Coding DNR

sautter.elizabeth@mayo.edu · January 2016

Any insight?

When our providers moved from a paper based to a completely electronic record they were required to enter their own orders.

Although our MD's order/enter a patients DNR status coding states they cannot code it unless the provider additionally notes it in a progress note somewhere. This is the smart tip they site:

Coding:Smartips:Z66:Do not resuscitate
Facility Related Coding This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Source: ICD-10-CM Official Coding Guidelines

Coding requires us to query the provider to add the DNR to their note in order for them to code/report it. We are not sure why entering and signing the order in our EMR is not enough to pick it up. Does anyone else have this issue?

Thanks,
Libby

ssalinas · January 2016

A DNR order is documentation by the physician. Orders can be used for coding. Coding Clinic 3rt Qtr 2005 pp 19-20 reiterates this.

Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

evanspx@sutterhealth.org · January 2016

Hello, Libby

I am curious - does this code impact ROM scores at all?

Thanks,

PE

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

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

sautter.elizabeth@mayo.edu · January 2016

Paul,

Yes! It is an AHRQ and additionally is one of the highest impacting diagnosis on a majority of risk models.

Thanks for the Coding clinic Sharon!

Thanks,
Libby

jschoonhoven · January 2016

Hi all,
I am not clear on this at all. When I entered a sample case in 3M to see the SOI/ROM impact of DNR (which I am not in the habit of including) it had no impact on the overall SOI/ROM, and as an independent diagnosis registers as a 1/1.
Is there a model in which this is more impactful? I am looking at APR.
Janice

Janice Schoonhoven RN, MSN, CCDS | Manager | Clinical Documentation Integrity
PeaceHealth | 3333 Riverbend Dr. | Springfield, OR 97477
office 541-222-5348 | fax 541-222-2427 | efax 541-335-2347

sautter.elizabeth@mayo.edu · January 2016

APR is a very limited way to look at ROM. Depending on the reporting agency and how they adjust risk, the value of any diagnosis may change. On the APR it looks like DNR it is just worth a 1/1. However some diagnosis (those that are not AHRQ's) do not give any impact. To help your ROM and SOI you would want to code at a minimum all diagnosis that are an AHRQ including DNR. If you only review to get to a 4/4 you would be missing a lot of opportunity.

This is a risk model. You can see here that DNR is worth 2.922 if I can get it coded in a case that goes to DRG group 177/178/179. The more diagnosis that hit one of the categories in this model the higher the ROM score will be for this patient (each DRG group has a different model). If you stopped at just documenting whatever diagnosis got you to a 4 on an APR you would be missing out on the value of all the other diagnosis that add risk to your patient.

Also remember that only diagnosis that are POA of Y will impact your Mortality score… those diagnosis with a POA of N are excluded from mortality but impact SOI.

[cid:image002.jpg@01D14A29.166CF910]

Understanding ROM/SOI is very complex and different reporting agencies can use different models… the key is if it is an AHRQ there is value of having it added.

Thanks,

Libby

gwojo · January 2016

Thank you Libby. Sent from my BlackBerry 10 smartphone. From: CDI TalkSent: Friday, January 8, 2016 3:27 PMTo: gwojo@wowway.comReply To: cdi_talk@hcprotalk.comSubject: RE:[cdi_talk] Coding DNR

APR is a very limited way to look at ROM. Depending on the reporting agency and how they adjust risk, the value of any diagnosis may change. On the APR it looks like DNR it is just worth a 1/1. However some diagnosis (those that are
not AHRQ's) do not give any impact. To help your ROM and SOI you would want to code at a minimum
all diagnosis that are an AHRQ including DNR. If you only review to get to a 4/4 you would be missing a lot of opportunity.

This is a risk model. You can see here that DNR is worth 2.922 if I can get it coded in a case that goes to DRG group 177/178/179. The more diagnosis that hit one of the categories in this model the higher the ROM score will be for this
patient (each DRG group has a different model). If you stopped at just documenting whatever diagnosis got you to a 4 on an APR you would be missing out on the value of all the other diagnosis that add risk to your patient.

Also remember that only diagnosis that are POA of Y will impact your Mortality score… those diagnosis with a POA of N are excluded from mortality but impact SOI.

