Clinical Issues Related to ICD9 Coding

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Clinical Issues Related to ICD-9 Coding

• Emily A. Boohaker, M.D.
• Associate Professor of Medicine
• Deborah Elder, RHIA, CCS, CPCH
• Sonja Davis, RHIT, CCS, CDMP
• University of Alabama Health System

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Objectives

• Review pathophysiology of diseases that create
  discomfort between coders and physicians
• Discuss clinical cases where query will be most
  effective in assigning an appropriate DRG
• Learn from audience effective strategies for
  queries leading to appropriate DRG assignment

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Disease States

• Sepsis
• Respiratory Failure
• Pneumonia

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Sepsis

• Suspected or proven infection plus a Systemic
  Inflammatory Response Syndrome (SIRS)
• gt 2 of the following
• HR gt 90
• RR gt 20 or PaCO2 lt 32 or vent
• Temp gt 38 C or lt 36 C
• WBC gt 12,000 or lt 4,000 or gt10 bands

N ENGL J MED 2006 3551699-1713
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Sepsis

• Severe sepsis with organ dysfunction
• Shock severe sepsis with hypotension
  despite adequate fluid resuscitation

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SepsisTherapeutic Plan

• N ENGL J MED 2006 355 1699- 1713

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SepsisCase 1

• Hx 66 yo male presents with abdominal pain,
  
• n/v and fever
• PE T 103.4, HR 114
• Abd tender diffusely, no peritoneal signs
• LABS WBC19.4, 89 segs
• CT scan dilated bowel loops, no diverticulitis

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Case 1Management

• Day 1 Presumptive Dx Diverticulitis, start
  broad spectrum antibiotics
  (pip/tazo) and IVF
• Day 2-4 Continue IV abx, cultures neg
• Day 5 Pt improved with less abd pain and
  WBC 9

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Case 1Query

• How might you query your physicians regarding a
  diagnosis of Sepsis?
• Ask question first Are you treating sepsis on
  admission based on clinical indicators of..?
• Present data first Based on the high white
  count, fever, tachycardia, which meet criteria
  for SIRS are you treating sepsis on admission?
• Use a reference Based on the NEJM article from
  Dec 2006, pt meets the criteria for diagnosis of
  sepsis.

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Case 1Query

• Based on presenting symptoms of fever,
  tachycardia, leukocytosis and intervention with
  aggressive fluids are you treating Sepsis on
  admission?

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Case 1Diagnosis

• Query declined
• Principal diagnosis documented as diverticulitis
• Impact

Pt LOS 5 days
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SepsisCase 2

• Hx 65 yo male with h/o obstructive nephropathy
  s/p
• percutaneous nephrostomy tube and
  foley catheter
• placement 2 weeks prior presents with
  
• fever/chills/diaphoresis/decreased
  urine output
• PE Ill appearing T 95, HR 75, RR 22
• suprapubic tenderness
• Labs WBC 12,000 10 bands, U/A wbc, bacteria,
  
• blood
• CT bladder wall thickening

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Case 2Management

• Day 1 Start broad spectrum abx for UTI
• Day 2-4 Urine/blood cultures-coag neg
  staph, now with complicated UTI,
  pyelonephritis, and bacteremia
• Day 5 Sepsis due to coag neg staph
• Day 6-7 Pyelonephritis, bacteremia, UTI
• Day 8 SIRS on admission with
  hypothermia

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Case 2Query

• This pt has an indwelling foley with positive
  blood/urine cultures and SIRS criteria
• Query needed to clarify the principal diagnosis
• Query made specifically asking if based on
  multiple indicators, PLEASE CLARIFY IF YOU ARE
  TREATING SEPSIS DUE TO AN INDWELLING URINARY
  CATHETER

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Case 2Diagnosis

• Physician documents sepsis secondary to
  indwelling urinary catheter
• Impact

Pt LOS 10 days
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Acute Respiratory Failure

• Failure to exchange gases in the setting of
  respiratory distress (difficulty breathing)
• Clinical values
• pO2 lt 60
• pCO2 gt 50
• pH lt 7.35 or gt 7.45
• RR gt 28
• Use of accessory muscles
• NO requirement for ventilatory support

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Acute Respiratory Failure
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Respiratory FailureCase 1

• Hx 75 yo female with h/o CAD, CHF,
• tobacco abuse presents with SOB, DOE,
  
• orthopnea despite 4L home O2
• PE In some resp distress using
• accessory muscles, RR 30, lungs with
  wheezes,
• crackles
• LABS ABG 7.34/ 59/64
• CXR Cardiomegaly unchanged, atelectasis and
• possible small bilateral pleural
  effusions

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Case 1 Management

• Day 1 Presumptive Dx CHF, COPD,
  hypoxia given IV lasix, Bi-Pap,
  aggressive nebs
• Day 2-4 Continued to do well with repeat
  ABGs improved
• sent home on baseline O2

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Case 1 Query

• In this case you have several diagnoses
• How would you query the physician?
• Go back to the ER doc and ask if he/she was
  treating pt for acute resp failure based on
  clinical indicators of ?
• Ask attending physician Are you treating acute
  respiratory failure based on symptoms, tachypnea,
  and ABG?
• Based on findings outlined, are you treating
  acute respiratory failure?
• Be sure to state that Mechanical Ventilation is
  not necessary to confirm diagnosis!

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Case 1Query

• Pt with CHF on 4L O2 at home presented to ER with
  clinical indicators of RESPIRATORY FAILURE pH
  7.34, pCO2 59, RR 30, labored breathing, low
  sats, treated with nebs, lasix, non-rebreather,
  Bi-Pap. CXR with atelectasis and possible
  bilateral effusions. Please document if this
  patient presented ON ADMISSION IN ACUTE
  RESPIRATORY FAILURE.

