Fixing What Ails You: Problem Diagnoses Jill O’Brien, M.D., CHCQM Physician Advisor to CDI/Coding Medical Director of Case Management The Miriam Hospital

Background Quality and Epidemiology data analysis require precise use of clinical terms Establishing clinical indicators for certain diagnoses will standardize the use of these clinical terms in your institution Help us all to communicate in the same language

What are Problem Diagnoses? Those conditions that commonly have inconsistent, imprecise, incomplete, or conflicting documentation in the chart. Review Clinical Validation Queries and Audits Review Retrospective Queries for “Conflicting Documentation”

Why are they a “Problem” There isn’t one acceptable set of criteria for these conditions Often on a continuum or spectrum of disease Coding Terminology does not match Clinical Terms LIPs are struggling just as much as your departments

A Solution System-wide clinical indicators for certain diagnoses Engage content experts, physician advisor, CDI/Coding Review Literature Medical Executive Committee approval Expand education to improve consistent documentation Support appeals process

ICD-10-CM Official Guidelines “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis” CODING CLINIC (4th quarter 2016 issue) “If the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis, that is a clinical issue, but it is not a coding error”

The Heart of the Problem…

Ischemia leads to… …Infarction This is why providers feel comfortable writing Type 2 Demand NSTEMI d/u demand ischemia It makes sense pathophysiologically …Infarction Thygesen, K, Alpert, J, et. al. Third Universal Definition of Myocardial Infarction. Circulation. 2012 Jan 3;125(1):e2-e220.

NOT ALL Troponin elevation is Myocardial Infarction Myocardial injury = trop elevation Myocardial infarction = trop rise and fall with evidence of ischemia You can have myocardial injury NOT due to ischemia Thygesen, K, Alpert, J, et. al. Third Universal Definition of Myocardial Infarction. Circulation. 2012 Jan 3;125(1):e2-e220.

May or May not be due to ischemia Troponin Elevation: May or May not be due to ischemia You can see there is overlap This makes it difficult for providers There is clinical judgment that needs to be made We do not have a good term for “myocardial injury” or “elevated troponins not due to ischemia” Thygesen, K, Alpert, J, et. al. Third Universal Definition of Myocardial Infarction. Circulation. 2012 Jan 3;125(1):e2-e220.

“Non-ischemic Myocardial Injury with Necrosis” Middle aged individual with no clinical history of CAD who is admitted with a serious infection. An elevated troponin level is often noted in such individuals in the absence of ischemic symptoms or ECG changes, and the clinical question is often posed “Does this patient have an acute myocardial infarction that requires urgent therapeutic intervention?”. We suggest that such patients do not have ACS, but rather a myocardial injury secondary to various factors associated with serious illness, that is, non-ischemic Myocardial injury with necrosis. We need this Term in Coding World Alpert, J, Thygesen, K et al. Diagnostic and Therapeutic Implications of Type 2 Myocardial Infarction: Review and Commentary. American Journal of Med. 2014 Feb 2; 127(105-108)

When to use “Demand Ischemia” Potential Clinical Scenario: Increased heart rate for “demand reason” with ischemic changes on EKG but NO troponin elevation This term in confusing Troponin elevation from ischemia indicates myocardial injury and if rise/fall of troponins with clinical ischemia should use term “Myocardial Infarction” I’m telling staff if you are not using this term for a clinical scenario such as outlined above don’t use the terminology at all.

Coding Clinic 2017 Coding Clinic First Quarter 2017 page 44

Clinical Indicators for Demand NSTEMI

What about VBP? 30 day mortality for AMI Thrombolytics within 30 min of arrival PCI within 90 min of arrival Will it be assumed to be hospital-acquired? Require Primary Diagnosis of AMI Demand NSTEMI is rarely a primary diagnosis POA status important AMI is not a listed HAC https://www.qualitymeasures.ahrq.gov/summaries/summary/49187/acute-myocardial-infarction-ami-hospital-30day-allcause-riskstandardized-mortality-rate-rsmr-following-ami-hospitalization

It Takes Wind Out of Us…

Respiratory Failure Variable interpretation amongst providers “anyone on oxygen”  “only ventilated patients” “This isn’t a Clinical Term, it’s only for Billing” No Standardized Definition in Literature Can rapidly change and correct

