clinical and coding conundrums - acdis · clinical indicators for functional quadriplegia signs and...

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Michael D. Teague, MD, SFHM, CCDSAssociate Medical Director Hospital Medicine Service and CDI Physician Advisor

Our Lady of the Lake Regional Medical CenterBaton Rouge, LA

Clinical and Coding Conundrums

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Learning Objectives

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

– Identify clinical clues and indicators for complex medical conditions

– Investigate these lesser‐reported diagnoses to ensure they are supported in the record

– Explore clinical and coding insights for:

• Functional quadriplegia

• MI

• Complex pneumonia

• Malnutrition

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Functional Quadriplegia (MCC)

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Paralytic Syndromes

• Hemiplegia (CC): Complete paralysis of one side of body

• Hemiparesis (CC): Incomplete paralysis of one side of body

• Quadriplegia (MCC): Complete paralysis of all 4 limbs

• Quadraparesis (MCC): Incomplete paralysis of all 4 limbs—“seequadriplegia”

• Diplegia (CC): Paralysis (or partial) of upper limbs

• Paraplegia (CC): Paralysis (or partial) of lower limbs

• Monoplegia (not CC/MCC): Paralysis of lower limb

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Coding Clinic Insight for Functional Quadriplegia Fourth Quarter 2008

• A new code was created in 2008 for functional quadriplegia

– Not a true paresis

– Inability to move due to another condition

• Dementia (most common cause), rheumatoid arthritis, contractures

– Immobile due to severe frailty or physical disability

– Functionally the same as a paralyzed person


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Functional Quadriplegia (MCC): By the Book

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Clinical Indicators for Functional Quadriplegia

Signs and symptomsFunctional quadriplegia

supported

Onset Years

Functional status (same as paralyzed patient)• Total care/complete immobility

• Maximum assistance required

• ADL‐dependent

Ambulatory or able to transfer No

Bedbound Yes

Can get into wheelchair?Yes—but requires total assistance (like spinal cord injury–induced quadriplegia)

Supporting evidence from physical exam Contractures, pressure ulcers, confusion

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Differentiating Quadriplegia by Etiology

Functional Neurologic

Parkinson’s disease Traumatic spinal cord injury

Alzheimer’s dementia Metastatic disease to spine

Rheumatoid arthritis Cervical epidural abscess

Severe contractures Spinal cord infarction


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What About Impact on Quality Scores?

• Functional quadriplegia (MCC)

– Risk adjustment

• Steady current of CDI

• Affects physicians and hospitals

– Affects SOI and ROM

• “Expected” mortality, readmissions, complications, PSI

• Receive credit for challenging patients

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Does Functional Quadriplegia Exclude PSI?

Postoperative Resp Failure(PSI 11)

Pressure Ulcer (PSI 03)

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What About Post‐Intensive Care Syndrome?

• Acute onset after severe illness requiring ICU stay– Was functional quadriplegia POA?

• CC• Affects SOI but not ROM• Critical illness myopathy (G72.81) (CC)

– Includes• Acute necrotizing myopathy• Acute quadriplegic myopathy• Intensive care (ICU) myopathy• Myopathy of critical illness

• Critical illness polyneuropathy (G62.81) (CC)– Includes

• Acute motor neuropathy


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What Is Not Functional Quadriplegia?

• Post‐intensive care syndrome (G62.81 and G72.81) (CCs)

• Spastic quadriplegic cerebral palsy G80.0 (MCC)

• Muscle weakness, generalized (M62.81) (not CC/MCC)

• Quadriplegia G82.5 (spinal cord disease) (MCC)

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Query Example

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Query Example


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Functional Quadriplegia

• NO

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Functional Quadriplegia Takeaways

• Complete immobility

• Unable to move without assistance

• Advanced dementia etc.

