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 Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA
Clinical documentation improvement (CDI) professionals strive to ensure the clinical documentation presented in the health record is of high quality and that it accurately reflects the true picture of the resources utilized to care for the patient.
Recently, I happened upon an article citing data from the Illinois Department of Public Health (IDPH) on Neonatal Abstinence Syndrome (NAS) that rang my internal CDI alarm, and I decided to investigate this topic further.
According to the IDPH website: “Neonatal abstinence syndrome refers to a collection of signs and symptoms that occur when a newborn is prenatally exposed to prescribed, diverted, or illicit opiates and experience opioid withdrawal. Symptoms of NAS include: irritability, tremors, feeding problems, vomiting, diarrhea, sweating, and in some cases, seizures.” Certainly, these neonatal patients should be considered as additional victims affected by the opioid crisis.
There are many signs and symptoms of NAS that mimic other conditions and vary in severity. I find the lack of a standard clinical definition concerning. Without a standard clinical definition, it would seem there may be issues with providers’ ability to recognize symptoms, leading to a lack of an accurate diagnosis and thus the most appropriate treatment for newborns.
If the syndrome is not recognized, and thus not documented, then the correct diagnosis code will not be assigned—which in turn impacts the state and national statistics regarding this syndrome. The capture of the most accurate diagnosis is essential for research and the development of the best practices to care for newborns with the condition. NAS increases the length of stay and costs for this patient population. The data may not be a true reflection of the actual number of newborns treated with this syndrome. Accurate data may support the need for more staff and dedicated beds to properly care for this population.
Several articles noted provider bias in the diagnosis of NAS, as providers may not want to create an association with this diagnosis and certain maternal populations.
It is recommended that a complete history of all medications and drugs be conducted during a prenatal visit. Mothers may be hesitant to divulge accurate information regarding illicit and licit drug use.
The Finnegan Neonatal Abstinence Scoring Tool created in the 1970s, along with a modified version from the American Academy of Pediatrics, are just two of the various assessment tools used by hospitals for the diagnosis and treatment of the condition. The lack of interrater reliability for many of these assessment tools is concerning.
The least complicated issue with NAS is the coding, if documented as such within the health record.
The ICD-10-CM Alphabetic Index under the main term syndrome, leads the reader to P96.1. The non-essential modifiers listed under P96.1 are:
- Drug withdrawal syndrome in infant of dependent mother
- Neonatal abstinence syndrome
Excluded in this diagnosis code are reactions and intoxicants from material opiates and tranquilizers administered during labor and delivery, which would be assigned P04.0.
How can CDI play a role in ensuring high-quality clinical documentation in these cases? Suggestions include:
- Collaborate with pediatricians, neonatologists, and obstetricians to schedule educational sessions regarding this conditional.
- Conduct research regarding the condition and tools that can be used for the accurate diagnosis; Present this information to organizational leadership.