Documentation & Coding Tools

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1 To access these tools and any new tools, go to: PacifiCare: MDQuickFax Provider Library Publication MDQuickFax Coding Resources Provider Library Resource Center Coding & Documentation Tools & Resources Documentation & Coding Tools UnitedHealthcare: MDQuickFax Tools & Resources Products & Services Medicare MDQuickFax Coding Resources Tools & Resources Products & Services Medicare Coding Resources 2008

2 Chronic Kidney Disease Reporting ICD-9-CM coding for Chronic Renal Failure, Category 585, changed in The Renal Physicians Foundation along with the National Kidney Foundation promoted code Category 585 being renamed and expanded to reflect the new clinical practice standards for treating Chronic Kidney Disease. (CKD) Chronic Kidney Disease is defined as either: 1 2 Kidney damage - pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. OR GFR (Glomerular Filtration Rate) < than 60 ml/min/1.73m for > than 3 months. The new code assignments, describe the different stages in the progression of Chronic Kidney Disease. The new staging system is based on estimates of the glomerular filtration rate at each stage, with each stage defined by level of kidney function. Higher stages represent lower GFR levels Chronic Kidney Disease, Stage I Glomerular Filtration Rate (GFR) 90mL/min or more Healthy kidneys or kidney damage with normal or high GFR Plenty of Kidney function but may have protein or albumin in their urine Chronic Kidney Disease, Stage II Mild Glomerular Filtration Rate (GFR) 60-89mL/min Kidney damage and mild decrease in GFR Chronic Kidney Disease, Stage III Moderate Glomerular Filtration Rate (GFR) ml/min Moderate decrease in GFR Chronic Kidney Disease, Stage IV Severe Glomerular Filtration Rate (GFR) ml/min Severe decrease in GFR Chronic Kidney Disease Stages Chronic Kidney Disease, Stage V Glomerular Filtration Rate (GFR) less than 15 ml/min or on dialysis Kidney Failure Append V45.1 if appropriate End Stage Renal Disease End-stage renal disease (ESRD) is an administrative term in the United States, based on the conditions for payment for health care by Medicare ESRD Program. ESRD includes patients treated by dialysis or transplantation, irrespective of the level of GFR. Dialysis Status Append V45.1 if appropriate Chronic Kidney Disease, Unspecified Includes: Chronic Renal Disease, Chronic Renal Failure NOS, and Chronic Renal Insufficiency ICD-9-CM instructs the coder to use an additional code to identify Kidney Transplant Status if applicable (V42.0). A kidney transplant may not fully restore kidney function, therefore, patients who have undergone a kidney transplant may still have some form of Chronic Kidney Disease. Code V42.0, Kidney replaced by transplant, may be assigned with the appropriate CKD code, based on the patient s post-transplant stage. Patients that have had a kidney transplant where documentation indicates the presence of failure or rejection, assign code Complication of kidney transplant followed by the appropriate CKD code. Sources: Renal Physicians Foundation, National Kidney Foundation K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification In addition, for Stage V and ESRD, use code V45.1, if appropriate. Diagnosis Coding and Documentation Patient: Jane Doe Date of Service: 10/30/06 Reason for visit: S: Voices no complaint except that she wishes she could visit her sister, who is hospitalized. States she is able to get around, including bathroom and cafeteria, without difficulty. Denies any pain or shortness of breath. No change in bowel or bladder habits. O: Patient alert, oriented to person, disoriented to place and time. No acute distress. Cardiac: RRR no rubs, gallops or murmurs noted Lungs CTA bilat. No cough or wheezing noted. Abd soft non tender to palpitation with Colostomy intact, skin dry and intact surrounding pink-red stoma, liquid brown feces. Diminished sensation LE bilaterally, skin cool with rubor. Old incision for L great toe amputation dry