Clinical Documentation Tip Sheets

Physician Advisor Program Clinical Documentation Tip Sheets

Welcome

PHYSICIAN ADVISOR PROGRAM

This tip sheet series is designed to support physicians in accurately assessing, diagnosing, and documenting the severity of illness for hospitalized patients within the electronic medical record (EMR). Comprehensive and condition-specific, these guides aim to enhance clinical clarity, ensure proper coding, and support the justification for medical necessity and appropriate level of care. By aligning documentation practices with current clinical and coding standards, providers can optimize communication, compliance, and quality outcomes.

Table of Contents

Cardiovascular Common Inpatient CC.MCC Diagnoses Critical Care Emergency Medicine Endocrinology General Medicine GI/Hepatology Hematology/Oncology Infectious Diseases Musculoskeletal Nephrology Neuroscience

Obstetrics & Gynecology Patient Safety Indicators Respiratory Surgical Specialties Trauma

Cardiovascular

Cardiovascular

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

HEART FAILURE

CARDIOMYOPATHY

PULMONARY EDEMA

> Acuity: Acute, Chronic, or Acute on Chronic > Type: Systolic (HFrEF), Diastolic (HFpEF), or Combined. Tip: Remember to add the type. Without type CHF codes to unspecified

> Acuity: Acute or Chronic

> Type: Ischemic, hypertrophic, dilated, restrictive. Tip: Remember to add associated heart failure with acuity and type.

> Type: cardiogenic, or non cardiogenic

Tip: Remember to add acuity. Without acuity pulmonary edema defaults to chronic.

COR PULMONALE

SHOCK > Type: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, shock liver (see GI/Hepatology), etc. Tip: Remember to add the type. Without type shock codes to unspecified

CARDIAC ARREST > Cause: Remember to add cause of cardiac arrest either known or suspected.

> Acuity: Acute or chronic

> Link to pulmonary embolism when appropriate

OTHER CARDIAC ARRHYTHMIAS

MYOCARDIAL INJURY > Myocardial infarction Type 1: Identification of a coronary thrombus by angiography or autopsy. Troponin elevation (delta) with one ore more of symptoms, EKG changes, echo changes. > Myocardial infarction Type 2: Imbalance between myocardial oxygen supply and demand unrelated to acute atherothrombosis. Troponin elevation (delta) with one ore more of symptoms, EKG changes, echo changes. > Non-ischemic myocardial injury: Troponin elevation without evidence of ischemia (acute for delta and chronic for no delta).

ATRIAL FIBRILLATION

> Paroxysmal: Terminates spontaneously or w/ intervention within 7days of onset > (Other) Persistent: Continuous sustained >7 days > Long-standing persistent (CC): Continuous >12 months > Permanent (CC): Decision to stop attempts to restore and/or maintain sinus rhythm Tip: “Chronic atrial fibrillation” may result in payment denial for Watchman procedures

> Type: Document type of arrhythmia

> Add: EKG findings to your notes and the clinical significance of the findings

> Demand ischemia: Symptoms/EKG changes without troponin elevation.

CHEST PAIN Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General Tip Card) Chest pain indicative of serious diagnosis other than coronary artery disease (eg, aortic dissection, pulmonary embolism) Presenting signs or symptoms (eg, chest pain) persist despite observation care

CARDIAC ARRYTHMIA Inpatient admission is indicated for 1 or more of the following: Sustained VT: 30 seconds or more of ventricular rhythm >100 beats/min Ventricular escape rhythm Second- or third-degree atrioventricular block New-onset left bundle branch block with suspected myocardial ischemia Continuous ECG monitoring needed beyond observation care Defibrillator that is repeatedly firing, malfunctioning, or in need of immediate adjustment of settings beyond observation care I npatient admission is indicated for 1 or more of the following: Severe persistent pulmonary edema, anasarca or peripheral edema Increased creatinine with reduction of more than 25% in glomerular filtration rate from baseline Pulmonary artery catheter monitoring needed Cardiac Arrythmia (see arrhythmia) Dyspnea or tachypnea that persist despite observation care Hemodynamic instability (See General Tip Card) Electrolyte abnormalities (see Nephrology Tip Card) Severe persistent altered mental status (See Neuro Tip Card) HEART FAILURE

HYPOTENSION Inpatient admission is indicated for 1 or more of the following: Severe persistent hypotension, as indicated by 1 or more of the following: Lactate of 2.0 mmol/L (18 mg/dL) or more secondary to hypotension Metabolic acidosis (arterial or venous pH less than 7.35)[ not otherwise explained Mean arterial pressure less than 65 mm Hg IV inotropic or vasopressor medication

ANTICOAGULATION I npatient admission is indicated for 1 or more of the following: Venous thromboembolism newly diagnosed

ATRIAL FIBRILLATION Inpatient admission is indicated for 1 or more of the following: Hypotension (see hypotension) Persistent symptomatic Tachycardia (eg, chest pain, dyspnea) despite observation care Acute myocardial ischemia that persists despite observation care Altered mental status that is severe or persistent Syncope with outpatient initiation or titration of medication (eg, for rate or rhythm control) not appropriate (eg, concern for bradycardia with need for telemetry monitoring beyond observation care) Heart failure (see heart failure) Suspected accessory pathway (eg, Wolff Parkinson-White syndrome) on ECG Medication toxicity (eg, digitalis) causing arrhythmia Initiation or adjustment of antiarrhythmic medication that requires cardiac monitoring (eg, telemetry) Inpatient admission is indicated for 1 or more of the following: Cardiac monitoring (eg, telemetry) appropriate, as cardiomyopathy, dilation, scar or fibrosis, disruption to normal cardiac electrical propagation, hypertrophy)​ Underlying sinus node or atrioventricular conduction disturbance (eg, tachy-brady syndrome)​ Prolonged QT interval​ Need for treatment with antiarrhythmic medication regimen that has significant proarrhythmic potential (eg, monomorphic ventricular tachycardia, torsades de pointes, bradycardia)[​ Patient without a sinus rhythm ECG to evaluate (eg, to determine QT interval, presence of accessory pathways) -Cardiac monitoring required that extends beyond observation care indicated by 1 or more of the following:​ Significant structural heart disease (eg,

