Effective Coding Under MS-DRGs - American Health Information ...

Effective Coding 

Under MS-DRGs 

Audio Seminar/Webinar 

February 14, 2008 

Practical Tools for Seminar Learning 

© Copyright 2008 American Health Information Management Association. All rights reserved.

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CPT ® five digit codes, nomenclature, and other data are copyright 2007 American 

Medical Association. All Rights Reserved. No fee schedules, basic units, relative 

values or related listings are included in CPT. The AMA assumes no liability for the 

data contained herein. 

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The faculty has reported no vested interests or disclosures regarding this 

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AHIMA 2008 Audio Seminar Series 

i

Faculty 

Sharalyn Milliken, RN, JD, CPC-H 

Ms. Milliken is a senior consultant with FTI Consulting based in Atlanta GA. For 

the past 20 years, her experience in healthcare spans many different venues 

such healthcare lawyer, consultant, documentation compliance specialist, 

coder, and case manager. Sharalyn has a Bachelor of Science Degree in 

Nursing from the Ohio State University and a Juris Doctorate Degree from 

Capital University Law School. Her expertise includes healthcare compliance, 

clinical documentation improvement, coding, DRG assignment and regulatory 

research. In 2002 while at OhioHealth, her department was awarded the 

prestigious National Council of Ethical Organization’s “Best Practice Award” for 

their Clinical Documentation Program. 

Email: sharalyn.milliken@fticonsulting.com 

James S. Kennedy, MD, CCS 

Dr. Kennedy is a Director with FTI Healthcare based in Brentwood, TN. Trained as a 

general internist at the University of Tennessee in Memphis, Dr. Kennedy’s experience 

includes medical private practice along with successful entrepreneurial healthcarerelated 

startups in the public and private sector. His expertise includes physicianhospital 

leadership, healthcare systems improvement, healthcare documentation, 

coding, DRG assignment compliance, and government relations. Dr. Kennedy recently 

completed the AHIMA book, Severity-Adjusted DRGs: a MS-DRG Primer. Contact Dr. 

Kennedy at 615-479-7021 or James.Kennedy@ftihealthcare.com 

AHIMA 2008 Audio Seminar Series 

ii

Table of Contents 

Disclaimer ..................................................................................................................... i 

Faculty .........................................................................................................................ii 

Today’s Goals ................................................................................................................ 1 

Polling Question ................................................................................................. 1 

Definition of a DRG ........................................................................................................ 2 

Patient Condition Components......................................................................................... 2 

ICD-9-CM 

Principal Diagnosis and Secondary Diagnosis ........................................................ 3 

Chronic Conditions – Coding Clinic 3Q 2007 .......................................................... 4 

Historical CMS-DRG System Structure .............................................................................. 5 

MS-DRGs....................................................................................................................... 5 

Base DRGs......................................................................................................... 6 

CC Changes ....................................................................................................... 6 

Impact of Prev. MD Documentation...................................................................... 7 

Most Common “Single Deleted CC” ...................................................................... 7 

New CCs/MCCs................................................................................................... 8 

V Codes............................................................................................................. 8 

CC/MCC Structure............................................................................................... 9 

Documentation and Coding Adjustment................................................................ 9 

Conclusion ........................................................................................................10 

Assessing our Circumstances 

MS-DRG Statistics..............................................................................................11 

CC and MCC Capture .........................................................................................11 

Other MS-DRG Metrics .......................................................................................12 

CC Capture Rate................................................................................................12 

Other Metrics ....................................................................................................13 

Specific Issues in CC and MCC Capture 

Principal Diagnosis – Principal Procedure .............................................................14 

Present on Admission Requirement .....................................................................14 

Pressure Ulcers .......................................................................................15 

Deleted CC 

COPD – Asthma – Hypoxemia.............................................................................15 

CC-MCC Differentiation 

Acute Respiratory Failure .........................................................................16 

Exacerbation of COPD/Asthma .................................................................16 

Congestive Heart Failure ....................................................................................17 

Heart Failure .............................................................................................................17 

Heart Failure Differentiation ...............................................................................18 

Cardiomyopathies..............................................................................................18 

Systolic/Diastolic Heart Failure............................................................................19 

Pericarditis........................................................................................................19 

Deleted CC – Angina Pectoris .........................................................................................20 

Atherosclerosis of CABG Graft ........................................................................................20 

Elimination of Major CV Diagnoses as Principal/Secondary Diagnoses ................................21 

Example - Acute MI POA Not a MCC................................................................................21 

Deleted CC – Atrial Fibrillation ........................................................................................22 

CC-MCC Differentiation – Ventricular Arrhythmias ............................................................22 

Deleted CC – Hypovolemia.............................................................................................23 

Electrolyte Imbalances...................................................................................................23 

Deleted CC – CKD/CRI NOS ...........................................................................................24 

AHIMA 2008 Audio Seminar Series

Table of Contents 

Deleted CC – Chronic Blood Loss Anemia ........................................................................24 

ICD-9-CM Official Guidelines for Coding and Reporting ....................................................25 

Acquired and Nonspecific Aplastic Anemia ...........................................................26 

Myelodysplastic Codes .......................................................................................26 

Hypercoagulable Syndrome ................................................................................27 

Deleted CC – Uncontrolled Diabetes................................................................................27 

Diabetic Ketacidosis – MCC.................................................................................28 

Nonketotic Hyperosmolar State – MCC ................................................................28 

Other CC Alternatives with Diabetes....................................................................29 

Altered Mental Status ....................................................................................................29 

Encephalopathy.................................................................................................30 

TIA vs. Stroke as CC/MCC ..................................................................................30 

Seizures ...........................................................................................................31 

Schizophrenia ...................................................................................................31 

Malnutrition .............................................................................................................32 

Chemical Dependency ...................................................................................................32 

Options to Consider in Chemical Dependency.......................................................33 

Bacteremia vs. Septicemia – Sepsis.................................................................................33 

Others .............................................................................................................34 

Resources ....................................................................................................................34 

Audience Questions 

Appendix ..................................................................................................................38 

DRG Documentation Tips ......................................................................................39 

CE Certificate Instructions .....................................................................................41 

NOTE: 

Additional Appendix “MS-DRG CC/MCC List Final Rule” can be downloaded at 

http://campus.ahima.org/audio/2008seminars.html 

AHIMA 2008 Audio Seminar Series

Effective Coding Under MS-DRGs 

Notes/Comments/Questions 

Today’s Goals 

• Provide an overview of 

MS-DRGs and its impact 

upon short-term and 

long-term acute care hospitals 

• Review the pathophysiology of the new 

CC-MCC structure as to support physician 

documentation and query. 

• Outline an organized process that 

accurately captures and reports CCs and 

MCCs in administrative coded data sets 

1 

Polling Question 

How has MS-DRGs affected your 

facility? 

*1 Our case mix index has risen; 

we couldn’t be more pleased. 

*2 Our case mix index has risen; 

we still have opportunity 

*3 Our case mix index is about the 

same; our CC and MCC has some 

issues. 

*4 Our case mix index has fallen 

and we can’t get it up. 

