Coding Tips

These tips are only meant as guidelines to help improve physician documentation in order to clarify patients’ clinical condition.

Acute Kidney Disease

When treating adult patient with “acute kidney disease”:

• Document ‘Acute Kidney Injury’(preferred) or ‘Acute Renal Failure’.

• Acute Kidney Injury is an abrupt (within 48 h) reduction in kidney function, not significantly responsive to IV hydration for 48h and associated with:

An absolute increase in serum creatinine of ≥ 0.3mg/dl (≥ 26.4 μmol/l) OR
A percentage increase in serum creatinine of ≥ 200% (2 times baseline) OR
A reduction in urine output with documented oliguria <0.5 ml/kg per hour for more than six hours*

• If suspected, document cause of acute kidney injury e.g.: acute tubular necrosis, diagnosed as elevated creatinine with significant granular cast in urine.

*Ravindra L Mehta et al; Acute Kidney Injury Network: Report of an Initiative to Improve Outcomes in Acute Kidney Injury, Critical Care 2007, 11: R 31 (doi: 10.1186/cc5713).

Alcohol/Substance Abuse

When treating adult patient with “alcohol/substance abuse”:

Avoid using the term ‘alcohol use’, instead use the term ‘alcohol abuse’.

Also clarify if a patient has alcohol abuse or alcohol dependence.

In case of alcohol abuse whether it is periodic vs. chronic dependence.

Document other body system effects or involvement from alcohol or drug abuse.

Clearly name the substance of abuse.

Using signs like (+) coc. Or (+) ETOH. Or just writing lab report results is not enough. Instead, write words like ‘cocaine abuse’ or ‘alcohol abuse’.

Blood Stream Infection – Central Catheter Related

When managing adult patients with possible “central catheter related blood stream infection”:

With a new fever of unknown source, sample a peripheral vein and each port of the catheter before antibiotics are given. Bacterial isolator blood cultures (not AFB or fungus) are preferred. These will grow yeast (e.g. Candida) just fine.

Isolators are not indicated each day when fever persists.

Do not pull the line if the blood cultures are negative. Inserting a new line carries its own risks of complications and infection. First do no harm!

Chest pain

When treating adult patients with “chest pain”:
• The most likely disease causing the symptom of chest pain should be documented.

• Cardiac chest pain is not a diagnosis; Use words like ‘unstable angina’ or ‘stable angina’.

• If exact cause of chest pain is not clear, then write the most likely diagnosis.

• Other common causes of chest pain are musculoskeletal pain, GERD, pleuritic pain etc.

COMA

When treating adult patient with “COMA”:

• Document the cause of COMA.

• A COMA is a deep state of unconsciousness, during which an individual is not able to react to the environment due to underlying significant medical or surgical condition or disease.

• A person dying due to terminal illness, when becomes unresponsive does not have a new diagnosis of COMA, rather part of the dying sequence.

• Avoid the use of words like unresponsive, obtundation, lethargy, stupor, or persistent vegetative state and instead use the word COMA.

Core Measures for Heart Failure

When treating patients with “heart failure”, the following “core measures” are recommended by CMS (Medicare) and The Joint Commission:
• Given an evaluation of left ventricular systolic function.

• Given ACE or ARB for left ventricular systolic dysfunction (EF<40%). • Heart failure written discharge instructions should be provided. • Heart failure discharge instructions included are: weight monitoring, salt/fluid intake, activity level, discussing discharge medications, contacting for worsening symptoms and follow up visit. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Discharge Instructions – Heart Failure

The following “discharge instructions” for heart failure patients are generally recommended:

• Weight monitoring: contact doctor if gains ≥3 Ibs in 2 days or ≥5 Ibs in a week.

• Monitor salt and fluid intake in diet.

• Contact your doctor for worsening symptoms of heart failure- increased swelling, weight and/or shortness of breath.

• Importance of clinic follow up within 3-5 days after hospital discharge should be stressed.

• Discussion about activity level.

• Explaining discharge medications.

Family & Social History

When documenting “family and social history” in the medical record:
• Document relevant history.

