TABLE OF CONTENTS - Pinson and...
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iii GUIDELINES 1 Coding Rules—Principal Diagnosis 2 Coding Rules—Secondary Diagnosis 9 APR-DRG Overview and Strategy 12 Cause and Effect 15 Clinical Validation 18 Coding and DRG Fundamentals 20 Complications of Care 26 Pay for Performance 30 Present on Admission (POA) 37 Risk Adjustment and HCCs 39 Signs, Symptoms, and Unspecified Codes 42 The Compliant Query 45 What Documentation Counts? 51 KEY REFERENCES 53 Accidental Puncture/Laceration 53 Acute Blood Loss Anemia 55 Acute Kidney Injury 57 Acute Tubular Necrosis 60 Body Mass Index (BMI) 62 Cardiac Arrest 64 Cardiac Arrhythmia 66 Cerebral Edema/Compression 69 Cerebrovascular Accident (CVA) 71 Chronic Kidney Disease 73 Coma 75 Cor Pulmonale 78 Diabetic Complications 81 Encephalopathy 84 Excisional Debridement 89 Functional Quadriplegia 91 Heart Failure 92 HIV/AIDS 96 Hypertension 100 Injuries & Fractures 102 Malnutrition—Adult 104 Mechanical Ventilation 109 Myocardial Ischemia 112 Neoplasms 116 Pancreatitis 119 Pancytopenia 122 Pathologic Fractures 124 Pneumonia 127 Pneumothorax 134 Poisoning & Toxic Effects 136 Pressure (Decubitus) Ulcers 138 Respiratory Failure—Acute 142 Respiratory Failure—Chronic 148 Respiratory Failure—Postprocedural 150 Sepsis 152 Sepsis-3 (2016) 157 Shock 159 SIRS—Non-infectious 161 Transbronchial Biopsy 163 Transient Ischemic Attack (TIA) 165 PEDIATRICS 167 Pediatric Guidelines 168 Asthma 171 Cerebral Palsy 173 Coma—Pediatrics 174 Cystic Fibrosis 175 Intellectual Disability 177 Malnutrition—Pediatrics 179 Respiratory Abnormalities—Neonates 181 Sepsis—Neonatal 184 Sepsis—Pediatric 186 COMORBID CONDITIONS 189 Comorbid Conditions—HCC 195 Comorbid Conditions—APRDRG 197 Comorbid Conditions 199 BMI Table 209 DRG TIPS 211 MS-DRG TABLE 255 TABLE OF CONTENTS
Transcript of TABLE OF CONTENTS - Pinson and...
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GUIDELINES � � � � � � � � � � � � � � � � � � � 1Coding Rules—Principal Diagnosis� � � � � � � � 2Coding Rules—Secondary Diagnosis � � � � � � 9APR-DRG Overview and Strategy � � � � � � � � � 12Cause and Effect � � � � � � � � � � � � � � � � � � � � � 15Clinical Validation � � � � � � � � � � � � � � � � � � � �18Coding and DRG Fundamentals � � � � � � � � � �20Complications of Care � � � � � � � � � � � � � � � � � 26Pay for Performance � � � � � � � � � � � � � � � � � �30Present on Admission (POA) � � � � � � � � � � � � 37Risk Adjustment and HCCs� � � � � � � � � � � � � � 39Signs, Symptoms, and Unspecified Codes � � 42The Compliant Query� � � � � � � � � � � � � � � � � � 45What Documentation Counts?� � � � � � � � � � � 51
KEY REFERENCES � � � � � � � � � � � � 53Accidental Puncture/Laceration� � � � � � � � � � 53Acute Blood Loss Anemia� � � � � � � � � � � � � � � 55Acute Kidney Injury � � � � � � � � � � � � � � � � � � � 57Acute Tubular Necrosis� � � � � � � � � � � � � � � � �60Body Mass Index (BMI) � � � � � � � � � � � � � � � � 62Cardiac Arrest � � � � � � � � � � � � � � � � � � � � � � �64Cardiac Arrhythmia � � � � � � � � � � � � � � � � � � �66Cerebral Edema/Compression � � � � � � � � � � � 69Cerebrovascular Accident (CVA) � � � � � � � � � � 71Chronic Kidney Disease � � � � � � � � � � � � � � � � 73Coma� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 75Cor Pulmonale� � � � � � � � � � � � � � � � � � � � � � �78Diabetic Complications � � � � � � � � � � � � � � � � 81Encephalopathy � � � � � � � � � � � � � � � � � � � � �84Excisional Debridement� � � � � � � � � � � � � � � �89Functional Quadriplegia � � � � � � � � � � � � � � � 91Heart Failure � � � � � � � � � � � � � � � � � � � � � � � � 92HIV/AIDS � � � � � � � � � � � � � � � � � � � � � � � � � � �96Hypertension � � � � � � � � � � � � � � � � � � � � � �100Injuries & Fractures � � � � � � � � � � � � � � � � � � 102Malnutrition—Adult � � � � � � � � � � � � � � � � 104Mechanical Ventilation � � � � � � � � � � � � � � � 109Myocardial Ischemia � � � � � � � � � � � � � � � � � 112
