Task Team Meeting - Rolling Agenda and Minutes 2020
List of items to bring to task meeting
Add to this by adding the following to the article where the problem is documented:
{{DiscussTask | explanation}}
| Question | Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by Semantic MediaWiki. | |
|---|---|---|
| Gangrene, NOS | can we use this code for necrosis or necrotic wounds? Lisa Kaita 11:57, 2024 April 17 (CDT)
| 25 April 2024 01:01:29 |
| ICD10 Guideline Sepsis | How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT)
| 25 April 2024 00:57:46 |
| Query s tmp Boarding Loc ER delay reasonable | There are many false positives due to ICU delays shorter than 30 mins. Do we want to change anything about that threshold? Discussed with Julie and Lisa today but can't remember the outcome. Ttenbergen 10:58, 2024 April 24 (CDT)
| 24 April 2024 20:59:31 |
| STB ICUs VAP Rate, CLIBSI Rate Summary |
| 8 April 2024 16:27:53 |
| Sepsis (SIRS due to infection, without acute organ failure) | How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT)
| 9 March 2019 21:24:42 |
| Task Questions | ||
Also see Task Team Meeting - Rolling Agenda and Minutes 2019
ICU Database Task Group Meeting - February 18, 2020
- Present: Allan, Iris, Joanna, Julie, Trish
- Absent: Barret, Tina
- Minutes prepared by: AG
- Action items in BOLD
1. Followup about working to reduce collector workload
- Regarding obtaining CBS TraceLine for all transfusion data. Allan will followup with Margaret Ring (margaret.ring@blood.ca) in the middle of February -- DONE, emailed Feb 19, no reply yet.
- Regarding obtaining RIS data for radiology tests. Allan will followup with Shared Health CIO Charles Conway [204-926-1400; cconway3@sharedhealthmb.ca] at the end of February.
2. Followup on having the ICU nurses do all TISS coding 'PLAN:'Jodi is arranging a conference call including herself, Allan and the ICU nurse managers in all 3 hospitals.
3. Followup on trying to get hospital-level data elements from EPR. Tina discovered that there is an application called Cognos which has capability to extract data elements from existing databases.
- Tina has opened incident 3845870 and is working with Alex Omsen and Mike Ocko on getting this set up; see Cognos#Phone call with Mike Ocko
4. Followup.
- PLAN: Awaiting Tina to add new ICD10 code, R41.88, which we will call “Cognitive impairment, NOS”.
5. After extensive searching we are unable to identify the rationale for the existing “rule” that we not combine sepsis codes with other infection codes (e.g. pneumonia).
- PLAN: we propose the following: -- Allan has altered Wiki articles to reflect all these items:
- Rescind this rule, allowing combining any of the 3 sepsis codes with a code for a specific infection -- Allan has altered the text in Template:ICD10 Guideline Sepsis, and
- Trish will notifying all the collectors.
- Guidelines for such combination to include:
- Combine if it is reasonably clear that a specific infection is the source of the sepsis episode. But if it is NOT clear then do not combine.
- Clear example, so DO combine: sepsis and the only evident infection is pneumonia
- Unclear example, so do NOT combine: Sepsis with both pneumonia and a UTI.
- Clear example, so DO combine. Sepsis with pneumonia developing around the same time, and then 5 days later a UTI occurs. Here it’s appropriate to combine the sepsis + pneumonia but not with the UTI.
- Clear example, so DO combine: Sepsis with pneumonia and Bacteremia, with the same bug isolated from the lungs and blood. Here it’s reasonable to conclude that all 3 are causally related and combine all 3, with the same bug as cause in all 3.
- Combine if it is reasonably clear that a specific infection is the source of the sepsis episode. But if it is NOT clear then do not combine.
