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: 

1. If the lactic acid levels are mild, they would be considered part of the sepsis diagnosis and not reportable under ICD-10 CM. 
2. 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. 
3. 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. 

The World Health Organization (WHO) declared monkeypox a public health emergency of international concern on July 23rd, 2022. Following consultations with global experts, WHO began using a new preferred term, “mpox” as a synonym for monkeypox. Both names are used simultaneously for one year while “monkeypox” is phased out.

Most patients will not be admitted to the hospital with mpox, but some patients with weakened immune systems, children under age 8, and pregnant or breastfeeding women can experience serious illness.

When a pregnant patient with mpox is encountered and mpox is the only complication, assign O98.51 – Other viral disease complicating pregnancy. The trimester is required, plus a Z code for the completed weeks of pregnancy. Assign B04 for mpox as well.  

BUT

It is also important to look for other complications such as Bronchopneumonia resulting in respiratory complications, Sepsis with organ failure, and in severe cases, neurological manifestations such as encephalitis with seizures or Guillain-Barre.

A query may be required to link mpox to sepsis, pneumonia, and other complications. Watch for neurological signs and symptoms without a diagnosis and query to clarify.

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.

The newly released and much anticipated 2022 UPDATE of the AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice is here! We’re offering two live webinar opportunities for you to be informed, stay up-to-date, and earn 1.5 AHIMA-approved CEUs. Choose your date and register: Friday, November 11th, 10 AM EST  or Thursday,  November 17th, 2 PM EST.

“Here come the ‘chart police.’” 

Every clinical documentation specialist (CDS) has heard it. “Chart police.” For those CDSs with a nursing background, it is often heard from those nurses they have worked alongside in the following ways: 

(1) when discussing their new role

(2) while explaining their current role

(3) when attempting to recruit bedside nurses into the CDS career path. 

How do we educate our bedside-loving peers about the value that their documentation brings to the final coded record? Show them. 

Nurses love evidence.

It has been the foundation of nursing practice since Florence Nightingale demonstrated that good hygiene improved outcomes. Pull up a stand-alone encoder and show them the difference made by inclusion of wound staging or body mass index. Clinical documentation integrity is an obscure role to most nurses so take the opportunity to translate the language. Instead of demonstrating the MS-DRG, show the difference in severity of illness (SOI) and risk of mortality (ROM) when including their documentation. Interpreting SOI and ROM is a quicker soap box discussion than CC/MCC capture and translates clinically with almost no discussion. 

ICD-10-CM Guidelines for Coding and Reporting allow us “few exceptions” to the rule that “code assignment is based on the documentation by patient’s provider” but, nurses need to know that their documentation often triggers CDSs to know that a query opportunity exists. Default templates utilized by providers may repeatedly explain that the patient is oriented, but night shift nurse documentation may paint a different picture of a sundowning patient. That picture is incredibly valuable to the accuracy of the coded record, particularly when the provider is documenting in progress notes when assessing the same patient during the day. 

The remote world has done wonders for production but can put a strain on those opportunities to engage our healthcare partners and demonstrate value. Other ways to engage our nursing colleagues in understanding the value of their education: round with them during an onsite day, engage nursing management to become part of the nursing skills fairs (quality documentation is inarguably a skill), or seek out the opportunity to present to new nursing hires during orientation. 

Measuring body mass index (BMI)requires the following equation:
BMI = (weight (lb) ÷ height² (in)) x 703

The Result?

BMI = A physiologically misleading indicator used to classify health status. Misleading because weight divided by height squared (x 703 to make up for the metric system) tells us nothing about a patient’s bone density or muscle mass, both of which tell us a great deal about a person’s physical health. This misleading indicator is then broken into categories that patients are often bucketed into: underweight (below 18.5), normal (18.5-24.9), overweight (25.0-29.9), obese (30.0-39.9), morbidly obese (over 40) without consideration of gender, ethnicity, age, or athleticism variances. Well-conditioned athletes and weightlifters often have notoriously high BMI’s due to exceptional bone health and increased muscle mass.

Clinical Significance

Coding Clinic addresses in Fourth Quarter 2018 that “obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In addition, if documented, the body mass index (BMI) code may be coded in addition to the obesity or morbid obesity code.” But what happens when the provider has not documented a diagnosis? One cannot assume the clinical significance of a number without an associated diagnosis. Without more information about a patient, we cannot be sure that the elevated BMI requires a diagnosis or is simply a numerical finding without clinical relevance because the patient is a world-renowned bodybuilder.