or within past 3 months Underlying malignancy

Patient with mechanical cardiac valve Underlying hypercoagulable state (eg, protein C or protein S deficiency, antithrombin deficiency, antiphospholipid antibodies) Patient at temporary high risk of thromboembolism (eg, status post orthopedic surgery) Atrial fibrillation with recent stroke or transient ischemic attack (within past 3 months) New-onset atrial fibrillation in patient with history of stroke, transient ischemic attack, or other thromboembolism HTN EMERGENCY Inpatient admission is indicated for 1 or more of the following: Hypertensive emergency indicated by SBP greater than 180 mm Hg or DBP greater than 120 mm Hg with evidence of acute or worsening target organ damage, as indicated by 1 or more of the following: –Hypertensive encephalopathy –Cerebral infarction –Intracranial hemorrhage –Myocardial ischemia or infarction –Heart failure –Aortic dissection –Acute kidney injury (see Nephrology) –Papilledema/Retinal Hemmorhage

Common Inpatient CC.MCC Diagnoses

Common Inpatient CC.MCC Diagnoses This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

METABOLIC ABNORMALITIES

CHRONIC CONDITIONS

HEART FAILURE

Acuity: Acute (MCC), Chronic (CC), or Acute on Chronic (MCC) Type: Systolic (HFrEF), Diastolic (HFpEF), or Combined.

In the H&P please list all the patient’s chronic conditions such as: COPD/ Asthma/ Chronic respiratory failure (when patient is on home O2) CHF with chronicity and type, e.g. chronic systolic CHF Obesity if BMI is 40 or above, underweight/malnutrition if BMI is 19 or less CKD with stage 1-4 (CKD 4 and 5 are CCs) or ESRD (MCC)

Document abnormal lab: Hypo/hypernatremia (CC), Acidosis (CC), Alkalosis (CC), Acute Lactic Acidosis (CC), Acute Metabolic Acidosis (CC) , etc. Tip: Acute respiratory acidosis is MCC

PNEUMONIA Type/Organism (either known or suspected): MRSA, MSSA, Klebsiella, Psuedomonas, Gram negative, Aspiration, Viral, Fungal, etc.

ARRHYTHMIA

PULMONARY EDEMA

Type: Always specify the type of cardiac arrhythmia e.g. Atrial flutter (CC), Ventricular tachycardia (CC) 3 Degree or Complete Heart Block (CC), Supraventricular Tachycardia(CC), Ventricular Fibrillation (MCC) rd Type of A-fib (3Ps): Paroxysmal, Persistent (CC), Permanent (chronic) (CC) ACUTE KIDNEY INJURY (AKI) Avoid: “Acute Renal Insufficiency” use “Acute Kidney Injury (CC), or Acute Renal Failure (CC)”

Acuity: Acute (MCC) or Chronic (CC

Pulmonary Embolism Acuity: Acute or Chronic (MCC)

All pneumonias are MCCs

ANEMIA

MALIGNANCY

Acuity: Acute or chronic

List All known or suspected primary and secondary (metastatic) sites (most are CCs).

Type: Acute blood loss Anemia (CC), iron deficiency, hemolytic, etc. Document abnormal CBC: anemia, leukopenia, thrombocytopenia or pancytopenia (CC)

Drug induced pancytopenia is MCC

PRESSURE (DECUBITUS) ULCERS

ACUTE TUBULAR NECROSIS (ATN)

MALNUTRITION

Mild and moderate(CC) Protein calorie malnutrition Severe (MCC) Protein-calorie malnutrition

Pressure ulcer stage 3 and 4 are MCCs.

ATN is MCC

DELIRIUM

ENCEPHALOPATHY

FUNCTIONAL QUADRIPLEGIA

Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, mixed etiology, etc. (all CCs when there is cause/type).

Acuity: Acute or Chronic

Functional Quadriplegia is MCC

Type/Cause: Metabolic (MCC), Septic (MCC), Toxic (MCC), Hepatic, Uremic, Hypertensive, Hypoglycemic, etc.

CVA/ STROKE

SHOCK

Unspecified shock is CC Type/Cause: shock with type is MCC: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, etc.

CVA/Stroke is MCC Brain compression (MCC) Cerebral Edema (MCC) Aphasia, hemiparesis, neglect (CC)

Critical Care

Critical Care

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

SHOCK

> Type: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, shock liver (see GI/Hepatology) , etc.

Tip: Remember to add the type. Without type shock codes to unspecified

CARDIAC ARREST

> Cause: Remember to add cause of cardiac arrest either known or suspected.

CRITICAL ILLNESS MYOPATHY AND POLYNEUROPATHY Definition: CIM: Flaccid weakness, often accompanied by difficulty weaning from mechanical ventilation.

CIP: Reduction in or absence of deep tendon reflexes and sensory loss.

DELIRIUM

> Acuity: acute, chronic

> Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, ICU delirium , mixed etiology, etc.

ENCEPHALOPATHY

> Type: metabolic, septic, toxic, hepatic, uremic, hypertensive, etc.

Tip: With hepatic encephalopathy also consider documenting metabolic encephalopathy if present.

COMA

> Definition: GCS score is below 9

> Document: the individual eye, verbal, and motor scores

RESPIRATORY FAILURE

> Acute: Document each of the following: 1. Respiratory distress: (eg, tachypnea, use of accessory respiratory muscles) 2. O2 requirement : ≥4L O2 required to maintain saturation of 92% for ≥2 hours OR ≥2L of O2 required for >24 hours 3. Hypoxia or hypoxemia: PaO2 <60 mm Hg on room air OR PaO2 /FiO2 ratio <300 mm Hg OR SpO2 <90% on room air

> Chronic: Consider for patients on home O2 other than PRN.

