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Clinical indicators for top diagnoses at Salem Health

Do patients meet these criteria?

By Coleen Elser, RN, CCDS, clinical documentation specialist

Payers often request clinical indicators when a particular diagnosis does not appear to meet the indicators set up by Salem Health’s established definition/criteria. These standard definitions can be found under the Epic icon on the top left corner of the Epic screen.

The conditions below are all listed with their spelled out standard definitions.

  • SIRS (systemic inflammatory response syndrome)/sepsis/severe sepsis and septic shock
  • Acute respiratory failure
  • Encephalopathy
  • Acute MI (myocardial infarction)
  • Diabetes mellitus
  • Functional quadriplegia or complete immobility
  • Malnutrition
  • Obesity and morbid obesity
  • Acute renal failure
  • Chronic renal failure
  • UTI/CAUTI (Urinary tract infection/catheter-associated urinary tract infection)

Centers for Medicare and Medicaid Services and other payers scrutinize these conditions when deciding whether to pay — based on conditions meeting the criteria we have set aside to define these illnesses. When CDI and/or coder see these conditions, it is our job to make sure they appear to meet criteria. If conditions do not, then coders are forced to query the physician on for that day to supply the criteria used to determine that the patient met Salem Health standard definitions. This person is not always the physician who wrote the diagnosis originally.

The top three conditions queried for clinical indicators are:

1.  Sepsis is a major condition that is queried frequently because the criteria used to determine cannot be explained by another disease entity. If a patient comes in with nausea/vomiting and diarrhea and they are dehydrated and have acute renal failure, it may be that the ARF is due to dehydration more than to the sepsis. However, if the physician feels that the ARF is due to the sepsis, then he/she must state this as being due to sepsis, which then makes the diagnosis severe sepsis as it has associated organ failure.

The diagnosis has to strongly meet the criteria. For example, a WBC 11.9, with a temperature 100.3, UTI, lactic acid 1.2, pro calcitonin 0.12 would not meet the criteria in the Salem Health standard definition.

SIRS no longer codes to sepsis if not otherwise specified, so we will usually query to see if that was your intent. Bacteremia does not equate to sepsis, so if the patient is septic with bacteremia, please document this. If the sepsis is due to a catheter or a line, please clearly state this to avoid a query being written.

2.  Acute respiratory failure should show a picture of a patient with some respiratory distress — even if only for a short period— if the patient required additional treatment and time. ABG’s are nice but not always available, so we can use O2 sats less than 89 percent on RA or less than 95 percent on supplemental O2, RR greater than 24, air hunger, cyanosis, use of accessory muscles to breathe or wheezing. When we use these criteria, they should be stated with your diagnosis of acute respiratory failure. Please document the cause (or suspected cause) of acute respiratory failure if possible, and don’t forget to mention ‘acute on chronic’ when appropriate. Any patient who is on home oxygen therapy is considered to have chronic respiratory failure as the reason for their need for oxygen, so remember to add chronic respiratory failure if you have these patients. These patients are usually more inclined to have increased respiratory problems while hospitalized, so this is considered a cc/comorbid condition.

ICD-10 guidelines require the words ‘acute’, ‘chronic’ or 'acute on chronic' when appropriate. They also require ‘with hypercapnia’ and/or ‘with hypoxia’ be used to distinguish both acute and chronic respiratory failure or the diagnosis will not be properly coded. The Smartphrase for this is — .cenacuterespfail.

3.  Malnutrition is becoming a very highly scrutinized diagnosis. CMS and other payers are now looking to see — not only that they meet criteria — but how we treated it. For coding purposes, adult malnutrition describes under-nutrition only and can be coded as mild, moderate (non-severe) or severe. Adults who lack adequate calories, protein or other nutrients needed for tissue maintenance and repair experience under-nutrition. This may be due to inadequate intake and/or increased requirements, impaired absorption, altered transport and altered nutrient utilization. We often query for malnutrition based on the RD recommendations using ASPEN criteria — which is based weight loss, insufficient energy intake, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation and diminished functional status as measured by handgrip strength — rather than body mass index. This means that, even though a patient may be morbidly obese, he or she can still be severely malnourished. When you order RD to review the patient, or when they make suggestions for nutritional supplements, please look at their note and see if the patient does indeed meet malnutrition guidelines. This will also prevent a query coming your way.

Hopefully, this will help clear up any questions you have as to why you get queries asking for clinical indicators and what you can do to prevent being queried in the future. Please always feel free to call any CDI member. We all work from home, but we always include our phone number on all our queries.

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