• Clearly identify the source of the information.

• Remember that some conditions, like psychiatric diagnoses and HIV status, may require specific consents from family members.
Note: The social history and medical history of the family may be now, or in the future, very relevant to a patient, their condition, and their care. But remember that as the medical record is shared with other medical institutions, physicians, other care providers, and insurance companies, the other persons identified in medical and social history did not consent to have their personal information shared or disclosed.

GI Bleed

When treating adult patient with “GI bleed”:
• Clearly document the site of bleeding, if known.

• If symptoms are suggestive of GI bleeding but site of bleeding is unclear, documentpossible site of bleeding (e.g.; possible bleeding duodenal ulcer).

• If bleeding patient has a very low B.P., requiring blood transfusion and/or vasopressors, document hypovolemic shock.

• If bleeding is associated with decreased hematocrit, specify acute and/or chronic blood loss anemia.

• Remember ‘rectal bleed’ originates in the rectum. If bleed is melena orhematochezia, use those terms instead.

Hyperglycemia

When treating adult patient with “hyperglycemia”:

• Use terms ‘Type 1 or Type 2 diabetes’. Avoid stating ‘IDDM’ or ‘NIDDM’.

• Write the reason for hyperglycemia if patient is not diabetic (e.g. steroid therapy, other endocrine dysfunction).

• Make clinical judgment to say if DM is ‘controlled or uncontrolled’.

• HbA1C level is one way of determining control of DM.

• Document relationship of diabetes with other manifestations of diabetes (e.g., diabetic neuropathy, gastro-paresis, nephropathy, or blindness).

Malignancy

When treating adult patient with “malignancy”:

• Document the primary source of malignancy.

• Clarify if primary source is still being treated or no longer present.

• Do not use the term “history of” if malignancy is still present. Only use this term if the primary source is believed to be gone.

• Differentiate between the organs of reappearance and organ of origin.

• Document if current symptoms are related to direct invasion of malignancy, pressure effect, or totally unrelated to malignancy.

• Terms like “mass” or “tumor” do not necessarily translate into malignancy. For coding purposes you do not need a biopsy confirmation if you believe it is malignancy from clinical judgment, x-rays and scans. If still in doubt then words like possible, likely or suspected malignancy can be used.

Pain

When treating adult patient with “pain”:
• Clarify if the pain is acute, chronic or acute on chronic.

• Document the site and underlying condition causing pain.

• Specify if pain control or management of the disease causing pain, is the main reason for admission.

• Document when a patient has postoperative pain that exceeds the routine or expected postoperative pain threshold.

Perioperative Treatment

Patients on “chronic beta blocker (BB) therapy”, when treated “perioperatively”:

• Make sure that beta blocker therapy (BB) is given within 24 hrs prior to surgical incision through 6 hrs after arrival in recovery.

• If BB is contra-indicated, then clearly document appropriate reason such as bradycardia (HR<50), etc. • NPO status is not one of the accepted reasons for not giving BB therapy peri-operatively. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Pneumonia – Flu Season

When treating adult patients with “pneumonia” remember:

• Flu season officially starts October 1st and goes through March 31st.

• Flu vaccination should be considered for all admitted patients particularly those aged 50 years old or older prior to discharge.

• Pneumonia vaccination is required for patient age 65 years old and older throughout the year, if the first dose was given more than five years ago.

• Pneumonia vaccine is also recommended for younger patients with certain chronic conditions like asthma, COPD.

• Pneumonia vaccine should be given if vaccination status is unclear.

Present On Admission (POA) Conditions

When managing adult patients with following conditions, document the words “POA” (present on admission) in admission note or soon after, if the condition was present at admission time:

• Catheter associated urinary tract infection.

• Vascular catheter associated infection.

• Pressure ulcers, especially stage 3 and 4.

• Three complications of diabetes- DKA, non-ketotic hyperosmolar coma, and hypoglycemic coma.

Present On Admission (POA) – Urinary Catheter

When admitting adult patient for “in-hospital treatment”:

• Document the presence of any urinary catheter at the time of admission.

