Documenting to Reduce Denials Timothy N

8/17/2016

www.BrundageMedicalGroup.com

Documenting to Reduce Denials Timothy N. Brundage, MD, CCDS Certified Clinical Documentation Specialist

 Principal Diagnosis ◦ The condition after study to be chiefly responsible for occasioning the admission to the hospital

 Secondary Diagnosis ◦ Conditions that consume one of the following  Clinical Evaluation  Therapeutic Treatment  Diagnostic procedures/testing  Extended length of stay (LOS)  Increased nursing care and/or monitoring

 High quality coding based language ◦ Supported by descriptive language  What “bought the bed” ◦ Learn to speak to your physicians ◦ Barriers to safe discharge – why can the patient not go home?  Action words ◦ Acute ◦ Worsening ◦ Decompensated ◦ Exacerbated  Physical examination ◦ Support acuity and severity of the diagnosis  Inability to tolerate PO ◦ Documented vomiting

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 Do NOT document versus… versus… versus…  Differential diagnosis as a vertical of Uncertain Diagnoses ◦ Possible diagnosis ◦ Probable diagnosis ◦ Likely diagnosis ◦ Suspected diagnosis

 “history of” ◦ Belongs in the PMHx ◦ A/P: Prefer documentation of Chronic diagnosis

 If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

◦ Auditor denial example  “probable sepsis” documented multiple times  hospitalist changed  UTI was documented on the DC summary

 “Audit Candy”

 Work with hospitalists to clarify and specify subspecialist documentation without conflicting it ◦ troponin leak, type 2 event, NSTEMI

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 Used by auditors to deny medical necessity ◦ Same note day after day without update or

 Can be used correctly if proof read and updated  Can be used to bring radiography and pathology reports into the clinical record

 Necessitates that all outpatient diagnoses and treatments are pertinent to the inpatient admission for 72 hours prior to admission  The 3 day rule - inpatient diagnosis supported by ◦ EMS ◦ ER evaluation ◦ PCP note ◦ Lower level of care documentation

 Respiratory failure diagnosed by the hospitalist ◦ ER and EMS data ◦ Protected a $10,000 MCC

 On July 1, 2015, CMS released the updates to the “Two Midnight” rule.  CMS emphasis on physician’s medical judgment  Physician or other practitioner must decide whether to admit as inpatient or treat as outpatient  CMS observed a higher frequency of extended observation services  Inpatient admissions will generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supports that reasonable expectation  All treatment decisions for beneficiaries were based on the medical judgment of physicians  CMS sought to respect the judgment of physicians

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 Patients hospitalized in Observation services have three options at the 48 hour mark (after 2 midnights) 1. Discharge 2. Patient remains OBS only if there is a delay in care, facility delay in testing, physician delay in consult, etc. 3. If the attending physician continues to opine that his/her patient requires continued hospitalization then the patient is changed to inpatient status by the attending physician and he/she will document in the chart his/her medical judgment as to why his/her patient requires continued hospitalization

Symptom Diagnosis Altered Mental Status Coma Altered Mental Status Encephalopathy Altered Mental Status Sepsis Altered Mental Status Shock

???

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 SIRS criteria  Altered Mental Status  Significant edema or positive fluid balance  Hyperglycemia in the absence of diabetes  CRP more than two SD above the normal value  Procalcitonin more than 2 SD above the normal value  UPDATED Hypotension (SBP < 90 mmHg or SBP decrease > 40 mmHg)  Hypoxemia (PaO2/FiO2 < 300)  Acute oliguria (urine output < 0.5mL/kg/hr for 2 hours)  Creatinine increase >0.5mg/dL  INR >1.5  Ileus  FEB 22, 2016 Thromobocytopenia (PLT < 100,000)  Hyperbilirubinemia (> 4 mg/dL)  Hyperlactatemia (> 1 mmol/L  Decreased capillary refill or mottling

 Severe Sepsis ◦ sepsis w/ evidence of end-organ damage ◦ Lactic Acid > 2.0  Septic shock ◦ sepsis refractoryUPDATED to fluid resuscitation (requiring pressors.) ◦ Lactic Acid > 4.0 FEB 22, 2016

 New Terms and Definitions  Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.  Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection. ◦ A SOFA score ≥2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.

http://jama.jamanetwork.com/article.aspx?articleid=2492875

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From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

