerative disorders

(dementia with behavioral manifestations)24




Other Metrics

CAP utilizing any antibiotic but ceftriaxone, azithromycin, or levofloxacin – option for DRG 177-179 00.51 (CRT) without 88.52 – radiology of right heart structureTransient ischemic attack receiving tPAUse of Xigris without code 995.92Blood transfusions in surgery without a CC (Acute Blood Loss Anemia – 285.1)Drug eluting stents Pacemakers vs. AICDsUse of BiPAP without sleep apnea or acute (on chronic) respiratory failure codeUse of mechanical ventilation without acute (on chronic) respiratory failure code

25

Specific Issues in CC and MCC Capture

26




Principal DiagnosisPrincipal Procedure

Simple vs. Complex PneumoniaSepsis vs. Underlying Cause

• “Febrile Neutropenia”Stroke or cerebral embolus vs. TIACAD in setting of angina pectorisComplications of carePathological vs. regular fracturesAcute Respiratory Failure vs. COPD or asthma exacerbationAcute Renal Failure vs. dehydrationNoncardiogenic pulmonary edemaAlternatives to PancytopeniaEncephalopathy or Neurodegenerative d/o vs. their psychiatric manifestationsComplications when admitted for “uncontrolled diabetes”

Ascertaining the relationship between the principal diagnosis and the any procedures that are done.Capturing significant procedures not done in the operating room• tPA administration with stroke• Angioplasties done in radiology• Excisional debridement done on

the floor• Procedures in the ER or within

72 hours of admissionLysis of Adhesions in surgeryExcisional vs. nonexcisional debridementCoronary vein angiography during lead placement of a cardiac resynchronization pacemaker implantation

Diagnoses Procedures

27

Present On Admission Requirement

Will not serve as CCs/MCCs if not POA1. Serious Preventable Event- Object left in surgery2. Serious Preventable Event- Air embolism3. Serious Preventable Event- Blood incompatibility4. Catheter Associated Urinary Tract Infections5. Pressure Ulcers (Decubitus Ulcers)6. Vascular Catheter Associated Infection7. Surgical Site Infection-Mediastinitis after

Coronary Artery Bypass Graft (CABG) surgery8. Injury due to Falls

28




Smith, D. M. Ann Intern Med 1995;123:433-438

Classification of Pressure Ulcers

29

Deleted CCCOPD – Asthma – Hypoxemia

Most common CC under CMS• While Coding Clinic allows COPD (not a CC) to be coded without overt

interventions, exacerbations (a CC) require interventions.Options• 518.83 – Chronic respiratory failure for patients on Home Oxygen –

chronic elevation of pCO2

• 428.20 – Chronic systolic right heart failure from chronic pulmonary hypertension – edema, jugular venous distension, RVH on ECG

• Exacerbations -a sustained worsening of the patient’s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD.

• Mild - Patient has an increased need for medication, which he/she can manage in own normal environment

• Moderate - Patient has an increased need for medication and feels the need to seek additional medical assistance

• Severe - Patient/caregiver recognizes obvious and/or rapid deterioration in condition, requiring hospitalization

• “Status Asthmaticus” – Asthma exacerbation that does not respond to standard treatments of bronchodilators and steroids

http://www.chestjournal.org/cgi/content/full/117/5_suppl_2/398S 30




CC-MCC DifferentiationAcute Respiratory FailureTwo out of three

Hypoxemia• Classical definition:

pO2 <60 mm Hg• Needs to be

“significant”hypoxemia”

Hypercapnia• Defined as pCO2

>50• pH usually <7.35

Respiratory Distress

pO2 <60 corresponds to O2 Sat <88%

31

CC-MCC DifferentiationExacerbation of COPD/Asthma

Other Causes - MCCs• Acute Pulmonary Embolus – Geneva Score

(5-8 intermediate risk; >8 high risk)• 1 point – Age >60, Pulse >100, pCO2 36-39, pO2 73-83;

Atelectasis • 2 points – Age >80; Previous PE or DVT; pCO2 <36;

pO2 61-72; • 3 points – Recent surgery or malignant disease; pO2 50-60• 4 points – pO2 <50

• Acute (systolic or diastolic) heart failure• Elevated BNP; increasing edema or hypotension