• At admission, if presenting symptoms are suggestive of urinary tract infection, consider documenting ‘possible urine catheter related infection’ as the cause of patients’ symptoms.

• Once final diagnosis is established by admission culture data as catheter related infection, this will ensure proper coding that urinary infection was present on admission and not acquired during hospital stay.

SIRS (Systemic Inflammatory Response Syndrome) or Sepsis

When treating adult patients with “SIRS” or “Sepsis”:

• Document SIRS (Systemic Inflammatory Response Syndrome) if evidence of widespread inflammatory response with two or more of the following:Temperature> 38C or < 36C, HR >90/min, RR> 20/min,WBC > 12,000 or < 4,000 cells/mm3 or > 10% BANDS.

• Document Sepsis or possible Sepsis, if there is evidence of SIRS (Systemic Inflammatory Response Syndrome) AND suspected or proven infection.

• Septic shock is sepsis with evidence of tissue hypoperfusion and persistent hypotension (SBP < 90 mm Hg) unresponsive to initial fluid resuscitation. • Remember ‘Sepsis’ and ‘UTI’ are two separate diagnoses. Avoid ‘Urosepsis’. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Tissue Debridement

When treating adult patient for “tissue debridement”:

• Document if debridement was Excisional or Non-excisional.

• Debridement is Non-excisional when brushing, irrigating, scrubbing or washing is used for devitalized, necrosed, or sloughed tissue and/or foreign material.

• Debridement is Excisional when surgical removal or cutting away of devitalized tissue in the OR or at the bedside is done. Note: minor scissors removal of loose tissue does not qualify as excisional debridement.

• ‘Sharp debridement’ is not always indicative of an excisional debridement. Definite cutting away of tissue by a sharp instrument needs to be documented.

• Document the site and depth (ex: skin, muscle, bone) of the debridement.

• Clarify whether the procedure was ‘debridement’ of toenails to differentiate it from ‘debridement’ of a foot ulcer.

Example of Excisional debridement: Operative Procedure: Excisional debridement of necrotic wound of the left thigh including the skin and subcutaneous tissue. Description of Procedure: Sharp dissection was used to excise the skin and subcutaneous tissue of the wound. Viable tissue was identified.

Example of Non-excisional debridement: Procedure: Non-excisional debridement – Enzyme debridement. Patient presents with stage II sacral pressure ulcer with partial thickness skin loss. Enzymatic debridement performed.

Abnormal Mental Status

When treating adult patient with “abnormal mental status”:

Use the term encephalopathy to describe a patient with abnormal mental status changes and avoid the terms acute confusional state.
It is preferable to use the word metabolic encephalopathy to describe a patient with acute delirium.
Clearly document the cause of encephalopathy, if known or suspected, e.g. metabolic, infection, and toxic effects of drugs or dehydration.
If exact cause is unclear then document possible contributing cause/causes of encephalopathy.

Anemia

When treating adult patient with “anemia”:

Document possible acute blood loss anemia for any sudden significant drop in HCT over a brief period of time, especially if requiring transfusion.

Blood loss occurring over time (weeks) signifies chronic blood loss anemia.

GI bleeding causing anemia should be documented with known or suspected site of bleeding.

‘Rectal bleed’ means bleeding originating from rectum.

If appropriate, use the terms melena or hematochezia instead of rectal bleed.

Blood Stream Infection – Vascular Catheter Related

CDC criteria for diagnosing “vascular catheter related blood stream infection” in adult patient is if:

• Patient has a recognized pathogen (S.Aureus, Enterococcus spp., Gram Negatives, or Candida spp. and others) cultured from one or more blood cx. AND organism cultured from blood is not related to an infection at another site OR

• Patient has at least one of the following signs or symptoms: fever (38 C), chills, or hypotension AND signs and symptoms and positive lab results are not related to an infection at another site AND common skin (organism) contaminant (*) is cultured from two or more blood cultures drawn on separate occasions.

