Q&A: Capturing severity on death charts

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Q: The revenue officer at our facility says all death charts should have a CC/MCC. I do try to find missed CC/MCCs on the records as well as the complete documentation, however, not all records end up having one. Can you help me understand the basis of this requirement and give me some advice as to how I should proceed?

A: The exclusive focus on the presence or absence of CC/MCC’s on a death chart is a bit of a misguided approach. If unexpected deaths occur in the ED or shortly after admission, etc., it is possible that no CC/MCCs exist because there was no time for any work or diagnoses to be documented before the patient expired. 

Another scenario occurs when a patient becomes a comfort measures patient and the physician simply doesn’t list the various diagnoses because they are not being treated. If the patient receives comfort care, make to report the standard palliative care and DNR status codes per coding guidelines, however, these codes do not risk adjust mortality metrics. Review the record for the underlying disease process which has resulted in the decision for comfort care and make sure you get that correct. Care should also be taken to make sure that any diagnoses which are treated during the stay which may be interrelated or subsequent to the decision for comfort care are reported. These conditions are what risk adjusts the denominator or “expected” mortality and most of these are generally identifiable at the time or very early in the admission process.

Conditions which are subsequent to the death process, and receive no treatment, and occur late in the death process are not reportable as they part of the dying process which is expected for example. For example, diagnoses such as subsequent organ failure not addressed during the death process or findings such as Cheyne strokes, breathing would not be separately reported.

If you have access to the severity of illness (SOI) and risk of mortality (ROM) levels, try to ensure that they are both at a level four for death charts, especially the ROM. This will generally only be possible when the patient is admitted and treated for several days, not when they expire shortly after admission. Uncertain diagnoses are still allowed to be reported in this circumstance under official coding guidelines, but they should be reported by some clinical evidence. I recommend the phrase “evidence of” (with a reference to what clinical is being utilized) rather than the phrase “possible”.

One final recommendation is to review the CMS quality metrics and risk adjustment methodologies. The exclusion which really counts is if they are Enrolled in the Medicare hospice program any time in the 12 months prior to the index admission, including the first day of the index admission, meaning that the decision for comfort care measures made up to the first day of admission counts. Use caution, the term “palliative care” and its corresponding code along with a DNR order and its corresponding code are of no help here.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.