D1 PPT 9 2019 ACDIS Outpatient CDI PPT Sharme Brodie Final 9_2019 OPCDI Symp_CDI... · there are...

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Clinically Speaking: Conditions Treated in the Outpatient Setting

Sharme Brodie, RN, CCDSCDI Educational InstructorHCPro/Simplify ComplianceMiddleton, MA

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify common conditions treated in the outpatient setting

– Describe common signs and symptoms seen in these conditions

– Identify and discuss laboratory testing used to diagnose or monitor these conditions

– Define documentation needed for appropriate code assignment

2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Types of Diabetes: Causes Vary by Type

• DM 1 (E10.‐): Patient’s pancreas produces little or no insulin—unknown cause.

• DM 2 (E11.‐): Patient’s body doesn’t produce enough insulin or doesn’t use it properly. Hallmark insulin resistance—unknown cause of insulin resistance.

• Latent autoimmune/DM 1.5 (E13.‐): Characteristics of both DM 1 and 2.

• Secondary DM: Caused by another condition.

• Gestational DM (O24.410): Hormones produced during pregnancy make cells more resistant to insulin.

• Coding will depend on type of diabetes and whether there is an assumed relationship between the DM and complication; if not, physician will need to document a cause and effect relationship using appropriate verbiage such as “due to.”

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Chronic Complications of Diabetes

• Cardiovascular disease: Diabetes increases risk of CAD, heart attack, stroke.

• Neuropathy: Nerve damage, tingling and numbness, burning or pain caused by damage to the blood vessels related to excess sugar. Can lead to diabetic foot ulcers.

• Nephropathy: Diabetes can cause damage to glomeruli, which could lead to kidney failure or end‐stage kidney disease. May require dialysis or kidney transplant.

• Retinopathy: Damage to blood vessels of the retina; can lead to blindness, cataracts, and glaucoma.

• Skin conditions (including bacterial or fungal).

• Hearing problems (more common in people with DM).


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Diabetes Mellitus: Type 1

• Signs and symptoms:– Increased thirst/dry mouth

– Frequent urination/incontinence

– Sweating

– Fast heart rate

– Nausea and vomiting

– Hunger/unintended weight loss

– Fatigue/weakness

– Blurred vision

– Mood change/irritability

– Delayed healing

– Periodontal disease

– Erectile dysfunction

– Fungal infection

Tests:• Blood glucose levels• A1C (glycated hemoglobin) indicates

average blood sugar level for past 2–3 months

• Urine glucose levels• Fasting plasma glucose (FPG)• Random plasma glucose (RPG)• Glycate hemoglobin• Glucose tolerance test (GTT)

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Diabetes

Treatment:• Diet

– Fiber‐rich foods– Low in fat and calories—no more than

30% fat (good fats: avocados, nuts, canola, olive and peanut oils)

– Heart‐healthy fish high in omega‐3 fatty acids

– Sugar‐free foods—simple carbohydrates– Healthy carbohydrates—fruits,

vegetables, whole grains– Legumes—beans and peas– Decreased alcohol consumption– Insulin (on next slide)


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Diabetes (cont.)

Insulin Type Brand Name Onset Peak Duration

Rapid‐acting HumalogNovologApidra

10–30 mins 30 mins–3 hours

3–5 hours

Short‐acting Regular (R) 30 mins–1 hour

2–5 hours Up to 12 hours

Intermediate‐acting

NPH (N) 1.5–4 hours 4–12 hours Up to 24 hours

Long‐acting LantusLevemir

0.8–4 hours Minimal peak Up to 24 hours

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Obesity (E66.0) vs. Morbid Obesity (E66.01)

Obesity:

• Occurs when a person’s body mass index (BMI) is 30 or greater.

• According to the National Institutes of Health (NIH), a person is considered “obese” when weighing 20% or more than his or her ideal body weight. At that point, the person's weight poses a health risk.

• Obesity becomes “morbid” or “clinically severe” when it significantly increases the risk of one or more obesity‐related health conditions or serious diseases (comorbidities).

