RSSAll Entries in the "Questions from the Mailbox" Category

Q&A: Acute pulmonary insufficiency

Have CDI questions?

Have CDI questions?

Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (PSI) if it’s failure. 

A: Our process is to review the chart and see if it meets clinical evidence for additional specificity such as acute respiratory failure. If it does not, does it meet clinical evidence for acute respiratory distress (now that there is a new code for that condition)? If it does not, then our CDI teams would not query. If it does meet the criteria, we would add all the relevant information from the record on the query and ask the physician if, in his or her medical opinion, the documented acute pulmonary insufficiency could be further specified. [more]

Q&A: Querying for acute respiratory failure

You've got questions? We've got answers.

You’ve got questions? Let us know!

Q: If a patient is extubated post-operatively but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?

A: To determine if this represents acute respiratory failure, the values for impaired oxygen exchange can be used, along with the amount of oxygen being administered to the patient.

The ratio of arterial oxygen concentration to the fraction of inspired oxygen (P/F ratio) can be a helpful tool to identify respiratory failure criteria above for a patient receiving supplemental oxygen:

  • The P/F ratio is an indicator of hypoxemia. This is a useful tool when a patient is on supplemental oxygen.
  • The P/F ratio is provided on arterial blood gas (ABG) tests.
  • A P/F ratio less than 300 suggests acute respiratory failure.

If an ABG test is not available, an estimated P/F ratio can be calculated:

  • The calculation is pO2 divided by FIO2:
    • The FIO2 is determined by the liters of oxygen the patient is receiving expressed as a decimal (e.g., 32% is .32).

An illustration of the calculation shows that if a patient is receiving 3L oxygen by nasal cannula, and has a pO2 of 40 mm Hg. That would be 40/.32, which results in 125 (acute respiratory failure). The P/F ratio is a useful tool to validate the presence of acute hypoxemic respiratory failure when patients are receiving supplemental oxygen. After following this formula, and acute respiratory failure is still in question, then a query to your physician is needed.

Editor’s note: This article was originally published in JustCoding. This question was answered by Robert Stein, MD, CCDS, associate director of the MS-DRG Assurance program for Enjoin. Join him for a webinar on this topic on March 21!

Conference Q&A: Hirsch offers insight into CDI utilization review contributions


Ronald Hirsch, MD

Editor’s Note: Over the comings weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada.  Today, we’ve reached out to Ronald Hirsch, MD, FACP, CHCQM-PHYADV, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who will present “Medicare Regulation Update: Practical Application for CDI Professionals.” Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians and serves on the Advisory Board of the American College of Physician Advisors. He is the co-author of The Hospital Guide to Contemporary Utilization Review, published in 2015.

Q: What’s the biggest challenge you’ve encountered related to implementing Medicare regulations?
Regulations and guidance from CMS are often vague and occasionally contradictory. These regulations affect everyone, including the doctor, the patient, the bedside nurse, the case managers, CDI staff, the billing and coding staff, and the C-suite (those working in upper administrative roles). Understanding the regulations and implementing them compliantly across the many affected groups is a challenge for hospitals.

Q: What are three things attendees can expect from your session?
Let me just list some of these out:

  1. To hear a simple explanation of the two-midnight rule
  2. To understand the practical application of medical necessity guidelines for CDI professionals
  3. To be familiarized with the required patient notifications

Q: What is one tool CDI professionals cannot live without?
A: If they learn the two-midnight rule as I teach it, they will become the hero of their institution.

Q: In what ways does your session challenge CDI professionals to think outside the box?
A: CDI professionals work hand in hand with case managers but often do not understand their work. Gaining an understanding of that work makes them a more indispensable part of the team.

Q: What are you most looking forward to about this year’s conference?
A: As a physician advisor expert, my CDI knowledge is quite cursory. With the breadth of courses available at the conference. I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference Boot Camp for physician advisors. It will be an honor to hear from Erica Remer, MD, and James Kennedy, MD, two of the most renowned physicians in CDI.

Q: Fun question: Do you have any pets?
My wife and I just got a new kitten three weeks ago. Leopold is a little wild thing during the day between naps but he loves to cuddle with us at night in bed.

