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Value Based Purchasing, Changes for ICD-10 and the Future of Anesthesia/Pain Mgt Robert S. Gold, MD

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Title: Value Based Purchasing, Changes for ICD-10 and the Future of Anesthesia/Pain Mgt Robert S. Gold, MD


1
Value Based Purchasing, Changes for ICD-10 and
the Future of Anesthesia/Pain Mgt Robert S. Gold,
MD
2
Medicine Under the Microscope
  • Morbidity
  • Mortality
  • Cost per patient
  • Resource utilization
  • Length of stay
  • Complications
  • Outcomes
  • ARE YOU SAFE avoiding harm, avoidable
    readmissions?

3
Value-Based Purchasing Program
  • Beginning in FY 2013 and continuing annually, CMS
    will adjust hospital payments under the VBP
    program based on how well hospitals perform or
    improve their performance on a set of quality
    measures. The initial set of 13 measures includes
    three mortality measures, two AHRQ composite
    measures, and eight hospital-acquired condition
    (HAC) measures. The FY 2012 IPPS final rule
    (available at http//tinyurl.com/6nccdoc)
    includes a complete list of the 13 measures.

4
Where Does This Data Come From?
  • Documentation leads to identification of
    diagnoses and procedures
  • Recognition of diagnoses and procedures lead to
    ICD codes THE TRUE KEY
  • ICD codes lead to APR-DRG assignment
  • APR-DRG assignment massaged to Severity
    Adjustments
  • Severity adjusted data leads to morbidity and
    mortality rates

5
World Health Organization and ICD Codes
  • Semantics
  • Coding guidelines and conventions
  • Use of signs, symbols, arrows
  • Accuracy and specificity
  • Relationship between accuracy and specificity of
    code assignment and Complexity of Medical
    Decision Making

6
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7
Is There a Diagnosis?
  • 82 yo WF altered mental status, shaking chills,
    fevers, decr UO, T 103, P 124, R 34, BP
    70/40 persistent despite 1 L NS, on Dopamine, pO2
    78 on non-rebreather, pH 7.18, pCO2 105,
    WBC 17,500, left shift, BUN 78, Cr 5.4, CXR
    Right UL infiltrates, start Cefipime, Clinda,
    Tx to ICU. May have to intubate full resusc.

8
Is There a Diagnosis?
  • Assessment/Plan
  • 82 YO F patient presented to ER with
  • 1. Sepsis,
  • 2. Septic Shock,
  • 3. Acute Hypercapnic Respiratory Failure,
  • 4. Acute Renal Failure due to 2, (dont forget
    CKD and stage, if present)
  • 5. Aspiration Pneumonia,
  • 6. Metabolic Encephalopathy
  • Will transfer to ICU, continue Dopamine and
    monitor respiratory status for possible ARDS,
    renal status with hydration and initiate
    Cefapime/clindamycin for possible aspiration
    pneumonia
  • CC time 1hr 45 minutes
  • John Smith MD

9
So Whats the Difference?
Principal Diagnosis Chills and Fever Sepsis
Secondary Diagnoses Altered mental status Septic Shock Acute Respiratory Failure Aspiration Pneumonia Acute Renal Failure (or AKI) Respiratory Acidosis Metabolic Encephalopathy
Medicare MS-DRG 864 Fever w/o CC/MCC Septicemia or severe Sepsis w/o MV 96 hrs w/ MCC
APR-DRG 722 Fever 720 Septicemia Disseminated infection
APR-DRG Severity Illness 1 Minor 4 Extreme
APR-DRG Risk of Mortality 1 Minor 4 - Extreme
Medicare MS-DRG Rel Wt 0.8153 1.8437
APR DRG Relative Weight 0.3556 2.9772
National Mortality Rate (APR Adjusted) 0.04 62.02
10
What Is An Index?
11
What Is An Index?
  • Mortality index
  • Complication index
  • Length of stay index
  • Cost per patient index

Observed Rate of Some Thing Severity Adjusted
Expected Rate of That Thing
1
12
Profiles Come from Severity Adjusted Statistics
lt1 preferred provider ????? significantly
better
1 as good as the next guy???
  • Observed mortality
  • Expected mortality
  • From severity adjusted DRGs

gt1 excessive mortality find another provider -
?
13
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14
Patient Safety
15
Issues of Concern
  • Severity of illness conditions that make the
    principal diagnosis more costly ALL diagnoses,
    ALL procedures
  • Risk of mortality conditions that add to the
    likelihood that a patient will die ALL
    diagnoses, ALL procedures
  • Patient safety identification of risk issues
    that can be minimized or controlled
  • Primum Non Nocere

16
Surgery Bundling Test Model
  • Disclosed May 16, 2008
  • ACE (Acute Care Episode) project
  • Combine Part B payments with Part A
  • Value Based Centers started with Texas,
    Oklahoma, New Mexico and Colorado
  • Value based purchasing
  • 28 cardiac and 9 orthopedic inpatient surgical
    services
  • Gainsharing also permitted here
  • Based on severity adjusted financial outcomes

17
Florida Blue and Mayo Clinic Introduce Knee
Replacement Bundled Payment Program
  • Friday, December 14, 2012
  • JACKSONVILLE, Fla. Florida Blue and Mayo Clinic
    jointly announce a new collaboration aimed at
    providing the utmost in quality care for knee
    replacement patients in Florida. The two Florida
    health care leaders are teaming up to create a
    bundled payment agreement specific to the
    treatment of knee replacement surgery.
  • Knee replacement surgery is the most common joint
    replacement procedure. According to the Agency
    for Healthcare Research and Quality, health care
    professionals perform more than 600,000 knee
    replacements annually in the United States.

18
Florida Blue and Holy Cross Create Accountable
Care Arrangement
  • Jacksonville and Fort Lauderdale, Fla. Florida
    Blue, Floridas Blue Cross and Blue Shield
    Company, and Holy Cross Physician Partners are
    pleased to announce that effective January 1,
    2013, Holy Cross Physician Partners will
    participate in the Florida Blue Accountable Care
    Program.
  • Florida Blue is excited to expand our
    relationship with Holy Cross surrounding this
    exciting new partnership, said Dr. Jonathan
    Gavras, chief medical officer and senior vice
    president for Florida Blue. In the age of
    reform, both organizations realize the importance
    of moving away from the fee-for-service model to
    one that focuses on quality outcomes that will
    benefit our members in South Florida.

19
Clinical Integration
  • CMS proposes to pay separately for complex
    chronic care management services starting in
    2015. 
  • "Specifically, we proposed to pay for
    non-face-to-face complex chronic care management
    services for Medicare beneficiaries who have
    multiple, significant, chronic conditions (two or
    more)."  Rather than paying based on face-to-face
    visits, CMS would use "G-codes" to pay for
    revision of care plans, communication with other
    treating professionals, and medication management
    over 90-day periods.
  • These code payments would require that
    beneficiaries have an annual wellness visit, that
    a single practitioner furnish these services, and
    that the beneficiary consent to this arrangement
    over a one-year period.