Neoplasms � � � � � � � � � � � � � � � � � � � � � � � � 116Pancreatitis � � � � � � � � � � � � � � � � � � � � � � � � 119Pancytopenia � � � � � � � � � � � � � � � � � � � � � � 122Pathologic Fractures � � � � � � � � � � � � � � � � � 124Pneumonia � � � � � � � � � � � � � � � � � � � � � � � � 127Pneumothorax � � � � � � � � � � � � � � � � � � � � � 134Poisoning & Toxic Effects � � � � � � � � � � � � � � 136Pressure (Decubitus) Ulcers � � � � � � � � � � � �138Respiratory Failure—Acute � � � � � � � � � � � 142Respiratory Failure—Chronic � � � � � � � � � �148Respiratory Failure—Postprocedural � � � � 150Sepsis � � � � � � � � � � � � � � � � � � � � � � � � � � � � 152Sepsis-3 (2016) � � � � � � � � � � � � � � � � � � � � � 157Shock � � � � � � � � � � � � � � � � � � � � � � � � � � � � 159SIRS—Non-infectious � � � � � � � � � � � � � � � 161Transbronchial Biopsy � � � � � � � � � � � � � � � � 163Transient Ischemic Attack (TIA) � � � � � � � � � 165PEDIATRICS � � � � � � � � � � � � � � � � � � � � � 167Pediatric Guidelines � � � � � � � � � � � � � � � � � 168Asthma � � � � � � � � � � � � � � � � � � � � � � � � � � � 171Cerebral Palsy � � � � � � � � � � � � � � � � � � � � � � 173Coma—Pediatrics � � � � � � � � � � � � � � � � � � 174Cystic Fibrosis � � � � � � � � � � � � � � � � � � � � � � 175Intellectual Disability � � � � � � � � � � � � � � � � 177Malnutrition—Pediatrics � � � � � � � � � � � � � 179Respiratory Abnormalities—Neonates� � � 181Sepsis—Neonatal � � � � � � � � � � � � � � � � � � 184Sepsis—Pediatric � � � � � � � � � � � � � � � � � � � 186
COMORBID CONDITIONS � � � 189Comorbid Conditions—HCC � � � � � � � � � � � 195Comorbid Conditions—APRDRG� � � � � � � � 197Comorbid Conditions� � � � � � � � � � � � � � � � � 199BMI Table � � � � � � � � � � � � � � � � � � � � � � � � � 209
DRG TIPS � � � � � � � � � � � � � � � � � � � � 211
MS-DRG TABLE � � � � � � � � � � � � � � 255
TABLE OF CONTENTS
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WHAT DOCUMENTATION COUNTS?
Any Healthcare “Provider.” Documentation in the medical record by any healthcare provider is appropriate for code assignment.
The term “provider” includes physicians and “any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis” such as consultants, residents, nurse practitioners, physi-cian assistants, etc. “Legally accountable” includes being licensed by the state and credentialed by the hospital, which may exclude first year interns if they are not licensed yet.
Exceptions: For BMI, depth of non-pressure chronic ulcers, pres-sure ulcer stage, Glasgow Coma Score, and NIH stroke scale codes, code assignment may be based on medical record documentation from non-providers. Nurses often document this information, BMIs are often based on height and weight entered by a non-provider, and EMTs or paramedics may document a GCS. A pertinent associated diagnosis must be documented by a provider (OCG section I.B.14).
Attending vs. Consulting Physician. Code assignment may be based on other physician documentation (i.e., consultants, residents, anesthe-siologists, etc.) as long as there is no conflicting information. Medi-cal record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting phy-sicians, is appropriate for the basis of code assignment.
A physician query is not necessary if a physician involved in the care and treatment of the patient has documented a diagnosis and there is no conflicting documentation from another physician. The attending physician does not have to confirm a diagnosis by another provider.
If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis.
It is important to distinguish between “conflicting” and “more spe-cific.” For example, pneumonia vs. bronchitis is conflicting and would require a query; pneumonia vs. aspiration pneumonia is more specific and would not.
