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Combined Presentation of Pneumonia, Pressure Ulcers, and Sepsis Documentation Compiled and Presented for TAHIMA Meeting on 16 April 2015 Charlene Haslam, CPC, RHIT Compiled and Presented by Charlene Haslam CPC, RHIT February 4, 2015 Terminology • “And” can mean “and/or.” Meaning it can be both or either one. • Excludes 1 – Two conditions that cannot be reported together. • Congenital cannot be coded with acquired form of same condition. • Excludes 2 – Although the excluded condition is not part of the condition it is excluded from, a patient may have both conditions at the same time. • It may be acceptable to use both codes together if supported my medical documentation. • NOS – For use when the information in the medical record is insufficient to assign a more specific code. • NEC – For use when the information in the medical record provides detail for which a specific code does not exist. 1) 2) 3) 4) Meet medical necessity criteria 1)Justify and explain need for inpatient services 1)Diagnosis 2)Evaluate 3)Treat Reflect items listed below to receive workload, achieve accurate morbidity and mortality risk scores 1)Specific type 2)Cause 3)Severity 4)Associated Conditions 5)Complications Demonstrate “Best Practice” guidelines Comply with Quality and Performance Measures Type of Pneumonia Causative Organism Aspiration Bronchopneumonia Lobar pneumonia Interstitial Lipid Allergic Hypostatic Bacterial, MRSA or MSSA, Viral, Other (candidiasis, mycoses, fungal, etc.) Medical or Surgical CareAssociated Pneumonia Ventilatorassociated J15.8 Post-procedural J95.4 Healthcare Associated (HAP) Community Acquired (CAP) J95.4 Document underlying conditions and/or suspected causes “due to”, “secondary to”, “caused by”, “resulting from”, etc. Example: “Lobar pneumonia due to Escherichia coli” Inpatient Use “due to,” “secondary to,” “caused by,” or “resulting from” to connect congestive heart failure to its underlying cause. To Qualify inpatient diagnoses use terms such as “possible,” “probable,” or “suspected”. Examples: Pneumonia due to Pneumocystis jirovecii Lobar pneumonia due to Escherichia coli Mycoplasma pneumonia Pseudomonas pneumonia of the right upper lobe resulting from aspiration pneumonia following the inhalation of food while eating Viral bronchopneumonia Out patient “Although it is appropriate to document an uncertain diagnosis as “possible”, “probable” or “suspected” to show medical decision making and to meet medical necessity criteria, uncertain diagnoses cannot be coded in the outpatient and physician office setting.” “The outpatient coding guidelines state that a condition can only be coded to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” Document all Conditions Coexisting or Associated with the Pneumonia CHF Asthma Bronchitis COPD HIV Liver disease Neoplastic disease Renal Disease Whooping cough Other infectious disease Influenza (specify type) Document any Complications resulting from the Pneumonia Sepsis Pleural effusion Spontaneous pneumothorax Pulmonary edema Lung abscess Acute respiratory failure (Hypoxic or hypercapnic) Acute respiratory distress syndrome (ARDS) 1. Signs and or symptoms of pneumonia present on admission 2. If developed during admission then give date, time it was first noticed. 3. Document if community or healthcare-associated acquired. 4. Document sputum samples and when they where sent for culture, x-ray ordered or performed and antibiotics started or changed. Curb-65 • • • • • Signs Confusion compared to baseline Urea (BUN) greater than 19 mg/dL Respiratory rate greater than 30 breaths/min Blood pressure [,90mm Hg systolic or ,60 mm Hg diastolic] 65 years or more • • • • • • • Fever Infiltrates on Chest x-ray Tachypnea AMS Hypoxemia Tachycardia Purulent sputum Symptoms • SOB • Fatigue • Loss of appetite • Cough • Dyspnea • Chest wall pain Diagnostic Tests • • • • • • • Biopsy Chest x-ray Bronchoscopies Lavages and brushings Gram stains Sputum cultures White blood counts ICU Admission Indicators • Septic shock or the need for mechanical ventilation, along with three from below: • Respiratory rate greater than 30/min • Multilobar disease • New onset confusion or disorientation • Leukopenia (leukocyte count less than 4,000 cells/IL • Hypothermia (core temp less than 36 °C (96.8°F) • Hypotension requiring fluid resuscitation • PO2/fraction of inspired oxygen (FIO2) ration under 250 • Uremia greater