• Pneumonia• New infiltrate on CXR treated with antibiotics

http://www.annals.org/cgi/reprint/144/6/390.pdf 32




Deleted CC428.0 Congestive Heart Failure

TITLEMS-DRGCMSICD-9

HEART FAILURE NOSCMS CC4289

AC/CHR SYST/DIA HRT FAILMSDRG MCCCMS CC42843

CHR SYST/DIASTL HRT FAILMSDRG CCCMS CC42842

AC SYST/DIASTOL HRT FAILMSDRG MCCCMS CC42841

SYST/DIAST HRT FAIL NOSMSDRG CCCMS CC42840

AC ON CHR DIAST HRT FAILMSDRG MCCCMS CC42833

CHR DIASTOLIC HRT FAILMSDRG CCCMS CC42832

AC DIASTOLIC HRT FAILUREMSDRG MCCCMS CC42831

DIASTOLC HRT FAILURE NOSMSDRG CCCMS CC42830

AC ON CHR SYST HRT FAILMSDRG MCCCMS CC42823

CHR SYSTOLIC HRT FAILUREMSDRG CCCMS CC42822

AC SYSTOLIC HRT FAILUREMSDRG MCCCMS CC42821

SYSTOLIC HRT FAILURE NOSMSDRG CCCMS CC42820

LEFT HEART FAILUREMSDRG CCCMS CC4281

CHF NOS (decomp – R Hrt Fail)CMS CC4280

33

Heart FailureManifestation - Is it heart failure?• Must differentiate from fluid overload in

normal heart• Acute, Chronic, or Acute on Chronic• Systolic vs. Diastolic vs. both

Underlying Cause• Cardiomyopathy – Pericardial Disease –

COPD – Cor Pulmonale – Accelerated HTN

Severity – Acute vs. Chronic• Acute = Flare up of HF symptoms• Decompensated doesn’t Count

Instigating – ?MI?, ?PE?Complication – Acute Respiratory Failure (MCC), Acute Renal Failure (MCC) pleural effusions (if addressed – CC)

Acute or Chronic?

Systolic: EF<40%; Diastolic: EF>40% or ?LVEDP 34




Heart Failure DifferentiationWithout EF

LVH on EKGS4 gallop

Abnl relax on ECHOMore likely is hypertensive

Diastolic

Combination of bothOK to say “possible or

probable”Both

Paroxysmal nocturnal dyspnea

Neck vein distention

Rales

Acute pulmonary edema or Increased BNP

Increased CVP >16 cm

Hepatojugular refluxPulmonary edema,

visceral congestion, or cardiomegaly at autopsy

Weight loss =4.5 kg in 5 days in response to treatment of

CHF

Cardiomegaly on CXRS3 gallop

Dilated on ECHOSystolic

Acute (MCC)Chronic (CC)

35

CardiomyopathiesAll are CCs except Ischemic CM

425.0 Endomyocardial fibrosis 425.1 Hypertrophic obstructive CM425.2 Obscure cardiomyopathy of

Africa 425.3 Endocardial fibroelastosis425.4 Other primary

cardiomyopathies• Cardiomyopathy:• NOS

• congestive• constrictive• familial• hypertrophic• idiopathic• nonobstructive• obstructive• restrictive• Cardiovascular collagenosis

425.5 Alcoholic cardiomyopathy 425.7 Nutritional and metabolic

cardiomyopathy • Code first underlying disease, as:

• amyloidosis (277.30-277.39) • beriberi (265.0) • cardiac glycogenosis (271.0) • mucopolysaccharidosis (277.5) • thyrotoxicosis (242.0-242.9) • gouty tophi of heart (274.82)

425.8 Cardiomyopathy in other diseases classified elsewhere

• Code first underlying disease, as:• Friedreich's ataxia (334.0) • myotonia atrophica (359.21) • progressive muscular dystrophy

(359.1) • sarcoidosis (135) • cardiomyopathy in Chagas' disease

(086.0)

425.9 Secondary cardiomyopathy, unspecified

36




Systolic/Diastolic Heart Failure due to Aortic and Mitral Valve Disease

398.91 – Rheumatic Heart Failure is a CC; • ICD-9-CM does not allow 428.xx codes serving as a MCC

Coding Clinic, 2nd Quarter, 2000, page 16-17• Stipulate that a coder is NOT to make an assumption that

congestive heart failure is rheumatic in nature when a physician documents valvular disease, including one listed in the subchapter 393-398 (397.0 – Diseases of the tricuspid valve).

• Unless ICD-9-CM directs the coder to assign the code for rheumatic congestive heart failure (which is not required under 396.x) or the physician states the condition is rheumatic, it isinappropriate to assign a code for rheumatic congestive heart failure.

Coding Clinic, 3rd Quarter, 2006, page 7 appears to support this as well.