• Additionally, URMC observation shows that if all the ports have <1cfu growth, the line is probably not the source of bacteremia. *common skin contaminants: (i.e., diphtheroids (Corynebacterium spp), Bacillus (not B anthracis) spp, Propionibacterium spp, coagulase-negative staphylococci (including S epidermidis), viridans group streptococci, Aerococcus spp, Micrococcus spp) [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Chronic Kidney Disease (CKD)

When treating adult patient with “chronic kidney disease”:
• Document the term chronic kidney disease’ with stage of the disease (below).

• If patient requires chronic dialysis, write ESRD on dialysis or chronic kidney disease stage 5 on dialysis.

• Avoid words like chronic renal insufficiency or chronic renal failure alone.

• Patients may have acute on chronic kidney disease based upon criteria mentioned in the tip for acute kidney disease.

Note: Stages of CKD:

Stage 1 — Kidney damage with clinical evidence of renal disease but normal or increased GFR (>90ml/min/1.73m2)

Stage 2 — Kidney damage with mild decrease GFR (60-89)

Stage 3 — Moderate decreased GFR (30-59)

Stage 4 — Severe decreased GFR (15-29)

Stage 5 — Kidney failure GFR (<15 or dialysis)

COPD/Asthma/Bronchitis

When treating adult patient with “COPD/asthma/bronchitis”, document:

• If status asthmaticus or acute asthma exacerbation is present.

• Acute on chronic bronchitis, and/or COPD exacerbation, not just bronchitis and COPD respectively.

• If patient is Oxygen dependent and has viral or bacterial pneumonia.

• The presence of acute respiratory failure, if acute respiratory distress was noted requiring significant change (increase) in Oxygen supplementation.

CVA

When treating adult patient with “CVA”:

• Document the cause of CVA.

• Avoid terms like RIND (reversible Isch Neuro deficit), CVA or stroke alone.

• Clarify if residual deficit/weakness is due to old CVA vs acute CVA.

• Clarify ‘hemorrhagic stroke’ (e.g., intracerebral hemorrhage, subarachnoid hemorrhage, etc) from occlusive or embolic ‘cerebral infarction’.

• Intracranial hemorrhage, occlusion, thrombosis, embolism, and/or stenosis are insufficient on their own when an infarction has also occurred.

• Document if patient has evolving stroke that was aborted by enzyme or anticoagulation therapy.

• Unspecified syndromes, such as basilar or vertebral artery syndromes, need additional documentation when the cause is known, for example, an infarct.

Echocardiogram Report

When reviewing “echocardiogram report” of adult patient with cardiac disease:

• Important echocardiographic findings must also be written in patient’s note.

• Evidence of pulmonary hypertension seen on echo with any required treatment modification need to be documented.

• Significant valvular heart disease or pericardial disease requiring monitoring of cardiac function should be clarified.

Fluid/Electrolyte/Acid-Base Imbalance

When treating adult patient with “fluid/electrolyte/acid-base imbalance”:
• Calculate serum osmolality if significant hypernatremia (Na > 150mm/l) or hyponatremia (Na < 130mm/l) and dehydration (BUN elevated > 3 times baseline) are noted.

• Serum osmolality should also be calculated if blood sugar exceeds 600mg/dl.

• Clearly document hyperosmolar state if serum osmolality exceeds reference range (lab range: (278-297mosmol/kg).

• It is important in diabetics with higher sugars to check for serum ketones and CO2 to clarify if ketosis or ketoacidosis (CO2 < 18 & AG > 10) is also present.

• Any history of decreased consciousness suggestive of possible comatose state due to hypoglycemia or hyperglycemia immediately prior to or at the time of admission should be documented.

Heart Failure

When treating adult patient with “heart failure”:
• Document the cause of heart failure e.g., hypertensive, ischemic, valvular, viral or alcohol heart disease.

• Clarify if heart failure is acute, chronic or acute on chronic.

• Specify if failure reflects systolic or diastolic dysfunction or both.

• It is important to document if patient had an acute MI within past eight weeks and if the present heart failure is related to that event.

• In chronic renal failure patients, volume overload or non-cardiac pulmonary edema usually leads to acute diastolic or systolic heart failure.

• Acute heart failure may results from IV fluid administration in septic patient.

