ACDIS day3-11 track3-11 pres 0515 Love f©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission

©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

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Coming to a Hospital Near You: “UHC Mortality Reviews” Based on Actual EventsJennifer Love, RN, BA, CCDS, CDIP

Senior CDI Consultant

United Audit Systems, Inc.

King, North Carolina

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify terminology & diagnoses needed for common mortality variables

– Recognize clinical diagnoses that a CDI professional may not routinely explore but are imperative in the mortality review world

– Script mortality queries that are effective, consistent, & concise


Audience Survey

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UHC‐University Health System Consortium:

• Alliance of the nation's leading nonprofit academic medical centers

• Formed in 1984

• Based in Chicago

• Fosters collaboration with its 117 academic medical center & 310 affiliated hospital members through its programs & services

• Helps its members achieve excellence in quality, safety, & cost‐effectiveness

Overview of 5 Common MS‐DRGsUHC Risk Modeling Summaries


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Male, 18 <= Age < 31 Female, 18 <= Age < 31

Low Socioecon Stat, Prim Payer = Medicaid Chronic Kidney Disease Congest ive Heart Failure Pulmonary Heart Disease Renal Disease/ Failure Arrhyt hmia Elect rolyt e Disorders Female, 51 <= Age < 65 Male, 5 1 <= Age < 65 Admit Source = Transf From Skilled Nursing/ Long Term CareMalnut rit ion

Admit Source = Transf From Acut e Acut e Repirat ory Failure Coagulopat hy Male, 6 5 <= Age < 75 Female, 65 <= Age < 75 Shock Lung Cancer Primary Liver Malignant Neoplasm Male, 7 5 <= Age < 80

Female, 75 <= Age < 80

Coma Acut e& Subacut e Necrosis of Liver

Severe Sepsis Male, 8 0 <= Age < 85 Chronic Liver Disease Female, 80 <= Age < 85 Vent on Admission Day Secondary Malignancy Male, Age >= 85 Female, Age >= 85 Acut e Myeloid Leukemia, Act ive

Cardiac Arrest

Septicemia w MV 96+ hours (MS‐DRG 870), Septicemia w/o MV 96+ hours w

MCC (MS‐DRG 871), Septicemia w/o MV 96+ hours w/o MCC (MS‐DRG 872)

Model Group: #903 ‐ (Age>=18)

Variable Definitions

Flyer Included

Variables for Model #903

**Definition of Variables**: These are found to be statistically significant

predictors of the outcome.

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Minor Stroke Sequelae

Cerebral Edema

Congestive Heart Failure

Coagulopathy

Aspiration PN

Male, 75 <= Age < 80

Female, Age >= 85

Male, 80 <= Age < 85

Sepsis


End Stage Renal Disease

Subendocardial AMI, Initial

Male, Age >= 85

Arrhythmia

Cerebral Hemorrhage

Hypotension

Anoxic Brain Damage

Metastatic Cancer

Leukemia

Obstructive Hydrocephalus

Shock

Coma

Brain Compression

Diabetes Insipidus

DNR

Cardiac Arrest

Vent on Admission Day


Intracranial hemorrhage or cerebral infarction w MCC (MS‐DRG 64), Intracranial hemorrhage or cerebral infarction w CC (MS‐

DRG 65), Intracranial hemorrhage or cerebral infarction w/o CC/

MCC (MS‐DRG 66)


Variable definitions

flyer included



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Male, 31 <= Age < 51

CC Valvular Disease

Severe Brain/Spinal Conditions

Admit Source = Transf From Skilled Nursing/Long Term Care

Respiratory Failure

Male, 75 <= Age < 80

Male, 80 <= Age < 85

CC Pulm Circulation Disease

Admit Source = Transf From Acute

CC Malnutrition

CC Liver Disease

CC Congestive Heart Failure

CC Coagulopthy

Fungal Infection

AMI Initial Episode

Acute Liver Disease

CC Lymphoma

Shock

CC Metastatic Cancer

DNR

Vent on Admission Day


Renal failure w MCC (MS‐DRG 682), Renal failure w CC (MS‐DRG 683), Renal failure

w/o CC/MCC (MS‐DRG 684)