An Inherent Issue

Clinical documentation integrity (CDI) specialists and coders are often trained to look for the BMI and the accompanying appearance of an associated diagnosis when a high or low value is noted. There is an inherent issue in this practice. Recall the inpatient guidelines for reporting additional diagnoses (Section III. Reporting Additional Diagnoses: General Rules for Other (Additional) Diagnoses):

“For reporting purposes, the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or treatment.”

The burden of proof rests on the CDI specialist or coder to demonstrate that a condition met “other” diagnosis criteria yet was not documented when initiating a query. Aside from being a questionable result to a math equation, how did the patient’s elevated or low BMI impact their hospital stay?

Many CDI specialists default back to “weight-based medications.” Can you identify the weight-based medications in a patient who did not receive anesthesia? Every nurse took a course in medication math to get through nursing school. If your patient received a heparin infusion at a weight-based dose, did a weight of 285 pounds in a 5’5” patient impact nursing care more than a weight of 285 pounds in a 6’5” patient would have when calculating a dose? There is an argument for therapeutic treatment varying but before you ask the question, be sure your argument is sound.

Indicators

There are indicators to look for that justify that some BMI-related diagnoses may be clinically significant. Read the nurse’s notes. Fully dependent or even partially dependent patients requiring “max assist” or “OOB w/ assist x2” demonstrates that additional nursing care was required. Specialty beds come at a premium and provide support to patients above and beyond that of a traditional inpatient bed. Nutrition consults to help a patient with a BMI of 17.0 gain weight are obviously targeted treatment.

Be on the lookout for “other” reasons for inaccurate BMI and avoid falling into the traps. Patients and clinicians are usually not accurate when guessing a patient’s weight. If you see a solid even number (say 300 pounds) entered into the electronic medical record, do some digging to see “how” the patient was weighed. Standing scales and bed scales are far more accurate than “self-report.” While it seems very specific, be mindful of bilateral amputees. Most electronic records automatically calculate BMI based on the input height and weight. Any amputee requires special consideration for the percentage of body surface lost.

Performing the CDI role is to assess a patient without the use of your senses. For those with a clinical background that required patient assessment, the CDI role requires that you do the same assessment without ever seeing, touching, or hearing the patient. Querying for accuracy in the patient record takes unique skills and it is important to exercise those skills prudently when attempting to assess a patient with a potentially misleading number.

Need help keeping your Coding and CDI teams up-to-date? Contact us to find out how we can help. Intellis offers in-depth education and training services led by our IQ Team of subject matter experts.

Since we have passed the one-year anniversary that COVID-19 was first identified in the United States, it is important to reflect on the long-term effects of COVID-19. Throughout the pandemic, the Intellis team has worked diligently to update COVID-19 resources. Research continues to evolve as the medical community seeks to better understand the disease’s impact, and the passage of time presents the opportunity to evaluate the effects on body systems.

According to the Journal of the American Medical Association, the pandemic has been accompanied by a COVID-19 “infodemic” with more than 11,000 COVID-19 papers submitted to JAMA since the start of the pandemic! It can be overwhelming to keep up. Our White Papers serve as a guide to remind coders and clinical documentation integrity (CDI) specialists to dig deeper into the medical record to uncover overlooked diagnosis documentation. The goal is to highlight some, but not all, of the commonly seen complications in the patient population infected with COVID-19.

White Paper: Sequelae of COVID-19 Part I – Cardiac, Pulmonary, Dermatological Complications
White Paper: Sequelae of COVID-19: Part II – Neurological, Psychological, Renal complications 

“1 in 2 people with very low kidney function who are not on dialysis do not know they have CKD (chronic kidney disease).” — Center for Disease Control

The implications of untreated or unmanaged kidney disease can be life-altering or lethal. CKD is a manageable co-morbid condition in its early stages with the potential for reversibility, however, once chronic kidney disease hits the later stages, management of the disease becomes significantly more resource consumptive. CMS is now in line with the clinical information by updating the most recent version of their HCC’s to reflect that even moderate CKD impacts the patient’s risk. 

The intention of hierarchical condition category (HCC) coding is to utilize the patient’s medical conditions, demographics, and interactions of the patient’s diseases to calculate a risk adjustment factor (RAF) score. The RAF score conveys the severity of the patient’s conditions in a calendar year in an attempt to reflect the level of resource consumption required to manage the patient. Anyone assigning diagnosis codes, regardless of setting, should be aware and educated on this risk-based payment methodology.

Inpatient care, awareness of kidney function matters for the management of other disease processes and medications. In coding, the accuracy of appropriate staging does not just impact the care rendered. Accuracy also ensures that the patient’s RAF score accurately reflects the resource consumption of their disease process. Through code assignment and documentation, the diagnosis can be linked to those underlying conditions that most often cause degradation of the kidneys- hypertension, and diabetes.

