Documentation Improvement Handbook 10-19-11 PROOF.PDF



Specificity: Coding rules require precise documentation as to location, laterality, device, approach, procedure, qualifier; eg., meningitis due to Lyme Disease, malignant neoplasm of lower quadrant of right female breast, atherosclerotic heart disease of native coronary artery with unstable angina pectoris

Consistency: Diagnoses are noted and then repeated throughout the patient’s stay. One time mention does not qualify as diagnosis for coding purposes.

Complication: Specify type complication: (infection, inflammation, if caused by implanted device, from operation or procedure. If current visit related to previous condition, specify diagnosis and late effect if present (CVA, MI, etc)

Present on Admission (POA): CMS requires all hospitals to report Present on Admission (POA) status for each diagnoses. Present at the time of inpatient admission or conditions that occur during an outpatient status (including ED) are POA

Indication for (treatment, medication, radiology etc): Include indication for medications, radiology orders (MRI, CT), procedures (PICC, EGD, colonoscopy), treatments (nebs), ultrasound (echo, diagnostic, gallstones, etc)

Principle Diagnosis: Is that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Acute Respiratory Failure:

Document cause, if possible (eg: exacerbation of COPD/ Bronchitis , Pneumonia, Acute pulm edema, etc)

*Abnormal ABGs or Acidosis: Specify corresponding diagnosis

Anemia: Document cause of anemia, if blood loss anemia, document acute or chronic, expected or unexpected, related conditions/complications. Establish cause and effect; eg., anemia secondary to acute blood loss from hemorrhagic ulcer

Neuro: Dementia - specify cause/type - “Alzheimer’s” Encephalopathy (type), Acute Stroke (cerebral infarction) TIA, cerebral edema, seizure disorder, late effects of a stroke (noting if greater than six months)

Altered Mental Status: Clarify to diagnosis; eg., delirium (cause), encephalopathy (type: metabolic toxic (drugs ?), hepatic); acute confusional state; psychosis

Cancer: Specify if treatment directed at primary site or metastatic site, include morphology, specify if anemia caused by anti-neoplastic drugs or disease process, include concurrent diagnoses such as malnutrition (type?)

Admission for Radiology/Chemotherapy : Include diagnosis for treatment, if metastasis, etc.

Sepsis: Document if due to UTI/Wounds/Resp. etc., source? (infection?) Urosepsis codes to UTI only! Establish cause and effect; eg., UTI secondary to indwelling urinary catheter.

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CLINICAL DOCUMENTATION EXCELLENCE

General Documentation Principles

cde@

Phone 202.660.6782 Fax 202.537.4477

Please answer CDE queries within 24 hours

Chronic Kidney Disease (CKD)/Chronic Renal Failure (>than 6 months of increased creatinine and/or decreased GFR)

End Stage Renal Disease (ESRD): Chronic dialysis (>3months)

Acute on Chronic Renal Failure:

Established CKD (stage?) with increase in creatinine above patient’s baseline creatinine of >.0.3-0.5.

Reference : nephronline/management/ckd.html

Acute Renal Failure(ARF)/Acute Kidney Injury(AKI): Creatinine increase of >0.3-0.5 or use RIFLE criteria.

*Specify cause of AKI: Sepsis, shock, drug toxicity, hypotension, obstruction (include hydronephrosis if present)

*Specify type of AKI: Acute tubular necrosis (ATN), interstitial nephritis, cortical or medullary necrosis

Hypertension: Specify type: Essential; Primary;Secondary; Malignant; Accelerated, include complications (CVA, etc, consider Hypertensive Heart and Kidney disease if manifestations present)

Diabetes: Specify DM-I or DM-II Controlled or Uncontrolled (Hgb A1c >7) Link DM to complications if present (e.g. ulcer, neuropathy, nephropathy, gastroparesis, retinopathy, cellulitis, osteomyelitis). Establish cause and effect; eg., peripheral vascular disease due to diabetes

Debridement: Include deepest layer debrided

*Specify if excisional or non-excisional:

Excisional: Definite, sharp, cutting away of tissue using scissors, blades, nippers, “surgical debridement”

Non-Excisional: Mechanical debridement using scrubbing, brushing, ultrasonic curettes, Versajet™, irrigation

Congestive Heart Failure (CHF): Acuity and Type

Acuity: Acute / Chronic / Acute on Chronic (exacerbation)

Type: - Systolic (EF < 40) or Diastolic (on echo), combined

*Document any CHF complications, ie arrhythmia, Resp failure, Acute pulmonary edema.