flyer included




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CC Congestive Heart Failure


CC Fluid & Electr Disorders

CC Coagulopthy

Hypotension

CC Solid Tumor w/o Metas

Male, 65 <= Age < 75


Renal Disease/Failure

Respiratory Failure


Acute GI Disorders

Male, 75 <= Age < 80


Aspiration Pneumonia/Pneumonitis

Acute Liver Disease

CC Lymphoma

Male, 80 <= Age < 85

Female, Age >= 85

Male, Age >= 85

Shock


Disorders of pancreas except malignancy w MCC (MS‐DRG 438), Disorders of pancreas except malignancy w CC (MS‐DRG 439), Disorders of pancreas except malignancy

w/o CC/MCC (MS‐DRG 440)



flyer included



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Male, 18 <= Age < 31



Renal Disease/Failure

Male, 65 <= Age < 75

CC Coagulopthy

Shock

CC Pulm Circulation Disease

Ischemic Stroke

Other Pulmonary

Female, Age >= 85

Acute Liver Disease

Lung Metastases

Fungal Pneumonia

CC Lymphoma

Severe Brain/Spinal Conditions

CC Solid Tumor w/o Metas

Male, Age >= 85

Male, 80 <= Age < 85

Infectious Pneumonia

Idiopathic Fibrosing Alveolitis


Cystic Fibrosis w/ Pulmonary Manifestations


Respiratory system diagnosis w ventilator support 96+ hours (MS‐DRG 207)



flyer included



Terminology & Diagnoses Needed for Common Mortality Variables


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Respiratory Failure Variable

Chronic respiratory failureAcute respiratory failure

Acute and chronic respiratory failureAcute edema of lung, unspecified

Acute respiratory failure following trauma and surgeryOther pulmonary insufficiency, not elsewhere classified, following

trauma and surgeryOther pulmonary insufficiency, not elsewhere classified

Please document all applicable diagnoses in the patient’s medical record & state if the conditions were present on admission or if they developed during the stay.

Examples of qualifying diagnoses if documented as present on admission

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Pulmonary Heart Disease Variable



Primary pulmonary hypertensionOther chronic pulmonary heart diseases

Chronic pulmonary heart disease, unspecified

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Severe Brain/Spinal Conditions Variable

Intracranial abscessAnoxic brain damageEncephalopathy

Compression of brainCerebral edemaBrain death

Toxic encephalopathyTemporal sclerosis

Benign intracranial HTN




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Arrhythmia Variable

Paroxysmal supraventricular tachycardiaParoxysmal ventricular tachycardia

Atrial fibrillationAtrial flutter

Ventricular fibrillationSupraventricular premature beats

Other premature beatsSinoatrial node dysfunction

Other specified cardiac dysrhythmias



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Electrolyte Disorders Variable

Volume depletionHypernatremiaHyponatremia

AcidosisHypovolemia

HyperpotassemiaHypopotassemia

AlkalosisDehydration



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Sepsis Variable

Streptococcal septicemiaMethicillin‐resistant Staphylococcus aureus septicemia

Septicemia due to gram‐negative organismToxic shock syndrome

Septicemia due to pseudomonasSepticemia due to serratia

Systemic inflammatory response syndromeSepsis

Severe sepsis




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Shock Variable


ShockCardiogenic shock

Septic shockTraumatic shock

Postoperative shock, unspecifiedPostoperative shock, cardiogenic

Postoperative shock, septicPostoperative shock, other


Scripting Mortality QueriesThat Are Effective, Consistent, & Concise

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Patient transferred from OSH with GI bleed • MICU H&P page 1, “Overnight prior to transfer had increase O2 requirement” “was

placed on Bipap” “Next morning, patient oriented less than baseline & satting upper 80’s & low 90’s”

• MICU page 2, “40% vent mask—obtunded” • H&P page 4, “Significant cardiopulmonary disease (Afib, severe AS, CAD, CHF, COPD,