• Coding will depend on the physician’s documentation of obesity versus morbid obesity along with the corresponding appropriate BMI.


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Obesity/Morbid Obesity (cont.)

Morbid (severe) obesity can be defined as:

BMI 40+ OR

BMI 35+ and at least 2 weight‐related comorbid conditions (diabetes, hypertension, etc.)

Must document relationship of weight to comorbid conditions

Use cause‐and‐effect language if relationship is not an assumed relationship (i.e., due to, related to)

• Weight may come from muscle, bone, fat, and/or body water

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• Health problems related to overweight/obesity/morbid obesity

– Type 2 DM

– High blood pressure (HTN)

– Heart disease

– Stroke

– Cancer

– Sleep apnea

– Osteoarthritis

– Fatty liver disease

– Kidney disease


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• Conditions causing obesity/morbid obesity– Hypothyroidism

– Insulin resistance

– Polycystic ovary syndrome

– Cushing syndrome

• Behavioral factors, eating habits, activity level

• Stress/anxiety

• Lack of sleep

• Studies have shown there could be a genetic component

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• Can be caused by certain medications:

– Tricyclic antidepressants/lithium/selective serotonin reuptake inhibitors

– Antiseizure/anticonvulsive

– Steroids—oral/inhaled

– Insulin

– Antihistamines

– Beta‐adrenergic blockers

– Hormone therapy or contraceptives

– Antipsychotics


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Chronic Obstructive Pulmonary Disease (J44.‐)

• Chronic inflammatory lung diseases that obstruct airflow from the lungs

• Emphysema (J43.‐)

– Reduces the surface area of the lungs, which leads to a decrease in the amount of oxygen in the bloodstream

• Chronic bronchitis (J20.9)

– By inflammation of the lining of the bronchial tubes

• No cure—treatment addresses symptoms

• Common etiologies

– Exposure to irritating gases or particulate matter, often from cigarette smoke

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Chronic Obstructive Pulmonary Disease (cont.)

Signs and symptoms:

• Shortness of breath

• Tachypnea

• Orthopnea

• Chest tightness

• Wheezing

• Cyanosis—lips & fingernails

• Frequent respiratory infections

• Lack of energy

• Swelling

• Dyspnea

• Altered mental status or decreased level of consciousness

• Cough

• Increased sputum production

• Unintentional weight loss


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Chronic Obstructive Pulmonary Disease (cont.)

Tests:

• Lung (pulmonary) function test

• Spirometry

• CXR/CT scan

• Laboratory test

– Arterial blood gases (ABGs)

– Alpha‐1‐antitrypsin (Aat) deficiency

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Bronchitis (J20.9)

Signs and symptoms:

• Production of mucus

• Coughing up thick mucus


• Fatigue

• Slight fever and chills

• Chest discomfort

Tests:

• Physical assessment to identify abnormal lung sounds

• CXR

• Sputum cultures

• Pulmonary function test

• Spirometer


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Bronchitis (cont.)

Treatment:

• Cough medicine

• Allergy medication

• Bronchodilators

• Non‐steroidal anti‐inflammatory drugs (NSAIDs)

• Narcotics

• Analgesics

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Emphysema

Tests:

• CXR

• CT scan

• ABGs

• Lung function test (spirometry)

Treatment:

• Bronchodilators

• Supplemental oxygen

• Corticosteroids

• Antibiotics

• Pulmonary rehabilitation

• Nutritional therapy


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Asthma (J45.‐)

• Characterized by inflammation of the bronchial tubes with increased production of sticky secretions inside the tubes

• Triggers—sinusitis, extreme emotional responses, physical exercise, and medications like aspirin, beta‐blockers, or NSAIDs

• Other factors like dietary insufficiencies in vitamins C and E, and omega‐3 fatty acids

• Bronchial asthma is the most common type of asthma

• Coding of asthma is based on the severity of the asthma and whether there are any complications such as an exacerbation or status asthmaticus

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Asthma (cont.)