Q&A: ‘Code first’ versus ‘in diseases classified elsewhere’

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I can’t distinguish between “code first” and “in diseases classified elsewhere.” Both are used with manifestations and both can’t be sequenced as principal diagnosis, and both need etiology codes so what is the difference?

A: Technically, not all “code first” notes are mandatory, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HCPro’s Certified Coder Boot Camp® programs, based in Middleton, Massachusetts. For example, ICD-10-CM category I50 includes a “code first” note but it is only used if applicable since heart failure can be a principal diagnosis.

The “code first” note informs us of two things, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist at ACDIS. First, it informs you that two codes may be required. Second, it provides sequencing direction. There are some “code first” notes that are only applicable in certain instances, such as McCall mentions, at “heart failure” the note talks about assigning codes for hypertensive heart failure, pregnancy related heart failure etc., first, if applicable.  Secondly, if, for example the CDI specialist reviews a Parkinson’s manifestation, such as a dementia, and they see “code first Parkinson’s,” in the tabular list then first code Parkinson’s disease (G20) followed by the code for the dementia F02.80. In this example, the “code first” note is positioned next to the manifestation code to remind you to code the etiology first.

In contrast, the phrase “in diseases classified elsewhere” informs coders that two codes are required and means this code must be sequenced as the second code. If you see “in diseases classified elsewhere” in a code description, then you know you are looking at a manifestation code. These codes should never be used as a principal diagnosis and must be reported in conjunction with a code for the underlying cause/diagnosis.

While these terms may seem very similar, Frady says, the “code first” terminology represents an instructional note while “in diseases classified elsewhere” is actually a part of the code title itself. You would only see the “code first” note if you look up the code in the tabular list and review the instructional notes, whereas you would see “in diseases classified elsewhere” if you were simply reading the code title or description in the alphabetic index.

Interestingly enough, if you index Dementia in a current 2017 code book, these conventions are not used.  The index entry is Dementia (with) Parkinson’s disease:   G20 [F02.80]. In this case the formatting of code first [bracketed code second] provides the sequencing.

Caution is warranted, if you index this condition by looking up the keyword “Parkinson’s,” you get an entirely different code as you get an instructional note to “See Parkinsonism” and following that pathway in either a book or an encoder you will arrive at codes G31.83 and F02.80.

Editor’s note: This answer was provided based on limited information submitted to ACDIS. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. For information regarding coding or CDI Boot Camps visit


Q&A: Pneumonia sequencing

Submit your inpatient coding and CDI questions reply to this post .

Submit your inpatient coding and CDI questions reply to this post .

Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy? I thought that the pneumonia would be the primary and the respiratory failure as secondary as the severity of illness/risk of mortality (SOI/ROM) as well as the MS-DRG would all increase. Yet, I’m getting some push back on this train of thought and I’m not sure where the error in my logic may lay. Any insight you could offer would be much appreciated!

A: This is an interesting and common question. I believe you are asking why would we choose the acute respiratory failure as the principal diagnosis when, if we choose the pneumonia with a secondary diagnosis of acute respiratory failure, we have an MCC and it would provide both higher reimbursement and SOI/ROM. Coders and CDI specialists were once taught that when two or more competing diagnoses are present on admission and they could choose the one providing the highest relative weight/increased reimbursement.

In our CDI Boot Camp we explore the concerns around code sequencing in depth and part of our in-class discussion challenges that traditional thought a bit and perhaps spurs our students to think about the matters differently. The traditional choice, to simply code the highest weighed MS-DRG as the principal diagnosis, often gets challenged by auditors. Which condition, they rightfully ask, actually occasioned the admission? Does a typical patient with pneumonia require an inpatient admission? Not usually. When will the physician discharge this patient; when the pneumonia is resolved, or when the acute respiratory failure is no longer a concern?

My bet is that the physician will send this patient home on antibiotics (treatment for the pneumonia) so the pneumonia is not exactly resolved on discharge is it?

I recently assisted an organization with two DRG validation denials from recovery auditors. The auditors agreed with all coded diagnoses but argued the sequencing choices involved. One such account was acute systolic heart failure and acute respiratory failure. Their argument was the choice for admission was based on the acute respiratory failure, not the heart failure. I could not defend against that logic. Once the patient was able to breath without intervention or assist, she was discharged. She was sent home with adjusted medication for her heart failure continuing and follow up with the cardiologist.