Pulm HTN, OSA) on home O2. Currently somnolent, SPO2 91%, 40% Vent mask” • PN page 4, “Bipap on 5/10 40%, A&O x 2” • PN page 6, “O2 requirement likely 2/2 volume” • Cards consult: “…developed progressive confusion” “SOB & was transferred” “…placed

on Bipap” • Death certificate: “cardiogenic shock”


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MD Query #1: Cardiogenic shock documented on death certificate, no other documentation. Please clarify if cardiogenic shock was confirmed for this admission. Yes, cardiogenic shock confirmed ____ No, cardiogenic shock was not confirmed ________ Other (Please specify) ___________ Clinically unable to determine_______ Please clarify if present on admit. Yes______ No _______ Clinically unable to determine_______

MD Query #2: Please clarify, based on your medical judgment, if there is a diagnosis which reflects the above information for this patient’s admission and if present on admit. Please Choose: Examples include but are not limited to‐‐Acute on chronic respiratory failure_______ Acute respiratory failure________ Acute respiratory distress_______ Other (Please specify)_______Clinically unable to determine________ Please clarify if present on admit.Yes_____ No_______ Clinically unable to determine______

Continued

TIP: Consider adding COLOR !

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• H&P page 3, “Septic shock, AKI on CKD suspect 2/2 to sepsis” • Consult page 7, “Transferred from OSH with septic shock suspect 2/2 to cholangitis‐‐‐‐‐

‐Lactate 5.5.” • PN page 12, “Septic Shock‐cholangitis‐‐‐‐AKI/CRI—monitor closely avoid nephrotoxins

meds” • 12/28, “CO2: 17 Bun 59 Creat 2.0 Lactate 5.5” • 12/28 Order #52 #67 ”Sodium Chloride 0.9% 1000 ml, 999 ml/hr”

MD Query: Please state the diagnosis indicated by the above elevated lactate levels. Examples >> Acidosis______ >> Lactic Acidosis________ >> Other (Please specify)________ >> Clinically unable to determine________ Please clarify if present on admit. >> Yes___>> No___ >> Clinically unable to determine if present on admit___

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• D/C Summary page 1: “88 year old male” “found unresponsive by his grandson” “taken to outside hospital where a CT head showed a massive subdural hemorrhage with significant midline shift” “intubated for airway protection” “transferred here” “On admission … neurological exam was as follows” “was intubated” “was not on any sedation” “did not open eyes” “Pupils were nonreactive bilaterally” “…did have a corneal reflex but did not have gag reflex” “…was extending in the bilateral uppers and withdrawing in the bilateral lowers”

• PN page 9, “SDH/ICH, resp failure, hypoxic” • CT brain 12/19, “Subdural hemorrhage measuring 30 mm at its widest point, …,

causing marked compression of the right hemisphere and subfalcine herniation. Right ventricular compression with trapping and dilatation of the left ventricle. 2. Right external capsule intraparenchymal bleed measuring 15‐20 mm.”

• 12/19, “Left/Right arm movement: Decelebrate” “Left & right leg movement: Triple Flex” “LOC: Comatose” “GCS: 5”

• “…made DNR and comfort measures only”


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MD Query #1: Please clarify, based on your medical judgment, if there is a diagnosis which reflects the above information for this patient’s admission. Examples :>> Coma________ >> Comatose________ >> Semi‐coma________ >> Other (Please specify)__________ >> Clinically unable to determine___________ Please clarify if present on admit. >> Yes______ >> No_______ >> Clinically unable to determine________

MD Query #2: Please clarify, based on your medical judgment, if there is a diagnosis which reflects the above information for this patient’s admission. Examples: >> Brain compression_________ >> Subfalcine herniation________ >> Other (Please specify)_________ >> Clinically unable to determine__________ Please clarify if present on admit.>> Yes______ >> No_______ >> Clinically unable to determine________