20
Patient Safety Indicators
  • Hospital acquired preventable diagnoses
  • Hospital falls that lead to patient damage
    (fractures, etc.)
  • Mediastinitis post-CABG
  • Catheter-associated UTIs
  • Vascular catheter associated infections
  • Pressure ulcers
  • Object accidentally left in patient
  • Air embolism
  • Reaction from blood incompatibility

21
What Does This Mean?
  • Properly identify complication of care when
    complication specify when due to a disease
  • We dont want to assign complication codes when
    not complication
  • If event due to disease, not a complication
  • If even doesnt exist, not a complication
  • Dont use the word post-op in the post-op
    period!

22
Is an Adverse Event Always a Complication?
  • Not at all.
  • Stuff happens.
  • Diseases cause adverse effects
  • Anemia due to blood loss is usually due to the
    disease and not to the surgery
  • State so anemia of chronic blood loss due to
    right colon cancer anemia of acute blood loss
    due to femur fracture dilutional drop in
    hematocrit is not anemia at all
  • Adverse effects are easily explained and defended
    in a patient with more risk factors. If you
    didnt name these, you lose.

23
Stuff that Can Happen
  • T88.2 Shock due to anesthesia
  • Use additional code for adverse effect, if
    applicable, to identify drug (T41.- with fifth or
    sixth character 5)
  • Excludes1 complications of anesthesia (in)
  • labor and delivery (O74.-)
  • pregnancy (O29.-)
  • puerperium (O89.-)
  • postprocedural shock NOS (T81.1-)
  • T88.3 Malignant hyperthermia due to anesthesia
  • T88.4 Failed or difficult intubation
  • T88.5 Other complications of anesthesia
  • T88.51 Hypothermia following anesthesia
  • T88.52 Failed moderate sedation during procedure
  • T88.59 Other complications of anesthesia

24
And During Pregnancy 6th digit of 1st trimester,
2nd trimester, 3rd trimester, 9 unspecified
trimester
  • O29 Complications of anesthesia during pregnancy
  • Includes maternal complications arising from the
    administration of a general, regional or local
    anesthetic, analgesic or other sedation during
    pregnancy
  • Use additional code, if necessary, to identify
    the complication
  • Excludes2 complications of anesthesia during
    labor and delivery (O74.-)
  • complications of anesthesia during the puerperium
    (O89.-)
  • O29.0 Pulmonary complications of anesthesia
    during pregnancy
  • O29.01 Aspiration pneumonitis due to anesthesia
    during pregnancy
  • O29.02 Pressure collapse of lung due to
    anesthesia during pregnancy
  • O29.09 Other pulmonary complications of
    anesthesia during pregnancy
  • O29.1 Cardiac complications of anesthesia during
    pregnancy
  • O29.11 Cardiac arrest due to anesthesia during
    pregnancy
  • O29.12 Cardiac failure due to anesthesia during
    pregnancy
  • O29.19 Other cardiac complications of anesthesia
    during pregnancy

25
Goals of Implementation Prove You Are Value
Based
  • Outstanding severity adjusted mortality and
    complication statistics
  • Reasonable occurrence of PSIs/HACs
  • Lower than average Readmissions for Pneumonia,
    Heart Failure, AMI
  • Cooperation with quality initiatives
  • Decent responses to a new questionnaire on
    discharge

26
Whats The Procedure For?
  • Provide the diagnosis for which the procedure is
    being performed
  • Tell why its necessary for that diagnosis
  • DONT just say that the patient is being admitted
    for the procedure
  • DONT just provide signs and symptoms

27
Complexity of Patient
  • Identify those things that make the patient
    ineligible for one technique rather than another
    tell the record your thought processes
  • Name other diseases patient has coming through
    the door chronic, stable conditions
  • Avoid Resume home meds unless you identify each
    disease being treated

28
Risk Stratification for Pulmonary Complications
Age Obstructive sleep apnea
Chronic lung disease Impaired sensorium
Cigarette use Surgical site
Congestive heart failure Elective vs emergency
ASA Class of comorbids Prolonged surgery
Functional dependence General anesthesia
Obesity Transfusion gt 4 units
29
Pre-Anesthesia Work-Up
  • Part of identification of ASA classification
    includes review of current illnesses that bring
    the patient to the operating room and ALL CURRENT
    ILLNESSES UNDER TREATMENT.
  • A good PMH, ROS, medication review is always
    expected.

30
Pre-Anesthesia Workup
  • Examination/interview of patient/record review
  • Evaluation of cardiac function
  • Evaluation of pulmonary function
  • Evaluation of CNS
  • Evaluation of circulatory system volume,
    hemoglobin
  • Evaluation of GI system (risk of aspiration)
  • Evaluation of oronasopharynx and teeth
  • Evaluation of physical abnormalities scoliosis,
    morbid obesity (short neck)

31
Pre-Anesthesia Workup
  • List current diseases chronic, stable
    conditions for which patient is under treatment
    and which can add morbidity to the case
  • List current medications
  • LINE THEM UP
  • List significant past conditions and reactions to
    anesthetics
  • List significant allergies

32
Change in the Entire System
  • ICD-9

ICD-10
33
Notable Changes
  • ICD-9 has maximum of 5 digits with rare
    alphanumeric codes (V-, E-) limiting breakdown
    for specificity or addition of categories ICD-10
    has three to seven alphanumeric places
  • ICD-9 14,000 codes ICD-10 73,000 codes
  • ICD-9 has no specificity as to which side of the
    body (e.g., percent burn on right or left arm or
    leg, side of paralysis after stroke)

34
Dont Wait Till Tomorrow for ICD-10
35
Specificity is NOT Always Possible
  • Sign/Symptom/Unspecified Codes
  • In both ICD-9-CM and ICD-10-CM, sign/symptom and
    unspecified codes have acceptable, even
    necessary, uses. While specific diagnosis codes
    should be reported when they are supported by the
    available medical record documentation and
    clinical knowledge of the patients health
    condition, there are instances when
    signs/symptoms or unspecified codes are the best
    choices for accurately reflecting the healthcare
    encounter.
  • Each healthcare encounter should be coded to the
    level of certainty known for that encounter.
  • If a definitive diagnosis has not been
    established by the end of the encounter, it is
    appropriate to report codes for sign(s) and/or
    symptom(s) in lieu of a definitive diagnosis.
  • When sufficient clinical information isnt known
    or available about a particular health condition
    to assign a more specific code, it is acceptable
    to report the appropriate unspecified code
    (e.g., a diagnosis of pneumonia has been
    determined, but not the specific type).
  • In fact, unspecified codes should be reported
    when they are the codes that most accurately
    reflects what is known about the patients
    condition at the time of that particular
    encounter. It would be inappropriate to select a
    specific code that is not supported by the
    medical record documentation or conduct medically
    unnecessary diagnostic testing in order to
    determine a more specific code.

