Clinical Documentation Integrity (CDI) Strategies for the Respiratory System

Codes Discussed: MS-DRG 137 (Respiratory infections), MS-DRG 177-179 (Respiratory infections), MS-DRG 139 (Simple pneumonia), MS-DRG 193-195 (Simple pneumonia), PSI 12 (Postoperative pulmonary embolism or DVT), HAC air embolism (Hospital-acquired condition), POA-N (Not present on admission), POA-U (Documentation insufficient to determine present on admission status)

Topics Covered: clinical documentation integrity for respiratory diagnoses, CDI respiratory system strategies, respiratory CDI, UHDDS documentation guidelines, ICD-10-CM respiratory documentation guidelines, respiratory diagnosis documentation specificity, MS-DRG assignment, SOI capture, ROM capture, quality reporting, HAC documentation, PSI documentation, respiratory failure denial prevention, pneumonia denial prevention, pneumonia specificity, gram-negative pneumonia, aspiration pneumonia, community-acquired pneumonia, CAP documentation, healthcare-associated pneumonia, HCAP documentation, hospital-acquired pneumonia, HAP documentation, ventilator-associated pneumonia, VAP documentation, respiratory system functions, gas exchange, oxygenation, carbon dioxide elimination, respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic alkalosis, respiratory signs and symptoms, shortness of breath, dyspnea, dyspnea on exertion, hemoptysis, wheezing, pulmonary edema, hypoxia, pleuritic chest pain, definitive diagnosis query, pleural effusion documentation, pleural effusion principal diagnosis, pleural effusion with CHF, malignant pleural effusion, thoracentesis documentation, CT drainage, decubitus x-rays, malignancy site query, pulmonary edema documentation, cardiogenic pulmonary edema, noncardiogenic pulmonary edema, acute pulmonary edema etiology, postoperative fluid overload, bacterial pneumonia, viral pneumonia, radiation pneumonitis, pulmonary venous fibrosis, congenital pulmonary vein stenosis, pulmonary venous occlusion, chronic pulmonary edema, pulmonary embolism documentation, acute pulmonary embolism, chronic pulmonary embolism, pulmonary embolus acuity, pulmonary embolus etiology, pulmonary embolus due to DVT, acute cor pulmonale, chronic cor pulmonale, septic pulmonary embolism, saddle pulmonary embolism, single subsegmental pulmonary embolism, multiple subsegmental pulmonary embolism, pulmonary embolism complicating pregnancy, echocardiogram findings, right ventricular enlargement, pulmonary artery hypertension, right ventricular failure, acute right heart failure distinction, air embolism documentation, air embolism POA status, iatrogenic air embolism, traumatic air embolism, lung trauma, mechanical ventilation after lung trauma, accidental air injection, brain surgery air embolism, explosion injury, blast injury, scuba diving air embolism, hyperbaric chamber treatment, postoperative pulmonary embolism, postoperative DVT, proximal deep vein thrombosis, phlebitis, thrombophlebitis, IVC filter, ECMO, acute brain injury, acute spinal injury, pneumonia documentation, uncertain pneumonia diagnosis, suspected pneumonia coding, probable pneumonia coding, suspected organism query, causative organism documentation, antibiotic escalation, antibiotic de-escalation, negative chest x-ray with pneumonia, sputum culture documentation, acute respiratory failure due to pneumonia, sepsis due to pneumonia, 7-14 day antibiotic course, simple pneumonia, complex pneumonia, MRSA pneumonia, Pseudomonas pneumonia, Klebsiella pneumonia, necrotizing pneumonia, lobar pneumonia, gram-positive pneumonia, drug-resistant gram-negative pneumonia, Zosyn treatment, cefazolin treatment, cefepime treatment, doxycycline treatment, Cipro treatment, aspiration pneumonia risk factors, CVA with residual dysphagia, degenerative neurological disease, ALS, multiple sclerosis, postural limitations, inebriation, general anesthesia, debilitation, Parkinson’s disease, GLP-1 receptor agonist aspiration risk, right lower lobe infiltrate, aspiration syndromes, GERD aspiration risk, swallowing dysfunction, neurological disorders, structural abnormalities, speech therapy consult, swallowing studies, thickened liquids, head of bed elevation, dysphagia history, pocketing, bedbound status, aspiration versus aspiration pneumonia, chemical pneumonitis, reflex airway closure, laryngospasm, pulmonary edema after aspiration, mechanical obstruction aspiration, atelectasis, foreign body removal, pneumonia query writing, compliant CDI query, provider query options, respiratory syncytial virus, RSV documentation, RSV respiratory compromise, COVID-19 symptoms, COVID-19 respiratory documentation, fever, cough, myalgia, malaise, loss of smell