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MD Query #3: Please clarify, based on your medical judgment, if there is a diagnosis which reflects the above information for this patient’s admission. Examples: >> Cerebral edema________ >> Other (Please specify)________ >> Brain edema________ >> Clinically unable to determine________ Please clarify if present on admit. >> Yes______ >> No_______ >> Clinically unable to determine________

MD Query #4: Please clarify, based on your medical judgment, diagnosis for mechanical ventilation. Examples: >> Acute resp failure____________ >> Acute resp distress_______ >> Airway protection________ >> Other (Please specify)_______ >> Clinically unable to determine_______

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MD Query #1: After study & if able, please clarify the clinical significance, if any, of the nutritionists finding of ‘severe protein calorie malnutrition’ below. In responding, please indicate the status of the condition at the time of inpatient admission.

Documentation/Clinical Indicators: Progress Notes (page 2 of 19): “Nutrition: Pt is NPO for port” “lost 60#in last four months” “decreased po intake” “Ht 6’0” Wt 189# Pt with severe protein calorie malnutrition” “Insufficient Energy Intake” Clinical Evaluation &/or Treatment Noted:Progress Notes (page 2 of 19): “start TF as able” “Add water flushes prn”

Part 1) Please confirm findings stated above by selecting one of the following:a) I agree: Patient suffered from severe protein calorie malnutrition. b) I disagree: (Please further explain):______________________c) Not clinically significant. d) Can not clinically determine. Part 2) Please choose: (if applicable) _____PRESENT ON ADMISSION (present at the time of the order to admit patient to inpatient status)

_____NOT PRESENT ON ADMISSION (a condition that happened during the inpatient hospitalization) OR _____CLINICALLY UNDETERMINED (you are unable to clinically determine whether the condition was present on

admission or not)

Response(s)/Comment(s):______________________


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MD Query #2: Please clarify any specific associated diagnoses for patient’s midline shift on this admission, if known. In responding, please indicate the status of the condition at the time of inpatient admission. Documentation/Clinical Indicators: Consults (page 1 of 3): “stable L frontal SDH”Radiology Result CTHE Exam Date: 10/15/2014: “Mild underlying mass effect with effacement of the sulci & 2mm midline shift to the right”

Part 1) Please Choose: (options include but are not limited to): a) Cerebral edema _____b) Brain compression _____c) Other diagnosis (specify):__________________________d) Unable to determine _____e) Not clinically significant ______Part 2) Please Choose: (if applicable) _____PRESENT ON ADMISSION (present at the time of the order to admit patient to inpatient status)

_____NOT PRESENT ON ADMISSION (a condition that happened during the inpatient hospitalization) OR _____CLINICALLY UNDETERMINED (you are unable to clinically determine whether the condition was present on

admission or not)

Response(s)/Comment(s):______________________

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MD Query: After study & if able, please indicate if the noted aspiration pneumonia & respiratory failure were present on admission or if they developed during the stay. Documentation/Clinical Indicators: Progress Notes (page 1 of 224): “intubated” “on propofol” Progress Notes (page 3 of 224): “A/C 26/550/80/10” “ID … Asp PNA” Progress Notes (page 9 of 224): “ID: Aspiration pneumonia—continue Vancomycin/ Zosyn day 1”

“Pulm: Acute respiratory failure—continue volume mode of ventilation” #1) Please Choose: for aspiration pneumonia _____PRESENT ON ADMISSION (a pre‐existing condition) OR _____NOT PRESENT ON ADMISSION (a condition that happened during the inpatient hospitalization) OR _____CLINICALLY UNDETERMINED (you are unable to clinically determine whether the condition was present on

admission or not)

Response:_______________________________

#2) Please Choose: for RESPIRATORY FAILURE _____PRESENT ON ADMISSION (a pre‐existing condition) OR _____NOT PRESENT ON ADMISSION (a condition that happened during the inpatient hospitalization) OR _____CLINICALLY UNDETERMINED (you are unable to clinically determine whether the condition was present on

admission or not)

Response:_______________________________

Mortality Case Study Based on Actual Events


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• Driver of van swerved for an unknown reason

• Van collided with gravel truck• Two-vehicle head-on collision • Gravel truck was loaded down with

asphalt• Neither driver was wearing a seat

belt at the time of the accident• Both drivers were thrown from their

vehicles

Use this clinical scenario

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ED Chart

• PMHx: Unknown.