• MCC with impact on risk and quality

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Complex Pneumonia File TM, et al. Prognosis of Community Acquired Pneumonia in Adults. In: JG Bartlett (Ed.), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)

• Mortality 37% for patients admitted to ICU– Immunocompromised

– Aspiration

– Chronically ill … bring CC/MCC to hospital

• < 10% of 17,000 Medicare patients with CAP had pathogen identified

• Empiric treatment– MD treatment protocols based

on host and location where acquired


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Clinical Indicators for PneumoniaBartlett JG. Diagnostic Approach to CAP in Adults. In: SB Calderwood (Ed.), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)File TM. Epidemiology, Pathogenesis, Microbiology, and Diagnosis of Hospital‐Acquired and Ventilator‐Associated Pneumonia in Adults. In JG Bartlett (Ed.), UpToDate, Waltham, MA. (Accessed on February 4, 2017.)

Symptoms Signs CXR and/or CT Diagnostic Tests

Fever/chills Temp > 100.4 or < 96.8 Lobar consolidationLeukocytosis or leukopenia

Cough Rigors Interstitial infiltratesSputum gram stain and culture

Shortness of breath Diaphoresis Cavitation Blood cultures

PleurisyCrackles, rhonchi,pleural rub Pleural effusion

Legionella and pneumococcalurinary antigen

Sputum productionTachypnea > 20

EmpyemaPCR studies for organisms including influenza

Nausea/vomiting Tachycardia Thoracentesis

DiarrheaHypoxemia Exudative pleural

fluid

Confusion Lethargic Pleural fluid cultures

Hemoptysis Impaired swallowing

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Clinical and Coding Disconnect

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“Can You Specify the Type of Pneumonia?”

MD query responses

• “Nothing grew on cultures”

• “How am I supposed to know?”

• “Unknown”

• “I’m not the attending”

• “Patient was at risk for HCAP, which was treated”

• “See culture result already in chart”

Information to provide to MDs

• + cultures are not required for documenting certain types of pneumonia

• Document suspected etiology by clinical setting and host

• Translate “What were you worried about?” into your notes

• “treating for, evidence of, suspected …”

• Must link culture, PCR, Gram stain results to the pneumonia


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Pneumonia: Connecting Clinical and Coding Worlds

Simple pneumonia Complex pneumonia (specific, Gram neg, asp)

Host(patient characteristics)

Often healthy at baseline• Lower risk• Few comorbidities

Chronically ill• Immunocompromised (e.g.,

on steroids)• Chronic organ failure (e.g.,

COPD)• Aspiration (e.g., dementia)

Patient setting(Where has the patient been? What bacteria has the patient picked up?)

Little contact with healthcare system

• NH resident/LTAC/rehab• Hospitalized < 90 days ago

for > 2 days• Dialysis• Wound care

Antibiotics prescribed• Limited to 1 or 2• Oral route often adequate• Outpatient treatment

• Often 3 or more• Intravenous route• Inpatient treatment

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High‐Risk Hosts for Complex PneumoniaMD Intuition: Do Not Under‐Treat These Patients (or RIP)

Immunocompromised patients Chronically ill patients

HIV/AIDS Diabetes mellitus

Immunosuppressive treatment• Steroids• Chemotherapy• TNF inhibitors

Organ failure• Heart: Chronic systolic heart failure• Kidney: CKD IV• Liver: Cirrhosis• Brain: Dementia• Lung: COPD/bronchiectasis

Solid or hematologic organ transplant recipient

Wounds

Malnutrition Advanced age

Alcoholism

Cancer

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Which Pneumonia Is Complex?

Complex pneumonia examples

• Certain specific organisms

– MRSA pneumonia J15.211

– Pneumonia d/t Klebsiella J15.0

– Varicella pneumonia B01.2

– Pneumonitis d/t solids and liquids J69.0

– Pneumonia d/t other aerobic Gram‐negative bacteria J15.6

DRG 177–179


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Supporting the Diagnosis of Complex Pneumonia

Aspiration pneumonia• Need all three

1. High‐risk host

• Diabetes mellitus, etc.

2. High‐risk setting

• Resides in nursing home, etc.