• There are numerous types of asthma

– Exercise‐induced bronchoconstriction (EIB): J45.990

– Allergic (triggered by allergens): J45.901

– Non‐allergic (does not involve immune response): J45.‐

– Occupational: J45.901

– Adult onset: J45.‐


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Asthma (cont.)

Signs and symptoms:

• Coughing

• Wheezing


• Difficulty speaking

• Chest tightness, pain, or pressure

• Retractions: tightened neck and chest muscles

• Feeling of anxiety or panic

• Fatigue

• Paleness

• Tachypnea

• Cyanosis (of lips and fingernails)

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Asthma (cont.)

Tests:

• Physical exam—lung sounds

• Spirometry

• Peak flow

• Oxygen saturation

• Methacholine challenge

• Allergy testing

• Exhaled nitric oxide test

• CXR/sinus x‐rays

• Sputum eosinophils

• GERD or reflux disease testing


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Type/Code Symptoms (Day) Symptoms (Night) Frequency of Attacks

Mild intermittent asthma (J45.2x)

Mild symptoms < 2x a week

Nighttime symptoms < 2x a month

Few asthma attacks

Mild persistent asthma (J45.3x)

Symptoms 3–6x a week

Nighttime symptoms 3–4x a month

Asthma attacks may affect activities

Moderate persistent asthma (J45.4x)

Symptoms every day Nighttime symptoms 5 or more times a month

Asthma attacks affect activities

Severe persistent asthma (J45.5x)

Ongoing symptoms Ongoing symptoms Frequency limits activities

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Hypertension (I10.‐)

Complications/comorbidities of hypertension:

• Stroke—weakened blood vessels to the brain

• Hypertensive encephalopathy—confusion, HA, convulsions

• Heart failure—damage to vessels causing strain on the heart

• Acute MI—coronary arteries become narrowed causing higher risk for clot

• Hypertensive cardiomyopathy—structural cardiac disorder

• Hypertensive nephropathy—damages arteries around kidneys, resulting in decreased blood to kidneys

• CKD—due to effects of HTN on kidneys

Coding requires the type of HTN along with any manifestations related to the HTN. ICD‐10 uses combination codes for HTN and related manifestations.


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Hypertension (cont.)

Common comorbidities/complications:

• Diabetes mellitus—too much insulin causes increase in blood pressure

• Obesity—increase in weight causes increase in work on the heart

• Hyperlipidemia—cause unknown

• Anxiety/depression—caused by heart disease related to hypertension

• Sexual problems—damage to arteries, erectile dysfunction

• Bone loss/osteoporosis—HTN causes lose of calcium, which reduces bone mass

• Hypertensive retinopathy—damage to retina

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Hypertension (cont.)

Treatment:

• Diet

• Thiazide diuretics

• Angiotensin‐converting enzyme (ACE) inhibitors

• Angiotensin II receptor blockers (ARBs)

• Calcium channel blockers

• Alpha‐blockers

• Alpha‐beta blockers

• Beta‐blockers

• Aldosterone antagonists

• Renin inhibitors

• Vasodilators

• Central‐acting agents

• Dietary supplements


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Cardiomyopathy (I42.‐)

There are many types of cardiomyopathy, with different causes:

• Hypertrophic cardiomyopathy (HCM) (I42.1):

– A condition in which the heart muscle becomes thick, making it harder for blood to leave the heart. This type of cardiomyopathy is usually inherited.

• Restrictive cardiomyopathy (RCM) (I42.5):

– A condition in which the walls of the heart are rigid, but not thickened, not allowing the heart to stretch and fill properly (least common type).

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Cardiomyopathy (cont.)

• Dilated or congestive cardiomyopathy (I42.0):

– A condition in which the heart becomes weak and the chambers get large.

– Characterized by ventricular dilation, contractile dysfunction, and symptoms of CHF. As a result, the heart cannot pump enough blood out to the body.

– Inherited in one‐third of cases.

