CDI Tips: Properly Capturing Lactic Acidosis

A recent discussion regarding lactic acidosis in a patient with sepsis has prompted a review of some important points that need clarification.

First and foremost, lactic acidosis is not considered inherent to Sepsis. Additionally, acidosis is not noted as an excludes 1 or excludes 2 note under code category “A41” – Other Sepsis.

A query would certainly be appropriate if the patient has elevated lactate and has met the criteria of a secondary diagnosis.

But don’t stop here; there is more to it!

Under category E87, “Other disorders of fluid, electrolyte, and acid-base balance” in the 2023 ICD-10-CM manual, the codes are as follows:

E87.2 Acidosis

Excludes1: diabetic acidosis – see categories E08-E10, E11, E13 with ketoacidosis

E87.20 Acidosis, unspecified

Lactic acidosis NOS Metabolic acidosis NOS
Code also, if applicable, respiratory failure with hypercapnia (J96. with 5th character 2)

E87.21 Acute metabolic acidosis

Acute lactic acidosis

E87.22 Chronic metabolic acidosis

Chronic lactic acidosis
Code first underlying etiology, if applicable

E87.29 Other acidosis

Respiratory acidosis NOS
Excludes 2: acute respiratory acidosis (J96.02) chronic respiratory acidosis (J96.12)

It is important to note the codes above are CCs and may change the SOI/ROM; however, in a septic patient, these diagnoses will most likely not affect the DRG itself.

This is very valuable information with regard to quality initiatives that may be important to your organization. This could indicate an increased severity of illness and support a longer length of stay. Consequently, this is one of the main reasons why many healthcare facilities are querying for acidosis in the presence of sepsis.

So, when do you query for lactic acidosis outside of the usual elevation of lactic acid in sepsis?

According to the ACDIS document (https://acdis.org/articles/qa-lactic-acidosis-and-sepsis)

Q&A: Lactic acidosis and sepsis

May 30, 2019 – CDI Strategies – Volume 13, Issue 24

“From a clinical standpoint, any patient with severe sepsis would be expected to have elevated lactate levels; they would not, however, be expected to always have a large anion gap and persistent levels of lactate > 5mmol/l after hydration. In fact, such a patient would be considered by many definitions (Sepsis-3 included) to be in septic shock.”

The article goes on to clarify when it would be appropriate to query and address the important query questions to ask.

To summarize:

If the lactic acid levels are mild, they would be considered part of the sepsis diagnosis and not reportable under ICD-10 CM.
If the lactic acid level is out of sync with the severity of the sepsis (a radically elevated lactic acid without severe sepsis or septic shock), a query to determine the underlying cause of the lactic acidosis would be appropriate. If another underlying cause is found, the acidosis may be reportable as long as it is not expected in the other associated diagnosis.
Septic shock, with severely elevated lactate levels and anion gap, would also be routinely associated with septic shock and not reportable using basic coding guidelines.

In closing, let’s review some considerations for queries:

Before querying lactic acidosis in conditions such as sepsis and respiratory failure, consider if the elevated lactic acid would be routinely associated with the diagnosis.
Also, consider if there could be another underlying cause for the elevation and if it is considered to be routinely associated with those diagnoses.
Then use your best critical thinking skills and your organization’s guidelines to determine if a query for lactic acidosis is compliant in that situation.

Keystone Health relies on Intellis to address data challenges

In a recent Health Data Management article, Keystone Health Chief Operating Officer David Grant addressed the importance of ensuring clinician satisfaction with data integrity during EHR conversion. Legacy data missing from a new EHR can result in data gaps causing physician frustration, redundant treatment, and disjointed care management. To help overcome the challenges caused by missing patient data, meet go-live deadlines, and ensure physician satisfaction, Keystone Health turned to Intellis.

Read the article here.

Find out more about Intellis HIT solutions.

Gold Star Ranking at RWJBarnabas Encompasses MPI and Data Integrity Work with Intellis

In October 2022, Intellis’ New Jersey-based client RWJBarnabas received an unprecedented perfect score from Epic for its EHR implementation project, as Becker’s Hospital Review reported. The Gold Star 10 ranking, the highest level of recognition a health system can achieve from Epic, places the organization in an elite class of health systems. An essential piece of RWJBarnabas Health’s Epic success was a keen focus on data integrity and master patient index (MPI) cleanup throughout the implementation process.

Joe Galdi, vice president of revenue cycle at RWJBarnabas Health, was recently interviewed by Healthcare Innovation regarding insights gained from moving nine different EHRs systems and 650 downstream systems to the new Epic enterprise-wide EHR. Galdi has been knee-deep in the massive Epic implementation for 14 hospitals and 1,000 providers, including consolidating services and standardizing workflows.

“Everybody is looking to put the patient first in all of this, but patient information exists in hundreds of places for health systems this size,” he said. “While the goal is to get to one system and reduce redundancies, it can be a nightmare for healthcare organizations with many information systems and various patient records.”

So how did RWJBarnabas tackle the consolidation of patient information in multiple places? Galdi shared three lessons learned during the Epic implementation process that helped the organization reduce the duplicate record rate to 2%, nearly two percentage points lower than most organizations.