than mg/dL • Thrombocytopenia (platelet count less than 100,000 cells/IL) Medical Treatments • • • • • Antibiotics Respiratory therapy Oxygen therapy Bronchodilators Smoking cessation Invasive Treatments • • • Thoracentesis Tracheostomy Mechanical ventilation (MV) (document time of intubation and duration) Response • Resolution of symptoms with improvement of condition • Lack of improvement to support change in antibiotic, or further intervention • Evidence of drug resistance Document/ Include Example Medical or Surgical CareAssociated Pneumonia Document underlying conditions and/or suspected causes Specific Organism Staphylococcal, pseudomonas Ventilatorassociated “due to”, “secondary to”, “caused by”, “resulting from”, etc. Post-procedural Type Severity of condition Aspiration, bacterial, viral Mild, Moderate, severe Example: “Lobar pneumonia due to Escherichia coli” PRIMARY DIAGNOSIS: Sepsis SECONDARY DIAGNOSIS: Pneumonia, COPD, PTSD, CKD, Depression Briefly, this is a 65 y/o man with hx of COPD (no PFT-at baseline gets SOB with showers and putting on clothes) who came yesterday to the MICU with 4 days of fever and worsening SOB, as well as nausea, vomiting and diarrhea; in the ER found to be febrile to 102, tachycardic to 133 and tachypneic to 30s; on exam he had accessory muscle use and decreased breath sounds in the left base; CXR showed a LLL infiltrate. Labs were remarkable for mild leukocytosis (10.3, no bands); creatinine = 1.30 (baseline); ABG = 7.48/29/62; lactate = 1.9. Because he met criteria for sepsis he was admitted to the MICU; received 2L of fluids and antibiotics and rapidly improved; this morning feels much better; BP is stable, HR is down to the high 90s; WBC is down to 8.2, however still remains febrile (T = 38.1). Of note, his creatinine has increased to 1.62 from 1.30. Medicine daily note xx-xx Dr.s XXX/XXXXX ASSESSMENT/PLAN: 65 year old man with presumed diagnosis of COPD was admitted to the MICU for sepsis 2/2 lobar PNA and repsiratory distress, now improved on Abx and transferred to the floor ICD-9 Coding Guidelines, Section 4, I. 2) ICD-10 Coding Guidelines, Section 4, H 3) MyVeHu, ICD-10 Clinical Documentation Improvement for Providers 4) Elsevier, Doc Briefs – Pneumonia 5) VHA – ARC Color VERA 2013 Patient Classification Hierarchy and Final Prices, http://vaww.arc.med.va.gov/reports/vera/vera2013_toc.asp 1) Pressure Ulcers Complied and presented by Charlene Haslam CPC, RHIT March 4, 2015 [email protected] X7-3522 Pressure Ulcers L89 Anatomic Site Laterality Severity of Stage Stage 1 – Persistent focal erythema. 707.21 Stage 2 – Partial thickness skin loss involving epidermis, dermis, or both. 707.22 Stage 3 – Full thickness skin loss extending through subcutaneous tissue. 707.23 Stage 4 – Necrosis of soft tissue extending to muscle and bone. 707.24 L89.xxx •L89 – Pressure Ulcer •.xx – site •.xxX - Stage Unstageable Pressure Ulcer 707.25 • Unstagable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. If slough and/or eschar obscure the true depth of the wound, the wound is considered unstageable. The presence of eschar on wound edges would not prohibit staging. Stable dry, adherent, intact eschar on the heels without erythema or fluctuance serves as the body’s natural (biological) cover and should not be removed. Treatment: Relieve and redistribute pressure. Protect perwound skin with barrier cream or past. May need debridement. Paint with betadine and leave open to air or apply a non-adherent contact layer (calcium alginate, xerofoam, or foam), cover with gauze, or ABD pad, secure with tape. Apply protective booties or float heels off the bed. Non-Pressure Wounds Suggested Wound Care for Description Cleanse Protect Contact Layer Cover Stasis dermatitis Thick, layered skin. Weepy, with small to moderate serous drainage. Red or Yellow crusty scale. Blanchable erythema. May be bilateral Normal saline, warm water, or no-rinse foam soap. Emollient cream or lotion to the skin. Ammonium lactate, urea, A&D ointment, Vaseline, or a steroid cream if inflamed Xeroform, Sorbact x 2 weeks, or calcium alginate. Refer to wound clinic. Kerlix and coban, unna boot, or 2 layer coban lite compression. Patient will likely need vascular studies before compression wraps. Venous ulcer Lower extremity. Chronic. Red base with slough, woody edema and maceration. Painful. Irregular shape, edges rolled. Hemosiderin staining. May have skin islands. Normal saline, warm