Webinar covid 19pdf

3M Special Webinar Series
COVID-19 | Implications for HIM and CDI

2©3M 2020. All Rights Reserved. 3M Confidential.
COVID-19 | Implications for HIM and CDI
Agenda
At the end of this presentation, attendees will be able to:
• Capture acuity, severity, and risk with secondary diagnoses
• Support epidemiology with chronic conditions and social
determinants of health
• Appreciate need for data integrity
• Explore workflows that mitigate burnout

Disclaimer
The information presented herein contains the views of the
presenters and does not imply a formal endorsement or consultation
engagement on the part of 3M. Participants are cautioned that
information contained in this presentation is not a substitute for
informed judgment. The participant and/or participant’s organization
are solely responsible for compliance and reimbursement decisions,
including those that may arise in whole or in part from participant’s
use of or reliance upon information contained in the presentation. 3M
and the presenters disclaim all responsibility for any use made of
such information.

Physician documentation and
CDI for COVID-19
Presenters: Cheryl Manchenton, RN, BSN
3M Project Manager, Quality Services Lead
Beth Wolf MD, CPC, CCDS
3M Physician Consultant

COVID-19
The spectrum of illness
Report from the Center for Disease Control and Prevention in China
44,500 confirmed infections
• Mild disease – 81%
• no or mild pneumonia
• Severe disease – 14%
• with dyspnea, hypoxia, or >50% lung involvement on imaging within 24-48 hours
• Critical disease – 5%
• with respiratory failure, shock, or multiorgan dysfunction
Overall case fatality rate was 2.3%
Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese
Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648

COVID-19 manifestations
Respiratory conditions

Bronchitis and upper respiratory infection
Image credit: https://www.cdc.gov/antibiotic-use/community/images/bronchitis-lg.jpg
Bronchitis
• Inflammation of the bronchial airways
due to infectious or non-infectious cause
Clarification of acuity needed
• Acute or subacute
• Chronic Unspecified
• Ensure linkage of causative organism to
respiratory disease
URI (upper respiratory infection)
*Please refer to 3M™ COVID-19 webinar from
3/25/20 for coding of respiratory conditions

Acute respiratory failure
Refer to organizational definitions of
acute respiratory failure
Ensure documentation of type and
acuity are present
• Acute, acute on chronic
• Hypoxic, hypercapnic or both
Adult respiratory failure cannot be coded
with adult respiratory distress syndrome
(ARDS)
*Please refer to 3M™ COVID-19 webinar from
3/25/20 for coding of respiratory conditions

Acute respiratory distress syndrome
Acute, diffuse, inflammatory form of lung injury, leading to increased pulmonary
vascular permeability, increased lung weight, and loss of aerated lung tissue
Berlin definition:
• Acute onset, within 1 week of an apparent clinical insult and with progression of respiratory
symptoms
• Bilateral opacities on CXR or CT scan
• Not explained by other causes (e.g. pneumonia, cardiogenic pulmonary edema, nodules, etc.)
• Decreased PF ratio
• Mild PF ratio 201-300
• Moderate PF ratio 101-200
• Severe PF ratio ≤ 100
• Requires minimum PEEP of 5

Acute respiratory distress syndrome (cont.)
Other documentation to look for . . .
• Conservative intravenous fluid strategy (in patients without shock)
• Ventilation management
• Non-invasive
• Invasive
• Lung protective ventilation strategies
• Periodic prone positioning during mechanical ventilation
• Consideration of extracorporeal membrane oxygenation
*Please refer to 3M™ COVID-19 webinar from 3/25/20 for coding of respiratory conditions
Fan E, etal. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice
guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. AmJRespirCritCareMed.2017; 195(9):1253-1263.

