Acquired Diagnosis / Complication

For other types of diagnoses, see Admit Diagnosis and Comorbid Diagnosis.

• Acquired Diagnoses, also referred to as complications, are problems or procedures that occur AFTER a patient has been accepted to a physician service ICU or Medicine regardless of physical location and has an Service tmp entry dttm. (While in ER collection starts at Accept DtTm).

When to code an Admit Diagnosis vs Acquired Diagnosis

• Distinction between Admit Diagnoses and Acquired Diagnoses relates to the start of a PatientFollow Project profile. An Admit Diagnosis needs to be present at the start of a PatientFollow Project profile. Diagnoses that occur after will be Acquired Diagnoses.
  • There are sometimes subtle issues here, especially for diagnoses that use lab test results.
  • An example is patient comes in to ED with shock presumed due to pneumonia and a lactate=1.7 --> this doesn't meet the requirement for Shock, septic, but by 3 hours later the next lactate checked in the ICU is 2.7, so that threshold for septic shock IS met. Clearly this person was "brewing" septic shock at admission and it seems logical to include that diagnosis as an admit diagnosis. THUS -- in such cases where it seems pretty clear, in retrospect, that a diagnosis was brewing/present at admission but only became fully evident after admission, that diagnosis SHOULD be coded as an Admit Diagnosis IF it becomes fully evident within 6 hours of admission.

Example:

Example1 -- patient's care is taken over by Medicine service while he is still in ED. The admission diagnosis is DKA. He remains on Medicine service in ED (due to lack of ward beds) for 2 days, after which he finally gets up to the Medicine ward and then has a stroke. The stroke is an Acquired Diagnosis, and would still be acquired even if it had occurred during those 2 days in ED. AND Dx is relevant to this admission in that it is either: (a) an acute or exacerbated condition (as opposed to a chronic, stable condition -- e.g. stable diabetes), OR (b) it is a condition not directly related to the reason(s) for admission, but its treatment is being actively managed -- and by actively we mean that during this admission changes are made to the management. Example2: Patient with TB has been treated for the past 5 (of his 9 expected) months admitted now for acute MI. Scenario#1:No changes made in his TB treatment ---> so NOT an Admit Diagnosis (but this active TB is a Comorbid Diagnosis ) Scenario#2:Changes are made to his TB treatment during this admission ---> so IS an Admit Diagnosis too

Onset not discovery

Code diagnoses are based on the onset of the condition, not necessarily when it was discovered. If a diagnosis is discovered after admission, but likely was present on admission (example, diabetes mellitus) then code it appropriately as a Comorbid Diagnosis or an Admit Diagnosis if it was related to the reason for admission.

Example:

Patient is admitted with what was thought to be a COPD exacerbation. A few days after admission, they decide the likely cause for this respiratory failure was actually pneumonia, and during these diagnostic tests, discover that the patient has an abdominal aorta aneurysm. In retrospect, it is clear that the pneumonia was the cause of the admission, so the Admit Diagnosis will be pneumonia not COPD exacerbation. The abdominal aorta aneurysm would have had to exist prior to admission, but is not relevant to why the patient is in hospital, and therefore should be coded as a Comorbid Diagnosis.

Diagnosis categories in relation to patients moving around the hospital

• This section explains how to determine the Dx Type as a patient moves from place to place within a hospital -- i.e. during a single hospitalization. In this section we'll refer to a person who moves from location A (ward) to location B (ICU) to location C (ward), which would constitute three separate patient profiles.
• Rule#1: Situation where a diagnosis is new to this hospitalization, do not code as a Comorbid Diagnosis. Comorbid diagnoses need to be a chronic, pre-existing disorder that existed prior to the patient’s initial hospitalization, regardless of their physical location throughout this stay.
  • Therefore, any new diagnosis that occur in location A, should not be coded as a comorbid diagnoses for the profiles for location B or location C.
    • if by the time they are transferred to the subsequent location it is resolved and no longer being treated, then it should not show up as any kind of diagnosis for that subsequent record. It will be captured in the data from the initial location.
    • if by the time they are transferred to the subsequent location it is still being dealt with medically, and indeed is part of the reasons they are going to the new location, then it should be listed as an Admit Diagnosis for that subsequent record.

Examples 1 and 2

Example 1: Patient is admitted to location A with pneumonia, then transfers to location B for worsening of the pneumonia, then improves and transfers to location C but remains on antibiotics. This encapsulates three separate database profiles, and pneumonia will be the Admit Diagnosis for all three profiles. Example 2: Patient is admitted to location A with pneumonia, then transfers to location B for worsening of the pneumonia. In location B, the pneumonia resolves and the course of antibiotics is finished. The patient is then transferred to location C for continued rehab for muscle wasting after the critical illness. Pneumonia would then be the admit diagnosis for location A and location B, but will not be captured on location C. The admit diagnosis for location C would be Muscle, wasting/atrophy NOS. Muscle, wasting/atrophy NOS would be captured as an Acquired Diagnosis in location B.

• Rule#2: The group of diagnoses that represent "past history" (e.g. Past history, loss of limb(s)) are also guided by Rule#1. Comorbid diagnosis must have been a chronic, pre-existing disorder that existed before the hospital admission.

