Clinical and Coding Conundrums - ACDIS

Clinical and Coding Conundrums

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

Our Lady of the Lake Regional Medical Center Baton Rouge, L1A

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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

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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--"see quadriplegia"

? 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 symptoms

Onset Functional status (same as paralyzed patient) Ambulatory or able to transfer Bedbound Can get into wheelchair? Supporting evidence from physical exam

Functional quadriplegia supported

Years

? Total care/complete immobility ? Maximum assistance required ? ADL-dependent

No

Yes

Yes--but requires total assistance (like spinal cord injury?induced quadriplegia)

Contractures, pressure ulcers, confusion

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Differentiating Quadriplegia by Etiology

Functional Parkinson's disease

Neurologic 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 Pneumonia

Bartlett 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 consolidation

Leukocytosis or leukopenia

Cough

Rigors

Interstitial infiltrates

Sputum gram stain and culture

Shortness of breath Diaphoresis

Cavitation

Blood cultures

Pleurisy

Crackles, rhonchi, pleural rub

Pleural effusion

Legionella and pneumococcal urinary antigen

Sputum production Tachypnea > 20

Empyema

PCR studies for organisms including influenza

Nausea/vomiting Tachycardia

Thoracentesis

Diarrhea

Hypoxemia

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

Host

(patient characteristics)

Simple pneumonia

Often healthy at baseline ? Lower risk ? Few comorbidities

Patient setting

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

Little contact with healthcare system

Complex pneumonia (specific, Gram neg, asp)

Chronically ill ? Immunocompromised (e.g.,

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

COPD) ? Aspiration (e.g., dementia)

? 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 Pneumonia

MD Intuition: Do Not Under-Treat These Patients (or RIP)

Immunocompromised patients

HIV/AIDS

Immunosuppressive treatment ? Steroids ? Chemotherapy ? TNF inhibitors

Chronically ill patients

Diabetes mellitus

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

Solid or hematologic organ transplant recipient

Malnutrition

Wounds

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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