I am not saying you should always sequence one way or another, rather, as a CDI specialist it’s your role to closely review the circumstances of admission and carefully consider which conditions meet the definition of principal diagnosis as “That condition after study that occasioned the admission.”

The Official Guidelines for Coding and Reporting tells us it should be a rare instance that two or more diagnoses qualify as the principal and we believe this guideline is used much more frequently than it should be.

Lastly, just to throw another log on the proverbial fire, depending on the circumstances in your example perhaps the encephalopathy could be the principal admission. Again it would depend on the circumstances of this patient and the treatment rendered.  This example is a great one to discuss with your fellow CDI specialists and coders.

Coding Clinic for CDI: Review of Third and Fourth Quarter 2016

Sharme Brodie

Sharme Brodie

by Sharme Brodie, RN, CCDS
The AHA’s Coding Clinic for ICD-10-CM/PCS had both its third and fourth quarter 2016 editions published at the same time this fall. The combined publication is very long—the longest I have ever reviewed—so let’s start by looking at some of the changes to the ICD-10-CM Official Guidelines for Coding and Reporting.

Trouble with ‘with’
As many of you have probably heard, Section A.15 of the new Guidelines states that any time the word “with” appears, either in the Alphabetic Index or in an instructional note not in the Tabular List, the classification presumes a causal relationship and the conditions will be linked even in the absence of provider documentation. Coding Clinic reiterates this fact. For CDI specialists, this may seem like a good thing, but it also means we need to do our homework and make sure all these assumed relationships are truly related. We may find we need more queries to verify these cases with the providers. So be careful and go over each case to make sure it is an accurate representation of what is going on with your patients.

Providers’ prerogative
Coding Clinic (p. 119) stresses the new Guidelines found in Section A.19, which state that assignment of a diagnosis code must be based on the provider’s diagnostic statement that the condition exists, not on clinical criteria used by the provider to establish the diagnosis. That’s not to say the clinical criteria don’t matter, but that coders and CDI specialists cannot decide when a condition exists based on whether we feel certain criteria are appropriate for a condition.

According to Coding Clinic (p. 8), coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This Coding Clinic states “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone.”

Editor’s Note: There’s a lot more to cover in these oversized editions of the fall 2016 Coding Clinic, and Brodie explores the highlights in an extended white paper available in the Resources section of the ACDIS website. Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Q&A: Refuting obesity denials

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I wanted to write you, concerning a denial letter I have received, regarding  morbid obesity. The letter states:

“Although morbid obesity and BMI were documented, from the information received [we] could not verify documentation that supported obesity required increased monitoring, evaluation, diagnostic/therapeutic treatment or increased length of stay, therefore it does not meet criteria for assignment as an additional diagnosis code assignment.”

It went on to say that the diagnosis code does not meet criteria for reporting on the claim due to the ICD-9-CM Official Guidelines for Coding and Reporting rules for assignment of other (additional) diagnosis, UHDDS’ definations of other diagnoses, and other Guidelines (they cited Section I, General Coding Guidelines and Section III, Reporting Additional Diagnoses).

We fought the denial from two angles. One the physician did recommend weight loss and dietitian was monitoring the patient. Second, Coding Clinic address this question specifically.  Coding Clinic, Third Quarter 2011, pp. 3-4. This addresses the question of the clinical significance of obesity. Also, Coding Clinic, Third Quarter 2007, pp. 13-14, addresses the issue of coding of chronic conditions. I am still waiting on an answer, but wanted to see if you would share your opinion regarding this situation.

A: I agree with you fully on the obesity. Coding Clinic states:

“Individuals who are overweight, obese, or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider.”

This statement is fairly definitive and I would encourage you NOT to make any facility specific policy changes based on this inappropriate audit finding.

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Hospital-acquired conditions versus hospital-acquired pneumonia

Have a question? Leave a comment below!

Have a question? Leave a comment below!

Q: Why is hospital-acquired pneumonia not considered a CMS hospital-acquired condition (HAC)?

A: This is confusing to a lot of people because of the similarity of terms used. Hospital-acquired pneumonia is a clinical descriptor. However, CMS’ hospital-acquired conditions are more of a payment classification than a clinical classification. Thus, those conditions that are certainly hospital acquired from a clinical perspective may or may not be a CMS hospital-acquired condition.