> Type: Hypoxic: PaO2 <60mmHg OR SpO2 <90% on room air. Hypercapnic: PaCO2 >50mmHg, PaCO2 change of at least 10mmHg above baseline

Tip: Avoid post-operative respiratory failure for patients on mechanical ventilation as expected after surgery

DYING PROCESS A patient who is dying frequently has many underlying serious conditions that should be included in documentation EVEN IF the patient is in comfort care measures only: Acute respiratory failure/ Acute pulmonary edema, Acute renal failure/ Acute tubular necrosis, Acute liver failure, Delirium/Encephalopathy with cause and type,

Avoid: “multi-organ failure” specify each organ failure

COMFORT CARE

> Document: DNR/DNI status and POA status

Emergency Medicine

Emergency Medicine This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

SUPPORT THE MOST APPROPRIATE VISIT LEVEL

DOCUMENTATION TIPS

> Medical decision making dictates the highest level code that can be chosen. Proper documentation supports the chosen level (see MDM Tip Card) > Document all of the following: Chief complaint, primary diagnosis (or differential), secondary diagnoses (or chronic conditions that impact the care of the patient). > A diagnosis is required for every condition that is Monitored, Evaluated, Assessed OR Treated (MEAT). See HCC Tip Card. > Diagnoses cannot be inferred from physician orders, lab or diagnostic test results; diagnoses need to be in the medical record. > Under the assessment and plan section: document your list of diagnoses with MEAT criteria when applicable. > Consistent documentation: make sure no contradicting information in your note, for example: A&P: “Occasional dysphagia-worse with solids. Review of systems: ENT: denies sore throat, dysphagia. > Document: "if known” risk of morbidity/mortality associated with the diagnosis. > Document: if the condition is resolved in the ED, need further treatment after admission or follow up as outpatient.

> Level 1: Self-limited or minor: a problem that is transient and is not likely to permanently alter the patient’s health status or has a good prognosis with management/compliance. > Level 2: Low severity: a problem in which the risk of morbidity without treatment is low, there is little to no risk of mortality without treatment. Requires straightforward medical decision making. > Level 3: Moderate severity : a problem in which the risk of morbidity and mortality without treatment is moderate, or there is an uncertain prognosis or increased probability of prolonged functional impairment. Requires low medical decision making. > Level 4: High severity, requires urgent evaluation but does not pose threat to life or physiologic function: A problem in which the risk of morbidity and mortality without treatment is high to extreme, or a high probability of severe, prolonged functional impairment. Requires moderate medical decision making. > Level 5: High severity, poses an immediate significant threat to life or physiologic function: same las level 4. Requires high medical decision making. > Critical care level: level 5 + at least one organ system failure + at least 30 minutes of care: Examples of organ system failure: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Requires high medical decision making.

> Document: decision to admit with medical necessity rationale (see MN Tip Card)

Endocrinology

Endocrinology

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

DIABETES

> Type: 1, 2, secondary, gestational

> Associated conditions: neuropathy, nephropathy, retinopathy, angiopathy, gastroparesis, PVD, ulcers, osteomyelitis

Tip: with diabetic foot ulcers also document the cause of the ulcer; diabetic PVD or diabetic neuropathy or both.

DIABETIC HYPERGLYCEMIA HYPEROSMOLAR STATE (HHS): Characterized by severe hyperglycemia, hyperosmolarity and dehydration without significant ketoacidosis, and usually some alteration in consciousness (coma if severe). HHS almost never occurs in Type 1 DM. Diagnostic criteria include: Blood sugar > 600mg/dl Serum osmolality > 320 mmol/L Exclusion of DKA: pH > 7.30, Bicarbonate > 18, absence of significantly elevated serum ketones

DIABETIC KETOACIDOSIS (DKA)

Characterized by hyperglycemia, acidosis, elevated serum ketones, and dehydration. Occurs primarily in Type 1 DM patients but can occur in Type 2. Diagnostic criteria require ALL of the following:

Blood sugar > 250 mg/dl Acidosis with pH < 7.30 Bicarbonate < 18 mEq/L (CO2/HCO3 on BMP or ABG)

Inpatient admission is indicated for 1 or more of the following: Hyperglycemia (plasma glucose greater than 250 mg/dL or less than 250 with pregnancy and chronic renal/liver disease. Ketonuria or ketonemia (eg, serum beta hydroxybutyrate 3.8 mmol/L or higher, or moderate to large ketonuria) Acidosis (eg, anion gap greater than 10 (or above the upper limit of normal for laboratory), pH 7.30 or less, or serum bicarbonate 18 mEq/L (mmol/L) or less)

Inpatient admission is indicated for 1 or more of the following: Metabolic acidosis (eg, anion gap greater than 10 (or above the upper limit of normal for local laboratory), or arterial or venous pH 7.30 or less) that recurs or persists despite observation care

Hypotension (See cardiovascular) Arterial or venous pH less than 7.0

Serum bicarbonate less than 10 mEq/L (mmol/L) Altered mental status that is severe or persistent Rise in creatinine to 2 times its baseline value or higher (ie, reduction of more than 50% in estimated glomerular filtration rate) Dehydration that persists despite observation care

ANTIDIURETIC HORMONE (ADH) DISORDERS

Diabetes Insipidus (Low ADH) > Cause: Pituitary gland damage/resection, hypothalamus damage drugs, infection, etc.

Syndrome of Inappropriate Antidiuretic Hormone (High ADH): > Cause : include CNS disorders like stroke, hemorrhage, infection, trauma; neoplasm; drugs; lung disease (especially pneumonia); HIV; hypothyroidism.

PITUITARY GLAND DISORDERS

> Overproduction effect: e.g., Acromegaly, galactorrhea, Cushing's disease, SIADH > Underproduction effect: e.g., hypothyroidism, hypogonadism, adrenocortical insufficiency, diabetes insipidus Tip: document every component of hormone imbalance associated with pituitary gland disorders

THYROID GLAND DISORDERS

> Type: hypothyroidism, hyperthyroidism > Cause: Grave’s disease, thyroidectomy, Hashimoto’s > Associated conditions: myxedema, cardiac arrhythmias, Grave’s ophthalmopathy, osteoporosis, etc.

