Q&A: Importance of treatment

Q: I recently listened to a webinar where treatment was emphasized especially for diagnoses such as sepsis, acute respiratory failure, and severe protein calorie malnutrition. How much emphasis should CDI professionals put on treatment?

For example, can we count treatment from a dietician’s recommendation of supplements such as Glucerna or Ensure even if the recommendation was never ordered or given? Or what if a provider ordered something, but the patient refused, or the nurse didn’t administer it?

A: Therapeutic treatment is one criterion within the Uniform Hospital Discharge Data Set (UHDDS) guidelines that makes a diagnosis eligible for code assignment as a secondary diagnosis. Therefore, treatment is always something to consider when performing case reviews. This holds especially true for certain diagnoses such as sepsis, acute respiratory failure, and severe protein calorie malnutrition as these are all diagnoses of significant severity that require treatment.

I find it helpful to ask myself what would happen if the treatment wasn’t provided. For example, if a provider doesn’t treat sepsis, what will happen? If the patient is truly septic, the patient will die. This is why there is so much emphasis on ensuring that IV antibiotics were given for a septic patient. Additionally, if antibiotics were deescalated on a septic patient and the diagnosis continues to be copy and pasted in subsequent notes, this scenario turns into a clinical validation opportunity for the CDI specialist. So, in the case of sepsis, treatment is vitally important.

Let’s apply the same question to acute hypoxic respiratory failure. If a patient meets the criteria of acute hypoxic respiratory failure with a partial pressure of oxygen (PaO2) of less than 60mmhg and doesn’t receive treatment, what will happen? The answer is that the patient will progress into cardio-pulmonary arrest. Additionally, the importance for treatment is actually two-fold for this diagnosis as the underlying etiology that causes or contributes to acute respiratory failure must also be corrected. We can’t send a patient in acute respiratory failure home. So again, treatment is of high importance.

Lastly, let’s look at severe protein calorie malnutrition. When this diagnosis exists, it carries a higher risk of mortality. There are usually numerous nutritional deficiencies that coincide with any type of malnutrition with varying degrees. How a patient responds to being in a malnourished state depends on how healthy they were when the condition began and what is being done about it. If malnutrition is not treated, the patient will deteriorate and can ultimately die. Therefore, treatment as well as identifying the underlying cause are important factors to focus upon, especially with severe protein calorie malnutrition.

I have seen numerous charts where a patient with the documented diagnosis of severe protein calorie malnutrition was discharged on a regular diet or “diet as tolerated” without any follow-up instructions noted. This is where provider education and clinical validation opportunities lie for the CDI specialist. So again, with this diagnosis, a CDI specialist should expect to not only see treatment being implemented but also follow-up and discharge instructions outlining the discharge diet (treatment) and the need for follow-up visits for outpatient evaluation of the condition.

Dieticians make recommendations to the provider, but the provider does not have to agree or implement a dietician’s recommendations. The only entity that can order treatment for any patient is the treating provider. Therefore, a dietician’s recommendations for treatment does not constitute therapeutic treatment and cannot be used as such to determine if a diagnosis can be coded as a secondary diagnosis.

It’s the patient’s right to refuse treatment, even if a provider orders treatment, but it doesn’t negate that the diagnosis exists. If a nurse doesn’t administer an ordered treatment, I would want to know why the treatment was withheld. Was it that they lost IV access and treatment was resumed upon reinsertion of viable IV access? Was it that the patient’s blood pressure was too low to tolerate the treatment? Or was the patient’s mental status not compatible with treatment delivery? These are all good questions to ask while going through the review process. If the answers to these questions aren’t clear and the CDI specialist is unsure of what action to take, they should consult their chain of command in leadership or discuss the case scenario with the provider when appropriate.

For those who may be unfamiliar with UHDDS guidelines, coding and reporting a diagnosis depends on at least one of the following criteria being met:

• The condition was evaluated and/or monitored,
• The condition was therapeutically treated,
• The condition had diagnostics performed,
• The condition increased nursing care, or
• The condition increased length of stay

Lastly, we must also remember that clinical validation is mandated by the False Claims Act and is a separate process from DRG validation. The False Claims Act mandates that all diagnoses billed, must be clinically valid. This is an important point to remember when assessing treatment plans.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.