water, or no-rinse foam soap. Protect the periwound skin with Cavilon barrier, Nutrashield, or Calazime cream if high exudate Protect the periwound skin with Cavilon barrier, Nutrashield, or Calazime cream if high exudate Unna boot or 2-layer Coban compression. Patient will likely need vascular studies before compression wraps. Refer to wound clinic. Arterial ulcer Lower extremity or foot. Very painful. Ruddy color. Relief when foot dependent. “Punched out” appearance. Base with black eschar or slough. Edges rolled. These wounds are very painful. Gentle flushing w/normal saline or warm water. Protect the periwound skin with Cavilon barrier, Nutrashield, or Calazime cream if high exudate Protect the periwound skin with Cavilon barrier, Nutrashield, or Calazime cream if high exudate Telfa, foam, Optiva gentle, or Optilock. Secure with Kling gauze. No compression until vascular studies are done. Refer to wound clinic Skin tears Usually upper extremities of frail elderly patients. Separation of epidermis/dermis. Edges may approximate, or roll. Note areas of bruising. Fragile skin, be gentle. Cleanse with normal saline or warm water. Try to approximate the edges. Cavillon barrier, Nutrashield, or Marathon skin glue Vaseline, Adaptic, or Xeroform gauze. Avoid Tegaderm directly on fragile skin. Telfa or foam with silicone tape, or wrap with Kerlix. Secure with netting. Braden Scale • The Braden Scale is made up of six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear) scored from 1 to 4 or 1 to 3 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6 to 23. A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines. • TX-70 Prevention and Management of Pressure Ulcers Appendix A & B • Braden Scale for Predicting Pressure Sore Risk Braden Scale for Predicting Pressure Ulcer Risk Score Sensory Perception 1. Completely 2. Very limited limited 3. Slightly limited Moisture. 1. Constantly moist 2. Often moist 3. Occasionally 4. Rarely moist moist Activity 1. Bedfast 2. Chair fast 3. Walks occasionally 4. Walks frequently Mobility 1. Completely 2. Very immobile limited 3. Slightly limited. 4. No limitations Nutrition 1. Very poor 2. Probably 3. Adequate inadequate Friction and Shear 1. Problem 2. Potential problem At Risk=15-18; High Risk= 10-12; 4. No impairment 4. Excellent 3. No apparent problem Moderate Risk= 13-14; Severe or Very High Risk= 9 or below Total Braden Scale Interventions Activity – Degree of physical activity 1. Bedfast 2. Chair fast Provide all Interventions as for level 3. Obtain wheelchair cushion. Instruct/assist to shift weight in interventions wheelchair every 15 minutes. Consider Consider specialized limiting wheelchair to 1 to 2 hour intervals. bed or support surface. Mobility – Ability to change and control body position 1. Completely 2. Very Limited Immobile Provide interventions for level 3. Limit wheelchair to 1 to 2 hours intervals. Provide all Consider pressure redistribution interventions. Use surface for wheelchair and/or bed. special pressure redistribution surface for bed 4. Walks Frequently Encourage activity as tolerated. Teach patient/family the importance of changing positions for Encourage activity as prevention of pressure ulcers. Encourage small frequent position tolerated changes. Consider wheelchair cushion. Consider PT/OT consult. 3. Slightly Limited 4. No Teach patient/family the importance of changing positions for prevention Limitations of pressure ulcers. Encourage small frequent position changes. Provide routine Encourage turning and repositioning at least every 2 hours when in bed. skin care Consider use of pillows to separate pressure areas, with special attention to off loading contracted joints. Elevate heels off bed. Consider use of foam wedges to help maintain positioning. Use draw sheet to lift up or turn in bed. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour. When elevating HOB, elevate the knee area 10 to 20 degrees. Instruct/assist to shift weight in wheelchair every 15 minutes. Consider use of assistive devices (trapeze). Consider PT/OT consult. Nutrition – Usual food intake pattern 1. Very Poor 2. Probably Inadequate Provide all Interventions as for level 3. Patient may need to be fed. Consider dietician consult. interventions Friction and Shear 1. Problem Provide all interventions Consider use of assistive device (trapeze). 