METABOLIC SYNDROME

> Document: with 3 of: DM, HTN, HLD, Obesity

HYPOGLYCEMIA

Inpatient admission is indicated for 1 or more of the following: Altered mental status that is severe or persistent Neurologic findings (eg, seizure, ataxia, dysphasia, focal deficit) that are recurrent or persist despite observation care Other significant clinical signs or symptoms of hypoglycemia that do not resolve despite observation care Persistent or recurrent hypoglycemia despite observation care Prolonged monitoring for recurrent hypoglycemia (beyond observation care)

HHS Hyperglycemic hyperosmolar state, as indicated by ALL of the following:

Plasma glucose greater than 600 mg/dL (33.3 mmol/L) Serum osmolality greater than 320 mOsm/kg (mmol/kg)[J] Neurologic dysfunction (eg, stupor, coma, seizure) Arterial or venous pH greater than 7.30[I] Serum bicarbonate greater than 18 mEq/L (mmol/L

General Medicine

General Medicine

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

CHRONIC CONDITIONS

> List all chronic conditions in the H&P and at least one progress note

> List all pertinent chronic conditions under the assessment & plan section with treatment, monitoring, or evaluation of each of the chronic conditions

> Diagnoses that are listed under the problem list can not be captured.

> Examples: CHF with chronicity and type, e.g., chronic diastolic heart failure continue metoprolol, COPD with chronic respiratory failure on home O2 on 2L NC, morbid obesity with BMI of 42; counseling, CKD stage 3a avoid nephrotoxic medications.

LAB ABNORMALITIES

> Always: check the lab

> Document: the lab abnormality as a diagnosis and the treatment, evaluation, or monitoring performed

> Example : hyponatremia Na 130 hold diuretics.

IMAGING REPORTS AND PATHOLOGY REPORTS > Remember to add to your notes the imaging reports and pathology reports and indicate the clinical significance of the findings

> Imaging and pathology reports diagnoses can not be captured unless added to treating provider notes.

> Example: chest x-ray shows clinically significant pleural effusion due to volume overload, increase dose of diuretics

UNCERTAIN DIAGNOSES > Include uncertain language to indicate your thought process and workup performed, e.g., chest pain rule out acute coronary syndrome; trend troponin, syncope suspected due to paroxysmal atrial fibrillation. > Clarify the uncertain diagnosis before discharge, e.g., syncope confirmed to be due to paroxysmal atrial fibrillation; rate control with Metoprolol and Eliquis for anticoagulation or acute coronary syndrome was ruled out with negative cardiac workup. > Add the diagnosis to your discharge summary if the diagnosis is still uncertain, e.g., lower GI bleed likely due to diverticulosis, F/U with GI to schedule colonoscopy as outpatient POA STATUS > Remember to add the POA status to acute or new diagnoses that were not documented on admission (in the H&P)

SPECIFICTY > Remember: acuity, type and etiology, e.g., acute on chronic HFpEFdue to hypertrophic cardiomyopathy

> Always document acuity with change from baseline

DIAGNOSTIC TERMINOLOGY

> Add: Diagnosis to each symptom and/or sign e.g., ascites due to liver cirrhosis > Use: Diagnostic terms in addition to the descriptive terms, e.g., supratherapeutic INR is not a diagnostic term, use coagulopathy in addition, with altered mental status use encephalopathy (with type) as well.

WOUND CARE AND NUTRITION NOTES > Add to your notes wound care and nutrition diagnoses, e.g., pressure ulcer of left buttock stage 3 wound care following, severe protein-calorie malnutrition agree with nutrition plan

HEMODYNAMIC INSTABILITY

Inpatient admission is indicated for 1 or more of the following: Tachycardia that persists despite appropriate treatment (eg, volume repletion, treatment of pain, treatment of underlying cause) Orthostatic hypotension that persists despite appropriate treatment (e.g., volume repletion) Hypotension as indicated by 1 or more of the following:

-Lactate of 2.0 or more secondary to hypotension -Metabolic acidosis (pH less than 7.35) -Mean arterial pressure less than 65 mm Hg -IV inotropic or vasopressor medication

SYNCOPE

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Altered mental status that is severe or persistent

Cardiac disease or finding that indicates necessity of immediate intervention (eg, AICD placement, electrophysiologic study, surgery), treatment (eg, initiation of antiarrhythmic medication) or monitoring (eg, telemetry) beyond observation care Syncope resulting in severe injury requiring inpatient care

Recurrent syncope (eg, loss of consciousness in observation care) Severe dehydration, as indicated by 1 or more of the following: –Acute renal failure (stage 3 acute kidney injury) (See AKI in Nephrology) –Serum sodium greater than 150 mEq/L (mmol/L) Persistent dehydration as indicated by ALL of the following:

–Oral rehydration therapy not tolerated or insufficient to adequately correct dehydration –Appropriate intravenous treatment (eg, fluids) does not readily correct dehydration.

