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Q&A: Defining “repair”

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Q: When I try to code Ileostomy takedown of the small bowel, with small bowel resection, and end-to-end anastomosis, I get to code 0DBB4ZZ.  However, I am not sure if this would this be a repair of the ileum, and therefore coded to 0DQB3ZZ? Coding Clinic notes code 0DBB4ZZ, but “repair” means “restore to previous function.” What is your advice for this scenario?

A: The Coding Clinic you are referring to reads:

The ileostomy takedown is coded as “Excision” because part of the ileum is removed, and the anas­tomosis is considered inherent to the surgery and not coded separately. The ICD-10-PCS Official Guide­lines for Coding and Reporting state “Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.” Assign the following ICD-10-PCS codes:

0DBB0ZZ Excision of ileum, open approach (for the ileostomy takedown)

0WQF0ZZ Repair abdominal wall, open approach (for parastomal hernia repair and stoma closure

You are absolutely correct; the definition of “repair” is “repairing to the extent possible, a body part to its normal anatomic structure and function.”

I do agree with you that the takedown does seem to fit the definition of a repair but, per the Coding Clinic advice, it is coded to the Root Operation of Excision. Until there is different guidance from Coding Clinic, this is how it would be coded.

I wish I could tell you that everything makes sense but, sometimes it does not.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Q&A: Code assignment for hospital acquired/healthcare associated conditions

Discerning the principal diagnosis is difficult at best.

We always want to obtain the etiology of pneumonia.

Q: Is it appropriate to assign code Y95, nosocomial condition, based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAC)? It is appropriate to assign code Y95, nosocomial condition, for documented healthcare associated conditions. Should this still be queried for specificity, and should the HAC condition (i.e. pneumonia) be coded as bacterial, viral, or something else?

A: When the provider uses terms such as “CAP,” “HAP,” or “HCAP,” these would default to code J18.9, pneumonia, unspecified organism, which maps to simple pneumonia MS-DRG 193/194/195.

Community acquired pneumonia (CAP) is typically a simple pneumonia, but could also be atypical pneumonia. Both hospital acquired pneumonia (HAP) and healthcare associated pneumonia (HCAP) can be considered nosocomial infections, and are most commonly caused by a gram negative organism.

Identification of the organism could move any of these from a simple pneumonia—MS-DRG 193, 194, or 195—to a complex pneumonia—MS-DRG 177, 178, or 179.  ICD-10-CM has numerous codes that link the causative organism and the pneumonia. Use of these codes is based on physician documentation linking the pneumonia and the causative organism.

Per AHA’s Coding Clinic, Third Quarter, 1994, we do not assign a code for bacterial pneumonia unless documentation if the medical record supports the presence of a bacteria.

If the physician identifies the pneumonia as a gram positive, mixed bacterial, or bacterial pneumonia without further specification, it would be coded to J15.9, unspecified bacterial pneumonia.

We always want to obtain the etiology of pneumonia. As the MS-DRG assignment will vary based on etiology, this may require a query. The physician’s clinical opinion is sufficient to diagnose the type of infection. Diagnostic data, such as a positive sputum cultures or chest x-ray, are not necessary for the diagnosis.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Q&A: Coding and sequencing clarification

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

Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially, they thought he had pulmonary nodular amyloidosis (PNA) but when they did an echo-cardiogram on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next day the patient had a cardiac arrest. Given the pericardial effusion, they did a bedside echo during resuscitation. This showed right atrial collapse and performed an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but deemed terminal and later died. No definitive treatment was directed at the lung cancer.

We are discussing two concerns related to this case:

  1. How to code the effusion: Our coder thinks it may be appropriate to only code C7989 (secondary malignant neoplasm) but I think that I39.3 (pleural effusion) should be coded.
  2. Sequencing: Our coder assigned C7989 as the principal diagnosis. If we code I39.3, would that end up being the principal? The Official Guidelines for Coding and Reporting say that complications of neoplasm should be listed as principal.

Any suggestions or thoughts you might have would be greatly appreciated.