3. IV antibiotics used to treat Gram‐negative pneumonia

• Ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, etc.

Gram‐negative Pneumonia• IV antibiotics used to treat aspiration

pneumonia

– Piperacillin/tazobactam, metronidazole, clindamycin, ampicillin/sulbactam, meropenem, etc.

• Also need one of these

1. Risk factors for aspiration

• Stroke, dementia, ALS

• Radiation to neck, obstruction, PEG in place

2. Specific treatment for aspiration

• Speech therapy

• Aspiration precautions

3. Abnormal swallowing study revealing aspiration

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Pneumonia by the Numbers

Simple Pneumonia (DRG 195) w/o CC/MCC

Complex Pneumonia (DRG 179, Resp Infections and Inflammation) w/o CC/MCC

Complex Pneumonia(DRG 179, Resp Infections and Inflammation) w/o CC/MCC

How documented CAP, HCAP, HAP, atypical,nosocomial

Gram neg pneumonia, pneumonia d/t specified organism

Aspiration pneumonia, asp. pneumonitis

Principal diagnosis Pneumonia, unspec. organism J18.9

Pneumonia d/t … Gram neg bacteria J15.6

Pneumonitis d/t inhal. food/vomit J69.0

Other diagnoses Essential HTN I10 Essential HTN I10 Essential HTN I10

DM2 w/neuropathy E11.40

DM2 w/neuropathy E11.40 DM2 w/neuropathy E11.40

Emphysema J439 Emphysema J439 Emphysema J439

Hypoxemia R09.02 Hypoxemia R09.02 Hypoxemia R09.02

SOI/ROM 2/1 2/1 2/2

Relative weight 0.7208 0.9325 0.9325

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Pneumonia by the Numbers with MCC

Simple Pneumonia (DRG 193) w/MCC

Complex Pneumonia (DRG 177, Resp Infections and Inflammation) w/MCC

Complex Pneumonia(DRG 177, Resp Infections and Inflammation) w/MCC

How documented CAP, HCAP, HAP, atypical,nosocomial

Gram neg pneumonia, pneumonia d/t specified organism

Aspiration pneumonia, asp. pneumonitis

Principal diagnosis Pneumonia, unspec. organism J18.9

Pneumonia d/t … Gram neg bacteria J15.6

Pneumonitis d/t inhal. food/vomit J69.0

Other diagnoses Essential HTN I10 Essential HTN I10 Essential HTN I10

DM2 w/neuropathy E11.40

DM2 w/neuropathy E11.40 DM2 w/neuropathy E11.40

Emphysema J439 Emphysema J439 Emphysema J439

Acute resp fail J96.01 Acute resp fail J96.01 Acute resp fail J96.01

SOI/ROM 3/3 3/3 3/3

Relative weight 1.386 1.8672 1.8672

Geometric mean LOS 4.8 days 6 days 6 days


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Pneumonia Query Examples

The patient admitted 9/6 after failed treatment for pneumonia at the nursing home. Patient’s history includes COPD and history of CVA with dysphagia. An abnormal swallow was noted per speech eval. The patient was treated with 7 days of IV Zosyn.

Can the patient’s type of pneumonia be further specified as:

• Gram‐negative pneumonia (excluding Haemophilus influenzae)

• Streptococcal pneumoniae pneumonia

• Aspiration pneumonia

• Other ____________

• Unable to provide any further information

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Pneumonia Query Examples

The patient was noted per H&P to have healthcare‐associated pneumonia. He has pancreatic cancer and is on chemotherapy. He was treated with Vancomycin and Zosyn and discharged on Avelox.