2 

AHIMA 2008 Audio Seminar Series 1 

CPT ® Codes Copyright 2007 by AMA. All Rights Reserved



Definition of a DRG 

• A Diagnosis Related Group (DRG) is 

a group of clinically coherent 

conditions with a similar pattern 

of resource intensity primarily 

determined by: 

• Principal diagnosis: 

• Significant additional diagnoses 

• Present on admission status may matter: 

• Procedures 

3 

Patient Condition Components 

(M.U.S.I.C.) 

• Manifestation 

• e.g. – Chest pain (angina, pleuritic pain, heart burn); Altered 

Mental Status (Acute Delirium, Chronic Dementia); Fever 

• Underlying Pathology 

• e.g. – Coronary artery disease, GERD, pleurisy, toxic 

encephalopathy from prescribed medications, pneumonia 

• Severity 

• Angina – At rest, Accelerated – progressed to MI 

• Sepsis – without or with organ dysfunction (severe sepsis) 

• Instigating or Precipitating Cause 

• Recent surgery 

• Medication noncompliance 

• Consequences 

• Acute Systolic Heart Failure 

• Acute Respiratory Failure 

• Acute Renal Failure 4 





ICD-9-CM 

Principal Diagnosis 

• Defined by the Uniform Hospital Discharge 

Data Set (UHDDS), the principal diagnosis 

is “the condition established after study to 

be chiefly responsible for occasioning the 

admission of the patient to the hospital for 

care.” 

• The circumstances of admission, the diagnostic 

approach and the treatment rendered factor 

into principal diagnosis selection. 

5 

ICD-9-CM 

Additional Diagnosis 

• ICD-9-CM states that for reporting purposes the definition for 

“other diagnoses” is interpreted as additional conditions that 

affect patient care in terms of requiring: 

• clinical evaluation; 

• or therapeutic treatment; 

• or diagnostic procedures; 

• or extended length of hospital stay; 

• or increased nursing care and/or monitoring. 

• The UHDDS item #11-b defines Other Diagnoses as “all 

conditions that coexist at the time of admission, that develop 

subsequently, or that affect the treatment received and/or 

the length of stay. Diagnoses that relate to an earlier episode 

which have no bearing on the current hospital stay are to be 

excluded.” 

6 





Coding Clinic, 3 rd Quarter, 2007 

Chronic Conditions 

• One of the QIOs will not allow the inclusion of COPD as a secondary 

diagnosis when it is only mentioned as a history of COPD and no active 

treatment is documented. Am I correct in stating the presence of a 

documented history of COPD in the physicians history and physical on 

an inpatient record is enough to code COPD as a secondary diagnosis, 

since this is a chronic condition that always affects the patients care 

and treatment to some extent? 

• If there is documentation in the medical record to indicate that the 

patient has COPD, it should be coded. Even if this condition is listed 

only in the history section with no contradictory information, the 

condition should be coded. Chronic conditions such as, but not limited 

to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are 

chronic systemic diseases that ordinarily should be coded even in the 

absence of documented intervention or further evaluation. 

Some chronic conditions affect the patient for the rest of his or her life 

and almost always require some form of continuous clinical evaluation 

or monitoring during hospitalization, 7 

Poll Results 

8 





Historical CMS-DRG System Structure 

• Did not account for patients with greater 

severity of illness 

• CCs had the same weight no matter how severe 

• Designated a CC by an increase in LOS by 

at least one day in 75% of the patients 

• Paired DRG system only required one 

secondary diagnosis to assign a CC 

• Patients with multiple CCs given same 

resource weight as those with one. 

9 

MS-DRGs 

• Implemented October 1, 2007 

• Still have 25 MDCs 

• Pre-MDC and DRGs with all MDCs remain 

• 745 total MS-DRGs 

• Increase from 538 CMS-DRGs 

• Base DRG structure basically the same 

• Complete overhaul of the CC structure 

10 






Base DRGs 

• For the most part, base 

DRG structure remains 

except for: 

• Creation of 1 new DRG 

• Elimination of 43 age 

differentiations (e.g. 0-17, 

Diabetes age




Impact of Prev. MD Documentation 

• Congestive Heart Failure (428.0) 

• CMS noted that resource utilization did not change significantly 

when physicians documented (and coders coded) CHF 

• Unfortunately, decompensated CHF codes to 428.0 

• The presence of more specific codes led to elimination of CHF 

as a CC 

• Malnutrition 

• Most physicians do not specify mild or moderate malnutrition 

• CMS found that malnutrition changed resource utilization 

whereas mild or moderate did not. As a consequence, 

malnutrition is a CC whereas mild/moderate malnutrition is not 

• CMS Medical Officers did not accept feedback on this issue and 

change the methodology. 

13 

Most 

Common 

“Single 

Deleted 

CC” 

Coders need 

a strategy 

to find 

alternatives 

14 





New MS-DRG CCs/MCCs 

CCs 

• Many SPECIFIED 

underlying infections, 

obstetrical/neonatal 

conditions, and 

malignancies 

• Crohn’s Disease and 

Ulcerative Colitis 

• Transient Ischemic Attack 

• Thiamine Deficiency 

• Chronic osteomyelitis 

• CABG Graft Stenosis 

• Precipitous Drop in 

Hematocrit 

MCCs 

• Many SERIOUS open 

fractures, underlying 

infections and 

OB/neonatal 

conditions (e.g. 

encephalitis, 

abortion with shock) 

• Bile duct obstruction 

• Encephalopathy 

15 

V-Codes in MS-DRGs - CCs 

V420 

KIDNEY TRANSPLANT STATUS 

V4322 

ARTFICIAL HEART REPLACE 

V421 

HEART TRANSPLANT STATUS 

V4611 

RESPIRATOR DEPEND STATUS 

V426 

LUNG TRANSPLANT STATUS 

V4612 

RESP DEPEND-POWR FAILURE 

V427 

LIVER TRANSPLANT STATUS 

V4613 

WEANING FROM RESPIRATOR 

V4281 

TRNSPL STATUS-BNE 

MARROW 

V4614 

MECH COMP RESPIRATOR 

V4282 

TRSPL STS-PERIP STM CELL 

V551 

ATTEN TO GASTROSTOMY 

V4283 

TRNSPL STATUS-PANCREAS 

V6284 

SUICIDAL IDEATION 

V4284 

TRNSPL STATUS-INTESTINES 

V850* 

BMI LESS THAN 19, ADULT 

V4321 

HEART ASSIST DEV REPLACE 

V854* 

BMI 40 AND OVER, ADULT 

*Coding Clinic –4 th Quarter, 2005 – pages 96-98 

16 





MS-DRG 

CC/MCC Structure 

• Overall statistics 

• Without CC -41.1% 

• With CC – 36.6% 

• With MCC – 22.2% 

• Code differentiation 

• MCC – 1,096 

• CC – 4,221 

• Non-CC – 8,232 

• MS-DRG CC/MCC Structure 

• CC does not matter 

• e.g. MS-DRG 313 – Chest Pain 

• No CC | MCC 

• CC carries no weight. 