Cardiac conditions

Elevated troponin
Common among critically ill patients
• Generally does not represent a type 1 (plaque rupture) myocardial infarction
Type 2 Myocardial Infarction (2018 Fourth Universal Definition of MI1)
• Rise and/or fall of the troponin with at least one value above the 99th percentile, AND
• Evidence of an imbalance between myocardial oxygen supply and demand unrelated to
coronary thrombosis, AND
• At least one of the following:
• Symptoms of acute myocardial ischemia
• New ischemic ECG changes
• Development of pathological Q waves
• Image evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern
consistent with an ischemic etiology
1J of the Amer College of Cardiology Volume 72, Issue 18, October 2018 DOI: 10.1016/j.jacc.2018.08.1038

Viral cardiomyopathy
Viral cardiomyopathy is a progression of viral myocarditis
The heart wall has three layers:
• Pericardium – the ‘sac’ that surrounds the heart;
• Endocardium – the inner lining of the heart; and
• Myocardium – this is the middle layer, the heart muscle
Myocarditis is an inflammation of the heart’s muscle wall
Viral cardiomyopathy involves thickening of the myocardium and dilation of the
ventricles (a type of dilated cardiomyopathy).
Diagnosed via echo, cardiac MRI, myocardial biopsy

Heart failure
Viral cardiomyopathy can further degenerate into
acute (or chronic) heart failure
Dilated ventricles result in low cardiac output
(ejection fraction)
• HFrEF/systolic heart failure
• Signs and symptoms similar to other causes of systolic heart
failure
Treatment is supportive (in other words supporting the compromised
heart via inotropic support (Dobutamine, etc.) and afterload reduction
with nitroglycerin

Cardiogenic shock
Treatment includes: fluid bolus, transfusions, vasopressors (such as neosynephrine) and inotropes (such as
dobutamine), IABP, ECMO
Sustained low blood pressure with tissue
hypoperfusion despite adequate left ventricular
filling pressure
• Cool clammy skin (especially extremities)
• Confusion, coma
• Severe hypotension
• Tachycardia with weak/thready pulse
• Low cardiac output
• Elevated cardiac filling pressures; JVD
• Oliguria
• Acidosis
• Pulmonary edema

Hepatic conditions

Elevated liver enzymes
Laboratory findings on hospital admission1
• Aspartate aminotransferase (AST)
• Alanine aminotransferase (ALT)
• Lactate dehydrogenase (LDH)
Viral hepatitis “due to” COVID-19
• Need acuity and clear link of hepatitis to COVID-19
• Acute hepatitis due to COVID-19
• Hepatitis unspecified
• Viral hepatitis
Risk Factors Associated with Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan,
China JAMA Intern Med. Published online March 13, 2020. doi:10.1001/jamainternmed.2020.0994cc
Patients are not presenting with fulminant
hepatitis but the liver is affected

Hepatic failure
Hepatitis may progress to hepatic failure
Hepatic failure may be the result of critical illness
• Specificity to acuity is needed
• Review for presence or documentation of coma
Review for evidence of hepatorenal syndrome
Ensure provider documents both the hepatic and
renal components
• Example: acute hepatic failure and AKI
• All three can be coded
Note: GCS scores cannot be reported with hepatic failure unless the GCS/mental status is noted as due to
other cause (such as sepsis, acute respiratory failure, metabolic encephalopathy, etc.)

Infectious conditions

Sepsis and septic shock
Various definitions exist
Sepsis-2
• SIRS due to infection (either suspected or confirmed) as manifested by two or more of the
criteria not easily explained by another co-existing condition.
Sepsis-3 (2016)
• Life-threatening organ dysfunction due to a dysregulated host response to infection
Septic shock: tissue hypoperfusion despite adequate volume resuscitation as
evidenced by acidosis and need for pressor support

Organ dysfunction in Sepsis-2 and Sepsis-3
Organ system Sepsis-2 Sepsis-3 (SOFA)
Respiratory Hypoxemia PaO2/FiO2 < 300 PaO2/FiO2 < 400
Cardiovascular Hypotension SBP < 90 MAP < 70 or Vasopressors
Liver Hyperbilirubinemia > 4mg/dl Bilirubin ≥ 1.2
Coagulation Thrombocytopenia < 100K Platelets < 150K
CNS Altered mental status Glasgow coma scale ≤ 14
Renal
Acute oliguria
Creatinine increase < 0.5mg/dl
Urine output < 500
Creatinine > 1.2
Severe sepsis