and intact. Able to ambulate to toilet and cafeteria with walker. A: Diabetes with peripheral circulatory disorders, currently controlled; with peripheral vascular disease due to diabetes; and diabetes with neurologic manifestations of diabetic polyneuropathy. Finger stick blood sugar ranges in past 2 weeks. Diabetes controlled on current regimen a.c. & h.s. insulin; sliding scale insulin if needed. V44.3 Functioning colostomy, no change in plan of care. V49.71 Old amputated L great toe stable Mild senile dementia (see notes October 10, 2006) Osteoporosis, unspecified Osteoporetic vertebral fractures (see notes September 13, 2006). P: Continue current diet & insulin regimen. Retain sliding scale order for prn with notification parameters. Continue current activity level. Authenticated by: Joseph A. Williams MD Model Progress Note 1 10

3 9 The Mechanics The of of Chart Documentation Documentation validates that services were provided, ensures continuity of care, supports medical necessity and verifies that services provided are reported with accuracy. Good documentation supports the level of service billed resulting in appropriate reimbursement. * The physician s signature and credentials must be on each chart entry. * The patient name and the date of service must be on each page of the patient chart. * The medical record must be complete and legible. * Only standard medical abbreviations should be used. * Use SOAP format when applicable. * Note all acute and chronic diagnoses with the current status and treatment plans in the progress note. ICD-9-CM Guidelines and Tips * Current year version of ICD-9-CM 2008 must be used for accurate diagnostic coding. * Superbills need to be managed, updated, expanded and revised yearly. * Diagnosis codes must be accurate and specific. If a code offers 5 digits in ICD-9-CM, five digits must be used. Each digit adds specificity. * Avoid unspecified codes.9 unless there is not a more specific code available. * Code both the etiology (underlying disease) and the manifestation of the disease. The underlying disease would be coded first, with the manifestation of the disease in 2 nd place. Example: Kaposi s sarcoma due to HIV 042 (HIV) underlying disease Kaposi s sarcoma (manifestation) * When a combination code is offered in ICD-9-CM to classify two diagnoses, it must be used. Example: Malignant Hypertensive Chronic Kidney Disease Chronic Kidney Disease Stage V Hypertensive chronic kidney disease, malignant, with ckd stage V or end stage renal disease Chronic kidney disease, Stage V Coding Valid 10/01/06 to 10/01/07 Stroke and Late Effects of Prior Stroke One of the most common coding errors seen in chart audit is the assignment of a stroke code in the present tense when the coder is actually trying to code for the residual conditions left behind by a prior stroke. Acute stroke is only coded during the initial episode of care. Cerebrovascular Accidents (Stroke) In a CVA, there is a decreased supply of blood to the brain that can result in an area of infarction (necrotic cerebral tissue). CVA occurs because of thrombosis, embolism, occlusion (code categories 433 or 434) or hemorrhage (Category 430 to 432). There are codes for each type of CVA. The fourth and fifth digits of these codes indicate either with or without infarction. Unless otherwise stated, CVA/stroke is considered an assumed ischemic infarction and is coded The fifth digit of 1 indicates infarction. After the Initial Acute Care Episode of Stroke After an initial stroke incident has occurred, generally one of two scenarios will exist. Either the patient will have deficits from the stroke (conditions left behind such as paralysis) or will make a recovery without any long lasting effects. If the patient recovers without any lingering problems related to the stroke, the code would be V12.54 Stroke NOS without residual deficits. If the patient has deficits present after the discharge from the initial acute care episode, all deficits are coded to Late Effects (Category 438). Prior to