Bottom Line – Unless the physician explicitly documents that the patient has rheumatic heart disease, use 428.xx 37

Pericarditis

All pericarditis codes are now CCs423.3 – cardiac tamponade - a CC• Consider acute

right diastolic failure (MCC) in this circumstance

38




Deleted CCAngina Pectoris

Angina Pectoris (not just CAD)• 413.9 Angina NOS – Not a CC• 413.0 Angina at rest (angina decubitus) – CC

• Suspect if the patient uses nitroglycerin w/i past month

Unstable Angina - CC• Occurs at rest and lasts for over 20 minutes OR• Severe, described of flank pain, and started within past

month, OR• Cresendo pattern

Non-Q wave Myocardial Infarction - MCC• Elevations of troponin in the setting of anginal

symptoms, EKG changes, post-angioplasty, or other cardiac manifestations

http://content.onlinejacc.org/cgi/content/full/50/7/e1 39

Atherosclerosis of CABG Graft“In-Stent Stenosis”

“In-stent” Stenosis NOSCABG Graft Occlusion NOSMSDRG CC99672

COR ATH BPS GRAFT TP HRTMSDRG CC41407

TITLECC DESIGNATIONCODE

COR ATH NATV ART TP HRTMSDRG CC41406

COR ATH ARTRY BYPAS GRFTMSDRG CC41404

CRN ATH NONATLG BLG GRFTMSDRG CC41403

CRN ATH ATLG VN BPS GRFTMSDRG CC41402

40




Elimination of Major CV Diagnoses as Principal/Secondary Diagnoses

Example:DRG 235 CABG w/MCC• R.W. 5.1381

DRG 236 CABG w/o MCC• R.W. 3.7307

MCVDs that are not MCCsBifascicular BlockTrifascicular Block Complete Heart BlockCHF NOS996.72 • Occluded graft• “In-stent stenosis”

Cerebral embolus w/o infarctionAcute Pericarditis

MCCs pertinent to CV surgerySepsis (995.91 and 995.92)SIRS due to CV surgery w/organ dysfunction (995.94)Acute Respiratory Failure (518.81)Pressure sores (Present on Admit)(Toxic-Metabolic) Encephalopathy • Instead of delirium/ICU psychosis

Acute Systolic/Diastolic heart failureIndication for amiodarone (vent. Fib)Non-Q-wave MI at referring hospital – possibly a MCC (see next slide)

Now requires MCC as athe secondary diagnosis

Principal no longer good enough

41

Acute MI Present on AdmissionNot a MCC

A 69 yo was admitted with severe chest pain. A left cardiac catheterization, coronary angiography, left ventriculography, and stenting of second obtuse margin was performed. The postoperative diagnosis was non-ST segment myocardial infarction with two-vessel coronary artery disease. What are the appropriate code assignments for this admission?

Answer: Assign code 410.71, Acute myocardial infarction, subendocardial infarction, initial episode of care, for the non-ST segment myocardial infarction, as the principal diagnosis.

Coding Clinic, 4th Quarter 2005, pages 69-72No MCC

42




Deleted CCAtrial Fibrillation

Atrial Fibrillation –427.31 – Not a CCAtrial Flutter –427.32• A CC

“Atrial Fib-Flutter”• Probably requires

both codes –427.31/427.32

Atrial Fibrillation

Atrial Flutter May have to look on nursing notes or telemetry strips to code these

43

CC-MCC DifferentiationVentricular Arrhythmias

427.1 Ventricular Tachycardia (>100/minute) - CC

• Sustained vs. Nonsustained• Not treated if <30 seconds

• Torsade de Pointes• Associated w Long QT Interval

• Amiodarone or Propafenone may be used to suppress further attack of V-tach

427.41 Ventricular Flutter - MCC427.42 Ventricular Fibrillation -

MCC• Cause of Sudden Cardiac Arrest• Look if present at referring hospital

Ventricular Flutter

Ventricular Fibrillation

Ventricular Tachycardia

Torsade de Pointes

44




Deleted CC – HypovolemiaAlternative: Acute Renal Failure (MCC)

An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in SCr of =0.3 mg/dl, a percentage increase in SCr of = to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours).

Mehta, et. al. the Acute Kidney Injury Network et al. Critical Care 2007 11:R31

If there is a change of the serum creatinine of ± 0.3 – 0.5 mg/dl in the hospitalization, consider acute renal failure

Biomarker: NGAL, Cystatin-C, IL-18 under consideration

45

Electrolyte Imbalances

Hyponatremia (CC)• SIADH (CC)• Metabolic encephalopathy (MCC)

Hyperkalemia (Not a CC)• Hypoaldosteronism (CC)

• ACE-Inhibitors, Angiotensin Receptor Blockers, Spironolactone

• CKD Stage IV-V (CC)• ESRD (MCC)

Hypercalcemia (Not a CC)• Metabolic encephalopathy (MCC)

Acidosis (CC) HCO3 <18Alkalosis (CC) HCO3 >28

Query –

Please describe the precise underlying etiologies/ mechanisms of this patient’s hyponatremia/ hypokalemia.

What are the consequences of this patient’s chronic illness?

Exactly how did hyponatremia or hypercalcemia cause this patient’s confusion?