• Must have MCC to change DRG 

• No CC | CC/MCC 

• CC and MCC have equal weight 

to change DRG 

• No CC | CC | MCC 

• CC and MCC have differing 

impacts to change DRG 

Lists available on CMS website: http://www.cms.hhs.gov 

17 


Documentation and Coding Adjustment 

• “Coding and Documentation 

Adjustment” 

• 0.6% reduction – FY2008 


• Can be more or less based on CMI changes 

experienced during the first few months of 



• Applies only to short-term acute care 

hospitals; LTACHs exempt from this 

18 






Conclusion 

• MS-DRGs is the most 

radical change in DRG 

methodology implemented 

• RAND study shows that MS-DRGs 

better predict resource utilization 

than CMS-DRGs 

• MS-DRGs are not going away 

• We have to address the issue 

19 

Assessing our Circumstances 

20 





MS-DRG Statistics 

• CMI Statistics 

• Total CMI 

• Total CMI w/o Pre-MDC 

• Medicine CMI w/o OB-Peds 

• Medicine CMI w/o OB-Peds, IP 

Psychiatry, Ventilators, and 

Rehabilitation 

• Surgery CMI w/o OB-Peds 

• Surgery CMI w/o OB-Peds, 

and Pre-MDC 

• OB-Neonatal CMI 

• Medicine RW analysis – compared 

to all Medicine DRG (OB-Peds- 

Vents Excluded) 

• Medicine DRG w/RW >0.9 

• Medicine DRG w/RW >0.6 but



Other MS-DRG Metrics 

• Complex to Simple Pneumonia 

• Pneumonia to COPD 

• Acute Respiratory Failure to 

COPD/CHF 

• COPD to Asthma 

• Sepsis to UTI/Pneumonia 

• Stroke to TIA 

• Sepsis to Other Respiratory 

Diagnosis with ventilator over 

96 hours 

• Pathological Fracture to 

Medical Back 

• MI with CC or MCC to MI 

without CC 

• Cardiac Cath with MCC to 

Cardiac Cath w/o 

• DVT with CC to DVT w/o CC 

• GI bleed with CC to GI bleed 

without CC 

Example: Complex to Simple Pneumonia Ratio 

Volume of 177, 178, 179 

Volume of 177, 178, 179, 193, 194, 195 

National Medicare volumes available at: 

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/FY2008Table7A.zip 

in the final rule or can be calculated from the MedPAR 23 

Example: 

CC Capture Rate in UGI Hemorrhage 

MS-DRG Medicare Statistics 

UGI Hemorrhage 

377 

378 

379 

UGI Hem w/MCC 

UGI Hem w/CC 

UGI Hem w/o CC 

19.2% 

44.8% 

36.0% 

285.1 – Acute Blood Loss Anemia is a CC 

Most patients admitted with an Upper GI bleed have 

acute blood loss anemia 

An obvious query opportunity 

Others include DVT (hypercoagulable disorder) 

and neurodegenerative disorders 

(dementia with behavioral manifestations) 

24 





Other Metrics 

• CAP utilizing any antibiotic but ceftriaxone, azithromycin, or 

levofloxacin – option for DRG 177-179 

• 00.51 (CRT) without 88.52 – radiology of right heart 

structure 

• Transient ischemic attack receiving tPA 

• Use of Xigris without code 995.92 

• Blood transfusions in surgery without a CC (Acute Blood 

Loss Anemia – 285.1) 

• Drug eluting stents 

• Pacemakers vs. AICDs 

• Use of BiPAP without sleep apnea or acute (on chronic) 

respiratory failure code 

• Use of mechanical ventilation without acute (on chronic) 

respiratory failure code 

25 

Specific Issues in 

CC and MCC Capture 

26 





Principal Diagnosis 

Principal Procedure 

Diagnoses 

• Simple vs. Complex Pneumonia 

• Sepsis vs. Underlying Cause 

• “Febrile Neutropenia” 

• Stroke or cerebral embolus vs. TIA 

• CAD in setting of angina pectoris 

• Complications of care 

• Pathological vs. regular fractures 

• Acute Respiratory Failure vs. COPD 

or asthma exacerbation 

• Acute Renal Failure vs. dehydration 

• Noncardiogenic pulmonary edema 

• Alternatives to Pancytopenia 

• Encephalopathy or 

Neurodegenerative d/o vs. their 

psychiatric manifestations 

• Complications when admitted for 

“uncontrolled diabetes” 

Procedures 

• Ascertaining the relationship 

between the principal diagnosis 

and the any procedures that are 

done. 

• Capturing significant procedures 

not done in the operating room 

• tPA administration with stroke 

• Angioplasties done in radiology 

• Excisional debridement done on 

the floor 

• Procedures in the ER or within 

72 hours of admission 

• Lysis of Adhesions in surgery 

• Excisional vs. nonexcisional 

debridement 

• Coronary vein angiography during 

lead placement of a cardiac 

resynchronization pacemaker 

implantation 

27 

Present On Admission Requirement 

Will not serve as CCs/MCCs if not POA 

1. Serious Preventable Event- Object left in surgery 

2. Serious Preventable Event- Air embolism 

3. Serious Preventable Event- Blood incompatibility 

4. Catheter Associated Urinary Tract Infections 

5. Pressure Ulcers (Decubitus Ulcers) 

6. Vascular Catheter Associated Infection 

7. Surgical Site Infection-Mediastinitis after 

Coronary Artery Bypass Graft (CABG) surgery 

8. Injury due to Falls 

28 





Classification of Pressure Ulcers 

Smith, D. M. Ann Intern Med 1995;123:433-438 

29 

Deleted CC 

COPD – Asthma – Hypoxemia 

• Most common CC under CMS 

• While Coding Clinic allows COPD (not a CC) to be coded without overt 

interventions, exacerbations (a CC) require interventions. 

• Options 

• 518.83 – Chronic respiratory failure for patients on Home Oxygen – 

chronic elevation of pCO 2 

• 428.20 – Chronic systolic right heart failure from chronic pulmonary 

hypertension – edema, jugular venous distension, RVH on ECG 

• Exacerbations -a sustained worsening of the patient’s condition, from the 

stable state and beyond normal day-to-day variations, that is acute in 

onset and necessitates a change in regular medication in a patient with 

underlying COPD. 

• Mild - Patient has an increased need for medication, which he/she can manage 

in own normal environment 

• Moderate - Patient has an increased need for medication and feels the need to 

seek additional medical assistance 

• Severe - Patient/caregiver recognizes obvious and/or rapid deterioration in 

condition, requiring hospitalization 

• “Status Asthmaticus” – Asthma exacerbation that does not respond to 

standard treatments of bronchodilators and steroids 

http://www.chestjournal.org/cgi/content/full/117/5_suppl_2/398S 30 






Acute Respiratory Failure 

Two out of three 

• Hypoxemia 

• Classical definition: 

pO 2 

50 

• pH usually 100, pCO 2 

36-39, pO 2 

73-83; 

Atelectasis 

• 2 points – Age >80; Previous PE or DVT; pCO 2 



Deleted CC 

428.0 Congestive Heart Failure 

ICD-9 

4280 

4281 

42820 

42821 

42822 

42823 

42830 

42831 

42832 

42833 

42840 

42841 

42842 

42843 

4289 

CMS 

CMS CC 















MS-DRG 

MSDRG CC 


MSDRG MCC 











TITLE 

CHF NOS (decomp – R Hrt Fail) 

LEFT HEART FAILURE 

SYSTOLIC HRT FAILURE NOS 

AC SYSTOLIC HRT FAILURE 

CHR SYSTOLIC HRT FAILURE 

AC ON CHR SYST HRT FAIL 

DIASTOLC HRT FAILURE NOS 

AC DIASTOLIC HRT FAILURE 

CHR DIASTOLIC HRT FAIL 

AC ON CHR DIAST HRT FAIL 

SYST/DIAST HRT FAIL NOS 

AC SYST/DIASTOL HRT FAIL 

CHR SYST/DIASTL HRT FAIL 

AC/CHR SYST/DIA HRT FAIL 

HEART FAILURE NOS 

33 

Heart Failure 

• Manifestation - Is it heart failure? 