October 2004, CVA not otherwise specified was coded to Category 436. In the current 2008 ICD-9- CM there is an exclusionary note specifically stating not to use this code for a cerebrovascular accident. Post-Operative Cerebrovascular Hemorrhage or Infarction A post-operative cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded Complications affecting specified body systems: Iatrogenic cerebrovascular infarction or hemorrhage. In addition, the specific type of infarction must be coded. The Time Line is Significant Example 1: Stroke initial incident Acute embolic CVA with infarction Example 2: Stroke initial incident; prior stroke with no deficits Acute embolic CVA, prior stroke with no deficits V12.54 Example 3: Stroke initial incident with deficits from prior stroke Acute embolic CVA with infarction; previous CVA with residual dysphagia Example 4: Follow-up for evaluation of dysphagia. The dysphagia was due to a stroke. Office visit to evaluate dysphagia from a stroke one month ago Example 5: The patient suffered a post-operative stroke; acute embolic CVA with infarction

4 Correctly Reporting Cancer Diagnoses: Current Cancer vs. History of Cancer To correctly report a diagnosis of cancer, one must determine whether the patient s cancer has been eradicated or is currently being treated. The neoplasm table in the ICD-9-CM code book establishes three categories of malignancy: primary, secondary and in-situ. Neoplasms should be coded to such and unknown sites must also be coded. Current Cancer Patients with cancer who are receiving active treatment for the condition should be reported with the malignant neoplasm code corresponding to the affected site. This applies even when a patient has had cancer surgery, but is still receiving active treatment for the disease. Example: Malignant neoplasm of kidney, Secondary Site with an Unknown Primary Site Example: Metastatic carcinoma from lung (Primary site lung) (secondary site unknown) Secondary Site with Active Primary Site A patient is admitted with metastatic bone cancer. The patient had a mastectomy 2 months ago and is having radiation treatments for the breast cancer. The neoplasm was located in the upper outer quadrant. Example: Code Neoplasm, bone, secondary Code Neoplasm, breast, upper outer quadrant History of Cancer Patients with a history of cancer and no evidence of current cancer should be reported as Personal history of malignant neoplasm using a code from the V10 series. These codes require additional digits to identify the type of cancer and should be reported only when there is no evidence of current cancer and a patient s presenting problem, signs, or symptoms may be related to the cancer history or impact the plan of care. These codes should not be reported routinely. Example: Personal history of malignant neoplasm, kidney, V Coding Clinic, 4 th Quarter 2002; Part-B News, Faye Brown s ICD-9-CM Coding Handbook, 2007 Aftercare Following Surgery for Neoplasm Visits to determine the effectiveness of cancer surgery that fall within the global post-operative period should be reported as Aftercare following surgery for neoplasm, code V58.42 and a second aftercare code to fully identify the reason for the encounter. Example: Aftercare following surgery for malignant neoplasm, kidney, V58.42; Aftercare following surgery of the digestive system, V58.75 Follow-up for Patients with History of Cancer Follow up exams to determine if there is any evidence of recurring or metastasizing cancers that result in no evidence of malignancy should be reported as Follow-up exam using a code from the V67 category to identify the most recent therapy carried out. Example: Follow-up exam following chemotherapy, V67.2 Cancer Drugs prescribed for reason other than Malignancy Patients with no history of cancer who take prophylactic cancer drugs should not be reported with an active cancer diagnosis or a personal history of malignant neoplasm. Instead, code the reason for the prescription. Example: Family history of malignant neoplasm, kidney