Documenting in the World of ICD-10 Capturing all your CCs and MCCs Crystal Coen, RN, MSN, FNP-BC 2017 NPSS Asheville, NC
Objectives Understand the importance of documenting to the highest specificity Understand the importance of documenting comorbid conditions Identify common comorbid conditions Practice identifying CCs and MCCs with case studies NCNA 2017 NPSS
Importance of documentation Risk adjustment score A higher risk adjustment score indicates a higher severity of illness which requires a higher cost of care and therefore higher potential reimburesment.
Importance of documentation What impact do CCs and MCCs have? DRG 293 Heart failure w/o CC/MCC Weight: 0.6762 GMLOS: 2.6 Reimbursed: $4,338 DRG 292 Heart failure w/cc Weight: 0.9824 GMLOS: 3.7 Reimbursed: $6,129 DRG 291 Heart failure w/mcc Weight: 1.5097 GMLOS: 4.7 Reimbursed: $9,213
Importance of documentation Pt admitted with COPD exacerbation, renal insufficiency, and heart failure. COPD with acute exacerbation, unsp disorder of kidney, unsp heart failure Weight: 0.7313 GMLOS: 2.7 Reimb: $4,636 COPE with acute exacerbation, acute kidney failure with tubular necrosis, acute diastolic CHF Weight: 1.1578 GMLOS: 4 Reimb: $7,142
Improving accuracy of documentation Name and link diseases Acuity Diagnosis for abnormal lab values with a treatment plan Chronic conditions that home meds are being continued Probable Suspect Be as specific as possible
General Sepsis, Severe Sepsis, Septic Shock SIRS non infectious, SIRS with organ dysfunction Temp >100.9 or <98.6 WBC > 12,000 or <4000 or bands>10% Lactate >1.0 (Shock >4.0) Tachycardia >90 Tachypnea >20 Evidence of end organ failure-severe sepsis Bacteremia
Nutrition Cachexia BMI <19 BMI >40 Mild and moderate malnutrition Severe malnutrition
Diabetes-be specific Type 1 or 2 Hypo or hyperglycemia Associated complications Hyperosmolar w/ or w/o coma Diabetic Ketoacidosis
Kidney disease Acute on chronic Renal failure, not insufficiency Creat increase 0.3 in 48 hours or 1.5x baseline Pre-renal, Renal, Post-renal Acute Tubular Necrosis Acute kidney injuiry
UTI?POA Organism ID Associated symptoms or conditions
Hyponatremia Hypernatremia
Cardiac ACS Unstable angina Demand ischemia Cardiomyopathy Hypertensive emergency/crisis PSVT/PAT Persistent Afib A flutter
Cardiac Acute MI V fib (d/c alive) Cardiogenic Shock Cor Pulmonale Cardiac arrest (d/c alive)
Cardiac-Heart failure Diastolic HF Systolic HF Acute diastolic HF Acute systolic HF
Pulmonary COPD acute exacerbation Chronic Respiratory Failure ARDS Atelectasis Pneumonia-aspiration or bacterial Acute pulmonary embolism Acute Respiratory Failure Unspecified Acute on chronic postprocedural
Neuro Dementia with behavioral disturbance Drug induced delirium Encephalopathy: alcoholic, hypoxic, hypertensive, Encephalopathy: metabolic, toxic, hepatic Hemiplegia, paraplegia Quadriplegia and functional quadriplegia
Gastrointestinal GI or rectal bleeding C Diff enteritis Esophageal erosions or ulcer Candida esophagitis Ileus Impaction or Obstruction Chronic pancreatitis
Gastrointestinal Acute pancreatitis Esophageal ulcer with bleeding
Drug dependence Hallucinations Oral Candidiasis DVT
Case Studies 61 yr old African American female with SOB, chills, decreased oral intake for 2 days, exertional dyspnea, increased wheezing. She has home O2 but only uses it as needed. PMH: HTN, anxiety, asthma, tobacco use She ran out of her albuterol 6 months ago. Has daily sx.
Labs Sodium 134 (L), CO2 19 (L), Creat 1.2 (H), Lactic acid 4.3, ph 7.47 pco2 26 po2 63 (arterial) WBC 7,000 O2 sat 89% RA, pulse 114, Temp 103, CXR neg Diffuse wheezing on exam. Initial diagnoses
Further work up reveals Glucose 186 (on steroids) CXR after fluids interstitial edema. No acute infectious process. BNP 844 Afebrile, WBC nl Diagnoses Repeat ABG ph 7.5, pco2 37 po2 55, CT chest-no PE. Emphysema. No PNA. Diagnoses
CONTACT INFO, REFERENCES, ETC. crystalcoen@gmail.com Pinson, R.D. (2016). 2017 CDI Pocket Guide. Brentwood, TN: HCPro. 2017 NPSS ASHEVILLE, NC