46




Deleted CC – CKD/CRI NOS

Term GFR Usual Serum Cr*585.1 – CKD Stage 1 >90 <0.9 585.2 – CKD Stage 2 60-89 1.0-1.3585.3 – CKD Stage 3 30-59 1.4-2.5**585.4 – CKD Stage 4 15-29 2.5-4.5 - CCs**585.5 – CKD Stage 5 <15 >4.5 - CCs***585.6 – ESRD – Need for chronic dialysis - MCCs585.9 – Chronic Renal Insuff. OR Failure NOS – NOT A CC*Serum Cr. for a 170 lb white male, age 65**Red Font = CC - ***Blue Font = Major CC

Source: http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm 47

Deleted CC –Chronic Blood Loss Anemia

285.1 - Acute Blood Loss Anemia• AHA Coding Clinic states that if postoperative

anemia is due to acute blood loss, assign 285.1 – Acute blood loss anemia (CC, 1st Quarter 2007)

790.01 - Drop in Hematocrit• Major Blood Loss defined as 20% blood loss

• Would correlate with drop in hematocrit of 8 if baseline is 40

48




49

ICD-9-CM Official Guidelines for Coding and Reporting

Excludes Notes• An excludes note under a code indicates that the terms

excluded from the code are to be coded elsewhere. • In some cases the codes for the excluded terms should not

be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together.

• In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present.

Conditions that are an integral part of a disease process • Signs and symptoms that are associated routinely

with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

790.01 should not

be combined

with excluded

codes unless Coding Clinicallows

otherwise

50




Acquired and Nonspecific Aplastic Anemia

284.81 Red cell aplasia (acquired) (adult) (with thymoma) - MCC• Red cell aplasia NOS

284.89 Other specified aplastic anemias (all three lineages) -MCC• Aplastic anemia (due to):

• chronic systemic disease • drugs • infection • radiation • toxic (paralytic)

284.9 Aplastic anemia, unspecified – Only a CC• Anemia:

• aplastic (idiopathic) NOS• aregenerative• hypoplastic NOS• nonregenerative• Medullary hypoplasia

Classification of Red Cell Aplasia

Self Limited• Transient erythoblastopenia of

childhood• Acute B19 parvovirus infectionFetal RBC aplasia• In utero B19 parvovirus Hereditary (Diamond-Blackfan)Acquired• Thymoma or malignancy• Connective Tissue Dz (lupus)• Virus (B19 Parvovirus, hepatitis, EB

virus)PregnancyDrugs (Dilantin, INH, azothiaprine)Unknown

51

Myelodysplastic Codes238.7 Other lymphatic and hematopoietic tissues238.72 Low grade Myelodysplastic syndrome lesions• Refractory anemia (RA)• Refractory anemia with

ringed sideroblasts (RARS)• Refractory cytopenia with

multilineage dysplasia (RCMD)

• Refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS)

238.73 High grade Myelodysplastic syndrome lesions• Refractory anemia with excess

blasts-1 (RAEB-1)• Refractory anemia with excess

blasts-2 (RAEB-2) 238.74 Myelodysplastic syndrome with 5q deletion• 5q minus syndrome NOS• Excludes:• constitutional 5q deletion

(758.39)• high grade Myelodysplastic

syndrome with 5q deletion (238.73)

238.75 Myelodysplastic syndrome, unspecified CCs are in the box 52




Hypercoagulable Syndrome - CCAssociation with DVT

Manifestation• Phlegma cerulea dolens• Pulmonary Embolus• Deep venous Thrombosis

Underlying cause• Virchow’s Triad –

1° or 2° Hypercoagulability; Thrombophlebitis; Stasis Usually present on admission – Estrogen Use, Cancer, PregnancyStill to be ruled out - Factor V Leiden, Protein C deficiency,

Protein S deficiency – As primary hypercoagulability

Instigating Cause – recent surgery, pregnancy, underlying cancer, drug use (e.g. hormones)

If patients are on chronic Coumadin®, warfarin, or heparin, inquire if patient has hypercoaguable syndrome 53

Deleted CCUncontrolled Diabetes

Still needs to be captured Dr. Kennedy defines this as:• Multiple Blood Glucoses over 250 mg/dl

requiring changes in therapeutic regimen• One fasting Blood Glucose over 300

mg/dl• Recurrent hypoglycemia requiring

multiple changes in therapeutic regimen• Hgb AlC over 7.0

54




Diabetic Ketoacidosis - MCC250.1x w/o Coma; 250.3x w/Coma

Results from complete deficiency of insulin AND excessive counter regulatory hormone excessHyperglycemia (300-600)Ketosis (4+ Plasma Ketones, 1:8 or greater)Diagnosis• Patient very dehydrated - Acute Renal Failure 2° Dehydration?• Kussmaul breathing, fever, possibly coma - MCC• Hyperglycemia and Ketosis• Metabolic Acidosis (pH 6.8-7.3, HCO3 < 15 meq/L, “elevated

anion gap”• Serum Potassium usually high due to acidosis; if normal, patient

very depleted.• Treatment can lead to cerebral edema

Patients with DKA invariably are Type 1 (but can be Type 2) and uncontrolled; Coding Clinic 3rd Quarter, 2006, directs DKA to be coded with a fifth digit of “3” unless MD states it is Type 2 diabetes 55

Nonketotic Hyperosmolar State – MCC Primarily in Type 2 Diabetics• Associated with absolute or relative insulin deficiency• Just enough insulin to prevent ketoacidosis, but not enough to

prevent hyperglycemia

Results in profound dehydration, hyperglycemia, and hyperosmolality (330-380)

• Blood glucose usually over 600• ?Acute Renal Failure 2° Dehydration?• pH is normal or slightly decreased due to dehydration• HCO3 usually normal• Creatinine moderately elevated due to dehydration.

