Download 252221

3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Clinical Potpourri:
A Review of Problematic
Diagnoses
William Haik, MD
Director, DRG Review, Inc.
Agenda
• Complex pneumonias
• Respiratory failure
• Sepsis
• Acute renal failure/injury
• Decubitus ulcer staging
• Malnutrition
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PNEUMONIA
Clinical Findings
Fever > 100.4° or hypothermia < 96.8°, chills, difficulty breathing,
worsening cough, malaise/lethargy, acute onset of confusion or
obtundation, Pleuritic chest pain, purulent sputum production,
tachypnea > 20, rales/crackles, decreased or coarse breath sounds, or
evidence of consolidation
Note: The above may be subtle or absent in the elderly.
OR
Pulmonary infiltrate
Note: An acute pulmonary infiltrate may not be present on the initial
chest x-ray in the presence of dehydration, leukopenia, aspiration of a
small volume, or normal pH, especially in the presence of structural
lung disease such as COPD, pulmonary fibrosis, etc.
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Aspiration Pneumonia
Criteria
Treatment with intravenous antibiotics
AND
Neurological and gastrointestinal risk factors for aspiration pneumonia
Impaired gag reflex (CVA, Parkinson’s disease, decreased sensorium, etc.
Impaired swallowing (GERD, esophageal obstruction, PEG/feeding tube, etc.)
OR
Abnormal swallowing study revealing evidence of aspiration
OR
Specific treatment for aspiration pneumonia
Aspiration precautions, speech or physical therapy, PEG tube insertion, etc.
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GRAM-NEGATIVE BACTERIAL PNEUMONIA
Gram’s Stain Differentiation
• Gram-positive
bacteria (482.9)
– Staphylococcus
– Streptococcus
pneumoniae
– Streptococcus
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• Gram-negative
bacteria (482.83)
–
–
–
–
Klebsiella
Pseudomonas
E. coli
Proteus
GRAM-NEGATIVE BACTERIAL PNEUMONIA
Risk Factors
• High-risk host for serious underlying disease
which results in failure to combat a Gram-negative
bacterial infection
– Chronic obstructive pulmonary disease, diabetes
mellitus, immunosuppression, chronic malnutrition,
advanced age, chronic alcoholism, chronic renal
disease, chronic liver disease, congestive heart
failure
• High-risk setting for colonization with Gramnegative bacteria
– Hospitalization within three months or a nursing home
patient, recent antibiotic therapy
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GRAM-NEGATIVE BACTERIAL PNEUMONIA
Treatment
• Intravenous antibiotics (excluding
penicillin, erythromycin, clindamycin,
azithromycin, vancomycin, Zyvox)
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ACUTE RESPIRATORY FAILURE
Criteria
• Inadequate exchange of oxygen and/or
carbon dioxide by the lungs
• Life-threatening disorder requiring aggressive
management and monitoring
• Evidence of increased work of breathing or
possibly cyanosis and/or paradoxical
breathing
• Absence of mechanical ventilation does not
exclude the diagnosis of acute respiratory
failure
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ACUTE RESPIRATORY FAILURE
ABGs
• A patient with acute respiratory failure with previously normal
lungs
– PO2 <60 mmHg, PCO2 >50 mmHg
• Acute respiratory failure in a patient with previously abnormal
lungs such as chronic obstructive lung disease
– pH <7.35 with a PCO2 >50 mmHg
OR
A change in the PO2 <60 mmHg representing a drop of 15
mmHg from the previous "normal" PO2
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ACUTE RESPIRATORY FAILURE
Treatment
• Oxygen monitoring and support
• Respiratory support (cpap, bipap,
mechanical ventilation)
• Treatment of underlying condition
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CHRONIC RESPIRATORY FAILURE
ABGs
• PO2 <55–60 mmHg / HBSat <88%–90%
OR
• pH >7.35 <7.38 with PCO2 >40 mmHg
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SEQUENCING ACUTE
RESPIRATORY FAILURE
1. Consider reporting acute respiratory failure as a principal diagnosis
(“that condition established after study chiefly responsible for
occasioning the admission of the patient to the hospital for care”) in
the following circumstance:
– If respiratory failure is associated with another acute condition that is equally
responsible for occasioning the patient’s admission to the hospital, and there are no
chapter-specific sequencing rules (see below), the guideline regarding two or more
diagnoses which equally meet the definition of principal diagnosis may be applied in
this situation.