V16.51 References: AHA Coding Clinic, July-August 1985; AHA A Comprehensive Diagnostic Patient Profile The Wave of the Future! Good coding and documentation clearly depicts the level of disease severity, co-morbidities, underlying disease and other factors that contribute to the level of complexity for the patient encounter. Per the ICD-9-CM Official Guidelines and Reporting: Code all documented conditions that coexist at the time of the encounter/visit, and require or effect patient care treatment or management. CMS reimbursement is increasingly leaning toward the principle of illness burden. Diagnosis codes are the criteria used for determining severity of illness, risk and resource utilization. Diagnostic coding influences the level of risk in determining CPT coding assignment. Moderate risk is equivalent to: a) One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment, or b) Two or more chronic stable illnesses High risk relates to: a) One or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or b) Acute or chronic illnesses or injuries that pose a threat to life or body function Status Codes do indicate and contribute to the complexity level of the encounter: Consider these V codes: Renal Dialysis Status V45.1 Tracheostomy Status V44.0 Respirator Dependence V46.XX Lower Limb Amputee V49.7X Artificial Openings for Feeding or Elimination V44.X Major Organ Transplant V42.X and V42.XX Asymptomatic HIV Status V08 The presence of one or more of these conditions would be taken into account by the physician in the decision making process and could effect patient care, treatment and management. Other diagnosis codes that are not often reported, although the patient is being treated for the conditions, are: Protein Calorie Malnutrition 263.X Major Depression 296.XX Drug Dependence & Alcohol Dependence 303.XX and 304.XX History of Heart Attack 412 Good documentation is reflective of the thought process of the physician in treating patients. All conditions effecting the patient should be documented and coded. 8

5 PATIENT NAME CHART # DATE OF SERVICE BLOOD BLOOD DISEASE DISEASE Anemia in Chr Kidney Disease Anemia, Iron Deficiency, unspec Anemia, NOS Anemia, Pernicious Anemia, Sec Blood Loss CARDIOVASCULAR/ / CARDIOLOGY CARDIOLOGY Acute MI, Initial Episode, NOS Acute MI, Sub Episode, NOS Angina Decubitus Angina Pectoris, NOS Angina, Unstable Atrial Fibrillation Cardiac Dysrhythmia, NOS Cardiomyopathies, Primary, NOS Congestive Heart Failure Occlusion, Coronary Artery, Complete Coronary Atherosclerosis, unspec Heart Disease Ischemic, Chronic Heart Failure, unspec Myocarditis, unspec 412 Old MI Sick Sinus Syndrome Tachycardia, Atrial Parox Tachycardia, Ventric Parox. CEREBROVASCULAR Cerebral Atherosclerosis 436 Cerebrovascular Disease, Ill Defined, Acute CVA/Stroke (Not for Office Use) Ischemic Cerebrovascular Disease TIA Late Effects Hemiplegia, Side unspec Hemiplegia, Dom. Side Hemiplegia, Non-dom. Side Monoplegia, L-Limb, Dom. Side Monoplegia, L-Limb, Non-dom. Side Monoplegia, L-Limb, unspec Side Monoplegia, U-Limb, Dom. Side Monoplegia, U-Limb, Non-dom. Side Monoplegia, U-Limb, unspec Side Speech / Language Deficits, unspec VASCULAR VASCULAR DISEASES DISEASES DVT, NOS Hypotension, Orthostatic Occlusion, Extr Artery, Total, Chronic Peripheral Vascular Disease, NOS Phlebitis, Femoral Vein Phlebitis, Lower Extr, Deep Varicose Lower Extr. w/ulcer Venous Insufficiency, Chronic, NOS DERMATOLOGY DERMATOLOGY Acne, Other Actinic Keratosis Atrophoderma Dermatitis, Atopic & Eczema Dermatitis, NOS Herpes Simplex w/o Comp Herpes Zoster w/o Comp Seb Keratosis, Inflamed Seb Keratosis, NOS Tinea of Nail ENDOCRINOLOGY ENDOCRINOLOGY Carcinoid Syndrome Dehydration DM Type II Controlled DM Type I Controlled DM Type II Uncontrolled DM Type I Uncontrolled (Add 5 th digits 0, 1, 2, or 3 to following DM Codes. Also, Use Additional Code to Identify Manifestations as Exemplified Under Each Code Category) 250.4x DM w/ Renal Manifestation(s) 585.x CKD or Chronic Renal Failure Nephritis / Nephropathy Nephrotic