Can the probable type of pneumonia being addressed be further specified as:

• Gram‐negative pneumonia (excluding Haemophilus influenzae)

• Streptococcal pneumoniae pneumonia

• Other ____________

• Unable to provide any further information

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Query Response for Pneumonia


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Complex Pneumonia Takeaways

• Pneumonia should be specified by etiology if organism is known

• + cultures are not required for documenting certain types of pneumonia

• Document suspected etiology by clinical setting and host

• DRG and quality impact

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Malnutrition E40–E46 (CC or MCC)

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MalnutritionFingar KR (Truven Health Analytics), Weiss AJ (Truven Health Analytics), Barrett ML (M.L. Barrett, Inc.), Elixhauser A (AHRQ), Steiner CA (AHRQ), Guenter P (American Society for Parenteral and Enteral Nutrition), Brown MH (Baxter International, Inc.). All‐Cause Readmissions Following Hospital Stays for Patients With Malnutrition, 2013. HCUP Statistical Brief #218. December 2016. Agency for Healthcare Research and Quality, Rockville, MD.

• Any disorder of nutrition; it may be due to unbalanced or insufficient diet or to defective assimilation or utilization of foods

• Malnutrition has been associated with longer and more costly hospital stays

• Greater likelihood of comorbidity and death among hospitalized patients

• In 2013, the all‐cause 30‐day readmission rate for patients with malnutrition was 23.0 per 100, compared with 14.9 per 100 for patients without malnutrition

• Acute hospitalization in older patients suggest that up to 71% are malnourished – Can occur at any BMI


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“Physician Criteria” for Malnutrition DxRitchie C et al. Geriatric Nutrition: Nutritional Issues in Older Adults. In: KE Schmader et al. (Ed.), UpToDate, Waltham, MA. (Accessed on January 19, 2016.)Bruera E et al. Palliative Care: Assessment and Management of Anorexia and Cachexia. In: RM Arnold et al. (Ed.), UpToDate, Waltham, MA. (Accessed on January 19, 2016.)

• No universally accepted approach to diagnosis

– Somebody else (RN, RD, etc.) responsible/better

– Subjective and non‐intuitive criteria that vary with clinical setting

– Incorrectly considered “inherent” to many acute or advanced diseases

– Poor pharmacotherapy options fraught with adverse effects

• Prealbumin, albumin, and other lab data

– Acute‐phase proteins and indicative of inflammation/injury

– Studies show limited correlation with malnutrition

– Does not respond to feeding interventions

• History and physical exam

– Cachexia/weight loss/BMI < 19/emaciation

– Anorexia

– “Failure to thrive”

• Clinician concern evident through orders/plan

– Nutrition consultation

– Calorie counts

– Double portions, supplements

– Appetite stimulants

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ASPEN Criteria: Gold Standard for the Diagnosis of MalnutritionWhite JV et al. JPEN J Parenter Enteral Nutr. 2012;36:275–283.

Criteria for the diagnosis of malnutrition have been recommended in a consensus statement from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN)

• Apply criteria based on clinical situation– Acute illness or injury

– Chronic illness (>3 months per National Center for Health Statistics)

– Impaired social/environmental circumstances (starvation)

• Two or more of the following six characteristics:– Insufficient energy intake

– Weight loss

– Loss of muscle mass

– Loss of subcutaneous fat

– Localized or generalized fluid accumulation that may mask weight loss

– Diminished functional status as measured by hand grip strength

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RD Progress Note Using ASPEN Criteria

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Differentiating and Documenting Malnutrition (E40–E46)

• Extremely uncommon in USA– E40 Kwashiorkor (MCC): Children in famine conditions;

protuberant abdomen. – E41 Nutritional marasmus (MCC): Children in famine;

diarrhea; withering/wasting– E42 Marasmic kwashiorkor (MCC): Characteristics of both– E45 Retarded development following protein‐calorie malnutrition

(CC)

• Common and underdiagnosed in USA– E43 Unspecified severe protein‐calorie malnutrition (MCC)– E44 Protein‐calorie malnutrition of moderate and mild degree (CC)

• E44.1 Moderate (CC)• E44.2 Mild (CC)

– E46 Unspecified protein‐calorie malnutrition (CC)

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Office of Inspector General (DHHS)Recommended Reading

ICD‐9 code 261 and 262 (ICD‐10 E41 and E43)

ICD‐9 code 260 (ICD‐10 E40)

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Kwashiorkor (E40)—BEWARE

• Form of severe protein‐calorie malnutrition

• Affects children during famines … extremely rare in U.S.