• SH: Lives with his two children. Son age 13. Daughter age 19.

• Meds: Unknown.

• HPI: Unknown age unrestrained drive s/p MVA. GCS 3 at scene with agonal breathing.

• Brought to trauma bay where pupils were fixed & dilated. Patient intubated in the bay with RSI.

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Progress Notes

• “Comatose, pupils 5mm fixed & dilated, no corneals, no cough, no gag”

• Severe shock—multi‐organ injury, likely due to overwhelming inflammatory cascade 2/2 trauma— +/‐sepsis

• ARDS with ventilatory‐dependent respiratory failure—possibly secondary to blood products from DIC

• Skull & facial fractures

• Concern for aspiration pneumonia


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Progress Notes (cont.)

• Acute kidney injury—likely ATN in setting of hypovolemia

• Acute disseminated intravascular coagulation—2/2trauma

• HPI: 42 y/o man admitted to hospital after open head traumatic brain injury from a MVA

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Progress Notes (cont.)

• Critically ill on multiple pressors with non‐survivable head injury; await formal brain death exam

• I spoke with mother who expressed to me that Mr. Roberts would not want to live in a vegetative state & we will advance his code status to DNR

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Male, 31 <= Age < 51

Low socioecon stat, prim payer = Medicaid

CC congestive heart failure

CC coagulopathy

Male, 80 <= age < 85

Female, 80 <= age < 85

Male, age >= 85

Hypotension

Admit source = Transf from skilled nursing/long-term care

Severe brain/spinal conditions

Shock

Vent on admission day

DNR

Traumatic stupor & coma, coma > hr w MCC (MS‐DRG 82)

99.49% expected mortalityWell above


An Autopsy Was Performed on Mr. Roberts Why?

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Required Autopsies

• An autopsy may be required in deaths that have medical and legal issues and that must be investigated by the medical examiner's or coroner's office, the governmental office that is responsible for investigating deaths that are important to the public's health and welfare

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Required Autopsies

Deaths that must be reported to and investigated by the medical examiner's or coroner's office can vary by state and may include those that have occurred:

• Suddenly or unexpectedly, including the sudden death of a child or adult, or the death of a person who was not under the care of a doctor at the time of death

• As a result of any type of injury, including a fall, motor vehicle accident (MVA), drug overdose, or poisoning

• Under suspicious circumstances, such as a suicide or murder

• Under other circumstances defined by law


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Required Autopsies

In some of these deaths, an autopsy may be required, and the coroner or medical examiner has the legal authority to order an autopsy without the consent of the deceased person's family (next of kin). If an autopsy is not required by law, it cannot be performed unless the deceased person's family gives permission.

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Autopsy Report Coding Clinic, First Quarter 2001, pp. 5–6 effective with discharges March 1, 2001

Question: One of our coders has asked if the autopsy report can be used in coding. The question is that since the autopsy is completed by the pathologist, wouldn’t this be similar to using a pathology report as a microscopic confirmation report when coding the postoperative diagnosis?

Answer: Yes, it is appropriate to consider the diagnostic statement on the autopsy report to provide greater detail on specificity. Coding is based on physician documentation. The pathologist is a physician. However, if there is conflicting information in the record, or if the autopsy report includes a condition not mentioned anywhere else on the record, query the attending for clarification & to determine whether the diagnosis should be included in the final diagnostic statement.

What Does His Autopsy Tell Us?


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Roy Lee RobertsMarch 2, 1956—May 18, 1998

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In loving memory of my dad

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Post Test


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References

• http://www.webmd.com/a‐to‐z‐guides/autopsy‐16080?page=2

• https://www.uhc.edu

• http://archive.ahrq.gov/professionals/quality‐patient‐safety/quality‐resources/tools/mortality/Meurer.html

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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Documents

ACDIS day3-11 track3-11 pres 0515 Love f©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission