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Q&A: Sepsis, septic shock, still cause for query confusion

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Q: If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?

A: You are not alone if you find the coding of sepsis to be challenging. In the case you describe above the documentation of septic shock would support both codes for the septicemia and the severe sepsis. (Septic shock cannot occur without sepsis and severe sepsis being present). You would need to add codes for the underlying condition (local infection) as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis. It is also a good practice to assign the code for causal organism if known.

The septic shock would provide the MCC as the secondary diagnosis.

The Official Guidelines of Coding and Reporting specifically outline the coding practices for sepsis, severe sepsis, and septic shock very clearly in the chapter Specific Coding Guidelines- Chapter 1: Certain Infectious and Parasitic Diseases. I always suggest that new CDIs take time to read the guidelines to assist with the special considerations related to this diagnosis.

Again, you are not the only one who has struggled with this difficult topic. For some additional reading please take a look at these previous articles and recommendations from the ACDIS website:

Q&A: Sleep apnea clarification opportunities

Q: Should I query for chronic respiratory failure if the documentation indicates the patient has sleep apnea with and is being treated with continuous positive airway pressure (CPAP) at night?

Ask your CDI question in the comment section.

Ask your CDI question in the comment section.

I love where you are going with this question, it demonstrates your critical thinking, one of the most important skills a CDI specialist can have.

First off, let’s think about the definition of respiratory failure and the biological processes which cause it. Respiratory failure can result from an inability to ventilate (take in oxygen, expel carbon dioxide) or an inability for the gas exchange to occur at the cellular level within the lungs.

The Merck Manual describes it as:

“A rise in [partial pressure of carbon dioxide] PaCO2 (hypercapnia) that occurs when the respiratory load can no longer be supported by the strength or activity of the system. The most common causes are acute exacerbations of asthma and [Chronic Obstructive Pulmonary Disease] COPD, overdoses of drugs that suppress ventilatory drive, and conditions that cause respiratory muscle weakness (e.g., Guillain-Barré syndrome, myasthenia gravis, botulism)… Treatment varies by condition but often includes mechanical ventilation.”

The manual goes on to describe that the balance between load (resistance to ventilation and neuromuscular competence (the drive to breath, and muscle strength) determines the ability to sustain alveolar ventilation. Sleep disordered breathing is listed as a contributing condition that can disrupt this balance.

If you come from case management experience, you might be aware that for a Medicare patient to qualify for CPAP, a sleep study must be performed that demonstrates need based on the number and length of episodes occurring within the study elapsed time.

If the patient is receiving treatment or monitoring within the hospital stay to address the sleep apnea, a query may be warranted. Make sure the hospital is providing CPAP support at night and review the respiratory therapy notes to show consistency within the record before submitting the query.

If your organization does not have agreed upon diagnostic criteria for chronic respiratory failure work with your CDI team and pulmonologists to define this condition and identify clinical indicators to support query. Discuss with the pulmonologist how sleep apnea and the use of CPAP supports this diagnosis.

When I was reviewing records I always thought of obesity alveolar hypoventilation syndrome (Pickwickian’s Syndrome) as a possible secondary diagnosis where obstructive sleep apnea was listed as a diagnosis. Check the patient’s BMI and if you have morbid obesity, consider whether that condition led to the obstructive sleep apnea. This also provides a CC.

Smart question and this is often a query opportunity that is overlooked.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit

Q&A: Defining subacute per coding guidelines

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Go ahead, ask us!

Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.

A: The Official Guidelines for Coding and Reporting offers no definition as to what is considered acute, subacute, or chronic. I have found subacute to mean something in between acute and chronic which is a vague description at best! For questions such as this I refer to the American Hospital Association’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS)® for assistance.

Coding Clinic, First Quarter 2011, p. 21 states:

Question: How is the diagnosis documented as “subacute deep vein thrombosis (DVT) code? There are index subentries for acute and chronic, but not for subacute?

Answer: Assign code 45.39, acute venous embolism and thrombosis of other specified veins, for a diagnosis of subacute DVT.

Now, this reference does not specifically describe a CVA but does offer guidance that the term subacute is interpreted as being acute. But I would like to see more guidance related to CVA. So let’s look at Coding Clinic, Second Quarter 2013, p. 10

Question: The patient suffered a subacute ischemic right posterior watershed infarct with small focus of subacute hemorrhage. How should this be coded?

Answer: Assign 434.91 Occlusion of Cerebral arteries, cerebral artery occlusion, unspecified with cerebral infarction AND 431- intracerebral hemorrhage, for the description subacute ischemic right posterior parietal watershed infarct with small focus of subacute hemorrhage. In this instance the patient had an ischemic stroke as well as a hemorrhagic stroke.