Examples 3 and 4

Example 3: Patient is admitted to location A for osteomyelitis. During this stay, the patient experiences a cardiac arrest and is transferred to location B. In location B, the leg is amputated as source control and the course of antibiotics is finished. There are no further cardiac arrhythmias and patient is no longer on any anti-arrhythmic medication. They are then transferred to location C. Osteomyelitis would be the admit diagnosis for location A, and an admit diagnosis for location B. It would not be captured as a diagnosis for location C as it is resolved. Cardiac arrest would be the acquired diagnosis for location A, the primary admit diagnosis for location B, and would not be captured as a diagnosis for location C. At no point is Past history, loss of limb(s) captured as it was not a chronic, pre-existing disorder prior to the overall hospital admission. Example 4: Patient is admitted to location A for osteomyelitis. During this stay, the patient experiences a cardiac arrest and transfers to location B. In location B, the leg is amputated as source control and the course of antibiotics is finished. There are no further cardiac arrhythmias, but the patient remains on anti-arrhythmic medication. They are then transferred to location C. Osteomyelitis would be the admit diagnosis for location A, and an admit diagnosis for location B. It would not be captured as a diagnosis for location C as it is resolved. Cardiac arrest would the acquired diagnosis for location A, the primary admit diagnosis for location B. As the cardiac arrhythmia is still being treated, an admit diagnosis for location C would be cardiac arrhythmia, NOS. At no point is Past history, loss of limb(s) captured as it was not a chronic, pre-existing disorder prior to the overall hospital admission.

• Rule#3: This is really an observation rather than a "rule". We recognize and accept that the above rules and examples can lead to a single diagnostic event seeming to occur multiple times, while in fact it only occurred once. In Example2, since the pneumonia is listed as an Admit Diagnosis for records A and B and C, it won't be possible to distinguish whether these were a single, ongoing pneumonia versus an original pneumonia plus subsequent separate pneumonia events. The underlying reason for this is the artificial nature of how we collect data -- i.e. when a person goes A-->B-->C this is a single hospital episode but we code it as 3 different records.

Attribution of infections

Attribution of infections provides more info on when to code infections as what Dx Type.

Legacy - prior to PatientFollow Project

expand for pre-PatientFollow Project info

Prior to PatientFollow Project there was one record per ward/unit stay, so the distinction between Admit Diagnosis and Acquired Diagnosis would have been made on a per-unit basis; since then it is made on a per-PatientFollow Project profile basis.

Controlling Dx Type for ICD10 codes

This wiki page talks about which ICD10 codes are allowed to be Comorbid Diagnosis vs. Admit Diagnosis vs. Acquired Diagnosis Dx Type. See Controlling Dx Type for ICD10 codes for a discussion about cross-checks for these.

Please read carefully below to understand how this works with Patient Follow started Oct 2020.

An Acquired Diagnosis / Complication is coded by setting the Dx_Type to "acquired".

• Distinction between admit and acquired diagnoses relate to the START of a database record.
  • As of October 2020, a single record may span direct transfers between different locations and even between different services. *Accordingly, an admit diagnosis only relates to the very start of a database record.
• Diagnoses that occur after the start of a database record will be acquired diagnoses.
  • Example -- patient's care is taken over by Medicine service while he is still in ER. The admission diagnosis is DKA. He remains on Medicine service in ER (due to lack of ward beds) for 2 days, after which he finally gets up to the Medicine ward and then has a stroke. The stroke is an acquired diagnosis, and would still be acquired even if it had occurred during those 2 days in ER while under Medicine physician.

• See Admit Diagnosis and Comorbid Diagnosis for info on coding dxs that happen prior to arrival on your ward.
• Acquired diagnoses are prioritized (Dx Priority field) in order of occurrence.
• Coding for Acquireds/complications follows the general ICD10 collection instructions.
• The Dx_Date is mandatory for Acquireds/complications.

Onset not discovery

Acquired diagnoses do not refer to diagnoses that have been discovered after the patient comes to the unit if it is likely that the patient was admitted to ward with the problem in the first place but it took a few days to figure that out. Code these as Comorbid Diagnosis, and also, if appropriate (i.e. it was related to the reason for admission) as a Admit Diagnosis.

this relates to Attribution of infections and we need to be sure to have it consistent.

• SMW

• Cargo

• Categories

Repeating Complications

• In general things that occur, fully resolve, and then recur SHOULD be coded each time they recur.
  • e.g. postop hemorrhage --> goes to OR to have it fixed --> IS fixed ---> 3 days later has more postop hemorrhage
• For things that happen multiple times, some we WANT to list multiply and others we only list once
  • The ones we only list once include that info: Template:ICD10 Guideline repeated events. These are generally signs/symptoms, and arrythmias.
  • Otherwise, DO list it multiply --- e.g. after admit has a stroke --> 4 days later has a NEW/DIFFERENT stroke.

Data Structure

Acquired Diagnoses are drawn from S_ICD10 table and stored in L_ICD10 table.

Cross checks

• Query check ICD10 date