Hypertension

When treating adult patients with “hypertension”:

• Use the words ‘accelerated hypertension’ instead of hypertensive emergency or urgency for very high BP (>180/120) and associated acute symptoms/conditions (eg: headache, chest pain, acute diastolic heart failure etc.).

• ‘Malignant hypertension’ is documented if very high BP is associated with retinal hemorrhages, exudates or papilledema.

• Hypertensive encephalopathy is due to very high BP causing mental status changes (or other signs of cerebral edema).

• The term “controlled hypertension” could be used if the blood pressure is fine, but the term “uncontrolled hypertension” should be used if the BP is <180/120 and requires medication adjustments. Avoid the term “elevated BP”. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Morbid Obesity

When treating adult patient with “morbid obesity”:

• Always document the word ‘morbid’ with obesity.

• New coding rules requires documentation of calculated adult BMI (Body Mass Index = weight (kg) / (height (m))2 in all patients with morbid obesity.

• Adult BMI of >40 may increase severity of illness and risk of mortality.

• Dietary consult should be considered in all morbidly obese patients.

Pericardial Disease

When treating adult patient with “pericardial disease”:
• Document pericardial effusion if seen on echo with or without heart failure.

• Echo showing evidence of tamponad physiology should be clearly documented.

• Acute pericarditis may be the likely diagnosis with chest pain and pericardial rub.

• Clarify if pericardial effusion is part of cardiac or systemic disease process.

Pneumonia – Type

When treating adult patient with “pneumonia”:

• Clarify the type of pneumonia, indicating community acquired, hospital acquired or aspiration pneumonia.

• If pneumonia is found in a patient with acute alcoholism, grand mal epilepsy or past history of significant CVA, it is considered aspiration pneumonia (and should be documented as possible aspiration pneumonia) until proven otherwise.

• If cultures are positive for any bacteria, document the type of bacterial pneumonia (strep, staph etc.) and mention if associated bacteremia is also present.

• Do not forget to order pneumonia (all year) and flu vaccines (during flu season) for these patients prior to discharge, if indicated.

Present On Admission (POA) – IV Line or Port

When admitting adult patient for “in-hospital treatment”:
• It is important to look for and document presence of any intravenous line or port at the time of admission.

• If presenting symptoms are suggestive of infection, consider documenting‘possible line infection’ as a cause of patients’ symptoms.

• Once final diagnosis is established by culture data as line infection, this will ensure proper coding that line infection was not acquired in the hospital.

Respiratory Failure

When treating adult patients with “respiratory failure”:
• Document if respiratory failure is acute or chronic.

• “Acute Respiratory Failure” is defined as a sudden change in respiratory status requiring increased need for supplemental oxygen without which the patient’s life would be threatened.

• Common conditions causing acute respiratory failure are acute heart failure, pneumonia, COPD exacerbation and acute asthma attack.

Symptoms Alone & Unclear Diagnoses

When treating adult patients for “symptoms alone” and “unclear diagnoses”:

• Remember to write the ‘possible diagnosis’ being considered and treated.

• The terms probable, likely, or suspected can be used before any possible diagnosis.

• Unless the probable diagnosis is written, symptoms like ‘shortness of breath, headache, and chest pain’, default to the lowest severity, even though patient may be severely sick.

Unresponsiveness

When treating adult patient with “unresponsiveness”:

• It is important to document the word coma, NOT Unresponsiveness if it is clinically relevant.

• Coma is a clinical state in which patients have impaired responsiveness (or are unresponsive) to external stimulation and are either difficult to arouse or are not arouseable.

Most cases of coma presenting to an emergency department are due to trauma, cerebrovascular disease, intoxications, and metabolic derangements; resuscitation from cardiac arrest and postictal state after a witnessed epileptic seizure are other causes of coma.

• Note patients with coma may improve with time during treatment but still needs to have documentation of transient coma or coma on admission.

Acute MI

When treating adult patients with “acute MI”:

Aspirin should be prescribed at discharge unless contraindicated.

Statin needs to be prescribed at discharge unless contraindicated.

Aspirin and statin related contraindications need to be clearly documented.