3. Walks Occasionally 3. Adequate 4. Excellent Provide tray set up and other routine assistance as needed Provide tray set up Encourage meals and assist with meals as needed. Offer ordered and other routine supplements. Assess needs for oral care, assist PRN. assistance as needed 2. Potential Problem 3. No Apparent Problem Use a draw sheet to lift up or turn in bed. Elevate heels off the bed. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour. When elevating HOB, elevate the knee area 10 to 20 degrees Consider heel/elbow pads or socks. Provide routine skin care Puget Sound VA • Listing of stages – Coders can find staging on Nursing Assessment Note • Hospital acquired – If H&P states nothing then day or two later pressure ulcer stated then hospital acquired. • Community acquired – If on H&P ulcer and stage is documented then community acquired Who Does What • Interdisciplinary Wound Care Committee • Nurses assume primary role in identifying at-risk Veterans and initiating/coordinating the plan of care for prevention. – – – – Nursing staff assumes a primary role by identifying at-risk Veterans. Initiating and coordinating the plan of care for prevention. Nurses may initiate a Wound and Skin Care Program consult. Wound & skin Care Program Certified wound care nurses and nurse practitioners Perform skin rounds on the units, Respond to inpatient and outpatient consult requests, Conduct outpatient wound clinics, Conduct quarterly pressure ulcer prevalence surveys, Provide education for staff and Veterans and/or the Veteran’s designated family members, surrogates, or authorized decision-makers on the prevention and treatment of pressure ulcers across the continuum of care, and » Order specialized beds and overlays, dressing supplies, turning schedules, and wound care for both inpatients and outpatients. » » » » » Who Does What continued • Providers – Education on skin integrity and the prevention and treatment of pressure ulcers is included in orientation and the annual review for all clinicians. – Collaborate in the prevention plan – May initiate Wound and Skin Care Program consults. • Dietitians – – – – • Nothing by mouth status or clear liquid diet for more than 5 days Less than 75% of food consumed on trays for >3 days Veteran has difficulty chewing or swallowing Significant weight loss of ≥ 5% in 30 days or ≥ 10 % in the previous 180 days. Pharmacists – Analysis of the medication profile, – Product availability – Parenteral nutrition formulation • Rehabilitation &/or SCI staff – Recommends strategies to improve mobility and the use of protective and pressureredistributing or relieving devices Documentation 1) Document within 24 hours both the pressure ulcer risk score and skin inspection each time they are performed using VHA nationally-standardized templates, as available. 2) Upon identification of a pressure ulcer, the following must be documented: i. Location, ii. Stage (unless unstageable, suspected deep tissue injury or mucosal pressure ulcer), NOTE: Determination of stage cannot be made until the ulcer is free of necrotic tissue and the deepest anatomic layer is visible. iii. Size in centimeters (cm) including length, width, and depth, iv. Wound characteristics, i. Undermining, tunneling, sinus tracts, and ii. Wound bed, is it granulation or epithelialization. i. Necrotic tissue, either i. Eschar, or ii. Slough ii. Granulation iii. Epithelialization v. Drainage, vi. Pain (the fifth vital sign criteria), vii. Odor, Documentation continued… i. Surrounding skin, to include: i. Erythema, ii. Other discoloration, iii. Induration (hardness), iv. Maceration, v. Crepitus (crackling, crunchy), and vi. Fluctuance (wave-like motion of fluid upon palpation). vii.Edema, viii.Warmth, ii. Improvement or deterioration, and iii. Treatment changes. iv. Preventative measures taken v. Patient education: All patients at risk for developing pressure ulcers or who have pressure ulcers or the family member providing care for the patient of concern should be educated on pressure ulcer causes, patient risk factors, pressure ulcer prevention techniques and pressure ulcer treatment options. vi. A nutrition consult must be initiated for patients with Branden Score less than 12, within 24 hours of discovery of a new pressure ulcer or worsening of a pre-existing pressure ulcer. When the patient is refusing nutrition supplements or consuming less than 75% of meals for greater than 3 days or more, a Registered Dietician (RD) needs to be consulted for assessment, evaluation and appropriate recommendations. 