Hospital-acquired conditions are conditions that CMS has classified as preventable, and thus are not subject to additional payment coverage. At this time, hospital-acquired pneumonia is not considered a HAC by CMS.

Here are some links for further reading:

I hope this helps!

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Community-acquired pneumonia

Q: How do we determine if a patient’s pneumonia is community acquired or not? What documentation should we look for to support this?

A: To be honest, any type of pneumonia can be acquired in the community. However, physicians often use the term “community acquired” to signify a simple pneumonia. Simple pneumonia is usually easily treatable, although the term is somewhat self-limiting. The diagnosis causes unique problems for CDI specialists.

In general, simple pneumonia cases would not and should not be admitted to the hospital for inpatient status. They could be admitted, however, if they have a number of other medical problems that further complicate the care of their pneumonia, or are becoming acute themselves—for example, a congestive heart failure (CHF) patient getting fluid overloaded, a diabetes patient with an out-of-control blood sugar level, or a very elderly patient who also has a urinary infection and has now become confused.

We certainly would not want to make a blanket statement that any patient admitted to the hospital probably has a gram-negative or complex pneumonia. But, oftentimes, the pneumonia by itself does not support the admission.

“Atypical” is a term used by physicians to describe a unique presentation of pneumonia that has its own set of chest x-ray findings, history, and treatment requirements. Generally, atypical pneumonia is usually caused by one of the organisms classified as a complex pneumonia for DRG assignment purposes. Unfortunately, the term “atypical” codes to one of the simple pneumonia types.

Interestingly enough, “hospital acquired” and “healthcare acquired” are almost always written when the physician is attempting to describe a more complex pneumonia, resistant to treatment, in a patient who has a higher acuity illness. Unfortunately, these terms code to simple pneumonia classifications, too. Physicians are almost always surprised (and often disagree) with these phrases being classified as “simple.”

For this reason, what I teach CDI specialists to ask for the specific organism, and to either document that organism as either confirmed or suspected at discharge. Getting the exact organism is not always possible. Nevertheless, physicians need to document their assessment based on the same clinical evidence that caused them to treat that patient in one manner versus another.

For CDI specialists, the moral here is that when physicians document “atypical,” “hospital-acquired,” and “healthcare-acquired” you may need to craft a query, so providers don’t get an inappropriate downgrade.

Furthermore, CDI specialists may need to query the physician regarding patients sick enough to be admitted to the hospital for community-acquired pneumonia, particularly if the physician did not include any additional documentation regarding comorbidities. It may be that the patient actually has sepsis, or reveal a more specific causative organism which changes the classification to a more complex pneumonia.

Worst case scenario, a reassessment of the utilization procedures may need to occur if a large population of simple pneumonias is actually being admitted with no complications, no co-morbidities, no risk factors, and they genuinely do have simple gram positive type pneumonias.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Morbid obesity

Have a question that is troubling you and your team? Ask us!

Have a question that is troubling you and your team? Ask us!

Q: Coding Clinic, Third Quarter 2011, p. 4 states:

“…morbid obesity is a chronic condition and; therefore, can be coded as a secondary diagnosis without treatment.” (emphasis added)

An article in the CDI Journal, “From the Forum: Manage denials for BMI morbid obesity,” seems to indicate that providers should document how the obesity affects patient care.

What level of patient care needs to be documented?

A: The Coding Clinic you are referring to states:


If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.


Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.

Coding Clinic clearly states that morbid obesity should be coded when it is documented by the provider. It speaks to the fact this condition is always clinically significant. That said, morbid obesity is almost always addressed by both the provider and the nursing staff caring for the patient. These patients are more prone for infections, musculoskeletal injury, skin breakdown, respiratory compromise, etc., and, therefore, the medical decision making and care for this patient will be more complicated. This is why we are able to code this diagnosis whenever it is documented by the provider.

After this Coding Clinic was released, I have not seen a denial for this diagnosis. If you feel you need to expand documentation related to the condition, ensure your nursing plans reflect care of a morbidly obese patient. Your provider should also include their concerns related to the condition in their assessments.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps visit