EXAMPLES OF LEVELS OF SEVERITY IN DIAGNOSES
CC = Comorbidity; MCC = Major Comorbidity
Low Severity: No CC
Altered Mental Status.
Unresponsive.
Somnolence/Obtunded.
Delirium.
Medium Severity: CC
Acute Delirium.
Vegetative State.
Drug Induced Delirium.
High Severity: MCC
Encephalopathy.
Metabolic Encephalopathy.
Toxic Encephalopathy.
Hepatic Encephalopathy.
Coma.
Epilepsy, Grand Mal.
Epilepsy, Petit Mal.
Low Severity: No CC
Angina.
Chest Pain.
Medium Severity: CC
Unstable Angina.
Acute Coronary
Syndrome.
Seizures.
Epilepsy.
Seizure Disorder.
Intractable Epilepsy.
Partial Epilepsy.
Intractable Seizure
Disorder.
Coronary
Atherosclerosis.
CAD (native or
unspecified).
Coronary Atherosclerosis
of bypass graft
COPD.
Asthma.
COPD Exacerbation.
Asthma with Exacerbation.
Abscess of lung or mediastinum.
Chest Pain
Endocarditis
Cor Pulmonale.
Pulmonary HTN.
Primary Pulmonary HTN
Acute Cor Pulmonale
Pericarditis
(unspecified).
Acute Pericarditis.
Constrictive Pericarditis.
Idiopathic Pericarditis.
Hypoxia.
Respiratory Distress.
Respiratory Insufficiency.
Chronic Respiratory
Failure.
Acute Respiratory Distress.
Acute Respiratory Failure.
Acute Respiratory Failure following
trauma or surgery.
CHF –Unspec./Exacerb.
Decompensated CHF.
Diastolic Dysfunction.
Systolic CHF.
Diastolic CHF.
High Severity: MCC
Myocardial Infarction (MI)all sites.
Bacterial Endocarditis.
Infectious Endocarditis.
(1)
Acute Systolic CHF.
Acute Diastolic CHF.
(2)
(Compensated).
Infiltrate.
Aspiration.
Pneumothorax.
Postprocedure aspiration
pneumonia.
Air leak.

Pneumonia.
Aspiration Pneumonia.
Streptococcal Pneumonia.
Pseudomonas Pneumonia.

PNEUMONIA NOTES:
If known, will you please document the type of pneumonia suspected and treated with or
without positive sputum? (Coding Advice AHA 3rd Q 1998).
Anemia.
Post Operative Anemia.
Acute Blood Loss Anemia.
Drop in Hematocrit.
Aplastic Anemia.
Pancytopenia.
Antineoplastic chemotherapy
induced pancytopenia.
Drug-induced pancytopenia.
Acute Abdomen
Ischemic Bowel
Acute Ischemic Bowel
Anemia.
Heme+ stool.
Diverticulosis.
Acute Blood Loss Anemia.
GI Bleed (unspecified).
Melena.
Ulcer w/hemorrhage
(Specify site).
Diverticulosis w/hemorrhage.
CHF NOTES:
1) Compensated Systolic or Diastolic Heart Failure= requires maintenance
medications such as Lasix , Bumex, etc.
2) Acute CHF requires the terms Systolic and/or Diastolic.
Uncontrolled HTN.
Accelerated
Hypertensive Crisis.
Hypertensive.
Hypertensive Urgency.
Malignant Hypertension.
Hypertensive
Encephalopathy.
Cholecystitis.
Acute-on-Chronic
Cholecystitis w/ Perforated
Chronic Cholecystitis.
Cholecystitis.
Gallbladder.
Cholelithiasis
Cholecystitis w/
Cholelithiasis.
Cholelithiasis with Acute &
Chronic Cholecystitis w/
Obstruction.
EXAMPLES OF LEVELS OF SEVERITY IN DIAGNOSES
Low Severity: No CC
Abdominal Pain
Medium Severity: CC
Acute Appendicitis
High Severity: MCC
Acute Appendicitis with Peritonitis,
Abscess, or Perforation
Low Severity: No CC
Acute Renal
Insufficiency.
Azotemia.
Renal Failureunspecified.
Febrile Illness.
Neutropenic Fever.
Medium Severity: CC
Acute Renal Failure
High Severity: MCC
Acute Tubular Necrosis
Constipation
Fecal Impaction.
Other digestive system
complications.
Perforation of intestine.
Angiodysplasia of intestine w/
hemorrhage.
UTI.
Bacteremia.
SIRS (due to infection).
UTI with Sepsis.
Sepsis.
Neutropenic Sepsis.
Gastric Ulcer.
Duodenal Ulcer.
Peptic Ulcer.
Gastritis.
Gastroenteritis.
Erosive Gastritis.
DM Uncontrolled.
DM with Hypoglycemia.
DM with Hyperglycemia.
Acute Gastric Ulcer.
Acute Duodenal Ulcer.
Acute Peptic Ulcer.
Infectious Gastroenteritis.
Bacterial Food Poisoning.
Radiation Gastroenteritis.
Hypoglycemic coma.
Postsurgical
hypoinsulinemia.
Gastric, Peptic or Duodenal
Ulcer w/hemorrhage.
Obstruction or Perforation.
Gastritis w/Hemorrhage.
Erosive Gastritis w/Hemorrhage.
Chronic Kidney Disease.
Chronic Renal Failure.
Chronic Kidney Disease.
Stage 4/ 5 Renal failure. *
End Stage Renal Disease.
DM with Hyperosmolarity.
Diabetic Coma.
Diabetic ketoacidosis.
Severe Hypovolemia.
Dehydration.
Diabetes insipidus.
Hypovolemic Shock
Low Albumin
Wasting
Obesity
Cachexia.
Malnutrition.
BMI <19.
BMI >40.
Skin ulcer
Severe Malnutrition
Hypotension
Postoperative shockunspecified.
Shock/Postoperative Shock
(Cardiac, Septic,
Hemorrhagic).
Skin Breakdown
* Decubitus or Pressure Ulcer
Skin Wound
(specify site and stage)
ULCER NOTE:
* Will you please indicate if the ulcer was present on admission (POA)?
Reminder notes:
1)
“S/P Organ Transplant” is not a diagnosis. Will you please document
diagnoses such as: Organ rejection?
* RENAL FAILURE NOTE:
When documenting Renal Failure, the stage should also be documented.
Fever.
Bacteremia
Sepsis*/Severe Sepsis.
Febrile Illness.
SIRS (due to infection).
* SEPSIS NOTES:
Negative or inconclusive blood cultures do not preclude a diagnosis of Sepsis in
patients with clinical evidence of the condition. (ICD-9-CM Official Coding Guidelines,
Infectious and Parasitic Diseases).
Critically Ill
Systolic CHF.
Acute Respiratory Failure.
Heart Failure/
Diastolic CHF.
Acute Systolic or Diastolic
Renal Failure.
Chronic Respiratory
CHF.
Failure.
Acute Renal Failure.
2) Probable, suspected, rule out and/or questionable diagnoses are coded
as if the condition actually exists on inpatient stays.
3) Abnormal lab values should have a diagnosis to support the findings.
Avoid symbol documenting- it does not translate into a code able
diagnosis. (Example: K =please document Hyperkalemia).
Based on Centers for Medicare & Medicaid Services (CMS) Federal Register Final Rule: Effective 10/1/11 (FY 2012).