1. 3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

2. William Haik, MD Director, DRG Review, Inc. Clinical Potpourri: A Review of Problematic Diagnoses

3. © DRG Review, Inc. Agenda Complex pneumonias Respiratory failure Sepsis Acute renal failure/injury Decubitus ulcer staging Malnutrition

4. © DRG Review, Inc. PNEUMONIA Clinical Findings Fever > 100.4° or hypothermia 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.

5. © 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.

6. © DRG Review, Inc. GRAM-NEGATIVE BACTERIAL PNEUMONIA Gram’s Stain Differentiation Gram-positive bacteria (482.9) – Staphylococcus – Streptococcus pneumoniae – Streptococcus Gram-negative bacteria (482.83) – Klebsiella – Pseudomonas – E. coli – Proteus

7. © DRG Review, Inc. 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 Gram- negative bacteria – Hospitalization within three months or a nursing home patient, recent antibiotic therapy

8. © DRG Review, Inc. GRAM-NEGATIVE BACTERIAL PNEUMONIA Treatment Intravenous antibiotics (excluding penicillin, erythromycin, clindamycin, azithromycin, vancomycin, Zyvox)

9. © 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

10. © DRG Review, Inc. ACUTE RESPIRATORY FAILURE ABGs A patient with acute respiratory failure with previously normal lungs – P O2 50 mmHg Acute respiratory failure in a patient with previously abnormal lungs such as chronic obstructive lung disease – pH 50 mmHg OR A change in the P O2 <60 mmHg representing a drop of 15 mmHg from the previous "normal" P O2

11. © DRG Review, Inc. ACUTE RESPIRATORY FAILURE Treatment Oxygen monitoring and support Respiratory support (cpap, bipap, mechanical ventilation) Treatment of underlying condition

12. © DRG Review, Inc. CHRONIC RESPIRATORY FAILURE ABGs PO2 <55–60 mmHg / HBSat <88%–90% OR pH >7.35 40 mmHg

13. © 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.

14. © 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.

15. © 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.

16. SIRS SEPSIS Severe SepsisUrosepsis SepticemiaSepsis Syndrome Bacteremia

17. © DRG Review, Inc. SEPSIS Infection: invasion of normally sterile tissue, fluid, or body cavity by pathogenic microorganisms

18. © DRG Review, Inc. SEPSIS Bacteremia: 790.7, a laboratory finding of viable bacteria in the blood without evidence of a systemic inflammatory response

19. © 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 10% bands) 3.Tachycardia (> 90 beats per minute) 4.Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mmHg)

20. © DRG Review, Inc. 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. SIRS criteria (as above) 2. Altered mental status 3. Oliguria (< 30 ccs per hour) 4. Hypotension (systolic blood pressure < 90 mmHg or a 40 mmHg drop from the previous normal blood pressure responsive to fluid resuscitation) 5. Evidence of hypoperfusion (increase anion gap, reduced arterial pH, elevated lactate level, and reduced skin perfusion) 6. Hyperglycemia, unexplained 7. Elevated biomarkers (C-reactive protein, procalcitonin, Interleukin-6)

21. © DRG Review, Inc. 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

22. © 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. Acute renal failure (creatinine > 2 x ULN or baseline) 2. ARDS (PaO2/FiO2 < 250) 3. DIC (thrombocytopenia – platelet count <100,000) 4. Encephalopathy 5. Hepatic failure (bilirubin or SGOT > 2 x ULN)

23. © DRG Review, Inc. 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

24. © 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.

25. ACUTE KIDNEY FAILURE CRITERIA Table 1The RIFLE and Acute Kidney Injury Network Classifications of Acute Kidney Injury ClassGlomerular filtration rate criteriaUrine output criteria RiskIncreased SCreat × 1.5 or GFR decrease > 25% UO < 0.5 ml/kg/hour × 6 hours Injury 1 Increased SCreat × 2 or GFR decrease > 50% UO < 0.5 ml/kg/hour × 12 hours FailureIncreased SCreat × 3, GFR decrease > 75% or SCreat > 4 mg/dL (acute rise > 0.5 mg/DL) UO < 0.3 ml/kg/hour × 24 hours, or anuria × 12 hours LossPersistent AKI: complete loss of kidney function > 4 weeks ESKDEnd-stage kidney disease: complete loss of kidney function > 3 months AKIN 1 2 I ncreased SCreat ≥ 0.3 mg/dL or increased ≥150% to 200% from dL baseline (1.5 to 2-fold) UO < 0.5 ml/kg/hour × 8 hours AKIN 2Increased SCreat > 200% to 300% from baseline (>2- to 3-fold) UO < 0.5 ml/kg/hour × 12 hours AKIN 3Increased SCreat to > 300% (3-fold) from baseline or SCreat ≥ 4 mg/dL with an acute rise of at least 0.5 mg/dL UO < 0.3 ml/kg/hour × 24 hours or anuria for 12 hours

26. © DRG Review, Inc. 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 1 Acute kidney injury should be both abrupt (within 1–7 days) and sustained (more than 24 hours). 2 AKIN criteria application requires normal intravascular volume and no urinary obstruction. Metha et al. Critical Care 2007 11:R31

28. © 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 Severe Malnutrition – Ideal body weight > 70% – Pre-albumin > 5 mg/dL – Albumin > 1.5 g/dL