Source Cooperating Parties for ICD-10-CM/PCS and
ICD-9-CM Coding, May 2013.
36
Pain Codes ICD-9
  • 338 Pain, not elsewhere classified
  • 338.0 Central pain syndrome
  • 338.1 Acute pain
  • 338.11 Acute pain due to trauma
  • 338.12 Acute post-thoracotomy pain
  • 338.18 Other acute postoperative pain
  • 338.19 Other acute pain
  • 338.2 Chronic pain
  • 338.21 Chronic pain due to trauma
  • 338.22 Chronic post-thoracotomy pain
  • 338.28 Other chronic postoperative pain
  • 338.29 Other chronic pain
  • 338.3 Neoplasm related pain (acute) (chronic)
  • 338.4 Chronic pain syndrome
  • Chronic pain associated with significant
    psychosocial dysfunction

37
Pain Codes ICD-10
  • G89 Pain, not elsewhere classified
  • Code also related psychological factors
    associated with pain (F45.42)
  • G89.0 Central pain syndrome
  • Thalamic pain syndrome (hyperesthetic)
  • G89.1 Acute pain, not elsewhere classified
  • G89.11 Acute pain due to trauma
  • G89.12 Acute post- thoracotomy pain
  • G89.18 Other acute postprocedural pain
  • G89.2 Chronic pain, not elsewhere classified
  • G89.21 Chronic pain due to trauma
  • G89.22 Chronic post-thoracotomy pain
  • G89.28 Other chronic postprocedural pain
  • Other chronic postoperative pain
  • G89.29 Other chronic pain
  • G89.3 Neoplasm related pain (acute) (chronic)
  • G89.4 Chronic pain syndrome
  • Chronic pain associated with significant
    psychosocial dysfunction

38
Pain Coding in ICD-10
  • Identify if acute or chronic
  • Identify organ involved with pain (joints, bones,
    chest, abdomen with parts of abdomen involved and
    character of the pain - generalized, RUQ, with
    tenderness or rebound)
  • Identify relationship to specific disease,
    trauma, deformity

39
Coding Issues with Pain
  • General coding information
  • Codes in category G89 may be used in conjunction
    with codes from other categories and chapters to
    provide more detail about acute or chronic pain
    and neoplasm-related pain, unless otherwise
    indicated below.
  • If the pain is not specified as acute or chronic,
    do not assign codes from category G89, except for
    post-thoracotomy pain, postoperative pain or
    neoplasm related pain, or central pain syndrome.
  • A code from subcategories G89.1 and G89.2 should
    not be assigned if the underlying (definitive)
    diagnosis is known, unless the reason for the
    encounter is pain control/ management and not
    management of the underlying condition.

40
Pain as Principal Diagnosis
  • Category G89 codes are acceptable as principal
    diagnosis or the first-listed code
  • When pain control or pain management is the
    reason for the admission/encounter (e.g., a
    patient with displaced intervertebral disc, nerve
    impingement and severe back pain presents for
    injection of steroid into the spinal canal). The
    underlying cause of the pain should be reported
    as an additional diagnosis, if known.
  • When an admission or encounter is for a
    procedure aimed at treating the underlying
    condition (e.g., spinal fusion, kyphoplasty), a
    code for the underlying condition (e.g.,
    vertebral fracture, spinal stenosis) should be
    assigned as the principal diagnosis and no code
    from category G89 should be assigned.

41
Sequencing
  • Sequencing of Category G89 Codes with
    Site-Specific Pain Codes
  • The sequencing of category G89 codes with
    site-specific pain codes (including chapter 16
    codes), is dependent on the circumstances of the
    encounter/admission as follows
  • If the encounter is for pain control or pain
    management, assign the code from category G89
    followed by the code identifying the specific
    site of pain (e.g., encounter for pain management
    for acute neck pain from trauma is assigned code
    G89.11, Acute pain due to trauma, followed by
    code 723.1, Cervicalgia, to identify the site of
    pain).
  • If the encounter is for any other reason except
    pain control or pain management, and a related
    definitive diagnosis has not been established
    (confirmed) by the provider, assign the code for
    the specific site of pain first, followed by the
    appropriate code from category G89.

42
Back Pain ICD-10 Spondylosis /Facet Joints
  • M47.1 Other spondylosis with myelopathy
  • Spondylogenic compression of spinal cord
  • Excludes1 vertebral subluxation (M43.3-M43.59)
  • M47.2 Other spondylosis with radiculopathy
  • M47.8 Other spondylosis
  • M47.81 Spondylosis without myelopathy or
    radiculopathy
  • M47.89 Other spondylosis
  • M47.9 Spondylosis, unspecified

Identify level 0 unspecified 1
occipito-atlanta-axial 2 cervical 3
cervicothoracic 4 thoracic 5 thoracolumbar 6
lumbar 7 lumbosacral 8 sacral and
sacrococcygeal
43
Back Pain ICD-10
  • M51.0 Thoracic, thoracolumbar and lumbosacral
    intervertebral disc disorders with myelopathy
  • M51.1 Thoracic, thoracolumbar and lumbosacral
    intervertebral disc disorders with radiculopathy
  • M51.2 Other thoracic, thoracolumbar and
    lumbosacral intervertebral disc displacement
  • Lumbago due to displacement of intervertebral
    disc
  • M51.3 Other thoracic, thoracolumbar and
    lumbosacral intervertebral disc degeneration

5th digits 4 thoracic 5 thoracolumbar 6
lumbar 7 - lumbosacral
44
Back Pain ICD-10
Identify level 0 unspecified 1
occipito-atlanta-axial 2 cervical 3
cervicothoracic 4 thoracic 5 thoracolumbar 6
lumbar 7 lumbosacral 8 sacral and
sacrococcygeal
  • M54.1 Radiculopathy
  • M54.2 Cervicalgia
  • M54.3 Sciatica
  • M54.4 Lumbago with sciatica
  • M54.5 Low back pain
  • M54.6 Pain in thoracic spine
  • M54.8 Other dorsalgia
  • M54.81 Occipital neuralgia
  • M54.89 Other dorsalgia

5th digits 0 unspecified side 1 right side 2
left side
45
SPINAL INJECTIONS
  • 62310-62319 are considered unilateral procedures.
    (CPT Assistant, January 2000 Article 1)
  • 62310 - Injection, single (not via indwelling
    catheter), not including neurolytic substance),
    of diagnostic or therapeutic substances(s),
    epidural or subarachnoid cervical or thoracic
  • 62311 - lumbar, sacral (caudal)

46
SPINAL INJECTIONS
  • 62318 Injection, including catheter placement,
    continuous infusion or intermittent bolus, not
    including neurolytic substances, of diagnostic
    or therapeutic substance(s), epidural or
    subarachnoid cervical or thoracic
  • 62319 lumbar, sacral (caudal)

47
FACET INJECTION(S)
48
SPINAL INJECTIONS
  • 62310-62319 - These codes are reported once per
    level, per side, regardless of the number and
    type of injections performed per level, per side.
  • It is inappropriate to report the spinal
    injection(s) code for each injection performed at
    a particular level and side.

