Q&A: Accounting for SOI/ROM in neonatal death

Q: I am looking for help on reviewing a neonatal intensive-care unit (NICU) death chart for severity ofillness/risk of mortality (SOI/ROM). Prior to birth the child was diagnosed with a severe brain abnormality, holoprosencephaly. The family decided upon comfort care once the baby was born, at which time (37 weeks) the child weighed 2207 grams, small-for-gestational age. The hospital kept the child comfortable until it passed the same day as the birth. The physician documented that baby would experience apnea and bradycardia as part of the dying process. The nursing flow sheet confirms the apnea and bradycardia but the physician did not actually document these conditions, only that the baby would be expected to experience them.

This baby was delivered and essentially treated as a hospice patient. All interventions were geared at comfort. As the case stands the SOI/ROM would be 1/1.

I could use some help identifying some possible diagnoses besides the regular birth codes, the anomaly codes, and the V66.7 code. Can we query for respiratory failure even though it is part of the dying process?

A: A query for respiratory failure would probably not be appropriate as the baby was comfortable, says Kerry Seekircher, RN, BS, CCDS, CDIP, Documentation Specialist Supervisor at Northern Westchester Hospital in Mount Kisco, NY. “If the baby struggled, was intubated, or placed on high flow oxygen, that would be different,” says Seekircher, who reviews all NICU charts at her facility and suggests double checking all interventions not geared at comfort to assess for a possible diagnosis.

Additionally, a diagnosis of “likely, suspected, evidence of” brain death (ICD-9-CM code 348.82) might be an effective query target, suggests Karen Bridgeman MSN, RN, CCDS, CDI educator, at Medical University of South Carolina in Charleston. Bridgeman points to Coding Clinic for ICD-9-CM and to the National Association of Children’s Hospitals and Related Institutions (NACHRI) specific request for a unique code for brain death.

She cautions that the physician did not document any brain death criteria; however, if such a diagnosis proved appropriate in this case it could move the SOI/ROM to 3/4.

Also look to the 764-779 codes, for “other condition originating in the perinatal period,” suggests Jolene File, RHIT CCS, CPC-H, CCDS, CDI specialist at Hays (Kansas) Medical Center, since such codes incorporate fetal weight, gestation, birth trauma, hematological disorders, etc.

“These NICU cases are difficult to code and, if not well documented, very difficult to know what to query for appropriately,” File says.

Editor’s Note: This Q&A exchange was adapted from CDI Talk, the ACDIS list serv and networking site,and was originally published on the ACDIS Blog.