A: J91.0 (Malignant pleural effusion) is a manifestation code and cannot be sequenced as the principal diagnosis, says Sharon Salinas, CCS, Health Information Management, at Barlow Respiratory Hospital in Los Angeles. “The underlying condition is to be sequenced first.  Per the National Institutes of Health, malignant pericardial effusion is also a manifestation so I think the lung neoplasm might have to be the principal – if that is the underlying cause.”

Look also at ICD-10-CM code I30.9 for acute neoplastic pericardial effusion present on admission (POA) plus the C code for secondary malignancy POA and finally, pericardial tamponade, not POA, suggests Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

Gold points to a AHA Coding Clinic, Second Quarter 1989, which directs coders to the Alphabetic Index entry for effusion, pericardium, which has a note to “see also pericarditis,” and leads to options of pericarditis (with effusion), neoplastic (chronic), and acute.

“The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor, either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas),” says Gold.

Unfortunately, says Salinas, ICD-10-CM lost some specificity for situations like this.  Code I313, for pericardial effusion isn’t specifically for malignant pericardial effusion but comes close. Code J91.0, is a manifestation code and cannot be sequenced as principal diagnosis.

“I would query for acuity and for underlying cause of effusion (primary, metastatic, other, undetermined. I think you need both queries to determine the principal,” she says.

Editor’s Note: This QA is an example of the information shared daily amongst ACDIS members on CDI Talk. Join the conversation and make the most of your ACDIS membership.

Q&A: Tips for new CDI specialists

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Q: I have been a CDI specialist for three months. I have been told that if a note states diagnosis X or Y, I could code one or the other, but not both. I’ve also been told that, if the note says X versus Y, then I can only code the symptom. As for non-surgical procedures, should I still code them or leave them for the coders?

A: There are a couple of guidelines in the ICD-10-CM Official Guidelines for Coding and Reporting, that are helpful to review. In Section II, C, states:

In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

Remember, for a diagnosis to be the principal diagnosis, it must meet the definition per the Uniform Hospital Discharge Data Set (UHDDS) as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Section II also states that the circumstances of the admission always govern the selection of the principal diagnosis—this is frequently referred to as “what bought the bed.”

This sounds a lot easier than it is to determine sometimes. The understanding of this guideline has changed over the years. Many coders were taught that if two conditions equally met the definition of the principal diagnosis, the condition that made the hospital the most money would (could) be chosen as the principal diagnosis. Now, we are taught to look at this guideline a little differently.

First the Official Guidelines for Coding and Reporting says “[i]n the unusual instance,” which indicates this should not happen frequently. Second, it says “determined by the circumstances of the admission,” which is considered the “ABCs of Nursing.” An example of this would be a patient that comes into the emergency department in acute respiratory failure and is also experiencing a stroke. We want to make sure that both conditions are clinically supported, even though both conditions are extremely important.

Based on the “ABCs of Nursing,” our first priority would be the patient’s respiratory status and, then, any other conditions present.  As long as the acute respiratory failure is clinically supported, it would likely be the principal diagnosis, and the stroke would be a secondary.

Now, there are times when either the Alphabetic Index or the Tabular List will dictate when a diagnosis must be sequenced first, and in those cases the rules have to be followed.

The second guideline is from Section II, D, which states:

In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed, and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

Again, we need to consider the circumstances of the admission—what was the reason they were admitted, and what bought the bed?

Some residual  confusion may linger due to a guideline deleted in October 1, 2014. It said if a documented symptom was followed by contrasting or comparative diagnoses, the symptom would be coded first. This is no longer a guideline.

I am not sure what your facility has you do as a CDI specialist as far as coding the chart, but regarding non-surgical procedures, they are always coded, but they do not move the MS-DRG to a surgical DRG. After establishing the principal diagnosis, you would want to know if the patient had any surgical procedures that would move your medical MS-DRG to a surgical DRG. Lastly, you would want to identify any secondary diagnoses that are classified as either a CC or MCC to assign the appropriate DRG.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Q&A: Respiratory failure in a drug overdose

Respiratory failure requires specific documentation.

If the patient is unable to maintain an open airway and perform ventilation, that is considered respiratory failure.

Q: I am looking for documentation or physician education tips related to ventilator management or “respiratory failure” due to combativeness for airway protection and/or toxic/metabolic encephalopathy in a drug overdose.

