A tri-fold documentation tip sheet has been developed to inform providers on documentation criteria of the most common high-risk variables to improve expected rates of mortality. This also impacts length of stay and readmission.

Please review the information in the sheet and included below, and please feel free to download the PDF for easier reference moving forward.

 Thank you for your support of this educational tool and resource to engage in our mortality improvement initiatives throughout Corewell Health East. We greatly appreciate your partnership.

Clinical Documentation Integrity

Accurate and complete documentation ensures optimal provider quality performance outcomes such as severity of illness, risk of mortality and expected length of stay and captures all conditions being managed for appropriate reimbursement. You deserve credit for the excellent care you provide to your patients.

The informational pamphlet has been developed to assist providers with documentation opportunities for the most frequent mortality risk variables.

The specificity and acuity of these common diagnoses should be documented when appropriate in order to ensure accurate code assignment:

• Cachexia
• Cardiac Arrhythmia
• Coagulation Defects
• Congestive Heart Failure
• Encephalopathy
• Fluid and Electrolyte Disorders
• Liver Failure
• Metastatic Cancer
• Malnutrition
• Respiratory Failure
• Shock

Specify type:

• Systolic or reduced EF or HFrEF (EF < 40%)
• Diastolic or preserved EF or HFpEF (EF > 50%)
• Mid-range or HFmrEF (EF 41- 49%)
• Systolic & Diastolic (EF < 50%) w/ diastolic dysfunction on echocardiogram

• End-stage CHF Stage D - Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

Specify Acuity/Status:

• Acute, Acute/Chronic
• Decompensated or exacerbated
• Chronic or compensated

E.g. Acute on Chronic Systolic CHF Decompensated Systolic CHF

Cardiac Arrhythmias

Specify Type:

• Atrial fibrillation
  • Paroxysmal
  • Persistent
  • Permanent
• Atrial Fib/Flutter
• Atrial Flutter
• Sinus bradycardia
• Supraventricular tachycardia (SVT)
• Ventricular tachycardia (Vtach)
• Ventricular fibrillation (Vfib)

• Dehydration
• Fluid overload
• Metabolic Alkalosis or Metabolic Acidosis
  

Specify condition associated with lab values:

• Low potassium = Hypokalemia 
• High potassium = Hyperkalemia 
• Low sodium = Hyponatremia
• High sodium = Hypernatremia

Specify Type:

• Alcoholic hepatic failure with or without coma
• Toxic liver disease with hepatic necrosis with or without coma
• Acute and subacute hepatic failure with or without coma
• Chronic hepatic failure with or without coma
• Hepatorenal syndrome
• Hepatopulmonary syndrome
• Hepatic encephalopathy
• Postprocedural hepatic failure

Please specify:

• If bleeding and on an antiplatelet/anticoagulant link the bleeding to the medication if related
  • Hereditary factor VIII, IX, and XI deficiency
  • Von Willebrand's disease
  • Hereditary deficiency of other clotting factors
  • Acquired hemophilia
  • Antiphospholipid antibody with hemorrhagic disorder
  • Other hemorrhagic disorder due to intrinsic circulatory anticoagulation
  • Acquired coagulation factor deficiency Specify cause:
    • hyperprothrombinemia
    • liver disease
    • vitamin K deficiency
• Activated protein C resistance
  • Prothrombin gene mutation
  • Other primary thrombophilia
  • Antiphospholipid syndrome
  • Lupus anticoagulant syndrome
  • Other thrombophilia - COVID
  • Other specified coagulation defects
  • Coagulation defect, unspecified

Specify type if known or suspected:

• Hypoxic Respiratory Failure
• Hypercapnic Respiratory Failure
• Hypoxic/Hypercapnic Respiratory Failure

Specify acuity if known or suspected:

• Acute, Chronic, Acute on Chronic

E.g. Acute on chronic Hypoxic Respiratory Failure

Hypoxemic (Not applicable for patients on continuous home 02 with chronic respiratory failure)

• p02 < 60 mmHg (Sp02 < 91%) on room air* or
• P/F ratio (p02/FIO2) < 300* or
• 10 mmHg decrease in baseline p02 (if known)

Hypercapnic

• pC02 > 50 mmHg with pH < 7.35 or
• 10 mmHg increase in baseline pC02 (if known)

Chronic Respiratory Failure:

• Hypoxemia
• Often with baseline p02 < 60 mmHg on room air
• Home 02 dependent
• Elevated CO2
• Elevated bicarbonate level (CO2 on BMP)

• Cardiogenic shock
• Hemorrhagic shock
• Hypovolemic shock
• Septic shock
• Shock secondary to an adverse effect
• Shock secondary to poisoning/OD
• Shock; unknown etiology
• Toxic shock syndrome

• Traumatic or post-traumatic shock

Lactate level > 4 mmol/L without BP parameters

 Hypotension that does not respond to effective fluid resuscitation (30-40 cc/kg over 1 hour)

• SBP   < 90 mmHg or
• MAP < 70 mmHg or
• Decrease in baseline BP of >/= 40 mmHg

Encephalopathy - diffuse disease of the brain that alters brain function (acute) or structure (chronic) that resolves when underlying systemic cause is corrected.

Specify type/underlying etiology:

• Metabolic - due to fever, infection, dehydration electrolyte imbalance, organ failure, etc.
• Toxic - due to effects of drugs, toxins, poisons
• Septic - clinical term that represents manifestations of severe sepsis
• Hepatic - due to severe end-stage liver disease
• Anoxic - due to sustained hypoxia
• Hypertensive - consequence of severe HTN

 Malnutrition

Specify if there is a diagnosis assoc. with a BMI <19:

• Cachexia– wt. loss of muscle mass; more than 5%
• Underweight
• Malnutrition (specify severity)

 SPCM—Severe Protein Calorie Malnutrition

 Two or more Clinical Indicators:

1. Decreased energy intake:
   •  < 50% energy intake > 5 days
2. Body fat depletion:
   • Moderate to severe
3. Muscle mass depletion/wasting:
   • Moderate to severe
4. Fluid accumulation:
   • Moderate to severe
5. % Weight loss:
   • > 5% in 1month, > 7.5% in 3 months
   • > 10% in 6 months, > 20% in 12 months

 Use supporting documentation from Dietitian summary; provider co-signature available

• Present on Admission, or POA - Clarify all diagnoses that are POA.
• The POA status of diagnoses may be updated anytime during the hospital admission.
• Review/manage the Problem List and update accordingly.
• After study, specify if conditions are ruled in or out.
• At the time of discharge “Probable”, “Suspected” or “Likely” can be coded as if the condition existed.
• Coders cannot code from abnormal labs, imaging and/or pathology reports. When clinically significant link the results to specific conditions and/or diseases.
• Point of Origin, or POO, for Admission/Visit is a required code. Examples of POO include Home, Physician/Clinic Office, Another Acute Care Facility, Skilled Nursing Facility, SNF, Intermediate Care Facility, ICF, Assisted Living Facility, ALF, Nursing Facility, NF, or Other Health Care Facility.

 Metastatic Cancer

• Specify primary site
• Specify any secondary sites
• Stage IV cancer does not code to metastatic cancer (must document metastatic sites)
• Suspected neoplasm at the time of discharge can be coded as confirmed

• Findings of neoplasm on surgical pathology report cannot be coded or reported unless the provider indicates clinical significance