• Must differentiate from fluid overload in 

normal heart 

• Acute, Chronic, or Acute on Chronic 

• Systolic vs. Diastolic vs. both 

• Underlying Cause 

• Cardiomyopathy – Pericardial Disease – 

COPD –Cor Pulmonale –Accelerated HTN 

• Severity – Acute vs. Chronic 

• Acute = Flare up of HF symptoms 

• Decompensated doesn’t Count 

• Instigating – ?MI?, ?PE? 

• Complication – Acute Respiratory Failure 

(MCC), Acute Renal Failure (MCC) pleural 

effusions (if addressed – CC) 

Acute or Chronic? 

Systolic: EF40% or ?LVEDP 34 





Heart Failure Differentiation 

Without EF 

Chronic (CC) 

Acute (MCC) 

Systolic 

Diastolic 

Cardiomegaly on CXR 

S3 gallop 

Dilated on ECHO 

LVH on EKG 

S4 gallop 

Abnl relax on ECHO 

More likely is 

hypertensive 

Paroxysmal nocturnal dyspnea 

Neck vein distention 

Rales 

Acute pulmonary edema or 

Increased BNP 

Increased CVP >16 cm 

Hepatojugular reflux 

Pulmonary edema, 

visceral congestion, or 

cardiomegaly at autopsy 

Both 

Combination of both 

OK to say “possible or 

probable” 

Weight loss =4.5 kg in 5 days 

in response to treatment of 

CHF 

35 

Cardiomyopathies 

All are CCs except Ischemic CM 

• 425.0 Endomyocardial fibrosis 

• 425.1 Hypertrophic obstructive CM 

• 425.2 Obscure cardiomyopathy of 

Africa 

• 425.3 Endocardial fibroelastosis 

• 425.4 Other primary 

cardiomyopathies 

• Cardiomyopathy: 

• NOS 

• congestive 

• constrictive 

• familial 

• hypertrophic 

• idiopathic 

• nonobstructive 

• obstructive 

• restrictive 

• Cardiovascular collagenosis 

• 425.5 Alcoholic cardiomyopathy 

• 425.7 Nutritional and metabolic 

cardiomyopathy 

• Code first underlying disease, as: 

• amyloidosis (277.30-277.39) 

• beriberi (265.0) 

• cardiac glycogenosis (271.0) 

• mucopolysaccharidosis (277.5) 

• thyrotoxicosis (242.0-242.9) 

• gouty tophi of heart (274.82) 

• 425.8 Cardiomyopathy in other 

diseases classified elsewhere 

• Code first underlying disease, as: 

• Friedreich's ataxia (334.0) 

• myotonia atrophica (359.21) 

• progressive muscular dystrophy 

(359.1) 

• sarcoidosis (135) 

• cardiomyopathy in Chagas' disease 

(086.0) 

• 425.9 Secondary cardiomyopathy, 

unspecified 

36 





Systolic/Diastolic Heart Failure 

due to Aortic and Mitral Valve Disease 

• 398.91 – Rheumatic Heart Failure is a CC; 

• ICD-9-CM does not allow 428.xx codes serving as a MCC 

• Coding Clinic, 2nd Quarter, 2000, page 16-17 

• Stipulate that a coder is NOT to make an assumption that 

congestive heart failure is rheumatic in nature when a 

physician documents valvular disease, including one listed in 

the subchapter 393-398 (397.0 – Diseases of the tricuspid 

valve). 

• Unless ICD-9-CM directs the coder to assign the code for 

rheumatic congestive heart failure (which is not required under 

396.x) or the physician states the condition is rheumatic, it is 

inappropriate to assign a code for rheumatic congestive heart 

failure. 

• Coding Clinic, 3rd Quarter, 2006, page 7 appears to support 

this as well. 

Bottom Line – Unless the physician explicitly documents that 

the patient has rheumatic heart disease, use 428.xx 37 

Pericarditis 

• All pericarditis 

codes are now CCs 

• 423.3 – cardiac 

tamponade - a CC 

• Consider acute 

right diastolic 

failure (MCC) in 

this circumstance 

38 





Deleted CC 

Angina Pectoris 

• Angina Pectoris (not just CAD) 

• 413.9 Angina NOS – Not a CC 

• 413.0 Angina at rest (angina decubitus) – CC 

• Suspect if the patient uses nitroglycerin w/i past month 

• Unstable Angina - CC 

• Occurs at rest and lasts for over 20 minutes OR 

• Severe, described of flank pain, and started within past 

month, OR 

• Cresendo pattern 

• Non-Q wave Myocardial Infarction - MCC 

• Elevations of troponin in the setting of anginal 

symptoms, EKG changes, post-angioplasty, or other 

cardiac manifestations 

http://content.onlinejacc.org/cgi/content/full/50/7/e1 39 

Atherosclerosis of CABG Graft 

“In-Stent Stenosis” 

CODE 

CC DESIGNATION 

TITLE 

41402 


CRN ATH ATLG VN BPS GRFT 

41403 


CRN ATH NONATLG BLG GRFT 

41404 


COR ATH ARTRY BYPAS GRFT 

41406 


COR ATH NATV ART TP HRT 

41407 


COR ATH BPS GRAFT TP HRT 

99672 


“In-stent” Stenosis NOS 

CABG Graft Occlusion NOS 

40 





Elimination of Major CV Diagnoses 

as Principal/Secondary Diagnoses 

Example: 

• DRG 235 CABG w/MCC 

• R.W. 5.1381 

• DRG 236 CABG w/o MCC 

• R.W. 3.7307 

MCVDs that are not MCCs 

• Bifascicular Block 

• Trifascicular Block 

• Complete Heart Block 

• CHF NOS 

• 996.72 

• Occluded graft 

• “In-stent stenosis” 

• Cerebral embolus w/o 

infarction 

• Acute Pericarditis 

Now requires MCC as a 

the secondary diagnosis 

Principal no longer good enough 

MCCs pertinent to CV surgery 

• Sepsis (995.91 and 995.92) 

• SIRS due to CV surgery w/organ 

dysfunction (995.94) 

• Acute Respiratory Failure (518.81) 

• Pressure sores (Present on Admit) 

• (Toxic-Metabolic) Encephalopathy 

• Instead of delirium/ICU psychosis 

• Acute Systolic/Diastolic heart failure 

• Indication for amiodarone (vent. Fib) 

• Non-Q-wave MI at referring hospital 

– possibly a MCC (see next slide) 

41 

Acute MI Present on Admission 

Not a MCC 

A 69 yo was admitted with severe chest pain. A left 

cardiac catheterization, coronary angiography, left 

ventriculography, and stenting of second obtuse 

margin was performed. The postoperative diagnosis 

was non-ST segment myocardial infarction with 

two-vessel coronary artery disease. What are the 

appropriate code assignments for this admission? 