Understanding ROM/SOI is very complex and different reporting agencies can use different models… the key is if it is an AHRQ there is value of having it added.

Thanks,

Libby

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 2:34 PM

Subject: RE:[cdi_talk] Coding DNR

Hi all,

I am not clear on this at all. When I entered a sample case in 3M to see the SOI/ROM impact of DNR (which I am not in the habit of including) it had no impact on the overall SOI/ROM, and as an independent diagnosis registers as a 1/1.

Is there a model in which this is more impactful? I am looking at APR.

Janice

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 12:03 PM

To: Schoonhoven, Janice <JSchoonhoven@peacehealth.org>

Subject: RE:[cdi_talk] Coding DNR

Paul,

Yes! It is an AHRQ and additionally is one of the highest impacting diagnosis on a majority of risk models.

Thanks for the Coding clinic Sharon!

Thanks,

Libby

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 1:30 PM

Subject: RE:[cdi_talk] Coding DNR

Hello, Libby

I am curious - does this code impact ROM scores at all?

Thanks,

PE

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

Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay

633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107

Cell: 415.412.9421

evanspx@sutterhealth.org

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 10:49 AM

To: Evans, Paul

Subject: [cdi_talk] Coding DNR

Any insight?

When our providers moved from a paper based to a completely electronic record they were required to enter their own orders.

Although our MD's order/enter a patients DNR status coding states they cannot code it unless the provider additionally notes it in a progress note somewhere. This is the smart tip they site:

Coding:Smartips:Z66:Do not resuscitate

Facility Related Coding This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Source: ICD-10-CM Official Coding Guidelines

Coding requires us to query the provider to add the DNR to their note in order for them to code/report it. We are not sure why entering and signing the order in our EMR is not enough to pick it up. Does anyone else have this issue?

Thanks,

Libby

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evanspx@sutterhealth.org · January 2016

Thank you, Libby

This is insightful. The various mortality models seem to be complex, to say the least. In your model, are your referring to HCC or acute inpatient?

“Typically”, when working with APR, I always try to capture any/all organ failures, as a general rule…other dysfunctions apparently also have some impact. A few odd codes that can impact APR would be hypotension and acidosis, but there are many others, too many to mention; but, I mention these 2 because I find many coders neglect to code these as 2ndry conditions when allowed per coding conventions.

I just coded a chart today and the code for GI bleeding had no impact on the ROM Model, but the code for ‘hematemesis’ will change the ROM upwards….not sure why this is ‘logical’, but this is what I generated as working the case.

Quite honestly, it seems to be ‘quite’ a hodgepodge of codes and conditions that factor into the various models…I mostly try to code ‘everything’ that is significant and reportable.

PE

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

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

[cid:image001.jpg@01D14A1C.FAB746F0]

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 08, 2016 1:46 PM
To: Evans, Paul
Subject: Re: [cdi_talk] Coding DNR

Thank you Libby.
Sent from my BlackBerry 10 smartphone.
From: CDI Talk
Sent: Friday, January 8, 2016 3:27 PM
To: gwojo@wowway.com
Reply To: cdi_talk@hcprotalk.com
Subject: RE:[cdi_talk] Coding DNR

APR is a very limited way to look at ROM. Depending on the reporting agency and how they adjust risk, the value of any diagnosis may change. On the APR it looks like DNR it is just worth a 1/1. However some diagnosis (those that are not AHRQ's) do not give any impact. To help your ROM and SOI you would want to code at a minimum all diagnosis that are an AHRQ including DNR. If you only review to get to a 4/4 you would be missing a lot of opportunity.

This is a risk model. You can see here that DNR is worth 2.922 if I can get it coded in a case that goes to DRG group 177/178/179. The more diagnosis that hit one of the categories in this model the higher the ROM score will be for this patient (each DRG group has a different model). If you stopped at just documenting whatever diagnosis got you to a 4 on an APR you would be missing out on the value of all the other diagnosis that add risk to your patient.

Also remember that only diagnosis that are POA of Y will impact your Mortality score… those diagnosis with a POA of N are excluded from mortality but impact SOI.

[cid:image002.jpg@01D14A1C.FAB746F0]

Understanding ROM/SOI is very complex and different reporting agencies can use different models… the key is if it is an AHRQ there is value of having it added.