- Regarding identifying the bug responsible for sepsis -- this also can be unclear, here is some guidance:
- In the presence of Bacteremia , with or without other infection(s) (e.g. pneumonia) ALL showing the same bug, consider that bug to be the agent for the sepsis
- Without Bacteremia, with one or more other infections occurring around the same time that all have the same bug, consider that bug to be the agent for the sepsis
- With multiple infections occurring around the same time as the sepsis, having DIFFERENT bugs, the bug responsible for the sepsis is not clear (even if one of those infections is Bacteremia it’s still not clear), so in this case choose Infectious organism, unknown. Allan has added to that Wiki page to clarify this.
6. Followup on a set of related issues that revolve around when an an actual admission to a service begins:
- This is about the need to creating a category for ICU patients akin to “EMIP”. For these we will create now “locations” for ICU patients who never get up to their designated unit. We NOTE that this will include not only those who are held in ED for the entire time, but also those who are held in other locations (such as PACU) for the entire time on ICU service.
- Regarding terminology we have to decide whether to use “ECIP” (which appears to identify them solely as remaining in ED) or to include other locations as well use something like NCIP as in “NonICU Critical Care Inpatient”.
- In any case, because of this new phenomenon, we agreed we must from now own consider an ICU record to begin when the patients is ACCEPTED, not when they ARRIVE. This must be put on the Wiki and communicated directly to collectors.
- First though, we must clarify the meaning of “accept date/time”. There is currently ambiguity around it because we now refer to it as when an agreement to accept is made, even if that never happens (e.g. patient accepted in principle from Churchill but they die before getting here). Thus, we will now define “accept” as the combination of ALL of the following:
- (i) the team has said they will accept taking over the primary care responsibility, and
- (ii) the patient has physically arrived at the hospital in question, and
- (iii) the team has actually begun providing care in the role of the primary team.
- An important example is person coming to SICU from Churchill, but they go directly from the plane to OR and are there for 4 hours, only thereafter arriving in ICU where the ICU team is actually caring for the patient. Those 4 hours in OR are not counted and the true accept date/time is when the ICU team is actually providing care as the primary team to the patient.
- An important example is a patient on a ward who codes and the ICU team comes and runs the code. This by itself is technically an ICU consult and while the ICU team is providing care, they have NOT generally taken over primary team responsibility. Indeed this will never happen if the patient does not survive the code. Only if/when the ICU team agrees to become the primary team and begins providing such care after the code (may be immediately after) does “accept” occur.
- Tina after reviewing the diagram/table of varibles that Julie will do up, she will need to alter the current screen on the laptops which explicitly indicates Accept DtTm as coming solely from ED. Now this can occur coming from ED, PACU, OR, ward -- pursuant to the 3 criteria listed above that must be met.
- We tentatively agreed that for the ICU patient who never does arrive at their destination, that the Arrive DtTm will be the Dispo DtTm -- this way elapsed time boarding (interval from accept to arrival) will be the entire stay.
- Plan: For next Task meeting Julie will bring a diagram of all variables related to Accept DtTm, Arrive DtTm, Dispo DtTm etc -- so we can make sure there are no internal contradications.
- APACHE scoring: the “first 24 hrs in ICU” now must begin at the Accept Date/Time --> thus collectors will increasingly have to look at labs and vital signs done before ICU arrival. If the entire first 24 hours on ICU service is prior to ICU arrival, then APACHE scores will entirely be based on that pre-ICU time.
- TISS -- the collectors will need to complete TISS forms for calendar days prior to ICU arrival. If in a single calendar day there is a partial TISS sheet filled out by collectors from prior to arriving in ICU, PLUS a partial TISS sheet completed by the ICU nurses, then for that calendar day the collector must combine them.
- Procedures -- procedures that occur before ICU arrival but after ICU service acceptance will generally be considered as Acquired Procedure
- Diagnoses --- conditions that begin before ICU arrival but after ICU service acceptance will be considered as Acquired Diagnosis / Complication
- Identification -- this is especially tricky for those who never make it to their ICU. We decided not to spend a lot of effort now on identifying such individuals at HSC or STB, pending obtaining ADT system data dumps.