Answer: Assign code 410.71, Acute myocardial infarction, 

subendocardial infarction, initial episode of care, for the 

non-ST segment myocardial infarction, as the principal 

diagnosis. 

Coding Clinic, 4th Quarter 2005, pages 69-72 

No MCC 

42 





Deleted CC 

Atrial Fibrillation 

Atrial Fibrillation 

Atrial Flutter 

• Atrial Fibrillation – 

427.31 – Not a CC 

• Atrial Flutter – 

427.32 

• A CC 

• “Atrial Fib-Flutter” 

• Probably requires 

both codes – 

427.31/427.32 

May have to look on nursing notes or 

telemetry strips to code these 

43 


Ventricular Arrhythmias 

Ventricular Tachycardia 

Torsade de Pointes 

Ventricular Flutter 

Ventricular 

Fibrillation 

• 427.1 Ventricular Tachycardia 

(>100/minute) - CC 

• Sustained vs. Nonsustained 

• Not treated if



Deleted CC – Hypovolemia 

Alternative: Acute Renal Failure (MCC) 

If there is a change of the serum creatinine 

of ± 0.3 – 0.5 mg/dl in the hospitalization, 

consider acute renal failure 

Biomarker: NGAL, Cystatin-C, IL-18 under 

consideration 

An abrupt (within 48 

hours) reduction in kidney 

function currently defined 

as an absolute increase in 

SCr of =0.3 mg/dl, a 

percentage increase in 

SCr of = to 50% (1.5-fold 

from baseline), or a 

reduction in urine output 

(documented oliguria of 

less than 0.5 ml/kg per 

hour for more than six 

hours). 

Mehta, et. al. the Acute Kidney Injury Network et al. Critical Care 2007 11:R31 

45 

Electrolyte Imbalances 

• Hyponatremia (CC) 

• SIADH (CC) 

• Metabolic encephalopathy (MCC) 

• Hyperkalemia (Not a CC) 

• Hypoaldosteronism (CC) 

• ACE-Inhibitors, Angiotensin 

Receptor Blockers, Spironolactone 

• CKD Stage IV-V (CC) 

• ESRD (MCC) 

• Hypercalcemia (Not a CC) 

• Metabolic encephalopathy (MCC) 

• Acidosis (CC) HCO 3 28 

Query – 

Please describe the 

precise underlying 

etiologies/ mechanisms 

of this patient’s 

hyponatremia/ 

hypokalemia. 

What are the 

consequences of this 

patient’s chronic illness? 

Exactly how did 

hyponatremia or 

hypercalcemia cause this 

patient’s confusion? 

46 





Deleted CC – CKD/CRI NOS 

Term GFR Usual Serum Cr* 

585.1 – CKD Stage 1 >90



49 

ICD-9-CM Official Guidelines for 

Coding and Reporting 

• Excludes Notes 

• An excludes note under a code indicates that the terms 

excluded from the code are to be coded elsewhere. 

• In some cases the codes for the excluded terms should not 

be used in conjunction with the code from which it is 

excluded. An example of this is a congenital condition 

excluded from an acquired form of the same condition. The 

congenital and acquired codes should not be used together. 

• In other cases, the excluded terms may be used 

together with an excluded code. An example of this 

is when fractures of different bones are coded to 

different codes. Both codes may be used together if 

both types of fractures are present. 

• Conditions that are an integral part of a 

disease process 

• Signs and symptoms that are associated routinely 

with a disease process should not be assigned as 

additional codes, unless otherwise instructed by the 

classification. 

790.01 

should not 

be 

combined 

with 

excluded 

codes 

unless 

Coding 

Clinic 

allows 

otherwise 

50 





Acquired and Nonspecific 

Aplastic Anemia 

• 284.81 Red cell aplasia (acquired) 

(adult) (with thymoma) - MCC 

• Red cell aplasia NOS 

• 284.89 Other specified aplastic 

anemias (all three lineages) - 

MCC 

• Aplastic anemia (due to): 

• chronic systemic disease 

• drugs 

• infection 

• radiation 

• toxic (paralytic) 

• 284.9 Aplastic anemia, 

unspecified – Only a CC 

• Anemia: 

• aplastic (idiopathic) NOS 

• aregenerative 

• hypoplastic NOS 

• nonregenerative 

• Medullary hypoplasia 

Classification of Red Cell Aplasia 

• Self Limited 

• Transient erythoblastopenia of 

childhood 

• Acute B19 parvovirus infection 

• Fetal RBC aplasia 

• In utero B19 parvovirus 

• Hereditary (Diamond-Blackfan) 

• Acquired 

• Thymoma or malignancy 

• Connective Tissue Dz (lupus) 

• Virus (B19 Parvovirus, hepatitis, EB 

virus) 

• Pregnancy 

• Drugs (Dilantin, INH, azothiaprine) 

• Unknown 

51 

Myelodysplastic Codes 

• 238.7 Other lymphatic 

and hematopoietic 

tissues 

• 238.72 Low grade 

Myelodysplastic 

syndrome lesions 

• Refractory anemia (RA) 

• Refractory anemia with 

ringed sideroblasts (RARS) 

• Refractory cytopenia with 

multilineage dysplasia 

(RCMD) 

• Refractory cytopenia with 

multilineage dysplasia and 

ringed sideroblasts (RCMD- 

RS) 

• 238.73 High grade Myelodysplastic 

syndrome lesions 

• Refractory anemia with excess 

blasts-1 (RAEB-1) 

• Refractory anemia with excess 

blasts-2 (RAEB-2) 

• 238.74 Myelodysplastic syndrome 

with 5q deletion 

• 5q minus syndrome NOS 

• Excludes: 

• constitutional 5q deletion 

(758.39) 

• high grade Myelodysplastic 

syndrome with 5q deletion 

(238.73) 

• 238.75 Myelodysplastic syndrome, 

unspecified CCs are in the box 52 





Hypercoagulable Syndrome - CC 

Association with DVT 

• Manifestation 

• Phlegma cerulea dolens 

• Pulmonary Embolus 

• Deep venous Thrombosis 

• Underlying cause 

• Virchow’s Triad – 

1° or 2° Hypercoagulability; Thrombophlebitis; Stasis 

Usually present on admission – Estrogen Use, Cancer, Pregnancy 

Still to be ruled out - Factor V Leiden, Protein C deficiency, 

Protein S deficiency – As primary hypercoagulability 

• Instigating Cause – recent surgery, pregnancy, 

underlying cancer, drug use (e.g. hormones) 

If patients are on chronic Coumadin ® , warfarin, or heparin, 

inquire if patient has hypercoaguable syndrome 53 

Deleted CC 

Uncontrolled Diabetes 

• Still needs to be captured 

• Dr. Kennedy defines this as: 

• Multiple Blood Glucoses over 250 mg/dl 

requiring changes in therapeutic regimen 

• One fasting Blood Glucose over 300 

mg/dl 

• Recurrent hypoglycemia requiring 

multiple changes in therapeutic regimen 

• Hgb A lC over 7.0 

54 





Diabetic Ketoacidosis - MCC 

250.1x w/o Coma; 250.3x w/Coma 

• Results from complete deficiency of insulin AND excessive 

counter regulatory hormone excess 

• Hyperglycemia (300-600) 

• Ketosis (4+ Plasma Ketones, 1:8 or greater) 

• Diagnosis 

• Patient very dehydrated - Acute Renal Failure 2° Dehydration? 