PAIN HInpatient admission is indicated for 1 or more of the following: IV opioid treatment required Pain control regimen not established in observation care Suspected new or deteriorating disease process as etiology (eg, new site of metastatic disease) requiring inpatient evaluation and treatment (e.g., urgent radiation therapy)

Palliative procedure planned that necessitates inpatient care for assessment and monitoring needs (e.g., celiac block, stent to relieve obstruction)

GI/Hepatology

GI/Hepatology

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

LIVER DISEASE > Acuity : Acute, chronic, acute on chronic > Type: Cirrhosis, viral hepatitis, autoimmune hepatitis, hepatic steatosis, alcoholic liver disease, NASH

GI HEMORRHAGE

LIVER FAILURE > Acuity: Acute, chronic, acute on chronic > With or without coma (GCS <9) > Criteria: Acute: prolonged and progressively increasing prothrombin time: INR of > 1.5. Both Acute and chronic : AST & ALT > 3x URL and Elevated bilirubin and Low platelet count

> Type: Add the GI bleed type/cause either known or suspected

> Add: EGD/Colonoscopy findings to your note > Associated conditions: acute blood loss anemia, orthostatic hypotension (see MN Tip Card)

> Symptoms/signs: Jaundice, ascites/edema, hypoalbuminemia

> Associated conditions: e sophageal varices with or without bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, portal vein thrombosis, hepatorenal syndrome (see nephrology) , coagulopathy, protein calorie malnutrition

> Document: associated acute/chronic liver failure

INFLAMMATORY BOWEL DISEASE > Type: Crohn’s disease, Ulcerative colitis > Site: small intestine, large intestine, both > Associated conditions: abscess, fistula, bleeding, obstruction, perforation

PANCREATITIS

SHOCK LIVER (ISCHEMIC HEPATITIS) > Cause: of ischemia, e.g., heart failure (with acuity and type)

> Acuity: Acute, chronic, acute on chronic > Type/cause: gallstone, alcoholic, etc. > Associated conditions: SIRS with or without organ dysfunction and specify the organ dysfunction (see infectious diseases)

> Associated conditions: e.g., coma, hepatorenal syndrome

HIGH/LOW OSTOMY OUTPUT

DIVERTICULITIS

ISCHEMIC BOWEL DISEASE > Acuity: Acute, chronic

> Acuity: Acute

> Cause: Infection, Intestinal malabsorption/obstruction, Malnutrition, Dumping syndrome, Short bowel syndrome

> Type: Diffuse, focal

> Associated conditions: sepsis, abscess, bleeding, perforation

> Site: small intestine, large intestine

> Cause: mesenteric artery ischemia, septic shock, Crohn’s disease, etc.

UPPER GI BLEED

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Ongoing active bleeding (eg, decreasing hematocrit) Mechanical ventilation necessary (eg, for airway protection)

Peptic ulcer with high-risk endoscopic features Variceal bleeding (eg, diagnosed on endoscopy) Anemia requiring inpatient admission, as indicated by 1 or more of the following:

–Tachycardia –Altered mental status –Heart failure –Chest pain –Dyspnea –Other findings suggesting inadequate perfusion (eg, syncope, peripheral or myocardial ischemia, end organ dysfunction) Gastric outlet or bowel obstruction Gastric or bowel perforation suspected (eg, Peritoneal signs, abdominal free air on imaging) Inability to maintain oral hydration (eg, IV fluid support needed) that persists despite observation care

LOWER GI BLEED

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (see General)

Active bleeding (eg, decreasing hematocrit) that persists despite observation care Colonoscopy findings that require continued hospitalization (eg, high risk for rebleed) Suspected or known ischemic colitis as etiology of bleeding Anemia requiring inpatient admission (See Above)

ACUTE PANCREATITIS

Inpatient admission is indicated for 1 or more of the following: Abdominal pain

Serum lipase greater than 3 times the upper limit of normal, or urinary trypsinogen-2 greater than 50 ng/mL Findings on imaging indicative of acute pancreatitis (eg, pancreatic inflammation, pancreatic necrosis, peripancreatic fluid collection)

LIVER DISEASE

Inpatient admission is indicated for 1 or more of the following: Acute liver failure in adult age 18 years or older, as indicated by ALL of the following - known chronic liver disease -Acute liver disease of less than 26 weeks' duration -INR greater than 1.5 and attributable to liver disease (eg, not due to vitamin K deficiency) -Hepatic encephalopathy of any degree Cirrhosis or chronic liver disease as indicated by ALL of the following: -Total serum bilirubin of 5 mg/dL (86 micromoles/L) or more -Elevation of prothrombin time to INR greater than 1.5 attributable to liver disease -Acute hepatic decompensation Hepatic encephalopathy Alcoholic hepatitis Hepatorenal syndrome Hepatic abscess Portal vein thrombosis Infected ascites

SPONTANEOUS BACTERIAL PERITONITIS

Inpatient admission is indicated for 1 or more of the following: Elevated polymorphonuclear neutrophils (PMN) in ascitic fluid (greater than or equal to 250 cells/mm3 (0.25 x109/L)) Fever (eg, when not masked by antipyretic medication such as acetaminophen or ibuprofen) Abdominal pain Altered mental status

ACUTE PANCREATITIS

Inpatient admission is indicated for ALL of the following: Alcohol as most likely etiology of liver disease (eg, history of heavy alcohol use) Manifestations of liver disease, as indicated by 1 or more of the following: –Maddrey Discriminant Function score greater than or equal to 32 –MELD score of 20 or more

Hematology/Oncology

Hematology/Oncology

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

LIVER DISEASLEUKEMIAS AND LYMPHOMASE

NEOPLASMS

> Behavior: Malignant, benign

> Acuity: Acute, chronic

> Site: Primary and metastatic sites when applicable

> Status: in remission, not in remission, in relapse

> Type: e.g., myeloid, lymphoblastic, etc

> Associated conditions: immunodeficiency, pancytopenia, hypercoagulopathy, protein-calorie malnutrition, cachexia, weight loss, neoplasm related pain, neoplasm related fatigue/debility, oral candidiasis

COAGULATION DISORDERS

> Type : Hypocoagulopathy (Hemorrhagic Disorders): Inherited causes: hemophilia B (Factor IX deficiency), Factor XI deficiency, and fibrinogen disorders. Acquired causes: anticoagulant/antithrombotic therapy, liver disease and Vitamin K deficiency. Hypercoagulopathy (Thrombotic Disorders): Inherited causes: Factor V Leiden mutation elevated Factor VIII, and deficiencies in protein S, protein C and antithrombin. Acquired causes: malignancy, pregnancy, drugs, autoimmune disease, immobilization.