Important Educational Points Supplemental oxygen Acute Respiratory Failure Chronic Supplemental oxygen need likely Chronic Hypoxic Respiratory Failure Talk with your providers about present practice; help everyone reach a consensus about what respiratory failure looks like

PSI 11: Post Operative Respiratory Failure Inclusion Criteria: Secondary Diagnosis Post-Operative Respiratory Failure Re-intubation one or more days following surgery Mechanical ventilation >96hours after surgery Exclusion Criteria: Principal Diagnosis Acute Respiratory Failure Acute Respiratory Failure POA Chronic Respiratory Failure Neuromuscular Disorders Degenerative Neurological Disorders (including Dementia) Lung Cancer/Lung Transplant Procedures Facial/ENT/Laryngeal DRGs Esophageal Resections MDC 4 and 5 – extensive list https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V60-ICD10/TechSpecs/PSI_11_Postoperative_Respiratory_Failure_Rate.pdf

Official Coding Guidelines It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the conditions, and an indication in the documentation that it is a complication. ICD-10- CM Official Guidelines for Coding and Reporting 2016; ICD-10-CM Expert for Hospitals

So what is a Complication? Post operative complications must meet all of the following requirements: Condition cannot be routinely expected after a procedure There must be evidence of evaluation, monitoring and treatment of the condition The condition must require added care that could result in a prolonged length of stay Condition must be directly related to the procedure The Physician must document that the condition is a complication Ensure accurate coding for postoperative conditions. Just Coding News: Inpatient September, 2012

“POST-OPERATIVE” Not just a time frame This phrase denotes a “Cause and Effect” relationship Signals to the coders the Condition is a Complication (even if providers don’t think it is)

What is NOT a Complication Category Example for Respiratory Failure Conditions caused by patient’s underlying disease process Neuromuscular disorder resulting in delayed extubation Conditions caused by anesthesia Atelectasis Condition present on admission Chronic Respiratory Failure Acute Respiratory Failure POA Condition is a normal part of recovery Delayed extubation in patients with underlying lung disease

Message to Providers Post-operative ventilation immediately following procedure post-operative respiratory failure CDI team will be looking for “Exclusions” work with them to get diagnoses properly documented in record

The Major Organ Dysfunction…

Surviving Sepsis Campaign 2012 Sepsis: 2+ SIRS with source of infection Severe Sepsis: Sepsis with signs of end organ damage (AKI, hypoxia, encephalopathy) Septic Shock: hypotension not responsive to fluids that is due to sepsis R. P. Dellinger, et. al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Medicine. February 2013, Volume 39, Issue 2, pp 165–228

SEPSIS 3 Singer, M. et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3). JAMA. 2016;315(8): 801-810

So What Definition Should We Use? Provider Choice Clinicians can use whichever clinical criteria they see fit But They Should Know: CMS has not adopted the “new” definition SEP-1 Bundle Requirement uses SIRS criteria Hospital initiatives will likely fall in line with CMS Supported by Content Experts… for now

SEP-1 Measure

Wasting Away…

Why is there an issue? LIPs have difficulty identifying and responding to nutritional needs of our patients Conceptually know that poor nutritional status results in prolonged recovery and healing Reliance on ancillary services and automatic referrals Various ICD10 Terms do not denote clinical significance for providers beyond “poor nutritional status”

Providers want to document properly Do not have these definitions memorized or think they have clinical significance other than pt is “malnurished” White JV, Guenter P, et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Under-nutrition). JPEN J Parent Ent Nutr. 2012; 36:275-283.

Losing Our Minds… Internal Survey of Medicine Interns at Lifespan Affiliate Hospitals

Delirium Encephalopathy DEFINITION for DELIRIUM: This is what Clinicians learn in training Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 Book by American Psychiatric Association

Definition adapted from: January ACP Hospitalist, copyright © 2015 by the American College of Physicians By Richard Pinson, MD, FACP

Message to Providers The terms Delirium, Altered Mental Status and Acute Encephalopathy may have similar definitions to Clinicians… …BUT have drastically different expected length of stay, risk of mortality and monetary reimbursement from a Coding Perspective.

Questions/ Concerns? jobrien8@lifespan.org