Treated with rehydration with isotonic/hypotonic saline and small doses of insulin; removal of underlying cause

Patients with NKHS invariably are Type 2 and uncontrolled; but, unlike DKA, the physician must state that a patient is uncontrolled. 56




Other CC Alternativeswith Diabetes

Autonomic Neuropathy - CC• Reason for using Viagra• Florinef used to fight orthostatic hypotension

Neurogenic Bladder - CCChronic Kidney Disease - CC• Stage 4 or 5 (Creatinine over 2.0 – 2.5 mg/dl)• ESRD – MCC – on dialysis

Diabetic Nephrosis – Nephrotic Syndrome• 4+ protein (over 3 grams per day)• Hypoalbumemia• Hyperlipidemia• Associated with Chronic Kidney Disease

Insulin Coma - MCC• Not just “hypoglycemia”

57

“Altered Mental Status”

M and S – What type of Altered Mental Status?• ACUTE Delirium, Dementia, Stupor, Coma, Mania, Confusion,

Psychosis (CC) , Hallucinations (CC) , Delusions (CC)U – Underlying Cause• Encephalopathy (MCC) – Toxic, Septic, Metabolic;• Alzheimer's Disease – must describe delusional/depressed/or

psychosis – behaviorial changes – to be a CC• Normal Pressure Hydrocephalus – (CC) – has a shunt in place• Multi-infarct Dementia (CC) – Late effect of stroke (no CC)• Lewy-Body Dementia (associated with Parkinson’s Disease); • Bipolar Disorder (CC)• Specified schizophrenia (CC)• Drug withdrawal (CC)• Seizure – Concussion• Stroke (MCC) – TIA (CC)

58




EncephalopathyA diffuse disease of the brain secondary to an otherwise nondefined neurological or a defined nonneurological illness or insultMultiple types in ICD-9-CM• Metabolic – due to metabolic

issues• Septic – due to sepsis• Toxic – due to drugs• Anoxic – due to lack of oxygen• Hypoglycemic – due to

hypoglycemia• Hypertensive – due to malignant

hypertension

Coding Clinic References:

“(Toxic) metabolic encephalopathy refers to an altered state of consciousness, usually denoting delirium.” -CC 4th Q 1993 p. 29

“Metabolic encephalopathy is always due to an underlying cause, seen in 12-33% of patients with organ failure –CC 4th Q 2003, p. 58-59

59

TIA vs. Stroke as CC/MCC

“TIA” (a CC) – Transient Neurological Symptoms due to ischemia LASTING LESS THAN ONE HOURand no evidence of Stroke (e.g. MRI, CT Scan)“Stroke” (a MCC) – Neurological symptoms due to ischemia with evidence of stroke on neuroimaging

• If symptoms >1 hour, 85% chance of stroke• Aborted stroke coded as a stroke

Consequences (if a stroke – present on DC)• 344.1 – Paraplegia (CC)• 344.61 – Neurogenic Bladder (CC)• 348.4 – Cerebral herniation (MCC)• 348.5 - Cerebral edema (MCC)• 784.1 – Transient limb paralysis (CC)• 784.3 – Aphasia (CC)• 781.8 – Neurologic Neglect Syndrome (CC)Code neurologic deficits of stroke on discharge?

Source: Sacco, et. al. Stroke, 37 (2): 577. (2006)

60




Seizures

Seizures and Seizure Disorder are not CC. Alternatives include:• Febrile Seizures (CC)• Other specified seizures disorders that are intractable (CC)

– query the physician if medications are being changed• Petit Mal (CC)• Focal (CC)

Seizures described as being in status are MCC• Continuous clinical or electrical seizure activity or

repetitive seizures with incomplete neurologic recovery interictally for a period of at least 30 minutes

61

Schizophrenia

Schizophrenia or Schizoaffective disorder NOS is not a CCALL of the specified schizophrenic or schizoaffective disorders ARE• e.g. Chronic schizophrenia• e.g. Simple schizophrenia• e.g. Chronic schizophrenic disorders

62




Malnutrition

CC• 263.8 – Specified

Malnutrition – NEC• 263.9 – Malnutrition

NOS

MCC• 260 - Kwashiorkor • 261 – Marasmus

• Severe Malnutrition• 262 – Other severe

malnutrition

<55-910-1718-45Prealbumin (mg/dl)