> Associated conditions: bleeding, thrombosis

Tip: If the patient is on anticoagulants document: coagulopathy due to the use of anticoagulants. Avoid supratherapeutic INR

ANEMIA Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability ( See General) Active hemolysis Active bleeding that cannot be controlled in observation care Altered mental status that is severe or persistent Recurrent syncope or near syncope Cardiac arrhythmias of immediate concern Acute peripheral ischemia (eg, cool, mottled, or cyanotic extremity) High-risk low platelet count Acute kidney injury ( See Nephrology) Clinically significant signs or symptoms that are severe or persist despite observation care as indicated by 1 or more of the following: -Heart failure

-Chest pain -Myocardial ischemia -Dyspnea at rest or with minimal exertion -Other severe sign or symptom secondary to anemia

MALIGNANCY Inpatient admission is indicated for 1 or more of the following: High-risk infection, as indicated by 1 or more of the following –Hypotension (See General) –Bacteremia (if blood cultures performed) –Catheter-related infection requiring inpatient monitoring and testing –Fever with neurologic abnormalities –Skin infection Tumor lysis syndrome Gastrointestinal complications, as indicated by 1 or more of the following –Mucositis requiring IV hydration support or parenteral nutrition

–Diarrhea that cannot be managed at other than inpatient level of care (eg, frequency, risk of dehydration) –Oral candidiasis that requires inpatient management (e.g, parenteral nutrition, pain control, parenteral antifungals)

–Significant abdominal pain with suspicion of colitis Severe electrolyte abnormalities (see nephrology) Severe Pain requiring inpatient management (see general) Pathologic fracture with major instability

HEMATOLOGIC ABNORMALITIES

ANEMIA

NEUTROPENIA

> Acuity: Acute, chronic

> Acuity: Acute, chronic

> Type: blood loss, iron deficiency, anemia of chronic disease, nutritional, megaloblastic, hemolytic, sickle cell, etc. > Cause: Malignancy, GI bleed, Vitamin deficiency, drug induced

> Cause: Malignancy, drug induced, infection, etc.

> Associated conditions: e.g., neutropenic fever, neutropenic sepsis, immunodeficiency

THROMBOCYTOPENIA

PANCYTOPENIA

> Document: pancytopenia when anemia, neutropenia and thrombocytopenia are present . > Cause: drug induced; chemotherapy induced pancytopenia

> Acuity: Acute, chronic

> Cause: Liver disease, drug induced, infection, ITP, etc. > Associated conditions: bleeding, medication adjustment, i.e., holding anticoagulants

Infectious Diseases

Infectious Diseases

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

SEPSIS

Sepsis 2 > Definition: Sepsis : 2 or more SIRS criteria + infection. Severe Sepsis: Sepsis + organ dysfunction, Septic Shock: Sepsis + hypotension not responding to fluids OR lactate

> Tip: Link the infection and organ dysfunction to sepsis

Sepsis 3: > Definition : Sepsis: 2-point increase from baseline of SOFA score, Septic shock : Sepsis + hypotension requiring vasopressors AND lactate >2 > SOFA: Respiratory (P/F ratio < 400), Coagulation (Platelets < 150k), Hepatic (Bilirubin ≥ 1.2), Cardiovascular (MAP < 70),, Neurologic (GCS < 15), Renal (Creatinine ≥ 1.2)

PNEUMONIA

HIV

URINARY TRACT INFECTIONS

> Type/Organism: Aspiration, gram positive, gram negative, MRSA, MSSA, Klebsiella, pseudomonas, etc. Tip: Adding the type/organism to pneumonia may change it from simple to complex pneumonia. Tip: HAP, CAP, HCAP is not recognized as pneumonia types and code to unspecified pneumonia.

> HIV disease and AIDS code to HIV disease code. > HIV, HIV infection and HIV positive code to asymptomatic HIV code. > Document: associated HIV defining conditions, e.g., HIV disease with associated pneumocystis pneumonia

> Acuity : Acute, chronic

> Type: Pyelonephritis, cystitis, etc.

> Etiology: catheter related (CAUTI), nephrostomy tube related, ureteral stent infection, any other cause

> Organism: known or suspected

> Symptoms: Fever, pyuria, dysuria or asymptomatic bacteriuria Tip : Document POA status if UTI is due to device Tip: No code for urosepsis, document sepsis due to UTI instead

ANTIBIOTIC RESISTANCE

WOUNDS

HEPATITIS

> Type: Viral (A, B, C, D, E), alcoholic, drug induced, autoimmune

> Type: Pressure injury, Diabetic, Neuropathic, Venous stasis, Vascular >Document: location, laterality, stage and POA status

> Document: antibiotic resistance when present

> Acuity: Acute, chronic

> Associated conditions: cirrhosis, liver failure, hepatic encephalopathy, hepatorenal syndrome, esophageal varices, etc

SEPSIS Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Bacteremia (if blood cultures performed) Hypoxemia (See Respiratory) Altered mental status that is severe or persistent New coagulopathy (eg, reduced platelet count consistent with disseminated intravascular coagulation)[E] Tachypnea that persists despite observation care Dehydration that is severe or persistent Inability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care Evidence of end organ dysfunction that is severe or persists despite observation care Core (rectal) temperature lower than 95 degrees F (35 degrees C) Parenteral antimicrobial regimen that must be implemented on inpatient basis (e.g, infusion or monitoring needs beyond capabilities of outpatient parenteral therapy) CELLULITIS Inpatient admission is indicated for 1 or more of the following: Clinical presentation (eg, acuity of infection, rapidity of progression) or treatment regimen (eg, complex wound care, antibiotic regimen not suitable for administration at lower level of care) Bacteremia (if blood cultures performed) Limb-threatening infection Orbital infection Suspected necrotizing soft tissue infection (eg, gas in tissue). Severe oral or head and neck cellulitis (eg, Ludwig angina) Preseptal or perineal infection that is severe or progressive Hemodynamic instability (See General) Altered mental status that is severe or persistent Severe pain requiring acute inpatient management (See General) •nability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care