49
Identify Your Chemicals
  • Clarification, steroid and anesthetic injections
    Coding Clinic, Third Quarter 2000 Page 15
  • Question
  • Central Office has received numerous requests for
    clarification since the publication of two
    questions in Coding Clinic, Second Quarter 1998,
    page 18 and First Quarter 1999 pages 7-8,
    regarding steroid and anesthetic injections into
    the spinal canal. In one question, both codes
    03.91 and 03.92 were given. In the other
    question, code 03.91 and 99.23 were given.
    Readers are questioning why all three codes could
    not be assigned or why codes 03.91 and 03.92
    should not be assigned in both cases? The
    question in Second Quarter 1998 does not specify
    whether there is one or two injections given.
    Does this matter?
  • Answer
  • Code 03.92, Injection of other agent into spinal
    canal, does not identify the specific agent
    injected. Therefore, it would be appropriate to
    assign both codes 03.92, Injection of other agent
    into spinal canal and 99.23, Injection of
    steroid, for a single injection of steroid into
    the spinal canal. This code assignment may be
    repeated for each injection. If, however, the
    injection includes both steroids and anesthetics
    assign code 03.92, Injection of other agent into
    spinal canal, code 03.91, Injection of anesthetic
    into spinal canal for analgesia, and code 99.23,
    Injection of steroid.

50
Pain from Cancer
  • Neoplasm Related Pain
  • Code G89.3 is assigned to pain documented as
    being related, associated or due to cancer,
    primary or secondary malignancy, or tumor. This
    code is assigned regardless of whether the pain
    is acute or chronic.
  • This code may be assigned as the principal or
    first-listed code when the stated reason for the
    admission/encounter is documented as pain
    control/pain management. The underlying neoplasm
    should be reported as an additional diagnosis.
  • When the reason for the admission/encounter is
    management of the neoplasm and the pain
    associated with the neoplasm is also documented,
    code G89.3 may be assigned as an additional
    diagnosis.

51
Primary and Metastatic Cancer
  • Tell where the primary is (was) and if it was
    previously removed or treated and treatment is
    over or currently under treatment
  • State where the metastatic sites are and if they
    (any) are symptomatic and if they are currently
    under treatment
  • State if new site is found and if it led to the
    symptoms that required admission ALWAYS LINK
    SYMPTOMS TO THE CANCER, when you can

52
Lung Cancer I-9
  • 162 Malignant neoplasm of trachea, bronchus, and
    lung
  • 162.0 Trachea
  • 162.2 Main bronchus
  • 162.3 Upper lobe, bronchus or lung
  • 162.4 Middle lobe, bronchus or lung
  • 162.5 Lower lobe, bronchus or lung
  • 162.8 Other parts of bronchus or lung
  • 162.9 Bronchus and lung, unspecified

53
Laterality of Lung Cancer I-10
  • C34.0 Malignant neoplasm of main bronchus
  • C34.00 Malignant neoplasm of unspec main
    bronchus
  • C34.01 Malignant neoplasm of right main bronchus
  • C34.02 Malignant neoplasm of left main bronchus
  • C34.1 Malignant neoplasm of upper lobe, bronchus
    or lung
  • C34.10 Malignant neoplasm of upper lobe, unspec
    bronchus or lung
  • C34.11 Malignant neoplasm of upper lobe, right
    bronchus or lung
  • C34.12 Malignant neoplasm of upper lobe, left
    bronchus or lung
  • C34.2 Malignant neoplasm of middle lobe, bronchus
    or lung
  • C34.3 Malignant neoplasm of lower lobe, bronchus
    or lung
  • C34.30 Malignant neoplasm of lower lobe, unspec
    bronchus or lung
  • C34.31 Malignant neoplasm of lower lobe, right
    bronchus or lung
  • C34.32 Malignant neoplasm of lower lobe, left
    bronchus or lung
  • C34.8 Malignant neoplasm of overlapping sites of
    bronchus and lung
  • C34.80 Malignant neoplasm of overlapping sites
    of unspec bronchus and lung
  • C34.81 Malignant neoplasm of overlapping sites
    of right bronchus and lung
  • C34.82 Malignant neoplasm of overlapping sites
    of left bronchus and lung

54
Mets to Bone
  • ICD-9
  • 198.5 Bone and bone marrow
  • ICD-10
  • C79.51 Bone
  • C79.52 Bone marrow

55
Traumatic Fracture vs Pathologic
  • M84.3 Stress fracture
  • M84.4 Pathologic fracture NEC
  • M84.5 Pathologic fracture in neoplastic disease
  • M84.6 Pathologic fracture in other specified
    disease name the disease, too (eg.,
    osteoporosis M80.x)

56
Pathologic Fracture
  • A fracture involving abnormal bone with trauma
    inadequate to have fractured a normal bone is a
    pathologic fracture. The abnormality may be due
    to disuse, a surgical defect, infection, a
    metabolic disorder, a primary benign tumor, a
    primary malignant tumor or metastatic carcinoma.
    These processes weaken the bone or reduce its
    viscoelastic properties and predispose the bone
    to fracture. The fracture occurs spontaneously
    or with minimal trauma.

57
Now the Fifth Digit for the Bone
  • 0 Head
  • Neck
  • Thorax
  • Abd/low back/pelv
  • Shoulder/upper arm
  • Elbow/forearm
  • Wrist/hand
  • Hip/thighs
  • Knee/lower leg
  • Ankle/foot/toes

58
Be Acquainted with Sixth Digit
59
Consider Issues That Make it Tough
  • Do other conditions of the patient make the
    route, positioning, choice of therapies more
    complex?
  • Kyphoscoliosis?
  • Chronic respiratory failure?
  • Hypoxemic? Hypercapnic?
  • Whats the cause? Pleural effusion? Ascites?
  • Morbid obesity?
  • Coagulopathies?

60
Example Changes in Epic to Support ICD-10
  • Diagnosis Calculator
  • For providers who directly enter diagnoses
    (encounter diagnoses, charge capture,
    order-association), guides users to more specific
    code by prompting for laterality, acuity, etc.
  • Updating Documentation Tools
  • To facilitate documentation of needed detail for
    the coders
  • Epic builders will work with you to update
    SmartTexts, SmartPhrases, Note templates, etc.

Questions Contact Dr. Jason Lyman, ICD-10
Physician Champion, lyman_at_virginia.edu
61
Respiratory Failure I-9
  • 518.81 Acute respiratory failure
  • Respiratory failure NOS
  • respiratory failure, newborn (770.84)
  • 518.82 Other pulmonary insufficiency, not
    elsewhere classified (ARDS)
  • Adult respiratory distress syndrome NEC
  • 518.83 Chronic respiratory failure
  • 518.84 Acute and chronic respiratory failure

62
Postop Respiratory Failure I-9
  • 518.51 Acute respiratory failure following trauma
    or surgery
  • 518.52 ARDS following trauma or surgery
  • 518.53 Acute and chronic respiratory failure
    following trauma or surgery

63
Respiratory Failure I-10
  • J96.0 Acute respiratory failure
  • J96.00 Acute respiratory failure, unspecified
    whether with hypoxia or hypercapnia
  • J96.01 Acute respiratory failure with hypoxia
  • J96.02 Acute respiratory failure with
    hypercapnia
  • J96.1 Chronic respiratory failure
  • J96.10 Chronic respiratory failure, unspecified
    whether with hypoxia or hypercapnia
  • J96.11 Chronic respiratory failure with hypoxia
  • J96.12 Chronic respiratory failure with
    hypercapnia
  • J96.2 Acute and chronic respiratory failure
  • J96.20 Acute and chronic respiratory failure,
    unspecified whether with hypoxia or hypercapnia
  • J96.21 Acute and chronic respiratory failure
    with hypoxia
  • J96.22 Acute and chronic respiratory failure
    with hypercapnia
  • J80 ARDS

64
Postop Respiratory Failure
  • J95.82 Postprocedural respiratory failure
  • J95.821 Acute postprocedural respiratory failure
  • J95.822 Acute and chronic postprocedural
    respiratory failure
  • Use of this term implies that the surgery caused
    the respiratory failure in the post operative
    phase was it due to unrelated disease?