• Kussmaul breathing, fever, possibly coma - MCC 

• Hyperglycemia and Ketosis 

• Metabolic Acidosis (pH 6.8-7.3, HCO 3 

< 15 meq/L, “elevated 

anion gap” 

• Serum Potassium usually high due to acidosis; if normal, patient 

very depleted. 

• Treatment can lead to cerebral edema 

Patients with DKA invariably are Type 1 (but can be Type 2) and 

uncontrolled; Coding Clinic 3 rd Quarter, 2006, directs DKA to be 

coded with a fifth digit of “3” unless MD states it is Type 2 diabetes 55 

Nonketotic Hyperosmolar State – MCC 

• Primarily in Type 2 Diabetics 

• Associated with absolute or relative insulin deficiency 

• Just enough insulin to prevent ketoacidosis, but not enough to 

prevent hyperglycemia 

• Results in profound dehydration, hyperglycemia, and 

hyperosmolality (330-380) 

• Blood glucose usually over 600 

• ?Acute Renal Failure 2° Dehydration? 

• pH is normal or slightly decreased due to dehydration 

• HCO 3 usually normal 

• Creatinine moderately elevated due to dehydration. 

• Treated with rehydration with isotonic/hypotonic saline and 

small doses of insulin; removal of underlying cause 

Patients with NKHS invariably are Type 2 and uncontrolled; but, 

unlike DKA, the physician must state that a patient is uncontrolled. 56 





Other CC Alternatives 

with Diabetes 

• Autonomic Neuropathy - CC 

• Reason for using Viagra 

• Florinef used to fight orthostatic hypotension 

• Neurogenic Bladder - CC 

• Chronic Kidney Disease - CC 

• Stage 4 or 5 (Creatinine over 2.0 – 2.5 mg/dl) 

• ESRD – MCC – on dialysis 

• Diabetic Nephrosis – Nephrotic Syndrome 

• 4+ protein (over 3 grams per day) 

• Hypoalbumemia 

• Hyperlipidemia 

• Associated with Chronic Kidney Disease 

• Insulin Coma - MCC 

• Not just “hypoglycemia” 

57 

“Altered Mental Status” 

• M and S – What type of Altered Mental Status? 

• ACUTE Delirium, Dementia, Stupor, Coma, Mania, Confusion, 

Psychosis (CC) , Hallucinations (CC) , Delusions (CC) 

• U – Underlying Cause 

• Encephalopathy (MCC) – Toxic, Septic, Metabolic; 

• Alzheimer's Disease – must describe delusional/depressed/or 

psychosis – behaviorial changes – to be a CC 

• Normal Pressure Hydrocephalus – (CC) – has a shunt in place 

• Multi-infarct Dementia (CC) – Late effect of stroke (no CC) 

• Lewy-Body Dementia (associated with Parkinson’s Disease); 

• Bipolar Disorder (CC) 

• Specified schizophrenia (CC) 

• Drug withdrawal (CC) 

• Seizure – Concussion 

• Stroke (MCC) – TIA (CC) 

58 





Encephalopathy 

• A diffuse disease of the brain 

secondary to an otherwise 

nondefined neurological or a 

defined nonneurological 

illness or insult 

• Multiple types in ICD-9-CM 

• Metabolic – due to metabolic 

issues 

• Septic – due to sepsis 

• Toxic – due to drugs 

• Anoxic – due to lack of oxygen 

• Hypoglycemic – due to 

hypoglycemia 

• Hypertensive – due to malignant 

hypertension 

Coding Clinic References: 

“(Toxic) metabolic 

encephalopathy refers to 

an altered state of 

consciousness, usually 

denoting delirium.” - 

CC 4 th Q 1993 p. 29 

“Metabolic encephalopathy 

is always due to an 

underlying cause, seen in 

12-33% of patients with 

organ failure – 

CC 4 th Q 2003, p. 58-59 

59 

TIA vs. Stroke as CC/MCC 

• “TIA” (a CC) – Transient Neurological Symptoms 

due to ischemia LASTING LESS THAN ONE HOUR 

and no evidence of Stroke (e.g. MRI, CT Scan) 

• “Stroke” (a MCC) – Neurological symptoms 

• due to ischemia with evidence of stroke on 

neuroimaging 

• If symptoms >1 hour, 85% chance of stroke 

• Aborted stroke coded as a stroke 

• Consequences (if a stroke – present on DC) 

• 344.1 – Paraplegia (CC) 

• 344.61 – Neurogenic Bladder (CC) 

• 348.4 – Cerebral herniation (MCC) 

• 348.5 - Cerebral edema (MCC) 

• 784.1 – Transient limb paralysis (CC) 

• 784.3 – Aphasia (CC) 

• 781.8 – Neurologic Neglect Syndrome (CC) 

Code neurologic deficits of stroke on discharge? 

Source: Sacco, et. al. 

Stroke, 37 (2): 577. (2006) 

60 





Seizures 

• Seizures and Seizure Disorder are not CC. 

Alternatives include: 

• Febrile Seizures (CC) 

• Other specified seizures disorders that are intractable (CC) 

– query the physician if medications are being changed 

• Petit Mal (CC) 

• Focal (CC) 

• Seizures described as being in status are MCC 

• Continuous clinical or electrical seizure activity or 

repetitive seizures with incomplete neurologic recovery 

interictally for a period of at least 30 minutes 

61 

Schizophrenia 

• Schizophrenia or Schizoaffective 

disorder NOS is not a CC 

• ALL of the specified schizophrenic or 

schizoaffective disorders ARE 

• e.g. Chronic schizophrenia 

• e.g. Simple schizophrenia 

• e.g. Chronic schizophrenic disorders 

62 





Malnutrition 

Lab Values 

Normal 

Mild 

Moderate 

Severe 

Albumin (g/dl) 

3.5-5.0 

3.0-3.4 

2.1-2.9 



Options to Consider in 

Chemical Dependency 

• Thiamine Deficiency 

(CC) 

• Most alcoholics get 

thiamine 100 mg IM 

• Drug induced delirium 

(CC) 

• Toxic Encephalopathy 

(MCC) 

• If the patient relapses 

and has “altered mental 

status”, the drug likely 

caused it 

• Alcohol or Drug 

Withdrawal 

• Does not necessarily 

have to be an illegal 

drugs. 

• Many drugs that are 

legally prescribed have 

withdrawal symptoms if 

abruptly discontinued by 

the patient or the 

physician 

65 

Bacteremia vs. Septicemia 

Sepsis 

• Bacteremia (790.7 - a CC): 

• Bacteria in the blood without 

an inflammatory response. 