• Medicare paid $711 million to U.S. hospitals for claims including E40

• OIG reviewing these claims

• Hospitals refunding overpayments!


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Nutritional Marasmus (E41)—BEWARE

• From OIG review: “Nutritional marasmus is a form of serious protein‐energy malnutrition that is caused by a deficiency in calories and energy and is found primarily in children”

• Medicare (coverage provided to patients > age 65)

• Stay tuned …

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Severe Malnutrition Impact

• Severe malnutrition E43– MCC– HCC (CC 21)– Excludes PSI 14,

Postoperative Wound Dehiscence Rate

• Considered an immunocompromised state by AHRQ

– Risk adjustment impact• Mortality• Readmissions• Complications• Length of stay

– Accurately reflect SOI/ROM

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SOI/ROM = 3


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SOI/ROM = 4

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Severe Malnutrition Takeaways

• “Superfood” diagnosis– DRG and quality impact

• Treatment needed (minimum not defined)

• Clinicians need assistance– Lab tests unreliable

– ASPEN criteria challenging

– Partner with RDs

• CMS final rule, 2015– “RDs best qualified to assess nutritional status”

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Myocardial Infarction


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Myocardial Infarction CriteriaThygesen K et al. Third Universal Definition of Myocardial Infarction. Circulation. 2012;126:2020–2035.

• Rise and/or fall in cardiac biomarkers (preferably troponin > 99% percentile)

• One of the following:– Typical symptoms of

ischemia

– New EKG changes:Q wave, STT changes, LBBB

– Imaging evidence: New loss of viable myocardium or wall motion abnormality on echo

– Intracoronary thrombus by angiography or autopsy

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Classification of MI by CauseReeder GS et al. Criteria for the Diagnosis of Acute Myocardial Infarction. In: CP Cannon et al. (Ed.), UpToDate, Waltham, MA. (Accessed on January 25, 2016.)

MI type Definition Clinical frequency Affects code selection?

Type 1• STEMI• NSTEMI

Coronary plaque disruption with thrombosis

Common No

Type 2 0xygen imbalance (sepsis, anemia, etc.)

Common No

Type 3Sudden cardiac death—no biomarkers

Less commonNo

Type 4a Related to PCI Uncommon No

Type 4bRelated to stent thrombosis

Less common No

Type 5 Related to CABG Uncommon No

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EKG Appearance for MI


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Coronary Artery Plaque and MI Type

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Anatomy of an Initial STEMI Goldberger AL et al. Electrocardiogram in the Diagnosis of Myocardial Ischemia and Infarction. In: F Verheugt et al. (Ed.), UpToDate, Waltham, MA. (Accessed on January 25, 2016.)

Location of MI EKG leads affected Coronary vessel (s) ICD‐10 codes

Anterior wall V2–V4 Left main, leftanterior descending (LAD), other

I21.01, I21.02, I21.09

Septal wall V1–V2 LAD, septal branch I21.29

Lateral wall 1, aVL, V5, V6 Circumflex, obtuse marginal (OM)

I21.21, I21.29

Inferior wall II, III, aVF Right coronary artery (RCA), other

I21.11, I21.19

Posterior wall V1–V4, V7–9V3R–V6R

Circumflex, RCA I21.29

Unspecified MI (guideline STEMI)

Consider query Pending query or unknown

I21.3

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Clinical Differentiation of ACS

Symptoms ofischemia

New EKG changes

Troponin (or CK‐MB) rise and/or fall

New loss of myocardiumor wall motion abn

Acutetreatment

STEMI(I21.1 etc.)