65
Chronic Respiratory Failure
  • Adds to severity of any admission
  • Adds to expected morbidity and mortality of any
    admission
  • Should be clarified if hypoxemic or hypercapnic,
    same as acute
  • Can be identified by pH7.4 and pCO2 over 50 60
    or pO2 under 50
  • May consider CO2 over 35 on BMP in absence of
    other acid-base issue

66
KDIGO Kidney Disease Improve Global Outcomes
Stage GFR Description Treatment stage
1 90 Normal kidney function but urine or other abnormalities point to kidney disease Observation, control of blood pressure
2 60-89 Mildly reduced kidney function, urine or other abnormalities point to kidney disease Blood pressure control, monitoring, find out why.
3 30-59 Moderately reduced kidney function More of the above, and probably diagnosis, if not already made.
4 15-29 Severely reduced kidney function Planning for endstage renal failure.
5 14 or less Very severe, or endstage kidney failure (established renal failure) See treatment choices for endstage renal failure.
67
Stages of AKI
Stg Serum creatinine criteria Urine output criteria
1 Increase in serum creatinine of more than or equal to 0.3 mg/dl or increase to more than or equal to 150 to 200 from baseline Less than 0.5 ml/kg per hour for more than 6 hours
2 Increase in serum creatinine to more than 200 300 from baseline Less than 0.5 ml/kg per hour for more than 12 hours
3 Increase in serum creatinine to more than 300 from baseline or serum creatinine of more than or equal to 4.0 mg/dl with an acute increase of at least 0l5 mg/dl Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
68
Diabetes
  • Identify type 1, type 2, due to other secondary
    cause, gestational
  • In type 2 or secondary cause, identify when using
    insulin long term
  • Identify all body systems affected by the
    diabetes (neuropathy and its manifestation,
    retinopathy and proliferative or
    nonproliferative, nephropathy and stage of CKD,
    dermopathy, vasculopathy, periodontopathy)
  • Identify all manifestations (ulcer, coma,
    gangrene, osteomyelitis, etc.)

69
Malnutrition
  • One third of hospital patients are affected by
    moderate or severe malnutrition
  • What we see
  • Cachexia
  • 20 lb wt loss in past month
  • Poor nutrition due to dysphagia
  • What we need
  • Mild, moderate or severe malnutrition

70
Who Does it Affect?
  • Elective surgery poor outcomes, bad healing
    with moderate to severe malnutrition
  • Emergency surgery - poor outcomes, bad healing
    with moderate to severe malnutrition
  • Patients with infections - poor outcomes, bad
    healing with moderate to severe malnutrition
  • Cancer patients unable to tolerate the cancer
    or the treatment with moderate to severe
    malnutrition

71
Paint the picture of the patient properly with
WORDS
may not be
So the coder can paint the same picture with
codes.
72
Motto For The Age
If you dont look good, we dont look good
Vidal sassoon, ca 1985 Father of modern medical
economics
73
Handling the Problem List
  • Its an Epic Task

74
Beware of cloned documentation
  • RACs and other auditors are on the lookout for
    cloned documentation, often a problem in teaching
    hospitals and large academic medical centers.
    "Auditors look for instances when the attending
    physician cuts and pastes from the resident's
    note into his own," says Nguyen.

CMS requires documentation of each encounter so
that the note stands on its own and represents
the actual services provided by the attending
physician for each date of service or encounter.
Data, including vital signs, may not be copied
from one visit to the next. CMS states that note
cloning raises concerns about the medical
necessity of continued hospitalization.
75
  • The U.S. Department of Health Human Services
  • and the Department of Justice have promised to
  • come down hard on providers who misuse
    electronic
  • health records to financially game the
    healthcare system.
  • HHS Secretary Kathleen Sebelius and U.S. Attorney
    General Eric Holder warned that law enforcement
    agencies are keeping an eye out for fraud and
    "will take action where warranted," in a letter
    sent to the American Hospital Association,
    Association of Academic Health Centers,
    Association of American Medical Colleges and
    others
  • Sebelius and Holder point to potential cloning of
    medical records as one of several indications
    that fraud could be on the rise. Medicare
    administrative contractor National Government
    Services earlier this month issued a notice,
    stating that cloned documents from EHRs mostly
    likely would result in payment denials.

76
If the docs don't get it, nothing else matters!
77
Questions and Answers Your Ideas and
Comments
78
Pain Codes ICD-9
  • 338 Pain, not elsewhere classified
  • 338.0 Central pain syndrome
  • 338.1 Acute pain
  • 338.11 Acute pain due to trauma
  • 338.12 Acute post-thoracotomy pain
  • 338.18 Other acute postoperative pain
  • 338.19 Other acute pain
  • 338.2 Chronic pain
  • 338.21 Chronic pain due to trauma
  • 338.22 Chronic post-thoracotomy pain
  • 338.28 Other chronic postoperative pain
  • 338.29 Other chronic pain
  • 338.3 Neoplasm related pain (acute) (chronic)
  • 338.4 Chronic pain syndrome
  • Chronic pain associated with significant
    psychosocial dysfunction

79
Pain Codes ICD-10
  • G89 Pain, not elsewhere classified
  • Code also related psychological factors
    associated with pain (F45.42)
  • G89.0 Central pain syndrome
  • Thalamic pain syndrome (hyperesthetic)
  • G89.1 Acute pain, not elsewhere classified
  • G89.11 Acute pain due to trauma
  • G89.12 Acute post- thoracotomy pain
  • G89.18 Other acute postprocedural pain
  • G89.2 Chronic pain, not elsewhere classified
  • G89.21 Chronic pain due to trauma
  • G89.22 Chronic post-thoracotomy pain
  • G89.28 Other chronic postprocedural pain
  • Other chronic postoperative pain
  • G89.29 Other chronic pain
  • G89.3 Neoplasm related pain (acute) (chronic)
  • G89.4 Chronic pain syndrome
  • Chronic pain associated with significant
    psychosocial dysfunction

80
Pain Coding in ICD-10
  • Identify if acute or chronic
  • Identify organ involved with pain (joints, bones,
    chest, abdomen with parts of abdomen involved and
    character of the pain - generalized, RUQ, with
    tenderness or rebound)
  • Identify relationship to specific disease,
    trauma, deformity

81
Coding Issues with Pain
  • General coding information
  • Codes in category G89 may be used in conjunction
    with codes from other categories and chapters to
    provide more detail about acute or chronic pain
    and neoplasm-related pain, unless otherwise
    indicated below.
  • If the pain is not specified as acute or chronic,
    do not assign codes from category G89, except for
    post-thoracotomy pain, postoperative pain or
    neoplasm related pain, or central pain syndrome.
  • A code from subcategories G89.1 and G89.2 should
    not be assigned if the underlying (definitive)
    diagnosis is known, unless the reason for the
    encounter is pain control/ management and not
    management of the underlying condition.

