Volume 1, Issue 5
11/08/2011
Clinical Documentation Improvement
Newsletter
Most “Hypertension” diagnosis have been dropped. These include Uncontrolled Hypertension, Hypertensive emergency, and Hypertensive urgency just to name a few.
The following “hypertension” diagnoses do count/increase severity of illness and risk of
mortality:
Accelerated Hypertension
Essential Hypertension
Malignant Hypertension
Portal Hypertension
Pulmonary Hypertension
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Have you done a Debridement today?
“Sharp” doesn’t cut it anymore!
Specific coding guidelines require clarity of documentation of debridement.
Please note excisional or non-excisional and to the level/
depth of debridement in operative reports as well as the type of
instrument being used.
Clear and concise physician documentation of all diagnoses and procedures is important to accurately reflect the severity and complexity of
those you treat.
P a g e
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C l i n i c a l
D o c u m e nt a t i o n
Decoding the language of physicians and coders:
A closer look at hypotension and ACS
The language of the practice of medicine doesn’t always mesh with the language of coding.
Sometimes we have common words or acronyms with different meanings. For example, ‘CC’
for coders means ‘complication and comorbidity,’ whereas for physicians, it means ‘chief
complaint.’
Sometimes coders and physicians use different phraseology that actually has the same intended meanings. However, coders just can’t use what the physicians provide. Let’s take a
look at a few examples.
Hypotension
There are so many causes of hypotension. If a coder reviews the chart of a patient in the emergency department
(ED) or CCU with documented symptoms, such as fever (or low temperature), elevated white cell count (or low white
cell count), altered mental status, evidence of an infection (e.g., pneumonia), pyelonephritis, a rigid abdomen with
speculation of diverticulitis or perforation of another intestinal organ, and hypotension, think of the following algorithm:
•
The chart may show that the physician gave the patient a bolus of saline or Ringer’s lactate and then another
bolus. If the patient perks up and feels better—and the creatinine drops from 5.4 to 2.7—then the patient
likely had hypotension due to severe dehydration. The rapid change in creatinine levels show that the patient was also in acute renal failure. Coders can’t code it when the physician doesn’t document it—even
when the evidence points to it. The patient may have had sepsis from that infectious process and metabolic
encephalopathy due to the dehydration with acute renal failure.
•
If the patient does not respond to the fluid challenge, and the physician starts the patient on pressors, such as
levophed, dobutamine, or dobutrex, coders may assume the patient is in shock. The question is, was it hypovolemic shock or septic shock? The physicians should document the etiology in this case.
Sometimes in the ED or CCU, coders see hypotension related to the positional change of a severely dehydrated patient. The physician may have called it orthostatic hypotension. When the physician’s documentation shows that the
patient was dehydrated, and the patient responds to IV fluids, then code the dehydration. However, if the physician
administers several boluses of fluid to this severely dehydrated patient and the fluids bring the creatinine level down,
as above, think of acute renal failure due to dehydration.
Consider the same scenario with a patient who is vomiting blood or having massive bloody stools. There’s a significant bleed going on somewhere. If the physician documented hypotension and the administration of large volumes
of saline or Ringer’s lactate, uncrossmatched bloods, and orthostatic hypotension, think of hypovolemia.
If the patient requires pressors to maintain perfusion and blood flow, perhaps there was hemorrhagic shock—but
don’t code it as orthostatic hypotension. The code for orthostatic hypotension is a chronic autonomic nerve condition—not acute volume changes.
Hypotension can happen in patients who have documented chest pain. The condition may be accompanied by one or
more of the following:
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Documented congestive heart failure with documentation of acuity and functional abnormality.
Arrhythmia.
Bradycardia with pulse rates about 45 or lower.
Ventricular tachycardia.
Ventricular fibrillation, in which case the physician likely used a defibrillator on the patient.
Acute coronary syndrome (ACS).
Was it a myocardial infarction (MI)? Check the troponins. If they are higher than the 99th percentile of high
normal for your hospital’s lab and the patient had symptoms consistent with acute MI, it was an MI.
Or was it unstable angina due to either a ruptured plaque (if the patient didn’t have a coronary artery bypass
graft) or some secondary cause (anemia or shock or tachycardia, etc.)?