Syndrome Nephropathy w/ HTN & CRF Proteinuria 250.5x DM w/ Ophthalmic Manifestation(s) Cataracts (Type I Only) Diabetic Retinopathy, NOS Glaucoma Prolif Diabetic Retinopathy 250.6x DM w/ Neurological Manifestation(s) Autonomic (Peripheral) Neuropathy Gastroparesis Impotence 7SENIOR SENIOR PATIENT PATIENT Neurogenic / Neuropathic Arthropathy Polyneuropathy in DM / Neuritis 707.1x Ulcers of Lower Limbs, Except Decubitus 250.7x DM w/ Peripheral Circulatory Disease Gangrene Impotence Peripheral Angiopathy 707.1x Ulcers of Lower Limbs, Except Decubitus 250.8x DM w/ Other Chronic Manifestation(s) Osteomyelitis (Also, Append the Appropriate Code from Category 730, Osteomyelitis, Periostitis, and Other Infections Involving Bone). (Ulcers: Assign to when Ulcers are not due to Neuropathy or PVD) Hypercholesterolemia Hyperlipidemia, Mixed Hyperparathyroidism, Unspec Hyperpotassemia Hyperthyroidism w/o Crisis Hypertriglyceridemia Hypogonadism, Testicular Hyponatremia Hypopotassemia Hypothyroidism, Postsurgical Hypothyroidism, unspec Obesity, Morbid Obesity, unspec Protein-Calorie Malnutrition GASTROENTEROLOGY Abdominal Pain, Epigastric Abdominal Pain, General Abdominal Pain, Left Lower Abdominal Pain, Left Upper Abdominal Pain, Right Lower Abdominal Pain, Right Upper Cholelithiasis w/o Obstruction Cirrhosis, Alcoholic Cirrhosis, Non-Alcoholic, Liver Constipation, unspec Crohn s Disease, NOS Diverticulitis, Colon w/o Hem Diverticulosis, Colon w/o Hem Dyspepsia Fecal Impaction Gastroenteritis, Noninfectious Gastroesophageal Reflux Hemorrhage, Rectum / Anus Hemorrhoids, NOS Hepatitis, Alcoholic Acute Hepatitis Chronic, unspec Hepatitis, Viral, NOS Irritable Bowel Syndrome Melena Pancreatitis, Acute Ulcerative Colitis, unspec GENITOURINARY DISEASE Calculus of Kidney Calculus of Ureter Note: For CKD Below, Code First Hypertensive Chronic Kidney Disease if Applicable, ( , ) Chronic Kidney Disease, Stage I Chronic Kidney Disease, Stage II Chronic Kidney Disease, Stage III Chronic Kidney Disease, Stage IV Chronic Kidney Disease, Stage V End Stage Renal Disease Chronic Kidney Disease, unspec Cystitis, Acute Hematuria Renal Disease, NOS Renal Failure Acute, unspec Urethritis, unspec Urinary Tract Infection, unspec GU GU DISORDERS / / FEMALE Abn. Pap Smear w/ HGSIL Abn. Pap Smear w/ LGSIL Abn. Pap Smear, Unsatisfactory Breast Lump / Mass Candidiasis, Vulva & Vagina Cervicitis Menopausal Symptoms Ovarian Cyst, NOS Vaginitis, NOS GU DISORDERS GU DISORDERS / MALE / MALE BPH w/ Obstruction Use additional code to identify the symptom(s) BPH w/o Obstruction Epididymitis / Orchitis, unspec Impotence, Organic Origin Prostatosis HYPERTENSIVE DISEASE DISEASE (Heart Failure Identify Type of Failure; CKD Identify Stage of Disease) Hypertension Essential, Benign Hypertensive Essential, Malignant Hypertension, unspec Hypertensive CKD, w/ CKD Stage I-IV, or unspec Hypertensive CKD w/ CKD Stage V, or ESRD, or unspec Hypertensive Heart & CKD w/ Heart Failure & CKD Stage I-IV, unspec Hypertensive Heart & CKD w/ Heart Failure & CKD Stage V, or ESRD, or unspec Hypertensive Heart & CKD, w/o Heart Failure w/ CKD Stage I-IV, unspec Hypertensive Heart & CKD, w/o Heart Failure, w/ CKD Stage V, or ESRD, or unspec Hypertensive Heart Disease w/ Heart Failure, unspec (Use Additional Code with to Identify the Heart Failure) Hypertensive Heart Disease w/o Heart Failure, unspec INFECTIOUS INFECTIOUS DISEASE DISEASE Cellulitis, Leg Cellulitis, NOS 042 HIV V08 HIV, Asymptomatic PPD Positive Viral Infection, NOS MUSCULOSKELETAL Arthritis, Rheumatoid Bursitis, Hip Bursitis Knee, NOS Bursitis Shoulder, NOS Cervical Radiculitis Chondromalacia Patella Contusion, Foot Contusion, Hand 920 Contusion, Head Contusion, Knee Contusion, Lower Leg Contusion, Shoulder DDD Cervical DDD Lumbar / Lumbosacral Displacement, Lumbar Disc FX Arm Upper, NOS, Closed FX Femur, unspec, Closed FX Finger(s), unspec, Closed FX, Hip, NOS, Closed FX Toe(s), Closed FX Vertebrae, Pathologic FX Wrist, NOS, Closed Gouty arthropathy Joint Pain, unspec Low Back Pain