Hypoxic Ischemic Encephalopathy (HIE)

Hypoxic ischemic encephalopathy (HIE) Hypoxic ischemic encephalopathy (HIE) is a life threatening condition that occurs due to lack of oxygen in the birth process and results in acute and/or subacute brain injury for the neonate. HIE has a high mortality and morbidity. The brain injury can have significant residual developmental impact. However, HIE can only be used in the neonatal record. The coding terminology to capture the HIE includes, mild, moderate, severe, and not otherwise specified.

Query Example 1: Patient is a neonate w/birth weight ______grams, via ______( birth type) at _____ weeks gestation. Progress notes dated ______states ______. Please note that coding can not code the stage of the HIE. Coding terminology reflects ‘mild/moderate/severe/unspecified. Coding can not make assumptions based on the stage. The physician must clearly state mild/moderate/severe/unspecified HIE to capture this condition. Please help us to accurately capture this patient’s severity of illness and risk or mortality by providing further specificity of the HIE, i.e.

Mild HIE Moderate HIE Severe HIE Other ______Clinically undetermined

Example 2: Patient is a six year old w/aspiration pneumonia with acute respiratory distress. H&P notes prematurity with HIE. Spastic CP from neonatal hypoxia. Patient is non-verbal with contracture of extremities. Please help us to accurately capture this patient’s severity of illness and risk of mortality by providing further specificity, i.e. Anoxia brain injury Mild mental retardation Moderate mental retardation Severe mental retardation Profound mental retardation Other ______Clinically insignificant

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Respiratory Failure

Example 1: Patient is 6 years old, admitted with asthma exacerbation with respiratory distress. H&P notes hypoxia with O2 sats 85% with increased O2 requirements to 7L via nasal cannula. Albuterol MDI administered. Emergency Department noted “SOB, wheezing, cough, nasal flaring, and sternal retractions. Despite continued albuterol treatments, the patient’s respiratory distress did not improve at OSH, the patient was transferred for further care for his respiratory status.” Please help us to accurately capture this patient’s respiratory condition by providing further specificity, e.g.

Acute respiratory failure Acute respiratory distress Other ______Clinically undetermined

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Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia is a chronic lung disease that develops in the neonatal period. The lungs become damage due to prematurity, mechanical ventilation and high oxygen needs. They may continue to have lung problems thoroughout their life. Coding guidelines states that BPD always originates in the neonatal period and the code 770.7 can be used regardless of the patient’s age.

Example 1: Patient is a 3-year-old with URI due to parainfluenza with rhinovirus and enterovirus. H&P notes prematurity with chronic lung disease. Please note that chronic lung disease will lead to a code for chronic airway obstruction, which may not accurately capture this patient’s respiratory condition. Please help us to accurately capture this patient’s severity of illness and risk of mortality by providing further specificity relating to his chronic lung disease, i.e.,

BPD Bronchopulmonary dysplasia Chronic lung disease originating in the newborn period Chronic airway obstruction Post inflammatory pulmonary fibrosis Other Clinically undetermined

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Feeding Problem Example 1: Patient is a 5-week-old with feeding intolerance and poor weight gain. Please help us to accurately capture this patient’s severity of illness by providing further clarification, i.e.,

Failure to thrive Feeding problem Feeding difficulty Other Clinically undetermined

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Maternal complications Coding guidelines states that maternal complications must be clearly linked to affect the newborn. Example 1: Patient is a neonate w/birth weight 880 gms via CSection at 26 weeks with extreme prematurity, RDS with surfactant given. Apnea of prematurity, thrombocytopenia, hyperbilirubemenia. Pre-eclampsia. Please note that the maternal condition affecting the neonate must be linked. Coders can not assume that a maternal condition, i.e. maternal pre-eclampsia has affected the neonate. Please help us to accurately capture the severity of illness and risk or mortality of this neonate by providing further specificity, i.e.,

Maternal pre-eclampsia affecting neonate Thrombocytopenia due to maternal pre-eclampsia Other ______Clinically undetermined