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Case 1Diagnosis

• Physician agreed
• Documentation clearly stated that pt was in acute
  respiratory failure on admission
• Impact

Pt LOS 5 days
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Case 2

• Hx 72 yo male with h/o DM, CAD, HTN,
• severe AS transferred at family
  request
• from outside hospital after suffering
  MI
• and Resp Failure 2 days prior.
  Extubated
• prior to transfer
• PE Severe respiratory distress, shallow breath,
  
• sluggish, RR 34, sat 88 on 6L O2,
  lungs clear,
• heart rrr with murmer
• Labs ABG 7.4/34/51

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Case 2Management

• Day 1 On arrival in severe respiratory
  distress Patient intubated emergently
• Day 2-6 Stabilize for possible AVR vs
  valvuloplasty
• Day 7 Valvuloplasty
• Day 8-11 Weaning vent
• Day 12 Transfer to Palliative Care
• Day 13 Pt expired

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Case 2Principal Diagnosis

• Pt admitted and noted to be in severe respiratory
  distress requiring vent
• Pt had suffered an acute MI 2 days prior and
  extubated before transfer
• Should principal dx be Resp Failure or AMI?

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Case 2Diagnosis

• Acute Respiratory Failure
• Impact

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Pneumonia

• Inflammation of alveoli and terminal airspaces
  due to infection
• Radiographic infiltrate in setting of following
• Tlt36 or gt38
• WBC lt 4,000 or gt 10,000 or gt 10 bands
• Macroscopically purulent sputum

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Pneumonia

• Community Acquired (CAP) Acute infection of
  pulmonary parenchyma acquired in the community
• Hospital Acquired (HAP) Pneumonia occurring gt
  48 hours or more after admission which was not
  incubating at the time of admission
• Healthcare-Associated (HCAP) Pneumonia acquired
  in other healthcare facilities

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PneumoniaCAP

• Pneumococcus most common pathogen in US
• Other pathogens include the following
• Chlamydia
• Mycoplasma
• Legionella
• Gram Negatives
• H. Influenzae
• Viruses
• Decision to admit based on risk factors for
  complications

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PneumoniaHAP

• Common pathogens include the following
• Gram negative bacilli
• P. aeruginosa
• Escherichia coli
• Klebsiella pneumoniae
• Acinetobacter species
• Gram positive cocci
• Staphylococcus aureus
• MRSA

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PneumoniaAspiration

• Pulmonary consequences resulting from abnormal
  entry of fluid, particulate exogenous substances,
  or endogenous secretions into the lower airways
• An infection caused by less virulent bacteria,
  primarily anaerobes, which are common in normal
  flora

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PneumoniaAspiration

• Predisposing factors
• Reduced consciousness
• Dysphagia from neurologic deficits
• Upper GI disorders
• Mechanical disruption of glottic closure
• Protracted vomiting, feeding gastrostomy,
  recumbent position
• CXR Lower lobes with upright position
• Upper lobes with recumbent position

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PneumoniaCase 1

• Hx 73 yo male with h/o CHF presents from
  outside ER with 2 weeks of productive cough,
  blood tinged sputum, SOB, chills
• PE No acute distress, T 99.2, RR 20
• lungs with bibasilar rales, rhonch on
  right
• Labs WBC 13.1, 89 segs, 5 bands
• CXR Infiltrate R base, bilateral pleural
  effusions

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Case 1Management

• Day 1 Start on Rocephin and Azithro for CAP
• Day 2 Change to Vanc/Clinda/Fortaz for CAP
  and HAP
• Day 3-4 Continue Abx
• Day 5 Sputum culture, M. Catarrhalis, change
  to Moxifloxicin.

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Case 1Query

• Does it matter where the pt acquired the
  pneumonia?
• Does where you get it reflect severity of
  illness?
• What matters is the kind of pneumonia pt is
  suspected of having to justify the treatment
• The question is ARE YOU TREATING THIS PT FOR A
  POSSIBLE GM NEG PNUEMONIA BASED ON CLINICAL
  SYMPTOMS OF?

NO
NO
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Case 1Diagnosis

• Physician denied query
• Impact

Pt LOS 8 days
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Case 2

• Hx 58 yo male with h/o htn, tobacco abuse
  presents with new gait imbalance and
  dysarthria. Pt falling asleep at breakfast
• PE No acute distress, vitals stable
• Alert, oriented, slow mentation, no clear
  dysarthria, gait unsteady
• Labs WBC 11, 80 segs
• CXR RLL infiltrate

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Case 2Management

• Day 1 Start azithromycin/ceftriaxone for
  pneumonia. CT, MRI negative for CVA
• Possible Myopathy
• Day 2 Mental status improved with IV
  antibiotics

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Case 2Query

• Given symptoms of lethargy, falling asleep at
  breakfast and RLL pneumonia is it appropriate to
  query for Aspiration Pneumonia?
• YES!!

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Case 2Diagnosis

• Physician agreed with aspiration pneumonia
• Impact

Pt LOS 1 day
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Co-morbid Conditions

• Diabetes episode of uncontrolled diabetes?
• Anemia acute blood loss anemia?
• Renal Failure acute renal failure?

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Summary

• We need to work together to make sure
• Most specific diagnoses documented to justify
  
• treatment
• Co-morbid conditions captured
• Queries adequately clarify what/how physicians
  
• need to document to assign severity of
  illness
• We all get credit for the great care delivered!