Other conditions

Clinical findings
• Petechiae, ecchymoses, oozing
• Venous thromboembolism
• Arterial thrombosis with organ ischemia
• GI/pulmonary/CNS bleeding
• Pulmonary microthrombi
• Delirium, coma, transient focal symptoms
• Adrenal failure (hyponatremia, hyperkalemia
Coagulation abnormalities
Laboratory findings
• Thrombocytopenia
• Prolonged PT and aPTT
• Low plasma fibrinogen
• Elevated plasma D-dimer
• Increased thrombin time
• Blood smear: microangiopathic changes (schistocytes
• Thrombocytopenia
• Coagulopathy
• Disseminated intravascular coagulation (acute)
• Systemic process with the potential for causing thrombosis and hemorrhage

Altered mentation
Delirium “due to” . . .
Encephalopathy “due to” . . .
Common clinical indicators (no widely endorsed definition)
• Acute/subacute change in baseline (usually does not wax and wane)
• Identified systemic cause
• Improves as cause is corrected
Documentation awareness
• Conflicting exam findings (beware of templates)
• Resolves quickly or does not increase length of stay
• No additional workup or attention
Comatose
Glasgow coma scale scores

Renal failure
Acute kidney injury
KDIGO diagnostic criteria
• Increase in serum creatinine by ≥ 0.3 mg/dL within 48 hours, or
• Increase in serum creatinine by ≥ 1.5 times baseline (which is known or presumed to have occurred within the prior
seven days), or
• Urine volumes < 0.5 mL/kg/hour for six hours
Acute tubular necrosis
Common clinical indicators
• Meets acute kidney injury definition
• Elevated above baseline > 72 hours despite effective fluid resuscitation
• Underlying risk factors (sepsis, hypotension, shock, rhabdo, IV contrast, NSAIDS, surgery)
• Diagnostic studies
• Urine microscopic: muddy brown granular casts
• Urine sodium > 40 mEq/L
• Fractional excretion of sodium (FeNa) > 2%
Use caution when interpreting
in chronic kidney disease

Hemophagocytic lymphohistocytosis (HLH)
• Life-threatening syndrome of excessive immune activation
• Viral infection is a common trigger in adults
• Characterized by fulminant hypercytokinemia with multiorgan failure
• Findings . . .
• Fever
• Cytopenia
• Hepatosplenomegaly
• Neurologic symptoms
• Pulmonary involvement
• High serum ferritin
• Diagnosis of HLH is made by identifying a mutation in an HLH gene, or by fulfilling diagnostic
clinical criteria
Mehta, etal. COVID-19: consider cytokine storm syndromes and immunosuppression. The Lancet. March 16, 2020. DOI: 10.1016/S0140-
6736(20)30628-0
McClain KL, Eckstein O. Clinical features and diagnosis of hemophagocytic lymphohistiocytosis. UpToDate. July 11, 2019c

Nosocomial infections
Ventilator-associated pneumonia (VAP) 1
• Develops ≥ 48 hours after endotracheal intubation
Hospital-acquired pneumonia (nosocomial pneumonia) 1
• Occurs ≥ 48 hours after admission and did not appear to be incubating at the time of admission
Catheter-related infections
• Urinary tract infection
• Bloodstream infection
Clostridium difficile
Drug-resistant organisms
1 Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases
Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61. Epub 2016 Jul 14.

