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 notqualify 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 requiresallhospitalstoreport Presenton Admission(POA)statusforeachdiagnoses. Presentatthetimeofinpatientadmissionorconditions that occurduringanoutpatientstatus(includingED) arePOA
Indicationfor(treatment,medication,radiology etc):Include indicationformedications,radiologyorders(MRI,CT), procedures(PICC,EGD, colonoscopy),treatments(nebs), ultrasound (echo,diagnostic,gallstones,etc)
PrincipleDiagnosis:Isthatconditionestablishedafterstudy tobechieflyresponsibleforoccasioningtheadmissionofthe patienttothehospital forcare.
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.
CLINICAL DOCUMENTATION EXCELLENCE
General Documentation Principles
Phone202.660.6782Fax 202.537.4477
Pleaseanswer CDEqueries within 24hours
Chronic Kidney Disease (CKD)/Chronic Renal Failure (>than 6 months of increasedcreatinine and/or decreased GFR)
End Stage Renal Disease (ESRD):Chronic dialysis (>3months)
Acute on Chronic Renal Failure:
Established CKD (stage?) with increase in creatinine abovepatient’s baseline creatinine of >.0.3-0.5.
Reference :
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 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 -
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 increasedcreatinine and/or decreased GFR)
End Stage Renal Disease (ESRD):Chronic dialysis (>3months)
Acute on Chronic Renal Failure:
Established CKD (stage?) with increase in creatinine abovepatient’s baseline creatinine of >.0.3-0.5.
Reference :
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 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 -
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
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 notqualify 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 requiresallhospitalstoreport Presenton Admission(POA)statusforeachdiagnoses. Presentatthetimeofinpatientadmissionorconditions that occurduringanoutpatientstatus(includingED) arePOA
Indicationfor(treatment,medication,radiology etc):Include indicationformedications,radiologyorders(MRI,CT), procedures(PICC,EGD, colonoscopy),treatments(nebs), ultrasound (echo,diagnostic,gallstones,etc)
PrincipleDiagnosis:Isthatconditionestablishedafterstudy tobechieflyresponsibleforoccasioningtheadmissionofthe patienttothehospital forcare.
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.
CLINICAL DOCUMENTATION EXCELLENCE
General Documentation Principle
Phone202.660.6782Fax 202.537.4477
Pleaseanswer CDEqueries
within 24hours