CONDITION SYMPTOMS INDICATORS

Acute Blood Loss Weakness, Pallor, Bleeding Drop in hemoglobin of 2 grams, with
Anemia; the lowest rate being <8.0; or patient
Acute Blood Loss admitted with <9.0, or >=800 ml
Anemia in Obstetric blood loss during surgery.
Patient;

Post-Operative Blood
Loss Anemia
Acute Renal Failure Decreased urine output, Increase in creatinine of 0.3 with
lower extremity edema, loss highest reading being >= 1.6
of appetite, nausea and
Acute Respiratory Diffuse wheezing, rapid pH <7.35
Failure respirations, tachycardia, PCO2 >50
cyanosis, use of accessory PaO2 <60 with normal or low PCO2,
Aspiration Pneumonia Fever, shortness of breath, CXR positive for infiltrate, often in
cough, chest pain, dysphagia, RLL (right lower lobe), swallowing
possible emesis/choking dysfunction, positive sputum culture
prior to pneumonia,
swallowing function test
showing aspiration risk

BMI (Body Mass Low or high based on weight

Index) and height
Cerebral Edema Change in mental status, Cerebral edema, mass effect, shift or
nausea, lack of coordination, herniation on brain CT or MRI
numbness, dizziness,
Chronic Renal Failure Nausea and vomiting, loss of GFR 30-59 (stage III) GFR 15-29
appetite, fatigue/weakness, (stage IV) GFR < 15
decreased urine output (stage V) Dialysis (end
Congestive Heart Ankle swelling/edema, Ejection fraction on Echo of <40%
Failure weight gain, shortness of systolic, EF > 50% or
breath preserved EF (PEF) diastolic,
Coronary Stent Chest pain, shortness of Cardiac Catheterization result of In-
Stenosis breath, or asymptomatic Stent Stenosis
Excisional
Debridement
Decubitus Ulcer Provider must document the Query if a stage III, stage IV, or
term decubitus or pressure unstageable if location is not
ulcer documented by physician
Dehydration/ Dry mucous membranes, BUN/creatinine elevated prior to IV,
Hypovolemia poor skin turgor H&H prior to IV fluids, orthostatic
blood pressure or pulse change
 Hypertension, If there is eye damage, look Systolic BP of >180 OR
malignant or for abnormal eye exam as Diastolic BP of >120 AND
accelerated showing papilledema, retinal end organ damage such as acute
hemorrhage, exudates encephalopathy, unstable angina,
intracerebral hemorrhage, acute
CHF, dissecting aortic aneurysm, or
acute MI

Hyponatremia Change in mental status, Sodium (Na) <132 (not

convulsions, fatigue, valid if elevated glucose)
headache, irritability, muscle
Intra-Operative Documentation of intra-
Complications operative finding
Intra-Operative Tear Documentation of intra-
operative tear
Malnutrition Documentation of *Albumin results, pre-albumin
malnutrition, poor oral results, BMI < 19, current weight %
intake, weight loss, muscle of standard weight, serum
wasting, cachexia transferrin <180

Mental Status Documentation of mental Abnormal EEG, abnormal CT/MRI

Changes status changes
Myocardial Infarction, Chest or arm or neck pain, Elevated troponin, abnormal EKG,
acute shortness of breath abnormal Echo, abnormal cardiac
catheterization
Neonatal Jittery, tremors, sweating, Glucose < 30 mg/dL in 1st 24 hours
Hypoglycemia irritability, tachypnea, pallor, of life
poor sucking/feeding, weak
or high-pitched cry, lethargy Glucose < 45 mg/dL after 1st 24
or coma, seizures, hours of life
hypotonia, apnea,
*Neurologic Deficits Documentation of clinical
condition associated with
deficits
Newborn Respiratory Grunting, flaring, apneic May have respiratory failure
Distress spells, cyanotic attacks, may documented, respiratory depression,
have respiratory failure fetal acidosis, anoxia, asphyxia,
Newborn Respiratory Grunting, flaring, respiratory Primarily seen with prematurity,
Distress Syndrome distress newborn deficient in surfactant,
(RDS) Abnormal CXR for pulmonary airless
Pathologic Fracture Fracture documented, Positive fracture on xray, bone
history of trauma, or fracture disease documented such as
occurring without trauma or osteoporosis, osteopenia, bone
Pneumonia Chest pain, cough with CXR/CT findings of infiltrate, opacity,
sputum production, fever, density, air space disease, positive
shortness of breath sputum culture

Post-operative Dyspnea, rapid, shallow Positive CXR for atelectasis, post-op

atelectasis breathing, cough fever 72 hours post-op
 Post-operative ileus Abdominal pain, bloating, Positive abdominal xray for ileus (not
nausea and vomiting, loss of needed to make a diagnosis)
appetite, no bowel function
after surgery