Prioritize MPI cleanup to capture information for each patient into a single record. Tap on outside resources if necessary.
Ensure data is clean before converting from legacy systems to Epic. For data that doesn’t automatically convert, build a plan for manual data abstraction to support clinicians and patient care.
Look ahead to new partnerships or acquisitions and ensure the availability of resources to support new MPI cleanup and data abstraction projects.

According to Galdi, RWJBarnabas has ten more hospitals and around 200 providers to convert to Epic. But the possibility of new partnerships or acquisitions could increase those numbers. Intellis is ready for continued MPI cleanup, data abstraction, and more with Galdi’s team.

Keep IT Agile During M&A

With no end in sight to M&A activity, CIOs and IT leaders must get involved early to plan for the situations listed above. Keeping outside services aligned and available to support massive system consolidations is essential. Click here to learn how Intellis can support MPI cleanup and related work to ensure data integrity.

CDI Tips: Dementia

Dementia: Will we need more queries?

The short answer is yes! We need documentation of none, other, or a specified type of mood disorder.

But here is the long answer:

“Dementia The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate, or severe). Selection of the appropriate severity level requires the provider’s clinical judgment, and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting) unless otherwise instructed by the classification. If the documentation does not provide information about the severity of dementia, assign the appropriate code for unspecified severity. If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.” (2023 ICD-10-CM official guidelines, page 43.)

To accurately assign dementia, it is necessary for the provider to document the severity of dementia as mild, moderate, or severe.

Mild is coded with the fourth character A
Moderate is coded with the fourth character B
Severe is coded with the fourth character C

For example, Vascular dementia, Moderate is coded to F01.B-. There is a code for unspecified severity F03.9, but as CDI specialists, if we are going to query for the type of behavioral disturbance, we could ask for severity as well. Unspecified severity can be coded if the provider really does not know. The severity of dementia does not determine if the code is a CC.

However, there is no code for unspecified mood disturbance, only for other and without. The dementia code without behavioral disturbance is not a CC. Specified disturbances such as psychotic disturbance, agitation, mood disturbance, or anxiety are CCs. The tabular section of the ICD-10-CM code book found at www.CMS.gov/Medicare/coding/ICD10 gives examples of what is included in these different behavioral disturbances.

Where do you find clinical indicators to support documentation of behavioral disturbances?

Previous encounters: Has the patient been seen previously with documentation of behavioral disturbances related to dementia? How were they described? Be sure to include the date and location of the information in your query!
Nursing documentation: Does nursing describe behaviors that could be included in your query to support the query regarding the specificity of behavioral disturbances?
Social services documentation: Is there documentation that indicates behavior has been a problem at home? Have family members indicated there are behavioral issues at home?
Consult notes: Has the patient been evaluated by psychiatry, neurology, or gerontology related to dementia?
Medications: Is the patient on medications that indicate there is a behavioral component of their dementia that is being treated?
Provider documentation: Does the doctor mention any signs and symptoms such as hallucinations, or “the patient is anxious”? Look for statements that could support a query for a specific behavioral disturbance.

Remember that complete and accurate documentation improves patient care across the continuum of care, and the clinical documentation specialist plays a key role in making this happen.

Today’s Tip: Lupus

When Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible.

For instance, document SLE (systemic lupus erythematosus) instead and add any complications that accompany this diagnosis. It is often accompanied by Sjogren’s syndrome or Sicca syndrome, which have very specific codes. Another solution is to develop facility or provider-specific guidelines to report M32.9 (SLE, unspecified) as a default for Lupus, unspecified.

Today’s Tip: Drug-induced Neuropathy

Drug-induced neuropathy (D62.0) is a diagnosis often missed by even the savviest and seasoned coders. It is sometimes seen in documentation as ‘CIPN’ (chemotherapy-induced peripheral neuropathy) and is a common side effect caused by antineoplastic agents. Treatment includes steroids and nerve pain medication such as Gabapentin.

Drugs related to neuropathy

The most likely chemotherapy drugs related to neuropathy include platinum drugs, such as oxaliplatin; taxanes, such as docetaxel; vinca alkaloids, such as vincristine; and myeloma treatments, such as bortezomib. This code can also be accompanied by another code for the adverse effect (T36-T50) to identify the drug.

Today’s Tip: Cachexia (R64)

Cachexia (R64) is also known as ‘wasting’ or ‘wasting syndrome’. It is a general state of weakness involving marked weight and muscle loss. Emaciated is another term that may be found in the documentation that also maps to code R64.

These diagnoses are often missed since they are commonly only seen in the Physical Exam or Review of Systems portion of a record. There are often ‘knee-jerk’ reactions that can lead a coder to investigate further if a patient may have these diagnoses.

What to look for

Cachexia is commonly seen in patients who have AIDS, cancer, or other advanced heart or lung disease. You will often see a lack of appetite, fatigue, low BMI, and malnutrition. Look for nutritional consults and a PEG tube in the documentation to trigger the search for cachexia in the documentation.

Why is this so important?

Cachexia is a diagnosis that can affect reimbursement for both Inpatient and Risk Adjustment. Don’t miss it!

E/M Hot Topic: Telemedicine Update

Jeanie Heck, our Director of Education, begins our 2022 series of E/M Hot Topics with a discussion on Telemedicine. January’s Hot Topic provides an update from the CMS Final Rule as well as some reliable and reputable sources of information regarding telehealth.