Smoking cessation advice/counseling provided and documented for all smokers who have smoked within the past year.

Atrial Fibrilation

When treating adult patient with “atrial fibrillation”:

Document atrial flutter if present along with atrial fibrillation.

Clarify if atrial fibrillation is due to unstable angina, STEMI or NSTEMI.

It is important to write if flutter/fibrillation is causing hypotension.

A trial fibrillation requiring cardioversion vs. medical management has different severity.

Cardiac Arrest

When treating adult patient with “cardiac arrest”:

• Document the word cardiac arrest and/or respiratory arrest or cardiopulmonary arrest.

• Clearly document the cause of cardiac arrest, if known. Example: cardiac arrest due to VF, AF, MI, or PE etc.

• Document the most likely cause, if exact cause is unknown.

• Remember, there is no diagnosis as “PEA” (Pulse less Electrical Activity). If PEA is seen then write cardiac arrest due to PEA.

• A person who is dying and goes into cardiac arrest does not have a diagnosis of cardiac arrest, rather it is part of the dying process.

Cocaine Abuse

When treating adult patient with “cocaine abuse”:
• Document if symptoms could be related to the offending drug.

• Differentiate between ‘drug abuse’ and ‘drug dependence’.

• Cocaine dependence/use may be associated with acute coronary syndrome and accelerated hypertension.

Core Measures – Definitions of Types

Definitions of different types of “core measures” are described below:

• Clinical processes of care measures are core measures that show, in percentage form or as a rate, whether or not a health care provider gives recommended care and treatment known to give the best results for most patients with a particular condition.

• Outcome measures are core measures designed to reflect the results of care, rather than whether or not a specific treatment or intervention was performed.

• Patient experience of care measures are measures by a national, standardized survey of hospital patients about their experiences during a recent inpatient hospital stay.

Diabetes Mellitus (DM)

When treating adult patient with “Diabetes Mellitus (DM)”:

• Clarify the type of DM, indicating type I or type II.

• Document presence of acute complications of DM e.g. ketosis, ketoacidosis or hyperosmollar state on admission.

• Hypoglycemic coma is another acute metabolic complication that involves altered state of consciousness (not necessarily an unconscious state).

Fall

When treating adult patient with “fall”:
• Remember, there is no diagnosis as ‘fall’.

• Underlying possible or known cause of the fall must be documented.

• Common causes of falls are dehydration, hypotension, syncope, cardiac arrhythmias, stroke, delirium and occult or known infection.

• Document conditions resulting from fall e.g. fracture or hematoma.

• Presence of/or history of concussion or transient loss of consciousness, even if resolved by the time you saw the patient, need to be documented.

Fractures

When treating adult patient with “fractures”:

• Document nature of a fracture whether traumatic or pathological or both.

• Compression fractures defaults to traumatic unless documented as pathological.

• Document when a patient has known or possible bone disease such as osteoporosis, bone metastasis; or x-ray evidence of osteopenia.

• Specific site of fracture should be noted e.g., fracture of shaft of femur instead of fracture femur.

• If patient lost enough blood from fracture to require monitoring or transfusion, it is acute post-traumatic hemorrhagic anemia — this is not a complication of surgery.

HIV

When treating adult patient with “HIV” disease:

• Always clarify if patient is HIV positive or has AIDS.

• Any history of AIDS related illness.

• The latest CD4 count (if available).

• If respiratory symptoms are present then possibility of PCP and/or CAP is being considered.

• Document other current and secondary conditions related to AIDS.

Low Blood Pressure

When treating adult patient with “low blood pressure”:

• The word ‘hypotension’ should be documented.

• Cause of hypotension noted ex: bleeding, dehydration or poor systolic heart function etc.

• Document shock if there is evidence of decreased tissue perfusion.

• Clarify between chronic hypotensive states vs. acute hypotension.

Multiple Co-Morbidities

When treating adult patient with “multiple co-morbidities”:

• Clearly document medical names of the acute diseases being treated.

• It is equally important to document medical names of the chronic/stable conditions being treated (ex. hypertension, COPD).

