Guide to Clinical Validation, Documentation and Coding

Contents Introduction ......................................................................................................... 1 Diagnoses ............................................................................................................. 7 Acidosis ..................................................................................................................................... 7 Acute Exacerbation ..............................................................................................................13 Acute Exacerbation/Decompensation of Chronic Obstructive Pulmonary Disease, Emphysema with Bronchitis and Asthma with COPD .................................13 Acute Kidney Injury ..............................................................................................................17 Acute Myocardial Infarction ...............................................................................................23 Acute Pulmonary Edema, Noncardiogenic ...................................................................28 AIDS ..........................................................................................................................................32 Aspiration Pneumonia/Pneumonitis/Bronchitis ...........................................................39 Atelectasis ...............................................................................................................................46 Bacteremia ..............................................................................................................................49 Candidiasis ..............................................................................................................................54 Cerebral Edema .....................................................................................................................59 Cerebrovascular Accident ...................................................................................................64 Chest Pain as Principal Diagnosis .....................................................................................72 Coagulopathy ........................................................................................................................76 Decubitus (Pressure) Ulcer .................................................................................................81 Deep Vein Thrombosis of Upper and Lower Extremities ............................................85 Dehydration as Principal Diagnosis ..................................................................................89 Empyema, Pleural or Pyothorax ........................................................................................93 Encephalopathy ....................................................................................................................97 Gastrointestinal Hemorrhage ......................................................................................... 101 Heart Failure (non-rheumatic) ........................................................................................ 108 Hepatic Encephalopathy/Hepatic Coma/Portosystemic Encephalopathy .......... 113 Hypernatremia ................................................................................................................... 116 Hyponatremia ..................................................................................................................... 120 Iatrogenic (Intraoperative) Puncture or Laceration (Tear) (Rent) ......................... 126 Ileus ....................................................................................................................................... 130 Intraop or Postop Hematoma/Hemorrhage/Seroma (not due to device, implant or graft) ........................................................................................................ 133 Intravenous/Dialysis Line/Catheter Infections ........................................................... 138 Malnutrition ........................................................................................................................ 143 Overdose, Poisoning, and Toxic Effects of Illicit Drugs, Prescribed Drugs, Nonprescribed Drugs, Alcohol and Solvents, Gases, Aerosols, Nitrates ..... 147 Pleural Effusion ................................................................................................................... 152 Postoperative Anemia ...................................................................................................... 157 Postoperative (Postprocedural) (Wound) Infection .................................................. 161

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Guide to Clinical Validation, Documentation and Coding

Cerebral Edema

Cerebral Edema G93.6

Cerebral edema

MCC

S06.1X0A

Traumatic cerebral edema without loss of consciousness, initial encounter

MCC

S06.1X[1,2,3,4]A

Traumatic cerebral edema with loss of consciousness of [30 min or less, 31 min to 59 min, 1 hour to 5 hours 59 min, 6 hours to 24 hours], initial encounter

MCC

S06.1X5A

Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

MCC

S06.1X6A

Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

MCC

S06.1X7A

Traumatic cerebral edema with loss of consciousness of any duration with MCC death due to brain injury prior to regaining consciousness, initial encounter

S06.1X8A

Traumatic cerebral edema with loss of consciousness of any duration with MCC death due to other cause prior to regaining consciousness, initial encounter

S06.1X9A

Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter

Diagnosis:

MCC

cerebral edema; traumatic cerebral edema

Discussion Cerebral (brain) edema is the excess collection of fluid and sodium in the brain. It may result in brain swelling which leads to elevated intracranial pressure (ICP) and compression, which displaces or herniates the brain tissue from one area to another with “a mass effect/midline shift.” Its clinical significance ranges from none/low to being an independent risk factor for mortality. The causes of cerebral edema are varied and include cerebral infarction/hemorrhage/ischemia, trauma, neoplasm, infection, toxicity, or metabolic disorders affecting the nervous system. The clinical significance of the cerebral edema must be stated and is the determining factor for reporting. If the edema is clinically insignificant (i.e., expected [postsurgery]), small, asymptomatic and resolves spontaneously without treatment, without further workup or monitoring, then it will not be reported. If it is symptomatic, requires workup, monitoring, treatment or causing further complications (neurological symptoms, herniation), it can be reported as long as the link is made to the clinical criteria and its significance stated. When reportable, cerebral edema, as a manifestation of the underlying condition or as a concurrent condition to traumatic brain injury, is a reflection of the condition having a higher severity of illness and risk of mortality than if the cerebral edema was inconsequential. When the clinical significance is unclear or there is contradictory information or incomplete documentation, query the attending physician or other qualified health care professional.

Coding Tip Code assignment cannot be based only on ancillary test results or therapies alone. A diagnosis and its clinical significance must be supported by both physician or other qualified health care professional documentation and clinical criteria. When it is unclear or there is contradictory information, query the physician or other qualified health care professional for clarification.

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Procedures Bone Marrow/Stem Cell Transplant Administration—Transfusion. Putting in blood or blood products. 302

Administration, Circulatory, Transfusion

Procedure:

bone marrow or stem cell transplant (infusion)

Discussion Although the actual procedural statement indicates transplant, a bone marrow or stem cell transplant is actually a transfusion procedure, by PCS definition and coded in section 3 Administration to the root operation 2 Transfusion. Administration procedures should not be confused with Transplantation procedures. Instilling autologous or nonautologous bone marrow or stem cells is coded to Administration, whereas implanting a functioning, living body part from another individual is coded to the root operation Transplantation in the Medical and Surgical section (0). Coding Guideline B3.16: Transplantation vs. Administration Putting in a mature and functioning living body part taken from another individual or animal is coded to the root operation Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section. Bone marrow or peripheral blood stem cell transplantation is a process that includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high-dose chemotherapy or radiotherapy prior to the actual transplant. The bone marrow or peripheral stem cells are harvested from either a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion. Harvested bone marrow is usually obtained from a large bone of the donor. The donor is given general or regional anesthesia. Needles are inserted through the skin over the pelvic (hip) bone and into the bone marrow to draw the marrow out of the bone. The harvested bone marrow is then processed to remove blood and bone fragments. Harvested bone marrow may be cryopreserved. Purging is a process to remove certain types of cells, such as cancer cells and T-lymphocytes, from stem cells prior to infusion. After the bone marrow is processed, the processed marrow is infused into the bloodstream of the recipient through an intravenous catheter. Hematopoietic stem cells are found in the bone marrow, in the bloodstream (peripheral blood stem cells) and in umbilical cord blood. Cells from each of these sources may be used in transplants. An autologous transplant uses the patient’s own bone marrow or stem cells for the transplant, while an allogeneic transplant uses a donor’s bone marrow or stem cells. For stem cell harvesting from peripheral blood, the progenitor cells are collected by apheresis, often after the donor is given a hematopoietic growth factor to mobilize progenitor cells into the bloodstream. The patient is prepared in much the same way as when giving a regular blood donation. Whole blood is drawn out of one arm and put into an instrument called a cell

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Appendix A. Query Guidelines, Examples, and Template

Guide to Clinical Validation, Documentation and Coding

Cerebral Edema Example Please review the following documentation/clinical data: (Enter the pertinent information from the documentation in the medical record.) cerebral infarction Reference coding guideline or clinical criteria: (Enter the appropriate references to be cited.) Increasing vasogenic cerebral edema causing mass effect noted on follow-up CT scan. Based on this information, please clarify: Was the finding of cerebral edema causing mass effect of any clinical significance, and if so, can it be described? Can the result of the mass effect be further defined (increasing intracranial pressure, brain herniation, other (specify), or unknown)? Physician response or supporting documentation:

Physician signature and date: Amendment to the medical record is required: If yes, please amend the following documents:

Clinical coder/clinical documentation improvement:

Phone: Email:

246

❑ yes

❑ no