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
- SIRS Criteria, 2 or more of the following:
- 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
- Severe Sepsis:
- National Institute of General Medical Sciences: Sepsis is a serious medical condition. It's caused by an overwhelming immune response to infection. The body releases immune chemicals into the blood to combat the infection. Those chemicals trigger widespread inflammation, which leads to blood clots and leaky blood vessels. As a result, blood flow is impaired, and that deprives organs of nutrients and oxygen and leads to organ damage.
With this information in mind, we ask ourselves the basic CDI question, "What are the providers saying, and will this documentation be as specific as possible when translated to an ICD-10-CM code?" Applying your organization's sepsis criteria, you also must consider if the patient meets that definition due to the identified infection (e.g., COVID-19, SARS-CoV-2 Pneumonia, hypotension requiring pressors, etc.). We put that consideration on the list as we continue through the medical record.
Other questions we seek to understand include:
- Is there documentation of cytokine response syndrome or cytokine storm?
- Is the provider describing a dysregulated inflammatory response to COVID-19?
And, we put those considerations on the list and continue through the medical record.
Next, we ask:
- Is there documentation of acute organ dysfunction?
- Is it related to infection such as COVID-19 (e.g., acute hypoxic respiratory failure due to COVID-19 pneumonia, transaminitis, etc.)?
We also include all of the standard CDI review elements, such as past medical history, past surgical history, pertinent social history, home medications, etc. and make note of those on our list as we continue through the medical record.
After going through the documented notes, we turn our attention to the diagnostic reports. First up are lab results. Laboratory findings for patient with positive COVID-19 test could include:
- White blood cell count may vary, but lymphopenia appears to be the most frequent characteristic
- Elevated Markers of Inflammation
- C-Reactive Protein (CRP)
- Erythrocyte Sedimentation Rate (ESR)
- Interleukin-6 (IL-6)
- Generally, procalcitonin (PCT) is within normal limits if pneumonia is limited to viral pneumonia (COVID-19), as it is typically elevated with bacterial infection
- Other findings could include:
- Elevated Liver Function Tests
- Total Bilirubin
- Elevated Kidney Function Tests
- Elevated Cardiac Enzymes
- Coagulopathy with results that could include elevated:
- Elevated Liver Function Tests
Other abnormal results would be noted in the CDI review, such as electrolytes, blood gases (venous and/or arterial), pulse oximetry, electrocardiogram, etc.
As we continue through the medical record, we turn our attention to imaging reports. COVID-19 chest imaging results typically include findings of ground glass opacities and may be with or without findings of consolidation.
After collecting references to documentation and diagnostics, we compare the notes collected over the course of the review and the interventions. Specifically, we verify if evidence of treatment implies an undocumented diagnosis or understated severity of illness. Treatment for patients with COVID-19 could include a variety of pharmaceuticals. These therapeutics are being updated as we learn more and as research uncovers interventions approved for clinical trial or compassionate use. The medications may include:
- Antiviral (e.g. Remdesivir, Titonavir)
- Antimalarial (e.g., hydroxychloroquine, chloroquine)
- Anti-inflammatory (e.g., tocilizumab, corticosteroids)
- Inhaled Prostacyclin, or PGI2 (relaxes blood vessels, antiplatelet aggregation and has anti-inflammatory properties in the lungs)
- Antibiotics (known or suspected bacterial superinfection)
- Vasopressors (shock management including but not limited to – norepinephrine, vasopressin, phenylephrine, Giapreza – synthetic human angiotensin II is approved for New Technology, include ICD-10-PCS code XW033H4 peripheral vein or XW043H4 central vein)
As CDI professionals, we apply the same scrutiny to patients with COVID-19 pneumonia diagnosis as we did with the two urinary tract infection patients receiving different intensity of service. We consider why one patient is admitted to medicine and another to critical care. CDI asks the same questions and evaluates the data in order to answer those questions.
Based on treatment and documentation, CDI consideration could include submitting a query to clarify sepsis. With evidence of acute organ dysfunction/failure or multiple organ dysfunction syndrome (MODS), CDI consideration could also include requesting additional specificity about organ dysfunction (e.g., defibrination syndrome, acute kidney failure, acute liver failure, etc.) linked to COVID-19 sepsis to meet the requirement for severe sepsis (refer to Coding Clinic Third Quarter 2016 for guidance about viral sepsis).
Providers may be reluctant to document sepsis because the care and/or work-up does not check all of the CMS SEP-1 Core Measures. Therefore, it may be necessary to speak with providers and explain that CDI follows American Hospital Association Coding Clinic guidance for viral sepsis assignment to the ICD-10-CM code A41.89 (refer to Coding Clinic Third Quarter 2016). At the time of this writing, no official announcement has been made about the SEP-1 core measure and its application to COVID-19 sepsis.
Based on the comorbid conditions, CDI review will also evaluate treatment and compare it to the preadmission treatment. If there has been an escalation of treatment, a query may be required to clarify an acute decompensation or exacerbation of the underlying condition.
Although the list of considerations could go on and on, it's important to note that CDI approach and practice has not changed as we look to clarify documentation. When necessary, CDI queries providers for clarification so the documentation most accurately tells the story of the care provided.
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