Neonatal Intensive Care Severity/Mortality Rates
Hello, Everyone:
I am looking for help on reviewing a NICU death chart for soi/rom. If a baby is known before birth to have a severe brain abnormality and the family has decided on comfort care, the baby is held and kept comfortable and passes the day of birth, what are some possible diagnoses that can be coded besides the regular birth codes, the anamoly codes and the v66.7 code? The MD documented that baby would experience apnea and bradycardia as part of the dying process. Flow sheet by nursing confirms the apnea and brady but MD did not document that the baby had apnea/brady, only that the baby would experience this. Can respiratory failure be queried for even though it is part of the dying process? Any other suggestions for queries? As is, the soi and rom are 1. Thank you for any ideas you all might have.
Janice Potter RN, CCDS
I am looking for help on reviewing a NICU death chart for soi/rom. If a baby is known before birth to have a severe brain abnormality and the family has decided on comfort care, the baby is held and kept comfortable and passes the day of birth, what are some possible diagnoses that can be coded besides the regular birth codes, the anamoly codes and the v66.7 code? The MD documented that baby would experience apnea and bradycardia as part of the dying process. Flow sheet by nursing confirms the apnea and brady but MD did not document that the baby had apnea/brady, only that the baby would experience this. Can respiratory failure be queried for even though it is part of the dying process? Any other suggestions for queries? As is, the soi and rom are 1. Thank you for any ideas you all might have.
Janice Potter RN, CCDS
Comments
A query for resp failure would probably not be appropriate as the baby was comfortable. If the baby struggled, etc and was intubated or placed on high flow o2, that would be different.
It sounds like you have covered the bases with coding anomalies and the palliative care code. I review all NNICU charts, though deaths are rare-just trying to think of what else you could look out for.
Just do a double check of all interventions (labs drawn? Cxr?, meds?)-if there are any that are not geared at comfort, assess for a possible diagnosis.
Thanks,
Kerry
Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
You are correct, these NICU cases are difficult to code & if not documented, very difficult to know what to query.
Good Luck!
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
BW 2207 gms, 37 weeks documented as term, SGA.
Thank you so much for responding. It helps to know that others have found these challenging.
It was holoprosencephaly.
It was also documented as semilobar holoprosencephaly vs hydranencephaly (no hydrocephales) and globe buphthalmus.
So I used 742.2, 743.20 but the hydranencephaly is tricky as the code for this 742.3 reads out congenital hydrocephalus. Not sure what to do about that one.
Here is some good information on palliative care-dying process.
Hope this helps to clarify....
CDI programs often fail to take advantage of documentation opportunities regarding do not resuscitate (DNR) or palliative care only patients, according to Tricia M. Litzinger, RN, CDS, CCM, inpatient consultant in the consulting services division of 3M Health Information Systems in Atlanta, GA.
“These cases are often 4/4 severity (extreme severity of illness and risk of mortality) with a known expectation of death of the patient, but physicians frequently do not document it, often because of the DNR order and because they may not have ordered diagnostics like labs,” Litzinger says.
For example, a patient with advanced cancer presents to the ER and is admitted with severe shortness of breath and pneumonia. Shortly into the stay the patient’s condition deteriorates related to the advanced cancer and she refuses further and heroic treatment.
Many physicians fail to document acute respiratory failure, acute renal failure, or other legitimate clinical manifestations (e.g., hypoxia, coma) in this and other similar instances. Often the physician will document IV hydration, family counseling, and palliative or comfort care measures, missing the opportunity to accurately capture the severity of illness and risk of mortality of the patient.
“At best the physician may document ‘respiratory insufficiency,’ ‘renal insufficiency,’ and ‘unresponsive,’ which do not accurately capture the clinical picture of the patient,” Litzinger says.
The result is an underrepresentation of the patient’s true severity of illness and risk of mortality and an under-coded final MS-DRG.
Tip: Ask the physician to document the dying process, Litzinger says. As the disease process consumes the body’s ability to function, organ failure, and other conditions may develop in these patients.
Kidney failure is a common result, followed by decreased perfusion resulting in hypoxia and eventual respiratory failure. Respiratory patterns such as apnea, Cheyne-Stokes, and hypoxia may also be present in these patients. Acid base imbalances such as acidosis may occur when the patient is actively dying. These conditions, along with the terminal disease process, may ultimately result in a comatose patient.
Many of the conditions listed above are likely opportunities for query, notes Litzinger. The criteria to capture these conditions as mandated by ICD-9-CM official guidelines are the diagnosis must be clinically monitored, evaluated, or treated, and/or result in an extended length of stay (LOS), and require nurse monitoring. You can establish this requirement by means other than labs or invasive diagnostic studies.
DNR patients, although beyond medical intervention, still present with clinical manifestations reflecting a status that requires appropriate documentation in the record. Physicians may or may not draw labs that would establish these diagnoses, but there are other signs/symptoms and clinical manifestations that Litzinger says are query worthy such as:
•Decreased urinary output or oliguria, which may be indicative of renal failure
•Respiratory patterns, which are visual and commonly documented by the nursing staff
•Oxygen saturation monitoring is often routine and low oxygen saturation is a further indicator of respiratory failure
In addition, many cancer patients are cachexic, malnourished, anemic, and have electrolyte imbalances that physicians can identify through labs drawn in the ER or follow up labs after admission.
“These patients are monitored and evaluated by nursing, respiratory, pain management, nutritional, and medical staff, to name a few,” Litzinger says. “Additionally, although aggressive medical treatment is not being pursued, resource consumption and length of stay is affected with the undertaking of these patients’ care, albeit for palliative or comfort care only.”
Teresa Russo RN,CCM,CCDS
Documentation Improvement Coordinator
University Health System
4502 Medical Drive
San Antonio, Texas 78229
ph:210-358-2456 fax: 210-358-4632
teresa.russo@uhs-sa.com