<117117-133134-175

176-315Transferrin (mg/dl)

<2.12.1-2.93.0-3.43.5-5.0Albumin (g/dl)

SevereModerateMildNormalLab Values

63

Chemical Dependency

Alcohol and Drug Use• Legal drug = Use; Illegal drug = abuse

Alcohol and Drug Abuse• Causes immediate consequences or bodily harm

Chemical dependency = Addiction• Lack of use causes withdrawal symptoms• Mental obsession to use• Continued use even though severe

consequences

Must be labeled as “CONTINUOUS or daily” to count as a CC – Alcohol and marijuana do not

count as CCs 64




Options to Consider in Chemical Dependency

Thiamine Deficiency (CC)• Most alcoholics get

thiamine 100 mg IM

Drug induced delirium (CC)Toxic Encephalopathy (MCC)• If the patient relapses

and has “altered mental status”, the drug likely caused it

Alcohol or Drug Withdrawal

• Does not necessarily have to be an illegal drugs.

• Many drugs that are legally prescribed have withdrawal symptoms if abruptly discontinued by the patient or the physician

65

Bacteremia vs. SepticemiaSepsis

Bacteremia (790.7 - a CC):• Bacteria in the blood without

an inflammatory response.

Septicemia (038.x - a MCC):• Pathological organisms (viruses,

bacteria, fungus, or other organisms) OR their toxins in the systemic blood.

SIRS • Due to infection (sepsis) – MCC• Due to non-infection –

Pancreatitis, Burns, Trauma• Without organ dysfunction – CC• With organ dysfunction – MCC

Systemic Inflammatory Response Syndrome (>2 of the following):

• Temperature >38 C or <36 C

• Pulse >90/min• Respirations >20/min• White Blood Cells

>12,000 or <4000 or >10% Bands formed

66




Others

Hypopituitarism• On chronic steroids, thyroid

replacement, testosteroneChild and Elder AbuseInternal or vascular injuriesSecondary Myasthenia and Parkinson’s DiseaseChronic kidney stonesUTISpecified locations of GI bleed Specified complications of pregnancy• Especially important if private

insurance uses MS-DRGs or APR-DRGs

Indications for Drugs• Amiodarone – atrial fibrillation,

ventricular tachycardia• Viagra – autonomic neuropathy• Neurotin – specified seizure

disorder• Coreg – chronic systolic HF• Lactulose – hepatic

encephalopathy• Methadone – continuous

chemical dependency• Sublingual nitroglycerin –

Angina at rest

67

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Resources

CC – MCC List can be downloaded athttp://campus.ahima.org/audio/2008seminars.html

DRG Documentation Tipsin Appendix of Resource Book

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Appendix

AHIMA 2008 Audio Seminar Series 38

DRG Documentation Tips ......................................................................................39 CE Certificate Instructions .....................................................................................41

NOTE: Additional Appendix “MS-DRG CC/MCC List Final Rule” can be downloaded at


© 2007 FTI Consulting – All Rights Reserved 8/2007 Used with permission – For Support, contact Dr. James Kennedy, 877-515-5354

DRG Physician Diagnosis Suggestions If You Write Consider ACS w/elevated troponin Non-Q wave MI

Any Infection, Bacteremia Sepsis if patient has Systemic (e.g. C. difficle colitis, Inflammatory Response Syndrome appenditicis, peritoneal (WBC > 14K, “left shift” Temp > 101, abscess Pulse > 90, Alt. Mental Status, ↑PCT)

due to that infection

Albumin 3.0, underweight Mild/Moderate/Severe malnutrition

Altered Mental Status Document alteration (ACUTE confusion, delirium, psychosis, dementia, coma), any probable underlying encephalopathy (toxic, septic, metabolic, traumatic, hypoxic, hypertensive) and other brain diseases present (Alzheimer’s, late effect of stroke, 1° or 2° Parkinsons)

Amiodarone/AICD use Underlying rhythm disturbance

Asthmaticus, Status Acute Resp. Failure if present

Azotemia, Cr ↑ from 1.0 Acute Renal Failure → AKI criteria of to 2.0 mg/dl, Acute acute rise of Cr of ≥ 0.3 mg/dl w/i 48 hr; Kidney Injury otherwise acute renal insufficiency

Blunt Abd. Trauma w/ Acute peritoneal Injury + Deep injury how solid organ was injured

CAD/Angina Document Stable Angina, Angina-at-rest or Progressive angina if present

Cardiac Arrest Its cause (prob. V-tach/V-fib/AMI)

Chest Pain Type of pain (angina, pleuritic, radicular, heartburn, biliary colic), its probable cause (e.g. GERD, gallstones, cocaine), & if at rest or accelerated.