3) Document a plan of care consistent with the Veteran’s current condition and national published guidelines. Refer to the Braden Scale interventions in Appendix B. Vera Impact • Diagnosis found in “Multiple Medical” due to it being with another condition that resulted in the Pressure Ulcer. • Usually secondary to something else – other condition as primary – multiple medical • Long term care – assumed as part of care for patient. • Home acquired – sitting in chair not using pads then sore developed. - Multiple Medical – HBPC – COPD and peripheral vascular disease could be Primary Dx • Means test – 1-6 service connected, no health insurance – 7-8 who are not Service connected other insurance ICD-10 CM Coding Guidelines 1) Pressure ulcer stages Pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable. Can use multiple codes to describe all the pressure ulcers the patient has 2) Unstageable pressure ulcers For pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9). 3) Documented pressure ulcer stage If the documentation does not state the stage then query the provider. 4) Patients admitted with pressure ulcers documented as healed No code is assigned if the documentation states that the pressure ulcer is completely healed. 5) Patients admitted with pressure ulcers documented as healing Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage. If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider. 6) Patient admitted with pressure ulcer evolving into another stage during the admission If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the highest stage reported for that site. References • ICD-10 Documentation Pitfalls - Presentation, slide 55; Deborah Meesing, MD, JD and Tina Schumacher, RHIA • TX-70 Prevention and Management of Pressure Ulcers, TX - Care of Patients, VA Puget Sound. • VHA Handbook - 1180.02 - Assessment and Prevention of Pressure Ulcer. Department of Veterans Affairs, Veterans Health Administration. July 1, 2011. Available online at http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2422. • http://www.ahrq.gov/professionals/systems/long-termcare/resources/pressure-ulcers/pressureulcertoolkit/putoolkit.pdf • WSC Program Booklet2014pdf.pdf pg. 21 Wound Care non-pressure wounds. http://center.pugetsound.med.va.gov/nurs/WoundCare/Staff%20Education/WSCProgramBoo klet2014pdf.pdf • VERA – Rich VandePlasch – telephone call 2/10/15 • ICD-10-CM Coding Guidelines 2015 https://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cmguidelines-2015.pdf • Coding Clinic, 2009 1Q, Stage II Pressure Ulcer Deteriorating to Stage III. How to Document Sepsis Compiled and Presented by Charlene Haslam CPC, RHIT March 26, 2015 253-583-3522 or x7-3522 30 Buzz Words Inpt Guidelines • Use words such as “due to,” “secondary to,” “caused by,” or “resulting from” to connect the SIRS or sepsis to its underlying condition. – Sepsis secondary to E. coli urinary tract infection. – Severe sepsis with respiratory failure resulting from streptococcus pneumonia • Use terms such as “possible,” “probable,” “likely,” or “suspected” when the sepsis or SIRS has not been confirmed but is under investigation and treated as if it were confirmed. Out Pt Guidelines • The condition can only be coded to the highest degree of certainty for that encounter/ visit, such as symptoms, signs abnormal test results, or other reason for the visit. – Possible sepsis resulting from cellulitis and stage 4 pressure ulcers of the left hip and sacrum 31 What is Sepsis? Not Sepsis • Bacteremia • Urosepsis • Sepsis syndrome • Multiple organ dysfunction syndrome (MODS) Is Sepsis • Systemic Inflammatory Response Syndrome – SIRS • Sepsis • Severe Sepsis Complication of Sepsis • Septic Shock 32 Documentation of Non-Infectious SIRS (Systemic Inflammatory Response Syndrome) Identifies nature of diagnosis. • Document the injuries or noninfectious conditions that led to the development of the noninfectious form of SIRS. • Specify any organ dysfunction and other complications that result from the SIRS. • Identify the cause-and-effect relationship between the injury or condition, the SIRS, and the organ dysfunction. • Use the term “systemic inflammatory response syndrome” or SIRS to identify the complex chain of events is related. Examples • Ruptured spleen and acute pancreatitis caused by bluntforce trauma to the abdomen, resulting in SIRS and concomitant coagulopathy. • Noninfectious SIRS triggered by severe dehydration and complicated by hypotension and acute renal failure. 