Answers

Answers to the newsletter case study.

32-year-old female to ED via EMS with shortness of breath

HPI:  Known COVID-19 exposure at work 6 days ago, nasal swab negative yesterday in setting of loss of taste and smell, general malaise and rigors, HA + sinus congestion, cough and tightness in chest.

(Hint:  Did she have a false negative test?  Signs and symptoms and risk/exposure are strong.  Need to stay alert for bedside confirmation despite negative lab result.)

PMH:  Obesity, asthma, HTN.

Home Meds:  inhalers, BCP 

Triage RN:  High-Fowler’s + tripod position on arrival, speaking in 1-2 word sentences.  94% on 6L NC, refusing venti-mask due to claustrophobia.

(Hint:  increased work of breathing precedes clinical decompensation.  Respiratory failure is on the horizon. Oxygen saturation is quite tenuous for patient’s age, while she is being supported on a high amount of supplemental O2.)

Arrival VS:  T 100.4 axillary P 116 R 36  BP 166/80  sat 94%

(Hint:  axillary temps are typically a degree lower than oral, so this may actually be the equivalent of a 101.4 temp.  Rectal temps are typically a degree higher, and you’d subtract a degree for an oral equivalent.  RNs at bedside take this into account but it’s often unspoken in the record.)

ED:  Acute respiratory distress, gradual onset over past two days became unbearable overnight when laying down in bed.  Slept sitting up leaned over pillow at kitchen table.  Husband called EMS when he arrived home at 6 AM after night-shift work.  Isolation, inpatient admit to ICU:  COVID-like symptoms, condition: guarded.

(Hint:  COVID-like is a term of uncertainty: however, terms of uncertainty are not sufficient when reporting certain infectious conditions such as COVID and AIDS per Chapter 1 Guidelines.)

Initial Labs:  WBC 13.7 Differential:  lymphocyte count L  , repeat COVID pending

(Hint:  Lining up the perfect storm.  4/4 SIRS + documented infection + acute organ dysfunction/resp failure.  

Be alert for sepsis and/or severe sepsis to arrive via natural progression, or generate a query if not spontaneously documented.

Also lymphocyte counts tend to be very low aka “lymphopenia” in our COVID patient population. )

CXR:  limited by body habitus w/? scattered opacities, correlate clinically for COVID-19

(Hint: obesity in this case is clinically significant b/c it’s making it harder to see the radiology findings.  Important in cases w/high BMI and corresponding diagnosis of obesity to validate reporting the CC.)

H&P:  No measurable improvement after IV steroids in ED, Remdisivir initiated.  Maintaining sat >90 on 6L high-flow NC w/increasing WOB.  Family notified of tenuous status.  SIRS improving. 

RN:  Flushed, anxious, tearful but wearing venti-mask.  Sats dropped into 80s prior to intubation by Anesthesia after receipt of ABG results @ 0815.

(Hint:  note intubation time.)

Hospital Day 1 Progress Note:  Updated husband over phone 2* no visitors per COVID-19 policy.  Maintain on vent for supportive care.  COVID- pna and hypoxic respiratory failure.

(Hint:  the provider has shifted from a term of uncertainty to a definitive diagnosis.  COVID pna is now reportable without a query.)

CDI Initial ReviewAssign working DRG_________________.

Is there a query opportunity?  Y ____ N____  If so, identify target DRG________________

CDI Initial Review:  Assign working DRG 208 (137) Resp System Dx w/Vent Support <=96*.

U07.1

J12.82

J96.91

5A1945Z

Is there a query opportunity?  YES

Target DRG 871 (720) Sepsis (viral A41.89 Other specified sepsis) 2* COVID pna.

(Hint:  MV @/+ 96 hours will result in natural progression to DRG 870 via 5A1955Z…if no one else throws a wrench in it. 🙂

Hospital Day 4 Progress Note:  tolerating T-piece during daytime, vent @ HS.  Spoke w/spouse who now mentions patient has not been on BCP x ? 6-8 weeks due to their recent health-insurance changes.  Unknown LMP.  Obtain UA pregnancy test.  Sepsis POA due to COVID pna w/resp failure, improving. 

(Hint:  At the 11th hour pregnancy may come into play on this record.)

Hospital Day 9 Discharge Summary:  Admitted for respiratory distress and COVID pna, required MV + ICU care for 5 days with gradual improvement, d/c home to care of family due to ongoing weakness.  Patient and husband discussing options including early termination of unplanned pregnancy in setting of obesity and ongoing health concerns, FU as OP.  Repeat COVID test yesterday was negative, d/c isolation. 

(Hints:  

Report MV >96 + hours as weaning time on T-piece is reported as “continuous” and pt. was in ICU care on vent a total of 5days.  

Provider is confirming pregnancy in the final diagnostic statement.    

The final COVID test result cited before d/c was negative, so patient is no longer infectious. 

This does not negate the previous & consistent documentation of COVID pna made at the bedside.  

Provider did not indicate whether the COVID test done at the time of admission was confirmed positive: this would be needed on record for additional 20% payment as of Sept. 1, 2020 however does not affect the reporting. )

Coder Initial Review:  Assign final DRG __________________.  

Is there a query opportunity?  Y ____ N____  If so, identify target DRG________________

Coder Initial Review:  Assign DRG 831 Other Antepartum Dx w/o OR Procedure w/MCC

O98.511 Other viral dz complicating pregnancy, 1st trimester

UO7.1

J12.82

R65.2 

(Hint:  R65 is reportable per Tabular review of synonyms for “severe sepsis” which include infection w/associated acute organ dysfunction. Seen above Sepsis POA due to COVID pna w/resp failure).

Is there a query opportunity?  YES  

Target DRG 870 Sepsis 2*COVID pna +MV 96+, achieved by querying to determine if this was an incidental pregnancy.

Cite source documents supporting the DRG assignment(s).  

j. Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium When assigning a chapter 15 code for sepsis complicating abortion, pregnancy, childbirth, and the puerperium, a code for the specific type of infection should be assigned as an additional diagnosis. If severe sepsis is present, a code from subcategory R65.2, Severe sepsis, and code(s) for associated organ dysfunction(s) should also be assigned as additional diagnoses.

s. COVID-19 infection in pregnancy, childbirth, and the puerperium 

During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter , code O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) should be assigned as additional diagnoses. Codes from Chapter 15 always take sequencing priority. If the reason for admission/encounter is unrelated to COVID-19 but the patient tests positive for COVID-19 during the admission/encounter, the appropriate code for the reason for admission/encounter should be sequenced as the principal/first- listed diagnosis, and codes O98.5- and U07.1, as well as the appropriate codes for associated COVID-19 manifestations, should be assigned as additional diagnoses.

Z33.1 Pregnant state, incidental

This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.

Z68 Body mass index (BMI)

BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity).

Do not assign BMI codes during pregnancy.

Duration of mechanical ventilation during weaning period

      ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2014 Page: 7 Effective with discharges: December 31, 2014

       Related Information

Question:

A patient status post tracheostomy was admitted as an inpatient on mechanical ventilation. Five days later the tracheostomy was removed and the patient was successfully weaned off of the ventilator. How should the hours of mechanical ventilation be counted during the weaning process?

Answer:

All of the period of weaning is counted during the process of withdrawing the patient from ventilatory support. The duration includes the time the patient is on the ventilator, the weaning period, and ends when the patient is extubated and the mechanical ventilation is turned off (after the weaning period).

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