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WHAT DOCUMENTATION COUNTS?
Code From the Entire Record. According to the Official Coding Guidelines: “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”
When documentation in the medical record is clear and consistent, coders may assign and report codes. Documentation is not limited to the face sheet, discharge summary, progress notes, history and phys-ical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding (Coding Clinic, First Quarter 2014, p. 11).
References• Coding Clinic, First Quarter 2014, p. 11.
• CMS MLN Matters SE1121.
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ACUTE KIDNEY INJURY
DEFINITION
Sudden reduction of kidney function, usually within a period of hours or days. Causes are classified as:
• Pre-renal: dehydration is the most common cause• Renal: such as acute tubular necrosis (ATN), acute papillary
necrosis, glomerulonephritis• Post-renal: obstruction of ureters or bladder
DIAGNOSTIC CRITERIA
The current consensus-based criteria for acute kidney injury (AKI) is the National Kidney Foundation (NKF) KDIGO conference defi-nition.
KDIGO defines AKI (applicable to both adult or pediatric patients) as any of the following:
• Increase Creatinine ≥ 0.3 mg/dl from a measured baseline in 48 hours or less; or
• Increase in Creatinine level to ≥ 1.5x baseline (historical or measured), which is known or presumed to have occurred within the prior 7 days; or
• Urine output <0.5 ml/kg/hr for 6 hours
When baseline Creatinine is unknown, KDIGO advises: “The low-est SCr [Creatinine level] obtained during a hospitalization is usually equal to or greater than the baseline. This SCr should be used to diag-nose (and stage) AKI.”
TREATMENT
IV fluid resuscitation/hydration, serial creatinine levels, nephrology consult.
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ACUTE KIDNEY INJURYACUTE KIDNEY INJURY
CODING AND DOCUMENTATION CHALLENGES
The terms acute renal/kidney failure and acute kidney injury are syn-onymous and assigned to code N17.9 which is a CC and often the principal diagnosis. AKI is the authoritative professional acronym for acute kidney injury pursuant to the KDIGO consensus definition.
Guidelines for applying the AKI criteria:
• The ≥ 0.3 criterion can only be applied prospectively when the baseline has been measured within the preceding 48 hours. It requires two separate measurements within 48 hours.
EXAMPLE Patient admitted with creatinine of 1.2 has an increase to 1.6 within 36 hours following IVP.
• The 1.5 times baseline criterion can be used prospectively and retrospectively with broad interpretation of the baseline level which may be one from 6 months or even 1 year previously. The baseline cannot be higher than the lowest currently measured level.
EXAMPLE (1) Creatinine on admission is 2.0 and decreases to 1.0 with IV fluids. (2) Patient with no known CKD is admitted with dehydration and a creatinine of 1.8 with a previous creatinine of 1.0 six months ago. (3) Patient with CKD and a stated baseline of 1.8 is admitted with a creatinine of 2.5 which decreases to 1.6 with IV fluids. 1.6 is the true baseline and 2.5 is > 1.5x this level.
• The urine output criterion of < 0.5 ml/kg/hr for 6 hours is based on weight; for example, a total output of < 200 ccs over 6 hours for a patient who weighs 150 lbs = 0.49 ml/kg/hr.
The diagnosis of AKI depends on what the normal baseline for an individual patient is, not the reference range for the test (often misun-derstood as “normal range”) on the lab report.
Reference range is a population-based statistic that is typically two standard deviations from the mean (average) test results in patients
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ACUTE KIDNEY INJURYACUTE KIDNEY INJURY
not known to have a condition related to the test. It does not necessar-ily indicate what is normal for an individual patient.
The AKI creatinine criteria are applied to the baseline without regard to the reference range.
EXAMPLES (1) Baseline = 0.4 md/dl with increase to 0.8 md/dl in 36 hrs meets both > 0.3 and 1.5x criteria (0.8 is 2x baseline of 0.4 = a substantial 50% loss of kidney function for this indivdual). (2) Creatinine on admission = 1.0 with decrease to 0.5 (baseline) over two days meets 1.5x criterion (1.0 is 2x baseline of 0.5).
The BUN should not be used as an indicator of AKI since it can be ele-vated for many other reasons. When dehydration occurs without renal failure, the BUN will be elevated but the creatinine will remain at or near baseline.
AKI should be coded first when it is due to dehydration even if the only treatment is IV hydration.
References• Kidney Disease: Improving Global Outcomes (KDIGO) Acute
Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Inter., Suppl. 2012; 2: 1–138
• Coding Clinic Third Quarter 2002, p. 2.