– May result from alcohol, heavy metals, CAD, cocaine use, and viral infections.

Coding requires the documentation of the type of cardiomyopathy.


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Signs and symptoms:

• Fatigue

• Swelling

• SOB

• Arrhythmia

• Chest pain

• Heart murmurs

• Fainting/dizziness

Tests:

• BNP—blood test

• EKG

• Echocardiogram (ECHO)

• Transesophageal echo (TEE)

• Stress test

• Cardiac catherization

• Coronary angiography

• Myocardial biopsy

• Genetic testing

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Treatment: (depends on type)

• Medication

• Iatrogenic/implanted pacemakers– For slow heart rates

• Defibrillators– For patients with fatal heart rhythms

• Ventricular assist devices (VADs)– For severe heart failure

• Ablation– For recurring dysrhythmias that cannot be eliminated with medication or mechanical

cardioversion

• Heart transplant


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Crohn’s Disease (K50.‐)

• Type of inflammatory bowel disease (IBD)• Appears to be an autoimmune disease• Can affect any part of the gastrointestinal tract (usual onset 15–30 years of age)• Tobacco users are 2x more likely to develop than non‐smokers• Complications include:

– Ulcers– Fistulas– Anal fissure– Malnutrition– Colon cancer

ICD‐10 uses multiple combination codes that represent the diagnosis of Crohn’s disease and associated complications. Physicians must use cause‐and‐effect language if association is not assumed in code set.

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Crohn’s Disease (cont.)

Signs and symptoms:

• Abdominal pain

• Steatorrhea

• Fecal incontinence

• Rectal tenesmus

• Fever

• Weight loss

• Cobblestone‐like appearance

Tests:

• Traditional colonoscopy with biopsy

• Capsule endoscopy

• CT scan/MRI

• Upper GI series or contrast radiography of upper GI tract

• Blood work

• Erythrocyte sedimentation rate (ESR)


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Crohn’s Disease (cont.)

Treatment:• Medications—corticosteroids, oral 5‐aminosalicylates, immune system

suppressors, antibiotics, antidiarrheals, pain meds, vitamin D, calcium, iron, B12 shots

• Dietary changes—low residue or low fiber

• Enteral/parenteral nutrition

• Reduction of stress

• Moderate activity and exercise

• Acupuncture (to treat inflammation)

• Surgery

– For complications such as partial or complete obstructions, fistulas, or abscesses

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Ulcerative Colitis (K51.‐)

• Long‐term condition that results in inflammation and ulcers of colon and rectum

• Cause is unknown

• Symptoms usually come on slowly and range from mild to severe, typically intermittent with periods of no symptoms between flares

• Complications can include megacolon, inflammation of eye, joints, or liver, and colon cancer

• Frequency: Up to 5 per 1,000 people


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Ulcerative Colitis (cont.)

Signs and symptoms:

• Rectal bleeding

• Bloody diarrhea

• Abdominal pain and cramping

Tests:

• Blood test for anemia

• Stool sample

• Colonoscopy

• Flexible sigmoidoscopy

• X‐ray

• CT/MRI

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Ulcerative Colitis (cont.)

Treatment:

• Dietary changes

• High‐calorie or lactose‐free diet

• Antidiarrheal drugs

• Iron, herbal, and nutritional supplements

• Probiotics

• Fish oil/turmeric (curcumin is a compound found in spice turmeric)

• Pain relievers

• Anti‐inflammatory drugs

– Aminosalicylates

– Mesalazine

– Sulfasalazine

– Corticosteroids

• Immunosuppressants

• Proctocolectomy


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Chronic Kidney Disease (CKD) or Chronic Kidney Failure (N18.‐)

• Disease of the kidneys leading to renal failure; can last for years or be lifelong

• Can’t be cured; usually gets worse slowly with symptoms not appearing to kidneys are badly damaged

• Classified in stages 1–5 based on the level of kidney function

• CKD can lead to end‐stage kidney failure, which can be fatal without artificial filtering (dialysis) or kidney transplant

