Q&A: Finding focus for CC/MCC reviews

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version of the webinar, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q: I’m having trouble with querying physicians for complication codes. Could you please provide guidance?

A: This is difficult. Unless there is an (coding) index directive, query the attending physician to determine if a condition occurring after surgery is due to, or caused by, the surgical procedure (such as atelectasis following surgery). From a medical perspective, the conditions which occur after surgery are not typically due to the surgery, but are due to other factors such as in atelectasis, operative pain, sedation, supine position, etc. Therefore, when I ask, it is when there is a high probability of being related to the surgical procedure (hematoma, excess hemorrhage which is addressed intraoperatively or immediately post-operatively). 

Q: Does systemic inflammatory response syndrome (SIRS) with pneumonia qualify for sepsis or should this be queried?

A: Unfortunately, in ICD-10-CM, there is no coding index entry for SIRS, and the previous index entry in ICD-9-CM for SIRS with infection no longer leads to sepsis. Therefore, the physician must be queried to clarify the documentation and assign an appropriate code.

Q: Should we query when the physicians use accelerated or malignant hypertension (HTN) in regards to hypertensive emergency/urgency?

A: Yes, as the former terms now are considered unspecified, a more specific condition should be sought.

Q: Would a physician query be necessary if the physician documentation indicates malnutrition (CC) and the dietician’s assessment documents mild to moderate malnutrition (CC)?

A: It is unnecessary to query a physician regarding the non-specific documentation of malnutrition. If the physician documents mild or moderate malnutrition, one would assign malnutrition, not otherwise specified, unless the physician specifies further.

Q: Do you have any suggestions for what CDI professionals should do if the physician documents a diagnosis but it is not supported by documentation in the chart or by clinical indicators?

A: I would ask the physician to review the record along with enclosed medical criteria regarding the condition in question. I have developed a handbook which provides evidence-based clinical indicators for common medical conditions. (For a copy, email Behaik@aol.com.)

Q: Should we query for electrolyte abnormalities on gastric bypass patients. We are told imbalances are normal due to diet restrictions.

A: Although electrolyte disturbances are common in gastric bypass patients, they are not normal and not integral to the procedure. The physician would typically would treated the patient if the levels were significantly clinically deranged. In this setting, I would query the attending physician to determine if the levels are merely lab abnormalities or if they should be clinically significant and reportable.

Q: When acute respiratory failure is reported in the postop period and is integral to the procedure (for example, the patient remains on mechanical ventilation for less than two days following post op), do we have to query to see if it is significant or should we code without a query?

A: From a clinical perspective, I assume major surgery (cardiopulmonary, esophageal, gastrointestinal resection surgery) often require prolonged ventilation. In minor surgeries, such as prostate biopsies, extremity surgeries, etc., if the patient is on mechanical ventilation longer than 24-hours and assuming the patient is awake, then I would tend to query regarding post-operative respiratory failure, particularly if there is a medical complication such as aspiration pneumonia, pulmonary edema, etc.

Q: What’s the difference between acute respiratory failure and acute pulmonary insufficiency? Would oxygen dependent Chronic Obstructive Pulmonary Disease (COPD) be insufficiency instead of failure?

A: Acute respiratory failure is a life-threatening condition which is typified by a pO2 of less than 60 on room air (in patients with previously normal lungs) in the clinical situation of a patient with rapid respirations and increased work of breathing in the acute setting. Acute pulmonary/respiratory insufficiency is a poorly defined term merely meaning non-life-threatening impairment of gas exchange. Therefore, it does not represent a pO2 of less than 60 (in patients with previously normal lungs), but not a completely normal pO2. Oxygen-dependent COPD is consistent with chronic respiratory failure as to obtain oxygen (via Medicare) one must have a pO2 of less than 60.

Q: Post-operative pulmonary insufficiency is an MCC, but post-operative respiratory insufficiency is neither a CC/MCC. Is there a way to differentiate these two diagnoses?

A: There is no medical differentiation between pulmonary and respiratory insufficiency. This is merely an idiosyncrasy of ICD-10-CM.

Q: According to resources, a lactate less than 1.0mmol/L, which is normal, is considered a sepsis indicator. Why is this an appropriate indicator if it is within normal limits rather than greater than 2 which is abnormal?

A: Despite the “normal” limits of lactate up to 2.2 in most hospitals, it has been determined, retroactively, a lactic acid level of greater than 1 is a finding seen in sepsis. It is not specific as there are other hypoperfusion states and/or chronic liver disease which may result in an elevated lactic acid level. Therefore, it must only be interpreted in the appropriate clinical circumstances.

Q: Is healthcare associated pneumonia (HCAP) synonymous with hospital acquired pneumonia?

A: They are similar, but not synonymous. HCAP includes nursing homes, long-term acute care facilities, chemotherapy, and dialysis centers. Hospital-acquired pneumonia requires a hospitalization of at least a three-day stay. The pathogenic organisms are similar as is the treatment.