Thanks,

Libby

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 08, 2016 2:34 PM
Subject: RE:[cdi_talk] Coding DNR

Hi all,

I am not clear on this at all. When I entered a sample case in 3M to see the SOI/ROM impact of DNR (which I am not in the habit of including) it had no impact on the overall SOI/ROM, and as an independent diagnosis registers as a 1/1.

Is there a model in which this is more impactful? I am looking at APR.

Janice

Janice Schoonhoven RN, MSN, CCDS | Manager | Clinical Documentation Integrity PeaceHealth | 3333 Riverbend Dr. | Springfield, OR 97477 office 541-222-5348 | fax 541-222-2427 | efax 541-335-2347

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 12:03 PM

To: Schoonhoven, Janice

Subject: RE:[cdi_talk] Coding DNR

Paul,

Yes! It is an AHRQ and additionally is one of the highest impacting diagnosis on a majority of risk models.

Thanks for the Coding clinic Sharon!

Thanks,

Libby

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 1:30 PM

Subject: RE:[cdi_talk] Coding DNR

Hello, Libby

I am curious - does this code impact ROM scores at all?

Thanks,

PE

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

Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay

633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107

Cell: 415.412.9421

evanspx@sutterhealth.org

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 10:49 AM

To: Evans, Paul

Subject: [cdi_talk] Coding DNR

Any insight?

When our providers moved from a paper based to a completely electronic record they were required to enter their own orders.

Although our MD's order/enter a patients DNR status coding states they cannot code it unless the provider additionally notes it in a progress note somewhere. This is the smart tip they site:

Coding:Smartips:Z66:Do not resuscitate

Facility Related Coding This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Source: ICD-10-CM Official Coding Guidelines

Coding requires us to query the provider to add the DNR to their note in order for them to code/report it. We are not sure why entering and signing the order in our EMR is not enough to pick it up. Does anyone else have this issue?

Thanks,

Libby

---

CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com

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Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

---

---

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Copyright 2013

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This message is intended solely for the use of the individual and entity to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable state and federal laws. If you are not the addressee, or are not authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, distribute, or disclose to anyone this message or the information contained herein. If you have received this message in error, immediately advise the sender by reply email and destroy this message.

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sautter.elizabeth@mayo.edu · January 2016

That particular model is from UHC (University HealthSystem Consortium) and is for Acute Inpatient.

Typically it is the co-morbid non CC/MCC diagnosis that we find our coders neglect… and that our CDI need to query specificity for…

For example… unspecified dementia is an AHRQ… and has value… and is attached to a model category called “dementia” but I know that the model category called “other neurologic disorders” occurs frequently and that unspecified dementia doesn’t count in that category but if I specify it as Alzheimer’s, vascular or Lewy body it will hit the category and increase my ROM so I know there is value in querying for that specificity. Likewise Restless Leg syndrome hits a category. Etc.. etc..

I would say the largest percent of our queries now (our program is established) are for non-CC/MCC specificity… and our biggest educational opportunities with coding are to help them to understand the importance/benifit of these diagnosis and making sure the POA designations are correct.

Thanks,
Libby

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 08, 2016 4:03 PM
Subject: RE: [cdi_talk] Coding DNR

Thank you, Libby

This is insightful. The various mortality models seem to be complex, to say the least. In your model, are your referring to HCC or acute inpatient?

“Typically”, when working with APR, I always try to capture any/all organ failures, as a general rule…other dysfunctions apparently also have some impact. A few odd codes that can impact APR would be hypotension and acidosis, but there are many others, too many to mention; but, I mention these 2 because I find many coders neglect to code these as 2ndry conditions when allowed per coding conventions.

I just coded a chart today and the code for GI bleeding had no impact on the ROM Model, but the code for ‘hematemesis’ will change the ROM upwards….not sure why this is ‘logical’, but this is what I generated as working the case.

Quite honestly, it seems to be ‘quite’ a hodgepodge of codes and conditions that factor into the various models…I mostly try to code ‘everything’ that is significant and reportable.