• Septicemia (038.x - a MCC): 

• Pathological organisms (viruses, 

bacteria, fungus, or other 

organisms) OR their toxins in 

the systemic blood. 

• SIRS 

• Due to infection (sepsis) – MCC 

• Due to non-infection – 

Pancreatitis, Burns, Trauma 

• Without organ dysfunction – CC 

• With organ dysfunction – MCC 

Systemic Inflammatory 

Response Syndrome 

(>2 of the following): 

• Temperature >38 C 

or 90/min 

• Respirations >20/min 

• White Blood Cells 

>12,000 or 10% Bands formed 

66 





Others 

• Hypopituitarism 

• On chronic steroids, thyroid 

replacement, testosterone 

• Child and Elder Abuse 

• Internal or vascular injuries 

• Secondary Myasthenia and 

Parkinson’s Disease 

• Chronic kidney stones 

• UTI 

• Specified locations of GI bleed 

• Specified complications of 

pregnancy 

• Especially important if private 

insurance uses MS-DRGs or 

APR-DRGs 

• Indications for Drugs 

• Amiodarone – atrial fibrillation, 

ventricular tachycardia 

• Viagra – autonomic neuropathy 

• Neurotin – specified seizure 

disorder 

• Coreg – chronic systolic HF 

• Lactulose – hepatic 

encephalopathy 

• Methadone – continuous 

chemical dependency 

• Sublingual nitroglycerin – 

Angina at rest 

67 

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Available now! 

Order online at 

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ISBN/ISSN: 978-1- 

58426-197-1 

68 





Resources 

• CC – MCC List can be downloaded at 


• DRG Documentation Tips 

in Appendix of Resource Book 

69 

Audience Questions 





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Appendix 

DRG Documentation Tips ......................................................................................39 

CE Certificate Instructions .....................................................................................41 

NOTE: 

Additional Appendix “MS-DRG CC/MCC List Final Rule” can be downloaded at 


AHIMA 2008 Audio Seminar Series 38

DRG Physician Diagnosis Suggestions 

If You Write 

ACS w/elevated troponin 

Consider 

Non-Q wave MI 

Any Infection, Bacteremia Sepsis if patient has Systemic 

(e.g. C. difficle colitis, Inflammatory Response Syndrome 

appenditicis, peritoneal (WBC > 14K, “left shift” Temp > 101, 

abscess 

Pulse > 90, Alt. Mental Status, ↑PCT) 

due to that infection 

Albumin 3.0, underweight 

Altered Mental Status 

Amiodarone/AICD use 

Asthmaticus, Status 

Azotemia, Cr ↑ from 1.0 

to 2.0 mg/dl, Acute 

Kidney Injury 

Mild/Moderate/Severe malnutrition 

Document alteration (ACUTE confusion, 

delirium, psychosis, dementia, coma), any 

probable underlying encephalopathy 

(toxic, septic, metabolic, traumatic, 

hypoxic, hypertensive) and other brain 

diseases present (Alzheimer’s, late effect 

of stroke, 1° or 2° Parkinsons) 

Underlying rhythm disturbance 

Acute Resp. Failure if present 

Acute Renal Failure → AKI criteria of 

acute rise of Cr of ≥ 0.3 mg/dl w/i 48 hr; 

otherwise acute renal insufficiency 

Blunt Abd. Trauma w/ Acute peritoneal Injury + 

Deep injury 

how solid organ was injured 

CAD/Angina 

Cardiac Arrest 

Chest Pain 

CHF (Stunned Heart) 

Closed Head Injury 

Cocaine/Illegal Drug Use 

Document Stable Angina, Angina-atrest 

or Progressive angina if present 

Its cause (prob. V-tach/V-fib/AMI) 

Type of pain (angina, pleuritic, radicular, 

heartburn, biliary colic), its probable 

cause (e.g. GERD, gallstones, cocaine), 

& if at rest or accelerated. 

Acute/Chronic, Systolic or Diastolic CHF 

(decompensated doesn’t count) 

Concussion, LOC x _____ min 

Cocaine (drug) intoxication with 

continuous chemical dependency 

(Document acc. angina, arrhythmias, 

psychosis, toxic encephalopathy, 

accelerated HTN and other comp) 

Chronic Renal Chronic Kidney Disease – Level 1, 2, 3 

Insufficiency or Failure 4, or 5 or ESRD based on GFR - dialysis 

COPD/Chronic Bronchitis 

Debridement of skin 

Documented if stable or exacerbated. 

Describe if Excisional – a scalpel used 

to remove (not scrape) necrotic flesh 

Diabetes, poorly contrld Uncontrolled Diabetes, if multiple BS > 

250, Hgb A1c > 7.0 or BS widely fluctuate. 

If BS>600, poss. hyperosmolar syndrome 

Hct 25 2° GI Bleed/Surg 

Drop in Hematocrit and/or Acute Blood 

Loss Anemia (See back) 

If you Write 

Hypertensive Emergency 

Hypertensive Urgency 

Hypotension 

K 6.5 due to Captopril 

K 2.0; Will give KCl 

LLL Infiltrate, Rx w/Zosyn 

Low Urine Output 

Marijuana or Alcohol Use 

Na = 125 

Neutropenic Fever 

Pleural effusion 

pH 7.25 pCO2 34, pO2 80 

Pneumonia 

Hospital-Acquired 

SNF-Acquired 

Ventilator-Associated 

Community-Acquired 

Ranson’s Criteria met 

Consider 

Accelerated or Malignant HTN. 

+ consequences: e.g. encephalopathy, 

Acute heart failure, acc. angina, 

State UNDERLYING cause (e.g. possible 

hypovolemia, autonomic. neuropathy 2° 

parkinson’s, Shy-Drager, diabetes) 

Hyperkalemia due to 

hypoaldosteronism due to Captopril 

Hypokalemia due to ______ 

Prob. Gram-negative pneumonia 

Oliguria, Anuria + cause 

Continuous chemical dependency if 

use is recurrent w/health consequences 

or if on chronic Rx (e.g. methadone) 

Hyponatremia & probable cause (e.g. 

SIADH, diuretics) 

Underlying systemic infection (sepsis) 

or bacterial infection for which antibiotics 

are prescribed. Capsofungin: prob. 

fungemia; Primaxin/Zyvox: prob. 

Bacterial infection of uncertain etiology. If 

sepsis is suspected, document that. 

State prob underlying condition (e.g. 

empyema, CHF) or condition to be r/o’d 

(e.g. metastatic cancer, TB) 

Metabolic Acidosis + cause 

Underlying organism for which the 

antibiotics are prescribed, i.e. if Zosyn is 

used, document prob. aspiration, gram 

negative. If vancomycin used, probable 

MRSA pneumonia. 