I understand that although this Coding Clinic is addressing the fact two codes would be assigned due to the fact there was both an ischemic and hemorrhagic stroke it also reinforces that the wording of subacute would apply to the codes for a CVA versus codes for a history of CVA. Coding Clinic offers much guidance when we encounter those “grey” areas of the code set and should be the reference that you seek in such situations.


Q&A: Atelectasis query for secondary diagnosis

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

Q: When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?

A: In order to answer your question more information surrounding the circumstances of the encounter would be required. Atelectasis is usually considered an integral condition when it occurs following surgery because the turning, coughing, and deep breathing is typically routine protocol for this type of patient.

There are specific guidelines for coding conditions that may be an integral part of a disease process. If the condition is routinely associated with the disease process or procedure and no additional monitoring or treatment is ordered to evaluate the condition then the additional code would not be separately assigned. If the attending provider orders additional monitoring or treatment to evaluate the condition, such as continued x-rays to monitor the progress and resolution of the Atelectasis, it would be a reportable condition. Some other examples of integral conditions would be an “ileus” following bowel surgery, or “pleural effusions” in a patient with congestive heart failure that is not aggressively treated.

Before we assign a code for a secondary diagnoses, we need to ask ourselves, does it meet UHDDS criteria for a secondary diagnoses? The CDI specialist needs to determine if the condition required:

  • Clinical evaluation
  • Therapeutic treatment or a diagnostic procedures
  • An extended length of stay
  • Increased nursing care and/or monitoring
  • Is it supported by at least one clinical indicator

Additionally, consider whether:

  • Other providers would arrive at the same conclusion/make the same diagnosis?
  • The diagnosis integral to another condition?
  • This diagnosis relates to this episode of care?
  • The diagnosis was documented by a treating provider?
  • There is a conflict with the attending provider?

Since abnormal findings (laboratory, x-ray, pathology, and other diagnostic results) are not coded and reported unless the attending provider indicates their clinical significance you first need to ensure the finding is a reportable diagnosis before you can query for the associated diagnosis to be added. If findings are outside the normal range and the attending has ordered other tests to evaluate the condition or prescribed treatment, it would be appropriate to query the physician to have the clinical significance clarified and diagnosis added.

Editor’s Note: CDI Boot Camp Instructor Sharme Brodie RN, CCDS, answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit

Q&A: Including diagnosis from consult notes

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Go ahead, ask us!

Q: How would the following be viewed if it was included in a cardiology consult note:

“Mr. X has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Y will allow. Goal International Normalized Ratio (INR) is 2-3.”

A: Because code assignment can be based on documentation of other physicians (e.g., consultants, residents, or anesthesiologists) that note meets criteria for a secondary diagnosis and doesn’t conflict with the attending physician. I can see where this case could be tricky, since it looks like the condition did not require further evaluation or diagnostic testing, and did not increase nursing care or increase the length of stay.

However, the cardiologist did want to restart the patient’s warfarin and if that occurred during this admission, then it would be treatment and make it a reportable condition. This could be a vulnerable claim if the physician does not document the atrial fibrillation in the discharge summary with the need for continued follow up-care regarding the warfarin.

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: Clinical definitions and core measure capture

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Go ahead, ask us!

Q: How have you handled situations when specialty physicians and hospitalists do not agree with diagnoses impacting core measures?

A: It becomes difficult because the clinical definitions of some disease processes are a little bit tricky. In specific scenarios such as acute myocardial infarction (AMI) and congestive heart failure (CHF), we’ve brought together a team of coding, quality, case management, and the physician groups involved to develop specific clinical definitions everyone can agree on. That cut down a lot of the back and forth that we’ve had along the way.
The coders got stuck in the middle of it. Coders don’t feel comfortable going up to a physician and saying, “Okay, Doctor Jones documented this as a STEMI, but you’re saying it’s not. You’re saying it’s not even an AMI.” That situation puts the coders and CDI staff in a very difficult position. We’re not the physician who’s ultimately responsible for the diagnosis of the patient, but we’re trying to dig through all the information.
We tried to select the most widely accepted clinical definition of CHF, because we don’t want to pick the most obscure definition that’s out there and narrow the field down to the point where we’re going to look odd when you compare us to other hospitals. By having an agreement about what that clinical picture is for a patient, a clinical definition for a diagnosis really sets the groundwork so that you don’t have all those conflicts back and forth in the chart.
It’s not a perfect world. We still have some cases that have to be clarified, but the nice thing you don’t have it happening all the time. You can follow the coding guidelines about the attending physician being ultimately responsible for the diagnoses of the patient and you can go back to that attending physician using the agreed upon clinical definitions.
Editor’s Note: Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Indiana, answered this question. This answer was originally published on JustCoding and is provided based on the limited information submitted to JustCoding.