- ALL of the above things must be delineated in various places in the Wiki.
7. Followup regarding those admitted initially to the new Medicine “X service”.
- PLAN: Tina has to fix some things to go forward with this (see 1/29/2020 minutes).
ICU Database Task Group Meeting - February 12, 2020
- Present: Allan, Barret, Iris, Julie, Michelle, Tina, Trish
- Absent: Joanna
- Minutes prepared by: AG
- Action items in BOLD
1. Followup about working to reduce collector workload
- Regarding obtaining CBS TraceLine for all transfusion data. Allan will followup with Margaret Ring (margaret.ring@blood.ca) in the middle of February.
- Regarding obtaining RIS data for radiology tests. Allan will followup with Shared Health CIO Charles Conway [204-926-1400; cconway3@sharedhealthmb.ca] at the end of February.
2. Followup on having the ICU nurses do all TISS coding -- we have not implemented this yet because:
- While we have top administrator agreement at HSC. Allan emailed Dan to arrange similar meetings at St. B and Grace, but he responded that he thinks Jodi is in the better position to do so. Allan will bring it up with Jodi.
3. Followup on trying to get hospital-level data elements from EPR. Tina discovered that there is an application called Cognos which has capability to extract data elements from existing databases. Tina has opened incident 3845870 and is working with Alex Omsen and Mike Ocko on getting this set up; see Cognos#Phone call with Mike Ocko.
4. Followup on using DSM data to generate the APACHE lab scores. All reported that he spoke to Bojan and Kendiss about this, and that they would not want to further delay reporting. So, given that Joanna told us that it is not very time-consuming to do it by hand, we will not currently pursue this. BUT we still want/need to know the timing around admission (and more to the point, around Accept Time) of the labs we get from DSM. Julie/Tina will report on this.
5. Request for cognitive impairment as a comorbid. We agreed to add R41.88, whose official ICD10 name is “Other and unspecified symptoms and signs involving cognitive functions and awareness”, but for ease of use we will rename it “Cognitive impairment, NOS”. Tina will add it.
6. Regarding sepsis coding, particularly the existing rule NOT to link the sepsis code with a specific infection. Allan sent an email to DCCC and DCMed saying this. That led to some additional collector questions. It also begs the question of why NOT to combine sepsis with a specific infection when are sufficiently certain they’re related. Allan tried to answer this by looking through past minutes, but going back as far as all of 2018 and 2019, he wasn’t able to locate the answer other than what he wrote in Sepsis (SIRS due to infection, without acute organ failure) , i.e. that is is because of “a technical reason having to do with how we combine diagnoses”. Allan will talk with Julie to try and noodle this out, but if we cannot, then we may change this rule. Will discuss at next Task Meeting.
7. Followup on a set of related issues that revolve around when an admission begins.
- The main new issue is that we have begun to experience (and project this will increase) the phenomenon where ICU patients spend long periods of time admitted to the ICU service BEFORE there is an ICU bed available. Indeed, some at Grace have already been spending their entire time on the ICU service in ED. But more generally this can be in ED, PACU, elsewhere.
- This latter is akin to “EMIP” patients, but we’ve never really had to deal with them before for ICU. For these we will create “locations” for ICU patients who never get up to their designated unit. We NOTE that this will include not only those who are held in ED for the entire time, but also those who are held in other locations (such as PACU) for the entire time on ICU service.
- We have to decide on terminology -- whether to use “ECIP” (which appears to identify them solely as remaining in ED) or to include other locations as well use something like NCIP as in “NonICU Critical Care Inpatient”.
- In any case, because of this new phenomenon, we agreed we must from now own consider an ICU record to begin when the patients is ACCEPTED, not when they ARRIVE. This must be put on the Wiki and communicated directly to collectors.
- This has implications regarding: identifying these people, APACHE scoring, TISS, procedures and diagnoses
- APACHE scoring: the “first 24 hrs in ICU” now must begin at the Accept Date/Time --> thus collectors will increasingly have to look at labs and vital signs done before ICU arrival. If the entire first 24 hours on ICU service is prior to ICU arrival, then APACHE scores will entirely be based on that pre-ICU time.
