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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 © DRG Review, Inc. 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. © DRG Review, Inc. 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. © DRG Review, Inc. GRAM-NEGATIVE BACTERIAL PNEUMONIA Gram’s Stain Differentiation • Gram-positive bacteria (482.9) – Staphylococcus – Streptococcus pneumoniae – Streptococcus © DRG Review, Inc. • 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 © DRG Review, Inc. GRAM-NEGATIVE BACTERIAL PNEUMONIA Treatment • Intravenous antibiotics (excluding penicillin, erythromycin, clindamycin, azithromycin, vancomycin, Zyvox) © DRG Review, Inc. 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 © DRG Review, Inc. 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 © DRG Review, Inc. ACUTE RESPIRATORY FAILURE Treatment • Oxygen monitoring and support • Respiratory support (cpap, bipap, mechanical ventilation) • Treatment of underlying condition © DRG Review, Inc. CHRONIC RESPIRATORY FAILURE ABGs • PO2 <55–60 mmHg / HBSat <88%–90% OR • pH >7.35 <7.38 with PCO2 >40 mmHg © DRG Review, Inc. 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. © DRG Review, Inc. 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. © DRG Review, Inc. 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. © DRG Review, Inc. SIRS Severe Sepsis Sepsis Syndrome Bacteremia SEPSIS Urosepsis Septicemia SEPSIS • Infection: invasion of normally sterile tissue, fluid, or body cavity by pathogenic microorganisms © DRG Review, Inc. SEPSIS • Bacteremia: 790.7, a laboratory finding of viable bacteria in the blood without evidence of a systemic inflammatory response © DRG Review, Inc. 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 © DRG Review, Inc. 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. © DRG Review, Inc. 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 © DRG Review, Inc. 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. © DRG Review, Inc. 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 © DRG Review, Inc. 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. © DRG Review, Inc. 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. © DRG Review, Inc. 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 © DRG Review, Inc. • Severe Malnutrition – Ideal body weight > 70% – Pre-albumin > 5 mg/dL – Albumin > 1.5 g/dL