COVID-19 spectrum of illness- post April 1 discharges example
Examples of levels of severity of illness (SOI) and risk of mortality (ROM)
Less sick -----------------------------------------------------------------------------------> More sick
Mild SOI 1
Acute bronchitis
Dyspnea
Hypoxemia
Acute respiratory
distress
Elevated liver
function tests
Viral
cardiomyopathy
Moderate SOI 2
Other viral
pneumonia** (ROM 1)
ARDS** (ROM 3)
AKI* (ROM 3)
Delirium*
Thrombocytopenia
Coagulation defect*
Major SOI 3
Viral myocarditis**
Acute systolic heart
failure**
Metabolic
encephalopathy**
Sepsis**
Extreme SOI 4
Acute respiratory failure**
Severe sepsis**
Cardiogenic shock**
ATN**
Acute liver failure**
DIC**
Coma/GCS 1 or 2**
Critical illness myopathy*
(ROM 3)
*Complication/comorbidity **Major complication/comorbidity
SOI/ROM utilizing APR DRG 137

COVID-19 – The importance of characterizing all patients
What we know (evolving)
Epidemiological risk factors2
• Older age
• Coronary artery disease
• Hypertension
• Diabetes
• Chronic pulmonary disease
We need to collect complete and accurate data.
2Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Fei Zhou. The
Lancet. 2020 Mar 9. doi: 10.1016/S0140-6736(20)30566-3

Lung disease and respiratory disorders
Risk adjustment factor (RAF) ------------------------------------------------------------> more sick
COPD risk factor bonus (community and/or institutional-based living)
 COPD and congestive heart failure . . . . + 0.155
 COPD and cardiorespiratory failure . . . . + 0.363
Hierarchical condition categories (CMS-HCC Listing V24)
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Respirator
dependence 82
Tracheostomy
status 82
Cystic fibrosis 110Chronic obstructive
pulmonary disease
(COPD) 111
Pulmonary fibrosis 112
Respiratory failure 84
Aspiration
pneumonia 114
Pneumococcal
pneumonia 84

Cardiac disease and vascular disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Atherosclerosis of
extremity w
ulceration or
gangrene 106
Angina, chronic 88
Chronic afib 95
Heart failure 85
Atherosclerosis of
extremity 108
Venous
thrombosis 108

Endocrine disease and metabolic disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Diabetes w acute
complications 17
Morbid obesity 22 Cachexia 21
Diabetes w chronic
complications 18
Diabetes wo
complications 19
BMI ≥ 40 22 Malnutrition 21
Diabetic
peripheral
angiopathy w
gangrene 106

Renal disease
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Dependence on
renal dialysis 134
CKD stage 3 138
CKD, stage 4 137
CKD, stage 5 136
ESRD 136
AKI 135
ATN 135
Renal risk factor bonus (community-based living)
 Renal stage 3, 4, 5, or ESRD and congestive heart failure . . . . + 0.156

Liver disease and gastrointestinal disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
End stage liver
disease 27
Esophageal varices 27
Cirrhosis 28
Alcoholic liver
disease 28
Crohn’s disease 35
Chronic hepatitis 29
Ulcerative colitis 35 Colostomy 188
Gastrostomy 188
Portal hypertension 27
Chronic
pancreatitis 34

Brain and nervous system disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Amyotrophic lateral
sclerosis 73
Quadriparesis70
Multiple sclerosis 77
Dementia with behavioral
disturbances 51
Seizure 79
Dementia 52
Monoplegia 104
Cerebral palsy 74
Hemiparesis 103
Coma 90
GCS total score 4-8 90
Paraparesis 71
Parkinson’s 78

Malignancy and hematologic disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Lung cancer 9
Metastases 8 –RAF 2.659
Breast cancer 12
Prostate cancer 12
Colorectal
cancer 11
Hypercoagulable state 48
Thrombocytopenia 48
Pancreatic cancer 9
MDS 46
Lymphoma 10
Renal cancer 11
Melanoma 12
Myelophthisis 46
Sickle cell disease 46
Pancytopenia due to chemo 47
s/p bone marrow transplant 186
RED – one of two RAF scores > 2.000