Post-operative Cyanosis, confusion, altered On mechanical ventilator > 48 hours

respiratory failure mental status, arrhythmia, after end of surgery, OR
shortness of breath reintubation after extubation
following surgery.
Statement by physician of
respiratory insufficiency or failure

pH <7.35
PCO2 >50
PaO2 <60 with normal or low PCO2,
pulse ox <90 on RA, pulse ox <95 on
O2, acidosis finding including pH
value

Pulmonary Embolism May have imaging + for a PE, (if

(PE), acute newly diagnosed)
PE diagnosed within 6 months
Pulmonary Embolism, May have Imaging + for Pulmonary
(PE) chronic embolism
Documentation that PE has been
Prematurity Low birthweight or Gestational age < 37 weeks in a
gestational age singleton (not a multiple birth)
Sepsis Acute mental status changes, Temp > 100.9F/38.3C or <96.8F/36C
confusion Tachycardic
with pulse/heart rate >90
Tachypnea with respiratory
rate >20
Systolic BP <90 or a drop of >/=
40
WBC >12.0 or <4.0
>10 bands on CBC differential

Transient Tachypnea Idiopathic tachypnea Retained fetal fluid, wet lung

syndrome

Urinary Tract History of recurrent UTI due Type of indwelling urinary device,
Infection, due to to device positive urine culture results
indwelling catheter
 Urinary Tract History of recurrent UTI due Type of indwelling urinary device,
Infection, due to to device positive urine culture results
indwelling catheter
TREATMENTS/ SPECIAL NOTES
TESTING
Blood Acute blood loss
Transfusion anemia is not a valid
diagnosis if the
Iron patient receives an
auto transfusion
during surgery. For
OB cases, must see a
change in treatment
such as increase in
iron from the at-home
IV fluids

Monitor for
Mechanical
ventilation
O2
Antibiotics of Patients at risk are
Ampicillin, those with debility, on
Sulbactam tube feedings, lack of
(Unasyn) gag reflex, or any
neurologic disorder
affecting the brain
Imipenem
(Primaxin)
Pipircillin-
Tazobactam
(Zosyn)

Vancomycin,
Telavancin,
Linelzolid

Provider must
document body
habitus status, such as
Anti-seizure Patients at risk –
medication, those with brain
Mannitol, IV injury, stroke,
Treatment is Chronic kidney
directed disease is defined as
toward cause kidney damaged or
IV or po
diuretics
(lasix, bumex,

Three criteria Documentation in

must be met medical record of
to assign a debridement in any
Wound Coder may assign a
dressing, code for the stage of
whirlpool, the ulcer from any
IV fluids
 IV Must see BP levels as
antihypertensi noted in column 3
ve medication plus organ damage in
or urgent oral eye, brain, heart, or
antihypertensi kidney
ve medication

IV fluids
(saline) 3%
saline, water
Query if unclear if the
complication was
expected, inherent,
Query if unclear if the
complication was
expected, inherent,
Nutrition *if only abnormal
Consult indicator is low
albumin, do not query
TPN
Nutritional
Support
(ensure, etc)

Possible Query for underlying

Neurology cause, if not
consult documented
Possible tPa,
nitro
IV glucose/IV Frequently
dextrose asymptomatic;
documentation of
symptoms optional;
frequently will be in
NICU

Send query to
differentiate between
respiratory distress
Intubation/ Send query to
ventilator, differentiate between
surfactant respiratory distress

IV antibiotics,
nebulizer,
steroids

Must see Do not query if the

work-up of procedure is any open
fever, may see chest surgery – lung,
Reinsertion of Length of stay
NG tube, NPO extended to due
status bowel function would
reordered support post-op ileus
after trial of
diet
advancement
failed, any Link must be
decrease in documented by the
bowel provider
function that
Mechanical Do not code if
ventilator indicators are not
met. Query if
documentation is
lacking but indicators
are met.

Link must be
documented by the
provider

On “Unspecified” in logic
anticoagulatio codes to acute; use
n therapy, caution in assigning
unless this code, as
contraindicate
On Unspecified
Aspirin onlyis(not
the
anticoagulatio anticoagulation) may
n therapy, be indicative of
Query if
documentation of
prematurity is lacking
IV antibiotics Two or more
indicators must be
met

No surfactant Most often found in

given, O2 full term infants,
given rather usually resolves within
than 24 hours, common
IVventilator
antibiotics withcaution
Use C-sections or
when
assigning POA
 Use caution when
assigning POA
Removal of
the indwelling
urinary device