Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s case study below:

Case Summary

This is a 67-year-old male with history of COPD who states he been in his baseline state of health until the day of ED presentation when he noted increasing wheezing and shortness of breath. He was found to have an acute COPD exacerbation with hypoxia requiring home O₂. He was started on aggressive pulmonary nebs as well as inhaled steroids and IV Solu-Medrol which was then he de-escalated to oral prednisone. He desaturated to 82% when oxygen was removed so he will need home O₂, and this was arranged. Bicarbonate levels ranged from 40-42 this admission.

DRG Options

Audit Considerations & Strategies

• Many patients with severe, long-standing, or end-stage COPD may also have chronic respiratory failure
• Clinical/diagnostic criteria for chronic respiratory failure may include:
  • Hypoxia/hypoxemia (decreased pO₂)
  • Normal pH
  • Elevated pCO₂ (>40)
  • Elevated bicarbonate level (found on basic metabolic panel)
  • Chronic steroid use
  • Chronic supplemental oxygen therapy (“home O₂”)
• Specific clinical criteria should be determined in collaboration with your organization’s physicians
• Whenever reviewing cases where the patient has long-standing/end stage COPD or other lung disease and requires chronic home 0₂ and clinical criteria are met, consider querying for chronic respiratory failure (see query example below)

Query Example

This is a 67-year-old male who was found to have an acute COPD exacerbation with hypoxia requiring home O₂. He was started on aggressive pulmonary nebs as well as inhaled steroids and IV Solu-Medrol which was then he de-escalated to oral prednisone. He desaturated to 82% when oxygen was removed so he will need home O₂, and this was arranged. Bicarbonate levels ranged from 40-42 this admission.

To ensure an accurate reflection of all relevant respiratory conditions are captured, please select from the options below:

• Patient has COPD with chronic respiratory failure
• Patient has COPD only
• Patient has COPD with other condition (specify)
• Unable to determine
• Other (specify)

References

1. ICD-10 Official Coding Guidelines, Section III. Reporting Additional Diagnoses – 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.
2. ACP Hospitalist – Revisiting Respiratory Failure, https://acphospitalist.org/archives/2013/10/coding.htm
3. Q&A: Establish clinical criteria prior to query for COPD, http://www.hcpro.com/HIM-306097-5707/QA-Establish-clinical-criteria-prior-to-querying-for-COPD.html