Usually ST elevation, new LBBB, new Q waves

Yes Yes Angioplasty,stent, or CABG+ medical

NSTEMI(I21.4)

Usually None to STT changes

Yes Yes Medical+revasc. if high risk

Unstable angina (I20.0)

Usually None to STT changes

No Possible Medical +revasc. if high risk

Old MI (> 28 days)(I25.2)

Unusual Old Q waves No No, thin walls, fails to contract

Medical


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Documentation That Does NOT Code to an MI

• “Acute myocardial injury” I24.8 (not in setting of trauma)– AHA Coding Clinic, First Quarter 1992: “It is inappropriate to extrapolate ‘acute

myocardial injury’ to infarction; in fact, the term acute myocardial injury is most commonly synonymous with acute myocardial ischemia”

– Troponin‐elevated “leak” and/or ischemic EKG changes

• “Demand ischemia” I24.8– Ischemia due to other diseases: Sepsis, severe anemia, etc.

– Troponin‐elevated “leak”

– Blood flow through coronary arteries is considered adequate

– Treatment directed at relieving increased demand

• “Acute coronary syndrome” (e.g., I24.89)– Unstable CAD or unstable angina

– May have troponin elevation or ischemic EKG changes

– Codes vary depending on native, graft, transplanted, atherosclerosis, etc.

• “Troponemia” R79.89– Other specified abnormal findings on blood chemistry

– Query needed for clarity

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Patient Presents to the ED With Chest Pain

• 68‐year‐old male smoker, DM2 with neuropathy and dyslipidemia. EMS transports due to CP, dizziness, SOB. O2 sat 82% with resp distress. CTA of chest showed bilateral PE.

– Troponin peaks at 1.3 ng/ml (< 0.3 is normal)

– EKG shown

• What should clinicians document?

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Physician DocumentationWhich One Is Correct?

Cardiologist final progress note

1. Demand ischemia due to PEs. Continue treatment with ASA and Apixaban. F/u 2 weeks.

2. Hyperlipidemia—begin statin.

3. DM2 per HMS.

4. Smoker—counselled.

5. HTN—continue carvedilol.

Hospitalist DC summary

1. Acute bilateral PE

2. Acute resp failure

3. Type 2 MI

4. DM2 with neuropathy

5. Dyslipidemia

6. Smoker

7. HTN

8. Anxiety

9. Obesity


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Points of Contention Regarding MI

• Not all CV societies or physicians embrace the universal definition of MI– “Clinically relevant MI”

• Demand ischemia (CC) vs. Type 1 or 2 MI (MCC)

• MI = “occlusion” and/or “revascularization”

• Implantable defibrillators < 40 days from “MI” diagnosis

• Opinion and experience—multiple correct answers

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MI Query Examples After surgery patient began having chest pain with EKG changes. Patient's troponins were elevated and he was taken to the cath lab where a thrombus and with freshly occluded saphenous vein graft was addressed with aspiration of thrombus and angioplasty. Per discharge summary, patient with acute coronary syndrome.

After study, can the patient's condition be further specified as:

• Acute myocardial infarction

• CAD with unstable angina

• Acute coronary syndrome only

• Other __________________

• Unable to be determined

____________________________________________________________________________________________

Patient admitted and treated for sepsis. During workup, patient found to have malignant sigmoid mass. Laparoscopic sigmoid resection performed. Documentation in the discharge summary refers to "a mild bump in his troponin to 0.3 which was thought to be Type 2, secondary to sepsis syndrome.” Troponins noted to be 0.32, 0.36, and 0.33. EKG from 11/17 shows ST&T wave abnormality, consider inferior ischemia.

Can the patient's elevated troponin and EKG changes be further specified as:

• Type II NSTEMI due to sepsis

• Demand ischemia

• Elevated troponins not otherwise specified

• Unable to determine

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MI Takeaways

• Diagnosis of MI is not challenging

• Opinions vary

• Use CDI physician advisor to seek consensus

• Multiple correct answers


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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 at the front of the program guide.


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clinical and coding conundrums - acdis · clinical indicators for functional quadriplegia signs and...

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