 Sepsis syndrome does not code to sepsis per coding clinic

 Sepsis resolving, does not code to sepsis per coding clinic

 Sepsis-2 is supported by the ACCP  Sepsis-3 is supported by the SCCM  Need consistent documentation by the providers that does not conflict ◦ Rule in or rule out sepsis by the date of discharge

 Auditor – “We know that is not sepsis”

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 KDIGO: increase in the patient’s serum creatinine of 0.3 mg/dl or more over their normal baseline level

 Link  Dehydration  Azotemia

 Do Not document  Acute Renal Insufficiency

 Acute Renal Failure is a Comorbidity/Complication (CC)  ATN is a Major Comorbidity/Complication (MCC)

 KDIGO published in 2012 ◦ Cr change of 0.3 mg/dl without mention of rehydration

 AKI changed from an MCC to a CC in 2010

 AKIN criteria published in 2007 ◦ Cr change of 0.3 mg/dl after hydration

 RIFLE criteria published in 2004 ◦ Cr up 2 times for injury ◦ Cr up 3 times for failure

 Question:  Please reconsider the advice previously published in Coding Clinic, First Quarter 2014, page 25, stating that the coder cannot assume either diastolic or systolic failure or a combination of both, based on documentation of heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Would it be appropriate to code diastolic or systolic heart failure when the provider documents HFpEF or HFrEF?  Answer:  Based on additional information received from the American College of Cardiology (ACC), the Editorial Advisory Board for Coding Clinic for ICD- 10-CM/PCS has reconsidered previously published advice about coding heart failure with preserved ejection fraction (HFpEF), and heart failure with reduced ejection fraction (HFrEF). HFpEF may also be referred to as heart failure with preserved systolic function, and this condition may also be referred to as diastolic heart failure. HFrEF may also be called heart failure with low ejection fraction, or heart failure with reduced systolic function, or other similar terms meaning systolic heart failure. These terms HFpEF and HFrEF are more contemporary terms that are being more frequently used, and can be further described as acute or chronic.  Therefore, when the provider has documented HFpEF, HFrEF, or other similar terms noted above, the coder may interpret these as "diastolic heart failure" or "systolic heart failure," respectively, or a combination of both if indicated, and assign the appropriate ICD-10-CM codes. 

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 Acute or Chronic  Heart failure ◦ Acute on Chronic ◦ not dysfunction ◦ Exacerbation ◦ Decompensated

 Systolic (EF < 40%) ◦ HFrEF  Diastolic (normal EF) ◦ HFpEF  Both ◦ Simply writing “EF=____%” is not sufficient

 Failed outpatient therapy  Severity of history ◦ Worsening, decompensated ◦ Hypoxia noted ◦ Dyspnea, fragmented sentences  Quality of physical examination ◦ Retractions, respiratory distress  Abnormal findings ◦ BNP ◦ chest X-ray  Documentation of aggressive intervention ◦ Frequency of IV diuretics

Framingham Criteria for CHF exacerbation diagnosis

Major Minor Acute Pulmonary Edema Ankle Edema Cardiomegaly on CXR Dyspnea on exertion (DOE) Hepatojugular reflex Hepatomegaly JVD Nocturnal cough PND or orthopnea Pleural effusion Rales Tachycardia Third Heart Sound (S3)

*Heart failure exacerbation is diagnosed when two major criteria or one major and two minor criteria are met Reference: http://www.aafp.org/

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 Acuity ◦ Acute, Chronic or Acute on Chronic  Type ◦ Hypoxic or hypercapneic

 Criteria for Acute respiratory failure includes 2 out of 3:  pO2 < 60mmHg  pCO2 > 50mmHg with pH <7.35  Respiratory Distress – document this in the Physical Exam

 Chronic Respiratory Failure ◦ Continuous home Oxygen or normal pH w/ high CO2

 History ◦ Failed outpatient treatment ◦ High frequency of Nebs outpatient ◦ Worsening dyspnea  Physical Exam findings – should demonstrate resp distress ◦ Retractions, tripoding ◦ Accessory muscle use ◦ Fragmented sentences, dyspnea ◦ BIPAP is always supportive of resp distress  Room Air ABG ◦ Extremely important to support hypoxia and/or hypercapnia  3 Day rule ◦ Key to supporting admission to the hospital in a patient who improved via therapy in the ER

 COPD with acute exacerbation ◦ COPD is a chronic condition ◦ Consider acute exacerbation  Steroids & nebs

