NLU Content for CDI Pediatric Rules

Content available as of NLU version 3.98

MDC 01 - Diseases & Disorders of the Nervous System

Encephalopathy - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
12012 Pediatric: Documentation of hypoxic ischemic encephalopathy without documentation of the severity of encephalopathy (age: < 1 year) HYPOXIC ISCHEMIC ENCEPHALOPATHY

Please document the severity of hypoxic ischemic encephalopathy.
 


MDC 03 - Diseases & Disorders of the Ear, Nose, Mouth & Throat

Cleft Palate or Lip - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
44001 Pediatric: Documentation of cleft palate without documentation of site Please document the site of cleft palate.        
44002 Pediatric: Documentation of cleft lip without documentation of laterality Please document the site of cleft lip.        


MDC 04 - Diseases & Disorders of the Respiratory System

Acute Bronchiolitis - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
40101 Pediatric: Documentation of bronchiolitis without documentation of the causative organism of bronchiolitis Please document the causative organism for acute bronchiolitis, if known.      
40102 Pediatric: Documentation of RSV without documentation of RSV bronchiolitis or pneumonia There is documentation of RSV. Please document any associated diagnosis.  


Asthma - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
PedAsthma-001 Pediatric: Documentation of asthma exacerbation (+/- medication or procedure evidence of asthma exacerbation) without documentation of the status of the status asthmaticus There is documentation of asthma exacerbation. Please specify whether or not status asthmaticus is present.    


Pneumonia - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001424 Pediatric: Documentation of pneumonia in the emergency department without documentation of pneumonia in the inpatient documentation Pneumonia is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.        


Respiratory Failure - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
PedRespFailure-001 Pediatric: Explicit mention or evidence of respiratory failure/distress without documentation of type and acuity. There is documentation or evidence of respiratory failure/distress, please document the **type** and **acuity** of respiratory failure.  


MDC 05 - Diseases & Disorders of the Circulatory System

Congenital Heart Disease - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
400001 Pediatric: Documentation of congenital heart disease without documentation of the type of congenital heart disease Please document the type of congenital heart disease.  


Hypertension

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
420001 Pediatric: Clinical evidence of hypertension (+/- medication evidence of hypertension) without documentation of elevated blood pressure or stage of hypertension (age: > 1 year) There is evidence of high blood pressure. Please document any associated diagnosis.      

Evidence

Evidence
Diagnoses:
Heart failure
Hypertension: accelerated, essential, malignant
Pre-eclampsia

Clinical signs and symptoms:
Chest pain
Dyspnea
Elevated blood pressure: systolic > 120 mm Hg, diastolic > 80 mm Hg
End organ damage
Headache
Hypertensive urgency: systolic > 180 mm Hg, diastolic > 110 mm Hg
Pregnancy: gravida, para, trimester
Shortness of breath

Medications and/or therapeutic treatments:
Angiotensin converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers (ARB)
Anti-hypertensives
Beta-blockers
Calcium channel blockers
Diuretics
Non-peptide inhibitors
Vasodilators

Diagnostic procedures and/or procedure findings:
Diastolic dysfunction
Hypertrophy: aorta, left atrium, left ventricle

Other Circulatory Conditions - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
430001 Pediatric: Clinical evidence of hypotension without documentation of hypotension There is evidence of low blood pressure. Please document any associated diagnosis.      


Shock

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
PedShock-001 Pediatric: Lab or clinical evidence of shock (+/- evidence of transfusion or vasopressor) without documentation of shock There is evidence of hypotension and lab and/or clinical evidence of organ dysfunction. Please document any associated diagnosis.

Evidence

Evidence
Diagnoses:
Encephalopathy
Hypotension
Lactic Acidosis
Shock

Clinical signs and symptoms:
Altered mental status
Capillary refill time: > 2 seconds
Low mean arterial pressure (MAP): < 65 mmHg
Low systolic blood pressure (SBP)
 Adults (ages > 18): < 90 mmHg
 Children (ages <= 18): age-based values
Peripheral pulse intensity: >= 1+

Labs:
Activated partial thromboplastin time (aPTT): > 60 seconds
Bilirubin: > 2 mg/dL
Creatinine: > 2 mg/dL
International normalization ratio (INR): > 1.5
Lactate: > 2 mmol/L
Platelets: < 100,000

Medications and/or therapeutic treatments:
Blood transfusion
Intravenous fluid administration
Inotropes
Vasopressors

Shock - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001463 Pediatric: Documentation of pediatric systolic hypotension and vasopressor or documentation of pediatric systolic hypotension and blood product administration without documentation of type of shock There is documentation of pediatric systolic hypotension and vasopressor or pediatric systolic hypotension and blood product. Please document any associated condition and type.      


