EXAMPLES OF LEVELS OF SEVERITY IN DIAGNOSES

CC = Comorbidity; MCC = Major Comorbidity

Low Severity: No CC / Medium Severity: CC / High Severity: MCC / Low Severity: No CC / Medium Severity: CC / High Severity: MCC
Altered Mental Status.
Unresponsive.
Somnolence/Obtunded.
Delirium. / Acute Delirium.
Vegetative State.
Drug Induced Delirium. / Encephalopathy.
Metabolic Encephalopathy.
Toxic Encephalopathy.
Hepatic Encephalopathy.
Coma. / Angina.
Chest Pain. / Unstable Angina.
Acute Coronary Syndrome. / Myocardial Infarction (MI)-all sites.
Seizures.
Epilepsy.
Seizure Disorder. / Intractable Epilepsy.
Partial Epilepsy.
Intractable Seizure Disorder. / Epilepsy, Grand Mal.
Epilepsy, Petit Mal. / 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 / Bacterial Endocarditis.
Infectious 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. (1)
Diastolic CHF.
(Compensated). / Acute Systolic CHF. (2)
Acute Diastolic CHF.
Infiltrate.
Aspiration. / Pneumothorax.
Postprocedure aspiration pneumonia.
Air leak. /
  • Pneumonia.
Aspiration Pneumonia.
Streptococcal Pneumonia.
Pseudomonas Pneumonia. / 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.
  • 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). / Uncontrolled HTN.
Hypertensive Crisis.
Hypertensive Urgency. / Accelerated Hypertensive.
Malignant Hypertension.
Hypertensive
Encephalopathy.
Anemia.
Post Operative Anemia. / Acute Blood Loss Anemia. Drop in Hematocrit.
Aplastic Anemia.
Pancytopenia. / Antineoplastic chemotherapy induced pancytopenia.
Drug-induced pancytopenia.
/ Cholecystitis.
Chronic Cholecystitis. / Acute-on-Chronic Cholecystitis. / Cholecystitis w/ Perforated Gallbladder.
Acute Abdomen / Ischemic Bowel / Acute Ischemic Bowel / Cholelithiasis / Cholecystitis w/ Cholelithiasis. / Cholelithiasis with Acute Chronic Cholecystitis w/ Obstruction.
Anemia.
Heme+ stool.
Diverticulosis. / Acute Blood Loss Anemia.
GI Bleed (unspecified).
Melena. / Ulcer w/hemorrhage
(Specify site).
Diverticulosis w/hemorrhage.

EXAMPLES OF LEVELS OF SEVERITY IN DIAGNOSES

Low Severity: No CC / Medium Severity: CC / High Severity: MCC / Low Severity: No CC / Medium Severity: CC / High Severity: MCC
Abdominal Pain / Acute Appendicitis / Acute Appendicitis with Peritonitis, Abscess, or Perforation / Acute Renal Insufficiency.
Azotemia.
Renal Failure- unspecified. / Acute Renal Failure / Acute Tubular Necrosis
Constipation / Fecal Impaction.
Other digestive system complications. / Perforation of intestine.
Angiodysplasia of intestine w/ hemorrhage. / Febrile Illness.
Neutropenic Fever. / UTI.
Bacteremia.
SIRS (due to infection). / UTI with Sepsis.
Sepsis. Neutropenic Sepsis.
Gastric Ulcer.
Duodenal Ulcer.
Peptic Ulcer. / Acute Gastric Ulcer.
Acute Duodenal Ulcer.
Acute Peptic Ulcer. / Gastric, Peptic or Duodenal
Ulcer w/hemorrhage.
Obstruction or Perforation. / Chronic Kidney Disease.
Chronic Renal Failure. / Chronic Kidney Disease.
Stage 4/ 5 Renal failure. * / End Stage Renal Disease.
Gastritis.
Gastroenteritis.
Erosive Gastritis. / Infectious Gastroenteritis.
Bacterial Food Poisoning.
Radiation Gastroenteritis. / Gastritis w/Hemorrhage.
Erosive Gastritis w/Hemorrhage. / *RENAL FAILURE NOTE:
When documenting Renal Failure, the stage should also be documented.
DM Uncontrolled.
DM with Hypoglycemia.
DM with Hyperglycemia. / Hypoglycemic coma.
Postsurgical hypoinsulinemia. / DM with Hyperosmolarity.
Diabetic Coma.
Diabetic ketoacidosis. / Severe Hypovolemia.
Dehydration. / Diabetes insipidus. / Hypovolemic Shock
Low Albumin
Wasting
Obesity / Cachexia.
Malnutrition.
BMI <19.
BMI >40. / Severe Malnutrition / Hypotension / Postoperative shock-unspecified. / Shock/Postoperative Shock (Cardiac, Septic, Hemorrhagic).
Skin Breakdown
Skin Wound / Skin ulcer / * Decubitus or Pressure Ulcer
(specify site and stage) / Fever.
Febrile Illness. / Bacteremia / Sepsis*/Severe Sepsis.
SIRS (due to infection).
ULCER NOTE:
* Will you please indicate if the ulcer was present on admission (POA)? / * 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).
Reminder notes:
1)“S/P Organ Transplant” is not a diagnosis. Will you please document diagnoses such as: Organ rejection?
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). / Critically Ill
Heart Failure/
Renal Failure. / Systolic CHF.
Diastolic CHF.
Chronic Respiratory Failure.
Acute Renal Failure. / Acute Respiratory Failure.
Acute Systolic or Diastolic CHF.

Based on Centers for Medicare & Medicaid Services (CMS) Federal Register Final Rule: Effective 10/1/11 (FY 2012).