and taste, vaping-related lung complications, EVALI documentation, e-cigarette lung injury, vaping-associated lung injury, bronchitis due to chemicals gases fumes and vapors, chemical pneumonitis, lipoid pneumonia, acute respiratory distress syndrome, pulmonary eosinophilia, acute interstitial pneumonitis, interstitial pulmonary disease, influenza documentation, H1N1 influenza, swine flu, H5N1 influenza, avian flu, seasonal flu, confirmed influenza coding, suspected influenza exception, probable influenza exception, bronchitis documentation, COPD documentation, asthma documentation, chronic obstructive pulmonary disease, COPD acute lower respiratory tract infection, COPD acute exacerbation, COPD causal organism, COPD with respiratory failure, COPD severity, acute on chronic respiratory failure, hypoxemic respiratory failure, hypercapnic respiratory failure, oxygen dependence, home oxygen documentation, chronic respiratory failure query, acute bronchitis, chronic bronchitis, obstructive bronchitis, aspiration bronchitis, bronchitis due to fumes and vapors, environmental bronchitis, viral bronchitis, rhinovirus, adenovirus, influenza A and B, parainfluenza, chest x-ray, sputum tests, pulmonary function test, antiviral medications, bronchodilators, anti-inflammatory medications, antibiotics, asthma acuity, asthma exacerbation, chronic asthma, obstructive asthma, exercise-induced asthma, allergy-induced asthma, occupational asthma, status asthmaticus, asthma severity classification, severe persistent asthma, moderate persistent asthma, mild persistent asthma, mild intermittent asthma, FEV1, peak expiratory flow, COPD exacerbation query, acute hypercapnic respiratory failure, oxygen saturation monitoring, Duo-Neb treatment, Solu-Medrol treatment, ABG documentation, respiratory failure documentation, arterial blood gases, pulse oximetry, O2 saturation, tachypnea, respirations greater than 29, accessory muscle use, cyanosis, BiPAP, CPAP, non-rebreather mask, hypoxemia, hypercapnia, confusion, somnolence, P/F ratio, pO2, FiO2, nasal cannula oxygen calculation, pCO2, hypoxemic respiratory failure type I, hypercapnic respiratory failure type II, acute respiratory failure principal diagnosis, acute respiratory failure secondary diagnosis, respiratory failure POA clarification, mechanical ventilation not required for respiratory failure, mechanical ventilation documentation, intubation for airway protection, impending respiratory failure, ventilator duration, ETT placement, tracheostomy with ventilator initiation, ventilator start time, ventilator hours, endotracheal tube replacement, SIMV, BiPAP trials, noninvasive mechanical ventilation, invasive mechanical ventilation, endotracheal tube, tracheostomy ventilation, assist control ventilation, PRVC ventilation, postoperative mechanical ventilation, ventilation less than 24 hours, ventilation 24-96 hours, ventilation greater than 96 hours, respiratory failure query, conflicting documentation query, intubated for airway protection versus acute respiratory failure, acute pulmonary insufficiency following surgery, postoperative acute pulmonary insufficiency, postoperative respiratory failure distinction, supplemental oxygen after surgery, intensified observation, acute respiratory distress, acute respiratory distress syndrome, ARDS versus respiratory distress, ARDS with sepsis, ARDS with pneumonia, ARDS with trauma, ARDS with aspiration, acute respiratory failure Excludes1, principal diagnosis selection, PDX selection, respiratory CDI record review, first-line pneumonia antibiotics, acute and chronic respiratory failure sequencing, bronchitis acuity query, asthma acuity query, obstructive component documentation, home oxygen duration, field intubation assessment, respiratory status at admission, pulmonary edema acuity query, respiratory surgical procedures, bronchoplasty, central ECMO, peripheral ECMO, lobectomy, wedge resection, lung transplant, mechanical pleurodesis, thoracoscopy, thoracotomy, transbronchial lung biopsy, mediastinoscopy, tracheostomy, bronchoscopy, talc pleurodesis, respiratory procedure objective, lung tissue ablation, embolectomy, total lung removal, partial lung removal, lung laterality, lung lobe documentation, bronchus documentation, procedure approach documentation, open approach, endoscopic approach, percutaneous approach, percutaneous endoscopic approach, converted procedure documentation, drain device, chest tube, endobronchial valve, IVC filter, radioactive element, respiratory query examples, COPD exacerbation with acute respiratory distress, acute respiratory failure POA query, chronic respiratory failure query, acute on chronic respiratory failure query