Making Trauma Documentation a Little Less Traumatic

Making Trauma Documentation a Little Less Traumatic

This is the last installment in my debrief about the annual ACDIS Conference held last month in Chicago. Trey La Charité, Medical Director for Clinical Documentation Integrity (CDI) and Coding at University of Tennessee Medical Center in Knoxville, gave a great talk on trauma service documentation.

He explained that CDI in trauma is important because many mortality-related cases stem from such services, and many such patients have no prior history with the facility, so comorbidities from prior encounters may not be discoverable. I pointed out that even if many trauma patients do not have health insurance, they increase the case mix index, which factors into the blended base rate.

Trey also mentioned the “halo effect,” which refers to the wider impact improved documentation can have. Surgical residents can take their CDI knowledge to other service lines, and trauma attendings usually also perform elective surgeries.

Specific advice was that every injury should be documented, because you never know what is going to throw the case into the Multiple Significant Trauma DRG. I think it is also important because medical necessity for specific tests and procedures often requires thoroughness in accounting of all injuries. One doesn’t order imaging of a right wrist for a ruptured spleen.

Additionally, he recommended documenting the separate Glasgow Coma Score components; his institution does so electronically by including a section in their trauma template. He also pointed out the importance of appropriately grading all solid-organ injuries. He stressed that it is important to specify presence and type of shock.

Words matter. “Mid-line shift” and “mass effect” need to be translated to “brain compression.” “Tear” indexes to laceration, but the word “rent,” does not. I say providers need to ascribe, not describe. Why is the kidney function abnormal? Why are the liver enzymes elevated? Why are you administering blood products?

He also addressed airway protection. My contribution here is that airways may need to be protected from blood, secretions, vomitus, redundant or swollen tissue, or foreign bodies. Airway protection is a proactive action; you are anticipating a problem.

Once you’ve cleared a path from the outside to the inside, for airway protection, you shouldn’t really need to ventilate or oxygenate. If you do need to do so, then you likely have some degree of respiratory failure. He offered the surgeon’s verbiage of “intubated for impending respiratory failure.” I objected to using the word “impending.”

The Official Guidelines discuss “impending.” If there is a subentry term for “impending” or “threatened,” then you can code that. If there is not, you need to determine if the condition really occurred or not. You code the condition if it developed, or you code signs/symptoms/other established conditions if the impending condition did not develop. There is no code for “impending respiratory failure” or “impending sepsis.”

If a patient is not exchanging air because there is airway obstruction or a severely decreased respiratory rate, you have respiratory failure. You needn’t wait for a catastrophic blood gas to prove the patient succumbed to hypoxemia and/or hypercapnia.

Examples of my suggestions for verbiage would be:

  • Acute respiratory failure due to neurologic depression from traumatic brain injury; or
  • Intubated for acute respiratory failure due to hypoventilation from opioid overdose.

If the provider knows which type of respiratory failure it is, hypoxic or hypercapnic (or both), they can (and should) add that detail.

Surgeons need to understand that acute respiratory failure has a huge impact on severity of illness and risk of mortality scores, and it does not have to be on the basis of a pulmonary derangement.

It is beneficial to educate surgical advanced practitioners, in addition to the residents, because they often do the lion’s share of the documenting. There are various ways by which education can be provided: lunch-and-learns, flyers or posters, emailing documentation tips of the week, or elbow rounds, but Trey’s experience was similar to mine. He found that participating in trauma morbidity and mortality review conferences gave the best bang for his buck. There is usually great attendance, and you can point out how the performance metrics could have been impacted.

I hope you learned something from what I got out of the ACDIS Conference this year.

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Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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