- THIS in turn, has implications for if DSM is even sending us that “prior” data to peruse to generate the correct APACHE scores. Julie to check on that.
- TISS -- the collectors will need to complete TISS forms for calendar days prior to ICU arrival
- Procedures -- procedures that occur before ICU arrival but after ICU service acceptance will generally be considered as Acquired Procedure
- Diagnoses --- conditions that begin before ICU arrival but after ICU service acceptance will be considered as Acquired Diagnosis / Complication
- Identification -- this is especially tricky for those who never make it to their ICU. Lisa at Grace has come up with a way to find them for now, but a separate method would likely be needed for the other sites. Luckily, this phenomenon is currently rare except at Grace. Tina points out that if/when we get a data dump from the ADT system (which she is currently working on, and it appears might actually happen), then she will be able to process this data to identify such individuals and then (after the fact of course) it will be possible for collectors to go back and obtain the data for them. Thus, we decided not to spend a lot of effort now on identifying such individuals at HSC or St. B, pending that plan.
8. After discussion, we agreed that Julie will do away with the designation of “Parked in ED” for direct admissions which spend a bit of time in ED.
9. Followup regarding those admitted initially to the new Medicine “X service”. Tina has to fix some things to go forward with this (see 1/29/2020 minutes).
ICU Database Task Group Meeting - January 29, 2020
- Present: Allan, Barret , Joanna, Julie, Michelle, Tina
- Absent: Trish
- Minutes prepared by: AG
- Action items in BOLD
1. Followup about working to reduce collector workload
- Regarding obtaining CBS TraceLine for all transfusion data. Allan will followup with Margaret Ring (margaret.ring@blood.ca) in the middle of February.
- Regarding obtaining RIS data for radiology tests. Allan will followup with Shared Health CIO Charles Conway [204-926-1400; cconway3@sharedhealthmb.ca] at the end of February.
2. Followup on having the ICU nurses do all TISS coding -- we have not implemented this yet because:
- While we have top administrator agreement at HSC, Allan has emailed Dan to arrange similar meetings at St. B and Grace
3. Followup on trying to get hospital-level data elements from EPR. Tina discovered that there is an application called Cognos which has capability to extract data elements from existing databases. Tina has opened incident 3845870 and is working with Alex Omsen and Mike Ocko on getting this set up; see Cognos#Phone call with Mike Ocko
4. Followup on pulling in certain lab results in addition to current counts via re-parsing all DSM data from 1/1/2019.
- We will soon have Julie work to do the programming needed to automatically do the lab-related APACHE II APS score.
5. New items:
- Request for cognitive impairment as a comorbid -- there is one to discuss next time: R41.88 = Other and unspecified symptoms and signs involving cognitive functions and awareness
- Question of whether to code Diabetes newly found during hospitalization as a comorbid --- we agreed Yes, as the general EXISTING rule for comorbids is to code it as such even when it was just newly discovered but MUST have been present previously, even if that wasn’t known.
- Regarding sepsis coding, particularly the existing rule NOT to link the sepsis code with a specific infection. Allan sent an email to DCCC and DCMed saying this. That led to some additional collector questions. It also begs the question of why NOT to combine sepsis with a specific infection when are sufficiently certain they’re related. To answer this, we need to search through the prior minutes to remember exactly why we made this rule.
- Regarding those admitted initially to the new Medicine “X service”. This is an extra medicine attending who takes patients before a regular service can deal with them. 90% do eventually get to a “permanent” service, and when that occurs they are officially considered to have always been on that permanent service. The question is how to handle the 10% who remain on X for their entire stay. There are a variety of practical issues related to this -- such as assignment of their DID (as it includes their location), and which collector covers which Medicine service. We decided not to change anything now, but Tina has to fix some things to go forward with this.