82
Pain as Principal Diagnosis
  • Category G89 codes are acceptable as principal
    diagnosis or the first-listed code
  • When pain control or pain management is the
    reason for the admission/encounter (e.g., a
    patient with displaced intervertebral disc, nerve
    impingement and severe back pain presents for
    injection of steroid into the spinal canal). The
    underlying cause of the pain should be reported
    as an additional diagnosis, if known.
  • When an admission or encounter is for a
    procedure aimed at treating the underlying
    condition (e.g., spinal fusion, kyphoplasty), a
    code for the underlying condition (e.g.,
    vertebral fracture, spinal stenosis) should be
    assigned as the principal diagnosis and no code
    from category G89 should be assigned.

83
Sequencing
  • Sequencing of Category G89 Codes with
    Site-Specific Pain Codes
  • The sequencing of category G89 codes with
    site-specific pain codes (including chapter 16
    codes), is dependent on the circumstances of the
    encounter/admission as follows
  • If the encounter is for pain control or pain
    management, assign the code from category G89
    followed by the code identifying the specific
    site of pain (e.g., encounter for pain management
    for acute neck pain from trauma is assigned code
    G89.11, Acute pain due to trauma, followed by
    code 723.1, Cervicalgia, to identify the site of
    pain).
  • If the encounter is for any other reason except
    pain control or pain management, and a related
    definitive diagnosis has not been established
    (confirmed) by the provider, assign the code for
    the specific site of pain first, followed by the
    appropriate code from category G89.

84
Back Pain ICD-10 Spondylosis /Facet Joints
  • M47.1 Other spondylosis with myelopathy
  • Spondylogenic compression of spinal cord
  • Excludes1 vertebral subluxation (M43.3-M43.59)
  • M47.2 Other spondylosis with radiculopathy
  • M47.8 Other spondylosis
  • M47.81 Spondylosis without myelopathy or
    radiculopathy
  • M47.89 Other spondylosis
  • M47.9 Spondylosis, unspecified

Identify level 0 unspecified 1
occipito-atlanta-axial 2 cervical 3
cervicothoracic 4 thoracic 5 thoracolumbar 6
lumbar 7 lumbosacral 8 sacral and
sacrococcygeal
85
Back Pain ICD-10
  • M51.0 Thoracic, thoracolumbar and lumbosacral
    intervertebral disc disorders with myelopathy
  • M51.1 Thoracic, thoracolumbar and lumbosacral
    intervertebral disc disorders with radiculopathy
  • M51.2 Other thoracic, thoracolumbar and
    lumbosacral intervertebral disc displacement
  • Lumbago due to displacement of intervertebral
    disc
  • M51.3 Other thoracic, thoracolumbar and
    lumbosacral intervertebral disc degeneration

5th digits 4 thoracic 5 thoracolumbar 6
lumbar 7 - lumbosacral
86
Back Pain ICD-10
Identify level 0 unspecified 1
occipito-atlanta-axial 2 cervical 3
cervicothoracic 4 thoracic 5 thoracolumbar 6
lumbar 7 lumbosacral 8 sacral and
sacrococcygeal
  • M54.1 Radiculopathy
  • M54.2 Cervicalgia
  • M54.3 Sciatica
  • M54.4 Lumbago with sciatica
  • M54.5 Low back pain
  • M54.6 Pain in thoracic spine
  • M54.8 Other dorsalgia
  • M54.81 Occipital neuralgia
  • M54.89 Other dorsalgia

5th digits 0 unspecified side 1 right side 2
left side
87
Pain from Cancer
  • Neoplasm Related Pain
  • Code G89.3 is assigned to pain documented as
    being related, associated or due to cancer,
    primary or secondary malignancy, or tumor. This
    code is assigned regardless of whether the pain
    is acute or chronic.
  • This code may be assigned as the principal or
    first-listed code when the stated reason for the
    admission/encounter is documented as pain
    control/pain management. The underlying neoplasm
    should be reported as an additional diagnosis.
  • When the reason for the admission/encounter is
    management of the neoplasm and the pain
    associated with the neoplasm is also documented,
    code G89.3 may be assigned as an additional
    diagnosis.

88
Identify Your Chemicals
  • Clarification, steroid and anesthetic injections
    Coding Clinic, Third Quarter 2000 Page 15
  • Question
  • Central Office has received numerous requests for
    clarification since the publication of two
    questions in Coding Clinic, Second Quarter 1998,
    page 18 and First Quarter 1999 pages 7-8,
    regarding steroid and anesthetic injections into
    the spinal canal. In one question, both codes
    03.91 and 03.92 were given. In the other
    question, code 03.91 and 99.23 were given.
    Readers are questioning why all three codes could
    not be assigned or why codes 03.91 and 03.92
    should not be assigned in both cases? The
    question in Second Quarter 1998 does not specify
    whether there is one or two injections given.
    Does this matter?
  • Answer
  • Code 03.92, Injection of other agent into spinal
    canal, does not identify the specific agent
    injected. Therefore, it would be appropriate to
    assign both codes 03.92, Injection of other agent
    into spinal canal and 99.23, Injection of
    steroid, for a single injection of steroid into
    the spinal canal. This code assignment may be
    repeated for each injection. If, however, the
    injection includes both steroids and anesthetics
    assign code 03.92, Injection of other agent into
    spinal canal, code 03.91, Injection of anesthetic
    into spinal canal for analgesia, and code 99.23,
    Injection of steroid.

89
Neonatal Respiratory Issues
  • Although low APGAR score implies respiratory
    problems, best to identify what is observed
  • Symptoms at presentation result of prenatal
    events or problems with delivery or after birth
  • Severe birth asphyxia
  • Mild or moderate birth asphyxia
  • Hypoxic/ischemic encephalopathy
  • Respiratory arrest of newborn
  • Hypoxemia of newborn
  • Respiratory acidosis or alkalosis
  • Cyanosis

90
Neonatal Respiratory Issues
  • Determined after evaluation primary lung or
    cardiac or both
  • Respiratory distress SYNDROME (RDS)
  • Wet lung syndrome transitory tachypnea of
    newborn
  • Aspiration with or without respiratory
    manifestations
  • Clear amniotic fluid
  • Meconium
  • Stomach contents
  • Of blood

91
Oryx Quality Core Measure HEART FAILURE
  • Left Ventricular function assessment
  • ACEI or ARB for LVSD
  • Angiotensin Converting Enzyme Inhibitor
  • Angiotensin Receptor Blocker
  • Change as of 1 January 2005
  • Smoking cessation counseling
  • Detailed DC instructions

92
Cardiomyopathy
  • CMP Vanilla
  • documentation
  • Is it hypertensive?
  • Is it ischemic?
  • Is it alcoholic, viral, other toxic?
  • Is it due to valvular disease?
  • Is it due to congenital disease?
  • Is it PostPartum Cardiomyopathy?

93
Do You Use 428/L50 for Your W/U?
  • 428.1 L50.1 Acute pulmonary edema from
    acute left heart failure
  • 428.20 L50.20 Unspecified systolic heart
    failure
  • 428.21 L50.21 Acute systolic heart failure
  • 428.22 L50.22 Chronic systolic heart failure
  • 428.23 L50.23 Acute on chronic systolic heart
    failure
  • 428.30 L50.30 Unspecified diastolic heart
    failure
  • 428.31 L50.31 Acute diastolic heart failure
  • 428.32 L50.32 Chronic diastolic heart failure
  • 428.33 L50.33 Acute on chronic diastolic heart
    failure
  • 428.40 L50.40 Unspecified combined systolic
    and diastolic heart failure
  • 428.41 L50.41 Acute combined systolic and
    diastolic heart failure
  • 428.42 L50.42 Chronic combined systolic and
    diastolic failure
  • 428.43 L50.43 Acute on chronic combined
    systolic and diastolic heart failure

94
Its in Our Literature Practice guidelines for
heart failure
95
Acute Coronary Syndrome
  • It used to be that there was an MI and there was
    NOT an MI
  • Now, to a great extent, its all a continuum of
    plaque rupture with varying results

96
Acute Myocardial Infarction
  • For STEMI, we have specific wall identification
  • Start identifying which vessel is blocked when
    known

97
Myocardial Infarction ICD-10
  • I21.0 ST elevation (STEMI) myocardial infarction
    of anterior wall
  • I21.01 ST elevation (STEMI) myocardial
    infarction involving left main coronary artery
  • I21.02 ST elevation (STEMI) myocardial
    infarction involving left anterior descending
    coronary artery
  • ST elevation (STEMI) myocardial infarction
    involving diagonal coronary artery
  • I21.09 ST elevation (STEMI) myocardial
    infarction involving other coronary artery of
    anterior wall
  • Acute transmural myocardial infarction of
    anterior wall
  • Anteroapical, Anterolateral, Anteroseptal
  • I21.1 ST elevation (STEMI) myocardial infarction
    of inferior wall
  • I21.11 ST elevation (STEMI) myocardial
    infarction involving right coronary artery
  • Inferoposterior transmural (Q wave) infarction
    (acute)
  • I21.19 ST elevation (STEMI) myocardial
    infarction involving other coronary artery of
    inferior wall
  • Acute transmural myocardial infarction of
    inferior wall, Inferolateral, Diaphragmatic wall,
    Transmural inferior (wall) NOS

97
98
  • I21.2 ST elevation (STEMI) myocardial infarction
    of other sites
  • I21.21 ST elevation (STEMI) myocardial
    infarction involving left circumflex coronary
    artery
  • ST elevation (STEMI) myocardial infarction
    involving oblique marginal coronary artery
  • I21.29 ST elevation (STEMI) myocardial
    infarction involving other sites
  • Acute transmural myocardial infarction of other
    sites
  • Apical-lateral transmural, Basal-lateral, High
    lateral, Lateral (wall), Posterior (true),
    Posterobasal, Posterolateral, Posteroseptal,
    Septal transmural (Q wave) infarction (acute) NOS
  • I21.3 ST elevation (STEMI) myocardial infarction
    of unspecified site
  • Acute transmural myocardial infarction of
    unspecified site
  • Myocardial infarction (acute) NOS
  • Transmural (Q wave) myocardial infarction NOS
  • I21.4 Non-ST elevation (NSTEMI) myocardial
    infarction
  • Acute subendocardial myocardial infarction
  • Non-Q wave myocardial infarction NOS
  • Nontransmural myocardial infarction NOS

99
Newest News in AMI
100
Five Types of AMI
  • True coronary artery occlusion
  • Demand MI usually NSTEMI due to supply demand
    mismatch
  • SCD which came first?
  • Periangioplasty MI
  • Immediate d/t flakes of plaque
  • Delayed related to occlusion of stent or
    reocclusion of dilated portion
  • Peri CABG AMI

101
Types Based on Condition of Coronary
102
But Dont Overdo It
103
Shock Codes
  • Cardiogenic
  • Circulatory collapse, septic, endotoxic
  • Hemorrhagic, hypovolemic
  • Complicating ectopic
  • Complicating labor
  • Related to surgery (blood loss, endotoxic)
  • Traumatic shock
  • Insulin shock

104
CLASSIFICATION OF HEMORRHAGIC SHOCK
Hypovolemia Hemorrhagic shock
105
Shock in General
  • Low blood pressure requiring more than volume to
    maintain perfusion pressors, LVAD when
    necessary
  • Decreased perfusion of skin, heart, kidneys,
    liver can lead to heart failure, shock liver,
    acute kidney injury
  • Decreased urine output, lethargy, respiratory
    collapse
  • Hypotension is not the equivalent of shock

106
ACS NSQIP Data Collection Overview The ACS
NSQIP collects data on 136 variables, including
preoperative risk factors, intraoperative
variables, and 30-day postoperative mortality and
morbidity outcomes for patients undergoing major
surgical procedures in both the inpatient and
outpatient setting.
107
Surgical Risk Stratification
  • NSQIP databases depend on identification of risk
    factors

Heart failure? MI? Lungs chronic?
Nutrition over? mal? Diabetes cont?
Renal status chr, ac. Malignancy?
Smoking, ETOH? Stroke residua?
Hepatic fxn name it Encephalopathy?
Immunocomp how? Sepsis? Org fail?
Use ster, insul, chemo Periph vasc?
108
Dear SIRS, I'm sorry to say that I don't like you
  • Dear SIRS, youre too sensitive
  • Dear SIRS, you dont help us understand the
    pathophysiology
  • Dear SIRS, youre not helping us in our practice
  • Dear SIRS, Im afraid we dont need you
  • Jean-Louis Vincent, Critical Care Med
    199725372-374

Dr. Vincent is the editor-in-chief of "Critical
Care", "Current Opinion in Critical Care", and
"ICU Management". He is member of the Editorial
Boards of 30 journals including "Critical Care
Medicine" (senior editor), "American Journal of
Respiratory and Critical Care Medicine",
"Intensive Care Medicine", "Lancet Infectious
Diseases", "Chest", "Shock", and "Journal of
Critical Care". Dr. Vincent is a past President
of the European Society of Intensive Care
Medicine and the European Shock Society, and the
Post-Chairman of the International Sepsis Forum.
109
Severe Sepsis
  • Intent is to identify sepsis with distant organ
    failure. Organs may include
  • Acute renal failure (due to sepsis)
  • ARDS with respiratory failure
  • Shock liver/ acute hepatic necrosis
  • Demand NSTEMI
  • Disseminated intravascular coagulopathy
  • Encephalopathy (metabolic due to sepsis) NOT
    TOXIC
  • Critical care myopathy / neuropathy
  • Circulatory system failure inability to perfuse
    vital organs CALLED SEPTIC SHOCK

