1. 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

2. 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

3. 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”

4. 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

5. 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

6. 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”

7. The Heart of the Problem…

8. 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 Jan 3;125(1):e2-e220.

9. 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 Jan 3;125(1):e2-e220.

10. 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 Jan 3;125(1):e2-e220.

11. “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 Feb 2; 127( )

12. 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.

13. Coding Clinic 2017
Coding Clinic First Quarter page 44

14. Clinical Indicators for Demand NSTEMI

15. 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

16. It Takes Wind Out of Us…

17. 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

19. 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

20. 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

21. 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

22. 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

23. “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)

24. 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

25. 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

26. The Major Organ Dysfunction…

28. 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, Intensive Care Medicine. February 2013, Volume 39, Issue 2, pp 165–228

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

30. 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

31. SEP-1 Measure

32. Wasting Away…

33. 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”

34. 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:

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

36. 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

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

38. 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.

39. Questions/ Concerns?