Skin ulcers
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Below the knee
amputation status 189
Colostomy 188
Gastrostomy 188
Chronic non-pressure ulcer 161
Pressure ulcer stage 3
or unstageable 158
Pressure ulcer stage 4 157
- RAF 2.028
Quadriplegia 5
Paraplegia 7
Pressure ulcer stage 2 159
RED – one of two RAF scores > 2.000

Psychiatric diseases and substance use conditions
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Major depression, single episode or recurrent
(mild, moderate, severe) full or partial remission 59
Alcohol abuse with alcohol-induced anxiety disorder 54
Bipolar disorder 59
Alcohol or opiate dependence, uncomplicated or in
remission 54

Inflammatory diseases and immune disorders
< 0.3 ≥ 0.3 ≥ 0.4 0.6-2.6
Hypogamma-
globulinemia 47
SLE/scleroderma 40
Rheumatoid arthritis,
unspecified 40
HIV disease 1
Graft-versus-host
disease 47
Opportunistic infections 6
Polyneuropathy 75
Myasthenia gravis 75

Social determinants of health
Z59.3 Problems related to living in residential institution
Z59.7 Insufficient social insurance and welfare support
Z60.4 Social exclusion and rejection
Z60.5 Target of (perceived) adverse discrimination and persecution

Data integrity versus staff
burnout

Data integrity
Need robust set of coded data
Better clinically understand this disease and all of its manifestations
• Avoid temptation to code the minimum data set as staff may be overwhelmed with claims to process
• Without the full list of both acute manifestations and sequelae as well as chronic conditions, it will be more
difficult to determine the full extent of this disease and who should need higher levels of care and/or
screening
Provide information for future pandemic preparation
• Bed, personal protective equipment (PPE) and ventilator capacity
• Robust set of data to prepare for the next pandemic

Strategies to ensure data integrity
Slow down and pay attention to the details of documentation, review and code
capture
CDI staff should work in an environment of quality versus quantity
• Full case review with appropriate clarifications (please be sensitive to the query volume)
Coding professionals should also work in an enviroment of quality over quantity
• Ensure all apppropriate conditions that meet UHDDS criteria are captured and sequenced amongst top 25
diagnosis
Providers need to fully document the acuity of the COVID-19 population
• Patient care needs are best supported by cold hard data
Revenue cycle leaders and hospital administrators should consider suspending benchmarks for
performance (e.g., productivity metrics, turn-around time) until this crisis has passed
• Organizations can be better prepared for the future with appropriate reflection of the population today

Strategies to mitigate burnout
Front-line clinicians
• Revisit query policy
• Assist with templates and favorites
• Combine efforts with communication
• Acknowledge clinicians’ situational stress; be empathetic
Clinical Documentation Integrity Specialists (CDIS) and coding professionals
• Perform CDI reviews and coding remotely
• Modify work hours
• Manage CDI workload if CDI staff are drafted into clinical roles

Abbreviations
Afib – atrial fibrillation
AKI – acute kidney injury
APR DRG – All Patient Refined Diagnostic Related
Group
ARDS – acute respiratory distress syndrome
ATN – acute tubular necrosis
BMI – body mass index
CDI – clinical documentation integrity
CKD – chronic kidney disease
CMS – Centers for Medicare and Medicaid Services
CNS – central nervous system
COVID-19 – SARS-CoV-2
CT scan – computed tomography scan
CXR – chest x-ray
ECG – electrocardiogram
ECMO – extracorporeal
ESRD – end stage renal disease
GCS – Glasgow coma scale
HFrEF – heart failure with reduced ejection fraction
HIV – human immunodeficiency virus
IABP – intra-aortic balloon pump
MAP – mean arterial pressure
MDS – myelodysplastic syndrome
PEEP – positive end expiratory pressure
PF ratio – “P” is the partial pressure of oxygen and
the “F” is the fraction of inspired oxygen
SLE – systemic lupus erythematosus
w – with
wo – without

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