Bridging the gap between the clinical transcript and coded data
COVID-19 may be the headline but, as a seasoned clinical documentation improvement (CDI) professional, I always ponder what’s the rest of the story? As we learn more about the disease and its effects on the body systems, CDI is challenged to look through the documented words and identify gaps between the written story and the data that will eventually be used to tell that story.
CDI’s challenge has always been to bridge the gap between the clinical transcript and the coded data. With a goal to make sure the coded translation agrees with the provider’s clinical determinations, CDI identifies and clarifies areas not in alignment (e.g., urosepsis versus sepsis associated with a urinary tract infection).
Another element of consideration during a CDI documentation review is to determine why patients with the same diagnoses receive different levels of care. For example, let’s say a patient with a urinary tract infection presented with altered mental status and fever with orders to admit to medical floor. Another patient with a urinary tract infection presented with altered mental status and fever with orders to admit to critical care. CDI looks to answer questions, such as:
* What is the difference between these two patients?
* Are both patients receiving the same antimicrobial management?
* Do comorbidities account for the difference in the intensity of service?
* Is there evidence of acute organ dysfunction or failure associated with the infection?
* Is there an undocumented diagnosis that requires critical care management?
Healthcare is now confronted with a disease that no one has ever had before. Coronavirus disease (COVID-19) is caused by the virus identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 clinical presentation is similar to, but not a direct match with, other disease processes. Treatment is different and changing as new data and new intervention results are analyzed. In unprecedented moves, Coding Guidelines published a temporary new code specifically for COVID-19 accompanied by interim Coding Clinic information for technical guidance. DRG groupers were also revised to accommodate these changes midway through Federal Fiscal Year 2020.
Against the backdrop of these changes, CDI evaluation of clinical documentation, through the lens of clinical and technical translations, did not change. What changed, however, was documentation describing COVID-19 and SARS-CoV-2 related illness, diagnostic results, and treatment. Let’s begin the CDI review with provider documentation and associated CDI considerations.
Documentation may include diagnostic statements such as “SARS-CoV-2 Pneumonia”, “SIRS due to COVID-19”, “COVID-19 Cytokine Response Syndrome”, “Acute Hypoxic Respiratory Failure due to SARS-CoV-2 Pneumonia”, and “Cytokine Storm due to COVID-19.” Before sorting through these or similar COVID-19 documentation findings, it may be necessary for CDI to consider:
* Cytokine Release Syndrome
* Refer to Coding Clinic First Quarter 2020 for a clarification of previously published coding guidance.
* As a “syndrome,” refer to the Official Coding Guidelines Section I.B.15 Syndromes.
* Cytokine Storm: An overwhelmingly dysregulated inflammatory response resulting in high levels of cytokines (immune system proteins).
* Section I.B.15 of the Official Coding Guidelines, Syndromes: *Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations **that are not an integral part of the disease process** may also be assigned when the condition does not have a unique code.* Although there is no ICD-10-CM code for systemic inflammatory response syndrome (SIRS) due to infection, SIRS is a “syndrome” and, as such, would be coded according to these Official Coding Guidelines.
* Definition of sepsis
* Sepsis-3 Definition: *In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.*
* CDC Sepsis Definition: *Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency.*
* CMS Sepsis Core Measure (SEP-1: the Early Management Bundle, Severe Sepsis/Septic Shock Measure is a CMS National Inpatient Quality Measure, which went into effect October 1, 2015) defines sepsis as:
* SIRS Criteria, 2 or more of the following:
* Heart Rate >90
* Respiratory Rate >20
* Temperature >100.9F or <96.8F * White Blood Cell Count >12K, <4K, or bands >10%
* AND known or suspected source of infection
* Severe Sepsis and Septic Shock are defined as:
* Severe Sepsis:
* Two SIRS criteria, AND
* Known or suspected source of infection, AND
* End-organ dysfunction which includes any one of the following and excludes evidence that is considered chronic or secondary to medication (e.g., ESRD with creatinine >2, Coumadin with INR >1.5):
* Prior lab values used to determine end-organ dysfunction must have been reported within 6 hours preceding the onset of severe sepsis.
* Hypotension defined as
* Systolic blood pressure <90, OR
* MAP <65, OR * Drop in systolic blood pressure of >40 mmHg from the last previously recorded systolic blood pressure considered normal for that patient
* Creatinine >2, OR Urine output <0.5ml/kg/hr for >2 hours
* Total Bilirubin >2
* Platelets <100K * Coagulopathy: INR >1.5, OR aPTT > 60 seconds
* Lactate >2 mmol/L
* Acute respiratory failure as evidenced by new need for invasive or non-invasive mechanical ventilation
* Septic Shock is severe sepsis with
* Hypoperfusion despite adequate fluid resuscitation, OR
* Lactate > 4