Clinical Documentation Integrity (CDI) is embarking on a series of eight to twelve messages with tips to improve documentation and facilitate the accurate representation of a patient’s clinical status that translates into coded data.

PURPOSE OF CLINICAL QUERIES
CDI nurses and coders send queries is to ensure ALL the appropriate diagnoses are documented in the chart so maximum credit is given for all that is being done. We are looking for certain “buzzwords” ─ a specific diagnosis to which we can assign an ICD-10 code.  The “buzzword” must be somewhere in the assessment and plan of one of your notes or it cannot be coded.  Unfortunately, the CDI nurses and coders cannot provide you with the actual buzzword they are looking for – they can only give you the clinical data which will support documentation of the diagnosis.  In order to help you determine which buzzword we are looking for, we are putting together a list of clinical hints with the appropriate buzzword attached.  We will present a buzzword weekly in the medical staff briefing and then compile a reference list.

THE TERM “HISTORY OF” VERSUS CHRONIC CONDITIONS
Using the term “history of” indicates a condition is no longer present or the patient no longer has the condition.  “History of” should not be used when referring to chronic conditions such as CHF, COPD, Angina and Diabetes.  Document instead:

    • Compensated diastolic CHF stable on Lasix.
    • Angina stable on Nitro Quick.
    • COPD controlled with Advair.
    • Type 1 diabetes mellitus without complication.

It is important to document chronic conditions even if they are stable to reflect the severity and complexity of the patient.

CHRONIC RESPIRATORY FAILURE
Chronic respiratory failure applies to any patient requiring continuous home oxygen.

If the CDI nurse sends you a query that states “Your documentation states “patient on X liters ​continuous home O2​”.  Can you please document a corresponding diagnosis for this clinical data?”, the buzzword we are looking for is ‘chronic respiratory failure’.

CONTINUOUS HOME O2  =  ​CHRONIC RESPIRATORY FAILURE
This is a CC (comorbidity or complication) and results in increased patient severity index, increased LOS and increased reimbursement. Please note that we are not looking for the cause of the chronic respiratory failure, only the buzzword.

PRESSURE ULCER AND INJURY
The Wound-Ostomy nurses do an excellent job documenting skin ulcers in the chart.  Unfortunately, an ICD10 code cannot be assigned from the Wound-Ostomy nurse consult note.  The type of ulcer (pressure, ischemic, diabetic, traumatic, venous, non-healing surgical wound), location of the ulcer and whether or not the ulcer was present on admission MUST be documented in the provider’s notes.  Documentation of a pressure ulcer not only increases patient severity, length of stay and reimbursement, but also is required by DNV and the state to track quality of care.

If the CDI nurse sends you a query that states “The Wound-Ostomy nurse has documented a skin ulcer….”, we are looking for documentation of the ulcer in your notes.  To help with your documentation, there is a dot phrase, .ICD10SKINULCER.

WOUND-OSTOMY NURSE NOTE = DOCUMENT SKIN ULCER
​In order to improve communication between the Wound-Ostomy Nurse (WON) and providers, the WON will now be communicating the presence of a pressure ulcer or injury on the physician sticky note, located on the Overview tab.

ACUTE ENCEPHALOPATHY
According to the NIH, encephalopathy is “any diffuse disease of the brain that alters brain structure or function.”  If your patient has an acute alteration in mental status, clearly different from baseline and due to a reversible condition,  consider documenting acute encephalopathy instead of confusion, altered mental status or delirium.  If possible, please specify toxic (due to meds, illicit drugs or toxic chemicals) or metabolic (due to hypoglycemia, sepsis/infection, dehydration/AKI, hypoxia, fever or electrolyte abnormalities).  By contrast, chronic encephalopathy is a permanent condition (e.g.  anoxic brain damage).

If the CDI nurse or coder sends you a clinical query stating “Documentation states patient has altered mental status and delirium….”,  we are asking you to consider documenting acute encephalopathy (either toxic or metabolic).  You can use .ICD10ENCEPHALOPATHY to assist your documentation.

ALTERED MENTAL STATUS OR DELIRIUM = ACUTE TOXIC OR METABOLIC ENCEPHALOPATHY
Acute toxic or metabolic encephalopathy is an MCC and increases severity index, length of stay and reimbursement.  Just plain encephalopathy is a CC, so there is less increase in severity index.

Contact Physician Advisor for CDI, Dr. DeAnn Cummings at Deann.Cummings@sjhsyr.org with questions.

 

SEVERE SEPSIS
As per the original Surviving Sepsis Campaign, the definition of severe sepsis is infection with associated organ dysfunction.  The definition of just sepsis is SIRS positive (2/4 values) and infection.  The documentation of severe sepsis indicates increased severity of illness beyond just sepsis.  While there are more recent guidelines which use the definition of severe sepsis for all sepsis, Medicare (CMS) still follows the original guideline as does New York State.

If the CDI nurse sends you a query that states “Sepsis is documented in the chart.  The following clinical indicators of organ dysfunction were also present.”, we are looking for documentation of SEVERE SEPSIS.

​SEPSIS PLUS ORGAN DYSFUNCTION = SEVERE SEPSIS
The easiest way to avoid a query and to get documentation correct the first time is to use .ICD10SEPSIS to assist with your documentation.