Metabolic Acidosis

christine.butka@hmhn.org

One of our CDI noted an elevated lactic acid and queried the physician for a diagnosis.  The patient did not have Sepsis.  Our physician advisor said not to do that because the next lactic acid was normal. She said we should also be looking for the underlying cause of the lactic acidosis and not querying for the diagnosis.  A diagnosis of lactic acidosis will give us a CC.  Other CDI's have said that if the elevated lactic acid was treated, monitored or evaluated we should be querying for the diagnosis.  Does anyone have any direction on how this should be handled? 
Is lactic acidosis always inherent in other conditions and that's what we should focus on?
What can we pick up the diagnosis by itself as a CC / when should we query to get to documented in the chart?
Are there any other clinical parameters we should be looking at when evaluating whether we should query such as the anion gap?
Is there a specific treatment for metabolic acidosis? 

Thank you,
Christine Butka RN MSN
CDI Lead
CentraState Medical Center
Freehold, NJ

ybattaglia@stanfordhealthcare.org

What a timely comment.   Recently, our coding auditor suggested that we should always keep an eye out for the cc  "acidosis".   It seems to me that lactic acidosis could be inherent to the disease process of sepsis and therefore should not be captured.   Any thoughts?

Yvonne B   RN  CDI  Salinas, CA.

shiloh.williams@ecrmc.org

Hello all! I agree, I believe lactic  acidosis is inherent to sepsis. It is one of the most important indicators that gives the clnician a clue that sepsis may be present. Our fluid administration policy was actually developed on the lactic acid result: the higher the number, the more fluid we bolused (in non-CHF patients, of course). In cases were Sepsis is determined not to be present, we will query the provider, providing they treated or monitored the acidosis in some manner
Shiloh

evanspx@sutterhealth.org

I'd not code metabolic acidosis if the condition is present w/ something such as Acute Respiratory Failure with acidosis or diabetic ketoacidosis as the CODES for these conditions and descriptions include acidosis.  However, per our clinical advisors, 'acidosis' is often, but not always present w/ Sepsis.  Plus, there are varying levels of severity of acidosis when a product of sepsis.   So, if /when present, and the UHDDS Definition for reporting are met, I believe it should be coded.  I'd say the same for any pt presenting with documented and uncompensated acidosis requiring either frequent monitoring of acid/base status, infusion of NaHCO3, so on...have seen frequently stated as a product of forms of acute renal failure, poisoning, ETHO to excess, SEVERE sepsis

kbalogun

This is fraud/frivolous querying.

You need the PH before you can query for lactic acidosis. High lactate alone does not mean the patient is acidotic. And lactic acidosis is not inherent in sepsis. 

This is exactly one of the issues I have with CDI, frivolous querying for the sake of money from people with lack of knowledge/understanding.

evanspx@sutterhealth.org

kbalogun

The discussion above did REFER to uncompensated acidosis, which of course means one would need to review the pH.  Further,  a code for metabolic acidosis w/ Sepsis has absolutely no impact upon the MS-DRG...none at all.  In ROM assignment, the presence of Acidosis, which of course must be present and eligible for reporting, can impact mortality measures.  Further, acidosis is NOT always present w/ Sepsis, and when it is present and qualifies, it should be coded.

Paul Evans, RHIA, CCDS, CCS, CCS-P

jmccorkl@stanfordhealthcare.org

kbalogun said:

This is exactly one of the issues I have with CDI, frivolous querying for the sake of money from people with lack of knowledge/understanding.

kbalogun, your above response comes across a bit harsh.  Can you please share some examples to clarify your viewpoint?  
I appreciate this forum as a 'safe' place to ask questions and learn from one another.

Jeanne McCorkle, BSN, RN, CCDS