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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.

Q&A: Query for “type 2 injury” 

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Do you have a CDI-related question? Leave us a comment below.

Q: I was reviewing a case with one of our CDI specialists this morning. Briefly, the following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a Type 2 injury.” Also documented in another note is “demand ischemia.”

The physician did not document the words “Type 2 myocardial infarction (MI).” Is the wording “Type 2 injury” enough to support a code for MI? Our physician advisor has given input and thinks Type 2 MI should code out to a NSTEMI. Should we query in this instance and, if so, what should we include in the query?

A: This is a great question and one that many CDI specialists struggle with. The issue is inconsistency with the use of Type 2 MI. The definition of a type 2 myocardial infarction is an MI secondary to ischemia due to either increased oxygen demand or decreased supply. Your physician advisor is correct that if the wording Type 2 MI was used an MI should be coded. But we must remember the physician needs to identify the MI as either an NSTEMI or STEMI. No differentiation is provided by the physician, the code will default to an assignment for STEMI.

You are also correct in identifying that the wording “type 2 injury” is vague and does require clarification. This could mean an MI but also could be interpreted as demand ischemia. With the documentation you have provided in your question, a query is needed. Consider a query similar to the following:

Dear Dr. Heart,

You documented the diagnosis of “type 2 injury” for this patient admitted with elevated cardiac enzymes in the presence of shock.  (List any other clinical indicators- complaints of chest pain, lab values etc and treatments provided). Please clarify the meaning of type 2 injury?

  1. Demand ischemia
  2. type II myocardial infarction- NSTEMI
  3. Unable to determine
  4. Other__________

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: CDI education for inpatient rehabilitation

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Got a question? Ask us!

Q: Our CDI nurses will be doing a presentation for our inpatient rehabilitation department, which includes physical therapy (PT), occupational therapy (OT), and speech therapy. We plan on providing an introduction to CDI—what it is, who we are, and the goals of our department—and, of course, we would like to address documentation specific to their department.

We will most likely mention that, although we cannot code based on their notes, it is helpful if they document specific words, such as “aspiration” or “L-sided hemiparesis” or “functional quadriplegia” so, in the event that we need to query the physicians, we can use their notes to support this.

Are we on the right track? Do you have any other ideas regarding documentation issues or concerns that we should include for this group?

A: Your question brings up a great point for CDI specialist and their role in education. Many people state that the education function of a CDI specialist is to teach the physicians about the needs for quality documentation. I do agree that the physicians are our primary focus, but I define our education responsibilities a bit differently. I feel it is our responsibility to educate everyone who documents in the chart.

As a CDI specialist, I called it my “CDI Roadshow” and visited as many different departments in the hospital that would welcome me, including nursing orientation programs and nursing staff meetings, and other departments such as PT/OT, respiratory therapy, dieticians, pharmacy, etc.

I agree you need to start with a basics—explaining why documentation is so important and how it influences your organization’s health to include both direct and indirect reimbursement, and reputation related to publically-reported quality data.

For the inpatient rehab department, I think your focus is spot on. I would encourage them to describe patient function, the presence of hemiparesis, and other neuromuscular deficits. Encourage them to ask and answer questions—is the patient prone to falls? Are there any anomalies related to gait?

Documentation of aspiration and swallow evaluations is also an important target. If your rehab department is involved with wound care, this may be an area for needed education.

I once had a dietician say to me, “You read my notes? I didn’t think anyone read my notes!” Let them know that you read their notes and how they are helpful to you. Good luck!

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

Q&A: Seeing oliguric and non-oliguric renal failure in documentation  

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 have seen documentation of oliguric renal failure and non-oliguric renal failure. What is the difference and does it impact coding?

A: We can define acute kidney injury (AKI) in terms of serum creatinine stages but we can also define it in terms of urinary output. Now the term “oliguric renal failure” is one we use where people have AKI but their urine output is less than normal.
Normal urine flow should be greater than a liter a day. If you have 500 cubic centimeters up to a normal amount of urine output in a day, then that’s what we call non-oliguric renal failure, because the patient is putting out urine. These people tend to have less injury to the kidney and have greater survival statistics and so forth.

Now if the patient’s urine flow is below 500 cc a day and this is in the face of adequate fluid replacement, then the patient is not making urine appropriately and we call those people oliguric. That indicates that the patient probably has a more severe expression of the AKI or the acute tubular necrosis.

Now if you get below 50 cc, we call that anuric. We don’t see that very often in AKI or acute renal failure but when we do, patients typically have massive necrosis and a lot of times these people have cortical necrosis. The whole surface of the kidney is ischemic. But you also can see it in bilateral urinary obstruction from tumors in the pelvis. Again, the typical AKI doesn’t produce anuria. But oliguric renal failure is not uncommon and providers try to catch people early and convert them from oliguric to non-oliguric. However, this only relates to urine flow and it really doesn’t change how you code it at all.

Editor’s Note: This article was originally published in JustCoding. Garry L. Huff, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and president of Huff DRG Review in Eads, Tennessee, answered this question on the HCPro webcast “Acute Kidney Injury: Use Case Studies to Improve Renal Coding, Querying.”

Q&A: Primary, principal, and secondary diagnoses

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Go ahead, ask us!

Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to enable me to discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

The primary diagnosis is often confused with the principal diagnosis. In the inpatient setting, the primary diagnosis describes the diagnosis that was the most serious and/or resource-intensive during the hospitalization or the inpatient encounter. Typically, the primary diagnosis and the principal diagnosis are the same diagnosis, but this is not necessarily always so.

Principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital, according to theICD-10-CM Official Guidelines for Coding and Reporting. We must remember that the principal diagnosis is not necessarily what brought the patient to the emergency room, but rather, what occasioned the admission.

For example, a patient might present to the emergency room because he is dehydrated and is admitted for gastroenteritis. Gastroenteritis is the principal diagnosis in this instance. Many people define it as the diagnosis that “bought the bed,” or the  diagnosis that led the physician to decide to admit the patient. A good question for CDI specialists to ask when examining the record is: “What is the diagnosis that was significant enough to require inpatient care?”

The physician doesn’t have to state the condition in the history and physical (H&P) in order for the coder to be able to use it as the principal diagnosis. However, the presenting symptomology that necessitated admission must be linked to the final diagnosis by the physician. Coders cannot infer a cause-and-effect relationship, according to the AHA’s Coding Clinic, Second Quarter 1984, pp. 9–10. It is the condition “after study” meaning we may not identify the definitive diagnosis until after the work up is complete.

Next, let us look at an example of when these two would differ. A patient is admitted for a total knee replacement for osteoarthritis. The patient is brought to pre-operative holding area to prepare for surgery and suffers a ST-segment elevation myocardial infarction (STEMI) before the surgery could begin. Instead of going to the operating room for the knee replacement, is the patient goes to the cath lab for a stent placement.

The first question we must ask is what was the diagnosis that occasioned the admission? What was the principal diagnosis? The answer would be the osteoarthritis. This is the diagnosis that brought the patient to the hospital and the diagnosis which occasioned the need for the inpatient bed.

The second question would be what is the diagnosis that led to the majority of resource use? What is the primary diagnosis? In this scenario, it would be the acute myocardial infarction, the STEMI. But we cannot use the STEMI as the principal diagnosis because it was not the “condition that occasioned the admission.”

Now you ask what is considered a secondary diagnosis. The Uniform Hospital Discharge Data Set (UHDDS) definition of “other diagnoses,” or secondary diagnoses, describes those conditions that coexist at the time of admission, or develop subsequently, and that affect the patient care for this current episode of care. I often describe these diagnoses as the patient’s “baggage,” or the diagnoses they bring along with them that must be considered when treating the principal diagnosis.

For example, our patient admitted with the principal diagnosis of osteoarthritis with the planned total knee replacement also has a history of type two diabetes, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). These diagnoses were present prior to admission, but were not the reason for admission. They would be coded as secondary diagnoses because they will require treatment and monitoring during the patient stay.

We must also consider those diagnoses that develop subsequently, and will affect the patient care for the current episode of admission. In our example, that would be the acute STEMI. It developed after admission, so it would be a secondary diagnosis.

To be considered a secondary diagnosis the condition must require:

  • Clinical evaluation or
  • Therapeutic treatment or
  • Diagnostic studies or
  • An extended length of stay or
  • Increased nursing care and/or monitoring

Identifying the principal and the secondary diagnosis can be confusing when you have a patient who is admitted with two or more acute issues present such as  a patient admitted with an aspiration pneumonia and acute cerebrovascular accident (CVA). In this case, there are specific coding guidelines that will assist you. I would suggest you review the 2016 Official Guidelines for Coding and Reporting . There are a number of guidelines that describe how to determine the principal diagnosis.

In this scenario of an acute aspiration and an acute CVA both being present on admission, it may be difficult to discern which should be the principal diagnosis. They both would likely lead to an inpatient admission, and would meet medical necessity. If it is thought both equally could lead to an admission, the Official Guidelines for Coding and Reporting tell us that either can be chosen as the principal diagnosis. If, in review of the record, it is not clear if the conditions equally contributed to the admission, or you wish confirmation, you should query the provider as to the diagnosis that led to the admission.

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: Emergency room documentation and radiology reports

Take CDI into the emergency room

If the ER physician documents a diagnosis, but you see no evidence of treatment or monitoring, query for the significance of the diagnosis.

Q: Can you code strictly from emergency room (ER) documentation? Can you code from test results and imaging (radiologist reports)?

A: I am unsure what your mean by “strictly” from. Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ER physicians or other providers (NPs and PAs) can be used to base code assignment.

There are two elements of caution I would add. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ER physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.

As for the second piece of your question, diagnoses codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnoses codes, as such physicians do not provide direct patient care. We would need to query the attending provider to assign the appropriate diagnosis code.

Further guidance exists from the AHA Coding Clinic for ICD-10-CM/PCS regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident (CVA) from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.

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: Ancillary providers response to queries postdischarge

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Ask your question!

Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?

A: This is a difficult question to answer without knowing the policies within your organization related to discharge summaries, amending summaries, and the retention of queries.

We certainly can apply code assignments from any provider (physician, NP, or PA) that has been involved in the care of the patient. So, in general, the PA or NP answering these queries is acceptable, if, of course, they provided care to the patient during the encounter.

If you ask them to amend the discharge summary, examine your organization’s policies related to who is allowed to amend discharge summaries. For example, if the PA is not the one who wrote the discharge summary, should they be the one to add a change? I would suggest you speak to your HIM director if this is an issue.

Lastly, if you ask a query due to conflict between providers (for example, the PA states one diagnosis and the attending is stating a completely different diagnosis) the clarification must come from the attending physician.

As is almost always the case in the world of CDI, coding, and medicine, it is a bit complicated!

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