Many of our providers document “respiratory failure,” when, in fact, they are using the ventilator to help with the work of breathing in order to prevent the patient from actually progressing to acute respiratory failure. By using the ventilator they are attempting to protect the airway due to encephalopathy or change in mental status, combative, or altered mentation.

A: This is a common question, and can be confusing for providers, the CDI specialists, and coders. The first thing is to identify any supportive clinical indicators for a diagnosis of acute respiratory failure.

Respiratory failure is traditionally defined as the inability to perform the lung’s function of gas exchange, or the transfer of oxygen and carbon dioxide within the blood. Respiratory failure can be a failure to oxygenate the tissues or a failure of ventilation, meaning a failure or impairment of airflow in and out of the lungs. Often it is a combination of the two mechanisms.

Often, patients admitted for poisoning, overdose, or trauma will exhibit clinical indicators for respiratory failure, and the documentation will state “intubated for airway protection.” If the patient is unable to maintain an open airway and perform ventilation, that is considered respiratory failure.

With this in mind, the first step in reviewing the record is to determine if the intubation/ventilation is performed to truly protect the airway, or if the airway is already impairing gas exchange. The record must be reviewed for clinical indicators to support an acute respiratory failure that includes oxygen saturations, blood gas, respiratory rate, respiratory distress, etc. Once the patient is intubated, a good clue as to the presence or absence of respiratory failure is a review of treatment related to the ventilator. If the patient requires frequent vent changes or intervention, this likely supports an acute respiratory failure.

If the reason for intubation is unclear, a query is likely needed. If, after this examination, you conclude there was no respiratory failure, then the diagnosis should not be coded.

Coding Clinic supports this. Although written for ICD 9-CM, they likely still apply to ICD-10. AHA Coding Clinic, 3rd Quarter 2012, p. 21, asks the question:

“QUESTION:A patient presents to the ED due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the ICU and comments that the patient was intubated for airway protection because of the overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the next day. Can the coder assume the patient was in respiratory failure, based on the fact the patient was intubated and placed on mechanical ventilation for airway protection.

“ANSWER: Do not assign the code for acute respiratory failure, simply because the patient was intubated and received ventilator support. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated needs to be clearly documented by the provider.”

So, long story short, if acute respiratory failure is documented in the situation you describe above, and there are no clinical indicators for the respiratory failure, I would query the provider to clarify the most appropriate diagnosis. If the patient is intubated to only protect an airway from potential compromise, that is not a respiratory failure and should not be diagnosed or coded as such.

One suggestion is to develop an organizational definition of both acute and chronic respiratory failure that your medical staff can use in these situations. I would suggest working with your physician advisor, intensivist, or pulmonologist to define the parameters. The diagnostic criteria would be used by CDI specialists and coders to identify a need for query. Providers can use the criteria to differentiate between the true reason for intubation.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Ask ACDIS: Creating Compliant Verbal Query Processes

Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.

Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query.

Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.

We write out the query form and discuss it with the physician. If the physician agrees, he or she adds the detail into the medical record. On the completed form, we simply add a “V” or the words “verbal query.”

Do you have any additional advice? How do you recommend programs track verbal queries for compliance?

A: Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query, says ACDIS Advisory Board member Anny P. Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI at Enjoin. All CDI programs need to establish policies and procedures surrounding verbal queries and how they are tracked. All organizations should have a permanent record of verbal query language in order to demonstrate compliance and allow for adequate quality monitoring.

Such policies should follow guidance from ACDIS/AHIMA, agrees ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital in Arizona, who offers the following tips:

  1. Determine if the verbal discussion was educational or related to a documentation opportunity.
    1. If the CDI specialist presents the physician with specific clinical indicators, diagnostic results, interventions, and treatment plan related to a particular patient with an expected outcome then it is a verbal query.
    2. If the discussion relates to general documentation tips regarding a diagnosis or disease process, it’s likely educational in nature.
  2. Verbal queries need to follow the same compliance standards as written queries, so the CDI specialist needs to document that query and ensure there was no mention of a diagnosis, and the intent of the query (e.g., if the query was to clarify conflicting documentation in the record). CDI staff also needs to include the applicable:
    1. clinical indicators
    2. treatments
    3. diagnostic results
    4. progress notes
    5. nursing notes
    6. possible diagnosis options along with other or unable to determine
  3. Monitor and trend verbal queries for educational and quality purposes just as with written queries. “These can be used in outcome assessments so it’s very important that verbal queries are documented and reviewed,” Schade says.