CHF (Stunned Heart) Acute/Chronic, Systolic or Diastolic CHF (decompensated doesn’t count)

Closed Head Injury Concussion, LOC x _____ min

Cocaine/Illegal Drug Use Cocaine (drug) intoxication with continuous chemical dependency (Document acc. angina, arrhythmias, psychosis, toxic encephalopathy, accelerated HTN and other comp)

Chronic Renal Chronic Kidney Disease – Level 1, 2, 3 Insufficiency or Failure 4, or 5 or ESRD based on GFR - dialysis

COPD/Chronic Bronchitis Documented if stable or exacerbated.

Debridement of skin Describe if Excisional – a scalpel used to remove (not scrape) necrotic flesh

Diabetes, poorly contrld Uncontrolled Diabetes, if multiple BS > 250, Hgb A1c > 7.0 or BS widely fluctuate. If BS>600, poss. hyperosmolar syndrome

Hct 25 2° GI Bleed/Surg Drop in Hematocrit and/or Acute Blood Loss Anemia (See back)

If you Write Consider Hypertensive Emergency Accelerated or Malignant HTN. Hypertensive Urgency + consequences: e.g. encephalopathy, Acute heart failure, acc. angina,

Hypotension State UNDERLYING cause (e.g. possible hypovolemia, autonomic. neuropathy 2° parkinson’s, Shy-Drager, diabetes)

K 6.5 due to Captopril Hyperkalemia due to hypoaldosteronism due to Captopril

K 2.0; Will give KCl Hypokalemia due to ______

LLL Infiltrate, Rx w/Zosyn Prob. Gram-negative pneumonia

Low Urine Output Oliguria, Anuria + cause

Marijuana or Alcohol Use Continuous chemical dependency if use is recurrent w/health consequences or if on chronic Rx (e.g. methadone)

Na = 125 Hyponatremia & probable cause (e.g. SIADH, diuretics)

Neutropenic Fever Underlying systemic infection (sepsis) or bacterial infection for which antibiotics are prescribed. Capsofungin: prob. fungemia; Primaxin/Zyvox: prob. Bacterial infection of uncertain etiology. If sepsis is suspected, document that.

Pleural effusion State prob underlying condition (e.g. empyema, CHF) or condition to be r/o’d (e.g. metastatic cancer, TB)

pH 7.25 pCO2 34, pO2 80 Metabolic Acidosis + cause

Pneumonia Underlying organism for which the Hospital-Acquired antibiotics are prescribed, i.e. if Zosyn is SNF-Acquired used, document prob. aspiration, gram Ventilator-Associated negative. If vancomycin used, probable Community-Acquired MRSA pneumonia.

Ranson’s Criteria met SIRS 2° Pancreatitis (+ organs affected)

Respiratory Insufficiency Resp. Failure (if pH < 7.35, pCO2 >50 Respiratory Acidosis PO2 < 60 & special resources utilized Hypoxia, Hypercapnia

Rhythm Stable Underlying arrhythmia (e.g. ventricular tachycardia, PAT) on monitor or Rx’d

RIND – possible TIA TIA if <1 hours; Stroke if >1 hr/ + MRI

Seizure Describe probable Underlying Cause – e.g. old CVA, alcohol withdrawal, epilepsy

Spontaneous Fracture Pathological Fracture, Osteoporotic Fracture

Syncope LOC prob. due to ___________

Underweight/Overweight Malnutrition/Morbid Obesity if present

Urosepsis Sepsis due to UTI (if SIRS criteria met)

© 2007 FTI Consulting – All Rights Reserved 8/2007 Used with permission – For Support, contact Dr. James Kennedy, 877-515-5354

Definition of Terms: Acute Respiratory Failure An impairment of exchange of respiratory gases requiring aggressive care and usually manifested as a respiratory

acidosis (pH ≤ 7.35), hypercapnia (pCO2 ≥ 50), and/or significant hypoxemia (pO2 ≤ 55; sPO2 ≤ 88% requiring >28% of FiO2). Metabolic alkalosis may alter these blood gas settings. The patient does not have to be on a ventilator to have acute respiratory failure but should receive intensive care (e.g. frequent monitoring or respiratory treatments, BiPAP).

Angina Pectoris Symptoms resulting from myocardial oxygen insufficiency that can be the result of coronary disease (including spasm

or Syndrome X) or increased muscle mass. Angina at rest lasts less than 10 minutes. Accelerated angina pectoris is an acute increase in symptoms usually lasting more than 10 minutes that require urgent diagnostic assessment. Once cardiac enzymes are substantially elevated, angina pectoris has evolved into an acute myocardial infarction.

