A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that the patient was alert and oriented when she arrived at the ED, but was somnolent when admitted to a bed in the ICU. The physician documented the patient’s blood pressure at 190/123, her blood urea nitrogen (BUN) at 80, and her creatinine at 5.66.
The physician documented a right basal ganglia hemorrhage with 6 mm midline shift, left facial droop, and left arm weakness. The patient then developed right intraparenchymal hemorrhage with extension into the lateral ventricle, 19 mm in size with associated mass effect.
The physician prescribed labetalol, a nicardipine drip, mannitol, and IV fluids. The patient also had a Foley catheter inserted.
The patient’s primary diagnosis of intracerebral hemorrhage (ICD-9-CM code 431) maps to MS-DRG 066 (intracranial hemorrhage or cerebral infarction without CC/MC). Based on the patient’s chart, the coder also reported the following secondary diagnoses:
- 403.90, hypertensive chronic kidney disease stage I through stage IV, or unspecified
- 428.0, congestive heart failure
- 496, chronic airway obstruction
- 729.89, musculoskeletal symptoms referable to limbs
- 438.89, late effects of cerebrovascular disease
- 781.94, facial weakness
- 585.9, chronic kidney disease (CKD), unspecified
- But does that really tell the patient’s story?
APR-DRGs
Using the APR-DRG that classifies severity of illness (SOI, the extent of physiologic decomposition or organ system loss of function) and risk of mortality (ROM, the likelihood of dying), the patient ends up with a score of 2 for SOI and 2 for ROM.
APR-DRG include four subclassifications for both SOI and ROM:
- 1, minor
- 2, moderate
- 3, major
- 4, extreme
The higher the score, the sicker the patient.
The stroke patient has a moderate SOI and a moderate ROM. However, the patient may actually be much sicker and/or have a greater risk of dying that what is currently represented.
Query opportunities
For this patient, clinical documentation improvement (CDI) specialists and coders can query for three different conditions that may change the patient’s SOI and ROM, says Rhonda Peppers, RN, BS, CCDS, a CDI consultant for MedPartners HIM in St. Louis. Each condition requires a separate query.
First, look at the patient’s blood pressure. Consider querying for what type of hypertension the patient has. For example:
In order to precisely reflect the severity of illness, please clarify if any of the following diagnoses were present:
Accelerated hypertension
Malignant hypertension
Benign hypertension
Other diagnosis
Unable to determine
“If you got accelerated hypertension and that's all you queried for, that did not raise, in this case, the SOI and ROM,” Peppers says.
The second condition that a CDI specialist or coder could query for is the severity of the renal failure. The documentation noted CKD, which has five stages and can be present with acute kidney injury. Consider the following query:
In order to precisely reflect the severity of illness, please clarify if any of the following diagnoses were present:
- Acute renal failure
- Acute renal failure with CKD (please provide stage)
- CKD (please provide stage)
- End-stage renal disease
- Other diagnosis
- Unable to determine
If the physician documents acute renal failure with CKD, that alone does not raise the SOI or ROM, Peppers says. However, if the physician documents acute kidney failure and accelerated hypertension, the patient’s ROM increases to 3 and the case now has a CC, which maps to a higher-weighted DRG.
The third condition to consider is the brain injury, Peppers says. Consider a query similar to this:
In order to precisely reflect the severity of illness, please clarify if any of the following diagnoses were present:
- Cerebral edema
- Brain compression
- Other diagnosis
- Unable to determine
Depending on the physician’s response, the SOI could increase to 3 and could add an MCC, Peppers says.
Querying correctly
CDI specialists and coders can start the query process by reviewing the clinical indicators. For example, the physician documented this patient’s creatinine level at 5.66 and BUN at 80. A normal creatinine level is between 0.6 and 1.3. Dehydration can cause creatinine levels to rise and this patient received IV fluids, which could indicate dehydration.
The patient also has a history of CKD.
Determine what indicators are significant for a complex diagnosis, and make sure to include them in the query, says Sara Baine, MSN-Ed, CCDS, a CDI consultant for MedPartners HIM.
Also include any treatment related to the condition specified in the query, Baines adds. For this patient, relevant treatment includes:
- IV fluids given
- Monitored in ICU
- Foley inserted
Most of the time with SOI and ROM, coders and CDI specialists are looking for a potential diagnosis that's not documented in the record, Baine says. The physician has alluded to a diagnosis with clinical indicators. “You've got to grab that information out and correlate it into a competent, clinical non-leading query,” she adds.
Proper queries lead to proper results and a better illustration of the patient’s condition. “It's more than just hunting for that basic MCC and CC,” Baines says. “You want to get a clear picture of the patient's condition. Do the patient a good service and find out what's going on and get it documented in the case.”
For more information about SOI and ROM, read Queries can help reflect accurate SOI, ROM on JustCoding. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.