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.
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.
CKD Staging
1
>90 GFR
*Clarify Renal Insufficiency to a
more specific diagnosis
2
60-89 GFR
*Indicate if DM complication
3
30-59 GFR
4
15-29 GFR
5
<15 (indicate if ESRD)
Reference : www.nephronline/management/ckd.html
Acute Renal Failure(ARF)/Acute Kidney Injury(AKI):
Creatinine increase of >0.3-0.5 or use RIFLE criteria.
http://www.smjr.org/files/nephro/RIFLE.PDF
*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)
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 antineoplastic 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.
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)
CLINICAL
DOCUMENTATION
EXCELLENCE
General Documentation Principles
cde@sibley.org
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries
within 24 hours
SIRS: Meets sepsis criteria (WBC, tachycardia, tachypnea,
fever) without infection. Caused by - trauma, CHF, acute COPD,
burns, arthritis, MI, drug abuse
BMI: both <19 or >40 typically require additional resources:
Morbid Obesity: BMI >40
Document both the BMI and the diagnosis (obesity, morbid)
Underweight/Cachexia: BMI <19
Document BMI, diagnosis and malnutrition if present
Malnutrition: Specify degree Normal Mild
Moderate
Severe
Malnutrition Malnutrition Malnutrition
Pre-Albumin >17
12-17
7-11
<7
Albumin
3.5-5.0 3.1-1-.4
2.4-3.0
2.4
Trans-ferrin 220-400 201-219
150-200
<150
BMI
19-24
Additionally, clarify type: protein-calorie, protein malnutrition,
calorie malnutrition
Also, document a diagnosis for a dietary consult
Pneumonia: Clarify type of pneumonia when possible eg:
bacterial (organism?); aspiration, ventilator-assoc, post-op. Also
document if POA and include any related conditions (Acute
Respiratory Failure, Sepsis)
Skin Ulcer: indicate if: decubitus (note location and stage),
diabetic, veno/arteriostasis, presence of infection
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.
CKD Staging
1
>90 GFR
*Clarify Renal Insufficiency to a
more specific diagnosis
2
60-89 GFR
*Indicate if DM complication
3
30-59 GFR
4
15-29 GFR
5
<15 (indicate if ESRD)
Reference : www.nephronline/management/ckd.html
Acute Renal Failure(ARF)/Acute Kidney Injury(AKI):
Creatinine increase of >0.3-0.5 or use RIFLE criteria.
http://www.smjr.org/files/nephro/RIFLE.PDF
*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)
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.
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)
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 antineoplastic 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.
SIRS: Meets sepsis criteria (WBC, tachycardia, tachypnea,
fever) without infection. Caused by - trauma, CHF, acute COPD,
burns, arthritis, MI, drug abuse
BMI: both <19 or >40 typically require additional resources:
Morbid Obesity: BMI >40
Document both the BMI and the diagnosis (obesity, morbid)
Underweight/Cachexia: BMI <19
Document BMI, diagnosis and malnutrition if present
Malnutrition: Specify degree Normal Mild
Moderate
Severe
Malnutrition Malnutrition Malnutrition
Pre-Albumin >17
12-17
7-11
<7
Albumin
3.5-5.0 3.1-1-.4
2.4-3.0
2.4
Trans-ferrin 220-400 201-219
150-200
<150
BMI
19-24
Additionally, clarify type: protein-calorie, protein malnutrition,
calorie malnutrition
Also, document a diagnosis for a dietary consult
Pneumonia: Clarify type of pneumonia when possible eg:
bacterial (organism?); aspiration, ventilator-assoc, post-op. Also
document if POA and include any related conditions (Acute
Respiratory Failure, Sepsis)
Skin Ulcer: indicate if: decubitus (note location and stage),
diabetic, veno/arteriostasis, presence of infection
CLINICAL
DOCUMENTATION
EXCELLENCE
General Documentation Principle
cde@sibley.org
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries
within 24 hours