Guest post: NICU CDI chart audits

October 2, 2020
CDI Blog - Volume 13, Issue 50

by Rabia Jalal, MBBS, CCS, CDIP, CCDS, RHIA

I have been a CDI specialist in a neonatal intensive care unit (NICU) for a few years now and had the pleasure of co-presenting on the topic at the 2018 ACDIS annual conference in San Antonio, Texas. A few days ago, I was perusing the ACDIS website for the latest articles posted when I came across a question about doing NICU chart audits. I was excited like a child in a candy store because I wanted to be part of this conversation. Not all facilities have a NICU or do chart audits, so NICU CDI specialists like myself are few and far between. I have put together a quick little how-to for those interested in doing chart audits for their facility’s NICU.

Neonatal terminology

  • Extra/extreme immaturity: Less than 28 weeks of gestation completed
  • Low birth weight: An infant born weighing less than 2,500 grams

Neonatal MS‐DRGs

They fall in the 700 DRG categories:

  • Normal Newborn: 795 
  • Full‐Term: 794 (with other problem)
  • Full‐Term: 793 (with major problem)
  • Premature: 792 (with other problem)
  • Premature: 791 (with major problem)
  • Extreme Immaturity/RDS: 790 
  • Expired/Transferred to another facility: 789

Note: For a newborn transferred from another facility, use the diagnosis that necessitated the transfer as the principal diagnosis rather than the Z38 code.

Note: Diagnoses that change DRG 795 to 794 are: Late acidosis of the newborn, meconium aspiration, hypomagnesemia, hypocalcemia, apnea, anemia of prematurity, and respiratory distress syndrome.

Neonatal coding guidelines

Principal diagnosis:

  • When coding the birth episode in a newborn record, assign a code from category Z38, Live born infants, according to place of birth and type of delivery, as the principal diagnosis. Do not code Z38 in the mother’s chart.

Observation and evaluation of newborns for suspected conditions not found:

  • Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study to not be present. Code Z05.1 should only be used with neonates with no symptoms—e.g., sepsis ruled out, use code Z05.1.
  • If the neonate was admitted or transferred for respiratory distress, etc., then the sign or symptom would be coed with the appropriate P code range. Code all conditions documented in the neonate’s chart including signs and symptoms if a diagnosis has not been determined. Diagnoses from a mother’s chart should not be coded in a baby’s chart unless they impact the baby and vice versa.
    • e.g., meconium staining and infant of a diabetic mother. Perinatal/congenital conditions can be reported throughout the life of a patient if it persists. Query the physician if a condition is not due to the birth process.

Query opportunities in the NICU

My most common queries include, but are not limited to:

  1. Sepsis (Rule in/out or if signs of infection, especially in babies with group B strep infection [GBS] positive mothers)
  2. Meconium staining/aspiration
  3. Respiratory failure versus respiratory distress syndrome (RDS; If RDS is mentioned, due not code respiratory failure as it is considered an integral symptom of RDS).

 

For a complete list of Neonatal CCs and MCCs, refer to the ACDIS Pocket Guide.

Editor’s note: Jalal is a CDI specialist/senior clinical analyst at Optum360, working at Marian Regional Medical Center in Santa Maria, California. Contact her at Rabia.Jalal@DignityHealth.org. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.