Lumbosacral Neuritis Myalgia / Myositis, NOS Osteoarthrosis, Ankle & Foot Osteoarthrosis, Hand Osteoarthrosis, Lower Leg Osteoarthrosis, NOS, unspec Osteoarthrosis, Shoulder Osteoporosis, unspec Pain in Limb Plantar Fasciitis 725 Polymyalgia Rheumatica Sprain / Strain Ankle Sprain / Strain Foot Sprain / Strain Hand Sprain / Strain / Hip Sprain / Strain Knee & Leg Sprain / Strain Lumbar Sprain / Strain Neck Sprain / Strain Shoulder Sprain / Strain Wrist Tendonitis, Elbow Tendonitis, NOS Tenonsynovitis, NOS Tietze s Disease NEUROLOGY NEUROLOGY Alzheimer s Disease Use Additional Code, where Applicable, to Identify: w/ Behavioral Disturbance (294.11), w/o Behavioral Disturbance (294.10) Carpal Tunnel Syndrome Epilepsy, unspec Headache, Migraine Parkinson s Disease Peripheral Neuropathy, unspec Malig Neo Disseminated 185 Malig Neo Prostate Malig Neo w/o Spec Site OPHTHALMOLOGY OPHTHALMOLOGY Cataract, unspec Conjunctivitis, Acute, unspec Conjunctivitis, Allergic FB Eye External, NOS OTOLARYNGOLOGY OTOLARYNGOLOGY Cerumen Impacted Eustachian Tube Dysfunction Otitis Externa, Infective Otitis Media, Serous, Acute Otitis Media, Serous, Chronic Otitis Media, Suppurative, Acute 462 Pharyngitis, Acute Sinusitis Acute, Maxillary Sinusitis Chronic, NOS PSYCHIATRY PSYCHIATRY Alcoholism, Chronic Anxiety State, unspec 311 Depressive Disorder, NEC Drug Dependence, unspec Dysthmic Disorder Major Depressive disorder, Single episode, unspec Major Depressive disorder, Recur episode, unspec Mood Disorder, episodic, unspec Organic Brain Syndrome PULMONARY PULMONARY Cor Pulmonale, Acute Pulm Embol / Infarct, Other Pulm Heart Disease Chronic, unspec RESPIRATORY RESPIRATORY Asthma, unspec Asthma, unspec, w/ Acute Exacerbation Bronchitis, Acute Bronchitis, Chronic, unspec 496 COPD Emphysema, NOS 486 Pneumonia, unspec Rhinitis, Allergic, Pollen Rhinitis, Chronic Sinusitis, Maxillary, Acute URI, Acute, NOS SIGNS SIGNS & SYMPTOMS & SYMPTOMS Chest Pain, unspec Cough Diarrhea, NOS Dizziness and Giddiness Dysphagia, unspec Dyspnea, unspec Edema Elevated BP w/o Hypertension Enlargement Lymph Nodes Fever Gangrene Headache Hyperventilation Insomnia w/ Sleep Apnea Insomnia, unspec Malaise and Fatigue, Other Nausea and Vomiting Palpitations Seizures, NOS Skin Sensation Disturbance Syncope and Collapse Urinary Incontinence, unspec Weight Loss Abnormal Wheezing V CODES V CODES V49.70 Amputation, Lower Limb, unspec V67.9 Follow-up Exam, unspec V67.00 Post-Op Exam V72.84 Pre-Op Exam V45.1 Renal Dialysis Status V76.2 Screen Mal Neo, Cervix V76.49 Screen Mal Neo, NOS V76.47 Screen Mal Neo, Vagina V74.5 Screen Venereal Disease V44.3 Status Colostomy V58.32 Suture Removal OTHER DIAGNOSIS ONCOLOGY ONCOLOGY Malig Neo Bone, Secondary COMMENTS Malig Neo Breast, Central Malig Neo Breast, unspec Malig Neo Bronchus / Lung Malig Neo Colon Ascending Malig Neo Colon Descending Malig Neo Colon Transverse Codes Valid 10/01/2007 to 10/01/2008 Coding Revision 10/01/07 In order to improve the reporting of malnutrition among the elderly, it is important for physicians to document the condition in the medical record and for coders to be aware of malnutrition as a potential diagnosis. Code Categories 262 and 263. The most severe malnutrition problems are associated with Protein Calorie Malnutrition (PCM), also known as Protein Energy Malnutrition (PEM), which occurs in both chronic and acute forms. Subjective Global Assessment (SGA) for PEM includes 6 clinical parameters, followed by a personal judgement as to whether the patient has (A) no malnutrition, (B) possible or mild malnutrition, or (C) significant malnutrition. 