1. APDIS Chapter Meeting Amy Bush RN, BSN, MJ
Clinical Documentation Improvement Specialist
Children’s Hospital of Philadelphia

2. CHOP at a Glance Patients from more than 50 nations
546-beds with over 29,500 admissions
170,188 inpatient Days
More than 40,000 annual inpatient and outpatient surgeries
Over 96,000 annual Emergency Department visits
More than 1.3 million outpatient visits
More than 1 million square feet of research space, helping to bring bench discoveries to bedside quickly

3. Children’s hospital of Philadelphia CDI Program
Started in November 2014
Payer Mix is approximately 6% APR-DRG
46% Medicaid
Remaining payers are per diem rate
3 Full time CDI specialist
1 Part time CDI specialist
1 physician advisor
Under the leadership of the case management department

4. Case Studies

5. Kaye is a previously health 3 year old presenting with 5 days of emesis and new onset of seizures. She was diagnosed on imaging with a posterior fossa mass and obstructive hydrocephalus.
Following surgery to remove the mass and perform an ETV, the patient was noted post operatively to have a constellation of symptoms including: mutism, dysphagia, ataxia; and, emotional lability.
Documentation indicated that the patient had ‘cerebellar mutism’.

6. CDI query to the physician, requested clarification on whether posterior fossa syndrome, which includes this constellation of symptoms could be used interchangeably with posterior fossa mutism.
Per the physician, posterior fossa mutism is not a diagnosis. Posterior fossa syndrome, the diagnosis indicated in this case, codes to G935 “compression of brain” and carries an SOI of 4, ROM 4. This condition is expected to be temporary and resolve over time.
Mutism, which can also be a sequelae of brain tumor excision, can be temporary or permanent. However, the coding of mutism is to R4701 aphasia, which carries an SOI of 3, ROM1.

7. Principal Diagnosis
C716 Malignant neoplasm of cerebellum
Secondary Diagnoses/
Procedures
G911 Obstructive hydrocephalus
00B00ZZ Excision of brain, open
00960ZZ Drainage of cerebral ventricle, open
G935 Compression of brain (posterior fossa syndrome)
00B00ZZ Excision of brain
00960ZZ Drainage of cerebral ventricle
APR-DRG
02 CRANIOTOMY EXC FOR TRAUMA
Severity of Illness 2 3
Risk of Mortality 1
Relative Weight
(V.35)
(V.35)

8. Principal Diagnosis
C716 Malignant neoplasm of cerebellum
Secondary Diagnoses/
Procedures
G911 Obstructive hydrocephalus
00B00ZZ Excision of brain, open
00960ZZ Drainage of cerebral ventricle, open
R4701 aphasia (mutism)
00B00ZZ Excision of brain
00960ZZ Drainage of cerebral ventricle
APR-DRG
02 CRANIOTOMY EXC FOR TRAUMA
Severity of Illness 2 3
Risk of Mortality 1
Relative Weight
(V.35)
(V.35)

9. Alpha is a 20 month old with newly diagnosed acute myeloblastic leukemia.
In addition to Alpha’s new oncology diagnosis, as her work up continues and chemotherapy is started, her providers document “risk for tumor lysis syndrome” and the treatments aimed at preventing it.
Labs are frequently drawn to monitor this condition. The next day, providers noted metabolic abnormalities of: hyperkalemia, hyperphosphatemia and hyperuricemia.
CDI should query the provider to ask if, based on the documented lab values, another diagnosis assignment is indicated.

10. Principal Diagnosis
C9200 Acute myeloblastic leukemia
Secondary Diagnoses
D6959 secondary thrombocytopenia
D630 anemia in neoplastic disease
CD6959 secondary thrombocytopenia
E883 Tumor lysis syndrome
APR-DRG
690 ACUTE LEUKEMIA
Severity of Illness 2 3
Risk of Mortality
Relative Weight
(V.35)
(V.35)

11. Questions