- Regarding defining start of an ICU admission. After discussion we agreed to use the accept date/time for this. Tina to fix this on Wiki.
- As a consequence, we also will need (given that ICU admissions are now waiting substantial times to actually get to ICU) to consider that the “first 24 hrs in ICU” are from accept date/time, not arrival. THIS in turn, has implications for if DSM is even sending us that “prior” data to peruse to generate the correct APACHE scores. Julie to check on that, and clearly we need to discuss this more and clearly document on Wiki and notify all collectors.
- There is a new phenomenon of extended “boarding” of ICU patients. This can be in ED, PACU, elsewhere. We now have to deal with this and so we probably need to make an ECIP designation, similar to EMIP. The problem is that they’re hard to capture if they never get to ICU we’re dependent on accidentally hearing about them. So, we need to devise a process at each of the 3 hospitals to do this. Trish will ask Lisa at Grace to work on it. Allan will talk to Bojan about having the ICU fellow or attending be responsible for adding these people to the paper ICU admission logs at each site.
ICU Database Task Group Meeting - January 23, 2020
- Present: Allan, Barret , Joanna, Julie, Michelle, Tina
- Absent: Trish
- Minutes prepared by: AG
- Action items in BOLD
1. Followup about working to reduce collector workload
- Regarding obtaining CBS TraceLine for all transfusion data. Allan reported that he followed up with Margaret Ring (margaret.ring@blood.ca) on 1/20/2020 and her reply was to expect a response in a few weeks. Allan will follow up with her in the middle of February.
- Regarding obtaining RIS data for radiology tests. Allan reported that he followed up with Shared Health CIO Charles Conway [204-926-1400; cconway3@sharedhealthmb.ca] on 1/20/2020, who replied that he’ll get back to Allan. Allan will follow up with him at the end of February.
2. Followup on having the ICU nurses do all TISS coding -- we have not implemented this yet because:
- While we have top administrator agreement at HSC, we are waiting for Dan to arrange similar meetings at St. B and Grace
3. Followup on trying to get hospital-level data elements from EPR. Tina discovered that there is an application called Cognos which has capability to extract data elements from existing databases. Tina has opened incident 3845870 and is working with Alex Omsen and Mike Ocko on getting this set up; see Cognos#Phone call with Mike Ocko
4. Follow up on how to code diagnostic sampling of pericardial fluid or the pericardium. See Jan 2, 2020 minutes for decisions. Tina has added (D) Pericardium with code 2.HA .
5. Followup on pulling in certain lab results in addition to current counts via re-parsing all DSM data from 1/1/2019.
- Barret proposed a schema, but after discussion we recognized that Julie is already pulling ALL the actual results into a SAS format, and that there is no impediment from doing this going forward. It means that for any specific question/project, Julie will have to write SAS code to pull and format the data elements of interest.
- We will then start to discuss having Julie work to do the programming needed to automatically do the lab-related APACHE II APS score.
6. Following up on fact that some collectors are applying priority 0 to unconfirmed diagnoses with priority 0. The concern about this is that Julie uses the lowest priority diagnosis for reporting of cause of readmission, and this is done with incomplete data (i.e. before the unconfirmed diagnoses are all figured out). But after discussion we realized that this will not be a problem if Julie adds to this analysis the requirement that there Dx Primary also be checked.
7. Followup on coding fistulas
- We already have codes for these: J95.03 for T-E, K31.6 for stomach or duodenum, K60.5 for anorectal, K63.2 for intestinal, N32.2 for bladder, N82 for female genital tract.
- We agreed NOT to add any others, which are rarer, and in those cases use a NOS code -- e.g. Gallbladder or bile duct disorder, NOS
- There are other issues related to fistulae -- e.g. that there are always 2 parts involved. So we decided that the rule will be to combine the two portions together, except when one end of the fistula is to outside (i.e. the skin). Tina has created Template:ICD10 Guideline Fistulas, and Allan will populate it with this information -- DONE.