33 Bacterial Pneumonia Is one of the most common causes of Sepsis. Any time the bacteria can be specified, do so. Do not be afraid to use the “buzz words,” probably, most likely, suspected. This lets the coder know the Veteran is being treated as if it is a bacterial infection. Always document the underlying Infection if known Gram – Negative A41.5 E. Coli A41.5 Pseudomonas A41.52 Anaerobes A41.1 Hemophilus influenzae A41.3 34 SIRS • ICD-9 • SIRS unspecified 995.90 • SIRS without Organ Failure 995.91 • ICD-10 SIRS of non-infectious origin – without acute organ dysfunction R65.10 – with acute organ dysfunction R65.11 • Non-infectious origin Always document the underlying Infection if known – Trauma • may lead to an infection – Burn – Heatstroke Gram – Negative A41.5 E. Coli A41.5 Pseudomonas A41.52 Anaerobes A41.1 Hemophilus influenzae A41.3 35 SIRS 36 Severe Sepsis • With Organ Failure 995.92 – Coded only when the term “Failure” is documented – Can be more than one organ • Acute Respiratory J96.9 unspecified – With Hypoxia J96.01 – With Hypercapnia J96.92 • Hepatic K72.90 unspecified w/o coma » With coma K72.91 – Acute & subacute without coma – Acute & subacute with coma Always document the underlying Infection if known • Acute Kidney N17.9 unspecified – With tubular necrosis N17.0 – With acute cortical necrosis N17.1 – With medullary necrosis N17.2 – Without Septic Shock R65.20 – With Septic Shock R65.21 Gram – Negative A41.5 E. Coli A41.5 Pseudomonas A41.52 Anaerobes A41.1 Hemophilus influenzae A41.3 37 Documentation for Sepsis and SIRS cases that usually have a cascade of clinical events • Clearly document when the • Document When the Sepsis patient was first determined or any suspected condition to have sepsis. has been ruled out after study. – Present on Admission – Hospital Acquired - if so • Document when conditions when. resolved; also document, in • ID if any significant localized the final note or summary, infections, organ the status of all remaining dysfunction or other conditions at the time of condition preceded the discharge. development of the sepsis or resulted from the sepsis or its progression. 38 Continuum of illness Due to Infection Bacteremia Septicemia Severe Sepsis w Septic Shock Sepsis Severe Sepsis MODS (Multiple Organ Dysfunction Syndrome) Death Document conditions that contribute or result from Sepsis/SIRS. 39 Current Pulmonary ICU Template 40 Example Template Note PRIMARY DIAGNOSIS FOR ICU ADMISSION: Severe sepsis with septic shock Source: Urinary tract infection Infection due to the presence of indwelling urinary catheter SECONDARY DIAGNOS(ES) FOR ICU ADMISSION: Acute respiratory failure, both hypercapnic and hypoxic Cause: Obesity hypoventilation Acute deep vein thrombosis (DVT), lower extremity Proximal, right Acute blood loss anemia due to gastrointestinal bleed Hyperglycemic hyperosmolar state Hyponatremia Hyperkalemia Malignant hypertension/hypertensive emergency Atrial flutter with rapid ventricular response Multifocal atrial tachycardia (MAT) AVNRT (Atrio-Ventricular Node Reentry Tachycardia) Status post cardiac arrest 41 Good Example PERTINENT HISTORY, EXAM AND DATA: Improved BP and oxygenation over night. Sedated but arousable this AM. PRIMARY DIAGNOSIS FOR ICU ADMISSION: Severe sepsis with septic shock Source: Bacteremia Culture Results: group a streptococcus SECONDARY DIAGNOS(ES) FOR ICU ADMISSION: Acute respiratory failure, both hypercapnic and hypoxic Cause: Bacterial pneumonia 42 PLAN: continue mechanical ventilation attempt to decrease PEEP continue albuterol for presumed underlying COPD with evidence of prolonged expiration on ventilator start enteral nutrition Questions? • Email – [email protected] prefer this method or call 73522. 43 References • ICD-9-CM, Code Book 2013, Coding Guidelines and codes. • ICD-10-CM, Draft Code Book, Coding Guidelines and codes. • StatRef, Sepsis – http://online.statref.com/PopupDocument.arpx?docAddress=sxw9siVw M1ZoPLzS. • Elsevier – DOC Briefs: Sepsis and Systemic Inflammatory Response Syndrome (SIRS) • Wiedemann, Lou Ann. "Coding Sepsis and SIRS." Journal of AHIMA 78, no.4 (April 2007): 76-78. • VERA – 2015 Patient Classification Hierarchy with Prices. http://vaww.arc.med.va.gov/reports/vera/vera2015_toc.asp • MerckManuals.com • VHA Directive 1082 Patient Care Directive.pdf http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3091 44