1. Clinical Collaborations for Improvement in CHF and Sepsis Coding
Kathy Fennick, RHIA, CCS

2. Objectives
Gain an understanding of the need to collaborate with clinical partners regarding coding for Congestive Heart Failure (CHF) and Sepsis
Discuss the impact of CHF readmissions
Discuss the impact of mortality due to sepsis
Understand the coding guidelines
Discuss implementing a collaborative process

3. Congestive Heart Failure
CHF - most common discharge diagnosis for patients age > 65.
Incidence of heart failure for patients age >80 is 9%.
CHF cases continue to increase and currently resulted in an annual expenditure of $10 billion for diagnosis and treatment.
Average hospital LOS for treatment of this disease is 9 days, and the overall five-year mortality rate is 50%.

4. Congestive Heart Failure
30% to 40% of CHF patients are readmitted within 6 months of hospitalization.
Studies show 40% of the CHF readmissions could be prevented.
Unnecessary readmissions contribute significantly to the cost of this disease both clinical and administratively.
New strategies can been introduced to help reduce the need for hospitalization/readmission.

5. Develop the Process CHF Patient Identification Protocol
Create a reporting protocol for CHF patients
Develop the list of codes that represent CHF (i.e. hypertensive cardiovascular disease
Add patient demographic information to the CHF log
Add FYI flag in EPIC or other EMR
FYI flag triggers the CHF resource nurse visit
CHF resource nurse provides discharge education including diet instructions
Coding performed once the patient is discharged
Coding notifies the CHF resource nurse all cases with CHF as the principal diagnosis that were coded each day prior to finalizing coding

6. Develop the Process CHF Patient Identification Protocol - continued
CHF resource nurse reconciles the case to the CHF log
Discrepancies are discussed and escalated to the physician liaison as needed
CHF clinical team analyzes cases that are not identified upon admission
CHF team meets on a weekly basis
Coding guidelines are discussed on a ad hoc basis
Physician queries are placed for ambiguous documentation
Coding reconciliation is presented to the team on a monthly basis
Measure the results using pre-defined metrics

7. Sepsis Mortality
Sepsis - most common cause of mortality in U.S. hospitals.
Nationally – 20% - 50% of the mortality for sepsis cases entering the hospital through the emergency department.

8. Develop the Team Core Team Members and Roles
Facilitator/Data Management
Clinical Champions
Leadership Support
Quality
Coding/Clinical Documentation Support

9. Coding SIRS/SEPSIS
Some patients—particularly those who are critically ill—may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria (e.g., heart rate > 90 and respiratory rate > 20)—which technically constitutes a SIRS diagnosis—but not have SIRS.

10. Coding SIRS/SEPSIS
As with all documentation challenges, coders should emphasize to physicians the importance of capturing patient severity. This includes the following elements related to sepsis and SIRS:
The inflammatory condition, whether infectious or noninfectious
The causal organism
Whether a noninfectious process is contributing to a patient's illness and the specific process
When in doubt, coders should query.

11. Coding SIRS/SEPSIS
Know how to apply sequencing guidelines. Applying sequencing guidelines is really clear if a patient comes in with some type of localized infection and then develops sepsis while they're in the hospital.
However, sequencing isn't as clear when patients appear to be admitted for organ failure, localized infection, or something else.

12. Develop the Process Sepsis Mortality Validation
Coding identifies mortality cases with PDX of sepsis
Coder places a mortality review coding status on case in EPIC and case is routed to Mortality work queue
Coding Quality Specialist performs coding validation
Clinical Documentation Specialist performs documentation review
Quality Specialist performs clinical protocol review
Physician query is used when needed
Review results entered in EPIC
Provide feedback to coders as needed
Review results are sent to the physician oversight committee
Coding guidelines are discussed on a ad hoc basis
Physician queries are placed for ambiguous documentation and Present On Admission (POA) clarification

13. Questions?
Kathy Fennick, RHIA, CCS