Acute Renal Failure Criteria and terminology not universally agreed upon. Most recent criteria for acute kidney injury (which encompases

all aspects of acute renal failure) is an abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in SCr of ≥ 0.3 mg/dl, a percentage increase in SCr of ≥ to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours). ICD-9-CM does not recognize Acute Renal Risk or Acute Renal Injury, allowing only acute renal insufficiency or acute renal failure. Underlying causes include hypovolemia, contrast nephropathy, (septic, hypovolemic) shock, toxins (e.g. NSAIDs, gentamicin), or ATN from other causes. Azotemia is only an elevation of creatinine and/or BUN and does not infer severity

Chronic Kidney Disease A kidney disorder manifested by radiological or urinary abnormalities (proteinuria, hematuria) or by a GFR less than 60 for more than three (3) months. CKD staging is defined by the GFR: Level GFR Please avoid the terms “Chronic Renal Insufficiency” or 1 >90 “Chronic Renal Failure” since these do not code to a 2 60-89 specific CKD code and thus do not infer severity. 3 30-59 4 15-29 5 < 15 or dialysis Please document underlying cause of the CKD if known

Diabetes Mellitus Defined by a fasting blood glucose of over 126 mg/dl or a 2-hour postpranial blood glucose of over 185 mg/dl.

Classified as Type 1 (absolute insulin deficiency due to autoimmune destruction of beta cells), Type 2 (impaired Insulin utilization), or secondary (due to destruction of beta cells by nonimmune causes such as surgery, infection, infiltrative disease or drugs or insulin resistance as the result of drugs (e.g. steroids). “Uncontrolled” diabetes has random blood glucoses over 250 mg/dl or Hgb A1C > 7.0, no matter what the cause. Comment if there are any consequences such as hyperosmolar state (BS over 600), ketoacidosis (HCO3 < 18 with uncontrolled diabetes), or complications (e.g. neuropathy, nephropathy, cardiomyopathy, radiculopathy, vasculopathy) specifically attributable to diabetes.

Drug or Alcohol Addiction An obsessive/compulsive disease manifested by alcohol/drug overindulgence for which physical or emotional

dependence develops associated with craving for which their use is continued despite adverse consequences. The disease can be continuous (currently active manifested by recent or daily use, especially if it impacts health), episodic, or in remission. Drug “abuse” is inappropriate use of the chemical (illegal drugs are always “abused”). Drug “use” is a reasonable consumption of a legal chemical (e.g. a glass of wine) that does not lead to adverse consequences.

Encephalopathy An underlying brain disease that is manifested by altered mental status, delirium, or dementia. This can be described

as septic, toxic, anoxic, metabolic, post-traumatic, or hypertensive and should be linked to an underlying process (e.g. sepsis, drug overdose, electrolyte imbalance, malignant hypertension).

Hypertension Staging According to the JNC 7, hypertensive emergency is defined by blood pressure over 180/120 with impending organ

failure. Hypertensive urgency is higher level Stage 2 hypertension (160-179/100-109) without organ dysfunction that may be associated with symptoms (e.g. dizziness, chest discomfort, anxiety). ICD-9-CM codes these as well controlled hypertension, thus the terms “malignant” or “accelerated” hypertension must be used respectively to define these.

Malnutrition An imbalance between the body's needs and the intake of nutrients, which can lead to syndromes of deficiency,

dependency, toxicity, or obesity. Malnutrition includes undernutrition, in which nutrients are undersupplied, and overnutrition, in which nutrients are oversupplied. When significant weight loss, hypoalbuminemia, or morbid obesity (BMI over 27) is present, malnutrition is probably present and warrants a dietary assessment.

Pneumonia An infection of lung alveoli manifested by a positive chest X-ray. If the patient has a negative chest X-ray, convincing

physical findings (whispered pectiloquoy, egophony, bronchial breath sounds) and/or an explanation for the negative chest X-ray (e.g. dehydration) is necessary. If the patient has signs and symptoms consistent with the Systemic Inflammatory Response Syndrome (see sepsis), documentation of “Sepsis due to Pneumonia” is appropriate.

Precipitous drop in Not defined in the literature. Since major blood loss is defined as a 20% loss of blood mass, “Precipitous drop in Hematocrit hematocrit can be arbitrarily defined as a 20% drop in hematocrit from baseline. Sepsis - SIRS Sepsis is a Systemic Inflammatory Response Syndrome (SIRS) due to a suspected or proven Infection. Signs and

symptoms that validate that a patient is “septic” were published by 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference; some of these include Temperature > 101, HR > 90, WBC > 12K or > 10% Bands, tachypnea, altered mental status, hyperglycemia, organ dysfunctions, and elevated cardiac output not explained by other causes. A positive blood culture is not necessary to substantiate sepsis given this definition. SIRS can occur as a result of non-infectious causes (e.g. pancreatitis, burns, trauma); appropriate documentation captures an appropriate severity of illness.

Ventricular Tachycardia A paroxysm of three or more PVCs in succession.

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Documents

Effective Coding Under MS-DRGscampus.ahima.org/audio/2008/RB021408.pdf · Faculty AHIMA 2008 Audio Seminar Series ii Sharalyn Milliken, RN, JD, CPC-H Ms. Milliken is a senior consultant