The important focus is that all queries should follow the same policy/procedure/process and are not leading or offering the diagnosis, she says.

At a minimum, says Yuen, programs should track:

  • Name of the CDI specialist conducting the query
  • Name of the physician being queried
  • Subject of the query
  • Date, time, and location of the verbal query
  • Result (i.e., agree, disagree, other)

“Always encourage adherence to the practice brief guidelines regarding documentation of verbal queries,” says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, CDIP, director of CDI services, Enjoin. “Verbal queries should be delivered in the same fashion as a written query (non-leading) including clinical indicators and treatments specific to the individual case (if using menu options, only offer clinically viable options specific to the scenario being presented), and the documentation of the occurrence for record keeping purposes should recount the conversation to ensure compliance with the query process. In regards to the specific scenario presented, it is always good practice to follow up a verbal query with a written or vice versa.”

If the verbal query is presented along with a completed written query, updating the response on the form itself should be sufficient for documentation purposes.

Tracking and query retention can be managed either manually and/or electronically. This will depend on the individual facilities resources.

Editor’s Note: ACDIS Advisory Board members offered the above responses as additional information following the November 2015 ACDIS Membership Quarterly Conference Call. Listen to a recording of the call or read additional questions and answers in the January/February edition of the CDI Journal.

Q&A: Accessing hospital data

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Q: I am a relatively new CDI specialist at a large health system and our physician managers wanted to know if there is a site where we could obtain the national or regional hospital case mix index (CMI) percentage capture rates per DRG grouping for MCCs. This would help us understand how effective we are each month in terms of national standings. How can we access this data?

A: Start with your organization’s PEPPER data. One person in your organization is sent this report quarterly—it is often the director of quality or compliance. This data compares your organization to others within your region, state and, nationally on a number of measures and will allow you to see your CC/MCC capture rate as compared to those in your region, state, and nation..

There is an art to understanding how to use this information, however, so spend some time with the “owner” of the report at your facility to see how he or she uses the information. Also take timeout to review the resources on the PEPPER website

Another resource, offered though CMS, is MEDPAR, which tracks inpatient history and patterns/outcomes of care over time

When comparing your organizations data to others’ compare apples to apples and oranges to oranges. Depending on the population your organization services, your numbers may be significantly different from the norm. For example, a large academic medical center that sees trauma patients and receives transfers from smaller facilities will have a higher CMI compared to the smaller hospital that likely “ships” more complicated patients out to other facilities.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: Clinically defining atrial fibrillation

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Ask us a question by leaving a comment here on the ACDIS Blog.

Q: Our facility is developing clinical definitions regarding types of atrial fibrillation (afib) given the specificity changes in ICD-10. Could you provide suggestions for these definitions? Do you think is it appropriate to query for persistent atrial fibrillation for the period of more than seven days and chronic afib sustained more than 12 months duration? Are you aware of any strategies other institutions are using when querying regarding atrial fibrillation?

A: The most recent clinical definitions of afib are:

  • Persistent afib is rate and rhythm control focus with afib sustained more than seven days
  • Permanent and chronic as defined.

The gray area is how we know when physician makes the decision to focus on rate control only from a rate and rhythm approach. Not all afib sustained more than seven days is persistent, as it may be permanent. So, to answer your question, using the timeframes of seven days to more than 12 months should not be the only criteria for persistent, because permanent falls in there, too. Certainly, you could ask each clinician to clarify, but such queries may have limited efficacy.

The best approach is to involve your physician advisor or local cardiologist to help the CDI team understand the local medications or typical practice patterns they use to address afib and incorporate it into the query process. Unless your inpatient medical record is shared with the ambulatory one, it is hard to get a feel for how the decision may be made.

One key is the use of anti-arrythmic medications, such as flecanide, amiodarone, ibutilide, and digoxin. These give you a hint that the physician is dealing with persistent afib, as there is an interest in rhythm and rate control. However, due to intolerance, medications like diltiazem, metoprolol, digoxin (which is also an anti-arrhythmic) can be used for rhythm control, too, but mostly these are for rate control only.