SIRS 2° Pancreatitis (+ organs affected) 

Respiratory Insufficiency Resp. Failure (if pH < 7.35, pCO2 >50 

Respiratory Acidosis PO2 < 60 & special resources utilized 

Hypoxia, Hypercapnia 

Rhythm Stable 

RIND – possible TIA 

Underlying arrhythmia (e.g. ventricular 

tachycardia, PAT) on monitor or Rx’d 

TIA if 1 hr/ + MRI 

Seizure Describe probable Underlying Cause – 

e.g. old CVA, alcohol withdrawal, epilepsy 

Spontaneous Fracture 

Syncope 

Underweight/Overweight 

Urosepsis 

Pathological Fracture, Osteoporotic 

Fracture 

LOC prob. due to ___________ 

Malnutrition/Morbid Obesity if present 

Sepsis due to UTI (if SIRS criteria met) 

© 2007 FTI Consulting – All Rights Reserved 8/2007 Used with permission – For Support, contact Dr. James Kennedy, 877-515-5354

Definition of Terms: 

Acute Respiratory Failure 

Angina Pectoris 

Acute Renal Failure 

An impairment of exchange of respiratory gases requiring aggressive care and usually manifested as a respiratory 

acidosis (pH ≤ 7.35), hypercapnia (pCO 2 ≥ 50), and/or significant hypoxemia (pO 2 ≤ 55; sPO2 ≤ 88% requiring >28% of 

FiO2). Metabolic alkalosis may alter these blood gas settings. The patient does not have to be on a ventilator to have 

acute respiratory failure but should receive intensive care (e.g. frequent monitoring or respiratory treatments, BiPAP). 

Symptoms resulting from myocardial oxygen insufficiency that can be the result of coronary disease (including spasm 

or Syndrome X) or increased muscle mass. Angina at rest lasts less than 10 minutes. Accelerated angina pectoris is 

an acute increase in symptoms usually lasting more than 10 minutes that require urgent diagnostic assessment. Once 

cardiac enzymes are substantially elevated, angina pectoris has evolved into an acute myocardial infarction. 

Criteria and terminology not universally agreed upon. Most recent criteria for acute kidney injury (which encompases 

all aspects of acute renal failure) is an abrupt (within 48 hours) reduction in kidney function currently defined as an 

absolute increase in SCr of ≥ 0.3 mg/dl, a percentage increase in SCr of ≥ to 50% (1.5-fold from baseline), or a 

reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours). 

ICD-9-CM does not recognize Acute Renal Risk or Acute Renal Injury, allowing only acute renal insufficiency or acute 

renal failure. Underlying causes include hypovolemia, contrast nephropathy, (septic, hypovolemic) shock, toxins (e.g. 

NSAIDs, gentamicin), or ATN from other causes. Azotemia is only an elevation of creatinine and/or BUN and does not 

infer severity 

Chronic Kidney Disease A kidney disorder manifested by radiological or urinary abnormalities (proteinuria, hematuria) or by a GFR less than 60 

for more than three (3) months. CKD staging is defined by the GFR: 

Level GFR Please avoid the terms “Chronic Renal Insufficiency” or 

1 >90 “Chronic Renal Failure” since these do not code to a 

2 60-89 specific CKD code and thus do not infer severity. 

3 30-59 

4 15-29 

5 < 15 or dialysis Please document underlying cause of the CKD if known 

Diabetes Mellitus 

Drug or Alcohol Addiction 

Encephalopathy 

Hypertension Staging 

Malnutrition 

Pneumonia 

Precipitous drop in 

Hematocrit 

Sepsis - SIRS 

Defined by a fasting blood glucose of over 126 mg/dl or a 2-hour postpranial blood glucose of over 185 mg/dl. 

Classified as Type 1 (absolute insulin deficiency due to autoimmune destruction of beta cells), Type 2 (impaired Insulin 

utilization), or secondary (due to destruction of beta cells by nonimmune causes such as surgery, infection, infiltrative 

disease or drugs or insulin resistance as the result of drugs (e.g. steroids). “Uncontrolled” diabetes has random 

blood glucoses over 250 mg/dl or Hgb A1C > 7.0, no matter what the cause. Comment if there are any consequences 

such as hyperosmolar state (BS over 600), ketoacidosis (HCO3 < 18 with uncontrolled diabetes), or complications (e.g. 

neuropathy, nephropathy, cardiomyopathy, radiculopathy, vasculopathy) specifically attributable to diabetes. 

An obsessive/compulsive disease manifested by alcohol/drug overindulgence for which physical or emotional 

dependence develops associated with craving for which their use is continued despite adverse consequences. The 

disease can be continuous (currently active manifested by recent or daily use, especially if it impacts health), episodic, 

or in remission. Drug “abuse” is inappropriate use of the chemical (illegal drugs are always “abused”). Drug “use” is a 

reasonable consumption of a legal chemical (e.g. a glass of wine) that does not lead to adverse consequences. 

An underlying brain disease that is manifested by altered mental status, delirium, or dementia. This can be described 

as septic, toxic, anoxic, metabolic, post-traumatic, or hypertensive and should be linked to an underlying process (e.g. 

sepsis, drug overdose, electrolyte imbalance, malignant hypertension). 

According to the JNC 7, hypertensive emergency is defined by blood pressure over 180/120 with impending organ 

failure. Hypertensive urgency is higher level Stage 2 hypertension (160-179/100-109) without organ dysfunction that 

may be associated with symptoms (e.g. dizziness, chest discomfort, anxiety). ICD-9-CM codes these as well controlled 

hypertension, thus the terms “malignant” or “accelerated” hypertension must be used respectively to define these. 

An imbalance between the body's needs and the intake of nutrients, which can lead to syndromes of deficiency, 

dependency, toxicity, or obesity. Malnutrition includes undernutrition, in which nutrients are undersupplied, and 

overnutrition, in which nutrients are oversupplied. When significant weight loss, hypoalbuminemia, or morbid obesity 

(BMI over 27) is present, malnutrition is probably present and warrants a dietary assessment. 

An infection of lung alveoli manifested by a positive chest X-ray. If the patient has a negative chest X-ray, convincing 

physical findings (whispered pectiloquoy, egophony, bronchial breath sounds) and/or an explanation for the negative 

chest X-ray (e.g. dehydration) is necessary. If the patient has signs and symptoms consistent with the Systemic 

Inflammatory Response Syndrome (see sepsis), documentation of “Sepsis due to Pneumonia” is appropriate. 

Not defined in the literature. Since major blood loss is defined as a 20% loss of blood mass, “Precipitous drop in 

hematocrit can be arbitrarily defined as a 20% drop in hematocrit from baseline. 

Sepsis is a Systemic Inflammatory Response Syndrome (SIRS) due to a suspected or proven Infection. Signs and 

symptoms that validate that a patient is “septic” were published by 2001 SCCM/ESICM/ACCP/ATS/SIS International 

Sepsis Definitions Conference; some of these include Temperature > 101, HR > 90, WBC > 12K or > 10% Bands, 

tachypnea, altered mental status, hyperglycemia, organ dysfunctions, and elevated cardiac output not explained by 

other causes. A positive blood culture is not necessary to substantiate sepsis given this definition. SIRS can occur as 

a result of non-infectious causes (e.g. pancreatitis, burns, trauma); appropriate documentation captures an appropriate 

severity of illness. 

Ventricular Tachycardia A paroxysm of three or more PVCs in succession. 

© 2007 FTI Consulting – All Rights Reserved 8/2007 Used with permission – For Support, contact Dr. James Kennedy, 877-515-5354

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