PNEUMONIA Inpatient admission is indicated for 1 or more of the following: Hypoxemia (See Respiratory) Hemodynamic instability (See General) Altered mental status that is severe or persistent Dehydration that is severe or persistent Ventilatory assistance needed (eg, mechanical ventilation, noninvasive ventilation) Bacteremia (if blood cultures performed) Moderate-risk-category or high-risk-category patient (Pneumonia Severity Index class IV or V, or CURB-65 score of 3 or greater) Respiratory finding (e.g., Tachypnea) that persists despite observation care Complicated pleural effusions (e.g, empyema, loculated) UTI Inpatient admission is indicated for 1 or more of the following: Persistence or worsening of clinical finding (eg, fever, pain, dehydration, vomiting) despite observation care Pregnancy with suspected pyelonephritis Significant uropathy (eg, obstructive defects, moderate to severe vesicoureteral reflux) Suspected infection of an indwelling prosthetic device, stent, implant, or graft Ureteral obstruction (e.g, stone) Bladder emptying significantly impaired (eg, bladder outlet obstruction) Renal or perinephric abscess Emphysematous pyelonephritis or emphysematous cystitis Pyonephrosis Hemodynamic instability (See General) Altered mental status that is severe or persistent Severe pain requiring acute inpatient management (See General) Inability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care

Musculoskeletal

Musculoskeletal

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

FRACTURES

> Type: traumatic, stress, pathological, osteoporotic, etc.

> Location of the fracture

> Specify: displaced or non-displaced and closed or open

Tip: With traumatic fractures document contributing factors to the fracture if present, e.g., osteoporosis, osteomyelitis, neoplastic disease.

RHABDOMYOLYSIS

> Type: traumatic, non traumatic: metabolic, inflammatory, ischemic

> Document: associated AKI, ATN, electrolyte imbalance

MOBILITY ISSUES

Contractures, Debility, Assistance w/ daily activities, Assistance w/ movement, Functional Quadriplegia

FUNCTIONAL QUADRIPLEGIA > Definition: Functional quadriplegia is used to describe patients who are completely immobile for reasons other than an injury to the spinal cord. Per CMS, these patients are completely bedbound and dependent on others for all ADLs (feeding, grooming, turning, bathing, etc.)

Tip : Complete immobility codes to functional quadriplegia

CRITICAL ILLNESS MYOPATHY AND POLYNEUROPATHY

Definition: CIM: Flaccid weakness, often accompanied by difficulty weaning from mechanical ventilation. CIP: Reduction in or absence of deep tendon reflexes and sensory loss.

SPINAL FUSIONS

> Specify:

Indication for surgery Associated symptoms Location/ level of involvement Approach and Column Insertion of device or material (eg, interbody fusion device, autologous material, non-autologous material, synthetic material) > Examples: “Anterior approach L3-4 Spinal fusion for lumbar spinal stenosis w/ neurogenic claudication” “Posterior approach T5-7 for thoracic spondylolisthesis w/ radiculopathy” “C3 spondylosis due to generative disc disease w/ myelopathy” > Note: Document a diagnosis rather than a symptom only such as “back pain” as the indication for surgery Document spine deformity when present e.g., scoliosis, kyphosis, kyphoscoliosis, lumbar lordosis

Nephrology

Nephrology

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

RENAL FAILURE

CHRONIC KIDNEY DISEASE

> Renal failure without acuity/chronicity codes to unspecified > Acute renal failure and acute kidney injury code to the same code

> Stage : Stage 1 (GFR: >90), Stage 2 (GFR: 60-89), Stage 3a (GFR: 45- 59), Stage 3b (GFR: 30-44), Stage 4: (GFR: 15-29), Stage 5 (GFR: <15), ESRD (any stage with regular dialysis).

>Tip : Document if the patient is dialysis dependent.

> Chronic renal failure codes to chronic kidney disease

> Renal insufficiency codes to a non-specific code

ACUTE KIDNEY INJURY

ACUTE TUBULAR NECROSIS >Definition: Rapid rise in serum creatinine with one of the following: urine sodium >40, FENA >2%, muddy casts in urinalysis >Tip: Contract induced nephropathy doesn’t code to ATN, consider adding ATN as well.

> Definition: Increase in creatinine level to ≥ 1.5x baseline within 7 days OR Increase (not decrease) in creatinine of ≥ 0.3 mg/dL within 48 hours OR Urine output < 0.5 ml/kg/hr for 6 hours

> Stage: Stage 1 (Cr increase: 1.5x), Stage 2 (Cr increase: 2x), Stage 3 (Cr increase: 3x)

RHABDOMYOLYSIS > Type: traumatic, non traumatic: metabolic, inflammatory, ischemic > Document: associated AKI, ATN, electrolyte imbalance

HEPATORENAL SYNDROME > Definition: Acute kidney injury due to acute or chronic liver disease. It is characterized by a progressive rise in creatinine in patients with liver disease (not due to another cause).

ELECTROLYTE DISORDERS

ACID/BASE DISORDERS

>Acuity: Acute, chronic

>Acuity: Acute, chronic

> Specify: the acid/base disorder, e.g., metabolic acidosis

> Specify: the electrolyte abnormality, e.g., hyponatremia

> Document: treatment/evaluation/monitoring performed

> Document: treatment/evaluation/monitoring performed, e.g., hyponatremia NA 131 monitor or hyponatremia NA 125 hypertonic saline ordered or hyponatremia NA 130 hold diuretics.

> Tip: Add the clinical significance of ABG findings to your notes

URINARY TRACT INFECTIONS

> Acuity: Acute, chronic

> Type: Pyelonephritis, cystitis, etc.