PE

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

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

[cid:image001.jpg@01CE983E.025F5700]

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 08, 2016 1:46 PM
To: Evans, Paul
Subject: Re: [cdi_talk] Coding DNR

Thank you Libby.
Sent from my BlackBerry 10 smartphone.
From: CDI Talk
Sent: Friday, January 8, 2016 3:27 PM
To: gwojo@wowway.com
Reply To: cdi_talk@hcprotalk.com
Subject: RE:[cdi_talk] Coding DNR

APR is a very limited way to look at ROM. Depending on the reporting agency and how they adjust risk, the value of any diagnosis may change. On the APR it looks like DNR it is just worth a 1/1. However some diagnosis (those that are not AHRQ's) do not give any impact. To help your ROM and SOI you would want to code at a minimum all diagnosis that are an AHRQ including DNR. If you only review to get to a 4/4 you would be missing a lot of opportunity.

This is a risk model. You can see here that DNR is worth 2.922 if I can get it coded in a case that goes to DRG group 177/178/179. The more diagnosis that hit one of the categories in this model the higher the ROM score will be for this patient (each DRG group has a different model). If you stopped at just documenting whatever diagnosis got you to a 4 on an APR you would be missing out on the value of all the other diagnosis that add risk to your patient.

Also remember that only diagnosis that are POA of Y will impact your Mortality score… those diagnosis with a POA of N are excluded from mortality but impact SOI.

[cid:image002.jpg@01D14A32.F2593D90]

Understanding ROM/SOI is very complex and different reporting agencies can use different models… the key is if it is an AHRQ there is value of having it added.

Thanks,

Libby

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 08, 2016 2:34 PM
Subject: RE:[cdi_talk] Coding DNR

Hi all,

I am not clear on this at all. When I entered a sample case in 3M to see the SOI/ROM impact of DNR (which I am not in the habit of including) it had no impact on the overall SOI/ROM, and as an independent diagnosis registers as a 1/1.

Is there a model in which this is more impactful? I am looking at APR.

Janice

Janice Schoonhoven RN, MSN, CCDS | Manager | Clinical Documentation Integrity PeaceHealth | 3333 Riverbend Dr. | Springfield, OR 97477 office 541-222-5348 | fax 541-222-2427 | efax 541-335-2347

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 12:03 PM

To: Schoonhoven, Janice

Subject: RE:[cdi_talk] Coding DNR

Paul,

Yes! It is an AHRQ and additionally is one of the highest impacting diagnosis on a majority of risk models.

Thanks for the Coding clinic Sharon!

Thanks,

Libby

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 1:30 PM

Subject: RE:[cdi_talk] Coding DNR

Hello, Libby

I am curious - does this code impact ROM scores at all?

Thanks,

PE

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

Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay

633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107

Cell: 415.412.9421

evanspx@sutterhealth.org

-----Original Message-----

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]

Sent: Friday, January 08, 2016 10:49 AM

To: Evans, Paul

Subject: [cdi_talk] Coding DNR

Any insight?

When our providers moved from a paper based to a completely electronic record they were required to enter their own orders.

Although our MD's order/enter a patients DNR status coding states they cannot code it unless the provider additionally notes it in a progress note somewhere. This is the smart tip they site:

Coding:Smartips:Z66:Do not resuscitate

Facility Related Coding This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Source: ICD-10-CM Official Coding Guidelines

Coding requires us to query the provider to add the DNR to their note in order for them to code/report it. We are not sure why entering and signing the order in our EMR is not enough to pick it up. Does anyone else have this issue?

Thanks,

Libby

---

CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com

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Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

---

---

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---

Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

This message is intended solely for the use of the individual and entity to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable state and federal laws. If you are not the addressee, or are not authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, distribute, or disclose to anyone this message or the information contained herein. If you have received this message in error, immediately advise the sender by reply email and destroy this message.

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Copyright 2013

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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

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evanspx@sutterhealth.org · January 2016

Thanks, Libby

Certainly agree lack of attention to NON CC/MCC secondary codes complicates proper coding of risk-adjusted models. However, given that the models are so complex, it is often difficult to determine where to spend time/attention for either coding or query for some of these ROM factors…(there are simply so many nuanced conditions, it is very difficult to tell someone precisely ‘where’ to focus)?

Hope that makes sense.

PE

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

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

Coding DNR

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