|CDI Conundrum Diagnoses, Presented by Dr. Tim Brundage at the American College of Physician Advisors (ACPA) National Physician Advisor Conference
Reviewed by Erica Remer, MD
“Tim Brundage and I have been friends for years, and we co-chair the ACPA CDI Education Subcommittee, but I never had the pleasure of hearing him present until NPAC 2018. The title was “CDI Conundrum Diagnoses,” and Tim masterfully demystified complex topics such as sepsis, heart failure, encephalopathy, and Type 2 myocardial infarction.
He began with and interspersed advice on general clinical documentation integrity. Rather than trying to get providers to internalize the stratification of comorbid conditions and complications (CCs) and major CCs (MCCs), Tim led providers to think of patients as being in three tiers: not sick, moderately ill, or maximally ill. He warned us that providers tend to undervalue their services and their work product. He pointed out that it “takes a licensed medical provider to make diagnoses,” in contradistinction to Dr. Mom who is able to identify symptoms.
Brundage cautioned us that conflicting documentation (“Troponin elevation” in one document, “Type 2 MI from demand ischemia” in another) is “audit candy.” Although I have openly declared war on copy and paste, I actually do agree with Tim’s position that judicious copy and paste with adequate editing is acceptable; indiscriminate and excessive use of the electronic tool by the lazy clinician is intolerable.
The UHDDS Federal Register from July 1985 (p. 123) detailed the definitions of principal and other (secondary) diagnoses. Coders and CDISs often overlook “conditions that coexist at the time of admission,” and Dr. Brundage related that diagnoses in the EMS encounter, the ED, the PCP’s note, and from a lower level of care, like the nursing home transfer sheet, may be utilized, if they are still actively being treated or impacting on the patient’s care during the present encounter. He referred to CMS’ 3-day payment window (72-hour rule), which I understand mandates that outpatient services at hospitals’ wholly owned entities have the technical component of said service bundled into the inpatient admission.
Regarding specific clinical conditions, Tim gave his opinion that providers are too narrow in their application of sepsis under any definition. He feels that patients present later, sicker, and already partially treated, than they used to. He opposes the implication that this is “gaming the system.”
For each clinical condition, a review of words, phrases, findings, and therapy which support the diagnosis and provide “audit protection” was presented. I especially liked his invoking the Framingham criteria for heart failure, and he made the point that this could be quite useful in the case of getting your TAVR into the correct DRG tier.
Similarly, he reminded us that encephalopathy can be bolstered by the liberal use of the Glasgow coma scale where the lowest individual components can serve as MCCs [my 2 cents – this is particularly useful in hepatic encephalopathy, which is only a CC. If your providers follow the mental status deterioration with the GCS, you may be able to capture the MCC, short of coma].
A thorough exploration of the Third Universal Definition of Myocardial Infarction was undertaken, with the caution that they are working on the Fourth Definition (Are you kidding me?!). Pneumonia points included the use of uncertain diagnoses (Why are you giving big-gun antibiotics? Is there likely aspiration?), and to be on the look-out for concomitant acute respiratory failure or sepsis.
After an excellent discussion of many tricky diagnoses, Brundage reminded us of our sacred Hippocratic oath. He reminded us that the words our providers choose, matter.”