> Etiology: catheter related (CAUTI), nephrostomy tube related, ureteral stent infection, any other cause

> Organism: known or suspected

> Symptoms: Fever, pyuria, dysuria or asymptomatic bacteriuria Tip: Document POA status if UTI is due to device

> Tip: No code for urosepsis, document sepsis due to UTI instead

ACUTE KIDNEY INJURY

Inpatient admission is indicated for 1 or more of the following: Within past 7 days, rise in serum creatinine to 3 times its baseline value or higher (AKI stage 3) Within past 7 days, rise in serum creatinine to at least 1.5 times (AKI stage 1) its baseline value and serum creatinine is greater than 4 mg/dL Initiation of renal replacement therapy (RRT) required Decreased urine output, as indicated by ALL of the following: -Assessment of urine output appropriate (eg, adequate volume status, no urinary obstruction)

Oliguria, as indicated by 1 or more of the following: -Urine output less than 0.3 mL/kg/hour for 24 hours -Urine output less than 0.1 mL/kg/hour) for 12 hours

ELECTROLYTE DISORDERS

Inpatient admission is indicated for 1 or more of the following: Sodium: –Sodium less than 130 mEq/L –Sodium less than 135 mEq/L and AMS/seizures –Sodium greater than 150 mEq/L –Sodium greater than 145 mEq/L and AMS/seizures Potassium: –Potassium less than 2.5 mEq/L –Potassium less than 3 mEq/L with severe finding (eg, paresis, paralysis, arrhythmia, cardiac conduction disturbance) –Potassium greater than 6.5 mEq/L –Potassium greater than 5 mEq/L with severe finding (eg, ECG findings, paresis, paralysis, arrhythmia, cardiac conduction disturbance) Calcium: –Calcium less than 7 mg/dL or ionized calcium less than 3.2 mg/dL –Calcium less than 8.6 mg/dL or ionized calcium less than 4.65 mg/dL with severe finding (eg, Altered mental status, seizures, arrhythmia, cardiac conduction disturbance) –Calcium greater than 14 mg/dL or ionized calcium greater than 10.0 mg/dL –Calcium greater than 12 mg/dL or ionized calcium greater than 8.0 mg/dL with severe finding requiring inpatient management (e.g., Altered mental status, arrhythmia, cardiac conduction disturbance)

Neuroscience

Neuroscience

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

FUNCTIONAL QUADRIPLEGIA

TIA

CVA/ STROKE

> Document: Neurologic deficits, e.g.. hemiparesis, quadriparesis, aphasia, dysphagia, neurologic neglect , etc. Tip: If CT/MRI shows “midline shift” or “mass effect” consider documenting brain compression . If CT/MRI shows “cerebral edema” or “brain herniation” consider adding those to your no

> Definition: Functional quadriplegia is used to describe patients who are completely immobile for reasons other than an injury to the spinal cord. Per CMS, these patients are completely bedbound and dependent on others for all ADLs (feeding, grooming, turning, bathing, etc.) Tip: Complete immobility codes to functional quadriplegia

> Document : a more specific diagnosis such as: carotid artery stenosis, vertebro-basilar artery syndrome, cerebral ischemia, amaurosis fugax, transient global amnesia, etc. > Avoid: cerebral insufficiency , document cerebral infarction instead

ENCEPHALOPATHY

DELIRIUM

COMA

> Type: metabolic, septic, toxic, hepatic, uremic, hypertensive, etc. Tip: Document if the encephalopathy (altered mental status) is same as baseline, more than baseline, worsened or improved

> Definition: GCS score is below 9

> Acuity: acute, chronic

> Document: the individual eye, verbal, and motor scores

> Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, ICU delirium, mixed etiology, etc

DEMENTIA

SEIZURES

CEREBRAL PALSY

> Type: Alzheimer’s, Vascular, Lewy body, etc. > With or without behavioral disturbance: e.g., anxiety, depression, behavioral, mood or psychotic disturbance. Tip: document delirium and/or encephalopathy superimposed on dementia when present.

>Type: Focal, generalized

>Type: spastic, dyskinetic, ataxic, hypotonic, and mixed > Associated Paralysis: diplegia, hemiplegia, quadriplegia > With or without intellectual disability

Intractable or not interactable With or without status epilepticus

TIA Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Focal neurologic signs Finding on brain imaging that requires inpatient care (eg, mass) Vascular imaging demonstrates extracranial carotid artery stenosis (50% to 99% stenosis) and ALL of the following: –Carotid artery stenosis is presumed etiology of TIA –Carotid intervention (carotid endarterectomy or carotid artery stenting) to be performed imminently (ie, during index hospitalization, no discharge to lower level of care with subsequent scheduling of elective procedure) Altered mental status that is severe or persistent Cardiac arrhythmias of immediate concern

CVA/STROKE

IInpatient admission is indicated for 1 or more of the following: National Institutes of Health Stroke Scale (NIHSS) score greater than 2 Evidence of hemorrhagic transformation Altered mental status that is severe or persistent

Dysphagia that warrants evaluation (eg, aspiration risk suspected) Significant arm or leg weakness (eg, limiting movement against gravity) Aphasia Gait impairment Finding on brain imaging that requires inpatient care (eg, mass, edema, large acute infarction) Clinical stability unclear (eg, recurrent or worsening findings) Acute ischemic stroke with clinical need for inpatient care or monitoring, as indicated by 1 or more of the following: –Hemodynamic instability –Cardiac arrhythmias of immediate concern –Thrombolysis or thrombectomy performed or planned

SEIZURE

IInpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Status epilepticus Brain disorder (eg, tumor, edema, trauma, hydrocephalus, encephalitis, meningitis) Etiology (eg, drug toxicity, withdrawal, nonadherence) Altered mental status that is severe or persistent Metabolic disorder (eg, hypoglycemia, electrolyte abnormality) that persists despite observation care Recurrent seizure and 1 or more of the following: –Recurrent seizure is of a different seizure type than previously known seizure disorder –Patient with baseline of infrequent seizures Medication initiation or adjustment that requires monitoring beyond observation care Increased intracranial pressure, cerebral edema, or hydrocephalus and monitoring needed