A patient starting beta-blockers or multiple medications, such as sleeping pills, antidepressants, seizure medications, and pain medications, may suffer from hypotension.
Continued page 4
V o l u m e
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I s s u e
5
L e v e l
P a g e
o f
C a r e
D e c i s i o n
Does the patient’s condition require treatment/
further evaluation that
can only be provided in
a hospital setting?
(ie, inpatient or observation)
Unsure
3
T r e e
No
Alternate level of care is
appropriate (outpatient,
home health care, extended care facility).
Additional time is
needed to determine if inpatient
admission is medically necessary;
Observation is appropriate.
YES
NO
Admit to Inpatient is
appropriate.
Can the patient’s condition be evaluated/treated
w/in 24° and/or is rapid
improvement of the patient’s condition anticipated w/in 24°?
YES
Place in Observation is appropriate.
CONTACT
INFORMATION
Organization
Continued from page 2
Physicians may discontinue or substitute these medicines until the patient can stand up without falling down. There are many potentially
necessary E codes with the iatrogenic hypotension code assigned.
Patients with true autonomic nervous system dysfunction may also suffer from hypotension:
Dan Bray, RN
Clinical Documentation Specialist
Patient Accounts
Phone: x4895
Mobile: x4868
Fax: (336) 248-4895
E-mail: dbray@lmh.cc
CHEST PAIN
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Coronary Artery Disease
Unstable Angina
Angina
Cardiac Arrhythmia ______Specify type
if known
Gastroesophagael Reflux Disease
Pleuritic
Musculoskeletal
Costochondritis
Stress / Anxiety
Psychogenic Chest Pain
Chest Pain – Etiology Undetermined
Patient does not have chest pain
Amyloidosis.
Familial dysautonomia.
Multiple system atrophy. There is no specific code for this. It is a
neurodegenerative disease that manifests as Parkinsonism,
cerebella dysfunction, and autonomic disturbances.
ACS
ACS describes a group of symptoms compatible with acute myocardial
ischemia. The true cause is inadequate delivery of oxygenated blood to
the heart muscles. The symptoms include chest pain, fatigue, weakness, and dizziness. The severity of the ACS symptoms can be unstable angina, non-ST-elevation MI, or ST-elevation MI. To top it off,
coronary occlusion can cause ACS, or ACS can be due to supply and
demand mismatch. So how do we know what the cause is?
A variety of clinical symptoms accompany ACS that is due to a supply/
demand mismatch:
Chest pain is considered a Sign & Symptom
•
diagnosis per coding guidelines. If possible,
be specific with the etiology for chest pain.
Listed below are examples of more specific
causes of chest pain.
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Diabetes, most commonly in the United States.
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Tachycardia, such as Atrial fibrillation (AF) with rapid ventricular
response or supraventricular tachycardia, with a heart rate in
the range of 160–240 per minute. Physicians will rapidly do
what they can to try to convert the rhythm or the heart rate to
something closer to normal—about 80 beats per minute. When
they accomplish that and see that the patient’s chest pain has
resolved, they’ll call it chest pain. When they see that the troponin came back 0.12 and then dropped to 0.05, they’ll call it a
troponin leak due to AF. If it was a demand acute NSTEMI, I
would strongly recommend also assigning a code for the tachycardia, or something more specific, but only if the physician
provides the appropriate documentation.
Anemia, whether it is chronic anemia common with chronic kidney
disease patients or an acute anemia due to a gastrointestinal
bleed. The patient may have presented with weakness, fatigue, or classic anginal chest pain that does not respond to
nitroglycerine but goes away when the physician gives the patient several units of packed red blood cells. Then the physiccians will see that the troponin bumped and call it a troponin
leak due to severe anemia. It was a demand NSTEMI, but
you’ll need the physician to document this.
Hypertensive urgency or emergency, eclampsia, thyrotoxicosis, carcinoid syndrome, or pheochromocytoma can all lead to severely
elevated blood pressures. If the heart faces a severe increase
in demand to work, any of these events can lead to acute diastolic heart failure or a demand MI. Be on the lookout for chest
pain on presentation, findings of one of these conditions, and
an elevated troponin which the physicians are not calling an
acute MI.