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Documentation Tip: Urosepsis

Posted on Mon, Jan 16, 2017
Documentation Tip: Urosepsis

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

UROSEPSIS: There is NO CODE in ICD-10. Documenting the term “urosepsis” is ambiguous and nonspecific for coding purposes.

Please consider: “Sepsis secondary to UTI.”

  • NO SOI (not sick) - Urosepsis
  • LOW SOI (sick) - UTI
  • HIGH SOI (very sick) - Sepsis due to UTI

This tip will help reflect severity of illness (SOI) and have your patient appear as sick on paper as they are in the bed.

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

Dr. Timothy Brundage

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Documentation Tip of the Week: Home Oxygen

Posted on Wed, Jul 15, 2015
Documentation Tip of the Week: Home Oxygen

Our weekly feature of documentation tips for clinicians.

Medicare is actively enforcing the following guidelines when documenting the need for home oxygen. The physician must clearly DOCUMENT the need for home oxygen in the medical record in order for it to be covered by Medicare.

The following criteria must be MET and DOCUMENTED by the PHYSICIAN to qualify for home O2:

  • PaO2 ≤ 55mmHg OR  
  • SaO2 ≤ 88% while awake, asleep, and at rest

If the above criteria are only met with exertion, 3 tests are required: 
  1. On room air, AT REST  
  2. On room air, DURING EXERTION  
  3. On oxygen, DURING EXERTION


If the test is done during sleep, it must show at least 5 minutes (not continuous) of SaO2 ≤ 88% or PaO2 ≤ 55mmHg

HOWEVER, if the patient has severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, this is acceptable for Medicare coverage. Values must be recorded within 48 hours prior to discharge from the hospital.

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip of the Week: Troponemia

Posted on Wed, May 13, 2015
Documentation Tip of the Week: Troponemia

Documentation tips for clinicians

Troponemia is a lab finding and is not a diagnosis. This lab finding is not benign. Surgical data demonstrates increased 30, 60 and 90 day mortality with elevated troponin associated with surgical procedures.
Documentation suggestions:


1) Not clinically relevant

  • Chronic Kidney Disease may be associated with elevation of troponin beyond the upper limits of normal, but the troponin level should remain relatively stable through the hospitalization.
  • If the troponin level increases or decreases through the hospitalization consider

2) Demand Ischemia
  • Does not code to an acute MI. Demand ischemia is due to supply demand mismatch.

3) NSTEMI type 2
  • This codes to an acute MI from a coding perspective.
  • Type 2 NSTEMI is also due to supply demand mismatch.
  • Associated with higher severity of illness 
  • Quality metrics tracked for AMI



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip of the Week: Coma

Posted on Wed, Apr 29, 2015
Documentation Tip of the Week: Coma

When documenting coma, include the duration of time in coma (greater or less than one hour)

This is especially important in patients with a principal diagnosis of:

  • subdural hematoma
  • closed head injury
  • skull fracture
  • subdural, extradural or subarachnoid hemorrhage
  • traumatic brain injury
ICD-10 will utilize the Glasgow Coma Scale. Total score documented on presentation may be used, however, the individual scores are preferred.

The documentation of coma supports higher severity of illness and increased length of stay as well as medical necessity. Coma is not integral to the death process, and can be an additional diagnosis when a patient expires.

This documentation will support your patient being as sick on paper as they are in the bed.


 Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

 

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Documentation Tip of the Week: Excisional Debridement

Posted on Wed, Apr 22, 2015
Documentation Tip of the Week: Excisional Debridement

Documentation tips for clinicians

Excisional Debridement Physicians/providers must now document “excisional debridement of bone, fascia or muscle,” otherwise the procedure will be coded as nonexcisional. Terms such as “sharp debridement” or statement of use of a scalpel alone are not considered sufficient for code assignment of excisional debridement.

The following information must also be documented by the provider:

  • Description of the area debrided
  • The instrument used (scalpel, scissors, forceps, etc.)
  • The depth of the debridement (up to and including skin, muscle, tendon, bone, etc.)  
  • Documentation of removal or cutting away of devitalized tissue, necrosis or slough

Coders may not assume that debridement of bone, fascia or muscle is excisional, nor may they assume that sharp debridement is excisional. The exact wording of “excisional debridement” with the supporting documentation must be present. Failure to document appropriately may result in problems with physician reimbursement and/or denials.

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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