• Proper documentation requires linking medication with disease, e.g. Synthroid for hypothyroidism rather than medication with organ, e.g. Synthroid for thyroid.

• Use of words like “acute” or “chronic” with disease conditions is also critical for proper coding.

• Chronic stable conditions need to be documented at least once per admission by a licensed provider to be valid.

Perioperative Consultation

When consulting on adult cardiac patient “perioperatively”.

• Surgery patients on chronic beta-blocker therapy should have received beta-blocker within 24 hours prior to surgical incision through 6 hours after arrival to recovery OR

• Document reason for not giving beta-blocker therapy perioperatively.

• Common reasons for not prescribing beta-blockers are bradycardia (HR <50), other reason by MD/NP/PA. NPO status of the patient is not a valid reason. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Pneumonia – Antibiotics

When treating adult patient with “pneumonia”, CMS and Joint Commission require us to comply with the following:

• Obtain blood cultures prior to the first dose of antibiotic.

• Give the 1st dose of antibiotic(s) within 6 hours of ER registration time.

• Use CMS/Joint Commission approved initial antibiotic(s). Commonly used in our hospital are Ceftriaxone + Azithromycin OR Moxifloxacin alone.

• If broader coverage required, document possible additional infections.

• Antibiotic may be changed later with clinical course and sensitivity report.

• Vaccinate all pneumonia diagnosis patients prior to discharge with both pneumovax (all year) and flu vaccine (flu season‐Oct 1st thru March 30th).

• Pneumovax is recommended if vaccination status is unknown.

• Provide (and document) Smoking cessation counseling for all who have smoked within one calendar year from admission time.

Poor Nutritional Status

When treating adult patients with “poor nutritional status”:

• Always document the word ‘malnutrition’ and the degree of malnutrition (mild, moderate or severe), as appropriate.

• New coding rules also requires documentation of calculated adult BMI (Body Mass Index = weight (kg) / (height (m)) 2.

• Adult BMI of <19 may increase severity of illness and risk of mortality. • Dietary consult should be considered in all malnourished patients. [/av_textblock] [av_hr class='short' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello'] [av_textblock size='' font_color='' color='']

Present On Admission (POA) – Pressure Ulcers

When admitting adult patient for “in-hospital treatment”:
• Look for and document any skin breakdown (pressure ulcer) on admission.

• Clarify the stage (see below) and site of pressure ulcer.

• Pressure ulcer documentation by physicians, NPs, or PAs is required in admission note or soon thereafter to be considered present on admission.

• Nursing documentation, although critical, is not sufficient for pressure ulcer coding and severity of illness.

Note: Stages of pressure ulcer:

National Pressure Ulcer Advisory Panel

Stage 1 — intact skin with non-blanch able redness.

Stage 2 — partial thickness loss of dermis -shallow open ulcer.

Stage 3 — full thickness tissue loss and visible subcutaneous fat.

Stage 4 — full thickness skin loss with exposed bone, tendon or muscle.

Severity of Illness & Risk of Mortality

To reflect the true “severity of illness” and “risk of mortality” properly:

• Avoid the use of “R/O”, “?”, up and down arrows and “+” or “- signs.

• Use the terms “possible”, “likely”, “suspected” or “probable” in situations where there is a reasonable likelihood of the diagnosis in question.

• Document all co-morbid conditions and complications.

• Document all lab findings, pathology reports and radiology findings in the progress notes.

• Write “acute”, “chronic” or “acute on chronic” to further define a condition. For example: “acute on chronic systolic heart failure”.

Syncope

When treating adult patient with “Syncope”:

• Trip/fall should be clarified from fall due to syncope or possible syncope.

• Document any identifiable event present in the history causing vasovagal syncope, such as post-micturition, cough, heat, or frightening event.

• Evidence of dehydration (skin turgor, orthostatic hypotension, and/or increased BUN/Creatinine), a common cause of elderly syncope should be clearly documented.

• If known, name the condition causing syncope or if unknown a possible cause of syncope, such as acute myocardial infarction, CVA, sepsis, drug-drug interaction, arrhythmia, GI bleed etc.