 Evaluate for: ◦ Acute Respiratory Failure  Increased oxygen requirement and respiratory distress ◦ Chronic Respiratory Failure  Continuous home oxygen

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Documentation to support Medical Necessity of Admission

 3 nebulizer treatments in the ER  Pulse ox < 89%  ABG with PaO2 < 60  Respiratory distress as noted by accessory muscle usage  Increased work of breathing as noted by fragmented sentences or hunched over posture

 Feedback from an insurance company medical director ◦ Biased view that is not evidence based ◦ Criteria are actually strict enough to support acute respiratory failure ◦ She basically told us she won’t approve COPD adm unless ARF

 ASPEN ≥ 2 criteria ◦ Insufficient Energy Intake ◦ Weight Loss ◦ Loss of Muscle Mass ◦ Loss of Subcutaneous Fat ◦ Localized or generalized fluid accumulation that may sometimes mask weight loss ◦ Diminished functional status as measured by hand grip strength

◦ Notice that ALBUMIN and PREALBUMIN are NOT criteria for diagnosis

 Physical Exam findings again critical ◦ Muscle mass ◦ Subcutaneous Fat ◦ Fluid accumulation that may sometimes mask weight loss ◦ Grip strength

 BMI is not an ASPEN criteria ◦ WHO recommends a BMI < 16

 ASPEN - authors from the University of Tennessee  WHO criteria written to include third world countries

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 Acute Blood Loss Anemia ◦ Anemia linked to a hemorrhagic process  GI bleed  Fracture  Any procedure or surgery ◦ This should be documented separately from it’s cause.

 Post-Procedure Anemia: ◦ Drop in hemoglobin/hematocrit due to CABG/C-Section ◦ Acute blood loss anemia due to hip fracture

 Post-Procedure Anemia: ◦ Expected drop in hemoglobin/hematocrit due to CABG/C- Section  Not integral to the procedure  Some CABG surgeries do not create anemia  Prolongs LOS  Acute blood loss anemia due to vaginal delivery  Physician: Monitor one more night and check Hgb in the AM

 UHC Louisiana denied because only 2 units transfused ◦ NOT evidence based ◦ ACP recommends transfusing ONE unit at a time for Hgb < 7

 Do NOT Document ◦ Altered mental status ◦ Mental status changes ◦ Confusion

 Encephalopathy ◦ Definition: Global cerebral dysfunction in the absence of structural brain disease

◦ Underlying etiology: -Toxic/Metabolic -Anoxic -Sepsis -Hypertensive

Reference Chen, R, Young, GB. Metabolic Encephalopathies. In: Bolton, CF, Young, GB, (Eds), Baillere's Clinical Neurology, Balliere Tindall, London 1996. p.577. 33

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 No consensus definition  Not integral to sepsis ◦ Sepsis-2 and Sepsis-3 have AMS as a criterion  Sepsis-2 has 21 other criteria  Sepsis-3 has 6 other criteria  Glasgow Coma Scale ◦ Physician or nursing notes  AMS caused by a medical diagnosis is encephalopathy

 AMS caused by a psychological manifestation is delirium ◦ American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) ◦ F05 – Delirium due to known psychological condition  Acute brain syndrome  Acute confusional state  Delirium superimposed on dementia  Sundowning http://www.acphospitalist.org/archives/2015/01/coding.htm

Due to lack of glucose, oxygen or metabolic cofactors Hypoglycemia Ischemia Hypoxia Hypercapnia Vitamin deficiencies Due to peripheral organ dysfunction Hepatic encephalopathy Uremic and dialysis encephalopathies

Butterworth RF. Metabolic Encephalopathies. In: Siegel GJ, Agranoff BW, Albers RW, et al., editors. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition. Philadelphia: Lippincott-Raven; 1999. Chapter 38. Available from: http://www.ncbi.nlm.nih.gov/books/NBK20383/

 Type 1 or Type 2 or due to underlying condition

 With hypo or hyperglycemia ◦ With or without coma ◦ With or without DKA

 Diabetes audit protection ◦ Nausea, vomiting and inability to tolerate PO ◦ Dehydration ◦ Hypokalemia

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 According to the Mayo Clinic ◦ A diabetic coma is a life-threatening diabetic complication that causes unconsciousness ◦ Unconscious codes to coma in ICD-10 ◦ Definition of UNCONSCIOUS  not knowing or perceiving : not aware  free from self-awareness