110
(No Transcript)
111
Cardiac Surgery Risk
112
DM - Is it Type 1 or Type 2 diabetes? Or is it
due to some other condition? PVD - Is it
peripheral arterial disease or venous? And are
there implications of that disease? COPD - Do you
know if the COPD is due to asthma or recurrent
aspiration or congenital or what? What are the
controlled systemic diseases?
113
Is it unstable angina or NSTEMI? Is it supply or
demand problem? Is the pump for cardiogenic
shock? Due to what? Is this a chronic heart
failure patient or is there acute heart failure?
Systolic? Diastolic? Right heart? Left heart?
Biventricular? Is the hypertension uncontrolled?
Malignant? Accelerated? Due to endocrine
disorder or noncompliance? Is it acute renal
failure or CKD? Or both?
114
Modified NSQIP Data Sheet
115
The Mayo Model of PreOperative
Medical Evaluation
  • Initial medical evaluation for risk
    stratification fill out POME
  • Lab and radiographic studies as indicated fill
    out POME
  • Consultative visits and tests as needed fill
    out POME
  • Visit to Anesthesiology with recommendations and
    results fill out preop anesthesia forms
  • Visit to surgeon with all needed risk factors
    complete complete HP
  • Eliminate cancelled surgeries, delays

116
Anticipate
  • 57 year old 540 pound black female on a
    ventilator
  • Name the likely diagnoses

117
Anticipate
  • Acute on chronic respiratory failure
  • Acute Aspiration pneumonitis (vs CHF)
  • Chronic Restrictive lung disease obesity
    hypoventilation syndrome
  • Right heart failure (cor pulmonale d/t 2o PAH)
  • Morbid obesity BMI 57? Short neck? Difficult
    intubation?
  • OSA - GERD
  • Type 2 diabetes
  • Hypertension with HHD
  • Hypertensive and diabetic CKD stage 3 or more
  • DVT cellulitis, legs, intertriginous, pannus
  • Secondary hypercoagulable state
  • Microvascular disease arterial insufficiency
    feet

118
Aspiration Syndromes
  • 1. Chemical Pneumonitis Aspiration of toxic
    agents such as gastric acid. Instantaneous injury
    with marked hypoxemia. Treatment requires
    positive-pressure ventilatory support. (Mendelson
    Syndrome)
  • 2. Reflex Airway Closure Aspiration of inert
    fluids (water, saline, nasogastric feedings) may
    produce laryngospasm and pulmonary edema with
    resultant hypoxemia. Treatment includes
    intermittent positive-pressure breathing with
    100 O2 and isoproterenol.
  • 3. Mechanical Obstruction Aspiration of inert
    fluid or particulate matter (partially digested
    food, hot dogs, peanuts) may produce simple
    mechanical obstruction. Coughing, wheezing, and
    dyspnea occur with atelectasis seen on X-ray of
    the chest. Treatment requires tracheobronchial
    suction and removal of the particulate matter by
    fiberoptic bronchoscopy.
  • 4. Aspiration Pneumonia Aspiration of food or
    gastric acid. Either glossopharyngeal
    dysfunction or GERD. Patients have a cough,
    fever, purulent sputum, and radiographic evidence
    of infiltrate. Treatment requires antibiotics.

119
Effects of Documentation What Makes a Difference
  • Acute respiratory failure
  • Definitions by chemistries agreed upon by coding
    guidelines and by Medical textbooks
  • Hypoxemic (Type 1)
  • Inability to maintain O2 sat of 90 w 6L
  • pO2 10 - 15 lower than expected for that patient
  • Hypercapnic (Type 2)
  • pH lt 7.30 and pCO2 gt 55

120
NOT Acute Respiratory Failure
  • Patients being purposely maintained on the
    ventilator after surgery because of weakness,
    chronic lung disease, massive trauma are NOT in
    acute respiratory failure
  • Just because the patient is on oxygen is NOT a
    reason to ask the doc for acute respiratory
    failure
  • Prevention of acute respiratory failure from
    angioedema, stroke, trauma when patient does NOT
    HAVE acute respiratory failure when intubated for
    airway protection

121
More NOT ARF
  • Patients with chronic respiratory failure from
    whatever cause who develop increased cough or
    wheezing or tachypnea and are identified as
    acute exacerbation of COPD or bronchiectasis
    or develop pneumonia who do not meet any criteria
    for acute respiratory failure by clinical
    presentation (NAD, speaking full sentences, etc.)
    or numbers (O2 sats, pH do not demonstrate
    significant change) should not be diagnosed as
    acute respiratory failure.

122
Ventilator Management
  • Describe the indication for need of the vent
    youre helping to manage
  • Acute respiratory failure due to AECB, ARDS as
    part of SIRS from necrotizing pancreatitis, acute
    diastolic failure from malignant hypertension in
    eclampsia patient, etc.
  • Chronic respiratory failure due to muscular
    dystrophy
  • Acute on chronic describe both conditions
  • Liver transplant patient with abdomen open to
    avoid abdominal compartment syndrome
  • Airway protection in cerebral hemorrhage patient
    being maintained in artificial coma
  • DONT CALL IT RESPIRATORY FAILURE WHEN ITS NOT

123
AKI Caveat
  • It is imperative to NOT CALL changes in
    creatinine AKI until the patient has been volume
    repleted for at least six hours. If creatinine
    bump persists after fluid resuscitation, there
    was likely AKI. If not, there was NOT AKI.
  • Acute kidney injury should be both abrupt
    (within 17 days) and sustained (more than 24
    hours).

124
What IS Encephalopathy?
  • Internally produced toxins in liver disease
    (hepatic encephalopathy), renal disease (uremic
    encephalopathy), persistent effects of lack of
    blood flow to the brain (hypoxic encephalopathy)
  • Internal poisoning by products produced by sepsis
    (metabolic encephalopathy), effects of
    hypertension (hypertensive encephalopathy)
  • Persistent effects of long term alcohol use
    (Korsakoffs, Wernickes a toxic encephalopathy)

125
Other Encephalopathies
  • Mitochondrial encephalopathy
  • Hashimotos encephalopathy
  • Lyme encephalopathy
  • Transmissable spongiform encephalopathy
  • Lyme encephalopathy
  • Hypoxic ischemic encephalopathy (HIE) newborns
    only

126
What ISNT Encephalopathy
  • Coma after stroke or head trauma
  • Drunkenness
  • Effects of illicit drugs or poisoning with
    overdosage of prescribed drugs
  • Adverse effects or desired effects of sedative
    medications
  • Still anesthetized hasnt metabolized or blown
    off agents
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