1. unremitting, involuntary weight loss that is greater than 10% in the previous months, and especially in the last few weeks 2. Food intake is severely curtailed 3. Muscle wasting and fat loss, with attention to the presence of edema, or ascites present on physical examination 4. Persistent, essentially daily gastrointestinal symptoms such as anorexia, nausea, vomiting, or diarrhea in the previous 2 weeks 5. Marked reduction in physical capacity 6. Presence of metabolic stress due to trauma, inflammation or infection *Any combination of these conditions (especially the first 3) indicates that the patient has significant PEM. Protein-Calorie Malnutrition Other standards are used and accepted as indicators of Protein Calorie Malnutrition: Body Weight as a value relative to the established norms in the general population; Body Mass Index (BMI) which can define Protein Calorie Malnutrition as well as Obesity; and a General Weight Loss Standard. The overall opinion is that no gold standard for the assessment of nutritional status exists. Protein-calorie malnutrition may accompany illnesses such as: Cancer Pancreatitis Alcohol Abuse and/or Dependence Liver Disease Chronic Kidney Disease Drug Abuse and/or Dependence Obesity (Post Bariatric Surgery) ESRD Alcoholic Hepatitis Cirrhosis Celiac Disease Cystic Fibrosis Anemia Depression References: CMAJ Nov 13, 2001 Clinical Nutrition: 1. Energy Malnutrition in the inpatient 4

6 5 Does at least one (1) of the following apply? Depressed mood most of the day, nearly everyday, as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). Do at least four (4) of the following apply? Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gain. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely selfreproach or guilt about being sick). Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. YES YES YES Diagnosis of Major Depression may be assigned. DETERMINING MAJOR DEPRESSION Do all of the following apply? The symptoms do not meet criteria for Mixed Episode (i.e., Major Depression and Mania). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of concern. The symptoms are not due to the direct physiological effects of a substance. The symptoms are not better accounted for by bereavement. The patient has had symptoms present for the same two week period. NO NO NO Does not meet diagnosis criteria for Major Depression. Does not meet diagnosis criteria for Major Depression. Does not meet diagnosis criteria for Major Depression. ICD-9 Diagnosis 296.2x Major Depression, Single Episode or 296.3x Major Depression, Recurrent Source: DSM-IV, 4 th Edition Sharp HealthCare Corporate Compliance 12/06 Diabetes Mellitus Diagnoses Codes and Associated Manifestations Diabetes Mellitus Diagnoses Codes and Associated Manifestations Fifth-digit subclassifications for use with category 250: Fifth-digit subclassifications for use with category 250: 0 Type 0II Type (NIDDM), II (NIDDM),Unspec type, not stated as as uncontrolled 1 Type 1I (IDDM), Type I (IDDM), not not stated stated as as uncontrolled 2 Type II (NIDDM),unspecified type, uncontrolled (adult-onset diabetic patients, 2 Type II (NIDDM), unspecified uncontrolled (adult-onset diabetic patients, even if patient requires insulin) (even if patient requires insulin) 3 Type 3I (IDDM), Type I (IDDM), uncontrolled uncontrolled Write the number (fifth digit) on the space provided Write the number (fifth digit) in the space provided DM without mention of Complication Diabetes with Ketoacidosis Diabetes with Neurological Manifestations Indicate fifth digit subclassification (0,1,2,3) Diabetes with Hyperosmolarity Diabetes with Other Coma Use additional code to identify manifestations: Peripheral autonomic neuropathy in disorders classified elsewhere Diabetes with Renal Manifestations Carpal tunnel syndrome Must specify kidney manifestation Other lesion of median nerve Nephritis and nephropathy, not spec as acute or Lesion of ulnar nerve chronic, in diseases classified elsewhere Lesion or radial nerve Nephrotic syndrome in disease classified elsewhere Causalgia of upper limb Diabetes with Ophthalmic Manifestation Indicate fifth digit subclassification (0,1,2,3) Use additional codes to identify manifestations: Mononeuritis multiplex Other mononeuritis of upper limb Mononeuritis of upper limb, unspecified Lesion of sciatic nerve Background diabetic retinopathy Meralgia paresthetica Proliferative diabetic retinopathy Other lesion of femoral