•
•
Example: Acute respiratory failure secondary to aspiration pneumonia.
Either acute condition may be sequenced as the principal diagnosis
depending on the circumstances of admission.
Example: Acute respiratory failure secondary to cardiogenic pulmonary
edema in a patient with an acute, anterior wall myocardial infarction. Either
acute condition may be sequenced as the principal diagnosis depending on
the circumstances of admission.
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SEQUENCING ACUTE
RESPIRATORY FAILURE
2. When acute respiratory failure is an adverse
reaction to a drug, follow the coding rule for
coding an adverse drug reaction sequencing
respiratory failure first, followed by the
appropriate external cause code for the drug
(E code).
Example: Respiratory failure secondary to aspirin taken as
prescribed. Respiratory failure is the principal diagnosis.
3. When the cause of the respiratory failure is not
identified. This may occur when the patient
expires or is transferred shortly after admission.
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SEQUENCING ACUTE
RESPIRATORY FAILURE
1. Do not code acute respiratory failure as the principal diagnosis when
there is a chapter-specific coding guideline (sepsis, obstetrics,
poisoning, HIV, newborn) or an alphabetic index or tabular directive
which takes precedence over the general respiratory failure
guidelines and examples listed above.
– Example #1: Acute respiratory failure, secondary to Pneumocystis
carinii pneumonia in a patient with HIV. The human immunodeficiency
virus (042) is reported as the principal diagnosis.
– Example #2: A patient is admitted with acute respiratory failure
secondary to Valium overdose. The poisoning (Valium overdose) is
reported as the principal diagnosis.
– Example #3: A patient is admitted with aspiration pneumonia with
associated sepsis and acute respiratory failure. Sepsis is reported as
the principal diagnosis.
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SIRS
Severe Sepsis
Sepsis Syndrome
Bacteremia
SEPSIS
Urosepsis
Septicemia
SEPSIS
• Infection: invasion of normally sterile
tissue, fluid, or body cavity by pathogenic
microorganisms
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SEPSIS
• Bacteremia: 790.7, a laboratory finding of
viable bacteria in the blood without
evidence of a systemic inflammatory
response
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SEPSIS
• Systemic Inflammatory Response
Syndrome (SIRS): 995.90, a syndrome
defined by the presence of two or more of the
following features of systemic inflammation:
1.
Fever (oral temperature > 38°C or
100.4°F) or hypothermia (oral temperature <
36°C or
96.8°F)
2.
Leukocytosis (white count > 12,000) or
leukopenia (white count < 4,000 or >
10% bands)
3.
Tachycardia (> 90 beats per minute)
4.
per
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Tachypnea (respiratory rate > 20 breaths
minute or a pCO2 of < 32 mmHg)
SEPSIS
• Sepsis: 995.91, is synonymous with SIRS due to infection without
organ dysfunction. This is an infection-induced syndrome defined
since 2003 to include the presence of multiple features of systemic
inflammation:
1.
2.
3.
4.
5.
6.
7.
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SIRS criteria (as above)
Altered mental status
Oliguria (< 30 ccs per hour)
Hypotension (systolic blood pressure < 90 mmHg or a 40 mmHg drop
from the previous normal blood pressure responsive to fluid
resuscitation)
Evidence of hypoperfusion (increase anion gap, reduced arterial pH,
elevated lactate level, and reduced skin perfusion)
Hyperglycemia, unexplained
Elevated biomarkers (C-reactive protein, procalcitonin, Interleukin-6)
SEPSIS
• Septicemia: 038.x, is an antiquated,
ambiguous term which has been used
nonspecifically in the past to imply either
bacteremia or sepsis; therefore, should be
eliminated from current medical usage
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SEVERE SEPSIS
• Severe sepsis: 995.92 (sometimes referred to as sepsis
syndrome), and is synonymous with SIRS due to infection
with organ dysfunction, 995.92. This condition occurs when
sepsis overwhelms the counterregulatory control mechanisms
resulting in organ dysfunction. This is typified as:
1.
2.
3.
4.
5.