Cardiomyopathy: Document separately from CHF and specify type (ischemic/non, hypertensive, sarcoid, primary)

Compression Fracture: Clarify if traumatic or pathologic

(degenerative), include osteopenia if present. Establish cause and effect; eg., fracture due to osteoporosis

Alcoholism: Include acuity (intoxication?), indication for CIWA scale, course of illness (episodic, continuous, in remission), complications (cirrhosis, gastritis, hepatitis, etc)

SIRS: Meets sepsis criteria ((WBC, tachycardia, tachypnea, fever) without infection. Caused by - trauma, CHF, acute COPD, burns, arthritis, MI, drug abuse

BMI: both 40 typically require additional resources:

Morbid Obesity: BMI >40

Document both the BMI and the diagnosis (obesity, morbid)

Underweight/Cachexia: BMI than 6 months of increased creatinine and/or decreased GFR)

End Stage Renal Disease (ESRD): Chronic dialysis (>3months)

Acute on Chronic Renal Failure:

Established CKD (stage?) with increase in creatinine above patient’s baseline creatinine of >.0.3-0.5.

Reference : nephronline/management/ckd.html

Acute Renal Failure(ARF)/Acute Kidney Injury(AKI): Creatinine increase of >0.3-0.5 or use RIFLE criteria.

*Specify cause of AKI: Sepsis, shock, drug toxicity, hypotension, obstruction (include hydronephrosis if present)

*Specify type of AKI: Acute tubular necrosis (ATN), interstitial nephritis, cortical or medullary necrosis

Hypertension: Specify type: Essential; Primary;Secondary; Malignant; Accelerated, include complications (CVA, etc, consider Hypertensive Heart and Kidney disease if manifestations present)

Diabetes: Specify DM-I or DM-II Controlled or Uncontrolled (Hgb A1c >7) Link DM to complications if present (e.g. ulcer, neuropathy, nephropathy, gastroparesis, retinopathy, cellulitis, osteomyelitis). Establish cause and effect; eg., peripheral vascular disease due to diabetes

Debridement: Include deepest layer debrided

*Specify if excisional or non-excisional:

Excisional: Definite, sharp, cutting away of tissue using scissors, blades, nippers, “surgical debridement”

Non-Excisional: Mechanical debridement using scrubbing, brushing, ultrasonic curettes, Versajet™, irrigation

Congestive Heart Failure (CHF): Acuity and Type

Acuity: Acute / Chronic / Acute on Chronic (exacerbation)

Type: - Systolic (EF < 40) or Diastolic (on echo), combined

*Document any CHF complications, ie arrhythmia, Resp failure, Acute pulmonary edema.

Cardiomyopathy: Document separately from CHF and specify type (ischemic/non, hypertensive, sarcoid, primary)

Compression Fracture: Clarify if traumatic or pathologic

(degenerative), include osteopenia if present. Establish cause and effect; eg., fracture due to osteoporosis

Alcoholism: Include acuity (intoxication?), indication for CIWA scale, course of illness (episodic, continuous, in remission), complications (cirrhosis, gastritis, hepatitis, etc)

SIRS: Meets sepsis criteria ((WBC, tachycardia, tachypnea, fever) without infection. Caused by - trauma, CHF, acute COPD, burns, arthritis, MI, drug abuse

BMI: both 40 typically require additional resources:

Morbid Obesity: BMI >40

Document both the BMI and the diagnosis (obesity, morbid)

Underweight/Cachexia: BMI 90 GFR |*Clarify Renal Insufficiency to a |

| | |more specific diagnosis |

| | |*Indicate if DM complication |

|2 |60-89 GFR | |

|3 |30-59 GFR | |

|4 |15-29 GFR | |

|5 |17 |12-17 |7-11 | ................
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