nerve Retinal edema Lesion of lateral popliteal nerve Glaucoma associated with systemic syndromes Lesion of medial popliteal nerve Diabetic cataract Tarsal tunnel syndrome Better eye: total impairment; lesser eye: total impairment Lesion of plantar nerve Better eye: near total impairment; lesser eye: not further specified Causalgia of lower limb Better eye: near total impairment; lesser eye: total impairment Other mononeuritis of lower limb Better eye: near-total impairment; lesser eye: near total-impairment Mononeuritis of lower limb, unspecified Better eye: profound impairment: lesser eye: not further specified Mononeuritis of unspecified site Better eye: profound impairment; lesser eye: total impairment Polyneuropathy in diabetes Better eye: profound impairment; lesser eye: near-total impairment Myasthenic syndromes in diseases classified elsewhere Better eye: profound impairment; lesser eye: profound impairment Arthropathy associated with neurological disorders Impairment level not further specified Better eye: severe impairment; lesser eye: blind, not further specified Better eye: severe impairment; lesser eye: total impairment Indicate fifth digit subclassification (0,1,2,3) Better eye: severe impairment; lesser eye: near-total impairment Use additional code to identify manifestations: Better eye: severe impairment; lesser eye: profound impairment Gangrene Better eye: moderate impairment; lesser eye: blind, not further specified Peripheral angiopathy in diseases classified elsewhere Better eye: moderate impairment; lesser eye: total impairment Better eye: moderate impairment; lesser eye: near total impairment Better eye: moderate impairment; lesser eye: profound impairment Indicate fifth digit subclassification (0,1,2,3) Impairment level not further specified Use additional code to identify manifestations: Better eye: severe impairment; lesser eye: not further specified Ulcer of lower limb, unspecified Better eye: severe impairment; lesser eye: severe impairment Ulcer of thigh Better eye: moderate impairment; lesser eye: not further specified Ulcer of calf Better eye: moderate impairment; lesser eye: severe impairment Ulcer of ankle Better eye: moderate impairment; lesser eye: moderate impairment Ulcer of heel and midfoot Unqualified visual loss, both eyes Ulcer of other part of foot Legal blindness, as defined in U.S.A Ulcer of other part of lower limb Impairment level not further specified Chronic ulcer of other specified sites One eye: total impairment; other eye: not specified Chronic ulcer of unspecified site One eye: total impairment; other eye: near normal vision Other bone involvement in diseases classified elsewhere One eye: total impairment; other eye: normal vision One eye: near-total impairment; other eye: not specified Diabetes with Unspecified Complications One eye: near-total impairment; other eye: near normal vision Indicate fifth digit subclassification (0,1,2,3) One eye: near-total impairment; other eye: normal vision One eye: profound impairment; other eye: not specified Diabetes Mellitus in Pregnancy, One eye: profound impairment; other eye: near normal vision Unspec. Episode of care or N/A One eye: profound impairment; other eye: normal vision Impairment level not further specified Diabetes Mellitus in Pregnancy, One eye: severe impairment; other eye: not specified Antepartum condition or complication One eye: severe impairment; other eye: near-normal vision Hypovolemia One eye: severe impairment; other eye: normal vision Myotonic Disorders One eye: moderate impairment; other eye, not specified P-Amniosalicylic Acid (pas) One eye: moderate impairment; other eye, near normal vision Polyhdramnios One eye: moderate impairment; other eye; normal vision Pre-Eclampsia Diabetes with Peripheral circulatory disorders Diabetes with Other Specified Manifestations Unqualified visual loss, one eye In addition report code from category 250 to indicate type of diabetes involved Unspecified visual loss **PLEASE NOTE THIS IS NOT AN INCLUSIVE MANIFESTATION LIST** 6