8. Followup on the uncertainty about what to do when in CCI, both diagnostic and therapeutic procedures are done on the same body part. We discussed this previously in the minutes, and under CCI_Collection#Related_Imaging.2C_Diagnostic_and_Therapeutic_procedures_performed_at_the_same_time it states when both are done to code them both.
9. Followup on how to code miscellaneous neuromuscular disorders? The solution(s) are:
- When the disease is KNOWN, and we don’t have a code for that specific disorder, collectors should find out (e.g. wikipedia) whether it is a primary nervous system disorder vs. a primary muscle disorder.
- If nervous system use the appropriate NOS code related to that system -- e.g. Kennedy’s disease, also called “Spinal and bulbar muscular atrophy”, is a degenerative disease of the CNS that results in muscle atrophy and thus the correct NOS code is Degenerative nervous system disorder, NOS. Other potentially useful NOS codes are Muscle disorder/myopathy (primary or secondary), NOS, Disorder of nervous system (any part), NOS, Movement disorder, NOS.
- When the specific diagnosis is not known at all, then we decided we’ll add dx Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems with code R29.8. Tina has done this.
10. Followup on issues of ESRD and Acute renal failure.
- Can ESRD be both and Admit and a Comorbid diagnosis? --> Answer is YES, if it was present prior to hospital admission AND it satisfies the criteria for an Admit diagnosis.
- Can a patient have both acute renal failure and ESRD (Stage 5)? --> Answer is YES, with limitation:.
- If the criteria for Stage 5 is being on dialysis, then the answer is No -- this is the limitation
- But if the criteria is creatinine clearance <15 ml/min in someone NOT yet on dialysis, then YES.
- The implications of these is that Tina has removed the checks currently in existence relating to each of these 2 items (they turn out to be 1 check, both dxs could not be present at same ward/unit admission).
11. New items:
- Coding procedures for control of bleeding -- The issue here is that in CCI one currently has two separate options for the “what was done” part of this procedure, i.e. Control of Bleeding of the body part bleeding, or Occlusion of the bleeding vessel (e.g. via clipping or embolization or sclerosis).
- After discussion we agreed that the most informative and favored option is to combine the body part bleeding with Control of Bleeding. Thus for control of bleeding esophageal varices, the body part to go along with it is (T) Esophagus. Allan will add to these wiki articles to make this clear -- DONE.
ICU Database Task Group Meeting – January 2, 2020
- Present: Allan, Barret , Joanna, Julie, Michelle, Tina, Trish
- Absent:
- Minutes prepared by: AG
- Action items in BOLD
1. Followup about working to reduce collector workload
- Regarding obtaining CBS TraceLine for all transfusion data. Allan will follow up with Margaret Ring (margaret.ring@blood.ca) and Tony Loewen (anthony.loewen@blood.ca)
- Regarding obtaining RIS data for radiology tests. Allan will follow up with RIS administrators (Angela Charbonneau 926-9874; Randy Roels 926-9871, rroels@sharedhealth.mb.ca).
- Regarding obtaining automated ABG data at HSC and St. B -- this has been implemented, getting that data from those sites from DSM data.
- Regarding consolidating some of the “what was done” components of CCI therapeutic interventions -- the plans from the 11/11/2019 meeting have been implemented.
2. Followup on having the ICU nurses do all TISS coding -- we have not implemented this yet because:
- While we have top administrator agreement at HSC, we are waiting for Dan to arrange similar meetings at St. B and Grace
3. Followup on trying to get hospital-level data elements from EPR. Tina discovered that there is an application called Cognos which has capability to extract data elements from existing databases.