• Other complications include gout, anemia, heart disease, hyperkalemia

• Coding is based on the stage of CKD and any related complications

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Stages of Chronic Kidney Disease (N18.1–N18.6)

Stage Kidney function eGFR

Stage 1 Kidney damage with normal kidney function

90 or higher

Stage 2 Mild loss of kidney function 89–60

Stage 3a Mild to moderate loss of kidney function

59–45

Stage 3b Moderate to severe loss of kidney function

44–30

Stage 4 Severe loss of kidney function 29–15

Stage 5, end‐stage renal disease (ESRD)

Kidney failure and need for transplant or dialysis

Less than 15


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Chronic Kidney Disease (cont.)

Signs and symptoms:

• Nausea/vomiting/loss of appetite

• Fatigue/weakness

• Sleep problems

• Changes in urination

• Decreased mental sharpness

• Chest pain

• SOB

• Hypertension (HTN)

• Swelling of feet/ankles

• Persistent itching

• Muscle twitches/cramps

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Tests:

• Blood test—creatinine, urea, eGFR

• Urine test with microscopic exam—acidity pH, protein, WBC, glucose, bilirubin, RBC, cast, crystals

• ACR—albumin to creatine ratio

• Ultrasound to assess kidney structure and size

• Kidney biopsy


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Treatment:

• Antihypertensive medications—ACE inhibitors, angiotensin II receptor blockers

• Medication to lower cholesterol levels (statins), treat anemia (hormone erythropoietin), relieve swelling (diuretics)

• Low‐salt/low‐protein diet

• Medications to protect bones—calcium, vitamin D

• Dialysis (end stage)

• Kidney transplant (end stage)

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Cancer

• Disease in which abnormal cells divide uncontrollably and destroy body tissue

• Can develop anywhere in the body with potential to spread and invade other areas of the body (metastasis)

• Coding varies based on location (including overlapping), behavior of cancer, and gender of patient

• Symptoms vary depending on type—over 100 types

• Histology

– Benign

– In situ

– Malignant

– Uncertain behavior


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Cancer (cont.)

Signs and symptoms:

• The presence of an unusual lump

• Changes in a mole on the skin

• Unexplained rash

• A persistent cough or hoarseness

• A change in bowel habits

• Abnormal bleeding

• Difficulty passing urine

• Unexplained weight loss, pain, fatigue, night sweats

• A persistent sore or ulcer

• Difficulty in swallowing or continuing indigestion

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TNM Cancer Staging

• The TNM system is one of the most widely used staging systems to describe neoplasms. The TNM system is based on:

– T: The extent of the tumor

– N: The extent of spread to the lymph nodes

– M: The presence of distant metastasis

– A number is added to each letter to indicate the size or extent of the primary tumor and the extent of cancer spread


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TNM Cancer Staging (cont.)

Primary Tumor (T)

TX Primary tumor cannot be evaluated

T0 No evidence of primary tumor

Tis Carcinoma in situ (CIS; abnormal cells are present but have not spread to neighboring tissue; although not cancer, CIS may become cancer and is sometimes called pre‐invasive cancer)

T1, T2, T3, T4 Size and/or extent of the primary tumor

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TNM Cancer Staging (cont.)

Regional Lymph Nodes

NX Regional lymph nodes cannot be evaluated

N0 No regional lymph node involvement

N1, N2, N3 Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)

Distant Metastases (M)

MX Distant metastasis cannot be evaluated

M0 No distant metastasis

M1 Distant metastasis is present


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National Cancer Institute Cancer Staging

For many cancers, TNM combinations correspond to one of five stages. Criteria for stages differ between types of cancer.

Stage Definition

Stage 0 Carcinoma in situ

Stage I, Stage II, and Stage III Higher numbers indicate more extensive disease: larger tumor size and/or spread of the cancer beyond the organ in which it first developed to nearby lymph nodes and/or organs adjacent to the location of the primary tumor

Stage IV The cancer has spread to another organ(s)

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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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