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Acute renal failure (creatinine > 2 x ULN or
baseline)
ARDS (PaO2/FiO2 < 250)
DIC (thrombocytopenia – platelet count <100,000)
Encephalopathy
Hepatic failure (bilirubin or SGOT > 2 x ULN)
SEPTIC SHOCK
• Septic shock: 785.52, is severe sepsis with
hypotension (systolic blood pressure <90
mmHg or a 40 mmHg drop from the previous
normal blood pressure) unresponsive to fluid
resuscitation, requiring vasopressor
intervention
– When physicians document septicemia with
shock or sepsis with septic shock, then the
correct code assignment is 038.9/995.92/785.52
and a code for the underlying infection
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COMMON SEQUENCING CONCERNS
REGARDING SIRS/SEPSIS/SEVERE SEPSIS
The underlying cause (such as infection or trauma) is sequenced before any code from 995.9
series, systemic inflammatory response syndrome (SIRS).
Reference: AHA’s Coding Clinic for ICD-9-CM, fourth quarter 2008, p. 14.
2.
If sepsis (995.91) or severe sepsis (995.92) meets the definition of principal
diagnosis, the systemic infection code (such as 038.xx) should be assigned as the principal
diagnosis followed by sepsis or severe sepsis. The localized infection (such as a urinary tract
infection, 599.0) should be reported as an additional diagnosis.
Reference: AHA’s Coding Clinic for ICD-9-CM, fourth quarter 2008, p. 15.
3.
When the admission is for treatment of a complication resulting from surgical or
medical care, the complication code (996–999) is sequenced as the principal diagnosis
followed by the appropriate sepsis codes.
Reference: AHA’s Coding Clinic for ICD-9-CM, second quarter 2005, pp. 19–20.
Reference: AHA’s Coding Clinic for ICD-9-CM, fourth quarter 2008, p. 218.
Reference: AHA’s Coding Clinic for ICD-9-CM, fourth quarter 2008, p. 303.
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ACUTE KIDNEY FAILURE CRITERIA
Table 1 The RIFLE and Acute Kidney Injury Network Classifications of Acute
Kidney Injury
Class
Glomerular filtration rate criteria
Urine output criteria
Risk
Increased SCreat × 1.5 or GFR
decrease > 25%
UO < 0.5 ml/kg/hour × 6
hours
Injury1
Increased SCreat × 2 or GFR
decrease > 50%
UO < 0.5 ml/kg/hour × 12
hours
Failure
Loss
Increased SCreat × 3, GFR decrease
UO < 0.3 ml/kg/hour × 24
hours, or anuria × 12 hours
> 75% or SCreat > 4 mg/dL (acute rise
> 0.5 mg/DL)
Persistent AKI: complete loss of kidney function > 4 weeks
ESKD
End-stage kidney disease: complete loss of kidney function > 3 months
AKIN 12
Increased SCreat ≥ 0.3 mg/dL or
AKIN 2
AKIN 3
increased ≥150% to 200% from dL
baseline (1.5 to 2-fold)
Increased SCreat > 200% to 300% from
baseline (>2- to 3-fold)
UO < 0.5 ml/kg/hour × 8
hours
UO < 0.5 ml/kg/hour × 12
hours
UO < 0.3 ml/kg/hour × 24
Increased SCreat to > 300% (3-fold)
from baseline or SCreat ≥ 4 mg/dL with hours or anuria for 12 hours
an acute rise of at least 0.5 mg/dL
AKI CRITERIA
•
Abbreviations: AKI, acute kidney injury; GFR, glomerular filtration rate;
SCreat, serum creatinine; UO, urine output.
•
Dennen, Douglas, Anderson et al. Critical Care Medicine January 2010
Volume 38 No. 1 pages 261-275 doi: 10.7097/CCM.obo13e3181bfb0b5
•
1Acute
•
2AKIN
•
Metha et al. Critical Care 2007 11:R31
kidney injury should be both abrupt (within 1–7 days) and sustained
(more than 24 hours).
criteria application requires normal intravascular volume and no
urinary obstruction.
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MALNUTRITION
• Malnutrition
– Ideal body weight >
70% but < 85%
– Pre-albumin > 5 mg/dL
but < 15 mg/dL
– Albumin > 1.5 g/dL but
< 3.5 g/dL
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• Severe Malnutrition
– Ideal body weight >
70%
– Pre-albumin > 5 mg/dL
– Albumin > 1.5 g/dL