This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Allen Frady, RN-BSN, CCDS, CCS, CRC
What do the Global Leadership Initiative on Malnutrition (GLIM), Fourth Universal Definition of Myocardial Infarction (4th UDMI), and the never-ending argument over sepsis all have in common? They are all reminders that a clinical documentation improvement (CDI) practice can never be complacent.
Given the dynamic nature of the human condition, the evidence for almost any diagnosis can be argued regarding the given variables within a record. This applies to both CDI professionals seeking to add diagnoses and auditors seeking to remove them. Per the Centers for Medicare and Medicaid Services, DRG assignment should most closely reflect a true measure of resource utilization for appropriate reimbursement. The Official Guidelines for Coding and Reporting instruct coding professionals that uncertain conditions at discharge in the inpatient setting are reported on the basis of similar resource consumption, as a confirmed condition. If the clinical evidence does not appear to support a diagnosis, a query may be needed for confirmation.
Clinical validation for malnutrition often centers around the fact that physicians defer to the dietician’s expertise. Recent high-profile audit results imply that a lack of physician involvement in the management of malnutrition as one (of several) pivotal causes for denial of reporting. GLIM separates malnutrition along two axes:
- Phenotype (observable) criteria of weight loss, low BMI and reduced muscle mass
- Etiologic (causative) criteria, an analysis of intake and active inflammation
One of GLIM’s most noteworthy statements, in the 2018 report, is the inclusion of albumin levels to support the measurement of inflammation.
The 4th UDMI has less restrictive definitions of the EKG changes associated with an infarction; moving from a list of specific changes to the more general language of EKG changes “associated with” ischemia. The 4th UDMI has introduced a concept which clinicians have been grappling with for some time now. Not all cardiac insults should be reported as an infarction, especially when they are due to a known or named myocardial problem which is non-ischemic in nature. There is presently no way to index such cardiac injury documentation appropriately in ICD-10-CM. Non-ischemic injuries will have their own category not associated with infarction, some of which will no doubt fall under the coding definition of “integral to” other existing cardiac insults. CDI should continue to pursue reviews for the necessary indicators when ischemia is in question, either in pursuit of adding the appropriate reporting solutions for infarction or in performing clinical validation.
Last year, Sepsis 3 was kicking off a new wave of debates, which are the stuff of legend in the CDI world. We haven’t yet reached consensus on the debates of which criteria should be used to support sepsis. Some high-profile payers are adopting the Sequential Organ Failure Assessment (SOFA) criteria, stating that the surviving sepsis campaigns (SSC) adoption of the sepsis 3 definition is an endorsement of the SOFA criteria, yet endorsement of the SOFA scoring methodology itself appears absent from the SSC. Not every patient is going to present with “standardized findings.” Many physicians feel organ failure is the benchmark for the dysregulated host response, the values given in the SOFA table may not meet a tissue-based definition of failure but rather represent dysfunction on a continuum.
Bored in CDI? You aren’t paying attention.
Centers for Disease Control and Prevention. ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf.
Jensen, Gordon L. et al. (2018). “GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report from the Global Clinical Nutrition Community.” Journal of Parenteral and Enteral Nutrition. September 2, 2018. https://onlinelibrary.wiley.com/doi/full/10.1002/jpen.1440.
Thygesen, Kristian et al. Fourth Universal Definition of Myocardial Infarction (2018). Journal of the American College of Cardiology. August 2018. http://www.onlinejacc.org/content/early/2018/08/22/j.jacc.2018.08.1038?_ga=2.161541694.302329110.1543255582-1738630742.1543255582.
Allen Frady (email@example.com) is CDI education specialist at ACDIS.