MDC 10 - Endocrine, Nutritional & Metabolic Diseases & Disorders

BMI/Obesity - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
40203 Pediatric: Documentation of BMI equal to 95th to less than the 99th percentile for age or BMI equal to 30 to less than 35 without documentation of obesity (age: >= 2 years) There is evidence of BMI at 95th to less than the 99th percentile for age or BMI equal to 30 to less than 35. Please document any associated diagnosis.      
40204 Pediatric: Documentation of BMI greater than or equal to 35 or greater than or equal to the 99th percentile without documentation of severe, class 2 or class 3 obesity (age: >= 2 years) There is evidence of BMI above or at 99th percentile for age or BMI greater than or equal to 35. Please document any associated diagnosis.  
40207* Pediatric notification: Documentation of BMI between the 5th and 85th percentile for age        
40208* Pediatric notification: Documentation of BMI between the 85th and 95th percentile for age        
40209* Pediatric notification: Documentation of BMI at or above the 95th percentile for age        


Diabetes Mellitus - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001445 Pediatrics: Documentation of gestational diabetes or impaired glucose tolerance or lab evidence of an elevated glucose or elevated A1C without documentation of the type of gestational diabetes, diet controlled (A1-GDM) or insulin controlled (A2-GDM) GESTATIONAL DIABETES - TYPE - B

Please document the type of gestational diabetes
       


Malnutrition - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
40206* Pediatric notification: Documentation of BMI below the 5th percentile for age        
40211 Pediatric: Documentation of failure to thrive or feeding difficulties (+/- evidence of BMI or weight below or at 3rd percentile) without documentation of malnutrition NUTRITIONAL INDICATORS - F

There is documentation of failure to thrive or feeding difficulty. Please document any associated diagnosis.


MDC 11 - Diseases & Disorders of the Kidney & Urinary Tract

Urinary tract infection - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001422 Pediatric: Documentation of UTI in the emergency department without documentation of UTI in the inpatient documentation UTI is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.        
51001423 Pediatric: Documentation of catheter associated UTI in the emergency department without documentation of catheter associated UTI in the inpatient documentation Catheter associated UTI is documented in the emergency department but has not been documented after admission. Please clarify the presence or absence of this diagnosis.        


MDC 14 - Pregnancy, Childbirth & the Puerperium

Obstetrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001462 Pediatric: Documentation of a thyroid medication during pregnancy without documentation of a thyroid condition There is documentation of thyroid medication during pregnancy. Please document any associated diagnosis.    


MDC 15 - Newborns & Other Neonates with Conditions Originating in Perinatal Period

Bronchopulmonary Dysplasia

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
40401* Pediatric notification: Documentation of bronchopulmonary dysplasia (age: < 28 days)        
40402 Pediatric: Documentation of chronic lung disease without documentation of the etiology of chronic lung disease Please specify the type of chronic lung disease.        

Evidence

Evidence

Necrotizing Enterocolitis

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
2060001 Pediatric: Documentation of necrotizing enterocolitis without documentation of the stage of necrotizing enterocolitis Please document the stage of necrotizing entercolitis (NEC).    

Evidence

Evidence



Nuchal Cord

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
ComplicationsL&D-001 Pediatric: Documentation of nuchal cord without documentation of POA status NUCHAL CORD

Please document whether the nuchal cord was present on admission.
       

Evidence

Evidence

Retinopathy of Prematurity

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
2200001 Pediatric: Documentation of retinopathy of prematurity without documentation of the stage, zone and eye laterality of the retinopathy of prematurity Please document the stage, zone, and laterality of the eye(s) affected by ROP.        


MDC 16 - Diseases & Disorders of Blood, Blood Forming Organs, Immunologic Disorders

Immunodeficiency - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
51001428 Pediatric: Evidence of immunosuppressant medications(s) or CAR T-cell therapy without documentation of immune status There is evidence of immunosuppressant treatment or CAR T-Cells therapy. Please document the immune status.    


Pancytopenia - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
PedAnemia-003 Pediatric: Lab evidence of pancytopenia without documentation of pancytopenia LOW HGB, PLATELETS, AND WBC - B

There is evidence of low hemoglobin, platelets, and white blood cell count. Please document any associated diagnosis.
   


MDC 19 - Mental Diseases & Disorders

Developmental Delay - Pediatrics

Rules

* Clinical Notification
Code Rule Physician Message Risk Classification
CC MCC HCC MS-DRG
40600 Pediatric: Documentation of a developmental delay without documentation of the type of development delay DEVELOPMENTAL DELAY

Please document the type of developmental delay.
   
5060005 Documentation of autism without documentation of the type of autism AUTISM - TYPE

Please document the type of autism.
   
5060006 Documentation of autism without documentation the cause of autism or presence/absence of associated conditions AUTISM

Autism was documented, please document the presence or absence of any **associated conditions**.