In earlier versions of CMS-HCCs, CKD did not carry significant risk (as demonstrated through weight) until the patient’s disease had reached stages 4, 5, or end-stage renal disease. In this case, the eGFR (estimated glomerular filtration rate) has typically dropped below 30, demonstrating a serious impact on the ability to clear waste products from the bloodstream.

CKD stage 3 (eGFR typically ranging 30-59) was not recognized as a hierarchical condition category code. This changed, however, with the introduction of CMS-HCC version 24. Why the change? CKD stage 3 (N18.30) has clinically significant ramifications for comorbid disease management and medication usage. Treating and managing a patient with CKD stage 3 before progression to later stages has a significant impact on the health of the patient. CMS did not outright make this statement but it’s a clinically logical deduction from the understanding of CKD disease progression.

In the inpatient setting, CKD stage 3 is not recognized as a complication or comorbidity (CC) so clinical documentation specialists may be overlooking this important risk adjusting condition. It is important that whether functioning in the inpatient or outpatient setting, CDI specialists and coders focus on getting accurate information reflecting the patient’s health status documented in the medical record. Take a deep look at the details of the patient encounter next time “CKD, unspecified” (N18.9) appears in the record.

Wondering about those more specific CKD stage 3 codes? Look for more information regarding CKD stages 3a and 3b in future tips!

February 2021

Now that we have been applying the new 2021 E/M guidelines for over a month, there’s no doubt that we have questions about some of the changes — especially the elements in MDM! Starting Feb 9th, Jeanie Heck, our Director of Education, will begin addressing “E/M Hot Topics” in monthly 10-20 minute presentations. 

For additional information about E/M Updates education, contact us.

Coding Tip

When anemia NOS is present as a current condition, and the patient has underlying chronic kidney disease (CKD) or end-stage renal disease (ESRD), it is a fast track to the usage of D63.1, Anemia in chronic kidney disease (manifestation). This is assigned unless the anemia is specified as a different form and/or attributed to another condition. Much like the diabetes category, ICD-10-CM “In/With” convention assumes “due to.”

ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I. A. 15.

“With” 

The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).

For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.

Clinical Insight

Anemia refers to the reduction of the total number of circulating red blood cells. It is diagnosed when there is the detection of decreased hemoglobin concentration, hematocrit, or red blood cell count. Anemia in chronic kidney disease specifically falls under the category of decreased red blood cell production. 

In CKD or ESRD, kidney function is compromised to the point that blood cannot be filtered of wastes and fluid. The kidneys also produce less erythropoietin (EPO), a hormone that signals the bone marrow to produce additional red blood cells. Furthermore, in CKD patients the red blood cells are not able to survive as long in the bloodstream and suffer a premature death. Due to associated nutrient deficiencies in underlying CKD, red blood cells are not reproduced as frequently or with the same cellular integrity as in a healthy patient.

Education Disclaimer: This coding tip is intended to serve the general community and may not account for all differences in coding routines, duties, or individual client policies. The information and opinions presented here are based on the experience, training, and interpretation of the author. Although the information has been researched and reviewed for accuracy, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This information is intended as a guide; it should not be considered a legal or consulting opinion or advice.

As healthcare continues to evolve, more procedures and care options have moved forward in the outpatient setting. This is primarily due to technological advances and value-based care incentives.

Health insurance plans and government programs have embraced the move toward offering more services in lower-cost care settings such as outpatient facilities. As the trend toward outpatient procedures continues, what is ahead for Percutaneous Coronary Intervention? Intellis Manager of Medical Coding Integrity & Education David Steinhage RHIT, CCS examines what is on the horizon in our latest IQ Point of View.

Get the IQ Point of View: White paper – Percutaneous Coronary Intervention in the OP Setting

Our COVID-19 coding and CDI education and training webinars are AHIMA-Approved for CEUs. We are constantly focused on COVID-19 coding and CDI, and we’re quick to recognize and share critical changes as they become available. Our FREE education and training webinars are led by the Intellis IQ team of subject matter experts. The information presented is based on trusted healthcare sources including the American Health Information Management Association (AHIMA), the American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services (CMS). The education presented is monitored continuously to reflect the most current healthcare and industry updates.

Schedule your FREE live webinars today!

Email our Intellis IQ Team

For information call: 484.264.1609

Each webinar includes a 1-hour education session presented by the Intellis IQ team of industry experts. Download the webinar overview or view below.