- Tina has opened incident 3845870 and is working with Alex Omsen and Mike Ocko on getting this set up; see Cognos#Phone call with Mike Ocko
4. Follow up on how to code diagnostic sampling of pericardial fluid or the pericardium. Answers are:
- for therapeutic pericardial drainage combine (T) Pericardium with Drainage, Evacuation
- for diagnostic pericardiocentesis -- we agreed today to add the “body part” item for diagnostic tests of 2.HA, (D) Pericardium. Then this is combined with the appropriate Biopsy (endoscopic) or Biopsy (non-endoscopic) depending how it was sampled. In other words, we are not distinguishing between a “fluid biopsy” of the pericardium and a true tissue biopsy of it. Tina added this.
5. Followup on pulling in certain lab results in addition to current counts vis re-parsing all DSM data from 1/1/2019
- Barret with help from Tina will generate a draft list of which tests to do this for, which we’ll discuss at the next Task meeting. It should include the tests needed to calculate APACHE 2. Care must be taken to balance usefulness with data storage issues.
- As part of this, we will work so that the labs values that are part of APACHE 2 no longer need to be dealt with by the data collectors.
6. Item we didn't discuss yet -- unconfirmed diagnoses with priority 0. We'll discuss next time.
7. Followup on query about coding for the myraid of other fistulas out there
- There are separate codes for all of these when nontraumatic.
- We already have codes for these: J95.03 for T-E, K31.6 for stomach or duodenum, K60.5 for anorectal, K63.2 for intestinal, N32.2 for bladder, N82 for female genital tract.
- We don’t have codes now for: K82.3 for gallbladder, M25.1 for joint, or less common ones (e.g. lacrimal duct) and have to decide whether to add either of them. We also have to decide how to handle the fact that there are always TWO things connected by the fistula. We already have a “Category:Fistula” but probably need to create a template for it too that references the category but also discusses the various issues. If Tina will do this, Allan will populate it.
8. New items:
- There is some uncertainty about what to do when in CCI, both diagnostic and therapeutic procedures are done on the same body part. We discussed this previously in the minutes, and under CCI Procedures it states when both are done to code them both.
- How to code miscellaneous neuromuscular disorders?
- This is problematic because although they are often discussed as if they were a single category of disorders, in fact they are two separate categories, comprising nervous system disorders and muscular disorders. This is why there is no ICD10 code for miscellaneous neuromuscular disorders.
- The example used, Kennedy’s disease, also called “Spinal and bulbar muscular atrophy”, and is a degenerative disease of the CNS that results in muscle atrophy.
- We already have sufficient “NOS” codes within the neuro and muscular disorders to handle this when the disorder is known but we don’t have a specific code for it (as in the Kennedy disease example, where one should use Degenerative nervous system disorder, NOS). The other potentially useful NOS codes are Muscle disorder/myopathy (primary or secondary), NOS and Disorder of nervous system (any part), NOS, and for when it’s a movement disorder Movement disorder, NOS.
- The bigger problem is when it’s not clear whether it’s a primary nervous system vs. muscle disorder. In this case, one can:
- wait to see whether the medical teams decide on nervous vs. muscular disorder
- use a code that represents the symptom(s) not the disease per se. For example, if the symptoms are movement-related, one can use existing code Involuntary movements, NOS. And lastly when none of this is good enough, we might consider adding the code R29.8, to be called “Other and unspecified symptoms and signs involving the nervous and musculoskeletal systems”. We’ll discuss this next meeting.
- Can ESRD be both and Admit and a Comorbid diagnosis? The answer is YES, if it was present prior to hospital admission AND it satisfies the criteria for an Admit diagnosis. This decision also answers the issue of having acute on chronic renal failure.
- What should be done when creatinine clearance is <15 ml/min but the patient is admitted for uremic symptoms? This is an issue because the definition of Chronic kidney disease (end-stage renal/kidney disease, ESRD), Stage 5, GFR LT 15 is either on dialysis or with clearance<15. But of course, there are some patients who don’t start dialysis until they have GFR<10 or sometimes even lower. The answer is to follow the definition, such a person qualifies for Stage 5 as a comorbid condition, and as directly above, that same code can be used as an Admit diagnosis, along with the specific reason for admission (e.g. hyperkalemia).