Not to make it more complex, but recent literature, in some instances, does not support rhythm control and only supports rate control for no change in outcomes.

As a hospitalist in clinical practice, I find this difficult to really standardize with general recommendations as it is a clinical decision of the cardiologist. If they are not documenting the detail, you may not know.

The only other comment I have is regarding postoperative afib. I would not strictly employ an absolute timeframe as the only criteria for post-op afib. I would make sure it meets the definition as a complication of care and not an expected occurrence. For example, 85-90% of all coronary artery bypass grafting and open value procedures have afib. It is not a complication, but expected due to the incision of the epicardium and myocardium and disruption of conduction system.

Remember, all things post-op are not complications of care, and physicians use the term “postoperative” as a temporal description only. The index assumes “postoperative” is a complication of care. I encourage physicians that I educate to avoid the word “postoperative” unless they mean a cause-and-effect relationship of the condition being described as a complication.

I hope this provided some insight from what I have seen, but I would now go to your local cardiologists to really explain the importance and understand practice patterns in your institution.

Editor’s Note: ACDIS Advisory Board Member, James P. Fee, MD, CCS, CCDS, Vice President at Enjoin, answered this question. Contact him at

Q&A: A recap of the ACDIS Quarterly Conference Call


James P. Fee, MD, CCS, CCDS

Editor’s Note: The ACDIS Quarterly Conference Call was held on November 19, and featured a roundtable discussion with 12 of our ACDIS Advisory Board members. The following questions were submitted by audience members after the call, and were answered by advisory board member, James P. Fee, MD, CCS, CCDS, Vice President at Enjoin.

Q: We are struggling with the definitions of acute respiratory failure and chronic respiratory failure issue. My clinicians are asking me for the clinical indicators. Any ideas where to turn? 

A: It is difficult to give a single source. Most medical textbooks define using arterial blood gases criteria and now some P/F ratios. However, true respiratory failure incorporates patient findings and symptoms, impaired oxygenation and ventilation, and intensity of treatment.

Q: I am wondering what the doctor has to say in order for the coder to take a fracture to the traumatic section. If the provider documents that the patient comes in with a “fracture from a fall,” and the patient doesn’t have a history of osteoporosis documented, can the coder take this to traumatic?

A: There are two separate entries in the code set Alphabetic Index: one for pathological and one for traumatic, at the same level. There is no default code in ICD-10, as in ICD-9, should the physician neglect to provide that additional detail, so the type of fracture must be specified. I recommend looking at the code book.

Q: In ICD-10, can you code chronic obstructive pulmonary disease (COPD) exacerbation with aspiration pneumonia?

A: There is no excludes 1 or 2 note under aspiration pneumonia (J69.0) or COPD with acute exacerbation (J44.1). Now there is a confusing note, under J44.0, to assign an additional code to identify the infection, but this would imply sequencing issues and really only applies to bronchitis or bronchiolitis (based on the instructional notes under those code categories).

Q&A: How can we ensure the right documentation for a level of care recommendation?

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Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?

A: The recent Outpatient Prospective Payment System rule states:

”The physician’s decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”

But another important consideration should be whether the patient requires hospital-level care.

This is the crux of the review. For example, a patient may have an exacerbation of a chronic illness, but the ACC or case manager then needs to ask whether hospitalization is required to resolve the problem. If this is a new illness, does it require hospitalization to find out the source? (Auditors inevitably deny so-called work up hospitalizations if the testing could be performed on an outpatient basis.) Finally, the ACC or case manager must see medical documentation that states that the care the patient requires is expected to exceed two midnights.

Reviewers should consider the history of present illness, the severity of the signs and symptoms of the patient’s current medical condition, and the expectation of a two midnight stay, in addition to:

  • The patient’s age
  • Disease processes
  • The medical predictability an adverse event

Also look at admitting orders. What are the patient’s current needs that require hospital-level care? What is the risk of not admitting the patient? I call this the “because clause”—if the patient is not admitted, given his history of pre-existing condition, he may be at risk for complication.

Editor’s Note: This question was answered by Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida. It was originally published in Case Management Insider.