 Diabetic Coma ◦ Altered Mental Status should make the physician consider the diagnosis of Diabetic Coma in the uncontrolled diabetic with hyper or hypoglycemia

Behavior Response Score Eye Opening Spontaneously 4 To Speech 3 To Pain 2 NoResponse 1 Best Verbal Response Oriented x 3 5

Confused 4 Inappropriate Words 3 Incomprehensible Words 2 No Response 1 Best Motor Response Obeys Commands 6

Moves to pain 5 Withdraws frompain 4 Abnormal flexion (decorticate) 3 Abnormal extension (decerebrate) 2 No Response 1

 Should be clarified ◦ With or without coma

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 Simple Pneumonia when a Principal Dx ◦ Community Acquired Pneumonia ◦ Healthcare Associated Pneumonia (HCAP) ◦ Nosocomial Pneumonia

 Probable gram negative pneumonia, Rx Zosyn  Probable MRSA pneumonia, Rx Vancomycin

 Suspected Aspiration pneumonia ◦ Clindamycin or Flagyl Rx

 Pneumonia can be diagnosed clinically or radiographically  Supporting documentation ◦ X-ray ◦ Physical examination  Crackles  Egophony  Tactile fremitus  Bronchial breath sounds ◦ Antibiotic choice and duration  Consistency among and between providers ◦ Hospitalist, Pulmonologist and ID

 The term acute myocardial infarction (MI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Under these conditions any one of the following criteria meets the diagnosis for MI. ◦ Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following:  Symptoms of ischemia  New or presumed new significant ST-segment-Twave (ST-T) changes or new left bundle branch block (LBBB)  Development of pathological Q waves on ECG  Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality  Identification of an intracoronary thrombus by angiography or autopsy ◦ Cardiac death prior to biomarkers ◦ PCI related AMI is troponin 5x URL ◦ Stent thrombosis related AMI ◦ CABG related AMI is troponin 10x URL

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 AMI Type 1: spontaneous MI from CAD  AMI Type 2: AMI due to ischemia imbalance ◦ Sepsis/Septic Shock ◦ Critically Ill patient  AMI Type 4a: AMI related to PCI – troponin > 5 times the 99th percentile of URL  AMI Type 5: AMI related to CABG

3rd Universal Definition of AMI

 Not Clinically Relevant ◦ CKD stage __

 Demand Ischemia ◦ Does not code to an AMI ◦ I24.8 Other forms of acute ischemic heart disease CC

 STEMI or NSTEMI

 Consistent documentation among providers ◦ Cardiologist, Hospitalist, ARNP  Clarification on the discharge summary ◦ NSTEMI ruled in or ruled out ◦ Demand ischemia ruled in or out ◦ Troponin elevation not clinically relevant related to CKD  Troponin should NOT rise/fall

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 Morbid Obesity BMI > 40

◦ Physician must ascribe clinical relevance to the BMI

◦ Cannot be taken from a calculated BMI  BMI > 40 Morbid obesity  BMI < 19 Underweight malnourished

 ALWAYS clinically relevant ◦ Even though insurance companies don’t want to agree ◦ Secondary diagnosis per coding guideline  Prolongs the LOS  Increases the nursing care or monitoring

 Coding clinic supports this

 Physicians should document the diagnosis so the BMI can be coded as a CC

 Action words ◦ Worsening ◦ Redness ◦ Tenderness  Failed outpatient therapy ◦ Keflex ◦ Doxycycline ◦ Bactrim

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 Action words ◦ Worsening ◦ Tenderness  Failed outpatient therapy ◦ Pain medication escalating doses  Laboratory findings (evidence based???) ◦ Lipase 3 x URL  Radiographic findings ◦ X-ray findings – calcifications ◦ CT findings – calcifications plus acute edema and/or inflammation

 New literature to support full regular diet without NPO ◦ Potential new denial opportunity for insurance providers

 Action words ◦ Worsening ◦ Exacerbated ◦ Excruciating  Failed outpatient efforts ◦ Escalating doses of PO medications without improvement ◦ Office injections ◦ Visits to PCP or ER  Physical exam findings supporting pain and debility  IV pain medications 6 times per day ◦ Dilaudid ◦ Morphine ◦ Toradol

 Ill appearing child ◦ Action words  Worsening  Exacerbated  Acute ◦ Failed outpatient therapy  Physical examination findings c/w an ill child ◦ Distress ◦ Febrile mother and/or child

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