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1 Diagnostic Criteria 101: Criteria to Diagnose 15 Common Hospital Medicine Diagnoses Timothy N. Brundage, MD, CCDS Medical Director Brundage Medical Group, LLC Redington Beach, Florida 2 Learning Objectives At the completion of this educational activity, the learner will be able to: Articulate common barriers to effective physician coding documentation Apply effective documentation coding strategies to 15 common acute care diagnoses 3

2 Clinical Documentation Integrity Program We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. CMS 2008 IPPS final rule, MS 1533 FC.pdf, p How to Help? Realize physicians have not been educated in clinical documentation integrity Educated by their professors in residency Have limited education in SOI ROM DRG CMI 5 The Staff Reviewing the Chart Doctors share the chart Nurses PT/OT/ST Case management/social worker Quality nurse Core measure nurse CDI 6

3 Understand Circumstances Physicians are not familiar with query rules Physicians Just tell me what to write. Cardiologist example Where are those ladies who tell me what to write in the chart? Can you say leading? 7 Education Opportunities Principal diagnosis The condition after study to be chiefly responsible for occasioning the admission to the hospital Secondary diagnosis Conditions that consume one of the following: Clinical evaluation Therapeutic treatment Diagnostic procedures/testing Extended length of stay (LOS) Increased nursing care and/or monitoring 8 Education Opportunities Principal diagnosis Must be present on admission Caution: Hospital acquired condition (HAC) Line sepsis example SIRS criteria were present on admission Nighttime hospitalist documented febrile Illness ID doctor came behind (after admission) and documented line sepsis DKA example ER doctor used D5NS in a diabetic who was NPO for N/V increasing his blood glucose and possibly contributing to DKA 9

4 Education Opportunities Diagnose using coding based language Make sure your doctors know to put the diagnoses into the chart at least once Consistently documented without conflicting documentation DC summary is most important MCC CC No SOI Secondary diagnoses 1,096 MCC 4,221 CC 8,232 non CC 10 Education Opportunities Educate doctors that insufficiencies do not impart severity of illness Educate physicians to document all disease processes Status of the condition Improving, worsening, resolving, resolved Use what is on your CDI pocket cards Educate them to avoid documenting disease processes as postop : Can code as a complication of procedure/surgery The operator or surgeon suffers the rating drop 11 Education Opportunities List all diagnoses on the discharge summary Possible, probable, likely, suspected... Educate your doctors to stop using history of Listen and cooperate with the coding documentation specialist nurses when they ask you to document something a particular way in the chart 12

5 Acute Renal Failure/Acute Kidney Injury KDIGO: Increase in the patient s serum creatinine of 0.3 mg/dl or more over their normal baseline level Do not document: Dehydration Azotemia Acute renal insufficiency Acute renal failure is a comorbidity/complication (CC) ATN is a major comorbidity/complication (MCC) Causes of ATN monitor for query opportunities Contrast dye (CT in the ER?) Rhabdomyolysis Medications e.g., antibiotics (Gentamycin) Septic shock or hypotension 13 Acute Renal Failure/Acute Kidney Injury Commonly documented diagnosis that needs more specificity Acute on chronic renal failure Educate them to use more specific language If they had CKD at baseline ARF on CKD, stage Remember to document baseline CKD stage This is a common query issue 14 Chronic Kidney Disease (Not CRI or CRF ) I n c r e a s i n g C M I Stage I Stage II Stage III Stage IV Stage V ESRD GFR = > 90 ml/min GFR = 60 to 89 GFR = 30 to 59 GFR = 15 to 29 HCC & CC GFR = < 15 HCC & CC On dialysis HCC & MCC CC Comorbidity Complication MCC Major Comorbidity Complication HCC Hierarchical Condition Category 15

6 Acute Renal Failure/Acute Kidney Injury Commonly documented diagnosis that needs more specificity Acute on chronic renal failure Educate them to use more specific language If they had CKD at baseline ARF on CKD, stage Remember to document baseline CKD stage This is a common query issue 16 Congestive Heart Failure Need both acuity and type of HF Acute or chronic or acute on chronic? Systolic (EF < 40%) not HFrEF Diastolic (normal EF) not HFpEF Both Simply writing EF = % is not sufficient Acute systolic heart failure (not dysfunction ) 17 Diabetes Mellitus Type 1 or Type 2 or secondary to another cause Steroids, gestational Controlled or Uncontrolled For ICD 9 but changes w/ ICD 10 Uncontrolled means an admission HbA1c 7.0 or Several blood sugars consistently > 200 while in the hospital Diabetes related complications: Diabetic peripheral neuropathy Diabetic nephropathy Diabetic vasculopathy, etc. Document causal link to manifestations (not 2/2) use due to Document link to wound, but MUST unlink wound (e.g., trauma) 18

7 Sepsis Sepsis = SIRS plus a possible source of infection SIRS = Two or more of the following: T > 100.4F or < 96.8F HR > 90 RR > 20 WBC s > 12,000 or < 4,000 or 10% bands Severe sepsis Sepsis w/ evidence of end organ damage Lactic acid > 2.0 Septic shock Sepsis refractory to fluid resuscitation (requiring pressors) Lactic acid > 4.0 Do NOT document urosepsis Codes to a simple UTI, no code in ICD 10 it is sepsis due to a UTI 19 Sepsis Can Also Be Diagnosed if Some of the Following Are Due to Infection SIRS criteria Altered mental status Significant edema or positive fluid balance Hyperglycemia in the absence of diabetes CRP more than two SD above the normal value Procalcitonin more than 2 SD above the normal value Hypotension (SBP < 90 mmhg or SBP decrease > 40 mmhg) Hypoxemia (PaO2/FiO2 < 300) Acute oliguria (urine output < 0.5mL/kg/hr for 2 hours) Creatinine increase > 0.5mg/dL INR > 1.5 Ileus Thrombocytopenia (PLT < 100,000) Hyperbilirubinemia (> 4 mg/dl) Hyperlactatemia (> 1 mmol/l) Decreased capillary refill or mottling Surviving Sepsis Campaign of 2012 Table 1 20 Respiratory Failure Acute, chronic, or acute on chronic ICU admission or intubation not required: Criteria for acute respiratory failure includes 2 out of 3: po2 < 60mmHg pco2 > 50mmHg with ph < 7.35 Respiratory distress document this in the physical exam Chronic respiratory failure Continuous home oxygen or normal ph w/ high CO2 21

8 Malnutrition ASPEN criteria Malnutrition should be diagnosed when 2 or more of the following 6 criteria are identified Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by hand grip strength Notice that ALBUMIN and PREALBUMIN are NOT criteria for diagnosis 22 Anemia Acute blood loss anemia Anemia linked to a hemorrhagic process GI bleed Fracture Any procedure or surgery This should be documented separately from its cause Post procedure anemia: Specify if expected Expected drop in hematocrit due to CABG/C section Expected acute blood loss anemia due to hip fracture Do not document BRBPR as it has no code» Consider lower GI bleed due to diverticulosis 23 Encephalopathy Do NOT document Altered mental status Mental status changes Confusion Acute confusional state (delirium) is a symptom Encephalopathy Definition: Global cerebral dysfunction in the absence of structural brain disease Major comorbidity/complication Underlying etiology: Toxic/metabolic UTI or sepsis Hepatic As a late effect of a stroke (i.e., multi infarct dementia) Anoxic Hypertensive 24

9 Pneumonia All these code to simple pneumonia Community acquired pneumonia Healthcare associated pneumonia (HCAP) Nosocomial pneumonia Why are you are choosing Zosyn/Vancomycin instead of Rocephin/Azithromycin? Because you suspect GNR or MRSA Do not need sputum or blood cultures Pneumonia due to possible GNR, will Rx Zosyn Pneumonia due to possible MRSA, will Rx Vancomycin Why are you adding Clindamycin or Flagyl? Because you suspect aspiration So tell us! Pneumonia due to suspected aspiration 25 Hypertension All these code to non specific hypertension Hypertensive urgency Hypertensive emergency Hypertensive crisis Accelerated or malignant hypertension (many definitions) Accelerated HTN = SBP > 180 or DBP > 110 Malignant HTN = Accelerated HTN plus symptoms Headache, CP or papilledema (pathognomonic) The key is urgent treatment either IV or STAT PO Hypertensive crisis due to malignant hypertension ICD 10 document the manifestations of HTN Hypertensive encephalopathy 26 Acute Myocardial Infarction Troponinemia is a lab finding, not a diagnosis It is not benign and is associated with poor outcomes Need cardiologist/physician to determine clinical relevance AMI is defined by elevation of troponin above the 99 th percentile with clinical signs/symptoms of ischemia AMI Type 1: Spontaneous MI from CAD AMI Type 2: AMI due to ischemia imbalance Sepsis/septic shock Critically ill patient AMI Type 4a: AMI related to PCI troponin > 5 times the 99 th percentile of URL AMI Type 5: AMI related to CABG 3rd Universal Definition of AMI 27

10 NSTEMI Type 2 vs. Demand Ischemia Very similar pathophysiologically Demand ischemia is due to supply demand mismatch NSTEMI type 2 codes to AMI Also due to supply demand mismatch but is categorized as an AMI and is associated with a higher severity of illness Quality metrics tracked for AMI 28 Stroke Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia Neuropathological Neuroimaging Clinical evidence of permanent injury AHA/ASA Expert Consensus Document An Updated Definition of Stroke for the 21 st Century Published May Stroke vs. TIA A time definition for symptoms (< 24 hours) should not be the only diagnostic criteria for TIA. Modern imaging findings obtained by diffusion weighted MRI highlight tissue changes several minutes after transient or permanent ischemic events. Stroke can be diagnosed with MRI findings regardless of symptoms and in less than 24 hours. 30

11 Stroke Hemiplegia and aphasia are comorbidity/ complications in CVA patients Document if dominant side for ICD 10 As a late effect of stroke Do NOT use history of stroke Hemiplegia or hemiparesis Aphasia Ataxia Dementia Contracture of a joint 31 Morbid Obesity Morbid obesity BMI > 40 Physician must ascribe clinical relevance to the BMI & document the diagnosis Cannot be taken from a calculated BMI BMI > 40 Morbid obesity BMI < 19 Underweight malnourished 32 COPD COPD with acute exacerbation COPD is a chronic condition Consider acute exacerbation Steroids & nebs Evaluate for: Acute respiratory failure Increased oxygen requirement and respiratory distress Chronic respiratory failure Continuous home oxygen 33

12 Miscellaneous Hypokalemia, hyponatremia, hypercalcemia Please write these out completely Do not use arrows and/or symbols Some can be CCs such as hypo and hypernatremia Acidosis (HCO3 < 18) Alkalosis (HCO3 > 28) These are CCs Bacteremia is a comorbidity/complication (CC) Septicemia is a major comorbidity/complication (MCC) 34 What About Your Quality Ratings? Predicted mortality rates for some disease processes: Community acquired pneumonia = 5% Sepsis = 12% Severe sepsis = 18% Septic shock = 20% If the patient survives, your ratings will be much higher in the public quality reporting data because you took care of a sicker patient Goal: Expected mortality higher than actual mortality 35 Thank you. Questions? DrBrundage@Gmail.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 36